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BACKGROUND Healthcare resource utilization and patient-reported outcomes (PROs) for intradural extramedullary (IDEM) spine tumors are not well reported. OBJECTIVE To analyze the PROs, costs, and resource utilization 1 year following surgical resection of IDEM tumors. METHODS Patients undergoing elective spine surgery for IDEM tumors and enrolled in a single-center, prospective, longitudinal registry were analyzed. Baseline and postoperative 1-year PROs were recorded. One-year spine-related direct and indirect healthcare resource utilization was assessed. One-year resource use was multiplied by unit costs based on Medicare national payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). RESULTS A total of 38 IDEM tumor patients were included in this analysis. There was significant improvement in quality of life (EuroQol-5D), disability (Oswestry and Neck Disability Indices), pain (Numeric rating scale pain scores for back/neck pain and leg/arm pain), and general physical and mental health (Short-form-12 health survey, physical and mental component scores) in both groups 1 year after surgery (P < .0001). Eighty-seven percent (n = 33) of patients were satisfied with surgery. The 1-year postdischarge resource utilization including healthcare visits, medication, and diagnostic cost was $4111 ± $3596. The mean total direct cost was $23 717 ± $7412 and indirect cost was $5544 ± $4336, resulting in total 1-year cost $29 177 ± $9314. CONCLUSION Surgical resection of the IDEM provides improvement in patient-reported quality of life, disability, pain, general health, and satisfaction at 1 year following surgery. Furthermore, we report the granular costs of surgical resection and healthcare resource utilization in this population.

Objective The aim of this study was to evaluate a tailored physical activity protocol performed in a work environment with a group of female workers employed in manual precision tasks to reduce upper limb pain. Methods Sixty female subjects were randomly assigned to an intervention group or a control group. The IG was administered of a 6-month, twice-a-week, tailored exercise program, whereas the CG received no intervention. Results The IG showed a reduction on shoulder pain accompanied by increases on the range of motion measures. In addition, reductions in upper limb pain and neck disability were detected with concomitant increases in grip strength. Conclusions This study indicated positive effects of a tailored workplace exercise protocol in female workers exposed to moderate risk for work-related musculoskeletal disorders, showing clinically meaningful reductions of pain symptoms and disability on upper limb and neck regions.

Background: Cervical radicular pain is a major cause of disability. No studies have been published comparing different types of nonsurgical therapy. Methods: A comparative-effectiveness study was performed in 169 patients with cervical radicular pain less than 4 yr in duration. Participants received nortriptyline and/or gabapentin plus physical therapies, up to three cervical epidural steroid injections (ESI) or combination treatment over 6 months. The primary outcome measure was average arm pain on a 0 to 10 scale at 1 month. Results: One-month arm pain scores were 3.5 (95% CI, 2.8 to 4.2) in the combination group, 4.2 (CI, 2.8 to 4.2) in ESI patients, and 4.3 (CI, 2.8 to 4.2) in individuals treated conservatively (P = 0.26). Combination group patients experienced a mean reduction of −3.1 (95% CI, −3.8 to −2.3) in average arm pain at 1 month versus −1.8 (CI, −2.5 to −1.2) in the conservative group and −2.0 (CI, −2.7 to −1.3) in ESI patients (P = 0.035). For neck pain, a mean reduction of −2.2 (95% CI, −3.0 to −1.5) was noted in combination patients versus −1.2 (CI, −1.9 to −0.5) in conservative group patients and −1.1 (CI, −1.8 to −0.4) in those who received ESI; P = 0.064). Three-month posttreatment, 56.9% of patients treated with combination therapy experienced a positive outcome versus 26.8% in the conservative group and 36.7% in ESI patients (P = 0.006). Conclusions: For the primary outcome measure, no significant differences were found between treatments, although combination therapy provided better improvement than stand-alone treatment on some measures. Whereas these results suggest an interdisciplinary approach to neck pain may improve outcomes, confirmatory studies are needed.

