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.

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.

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 / 대한통증학회지

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.

Tageted bipolar radiofrequency decompression with vertebroplasty for intractable radicular pain due to spinal metastasis: a case report / 대한마취과학회지

Metastatic spinal tumors are usually quite difficult to treat. In patients with metastatic spinal tumors, conventional radiotherapy fails to relieve pain in 20-30% of cases and open surgery often causes considerable trauma and complications, which delays treatment of the primary disease. Percutaneous vertebroplasty (PVP) is considered to be useful in achieving rapid pain control and preventing further vertebral collapse due to spinal metastasis. However, symptoms of intraspinal neural compression can be contraindications to PVP. To overcome this problem, we performed PVP following targeted bipolar radiofrequency decompression, and examined the effect of the combined treatment in relieving severe radicular pain related to spinal cord compression caused by malignant metastatic tumors.

A Modified Approach of Percutaneous Endoscopic Lumbar Discectomy (PELD) for Far Lateral Disc Herniation at L5-S1 with Foot Drop

Foraminal or extraforaminal Far Lateral Disc Herniations (FLDH) extending into or beyond the foraminal zone have been recognized as between 7-12% of all lumbosacral disc herniations. Conventional posterior laminectomy may not provide good access to a herniation that lies far lateral to the lateral margin of the pedicle. Use of the endoscopic technique through a percutaneous approach to treat such FLDH patients can decrease the surgical morbidity while achieving better outcomes. We made an effort to utilize the advantages of percutaneous endoscopic lumbar discectomy (PELD) and to determine the appropriate approach for FLDH at the level between the 5th Lumbar and first Sacral vertebrae(L5-S1). The authors present a case of an endoscopically resected lumbar extruded disc of the left extraforaminal zone with superior foraminal migration at the level of L5-S1, which had led to foot drop, while placing the endoscope in the anterior epidural space without facetectomy.

Effect of intraoperative infusion of ketamine on remifentanil-induced hyperalgesia / 대한마취과학회지

BACKGROUND: Opioid induced hyperalgesia (OIH) is related with high opioid dosage, a long duration of opioid administration, and abrupt discontinuation of infused opioids in anesthetic settings. Ketamine is known to attenuate OIH efficiently, but methods of administration and methods to quantify and assess a decrease in OIH vary. We demonstrated the existence of remifentanil-induced hyperalgesia and investigated the ability of ketamine to attenuate OIH. METHODS: Seventy-five patients undergoing laparoscopic gynecologic surgery under remifentanil-based anesthesia were assigned to one of the following groups: (1) group RL (remifentanil 0.05 microg/kg/min), (2) group RH (remifentanil 0.3 microg/kg/min), or (3) group KRH (remifentanil 0.3 microg/kg/min + ketamine 0.5 mg/kg bolus with 5 microg/kg/min infusion intraoperatively). Desflurane was administered for maintenance of anesthesia to target bispectral index scores (40-60) and hemodynamic parameters (heart rate and blood pressure < +/- 20% of baseline values). All parameters related to OIH and its attenuation induced by ketamine were investigated. RESULTS: There was no significant difference among the three groups related to demographic and anesthetic parameters except the end-tidal concentration of desflurane. Additional analgesic consumption, numerical rating scale scores at 6 and 24 h, and cumulative fentanyl dose were significantly higher in group RH than in the other two groups. The value difference of the Touch-Test sensory evaluation was significantly higher negative in group RH than in the other two groups. CONCLUSIONS: Remifentanil-induced hyperalgesia is significantly attenuated by intraoperative bolus and infusion of ketamine. Ketamine also decreased tactile sensitization, as measured by Touch-Test sensory evaluation.

The Effect of Stellate Ganglion Block on Intractable Lymphedema after Breast Cancer Surgery

Lymphedema of the upper limb after breast cancer surgery is a disease that carries a life-long risk and is difficult to cure once it occurs despite the various treatments which have been developed. Two patients were referred from general surgery department for intractable lymphedema. They were treated with stellate ganglion blocks (SGBs), and the circumferences of the mid-point of their each upper and lower arms were measured on every visit to the pain clinic. A decrease of the circumference in each patient was observed starting after the second injection. A series of blocks were established to maintain a prolonged effect. Both patients were satisfied with less swelling and pain. This case demonstrates the benefits of an SGB for intractable upper limb lymphedema.

