Relationship between first dorsal sacral foramen and lumbar facet joint connecting line in South Korea populations: Retrospective study.

The first sacral nerve root block (S1 nerve root block) is a practical procedure for patients with radiating lower back pain. In general, S1 nerve root block is performed under x-ray fluoroscopy. It is necessary to adjust the position of the patient and angle of fluoroscopy to properly visualize the first dorsal sacral foramen (dorsal S1 foramen). The purpose of this study was to analyze the location of dorsal S1 foramen and lumbar facet joint in S1 nerve root block.A total of 388 patients undergoing x-ray fluoroscopy-guided S1 nerve root block in the prone position were examined. X-ray fluoroscopy was fixed at the corresponding location of facet joint of L4-5 and L5-S1. The relationship of the connecting line vertical to L5-S1 facet joint and upper margin sacrum was evaluated. The surface anatomical relationships between dorsal S1 foramen and lumbar facet joint were assessed.Based on the localization of dorsal S1 foramen, the line drawn from point to upper margin sacrum passed through the dorsal S1 foramen in all cases. The horizontal distance from the spinous process to the dorsal S1 foramen was 25.9 ±â€Š3.0 mm for men and 26.2 ±â€Š1.4 mm for women. The horizontal distance from the between posterior superioriliac spine to the dorsal S1 foramen was 26.2 ±â€Š2.7 mm for men and 26.8 ±â€Š1.7 mm for women. The vertical distance from the upper margin of sacrum to dorsal S1 foramen to the dorsal S1 foramen was 45.6 ±â€Š6.5 mm for men and 43.8 ±â€Š6.0 mm for women.The connecting line vertical to L5-S1 facet joint and upper margin sacrum is located on the same line from the dorsal S1 foramen. For difficult cases of locating dorsal S1 foramen, the lumbar facet joint can assist in predicting the vertical location of the dorsal S1 foramen.

Transsacrococcygeal approach to ganglion impar block for treatment of chronic coccygodynia after spinal arachnoid cyst removal: A case report.

BACKGROUND: Coccygodynia is a pain in the region of the coccyx that radiates to the sacral, perineal area. The cause of the pain is often unknown. Coccygodynia is diagnosed through the patient's past history, a physical examination, and dynamic radiographic study, but the injection of local anesthetics or a diagnostic nerve blockade are needed to distinguish between somatic, neuropathic, and combined pain. Ganglion impar is a single retroperitoneal structure made of both paravertebral sympathetic ganglions. Although there are no standard guidelines for the treatment of coccygodynia, ganglion impar blockade is one of the effective options for treatment. METHODS: Here, we report a 42-year-old female patient presenting with severe pain in the coccygeal area after spinal arachnoid cyst removal. RESULTS: Treatment involved neurolysis with absolute alcohol on the ganglion impar through the transsacrococcygeal junction. Pain was relieved without any complications. CONCLUSION: Our case report offers the ganglion impar blockade using the transsacrococcygeal approach with absolute alcohol can improve intractable coccydynia.

Seborrheic dermatitis treatment with stellate ganglion block: a case report.

Seborrheic dermatitis is a chronic recurrent inflammatory disorder presumed to be caused by increased sebaceous gland secretion, metabolic changes in the cutaneous microflora, and changes in the host immune function. Stellate ganglion block (SGB) is known to increase the blood flow rate without altering the blood pressure, heart rate, or cardiac output, to stabilize hypertonic conditions of the sympathetic nerves, and to affect the endocrine and immune systems. It is used in the differential diagnosis and treatment of autonomic nervous system disorders of the head, neck, and upper limbs. The authors report the first case of successful treatment of a patient with seborrheic dermatitis through repeated SGB trials.

Endotracheal intubation using i-gel® and lightwand in a patient with difficult airway: a case report.

This case report involves tracheal intubation using i-gel® in combination with a lightwand in a patient with a difficult airway, classified as Cormack-Lehane grade 3. I-gel® was used during anesthesia induction to properly maintain ventilation. The authors have previously reported successful tracheal intubation on a patient with a difficult airway through the use of i-gel® and a fiberoptic bronchoscope. However, if the use of a fiberoptic bronchoscope is not immediately available in a patient with a difficult airway, tracheal intubation may be performed by using i-gel® and a lightwand in a patient with difficult airway, allowing the safe induction of anesthesia.

Comparison of dexmedetomidine and epinephrine as an adjuvant to 1% mepivacaine in brachial plexus block.

