Jae Hun Kim

Radiation Safety and Education in the Applicants of the Final Test for the Expert of Pain Medicine

Background The C-arm fluoroscope is known as the most important equipment in pain interventions. This study was conducted to investigate the completion rate of education on radiation safety, the knowledge of radiation exposure, the use of radiation protection, and so on. Methods Unsigned questionnaires were collected from the 27 pain physicians who applied for the final test to become an expert in pain medicine in 2011. The survey was composed of 12 questions about the position of the hospital, the kind of hospital, the use of C-arm fluoroscopy, radiation safety education, knowledge of annual permissible radiation dose, use of radiation protection, and efforts to reduce radiation exposure. Results In this study, although most respondents (93%) had used C-arm fluoroscopy, only 33% of the physicians completed radiation safety education. Even though nine (33%) had received education on radiation safety, none of the physicians knew the annual permissible radiation dose. In comparing the radiation safety education group and the no-education group, the rate of wearing radiation-protective glasses or goggles and the use of radiation badges or dosimeters were significantly higher in the education group. However, in the use of other protective equipment, knowledge of radiation safety, and efforts to reduce radiation exposure, there were no statistical differences between the two groups. Conclusions The respondents knew very little about radiation safety and had low interest in their radiation exposure. To make the use of fluoroscopy safer, additional education, as well as attention to and knowledge of practices of radiation safety are required for pain physicians.

Radiation Exposure of the Hand and Chest during C-arm Fluoroscopy-Guided Procedures

Background The C-arm fluoroscope is an essential tool for the intervention of pain. The aim of this study was to investigate the radiation exposure experienced by the hand and chest of pain physicians during C-arm fluoroscopy-guided procedures. Methods This is a prospective study about radiation exposure to physicians during transforaminal epidural steroid injection (TFESI) and medial branch block (MBB). Four pain physicians were involved in this study. Data about effective dose (ED) at each physicians right hand and left side of the chest, exposure time, radiation absorbed dose (RAD), and the distance from the center of the X-ray field to the physician during X-ray scanning were collected. Results Three hundred and fifteen cases were included for this study. Demographic data showed no significant differences among the physicians in the TFESIs and MBBs. In the TFESI group, there was a significant difference between the ED at the hand and chest in all the physicians. In physician A, B and C, the ED at the chest was more than the ED at the hand. The distance from the center of the X-ray field to physician A was more than that of the other physicians, and for the exposure time, the ED and RAD in physician A was less than that of the other physicians. In the MBB group, there was no difference in the ED at the hand and chest, except for physician D. The distance from the center of the X-ray field to physician A was more than that of the other physicians and the exposure time in physician A was less than that of the other physicians. Conclusions In conclusion, the distance from the radiation source, position of the hand, experience and technique can correlate with the radiation dose.

A Randomized Controlled Trial about the Levels of Radiation Exposure Depends on the Use of Collimation C-arm Fluoroscopic-guided Medial Branch Block

Background C-arm fluoroscope has been widely used to promote more effective pain management; however, unwanted radiation exposure for operators is inevitable. We prospectively investigated the differences in radiation exposure related to collimation in Medial Branch Block (MBB). Methods This study was a randomized controlled trial of 62 MBBs at L3, 4 and 5. After the patient was laid in the prone position on the operating table, MBB was conducted and only AP projections of the fluoroscope were used. Based on a concealed random number table, MBB was performed with (collimation group) and without (control group) collimation. The data on the patients age, height, gender, laterality (right/left), radiation absorbed dose (RAD), exposure time, distance from the center of the field to the operator, and effective dose (ED) at the side of the table and at the operators chest were collected. The brightness of the fluoroscopic image was evaluated with histogram in Photoshop. Results There were no significant differences in age, height, weight, male to female ratio, laterality, time, distance and brightness of fluoroscopic image. The area of the fluoroscopic image with collimation was 67% of the conventional image. The RAD (29.9 ± 13.0, P = 0.001) and the ED at the left chest of the operators (0.53 ± 0.71, P = 0.042) and beside the table (5.69 ± 4.6, P = 0.025) in collimation group were lower than that of the control group (44.6 ± 19.0, 0.97 ± 0.92, and 9.53 ± 8.16), resepectively. Conclusions Collimation reduced radiation exposure and maintained the image quality. Therefore, the proper use of collimation will be beneficial to both patients and operators.

