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Background: Existing therapies for myofascial and neuralgic forms of cervicobrachial pain may have unsatisfactory outcomes. Alternative therapies may be considered, particularly for individuals who have failed to respond. Contemporary conceptualizations of chronic pain mechanisms include the contribution of inflammatory factors; therefore, locally targeted antiinflammatory administrations may play a role in treatment of cervicobrachial pain. Alpha 2 macroglobulin (A2M) is a plasma protein that acts as a molecular trap for inflammatory factors such as tumor necrosis factor. After plasma is enriched for A2M, it may be considered as a possible injectable agent to counteract inflammation that may occur with a cervicobrachial pain syndrome. Objectives: This retrospective review evaluates patient response to the use of plasma concentrate enriched for alpha 2 macroglobulin (A2M-PPP) in treatment of neurogenic thoracic outlet syndrome (TOS) and other forms of cervical brachial syndrome. Study Design: Observational Study. Setting: Outpatient interventional neurology practice. Methods: There were 62 patients, including 46 women and 16 men ages 23-77 years. Twenty-three of these patients were diagnosed with complex regional pain syndrome (CRPS) or fibromyalgia, 18 with TOS, and 21 with musculotendinous pain (MTP). At baseline, 1 month, 3 months, and 6 months, patient status was evaluated with a Brief Pain Inventory (BPI) that included a composite pain score and a functional interference score. Patients were asked to estimate overall satisfaction with a Patient Global Impression of Change (PGIC) scale. Criterion for clinically significant improvement included >30% betterment in the BPI pain and functional interference subscales and a PGIC of > 5 at the 3-month mark. Results: Three patients, one with CRPS and 2 with TOS, complained of several days of worsened pain or dysesthesias. No serious or permanent complications were encountered. For patients with TOS at the 3-month mark, 61% achieved clinical endpoints of success compared with 35% with CRPS/fibromyalgia and 24% for patients with MTP (P < 0.05, chi-square). By 6 months, 22% of individuals in the neuropathic TOS group had > 30% improvements in pain and functional interference scores compared with 13% of the individuals in the CRPS/fibromyalgia group and 18% in the MTP group. Limitations: This article does not differentiate the added benefit of A2M-PPP from hydrodissection alone. Additionally, this article does not evaluate the actual benefit of the A2M molecule apart from other factors present in the platelet-poor concentrate such as exosomes and cytokines. With the advent of pure engineered A2M, more focused studies will be possible. Also, an independent assay was not done, and therefore we cannot be precisely sure about the exact quantity of platelets, if any, which were contained in the platelet-poor concentration. Conclusions: Results suggest that A2M-PPP, when injected into muscle, tendon, and epineurium with live ultrasound guidance, appears to be relatively safe and free of postinjection inflammatory reactions that are often seen after platelet-poor plasma injection. A2M-PPP appears to be associated more frequently with good outcomes when injected into brachial plexus targets in patients with TOS compared with outcomes observed after injection of the plexus in patients with CRPS/fibromyalgia. Key words: Plasma concentrate enriched for alpha 2 macroglobulin, neurogenic thoracic outlet syndrome, cervical brachial syndrome

BACKGROUND: This study sought to validate the clinical utility of multimodal magnetic resonance imaging (MRI) techniques in the assessment of neurodegenerative disorders. We intended to demonstrate that advanced neuroimaging techniques commonly used in research can effectively be employed in clinical practice to accurately differentiate heathy aging and dementia subtypes. METHODS: Twenty patients with dementia of the Alzheimer’s type (DAT) and 18 patients with Parkinson’s disease dementia (PDD) were identified using gold-standard techniques. Twenty-three healthy, age and sex matched control participants were also recruited. All participants underwent multimodal MRI including T1 structural, diffusion tensor imaging (DTI), arterial spin labeling (ASL), and magnetic resonance spectroscopy (MRS). MRI modalities were evaluated by trained neuroimaging readers and were separately assessed using cross-validated, iterative discriminant function analyses with subsequent feature reduction techniques. In this way, each modality was evaluated for its ability to differentiate patients with dementia from healthy controls as well as to differentiate dementia subtypes. RESULTS: Following individual and group feature reduction, each of the multimodal MRI metrics except MRS successfully differentiated healthy aging from dementia and also demonstrated distinct dementia subtypes. Using the following ten metrics, excellent separation (95.5% accuracy, 92.3% sensitivity; 100.0% specificity) was achieved between healthy aging and neurodegenerative conditions: volume of the left frontal pole, left occipital pole, right posterior superior temporal gyrus, left posterior cingulate gyrus, right planum temporale; perfusion of the left hippocampus and left occipital lobe; fractional anisotropy (FA) of the forceps major and bilateral anterior thalamic radiation. Using volume of the left frontal pole, right posterior superior temporal gyrus, left posterior cingulate gyrus, perfusion of the left hippocampus and left occipital lobe; FA of the forceps major and bilateral anterior thalamic radiation, neurodegenerative subtypes were accurately differentiated as well (87.8% accuracy, 95.2% sensitivity; 85.0% specificity). CONCLUSIONS: Regional volumetrics, DTI metrics, and ASL successfully differentiated dementia patients from controls with sufficient sensitivity to differentiate dementia subtypes. Similarly, feature reduction results suggest that advanced analyses can meaningfully identify brain regions with the most positive predictive value and discriminant validity. Together, these advanced neuroimaging techniques can contribute significantly to diagnosis and treatment planning for individual patients.

