Publications by authors named "Seong-Soo Choi"

94 Publications

Adjuvant administration of hypertonic saline in lumbar epidural intervention may be associated with successful response in patients with probable neuropathic radicular pain Screened by Douleur Neuropathique 4.

Int J Med Sci 2021 17;18(12):2736-2742. Epub 2021 May 17.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Chronic lumbar radicular pain often accompanies neuropathic pain. The treatment may follow a screening for probable neuropathic pain rather than the definitive diagnosis, which is often difficult in daily practice. However, interventional management may have limited effects on symptoms in patients with neuropathic radicular pain refractory to conservative treatments. The purpose of this study is to evaluate the factors associated with successful responses after lumbar epidural intervention in patients with chronic lumbar neuropathic radicular pain determined by Douleur Neuropathique 4 (DN4). We retrospectively reviewed 221 chronic lumbar radicular pain patients using a DN4 questionnaire prior to the epidural interventional procedure. The patients were divided into two groups according to the DN4 questionnaire: <4-point DN4 and ≥4 DN4. The numerical rating scale (NRS) for pain intensity, changes in physical functional status, and the use of pain medication were obtained before and 1 month after the procedure. Successful responder was defined based on robust combination of outcome parameters. The factors associated with successful response were analyzed using univariate and multivariate regression. We found 170 (76.9%) patients with DN4 <4 and 51 (23.1%) with a score ≥4. Among the total 221 patients, 129 (58.4%) were successful responders and 92 (41.6%) were non-responders regardless of DN4 score. We observed a significantly lower proportion of successful responders among patients with a DN4 score ≥4 (22, 43.1%) than patients with a score <4 (107, 62.9%) (P=0.012). After adjusting in multivariate regression analysis, the DN4 score was independently associated with response after lumbar epidural intervention (odds ratio [OR]=0.838; 95% confidence interval [CI]=0.718-0.978; P=0.025). In subgroup logistic regression analysis according to the DN4 score, adjuvant administration of hypertonic saline during epidural interventions in patients with a DN4 score ≥4 (OR=3.71; CI=1.142-12.457; P=0.029) was associated with the success of the lumbar epidural procedure at 1 month. The adjuvant use of hypertonic saline in lumbar epidural interventions may be effective at least 1 month after the intervention in patients with probable neuropathic lumbar radicular pain ≥4 using the DN4.
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http://dx.doi.org/10.7150/ijms.59695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176191PMC
May 2021

Relationship of epidural patient-controlled analgesia with postoperative bleeding after unilateral total knee arthroplasty: a propensity score-matching analysis.

Sci Rep 2021 May 28;11(1):11284. Epub 2021 May 28.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.

Although epidural patient-controlled analgesia (PCA) to control postoperative pain after total knee arthroplasty (TKA), the relationship of epidural PCA with postoperative bleeding remains controversial. Therefore, we aimed to evaluate the effect of epidural and intravenous PCA on postoperative bleeding in patients undergoing unilateral TKA. Total of 2467 patients who underwent TKA were divided to intravenous PCA (n = 2339) or epidural PCA (n = 128) group. After 1:1 propensity score-matching, 212 patients were analyzed to assess the associations between the perioperative blood loss and epidural PCA between the groups. Mean postoperative blood loss was significantly greater in epidural PCA than in intravenous PCA (900.9 ± 369.1 mL vs. 737.8 ± 410.1 mL; P = 0.007). The incidence of red blood cell (RBC) administration (> 3 units) was significantly higher in epidural PCA than in intravenous PCA (30.2% vs. 16.0%; OR 2.5; 95% CI 1.201-5.205; P = 0.014). Epidural PCA may be strongly related to postoperative bleeding and the incidence of RBC transfusion of more than 3 units after unilateral TKA, as compared to intravenous PCA. Therefore, the use of epidural PCA may be carefully considered for postoperative pain management in TKA.
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http://dx.doi.org/10.1038/s41598-021-90946-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8163755PMC
May 2021

Arrhythmia incidence and associated factors during volatile induction of general anesthesia with sevoflurane: a retrospective analysis of 950 adult patients.

Anaesth Crit Care Pain Med 2021 Jun 5;40(3):100878. Epub 2021 May 5.

Department of Anaesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea. Electronic address:

Background: Sevoflurane has been used to induce anaesthesia in adults due to its suitability for airway management and haemodynamic stability. Few studies have reported arrhythmia during volatile induction with sevoflurane in adults. Here, we investigated the incidence of arrhythmia and risk factors associated with its occurrence during sevoflurane induction of anaesthesia in adults.

Patients And Methods: We retrospectively analysed 950 adult patients who underwent elective ear nose and throat surgery with volatile induction using sevoflurane between May and December 2015. The incidence of arrhythmia and the factors associated with its development were analysed.

Results: Arrhythmia was observed in 164 (17.3%) of 950 adult patients. The most frequently observed arrhythmia was sinus tachycardia (heart rate > 120 bpm) (77 patients, 47.0%). The multivariable logistic analysis showed four independent risk factors: age (odds ratio [OR] = 0.984, 95% confidence interval [CI] = 0.973-0.996, p = 0.006), coronary artery disease (OR = 3.749, 95% CI = 1.574-8.927, p = 0.003), maximal concentration (8 vol%) of sevoflurane from the start of induction (OR = 2.696, 95% CI = 1.139-6.382, p = 0.024), and maintenance of 8 vol% sevoflurane concentration after eyelash reflex loss (OR = 1.577, 95% CI = 1.083-2.296, p = 0.018). The risk of hypotension was greater in patients in whom arrhythmia occurred, although blood pressure recovered to baseline after the concentration of sevoflurane was adjusted.

