Chronic low back pain (CLBP) has become more prominent with globally increasing life expectancy. Its cause is more attributable to degenerative changes than to traumatic lesions. Although the diagnosis of CLBP is recently on higher demand, lack of clinical features and non-informative imaging findings in patients with CLBP are challenging to clinicians to establish the diagnosis. Therefore, understanding of the new concept of pathogenesis, elimination of prejudice, and evidence-based diagnostic steps are required to resolve the question of pain source. Analysis of pain distribution patterns and careful history taking can be utilized as an initial guide to divide CLBP into somatic and radicular pain. Zygapophyseal joint pain and sacroiliac joint pain representing somatic pain can be further investigated using medial branch and sacroiliac joint blocks. However, comparative blocks are essential to decreased false positive rate. Infiltration of a small volume of local anesthetics can increase the specificity of the procedures. Discogenic pain stemming from internal disk derangement can be confirmed by pressure-controlled discography. Automated discography is recommended to provide the constant rate of dye injection with obviating the fluctuation of intradiscal pressure. Evidencebased concept and diagnostic procedures can provide more accurate and efficient methods to establish the diagnosis of CLBP.
Anesthetics, Local ; Diagnosis ; Evidence-Based Medicine ; Humans ; Life Expectancy ; Low Back Pain* ; Nerve Block ; Nociceptive Pain ; Prejudice ; Sacroiliac Joint ; Sensitivity and Specificity ; Zygapophyseal Joint

OBJECTIVE: The sacroiliac joint complex is often related with functionally incapacitating pain in old aged people. The purpose of this study is to delineate the investigation strategies and to determine the long-term effect of radiofrequency (RF) neurotomies for pain arising from sacroiliac joint dysfunction(SIJD) METHODS: Sixteen patients were diagnosed as having chronic pain from SIJD by comparative controlled blocks on L5 dorsal rami, sacroiliac joints and deep interosseous ligaments. After confirming the positive response (more than 50% of pain relief), sensory stimulation was applied to detect the `pathological' branches. Subsequently, RF neurotomies were performed on the selected nerve branches. Surgical outcome was graded as successful, moderate improvement, and failure after a 6month follow-up period. RESULTS: Stimulation intensity was 0.45V to elicit pain response in the L5 dorsal rami and lateral sacral branches. The number of RF-lesioned nerve branches was 6per patient. The average number of lesions for each branch was 1.3. Most commonly selected branches were L5 dorsal ramus (88%) and S2-upper division (88%). Ten patients (63%) reported a successful outcome according to the outcome criteria after 6months of follow-up, and five patients (31%) reported complete relief (100%). Five patients (31%) showed moderate improvements. One patient reported failure. CONCLUSION: RF neurotomy of lateral sacral branches is an excellent treatment modality for the pain due to SIJD, provided that comparative controlled block shows a positive response.
Chronic Pain ; Follow-Up Studies ; Humans ; Ligaments ; Sacroiliac Joint*

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.
Humans ; Intervertebral Disc ; Leg ; Low Back Pain ; Posture

Stroke is a leading cause of adult disability and the second-leading cause of death in Korea. It is also the third-leading cause of death in the United States, leading to a serious demand for new interventions to improve the quality of life in stroke survivors. To this end, direct cortical stimulation using an epidural electrode has been reported with promising results in animal and human studies, showing the potential for enhancing the recovery in chronic stroke patients. For optimal results, doctors must be able to modify the stimulation pattern as frequently as needed over a period of time for a given patient. However, severe aftereffects caused by stroke limit patients' activities, making regular doctor visits for treatment difficult. This study aims to develop a prototype of a telemedicine system to enhance stroke recovery by using a ZigBee-based wireless neuro-stimulator. The ZigBee is a stable platform for many low-power wireless applications. To allow stroke patients to remotely obtain neuro-stimulation treatments from their doctors, we connected the ZigBee to the internet. The system also allows doctors to personalize treatment based on the history of the stimulation parameters. The system developed here can also be beneficial as a common platform for a wide range of brain diseases and clinical care for which electric stimulation is used.
Adult ; Animals ; Brain Diseases ; Cause of Death ; Electric Stimulation ; Electrodes ; Humans ; Internet ; Korea ; Quality of Life ; Stroke ; Survivors ; Telemedicine ; United States

