Facet Joint Versus Transforaminal Epidural Steroid Injections in Patients With Cervical Radicular Pain due to Foraminal Stenosis: A Retrospective Comparative Study

Background@#A cervical transforaminal epidural (TFE) steroid injection is a useful treatment option for cervical radicular pain, but it carries a small risk of catastrophic complications.Several studies have reported that cervical facet joint (FJ) steroid injection can reduce cervical radicular pain through an indirect epidural spread. The aim of this retrospective comparative study was to evaluate the pain scores and functional disability in subjects receiving cervical FJ or TFE steroid injection for the treatment of cervical radicular pain due to foraminal stenosis (FS). @*Methods@#We selected 278 patients 18 years of age and older who underwent cervical FJ (n = 130) or TFE (n= 148) steroid injection for cervical radicular pain. The primary outcomes included pain scores and functional disability during hospital visits one, three, and six months after the initial injection. Secondary outcomes were the proportion of responders and Medication Quantification Scale (MQS) scores. Adverse events and variables correlating with effectiveness one month after the initial injection were also evaluated. @*Results@#The Numeric Rating Scale and Neck Disability Index scores showed a significant improvement one, three, and six months after the initial injection in both groups, with no significant differences between the groups. No significant differences were observed in the success rates of the procedure one, three, and six months after the initial injection for either group. There were no significant differences in MQS between the groups during the followup period. Univariate and multivariate logistic regression analyses revealed that the injection method, age, sex, number of injections, FS severity, MQS, pain duration, and the presence of cervical disc herniation were not independent predictors of treatment success. @*Conclusion@#The efficacy of FJ steroid injection may not be inferior to that of TFE steroid injection in patients with cervical radicular pain due to FS.

Effects of Local Anesthetics With or Without Steroids in High-Volume Transforaminal Epidural Blocks for Lumbar Disc Herniation: A Randomized, Double-Blind, Controlled Trial

Background@#Lumbar transforaminal epidural block (TFEB) is an effective treatment modality for radicular pain due to lumbar disc herniation (LDH). The addition of steroids is more effective than local anesthetic alone in TFEBs for patients with LDH. Moreover, the efficacy of TFEBs has been reported to be positively correlated with the volume of injectate. We hypothesized that high-volume TFEBs without steroids effectively alleviate axial back and radicular pain associated with LDH. This study compared the efficacy of high-volume TFEBs with vs. without steroids for the management of the axial and radicular pain caused by LDH. @*Methods@#A total of 54 patients were randomly assigned to either group L or group D.Patients in group L received 8-mL injections of 0.33% lidocaine only. Patients in group D received 8-mL injections of 0.33% lidocaine with 5 mg of dexamethasone. The primary outcomes were pain intensity at baseline and 4 weeks after the procedure. The secondary outcomes included the change of functional disability between baseline and 4 weeks after the procedure, pain scores during injection, and adverse effects. @*Results@#Both groups showed a significant reduction in axial and radicular pain and improvement in the functional status at the outpatient visit 4 weeks after TFEB. However, there were no significant differences between the groups in terms of changes in back pain (10.00 [20.00] vs. 10.00 [22.50]; P = 0.896) or radicular pain (5.00 [20.00] vs.10.00 [12.50]; P = 0.871). @*Conclusion@#High-volume TFEBs with and without steroid administration yielded similar significant pain reductions and functional improvements among LDH patients 4 weeks after the procedure.

More Effective Way to Perform Complete Percutaneous Vertebroplasty for Patients in Kummell’s Disease: A Case Report / 이화의대지

An 84-year-old woman visited our pain clinic with complaints of low back pain and severe radiating pain in the right lower extremity during walking. The patient demonstrated subacute compression fracture of L3 with vacuum change in lumbar spine plain radiographs and MRI which suggest Kummell’s disease. Despite our conservative treatments, she had little back pain relief. Therefore, we planned a percutaneous vertebroplasty. Manual compression could help perform percutaneous vertebroplasty more effectively by expanding the vertebral body. In addition, the spontaneous recovery of vacuum cleft width using negative pressure could help perform the technique more effectively. We successfully performed percutaneous vertebroplasty using these combination therapies for our patient.

