Background and Objectives: Although epidural steroid injections are used as an effective treatment, this technique is associated with rare but serious ischemic complications, especially when particulate steroids are used. However, recent studies have reported that even if non-particulate steroids are used, particulates are formed by the interaction with some local anesthetics (LA), causing ischemic complications. This observational study evaluated commonly used combinations of non-particulate steroids and LA with contrast media via microscopic analysis and analyzed the chemical properties of each mixture to identify the correlation of particulate formation. Materials and Methods: Commonly used clinical non-particulate and particulate steroids, contrast media, and LA agent combinations were evaluated macroscopically and microscopically. The pH values were also measured at both room temperature (26 °C) and body temperature (36 °C). Where particulates were observed, the particulate size was measured. Results: Macroscopically, the mixture of non-particulate steroid and ropivacaine had a slightly cloudy appearance at all concentrations, but there was no visible particulate. However, when observed under a microscope, the pH-dependent particulate formation was observed at all concentration combinations tested. (0.1% ropivacaine: from 19 μm to 70 μm, and 0.2% ropivacaine: from 37 μm to 108 μm at room temperature (26 °C)). When contrast media was mixed or the temperature was raised to body temperature (36 °C), the number and size of the particulates decreased or dissolved. Conclusions: The combination of ropivacaine and dexamethasone, a non-particulate steroid, mainly used in epidural injections, forms particulates. However, when mixed with contrast media, particulates are dissolved because of changes in pH and factors affecting particulate formation. In fluoroscopy-guided injections, the use of contrast media could resolve particulate formation.
Cervical facet joint (CFJ) syndrome is a common cause of neck pain. For its diagnosis and treatment, CFJ injection with arthrogram is generally performed. This study aimed to investigate the frequency of extra-CFJ flow on CFJ arthrograms during injections and its differences according to age, sex, and cervical vertebral level. We analyzed 760 CFJ arthrograms administrated to 208 patients diagnosed with CFJ syndrome. Arthrograms at each vertebral level were collected to evaluate the normal CFJ and extra-CFJ flow. The primary and secondary outcomes were frequency of extra-CFJ flow according to cervical vertebral level, age, and sex and according to pairwise cervical levels, respectively. Extra-CFJ flow at the cervical spine occurred during 179 injections, and the overall incidence was 3.3–36.2% at different cervical levels. The incidence of extra-CFJ flow at each cervical vertebral level according to age and sex was not significant. Extra-CFJ flow was the highest at C6 and C7, but there was no statistical significance. Extra-CFJ flow was higher at lower vertebral levels (C5–C7) than at upper levels (C3 and C4). Additional clinical studies and anatomical evaluations are needed to support its clinical value and enable the development of new injection techniques.
Background: This study aimed to identify exact anatomical landmarks and ideal injection volumes for safe adductor canal blocks (ACB).Methods: Fifty thighs from 25 embalmed adult Korean cadavers were used.The measurement baseline was the line connecting the anterior superior iliac spine (ASIS) to the midpoint of the patellar base.All target points were measured perpendicular to the baseline.The relevant cadaveric structures were observed using ultrasound (US) and confirmed in living individuals.US-guided dye injection was performed to determine the ideal volume.Results: The apex of the femoral triangle was 25.3 ± 2.2 cm distal to the ASIS on the baseline and 5.3 ± 1.0 cm perpendicular to that point.The midpoint of the superior border of the vasto-adductor membrane (VAM) was 27.4 ± 2.0 cm distal to the ASIS on the baseline and 5.0 ± 1.1 cm perpendicular to that point.The VAM had a trapezoidal shape and was connected as an aponeurosis between the medial edge of the vastus medialis muscle and lateral edge of the adductor magnus muscle.The nerve to the vastus medialis penetrated the muscle proximal to the superior border of the VAM in 70% of specimens.The VAM appeared on US as a hyperechoic area connecting the vastus medialis and adductor magnus muscles between the sartorius muscle and femoral artery.Conclusions: Confirming the crucial landmark, the VAM, is beneficial when performing ACB.It is advisable to insert the needle obliquely below the superior VAM border, and a 5 mL injection is considered sufficient.
