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Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Safeguards to Prevent Neurologic Complications after Epidural Steroid InjectionsConsensus Opinions from a Multidisciplinary Working Group and National Organizations. Cervical total disc replacement is superior to anterior cervical decompression and fusion: a meta-analysis of prospective randomized controlled trials. Interventional Pain Management 12 Paravertebral Facet Injection/Nerve Block/Neurolysis Description Paravertebral facet joints, also referred to as zygapophyseal joints or Z-joints, have been implicated as a source of chronic neck and low back pain with a prevalence of up to 70% in the cervical spine, and up to 30% in the lumbar spine. Neither physical exam nor imaging has adequate diagnostic power to confidently identify the facet joint as a pain source. Facet joint injection techniques have evolved primarily as a diagnostic tool for pain originating in these joints, but have been widely utilized to treat chronic pain shown to be of facet origin. Injections may be performed at one of two sites, either the joint itself (intraarticular injection) or the nerve that supplies it (medial branch of the dorsal ramus of segmental spinal nerves). Diagnostic injections are performed with an anesthetic agent alone, while therapeutic injections involve administration of a corticosteroid, with or without an anesthetic. Studies have validated the efficacy of this intervention in chronic pain of facet origin. A positive response is defined as at least 80% relief of the primary (index) pain, with the onset and duration of relief being consistent with the agent employed. Note: the patient must be experiencing pain at the time of the injection (generally rated at least 3 out of 10 in intensity) in order to determine whether a response has occurred. Provocative maneuvers or positions which normally exacerbate index pain should also be assessed and documented before and after the procedure. A confirmatory injection is indicated only if the first injection results in a positive response. If the second injection also results in a positive response, the target joint(s) is/are the confirmed pain generator(s). One additional diagnostic block may be indicated prior to a repeat neurotomy when there is diagnostic uncertainty about the source of pain. A Best-Evidence Systematic Appraisal of the Diagnostic Accuracy and Utility of Facet (Zygapophysial) Joint Injections in Chronic Spinal Pain. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: a meta-analysis of clinical and radiological outcomes. Interventional Pain Management 18 Regional Sympathetic Nerve Block Description Sympathetic blockade includes procedures that temporarily obstruct the local function of the sympathetic nervous system. Anesthetic is injected directly into sympathetic neural structures that serve affected limb(s), such as the stellate ganglion or the lumbar sympathetic chain. Regional sympathetic nerve block has been utilized primarily for treatment of complex regional pain syndrome. Despite limited evidence supporting its efficacy, it has also been investigated in treating a number of other pain syndromes thought to be sympathetically mediated. This and other interventional procedures should be considered only when the full spectrum of noninvasive management strategies has not provided sufficient relief of symptoms. General Requirements Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including but not limited to the following: Prescription strength anti-inflammatory medications and analgesics Adjunctive medications such as nerve membrane stabilizers or muscle relaxants Physician-supervised therapeutic exercise program or physical therapy Manual therapy or spinal manipulation Alternative therapies such as acupuncture Appropriate management of underlying or associated cognitive, behavioral or addiction disorders Documentation of compliance with a plan of therapy that includes elements from these areas is required. Imaging studies - All imaging must be performed and read by an independent radiologist. A positive response is defined as a significant reduction in pain (at least 80% reduction) and improvement in function with the duration of relief being consistent with agent employed, and objective evidence that the block was physiologically effective. For procedures that target pain in a limb, there must be documentation of a rise in temperature from baseline of the ipsilateral limb. Interventional Pain Management 20 Benefit has been demonstrated by prior blocks as evidenced by all of the following: o Decreased use of pain medication o Improved level of function (e. If there is no sustained benefit in pain and function after three (3) sympathetic blocks from baseline (pre block) pain and function, then additional blocks are not warranted. If there is sustained benefit after the first three (3) sympathetic blocks then up to three (3) additional blocks may be performed. Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. Invasive treatments for complex regional pain syndrome in children and adolescents: a scoping review. There is persistent typically unilateral non-radicular pain that is predominantly below the lumbar spine (L5) and is primarily localized over the region of the sacroiliac joint and has been present for at least three (3) months. There is no evidence of acute or subacute radicular pain/radiculopathy or neurogenic claudication. If there is evidence of radicular pain/radiculopathy or neurogenic claudication the condition must be fixed and stable and have been maximally addressed through comprehensive treatment. Dual intraarticular sacroiliac joint injections, defined as injections performed in the same joint on 2 separate occasions, are necessary to confirm the diagnosis due to the unacceptably high false positive rate of single intraarticular sacroiliac joint injections. A second confirmatory injection is indicated only if the first injection produces greater than or equal to 80% relief of the primary (index) pain and the onset and minimum duration of relief is consistent with the agent employed. This confirmatory block confirms the tested sacroiliac joint as the source if the index pain is reduced by greater than or equal to 80% and the onset and minimum duration of relief is consistent with the agent employed. Injections may not be repeated at intervals of less than three (3) months, with a maximum of three (3) injections in a 12-month period. Treatment with therapeutic injections should be accompanied by participation in an ongoing active rehabilitation program, home exercise program, or functional restoration program. Ultrasound-guidance Ultrasound is the only imaging-guidance appropriate for use during pregnancy Exclusions Indications other than those addressed in this guideline are considered not medically necessary, including but not limited to the following: Intraarticular sacroiliac joint injections performed on the same day as other spine injection procedures. Comparison of the short- and long-term treatment effect of cervical disk replacement and anterior cervical disk fusion: a meta-analysis. Surgical and clinical efficacy of sacroiliac joint fusion: a systematic review of the literature. Interventional Pain Management 24 Spinal Cord Stimulators Description Spinal cord stimulators, also known as dorsal column stimulators ("stimulators"), are implantable devices used to treat chronic pain. Electrodes are surgically placed within the dura mater via laminectomy, or by percutaneous insertion into the epidural space. Low voltage electrical signals are delivered to the dorsal column of the spinal cord in order to override or mask sensations of pain. The lead may incorporate four (4) to eight (8) electrodes, with 8 electrodes typically used for complex pain patterns, such as bilateral pain or pain extending from the limbs to the trunk. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed (defined as at least 50% reduction in pain), the electrodes and radio receiver/ transducer are permanently implanted. Extensive programming of the neurostimulators is often required to achieve optimal pain control. General Requirements Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including but not limited to the following: Prescription strength anti-inflammatory medications and analgesics Adjunctive medications such as nerve membrane stabilizers or muscle relaxants Physician-supervised therapeutic exercise program or physical therapy Manual therapy or spinal manipulation Alternative therapies such as acupuncture Appropriate management of underlying or associated cognitive, behavioral, or addiction disorders Documentation of compliance with a plan of therapy that includes elements from these areas is required. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure. Interventional Pain Management 25 Criteria All of the following criteria are required: Severe pain and disability with documented pathology or an objective basis for the pain. Dorsal column stimulation is being used as a late or last resort after documented failure of at least six (6) consecutive months of physician-supervised conservative management.