Conclusions: We recommend that the sevoflurane concentration be gradually increased with continuous and vigilant electrocardiogram and blood pressure monitoring. The sevoflurane concentration should be adjusted after sufficient unconsciousness is reached.
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http://dx.doi.org/10.1016/j.accpm.2021.100878DOI Listing
June 2021

Successful electrode insertion for spinal cord stimulation after balloon adhesiolysis in a patient with epidural adhesion - A case report.

Anesth Pain Med (Seoul) 2021 Apr 21;16(2):191-195. Epub 2021 Apr 21.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background: Spinal cord stimulation (SCS) can be successfully performed using highly developed implantation techniques. However, anatomical barriers, such as epidural adhesion, may impede placing the electrode for SCS in an adequate position.

Case: A 60-year-old female who had SCS with an electrode at the T9-10 level removed because she had a wound infection at the back incision site. After the wound infection was completely resolved, we tried to re-insert the SCS electrode. However, it was difficult to advance it up to the T11 level due to epidural adhesion. We performed a combined epidural adhesiolysis using balloon decompression with an inflatable balloon catheter. After that, the SCS lead was successfully placed up to the T11 level, and implantation of SCS was performed.

Conclusions: When a patient has epidural adhesion, an epidural adhesiolysis with an inflatable balloon catheter may help the insertion of the SCS electrode in the epidural space.
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http://dx.doi.org/10.17085/apm.20084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107254PMC
April 2021

Real-time ultrasound-guided low thoracic epidural catheter placement: technical consideration and fluoroscopic evaluation.

Reg Anesth Pain Med 2021 Jun 23;46(6):512-517. Epub 2021 Apr 23.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (the Republic of).

Background And Objective: Thoracic epidural analgesia can significantly reduce acute postoperative pain. However, thoracic epidural catheter placement is challenging. Although real-time ultrasound (US)-guided thoracic epidural catheter placement has been recently introduced, data regarding the accuracy and technical description are limited. Therefore, this prospective observational study aimed to assess the success rate and describe the technical considerations of real-time US-guided low thoracic epidural catheter placement.

Methods: 38 patients in the prone position were prospectively studied. After the target interlaminar space between T9 and T12 was identified, the needle was advanced under real-time US guidance and was stopped just short of the posterior complex. Further advancement of the needle was accomplished without US guidance using loss-of-resistance techniques to normal saline until the epidural space was accessed. Procedure-related variables such as time to mark space, needling time, number of needle passes, number of skin punctures, and the first-pass success rate were measured. The primary outcome was the success rate of real-time US-guided thoracic epidural catheter placement, which was evaluated using fluoroscopy. In addition, the position of the catheter, contrast dispersion, and complications were evaluated.

Results: This study included 38 patients. The T10-T11 interlaminar space was the most location for epidural access. During the procedure, the mean time for marking the overlying skin for the procedure was 49.5±13.8 s and the median needling time was 49 s. The median number of needle passes was 1.0 (1.0-1.0). All patients underwent one skin puncture for the procedure. The first-pass and second-pass success rates were 76.3% and 18.4%, respectively. Fluoroscopic evaluation revealed that the catheter tips were all positioned in the epidural space and were usually located between T9 and T10 (84.2%). The cranial and caudal contrast dispersion were observed up to 5.4±1.6 and 2.6±1.0 vertebral body levels, respectively. No procedure-related complications occurred.

Conclusion: Real-time US guidance appears to be a feasible option for facilitating thoracic epidural insertion. Whether or not this technique improves the procedural success and quality compared with landmark-based techniques will require additional study.

Trial Registration Number: NCT03890640.
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http://dx.doi.org/10.1136/rapm-2021-102578DOI Listing
June 2021

Comparative Effectiveness of Parasagittal Interlaminar and Transforaminal Cervical Epidural Steroid Injection in Patients with Cervical Radicular Pain: A Randomized Clinical Trial.

Pain Physician 2021 Mar;24(2):117-125

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: Cervical epidural steroid injections (ESI) are performed either by interlaminar (IL) or transforaminal (TF) approaches; however, there is controversy over which is better for safety and efficacy.

Objectives: This clinical trial aimed to compare the effectiveness of the parasagittal IL and TF approaches for cervical ESI in patients who were suffering from cervical radicular pain.

Study Design: A prospective randomized assessor-blind study.

Setting: The study took place at a single pain clinic within a tertiary medical center in Seoul, Republic of Korea.

Methods: This prospective randomized, assessor-blind trial included 80 patients with cervical radicular pain. We randomly assigned patients to the TF or parasagittal IL approach for cervical ESI. The effectiveness of the 2 groups was compared based on pain intensity using the Numeric Rating Scale (NRS-11) at 1 and 3 months. The Neck Disability Index (NDI), Medication Quantification Scale (MQS), and responders at 1 and 3 months between the 2 groups were compared.

Results: The pain intensity of both groups significantly reduced after 1 and 3 months after each procedure (P < 0.001). Two-way repeated measures of analysis of variance showed no significant interaction between group and time for cervical radicular pain (P = 0.266), although NRS-11 pain score was lower in the TF group than the parasagittal IL group after 1 month (P = 0.010). NDI, MQS, and successful responders were not different between the 2 groups at 1 and 3 months after the procedure. We observed 7 cases (18.4%) of vascular visualization in the TF group, although no serious complications were found in either group.

