Epidural steroid injection (ESI) is one of the most common procedures for patients presenting low back pain and radiculopathy. However, there is no clear consensus on what constitutes appropriate steroid use for ESIs. To investigate optimal steroid injection methods for ESIs, surveys were sent to all academic pain centers and selected private practices in Korea via e-mail.Among 173 pain centers which requested the public health insurance reimbursements for their ESIs and were enrolled in the Korean Pain Society, 122 completed questionnaires were returned, for a rate of 70.5%; also returned were surveys from 39 academic programs and 85 private practices with response rates of 83.0% and 65.9%, respectively.More than half (55%) of Korean pain physicians used dexamethasone for ESIs. The minimum interval of subsequent ESIs at the academic institutions (3.1 weeks) and the private practices (2.1 weeks) were statistically different (P = 0.01).Although there was a wide range of variation, there were no significant differences between the academic institutions and the private practices in terms of the types and single doses of steroids for ESIs, the annual dose of steroids, or the limitations of doses in the event of diabetes, with the exception of the minimum interval before the subsequent ESI.
Coccydynia is a debilitating pain disorder.However, its pathophysiology is not well understood.When approaching coccydynia, the exact underlying cause of pain must be identified to develop an appropriate treatment plan.The specific approach to coccydynia can vary depending on an individual's condition and the underlying cause.Thorough evaluation by a pain physician is essential to determine the most appropriate course of treatment.The purpose of this review is to examine the various causes contributing to coccygeal pain and specifically focus on the exact anatomical neurostructures, such as the anococcygeal nerve, perforating cutaneous nerve, and ganglion impar.We also reviewed the relevant clinical outcomes and suggested recommendations for each anatomical structure.
A 12-years-old boy (165 cm/72 kg) complained of severe posterior neck pain radiating to the right arm. The resting pain score was VAS 80 of 100 and on moving the neck the VAS was 90/100. X-ray and MRI showed C7-T1 intervertebral disc calcification (IDC) with right C8 nerve compression (Fig. 1). Conservative treatment such as, pain medication, physical therapy, and trigger point injection administered at another hospital, failed to relive his pain. Operation was recommended but parental consent was denied. The patient consulted our clinic for pain management. Laboratory finding were normal, and physical examination showed no neurological signs, with non specific electromyography. The severe pain was unresponsive to conservative treatment. We decided to perform cervical root block (CRB) instead of epidural block that was not suitable to the location, and caused fear in the pediatric patient.
Fig. 1
Radiological image of the cervical spine and ultrasound image of C8 nerve root block. Lateral X-ray image (A) and sagittal (B), and axial (C) MRI show C7-T1 intervertebral disc calcification (IDC). This IDC caused C8 nerve root compression. Four ventral ...
Dual-guided CRB was performed with the patient in the left lateral position, after pre-scanning with ultrasound. We surgically disinfected both cervical areas and protected the ultrasound probe and cable with a sterile ultrasound probe cover (SonoLab™ 18 × 120 cm, Lucky Medical, Seoul, Korea). Right sided 8th CRB was performed with a portable ultrasound instrument, and a 50 mm linear 15-6 MHz probe (SonoSite M-Turbo™, SonoSite Inc., Bothell, WA, USA). The 8th CRB was performed as follows: The 5th, 6th, 7th and 8th cervical roots were identified by scanning from the supraclavicular area to the 6th transverse process. The skin was infiltrated with 1 ml of lidocaine 1%. A nerve stimulating needle with 30o bevel (22-guage, 50 mm, Stimuplex® D, B.Braun, Melsungen, Germany) was inserted under dual-guidance. We used 2 Hz stimulation frequency and an impulse duration of 0.1 ms. The intensity of the stimulating current initially set to deliver 1.5 mA, was decreased to obtain the minimal stimulating current. The needle was repositioned until the minimal stimulating current was ≤ 0.3 mA (Fig. 1). Five ml ropivacaine 0.2% with 10 mg of triamcinolone acetate was injected surrounding the 8th nerve root after careful air bubble removal and an aspiration test.
The block was performed 4 times during 2 weeks. VAS was improved by 50% after the first block and the VAS was 20/100 after the 4th procedure. The patient was discharged after 2 weeks since there was no pain. Subsequently, pain relief was with aceclofenac 100 mg for 2 weeks. We did not administer further medication or nerve block. The patient had no pain and neurologic symptoms at the 2 month follow-up visit.
Pediatric IDC is a rare disorder without any clear etiologies and mechanisms. Calcification is mostly reported at the level of C6-7, but it may occur at any location [1]. IDC has a higher incidence in males, aged 7 to 8 years [1]. Various clinical symptoms have been reported. Neck pain and stiffness are most common. Low fever, limitation of motion, and muscle spasm are also commonly reported [1]. Neurologic symptoms appear due to compression of the nerve root and spinal cord from herniation, as a result of calcification. Signs of neurologic deficiency, including weakness, sensory loss, and myelopathy are rare [1]. However, 20% of patients exhibit neurologic symptoms due to epidural calcifications. In this case, the patient complained of severe pain, resulting from irritation of the cervical root by the irritants from the calcified cervical disc.