Pain localized in the deep tissues occurs frequently in complex regional pain syndrome (CRPS). In addition, hyperalgesia to blunt pressure over muscles is common in CRPS, but it often appears in limb pain of other origin as well. Considering that 3-phase bone scintigraphy (TPBS) reveals periarticular enhanced bone metabolism in CRPS, joint-associated hyperalgesia to blunt pressure might be a more specific finding than hyperalgesia over muscles. In 34 patients with upper limb pain (18 CRPS, 16 non-CRPS; diagnosed in accordance to the Budapest criteria) and in 18 healthy controls, pressure-pain thresholds (PPT) were assessed bilaterally over the thenar (PPTThenar), the metacarpophalangeal (PPTMCP), and the proximal interphalangeal (PPTPIP) joints using a pressure algometer (Somedic, Sweden). Beforehand, all patients had received TPBS for diagnostic purposes independently of the study. Region-of-interest (ROI) ratios (mineralization phase) for the MCP and PIP, excluding fracture sites, were correlated with the PPT. In CRPS, all ROI ratios were significantly increased and all PPT of the affected hand were decreased compared to non-CRPS (PPTThenar: 243±150kPa vs 358±197kPa, PPTMCP: 80±67kPa vs 159±93kPa, PPTPIP: 80±56kPa vs 184±110kPa; P

In patients with complex regional pain syndrome (CRPS) type 1, processing of static tactile stimuli is impaired, whereas more complex sensory integration functions appear preserved. This study investigated higher order multisensory integration of body-relevant stimuli using the rubber hand illusion in CRPS patients. Subjective self-reports and skin conductance responses to watching the rubber hand being harmed were compared among CRPS patients (N = 24), patients with upper limb pain of other origin (N = 21, clinical control group), and healthy subjects (N = 24). Additionally, the influence of body representation (body plasticity [Trinity Assessment of Body Plasticity], neglect-like severity symptoms), and clinical signs of illusion strength were investigated. For statistical analysis, 1-way analysis of variance, t test, Pearson correlation, with α = 0.05 were used. CRPS patients did not differ from healthy subjects and the control group with regard to their illusion strength as assessed by subjective reports or skin conductance response values. Stronger left-sided rubber hand illusions were reported by healthy subjects and left-side-affected CRPS patients. Moreover, for this subgroup, illness duration and illusion strength were negatively correlated. Overall, severity of neglect-like symptoms and clinical signs were not related to illusion strength. However, patients with CRPS of the right hand reported significantly stronger neglect-like symptoms and significantly lower illusion strength of the affected hand than patients with CRPS of the left hand. The weaker illusion of CRPS patients with strong neglect-like symptoms on the affected hand supports the role of top-down processes modulating body ownership. Moreover, the intact ability to perceive illusory ownership confirms the notion that, despite impaired processing of proprioceptive or tactile input, higher order multisensory integration is unaffected in CRPS.

