Evaluation of the resection efficiency and safety of an enhanced power plasma generator using cadaveric intervertebral discs.

Plasma energy has been used to provide minimally invasive interventional treatment for spinal problems. However, this procedure has been used for limited indications mainly because of its small resection range. To overcome this problem, we designed the enhanced power plasma device. This device seeks to maximize the resection area by modifying the electrode arrangement and enhancing the maximum electric power. The purpose of this study is to assess the efficiency and safety of this newly designed plasma generator, a device for percutaneous disc decompression. We performed an intradiscal procedure on 7 fresh human cadaver lumbar spine specimens using the enhanced power plasma under C-arm fluoroscopic guidance at various voltages. As a result, the volume of the removed area was proportional to the applied magnitude of the electric power level. In particular, under the high-power level condition after 500 s treatment, nearly the entire nucleus pulposus was eliminated. The generated plasma density also tends to grow along with the given electric power. The highest level of temperature rise did not exceed the level that would lead to degeneration in the collagen tissue of the intervertebral disc. Histopathologic examination also demonstrated that there was no thermal damage to the surrounding neural tissues. In conclusion, we speculate that the concepts of this newly designed enhanced plasma generator could be applied to remove huge disc materials without thermal or structural damage to the adjacent target tissues in future spine clinics.

Optimal placement for needle electromyography of the supinator muscle: Cadaveric studies.

INTRODUCTION/AIMS: The existing methods for needle electromyography are confusing as to which is the safest and most effective. Our aim was to identify the optimal and safest needle electromyographic insertion site in the supinator muscle. METHODS: We performed a two-step cadaveric dissection of the supinator muscle and related neurovascular structures. The study was performed using 18 upper limbs of 9 fresh adult cadavers (step 1) and 14 upper limbs of 7 fresh adult cadavers (step 2). In step 1, an imaginary line connecting the radial head (RH) and midpoint of the dorsal wrist (RW line) was drawn, and the distance from the RH to the point where the RW line and posterior interosseous nerve (PIN) intersect (L_CROSS) was measured on the RW line. In step 2, the needle was inserted 30 mm distal to the RH according to the results of step 1. After injection with India ink, dissection was performed to measure the distance between the needle insertion site and PIN (L_CROSS_Inj) on the RW line. RESULTS: The median L_CROSS was 51.4 (35.5-65.6) mm. Needle insertion spared the PIN in all cases during step 2, and the needle was inserted into the supinator muscle in all cases. The median L_CROSS_Inj was 27.4 (13.2-39.8) mm. DISCUSSION: A safe and accurate needle insertion site for the supinator muscle is approximately 30 to 40 mm distal to the RH along the RW line.

An Updated Overview of Low Back Pain Management.

We aimed to determine the recommendation level for the treatment of acute and chronic low back pain (LBP). A systematic review (SR) of the literature was performed and all English-language articles that discuss acute and chronic LBP, including MEDLINE and the Cochrane Database of Systematic Reviews, were searched. Of the 873 searched literature reports, 259 articles, including 131 clinical trials, 115 SRs, nine meta-analyses, and four clinical guidelines were analyzed. In these articles, high-quality randomized controlled trials, SRs, and used well-written clinical guidelines were reviewed. The results indicated multiple acute and chronic LBP treatment methods in the literature, and these reports when reviewed included general behavior, pharmacological therapy, psychological therapy, specific exercise, active rehabilitation and educational interventions, manual therapy, physical modalities, and invasive procedures. The Trial conclusions and SRs were classified into four categories of A, B, C, and D. If there were not enough high-quality articles, it was designated as "I" (insufficient). This review and summary of guidelines may be beneficial for physicians to better understand and make recommendations in primary care.

Immediate effects of static and proprioceptive neuromuscular facilitation stretching of hamstring muscles on straight leg raise, craniovertebral angle, and cervical spine range of motion in neck pain patients with hamstring tightness: A prospective randomized controlled trial.