Anxiety Disorders are prevalent and often chronic, recurrent conditions that reduce quality of life. The first-line treatments, such as serotonin reuptake inhibitors and cognitive behavioral therapy, leave a significant proportion of patients symptomatic. As psychiatry moves toward targeted circuit-based treatments, there is a need for a theory that unites the phenomenology of anxiety with its underlying neural circuits. The Alarm, Belief, Coping (ABC) theory of anxiety describes how the neural circuits associated with anxiety interact with each other and domains of the anxiety symptoms, both temporally and spatially. The latest advancements in neuroimaging techniques offer the ability to assess these circuits in vivo. Using Neurosynth, a large open-access meta-analytic imaging database, the association between terms related to specific neural circuits was explored within the ABC theory framework. Alarm-related terms were associated with the amygdala, anterior cingulum, insula, and bed nucleus of stria terminalis. Belief-related terms were associated with medial prefrontal cortex, precuneus, bilateral temporal poles, and hippocampus. Coping-related terms were associated with the ventrolateral and dorsolateral prefrontal cortices, basal ganglia, and anterior cingulate. Neural connections underlying the functional neuroanatomy of the ABC model were observed. Additionally, there was considerable interaction and overlap between circuits associated with the symptom domains. Further neuroimaging research is needed to explore the dynamic interaction between the functional domains of the ABC theory. This will pave the way for probing the neuroanatomical underpinnings of anxiety disorders and provide an evidence-based foundation for the development of targeted treatments, such as neuromodulation.

Objective Transcranial Focused Ultrasound (tFUS) is a promising new potential neuromodulation tool. However, the safety of tFUS neuromodulation has not yet been assessed adequately. Patients with refractory temporal lobe epilepsy electing to undergo an anterior temporal lobe resection present a unique opportunity to evaluate the safety and efficacy of tFUS neuromodulation. Histological changes in tissue after tFUS can be examined after surgical resection, while further potential safety concerns can be assessed using neuropsychological testing. Methods Neuropsychological functions were assessed in eight patients before and after focused ultrasound sonication of the temporal lobe at intensities up to 5760 mW/cm2. Using the BrainSonix Pulsar 1002, tFUS was delivered under MR guidance, using the Siemens Magnetom 3T Prisma scanner. Neuropsychological changes were assessed using various batteries. Histological changes were assessed using hematoxylin and eosin staining, among others. Results With respect to safety, the histological analysis did not reveal any detectable damage to the tissue, except for one subject for whom the histology findings were inconclusive. In addition, neuropsychological testing did not show any statistically significant changes in any test, except for a slight decrease in performance on one of the tests after tFUS. Significance This study supports the hypothesis that low-intensity Transcranial Focused Ultrasound (tFUS) used for neuromodulation of brain circuits at intensities up to 5760 mW/cm2 may be safe for use in human research. However, due to methodological limitations in this study and inconclusive findings, more work is warranted to establish the safety. Future directions include greater number of sonications as well as longer exposure at higher intensity levels to further assess the safety of tFUS for modulation of neuronal circuits.

The presence of clinical features of neurogenic thoracic outlet syndrome (NTOS) including confirmatory anatomical changes with advanced imaging is not a sufficient predictor of a successful outcome to NTOS targeted therapy. It is often the attention given to the treatment of co-morbid factors that determine a good result. Co-existing conditions that require attention include distal nerve entrapments, conditions characterized by increased pain sensitivity, regional musculoskeletal pain conditions and depression.

In non-surgical patients and in patients awaiting surgery various interventional techniques are available to help control pain and disability without having to rely entirely on medications. Botulinum toxin can be effective for treating muscle spasm and also for providing at least temporary decompression of the thoracic outlet. Stellate ganglion blocks and brachial plexus blocks may be considered for neuropathic pain control. Co-morbid axial neck pain and myofascial pain may be treated with targeted approaches as well.

Scalene blocks are performed to determine if patients presenting with signs and symptoms of possible TOS will eventually respond well to targeted therapy. Coexisting conditions may negatively affect outcomes even when the TOS surgery is done well. In these circumstances, the scalene block essentially gives the patient and physician a chance to have a “trial run” prior to committing to targeted therapy.