One-stage multi-level vertebroplasty for a patient with a rapidly deteriorating condition due to multiple vertebral compression fractures: A case report

Vertebral compression fractures are the most prevalent complications of osteoporosis, with symptoms of low back pains. Basically, the vertebral compression fractures are regarded as a self-limiting disease, and thus, conservative treatment is enough for most cases, but nevertheless, they have the potential to cause significant rates of disability and morbidity. Percutaneous vertebroplasty is a widely used minimally invasive procedure, where the outcome is largely affected according to appropriate selections of patients and the time of the procedures. We hereby report a multi-level percutaneous vertebroplasty for a patient with multiple compression fractures which accompanies the Kummell's disease with rapidly deteriorating general condition despite his conservative treatments.

Successful Treatment of Severe Sympathetically Maintained Pain Following Anterior Spine Surgery

Sympathetic dysfunction is one of the possible complications of anterior spine surgery; however, it has been underestimated as a cause of complications. We report two successful experiences of treating severe dysesthetic pain occurring after anterior spine surgery, by performing a sympathetic block. The first patient experienced a burning and stabbing pain in the contralateral upper extremity of approach side used in anterior cervical discectomy and fusion, and underwent a stellate ganglion block with a significant relief of his pain. The second patient complained of a cold sensation and severe unexpected pain in the lower extremity of the contralateral side after anterior lumbar interbody fusion and was treated with lumbar sympathetic block. We aimed to describe sympathetically maintained pain as one of the important causes of early postoperative pain and the treatment option chosen for these cases in detail.

Vertebral level of Tuffier's line measured by ultrasonography in parturients in the lateral decubitus position / 대한마취과학회지

BACKGROUND: It is known that Tuffier's line intersects the spine at the L4 spinous process or at the L4-L5 intervertebral space. Full term parturient women undergo various physical changes. Therefore, determining the vertebral level with Tuffier's line based on palpation inevitably is not very accurate. The aim of this study was to use ultrasound to verify the difference between vertebral levels for the palpated Tuffier's line in parturient and non-parturient women in the lateral decubitus position. METHODS: We consecutively enrolled 40 parturient women at 37-41 weeks of gestation and 40 non-parturient women scheduled for regional anesthesia. In the left lateral position, the location of the vertebra was identified using ultrasonography. We marked every intervertebral space from L5 to L2 vertebra, divided each spinous process into two equal parts, and numbered the spaces sequentially from 1 to 9. We drew a Tuffier's line by palpating, recorded the vertebral level that this line intersected. RESULTS: The mean value of an arbitrary number of vertebral level of Tuffier's line was 6.4 +/- 0.9 in the non-pregnant group and this represents L4-lower vertebral level. In the pregnant group, the mean value was 3.0 +/- 1.0 which represents L3-lower vertebral level. There was a significant difference between the two groups (P < 0.05). CONCLUSIONS: We compared using an available ultrasound technique the vertebral levels intersected by the palpated Tuffier's line between parturient and non-parturient women and found that the vertebral levels were more cephalad in the parturient women compared to the non-parturient women.

The Effects of a Forceful Transforaminal Epidural Steroid Injection on Radicular Pain: A Preliminary Study / 대한통증학회지

BACKGROUND: Lumbar transforaminal epidural steroid injections (TFESIs) are performed to provide symptom relief in patients with radicular pain. Recent articles suggested that injected volume itself have analgesic effects and higher volumes are associated with better outcomes. To date, few studies have been conducted to investigate the effects of volume. Therefore, well-designed controlled studies were necessary to confirm the effect of volume itself on pain relief. The purpose of this study was to examine the effectiveness of a forceful saline injection on lumbar TFESI using non-particulate steroids. METHODS: Fifty consecutive patients with lumbar radicular pain were enrolled. The participants were allocated into one of two groups: dexamethasone with volume (Group DV) and dexamethasone alone (Group DO). The volume was delivered by a forceful injection of 5ml of normal saline. The primary end-point for this study was a VAS pain score and modified MacNab score indicating the rate of effectiveness at the four-week follow-up. RESULTS: There were no significant post-procedural VAS differences between two groups (P = .252). The effectiveness rate among the patients was 47.8% in DV group, 34.8% in DO group, measured by modified MacNab score. The difference was not statistically significant (P = .117). CONCLUSIONS: A forceful saline injection did not have a significant effect during the treatment of radicular pain. Further studies with greater volumes and with additional techniques would offer a more conclusive perspective.

