• The Korean Journal of Pain
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• v.10 no.2
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• pp.270-273
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• 1997

Caudal epiduroscopy has been introduced as an alternative technique for direct injection of epidural steroid and lysis of adhesion. Futher, it gives a better understanding of the role of epidural adhesion in recurrence of sciatica and low back disorder after surgery. We experienced a clinical application of flexible fiberoptic epiduroscope inserted through the sacral canal. A 37-year-old woman was suffering from right lumbar radiculopathy after an operation for a herniated disc. A series of volumetric caudal steroid injections and physical therapy had little effect on her symptoms. Patient was thought to be a good candidate for epiduroscopy. Flexible flberoptic epiduroscopy was as follows: 60 ml of normal saline irrigation and epidurogram, 40 mg of triamcinolone in 10m1 of normal saline was directed around right L5 nerve root. The following morning, patient reported reduced pain in her leg.

• The Korean Journal of Pain
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• v.2 no.1
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• pp.61-65
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• 1989

Chloroma is a localized myeloblastic tumor which may develop during the course of myelogenous leukemia or as a presenting sign of the disease. A 47-year-old female diagnosed as chronic myelogenous leukemia in her hematologic remission period complained of left lower leg pain. The lumbar-spine series showed multiple osteolytic changes in the left lateral border of the lumbar spine. An inhomogenous soft tissue mass involving left lateral aspects of lumbar vertebrae was identified by CT-scanning. At the first pain attack, lumbar epidural steroid and local anesthetic injection could abolish her pain and the patient could go a few days without pain. The following radiation therapy could also improve the symptom and retain the pain free interval. One month later, a second pain attack occurred and lumbar and caudal epidural steroid and local anesthetic injections could result only in an incidental relief of pain. Radiation and chemotherapy were started but failed to relieve pain. A neurolytic block was considered but the patient's general condition was aggravated and even verbal communication with her became impossible.

• The Korean Journal of Pain
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• v.23 no.1
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• pp.18-23
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• 2010

Background: Complications following lumbar transforaminal epidural injection are frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection. The generally accepted technique during epidural steroid injection is intermittent fluoroscopy. In fact, this technique may miss vascular uptake due to rapid washout. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. However, when vascular contrast patterns are overlapped by expected epidural patterns, it is hard to distinguish them even on live fluoroscopy. Methods: During 87 lumbar transforaminal epidural injections, dynamic contrast flows were observed under live fluoroscopy with using digital subtraction enhancement. Two dynamic fluoroscopy fluoroscopic images were saved from each injection. These injections were performed by five physicians with experience independently. Accuracy of live fluoroscopy was determined by comparing the interpretation of the digital subtraction fluoroscopic images. Results: Using digital subtraction guidance with contrast confirmation, the twenty cases of intravascular injection were found (the rate of incidence was 23%). There was no significant difference in incidence of intravascular injections based either on gender or diagnosis. Only five cases of intravascular injections were predicted with either flash or aspiration of blood (sensitivity = 25%). Under live fluoroscopic guidance with contrast confirmation to predict intravascular injection, twelve cases were predicted (sensitivity = 60%). Conclusions: This finding demonstrate that digital subtraction fluoroscopic imaging is superior to blood aspiration or live fluoroscopy in detecting intravascular injections with lumbar transforaminal epidural injection.

• The Korean Journal of Pain
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• v.22 no.1
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• pp.92-95
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• 2009

Transverse myelitis is a focal inflammatory disorder of the spinal cord characterized by motor, sensory, and autonomic dysfunction. A 41-year-old man with transverse myelitis and no pre-existing neurologic disease presented with hypesthesia, numbness, weakness in the both lower extremities, back pain, decreased libido, constipation, and dysuria. A MRI test showed intramedullary high signal intensity between T4 and T8 on a T2-weighted image. After high-dose intravenous methylprednisolone and oral prednisolone therapy, he showed facial swelling and acneiform eruption. Therefore, we injected 40 mg methylprednisolone via an epidural route. A 7-dose serial treatment improved most symptoms. A follow up MRI showed radiological improvement. We report a case of transverse myelitis treated by epidural steroids.

