BACKGROUND: The transforaminal (TF) epidural steroid injection (ESI) is suggested as more effective than the interlaminar (IL) route due to higher delivery of medication at the anterior epidural space. However, serious complications such as spinal cord injury and permanent neural injury have been reported. The purpose of this study is to evaluate and compare the clinical effectiveness, technical ease, and safety of the TF and parasagittal IL (PIL) ESI. METHODS: A total of 72 patients were randomized to either the PIL group (n = 41) or the TF group (n = 31) under fluoroscopic guidance. Patients were evaluated for effective pain relief by the numerical rating scale (NRS) and Oswestry Disability Index (ODI) (%) before and 2 weeks after the ESI. The presence of concordant paresthesia, anterior epidural spread, total procedure time, and exposed radiation dose were also evaluated. RESULTS: Both the PIL and TF approach produced similar clinically significant improvements in pain and level of disability. Among the 72 patients, 27 PIL (66%) and 20 TF (64%) patients showed concordant paresthesia while 14 (34%) and 11 (36%) patients in the same respective order showed disconcordant or no paresthesia. Radiation dose and total procedure time required were compared; the PIL group showed a significantly lower radiation dose (30.2 ± 12 vs. 80.8 ± 26.8 [Cgy/cm²]) and shorter procedure time (96.2 ± 31 vs. 141.6 ± 30 seconds). CONCLUSIONS: ESI under fluoroscopic guidance with PIL or TF approach were effective in reducing the NRS and ODI. PIL ESI was a technically easier and simple method compared to TF ESI.
Epidural Space ; Humans ; Methods ; Paresthesia ; Spinal Cord Injuries ; Treatment Outcome*

A model that provides reproducible, submaximal yet sufficient spinal cord injury is needed to allow experiments leading to development of therapeutic techniques and prediction of clinical outcome to be conducted. This study describes an experimental model for spinal cord injury that uses three different volumes of balloon inflation and durations of compression to create a controlled gradation outcome in adult dogs. Twenty-seven mongrel dogs were used for this study. A 3-french embolectomy catheter was inserted into the epidural space through a left hemilaminectomy hole at the L4 vertebral arch. Balloons were then inflated with 50, 100, or 150 microliter of a contrast agent at the L1 level for 6, 12, or 24 h and spinal canal occlusion (SCO) measured using computed tomography. Olby score was used to evaluate the extent of spinal cord injury and a histopathologic examination was conducted 1 week after surgery. The SCO of the 50, 100, and 150 microliter inflations was 22-46%, 51-70%, and 75-89%, respectively (p < 0.05). Olby scores were diminished significantly by a combination of the level of SCO and duration of inflation in all groups. Olby scores in the groups of 150 microliter-12 h, 150 microliter-24 h, and 100 microliter-24 h were 0.5, 0, and 1.7, respectively. Based on these results, a SCO > 50% for 24 h, and > 75% for 12 h induces paraplegia up to a week after spinal cord injury.
Animals ; Balloon Dilatation/*methods ; *Disease Models, Animal ; *Dogs ; Epidural Space/injuries ; Spinal Cord Compression/*etiology/pathology ; Tomography, X-Ray Computed

Epidural morphine has been used successfully for the relief of acute or chronic pain by direct injection or catheter method. We report the use of morphine for postoperative pain control in 18 herniated lumbar disc patients. These patients were compaired with 25 others who were not received epidural morphine. Without using of epidural catheter, single small dose morphine(3~5mg) in 1.5ml normal saline was administered under the direct infution into the epidural space just before closure of the lumbar operative wound. Epidural morphine group required only 2 times of parenteral narcotics injections within the first 24 hours after lumbar laminectomy, whereas nonmorphine group required 48 injections. The average narcotics injection frequencies were statistically significant(p<0.01). Hypotension were occured in three cases and pruritus in two cases. But more investication and study were needed for hypotension which was true side effect or not. Respiratory depression was not occured.
Catheters ; Chronic Pain ; Epidural Space ; Humans ; Hypotension ; Laminectomy* ; Morphine* ; Narcotics ; Pain, Postoperative ; Pruritus ; Respiratory Insufficiency ; Wounds and Injuries