BACKGROUND: The cranio-cervical flexion exercise and sub-occipital muscle inhibition technique have been used to improve a forward head posture among neck pain patients with straight leg raise (SLR) limitation. However, little is known about the cranio-vertebral angle (CVA) and cervical spine range of motion (CROM) after applying stretching methods to the hamstring muscle. OBJECTIVE: To compare the immediate effects of static stretching and proprioceptive neuromuscular facilitation stretching on SLR, CVA, and CROM in neck pain patients with hamstring tightness. METHODS: 64 subjects were randomly allocated to the static stretching (n1= 32) or proprioceptive neuromuscular facilitation (n2= 32) stretching group. The SLR test was performed to measure the hamstring muscle's flexibility and tightness between the two groups, with CROM and CVA also being measured. The paired t-test was used to compare all the variables within each group before and after the intervention. The independent t-test was used to compare the two groups before and after the stretching exercise. RESULTS: There were no between-group effects for any outcome variables (P> 0.05). However, all SLR, CVA, and CROM outcome variables were significantly improved within-group (P< 0.05). CONCLUSIONS: There were no between-group effects for any outcome variable; however, SLR, CVA, and CROM significantly improved within-group after the one-session intervention in neck pain patients with hamstring tightness.

Optimal Parameters for Intervertebral Disk Resection Using Aqua-Plasma Beams.

OBJECTIVE: A minimally invasive procedure for intervertebral disk resection using plasma beams has been developed. Conventional parameters for the plasma procedure such as voltage and tip speed mainly rely on the surgeon's personal experience, without adequate evidence from experiments. Our objective was to determine the optimal parameters for plasma disk resection. METHODS: Rate of ablation was measured at different procedural tip speeds and voltages using porcine nucleus pulposi. The amount of heat formation during experimental conditions was also measured to evaluate the thermal safety of the plasma procedure. RESULTS: The ablation rate increased at slower procedural speeds and higher voltages. However, for thermal safety, the optimal parameters for plasma procedures with minimal tissue damage were an electrical output of 280 volts root-mean-square (Vrms) and a procedural tip speed of 2.5 mm/s. CONCLUSION: Our findings provide useful information for an effective and safe plasma procedure for disk resection in a clinical setting.

Two-year clinical outcomes of radiofrequency focal ablation using a navigable plasma disc decompression device in patients with lumbar disc herniation: efficacy and complications.

PURPOSE: To report on the 2-year clinical outcomes of focal ablation using a navigable plasma disc decompression device in patients with lumbar herniated nucleus pulposus (HNP). PATIENTS AND METHODS: This was a prospective, single-cohort study conducted in a clinical center. A total of 170 patients with lumbar HNP were assessed for pain intensity using the visual analog scale (VAS), for disability level using the Oswestry Disability Questionnaire (ODI), for health-related quality of life using the short form-36 version 2 of the bodily pain scale (SF-36 BP), and for the angles of passive straight leg raise (SLR) test. The herniated portions of the target discs were ablated using a navigable catheter under a well-instructed protocol with informed consent. Outcome data were prospectively collected before the procedure: 1 week after the procedure: and then 1, 3, 6, 12, and 24 months postoperatively. For statistical analysis, repeated-measures analysis of variance was performed. RESULTS: Two years after the procedure, the mean VAS decreased from 7.1±1.7 to 2.1±1.9, the mean ODI decreased from 50.9±17.2 to 20.3% ± 14.6%, and the mean SF-36 BP increased from 38.8±8.4 to 45.8±9.4 (P<0.05). On the SLR test, the angular change after 2 years improved considerably from 51.2±17.3 to 85.0±9.3 degrees. There was 90%-100% VAS improvement in 25.9% and 50%-90% VAS improvement in 52.4% of the patients; 1.8% experienced pain aggravation compared with the initial VAS. Two subjects showed short-term foot drop, whereas one subject showed the severe complication of foot drop for more than 6 months. The recurrence rate ranged from 4.7% to 11.5%. CONCLUSION: These findings suggest that focal ablation of herniated discs using a navigable disc decompression device is worth considering for relieving pain related to lumbar HNP. However, the development of more advanced technologies and methods for safety and efficiency is necessary.

Effects of assisted sit-up exercise compared to core stabilization exercise on patients with non-specific low back pain: A randomized controlled trial.

BACKGROUND: Traditional sit-up exercise is a simple method to strengthen core muscles. However, it can increase the potential of lumbar spine injury during the bending process. OBJECTIVE: To evaluate the effect of assisted sit-up exercise (SUE) using a new training device, HubEX-LEX®, on strengthening core muscles and improving non-specific low back pain (NSLBP) compared to conventional core stabilization exercise (CSE). METHODS: Subjects with chronic NSLBP were randomly divided into two groups: SUE (n= 18) or CSE (n= 18). They participated in 12 sessions of the exercise program. Before and after the training, thickness and activity of core muscles were measured using ultrasonogram and surface electromyography respectively. Pain and disability were assessed using two questionnaires. RESULTS: Thickness ratios (contracted/rest) of rectus abdominis and external oblique in the SUE group and those of transversus abdominis in the CSE group showed statistically significant difference between before and after exercise (p< 0.05). The ratio of activation of internal oblique relative to rectus abdominis and all measurements for pain and disability showed statistically significant improvement in both groups (p< 0.05). CONCLUSIONS: Assisted SUE using new training device can be an effective therapeutic exercise to strengthen dynamic abdominal muscles and improve core muscle activation pattern in NSLBP patients.

