Investigation of genicular neurotomy of the knee: MRI characterization of anatomy and implications for intervention.
- 作者列表："Kwon SS","Chazen JL","Kishore S","Habibi BA","Chi M","Rand E","Lowder R","Singh JR
BACKGROUND:Genicular nerve block and subsequent radiofrequency neurotomy (RFN) has emerged as a novel intervention and alternative for total knee arthroplasty in patients with refractory pain from knee osteoarthritis (OA). To our knowledge, there is no cited report correlating the accuracy of localizing the genicular nerves using bony landmarks on magnetic resonance imaging (MRI). OBJECTIVES:To quantify the proximity of superomedial genicular nerve (SMGN), superolateral genicular nerve (SLGN), and inferomedial genicular nerve (IMGN) from a target point. The target point was an intersection marked by a line parallel to the diaphysis and a separate line parallel to the metaphyseal flare along the cortical surfaces of both the femur and tibia. DESIGN:Retrospective chart review. PATIENTS:A total of 25 de-identified knee MRIs were reviewed. METHODS:The coronal proton density fat suppressed sequence was used for identification and localization of the SLGN, SMGN, and IMGN. The neurovascular bundles were traced from posterior location along their origin as they wrap around the distal diaphysis. The nerve locations were determined by consensus measurements performed by two board-certified radiologists with certificates of added qualification in neuroradiology and interventional radiology. The proximity of each respective genicular nerves was measured by drawing a perpendicular line from each genicular nerve to the height of the target point. All measurements were taken on the mid-coronal view at the point of maximal epiphyseal flare. MAIN OUTCOME MEASUREMENTS:Positive values indicated the location of the neurovascular bundle to be superior to the target point. Negative values indicated the location of the neurovascular bundle to be inferior to the target point. RESULTS:The distance between our target point and the inferior border of SLGN ranged from -3 mm to 6 mm. Twenty-three out of 25 (92%) SLGN lied exactly at or above our target intersection. The distance between our target point and the inferior border of SMGN ranged from -1 mm to 2 mm with twenty-two out of 25 (88%) SMGN lied exactly at or above our target point. The distance between our target point and the superior border of IMGN ranged from 0 mm to 3 mm with all (100%) IMGN lying exactly at or above the target point. CONCLUSION:The intersection of the femoral diaphyseal shaft to a line along the metaphyseal flare and the intersection of the tibial diaphyseal shaft to a line along the medial metaphyseal can be used as a target point to localize the genicular nerves with close proximity.
背景: 膝状神经阻滞和随后的射频神经切断术 (RFN) 已经成为全膝关节置换术治疗膝关节骨性关节炎 (OA) 顽固性疼痛患者的一种新型干预和替代方法。据我们所知，在磁共振成像 (MRI) 上没有引用与使用骨性标志定位膝神经的准确性相关的报告。 目的: 量化膝上神经 (SMGN) 、膝上外侧神经 (SLGN) 和膝下神经 (IMGN) 从靶点的接近程度。靶点是沿着股骨和胫骨皮质表面平行于骨干的线和平行于干骺端耀斑的单独线标记的交叉点。 设计: 回顾性图表回顾。 患者: 共回顾了 25 例去鉴别的膝关节mri。 方法: 采用冠状位质子密度脂肪抑制序列对SLGN、SMGN和IMGN进行鉴定和定位。神经血管束在缠绕远端骨干时，沿其起源从后部追踪。神经位置由两名具有神经放射学和介入放射学附加资格证书的委员会认证放射科医生进行共识测量确定。通过绘制从每个膝神经到目标点高度的垂直线来测量各个膝神经的接近程度。所有测量均在最大骨骺耀斑点的中冠状视图上进行。 主要结局测量: 阳性值表示神经血管束的位置优于目标点。负值表示神经血管束的位置低于目标点。 结果: 我们的目标点与SLGN下缘的距离为-3mm ~ 6mm。25 (92%) 个SLGN中有 23 个恰好位于我们的目标交叉点或上方。我们的目标点与SMGN的下边界之间的距离范围为-1 毫米至 2 毫米，22 出 2 5 (88%) SMGN恰好位于或高于我们的目标点。我们的目标点与IMGN上缘之间的距离为 0mm ~ 3mm，所有 (1 0 0%) IMGN恰好位于目标点或以上。 结论: 股骨骨干轴与干骺端耀斑线的交点和胫骨骨干轴与内侧干骺端线的交点可以作为定位膝部的目标点。接近的神经。
METHODS:OBJECTIVE:Patients with immune-mediated inflammatory diseases such as rheumatoid arthritis or systemic lupus erythematosus are at increased risk of cardiovascular disease. However, the cardiovascular risk of patients with primary Sjögren's syndrome (SS) remains poorly studied. We aimed to investigate the association between primary SS and cardiovascular morbidity and mortality. METHODS:We performed a systematic review of articles in Medline and the Cochrane Library and recent abstracts from US and European meetings, searching for reports of randomized controlled studies of cardiovascular morbidity and cardiovascular mortality in primary SS. The relative risk (RR) values for cardiovascular morbidity and mortality associated with primary SS were collected and pooled in a meta-analysis with a random-effects model by using Review Manager (Cochrane