The Clinical Results of Radial and Focused Extracorporeal Shockwave Therapy on Periscapular Myofascial Pain Syndrome / 대한정형외과학회잡지

Purpose@#In the past 20 years, studies on extracorporeal shock wave therapy in myofascial pain syndrome have been conducted in various ways, but no studies have compared the effects of the radial and focused type directly. This study examined the clinical treatment effects of periscapular myofascial pain syndrome according to the type of extracorporeal shock wave. @*Materials and Methods@#From January 2018 to February 2019, 66 patients were diagnosed with periscapular myofascial pain syndrome and subjected to extracorporeal shock waves. Twenty-four patients were in the radial extracorporeal shock wave treatment group, and 42 patients were in the focused extracorporeal shock wave treatment group. Before starting treatment, the visual analog pain scale, Constant Murley scale, and UCLA score were examined. After six shock wave treatments were completed at intervals of one week, the visual analog pain scale, Constant Murley scale, and UCLA score were re-evaluated. @*Results@#The visual analog pain scale improved from pre-treatment 3.66 points to post-treatment 2.54 points in the radial extracorporeal shock wave treatment group (p=0.007), and improved from pre-treatment 3.26 points to post-treatment 2.52 points in the focused extracorporeal shock wave treatment group (p=0.010). For the shoulder function evaluation, the Constant Murley scale and UCLA score in the radial extracorporeal shock wave treatment group improved from 64.60 points and 24.96 points, respectively, before treatment to 71.76 points and 27.98 points after treatment, respectively (p<0.001, p=0.006). The Constant Murley scale and UCLA score in the focal extracorporeal shockwave treatment group improved from 64.06 points and 25.26 points, respectively, to 72.19 points and 28.80 points after treatment (p<0.001, p<0.001). @*Conclusion@#Both radial and focused extracorporeal shockwave therapy were effective in reducing pain and increasing the shoulder function in patients with periscapular myofascial pain syndrome.

Caudal Epidural Injection with a Catheter in Patients with Failure of Conventional Epidural Blocks

OBJECTIVES@#The purpose of this study was to analyze and report the results of caudal epidural injections using a catheter in patients in whom conventional epidural block had failed.SUMMARY OF LITERATURE REVIEW: Epidural nerve block is often used to treat chronic back pain and radicular pain in degenerative lumbar disease, and percutaneous epidural neuroplasty or surgery may be an alternative if it fails.@*MATERIALS AND METHODS@#In total, 146 patients who were treated with caudal epidural block using a catheter were recruited for this study from January 1, 2015 to June 30, 2019. Forty-five patients who had not undergone any epidural block in the past were excluded from the study. Among patients who did not have a fracture and were followed up for at least 1 month, the medical records of 61 patients with degenerative disc herniation, spondylosis, and stenosis were reviewed retrospectively. Visual analogue scale (VAS) scores were evaluated before and after the procedure.@*RESULTS@#Of the 61 patients who had undergone epidural block through a transforaminal caudal approach with no pain control effect, there were 18 males and 43 females. Their mean age was 66.3 years and the average follow-up period was 2.64 months. There were 46 cases of spinal stenosis, 33 cases of spondylosis, 2 cases of spondylolisthesis, 9 cases of disc herniation and 1 case of ankylosing spondylitis. The mean number of epidural blocks was 5.85 (times) before the procedure. The mean initial VAS score was 5.34 and the final follow-up VAS score was 2.70. There was a significant difference between before and after the procedure (p<0.05). The mean duration of effect after the procedure was 1.84 months and the mean number of procedures was 2.30. After the procedure, there were 4 cases of surgical treatment, 2 cases of neuroplasty, and 3 cases of epidural block using other methods over more than 1 year of follow-up.@*CONCLUSIONS@#The result of this clinical study suggests that caudal epidural injections using a catheter may be effective for patients with low back pain who have not responded to previous epidural blocks before surgical treatment.