Limitations: This study had no placebo control group and limited follow-up time.

Conclusions: Parasagittal IL ESI may be recommended over the TF ESI in reducing cervical radicular pain, considering both clinical effectiveness and safety.
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March 2021

Predictors Associated with Outcomes of Epidural Blood Patch in Patients with Spontaneous Intracranial Hypotension.

J Clin Med 2021 Feb 28;10(5). Epub 2021 Feb 28.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.

An autologous epidural blood patch (EBP) is a mainstay of treatment in patients with spontaneous intracranial hypotension (SIH). EBP, however, is less effective for SIH than post-dural puncture headaches. Therefore, patients with SIH frequently require an additional EBP. The aim of this study was to identify factors associated with poor response to EBP. This single-center retrospective observational study used the institutional registry records of 321 patients who underwent EBP between September 2001 and March 2016. Patients were divided into two groups, a poor responder group, consisting of patients who underwent EBP at least three times or more, and a good responder group of patients who experienced sufficient symptom relief after two or fewer EBP. The demographic characteristics, clinical features, radiologic findings, procedural data, and laboratory data were analyzed. Univariate analysis showed that the neutrophil-to-lymphocyte ratio (NLR; = 0.004) and platelet-to-lymphocyte ratio ( = 0.015) were significantly lower in poor than in good responders. Multivariate analysis found that NLR was the only independent factor associated with a poor response (odds ratio = 0.720; = 0.008). These findings indicate that a low NLR was associated with three or more EBP administrations for the sufficient improvement of symptoms in patients with SIH.
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http://dx.doi.org/10.3390/jcm10050922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957726PMC
February 2021

A Prospective Randomized Comparison of Postoperative Pain and Complications after Thyroidectomy under Different Anesthetic Techniques: Volatile Anesthesia versus Total Intravenous Anesthesia.

Pain Res Manag 2021 2;2021:8876906. Epub 2021 Feb 2.

Department of Anesthesiology and Pain Medicine, Laboratory for Perioperative Outcome Research, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.

While the postoperative outcome is favorable, post-thyroidectomy pain is considerable. Reducing the postoperative acute pain, therefore, is considered important. This study investigated whether the pain intensity and need for rescue analgesics during the immediate postoperative period after thyroidectomy differ according to the methods of anesthesia. Seventy-two patients undergoing total thyroidectomy under general anesthesia were examined. Patients were randomly assigned to undergo either total intravenous anesthesia with remifentanil and propofol (TIVA,  = 35) or propofol induction and maintenance with desflurane and nitrous oxide (volatile anesthesia [VA],  = 37). The mean administered dose of remifentanil was 1977.7 ± 722.5 g in the TIVA group, which was approximately 0.268 ± 0.118 g/min/kg during surgery. Pain scores based on a numeric rating scale (NRS) and the need for rescue analgesics were compared between groups at the postoperative anesthetic care unit (PACU). The immediate postoperative NRS values of the TIVA and VA groups were 5.7 ± 1.7 and 4.7 ± 2.3, respectively ( = 0.034). Postoperative morphine equianalgesic doses in the PACU were higher in the TIVA group than in the VA group (16.7 ± 3.8 mg vs. 14.1 ± 5.9 mg,  = 0.027). The incidence of immediate postanesthetic complications did not differ significantly between groups. In conclusion, more rescue analgesics were required in the TIVA group than in the VA group to adequately manage postoperative pain while staying in the PACU after thyroidectomy.
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http://dx.doi.org/10.1155/2021/8876906DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872752PMC
June 2021

Association between Postoperative Opioid Requirements and the Duration of Smoking Cessation in Male Smokers after Laparoscopic Distal Gastrectomy with Gastroduodenostomy.

Pain Res Manag 2021 28;2021:1541748. Epub 2021 Jan 28.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea.

Smoking is clinically associated with high postoperative pain scores and increased perioperative analgesic requirements. However, the association between the duration of smoking cessation and postoperative opioid requirements remains unclear. Therefore, this study aimed to evaluate the association between the duration of smoking cessation and postoperative opioid requirements. We retrospectively analyzed the data of 144 male patients who received intravenous patient-controlled analgesia (IV PCA) after laparoscopic distal gastrectomy with gastroduodenostomy. All patients were divided into three groups: G0, nonsmoker; G1, smoker who quit smoking within 1 month preoperatively; G2, smoker who quit smoking over 1 month preoperatively. Analgesic use, pain intensity, and IV PCA side effects were assessed up to postoperative day 2. As the duration of smoking cessation increased, the amount of postoperative opioid consumption decreased ( = -0.08; 95% confidence interval (CI), -0.11 to -0.04; < 0.001). The total postoperative opioid requirements in G1 were significantly higher than those in G0 and G2 (G0, 75.5 ± 15.9 mg; G1, 94.6 ± 20.5 mg; and G2, 79.9 ± 19.4 mg ( < 0.001)). A multivariate regression analysis revealed that G1 was independently associated with increased postoperative opioid requirements ( = 12.80; 95% CI, 5.81-19.80; < 0.001). Consequently, male patients who had ceased smoking within 1 month of undergoing a laparoscopic distal gastrectomy with gastroduodenostomy had higher postoperative opioid use than patients who had ceased smoking for more than 1 month and nonsmokers.
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http://dx.doi.org/10.1155/2021/1541748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7861925PMC
June 2021

Effects of Curcumin Treatment in a Diabetic Neuropathic Pain Model of Rats: Involvement of c-Jun N-Terminal Kinase Located in the Astrocytes and Neurons of the Dorsal Root Ganglion.