More than 1.5 million individuals in the United States use manual wheelchairs for community mobility.1 This mode of ambulation places significant demand on the upper extremities secondary to the forceful, repetitive nature of wheelchair propulsion. Consequently, both upper extremities are at risk for overuse pathology. Among spinal cord injured individuals who are manual wheelchair users, the shoulder is the most common injury site. The prevalence of shoulder pain has been reported between 31 and 73% for this population.2–5 Neither surgical6 nor nonoperative7 treatment of shoulder injuries in persons with spinal cord injury reliably restores premorbid function. The treatment ineffectiveness may be explained, in part, by the fact that primary contributing factors to upper limb pain including wheelchair propulsion cannot be avoided.7 Injury prevention may, therefore, be a more effective strategy to address the pain and compromised daily function frequently encountered by manual wheelchair users. Investigation of wheelchair propulsion biomechanics is one mechanism to gain insight to factors that may contribute to upper extremity pathology.8 Based on the results of their multicenter trial, Boninger et al.9 identified propulsion cadence and magnitude of force as risk factors for upper extremity injury in manual wheelchair users. The authors suggested altering propulsion recovery patterns, using the lightest wheelchair possible, and limiting patient weight gain as injury prevention strategies.9 These studies were performed, however, while subjects were secured to a wheelchair dynamometer that simulated propulsion over smooth, level tile flooring. The impact of environment on wheeling biomechanics and injury risk were not evaluated. Few investigators have evaluated wheelchair propulsion outside of the laboratory setting. Koontz et al.10 measured right upper extremity propulsion kinetics as subjects traversed terrain that included grass, concrete, carpet, tile, wood, and ramped surfaces. The investigators reported kinetic values during the start-up phase of wheeling were significantly different across ground conditions, and when compared with steady-state propulsion across smooth, level concrete. Temporal-distance differences were also identified during ramp and grass terrain propulsion compared with the other ground conditions. Koontz et al.10 stated that these results highlight the importance of evaluating wheelchair propulsion over a range of surfaces. The investigation was limited, however, to an analysis of propulsion technique for only one extremity during the start-up phase of wheeling. A bilateral upper extremity analysis during the steady-state interval of wheeling would further elucidate the impact of terrain on wheelchair propulsion patterns. Determining the impact of level wheeling terrain on propulsion biomechanics may contribute to additional injury prevention strategies for manual wheelchair users. Therefore, the purpose of this study was to evaluate manual wheelchair propulsion across ground conditions that are encountered during everyday life. Using instrumented wheelchair rims, we evaluated bilateral temporal and kinetic characteristics of wheelchair propulsion as the subject traversed level aggregate concrete, smooth concrete, carpet, and tile surfaces. We hypothesized propulsion forces, moments, and contact time would be greater, and velocity and cadence lower during propulsion across uneven terrain (i.e., aggregate concrete) compared with smooth terrain (tile flooring), and that kinetic and temporal values measured during carpet and smooth concrete ground conditions would be intermediate to aggregate concrete and tile terrain. Side-to-side differences between extremities have included greater power production from the dominant limb during manual wheelchair propulsion across outdoor terrain.11 Therefore, we also hypothesized there would be significant differences between extremities for kinetic variables, with forces and moments measured for the dominant upper extremity to be significantly higher than the nondominant extremity.

Little is known about the distribution and determinants of pain at multiple sites in the neck and upper limb. To investigate the prevalence, pattern, and clustering of such pains and the association of extensive involvement with putative risk factors, we mailed a questionnaire to a community sample of 9696 working-aged adults. Age-sex specific prevalence rates for pain were estimated and the frequency of bilateral involvement, pairwise overlap at different sites, and extent to which reports clustered within individuals were explored. Associations of multi-site involvement with age, gender, psychological health, smoking, and employment status were assessed by logistic regression. Among 6038 responders, 2657 reported at least a day of neck or upper limb pain in the past 7 days, including 1843 whose symptoms rendered normal activities difficult or impossible. Pain was frequently bilateral or in the dominant arm. Significant associations were seen for pain at anatomically adjacent sites. Pain affecting every site considered (neck, shoulders, elbows, wrists/hands) was far more common than might be expected if each site were statistically independent (observed/expected ratio 8750). Being female, unemployed, a blue-collar worker, or a smoker were independent risk factors for such extensive pain, but the strongest association was with psychological ill-health (odds ratio for worst vs. best third of the SF-36 low vitality score, 30.3, 95% CI 7.1-129.0). Neck and upper limb pain commonly cluster, and frequently display symmetry and adjacent patterns of involvement. Extensive neck and upper limb pain is far more strongly associated with poor mental vitality than localised pain.

To determine the value of F waves in provocative positions for the diagnosis of thoracic outlet syndrome, we performed provocative maneuvers on three patients with a clinical diagnosis of thoracic outlet syndrome. The patients had complained of intermittent upper limb pain with associated weakness and paresthesias for several years, and previous evaluations included essentially normal cervical and shoulder imaging studies and electrodiagnostic studies. Although upper limb nerve conduction studies, including ulnar and median F waves, were within normal limits, provocative F waves were obtained in the symptomatic and asymptomatic arm. When routine nerve conduction studies are normal, despite a strong clinical suspicion, provocative maneuvers may help to show subtle electrodiagnostic abnormalities to support the diagnosis of thoracic outlet syndrome.