collaboration). RESULTS:The literature search revealed 484 articles and abstracts of interest; 14 studies (67,124 patients with primary SS) were included in the meta-analysis. With primary SS versus control populations, the risk was significantly increased for coronary morbidity (RR 1.34 [95% confidence interval (95% CI) 1.06-1.38]; P = 0.01), cerebrovascular morbidity (RR 1.46 [95% CI 1.43-1.49]; P < 0.00001), heart failure rate (odds ratio 2.54 [95% CI 1.30-4.97]; P < 0.007), and thromboembolic morbidity (RR 1.78 [95% CI 1.41-2.25]; P < 0.00001), with no statistically significant increased risk of cardiovascular mortality (RR 1.48 [95% CI 0.77-2.85]; P = 0.24). CONCLUSION:This meta-analysis demonstrates that primary SS is associated with increased cardiovascular morbidity, which suggests that these patients should be screened for cardiovascular comorbidities and considered for preventive interventions, in a multidisciplinary approach with cardiologists.
METHODS:OBJECTIVE:We aimed to evaluate the comparative risk of hospitalized infection among patients with rheumatoid arthritis (RA) who initiated abatacept versus a tumor necrosis factor inhibitor (TNFi). METHODS:Using claims data from Truven MarketScan database (2006-2015), we identified patients with RA ages ≥18 years with ≥2 RA diagnoses who initiated treatment with abatacept or a TNFi. The primary outcome was a composite end point of any hospitalized infection. Secondary outcomes included bacterial infection, herpes zoster, and infections affecting different organ systems. We performed 1:1 propensity score (PS) matching between the groups in order to control for baseline confounders. We estimated incidence rates (IRs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) for hospitalized infection. RESULTS:We identified 11,248 PS-matched pairs of patients who initiated treatment with abatacept and TNFi with a median age of 56 years (83% were women). The IR per 1,000 person-years for any hospitalized infection was 37 among patients who initiated treatment with abatacept and 47 in those who initiated treatment with TNFi. The HR for the risk of any hospitalized infection associated with abatacept versus TNFi was 0.78 (95% CI 0.64-0.95) and remained lower when compared to infliximab (HR 0.63 [95% CI 0.47-0.85]), while no significant difference was seen when compared to adalimumab and etanercept. The risk of secondary outcomes was lower for abatacept for pulmonary infections, and similar to TNFi for the remaining outcomes. CONCLUSION:In this large cohort of patients with RA who initiated treatment with abatacept or TNFi as a first- or second-line biologic agent, we found a lower risk of hospitalized infection after initiating abatacept versus TNFi, which was driven mostly by infliximab.
METHODS:OBJECTIVE:Reducing pain is one of the main health priorities for children and young people with juvenile idiopathic arthritis (JIA); however, some studies indicate that pain is not routinely assessed in this patient group. The aim of this study was to explore health care professionals' (HCPs) beliefs about the role of pain and the prioritization of its assessment in children and young people with JIA. METHODS:Semi-structured interviews were conducted with HCPs who manage children and young people with JIA in the UK (including consultant and trainee pediatric rheumatologists, nurses, physical therapists, and occupational therapists). Data were analyzed qualitatively following a framework analysis approach. RESULTS:Twenty-one HCPs participated. Analyses of the data identified 6 themes, including lack of training and low confidence in pain assessment, reluctance to engage in pain discussions, low prioritization of pain assessment, specific beliefs about the nature of pain in JIA, treatment of pain in JIA, and undervaluing pain reports. Assessment of pain symptoms was regarded as a low priority and some HCPs actively avoided conversations about pain. CONCLUSION:These findings indicate that the assessment of pain in children and young people with JIA may be limited by knowledge, skills, and attitudinal factors. HCPs' accounts of their beliefs about pain in JIA and their low prioritization of pain in clinical practice suggest that a shift in perceptions about pain management may be helpful for professionals managing children and young people with this condition.