Caudal Epidural Injection with a Catheter in Patients with Failure of Conventional Epidural Blocks

STUDY DESIGN: Retrospective study. OBJECTIVES: The purpose of this study was to analyze and report the results of caudal epidural injections using a catheter in patients in whom conventional epidural block had failed. SUMMARY OF LITERATURE REVIEW: Epidural nerve block is often used to treat chronic back pain and radicular pain in degenerative lumbar disease, and percutaneous epidural neuroplasty or surgery may be an alternative if it fails. MATERIALS AND METHODS: In total, 146 patients who were treated with caudal epidural block using a catheter were recruited for this study from January 1, 2015 to June 30, 2019. Forty-five patients who had not undergone any epidural block in the past were excluded from the study. Among patients who did not have a fracture and were followed up for at least 1 month, the medical records of 61 patients with degenerative disc herniation, spondylosis, and stenosis were reviewed retrospectively. Visual analogue scale (VAS) scores were evaluated before and after the procedure. RESULTS: Of the 61 patients who had undergone epidural block through a transforaminal caudal approach with no pain control effect, there were 18 males and 43 females. Their mean age was 66.3 years and the average follow-up period was 2.64 months. There were 46 cases of spinal stenosis, 33 cases of spondylosis, 2 cases of spondylolisthesis, 9 cases of disc herniation and 1 case of ankylosing spondylitis. The mean number of epidural blocks was 5.85 (times) before the procedure. The mean initial VAS score was 5.34 and the final follow-up VAS score was 2.70. There was a significant difference between before and after the procedure (p<0.05). The mean duration of effect after the procedure was 1.84 months and the mean number of procedures was 2.30. After the procedure, there were 4 cases of surgical treatment, 2 cases of neuroplasty, and 3 cases of epidural block using other methods over more than 1 year of follow-up. CONCLUSIONS: The result of this clinical study suggests that caudal epidural injections using a catheter may be effective for patients with low back pain who have not responded to previous epidural blocks before surgical treatment.

Overview of the Management of Chronic Non-Cancer Pain in Patients with Spinal Disease

STUDY DESIGN: Cross-sectional, multi-center survey study. OBJECTIVES: The objective of this study was to investigate the pain status, pain management methods, and pain experience after treatment among patients suffering from chronic non-cancer pain due to spinal disease. SUMMARY OF LITERATURE REVIEW: No thorough investigation of the current status of chronic non-cancer pain management in patients with spinal disease has recently been reported. MATERIALS AND METHODS: We surveyed 330 patients with chronic non-cancer pain who visited spine clinics in Korea. RESULTS: Prior to treatment, 86.7% of the patients had severe pain and 99.4% of the patients had taken oral analgesics for pain control. After treatment, the percent of patients with severe pain was reduced to 42.1%, and 52.4% of patients responded that they experienced intermittent pain. End of dose failure was experienced by 29.1% of patients, and 41.7% of patients experienced pain again 3–6 hours after taking analgesics. Furthermore, 8.2% of patients experienced breakthrough pain, and 29.1% of patients experienced pain that interfered with sleeping. CONCLUSIONS: Many patients with chronic pain reported experiencing pain due to end of dose failure after medication. As the causes of chronic pain are complex, appropriate analgesics should be considered and selected for effective pain management.

Overview of the Management of Chronic Non-Cancer Pain in Patients with Spinal Disease

OBJECTIVES@#The objective of this study was to investigate the pain status, pain management methods, and pain experience after treatment among patients suffering from chronic non-cancer pain due to spinal disease.SUMMARY OF LITERATURE REVIEW: No thorough investigation of the current status of chronic non-cancer pain management in patients with spinal disease has recently been reported.@*MATERIALS AND METHODS@#We surveyed 330 patients with chronic non-cancer pain who visited spine clinics in Korea.@*RESULTS@#Prior to treatment, 86.7% of the patients had severe pain and 99.4% of the patients had taken oral analgesics for pain control. After treatment, the percent of patients with severe pain was reduced to 42.1%, and 52.4% of patients responded that they experienced intermittent pain. End of dose failure was experienced by 29.1% of patients, and 41.7% of patients experienced pain again 3–6 hours after taking analgesics. Furthermore, 8.2% of patients experienced breakthrough pain, and 29.1% of patients experienced pain that interfered with sleeping.@*CONCLUSIONS@#Many patients with chronic pain reported experiencing pain due to end of dose failure after medication. As the causes of chronic pain are complex, appropriate analgesics should be considered and selected for effective pain management.

