History and Concept of Manual Therapy / 대한정형외과학회잡지

Manual therapy has undergone parallel development throughout many parts of the world dating back to ancient times for at least 2,500 years. The earliest historical reference to the practice of manual therapy in Greece, dates back to 400 B.C. Over the centuries, manual medicines have fallen in and out of favor with the medical profession. To truly understand the principle, it is important to know that manual therapy was initially the mainstay of the three leading alternative health care systems, osteopathy, chiropractic, and most notably physical therapy. These were all founded in the latter part of the 19th century in response to the shortcomings in allopathic medicine. Although it has been around for a long time and has been used all over the world, there are a few reports on manual therapy treatment, and most papers provided a low level of evidence. Despite the controversies over manual therapy, its use appears to be increasing gradually. This article reviews the history of manual therapy from ancient times to the present including Korean history, discusses the current state of knowledge on manual therapy, and informs physicians who manage musculoskeletal pain.

Prolotherapy / 대한정형외과학회잡지

Prolotherapy is defined as “the rehabilitation of an incompetent structure such as ligament or tendon by induced proliferation of new cells” in the dictionary. It may include any treatment promoting the proliferation of new cells such as stem cell therapy. Traditionally, prolotherapy has been thought of as a method of strengthening a lax ligament by injecting various types of sclerosing or proliferant solutions which have commonly included hypertonic dextrose. And this therapy should involve the process of injecting solutions at the enthesis, where tendons and ligaments attach to the bone, to cause an inflammatory reaction. This inflammation initiates the regeneration and repair processes of the injured tissue in and around the joint to promote tissue proliferation and growth. Therefore, the method of prolotherapy includes the injection of small volumes of an irritant solution at painful ligament and tendon insertion sites over several treatment sessions. Because prolotherapy is a treatment modality that may provide a solution to a patient who complains of enthesopathic pain symptoms, it may be beneficial prior to long-term medication treatment or surgical intervention. Despite controversies over prolotherapy, its usage appears to be increasing gradually. This article discusses the current state of knowledge on prolotherapy and informs it to the physicians who manage the musculoskeletal pains.

Sonography of the Rotator Cuff: Comparison of Arm Positions / 대한정형외과학회잡지

PURPOSE: To evaluate the objective difference of the shoulder position during ultrasound examination regarding diagnostic value for shoulder lesion, view range and visibility. MATERIALS AND METHODS: A prospective study was performed enrolling 312 patients who underwent diagnostic ultrasonography due to shoulder pain between January 2016 and June 2016. Examination was performed by a single orthopaedic surgeon with 5 years of musculoskeletal ultrasonography experience. Images of the longitudinal and transverse plane of the supraspinatus tendon and the nearby soft tissues (subscapularis and biceps long head tendon, subdeltoid bursa, etc.) were obtained in the three different positions, shoulder extension, modified Crass, and Crass position. The correlation between the demographic data (age, sex and body mass index) and the visual analogue scale (VAS) of the affected shoulder & the capable shoulder position was analyzed. Another orthopaedic independently measured the size of the tear and using classified the image visibility of the supraspinatus, subscapularis, and biceps long head tendon on the short-axis view from the rotator interval into I to III and X. RESULTS: Of the 312 patients, 126 were excluded and total of 186 cases were included in this study. None of the demographic data were related to the possible arm position. However, VAS for pain was the only factor related with the number of possible arm positions during sonography. Kappa agreements for the diagnosis were mostly high of over 0.90. Grades of the short-axis view from the rotator interval in each position were mostly grade II or grade III, which refers to that the anterior portion of supraspinatus tendon, which is the most fragile portion to the tear and it was well-defined regardless of the arm position. The average longitudinal tear sizes were 1.48, 1.52, and 1.61 cm in the shoulder extension, modified Crass (Middleton), and Crass position, respectively. CONCLUSION: Shoulder extension position during ultrasonography examination of shoulder shows similar diagnosis rate of supraspinatus tendon tear or calcific tendinitis compared to modified Crass (Middleton) or Crass position, the two well-known standard positions. It is also a useful position for patients who suffer with severe shoulder pain.

