Reduction of Radiation Exposure by Modifying Imaging Manner and Fluoroscopic Settings during Percutaneous Pedicle Screw Insertion

Objective@#: Percutaneous pedicle screw (PPS) fixation is a needle based procedure that requires fluoroscopic image guidance. Consequently, radiation exposure is inevitable for patients, surgeons, and operation room staff. We hypothesize that reducing the production of radiation emission will result in reduced radiation exposure for everyone in the operation room. Research was performed to evaluate reduction of radiation exposure by modifying imaging manner and mode of radiation source. @*Methods@#: A total of 170 patients (680 screws) who underwent fusion surgery with PPS fixation from September 2019 to March 2020 were analyzed in this study. Personal dosimeters (Polimaster Ltd.) were worn at the collar outside a lead apron to measure radiation exposure. Patients were assigned to four groups based on imaging manner of fluoroscopy and radiation modification (pulse mode with reduced dose) : continuous use without radiation modification (group 1, n=34), intermittent use without radiation modification (group 2, n=54), continuous use with radiation modification (group 3, n=26), and intermittent use with radiation modification (group 4, n=56). Post hoc Tukey Honest significant difference test was used for individual comparisons of radiation exposure/screw and fluoroscopic time/screw. @*Results@#: The average radiation exposure/screw was 71.45±45.75 μSv/screw for group 1, 18.77±11.51 μSv/screw for group 2, 19.58±7.00 μSv/screw for group 3, and 4.26±2.89 μSv/screw for group 4. By changing imaging manner from continuous multiple shot to intermittent single shot, 73.7% radiation reduction was achieved in the no radiation modification groups (groups 1, 2), and 78.2% radiation reduction was achieved in the radiation modification groups (groups 3, 4). Radiation source modification from continuous mode with standard dose to pulse mode with reduced dose resulted in 72.6% radiation reduction in continuous imaging groups (groups 1, 3) and 77.3% radiation reduction in intermittent imaging groups (groups 2, 4). The average radiation exposure/screw was reduced 94.1% by changing imaging manner and modifying radiation source from continuous imaging with standard fluoroscopy setting (group 1) to intermittent imaging with modified fluoroscopy setting (group 4). A total of 680 screws were reviewed postoperatively, and 99.3% (675) were evaluated as pedicle breach grade 0 (<2 mm). @*Conclusion@#: The average radiation exposure/screw for a spinal surgeon can be reduced 94.1% by changing imaging manner and modifying radiation source from real-time imaging with standard dose to intermittent imaging with modified dose. These modifications can be instantly applied to any procedure using fluoroscopic guidance and may reduce the overall radiation exposure of spine surgeons.

Influence of combined oral contraceptives on polycystic ovarian morphology-related parameters in Korean women with polycystic ovary syndrome

Feasibility of Posterior Cervical Foraminotomy for Adjacent Segmental Disease after Anterior Cervical Fusion

Objective@#: The aim of this study is to evaluate the feasibility of posterior cervical foraminotomy (PCF) for adjacent segmental disease (ASD) after anterior cervical fusion (ACF). As ACF is accepted as the standard treatment for cervical spondylosis, many studies have been conducted to evaluate the efficacy of various surgical techniques to overcome symptomatic ASD after the previous surgery. Herein, PCF was performed for the treatment of symptomatic ASD and the feasibility of the surgery was evaluated. @*Methods@#: Forty nine patients who underwent PCF due to symptomatic ASD from August 2008 to November 2017 were identified. For demographic and perioperative data, the sex, age, types of previous surgery, ASD levels, operation times, and bleeding amount were recorded. The clinical outcome was assessed using the visual analogue scale for the neck and arm, the modified Odom’s criteria as well as neck disability index. Radiologic evaluations were performed by measuring disc softness, disc height, the cervical 2–7 sagittal vertical axis, cervical cobb angle, and facet violation. @*Results@#: Thirty-seven patients were enrolled in this study. The patients were divided into two groups based on the location of the pathology; paracentral (group P) or foramina (group F). Both groups showed significant clinical improvement (p0.05). @*Conclusion@#: PCF showed satisfactory clinical and radiologic outcomes for both paracentral and foraminal pathologies of ASD after ACF. Complications related to anterior revision were also avoided. PCF can be considered a feasible and safe surgical option for ASD after ACF.

Author's reply: Questions and comments on: Efficacy of transforaminal laser annuloplasty versus intradiscal radiofrequency annuloplasty for discogenic low back pain

No abstract available.