Changes in the Adjacent Segment After Thoracolumbar Posterior Instrumentation and Fusion Surgery in Thoracolumbar Junction Fractures

STUDY DESIGN: Retrospective study. OBJECTIVES: To evaluate changes in the adjacent segment after posterior instrumentation and fusion in thoracolumbar spinal fractures. SUMMARY OF LITERATURE REVIEW: The incidence of adjacent-segment disease is increasing as spinal surgery becomes more common. Many studies have been conducted on the risk factors for adjacent-segment changes in the lumbar spine, but few articles have been published on this topic in the thoracolumbar spine. MATERIALS AND METHODS: The records of 50 patients who received treatment from 2000 to 2013 were reviewed retrospectively. They underwent posterior instrumentation and fusion due to thoracolumbar fracture and were followed up for more than 2 years. To evaluate changes in the adjacent segment, immediate postoperative and last follow-up values of the sagittal angle, disc height, and disc angle were compared between groups divided by age (more or less than 50 years), laminectomy, and fusion levels. The Pfirrmann grade of the discs proximal and distal to the fusion level was also measured using preoperative magnetic resonance imaging. RESULTS: Thirty-six patients were male and 14 were female. The average age of the 50 patients was 45.6 years, and the mean follow-up period was 4.3 years. There were no cases of adjacent-segment disease. The mean kyphotic sagittal angle progression was 6.8° (range, −11° to 28.5°, p=0.000). The mean change of disc height of the proximal adjacent segment was 0.3 mm (range, −1.6 to 3.4 mm, p=0.013) and 0.6 mm (range, −4.1 to 5.8 mm, p=0.013) in the distal adjacent segment. Laminectomy did not make a significant difference. In the group below 50 years of age, the angle of the adjacent segment discs increased by 0.8° (range, −3.1° to 5.1°, p=0.004) at the proximal adjacent segment and by 0.5°(range, −4.8° to 2.9°, p=0.016) at the distal adjacent segment. Proximal adjacent disc height decreased as the fusion levels increased. As the preoperative Pfirrmann grade increased, degenerative changes in the proximal adjacent segment disc tended to accelerate. CONCLUSIONS: Adjacent-segment disease after lumbar fusion surgery was not found in adjacent segments of the thoracolumbar spine. This seems to be due to the anatomical characteristics of the lumbar spine, which is more flexible than the thoracolumbar vertebra. The mobile segments of the lumbar spine may account for this difference, rather than the instrumentation and fusion procedure itself.

Extensive Intradural Epidermoid Cysts with Cauda Equina Syndrome in the Lumbosacral Spine: Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of extensive epidermoid cysts in the lumbosacral spine. SUMMARY OF LITERATURE REVIEW: The intradural epidermoid cyst with extensive involvement is rare, and previous reports have reported only extensive intramedullary epidermoid cysts. MATERIALS AND METHODS: A 75-year-old male presented with progressive motor weakness of both extremities beginning 3 days prior. MRI showed extensive intradural extramedullary epidermoid cysts in the lumbosacral region. We performed total laminectomy from the L1 to the L5 level, and the cystic mass was removed. RESULTS: We confirmed the epidermoid cyst on histopathologic examination. CONCLUSIONS: Extensive extramedullary epidermoid cysts are difficult to remove completely. Attempting complete removal may result in neurological deficit. Therefore, when surgical intervention is planned, the poor postoperative prognosis should be taken into consideration.