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In addition to the civil fine authorized under section 12611, a local health department may enforce this part and part 129 and any rules promulgated under this part through an action commenced pursuant to section 2465 or any other appropriate action authorized by law. The use of 1 remedy by a person shall not bar the use of other lawful remedies by that person or the use of a lawful remedy by another person. The person shall submit the drilling record required by section 12707 and comply with the rules and construction code promulgated under section 12714. A licensed master plumber may perform the work of a pump installer prescribed in sections 12701 to 12715 or rules and construction code promulgated under section 12714 without a certificate of registration as a pump installer. The initial registration fee and the annual renewal registration fee for a well drilling contractor is $40. A registered well drilling contractor may do any of the work of a pump installer without payment of the fee for a pump installer. After July 1 of each year a certificate of registration may be renewed only upon application for renewal and payment of a fee of 50% of the basic registration fee in addition to the regular registration fee. The advisory board created by section 12711 shall determine and advise the department as to the eligibility of a well drilling contractor or pump installer for registration. A well drilling contractor or pump installer which is a firm, partnership, or corporation shall designate at least 1 partner, officer, or responsible full-time employee to take the examination on its behalf. A seal furnished by the department designating the year the certificate of registration was issued or renewed and the words "Michigan registered water well drilling contractor" shall be affixed directly adjacent to the registration number. The department or local health department shall send 1 copy of the record to the director of the department of natural resources not later than 30 days after its receipt from the well drilling contractor. The department or local health department may enter and inspect, at reasonable hours, an installation on public or private property for the development or abandonment of ground water supplies. If the department or local health department establishes that a violation has been committed, the department or the local health department shall order the responsible person to make the proper corrections. A person who receives notice from the department that his or her certificate of registration is suspended, upon request, shall be granted a hearing before the department or an authorized representative of the department. If a petition for a hearing is not filed within 30 days after the day on which the certificate of registration was suspended, the certificate of registration is automatically revoked. Of 4 well drilling contractors 1 shall be from each of 4 geographic regions: (a) Region 1: the Upper Peninsula. The terms of the 5 members registered under sections 12701 to 12715 shall alternate so that not more than 2 are appointed each year, except that of the first appointees, 1 shall be appointed for 1 year and 2 each shall be appointed for 2 and 3 years. The terms of the members representing the department of natural resources, the water resources commission, and the local health department shall alternate so that only 1 is appointed each year, except that of the first appointees 1 member shall be appointed for 1 year, 1 for 2 years, and 1 for 3 years. Vacancies shall be filled by appointment for the balance of the unexpired terms by the respective officials designated in section 12711. Thereafter, annually when new members are appointed to the board, a chairperson shall be elected at the next board meeting. Additional meetings may be called by the chairperson or director as may be reasonably necessary to carry out sections 12701 to 12715. The business which the advisory board may perform shall be conducted at a public meeting of the advisory board held in compliance with Act No. The department, with the advice of the advisory board, shall promulgate rules and a construction code reasonably necessary to implement sections 12701 to 12715. The rules and construction code shall include provisions for qualifications and examination of well drilling contractors and pump installers, standards for the construction and installation of developments of ground water supplies, dewatering wells, abandonment of wells and dewatering wells, and for the administration of sections 12701 to 12715. As used in sections 12752 to 12758: (a) "Acceptable alternative greywater system" means a system for the treatment and disposal of waste water which normally does not receive human body wastes or industrial waste and is approved for use by a local health department. An acceptable innovative or alternative waste treatment system may include, but is not limited to, an organic waste treatment system or compost toilet which operates on the principle of decomposition of heterogeneous organic materials by aerobic and facultatively anaerobic organisms and utilizes an effectively aerobic composting process which produces a stabilized humus. Acceptable innovative or alternative waste treatment system does not include a septic tankdrain field system or any other system which is determined by the department to pose a similar threat to the public health, safety and welfare, and the quality of surface and subsurface waters of this state. Public sanitary sewer systems are essential to the health, safety, and welfare of the people of the state. Septic tank disposal systems are subject to failure due to soil conditions or other reasons. Failure or potential failure of septic tank disposal systems poses a threat to the public health, safety, and welfare; presents a potential for ill health, transmission of disease, mortality, and economic blight; and constitutes a threat to the quality of surface and subsurface waters of this state. The governmental unit may join any number of owners of structures situated within the governmental unit in the action to compel each owner to connect to an available sanitary sewer system immediately. Upon receipt of evidence of hardship, the local unit of government may defer partial or total payment of the fee. As a condition to the granting of the deferred or partial payment of the tap-in fee, the local unit of government may require mortgage security on the real property of the beneficiary payable on or before death, or, in any event, on the sale or transfer of the property. The installation and use of an acceptable innovative or alternative waste treatment system or an acceptable innovative or alternative waste treatment system in combination with an acceptable alternative greywater system in a structure shall be subject to regulation by the local health department in accordance with the ordinances and regulations of the local units of government in which the structure lies. A local health department may inspect each acceptable innovative or alternative waste treatment system within its jurisdiction at least once each year to determine if it is being properly operated and maintained. A local health department may charge the owner of an acceptable innovative or alternative waste treatment system a reasonable fee for such an inspection and for the plan review and installation inspection. A copy of the approved application or permit to install and use an alternative system and a copy of each maintenance inspection report shall be forwarded to the department and to the local unit of government in which the structure lies. The department shall maintain a record of approved alternative systems and their maintenance and operation. The department shall advise local health departments regarding the appropriate installation and use of acceptable innovative or alternative waste treatment systems and acceptable innovative or alternative waste treatment systems in combination with acceptable alternative greywater systems. In lieu of connection or user fees, an owner may be required by the local unit of government to pay a sewer availability fee if that fee is to be used for the purpose of paying a proportionate share of financing the construction of an existing available public sanitary sewer system. The exemption from connection or user fees under this subsection shall not apply to an owner connected to an available public sanitary sewer system on the effective date of this act. An outhouse not constructed or maintained as required by this section or the rules promulgated pursuant to this section shall be a public nuisance. The inspecting entity shall determine compliance with this section during each inspection. If a violation of this section is identified and not corrected as ordered by the local health department within 2 days after receipt of the order by the food service establishment, the local health officer may issue an order to