• Journal of Acupuncture Research
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• v.40 no.1
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• pp.78-89
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• 2023

This paper presents the clinical outcome of an 82-year-old female who experienced sudden back pain combined with lower limb paresthesia and weakness after epidural steroid injection. The magnetic resonance imaging of the thoracolumbar spine showed a spinal epidural hematoma (SEH) extending from T8 to L4. She was treated non-operatively in the traditional Korean medicine (TKM) hospital. The patient's progress was assessed using the Numerical Rating Scale (NRS), American Spinal Injury Association (ASIS), Spinal Cord Independence Measure version III (SCIM III), and self-reported symptoms. During the 22-day hospitalization period,the NRS score decreased from 7 to 2 points, the motor score on the ASIS scale increased from 65 to 95 points. The subjective sense of lower extremities was felt by 1 increased to 8. The SCIM III score increased from 32 to 69 points. These results suggest that TKM could effectively reduce pain and aid the rehabilitation of patients with SEH.

• The Korean Journal of Pain
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• v.33 no.2
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• pp.192-198
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• 2020

Background: Previous studies have shown varying results between lumbosacral transforaminal epidural steroid injections (TFESIs) performed with particulate versus non-particulate corticosteroids. The purpose of this study was to investigate the difference in pain relief and functional improvement between particulate and nonparticulate lumbosacral TFESIs in patients who had undergone both injections, sequentially. Methods: This was a self-controlled, retrospective study of 20 patients who underwent both a methylprednisolone and a dexamethasone TFESI to the same vertebral level and side. Primary outcomes included pain relief according to the visual analogue scale (VAS) and functional improvement determined by a yes/no answer to questions regarding mobility and the activities of daily living. Post-injection data was recorded at 2, 3, and 6 months. Results: A decrease in VAS scores of -3.4 ± 3.0 (mean ± standard deviation), -3.1 ± 3.1, and -2.8 ± 3.4 was seen for the methylprednisolone group at 2, 3, and 6 months, respectively. Similar decreases of -3.9 ± 3.5, -3.4 ± 2.8, and -2.3 ± 3.4 were seen in the dexamethasone group. There was no significant difference in pain relief at any point between the two medications. The percentage of subjects who reported improved function at 2, 3, and 6 months was 65%, 51%, and 41%, respectively, for the methylprednisolone group and 75%, 53%, and 42% for the dexamethasone group. Conclusions: These findings support the use of non-particulate corticosteroids for lumbosacral TFESIs in the context of documented safety concerns with particulate corticosteroids.

• The Korean Journal of Pain
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• v.21 no.2
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• pp.136-142
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• 2008

Background: A transforaminal epidural steroid injection (TFESI) is one of the methods for the conservative treatment of the lumbar spinal stenosis. As efforts to prolong the therapeutic duration and to predict the outcome of TFESI are very important, we analyzed factors considered to be associated with the therapeutic duration of a TFESI. Methods: Between August 2006 and March 2007, 69 patients (Group A: patients with no pain relief, Group B: patients with pain relief of less than 6 months, Group C: patients with pain relief of more than 6 months) who failed to the medical treatment were included to undertake a fluoroscopic-guided TFESI. Prior to treatment, the VAS (visual analogue scale), ODI (Oswestry disability index), BDI (Beck depression inventory), and BAI (Beck anxiety inventory) scores were determined to evaluate the degree of pain, disability, and psychological status. The VAS and ODI scores were used to assess the degree of pain relief. To identify the total duration of pain relief, regular outpatient visits for six months were conducted, and for the patients who were not able to visit the outpatient clinic regularly, outcome was assessed by telephone interviews after six months. Results: The dural sac cross-sectional area (DSCSA), ODI, pain duration, BDI, BAI, and age showed similar distribution for patients in the A, B, and C groups. Conclusions: The DSCSA, ODI, pain duration, BDI, BAI, and age were not associated with the therapeutic duration of TFESI in lumbar spinal stenosis patients.