A number of reports have shown that intrathecal and epidural administration of morphine provides acute or chronic pain relief. We report the use of morphine for postoperative pain control in 84 lumber laminectomy patients. These patients were compared to the 24 control patients. Single dose of morphine in 0.5ml saline was administered under the direct vision into the intrathecal or the epidural space just before the closure of the lumbar operative wound. Intrathecal group was divided into 4 subgroups 0.2mg, 0.5mg, 1mg and 2mg and epidural group was also divided into 2 subgroups 2mg, 5mg, respectively. Under the visual pain analogue scale, postoperative pain control were statistically significant in intrathecal 0.5mg, 1mg and epidural 2mg, 5mg group, respectively(P<0.01). Respiratory depression was occurred in 2 cases of intrathecal 2.0mg group and nausea with vomiting was occurred in 10 cases but prutitus was not occurred. Urinary Retention was developed between 86.7% and 100% of study group compared to 45.8% of control group.
Chronic Pain ; Epidural Space ; Humans ; Laminectomy* ; Morphine* ; Nausea ; Pain, Postoperative* ; Respiratory Insufficiency ; Urinary Retention ; Vomiting ; Wounds and Injuries

Recent studies have shown that narcotic druga produce an unusually intense, prolonged and segmental analgesic action in man when injected into the spinal subarachnoid or epidural space (Wang et al, 1979; Behar et al, 1979; Cousins et al, 1979; Magora et al, 1980, Johnston and McCaughey, 1980). Since 1960, many investigatora claimed that low molecular weight(LMW) dextran increased the clinical duration of lidocaine(Loder, 1960; Loder, 1962), tetracaine(Chinn and Wirjoatmadja, 1967) and bupivacaine(Kaplan et al, 1975) in man but the mechanism of the action of dextran was unclear. But Curtiss and Scurlock(1979), and Buckley and Fink(1979) claimed that LMW dextran has no effect on the duration of action of bupivacaine in animal studies. The present study was performed to evaluate the clinical efficacy of analgesia by the thoracic epidural injection of morphine and bupivacaine mixture for the relief of pain due to fractured or contused ribs, to evaluate the duration of analgesic effect by the use of the above mixture in a hypertonic solution(dextran 70 or 50% dextrose in water) and to observe the possibility of improvement in the lung function after the pain block. The complications following the pain block were also observed. The 50 single thoracic epidural injections of the mixture were divided into three groups: Group 1(n=15) served as a control group and drugs used for the relief of pain were as follows(Mean+/-S.D.): morphine(2.13+/-1.64 mg), 0.5% bupivacaine(3.10+/-1.04 ml) and 0.9% saline(3.64+/-1.11 ml). Group 2(n=16) served as an experimental group and drugs were as follows(Mean+/-S.D.): morphine(2.13+/-0.72 mg), 0.5% bupivacaine(3.06+/-0.77 ml) and dextran 70(3.75+/-1.29 ml). Croup 3(n=19) served as an experimental group and drugs were as followa(Mean+/-S.D.): morphine(2.42+/-0.51 mg), 0.5% bupivacaine(3.21+/-0.71 ml) and 50% dextrose in water(3.68+/-1.11 ml). The results are were follows: 1) The number of patients who obtained excellent and good analgesic effecta following the block were greater in the experimental Group 2(94%) and Group 3 (90%) than those of the control GrouP 1 (80%). 2) The duration of pain relief which lasted more than 3 days after the epidural block was longer in the experimental Group 2 (81%) and Group 3 (75%) than those of the control Group 1(67%). 3) The pulmonary reserve(FVC%+FEV1.0%) of 27 caaes who were treated by the pain block between 1 and 31 days following the chest injury was increased to about 13% than those before the block, and that of 13 cases between 32 and 82 days following the chest injury was decreased to about 4% than those before the block. 4) Of the complications following the pain block, there were 5 cases(10%) of nausea within 2 hours following the block, 4 cases(8%) of vomiting after 2 hours following the block, 10 cases(20%) of pruritus after 3-4 houra following the block, 17 cases(34%) of transient urinary retention which lasted 8 to 19 hours, 3 cases(6%) of headache within 2 hours following the block and 2 caaes(4%) of dural puncture. In conclusion, it is suggested that the clinical duration of analgesic effect produced by morphine and bupivacaine mixture can he prolonged by addition of the hypertonic solution to the mixture.
Analgesia* ; Animals ; Bupivacaine* ; Croup ; Dextrans ; Epidural Space ; Glucose ; Headache ; Humans ; Injections, Epidural ; Lung ; Morphine* ; Nausea ; Pruritus ; Punctures ; Ribs ; Thoracic Injuries ; Urinary Retention ; Vomiting