Efficacy of erector spinae plane block with opioid-sparing analgesic technique in breast-conserving surgery

Purpose@#Breast-conserving surgery (BCS) is a surgical method designed to minimize intraoperative tissue injury. Although this technique is minimally invasive, it can cause significant postoperative pain and may be a risk factor for persistent pain.Erector spinae plane block (ESPB) is an easy interfascial plane block for analgesia in patients undergoing breast surgery. The primary outcome was the numeric rating scale scores measured separately on the breast and axilla. Secondary outcomes included correlation between pain score and skin sensitivity test. @*Methods@#Forty patients were divided into 2 groups (ESPB group and control group). Patients in the ESPB group received an ESPB 30 minutes before the induction of general anesthesia, whereas patients in the control group did not receive any regional analgesia during the perioperative period. @*Results@#Median pain scores of the breast were significantly lower in the ESPB group than that in the control group at 12, 24, and 48 hours after surgery. However, the median pain scores of the axilla were not significantly different between the groups, and the pain score was unrelated to skin sensitivity. @*Conclusion@#ESPB can effectively alleviate acute postoperative pain with an opioid-sparing analgesic technique in patients undergoing BCS, and a strong correlation is lacking between pain scores and skin sensitivity test.

More Effective Way to Perform Complete Percutaneous Vertebroplasty for Patients in Kummell’s Disease: A Case Report / 이화의대지

An 84-year-old woman visited our pain clinic with complaints of low back pain and severe radiating pain in the right lower extremity during walking. The patient demonstrated subacute compression fracture of L3 with vacuum change in lumbar spine plain radiographs and MRI which suggest Kummell’s disease. Despite our conservative treatments, she had little back pain relief. Therefore, we planned a percutaneous vertebroplasty. Manual compression could help perform percutaneous vertebroplasty more effectively by expanding the vertebral body. In addition, the spontaneous recovery of vacuum cleft width using negative pressure could help perform the technique more effectively. We successfully performed percutaneous vertebroplasty using these combination therapies for our patient.

Efficacy of erector spinae plane block with opioid-sparing analgesic technique in breast-conserving surgery

Purpose@#Breast-conserving surgery (BCS) is a surgical method designed to minimize intraoperative tissue injury. Although this technique is minimally invasive, it can cause significant postoperative pain and may be a risk factor for persistent pain.Erector spinae plane block (ESPB) is an easy interfascial plane block for analgesia in patients undergoing breast surgery. The primary outcome was the numeric rating scale scores measured separately on the breast and axilla. Secondary outcomes included correlation between pain score and skin sensitivity test. @*Methods@#Forty patients were divided into 2 groups (ESPB group and control group). Patients in the ESPB group received an ESPB 30 minutes before the induction of general anesthesia, whereas patients in the control group did not receive any regional analgesia during the perioperative period. @*Results@#Median pain scores of the breast were significantly lower in the ESPB group than that in the control group at 12, 24, and 48 hours after surgery. However, the median pain scores of the axilla were not significantly different between the groups, and the pain score was unrelated to skin sensitivity. @*Conclusion@#ESPB can effectively alleviate acute postoperative pain with an opioid-sparing analgesic technique in patients undergoing BCS, and a strong correlation is lacking between pain scores and skin sensitivity test.

The effect of needle tip position on the analgesic efficacy of pulsed radiofrequency treatment in patients with chronic lumbar radicular pain: a retrospective observational study

BACKGROUND: Pulsed radiofrequency (PRF) is a treatment modality that alleviates radicular pain by intermittently applying high-frequency currents adjacent to the dorsal root ganglion. There has been no comparative study on analgesic effect according to the position of the needle tip in PRF treatment. The objective of this study is to evaluate the clinical outcomes of PRF according to the needle tip position. METHODS: Patients were classified into 2 groups (group IP [group inside of pedicle] and group OP [group outside of pedicle]) based on needle tip position in the anteroposterior view of fluoroscopy. In the anteroposterior view, the needle tip was advanced medially further than the lateral aspect of the corresponding pedicle in group IP; however, in group OP, the needle tip was not advanced. The treatment outcomes and pain scores were evaluated at 4, 8, and 12 weeks after applying PRF. RESULTS: At 4, 8, and 12 weeks, there were no significant differences between the successful response rate and numerical rating scale score ratio. CONCLUSIONS: The analgesic efficacy of PRF treatment did not differ with the needle tip position.