Multifocal Extensive Spinal Tuberculosis Accompanying Isolated Involvement of Posterior Elements: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of atypical spinal tuberculosis. SUMMARY OF LITERATURE REVIEW: In spinal tuberculosis, non-contiguous multifocal involvement and isolated involvement of posterior elements of the spine have been considered atypical features. There have been a few reports of each of these atypical features but no reports have described spinal tuberculosis with both of these atypical features. MATERIALS AND METHODS: A 39-year-old man presented with back pain and progressive weakness of both lower extremities. He was diagnosed with spinal tuberculosis from the cervical to sacral spine, showing multifocal non-contiguous involvement with multiple abscesses on magnetic resonance imaging. Notably, in the thoracic spine area, isolated involvement of posterior elements was found with an epidural abscess compressing the spinal cord. He underwent a total laminectomy of the thoracic spine and multiple abscesses were drained with pigtail catheter insertions into the cervical, thoracic, and lumbar spine. RESULTS: At the 8-month follow-up, the patient's neurologic status had improved to Frankel Grade D, and the patient was able to walk with the support of a walker. At the 3-year follow-up, the patient had recovered completely without any neurologic deficit. CONCLUSIONS: Since atypical spinal tuberculosis may show various patterns, examination of the entire spine is important for early diagnosis. Treatment should be provided properly from minimally invasive procedures to open surgery depending on the extent of structural instability and neurologic deficit.

Relationship of the Pre-operative Condition of Paravertebral Muscle with Post-operative Functional Disability in Patients with Degenerative Lumbar Spinal Disease

STUDY DESIGN: A retrospective study on the outcomes of surgical treatment for degenerative lumbar spinal disease. OBJECTIVES: To evaluate the pre-operative paravertebral muscle condition as a predictive factor in patients with degenerative lumbar spinal disease who undergo surgery. SUMMARY OF LITERATURE REVIEW: Previous studies have reported that the atrophy of the paravertebral muscle is associated with chronic low back pain. However, few studies have reported on the relationship of the pre-operative paravertebral muscle status with the postoperative functional disability scale. MATERIALS AND METHODS: In this study, we reviewed the history of 20 patients with degenerative lumbar spinal disease treated by decompression and posterior lumbar interbody fusion with posterior instrumentation between 2010 and 2011. The evaluation included the paravertebral muscle volume, fat infiltration on magnetic resonance imaging (MRI), preoperative lumbar lordosis, levels operated on, and the Oswestry Disability Index (ODI). Further, the inter-relationship of the pre-operative paravertebral muscle status, lumbar lordosis, and levels operated on with the post-operative ODI was analyzed. RESULTS: The mean cross-sectional area (CSA) of the paravertebral muscle at the L3-4 and L4-5 levels was 21.9+/-3.4 cm2 and 21.4+/-3.3 cm2, respectively. The mean pre- and post-operative lumbar lordotic angle was 41.0+/-17.5degrees, and 42.3+/-11.1degrees, respectively. The lumbar lordotic angle and the levels operated on were not correlated with the post-operative ODI. However, the CSA of the paravertebral muscle at the L3-4 (r=-0.582, p<0.01) and L4-5 (r=-0.568, p<0.01) levels showed a negative correlation with the post-operative ODI. The levels operated on showed a positive correlation with the post-operative ODI (r=0.420, p<0.01). CONCLUSIONS: The mean CSA of the paravertebral muscle and the levels operated on in patients with degenerative lumbar spinal disease have a significant correlation with the post-operative clinical outcome.

Analysis of Grip and Pinch Strength in Korean People / 대한정형외과학회잡지

PURPOSE: We wanted to investigate the grip and pinch strength of hands and establish the clinical normative data for Korean people. MATERIALS AND METHODS: A sample of 234 Korean males and 281 Korean females (age: 10 to 84) were tested. Grip strength and pinch strength were tested twice with 5 minute interval between tests. RESULTS: Generally, hand strength peaked at 30 to 39 of age for both males and females. The average grip strength was 48.8 kg for males and 28.23 kg for females and they were 11% stronger than 12 years before in both groups. Tip pinch strength peaked in the forties, but key pinch and tripod pinch peaked in the thirties. All the peak hand strength was obtained in the 30 to 39 age group of females. Among the pinch strengths, key pinch was the strongest. For the right-handed people, the grip and pinch strengths of the right hand were stronger than those of the left hand. However, for the left-handed people, the left hand was stronger than the right hand only for the tripod pinch (p<0.005). CONCLUSION: The hand strength of Koreans peaked in the 30 to 39 age group. Key pinch was the strongest among the three pinch strengths. Right-handed people have a stronger right hand than the left hand, but the left-handed people have almost the same hand strength in both hands, except for the tripod pinch.