BACKGROUND: Although thoracic epidural analgesia is a common practice in neuroaxial blockade for effective post-operative pain relief especially in major abdominal or thoracic surgery, difficult access to the thoracic epidural space is a frequent problem and can cause neurological complications like spinal cord injury and total spinal block. To minimize complications, we should to guess the distance for thoracic epidural space before this procedure. METHODS: One hundred fifty patients having preoperative upper abdominal computed tomography (CT) for diagnosis of their disease presented to major abdominal operation requiring mid-thoracic epidural analgesia for postoperative pain relief. The patient was placed in the sitting position and the levels of T7 and T8 spinous processes were identified. Using a paramedian approach with loss of resistance technique, when the insertion angles of Tuohy needle was measured by a protractor; inward angle (alpha) to the sagittal plane and downward angle (beta) to the transverse section of the spine. Entry of the needle into the epidural space, actual length (A) of the needle was marked and then measured with a ruler. Reviewing the abdominal CT films using the Picture Archiving and Communication System (PACS), the distance (B) from epidural space to skin on the transverse CT plane was measured at the corresponding to T7-T8 seemed to the level of the lowest scapular. The estimated length (Ac) of the skin to the epidural space was calculated by principle of trigonometry with alpha, beta and B. RESULTS: Mean (SD) age, height, weight, BMI were 56 (11) yr, 164 (6.9) cm, 61 (11.5) kg, and 37 (6.2) kg/m2, respectively. The A, B, Ac value and alpha, beta were 5.4 (0.77), 4.3 (0.76), 5.4 (0.85), 12 (3.4)o, 33 (9.6)o. There were significant correlation of both actual length of the needle and the estimated distance on CT film. Actual length of the needle tended to have 1.25 times longer than the estimated distance on CT film. There were also significances both A and weight, BMI, but not age, height. CONCLUSIONS: The distance from epidural space to skin measured on the transverse CT plane may be helpful as a guide for mid-thoracic epidural catheter insertion.
Analgesia, Epidural ; Catheters ; Diagnosis ; Epidural Space* ; Humans ; Needles ; Pain, Postoperative ; Skin* ; Spinal Cord Injuries ; Spine ; Thoracic Surgery ; Tomography, X-Ray Computed

OBJECTIVETo study the utility and effect of suturing menisci with epidural transfixion pin to treating acute meniscus tear under arthroscope.

METHODSTwenty-two cases with acute meniscus tear were selected, in which 18 were male and 4 were female,aged from 17 to 42 years with average of 28.5. The tearing menisci were sutured with epidural transfixion pin and unabsorbed suture. The follow-up were 6-12 months after operation. Meanwhile, Lysholm score, subjective symptoms and examination were recorded.

RESULTSPreoperative Lysholm scores were 46.72 +/- 13.46, whereas, postoperative ones were 89.43 +/- 18.21. There was significant difference between before and after operation (t = 1.85, P < 0.01). No recurrent interlocking, no pain in joint medialis and post-medialis space. McMurray test was negative. The complications about injury of blood vessel, nerves and tendons were not found during 6-12 months follow-up.

CONCLUSIONThe technique is advantageous in convenience, reliability, large suture strength and definite curative effect.

Adolescent ; Adult ; Bone Nails ; Endoscopy ; adverse effects ; Epidural Space ; Female ; Humans ; Male ; Menisci, Tibial ; surgery ; Postoperative Complications ; Sutures ; Tibial Meniscus Injuries ; Treatment Outcome

OBJECTIVE: The purpose of this study is to compare a neuroprotective effect of thoracic cord neuromodulation to that of sacral nerve neuromodulation in rat thoracic spinal cord injury (SCI) model. METHODS: Twenty female Sprague Dawley rats were randomly divided into 4 groups: the normal control group (n=5), SCI with sham stimulation group (SCI, n=5), SCI with electrical stimulation at thoracic spinal cord (SCI + TES, n=5), and SCI with electrical stimulation at sacral nerve (SCI + SES, n=5). Spinal cord was injured by an impactor which dropped from 25mm height. Electrical stimulation was performed by the following protocol: pulse duration, 0.1ms; frequency, 20 Hz; stimulation time, 30 minutes; and stimulation duration at thoracic epidural space and S2 or 3 neural foramina for 4 weeks. Locomotor function, urodynamic study, muscle weights, and fiber cross sectional area (CSA) were investigated. RESULTS: All rats of the SCI + TES group expired within 3 days after the injury. The locomotor function of all survived rats improved over time but there was no significant difference between the SCI and the SCI + SES group. All rats experienced urinary retention after the injury and recovered self-voiding after 3-9 days. Voiding contraction interval was 25.5+/-7.5 minutes in the SCI group, 16.5+/-5.3 minutes in the SCI+SES group, and 12.5+/-4.2 minutes in the control group. The recovery of voiding contraction interval was significant in the SCI + SES group comparing to the SCI group (p<0.05). Muscle weight and CSA were slightly greater in the SCI + SES than in the SCI group, but the difference was not significant. CONCLUSION: We failed to establish a rat spinal cord stimulation model. However, sacral neuromodulation have a therapeutic potential to improve neurogenic bladder and muscle atrophy.
Animals ; Contracts ; Electric Stimulation ; Epidural Space ; Female ; Humans ; Muscles ; Muscular Atrophy ; Neuroprotective Agents ; Rats ; Rats, Sprague-Dawley ; Salicylamides ; Spinal Cord ; Spinal Cord Injuries ; Spinal Cord Stimulation ; Tromethamine ; Urinary Bladder, Neurogenic ; Urinary Retention ; Urodynamics ; Weights and Measures