cease food service operations until compliance with this section is achieved. It is an affirmative defense to a prosecution or civil or administrative action for a violation of this section that the owner, operator, manager, or person in control of a food service establishment where smoking is prohibited under this section made a good faith effort to prohibit smoking by complying with section 12603(2). To assert the affirmative defense under this subsection, the owner, operator, manager, or person shall file a sworn affidavit setting forth his or her efforts to prohibit smoking and his or her actions of compliance with section 12603(2). The department may promulgate rules to prescribe minimum standards of sanitation for the protection of the public health and otherwise provide for the implementation of this part. The department in promulgating these rules shall seek the advice and counsel of local health departments and the food service industry. Upon written request from a local health department, the department may recognize certain enforcement procedures other than those contained in this part and rules promulgated under this part, when the procedures will result in enforcement which is equivalent in effectiveness and have been legally adopted by the local department of health. This subsection shall expire September 30, 1981 or when the rules promulgated under subsection (1) are promulgated, whichever is sooner. For transfer of powers and duties of the food service sanitation program from the department of public health to the director of the department of agriculture, see E. Notwithstanding any other provision of this act to the contrary, the department shall not promulgate rules to implement or administer the provisions of this part that were added by the amendatory act that added this section. A county, city, village, or township shall not regulate those aspects of food service establishments or vending machines which are subject to regulation under this part except to the extent necessary to carry out the responsibility of a local health department pursuant to sections 12906 and 12908. This part shall not relieve the applicant for a license or a licensee from responsibility for securing a local permit or complying with applicable local codes, regulations, or ordinances not in conflict with this part. A person who violates this part or a rule promulgated under this part is guilty of a misdemeanor. Any tattooing, branding, or body piercing occurring in this state other than at a facility licensed under this part is considered an imminent danger under section 2251 or 2451 and the department or a local health department shall order the immediate cessation of that activity in the manner prescribed in this act. The department shall issue a license on an annual basis to a body art facility that meets the requirements of this part or for a time period not to exceed 14 consecutive days to a temporary body art facility that meets the requirements of this part. Except for a temporary license issued under this part, the license is effective for up to 1 year and expires at 12 midnight on December 31.

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Myocardial infarction refers to necrosis of the cardiac muscle secondary to a severe reduction in coronary blood supply. Predisposing factors include heredity, obesity, tobacco use, lack of physical exercise, diet, emotional stress, and hostility and anger. A careful history is important in diagnosing the referred oral pain of myocardial infarction. Usually, the patient has a rather unusual story to tell, with fairly severe pain that began rather suddenly in the left jaw and grew in intensity. Radiographs and pulp testing of all of the teeth in the site of pain or rinsing with ice water will be equivocal. If cardiac pain is suspected, the patient must be referred to an emergency room immediately. If pain is severe, 5 to 10 mg of morphine sulfate should be administered intramuscularly or intravenously. Further exertion by the patient should be avoided to minimize oxygen demands placed on the heart. The thyroid is a butterfly-shaped gland situated in the neck superficial to the trachea at or below the cricoid cartilage. Disorders of the thyroid gland are prevalent in medical practice, second only to diabetes as an endocrine disorder. The typical symptom picture includes pain over at least one lobe of the thyroid gland or pain radiating up the sides of the neck and into the lower jaws, ears, or occiput. There may be mild Figure 8-21 Benign thyroid tumor that recurred following thyroidectomy is referring pain into the mandibular first molar on the homolateral side. The patient with carotidynia will most likely complain of constant or intermittent dull, aching, rarely pulsing jaw and neck pain, with intermittent sore throat or swollen glands. The nerves innervating the adventitial and intimal walls of the carotid artery are considered part of the visceral nervous system. Some authors feel that the artery and its peripheral branches are inflamed and that biopsy may reveal the presence of inflammatory and giant cells. Examination may reveal tenderness and swelling over the ipsilateral carotid artery along with pronounced throbbing of the carotid pulse. Similarly, the external branches of the carotid system and surrounding areas may also be tender. This may include the masticatory and cervical muscles, which may contain myofascial TrPs and lead to an erroneous diagnosis of musculoskeletal pain. Palpation over the sternocleidomastoid may aggravate the pain because of incidental irritation of the carotid vessel. Medications used in the treatment and prevention of migraine headaches have been shown to be effective in controlling the symptoms of carotidynia. Disorders of the cervical spine and neck area may refer pain into the facial region owing to convergence of cervical and trigeminal primary afferent nociceptors in the nucleus caudalis of the spinal 319 trigeminal tract. The normal cervical spine has 37 individual joints, making it the most complicated articular system in the body. Nonmusculoskeletal pain-producing structures of the neck include the cervical nerve roots and nerves and the vertebral arteries. Acute trauma and primary pathologic processes of the neck are obviously not in the realm of the dentist to diagnose and treat; therefore, these will not be discussed. However, the cervical spine must be recognized as a potential source of dermatomal and referred pain into the head and orofacial region. Chronic subclinical dysfunction of the cervical spine may produce complaints that first appear in the dental office. This dysfunction may serve as a powerful perpetuating factor in temporomandibular and facial pain disorders and must be screened for and appropriately managed for successful treatment outcome. Cervical joint dysfunction refers to a lack of normal anatomic relationship and/or restricted functional movement of individual cervical vertebral joint segments. In the craniocervical region, cervical joint dysfunction may occur as the result of trauma (eg, a whiplash injury), degenerative osteoarthritis, or chronic poor postural habits that result in sustained muscular contraction and immobility. As the cervical spine loses mobility and adapts to abnormal positions, nerve compression, nerve root irritation, neurovascular compression, posterior vertebral joint irritation, and peripheral entrapment neuropathies may result. Although C1, C2, and C3 nerve roots are not thought to be involved in compression or peripheral entrapment-type problems,122 they do become inflamed through mechanical irritation by other neighboring structures such as the vertebral processes, muscles, or connective tissue capsules. Radiographic evaluation may reveal osteoarthritis or show a decreased cervical lordosis, evidence of soft tissue spasm, or muscular shortening. More sophisticated radiographic techniques can pick up decreased cervical mobility. Physical therapy, including cervical joint mobilization along with a comprehensive home exercise program and postural retraining, is required to treat pain of cervical origin. Local treatment of referred symptoms does not provide long-lasting, if any, relief. If pain exists in both regions, it is likely that the cervical problem is perpetuating the facial pain. Case History the following is a classic example of misdiagnosis of a referred cervical pain problem. Because of the unilateral distribution, they had previously been misdiagnosed and unsuccessfully treated as migraine. However, the pain was strictly unilateral and was present on a continuous daily basis (unlike migraine), with intermittent exacerbations. The quality of the pain was described as dull and aching, progressing to throbbing only when severe. The patient also had an endodontic history involving the upper left second premolar, reportedly still sensitive. The dental examination revealed slight hyperocclusion of the involved premolar, which was corrected. Pain