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To evaluate the prevalence of vulnerable blood vessels around cervical nerve roots before cervical nerve root block in the clinical setting.
This retrospective study included 74 patients with cervical radiculopathy who received an ultrasonography-guided nerve block at an outpatient clinic from July 2012 to July 2014. Before actual injection of the steroid was performed, we evaluated the vulnerable blood vessels around each C5, C6, and C7 nerve root of each patient's painful side, with Doppler ultrasound.
Out of 74 cases, the C5 level had 2 blood vessels (2.7%), the C6 level had 4 blood vessels (5.45%), and the C7 level had 6 blood vessels (8.11%) close to each targeted nerve root. Moreover, the C5 level had 2 blood vessels (2.7%), the C6 level 5 blood vessels (6.75%), and the C7 level had 4 blood vessels (5.45%) at the site of an imaginary needle's projected pathway to the targeted nerve root, as revealed by axial transverse ultrasound imaging with color Doppler imaging. In total, the C5 level had 4 blood vessels (5.45%), the C6 level 9 blood vessels (12.16%), and the C7 level 10 had blood vessels (13.51%) either at the targeted nerve root or at the site of the imaginary needle's projected pathway to the targeted nerve root. There was an unneglectable prevalence of vulnerable blood vessels either at the targeted nerve root or at the site of the needle' projected pathway to the nerve root. Also, it shows a higher prevalence of vulnerable blood vessels either at the targeted nerve root or at the site of an imaginary needle's projected pathway to the nerve root as the spinal nerve root level gets lower.
To prevent unexpected critical complications involving vulnerable blood vessel injury during cervical nerve root block, it is recommended to routinely evaluate for the presence of vulnerable blood vessels around each cervical nerve root using Doppler ultrasound imaging before the cervical nerve root block, especially for the lower cervical nerve root level.
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To investigate the predictive value of enhanced-magnetic resonance imaging (MRI) and fluoroscopic factors regarding the effects of transforaminal epidural steroid injections (TFESIs) in low back pain (LBP) patients with lumbosacral radiating pain.
A total of 51 patients who had LBP with radiating pain were recruited between January 2011 and December 2012. The patient data were classified into the two groups ‘favorable group’ and ‘non-favorable group’ after 2 weeks of follow-up results. The favorable group was defined as those with a 50%, or more, reduction of pain severity according to the visual analogue scale (VAS) for back or leg pain. The clinical and radiological data were collected for univariate and multivariate analyses to determine the predictors of the effectiveness of TFESIs between the two groups.
According to the back or the leg favorable-VAS group, the univariate analysis revealed that the corticosteroid approach for the enhanced nerve root, the proportion of the proximal flow, and the contrast dispersion of epidurography are respectively statistically significant relative to the other factors. Lastly, the multiple logistic regression analysis showed a significant association between the corticosteroid approach and the enhanced nerve root in the favorable VAS group.
Among the variables, MRI showed that the corticosteroid approach for the enhanced target root is the most important prognostic factor in the predicting of the clinical parameters of the favorable TFESIs group.
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Intestinal entrapment between two vertebral bodies is very rare. In all previous cases, it occurred by major trauma. However, the bowel entrapment between two vertebral bodies without trauma has never been reported, not to mention as the cause of lower extremity radicular pain. We describe the case of an 82-year-old female patient with right lower extremity radicular pain without recent trauma history. The patient was diagnosed sigmoid colon entrapment between the L5 and S1 vertebrae by lumbar spinal computerized tomography and magnetic resonance imaging, and showed improvement in radicular pain after manual reduction of interpositioned colon during surgery. Intestinal entrapment between two vertebrae without trauma is caused by degenerative and vacuum changes of the intervertebral disc combined with the anterior longitudinal ligament injury.
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To determine clinical and radiological factors that predict the successful outcome of percutaneous disc decompression (PDD) in patients with lumbar herniated nucleus pulposus (HNP).
We retrospectively reviewed the clinical and radiological features of patients who underwent lumbar PDD from April 2009 to March 2013. Sixty-nine patients with lumbar HNP were studied. Clinical outcome was assessed by the visual analogue scale (VAS) and the Oswestry Disability Index (ODI). Multivariate logistic regression analysis was performed to assess relationship among clinical and radiological factors and the successful outcome of the PDD.
The VAS and the ODI decreased significantly at 1 year follow-up (p<0.01). One year after PDD, the reduction of the VAS (ΔVAS) was significantly greater in the patients with pain for <6 months (p=0.03) and subarticular HNP (p=0.015). The reduction of the ODI (ΔODI) was significantly greater in the patients with high intensity zone (p=0.04). Multivariate logistic regression analysis revealed the following 5 factors that were associated with the successful outcome after PDD: pain duration for <6 months (odds ratio [OR]=14.036; p=0.006), positive straight leg raising test (OR=8.425, p=0.014), the extruded HNP (OR=0.106, p=0.04), the sequestrated HNP (OR=0.037, p=0.026), and the subarticular HNP (OR=10.876, p=0.012).