Data on the use of various therapeutic interventions among working populations at risk for musculoskeletal disorders are rare, despite the need for such information in assessing adherence to best practices. Using the results of a cross-sectional survey of newspaper workers who reported neck and upper limb pain or discomfort (n = 309), we describe the prevalence of a wide range of clinical and workplace interventions. Information/education, exercises, and physical treatments were the most common interventions, and work changes were less prevalent. Those with more frequent, longer-duration, and/or more severe symptoms more commonly reported visits to physiotherapists and health practitioners at work and use of physical treatments, medications, and devices. The multiplicity of interventions used pose evaluation challenges for occupational health practitioners and researchers.

The ability of Elvey's "brachial plexus tension test" to identify pain referred from the cervical region was investigated in 50 patients with unilateral shoulder and upper arm pain: 25 reported symptoms commencing after open heart surgery, indicating a high probability of referred pain due to that procedure; 25 were athletes with injuries from throwing movements, a cause appearing much less likely to cause referred pain. Twenty-five asymptomatic subjects with no history of spinal or limb pain also were tested. Cervical and upper limb maneuvers of the test were assessed goniometrically. The cardiac group showed significantly greater test results than those of the other groups, suggesting that the test is able to discriminate referred and local sources of upper limb pain.

Objective: To present two cases of sulcal artery syndrome. Background Sulcal (also known as central and sulcocommisural) arteries are perforating branches of the anterior spinal artery, which perfuse the anterior 2/3 of a hemicord. Sulcal arteries alternatively perforate the right or left side of the spinal cord at successive levels. Unilateral spinal cord infarction restricted to the perfusion territory of sulcal artery is very rare. All of the four previously reported cases have been associated with vertebral dissection. Design/Methods: Case 1: A 16 year old boy experienced sudden onset of a shooting pain on the right neck and arm after throwing a basketball. Over the next few hours, he developed right arm and leg paralysis. Examination showed right sided hemiplegia and impaired pain and temperature sensation on the left side. Vibratory sensation and proprioception were normal. Case 2: A 41 year old man presented with sudden onset of vertigo, pain on his left shoulder radiating to the nape of the neck and back of the head. Examination showed left upper and lower limb weakness, and impaired pain and temperature sensation on the right side. Results: Case 1: Cervical spinal MRI showed T2 WI signal intensity abnormality extending from C3 to C4 with mild cord expansion. Axial diffusion weighted image showed restricted diffusion in the right hemicord. CT angiogram showed hypoplastic right vertebral artery but no definitive dissection. Case 2: MRI showed acute infarct in the left cerebellum and in the left hemicord from C3-C5. CT angiogram demonstrated a left vertebral artery dissection. Conclusions: Sulcal artery syndrome is to be considered in acute onset of hemiplegia and contralateral pain and temperature impairment. Both of our cases had neck and upper limb pain, which is very uncommon with hemispheric or brainstem strokes. Disclosure: Dr. Da Silva has nothing to disclose. Dr. Brorson has received personal compensation for activities with CVS Caremark Corporation as a consultant. Dr. Rezania has nothing to disclose.

Background and Objectives Peripheral nerve catheterization techniques were used in two patients with severe pain associated with the terminal stages of metastatic cancer. The first patient had severe upper limb pain and lymphedema secondary to breast carcinoma, and the second patient had an acutely ischemic leg secondary to pelvic obstruction from an ovarian tumor. The goal of treatment was to relieve the pain, which was resistant to opioid drugs, and to optimize the quality of life that remained, estimated to be only a few weeks. Methods The first patient received a continuous brachial plexus block via an epidural catheter, introduced by means of a Tuohy needle and a peripheral nerve stimulator to locate the plexus accurately. The second patient required catheterization of both the sciatic and femoral nerves, again with a peripheral nerve stimulator used to locate the nerves prior to inserting the catheters. Results Analgesia was established with a bolus of local anesthetic and maintained with a continuous infusion of local anesthetic in the first patient. For the second patient, fentanyl was added to the local anesthetic, as it had been shown to improve analgesia in the lower limb in previous work. In the first patient, the analgesia allowed active treatment of the lymphedema and mobilization of the limb, and she remained pain free until her death 2 weeks later. In the second patient, the infusions controlled the pain both before and after surgical amputation of the limb, until the stump was well healed. Conclusions Peripheral nerve catheterization proved beneficial in two patients who presented with difficult pain management problems and should be more widely considered for the relief of severe cancerrelated pain in both the upper and lower limbs.