impulses from the first four upper cervical roots are thought to be referred to the trigeminal region (mainly V1 and V2) as a result of the proximity of the nucleus caudalis in the spinal trigeminal tract. These dermatomal and referred pain syndromes are particularly important to the dentist. Local symptoms of cervical dysfunction may include stiffness, pain, and a limited range of motion of the head and neck. Referred pains are usually deep and aching and may present as a unilateral headache, as in a headache syndrome known as "cervicogenic headache. The patient may note that cervical movement or pressure on certain spots in the neck will precipitate a headache. The upper figure (A) depicts the C2 and C3 tactile dermatomes previously defined by Foerster. Nonodontogenic Toothache and Chronic Head and Neck Pains examination revealed several active TrPs that reproduced her pain complaint. Physical therapy, including cervical joint mobilization along with a comprehensive home exercise program and postural retraining, was instituted. The role of cervical dysfunction and myofascial trigger points in this type of pain presentation has been thoroughly discussed. However, on examination, a restricted mandibular range of motion was found, as well as radiographic evidence of degenerative joint disease. Alternatively, if the internal derangement is painful or the joint is inflamed, it may also be a contributing factor. Neurologic or neurosurgical evaluation is critical to rule out space-occupying lesions, intracranial infections, or neurologic syndromes. Intracranial causes of head and neck pain can be classified into two groups: those caused by traction on pain-sensitive structures (which include the venous sinuses, dural and cerebral arteries, pia and dura mater, and cranial nerves) and those caused by specific central nervous system syndromes, such as neurofibromatosis, meningitis, or thalamic pain126,127 (Table 8-10). Different types of cerebrovascular accidents and venous thrombosis may also cause painful central Table 8-10 Intracranial Causes of Pain Neurofibromatosis Meningitis Thalamic pain 321 Neoplasm Aneurysm Hematoma/hemorrhage Edema Abscess Angioma Cerebrovascular accidents Venous thrombosis nervous system lesions.

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Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. When deciding coverage, the member specific benefit plan document must be referenced. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. If precertification is not obtained, Oxford may review for medical necessity after the service is rendered. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage. Thermal radiofrequency ablation of facet joint nerves is unproven and not medically necessary: When there has been no positive response to medial branch block injection; or When performed more frequently than every six months For additional information regarding frequency guidelines, click here. Documentation requirements for the aforementioned procedures must include: Temperature of procedure Duration of ablation Specific identification of side and level of medial branch blocks Specific identification of side and level of ablation Percentage of pain relief with prior ablation if applicable Duration of improvement from previous ablation if applicable. Additional well-designed, longer-term randomized controlled trials are required to evaluate the safety and efficacy of radiofrequency ablation and to compare this technique with other medical or surgical therapies for pain. The clinical value needs to be examined in well-designed, randomized controlled trials with large sample size and long term follow-up. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Therefore, the unlisted code 64999, Unlisted procedure, nervous system, should be reported. When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (e. Thermal ablation (non-pulsed) involves the percutaneous placement of a needle or electrode that destroys the bone lesion or nerves around the facet joint. This technique is reported to reduce the risk of destruction of neighboring tissue. It does not destroy targeted nerves and therefore requires less precise electrode placement. Recently, a posterior endoscopic method also known as dorsal endoscopic rhizotomy has been developed as alternative to percutaneous electrode radiofrequency ablation to target the medial, intermediate and lateral branches of the dorsal ramus using a modification of the Yeung Endoscopic Spinal Surgery (Y. Cryoablation is a minimally invasive procedure that involves the use of extreme cold to destroy abnormal tissue. The damage to nerve tissue reduces its ability to transmit pain signals, thereby reducing pain sensation. Laser ablation involves the removal of material from a solid (or occasionally liquid) surface by irradiating it with a laser beam. Usually, laser ablation refers to removing material with a pulsed laser, but it is possible to ablate material with a continuous wave laser beam if the laser intensity is high enough. Further high quality controlled trials are needed that compare this procedure in defined populations with placebo and with alternative treatments. In 2013, Manchikanti and colleagues provided an updated evidence-based clinical practice guideline for interventional techniques. Authors conclude that the evidence is fair for radiofrequency neurotomy for use in the treatment of sacroiliac joint. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria for randomized trials of interventional techniques and the criteria developed by the Newcastle-Ottawa Scale for observational studies. The level of evidence was classified as good, fair, or poor based on the definitions developed by the U. The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term relief = greater than 6 months). Most complications reported in the reviewed studies were transient, and consisted primarily of pain or discomfort during or subsequent to treatment. Therefore, questions remain as to the comparative efficacy and safety of these treatments. There has not been sufficient evidence to effectively evaluate the efficacy of radiofrequency ablation of the sacroiliac joint. The authors concluded that further studies are needed, preferably randomized controlled studies, to evaluate whether radiofrequency ablation improves health outcomes in patients with sacroiliac joint pain. Patients were randomized equally to receive both a L4-L5 primary dorsal rami and S1-S3 lateral branch radiofrequency denervation using cooling-probe technology after a local anesthetic block, or local anesthetic block followed by placebo denervation. Patients who did not respond to placebo injections crossed over and were treated with radiofrequency denervation using conventional technology. At 1, 3, and 6 months after the procedure, 11 (79%), 9 (64%), and 8 (57%) radiofrequency-treated patients experienced pain relief of 50% or greater and significant functional improvement. In contrast, only 2 patients (14%) in the placebo group experienced significant improvement at their 1-month follow-up, and none experienced benefit 3 months after the procedure. In the crossover group (n = 11), 7 (64%), 6 (55%), and 4 (36%) experienced improvement 1, 3, and 6 months after the procedure. One year after treatment, only 2 patients (14%) in the treatment group continued to demonstrate persistent pain relief. The authors concluded radiofrequency denervation may provide intermediate-term pain relief and functional benefit in selected patients with suspected sacroiliac joint pain; however, larger studies are needed to confirm these results and to determine the optimal candidates and treatment parameters for this disorder. The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either > 6 months of relief. Each manuscript included in the assessment was reviewed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level I to level V. Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level I, based on a range of level I to V derived from a best evidence synthesis. This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain. A systematic literature review of randomized controlled trials on radiofrequency ablation procedures for spinal pain performed by Geurts et al. All patients were examined by an orthopaedic surgeon before and 6 months after the treatment (sham or active). The active treatment group showed statistically significant improvement not only in back and leg pain but also back and hip movement as well as the sacro-iliac joint test. There was significant improvement in quality of life variables, global perception of improvement, and generalized pain. The improvement seen in the active group was significantly greater than that seen in the placebo group. The investigators concluded that radiofrequency facet denervation could be used in the treatment of carefully selected patients with chronic low back pain. This study is limited by short-term follow-up as well as subjective outcome measurements.