Foot drop caused by a movable cystic mass during knee motion.

BACKGROUND: Nerve injury due to a movable cystic mass during knee motion is a rare neuropathy, which can be diagnosed precisely using a dynamic ultrasonogram. OBJECTIVE: To present a case with foot drop and common peroneal neuropathy that involved a movable cystic mass during knee flexion adjacent to the proximal tibiofibular joint. METHODS: Case report. RESULTS: A 47-year-old female was referred to our institute for a right foot drop. Common peroneal nerve (CPN) injury was confirmed by an electrophysiologic study. Upon a dynamic ultrasonographic study during knee flexion, a cystic mass was found that was not scanned on the static images. The mass displaced the lateral head of the gastrocnemius muscle and CPN. A cystic mass that was adjacent to the proximal tibiofibular joint was confirmed by magnetic resonance imaging. CONCLUSION: Ultrasonography is a convenient first-line diagnostic method of peripheral nerve disorder by virtue of its higher spatial resolution, cost-effectiveness, and prompt diagnosis. The real-time and dynamic scanning attributes are the discriminative merits of this imaging tool. This case report suggests that CPN compression occurred due to a movable cystic mass during knee flexion. Dynamic ultrasonographic evaluations could be helpful to diagnose pathologic musculoskeletal conditions.

Modification of therapeutic temperature range in cryotherapy could improve clinical efficacy in tension type headache.

BACKGROUND: Cold pack therapy is not used frequently in clinics in spite of its effectiveness in clinical reports. Low compliance due to cold intolerance may be a disturbance factor that hinders patients from using the modality. OBJECTIVE: To demonstrate the improved compliance and clinical efficacy as new devised cold modality with a different composition is applied to target different therapeutic temperature range in tension-type headache (TTH) patients. METHODS: A randomized, controlled, comparative trial involving 53 patients with tension-type headache was conducted. A new cold modality that targets upper normal therapeutic temperature range was devised and applied to one group (n= 27) and ice pack was applied to the other group (n= 26). RESULTS: After application of two modalities for 4 weeks, the amount of analgesics intake, modality use per week, and Likert survey of cold intolerance were significantly different between the two groups. CONCLUSIONS: Rather than focusing on lowering the skin temperature indefinitely, optimizing tolerability by targeting the temperature at the upper therapeutic range could be more effective in cold modality application.

Feasibility of Navigable Percutaneous Disk Decompressor (L'DISQ-C) for Cervical Disk Herniation.

OBJECTIVE: To assess the procedural efficacy and safety of a Navigable Percutaneous Disk Decompressor (L'DISQ-C) for cervical disk herniation. METHODS: We performed intradiskal decompression on cervical spine specimens from five human cadavers using the L'DISQ-C under C-arm fluoroscopic guidance. We evaluated our success for positioning the navigable wand tip into the target region and recorded temperature variation at various distances from the wand tip in the cervical nucleus pulposus. The histologic effect of plasma decompression was examined microscopically using harvested tissues adjacent to the procedure site. RESULTS: We successfully navigated the tip of the L'DISQ-C into the target region of the posterior cervical disks on the first insertion attempt in all C3-C4 to C6-C7 disks and in 50% of the C2-C3 and C7-T1 disks. The average temperature elevations within the nucleus pulposus ranged from 4.14 ± 0.08°C to 12.17 ± 0.76°C at various distances from the wand tip with or without saline infusion. A histologic examination showed only minor denaturation at the marginal border of the procedure tract. CONCLUSION: We effectively navigated the L'DISQ-C wand tip into the posterior target region of six cadaveric cervical disks and performed percutaneous resection of the target disk tissues without significant thermal or structural damage to adjacent tissues.

Clinical Efficacy of Selective Focal Ablation by Navigable Percutaneous Disc Decompression Device in Patients With Cervical Herniated Nucleus Pulposus.