PDD provided significant improvement of pain and disability of patients. The results of the analysis indicated that the duration of pain <6 months, positive straight leg raising test, the subarticular HNP, and the protruded HNP were predicting factors associated with the successful response of PDD in patients with lumbar HNP.
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To investigate the correlation among age, disc morphology, positive discography, and prognosis in patients with chronic low back pain.
A total of 183 intervertebral discs in 72 patients with chronic low back pain were studied. Discography was performed using a pressure-controlled manometric technique. The pain reaction during discography at each level was recorded as follows: no pain, dissimilar pain, similar pain, or concordant pain. Discs with similar or concordant pain were classified as positive. All the examined discs were assessed morphologically using axial computed tomography imaging. The grade of general degeneration and annular disruption of the discs were assessed according to the Dallas discogram description (DDD). Intradiscal injection of steroid was tried for patients with symptomatic disc identified during provocative discography and who did not consent to surgical operation.
There was a higher correlation between general degeneration and age, as compared with annular disruption and age. Higher general degeneration and annular disruption grades had higher positive rates of discography. However, annular disruption alone was independently associated with positive discography. Age and grade of general degeneration did not affect the prognosis.
The grade of general degeneration was associated with age, but it was not correlated with positive discography and prognosis. In addition, high grade of annular disruption correlated with positive discography.
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Recent years, various percutaneous procedures including cervical nucleoplasty have been developed for disc decompressions to relieve radicular pains caused by disc herniations. We report the application of percutaneous cervical nucleoplasty (PCN) by using the navigable disc decompression device in two patients of cervical herniated intervertebral discs (HIVD). A 38-year-old female diagnosed with C4-C5 disc extrusion with bilateral C5 roots impingement received nucleoplasty twice at C4-C5 disc level. After second procedure, her pain was improved from 6-7/10 to 1-2/10 by visual analog scale (VAS). The second case, a 51-year-male was diagnosed with C6-C7 disc extrusion with right C7 roots impingement and received the procedure at C6-C7 disc level. The pain improved from 8/10 to 3-4/10 by VAS. Successfully, we decompressed cervical herniated discs in 2 HIVD patients without major complications. The PCN with the navigable device will be recommended as an alternative treatment method for cervical HIVD.
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The postoperative infectious spondylitis has been reported to occur among every 1% to 12%. It is difficult to early diagnose in some cases. If the diagnosis is delayed, it can be a life-threatening condition. We report a 32-year-old male patient with postoperative infectious spondylitis. He had surgical treatments for traumatic intervertebral disc herniations in L3-4 and L4-5. Three weeks after surgery, he complained for fever and paraplegia. Cervicothoracic magnetic resonance imaging showed the collapsed T2 and T3 vertebral body with changes of bone marrow signal intensity. Moreover, it showed anterior and posterior epidural masses causing spinal cord compressions which suggested infectious spondylitis. After the use of antibiotics and surgical decompressions T2-T3, his general conditions were improved and muscle power of lower extremities began to be gradually restored. However, we could not identify the exact organisms that may be the cause of infectious spondylitis. It could be important that the infectious spondylitis, which is presented away from the primary operative level, should be observed in patients with fevers of unknown origin and paraplegia.
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Objective: The purpose of this study is to evaluate the efficacy of stellate ganglion block for the patients with cervical Herniated Intervertebral Disc (HIVD).
Method: Forty patients with cervical HIVD were selected for the study. Patients were randomly assigned to one of two groups: Group 1, stellate ganglion block of 1% lidocaine and physical modalities (n=20); Group 2, only physical modalities as a control group (n=20). Group 1 patients were treated with the stellate ganglion block of 1% lidocaine three times over two-week period. The efficacy of stellate ganglion block was assessed with Visual Analog Scale (VAS) on pre- and post-stellate ganglion blocks and with Rubin scale (success rate).
Results: The VAS scores of post-block were significantly lower than pre-score (p＜0.05) in both groups, but there was no statistically significance between the two groups. After treatment, Rubin scale was with excellent or good in 75% in group 1 and in 50% in group 2, but there was no statistically significance.
Conclusion: The stellate ganglion block may be effective therapeutic method for patient with cervical HIVD. But the efficacy of additional stellate ganglion block for cervical HIVD remains controversial. (J Korean Acad Rehab Med 2002; 26: 567-570)
Magnetic resonance imaging(MRI) is clearly more reliable than computer tomography and myelography in radiological diagnosis of lumbar herniated intervertebral disc. Moreover, MRI can also detect degenerative changes of intervertebral discs. The purpose of this study was to determine the utility and accuracy of MRI in conjuntion with the diagnosis of lumbar herniated intervertebral disc and to compare findings with operative findings.
Comparisons of operative findings and MRI were done in 133 cases. Each patients had been diagnosed by MRI as having lumbar herniated intervertebral disc. MRI findings included those of spin echo T1-weighted images and T2-weighted images, gradient echo T1-weighted images and T2-weighted images, and gadolinium-DTPA enhancement when needed.
In 32 protrusion disc cases diagnosed by MRI, 28 cases were confirmed by operation and four were actually extrusion disc. In 77 cases diagnosed by MRI as extrusion disc, 72 cases were confirmed by operative findings, while 5 cases were found to be protrusion disc. 4 cases of sequestration disc diagnosed by MRI were confirmed by operative findings. Specific dimensions of MRI use yielded the following results: protrusion disc indicated 84.8% in sensitivity, 95% specificity, 87.5% in accuracy; extrusion disc showed 94.7%, 86.5%, 93.5%, respectively; and sequestration disc revealed 100% in all categories. In this study, the average accuracy of lumbar herniated intervertebral disc diagnosed by MRI was 93.6% on average.
Accordingly, MRI has shown itself to be a good diagnostic tool for determining anatomical and biological change in lumbar herniated intervertebral disc.
Method: MRI images were reviewed from thirty two patients who were diagnosed electrodiagnostically as unilateral S1 radiculopathy. Areas of herniated disc and spinal canal were measured and the ratio of disc herniation was calculated from the axial images stored and analyzed by PACS. The radiologic measurements were compared with the results of electrodiagnostic studies. Results: The presence of abnormal spontaneous activities in needle EMG and no response in H reflex were associated with larger disc herniation (p＜0.05). There was no other single electrodiagnostic study that showed correlation with any of radiologic measurements. With increasing number of abnormal electrodiagnostic tests, area of disc herniation grew larger (p＜0.05). Area of spinal canal and the ratio of disc herniation did not show difference between normal and abnormal groups in most of electrodiagnostic studies. Conclusion: There were limited correlations between electrodiagnostic results and severity of disc herniation. The size of disc herniation, regardless of the size of spinal canal, was associated with abnormal results of electrodiagnostic tests. (J Korean Acad Rehab Med 2008; 32: 194-199)
Objective: To examine the correlation between bone mineral density and intervertebral disc degeneration through retrospective study.
Method: Bone mineral density (BMD) and Magnetic resonance (MR) image of lumbar spine from 61 postmenopausal women were assessed to examine the correlation between bone mineral density and intervertebral disc degeneration. We determined BMD of lumbar spine using the dual energy X-ray absorptiometry (DEXA). And we evaluated signal intensity of intervertebral disc, disc height and disc herniation at each lumbar disc level using the MR image. The correlation between BMD (mean value of 2nd, 3rd and 4th lumbar spine BMD) and the sum of grading scores of intervertebral disc degeneration was assessed in all the patients.
Results: There was a positive correlation between BMD of lumbar spine and the sum of grading scores of intervertebral disc degeneration (r=0.415, p value=0.00087).
Conclusion: Bone mineral density has an inverse correlation to intervertebral disc degeneration and which is important when considering degenerative spinal disease and osteoporosis.
Method: Sixty patients of low back pain with the age below 60 were enrolled. They didn't have spondylolisthesis or the history of spine surgery. MRI films of these patients were reviewed. Anteroposterior and transverse diameter of endplates, height of vertebral body and intervertebral discs were measured. The relation of these data and intervertebral disc herniation, body weight, height, body mass index (BMI) were statistically studied.
Results: Patients' weight, BMI, the vertebral body area and the shape of the endplate were related to disc herniations. Furthermore, the larger and circular vertebral body was observed in the patients with disc herniation. In the patients with lower back pain, men were diagnosed disc herniations of the MRI finding more than women.
Conclusion: In anatomical aspect, the area and the shape of the vertebral body at the endplate level were important factors contributing to the development of disc herniations at L4-L5 and L5-S1. (J Korean Acad Rehab Med 2003; 27: 399-403)
Objective: To investigate the neuropathic changes induced by nucleus pulposus and possible role of nitric oxide (NO) in the pathogenesis of painful radiculopathy.
Method: Autologous nucleus pulposus was harvested from the rat coccygeal intervertebral disc and grafted to the sciatic nerve. Pain behavior, neurophysiologic and pathologic changes were compared between autografted and sham operated group during 14-day-period. Western immunoblotting and immunohistochemistry with anti-nitrotyrosine mouse monoclonal antibody were used to compare the NO production and nerve damage in autografted and sham operated nerve tissues.
Results: Mechanical allodynia and thermal hyperalgesia were observed 2 days after autograft of nucleus pulposus and persisted during 14-day-period (p＜0.05). Motor nerve conduction latency was delayed and compound muscle action potential amplitude was decreased 5 days after autograft (p＜0.05). Histologically, nucleus pulposus induced severe inflammatory reaction with fibroblast proliferation and foamy macrophage infiltration, which were persisted during 14-day- period. More nitrated proteins were detected consistently in nerve tissues with autograft of nucleus pulposus and immunohistochemical staining of nitrotyrosine was prominent around foamy macrophages.
Conclusion: These data suggest that nucleus pulposus induce mechanical allodynia, thermal hyperalgesia and nerve dysfunction through inflammatory reaction with macrophage infiltration. NO and NO related tissue injury may play an important role in the pathogenesis of painful radiculopathy.
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