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Nerve Hydrodissection for Peripheral Nerve Entrapment Nerve hydrodissection entails the injection of fluid (e. The primary outcome was onset time of successful anesthesia defined by a complete abolition of light touch sensation for the index finger. Success rate at 30 mins (defined as complete abolition for cold and light touch at index finger) was noted in 100 % and 98. The assumption that this procedure may reduce the risk of intra-vascular injection and systemic toxicity remains to be demonstrated. Fader et al (2015) noted that symptomatic neuromas of the sural nerve are a rare but significant cause of pain and debilitation in athletes. Presentation is usually in the form of chronic pain and dysesthesias or paresthesia of the lateral foot and ankle. These researchers reported a case of sural nerve entrapment in a 34-year old male triathlete with a history of recurrent training-induced right-sided gastrocnemius strains. The patient presented with numbness in the right lateral foot and ankle that had persisted for 3 months, after he was treated unsuccessfully with extensive non-operative measures, including anti-inflammatory drugs, activity modification, and a dedicated physical therapy program of stretching and strengthening. Orthopedic assessment showed worsening pain with forced passive dorsiflexion and manual pressure applied over the distal aspect of the gastrocnemius. The patient had complete relief of symptoms and full return to the pre-injury level of participation in competitive sports. The authors concluded that the findings of this case report showed that hydrodissection, when performed by an experienced physician, could be an effective, minimally invasive technique for neurolysis in the setting of sural nerve entrapment, resulting in improvement in clinical symptoms. This was a single-case study; its findings need to be validated by welldesigned studies. Proprietary 38/56 Nerve Blocks - Medical Clinical Policy Bulletins Aetna Cass (2016) stated that nerve hydrodissection is a technique used when treating peripheral nerve entrapments. It involves using an anesthetic or solution such as saline to separate the nerve from the surrounding tissue, fascia, or adjacent structures. The author concluded that there were no high-level studies to determine the need or effectiveness of hydrodissection or to establish its safety. Low-level studies showed some safety and effectiveness for the technique, but further research is needed. Popliteal Block for Open Reduction Internal Fixation of Ankle Fracture In a prospective randomized study, Goldstein et al (2012) compared post-operative pain control in patients treated surgically for ankle fractures who receive popliteal blocks with those who received general anesthesia alone. All patients being treated with open reduction internal fixation for ankle fractures who met inclusion criteria and consented to participate were enrolled. At 12 hours, there was no significant difference between the 2 groups with regard to pain control. However, by 24 hours, those who had received popliteal blocks had significantly higher pain with no difference by 48 hours. The authors concluded that popliteal block provided equivalent postoperative pain control to general anesthesia alone in patients undergoing operative fixation of ankle fractures. However, patients who receive popliteal blocks experienced a significant increase in pain between 12 and 24 hours. Recognition of this "rebound pain" with early narcotic administration may allow patients to have more effective post-operative pain control. They found that popliteal block patients were no more likely to be discharged to home than those who received general anesthesia. Saphenous Nerve Block for Saphenous Neuralgia Luerssen et al (1983) reported the findings of 6 patients representing 7 cases of spontaneous (non-traumatic) saphenous neuralgia secondary to entrapment of the nerve in the sub-sartorial canal. Clinical findings included tenderness over the sub-sartorial canal and sensory changes in the cutaneous distribution of 1 or both terminal branches of the saphenous nerve. All 6 patients initially underwent external neurolysis; however, 3 patients required saphenous neurectomy for recurrent symptoms. Saphenous neuralgia should be considered in the differential diagnosis of medial lower extremity pain. Tsai et al (2010) noted that the saphenous nerve, a branch of the femoral nerve, is a pure sensory nerve that supplies the antero-medial aspect of the lower leg from the knee to the foot. Patient demographics and data were recorded, including block characteristics, intra-operative anesthetic management, pre-block, post-block, and post-operative pain scores, as well as post-operative analgesic dosing. Post-operative block success was defined by reduction of pain score to 0 without need for additional analgesic dosing. The success rate was based on stringent criteria with an end-point of post-operative analgesia. Moreover, they stated that a randomized prospective study would provide a more definitive answer regarding the efficacy of this technique for surgical anesthesia. Recently, his pain became worse even with imipramine 75-mg and carbamazepine 100-mg a day, which relieved effectively the patient from the pain for the last 3 years. Several days before the block, electric stimulation to control his pain was tested. The laser irradiation induced warm sensation in her face followed by an excellent pain relief. Supraorbital and supratrochlear nerve blockade with modified van-Lint technique was planned, as the classical nerve block sites were covered with active vesicles. Furthermore, an UpToDate review on "Postherpetic neuralgia" (Ortega, 2019) does not mention nerve block as a therapeutic option. Suprascapular Nerve Block for Cervical Spondylosis An UpToDate review on "Treatment and prognosis of cervical radiculopathy" (Robinson and Kothari, 2019) does not mention nerve block as a therapeutic option. The block has been developed for post-operative pain control after gynecologic and abdominal surgery. The surgical procedures included large bowel resection with a mid-line abdominal incision, caesarean delivery via the Pfannenstiel incision, abdominal hysterectomy via a transverse lower abdominal wall incision, open appendectomy and laparoscopic cholecystectomy. Overall, the results were encouraging and most studies have demonstrated clinically significant reductions of post-operative opioid requirements and pain, as well as some effects on opioid-related side effects (sedation and post-operative nausea and vomiting). A total of 18 intermediate-quality to good-quality randomized trials that included diverse surgical procedures were identified. Improved analgesia was noted in patients undergoing laparotomy for colorectal surgery, laparoscopic cholecystectomy, and open and laparoscopic appendectomy. There was a trend toward superior analgesic outcomes when 15ml of local anesthetic or more was used per side compared with lesser volumes. Putting evidence into practice: Evidence-based interventions for chemotherapy-induced peripheral neuropathy. Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain - an evidence-based clinical practice guideline from the American Pain Society. Practice guidelines for chronic pain management: An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Ashkenazi A, Blumenfeld A, Napchan U, et al; Interventional Procedures Special Interest Section of the American. Peripheral nerve blocks and trigger point injections in headache management - a systematic review and suggestions for future research. Hartemann A, Attal N, Bouhassira D, et al; Working Group on the Diabetic Foot from the French-speaking Society of Diabetology. Evidence-based guideline: Treatment of painful diabetic neuropathy - report of the American Association of Neuromuscular and Electrodiagnostic Medicine, the American Academy of Neurology, and the American Academy of Physical Medicine & Rehabilitation. Clinical practice guidelines for management of neuropathic pain: Expert panel recommendations for South Africa. Evidence-based guideline for neuropathic pain interventional treatments: Spinal cord stimulation, intravenous infusions, epidural injections and nerve blocks. Management of neuropathic pain with methylprednisolone at the site of nerve injury. Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Local anesthetic blockade of peripheral nerves for treatment of neuralgias: Systematic analysis. Diabetes mellitus and subclinical neuropathy: A call for new paths in peripheral nerve block research. Paravertebral block for inguinal herniorrhaphy: A systematic review and meta-analysis of randomized controlled trials. Combination of dexamethasone and local anaesthetic solution in peripheral nerve blocks: A meta-analysis of randomised controlled trials.