ObjectiveLow-Intensity Focused Ultrasound Pulsations (LIFUP) is a promising new potential neuromodulation tool. However, the safety of LIFUP neuromodulation has not yet been adequately assessed. Patients with refractory temporal lobe epilepsy electing to undergo an anterior temporal lobe resection present a unique opportunity to evaluate the safety and efficacy of LIFUP neuromodulation. Because the brain tissue in these patients will be removed, histological changes in tissue after LIFUP can be examined. Evidence of effective neuromodulation was assessed using functional MRI and EEG, while further potential safety concerns were assessed using neuropsychological testing.MethodsEEG, functional MRI, and neuropsychology were assessed in six patients before and after focused ultrasound sonication of the temporal lobe at intensities up to 5760 mW/cm2. Using the BrainSonix Pulsar 1002, LIFUP was delivered under MR guidance, using the Siemens Magnetom 3T Prisma scanner. Neuropsychological changes were assessed using various batteries. EEG was recorded using the Electrical Geodesics EGI 256 channel system. Histological changes were assessed using hematoxylin and eosin staining, among others.ResultsLIFUP was not able to modulate the BOLD signal on fMRI in a reliable and consistent manner. The EEG data that was available did not demonstrate a change in activity after LIFUP in all but one subject. Likewise, the neuropsychology testing did not show any statistically significant changes in any test, except for a slight decrease in performance on the one test after LIFUP. Lastly, the histology did not reveal any detectable damage to the tissue, except for one subject for whom the histology findings were inconclusive.SignificanceThe safety in the histology was the primary endpoint, and as such, longer exposure at the highest intensity levels will be administered moving forward.Key PointsLIFUP is a novel brain stimulation technique with not yet fully established safety guidelines.LIFUP was administered to patients electing to undergo resective brain surgery.LIFUP does not appear to cause damage to tissue.Longer exposure times are needed to further show safety at these intensity levels.

Background: Several cell-based therapies have been proposed in recent years the management of low back pain, including the injection of medicinal signaling cells or mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP). However, there is only emerging clinical evidence to support their use at this time. Purpose: To assess the effectiveness of MSCs or PRP injections in the treatment of low back and lower extremity pain. Study Design: A systematic review and metaanalysis of the effectiveness of PRP and MSCs injections in managing low back and lower extremity pain. Data Sources: PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematic reviews, and reference lists. The literature search was performed from 1966 through June 2018. Study Selection: Randomized trials, observational studies, and case reports of injections of biologics into the disc, epidural space, facet joints, or sacroiliac joints. Data Extraction: Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Data Synthesis: Twenty-one injection studies met inclusion criteria. There were 12 lumbar disc injections, 5 epidural, 3 lumbar facet joint, and 3 sacroiliac joint studies Results: Evidence synthesis based on a single-arm metaanalysis, randomized controlled trials (RCTs), and observational studies, disc injections of PRP and MSCs showed Level 3 evidence (on a scale of Level I through V). Evidence for epidural injections based on single-arm metaanalysis, a single randomized controlled trial and other available studies demonstrated Level 4 (on a scale of Level I through V) evidence. Similarly, evidence for lumbar facet joint injections and sacroiliac joint injections without metaanalysis demonstrated Level 4 evidence (on a scale of Level I through V).. Limitations: Lack of high quality RCTs. Conclusion: The findings of this systematic review and single-arm metaanalysis shows that MSCs and PRP may be effective in managing discogenic low back pain, radicular pain, facet joint pain, and sacroiliac joint pain, with variable levels of evidence in favor of these techniques. Key Words: Chronic low back pain, regenerative therapy, medicinal signaling or mesenchymal stem cells, platelet-rich plasma, disc injection, lumbar facet joint injections, sacroiliac joint injections

A 29-year-old woman presented with head and neck dystonia, as well as functional seizures. The patient was an active military service member with a history of combat-related trauma. Resting blood oxygen level dependent (BOLD) functional MRI (fMRI) scans of the brain demonstrated an increased anterior cingulate component of the salience network and hyper-connectivity between the insula and cingulate. Following neurological and psychiatric evaluation, she was diagnosed with dissociative post-traumatic stress disorder, partially presenting as a functional movement disorder. Inhibitory repetitive transcranial magnetic stimulation (rTMS) was prescribed with the anterior cingulate as the primary target, and supplementary motor and premotor cortices as secondary targets. The treatment was intended to suppress tremors both directly and indirectly. Thirty-six sessions later, her symptoms were in remission, and she returned to active duty. This case demonstrates the potential efficacy of fMRI-guided rTMS in the treatment of dissociative PTSD.

Introduction Preclinical studies support investigation of focused ultrasound for breakdown of cerebral pathologies in neurodegenerative conditions including Alzheimer's disease (AD) and Parkinson's disease (PD). Methods A focused transcranial Doppler device with probes (2 MHz, 520 mW/cm2) affixed bilaterally was used to target the hippocampus (AD) or substantia nigra (PD) with functional magnetic resonance imaging navigation for enhanced plaque removal. A total of 22 patients (n = 11 AD, n = 11 PD) underwent 8 consecutive, weekly, 1-hour treatments wherein sleep was encouraged naturally or pharmacologically. Cognitive and motor functioning assessment was carried out using standardized evaluations at baseline and conclusion. Results Of all, 62.5% of patients had one or more improved cognitive scores without data incongruence, 87% had stable or improved fine motor scores, and 87.5% had stable or improved gross motor scores. No adverse events were reported. Discussion The safety of focused transcranial Doppler and possible enhancement in patient functioning were suggested by outcome data.

The cervical nerves may play a significant role in primary headache disorders. We reviewed the patterns of pain evoked by stimulation of the first 3 cervical nerves (C1-C3) in 10 patients with chronic occipital pain, 6 of whom also had migraine. Stimulation at the C1 level evoked periorbital and frontal pain in 6 of 6 patients with migraine but evoked occipital or cervical pain in those without migraine. C2 and C3 stimulation resulted in occipital or cervical pain in all patients. The C1 nerve may have an important sensory function in headache disorders that have orbital and frontal pain as a prominent feature.

