Ji Hee Hong

Epidural Blood Patches in a Patient With Multi-level Cerebrospinal Fluid Leakage That Was Induced by Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is considered to be a very rare disorder. It is characterized by an orthostatic headache that is aggravated with the patient in the upright position and it is relieved by the patient assuming the supine position. SIH is caused by a spontaneous spinal cerebrospinal fluid leakage without the patient having undergone trauma, surgery or dural puncture or having any other significant medical history. An autologous epidural blood patch (EBP) is effective in relieving SIH. We report here on a case of SIH with cerebrospinal fluid leakage at the upper cervical vertebral level and the middle thoracic vertebral level. The points of leakage were identified by radionuclide cisternography, and this patient was successfully managed by injecting an EBP at each level of leakage.

Generalized infection following facet joint injection -A case report-

Facet joints have been shown to be a source of chronic low back pain, and it is generally accepted in clinical practice that diagnostic and therapeutic facet joint injections are the most reliable technique for the treatment of facet joint pain, which is considered to be an easy and safe procedure. Serious complications and side effects are uncommon after facet joint injection. However, infectious complications including septic arthritis, epidural abscess, meningitis and endocarditis have been reported following facet joint injections. We report here the first case of death following lumbar facet joint injection due to generalized infection.

Comparison of Multilevel with Single Level Injection during Lumbar Sympathetic Ganglion Block: Efficacy of Sympatholysis and Incidence of Psoas Muscle Injection

Background We prospectively evaluated the incidence and possible factors causing intramuscular injection during lumbar sympathetic ganglion block and compared the multiple needle technique to the single technique to obtain a profound and complete block effect. Methods Among 83 patients, 58 patients (group A, n = 27, multiple needle technique and group B, n = 31, single needle technique) were reevaluated for the changes of skin temperature (Ts) and mean segment of longitudinal contrast spread. After injecting the contrast agent, the incidence of psoas muscle injection and the change of Ts was compared between two groups. Results The incidence of psoas muscle injection was 21.3% (46/216) and it was associated with the level of injection (L2) significantly (χ2 = 14.773, P = 0.001). DTpost (postblock temperature difference between ipsilateral and contralateral great toe, 4.6 ± 2.8℃, 1.8 ± 1.6℃, P < 0.001 for group A and B) and DTnet (DTpost - DTpre, 3.9 ± 2.7℃, 1.5 ± 1.5℃, P < 0.001 for group A and B) was significantly higher in group A. The mean segment of longitudinal contrast spread was 8.1 ± 0.9 for group A and 3.2 ± 1.6 for group B (P < 0.001). Conclusions The LSGB at the L2 level showed the lowest incidence of psoas muscle injection of contrast. Multiple needle approach showed more significant increase of DTnet and DTpost.

Assessment of depression, anxiety, sleep disturbance, and quality of life in patients with chronic low back pain in Korea.

Background Chronic low back pain (CLBP) has a significant effect on quality of life and imposes a great economical burden on society. In a number of studies, validated questionnaires had been given to CLBP patients to determine their health-associated quality of life, sleep disturbance, and psychological status. However, such outcome studies had not been performed previously in Korea. Methods We used self-report questionnaires to compare CLBP patients with an age- and sex-matched healthy control group. Between September 2012 and August 2013, we enrolled 47 patients who had CLBP for more than 3 months (group P) and 44 healthy age- and sex-matched controls (group C), who completed the following self-report questionnaires: 36-Item Short Form Health Survey (SF-36), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Oswestry Disability Index (ODI), and Pittsburgh Sleep Quality Index (PSQI). Results The scores from the ODI, BDI, and BAI were significantly higher in group P than in group C. The SF-36 scores were significantly lower in group P than in group C, suggesting lower quality of life in group P. The incidence of depression and anxiety was significantly higher in group P than in group C. However, neither the PSQI score nor the incidence of sleep disturbance was significantly different between the groups. Conclusions Patients with CLBP showed considerable functional disability and significant impairment of psychological status with a low quality of life. Hence, it is important to evaluate CLBP patients to provide adequate psychological support.