Percutaneous Epidural Neuroplasty / 대한정형외과학회잡지

Interventional pain management by percutaneous epidural neuroplasty (PEN) has potential as a useful treatment method in chronic low back and/or radicular pain that is refractory to other conservative treatments. The effect of PEN is known to result from targeting of drug delivery to areas of pathology in the spinal epidural space. The procedure involves removing barriers, such as epidural fibrosis, that prevent drug from reaching target sites. Therefore, the goal during lysis of epidural adhesions is to penetrate mechanical barriers impeding injected material from spreading effectively into the areas of pathology in the epidural space by the catheter. An additional lavage effect, reducing the local concentration of proinflammatory substances seems possible. Although a true mechanical lysis of postsurgical adhesions or scar tissues by means of PEN appears to be impossible because it has been proven by experimental biomechanical study, mild to moderate adhesions may be broken up by a PEN catheter allowing the medications to reach the target site through the new channel made by the catheter. This review will focus on the adhesiolysis technique using the sacral hiatus approach in treatment of chronic low back pain with/without lumbosacral radiculopathy.

Ultrasonography and Ultrasound-guided Interventions of the Shoulder

Nowadays shoulder ultrasound is commonly used in the assessment of shoulder diseases and is as accurate as magnetic resonance imaging in the detection of several pathologies. Operator dependence is the main disadvantage of shoulder ultrasound. After adhering to a strict examination protocol, good knowledge of normal anatomy and pathologic processes and an awareness of common pitfalls, it can be used as a focused examination providing rapid, real-time diagnosis, and treatment by ultrasound-guided interventions in desired clinical situations. Also shoulder ultrasound can help the surgeon decide whether treatment will be surgical or nonsurgical. If arthroscopy is planned, sonographic findings help to counsel patients regarding surgical and functional outcomes. If a nonsurgical approach is indicated, ultrasound can be used to follow patients. This review article presents the examination techniques, the normal sonographic appearances and the main pathologic conditions found in shoulder ultrasound. And also addresses a simplified approach to scanning and ultrasound-guided intervention. Knowledge of optimal techniques, normal anatomy, dynamic maneuvers, and pathologic conditions is essential for optimal performance and interpretation of images.

Ultrasound-Guided Intervention in Cervical Spine / 대한정형외과학회잡지

Interventional procedures around the cervical spine have been classically performed under the guidance of fluoroscopy with radiation hazards to patients and doctors. Even though under fluoroscopic guidance, vascular and nerve structures cannot be shown and there are actual risks for the patient. Nowadays, we can use high resolution image ultrasound around cervical spine procedures. Real time imaging is possible. Cervical root block, medial branch block and many other interventions can be performed under ultrasound guidance. In out-patient clinics, ultrasound is very helpful in management of cervical problems in differentiating the origin of pain and treatment for the pain. Ultrasound is radiation free, easy to use and the imaging can be performed continuously while the injectant is visualized in real-time, increasing the precision of injection. Importantly, ultrasound enables visualization of major nerves and vessels and thus leads to improved safety of cervical interventions by decreasing the incidence of injury or injection into nearby vasculature. We therefore performed a review to investigate the feasibility of performing cervical interventions under real-time ultrasound guidance.

Ultrasound-Guided Intervention in Thoracic Spine / 대한정형외과학회잡지

Even though thoracic spinal pain may be less common than low back and neck pain, the prevalence of thoracic pain in the general population is 13% to 15% in the literature and it can be as disabling as lumbar or cervical pain. Although thoracic interventions have been reported to be effective, it is rarely performed due to concerns of creating iatrogenic pneumothorax. Fluoroscopy-guided interventions are more accurate procedures than blind technique but still cannot prevent pneumothorax. In recent reports in the literature, use of ultrasound-guided interventions minimized the risk of pneumothorax and vascular puncture because ultrasound can visualize lung with pleura and also detect vascular structures by Doppler scan. Compared with fluoroscopy, ultrasound imaging has no known contraindications, produces no ionizing radiation, enables direct visualization of neurovascular and soft tissue structures, and provides real-time visualization of needle passage toward the intended target. We therefore conducted a review to investigate the feasibility of performing thoracic interventions under real-time ultrasound guidance.

Ultrasonography and Ultrasound-guided Interventions of the Shoulder

Nowadays shoulder ultrasound is commonly used in the assessment of shoulder diseases and is as accurate as magnetic resonance imaging in the detection of several pathologies. Operator dependence is the main disadvantage of shoulder ultrasound. After adhering to a strict examination protocol, good knowledge of normal anatomy and pathologic processes and an awareness of common pitfalls, it can be used as a focused examination providing rapid, real-time diagnosis, and treatment by ultrasound-guided interventions in desired clinical situations. Also shoulder ultrasound can help the surgeon decide whether treatment will be surgical or nonsurgical. If arthroscopy is planned, sonographic findings help to counsel patients regarding surgical and functional outcomes. If a nonsurgical approach is indicated, ultrasound can be used to follow patients. This review article presents the examination techniques, the normal sonographic appearances and the main pathologic conditions found in shoulder ultrasound. And also addresses a simplified approach to scanning and ultrasound-guided intervention. Knowledge of optimal techniques, normal anatomy, dynamic maneuvers, and pathologic conditions is essential for optimal performance and interpretation of images.