Optic nerve sheath diameter changes during gynecologic surgery in the Trendelenburg position: comparison of propofol-based total intravenous anesthesia and sevoflurane anesthesia

BACKGROUND: Elevated intracranial pressure (ICP), a disadvantage of laparoscopic or robotic surgery, is caused by the steep angle of the Trendelenburg position and the CO₂ pneumoperitoneum. Recently, sonographically measured optic nerve sheath diameter (ONSD) was suggested as a simple and non-invasive method for detecting increased ICP. This study aimed to explore the changes in ONSD in relation to different anesthetic agents used in gynecologic surgery.METHODS: Fifty patients were randomly allocated to two groups, sevoflurane (group SEV, n = 25) and propofol-based total intravenous anesthesia (TIVA) group (group TIVA, n = 25). The ONSD was measured at five time points (T0–T4): T0 was measured 5 min after induction of anesthesia in the supine position; T1, T2, and T3 were measured at 5, 15, and 30 min after CO₂ pneumoperitoneum induction in the Trendelenburg position; and T4 was measured at 5 min after discontinuation of CO₂ pneumoperitoneum in the supine position. Respiratory and hemodynamic variables were also recorded.RESULTS: The intra-group changes in mean ONSD in the Trendelenburg position were significantly increased in both groups. However, inter-group changes in mean ONSD were not significantly different at T0, T1, T2, T3, and T4. Heart rates in group TIVA were significantly lower than those in group SEV at points T1–T4.CONCLUSIONS: There was no significant difference in the ONSD between the two groups until 30 min into the gynecologic surgery with CO₂ pneumoperitoneum in the Trendelenburg position. This study suggests that there is no difference in the ONSD between the two anesthetic methods.

The Effect of Stellate Ganglion Block on Breast Cancer-Related Infectious Lymphedema / 한국호스피스완화의료학회지

Breast cancer related lymphedema (BCRL) is one of the most intractable complications after surgery. Patients suffer from physical impairment, as well as psychological depression. Moreover, a recent study revealed that cellulitis significantly increased the risk of BCRL, and cellulitis has been suggested as a risk factor of BCRL development. We describe a patient treated with stellate ganglion blocks (SGBs) without steroid for relief of symptoms and reduction of the arm circumference of breast cancer-related infectious lymphedema in a month. We measured the arm circumference at four locations; 10 cm and 5 cm above and below the elbow crease, numeric rating scale (NRS) score, lymphedema and breast cancer questionnaire (LBCQ) score on every visit to the pain clinic. A serial decrease of the arm circumference and pain score were observed after second injection. In the middle of the process, cellulitis recurred, we performed successive SGBs to treat infectious lymphedema. The patient was satisfied with the relieved pain and swelling, especially with improved shoulder range of motion as it contributes to better quality of life. This case describes the effects of SGB for infectious BCRL patients. SGB could be an alternative or ancillary treatment for infectious BCRL patients.

Effect of short-term prewarming on body temperature in arthroscopic shoulder surgery

BACKGROUND: Hypothermia (< 36°C) is common during arthroscopic shoulder surgery. It is known that 30 to 60 minutes of prewarming can prevent perioperative hypothermia by decreasing body heat redistribution. However, the effect of short-term prewarming (less than 30 minutes) on body temperature in such surgery has not been reported yet. Therefore, the aim of this prospective study was to investigate the effect of short-term prewarming for less than 30 minutes using forced-air warming device on body temperature during interscalene brachial plexus block (ISBPB) procedure in arthroscopic shoulder surgery before general anesthesia. METHODS: We randomly assigned patients scheduled for arthroscopic shoulder surgery to receive either cotton blanket (not pre-warmed, group C, n = 26) or forced-air warming device (pre-warmed, group F, n = 26). Temperature was recorded every 15 minutes from entering the operating room until leaving post-anesthetic care unit (PACU). Shivering and thermal comfort scale were evaluated during their stay in the PACU. RESULTS: There were significant differences in body temperature between group C and group F from 30 minutes after induction of general anesthesia to 30 minutes after arrival in the PACU (P < 0.05). The median duration of prewarming in group F was 14 min (range: 9-23 min). There was no significant difference in thermal comfort scale or shivering between the two groups in PACU. CONCLUSIONS: Our results showed that short-term prewarming using a forced-air warming device during ISBPB in arthroscopic shoulder surgery had beneficial effect on perioperative hypothermia.