Background: Botulinum chemodenervation has been increasingly used for treating conditions characterized by muscular pain and dystonia. Complication rates commonly exceed 10 percent in published accounts due to an inadvertent spread of toxin. Various techniques of precision targeting have been described to minimize undesirable toxin effects. The present study reports on a clinical experience combining ultrasonography and electromyography in order to demonstrate how favorably this approach compares to previously described techniques in terms of minimizing complications while maintaining efficacy. Design: Retrospective case series Methods: The present study is a retrospective clinical analysis of patients treated with botulinum toxin using 2 different combined targeting techniques; one using ultrasonography and electromyography and the other using fluoroscopy and electromyography. Results: Combined ultrasonography and electromyography was used in 77 of 245 procedures; in 168 procedures, fluoroscopy and electromyography was used. There were no complications with ultrasonography guided procedures; the complication rate for combined fluoroscopy and electromyography was 1.8 percent (3/168; Fisher exact p = 0.3206). For combined ultrasonography and electromyography, after 70 out of 77 procedures (91%) there was a good outcome compared to 136 out of 168 (81%) after procedures utilizing a combination of fluoroscopy and electromyography (Fisher exact p= 0.331). Conclusions: There was no significant difference in complication rate or successful outcomes comparing the 2 forms of imaging guidance when targeting muscles for botulinum injection. Since outcomes are comparable, other factors such as cost and radiation exposure may be considered in choosing which imaging modality to use. Key words: thoracic outlet syndrome, brachial plexus, botulinum toxin, ultrasound

Objective: The present study was undertaken to determine which factors differentiate patients with a good outcome after treatment for Thoracic Outlet Syndrome (TOS) from patients with a poor outcome. Methods: A total of 85 patients, who were examined during one year, had at least 6 months of follow up after treatment for TOS with either surgery or botulinum chemodenervation. Results: Socioeconomic factors of work disability or workers’ compensation claims did not differentiate treatment-responsive TOS from treatment-resistant cases. There was no difference between the 2 groups regarding the presence of anomalous anatomy detected by ultrasonography or regarding the presence of subclavian artery flow acceleration or occlusion detected by duplex sonography. Several factors were noted more frequently in treatment-resistant patients: sensory complaints extending beyond lower trunk dermatomes (42% vs. 10%), weakness extending beyond lower trunk myotomes (19% vs. 2%), histories of previous non-TOS surgery of the neck or upper limbs (50% vs.17%), comorbidities of fibromyalgia or complex regional pain syndrome (81% vs. 12%), and depression (35% vs. 10%). Treatment-resistant patients complained about more widespread functional impairments on a validated Cervical Brachial Symptom Questionnaire (CBSQ) than treatment-responsive patients. Resistant cases responded less often to a scalene test block (38% vs. 100%), which is designed to simulate the effects of targeted treatment. Conclusion: In summary, compared to patients with a good outcome after targeted treatment, patients with a poor outcome had more diffuse complaints and responded less often to a scalene test block. Keywords: Cervical brachial pain, chemodenervation, thoracic outlet syndrome, ultrasound

Thoracic outlet syndrome (TOS) is a group of disorders all having in common compression at the thoracic outlet. Three structures are at risk: the brachial plexus, the subclavian vein, and the subclavian artery, producing neurogenic (NTOS), venous (VTOS), and arterial (ATOS) thoracic outlet syndromes, respectively. Each of these three are separate entities, though they can coexist and possibly overlap. The treatment of NTOS, in particular, has been hampered by lack of data, which in turn is the result of inconsistent definitions and diagnosis, uncertainty with regard to treatment options, and lack of consistent outcome measures. The Committee has defined NTOS as being present when three of the following four criteria are present: signs and symptoms of pathology occurring at the thoracic outlet (pain and/or tenderness), signs and symptoms of nerve compression (distal neurologic changes, often worse with arms overhead or dangling), absence of other pathology potentially explaining the symptoms, and a positive response to a properly performed scalene muscle test injection. Reporting standards for workup, treatment, and assessment of results are presented, as are reporting standards for all phases of VTOS and ATOS. The overall goal is to produce consistency in diagnosis, description of treatment, and assessment of results, in turn then allowing more valuable data to be presented.

Thoracic outlet syndrome (TOS) is a group of disorders all having in common compression at the thoracic outlet. Three structures are at risk: the brachial plexus, the subclavian vein, and the subclavian artery, producing neurogenic (NTOS), venous (VTOS), and arterial (ATOS) thoracic outlet syndromes, respectively. Each of these three are separate entities, though they can coexist and possibly overlap. The treatment of NTOS, in particular, has been hampered by lack of data, which in turn is the result of inconsistent definitions and diagnosis, uncertainty with regard to treatment options, and lack of consistent outcome measures. The Committee has defined NTOS as being present when three of the following four criteria are present: signs and symptoms of pathology occurring at the thoracic outlet (pain and/or tenderness), signs and symptoms of nerve compression (distal neurologic changes, often worse with arms overhead or dangling), absence of other pathology potentially explaining the symptoms, and a positive response to a properly performed scalene muscle test injection. Reporting standards for workup, treatment, and assessment of results are presented, as are reporting standards for all phases of VTOS and ATOS. The overall goal is to produce consistency in diagnosis, description of treatment, and assessment of results, in turn then allowing more valuable data to be presented.