• The Korean Journal of Pain
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• v.20 no.1
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• pp.26-30
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• 2007

Background: Epidural steroid injections (ESI) are a common treatment for spinal disorders. Previous research has shown that aspiration of the syringe is not a sensitive test for placement of an intravascular needle. Serious complications have been reported from injection of steroids and local anesthetics into the vascular space. In addition to safety concerns, the efficacy may decline with partial injection outside the desired epidural location. We hypothesized that incidence of vascular problems is increased in patients who undergo spine surgery compared with the patients who don't undergo spine surgery. We investigated the incidence of vascular problems during lumbosacral transforaminal ESI and we compared the difference of vascular problems between the patients who undergo spinal surgery and those patients who don't undergo spinal surgery. Methods: Two hundreds and three patients were consecutively recruited and they received 299 fluoroscopically guided lumbosacral transforaminal ESIs. Injection of contrast was performed under live dynamic fluoroscopy with using digital substraction analysis. The observed uptake pattern was classified into one of three categories: flashback, aspirated, and positive contrast with negative flashback and aspiration. Results: The vascular incidence rate was 20.4%. Transforaminal ESIs performed at S1 had avascular incidence rate of 27.8% compared with 17.7% for all the other lumbar injection sites. The sensitivity of spontaneous observation of blood in the needle hub or blood aspirate for predicting an intravascular injection in lumbar transforaminal ESIs was 70.4%. Conclusions: There is a high incidence of intravascular problems when performing transforaminal ESIs, and this is significantly increased in patients with previous spine surgery. Using a flash or blood aspiration to predict an intravascular injection is not sensitive therefore; a negative flash or aspiration is not reliable. Fluoroscopically guided procedures without contrast confirmation are prone to instill medications intravascularly. This finding confirms the need for not only fluoroscopic guidance, but also for contrast injection instillation when performing lumbosacral transforaminal ESIs, and especially for patients with previous spine surgery.

• The Korean Journal of Pain
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• v.34 no.4
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• pp.509-533
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• 2021

Background: Postherpetic neuralgia (PHN) is a refractory complication of herpes zoster (HZ). To prevent PHN, various strategies have been aggressively adopted. However, the efficacy of these strategies remains controversial. Therefore, we aimed to estimate the relative efficacy of various strategies used in clinical practice for preventing PHN using a network meta-analysis (NMA). Methods: We performed a systematic and comprehensive search to identify all randomized controlled trials. The primary outcome was the incidence of PHN at 3 months after acute HZ. We performed both frequentist and Bayesian NMA and used the surface under the cumulative ranking curve (SUCRA) values to rank the interventions evaluated. Results: In total, 39 studies were included in the systematic review and NMA. According to the SUCRA value, the incidence of PHN was lower in the order of continuous epidural block with local anesthetics and steroids (EPI-LSE), antiviral agents with subcutaneous injection of local anesthetics and steroids (AV + sLS), antiviral agents with intracutaenous injection of local anesthetics and steroids (AV + iLS) at 3 months after acute HZ. EPI-LSE, AV + sLS and AV + iLS were also effective in preventing PHN at 1 month after acute HZ. And paravertebral block combined with antiviral and antiepileptic agents was effective in preventing PHN at 1, 3, and 6 months. Conclusions: The continuous epidural block with local anesthetics and steroid, antiviral agents with intracutaneous or subcutaneous injection of local anesthetics and a steroid, and paravertebral block combined with antiviral and antiepileptic agents are effective in preventing PHN.

• The Korean Journal of Pain
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• v.32 no.3
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• pp.178-186
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• 2019

Background: Epidural steroid injections (ESIs) have been widely used in managing spinal pain. Dexamethasone has recently emerged as a useful drug in this setting, relative to particulate steroids, although the associated systemic effects have not been fully elucidated. This study aimed to investigate the incidences and types of systemic effects after fluoroscopically guided ESI with dexamethasone. Methods: This retrospective study included 888 ESIs with dexamethasone (fluoroscopically guided at the cervical and lumbosacral levels) performed on 825 patients during January to June 2017. Data regarding systemic effects were collected via telephone interviews using a standardized questionnaire at 2 weeks after the procedure. Data on patient demographic, clinical, and procedural characteristics were collected and analyzed to identify factors that were associated with systemic effects. All statistical analyses were performed using the chi-squared test. Results: Among the 825 patients, 40 patients (4.8%) experienced systemic effects during the 2-week follow-up period. The most common systemic effect was facial flushing (12 patients, 1.5%), which was followed by urticaria (7 patients, 0.8%) and insomnia (7 patients, 0.8%). A history of spine surgery was significantly associated with the occurrence of systemic effects (P = 0.036). Systemic effects were significantly more common for injections at the cervical level than at the lumbar level (P = 0.019). Conclusions: Approximately 4.8% of the patients who underwent ESI with dexamethasone experienced minor and transient systemic effects. These effects were more common in patients who had undergone a previous spine surgery or received a cervical ESI.