BACKGROUND: Dexmedetomidine extends the duration of nerve block when administered perineurally together with local anesthetics by central and/or peripheral action. In this study, we compared the duration of nerve block between dexmedetomidine and epinephrine as an adjuvant to 1% mepivacaine in infraclavicular brachial plexus block. METHODS: Thirty patients, scheduled for upper limb surgery were assigned randomly to 3 groups of 10 patients each. We performed brachial plexus block using a nerve stimulator. In the control group (group C), patients received 40 ml of 1% mepivacaine. In group E, patients received 40 ml of 1% mepivacaine containing 200 µg of epinephrine as an adjuvant. In group D, patients received 40 ml of 1% mepivacaine containing 1 µg/kg of dexmedetomidine as an adjuvant. Sensory block duration, motor block duration, time to sense pain, and onset time were assessed. We also monitored blood pressure, heart rate, oxygen saturation and bispectral index. RESULTS: In group D and group E, sensory block duration, motor block duration and time to sense first pain were prolonged significantly compared to group C. However, there was no significant difference between group D and group E. CONCLUSIONS: Perineural 1 µg/kg of dexmedetomidine similarly prolonged nerve block duration compared to 200 µg of epinephrine, but slowed heart rate. Thus, dexmedetomidine is expected to be a good alternative as an adjuvant to local anesthesia in patients who are cautioned against epinephrine.

Comparison of the preventive effects of pretreatment of lidocaine with a tourniquet and a premixed injection of lidocaine on propofol-LCT/MCT injection pain.

BACKGROUND: Lidocaine has been used widely to prevent propofol injection pain. Various methods of administration exist, such as lidocaine premixed with propofol or lidocaine pretreatment using a tourniquet, but it is unclear which method of lidocaine administration is more effective for the prevention of injection pain of propofol LCT/MCT. The purpose of this study was to compare pretreatment of lidocaine with a tourniquet and a premixed injection of lidocaine to prevent injection pain of propofol-LCT/MCT. METHODS: Patients were randomly allocated into the pretreatment group (n = 117) or the premixed group (n = 117). The pretreatment group was pretreated with 2 ml of lidocaine 2%, held with a tourniquet, before propofol-LCT/MCT injection. The premixed group was injected with a premixed solution of propofol-LCT/MCT and 2 ml of lidocaine 2%. To evaluate the incidence and severity of pain, spontaneous verbal expressions of pain, movement of hand, frowning, and moaning were recorded, and the patients were asked to recall their pain with the visual analogue score (VAS) 30 minutes after awakening from anesthesia. RESULTS: Overall, injection pain occurred in 13.7% of the pretreatment group and 15.4% of the premixed group, without any statistical difference (P = 0.71). There was no difference in spontaneous verbal expressions of pain, movement of hand, frowning, and moaning between the two groups. The pain intensity (VAS) also showed no difference between the two groups (P = 0.49). CONCLUSIONS: Pretreatment of lidocaine with a tourniquet showed no more benefit to prevent injection pain of propofol LCT/MCT compared to a premixed injection with lidocaine.

Asymptomatic pneumomediastinum resulting from air in the epidural space -a case report-.

There are no reports regarding pneumomediastinum caused by thoracic epidural block complications. We believe that it is possible to experience an occurrence of pneumomediastinum caused by air in the epidural space after performing a thoracic epidural block using the loss of resistance (LOR) technique with air. We report a witnessed case where pneumomediastinum appeared after a thoracic epidural block. Pneumorrrhachis, paravertebral muscle emphysema, and pneumomediastinum were diagnosed by Positron Emission Tomography-Computed Tomography. Although extremely rare, pneumomediastinum can be caused by an epidural block using LOR technique with air. In order to avoid the above danger, the use of saline or very minimal amount of air is required during a careful LOR technique.

Pyomyositis of the iliacus muscle and pyogenic sacroiliitis after sacroiliac joint block -A case report-.

Sacroiliac joint block can be performed for the diagnosis and treatment of sacroiliac joint dysfunction. Although sacroiliac joint block is a common procedure, complications have not been reported in detail. We report a case of iliacus pyomyositis and sacroiliac joint infection following a sacroiliac joint block. A 70-year-old female patient received sacroiliac joint blocks to relieve pelvic pain. The patient was admitted to the emergency room two days after the final sacroiliac joint block (SIJB) with the chief complaints of left pelvic pain corresponding to a visual analogue scale (VAS) score of 9 and fever. A pelvic MRI indicated a diagnosis of myositis. After 1 month of continuous antibiotic therapy, the patient's erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level remained elevated. A (67)Ga SPECT/CT was done. Abnormal uptake was seen at the left sacroiliac joint (SIJ), and septic sacroiliitis was suspected. The CRP normalized to 0.29 mg/dl and the ESR decreased to 60 mm/hr, and the patient had no fever after 57 days of antibiotic therapy. She was directed for follow up at an outpatient clinic.