Pain Res Manag 2021 18;2021:8787231. Epub 2021 Jan 18.

Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.

Curcumin (diferuloylmethane) is a major component of turmeric, which is isolated from the rhizomes of L. from the family Zingiberaceae. It is used as a dietary pigment for curry and in traditional Indian medicine for its anti-inflammatory and attenuating pain effects. This study aimed to evaluate the beneficial effects of curcumin in a rat model of diabetic neuropathic pain. Additionally, we investigated the involvement of the phosphorylated form of c-Jun N-terminal kinase (pJNK) located in the neurons and astrocytes of the dorsal root ganglion (DRG). To induce diabetic neuropathic pain in rats, 50 mg/kg of streptozotocin (STZ) was intraperitoneally injected. After 4 weeks, rats were administered the vehicle, 10 mg/kg/day curcumin, or 50 mg/kg/day curcumin orally for 4 consecutive weeks. One day after the final drug administration, we performed behavioral tests to measure responses of rats to mechanical, heat, cold, and acetone-induced cold stimuli. After behavioral tests, pJNK expression in the DRG was evaluated using western blot assay and immunohistochemistry. Curcumin treatment for 4 consecutive weeks in STZ-induced diabetic neuropathic pain rats improved behavioral responses to mechanical, cold, and thermal stimuli. Increased pJNK expression in the astrocytes and neurons of the DRG in STZ-induced diabetic neuropathic pain rats was reduced by curcumin treatment for 4 consecutive weeks. We suggest that curcumin can be an option for the treatment of diabetes-related neuropathic pain, and one of the mechanisms that underlie the action of curcumin may involve pJNK expression in the astrocytes and neurons of the DRG.
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http://dx.doi.org/10.1155/2021/8787231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837777PMC
June 2021

Negative pressure pulmonary edema in a patient undergoing open rhinoplasty: A case report.

Medicine (Baltimore) 2021 Jan;100(1):e24240

Department of Anesthesiology and Pain Medicine.

Rationale: Negative pressure pulmonary edema (NPPE) is associated with serious postoperative complications. Compact nasal packing is always done after an open rhinoplasty procedure which makes it difficult to achieve positive pressure ventilation via a mask if NPPE arises.

Patient Concerns: A 21-year-old healthy man got an open rhinoplasty, septal perforation repair, and revisional septal reconstruction. After surgery, he became so agitated that it was difficult to calm him. We decided to remove the endotracheal tube. On arrival at the post-anesthesia care unit, he was cyanotic and his SpO2 had decreased to about 2%. We attempted positive pressure ventilation using mask bagging; however, it was ineffective due to the nasal packing.

Diagnoses: Negative pressure pulmonary edema.

Interventions: Emergent reintubation was immediately done and Ambu bagging was commenced. A considerable pinkish secretion came out of the tube. A T-piece was applied to him using 15 L/min of oxygen supply. The patient was eventually transferred to the intensive care unit of our hospital.

Outcomes: On postoperative day (POD) 1, a decision was made to extubate, and the oxygen supply was shifted to 3L/min using a venturi-mask. On POD 2, a chest posteroanterior radiograph was taken and indicated no active lung lesion. The patient was subsequently discharged without any complications. He had no symptoms on POD 6, 11, and 18 at follow-up visits to our outpatient clinic.

Lessons: Anesthesiologists should be alert to the possibility of NPPE and its treatment because of its rapid onset but positive clinical outcome if there is a proper intervention. In nasal surgery cases in particular, early re-intubation should be conducted and extubation should be done to fully awaken the patients.
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http://dx.doi.org/10.1097/MD.0000000000024240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793335PMC
January 2021

Evaluation of Contralateral Oblique and Lateral Views for Mid-Thoracic Epidural Access: A Prospective Observational Study.

Pain Physician 2021 01;24(1):E51-E59

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: The mid-thoracic region has been known to be the most difficult area when accessing epidural space despite using fluoroscopy. Contralateral oblique (CLO) view has been considered for use; however, it has not been evaluated in the mid-thoracic region.

Objective: To evaluate the CLO view for mid-thoracic epidural access (TEA).

Study Design: A prospective observational study.

Setting: The study took place at a single pain clinic within a tertiary medical center in Seoul, Republic of Korea.

Methods: A total of 30 patients participated in this study. After securing the mid-thoracic (T4-8) epidural space, fluoroscopic images were obtained. The needle tip location relative to the ventral interlaminar line (VILL), and the needle tip and laminar visualization were measured and analyzed on the CLO views at 40, 50, 60 degrees, and measured angle, and the lateral view.

Results: The needle tip was clearly visualized in all CLO views, compared with the lateral view (100% vs. 36.7%, P < 0.001). The visualization of the laminar margin and the needle tip location on (or just anterior to) VILL using the CLO measured angle were significantly clearer compared with those in the CLO view at 40 and 50 degrees and the lateral view (laminar margin: 40°, 56.7% vs. 3.3%, P < 0.001; 50°, 56.7% vs. 26.7%, P = 0.012; 90°, 56.7% vs. 26.7%, P = 0.035; needle tip location: 40°, 96.7% vs. 26.7%, P < 0.001; 50°, 96.7% vs. 63.3%, P = 0.002; 90°, 96.7% vs. 66.7%, P = 0.012). There was no difference in these values between the CLO view at 60 degrees and CLO measured angle.