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Insurance carriers, healthcare clearinghouses, and healthcare providers are required to comply with its privacy standards. It gives consumers the right to request to inspect, copy, or amend their medical records, and to limit disclosure of information. People with disabilities can file a complaint by calling the division or any of its enforcement branches. Complaints must be filed with the Division on Civil Rights within 180 days after the alleged act of discrimination. The Department of Health is appointed by the Governor as the state lead agency for the Early Intervention System. Services are available to low and no income families as well as families experiencing unemployment, military deployment and other interim family financial hardships. Eligible New Jersey Residents must be 65 years of age or older and have an income of no more than 250% of the federal poverty level - $27,189 if single; $33,334 if married. Part A helps to pay for care in hospitals, skilled nursing facilities, and hospice care. Part B helps pay for doctors, outpatient hospital care, and some other services not covered under Part A. Part C, also known as Medicare Advantage, is a managed care option through which enrollees get Parts A, B and D benefits. Part D, administered by private insurance companies approved by Medicare, provides coverage for prescriptions. Waivers have clinical and financial eligibility criteria which must be met prior to enrollment. Marketplaces or "exchanges" offer consumers and small businesses a choice of standardized health plans. For the most part, these marketplaces serve people who are not offered insurance by a large employer. Enrollment periods are limited; however, special enrollment opportunities for those who need it are available throughout the year. Their staff work out of regional offices, providing a 24/7 mobile response to people who are in crisis. Population served are individuals 21 and older with a dual diagnosis of a serious mental illness and a developmental disability. Make sure medical equipment such as wheelchairs and prosthetic devices "fit" properly. Keep a list of concerns or questions in between appointments and bring it with you to your appointments. The required number of credits varies depending on your age at the time you became disabled. The child must have been 21 years old or younger when the medical bills were incurred. Participants are asked to partner with the program to develop and carry out a household energy savings Action Plan. The benefit is also available to customers who have electric and gas costs included in their rent. Benefits appear as a credit on the household electric and/or gas bill (capped at $1,800 per year). You cannot apply for Fresh Start, but if you are eligible you will be enrolled by your utility company and receive information about the program in the mail. Eligibility is determined based on your income or participation in other assistance programs. It covers emergency treatment immediately following an accident, and treatment of serious brain and spinal cord injuries up to $250,000. The ultimate goal is for children to maximize their potential to lead full, productive lives with their families and within their own communities. A State Interagency Coordinating Council, appointed by the governor, advises and assists the Department of Health as the lead agency in the development and implementation of early intervention for infants and toddlers with developmental delays or disabilities, and their families. If the child is not eligible for early intervention, recommendations may be made for referral to other appropriate resources. The service coordinator will arrange evaluation for eligibility at no cost to the family. The collaboratives are responsible for child find, public awareness, initial referral, service coordination, training and technical assistance and family support. The New Jersey Department of Education administers state and federally funded aid programs for more than 1. For children age three to five, the child study team includes a speech correctionist or speech-language specialist. Upon completion of the evaluation and prior to placement in special education, an Individualized Education Program, with stated goals and objectives, is written with the participation of the parents. According to New Jersey Administrative Code, a full continuum of alternative placements shall be available to meet the needs of children with educational disabilities. Services for people with disabilities include vocational evaluation and assessment, training, counseling, education, job placement assistance, supported employment and support for entrepreneurs with disabilities. Vocational rehabilitation counselors work with individuals and their families to develop and carry out a plan for training and placement. If financial need is established, the division will purchase other rehabilitative services from private providers, such as further evaluation or counseling, training at a vocational center or technical school and on-the-job training. The goals of the program are to offer beneficiaries with disabilities expanded choices when seeking service and supports to enter, re-enter, and/or maintain employment; to increase the financial independence and self-sufficiency of beneficiaries with disabilities; and to reduce and, whenever possible, eliminate reliance on disability benefits. While participating in the Ticket to Work Program, beneficiaries can get the help they need to safely explore their work options without immediately losing their benefits. Beneficiaries also can use a combination of work incentives to maximize their income until they begin earning enough to support themselves. Individuals with an interest in becoming self-employed should present this option to their vocational rehabilitation counselor. If a solid business plan is put together, there may be capital investment available for a variety of start-up needs. Support primarily consists of training in business management and assistance in establishing vending locations. People with disabilities who are employed and are between the ages of 16 to 64 can qualify for the program with an annual gross earned income of up to approximately $61,500. Its Community Development Division administers several programs targeted to people with special needs. New Jersey Housing Resource Center the Housing Resource Center provides individuals with information on accessible and affordable housing throughout the state. The number of hours authorized is based upon medical necessity, as determined by a nursing assessment. Personal assistants help with such tasks as light housekeeping, bathing, dressing, meal preparation, shopping, driving or using public transportation. Services available to eligible individuals may include: outreach, case management, transportation, senior centers, volunteer opportunities, health promotion, nutrition programs, education, health insurance counseling, adult protective services, senior employment, respite care options, and information on housing and long-term care options. They advocate for quality care and services for individuals who are frail, elderly, and/or have disabilities. The agency offers peer to peer support and educates health care professionals and the general public about the special challenges and unique issues "well" spouses face every day. Alliance members include grassroots organizations, professional associations, service organizations, disease-specific organizations, a government agency, and corporations. Through a customized search, the site provides information on eligibility, costs, and how to arrange for a ride. Access Link is a service for those who are not able to use a regular fixed-route bus. New Jersey Transit also provides a reduced fare program for senior citizens and people with disabilities. Personal assistants ride for free when proper identification is presented by the person with a disability. The following contact numbers are resources for current information on local paratransit services, including hours of operation, reservation procedures, fees (if any), priorities for services, consumer representation on advisory committees, etc. Instruction is available in English and Spanish For more information visit the website at: njtip.