Comparison between digital subtraction angiography and real-time fluoroscopy to detect intravascular injection during lumbar transforaminal epidural injections

Background and Objective Infrequent but serious complications of transforaminal epidural steroid injection (TFESI) are thought to be due to inadvertent intravascular injection (embolization of corticosteroid particulates via the vertebral or thoracolumbar radiculomedullary arteries). Recent studies suggest that real-time fluoroscopy often fails to detect intravascular injection and that digital subtraction angiography (DSA) may help reduce the incidence of accidental vascular injection. The goal of this prospective study was to evaluate the sensitivity of real-time fluoroscopy versus DSA in detecting intravascular injection during TFESI. Methods From September 2012 to July 2013, 239 consecutive patients were enrolled and received 249 fluoroscopically guided TFESI using the classic technique by one physician. We collected data of patient demographics, reason for TFESI, occurrence of accidental intravascular injection based on real-time fluoroscopic images and DSA, and spinal levels at which TFESI was performed. Intravascular spread was assessed initially using real-time fluoroscopy and subsequently with DSA. Results The overall incidence of intravascular injection was 12.4% (31/249). Real-time fluoroscopy failed to detect 9 cases of intravascular injections that were subsequently detected by DSA (real-time fluoroscopy sensitivity, 71.0%). Conclusions Digital subtraction angiography is superior to real-time fluoroscopy for detecting intravascular injections.

Diagnosis of Iliotibial Band Friction Syndrome and Ultrasound Guided Steroid Injection

A 64-year-old woman visited our pain clinic with the pain of right lateral side of thigh for one year. Her pain always started from knee and was radiated to buttock area when symptom was severe. She showed significant tenderness at knee lateral side and local tightness at lateral thigh. Magnetic resonance image of the knee was performed and we could identify high signal intensity of iliotibial band through coronal and axial view. In spite of medication and physical stretching exercise of iliotibial band for one month, she did not show any improvement of pain. To alleviate her symptom, ultrasound guided local corticosteroid injection targeting beneath the iliotibial band was performed. After the procedure, the reduction of pain was significant and there was no need for further management.

Does spinal stenosis correlate with MRI findings and pain, psychologic factor and quality of life?

Background To investigate and analyze MRI findings in relation to visual analogue scale (VAS), Oswestry Disability Index (ODI), psychological-factor, sleep-quality, and Short-Form Health Survey (SF-36) scores among patients with central lumbar spinal stenosis (LSS) for the purpose of elucidating a correlation. Methods From July 2013 to May 2014, 117 consecutive patients with central LSS were included in this study. All of the MRIs were evaluated by one of the authors, and the evaluated items were the dural sac cross-sectional area (DSCSA), the number of stenotic levels, and the presence and levels of spondylolisthesis. The ODI, VAS, 36-item SF-36, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Pittsburgh Sleep Quality Index (PSQI) questionnaires were used to evaluate the participants. Results There are no correlations between the ODI, VAS, BDI, BAI, PSQI, and SF-36 scores and the minimum DSCSA; however, a significant correlation was found between the ODI scores and multilevel LSS. The BDI, BAI, and PSQI scores are higher for multilevel LSS compared with single-level LSS, but the difference of this mean value is not statistically significant. Conclusions A significant correlation was shown between those patients with multilevel LSS and the ODI scores; however, significant correlations were not found between the MRI findings and the psychological factors pertaining to sleep and life qualities.

Infliximab partially alleviates the bite force reduction in a mouse model of temporomandibular joint pain.