Spinal cord injury may occur during surgical correction of spinal deformity. In this situations, administrations of opiate receptor antagonists have known to improve spinal cord damage. Although those therapeutic modalities for the management of acute trauma of the spinal cord, impsoved the mean systemic arterial pressure controversy continues regarding their effectiveness Because opioids or inhalational anesthetics are used clinically, the effect of an opiate antagonist was evaluated by cortical somatosensory evoked potentials(cortical SEPs) which occur in 24 cats undergoing compressive injury on the posterior spinal cord during fentanyl or halothane anesthesia. Anesthesia was induced with pentobarbiturate(50 mg/kg, im). A balloon tipped catheter was inserted in the epidural space with tip located at thoracolumbar Junction. Spinal cord compressive injury was produced by balloon inflation for 20 minutes during intravenous saline infusion (control group), fentanyl(group l) or halothane(group 2) anesthesia Naloxone(5mg/kg) was administered intravenously following injury to all animals. Cortical SRPs were determined before and after induction of anesthesia, during the spinal cord compressive injury for 5 minutes, 10 minutes, l5 minutes, 20 minutes, after naloxone administration, and after removal of compressive injury. General anesthesia resulted in increases of latency and reductions of amplitude in the cortical SEPs. The reductions of amplitude were more marked than increases of latency in group 1, 2. During the cord injury, group 1 resulted in more reductions of amylitude than the other groups. But there were no significant differences among the groups. The administration of naloxone far improved latencies and amplitudes in the cortical SEPs of group 1 more than in other two groups. But there were no significant differences among the groups. Less recovery of the cortical SRPs response to naloxone in control group than the other groups. These results do nat support the supposition that opioid anesthesia produces an adverse effect upon cortical SEPs following spinal cord compressive injury and treatment with naloxone in the dose used in this study improves neurologic recovery of cortical SEPs less significantly.
Analgesics, Opioid ; Anesthesia* ; Anesthesia, General ; Anesthetics ; Animals ; Arterial Pressure ; Catheters ; Cats ; Congenital Abnormalities ; Epidural Space ; Evoked Potentials, Somatosensory ; Fentanyl* ; Halothane* ; Inflation, Economic ; Naloxone* ; Receptors, Opioid ; Spinal Cord Injuries* ; Spinal Cord*

STUDY DESIGN: A case report and review of the literature. OBJECTIVE: To discuss the intraspinal gas associated with lumberjack injury and review the literature. MATERIAL AND METHOD: A 60-year-old man developed chest pain & paraplegia by fall down from 4m height, having hypoes-thesia on T7-8 dermatome and complete motor-sensory loss below T9. RESULTS: Multiple rib fractures and hemopneumothorax were observed on chest radiograph and only mild offset was noted on plain spine lateral radiograph. CT scan reveals multiple air bubbles around epidural space at T7-8 and fracture of T7 pedicle. MRI shows rupture of both anterior and posterior longitudinal ligaments and extruded intervertebral disc of T7-8. Posterior decompression and stabilization with posterolateral fusion was performed on T5-9, but pain was persisted and paralysis was not improved after surgery. SUMMARY: The intraspinal gas of this case is supposed to be made by air migration from pleural cavity to intraspinal canal because of severe soft tissue injuries and fistula formation. Immediate and precise diagnosis with operative treatment was con-sidered to be important.
Chest Pain ; Decompression ; Diagnosis ; Epidural Space ; Fistula ; Hemopneumothorax ; Humans ; Intervertebral Disc ; Longitudinal Ligaments ; Magnetic Resonance Imaging ; Middle Aged ; Paralysis ; Paraplegia ; Pleural Cavity ; Radiography, Thoracic ; Rib Fractures ; Rupture ; Soft Tissue Injuries ; Spine ; Tomography, X-Ray Computed