The etiology is unclear. Laboratory tests show mostly normal results or moderate inflammatory syndrome [1]. There were non-specific findings in the study case. Radiographs reveal oval or round shaped calcifications that are most often located in the middle of the disk, but sometimes occupy the entire disk. MRI shows regions of reduced signal intensity on both, the T1- and the T2-weighted images, reflecting low proton density of the herniated calcific nucleus pulposus and its relation with myelin and the nerve roots. Rapid confirmation with MRI is very critical when the patient has neurologic symptoms.
The symptom disappears within one month, in most cases. Calcification regresses over the course of months to years, but may linger longer without symptoms. IDC is normally a benign condition. Majority of cases are treated conservatively and have good outcomes [2]. Therefore, the treatment of choice is conservative and symptomatic. It includes analgesics, nonsteroidal antiinflammatory medication, muscle relaxants, cervical soft collar, and limited physical activity [1]. The use of corticosteroids therapy has not been discussed in literature to date. IDC is known to be self limited with favorable results on conservative treatment, as described above. Severe pain, uncontrolled by medication, with successful interventional treatment such as CRB, has not been previously reported. Surgery is required in patients who develop progressive neurological deficit [1,3]. A decompression of the spinal cord with an anterior cervical diskectomy and an anterior fusion is usually required. Few cases in literature comment on recurrent neurological symptoms after surgical treatment [1].
Surgical treatment is a good approach for the short term, but it has not been scientifically validated by long term observation of symptoms [3,4]. It is based on the unique anatomic features of the pediatric spine. Curvature forms at age 10, and the adult skeleton completes from then on [5]. Therefore, careful surgical consideration of the effect on the biomechanism in the postadult spine is necessary. The results from a study with long-term observation of 381 young patients with surgery, showed degenerative changes at the adjacent level, and affected curvature [5].
Conservative management is currently the main treatment modality. However, in situations of uncontrolled pain in patients with IDC, CRB with ultrasound guidance is recommended for good results.
Lumbar facet joints have been identified as a potential source of chronic low back pain (LBP) in 15% to 45% of patients, with the prevalence of such pain varying based on specific populations and settings examined. Lumbar facet joint interventions are useful in the diagnosis as well as the therapeutic management of chronic LBP. Radiofrequency ablation (RFA) of medial branch nerves is recognized as a safe and effective therapy for chronic facet joint pain in the lumbosacral spine, and its efficacy has already been established. The use of RFA is currently widespread in the management of spinal pain, but it is noteworthy that there have been works in the literature reporting complications, albeit at a very low frequency. We present a case of third-degree skin burns following radiofrequency ablation (RFA) for the management of facet joint syndrome. Postoperatively, the patient's skin encircling the needle displayed a pallor and exhibited deterioration in conjunction with the anatomical anomaly. The affected area required approximately 5 months to heal completely. During RFA, heat can induce burns not only at the point of contact with the RF electrode but also along the length of the needle. Vigilant attention is necessary to ensure patient safety and to address any potential complications that may arise during the procedure, including the possibility of minor technical errors.
Patients with burning mouth syndrome (BMS) report burning sensation and pain involving the tongue and oral mucosa without any apparent medical or dental cause. The pathogenesis of this syndrome remains unclear and there is currently no standard treatment. BMS is, therefore, often misdiagnosed and its management is complex. This lack of clinical expertise may result in decreased health-related quality of life and increased psychological distress among patients with BMS. The present case report involves a 77-year-old female patient with BMS refractory to conventional treatment with nerve block and medication, who was successfully treated with duloxetine. Duloxetine may become a new therapeutic option in the management of BMS.
The aims of this study were to investigate the current clinical practice of ultrasound (US)-guided stellate ganglion block (SGB) using a bi-national survey of Korea and Japan, and to clarify the anatomical relation of the cervical sympathetic trunk with the prevertebral fascia at the level of cervical vertebrae. The current clinical practice of US-guided SGB in Korea and Japan was investigated using an Internet survey, which received 206 (10.2%) replies from Korea and 97 (8.8%) replies from Japan. The survey questionnaire addressed the actual clinical practice for US-guided SGB, including where the tip of the injection needle is placed. Additionally, 16 half necks of 8 embalmed cadavers were used in an anatomical study. An in-plane needle approach technique and administering 5 ml of local anesthetic were preferred in both countries. However, the type of local anesthetic differed, being lidocaine in Korea and mepivacaine in Japan. The final position of the needle tip also clearly differed in an US image, being predominantly positioned above the prevertebral fascia in Korea (39.3%) and under the prevertebral fascia in Japan (59.8%). In all of the anatomic dissections, the cervical sympathetic trunk was over the prevertebral fascia at the level of the sixth vertebra and under the prevertebral fascia at the level of the seventh vertebra. These results are expected to improve the knowledge on the current clinical practice and to suggest future studies.