Bony Landmarks for Determining the Mechanical Axis of the Femur in the Sagittal Plane during Total Knee Arthroplasty

BACKGROUND: There is no accepted landmark for the mechanical axis of the femoral axis in sagittal plane in conventional total knee arthroplasty. METHODS: As palpable anatomic landmarks of the femur, lateral epicondyle, and anterior margin of the greater trochanter were identified. The line connecting these two landmarks was defined as the "palpable sagittal axis". The mechanical axis of the femur was compared with the palpable sagittal axis and the distal femoral anterior cortex axis. These axes were also compared with sagittal bowing of the femur. RESULTS: The distal femoral anterior cortex axis and the palpable sagittal axis were flexed by 4.1degrees and 2.4degrees more than the sagittal mechanical axes, respectively (p < 0.05). However, the palpable sagittal axis was not correlated with sagittal bowing of the femur (Spearman's rs, 0.17; p = 0.14). CONCLUSIONS: The palpable sagittal axis showed a consistent relationship with the sagittal mechanical femoral axes regardless of the severity of the sagittal bowing of the femur.

Comparison of Radiologic and Clinical Results between Locking Compression Plate and Unlocked Plate in Proximal Humerus Fractures

PURPOSE: The purpose of this study is to compare the results of using a locking compression plate and an unlocked plate for treating proximal humeral fractures. MATERIALS AND METHODS: This study was based on 20 patients who underwent plate fixation for proximal humeral fractures out of the 87 patients with proximal humeral fractures and who were admitted from 2003 to 2007 in our hospital. Of the 20 patients, 10 were treated with a locking compression plate and the other 10 were treated with an unlocked plate. Each group was evaluated according to the humeral neck shaft angle, the period until bony union, the complications and the Constant score. The humeral neck shaft angle was based on plain x-rays taken immediately after the operation and at 6 months postoperatively. The Constant score was evaluated on the last visit to our clinic. RESULTS: There was no significant statistical difference between the two groups in terms of the neck shaft angle, the period until bony union and the Constant score. Yet, there were three cases of screw migration in the unlocked plate group. CONCLUSION: There was no significant difference between the two groups in terms of the neck shaft angle, the period until bony union and the Constant score. The locking compression plate is considered to achieve more effective fixation for proximal humerus fractures because there were less complications such as screw migration.

Effectiveness of Arterial Embolization in Hemodynamically Unstable Pelvic Fracture

Purpose: To assess the effectiveness and appropriate time for arterial embolization with angiography in patients who sustained a hemodynamically unstable pelvic bone fracture Materials and methods: Nineteen cases with hemodynamically unstable pelvic bone fractures that were managed with arterial embolization out of 287 pelvic bone fractures between May, 2002 and February, 2007 were reviewed retrospectively. The blood pressure, pulse rate, hemoglobin, prothrombin time, partial prothrombin time and platelet checked were evaluated immediately after arrival at the emergency room, before and after embolization. Repeated measures analysis of variance was used for the statistical evaluation. Results: The blood pressure showed a statistically significant increase from before and after embolization. The hemoglobin and prothrombin time checked upon arrival were significantly lower than those checked before embolization. In addition, the hemoglobin and prothrombin time was significantly higher before embolization than after embolization. The partial thromboplastin time and platelet checked immediately upon arrival were significantly lower than those checked before embolization. Conclusion: Interventional angiography and embolization can be an effective treatment modality in patients with hemodynamically unstable pelvic bone fractures showing rapid changes in the hemoglobin level, prothrombin time, partial thromboplastin time and platelet count but little response to fluid and transfusion resuscitation,.