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Ashi points are considered to represent the earliest stage of acupuncture point evolution in China and may be also considered as appropriate acupuncture points for a physiological pain approach to What is the idea behind the acupuncture points? The principle that each person is governed by opposing, but complementary, forces of yin and yang, is central to all Chinese thought. Qi is thought to circulate throughout the body in invisible channels (other translations of the Chinese term jing luo include "conduit" and "meridian"). How is this very different medical philosophy on disease incorporated into Western medical concepts? From the frequent use of quotation marks, it should be obvious that acupuncture is not easily transferred or translated into the Western concept of medicine. A great number of different schools for acupuncture exist, using different point localizations and point selections. Hence it is not possible to interpret acupuncture and redefine it into a pragmatic pain approach. Recent large-scale studies in Germany have added a lot to this discussion by showing that acupuncture per se, but not the strict following of classical traditional Chinese rules for acupuncture point selection, is effective in treating pain. Therefore, it may be a pragmatic solution to adapt traditional Chinese acu- puncture into a simplified acupuncture point selection for practical use. These effects do not seem to be acupoint-specific and are at least partly a psychophysiological phenomenon. Some areas may be more sensitive and feel like a small pinch as the needle in inserted, but that lasts for less than a second. The acupuncture needles are held between thumb, index finger, and middle finger, with the needle parallel to the index finger. During this time the needles may be manipulated to achieve the effect of toning or sedating the Qi, according to the situation. Needle manipulations generally involve lifting, thrusting, twisting, and rotating, according to treatment specifications for the health problem. As always, specialists are convinced that their own method is superior, and therefore acupuncturists tend to see acupuncture as a panacea (cure-all). Nevertheless, experienced pain therapists who use acupuncture and go through a thorough training would use a more sophisticated view: creating an antagonism between these two approaches of acupuncture and conventional pain management would be counterproductive for acupuncture in the long run, since its effects are considerable but not overwhelming. Therefore, pain specialists are trying to incorporate acupuncture as a complementary technique into regular pain management as one module together with manual therapy, therapeutic exercises, and psycho- and pharmacotherapy within a therapeutic, rehabilitative, and preventive management complex. Before applying acupuncture, a proper diagnosis should be established, and it should be decided if acupuncture or another mode of therapy is more promising. Pain is assessed, as always, by using the visual analogue scale What are the complications and side effects of acupuncture? However, this concept is not widely recognized, and existing scientific literature has not evaluated this pragmatic approach. Since the technique of needle placement is simple and acupuncture needles are widely available and relatively inexpensive, it would be a pity if acupuncture would not be used because of the lack of adequate training facilities. Due to the increase in popularity of acupuncture, acupuncture needles are now widely available. Costs may vary, but have to be set in relation to the savings from using less or shorter-lasting pharmacotherapy. Acupuncture should never be used-after adequate Western medicine diagnosis-as the exclusive method of treatment, since it might prevent patients, such as cancer patients, from receiving other effective treatments. There is strong evidence from studies and meta-analysis that acupuncture has a role in reducing opioid-related side-effects like nausea, vomiting and sedation. How can I perform acupuncture for pain without knowing complicated acupuncture point selection using the meridian system? The questioner is often a kind-hearted person who is interested in relieving human suffering, but feels at a loss about what the next step should be. It needs to be remembered that any change is likely to be resisted anywhere in the world. Professionals: Due to lack of professional education on pain and its treatment, unfortunately, medical and nursing professionals often form the biggest barriers to access to pain relief. The explosion of knowledge in pain physiology and management, at the present time, remains limited to developed countries. In general, the approach is disease- or syndrome-oriented and not patient- or symptom-oriented. Professionals, hence, have a poor concept of the need for pain relief and have an unnecessary fear of analgesics, particularly of opioids. Besides, chronic pain is not a "killer disease," and so it is pushed aside in statistics and receives little attention. The public: the public is not aware that pain relief is possible and tends to accept pain as inevitable. Drug availability: the widely prevailing fear of opioids has resulted in complicated restrictions on licensing of opioids and on prescription practices. It is important to remember that all three sides of the following 317 Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Personnel with the required training, access to affordable essential drugs, and a supportive administrative system are all needed. If one side of these three components is lacking, the whole system fails, naturally. The participants gain enough here in all three domains of knowledge, skills, and attitude to start practicing pain management, but they need continued mentoring. Hence, the following scheme of action would be good for initial practice: What are the challenges regarding education? Educational needs of professionals must be considered against a background in which generations of professionals in developing countries have had no exposure to modern pain management. It is important that such education be appropriate for the local sociocultural realities. The organization or the individual trying to set up a pain management program needs to identify the most appropriate training program available to them in the region. All professionals in the hospital and in the neighborhood should be offered the opportunity to attend such a program. All the professionals involved in some way with the pain management program, including nurses, should be able to evaluate pain and should understand the fundamentals of pain management. Multidisciplinary approach: Ideally, pain management should be a multidisciplinary effort. At the same time, the better the interaction is between the social worker, the nurse, and the pain therapist, the better the outcome is likely to be. Sadly, very often, the most expensive medication would be available in developing countries, while the inexpensive drugs tend to slowly fade away and go off the market. Quality of life as the objective: the goal of management should be improved quality of life rather than just treatment of pain as a sensation. Given that anxiety and depression form part of the pain problem, there should be routine screening of patients for psychosocial problems. Partnership with the patient and family: Successful pain management would mean an essential partnership between the patient, the family, and the therapist. The nature of the problem and treatment options must be discussed with the patient and family and a joint plan arrived at. In developing countries, lack of literacy is often pointed out as the reason for not giving enough explanations to the patient. The illiterate villager, with his experience of a hard life, is usually able to understand problems very well if we remember to avoid jargon and speak in his language. And often he will be more capable of making difficult decisions than a more sophisticated, educated patient. Affordability of treatment: Affordability of a treatment modality should be taken into consideration when treatment options are discussed. Whether the pain service is part of a hospital or a stand-alone service, some clear policy decisions are needed.