Hip disarticulation is a salvage procedure for several hip and pelvic pathologies including recalcitrant pressure sores and pelvic soft tissue and bone neoplasms. This 'How I do it' article provides a detailed technique for hip disarticulation utilizing an anteromedial thigh myocutaneous flap. Hip disarticulation is a salvage procedure for several hip and pelvic pathologies including recalcitrant pressure sores and pelvic soft tissue and bone neoplasms. The novel technique described here utilizes a large myocutaneous flap comprising of the anterior and medial (adductor) compartments of the thigh for stump coverage. It is technically straightforward and produces reliable and durable results. The traditional technique for hip disarticulations, as described by Boyd, utilizes a posteriorly-based soft tissue flap containing the gluteal muscles and buttock skin.1 Posterior tissues, however, are frequently scarred or unavailable due to previous surgery, infection or wounds. Even when usable, a traditional posteriorly-based flap generates a particularly long length-to-breadth flap ratio, increasing the risk of wound healing complications from the watershed vascular supply of the distal flap. The novel technique described herein utilizes anterior and medial thigh tissues which are nearly always virginal. Moreover, the flap contains cutaneous and muscle elements that are supplied in an axial fashion by the femoral vessels all the way to the flap's distal limit, greatly limiting wound complications. Axiality of the flap also preserves flap sensation (due to preservation of the femoral and obturator nerves), which is critical to long-term stump care. The patient is placed lateral with the affected side facing up. The lateral intermuscular septum of the thigh is marked from proximal to distal and then carried medially above the proximal border of the patella before a longitudinal medial incision corresponding to the posterior border of the gracilis muscle is drawn (Figs. 1 and 2). Incisions are carried through skin and crural fascia around the circumference of the flap. The lateral incision is then deepened anterior to the lateral intermuscular septum toward the femur before the quadriceps muscles are divided distally above the patella. This exposes a large segment of mid to distal femur, and subperiosteal dissection over a broad front from lateral to medial quickly exposes the superficial femoral vessels as they enter the adductor hiatus. The vessels are ligated and the adductor muscles are then divided from lateral to medial, creating a large anteriorly-based myocutaneous flap vascularised by the common and superficial femoral arteries. The femur is then filleted from distal to proximal with subperiosteal dissection as the profunda femoris and its divisions are carefully controlled. Large Homan retractors around the femur facilitate rapid distal to proximal dissection. Posteriorly, an oblique incision from the greater trochanter to 5 cm above the ischial tuberosity is deepened before the origin of the posterior compartment muscles and the gluteal muscles are encountered and divided. The sciatic nerve is divided on traction. The hip joint capsule is opened transversely at the head of the femur to enable complete disarticulation of the lower limb at the hip joint (Figs. 3 and 4). The acetabulum is reamed to remove hyaline cartilage. A myodesis is achieved between the distal anterior and medial thigh compartment muscles, and the origin of the posterior thigh muscles. Closure is then performed over suction drains in layers (Fig. 5). An incisional negative pressure wound dressing is applied. Postoperatively the patient is nursed predominantly on the contralateral side to offload the wound and flap. Yewon David Kim: Data curation; methodology; writing – original draft. Rowan Gillies: Conceptualization; formal analysis; methodology; writing – review and editing. Varun Harish: Conceptualization; methodology; writing – original draft; writing – review and editing.
The aim of this study was to clarify the topographical relationships between the dorsal scapular nerve (DSN) and the dorsal scapular artery (DSA) in the interscapular region to identify safe and convenient injection points related to DSN blockade.Thirty shoulders of embalmed Korean cadavers and 50 live subjects were used for dissection and ultrasound (US) analysis.The running patterns of the DSA and DSN in the interscapular region were classified into 3 types. Type I was defined as nerves that were medial to the artery and parallel without changing location (80.0% of specimens). In type II (13.3%), the nerve and artery traversed one another only one time over their entire length. In type III (6.7%), the nerve and artery traversed one another, resembling a twist. Above the level of the scapular spine, the nerve was always medial to the artery. Below the scapular spine, the number of arteries was obviously decreased. Most of the arteries were lateral to the medial border of the scapula, except at the level of the superior angle of the scapula artery (SA). The positional tendency of the DSN toward the medial or lateral sides from the medial border of the scapula was similar. In US imaging of live subjects, the DSA was most observed at the level of the SA (94.0%).Results of this study enhance the current knowledge regarding the pathway of the DSN and DSA and provide helpful information for selective diagnostic nerve blocks in the interscapular region.
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