Ultrasound-Guided Greater Occipital Nerve Block for Primary Headache: Comparison of Two Techniques by Anatomical Injection Site

OBJECTIVE: Greater occipital nerve block (GONB) is a widely accepted treatment of primary headaches. Two ultrasound (US)-guided blockade techniques exist: 1) the classical distal nerve block technique performed medial to the occipital artery at the superior nuchal line, and 2) the new proximal nerve block technique performed at the obliquus capitis inferior muscle at the level of C2. Our study aim was to perform a head-to-head comparative study of these two US-guided techniques.METHOD: Forty-nine patients with primary headache treated in our university hospital were recruited. Patients were randomized into two groups of the classical nerve block and the new proximal nerve block techniques. The headache questionnaire was made to assess the intensity of the pain of headache attacks, number of days they experience headache, duration of headache, and amount of pain medication they consumed.RESULTS: In both groups, a decrease in the severity and frequency of the headache was observed. There was no measurable difference in outcome between the two groups.CONCLUSION: Our study showed that the classic and new proximal techniques are equally effective in decreasing the headache severity and frequency.

Radiating Pain and Postural Balance with Pulsed Radiofrequency Treatment in Patients with Lumbosacral Radiculopathy

OBJECTIVE: To investigate the effect of pulsed radiofrequency (PRF) treatment on pain and balance in patients with lumbosacral radiculopathy.METHOD: This study included twenty-five patients who were diagnosed with chronic lumbosacral radiculopathy. They underwent PRF treatment in prone position under the fluoroscopic guidance. The effect of PRF was measured by the visual analog score (VAS). Patient ability to balance was evaluated by using the Tetra-ataxiometric posturography (Tetrax).RESULTS: After PRF all patients showed improvement in pain as measured by VAS (p < 0.001) and none of the patients reported any side effects. The posturographic balance, which was evaluated by Tetrax showed no significant decline after PRF treatment. The weight distribution index (WDI) with eyes open before treatment was 5.43 ± 2.88 and after treatment was 5.37 ± 2.65 (p=0.917). The mean stability index (SI) with eyes open before treatment was 16.52 ± 6.05 and after treatment was 16.61 ± 4.85 (p=0.906). The mean WDI with eyes closed before treatment was 5.66 ± 2.81 and after treatment was 5.16 ± 2.70 (p=0.470). Finally, the mean SI with eyes closed before was 25.88 ± 9.88 and after treatment was 25.99 ± 12.30 (p=0.962).CONCLUSION: The results suggest that PRF has an effect on pain in patients with chronic lumbosacral radiculopathy. The patients did not experience adverse effects, such as hypoesthesia, dysesthesia and decreased proprioception after PRF, and there were no significant declines in balance.

MR Imaging in Bell's Palsy and Herpes Zoster Oticus: Correlation with Clinical Findings

PURPOSE: To evaluate the MRI findings of acute facial nerve paralysis in Bell's palsy and herpes zosteroticus, and to correlate these with the clinical findings. MATERIALS AND METHODS: We retrospectively reviewed theMRI findings in six cases of Bell's palsy(BP) and two of herpes zoster oticus(HZO), and compared them with thefindings for 30 normal facial nerves. This nerve was considered abnormal when its signal intensity was greaterthan that of brain parenchyma or the contralateral normal side on Gd-enhanced T1-weighted axial and coronal MRimages. We analysed the location and degree of contrast enhancement, interval change, and clinical progression incorrelation with House-Brackmann(HB) grade and electroneuronography(ENoG) findings. RESULTS: Fifteen of 30 normalfacial nerves(50%) seen on Gd-enhanced MRI were mildly enhanced in the geniculate ganglion, the proximal tympanic,and the proximal mastoid segment of the facial nerve. No enhancement of the internal auditory canal(IAC) orlabyrinthine segment of the facial nerve was noted, however. In BP and HZO, Gd-enhanced MR images revealed fair tomarked enhancement for more than two segments from the internal auditory canal to the mastoid segment of thefacial nerve. During follow-up MRI, enhancement of the facial nerve varied in location and signal intensity,though gradually decreased in intensity approximately eight weeks after the onset of facial nerve palsy. Nocorrelation between clinical HB grade, ENoG, and follow up MRI findings was noted. CONCLUSION: Except in theinternal auditory canal and labyrinthine segment, normal facial neve may show mild and relatively symmetricalenhancement. In BP and HZO, the facial nerve showed diffuse enhancement from the IAC to the mastoid segment.