Patients with thoracic outlet syndrome (TOS) who improve temporarily after anesthetic blockade of the anterior scalene muscles have been shown to improve after ultimate surgical decompressions at the interscalene triangle. Anesthetic blockade of the scalene muscles, even with the addition of steroids, however, rarely produces any prolonged relief as patients are awaiting definitive surgery. The present study was undertaken to determine if more effective and prolonged relief might be obtained with electrophysiologically and fluoroscopically guided selective injection of the scalene muscles with botulinum toxin, which has been used in the past for treating conditions associated with spasm of cervical muscles. In 14 of 22 patients (64%) with a clinical diagnosis of TOS, there was more than a 50% reduction of symptoms measured by a 101-point scale for at least 1 month after botulinum chemodenervation of the scalene muscles. Only 4 of the 22 patients (18%) had a 50% reduction of symptoms for at least 1 month after injection with lidocaine and steroids. In no patient were the results of lidocaine and steroid injection superior to botulinum chemodenervation. Chemodenervation had a mean duration of effect of 88 days. No significant side effects were encountered with botulinum chemodenervation except for mild transient dysphagia in two cases. These results appear to demonstrate that botulinum chemodenervation of the scalene muscles may be helpful in alleviating symptoms in patients with TOS awaiting definitive surgical decompression.

This article examines the types of forces that the brain is subjected to in soccer, secondary to both acute brain injury and repetitive heading of the ball. The incidence of acute brain injury is reviewed, as well as studies documenting the effects of heading the ball. Finally, 10 actions are proposed that would make soccer a safer sport with respect to brain injuries and provide avenues for further study in this area.

Patients in whom the diagnosis of NTOS is being considered usually have neck and arm pain, sensory changes, and weakness that may be exacerbated by certain stress maneuvers. As discussed in Chap. 7, the presence of these features in a patient’s history and the reproduction of concordant experiences by bedside examination are two fundamental processes that start the diagnostic process.

Thoracic outlet syndrome / , Thoracic outlet syndrome / , کتابخانه دیجیتال جندی شاپور اهواز

The diagnosis of Neurogenic Thoracic Outlet Syndrome (NTOS) is often considered in patients presenting with neck, shoulder, and arm pain, sensory disturbance and weakness especially when these complaints are worsened when assuming certain postures or when performing activities such as reaching overhead. The label of NTOS should be considered when it explains a patient’s suffering and disability; it is important for the clinician to differentiate ubiquitous complaints of innocuous positional numbness from those features of a condition that really are responsible for the patient’s disability. The main goal of the clinician is to determine for whom NTOS targeted therapy would lead to both alleviation of suffering and improve functional impairment.

The incidence and prevalence of TOS in the US is somewhat of an enigma, largely due to the absence of objective criteria for diagnosis and inconsistent reporting standards, but there are approximately 2,000 to 2,500 first rib resections performed in the US per year. This is a disease of younger individuals that has significant impact on the working cohort and can lead to significant disability and lost productivity if not recognized and treated. Surgery done for TOS in the United States is performed mostly for neurogenic reasons, and with excellent outcomes as a whole. Morbidity and mortality is minimal, and the majority of operations are being performed by vascular surgeons. The best outcomes are found in centers of higher volume and in teaching institutions. A better understanding of the incidence and prevalence of this condition will help the primary care physicians who initially hear about vague complaints and symptoms and must recognize these quickly enough to refer to the appropriate specialist for prompt therapy.

For targeted therapy such as TOS surgery to be effective, it must be determined that a particular patient has a disability actually caused by TOS and that this component overshadows any coexisting causes of disability. When the TOS component of a cervicobrachial syndrome is temporarily reversed with selective blockade it is expected that the longer term benefits of a targeted approach may be predicted. The present chapter will discuss the evolution and implementation of scalene test blocks in performing the role of predicting outcomes to TOS targeted therapy. For those patients who are not TOS surgical candidates other pain interventional techniques are discussed.

We designed a study to determine whether chronic encephalopathy occurs in elite, active soccer players resulting from repetitive heading of the soccer ball. Studies have suggested that the cumulative effects of heading a ball can cause a chronic brain syndrome similar to dementia pugilistica, which is seen in profes sional boxers. Twenty of 25 members of the U.S. Men's National Soccer Team training camp (average age, 24.9; average years of soccer, 17.7), who com pleted a questionnaire on head injury symptoms and had magnetic resonance imaging of the brain, were compared with 20 age-matched male elite track ath letes. The soccer players were surveyed about playing position, teams, number of headers, acute head inju ries, and years of playing experience. An exposure index to headers was developed to assess a dose- response effect of chronic heading. The soccer and track groups were questioned regarding alcohol use and history of acute head traumas. Questionnaire anal ysis and magnetic resonance imaging demonstrated no statistical differences between the two groups. Among the soccer players, symptoms and magnetic resonance imaging findings did not correlate with age, years of play, exposure index results, or number of headers. However, reported head injury symptoms, especially in soccer players, correlated with histories of prior acute head injuries ( r = 0.63). These findings suggest that any evidence of encephalopathy in soccer players relates more to acute head injuries received playing soccer than from repetitive heading.