Effect of short-term prewarming on body temperature in arthroscopic shoulder surgery

BACKGROUND: Hypothermia (< 36°C) is common during arthroscopic shoulder surgery. It is known that 30 to 60 minutes of prewarming can prevent perioperative hypothermia by decreasing body heat redistribution. However, the effect of short-term prewarming (less than 30 minutes) on body temperature in such surgery has not been reported yet. Therefore, the aim of this prospective study was to investigate the effect of short-term prewarming for less than 30 minutes using forced-air warming device on body temperature during interscalene brachial plexus block (ISBPB) procedure in arthroscopic shoulder surgery before general anesthesia. METHODS: We randomly assigned patients scheduled for arthroscopic shoulder surgery to receive either cotton blanket (not pre-warmed, group C, n = 26) or forced-air warming device (pre-warmed, group F, n = 26). Temperature was recorded every 15 minutes from entering the operating room until leaving post-anesthetic care unit (PACU). Shivering and thermal comfort scale were evaluated during their stay in the PACU. RESULTS: There were significant differences in body temperature between group C and group F from 30 minutes after induction of general anesthesia to 30 minutes after arrival in the PACU (P < 0.05). The median duration of prewarming in group F was 14 min (range: 9-23 min). There was no significant difference in thermal comfort scale or shivering between the two groups in PACU. CONCLUSIONS: Our results showed that short-term prewarming using a forced-air warming device during ISBPB in arthroscopic shoulder surgery had beneficial effect on perioperative hypothermia.

A comparative study among normal saline, water soluble gel and 2% lidocaine gel as a SLIPA lubricant / 대한마취과학회지

BACKGROUND: This study was designed to find appropriate lubricant for streamed lined liner of pharyngeal airway(TM) (SLIPA(TM)). We evaluated the incidence of sore throat, nausea, vomiting, hoarseness, paresthesia and blood stain after using saline, water soluble gel and 2% lidocaine gel as a SLIPA(TM) lublicant. METHODS: One hundred twenty three patients scheduled for minor surgery to whom the SLIPA(TM) was considered suitable were randomly allocated to one of three groups which receive normal saline, water soluble gel or 2% lidocaine gel as a SLIPA(TM) lublicant. Patients were interviewed at recovery room, post operation 6-12 hour, post operation 18-24 hour about sore throat and other complications. RESULTS: There were no statistical difference in sore throat and blood stain among three groups. Also there were no statistical differences in hoarseness, nausea, vomiting. The incidence of paresthesia in 2% lidocaine gel group was significantly higher than those of the other two groups immediately after operation, but it was resolved after leaving the recovery room. CONCLUSIONS: Our results suggest that normal saline, water soluble gel and 2% lidocaine gel are all available as a SLIPA(TM) lubricant. Size of SLIPA(TM), insertion technique and difficulty of insertion should be further investigated as the main causes of a sore throat and other complications which can occur after the insertion of SLIPA(TM).

Ultrasound-Assisted Mental Nerve Block and Pulsed Radiofrequency Treatment for Intractable Postherpetic Neuralgia: Three Case Studies

Postherpetic neuralgia (PHN) is one of the most difficult pain syndromes to treat. Invasive treatments may be considered when patients fail to obtain adequate pain relief from noninvasive treatment approaches. Here, we present three cases of PHN in the mandibular branch treated with ultrasound-assisted mental nerve block and pulsed radiofrequency treatment. None of the patients had adequate pain relief from the medical therapy, so we performed the mental nerve block on the affected side under ultrasound assistance. Two patients showed satisfactory pain relief continuously over 12 months without any further interventions, whereas one patient only had short-term pain relief. For the patient had short-term pain relief we performed pulsed radiofrequency treatment (PRFT) on the left mental nerve under ultrasound assistance. After PRFT, the patient had adequate pain relief for 6 months and there was no need for further management.