Efficacy of transforaminal laser annuloplasty versus intradiscal radiofrequency annuloplasty for discogenic low back pain

BACKGROUND: Discogenic pain is a common cause of disability and is assumed to be a major cause of non-specific low back pain. Various treatment methods have been used for the treatment of discogenic pain. This study was conducted to compare the therapeutic success of radiofrequency (an intradiscal procedure) and laser annuloplasty (both an intradiscal and extradiscal procedure). METHODS: This single-center study included 80 patients and followed them for 6 months. Transforaminal laser annuloplasty (TFLA, 37 patients) or intradiscal radiofrequency annuloplasty (IDRA, 43 patients) was performed. The main outcomes included pain scores, determined by the numeric rating scale (NRS), and Oswestry disability index (ODI), at pre-treatment and at post-treatment months 1 and 6. RESULTS: The patients were grouped according to procedure. In all procedures, NRS and ODI scores were significantly decreased over time. Mean post-treatment pain scores at months 1 and 6 were significantly lower (P 40%. CONCLUSIONS: Our results indicate that annuloplasty is a reasonable treatment option for carefully selected patients with lower back and radicular pain of discogenic origin, and TFLA might be superior to IDRA in patients with discogenic low back pain.

Association between serum gonadotropin level and insulin resistance-related parameters in Korean women with polycystic ovary syndrome

OBJECTIVE: To evaluate the relationship between serum gonadotropin level and parameters related to insulin resistance in Korean women with polycystic ovary syndrome (PCOS). METHODS: This retrospective study included 138 women aged 18 to 35 years who were newly diagnosed with PCOS according to the Rotterdam consensus. Participants were divided into three groups based on the serum luteinizing hormone to follicle-stimulating hormone (LH/FSH) ratio in the early follicular phase: group 1 (LH/FSH 2.0), and group 3 (LH/FSH ≥2.0). The correlations between the LH/FSH ratio and various metabolic parameters were evaluated using Pearson correlation coefficients. RESULTS: Patients with higher LH/FSH ratios showed higher total antral follicle counts and higher total ovarian volume. In the comparison of anthropometric and biochemical parameters among the three groups, the waist to hip ratio was the only parameter that differed significantly among the groups (P=0.003). Correlation analysis revealed no significant correlations between serum LH/FSH ratios and biochemical parameters related to insulin resistance. However, after adjustments for age and body mass index, a significant correlation between total cholesterol level and serum LH/FSH ratio was observed (r=0.221, P=0.018). CONCLUSION: Most parameters related to insulin resistance, with the exception of total cholesterol level, are unrelated to the inappropriate pattern of serum gonadotropin secretion in Korean women with PCOS.

Risk factors for malignant transformation of mature cystic teratoma

OBJECTIVE: The aim of this study was to investigate the preoperative characteristics of benign mature cystic teratoma (MCT) and struma ovarii and their risk factors associated malignancies, and determine the appropriate treatment options for these tumors. METHODS: This was a retrospective study on 248 patients who were pathologically diagnosed with ovarian MCT, struma ovarii, or malignant transformations of these tumors at Inje University Haeundae Paik Hospital from March 2010 to January 2015. Routinely evaluated results of adnexal masses before surgery were compared. RESULTS: A total of six patients (2.4%) were confirmed to have malignant tumors. Of the struma ovarii patients, two out of five patients (40%) were confirmed to have malignancy. The mean age at the diagnosis of patients with malignant transformation of teratomas was 43.0 years (range, 27 to 67 years), which was higher than that of patients with benign teratomas (36.5 years). The mean diameter of the tumor before surgery in the malignant tumor group was 11.4 cm and larger than 6.5 cm of benign group (P=0.003). The mean CA-125 level in the malignant tumor group was higher than that in the benign tumor group (P=0.01). CONCLUSION: Risk factors for malignant transformation of MCT include elevated CA-125 levels, older age, large tumor masses, and postmenopausal status.

