True Posterior Communicating Artery Aneurysms with High Risk of Rupture despite Very Small Diameter.

OBJECTIVE: This retrospective study investigated the clinical and angiographic characteristics of ruptured true posterior communicating artery (PCoA) aneurysms in comparison with junctional PCoA aneurysms presenting with a subarachnoid hemorrhage. METHODS: The medical records and radiological data of 93 consecutive patients who underwent three-dimensional rotational angiography and surgical or endovascular treatment for a ruptured junctional or true PCoA aneurysm over an 8-year period were examined. RESULTS: The maximum diameter of the ruptured true PCoA aneurysm (n=13, 14.0%) was significantly smaller than that of the ruptured junctional PCoA aneurysms (n=80, 4.45±1.44 vs. 7.68±3.36 mm, p=0.001). In particular, the incidence of very small aneurysms <4 mm was 46.2% (six of 13 patients) in the ruptured true PCoA aneurysm group, yet only 2.5% (two of 80 patients) in the ruptured junctional PCoA aneurysm group. Meanwhile, the diameter of the PCoA was significantly larger in the true PCoA aneurysm group than that in the junctional PCoA aneurysm group (1.90±0.57 vs. 1.15±0.49 mm, p<0.001). In addition, the ipsilateral PCoA/P1 ratio was significantly larger in the true PCoA aneurysm group than that in the group of a junctional PCoA aneurysm (mean PCoA/P1 ratio±standard deviation, 2.67±1.22 vs. 1.14±0.88; p<0.001). No between-group difference was identified for the modified Fisher grade, clinical grade at admission, and 3-month modified Rankin Scale score. CONCLUSION: A true PCoA aneurysm was found to be associated with a larger PCoA and ruptured at a smaller diameter than a junctional PCoA aneurysm. In particular, the incidence of a ruptured aneurysm with a very small diameter <4 mm was significantly higher among the patients with a true PCoA aneurysm.

Thirteen-week oral toxicity study of fermented ginseng, GBCK25, in Sprague-Dawley rats.

Ginseng (Panax ginseng) is commonly used in Asia as a medicinal herb. In particular, fermented ginseng, GBCK25, has been recently developed to increase ginsenoside absorption. It also has other beneficial biological effects such as hemodynamic and anti-inflammation functions. Here, we investigated the potential toxicity of GBCK25 in Sprague-Dawley rats following 13 weeks of GBCK25 treatment by oral gavage at doses of 250, 500, or 1000 mg/kg/day and reversible toxic effects over a 4-week recovery phase. Ten male and female rats per group were randomly allocated to the main toxicology groups and five male and female rats per group were allocated to the 0 and 1000 mg/kg/day recovery groups, respectively. There was no mortality; significant clinical toxicity or microscopic findings; and changes in body weight, food consumption, hematological parameters, serum biochemistry, or absolute and relative organ weights in any of the groups. In conclusion, there were no toxicological changes upon repeated oral gavage of GBCK25 at doses of 250, 500, or 1000 mg/kg/day in Sprague-Dawley rats over 13 weeks. The no-observed-adverse-effect level of GBCK25 was 1000 mg/kg/day in both sexes of Sprague-Dawley rat.

Clinical and radiological findings of discogenic low back pain confirmed by automated pressure-controlled discography.

OBJECTIVE: Few studies on the clinical spectrum of automated pressure-controlled discography (APCD)-defined positive discs have been reported to date. Thus, the present study was undertaken to analyze clinical parameters critical for diagnosis of discogenic pain and to correlate imaging findings with intradiscal pressures and pain responses in patients with APCD-positive discs. METHODS: Twenty-three patients who showed APCD-positive discs were selected for analysis. CT discogram findings and the degrees of nuclear degeneration seen on MRI were analyzed in comparison to changes of intradiscal pressure that provoked pain responses; and clinical pain patterns and dynamic factors were evaluated in relation to pain provocation. RESULTS: Low back pain (LBP), usually centralized, with diffuse leg pain was the most frequently reported pattern of pain in these patients. Overall, LBP was most commonly induced by sitting posture, however, standing was highly correlated with L5/S1 disc lesions (p < 0.01). MRI abnormalities were statistically correlated with grading of CT discogram results (p < 0.05); with most pain response observed in CT discogram Grades 3 and 4. Pain-provoking pressure was not statistically correlated with MRI grading. However, it was higher in Grade 3 than Grade 4. CONCLUSION: APCD-positive discs were demonstrated in patients reporting centralized low back pain with diffuse leg pain, aggravated by sitting and standing. MRI was helpful to assess the degree of nuclear degeneration, yet it could not guarantee exact localization of the painful discs. APCD was considered to be more useful than conventional discography for diagnosis of discogenic pain.

Clinical relevance of pain patterns in osteoporotic vertebral compression fractures.