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They may be spontaneous or reflexive, triggered by stimuli, such as noise and touch. Neural proliferation Neural migration Presence of subplate Axon + dendrite sprouting Synapse formation Glial proliferation Myelination Programmed cell death Axon retraction Synapse elimination 0w 10w 20w 30w 40w 6m 12m 18m 2y 5y 10y 20y 40y Birth Fig. Radiological patterns of disordered development reflect the stage at which developmental progress was disrupted (Figure 3. This can either reflect a genetic (programming) error of brain development, or disruption by external injury or other noxious influences in what was an otherwise normally developing brain. Evidence of bilateral, largely symmetrical changes indicate a likely genetic origin (with potential recurrence risk implications). Unilateral or strongly asymmetric patterns of involvement generally suggest acquired injury (with potentially lower recurrence risk implications); however, there are exceptions to this rule. These genes have relatively characteristic appearances in terms of the distribution of changes. A2 lissencephaly with thick cortex and typical cell sparse layer (arrow); B2 focal periventricular heterotopia (arrow). A3 polymicrogyriaschizencephaly with polymicrogyric cortex lining the bilateral clefts; A4 generalized polymicrogyria; B3 unilateral schizencephaly. A7 parasagittal hypoperfusion injury with cortical and subcortical damage in the parasagittal area (arrow); A8 acute severe term asphyxial insult of basal ganglia and thalamus lesions (left) with typical involvement of thalamus, globus pallidus and putamen (arrows), and lesions of the central region (arrows, right). B5 middle cerebral artery infarction with cortical, subcortical and thalamic involvement. The clinical patterns and molecular genetics of lissencephaly and subcortical band heterotopia. These can cause anxiety to inexperienced clinicians, radiologists, and of course, families. Minimize the risk of unearthing incidentalomas by resisting the temptation to perform non-indicated examinations! If the site of the incidentaloma is distant from the likely site of pathology, given the examination findings, then it is easier to be reassuring about its non-significance. The large majority of these spontaneously close in early infancy, but may persist into adulthood. Small cysts, such as that shown, are commonly asymptomatic (the location at the anterior pole of the temporal lobe is typical). Haemorrhage into very large cysts is also recognized; however, a cyst as small as that illustrated is very benign and should be ignored. In situations of greater tonsillar descent, radiological evidence of foramen magnum crowding, and symptoms of headache, the findings may be significant. In unclear situations a follow-up study after an interval of 12 mths may clarify its non-progressive nature. Recall that testing spinothalamic sensation in relevant dermatomes is the most sensitive clinical indicator of a syrinx (see b p. If appearances are striking, and head circumference is large, consider benign external hydrocephalus (see Figure 3. Approach the first step is to distinguish hypomyelination or delayed myelination from dysmyelination (i. This is done by comparison of the T1 and T2 characteristics of the white matter in relation the appearance of grey matter structures. Because of physiological changes in white matter signal appearance in the first 2 yrs of life reflecting myelination (see b p. After this time, white matter should be normally be dark (reflecting completed myelination) on T2 (Figure 3. Further characterization is based on a combination of radiological features (particularly the anatomical location of abnormal white matter) and associated clinical features. Please note that variant and atypical forms make this a more complex process than the flowchart necessarily suggests (Schiffmann and van der Knaap, 20091)! Cortex White matter Basal ganglia T1 T2 Normal (after ~ 18m) or or T1 T2 Leukoencephalopathy or Leukodystrophy T1 T2 T1 T2 T1 T2 Hypomyelination Fig. Proximal arm/shoulder pain or dysaesthesia often precedes the weakness of neuralgic amyotrophy. Much more commonly a child with developmental disability will show indifference to pain: he feels (and withdraws automatically from) painful stimuli but shows little emotional distress (i. Such disturbances will typically be reported in patchy distributions that do not correspond to anatomical segmental or peripheral nerve territory distributions. Difficulties raising head from pillow, combing hair, brushing teeth, shaving, raising arms above head, getting up from chair, stairs and use of banisters, running, hopping, jumping. Difficulties opening screw cap or door knob, turning key, buttoning clothes, writing, falling on uneven ground, tripping, hitting curb, difficulty in heel walking, toe walking, foot drop. Difficulties bending forward, lifting head off the bed, respiratory involvement, nocturnal hypoventilation, and diaphragmatic weakness; seen in congenital myopathies and glycogen storage disorders. Antenatal onset suggested by polyhydramnios, reduced foetal movements, unusual foetal presentation in labour, contractures (arthrogryposis including foot deformity), congenital dysplasia of the hip. This latter is particularly a consideration in the presence of myoclonic seizures (see b p. The six commonest diagnostic groups were leukoencephalopathies (7% combined), neuronal ceroid lipofuscinoses (5% combined), mitochondrial diseases (5%), mucopolysaccharidoses (4%), gangliosidoses (4%), and peroxisomal disorders (3%). Ask about history of sudden infant death, unexplained illness, or neurological presentations in family members. The epidemiology of progressive intellectual and neurological deterioration in childhood. Clues from imaging, electrophysiology and ophthalmology examination For approach to white matter abnormalities see b p. It can be hard to tell whether the problem is, in fact, longstanding, but has recently come to light due to increasing academic expectations (e. Parental observations should be supplemented by reports from schoolteachers and/or educational psychologists. Examination the child will be older and a formal (adult style) neurological examination with assessment of higher mental function (see Box 1. Examination Pay particular attention to physical factors that may disturb sleep (e. Excessive daytime sleepiness Likely to be due to poor nocturnal sleep hygiene but consider obstructive sleep apnoea and narcolepsy (under-recognized) (see b p. Disturbed episodes related to sleep (parasomnias) these are recurrent episodes of behaviour, experiences, or physiological changes that occur exclusively or predominantly during sleep. Decide whether these are primary, or secondary to neurodevelopmental or neuropsychiatric issues (see b p. Measures the time taken to get to sleep during 5 opportunities at least 2 h apart during the day. Neuromotor speech disorders Apraxia Abnormal planning, sequencing, and coordination of articulation not due to muscle weakness. Dysarthria Weakness/paralysis of the musculature of speech (larynx, lips, tongue, palate, and jaw).