Demineralized Bone Matrix, as a Graft Enhancer of Auto-Local Bone in Posterior Lumbar Interbody Fusion

STUDY DESIGN: A case controlled study with prospective data collection. PURPOSE: To evaluate the early influence and the final consequence of demineralized bone matrix (DBM) on auto-local bone as a graft enhancer in posterior lumbar interbody fusion (PLIF). OVERVIEW OF LITERATURE: DBM is known as an osteoinductive material; however, it has not been clearly recognized to enhance auto-local bone with a small amount. METHODS: Patients who had a PLIF were allocated into two groups. Group I (70 cases) used auto-local bone chips and group II (44 cases) used DBM as an additive to auto-local bone, 1 mL per a segment. Group selection was alternated. Early assessment was performed by computed tomography at 6 months and final assessment was done by simple radiography after 24 months at least. The degree of bone formation was assessed by 4 grade scale. RESULTS: The subjects of both groups were homogenous and had similar Oswestry Disability Index at final assessment. The ratio of auto-local bone chips and DBM was 6:1. The degree of bone formation at 6 months after surgery was superior in group II. However, there was no significant difference between the two groups at the final assessment. CONCLUSIONS: DBM was not recognized to enhance auto-local bone with small amount.

Ossification of the Ligamentum Flavum

Ossification of the ligamentum flavum is a rare cause of thoracic myelopathy. It develops in East Asians more frequently than in people from other areas. The exact pathophysiology has not been elucidated yet; however, it largely depends on biomechanical alterations, especially changes in the tensile force. Because the spinal cord is compressed from the posterior side, the first and most common clinical manifestation is usually loss of functional gait and spastic paralysis, which develop as the spinal cord compression progresses. The choice of diagnostic imaging is T2 sagittal magnetic resonance imaging scanning. Whole spine scanning is mandatory to identify multiple areas of compression and any associated distal lumbar diseases. Fine computed tomography imaging is necessary to make a differential diagnosis and set up a precise surgical plan. Conservative treatment does not work in this disorder. Decompression surgery is the only option and prognosis after surgical treatment is better with this disorder than with other causes of thoracic myelopathy. The severity of preoperative symptoms and the time interval before surgical treatment are the most important prognostic factors.

Comparison of Lidocaine and Bupivacaine in Lumbar Medial Branch Block

STUDY DESIGN: This is a retrospective clinical study. OBJECTIVES: To compare the efficacy of lidocaine and bupivacaine for the ultrasound-guided lumbar medial branch block in chronic low back pain. SUMMARY OF LITERATURE REVIEW: There is no study for comparison of the efficacy between lidocaine and bupivacaine for the medial branch block. MATERIALS AND METHODS: From August 2011 to May 2013, 186 patients were assigned 0.5% lidocaine(n=136) or 0.25% bupivacaine(n=45) for the ultrasound-guided lumbar medial branch block. All procedures have been performed by the same operator, and 23G, 10 cm needle was placed and drug was injected under ultrasound guide. To target medial branches from lumbar spinal nerve, the groove at the root of transverse process and the base of superior articular process has been identified on transverse scan. Patients were evaluated by pre- and post-interventional(1 hour) Visual Analog Scale and analyzed statistically. RESULTS: Reduction of VAS score in bupivacaine group is significantly greater than that in lidocaine group and post-interventional VAS score in bupivacaine group is significantly lower than that in lidocaine group through analysis of covariance test with adjusted pre-interventional VAS score. In multivariate analysis, while age, sex and treatment level were not significant factors, pre-interventional VAS score and the kind of drug were significant factors. Severe pain before treatment and bupivacaine was indicator of better result. Bupivacaine group reduced pain score in the VAS 2.285 more than lidocaine group with adjustment with other factors. CONCLUSIONS: Bupivacaine is more effective than lidocaine in the reduction of pain after ultrasound-guided lumbar medial branch blocks in posterior facet joint syndrome.