Newly developed urinary retention and motor weakness of lower extremities in a postherpetic neuralgia patient.

During the early stage of postherpetic neuralgia, an epidural block on the affected segment is helpful in controlling pain and preventing progression to a chronic state. The main neurologic complication following an epidural block is cord compression symptom due to an epidural hematoma. When neurologic complications arise from an epidural block for the treatment of postherpetic neuralgia, it is important to determine whether the complications are due to the procedure or due to the herpes zoster itself. We report a case of a patient who was diagnosed with herpes zoster myelitis during treatment for postherpetic neuralgia. The patient complained of motor weakness in the lower extremities after receiving a thoracic epidural block six times. Although initially, we believed that the complications were due to the epidural block, it was ultimately determined to be from the herpes zoster myelitis.

Minimal volume of local anesthetic required for an ultrasound-guided SGB.

BACKGROUND: Compared with the blind technique, ultrasound-guided stellate ganglion block (SGB) reduces the amount of local anesthetic needed for a successful block. The purpose of this study is to determine the minimal, optimal volume of local anesthetic required for successful ultrasound-guided SGB and to reduce its adverse effects. METHODS: Thirty-five patients with postherpetic neuralgia and complex regional pain syndrome of the upper extremity and the facial area were selected. For ultrasound-guided SGB by subfacial method, each patient was injected with 0.5% mepivacaine mixed with contrast media in 2 mL, 3 mL, and 4 mL doses at 2-week intervals. After the procedure, the spread of contrast media in the spine was checked by fluoroscopy. Ptosis and conjunctival flushing were rated and recorded. Adverse effects, such as hoarseness, foreign body sensation, swallowing difficulty, and upper arm weakness, were also recorded. RESULTS: Out of the 35 initial patients, the results for 33 patients who received all three SGBs were included in this study. The contrast media spread to 4.80 ± 0.82, 4.94 ± 0.86, and 5.09 ± 0.97 total spinal segments in the 2 mL, 3 mL, and 4 mL groups, respectively. The cephalad spread of contrast media was 2.16 ± 0.74, 2.23 ± 0.85, and 2.30 ± 0.78 spinal segments for the 2 mL, 3 mL, and 4 mL groups, respectively, and the caudad spread of contrast media was 2.64 ± 0.51, 2.70 ± 0.61, and 2.89 ± 0.64 segments in the 2 mL, 3 mL, and 4 mL groups, respectively. There were no significant statistical differences in any segments for the three groups (P > 0.05). Review of the fluoroscopic images showed spread of the contrast media below the C7-T1 junction in all three groups. Ptosis developed in all three groups after the procedure. CONCLUSION: In conclusion, when performing an ultrasound-guided SGB, 2 mL dosage was sufficient for a successful block as the previous, conventional volume. Therefore, when performing an ultrasound-guided SGB, we recommend the 2 mL dosage of local anesthetics for a successful block.

Depth by ultrasound from skin surface to the C6 transverse process while applying pressure.

BACKGROUND: A stellate ganglion block is commonly performed on the anterior tubercle of sixth cervical spine's transverse process. When the procedure is performed, identifying the anatomical landmarks and confirming the depth of the needle insertion to the transverse process are essential for ensuring safety. The purpose of this study was to determine the depth of the needle insertion from the skin to the transverse process for a safe stellate ganglion block. METHODS: One hundred patients were enrolled for this study. The patients' heights, weights, and neck circumferences were measured. In the supine position, the anterior tubercle of the transverse process were palpated and pressed with the examiner's fingers. While spreading the fingers, an ultrasound probe was placed with the same strength as the fingers and the depth from the skin to the transverse process was measured. RESULTS: The mean depth from the skin to the transverse process in men was 9.5 ± 2.7 mm on the left side and 9.7 ± 2.5 mm on the right side, whereas in women, it was 8.0 ± 2.2 mm on the left side and 8.2 ± 2.0 mm on the right side. There was no significant difference between the right and left sides among or between the genders but men showed greater depths than women. Although both genders showed a correlation between body mass index and depth, only men showed a correlation between the neck circumference and depth. CONCLUSIONS: In this study, the mean depth from the skin to the transverse process did not exceed 10 mm in both genders and the maximum depth was 16.6 mm.

Inadvertent discogram during transforaminal epidural injection in patients with lumbar disc herniation -A report of 2 cases-.

The transforaminal epidural injection (TFEI) has been preferred in many cases because it can deliver the injected dose of medication closer to the nerve root and better facilitate ventral epidural flow compared to other methods. However, in patients with deformities not demonstrated on fluoroscopic imaging, the needle may enter unwanted locations. We treated two cases of intradiscal injection of contrast dye, during the TFEI, in patients with lumbar disc herniation.