Object.Because lumbar magnetic resonance (MR) imaging fails to identify a treatable cause of chronic sciatica in nearly 1 million patients annually, the authors conducted MR neurography and interventional MR imaging in 239 consecutive patients with sciatica in whom standard diagnosis and treatment failed to effect improvement.Methods.After performing MR neurography and interventional MR imaging, the final rediagnoses included the following: piriformis syndrome (67.8%), distal foraminal nerve root entrapment (6%), ischial tunnel syndrome (4.7%), discogenic pain with referred leg pain (3.4%), pudendal nerve entrapment with referred pain (3%), distal sciatic entrapment (2.1%), sciatic tumor (1.7%), lumbosacral plexus entrapment (1.3%), unappreciated lateral disc herniation (1.3%), nerve root injury due to spinal surgery (1.3%), inadequate spinal nerve root decompression (0.8%), lumbar stenosis (0.8%), sacroiliac joint inflammation (0.8%), lumbosacral plexus tumor (0.4%), sacral fracture (0.4%), and no diagnosis (4.2%).Open MR—guided Marcaine injection into the piriformis muscle produced the following results: no response (15.7%), relief of greater than 8 months (14.9%), relief lasting 2 to 4 months with continuing relief after second injection (7.5%), relief for 2 to 4 months with subsequent recurrence (36.6%), and relief for 1 to 14 days with full recurrence (25.4%). Piriformis surgery (62 operations; 3-cm incision, transgluteal approach, 55% outpatient; 40% with local or epidural anesthesia) resulted in excellent outcome in 58.5%, good outcome in 22.6%, limited benefit in 13.2%, no benefit in 3.8%, and worsened symptoms in 1.9%.Conclusions.This Class A quality evaluation of MR neurography's diagnostic efficacy revealed that piriformis muscle asymmetry and sciatic nerve hyperintensity at the sciatic notch exhibited a 93% specificity and 64% sensitivity in distinguishing patients with piriformis syndrome from those without who had similar symptoms (p < 0.01).Evaluation of the nerve beyond the proximal foramen provided eight additional diagnostic categories affecting 96% of these patients. More than 80% of the population good or excellent functional outcome was achieved.

In the world of sports, soccer is unique because of the purposeful use of the unprotected head for controlling and advancing the ball. This skill obviously places the player at risk of head injury and the game does carry some risk. Head injury can be a result of contact of the head with another head (or other body parts), ground, goal post, other unknown objects or even the ball. Such impacts can lead to contusions, fractures, eye injuries, concussions or even, in rare cases, death. Coaches, players, parents and physicians are rightly concerned about the risk of head injury in soccer. Current research shows that selected soccer players have some degree of cognitive dysfunction. It is important to determine the reasons behind such deficits. Purposeful heading has been blamed, but a closer look at the studies that focus on heading has revealed methodological concerns that question the validity of blaming purposeful heading of the ball. The player’s history and age (did they play when the ball was leather and could absorb significant amounts of water), alcohol intake, drug intake, learning disabilities, concussion definition and control group use/composition are all factors that cloud the ability to blame purposeful heading. What does seem clear is that a player’s history of concussive episodes is a more likely explanation for cognitive deficits. While it is likely that the subconcussive impact of purposeful heading is a doubtful factor in the noted deficits, it is unknown whether multiple subconcussive impacts might have some lingering effects. In addition, it is unknown whether the noted deficits have any affect on daily life. Proper instruction in the technique is critical because if the ball contacts an unprepared head (as in accidental head-ball contacts), the potential for serious injury is possible. To further our understanding of the relationship of heading, head injury and cognitive deficits, we need to: learn more about the actual impact of a ball on the head, verify the exposure to heading at all ages and competitive levels, determine stable estimates of concussive injury rates across the soccer spectrum, conduct prospective longitudinal studies on soccer players focusing on exposure, injury and cognition, and determine the minimum safe age to begin instruction on the skill of heading. Only then will we be able to speak with some authority on the issue of heading and head injuries in soccer.

There is no "gold standard" for diagnosing thoracic outlet compression syndrome (TOS), however, anesthetic blocks of the anterior scalene muscle (ASM) have been used as a means of predicting which patients may benefit from surgical decompression. The standard technique of using surface landmarks often results in inadvertent somatic block and sympathetic block because there is no reliable verification of needle tip localization. The present study was undertaken to determine if needle tip localization can be improved by using electrophysiological guidance. ASM blocks were performed for patients with a diagnosis of possible TOS. An insulated hypodermic needle was inserted into the ASM which was identified during electromyogram (EMG) activation maneuvers. Stimulation was performed to make sure that the needle tip was not in the brachial plexus. Local anesthetic was instilled and the intensity of pain induced by TOS stress maneuvers was compared to pain ratings obtained after control injections. The ASM could be identified electromyographically in all 122 cases. There were no instances of inadvertent somatic block nor sympathetic block. Of 38 patients who underwent surgical decompression of the thoracic outlet, 30 of 32 (94%) with a positive block had a good outcome compared with 3 of 6 (50%) who underwent surgery in spite of a negative block. Electrophysiological guidance facilitates accurate needle tip placement in the performance of ASM blocks; the results of these blocks appear to correlate with surgical outcomes.