Limitations: Subjective and ambiguous criteria of evaluation may induce bias despite final measured values based on the consensus of an independent investigator.

Conclusion: A CLO view at 60 degrees and CLO measured angle view can provide clearer visualization and more consistent needle tip location than the lateral and other CLO angle views for mid-TEA. A CLO view at 60 degrees and CLO measured angle views could be used to identify the needle location and achieve success in mid-TEA.
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January 2021

EUS-Guided Versus Percutaneous Celiac Neurolysis for the Management of Intractable Pain Due to Unresectable Pancreatic Cancer: A Randomized Clinical Trial.

J Clin Med 2020 Jun 1;9(6). Epub 2020 Jun 1.

Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.

Although endoscopic ultrasound-guided celiac neurolysis (EUS-CN) and percutaneous celiac neurolysis (PCN) are utilized to manage intractable pain in pancreatic cancer patients, no direct comparison has been made between the two methods. We compared the efficacy and safety of EUS-CN and PCN in managing intractable pain in such patients. Sixty pancreatic cancer patients with intractable pain were randomly assigned to EUS-CN ( = 30) or PCN ( = 30). The primary outcomes were pain reduction in numerical rating scale (NRS) and opioid requirement reduction. Secondary outcomes were: successful pain response (NRS decrease ≥50% or ≥3-point reduction from baseline); quality of life; patient satisfaction; adverse events; and survival rate at 3 months postintervention. Both groups reported sustained decreases in pain scores up to 3 months postintervention (mean reductions in abdominal pain: 0.9 (95% confidence interval (CI): -0.8 to 4.2) and 1.7 (95% CI: -0.3 to 2.1); back pain: 1.3 (95% CI: -0.9 to 3.4) and 2.5 (95% CI: -0.2 to 5.2) in EUS-CN, and PCN groups, respectively). The differences in mean pain scores between the two groups at baseline and 3 months were -0.5 ( = 0.46) and -1.4 ( = 0.11) for abdominal pain and 0.1 ( = 0.85) and -0.9 ( = 0.31) for back pain in favor of PCN. No significant differences were noted in opioid requirement reduction and other outcomes. EUS-CN and PCN were similarly effective and safe in managing intractable pain in pancreatic cancer patients. Either methods may be used depending on the resources and expertise of each institution.
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http://dx.doi.org/10.3390/jcm9061666DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7356927PMC
June 2020

Comparison between total intravenous anesthesia and balanced anesthesia on postoperative opioid consumption in patients who underwent laparoscopic-assisted distal gastrectomy.

Medicine (Baltimore) 2020 May;99(19):e20224

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine.

Remifentanil is the most frequently prescribed opioid for total intravenous anesthesia (TIVA) or balanced anesthesia (BA), due to its favorable pharmacological properties. However, several studies have reported opioid-induced hyperalgesia and/or acute tolerance after intraoperatively using remifentanil. In addition, it is imperative to control postoperative pain with lower doses of opioid anesthetic agents. Therefore, we compared the amount of opioid consumption between TIVA with propofol-remifentanil and BA with desflurane-remifentanil, to control postoperative pain in patients who underwent laparoscopic-assisted distal gastrectomy (LADG) with gastroduodenostomy.We retrospectively evaluated demographic variables (age, gender, height, weight, and smoking habits), the duration of general anesthesia (GA), and intraoperatively administered remifentanil consumption through the electronic medical records of patients who underwent LADG with gastroduodenostomy due to early stomach cancer. The primary outcome was postoperative opioid consumption during postoperative day (POD) 2. The secondary outcomes were the incidence of any rescue opioid analgesics administered, numeric rating scale, and various adverse effects during POD 2. We categorized the data in 2 patient groups to compare TIVA with propofol-remifentanil (TIVA group) to BA with desflurane-remifentanil (BA group) on the postoperative opioid analgesic consumption.We divided 114 patients into the TIVA (46 patients) and BA (68 patients) groups. Opioid consumption as a primary outcome was significantly higher in the BA group than in the TIVA group during POD 2 except in the post-anesthesia care unit. The cumulative opioid consumption was significantly higher in the BA than in the TIVA group. The incidence of rescue analgesic at POD 2 was higher in the BA than in the TIVA group. In the TIVA group, remifentanil consumption was higher, and the duration of GA was shorter than that in the BA group. No statistically significant differences were observed when comparing other variables.Our results indicated that the maintenance of GA with TIVA (propofol-remifentanil) reduces opioid consumption for postoperative pain control compared to BA (desflurane-remifentanil) in patients undergoing LADG with gastroduodenostomy.
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http://dx.doi.org/10.1097/MD.0000000000020224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7220423PMC
May 2020

Effectiveness of and Factors Associated with Balloon Adhesiolysis in Patients with Lumbar Post-Laminectomy Syndrome: A Retrospective Study.

J Clin Med 2020 Apr 16;9(4). Epub 2020 Apr 16.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.