Fluoroscope guided epidural needle insertioin in midthoracic region: clinical evaluation of Nagaro's method / 대한마취과학회지

BACKGROUND: In the midthoracic region, a fluroscope guided epidural block has been proposed by using a pedicle as a landmark to show the height of the interlaminar space (Nagaro's method). However, clinical implication of this method was not fully evaluated. We studied the clinical usefulness of a fluoroscope guided thoracic epidural block in the midthoracic region. METHODS: Twenty four patients were scheduled to receive an epidural block at the T6-7 intervertebral space. The patients were placed in the prone position. The needle entry point was located at the junction between midline of the pedicle paralleled to the midline of the T7 vertebral body (VB) and the lower border of T7 VB on anteroposterior view of the fluoroscope. The needle touched and walked up the lamina, and the interlaminar space (ILS) was sought near the midline of the VB at the height of the pedicle. RESULTS: The authors could not insert an epidural needle at T6-7 ILS in two patients and it was instead inserted at T5-6 ILS. However, other patients showed easy insertion at T6-7 ILS. The mean inward and upward angulations were 25degrees and 55degrees respectively. The mean actual depth and calculated depth from skin to thoracic epidural space were 5.1 cm and 6.1 cm respectively. Significant correlation between actual needle depth and body weight, podendal index (kg/m) or calculated needle depth was noted. CONCLUSIONS: The fluorposcope guided epidural block by Nagaro's method was useful in the midthoracic region. However, further study for the caudal shift of needle entry point may be needed.

Brazing characteristics of ZrO2 and Ti-6Al-4V brazed joints with increasing temperature / 대한치과보철학회지

PURPOSE: In this study, brazing characteristics of ZrO2 and Ti-6Al-4V brazed joints with increasing temperature were investigated. MATERIALS AND METHODS: The sample size of the ZrO2 was 3 mm x 3 mm x 3 mm (thickness), and Ti-6Al-4V was 10 mm (diameter) x 5 mm (thickness). The filler metal consisted of Ag-Cu-Sn-Ti was prepared in powder form. The brazing sample was heated in a vacuum furnace under 5 x 10(-6) torr atmosphere, while the brazing temperature was changed from 700 to 800degrees C for 30 min. RESULTS: The experimental results shows that brazed joint of ZrO2 and Ti-6Al-4V occurred at 700 - 800degrees C. Brazed joint consisted of Ag-rich matrix and Cu-rich phase. A Cu-Ti intermetallic compounds and a Ti-Sn-Cu-Ag alloy were produced along the Ti-6Al-4V bonded interface. Thickness of the reacted layer along the Ti-6Al-4V bonded interface was increased with brazing temperature. Defect ratios of ZrO2 and Ti-6Al-4V bonded interfaces decreased with brazing temperature. CONCLUSION: Thickness and defect ratio of brazed joints were decreased with increasing temperature. Zirconia was not wetting with filler metal, because the reaction between ZrO2 and Ti did not occur enough.

The Influence of Fixation Rigidity on Intervertebral Joints - An Experimental Comparison between a Rigid and a Flexible System

OBJECTIVE: Spinal instrumentation without fusion often fails due to biological failure of intervertebral joints (spontaneous fusion, degeneration, etc). The purpose of this study is to investigate the influence of fixation rigidity on viability of intervertebral joints. METHODS: Twenty pigs in growing period were subjected to posterior segmental fixation. Twelve were fixed with a rigid fixation system(RF) while eight were fixed with a flexible unconstrained implant(FF). At the time of the surgery, a scoliosis was created to monitor fixation adequacy. The pigs were subjected to periodic radiological examinations and 12pigs (six in RF, six in FF) were euthanized at 12-18months postoperatively for analysis. RESULTS: The initial scoliotic curve was reduced from 31+/-5degrees to 27+/-8degrees in RF group (p=0.37) and from 19+/-4degrees to 17+/-5degrees in FF group (p=0.21). Although severe disc degeneration and spontaneous fusion of facet joints were observed in RF group, disc heights of FF group were well maintained without major signs of degeneration. CONCLUSION: The viability of the intervertebral joints depends on motion spinal fixation. Systems allowing intervertebral micromotion may preserve the viability of intervertebral discs and the facet joint articular cartilages while maintaining a reasonably stable fixation.