Letters to the Editor gives readers a chance to comment on articles we publish and on other issues important to sports medicine practitioners. Illustrative figures are welcome. Send letters to Editor, the physician and sportsmedicine, 4530 W 77th St, Minneapolis, MN 55435; e-mail to psmletters@mcgraw-hill.com.

To the Editor .—We agree with many of the conclusions and observations made by Elmore and colleagues 1 in the June 1990 issue of theArchivesregarding monitoring for carotid endarterectomy with computerized electroencephalographic (EEG) brain mapping. However, in their discussion of our previous reports on this topic, they incorrectly cited the criteria we used. They said we used only new asymmetry as a criterion for EEG "change." However, we actually reported 2,3 on any significant EEG "change" on carotid cross-clamping, whether it was a new asymmetry or a generalized change from intraoperative preclamp baseline EEG. We only required that the change be substantially greater than the ordinary fluctuations seen during the routine baseline portion of the operation, prior to clamping. Many of the changes reported in our study were indeed generalized changes of the EEG background, including generalized loss of fast activity, increase in slow activity, or, occasionally, a

The effectiveness of a light-out procedure in reducing periods of off-task behavior in retarded children was evaluated. Four children ages 3 to 10 yr. (mean IQ 32) were trained on a lever-pressing task as an analogue to discrete-trial training procedures. Positive reinforcement sessions were alternated with concurrent escape/avoidance procedures during which light-out was contingent upon nonresponding in an alternating treatment design. The light-out contingency rapidly and effectively reduced the length of time off-task and slightly increased response rate. Educational and therapeutic implications for retarded and autistic children include adaptation of the procedure for decreasing off-task behavior during discrete-trial training, such as in speech and language remediation.

To determine the usefulness of computed electroencephalographic (EEG) topographic (CET) brain mapping to monitor neurologic function during carotid endarterectomy (CEA), 46 consecutive patients having CEA were monitored preoperatively, intraoperatively, and immediately postoperatively by CET brain mapping and simultaneous 16-lead EEG. Preoperative studies revealed that 7 of 16 asymptomatic patients, 5 of 11 patients with amaurosis fugax, and 8 of 12 patients with transient ischemic attacks (TIAs) had abnormal CET brain mapping suggestive of previous subclinical stroke. EEG was abnormal in only 8 of the 20 patients with abnormal CET brain mapping. Intraoperatively during carotid cross-clamping, ischemic changes were seen on CET brain mapping in 23 patients whereas EEG detected these changes in only 13 patients. Ischemic changes detected by intraoperative CET brain mapping were more likely to occur in patients with previous stroke (six of seven) than in patients without previous stroke (17 of 39), p p

A group of experts from the University of California, Los Angeles, met to discuss a case from another institution. This case conference is part of a series featuring a variety of sports medicine topics.

Frequency analysis and topographic mapping of EEG were studied in 20 consecutive patients with mild stroke and in 20 age-matched normal subjects. Abnormally large increases in delta and decreases in alpha activity were seen over the scalp in 17 of 20 patients and in no normal subjects. Theta was unreliable by itself. The scalp area so localized appeared correct in each case compared with signs, symptoms, and neuroimaging studies. These computerized EEG analysis techniques were abnormal significantly more often than routine EEGs. The results obtained here with simple techniques agree with past studies done with more complex types of EEG analysis.

In elderly patients presenting to an ambulatory practice with complaints of cognitive disturbance, early dementia must be differentiated from depression. The present paper describes the application of standard electroencephalography and evoked potential testing (EEG/EP) and computerized electroencephalography with evoked potential mapping (CEEG/EPM) in the analysis of 64 elderly patients complaining of cognitive disturbance. Although previous reports have claimed a sensitivity level of up to 80% for EEG in demented patients, it appears that a lower sensitivity (37% for EEG alone and 61% for EEG/EP) may be expected at the time of early presentation according to the present study. No EEG/EP abnormalities were detected in patients with depression. In demented patients, CEEG/EPM was abnormal in 85% (46 of 54) of cases compared to 10% (1 of 10) of cases with depression. Specific information was obtained from EEG/EP studies that helped differentiate the various causes of dementia in three cases. In CEEG/EPM studies, a pattern of relative suppression of alpha activity or suppressed auditory P300 amplitude in the posterior parietal regions was observed in 11 or 23 (48%) patients with Alzheimer's disease and 2 of 31 (6%) patients with other forms of dementia. None of the depressed patients demonstrated such changes. Based on the present study, it appears that computerized techniques may hold promise as an adjunct to standard EEG evaluation of patients with mild cognitive change in whom diagnosis of dementia or depression is in doubt. Although standard EEG rarely demonstrates characteristic changes that may help differentiate causes of dementia, CEEG/EPM appears to demonstrate, on occasion, abnormalities in the posterior temporal and parietal regions in patients with a diagnosis of probable Alzheimer's disease and rarely in other forms of dementia or depression.