OBJECTIVE: To evaluate the clinical efficacy and safety following percutaneous disc decompression, using navigable disc decompression device for cervical herniated nucleus pulposus (HNP). METHODS: Twenty subjects diagnosed with cervical HNP and refractory to conservative management were enrolled for the study. The herniated discs were decompressed under fluoroscopic guidance, using radiofrequency ablation device with navigable wand. The sagittal and axial plain magnetic resonance images of the clinically significant herniated disc, decided the space between the herniated base and outline as the target area for ablation. Clinical outcome was determined by Numeric Rating Scale (NRS), Neck Disability Index (NDI), and Bodily Pain scale of Short Form-36 (SF-36 BP), assessed after 48 weeks. After the procedure, we structurally matched the magnetic resonance imaging (MRI) and C-arm images through bony markers. The wand position was defined as being 'correct' if the tip was placed within the target area of both AP and lateral views; if not, the position was stated as 'incorrect'. RESULTS: The average NRS fell from 7 to 1 at 48 weeks post procedure (p<0.05). In addition, statistically significant improvement was noted in the NDI and SF-36BP (p<0.05). The location of the wand tip resulted in 16 correct and 4 incorrect placements. Post-48 weeks, 3 of the incorrect tip cases and 1 correct tip case showed unsuccessful outcomes. CONCLUSION: The study demonstrated the promising results and safety of the procedure. Thus, focal plasma ablation of cervical HNP with navigable wand can be another effective treatment option.

The Factors Associated With the Successful Outcomes of Percutaneous Disc Decompression in Patients With Lumbar Herniated Nucleus Pulposus.

OBJECTIVE: To determine clinical and radiological factors that predict the successful outcome of percutaneous disc decompression (PDD) in patients with lumbar herniated nucleus pulposus (HNP). METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Effectiveness of a new navigable percutaneous disc decompression device (L'DISQ) in patients with lumbar discogenic pain.

OBJECTIVE: This study is a pilot study to assess the clinical outcomes of percutaneous disc decompression using the L'DISQ in patients with lumbar discogenic pain. STUDY DESIGN: An institutional, prospective clinical data analysis. METHODS: We ablated the torn annulus using L'DISQ on 20 patients with axial low back pain for at least 3 months (average 29 months) unresponsive to conservative management. Before the therapeutic procedure, all the patients had been diagnosed with lumbar discogenic pain through provocation discography, which had confirmed the level of painful discs. The torn annulus was identified through lumbosacral magnetic resonance image and computed tomographic discogram. Baseline data were prospectively gathered before the procedure and at 1, 4, 12, 24, and 48 weeks post-procedure. Data included pain intensity (visual analog scale [VAS]), measure of disability (Oswestry Disability Index [ODI] and Rolando-Morris Disability Questionnaire [RM]), and health-related quality of life (Bodily Pain Scale of Short Form-36 version 2 [SF-36 BP]). RESULTS: At 48 weeks, the VAS fell from 7.55 ± 1.28 to 3.60 ± 2.28 scores, the ODI and RM had decreased significantly, and the SF-36 BP showed significant improvement (P < 0.05). The success rates of procedure were 55.0% at 48 weeks. There were no complications with the exception of a minor venous bleeding at the site of needle puncture. CONCLUSIONS: The L'DISQ device is specifically designed to ablate adjacent disc tissue using a wand that can be navigated into a torn annulus. Following ablation, we measured clinically significant pain improvement and decreased disability for patients with axial low back pain.

Percutaneous transforaminal epidural injection method in an experimental rat: minimally invasive drug delivery method to spinal epidural space.

OBJECTIVE: To compare a newly developed minimally-invasive method for percutaneous transforaminal epidural injection (INJ group) with the existing method for lumbar epidural catheterization (CATH group). METHOD: Through anatomical review of experimental rats, the cephalic one fourth of the neural foramen was selected as the target point for drug delivery. After the rats had undergone lumbar epidural catheterization, lidocaine, and 1% methylene blue were injected through the unilateral or bilateral L5/6 neural foramen in the INJ group, and through an epidural catheter in the CATH group. Measurement of body weight and the mechanical allodynia test before and after injection of lidocaine, and fine dissection after injection were performed. RESULTS: Results of the mechanical allodynia test of 1.0% lidocaine 50 µl injection in the CATH group were statistically similar to those of 0.5% lidocaine 100 µl injection in the INJ group. The results of 2.0% lidocaine 50 µl injection in the CATH group were statistically similar to those of 1.0% lidocaine 100 µl injection in the INJ group. After dissection, only one distal partial spinal nerve was stained by methylene blue 50 µl through the transforaminal pathway. However, the dorsal root ganglion, nerve root, and adjacent hemi-partial spinal cord were stained by methylene blue 100 µl through the transforaminal pathway. CONCLUSION: The percutaneous transforaminal epidural injection is practical, easy, and safe, and, in particular, does not cause significant pain compared to the existing lumbar epidural catheterization. We expect this method to be effective in an animal study showing that drug delivery to the spinal epidural space is necessary.

An assessment of a new navigatable percutaneous disc decompression device (l'DISQ) through histologic evaluation and thermo-mapping in human cadaveric discs.

STUDY DESIGN: This is an in vitro experimental study of the technical capability and safety study of a navigable percutaneous disc decompression device named L'DISQ. OBJECTIVES: The objectives of this study were to determine if L'DISQ could adequately reach certain target zones in the disc and to measure the distribution of rises in temperature in the surrounding tissue when the device was used to ablate the disc. METHODS: Placement of the wand of L'DISQ was attempted into the posterior annulus of the discs of four fresh human cadavers. During disc ablation, thermocouple probes were used to measure the temperature within the nucleus pulposus and annulus fibrosus, on the surface of the annulus, and on the posterior longitudinal ligament. Tissues harvested from around the disc were examined histologically. RESULTS: The tip of the wand could be successfully navigated to the posterolateral or posterocentral annulus at all levels above L5-S1 using a lateral approach. Rises in temperature did not exceed 13.25 ± 0.84°C within the disc, and did not exceed 1°C on the surface of the disc. Histology demonstrated no thermal damage to the surrounding neural tissues. CONCLUSION: L'DISQ can be successfully navigated to the target zones, and disc tissue ablated without thermal or structural damage to the adjacent neural tissues.

Ulnar neuropathy at the wrist in a patient with carpal tunnel syndrome after open carpal tunnel release.

Ulnar neuropathy at the wrist is rarely reported as complications of carpal tunnel release. Since it can sometimes be confused with recurrent median neuropathy at the wrist or ulnar neuropathy at the elbow, an electrodiagnostic study is useful for detecting the lesion in detail. We present a case of a 51-year-old woman with a two-week history of right ulnar palm and 5(th) digit tingling sensation that began 3 months after open carpal tunnel release surgery of the right hand. Electrodiagnostic tests such as segmental nerve conduction studies of the ulnar nerve at the wrist were useful for localization of the lesion, and ultrasonography helped to confirm the presence of the lesion. After conservative management, patient symptoms were progressively relieved. Combined electrodiagnostic studies and ultrasonography may be helpful for diagnosing and detecting ulnar neuropathies of the wrist following carpal tunnel release surgery.

Efficacy of a new navigable percutaneous disc decompression device (L'DISQ) in patients with herniated nucleus pulposus related to radicular pain.

STUDY DESIGN: An institutional, prospective clinical data analysis. OBJECTIVE: To evaluate the safety and efficacy of a new navigable percutaneous disc decompression device (L'DISQ) in patients with lumbar disc herniation with radicular pain. METHODS AND OUTCOME MEASURES: We performed disc decompressions using L'DISQ on 27 patients with persistent disabling back and leg pain for 1 month or longer (average 6.48 months) due to a herniated lumbar intervertebral disc. Baseline data were prospectively gathered before the index procedure and at 1, 4, 12, and 24 weeks post-procedure. Data included pain intensity (visual analog scale [VAS]), measure of disability (Oswestry Disability Index [ODI] and Rolando-Morris Questionnaire [RM]), health-related quality of life (Bodily Pain Scale of Short Form-36 version 2 [SF-36 BP]), and passive straight leg raising test (SLR). RESULTS: The VAS fell from 7.08±1.22 to 1.84±0.99 scores at 24 weeks post-procedure. At 24 weeks, the ODI had fallen from 41.88±10.61 to 16.66±8.55% and the RM from 11.52±3.91 to 2.68±1.97 points. The SF-36 BP dropped significant improvement from 32.89±5.83 to 49.57±4.96 scales. In the SLR test, the angular change of 24 weeks showed considerable improvement from 60.20±20.02 to 83.00±14.29 degrees. No major complication occurred, although two cases developed a disc reherniation 1 month post-procedure. CONCLUSIONS: The L'DISQ device is specifically designed to remove herniated disc using a wand that can be navigated into a disc protrusion or extrusion. Following decompression, we measured clinically significant pain improvement and decreased disability for patients with both radicular and axial pain caused by protruded and extruded discs.