Temporomandibular joint (TMJ) disorder is clinically important because of its prevalence, chronicity, and therapy-refractoriness of the pain. In this study, we investigated the effect of infliximab in a mouse model of TMJ pain using a specially-engineered transducer for evaluating the changes in bite force (BF). The mice were randomly divided into three groups (7 mice per group): the control group, the complete Freunds adjuvant (CFA) group, and the infliximab group. BF was measured at day 0 (baseline BF). After measuring the baseline BF, CFA or incomplete Freunds adjuvant was injected into both TMJs and then the changes in BF were measured at days 1, 3, 5, 7, 9, and 13 after the TMJ injection. For measuring the BF, we used a custom-built BF transducer. Control, CFA, and infliximab groups showed similar baseline BF at day 0. From day 1, a significant reduction in BF was observed in the CFA group, and this reduction in BF was statistically significant compared to that in the control group (P < 0.05). This reduction in BF was maintained until day 7, and BF started to recover gradually from day 9. In the infliximab group also, the reduction in BF was observed on day 1, and this reduction was maintained until day 7. However, the degree of reduction in BF was less remarkable compared to that in the CFA group. The reduction in BF caused by injection of CFA into the TMJ could be partially alleviated by the injection of anti-tumor necrosis factor alpha, infliximab. Graphical Abstract

Analysis of Inadvertent Intradiscal Injections during Lumbar Transforaminal Epidural Injection

Background Recently, there have been several case reports and retrospective studies about the incidence of intradiscal (ID) injection during transforaminal epidural steroid injection (TFESI). Inadvertent ID injection is not a rare complication, and it carries the risk of developing diskitis, although there has been no report of diskitis after TFESI. We prospectively evaluated the incidence of inadvertent ID injection during lumbar TFESI and analyzed the contributing factors. Methods Ten patients received 2-level TFESI, and the remaining 229 patients received 1-level TFESI. When successful TFESI was performed, 2 ml of contrast dye was injected under real-time fluoroscopy to check for any inadvertent ID spread. A musculoskeletal radiologist analyzed all magnetic resonance images (MRIs) of patients who demonstrated inadvertent ID injection. When reviewing MRIs, the intervertebral foramen level where ID injection occurred was carefully examined, and any anatomical structure which narrowing the foramen was identified. Results Among the 249 TFESI, we identified 6 ID injections; thus, there was an incidence of 2.4%. Four patients had isthmic spondylolisthesis, and the level of spondylolisthesis coincided with the level of ID injection. We further examined the right or left foramen of the spondylolisthesis level and identified the upward migrated disc material that was narrowing the foramen. Conclusions Inadvertent ID injection during TFESI is not infrequent, and pain physicians must pay close attention to the type and location of disc herniation.

Comparison of clinical efficacy in epidural steroid injections through transforaminal or parasagittal approaches

Background The transforaminal (TF) epidural steroid injection (ESI) is suggested as more effective than the interlaminar (IL) route due to higher delivery of medication at the anterior epidural space. However, serious complications such as spinal cord injury and permanent neural injury have been reported. The purpose of this study is to evaluate and compare the clinical effectiveness, technical ease, and safety of the TF and parasagittal IL (PIL) ESI. Methods A total of 72 patients were randomized to either the PIL group (n = 41) or the TF group (n = 31) under fluoroscopic guidance. Patients were evaluated for effective pain relief by the numerical rating scale (NRS) and Oswestry Disability Index (ODI) (%) before and 2 weeks after the ESI. The presence of concordant paresthesia, anterior epidural spread, total procedure time, and exposed radiation dose were also evaluated. Results Both the PIL and TF approach produced similar clinically significant improvements in pain and level of disability. Among the 72 patients, 27 PIL (66%) and 20 TF (64%) patients showed concordant paresthesia while 14 (34%) and 11 (36%) patients in the same respective order showed disconcordant or no paresthesia. Radiation dose and total procedure time required were compared; the PIL group showed a significantly lower radiation dose (30.2 ± 12 vs. 80.8 ± 26.8 [Cgy/cm2]) and shorter procedure time (96.2 ± 31 vs. 141.6 ± 30 seconds). Conclusions ESI under fluoroscopic guidance with PIL or TF approach were effective in reducing the NRS and ODI. PIL ESI was a technically easier and simple method compared to TF ESI.