Effect of Ultrasound-guided Lumbar Medial Branch Block in Chronic Low Back Pain / 대한정형외과연구학회지

PURPOSE: To examine the use of ultrasound as an alternative imaging technique to block lumbar medial branches in chronic low back pain. MATERIALS AND METHODS: From August 2011 to September 2012, 27 patients with lumbar facet joint syndrome diagnosed by strict inclusion criteria among chronic low back pain patients have undergone medial branch block. All procedures have been performed by the same operator, and 23G, 10cm needle was placed and 0.5% lidocine was injected under ultrasound guide. To target medial branches from L1 to L5, the groove at the root of transverse process and the base of superior articular process has been identified on transverse scan. Patients were followed up by Visual Analog Scale and Oswestry Disability Index at 1 week after medial branch block. RESULTS: VAS showed that preprocedure pain(7.0+/-1.4; mean+/-SD) significantly decreased after block(1.8+/-1.6)(p=0.0000). ODI also showed that preprocedure score(30.3+/-6.4) significantly decreased(9.0+/-7.7)(p=0.0000). Analysis of patient-reported pain and functional scores measured with VAS and ODI showed definite improvements after ultrasound-guided medial branch block. There was one complication of dizziness and weakness in both lower extremities immediate after procedure. CONCLUSION: Ultrasound guidance offers a reliable alternative to fluoroscopy or computed tomography for lumbar medial branch blocks and can be safely performed without radiation exposure.

Effect of Ultrasound-guided Lumbar Medial Branch Block in Chronic Low Back Pain / 대한정형외과연구학회지

PURPOSE: To examine the use of ultrasound as an alternative imaging technique to block lumbar medial branches in chronic low back pain. MATERIALS AND METHODS: From August 2011 to September 2012, 27 patients with lumbar facet joint syndrome diagnosed by strict inclusion criteria among chronic low back pain patients have undergone medial branch block. All procedures have been performed by the same operator, and 23G, 10cm needle was placed and 0.5% lidocine was injected under ultrasound guide. To target medial branches from L1 to L5, the groove at the root of transverse process and the base of superior articular process has been identified on transverse scan. Patients were followed up by Visual Analog Scale and Oswestry Disability Index at 1 week after medial branch block. RESULTS: VAS showed that preprocedure pain(7.0+/-1.4; mean+/-SD) significantly decreased after block(1.8+/-1.6)(p=0.0000). ODI also showed that preprocedure score(30.3+/-6.4) significantly decreased(9.0+/-7.7)(p=0.0000). Analysis of patient-reported pain and functional scores measured with VAS and ODI showed definite improvements after ultrasound-guided medial branch block. There was one complication of dizziness and weakness in both lower extremities immediate after procedure. CONCLUSION: Ultrasound guidance offers a reliable alternative to fluoroscopy or computed tomography for lumbar medial branch blocks and can be safely performed without radiation exposure.

Ossified Meningioma: A Case Report

STUDY DESIGN: A case report OBJECTIVES: To report an extremely rare case of the spinal meningioma containing bone. SUMMARY OF LITERATURE REVIEW: Spinal meningiomas represent 16.6-46.7% of the primary spinal tumors and 1 to 5% of them are calcified. Ossification is an extremely uncommon event that complicates the resection surgery. MATERIALS AND METHODS: We experienced a 59-year-old patient who complained of weakness in the lower limbs and gait disturbance. Spinal cord compressing mass was discovered on a MRI at T6 and there was a vertical plate at the posterior side of the mass. Surgical finding showed complete ossification in the dural attachment site of the mass. Though the tumor mass could be excised with the inner layer of the dura mater en masse, more forceful retraction of the spinal cord was unavoidable than the other soft mass resection. RESULTS: The preoperative neurological impairment improved after the surgery and she was able to walk well. CONCLUSIONS: Ossification makes a resection difficult and vulnerable to develop neurological deterioration. But if we could suspect such an ossification through an image test, it would be helpful to make a surgical plan to avert a neurologic complication.

Study on the Removal of Segmentally Broken Interlocking Screw in Intramedullary Nail / 대한정형외과연구학회지

In the literature, it is extremely difficult and takes long time to remove middle part of segmentally broken screws using ball-tip guide and extraction hook after femoral interlocking intramedullary nailing. Proximal part of broken locked screw can be removed with screwdriver easily, but it is very difficult to remove distal and especially middle part of broken screw which are usually angulated and should be removed to avoid interference with further procedure and complications. So we designed a technique for removal of segmentally broken distal locked screw which can be removed after withdrawal of nail proximally to realign screw segments and then actually applied this method to real case with short operative time and satisfactory outcome.