OBJECTIVE: Neuroimaging data are of paramount importance in making correct diagnosis. We herein evaluate the clinical usefulness of image transfer using cellular phones to facilitate neurological diagnosis and decision-making. METHODS: Selected images from CT, MRI scans, and plain films obtained from 50 neurosurgical patients were transferred by cellular phones. A cellular phone with a built-in 1,300,000-pixel digital camera was used to capture and send the images. A cellular phone with a 262,000 color thin-film transistor liquid crystal display was used to receive the images. Communication between both cellular phones was operated by the same wireless protocol and the same wireless internet service. We compared the concordance of diagnoses and treatment plans between a house staff who could review full-scale original films and a consultant who could only review transferred images. These finding were later analyzed by a third observer. RESULTS: The mean time of complete transfer was 2~3 minutes. The quality of all images received was good enough to make precise diagnosis and to select treatment options. Transferred images were helpful in making correct diagnosis and decision making in 49/50 (98%) cases. Discordant result was caused in one patient by improper selection of images by the house staff. CONCLUSION: The cellular phone system was useful for image transfer and delivery of patient's information, leading to earlier diagnosis and initiation of treatment. This usefulness was due to sufficient resolution of the built-in camera and the TFT-LCD, the user-friendly features of the devices, and their low cost.
Cellular Phone* ; Consultants ; Decision Making ; Diagnosis ; Humans ; Internet* ; Internship and Residency ; Liquid Crystals ; Magnetic Resonance Imaging ; Neuroimaging ; Telemedicine ; Teleradiology

Lumbo-sacral junction is a transition zone between the mobile lumbar spine and immobile pelvis. Lumbosacral junction has been considered to be the most troublesome portion of the spine to be fused because of the difference in anatomical and biomechanical factors between spine and pelvis. A metastatic sacral tumor in a 57-year-old man was resected, followed by unilateral lumbo-iliac fixation across lumbosacral junction using modified Galveston technique. Rigid fixation was successfully achieved. Detailed anatomy and surgical techniques are presented.
Arthrodesis ; Humans ; Middle Aged ; Pelvis ; Spine

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.
Tomography, X-Ray Computed ; Pressure ; Pain Measurement ; Middle Aged ; Male ; Low Back Pain/*radiography ; Intervertebral Disk/*radiography ; Humans ; Female ; Aged, 80 and over ; Aged ; Adult

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.
Adult ; Aged ; Aged, 80 and over ; Back Pain/etiology/surgery ; Brachial Plexus/pathology/*surgery ; Brachial Plexus Neuritis/complications/diagnosis/*surgery ; Chronic Disease ; Electrosurgery/methods ; Female ; Humans ; Male ; Middle Aged ; Neck Pain/etiology/surgery ; Nerve Block/methods ; Neurosurgical Procedures/instrumentation/*methods ; Treatment Outcome

OBJECTIVE: The purpose of this study is to find the optimal stiffness and volume of bone cement and their biomechanical effects on the adjacent vertebrae to determine a better strategy for conducting vertebroplasty. METHODS: A three-dimensional finite-element model of a functional spinal unit was developed using computed tomography scans of a normal motion segment, comprising the T11, T12 and L1 vertebrae. Volumes of bone cement, with appropriate mechanical properties, were inserted into the trabecular core of the T12 vertebra. Parametric studies were done by varying the volume and stiffness of the bone cement. RESULTS: When the bone cement filling volume reached 30% of the volume of a vertebral body, the level of stiffness was restored to that of normal bone, and when higher bone cement exceeded 30% of the volume, the result was stiffness in excess of that of normal bone. When the bone cement volume was varied, local stress in the bony structures (cortical shell, trabecular bone and endplate) of each vertebra monotonically increased. Low-modulus bone cement has the effect of reducing strain in the augmented body, but only in cases of relatively high volumes of bone cement (>50%). Furthermore, varying the stiffness of bone cement has a negligible effect on the stress distribution of vertebral bodies. CONCLUSION: The volume of cement was considered to be the most important determinant in endplate fracture. Changing the stiffness of bone cement has a negligible effect on the stress distribution of vertebral bodies.
Bone Cements ; Finite Element Analysis ; Spine ; Sprains and Strains ; Vertebroplasty

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.
Adult ; Aged ; Decision Making ; Female ; Humans ; Joint Diseases/*diagnosis/therapy ; Low Back Pain/*diagnosis/therapy ; Magnetic Resonance Imaging ; Male ; Middle Aged ; *Pain Measurement ; *Sacroiliac Joint ; Treatment Outcome ; *Zygapophyseal Joint