Relationship between Complex Regional Pain Syndrome and Working Life: A Korean Study

Complex regional pain syndrome affects the quality of life of the patient. The aim of this study was to investigate the epidemiological features of this syndrome and evaluate its effect on the patients working life. We demonstrated that the disease has a male preponderance and is 3 times more likely to affect the lower extremities. In this study, 11 participants (20%) retained their employment, whereas 44 (80%) became unemployed. Mean age and pain score were lower in the employment group than in the unemployment group (29.1 ± 16.8 yr vs 40.1 ± 12.6 yr, P = 0.021, and 4.5 ± 2.9 vs 7.0 ± 2.0, P = 0.002, respectively). Subjects diagnosed within 8 months (P = 0.044), those who had achieved higher levels of education (P = 0.028), and those working in white-collar jobs (P = 0.011) had higher employment-retention rates. Therefore, patients must manage their jobs (lower physical demand and decrease the number of working hours) if they are to improve their occupational life. To achieve satisfactory outcomes and a high employment-retention rate, clinicians must be aware of the importance of an early diagnosis (within 8 months), appropriate treatment, and a reduction in the patients pain score.

The Survey about the Degree of Damage of Radiation-Protective Shields in Operation Room

Background Medical doctors who perform C-arm fluoroscopy-guided procedures are exposed to X-ray radiation. Therefore, radiation-protective shields are recommended to protect these doctors from radiation. For the past several years, these protective shields have sometimes been used without regular inspection. The aim of this study was to investigate the degree of damage to radiation-protective shields in the operating room. Methods This study investigated 98 radiation-protective shields in the operation rooms of Konkuk University Medical Center and Jeju National University Hospital. We examined whether these shields were damaged or not with the unaided eye and by fluoroscopy. Results There were seventy-one aprons and twenty-seven thyroid protectors in the two university hospitals. Fourteen aprons (19.7%) were damaged, whereas no thyroid protectors (0%) were. Of the twenty-six aprons, which have been used since 2005, eleven (42.3%) were damaged. Of the ten aprons, which have been used since 2008, none (0%) was damaged. Of the twenty-three aprons that have been used since 2009, two (8.7%) of them were damaged. Of the eight aprons used since 2010, one (12.3%) was damaged. Of the four aprons used since 2011, none (0%) of them were damaged. The most common site of damage to the radiation-protective shields was at the waist of the aprons (51%). Conclusions As a result, aprons that have been used for a long period of time can have a higher risk of damage. Radiation-protective shields should be inspected regularly and exchanged for new products for the safety of medical workers.

Paraplegia Following Intercostal Nerve Neurolysis with Alcohol and Thoracic Epidural Injection in Lung Cancer Patient

The goal of cancer treatment is generally pain reduction and function recovery. However, drug therapy does not treat pain adequately in approximately 43% of patients, and the latter may have to undergo a nerve block or neurolysis. In the case reported here, a 42-year-old female patient with lung cancer (adenocarcinoma) developed paraplegia after receiving T8-10 and 11th intercostal nerve neurolysis and T9-10 interlaminar epidural steroid injections. An MRI results revealed extensive swelling of the spinal cord between the T4 spinal cord and conus medullaris, and T5, 7-11, and L1 bone metastasis. Although steroid therapy was administered, the paraplegia did not improve.

How Effective Are Radiation Reducing Gloves in C-arm Fluoroscopy-guided Pain Interventions?