Comparison of Morphine and Tramadol in Transforaminal Epidural Injections for Lumbar Radicular Pain

BACKGROUND: Transforaminal epidural steroid injections are known to reduce inflammation by inhibiting synthesis of various proinflammatory mediators and have been used increasingly. The anti-inflammatory properties of opioids are not as fully understood but apparently involve antagonism sensory neuron excitability and pro-inflammatory neuropeptide release. To date, no studies have addressed the efficacy of transforaminal epidural morphine in patients with radicular pain, and none have directly compared morphine with a tramadol for this indication. The aim of this study was to compare morphine and tramadol analgesia when administered via epidural injection to patients with lumbar radicular pain. METHODS: A total of 59 patients were randomly allocated to 1 of 2 treatment groups and followed for 3 months after procedure. Each patient was subjected to C-arm guided transforaminal epidural injection (TFEI) of an affected nerve root. As assigned, patients received either morphine sulfate (2.5 mg/2.5 ml) or tramadol (25 mg/0.5 ml) in combination with 0.2% ropivacaine (1 ml). Using numeric rating scale was subsequently rates at 2 weeks and 3 months following injection for comparison with baseline. RESULTS: Both groups had significantly lower mean pain scores at 2 weeks and at 3 months after treatment, but outcomes did not differ significantly between groups. CONCLUSIONS: TFEI of an opioid plus local anesthetic proved effective in treating radicular pain. Although morphine surpassed tramadol in pain relief scores, the difference was not statistically significant.

Effect of Intravenous Lidocaine on the Neuropathic Pain of Failed Back Surgery Syndrome

BACKGROUND: An intravenous infusion of lidocaine has been used on numerous occasions to produce analgesia in neuropathic pain. In the cases of failed back surgery syndrom, the pain generated as result of abnormal impulse from the dorsal root ganglion and spinal cord, for instance as a result of nerve injury may be particularly sensitive to lidocaine. The aim of the present study was to identify the effects of IV lidocaine on neuropathic pain items of FBSS. METHODS: The study was a randomized, prospective, double-blinded, crossover study involving eighteen patients with failed back surgery syndrome. The treatments were: 0.9% normal saline, lidocaine 1 mg/kg in 500 ml normal saline, and lidocaine 5 mg/kg in 500 ml normal saline over 60 minutes. The patients underwent infusions on three different appointments, at least two weeks apart. Thus all patients received all 3 treatments. Pain measurement was taken by visual analogue scale (VAS), and neuropathic pain questionnaire. RESULTS: Both lidocaine (1 mg/kg, 5 mg/kg) and placebo significantly reduced the intense, sharp, hot, dull, cold, sensitivity, itchy, unpleasant, deep and superficial of pain. The amount of change was not significantly different among either of the lidocaine and placebo, or among the lidocaine treatments themselves, for any of the pain responses, except sharp, dull, cold, unpleasant, and deep pain. And VAS was decreased during infusion in all 3 group and there were no difference among groups. CONCLUSIONS: This study shows that 1 mg/kg, or 5 mg/kg of IV lidocaine, and palcebo was effective in patients with neuropathic pain attributable to FBSS, but effect of licoaine did not differ from placebo saline.

Sacral Nerve Stimulation Through the Sacral Hiatus

Sacral nerve stimulation through the retrograde approach has been used for peroneal or irritable bowel syndrome through the retrograde approach. However, several reasons, lead could not be advanced down ward. In this case, anterograde sacral nerve stimulation through the sacral hiatus could be used. The aim of this report is to present of technique of sacral nerve root stimulation through the sacral hiatus approach.

Piriformis Muscle: Clinical Anatomy with Computed Tomography in Korean Population

BACKGROUND: The objective was to evaluate the distance from the skin and the diameter of the piriformis muscle and their relationship to the body mass index (BMI). METHODS: The study was a prospective study involving 60 patients. Patients were prepared on a radiological table in the prone position. Several images were obtained of each. In this view, the distance between the subcutaneous tissue and the piriformis muscle, and the diameter of the piriformis, were measured at three points (medially to laterally). RESULTS: The distance to the piriformis from the skin was 6.6 +/- 0.9 cm, 6.3 +/- 0.8 cm, and 5.2 +/- 0.9 cm in terms of the lateral, center, and medial measurement, respectively. The center of the piriformis had a greater diameter with 1.7 +/- 0.4 (0.9-2.5) cm. The distance to the piriformis increased with BMI. CONCLUSIONS: This study shows that the lateral of the piriformis muscle has a relatively greater distance from the skin. The center of the piriformis showed a greater diameter than other two portions. We found that the distance of the piriformis from subcutaneous tissues was correlated with BMI, but the diameter of the piriformis was not affected by BMI. These measurements can be used as a reference for determining the piriformis injection site in patients with piriformis syndrome.