Topographic maps of EEG can contain artifacts that are foreign to clinical electroencephalographers trained to read traditional EEG records. Several spatial artifacts are described and discussed here, including the centrifugal effect, ring enhancement, spatial aliasing, electrode hills and holes, color-step effects, and restriction of minima/maxima to electrode sites. Users of quantitated EEG with topographic maps should be aware of these artifacts and should have a high suspicion for other analogous artifactual spatial phenomena when interpreting individual patient records.

To evaluate the assessment of thoracic outlet compression syndrome (TOS) by objective methods, we prospectively studied a group of 80 consecutive patients with disabling TOS who had been selected for surgical therapy. Comprehensive pre- and postoperative neurophysiologic tests were used and included electromyography, nerve conduction times, F wave determination, and somatosensory evoked potentials (SEPs) of median and ulnar nerves in neutral and stressed positions. Measurements were made of Erb's point peak (N9), cervical peak (P/N13), and cortical complex (N18-P22). Amplitude ratios were calculated for each side, and interpeak latencies were measured for N9-P/N13, P/N13-N18, and N9-N18. SEP results were abnormal on the affected side in 59 of 80 patients (74%); ulnar peak amplitudes were either less than 33% of median, reduced by more than 50% in the stressed position, or reduced by more than 50% when compared with the contralateral side. Of 64 patients studied pre- and postoperatively with SEP, 40 of 47 abnormal tests showed improvement, with 30 of these returning to normal values in the early postoperative period. Excellent clinical correlation was evident in 43 of these 47 patients (92%) who had pre- and postoperative tests; with relief of symptoms reflected in improved SEP, or continued symptoms explained by evidence of persistent or residual nerve dysfunction. The present methodology and criteria for test interpretation demonstrate that SEP can document the neurocompressive component of TOS and provide an objective assessment of pre- and postoperative clinical observations.

Background: Regenerative medicine is a medical subspecialty that seeks to recruit and enhance the body’s own inherent healing armamentarium in the treatment of patient pathology. This therapy’s intention is to assist in the repair, and to potentially replace or restore damaged tissue through the use of autologous or allogenic biologics. This field is rising like a Phoenix from the ashes of underperforming conventional therapy midst the hopes and high expectations of patients and medical personnel alike. But, because this is a relatively new area of medicine that has yet to substantiate its outcomes, care must be taken in its public presentation and promises as well as in its use. Objective: To provide guidance for the responsible, safe, and effective use of biologic therapy in the lumbar spine. To present a template on which to build standardized therapies using biologics. To ground potential administrators of biologics in the knowledge of the current outcome statistics and to stimulate those interested in providing biologic therapy to participate in high quality research that will ultimately promote and further advance this area of medicine. Methods: The methodology used has included the development of objectives and key questions. A panel of experts from various medical specialties and subspecialties as well as differing regions collaborated in the formation of these guidelines and submitted (if any) their appropriate disclosures of conflicts of interest. Trustworthy standards were employed in the creation of these guidelines. The literature pertaining to regenerative medicine, its effectiveness, and adverse consequences was thoroughly reviewed using a best evidence synthesis of the available literature. The grading for recommendation was provided as described by the Agency for Healthcare Research and Quality (AHRQ). Summary of Evidence: Lumbar Disc Injections: Based on the available evidence regarding the use of platelet-rich plasma (PRP), including one high-quality randomized controlled trial (RCT), multiple moderate-quality observational studies, a single-arm meta-analysis and evidence from a systematic review, the qualitative evidence has been assessed as Level III (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best-evidence synthesis. Based on the available evidence regarding the use of medicinal signaling/ mesenchymal stem cell (MSCs) with a high-quality RCT, multiple moderate-quality observational studies, a single-arm meta-analysis, and 2 systematic reviews, the qualitative evidence has been assessed as Level III (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Lumbar Epidural Injections Based on one high-quality RCT, multiple relevant moderate-quality observational studies and a single-arm meta-analysis, the qualitative evidence has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Lumbar Facet Joint Injections Based on one high-quality RCT and 2 moderate-quality observational studies, the qualitative evidence for facet joint injections with PRP has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Sacroiliac Joint Injection Based on one high-quality RCT, one moderate-quality observational study, and one low-quality case report, the qualitative evidence has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Conclusion: Based on the evidence synthesis summarized above, there is Level III evidence for intradiscal injections of PRP and MSCs, whereas the evidence is considered Level IV for lumbar facet joint, lumbar epidural, and sacroiliac joint injections of PRP, (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Regenerative therapy should be provided to patients following diagnostic evidence of a need for biologic therapy, following a thorough discussion of the patient’s needs and expectations, after properly educating the patient on the use and administration of biologics and in full light of the patient’s medical history. Regenerative therapy may be provided independently or in conjunction with other modalities of treatment including a structured exercise program, physical therapy, behavioral therapy, and along with the appropriate conventional medical therapy as necessary. Appropriate precautions should be taken into consideration and followed prior to performing biologic therapy. Multiple guidelines from the Food and Drug Administration (FDA), potential limitations in the use of biologic therapy and the appropriate requirements for compliance with the FDA have been detailed in these guidelines. Key words: Regenerative medicine, platelet-rich plasma, medicinal signaling cells, mesenchymal stem cells, stromal vascular fraction, bone marrow concentrate, chronic low back pain, discogenic pain, facet joint pain, Food and Drug Administration, minimal manipulation, evidence synthesis