Background The physicians hands are close to the X-ray field in C-arm fluoroscopy-guided pain interventions. We prospectively investigated the radiation attenuation of Proguard RR-2 gloves. Methods In 100 cases, the effective doses (EDs) of two dosimeters without a radiation-reducing glove were collected. EDs from the two dosimeters-one dosimeter wrapped with a glove and the other dosimeter without a glove- were also measured at the side of the table (Group 1, 140 cases) and at a location 20 cm away from the side of the table (Group 2, 120 cases). Mean differences such as age, height, weight, radiation absorbed dose (RAD), exposure time, ED, and ratio of EDs were analyzed. Results In the EDs of two dosimeters without gloves, there were no significant differences (39.0 ± 36.3 µSv vs. 38.8 ± 36.4 µSv) (P = 0.578). The RAD (192.0 ± 182.0 radcm2) in Group 2 was higher than that (132.3 ± 103.5 radcm2) in Group 1 (P = 0.002). The ED (33.3 ± 30.9 µSv) of the dosimeter without a glove in Group 1 was higher than that (12.3 ± 8.8 µSv) in Group 2 (P < 0.001). The ED (24.4 ± 22.4 µSv) of the dosimeter wrapped with a glove in Group 1 was higher than that (9.2 ± 6.8 µSv) in Group 2 (P < 0.001). No significant differences were noted in the ratio of EDs (73.5 ± 6.7% vs. 74.2 ± 9.3%, P = 0.469) between Group 1 and Group 2. Conclusions Proguard RR-2 gloves have a radiation attenuation effect of 25.8-26.5%. The radiation attenuation is not significantly different by intensity of scatter radiation or the different RADs of C-arm fluoroscopy.

Epidural Steroid Injection in Korean Pain Physicians: A National Survey

Background 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. Methods 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. Results 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). Conclusions 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.

An intrathecally located broken catheter used for an intrathecal drug delivery system.

The intrathecal drug delivery system (ITDDS), an effective treatment tool for intractable spasticity and pain, is associated with various complications but breakage of the catheter is rare. We report the case of a 50-yr-old man with ITDDS, in whom an intrathecal catheter was severed, resulting in a 28.6-cm-long intrathecal fragment. The catheter completely retracted into the intrathecal space from the anchor site. The catheter was severed during spine flexion, and the total distal fragment was repositioned in the intrathecal space. Although the outcome of ITDDS was associated with the length or diameter of the broken catheter, no neurologic complications occurred in our patient. Thus, we inserted another catheter instead of removing the old one. Thereafter, the patient has been regularly followed up, and no neurologic complications have developed during the 28 months.

Effects of Low and High Molecular Weight Hyaluronic Acids on Peridural Fibrosis and Inflammation in Lumbar Laminectomized Rats

Background Postlaminectomy peridural fibrosis is inevitable. Some studies have compared and identified the effects of high molecular weight hyaluronic acids (HMWHA) and low molecular weight hyaluronic acids (LMWHA) on peridural fibrosis in postlaminectomy animal models. However, no studies have been found that compare pain behaviors between hyaluronic acids or among hyaluronic acids and other solid materials. The purpose of this study was to examine the correlation between pain-related behaviors and histopathologic changes in laminectomized rats using various peridurally administered materials. Methods Forty male Sprague-Dawley rats, laminectomized at the L5 and L6 levels, were divided into four groups: group C, laminectomy only; group L, laminectomy and LMWHA application; group H, laminectomy and HMWHA application; group F, laminectomy and fat interposition. Pain behaviors were checked before, 3 days, 1 week, and 3 weeks after surgery. Histopathological changes were checked at the L5 level 3 weeks after the surgery. Results The 50% withdrawal thresholds in groups L and H were higher than that in groups C and F three days after laminectomy (P < 0.05). The paw withdrawal time did not change among the groups and in each group during the study period. Peridural fibrosis in group F was significantly lower than in the other groups (P < 0.05). Conclusions Hyaluronic acids significantly reduced mechanical allodynia but not thermal hyperalgesia. Peridural fibrosis did not show any correlation with pain behaviors. There have been limited studies on the correlation between peridural fibrosis and pain behavioral change, which should be verified by further studies.