The Effects of a Forceful Transforaminal Epidural Steroid Injection on Radicular Pain: A Preliminary Study

BACKGROUND: Lumbar transforaminal epidural steroid injections (TFESIs) are performed to provide symptom relief in patients with radicular pain. Recent articles suggested that injected volume itself have analgesic effects and higher volumes are associated with better outcomes. To date, few studies have been conducted to investigate the effects of volume. Therefore, well-designed controlled studies were necessary to confirm the effect of volume itself on pain relief. The purpose of this study was to examine the effectiveness of a forceful saline injection on lumbar TFESI using non-particulate steroids. METHODS: Fifty consecutive patients with lumbar radicular pain were enrolled. The participants were allocated into one of two groups: dexamethasone with volume (Group DV) and dexamethasone alone (Group DO). The volume was delivered by a forceful injection of 5ml of normal saline. The primary end-point for this study was a VAS pain score and modified MacNab score indicating the rate of effectiveness at the four-week follow-up. RESULTS: There were no significant post-procedural VAS differences between two groups (P = .252). The effectiveness rate among the patients was 47.8% in DV group, 34.8% in DO group, measured by modified MacNab score. The difference was not statistically significant (P = .117). CONCLUSIONS: A forceful saline injection did not have a significant effect during the treatment of radicular pain. Further studies with greater volumes and with additional techniques would offer a more conclusive perspective.

The effect of head rotation on efficiency of ventilation and cuff pressure using the PLMA in pediatric patients / 대한마취과학회지

BACKGROUND: This study examined whether changing the head position from neutral to side can affect expiratory tidal volume (TV) and cuff pressure when the appropriate sizes of a Proseal(TM) Laryngeal Mask Airway (PLMA)-depending on the body weight -are used in pediatric patients during pressure controlled ventilation (PCV). METHODS: Seventy-seven children (5-30 kg) were divided into three groups according to their body weight, PLMA#1.5 (group I, n = 24), #2 (group II, n = 26), and #2.5 (group III, n = 27). After anesthesia induction, a PLMA was placed with a cuff-pressure of 60 cmH2O. The TV and existence of leakage at the peak inspiratory pressure (PIP) of 20 cmH2O, and the appropriate PIP for TV 10 ml/kg were examined. Upon head rotation to the left side, the TV, PIP, cuff pressure changes, and the appropriate PIP to achieve a TV 10 ml/kg were evaluated. RESULTS: Head rotation of 45 degrees to the left side during PCV caused a significant increase in cuff pressure and a decrease in TV, and there was no definite leakage. Changes in PIP and TV were similar in the three groups. The cuff pressure increased but there was no significant difference between the three groups. CONCLUSIONS: Although cuff pressure and TV of the PLMA were changed significantly after turning the head from the neutral position to the side, a re-adjustment of the cuff pressure and PIP to maintain a TV of 10 ml/kg can make the placed PLMA useful and successful in pediatric patients under general anesthesia.

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.

Plasma Concentrations of Morphine during Postoperative Pain Control

BACKGROUND: Morphine has been commonly used for postoperative pain control. We measured plasma concentrations of morphine and compared the efficacy and safety of continuous epidural analgesia (CEA) using morphine-bupivacaine with intravenous patient controlled analgesia (IV-PCA) with morphine for 48 hrs after the end of the operation. METHODS: Nineteen patients undergoing Mile's operation were assigned to receive a morphine loading dose of 5 mg followed by IV-PCA with 0.1% morphine (IV-PCA group, n = 9) or a morphine loading dose of 2 mg and 0.125% bupivacaine 10 ml, followed by CEA with 0.004% morphine and 0.075% bupivacaine at a rate of 5 ml/hr (CEA group, n = 10). The plasma concentrations of morphine were measured and visual analog scales (VAS) for pain were recorded at 1, 6, 12, 24, and 48 hr postoperatively and the effects on respiration and any other side effects were noted. RESULTS: The mean maximal and minimal levels of plasma morphine were 40.2 +/- 21.2 ng/ml and 23.4 +/- 9.7 ng/ml for the IV-PCA group and 11.8 +/- 3.5 ng/ml and 8.2 +/- 1.9 ng/ml for the CEA group, respectively. Resting and dynamic pain scores were significantly lower in the CEA group than in the IV-PCA group. There were no significant differences for the effects on respiration and for any side effects between the two groups. CONCLUSIONS: We evaluated plasma concentrations of morphine with CEA using morphine-bupivacaine and IV-PCA using morphine for the postoperative pain control. The CEA group had better postoperative analgesia than that of the IV-PCA group and the incidence of side effects were not significantly different between the two groups.