Several complications are possible after a lumbar epidural block. However pneumocephalus are rare. In this case, we report a case of pneumocephalus. A 68-year-old male patient received lumbar epidural block with the loss of resistance technique using air, and after 35 minutes, apnea, unconsciousness, hypotension, and bradycardia occurred. Immediately, brain CT was done, and we found pneumocephalus. The patient complained of severe occipital headache and itchiness due to pneumocehalus. After conservative treatment, the patient recovered without neurologic complications, and on the seventh day of his hospitalization, he was discharged from the hospital.
Background/Objectives: Central venous access is an essential part of neonatal care. In addition, a thorough knowledge of the techniques for cannulation and placement of venous lines Methods/Statistical analysis: We describe percutaneous cannulation of the subclavian vein and case of breakage of guidewire during cannulation in a infants and describe the condition. Findings: It showed that the distal portion of the guidewire had been cut and left twisted under the clavicle. The tip of the guidewire was found in the tissue below the subclavian vein and surgically removed. Improvements/Applications: The standard approach, as well as potential difficulties and other considerations are described with literature review.
Lumbar facet joints have been implicated in chronic low back pain in up to 45% of patients with low back pain (LBP). Facet joint pain diagnosis and management are always challenging for pain physicians. Facet joint pain is not diagnosed by specific demographic features, pain characteristics, or physical findings, even though electrodiagnostic studies and imaging modalities are available. Although comparative local anesthetics or placebo saline injections can be used, diagnostic blocks are the only reliable diagnostic measures according to the current literature. Treatment of chronic LBP arising due to facet joint includes intraarticular injections, medial branch blocks, and radiofrequency neurotomy. However, the evidence of their clinical efficacy is continuously under scrutiny. Pain physicians must have a detailed understanding of the spinal anatomy in order to perform safe and effective interventional procedures. This review outlines the important aspects of spinal anatomy as they relate to interventional pain management related to facet joint injections. Additionally, we provide a comprehensive review of the procedure and clinical evidence. Keywords: Facet joint injection; Imaging-guided injections; Interventional spinal procedures; Low back pain; Zygapophyseal joint
Background: Trigeminal neuralgia (TN) is one of the most painful disorder in the orofacial region, and many patients have suffered from this disease.For the effective management of TN, fundamental epidemiologic data related to the target population group are essential.Thus, this study was performed to clarify the epidemiological characteristics of TN in the Korean population.This is the first national study to investigate the prevalence of TN in Korean patients.Methods: From 2014 to 2018, population-based medical data for 51,276,314 subscribers to the National Health Insurance Service of Korea were used for this study.Results: The incidence of TN was 100.21 per 100,000 person-years in the year of 2018 in Korea, and the male to female ratio was 1:2.14.The age group of 51-59 years had the highest prevalence of TN.Constant increases in medical cost, regional imbalance, and differences in prescription patterns by the medical specialties were showed in the management of TN. Conclusions:The results in this study will not only help to study the characteristics of TN, but also serve as an important basis for the effective management of TN in Korea.
Percutaneous radiofrequency thermocoagulation (RFTC) has been widely utilized in the management of trigeminal neuralgia. Despite using image guidance, accurate needle positioning into the target area still remains a critical element for achieving a successful outcome. This study was performed to precisely clarify the anatomical information required to ensure that the electrode tip is placed on the sensory component of the mandibular nerve (MN) at the foramen ovale (FO) level.The study used 50 hemi-half heads from 26 South Korean adult cadavers.The cross-sectioned anterior and posterior divisions of the MN at the FO level could be distinguished based on an irregular boundary and color difference. The anterior division was clearly brighter than the posterior one. The anterior division of the MN at the FO level was located at the whole anterior (38.0%), anteromedial (6.0%), anterior center (8.0%), and anterolateral (22.0%) parts. The posterior division was often located at the whole posterior or posterolateral parts of the MN at the FO level. The anterior divisions covered the whole MN except for the medial half of the posterolateral part in the overwrapped images of the cross-sectional areas of the MN at the FO level. The cross-sectional areas of the anterior divisions were similar in males and females, whereas those of the posterior divisions were significantly larger in males (P = 0.004).The obtained anatomical information is expected to help physicians reduce unwanted side effects after percutaneous RFTC within the FO for the MN.
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