Improvement in Dropped Head Syndrome (DHS) Following Corticosteroid Injections on the Tender Points at the Upper Thoracic Spine : A Case Report / The Japanese Journal of Rehabilitation Medicine

　An 83-year-old woman presented with dropped head syndrome (DHS), that had been progressing during the previous 6 months. She had no history of neuromuscular diseases and, on examination, no neuromuscular abnormalities were observed except for isolated weakness of the neck extensors, mainly of the semispinalis cervicis. On the paravertebral sites of the T1-T5 spine on both sides, a total of eight points with marked tenderness were noted, four on each side. These eight points coincided with the anatomically narrow spaces through which the posterior rami emerged from their deep exits in the spine (i.e., the intervertebral foramina) to the superficial paravertebral sites, where they bifurcated into the lateral and medial branches, the latter innervating the semispinalis cervicis. Repeated local corticosteroid injections once a week on these eight tender points, with 3.3 mg Decadron (dexamethasone sodium phosphate) mixed with 20 mL of 0.5% xylocaine divided among the eight tender points, improved DHS in 3 months. This case suggests that the anatomically narrow pathway of the medial branches of the posterior rami at the upper thoracic spine could induce inflammations of the passing nerves, resulting in neck extensor weakness.

The Effect of Lumbar Medial Branch Block on Low Back Pain

OBJECTIVE: The goal of this study was to establish the benefit and prognostic factors of lumbar medial branch block(MBB) for low back pain. METHODS: A retrospective analysis was based on the data obtained from 281 patients with low back pain, who visited our hospital between January 2001 and November 2004. Pain relief was evaluated at 2 weeks, 1 month and 3 months. The authors analyzed the results of MBB according to the patient's age, sex, symptom duration, pathologic condition, and presence of radiating pain. RESULTS: Two hundred eighty one patients had sprain (151), lumbar fracture (27), spinal stenosis (50), herniated lumbar disc (24) acute post-operative pain (8), and chronic post-operative pain (21) with success rate of 63.6%, 59.3%, 26.0%, 25.0%, 87.5% and 42.9%, respectively. The effects of MBB in sprain, lumbar fracture, and acute post-operative pain were significantly better than those in stenosis, hern iated lumbar disc and chronic post-operative pain patients. The patients in young age group (<60 years), with short symptom duration (<6 months) and without radiating pain showed good response to lumbar MBB. CONCLUSION: The lumbar MBB appears to be safe and effective for low back pain in certain selected patients. Good prognostic factors were low back pain without surgical conditions and radiating pain, with short symptom duration (<6 months), and in relatively young age (<60 years) group.

Prognostic Factors of Percutaneous Radiofrequency Neurotomy on the Posterior Primary Ramus

OBJECTIVE: We report our experience of percutaneous radiofrequency neurotomy(PRN) on the posterior primary ramus with at least two years follow up. METHODS: Two hundred and twenty-eight patients were underwent PRN on the posterior primary ramus for refractory low back pain during last three years. One hundred and twenty-eight patients were met all inclusion criteria indicating facetal originated pain(group II), and 100 patients were not(group I). Radiofrequency procedures were done in usual manner. Pain reliefs were estimated at 1 week, 1 month, 6 months and 2 years using visual analog scale. RESULTS: Positive responders were 56% at 1 week, 46% at 1 month, 18% at 6 months, and 13% at 2 years after PRN in group I, and 78.9% at 1 week, 75.4% at 1 month, 62.5% at 6 months, and 54.7% at 2 years in group II. Prominent local tenderness, percussion tenderness, pain on getting up, extension and transitional movement, radiating pain on buttock and/or posterior thigh, and good immediate response were found to be significantly related to outcome. And age, sex, symptom duration, bilateral symptoms, favorable imaging study results, previous lumbar surgery, and degrees of pain relief from diagnostic block were not. CONCLUSION: Percutaneous radiofrequency neurotomy on the posterior primary ramus has long-term beneficial effect, without any morbidity in our series. And the long-term good results will be anticipated after proper selection among patients with facet joints related low back pain.

Prognostic Factors of Percutaneous Radiofrequency Neurotomy for Chronic Low Back Pain

BACKGROUNDS: Percutaneous radiofrequency neurotomy of posterior primary ramus has been in use as a treatment for persistent, mechanical low back pain for two decades. However, there has been limited studies regarding to prognostic factors related to outcome. We report our experience with at least 2-year follow up with special aftention on prognostic factors. METHODS: Of total 228 patients who underwent percutaneous radiofrequency neurotomy (PRN) of posterior primary ramus for refractory low back pain during last 3 years, 128 patients whose pain was considered to be originated from facets joints or their surrounding soft tissue and responded to temporary blocks were assigned to a group II. All patients had more than 6 months of pain. These patients were compared with 100 patients to whom PRN were provided for chronic nonspecific low back pain without all inclusion criteria (Group I). RF procedures were done under local anesthesia with C-arm intensifier guidance. Pain reliefs were estimated at 1week, 1month, 6months and 2 years using visual analog scale(VAS). For patients with more that 50% reduction of previous pain was regarded as positive responder. Various clinical variables such as age, sex, symptom duration, types of pain, bilaterality, and previous surgery were studied for prognostic factors. RESULTS: Positive responders were 56% at 1week, 46% at lmonth, 18% at 6months, and 13% at 2years after PRN in group I, and 78.9% at lweek, 75.4% at lmonth, 62.5% at 6months, and 54.7% at 2years in group II. Some variables were found to be significantly related to outcome including prominent local tenderness, percussion tenderness, combination of symptoms with pain on gefting up, extension, transitional movement, pain radiating to buttock and/or posterior thigh, and good immediate response. Age, sex, symptom duration, bilaterality, imaging study results, previous lumbar surgery, and degrees of pain relief from diagnostic block were not related to outcome. CONCLUSIONS: These results indicate that PRN of posterior primary ramus has a moderate overall long-term beneficial effect, with no morbidity in our series. But, the long-term good results will be anticipated only in properly selected patients with low back pain originating from facet joints and surrounding structures.