Post-laminectomy syndrome (PLS) is characterized by chronic pain and complex pathological entity after back surgery. An epidural adhesiolysis is considered an effective treatment option for lumbar PLS. In this study, we retrospectively analyzed the outcome and evaluated the predictive factors of combined epidural adhesiolysis and balloon decompression using inflatable balloon catheters in lumbar PLS cases. One hundred and forty-seven subjects were retrospectively assessed and analyzed. The percentages of patients who exhibited treatment response were 32.0%, 24.5%, and 22.4% of the study population at 1, 3, and 6 months, respectively. In multivariate logistic regression analysis, the pain duration was independently associated with the treatment response six months after combined epidural adhesiolysis and balloon decompression (odds ratio = 0.985, 95% confidence interval = 0.971-0.999; = 0.038). In addition, the receiver operating characteristic curve analysis showed that the area under the curve of pain duration after lumbar surgery was 0.680 (95% confidence interval = 0.597-0.754, = 0.002), with an optimal cut-off value of ≤14 months, sensitivity of 51.5%, and specificity of 81.4% Our results suggest that an early intervention using combined epidural adhesiolysis and balloon decompression in lumbar PLS patients may be associated with a favorable outcome, even though it has limited effectiveness.
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http://dx.doi.org/10.3390/jcm9041144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230941PMC
April 2020

Transforaminal Epidural Balloon Adhesiolysis via a Contralateral Interlaminar Retrograde Foraminal Approach: A Retrospective Analysis and Technical Considerations.

J Clin Med 2020 Apr 1;9(4). Epub 2020 Apr 1.

Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul 03080, Korea.

Several treatment modalities have been proposed for foraminal stenosis, but the treatment options remain unsatisfactory. Previous studies have shown that transforaminal balloon adhesiolysis may be effective in patients with refractory lumbar foraminal stenosis. However, in patients with a high iliac crest, balloon catheter insertion may be difficult via a conventional transforaminal approach (particularly targeting the L5-S1 foramen). It has been reported that an epidural catheter can be placed easily by a contralateral interlaminar retrograde foraminal approach. Therefore, we applied this approach to L5-S1 transforaminal balloon adhesiolysis in patients with a high iliac crest. We retrospectively analyzed data from 22 patients who underwent combined epidural adhesiolysis and balloon decompression (balloon adhesiolysis) using the novel foraminal balloon catheter via a contralateral interlaminar retrograde foraminal approach. The pain intensity significantly decreased over the three-month period after balloon adhesiolysis ( < 0.001). There were no complications associated with the balloon procedure. The present study suggests that balloon adhesiolysis for L5-S1 foramen via a contralateral interlaminar retrograde foraminal approach may be an effective alternative for patients with a high iliac crest and refractory lumbar radicular pain due to lumbar foraminal stenosis. In addition, detailed procedural aspects are described here.
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http://dx.doi.org/10.3390/jcm9040981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230206PMC
April 2020

Comparison of preoxygenation with a high-flow nasal cannula and a simple mask before intubation during induction of general anesthesia in patients undergoing head and neck surgery: Study protocol clinical trial (SPIRIT Compliant).

Medicine (Baltimore) 2020 Mar;99(12):e19525

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea.

Background: To assess the arterial oxygen partial pressure (PaO2) at defined time points during preoxygenation and to compare high-flow heated humidified nasal oxygenation with standard preoxygenation using oxygen insufflation via a facemask for at least 5 minutes, before intubation during induction of general anesthesia.

Methods: This randomized, single-blinded, prospective study will be conducted in patients undergoing head and neck surgery. After standard monitoring, the artery catheter at the radial artery or dorsalis pedis artery will be placed and arterial blood gas analysis (ABGA) for baseline values will be performed simultaneously. Each group will be subjected to 1 of 2 preoxygenation methods (high-flow nasal cannula or simple facemask) for 5 minutes, and ABGA will be performed twice. After confirming intubation, we will start mechanical ventilation and check the vital signs and perform the final ABGA.

Discussion: This trial aims to examine the trajectory of PaO2 levels during the whole preoxygenation procedure and after intubation. We hypothesize that preoxygenation with the high-flow nasal cannula will be superior to that with the face mask.

Study Registration: This trial was registered with the Clinical Trial Registry (NCT03896906; ClinicalTrials.gov).
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http://dx.doi.org/10.1097/MD.0000000000019525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7220443PMC
March 2020

Current status of pain medicine training in anesthesiology and pain medicine residency programs in university hospitals of Korea: a survey of residents' opinions.

Reg Anesth Pain Med 2020 04 26;45(4):283-286. Epub 2020 Jan 26.

Department of Anesthesiology and Pain Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

Background: In Korea, anesthesiologists are expected to be mainstream pain medicine (PM) practitioners. However, anesthesiology and pain medicine (APM) residency programs mostly emphasize anesthesia learning, leading to insufficient PM learning. Therefore, this study evaluated the current status of PM training in APM residency programs in 10 Korean university hospitals.

Methods: Overall, 156 residents undergoing APM training participated anonymously in our survey, focusing on PM training. We assessed the aim, satisfaction status, duration, opinion on duration, desired duration, weaknesses of the training programs and plans of residents after graduating. We divided the residents into junior (first and second year) and senior (third and fourth year). Survey data were compared between groups.

Results: Senior showed significantly different level of satisfaction grade than did junior (p=0.026). Fifty-seven (81.4%) residents in junior and forty (46.5%) residents in senior underwent PM training for ≤2 months. Most (108; 69.2%) residents felt that the training period was too short for PM learning and 95 (60.9%) residents desired a training period of ≥6 months. The most commonly expressed weakness of the training was low interventional opportunity (29.7%), followed by short duration (26.6%). After residency, 80 (49.1%) residents planned to pursue a fellowship.

Conclusions: Dissatisfaction with PM training was probably due to a structural tendency of the current program towards anesthesia training and insufficient clinical experience, which needs to be rectified, with a change in PM curriculum.
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http://dx.doi.org/10.1136/rapm-2019-100995DOI Listing
April 2020

Factors Associated with Successful Response to Balloon Decompressive Adhesiolysis Neuroplasty in Patients with Chronic Lumbar Foraminal Stenosis.