Early Stress Fracture of the Pelvic Ring Following Proximal Extension of an Instrumented Lumbosacral Fusion to Treat Junctional Kyphosis

We report a case of early stress fracture of the pelvic ring following an extension of a multilevel instrumented lumbosacral fusion in an osteopenic female. Surgeons should be aware of possibilities of pelvic complications in osteopenic patients with lumbosacral arthrodesis and should take care when harvesting iliac bone graft.

Radiologic Measurement of Pelvic Sagittal Incidence and Lordosis in Young Korean Women / 대한정형외과학회잡지

PURPOSE: To determine the normative data for the pelvic morphology parameters in the young Korean female population. MATERIALS AND METHODS: Young Korean female patients in 20s and 30s who had visited the outpatient clinic for a first attack acute sprain underwent a telephone interview at a minimum of 1 year after their last hospital visit. Those who had recovered completely and had no back-related complaints were selected for the pelvic lordosis angle (PRS1)and pelvic angle of incidence (AOI)measurements (n=40 each age group). RESULTS: There was no age difference in both parameters. The PRS1 in the young female population was 38.7+/-8.3 degrees (range: 13.6-52.9 degrees and the AOI was 48.5 +/-9.4 degrees(range: 30.5-74.7 degrees, which shows a close correlation between the two parameters (correlation coefficient, r=-0.965). The linear regression equation obtained is as follow; Equation I: PRS1=79.909-0.850 x AOI, Equation II: AOI=90.902-1.096xPRS1 (linear regression analysis, p=0.000, R2 =0.931). CONCLUSION: The data obtained from the study may be used for future studies related to the sagittal spinopelvic balance.

The Effect of Segmental Pedicle Screw Instrumentation on Actively Growing Spine: A Long-term Experimental Study

OBJECTIVE: Pedicle screw is gaining popularity in pediatric deformities. However, biological response of actively growing spine to rigid pedicle screw fixation remains unclear. The objective of this study is to determine the biological response of growing spine to rigid segmental fixation. METHODS: Twelve mini pigs in actively growing period were subjected to posterior segmental screw -rod instrumentation spanning nine levels and creation of experimental scoliosis. There was no attempt of posterior arthrodesis. The pigs were subjected to periodic radiological examinations and were euthanized at 18 months for analysis. RESULTS: There was no significant fixation failure despite conspicuous growth of the animals. Initial scoliosis of 31+/-5degrees was reduced to 27+/-8degrees at 18 months, but there was no statistical significance (p=0.37). Though there was no change in length of the implant construct, the vertebrae within the instrumented section showed mean longitudinal growth of 6+/-3 mm (p=0.000). The growth occurred at expense of the disc spaces that progressively narrowed with time. On necropsy, the instrumented region was completely fused posteriorly with crossing of the osseous traberculae across the former facet joints. Intervertebral discs were severely atrophic in all the discs with occasional spontaneous fusion. CONCLUSION: Even in the actively growing spine, the force of growth does not overcome the fixation offered by segmental pedicle screws. Longitudinal growth occurs at the expense of the joint spaces and leads to spontaneous intervertebral fusion. Our results may explain the favorable outcomes in pedicle fixations in pediatric population, showing little implant failure or nonunion.

One Case of Primary Malignant Mixed M llerian tumor of the Pelvic Peritoneum / 대한산부인과학회잡지

Malignant mixed m llerian tumors (MMMTs) are highly aggressive biphasic neoplasm composed of carcinomatous and sarcomatous components. In the female genital tract, most cases arise from the endometrium, but cases also are encountered, although less frequently, in the ovaries, fallopian tubes, cervix, and vagina. Extragenital primary peritoneal MMMTs are rare and to our knowledge, 29 cases with primary peritoneal MMMTs have been reported in the literature. We experienced a case of extragenital primary peritoneal MMMT and report with a brief review of literature.