Retrospective analysis of low-dose methadone and QTc prolongation in chronic pain patients / 대한마취과학회지

BACKGROUND: Methadone is a synthetic opioid that is widely used for the treatment of chronic pain. The association between methadone treatment and QT interval prolongation or which can lead to torsades de pointes has been confirmed with larger studies on high dose methadone. The aim of this study was to determine the effect of methadone on the QTc interval in patients, whether the daily dose of methadone should be lower than what has been previously investigated. METHODS: A total of 130 patients were included, with 90 patients in the methadone group and 40 patients in the control group. For each ECG, heart rate, QT interval and corrected QT (QTc) interval were recorded. The patient demographics, methadone dose and serum level, duration of methadone use and past medical history were collected. RESULTS: The QTc interval was significantly longer in the treatment group than in the control group (443 +/- 30.0 ms versus 408 +/- 28.0 ms, respectively, P < 0.0001) and more patients in the treatment group had a QTc interval greater than 450 ms (36.7% versus 7.5%, respectively, P = 0.0005). The QTc interval was not associated with methadone dose P = 0.9278), serum level (P = 0.2256) or duration of treatment (P = 0.1822). CONCLUSIONS: This study has shown that methadone use is associated with longer QTc intervals, even among patients with daily doses of less than 80 mg. In this study, no correlation was found between QTc duration and methadone dose, serum levels or duration of use. However, the magnitude of the QTc interval was associated with female gender and the use of antidepressants.

Involvement of Selective Alpha-2 Adrenoreceptor in Sympathetically Maintained Pain

OBJECTIVE: Peripheral nerve injury often leads to neuropathic pain, which is characterized by burning pain, allodynia, and hyperalgesia. The role of the sympathetic nervous system in neuropathic pain is a complex and controversial issue. It is generally accepted that the alpha adrenoreceptor (AR) in sympathetic nerve system plays a significant role in the maintenance of pain. Among alpha adrenoreceptor, alpha-1 receptors play a major role in the sympathetic mediated pain. The primary goal of this study is to test the hypothesis that sympathetically maintained pain involves peripheral alpha-2 receptors in human. METHODS: The study was a randomized, prospective, double-blinded, crossover study involving twenty patients. The treatments were : Yohimbine (30 mg mixed in 500 mL normal saline), and Phentolamine (1 mg/kg in 500 mL normal saline) in 500 mL normal saline at 70 mL/hr initially then titrated. The patients underwent infusions on three different appointments, at least one month apart. Thus, all patients received all 2 treatments. Pain measurement was by visual analogue scale, neuropathic pain questionnaire, and McGill pain questionnaire. RESULTS: There were significant decreases in the visual analogue scale, neuropathic score, McGill pain score of yohimnine, and phentolamine. CONCLUSION: We conclude that alpha-2 adrenoreceptor, along with alpha-2 adrenoreceptor, may be play role in sympathetically maintained pain in human.

Comprasion of Effectiveness of CT vs C-arm Guided Percutaneous Radiofrequency Lumbar Facet Rhizotomy

BACKGROUND: Facet joint have been implicated as a source of chronic low back pain. Radiofrequency denervation has demonstrated the most solid evidence. To increase safety and efficacy of treatment, computed tomography (CT) guidance injection has been used in several disease. The purpose of this study was to evaluate the efficacy of CT-guided radiofrequency rhizotomy in the treatment of facet joint pain. METHODS: A total of 40 patients were randomized to undergo radiofrequency facet joint denervation under CT guidance or C-arm guidance. All patients were examined visual analogue scale (VAS) score before treatment, 1 month, and 3 months after treatment. RESULTS: The VAS in both groups showed significant improvement over the 1-month interval. No significant difference in the VAS score among the group was observed. CONCLUSIONS: In this study there was no significant difference between CT guidance lumbar rhizotomy and C-arm guidance lumbar rhizotomy. Therefore CT-guided radiofrequency denervation of the lumbar facet joint was a minimally invasive technique that appears effective.

Investigation of High-Sensitivity C-reactive Protein and Erythrocyte Sedimentation Rate in Low Back Pain Patients

BACKGROUND: Chronic low back pain can be a manifestation of lumbar degenerative disease, herniation of intervertebral discs, arthritis, or lumbar stenosis. When nerve roots are compromised, low back pain, with or without lower extremity involvement, may occur. Local inflammatory processes play an important role in patients with acute lumbosciatic pain. The purpose of this study was to assess the value of erythrocyte sedimentation rate (ESR) and high sensitivity C-reactive protein (hsCRP) measurements in patients with chronic low back pain or radiculopathy. METHODS: ESR and hsCRP were measured in 273 blood samples from male and female subjects with low back pain and/or radiculopathy due to herniated lumbar disc, spinal stenosis, facet syndrome, and other diseases. The hsCRP and ESR were measured prior to lumbar epidural steroid injection. RESULTS: The mean ESR was 18.8 mm/h and mean hsCRP was 1.1 mg/L. ESR had a correlation with age. CONCLUSIONS: A significant systemic inflammatory reaction did not appear to arise in patients with chronic low back pain.