J Clin Med 2019 Oct 23;8(11). Epub 2019 Oct 23.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.

Epidural neuroplasty, often called percutaneous epidural adhesiolysis, is often performed in refractory patients with chronic lumbar radiculopathy or neurogenic claudication. Recent studies have showed that decompressive adhesiolysis with an inflatable balloon catheter (balloon neuroplasty) is efficient in patients who experience refractory pain from epidural steroid injection or even epidural neuroplasty with a balloon-less catheter. However, exact indications or predictive factors for epidural balloon neuroplasty have not been fully evaluated. Therefore, to assess associated factors that could affect a favorable outcome, we analyzed a prospectively collected multicenter cohort of patients with chronic refractory lumbar foraminal stenosis after balloon neuroplasty. At the 6-month point in follow-up, 92 (44.4%) patients among 207 subjects were classified as successful responders according to a robust combination of outcome measures. Multivariate logistic regression analysis also showed that mild grade lumbar foraminal stenosis may be an independent factor associated with a successful response 6 months after balloon neuroplasty (odds ratio = 2.829; 95% confidence interval = 1.351-5.923; = 0.006). However, we found that there were 29.4% and 24.6% successful responders with moderate and severe foraminal stenosis, respectively. Attempting balloon neuroplasty in refractory lumbar foraminal stenosis, especially mild grade, may be worthwhile..
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http://dx.doi.org/10.3390/jcm8111766DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6912426PMC
October 2019

Contrast Dispersion on Epidurography May Be Associated with Clinical Outcomes After Percutaneous Epidural Neuroplasty Using an Inflatable Balloon Catheter.

Pain Med 2020 04;21(4):677-685

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: Contrast dispersion pattern on epidurography may be associated with clinical improvement after epidural neuroplasty. However, insufficient evidence supports this theory. The current study aims to evaluate the relevance of contrast dispersion and clinical improvement after percutaneous epidural neuroplasty using an inflatable balloon catheter.

Methods: One hundred patients with lumbar spinal stenosis who underwent combined balloon decompression and epidural adhesiolysis between March 2015 to December 2015 participated in the present study. Participants were divided into two groups by contrast dispersion pattern on postprocedural epidurography: the complete contrast dispersion (CCD) and incomplete contrast dispersion (ICCD) groups. The numeric rating scale (NRS), Oswestry Disability Index (ODI), and global perceived effects (GPE) were each assessed before and one, three, six, nine, and 12 months after the intervention.

Results: After combined balloon decompression and adhesiolysis, significant pain reduction and functional improvement were maintained up to 12 months in patients with lumbar spinal stenosis. NRS and GPE in the CCD group were significantly lower than in the ICCD group from six to 12 months after the intervention. The ODI in the CCD group was also significantly lower compared with that in the ICCD group from one to 12 months after the intervention.

Conclusions: Combined balloon decompression and adhesiolysis with the inflatable balloon catheter can provide noteworthy pain reduction and improvement of physical function for a long-term period in patients with lumbar spinal stenosis. Because CCD showed better clinical improvement compared with ICCD, a contrast dispersion pattern may be associated with an improved clinical outcome.
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http://dx.doi.org/10.1093/pm/pnz225DOI Listing
April 2020

Comparison of Nonimage- and Fluoroscopy-Guided Interlaminar Epidural Block: A Matched Paired Analysis in the Same Individuals.

Pain Res Manag 2019 1;2019:7513617. Epub 2019 Apr 1.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: Although fluoroscopic guidance is recommended highly for more accurate lumbar interlaminar epidural steroid injection (L-ESI), many physicians still use a nonimage-guided approach for L-ESIs. However, because of its associated risk of radiation and increased medical expense, the cost-effectiveness and safety of fluoroscopy-guided ESI have been called into question. The goal of this retrospective matched paired analysis in the same individuals was to assess the effectiveness and prevalence of complications of nonimage-guided L-ESI compared to those of fluoroscopy-guided L-ESI. Between 2015 and 2016, 94 patients who received both nonimage- and fluoroscopy-guided L-ESIs were analyzed retrospectively. The changes of the numeric rating scale (NRS) in pain intensity and functional outcome and the differences in the number of complications between blind and fluoroscopy-guided L-ESIs in the same individuals were evaluated by a matched paired analysis.

Results: Of the 94 patients, the differences in NRS before and after the procedure were 1.29 (95% confidence interval (CI) = 0.94-1.65) for the nonimage-guided group and 1.64 (95% CI = 1.28-2.01) for the fluoroscopy-guided group (=0.16). More subjective functional improvement was observed in fluoroscopy-guided L-ESI (57, 60.6%) than in nonimage-guided L-ESI (47, 50.0%) without statistical significance (=0.16). Nine (9.6%) patients in the nonimage-guided group experienced complications related to the procedure overall compared to 4 (4.3%) in the fluoroscopy-guided group (=0.27).

Conclusions: In this study, both blind and image-guided L-ESI techniques included similar extents of postprocedural outcomes and complications. Physicians should consider the risks associated with the two different techniques overall and develop ways to individualize the procedure to decrease the risk of complications and improve the positive outcomes of lumbar epidural steroid injections.
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http://dx.doi.org/10.1155/2019/7513617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6466840PMC
December 2019

Relationship of Success Rate for Balloon Adhesiolysis with Clinical Outcomes in Chronic Intractable Lumbar Radicular Pain: A Multicenter Prospective Study.