Pharmacodynamic Changes of Rocuronium during Induced Liver Cirrhosis Using Carbon Tetrachloride Intoxication in Rabbits / 대한마취과학회지

BACKGROUND: A reproducible animal model of liver cirrhosis by carbon tetrachloride (CCl4) is highly desirable for metabolic and therapeutic studies. The current study was undertaken to evaluate the neuromuscular blockade of rocuronium in CCl4 induced liver cirrhosis in rabbits. METHODS: Cirrhosis was induced by CCl4 treatment for 11 weeks. Rabbits were randomly assigned to two groups; control group: corn oil 0.5 ml/kg/2 days IM; study group: CCl4 0.5 ml/kg/2 days mixed 1 : 1 with corn oil IM. In the first study, the dose-response relations of rocuronium were studied in twenty rabbits. In the second study, time course of rocuronium 0.6 mg/kg in twenty rabbits was evaluated in each groups. Three fragments of each liver lobe at the end of the experimental period were collected and performed the histological examination. RESULTS: Eleven-week CCl4 treatment resulted in liver cirrhosis, and increased AST and ALT compared with controls. In the first study, the calculated ED95 was 86.7 +/- 8.7microgram/kg and 132.4 +/- 9.1microgram/kg, respectively, in control and study group (P<0.0001). In the second study, the recovery times after rocuronium 0.6 mg/kg in study group were significantly prolonged than those in control group (P<0.05). CONCLUSIONS: The model described in the present study was successful in producing liver cirrhosis used by CCl4 for 11 weeks in rabbits. Rocuronium has a decreased potency, and a prolonged duration of action in CCl4 induced liver cirrhosis in rabbits.

Epidural Catheter Migration Associated with Patient Movement / 대한마취과학회지

BACKGROUND: A properly placed epidural catheter tip may become displaced out of the epidural space after being secured as a result of patient movement, a common cause of inadequate analgesia. This study was performed to evaluate the migration of an epidural catheter with patient movement. METHODS: Forty-six parturients planning to undergo a cesarean section under epidural anesthesia were enrolled. Patients were divided into two groups according to body mass index (BMI): 26 kg/m2. A 19-gauge single-orifice epidural catheter (Flextip Plus(TM), Arrow, USA) was inserted at the L(2-3) or L(3-4) interspace with the patient in the sitting flexed position. The distance to the epidural space and length of catheter position change was measured before the catheter was secured to the skin, as the patient moved from the sitting flexed to sitting upright and then to the lateral decubitus position with flexion and extension. RESULTS: Catheters were drawn inward with position change from the sitting flexed to lateral decubitus position, the magnitude increasing with BMI (0.73 +/- 0.40 cm vs. 0.98 +/- 0.35 cm). CONCLUSIONS: This study shows that the indrawing of the catheter with reference to the skin occurs as a patient changes position, and this indrawing can result in catheter dislodgement out of the epidural space.

Amitriptyline, Desipramine, and Paroxetine Inhibit Nitric Oxide Production in Primary Schwann Cell Cultures of Rats / 대한마취과학회지

BACKGROUND: Antidepressants are being used as supplemental therapy in neuropathic and inflammatory pain. The mechanism of their inhibitory effect on experimental animal inflammation is not clear. Studies during the past few years clearly indicate an important role for nitric oxide (NO) in the inflammation and pain-processing system. We evaluated the effects of amitriptyline, desipramine and paroxetine on NO production in primary Schwann cell cultures. METHODS: Primary cultures of the Schwann cell were prepared from dorsal root ganglia of 1- to 3-day old Spraque-Dawley rats. Schwann cells were cultured in the presence or absence of interferon-gamma (500 ng/ml) plus tumor necrosis factor-alpha (500 ng/ml), amitriptyline, desipramine or paroxetine. Production of NO was determined in the supernatant of the culture media. RESULTS: Amitriptyline (10ng/ml), desipramine (10ng/ml) and paroxetine (10ng/ml) inhibited NO release by 29.8%, 51.4%, and 66.8%, respectively. No drug had a toxic effect on cultured cells, which was determined by an LDH assay. CONCLUSIONS: Inhibition of NO production by Schwann cells may be a mechanism by which some antidepressant medications affect inflammatory and neuropathic pain.