Permanent Peripheral Nerve Stimulation for Chronic Occipital Neuralgia: Case reports / 대한통증학회지

This report presents the application of occipital nerve stimulation in two patients with severe and disabling bilateral occipital neuralgia. Pain persisted despite the use of several procedures and the administration of medication in the patients. The patients underwent peripheral nerve stimulation for the treatment of headache. Peripheral nerve stimulation was accomplished via implantation of a subcutaneous electrode to stimulate the peripheral nerve in the occipital area. The patients reported a 90% improvement in overall pain. These cases illustrate the possible utilization of peripheral nerve stimulation for the treatment of occipital neuralgia.

Anterior Epidural Irrigation in a Lumbar Spinal Stenosis Patient / 대한통증학회지

BACKGROUND: Pain due to spinal stenosis is one of the major causes of low back pain, and it sometimes does not respond to conservative treatment. We postulated that anterior epidural irrigation could be a good choice for treating lumbar spinal stenosis patients. However, the effects and theoretical basis of anterior epidural irrigation have not been investigated for spinal stenosis. So, this study was designed to identify the clinical efficacy of anterior epidural irrigation for treating lumbar spinal stenosis. METHODS: 71 patients with lumbar spinal stenosis underwent anterior epidural irrigation. Anterior epidural irrigation was performed with normal saline and a mixture of local anesthetic with steroid through a catheter under fluoroscopic guidance. The findings were evaluated with using visual analogue scales for low back pain and leg symptoms. RESULTS: Relief from low back pain and leg pain was observed for up to 12 months after anterior epidural irrigation. None of the patients showed any deterioration of their motor or sensory deficits during follow up. CONCLUSIONS: Anterior epidural irrigation is effective for the relief of back and leg pain in spinal stenosis patients.

Effect of the Oblique Fluoroscopic Approach for Performing Stellate Ganglion Block / 대한통증학회지

BACKGROUND: Stellate ganglion block (SGB) is a selective sympathetic blockade that affects the head, neck and the upper extremities. It is an important method that has been frequently used in pain clinics due to its wide range of indications. But there were some problem with performing SGB at C6 or C7. Thus, various techniques have been recently introduced to successfully perform SGB; among them, there is the oblique approach. This study was performed to evaluate the effectiveness of the oblique approach for performing SGB in C7. METHODS: Forty six patients with sudden hearing loss were studied. In group I, the patient underwent C7 oblique SGB with 1% mepivacaine (3 ml) under fluoroscopic guidance. In group II, the patients underwent the C7 classical anterior approach SGB with 1% mepivaine (5 ml) under fluoroscopic guidance. We compared the occurrence of Horner's syndrome, the side effects and the changes of temperature of the skin of the hand. RESULTS: The rate of Horner's syndrome was 81.5% in the group I and 84.2% in the group II. The rate of incurring increased skin temperature (> or = 34 degree C) of the fingers was 77.7% and 79.4% in each group, respectively. CONCLUSIONS: The C7 oblique approach for SGB showed the same SGB effect compared with the C7 anterior approach for SGB, and there were also fewer complications. We conclude that C7 oblique SGB may be a beneficial method for treating patients with this particular malady.

Treatment of Failed Back Surgery Syndrome with a Spinal Cord Stimulator: A report of 2 cases / 대한통증학회지

Spinal cord stimulation (SCS) has been used since 1967 for refractory chronic pain. SCS has recently undergone a variety of technical modifications and advances, and it has been applied in a variety of pain conditions. SCS has been most commonly applied for those patients with chronic back and leg pain and failed back surgery syndrome (FBSS). The clinical hallmark of FBSS is chronic postoperative pain. The pain pattern varies and the pain may show an axial or radicular distribution. Chronic intractable pain after FBSS is difficult to treat. This report describes our experience with treating chronic pain in two patients who suffered from FBSS with a spinal cord stimulator. A permanent spinal cord stimulator was implanted after a successful trial of stimulation with temporarily implanted electrodes. After 5 months of follow-up, the two patients had satisfactory improvement of their pain.