The industrial upper limb pain epidemic colloquially known as repetition strain injury rapidly increased in the early 1980s to peak in 1985. Its less precipitous decline coincided with an awareness that repetition strain injury was a nonphysical sociopolitical phenomenon and a corresponding loss of the pecuniary benefits enjoyed by the powerful vested interest groups. Although its protagonists incorrectly claimed that this was a new disease, the rise and fall of repetition strain injury followed its historical predecessors including telegraphists' wrist and writer's cramp. Those affected by this phenomenon, a clearly defined cohort, were all employees who were highly suggestible and engaged in menial repetitious tasks with little job satisfaction. These patients were differentiated from those with genuine work related injuries whose symptoms are reproducible, with physical signs easily defined, disease identifiable, and response to physical treatment predictable. Most patients with repetition strain injury genuinely suffered the symptoms of which they complained and made little secondary gain relative to the protagonists of repetition strain injury who had a vested interest. The similarities between Australian repetition strain injury in the 1980s and American cumulative trauma disorder in the 1990s is compelling.

Between 1963 and 1980, one or more posterior-lateral foraminotomies were performed for simple cervical radiculopathy as the sole operative procedure for 736 patients. One hundred three patients (14%) required a second posterior procedure, but only 24 (3%) cases represented true recurrent radiculopathy. There were 13 minor complications (1.5%) and no deaths or detectable incidence of air embolism. All operations were done with the patient in the sitting position. Central venous pressure monitoring was used only infrequently. There was a 96% incidence of relief of significant arm pain and/or paresthesia and a 98% incidence of resolution of preoperatively present motor deficit. Eight hundred twenty-eight procedures (98%) were preceded by Pantopaque cervical myelography. There was a 71.5% incidence of correlation between preoperative clinical findings (both sensory and motor) and operative findings. In 13% of the cases, two spaces were thought by the operating surgeon to be equally involved by the spondylotic process. Most (91.5%) of the patients describe themselves as either “good or excellent” postoperatively. There was no significant difference postoperatively regarding results or recurrence between patients with suspected soft or hard disc protrusions and those with strictly spondylotic radiculopathy. Nor was there any statistical difference in results among the three patient population groups (“private” vs. compensation vs. liability). The mean length of time to return to work or other “normal” activities was 9.4 weeks. The mean length of follow-up time was 146 weeks (2.8 years). There was an associated incidence of significant lumbar disc and/or foraminal disease requiring operation of 33.4%.

Compression of the lower portion of the brachial plexus by a cervical band continuous with the scalenus medius is a rare but well-defined cause of arm pain. The syndrome should be suspected in a patient who presents with chronic arm pain and thenar atrophy. Cervical ribs or prominent C-7 transverse processes will be present on an anteroposterior roentgenogram of the cervical spine, and the diagnosis is confirmed by characteristic electromyographic findings. The syndrome should be differentiated from other causes of chronic arm pain, such as herniated cervical disc, syringomyelia, spinal cord tumor, or carpal tunnel syndrome. The condition is readily treated by surgical division of the compressive band, approached through a supraclavicular incision.

Ketanserin, a selective S2 serotonergic antagonist, was assessed against placebo in a double-blind cross-over study of 16 patients with chronic peripheral burning pain. Nine of these had signs of reflex sympathetic dystrophy (RSD). All patients underwent 4 intravenous regional treatments, 2 with ketanserin (10 mg for upper limb pain, 20 mg for lower limb pain) and 2 with placebo. In those patients with RSD ketanserin and not placebo provided significant (P less than 0.05) sustained pain relief as assessed by linear analogue scales. In patients who did not fulfil the criteria for RSD no significant relief was seen with placebo or ketanserin. Following tourniquet release, drowsiness, shakiness and faintness were reported at a higher (P less than 0.05) frequency after ketanserin than after placebo. All side effects were mild and transient, and no changes occurred in heart rate or blood pressure following ketanserin that were significantly different from those seen following placebo. A role for serotonin in the pathogenesis of RSD is proposed.