Few studies have been conducted to explain the pain patterns resulting from osteoporotic vertebral compression fractures (OVCF). We analyzed pain patterns to elucidate the pain mechanism and to provide initial guide for the management of OVCFs. Sixty-four patients underwent percutaneous vertebroplasty (N=55) or kyphoplasty (N=9). Three pain patterns were formulized to classify pains due to OVCFs: midline paravertebral (Type A), diffuse paravertebral (Type B), and remote lumbosacral pains (Type C). The degree of compression was measured using scale of deformity index, kyphosis rate, and kyphosis angle. Numerical rating scores were serially measured to determine the postoperative outcomes. As vertebral body height (VBH) decreased, paravertebral pain became more enlarged and extended anteriorly (p<0.05). Type A and B patterns significantly showed the reverse relationship with deformity index (p<0.05), yet Type C pattern was not affected by deformity index. Postoperative pain severity was significantly improved (p<0.05), and patients with a limited pain distribution showed a more favorable outcome (p<0.05). The improvement was closely related with the restoration of VBH, but not with kyphosis rate or angle. Thus, pain pattern study is useful not only as a guide in decision making for the management of patients with OVCF, but also in predicting the treatment outcome.

Usefulness of pain distribution pattern assessment in decision-making for the patients with lumbar zygapophyseal and sacroiliac joint arthropathy.

There are currently no initial guides for the diagnosis of somatic referred pain of lumbar zygapophyseal joint (LZJ) or sacroiliac joint (SIJ). We developed a classification system of LZJ and SIJ pain, the ''pain distribution pattern template (PDPT)'' depending on the pain distribution patterns from a pool of 200 patients whose spinal pain source was confirmed. We prospectively applied the PDPT to determine its contribution to clinical decision-making for 419 patients whose pain was presumed to arise from the LZJs (259 patients) or SIJs (160 patients). Forty-nine percent (128/259) of LZJ and 46% (74/160) of SIJ arthopathies diagnosed by PDPT were confirmed by nerve blocks. Diagnostic reliabilities were significantly higher in Type A and C patterns in LZJ and Type C in SIJ arthropathies, 64%, 80%, and 68.4%, respectively. For both LZJ and SIJ arthropathies, favorable outcome after radiofrequency (RF) neurotomies was similar to the rate of positive responses to diagnostic blocks in Type A to Type D, whereas the outcome was unpredictable in those with undetermined type (Type E). Considering the paucity of currently available diagnostic methods for LZJ and SIJ arthropathies, PDPT is useful in clinical decision- making as well as in predicting the treatment outcome.

Diagnostic relevance of pressure-controlled discography.

Discogenic pain is a leading cause of chronic low back pain. The authors investigated the efficacy of pressure-controlled discography to determine its role in clinical decision-making for the management of patients with discogenic pain. Pressure-controlled discography was performed in 21 patients (51 discs) with pain-provocation, followed by post-discography computerized tomography scans. Pain response was classified as positive response and negative response, and measured with visual analog scale scores. Discographic findings were graded by the modified Dallas discogram scale. Elastance, pain provocation on intradiscal pressure, pressure and volume of initial pain response, and pain response intensity were statistically analyzed. Elastance showed significant differences between Grade 0 and Grade 4 and 5. Decreased elastance with positive pain response group was a good indicator to imply that disc degeneration presumably is a pain generator. Results of pain response were well correlated with intradiscal pressure but not with the amount of injected volume. Among 31 discs of Grade 4 and 5, 74% showed negative pain response and 26% showed positive response. It was concluded that pressure-controlled discography was useful to diagnose discogenic pain and excellent guide in decision-making for spinal operations.

Radiofrequency neurotomy of cervical medial branches for chronic cervicobrachialgia.

Chronic neck and arm pain or cervicobrachialgia commonly occurs with the degeneration of cervical spine. Authors investigated the usefulness of radiofrequency (RF) neurotomies of cervical medial branches in patients with cervicobrachialgia and analyzed the factors which can influence the treatment outcome. Demographic data, types of pain distribution, responses of double controlled blocks, electrical stimulation parameters, numbers and levels of neurotomies, and surgical outcomes were evaluated after mean follow-up of 12 months. Pain distribution pattern was not significantly correlated with the results of diagnostic blocks. Average stimulation intensity was 0.45 V, ranging from 0.3 to 0.69, to elicit pain response in cervical medial branches. The most common involvement of nerve branches was C4 (89%), followed by C5 (82%), C6 (75%), and C7 (43%). Among total of 28 patients, nineteen (68%) reported successful outcome according to outcome criteria after 6 months of followup (p=0.001), and eight (42%) of 19 patients reported complete relief (100%) of pain. Four patients showed recurrence of pain between 6 and 12 months. It was therefore concluded that cervical medial branch neurotomy is considered useful therapeutic modality for the management of cervicobrachialgia in selected patients, particularly in degenerative zygapophyseal disorders.