J Clin Med 2019 May 3;8(5). Epub 2019 May 3.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.

Combined balloon decompression and epidural adhesiolysis has been reported to be effective in refractory lumbar spinal stenosis. Many cases of intractable stenosis have symptom-related multiple target sites for interventional treatment. In this situation it may not be possible to perform balloon adhesiolysis, or even only epidural adhesiolysis, for all target sites. Therefore, this multicenter prospective observational study aimed to evaluate the relationship of successful ballooning rate for multiple target sites with clinical outcome. Based on the ballooning success rate of multiple target sites, the patients were divided into three groups: below 50%, 50-85%, and above 85% ballooning. A greater ballooning success rate for multiple target sites provided a more decreased pain intensity and improved functional status in patients with chronic refractory lumbar spinal stenosis, and the improvement was maintained for 6 months. The estimated proportions of successful responders according to a multidimensional approach in the below 50%, 50-85%, and above 85% balloon success groups at 6 months after the procedure were 0.292, 0.468, and 0.507, respectively ( = 0.038). Our study suggests the more successful balloon adhesiolysis procedures for multiple target lesions are performed, the better clinical outcome can be expected at least 6 months after treatment.
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http://dx.doi.org/10.3390/jcm8050606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6572522PMC
May 2019

Combined epidural adhesiolysis and balloon decompression can be effective in intractable lumbar spinal stenosis patients unresponsive to previous epidural adhesiolysis.

Medicine (Baltimore) 2019 Apr;98(15):e15114

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul.

Moderate evidence exists regarding percutaneous epidural adhesiolysis (PEA) being an effective treatment for lumbar spinal stenosis (LSS). Although PEA is successfully performed using balloon-less epidural catheters, many patients with severe adhesions cannot obtain satisfactory results. Combined treatment with balloon-inflatable catheters for PEA and balloon decompression recently demonstrated sufficient pain relief and functional improvement in patients with intractable LSS. We compared the effects of PEA and balloon decompression in patients with intractable LSS who did not undergo PEA and those who were unresponsive to previous PEA with a balloon-less catheter.We examined 315 patients who underwent PEA and balloon decompression with balloon-inflatable catheters. Patients with intractable LSS were divided into those without previous PEA (No-PEA) and those unresponsive to previous PEA using balloon-less catheters (Prev-PEA). The numeric rating scale, Oswestry disability index, and global perceived effect of satisfaction scale were measured at 0, 1, 3, and 6 months after the intervention. Responder analysis was performed based on changes in measured scales and indices.A successful treatment response was observed at 1, 3, and 6 months after the intervention in 56.4%, 42.7%, and 32.9%, respectively, of the No-PEA group and in 48.9%, 37.8%, and 25.6%, respectively, of the Prev-PEA group. No significant between-group differences were detected. Pain intensities and functional status improved and were maintained throughout follow-up after PEA with balloon decompression using balloon-inflatable catheters.This modality may represent a useful alternative to overcome the limitations of preexisting adhesiolysis procedures.
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http://dx.doi.org/10.1097/MD.0000000000015114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6485831PMC
April 2019

A Prospective Randomized Comparison of the Efficacy of Ultrasound- vs Fluoroscopy-Guided Genicular Nerve Block for Chronic Knee Osteoarthritis.

Pain Physician 2019 03;22(2):139-146

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: Recently, genicular nerve block and radiofrequency ablation were introduced to alleviate knee pain in patients with chronic knee osteoarthritis. Both ultrasound- and fluoroscopy-guided genicular nerve blocks have been used. However, whether one is superior to the other remains unknown.

Objectives: The present study compares the efficacy of ultrasound- vs fluoroscopy-guided genicular nerve blocks.

Study Design: This research used a prospective randomized comparison design.

Setting: The study took place at a single pain clinic within a tertiary medical center in Seoul, Republic of Korea.

Methods: From July 2015 to September 2017, a randomized controlled study was performed to analyze the difference in the efficacy of ultrasound- vs fluoroscopy-guided genicular nerve blocks. The Numeric Rating Scale (NRS-11), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Global Perceived Effect Scales (GPES), and complications were evaluated pre-procedure, and 1 and 3 months after genicular nerve block.

Results: A total of 80 patients were enrolled and randomly distributed to groups U (ultrasound-guided, n = 40) and F (fluoroscopy-guided, n = 40). Those who were lost to follow-up or had undergone other interventions were excluded, resulting in 31 and 30 patients in groups U and F, respectively. No differences in NRS-11 or WOMAC were observed between the 2 groups at baseline or during the follow-up period. GPES and complication rates were also similar between both groups.

Limitations: We were unable to perform double-blind randomization and did not evaluate patients' baseline emotional states.

Conclusions: Pain relief, functional improvement, and safety were similar between groups receiving ultrasound- and fluoroscopy-guided genicular nerve blocks. Therefore, either of the 2 imaging devices may be utilized during a genicular nerve block for chronic knee pain relief. However, considering radiation exposure, ultrasound guidance may be superior to fluoroscopic guidance.The study protocol was approved by our institutional review board (2015-0369), and written informed consent was obtained from all patients. The trial was registered with the Clinical Research Information Service (KCT 0002846). This work was presented in part as D-H Kim's MS thesis at the University of Ulsan College of Medicine (2018).

Key Words: Genicular nerve block, ultrasound, fluoroscopy, knee osteoarthritis, