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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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To compare the treatment effects of epidural neuroplasty (NP) and transforaminal epidural steroid injection (TFESI) for the radiating pain caused by herniated lumbar disc.
Thirty-two patients diagnosed with herniated lumbar disc through magnetic resonance imaging or computed tomography were included in this study. Fourteen patients received an epidural NP and eighteen patients had a TFESI. The visual analogue scale (VAS) and functional rating index (FRI) were measured before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment.
In the epidural NP group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.00±1.52, 4.29±1.20, 2.64±0.93, 1.43±0.51 and those of FRI were 23.57±3.84, 16.50±3.48, 11.43±2.44, 7.00±2.15. In the TFESI group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.22±2.05, 4.28±1.67, 2.56±1.04, 1.33±0.49 and those of FRI were 22.00±6.64, 16.22±5.07, 11.56±4.18, 8.06±1.89. During the follow-up period, the values of VAS and FRI within each group were significantly reduced (p<0.05) after the treatment. But there were no significant differences between the two groups statistically.
Epidural NP and TFESI are equally effective treatments for the reduction of radiating pain and for improvement of function in patients with a herniated lumbar disc. We recommend that TFESI should be primarily applied to patients who need interventional spine treatment, because it is easier and more cost-effective than epidural NP.
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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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To evaluate the efficacy of intradiscal methylene blue (MB) injection in patients with chronic discogenic low back pain.
Twenty patients with discogenic low back pain (4 males, 16 females; mean age 45.6 years) refractory to conservative management were recruited. All subjects underwent MB injection in target lumbar intervertebral discs confirmed by provocative discography. The clinical outcome was assessed by visual analog scale (VAS) and Oswestry disability index (ODI) at baseline and 1, 3, 6 and 12 months after treatment. Successful outcome was described as minimum of 2 points reduction in pain intensity compared with the baseline.
VAS and ODI significantly decreased after one injection. The average VAS and ODI were reduced significantly from 5.1 and 38.0 at baseline to 3.2 and 27.4 at 3 months after injection (p<0.05). However, the mean score of VAS at 12 month follow-up was 4.5 and we could not observe any difference between 12 months after injection and pretreatment. Eleven of twenty patients (55%) reported successful outcomes after intradiscal MB injection at 3 month follow up and the average VAS was reduced by 3.3±1.1 (p<0.05). At the time of 12 month follow up, pain had relapsed in 6 patients who have had satisfactory effect at 3 month follow up. Successful outcome was maintained in only 5 patients (20%) for 1 year.
The intradiscal MB injection is a short-term effective minimally invasive treatment indicated for discogenic back pain but it may lose its effectiveness long-term.
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To investigate the efficacy and safety of percutaneous intradiscal monopolar pulsed radiofrequency (PRF) in patients with chronic disabling discogenic back pain.
Twenty-six subjects (7 males; mean age 43.2 years) with chronic back pain refractory to active rehabilitative management were recruited. All subjects underwent MRI for evaluation of Modic changes, and monopolar PRF (20 min at 60 V) at the center of target lumbar intervertebral disc confirmed by pressure-controlled provocative discography. Clinical outcomes were measured by the visual analogue scale (VAS), Oswestry disability index (ODI), and sitting tolerance time (ST) for 12 months after treatment. Successful clinical outcome was described as a minimum of 2 point reduction in VAS compared with the baseline at each follow-up period.
The mean VAS for low back pain reduced significantly from 6.4±1.1 at pre-treatment to 4.4±1.9 at 12 months (p<0.05). The mean ODI score was 47.3±15.4 points at pre-treatment and 36.7±19.5 at 12 months (p<0.001). The ST was 27.8±20.4 minutes at pre-treatment and 71.5±42.2 at 12 months (p<0.001). However, successful clinical outcome was achieved at 58%, 50%, and 42%, measured at 3, 6, and 12 months post-treatment. There were no significant relationship between the clinical outcome and Modic changes; no adverse events were recorded.
The results demonstrated that the application of intradiscal monopolar PRF might be relatively effective but limited; successful intervention for chronic refractory discogenic back pain is needed. To achieve the optimal outcome through intradiscal PRF, we suggested further studies about stimulation duration, mode, and intensity of PRF.
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To describe inpatient course and length of hospital stay (LOS) for people who sustain brain disorders nationwide.
We interviewed 1,903 randomly selected community-dwelling patients registered as 'disabled by brain disorders' in 28 regions of South Korea.
Seventy-seven percent were initially admitted to a Western medicine hospital, and 18% were admitted to a traditional Oriental medicine hospital. Forty-three percent were admitted to two or more hospitals. Mean LOS was 192 days. Most patients stayed in one hospital for more than 4 weeks. The transfer rate to other hospitals was 30-40%. Repeated admissions and increased LOS were related to younger onset age, higher education, non-family caregiver employment, smaller families, and more severe disability.
Korean patients with brain disorders showed significantly prolonged LOS and repeated admissions. Factors increasing burden of care influenced LOS significantly.
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To observe the contrast spreading patterns in the retrodiscal (RD) approach for transforaminal epidural steroid injections and their effect on pain reduction.
Patients with L5 radiculopathy who were scheduled to receive lumbar TF-EPB were consecutively included. We randomly divided them into the L4-5 RD and L5-S1 RD groups and administered 1 cc of contrast dye into epidural space. We observed the shape and the location of contrast dye on the anterior-posterior and lateral views. We injected 1 cc of 0.5% lidocaine mixed with 20 mg of triamcinolone, and checked the pain intensity before and two weeks after the procedure by using visual analogue scale (VAS).
In the L4-5 RD group (n=30), contrast spread over the L4 nerve root in 27 cases and the L4 and L5 nerve roots in 3 cases. In the L5-S1 RD group (n=33), contrast spread over the L5 nerve root in 20 cases, the S1 nerve root in 3 cases, and the L5 and the S1 nerve roots in 10 cases. The contrast spreading patterns could be divided into 4 patterns: the proximal root in 40 cases, the distal root in 19 cases, the anterior epidural space in 3 cases and an undefined pattern in 1 case.
In RD lumbar TF-EPB, the contrast dye mostly went into the cephalic root and about 60% spread over the proximal nerve root. There was less pain reduction when the contrast dye spread over the distal nerve root.
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Effect of Needle Tip Position on Contrast Media Dispersion Pattern in Transforaminal Epidural Injection Using Kambin’s Triangle Approach
To provide the latest statistics about the length of hospital stay (LOS) and the number of hospitals where the patient was admitted (NHA) for patients with spinal cord injury (SCI) and to investigate the correlated demographic characteristics.
In total, 277 patients with SCI who were members of the Korea Spinal Cord Injury Association were included in the analysis. The survey was conducted by self-completed questionnaires to collect data on LOS, NHA, and demographic variables.
Mean LOS was 13.5±9.7 months and the mean NHA was 2.7±1.4. Patients who suffered from SCI by traffic accidents showed a longer LOS and larger NHA than those with other causes. The mean LOS for patients with traumatic SCI was longer than that whose cause of injury was disease. Patients discharged in the 2000s had a longer LOS and a larger NHA than those discharged earlier. Other factors such as gender, age at the time of injury, neurological category, and ambulation capability did not result in a significant difference in either LOS or NHA.
The mean LOS of domestic patients with SCI was longer than the values reported in foreign studies. Interestingly, neither neurological category nor functional status were related to LOS. These findings suggest that other factors such as socio-psychological factors, other than the medical state of the patient, have an effect on the LOS of patients with SCI in Korea.
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To compare the technical strengths and weaknesses between retrodiscal (RD) and conventional subpedicular (SP) approaches of transforaminal epidural block (TF-EPB).
Sixty-one patients with L5 radiculopathy who planned to undergo TF-EPB were consecutively enrolled as study subjects. Subjects were randomly assigned to one of two groups. For the RD approach, the positioning of the patient and the C-arm were similar to that for lumbar discography. We compared the pattern of dye spreads, the frequency of complications during the procedures, and the effect of the pain block 2 weeks after the procedure between the two groups.
For the RD group (n=24), the contrast dye diffused around the L5 and S1 nerve roots in 16 cases (67%), but it diffused around only the L5 root in 27 cases (73%) in the SP group (n=37) (p<0.05). Two weeks after the procedure, the visual analogue scale (VAS) decreased by the same amount in both groups (RD group: 3.1±1.6, SP group: 3.2±2.6). Symptoms of nerve root irritation occurred in 1 case of the RD group and in 10 cases of the SD group (p<0.05).
The RD approach was as efficient as the SP approach for temporary diagnostic relief and offered considerable advantages, such as lower nerve root irritation possible lower risk of vascular injection. Thus, it could be a useful technique when a herniated disc segment is stuck or when the foraminal stenosis is severe.
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Effect of Needle Tip Position on Contrast Media Dispersion Pattern in Transforaminal Epidural Injection Using Kambin’s Triangle Approach
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)
Objective: To classify the findings of magnetic resonance imaging of the lumbar interspinous ligaments in relation to the lumbar disc herniation, disc degeneration, and lordosis.
Method: The subjects were 45 herniated intervertebral disc (HIVD) patients and 35 normal subjects on MRI finding. The magnetic resonance features of the interspinous ligament were classified into five categories according to their signal intensities: type 1A (low intensity on T1- and T2- weighted images without hypertrophy of spinal process); type 1B (same signal pattern as in type 1A with hypertrophy of spinal process); type 2 (low intensity on T1- and high intensity on T2-weighted images); type 3 (high intensity on T1-weighted images); type 4 (others).
Results: The most common type in both HIVD patients and normal subjects was type 3. The mean age and disc degeneration grade of the type 1B ligaments were significantly higher. Lordosis of type 1B of L5-S1 interspinous ligament was increased with significant difference.
Conclusion: The classification of the MRI findings of interspinous types didn't show statistical difference between HIVD patients and normal subjects, but was helpful in assessing the degree of the degeneration of the intervertebral disc and age. (J Korean Acad Rehab Med 2002; 26: 449- 455)
Objective: This research aimed to define the relationship between the lower lumbar disc herniation and the morphology of the iliolumbar ligaments using magnetic resonance imaging.
Method: 24 male and 36 female patients were classified into two groups according to their disc herniation grade- those in whom the L5-S1 disc was less herniated than L4-5 disc, those in whom the L5-S1 disc was more herniated than the L4-L5 disc on magnetic resonance images. The lengths of iliolumbar ligaments were measured on T1- weighted coronal images. The angles of iliolumbar ligaments were measured on T1-weighted axial images.
Results: The length of iliolumbar ligament was not different between L4-L5 disc herniation and L5-S1 disc herniation. The degree of iliolumbar ligament angle difference (asymmetry of direction) at L5-S1 disc herniation was more deviated in paracentral disc herniation compared with central disc herniation.
Conclusion: The morphology of the iliolumbar ligament, especially its asymmetry of direction, may be a factor influencing the development of disc herniation at L5-S1. (J Korean Acad Rehab Med 2002; 26: 439-444)
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.
Objective: The purposes of this study were to observe the radiographic changes of lumbar facet joints by magnetic resonance imaging (MRI) in conservatively and operatively treated groups of patients with herniated intervertebral disc, and to compare the biomechanical effects to lumbar facet joints according to the treatment methods
Method: The patients composed of 20 conservatively treated control group and 40 operatively treated group who had disc herniation at lower lumbar spine. Follow-up MRIs were performed in order to assess the radiographic changes of intervertebral disc and lumbar facet joints, such as disc degeneration, lumbar facet joint angle and tropism in either treatment groups individually.
Results: There are significant increase in lumbar facet joint angle in operatvely treated group at the level of both L4/5, right L5/S1 compared to that of conservately treated group, but the disc degeneration and facet joint tropism were not changed after treatment in both groups. There's no relationship between treatment period and each parameters.
Conclusion: The radiographic biomechanical lumbar facet joint changes on MRI seems to be related to degenerative change of lumbar facet joint in operatively treated group with a lumbar disc herniation. Therefore, careful selection of optimal operation time and criteria would be important.
Method: The study included 27 children with hemiplegic cerebral plasy and 12 normal control group who were taken Bell-Thomson's view x-ray for measuring of leg length. The patient group was divided into the group with LLD and the group without LLD. Then we evaluated the relationship between the rate of leg length shortening (LLS) and clinical factors.
Results: Of the total 27 cerebral palsy children, 18 children (66.7%) had LLD, whose average rate of LLS was 2.0 percent. Nine children didn't have LLD, whose average rate of LLS was 0.6 percent. There was no specific relationship between the rate of LLS and the age, muscle power or spasticity, but there was negative correlation between the rate of LLS and the score of gross motor functional measure (GMFM).
Conclusion: It is necessary to define the LLD in children with hemiplegic cerebral palsy by the rate of LLS and to be concerned about the LLD due to its possible correlation with poor functional outcome. (J Korean Acad Rehab Med 2003; 27: 850-854)
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 investigate the relationship between commonly used radiologic parameters and occurrence of low back pain (LBP) through prospective study using pre-employment radiologic examination in high risk workplace.
Method: One hundred and fifty four male workers in high risk workplace were evaluated. Lumbar lordosis, lumbosacral angle, lumbar gravity line and lumbar disc height- related parameters were measured using simple radiologic films of lateral lumbosacral view taken during pre-employment medical check. Relationship between occurrence of LBP during post-employment period with a mean 1.7⁑1.0 years and radiologic parameter was investigated.
Results: Lumbar lordosis, lumbosacral angle and lumbar disc height were not significantly correlated to the occurrence of LBP. Amount of anterior shift of lumbar gravity line did not showed correlation to occurrence of LBP, but subjects with posterior displacement of lumbar gravity line showed significantly low rate of occurrence of LBP.
Conclusion: These results suggest that commonly used radiologic parameters are not so useful to predict occurrence of LBP in high risk workers. The possibile preventive effect of posterior shift of lumbar gravity line seems to be worth further researching. (J Korean Acad Rehab Med 2002; 26: 67-72)
Method: Seventy-one patients with lumbar discogenic pain and total 109 discography were studied. During contrast mediun injection, the patient's pain response was reported. The patients were invited to choose among the following options: 'no pain or only pressure feeling', 'dissimilar', 'similar', and 'exact'. And pain location was chosen among the followings: 'low back', 'buttock', 'anterior thigh', 'posterior thigh', and 'lateral thigh'. Correlation between degeneration and provocation response was analyzed. And discography level and provocation area were evaluated.
Results: Low back and buttock area was the most common provocation pain site, but it was not specific by disc level. And provocation pain frequently appeared in irregular and fissured types, but the existence of provocation pain was significantly low in ruptured type.
Conclusion: There was no correlation between provocation pain area and discography level. And existence rate of provocation pain in ruptured disc was very low. It might be due to low mechanical compression with little stimulation of nociceptor. We suggested that if patients have a ruptured disc with chemical irritation, provocation pain was not a good indicator of diagnosis of discogenic back pain.
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.
Objective: To observe histological changes of the intervertebral disc injected with intradiscal steroid and mollification of discogenic pain.
Method: A study group of 25 Sprague-Dawely rats was divided into five subgroups. A control group of 10 Sprague-Dawely rats was divided into five subgroups. The rats' intervertebral discs were exposed by an anterior surgical approach. For study group, the rats were injected intradiscally methylprednisolone acetate 4 mg (Depomedrol, 40 mg/ml) to the L4-L5 intervertebral disc, methylprednisolone sodium succinate 4 mg (Solumedrol, 40 mg/ml) to the L5-L6 intervertebral disc, and triamcinolone acetonide 4 mg (Triamcinolone, 40 mg/ml) to the L6-S1 intervertebral disc. For control group, the rats were injected intradiscally 0.1 ml of saline to the L5-L6 intervertebral disc and a needle was inserted in the L6-S1 intervertebral disc. The intervertebral discs were extracted after 1 week, 2 weeks, 3 weeks, 4 weeks, and 16 weeks. The extracted intervertebral discs were stained with Hematoxylin-Eosin and examined histomorphometrically.
Results: There is no significant histological change in either group until 4 weeks after the different types of steroid were injected. Focal fibrotic change was present in the Solumedrol and Triamcinolone injection subgroups after 16 weeks.
Conclusion: We concluded that rapid mollification of discogenic pain following intradiscal steroid injection may not result from histological change of the disc. Further biochemical study will be neccessary to clarify mollification mechanism of discogenic pain by intradiscal steroid injection.
목 적: 성인의 요추간 원판염은 대부분 수술이나 침습적 진단후 이차적으로 발생되는 반면, 일차적인 원판염은 매우 드물다. 때문에 일차적 원판염은 조기 진단과 적절한 항생제 치료가 중요함에도 불구하고 간과되기 쉽고, 골주사나 자기공명영상 검사상 원판염 소견을 얻기 전까지는 확진이 어려워 치료가 늦어질 가능성이 높다. 이에 저자들은 재생불량성빈혈 환자에게 발생한 자발적 일차적 요추간 원판염에 의한 요통의 진단이 지연되었던 증례를 고찰과 함께 보고한다.
증례요약: 재생불량성 빈혈과 항림프구글로불린 치료 과거력을 가진 19세 남자가 패렴 치료중 요통을 호소하였다. 의료진은 원인을 혈청병 혹은 장기간 침상생할에 의한 것으로 판단하고 보존적 치료후 퇴원시켰다. 이후 환자는 요통의 악화로 다시 입원하였으며 재활의학과 의사의 요추간 원판염의 진단하에 항생제 치료를 하여 요통은 완화되었으나 대퇴골두에 발생한 화농성 괴사로 고관절 치환술을 시행받았다.
결 론: 원판염은 항생제 치료에 빠른 효과를 볼 수 있는 질환이다. 그러므로 면역력이 저하된 환자나 침습적 시술을 받은 환자가 심한 요통을 호소하는 경우 원판염도 반드시 고려해야 한다.
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 determine the relationship between magnetic resonance imaging (MRI) and discography in visualization of disc degeneration.
Method: Forty-eight patients with suspected discogenic pain in lumbar spines and degenerative changes of the lumbar intervertebral discs in T2-weighted magnetic resonance imaging were studied. Five types of discogram (cottonball, lobular, irregular, fissured, and ruptured) were classified by identifiable features in shape and density of radio-opaque shadow. Three types of MRI (bulging, protrusion, and extrusion) were classified by degrees of disc herniation. The correlation between two imaging techniques of lumbar intervertebral discs were analyzed using Spearman's correlation coefficient.
Results: Of sixty-three discs, MRI finding of the disc herniation revealed as follows: bulging, 17 discs; protrusion, 20 discs; extrusion, 26 discs. Discography revealed as follows: cottonball, 15 discs; lobular, 2 discs; irregular, 11 discs; fissured, 10 discs; ruptured, 25 discs. 46 discs of 63 discs showed internal structural abnormalities (irregular, fissured, or ruptured). There was no statistically significant correlation between MRI and discography in visualization of the disc degeneration (r=0.081).
Conclusion: Severity of the lumbar intervertebral disc degeneration in MRI was not correlated with degenerative severity of discographic imaging. Supplementary discography may be useful in evaluation of patients with discogenic pain since discographic imaging when compared to MRI visualizes disc degeneration more accurately.
The purposes of this study were to identify lumbar lordosis in low back pain patients and to investigate differences in lumbar lordosis in low back pain patients according to etiologies.
On the basis of the findings of spinal roentgenogram, MRI, and SPECT imagies, the patients were divided into four groups; 1) facet syndrome with facet joint inflammation or degenerative change, 2) disc herniation including disc bulging or extrusion, 3) combined low back pain accompaning facet joint lesion with disc herniation, 4) simple low back pain with no abnormal imaging findings.
There were statistically significant decrease in low back pain patients compared with normal controls in terms of lumbosacral curvature. No sex and age differences were observed within low back pain patients and normal controls in terms of lumbosacral curvature. The review disclosed a significant decrease of the lumbosacral angle in order of simple low back pain, disc herniation, combined low back pain compared with normal controls. But facet syndrome patients showed no change of lumbosacral angle. Patients with disc bulging showed no significant decrease of lumbosacral angle compared with normal controls but patients with disc extrusion showed significant decrease.