Transient quadriplegia after fluoroscopic-guided selective cervical nerve root block in a patient who received cervical interbody fusion -A case report-.

Selective cervical nerve root block is executed for patients who have symptoms of cervical radiculopathy for diagnostic and therapeutic purposes. However several catastrophic complications caused by this procedure have been reported including neurological complications. A 43-year-old male received a C5 selective cervical nerve root block procedure due to continuous radiating pain even after cervical discectomy and interbody fusion was performed. At the time of the procedure, the contrast outline revealed reflux of the nerve root and epidural space. But after the procedure was performed, the patient experienced decreased sensation in the upper and low extremities as well as motor paralysis of both extremities. Our sspecting diagnosis was anterior spinal artery syndrome but both sensory and motor functions were subsequently recovered within a few hours after the procedure was completed. Due to the difficult nature of this case, we reported these complications and reviewed current literature related to this study.

Position of dorsal root ganglia in the lumbosacral region in patients with radiculopathy.

BACKGROUND: When applying pulsed radiofrequency on dorsal root ganglia for treating chronic lower back pain, maximum efficiency can be expected when a needle is placed 1-2 cm peripheral to the dorsal root ganglion. The object of this study is to analyze images taken after adding contrast to transforaminal epidural injection, categorize root ganglia according to anatomical position, and provide a reference for efficient needle positioning in applying pulsed radiofrequency on dorsal root ganglia. METHODS: From January 2008 to January 2009, 457 patients who visited our hospital for root pain or radiculopathy were treated with transforaminal epidural injection on the nerve roots based on the dermatome of the painful area. Anteroposterior views were taken after injection of contrast. A virtual line was made by connecting the internal and external parts of the spinal pedicle from the contrast images. Then the dorsal root ganglia were categorized as intraspinal (IS), intraforaminal (IF), or extraforaminal (EF). RESULTS: In the fourth lumbar spine, dorsal root ganglia positions were 48% IF, 41% IS, and 6% EF. In the fifth lumbar spine, dorsal root ganglia positions were 75% IF, 10% IS, and 6% EF. In the first sacral spine, dorsal root ganglia locations were 8% IF and 83% IS. CONCLUSIONS: Positional categorization of dorsal root ganglia according to contrast images was proven to be good anatomical references for effective radiofrequency or blocking of dorsal root ganglia.

Phrenic nerve palsy following coracoid infraclavicular brachial plexus block.

Various methods of infraclavicular brachial plexus block have been introduced in the past, of which Wilson's coracoid infraclavicular brachial plexus block, a more lateral approach, consequently thought to be easier and safer. While only a few cases of transient ipsilateral phrenic nerve palsy after infraclavicular brachial plexus block have been reported, we describe a rare case of phrenic nerve palsy after Wilson's coracoid infraclavicular brachial plexus block.

Hyaline cartilage regeneration using mixed human chondrocytes and transforming growth factor-beta1- producing chondrocytes.

The purpose of this study was to investigate the efficacy of cartilage regeneration when using a mixture of transforming growth factor-beta1 (TGF-beta1)-producing human chondrocytes (hChon-TGF-beta1) and primary human chondrocytes (hChon) ("mixed cells"), compared with either hChon-TGF-beta1 or hChon cells alone. Specifically, mixed cells or hChon cells were first injected intradermally into the backs of immune-deficient nude mice to test the feasibility of cartilage formation in vivo. Both the mixed cells and the hChon-TGF-beta1 cells alone induced cartilage formation in nude mice, whereas hChon cells alone did not. To further test the efficacy of the cells in generating cartilage, an artificially induced partial thickness defect of the femoral condyle of a rabbit knee joint was loaded with hChon-TGF-beta1 cells with or without mixing additional untransduced hChon cells, and hyaline cartilage regeneration was observed at 4 or 6 weeks. The efficiency of complete filling of the defect and the quality of tissue generated after implanting were evaluated on the basis of a histological grading system modified from O'Driscoll et al. (J. Bone Joint Surg. 70A, 595, 1988). Significantly, mixed cells (14.2 +/- 0.9) produced significantly better results than hChon-TGF-beta1 (9.0 +/- 1.7) or hChon (8.0 +/- 1.8) cells alone. Histological and immunohistochemical staining of the newly repaired tissues produced after treatment with either mixed cells or hChon-TGF-beta1 cells alone showed hyaline cartilage- like characteristics. These results suggest that the implantation of mixed cells may be a clinically efficient method of regenerating hyaline articular cartilage.