The Clinical Usefulness of a Skin Analysis Instrument (The Clarity(TM) Skin Advisor System) / 대한피부과학회지

BACKGROUND: Although a number of tools are currently available for objectively evaluating skin, there are not sufficient about the use of these instruments in the Korean dermatologic literature. OBJECTIVE: The purpose of this study is to investigate the clinical application of a skin analysis instrument (Claritytrade mark Skin Advisor system, BrighTex Bio-Photonics, USA) for the evaluation of pigmentation, erythema, enlarged pores and wrinkles on the face. METHODS: In this prospective clinical study, we enrolled 28 patients who visited our clinic during 3 months. Before and after the treatment, assessment of the facial skin was performed with the skin analysis instrument. The objective improvement evaluation was done by a trained observer. The subjective patient assessment and patient satisfaction were checked via a questionnaire. We analyzed the relationships between the five measuring items (spot count, the area affected, diffuse erythema, the enlarged pore count and the wrinkle count) and the subjective improvement, the patient satisfaction and the objective improvement. RESULTS: A total of 28 subjects (9 males and 19 females) with facial pigmentary disorder, erythema, enlarged pores and/or prominent wrinkles were recruited. There was a statistically significant relationship between the objective improvement and four (spot count, diffuse erythema, enlarged pore count, wrinkle count) of the five measurement items (p<0.05). But only diffuse erythema showed a statistically significant relationship with subjective improvement, and only the wrinkle count showed a statistically significant relationship with patient satisfaction (p<0.05). CONCLUSION: In this paper, we suggest the possible clinical usefulness of the skin analysis instrument for assessing the change of the skin state in patients with cosmetic complaints.

Acroosteolysis of Scleroderma Associated with a Felon / 대한정형외과학회잡지

The Scleroderma is a chronic inflammatory disease of the connective tissue with involvement of the skin and other organs. It can be a manifestation of various disorders and occasionally acroosteolysis in the phalanges. Acroosteolysis is characterized by bone resorption or destruction in the phalanges, while the base is preserved. The pathogenesis of acroosteolysis in patients with scleroderma is a blood-flow disorder that is mainly associated with an abnormal accumulation of collagen in all tissues, microangiopathy and infections in the phalanges. The phalanges in patients with scleroderma are prone to continuous infections as a felon or skin ulcers due to atrophy of the subcutaneous tissue, dry and sclerotic skin, or a disorder of the immune system. We experienced a patient who had acroosteolysis with scleroderma of the phalanges, and this was associated with a felon. We report on this case along with a brief review of the literature.

Large Pulmonary Embolus after Percutaneous Vertebroplasty: A Case Report / 대한척추외과학회지

Percutaneous vertebroplasty for osteoporotic compression fractures or malignant osteolytic spinal tumors provides pain relief. A pulmonary embolism caused by polymethylmethacrylate migration after this procedure is rare and its major complication, pulmonary infarction, involves necrosis of the lung parenchyme, resulting from interference with the blood supply. We report a case of a large pulmonary embolus (diameter 2 cm) after cement vertebroplasty for an osteoporotic vertebral compression fracture and successful management with anticoagulation only.

Gossypiboma Encountered 40 Years after Lumbar Partial Laminectomy: A Case Report / 대한척추외과학회지

Gossypiboma is a mass within body consisting of a cotton matrix surrounded by a foreign-body reaction. Some patients may remain asymptomatic, while others develop early persistent infected conditions. Gossypiboma should be included in a differential diagnosis of a paravertebral mass in postoperative patients, and a thorough and a careful inspection of the surgical field before closure must be performed by surgeons to avoid the complications of gossypiboma even when there are correct counts. We present a patient in whom a gossypiboma at the 4th lumbar spine was encountered 40 years after a partial laminectomy with no subjective symptoms.

Effect of Ball Joint Location in External Fixator on Wrist Motion in Distal Radius Fractures / 대한정형외과연구학회지

PURPOSE: The effects of ball joint location from axis of rotation on postoperative wrist motion in dynamic external fixator for displaced intra-articular fractures in distal radius were evaluated. MATERIALS AND METHODS: 33 patients who had dynamic external fixative surgery after closed reduction within acceptable range and could be followed at least 1 year were reviewed. They were divided into two groups according to distance (5 mm, 10 mm) of ball joint center from axis of wrist rotation which located in proximal cortex of capitate. These groups were compared by clinical results which were evaluated by range of motion of wrist (flexion, extension, radial deviation, ulnar deviation, pronation, supination) and pain evaluation system. They were also divided into two groups according to direction of ball joint migration (proximal, distal) and evaluated by the same methods. RESULTS: No difference in range of motion and pain was observed between distance 0 mm-5 mm group and >5 mm group (p>0.05). Distance 0 mm-10 mm group showed statistically significant more range of motion in extension, supination and pronation than >10mm group (P0.05). Also no difference in range of motion and pain was observed between proximal migration group and distal group (p>0.05). DISCUSSION AND CONCLUSION: In retrospective analysis of dynamic external fixator, range of wrist motion should be preserved by decrease of changes of ball joint location within 10mm from center of rotation.