It is believed that the decrease of lumbosacral angle in low back patients results from a pathokinesiological effort to keep facet joint from pressure stemed from facet overlying and to minimize the shearing force over lumbosacral joint. The facet joint stiffness due to inflammation may play a major role in no change of lumbosacral angle in facet syndrome patients. In conclusion, different causes of low back pain should be taken into consideration for the assessment of lumbosacral angle.
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.
Objective: To assess the abnormal spontaneous activities in needle electromyography (EMG) according to the type of herniated lumbar disc and anteroposterior the diameter of dural sac in magnetic resonance imaging (MRI).
Method: We performed the MRI on 120 patients with low back pain (LBP) and measured the midline anteroposterior diameter of dural sac in a MRI axial view. Fifty patients with a disc protrusion or extrusion in MRI were reviewed for the clinical findings on physical examination and assessed for the abnormal spontaneous activities (ASA) in needle EMG.
Results: Seventy cases with a normal finding in MRI did not have differences in a dural sac diameter regardless their age or sex. Fifty cases with a protrusion or extrusion in MRI showed that the dural sac size decreased more in an extrusion than in a protrusion, and more in a paracentral type than in a central type. The incidence of ASA in a needle EMG increased more in an extrusion than in a protrusion, and more in a paracentral type than in a central type. The incidence also increased according to the decrement of a dural sac diameter. The incidence of ASA were 100% in a group with both motor and sensory signs, 94% in a group with a motor sign, 86% in a group with a sensory sign, 26% in a group without motor or sensory sign.
Conclusion: We concluded that the abnormalities in needle EMG must be correlated with the direction of herniated lumbar disc and anteroposterior diameter of the dural sac in MRI as well as clinical findings.
Method: Medical records of the 108 patients with stroke, spinal cord injury and traumatic brain injury were reviewed after the discharge from acute rehabilitation care. The demographic factors, socioeconomic status, disease characteristics and functional status of the patients were evaluated to investigate the affecting factors to the discharge destinations.
Results: Discharge destinations were subdivided into homes 67 (62%), transfer to other hospitals 31 (29%) and transfer to oriental medicine hospitals 10 (9%). The Functional independence measure (FIM) score, length of rehabilitation care, type of payment, operation and diagnosis significantly influenced discharge destinations (p＜0.05). The patients who were transferred to other hospital showed significantly lower FIM score and longer length of rehabilitation care compared with patients who were discharged to home or transferred to oriental medicine hospital (p＜0.05).
Conclusion: The FIM score, length of rehabilitation care, type of payment, operation, and diagnosis significantly influenced the discharge destinations of patients after rehabilitation. It is necessary to increase the subacute or chronic rehabilitation facilities for the case of patients with severe physical disabilities. (J Korean Acad Rehab Med 2003; 27: 269-274)
Method: Seventeen patients with lumbar discogenic pain who have not received other interventional procedures were studied. After confirmation of needle placement into the discs by C-arm fluoroscopy, discogram was done. And 40 mg of triamcinolone and 0.5 cc of 2% lidocaine were injected into the nucleus. Correlation between degeneration and Visual Analogue Scale (VAS) was analyzed. The effects of steroid injection were evaluated using VAS and limitation of lumbar flexion at pre-injection, 1 week post-injection, 1 month post-injection, and 3 months post-injection. Changes over time were assessed statistically using ANOVA and chisquare.
Results: Correlation between degeneration and VAS was high (r=0.7). The averages of VAS reduced significantly from 6.1⁑1.6 at pre-injection, to 2.4⁑1.8 at 1 week post- injection, to 1.8⁑1.2 at 3 months post-injection, respectively (p＜0.05). The number of group of highly or moderately limited lumbar flexion was decreased from 10 at pre- injection to 4 at 1 day post-injection. Fourteen of 17 patients (82.4%) had a successful outcome reporting at least 50% reduction between pre and 3 months post-injection in VAS.
Conclusion: Intradiscal steroid injection was an effective treatment for patients with lumbar discogenic pain. (J Korean Acad Rehab Med 2003; 27: 240-244)
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