Follow-up Magnetic Resonance Imaging Study of Patients with Herniated Lumbar Intervertebral Disc Who Were Treated Conservatively

OBJECTIVE: To clarify the relationship between the morphologic changes of disc herniation and the clinical course of conservatively treated herniated lumbar disc patients. METHOD: Follow-up MRIs and clinical assessments by the Visual Analogue Scale and Japanese Orthopaedic Association(JOA) Score were performed in 20 patients at a mean interval of 11.3 month. RESULTS: An average reduction ratio of herniation on the sagittal and axial images, were 21.4% and 20.8% respectively. The clinical features improved significantly and the degree of clinical improvement correlated with the reduction ratio of herniation, althougy 4 patients improved symptomatically despite increased or unchanged degree of herniation. Ten patients with extruded discs showed a higher reduction ratio of heniation with better clinical outcome than those with protruded discs. CONCLUSION: The morphologic change verified on MRI of conservatively treated patients with a lumbar disc herniation is responsible for the clinical outcome although the anatomical factor alone is not enough to explain the outcome. The patients with extruded disc herniation shows more morphologic changes on MRI and better clinical outcomes than the patients with protruded discs.

MR Arthrography of the Labral-Capsular-Ligamentous Complex: Normal Anatomy, Anatomic Variations, and Pitfalls - Preliminary Study

PURPOSE: To evaluate anatomic variations and pitfalls of the labral-capsular-ligamentous complex in the shoulder joint for the proper interpretation of magnetic reasonance arthrographic images. MATERIALS AND METHODS:To determine the presence of sublabral sulci, undercutting of the base of the glenoid labrum by the articular cartilage, and the proximity of the middle glenohumeral ligament to the anterior glenoid labrum, 56 MR arthrograms of 41 asymptomatic volunteers were prospectively evalvated for labral shape and capsular insertion. We also evaluated the axillary fold, which was often confused with a loose body. RESULTS: The anterior and posterior parts of the labra, varied but their shape showed several dominant features; triangular(72%, 36%, respectively), rounded(13%, 35%), cleaved(8%, 1%), notched(2%, 0%), flat(5%, 24%), and absent(0%, 4%). Anterior capsular insertion was type 1 in 82% of cases, type 2 in 13% and type 3 in 5%, whereas posterior insertion was type 1 in 62%, type 2 in 36% and type 3 in 2%. We could also detect many pitfalls, such as undercutting of the base of theglenoid labrum by the articular cartilage(29%), sublabral sulci(25%), a prominent axillary fold(38%), and the middle glenohumeral ligament in proximity to the anterior labrum(5%). CONCLUSION: Our study revealed wide variability in the MR arthrographic appearance of the labral-capsular-ligamentous complex in asymptomatic shoulders. A good understanding of normal variation and pitfalls of the normal shoulder may be helpful pathologic condition in case of glenouhumeral instability.

Recurrent Dislocation of the Shoulder: MR Imaging and MR Arthrographic Findings

PURPOSE: To evaluate and compare the diagnostic findings and usefulness of MRI and MR arthrogram in recurrent anterior dislocation of the shoulder. MATERIALS AND METHODS: MRI and MR arthrogram of thirty-two cases of thirty patients with recurrent anterior dislocation of the shoulder were retrospectively analyzed to evaluate glenohumeral ligaments, pattern of labral injury, bony Bankart lesion, capsular stripping, Hill-Sachs lesion, and loose body. RESULTS: Labral abnormalities was detected on MRI in 23 cases(72%) and MR arthrogram in 22 cases(69%) as labral tear, detachment, and deficiency. All cases involved anteroinferior labrum. On MR arthrogram, labral abnormalities was confined to anteroinferior portion in 4 cases(18%), extended into midglenoid level in 13 cases(59%), and that into anterosuperior portion in 5 cases(23%). Capsular stripping was noted on MRI in 6 cases(19%) and MR arthrogram in 12 cases(38%). Loose body was detected only on MR arthrogram in 5 cases (16%). Bony Bankart lesion and Hill-Sachs lesion was detected equally on MRI and MR arthrogram in 2 cases (6%) and 21 cases(66%) respectively. We obtained identical findings on both MR arthrogram and operation field in 6 patients. CONCLUSION: MRI with its excellent soft tissue contrast resolution and multiplanar imaging capafility helps detection of labral injury in recurrent anterior dislocation of the shoulder. MR arthrogram is slightly invasive, but shows good artatomic details of labral-ligamentous-capsular relationship and thus provides accurate detec- tion of pattern of labral injury, capsular stripping, and loose body.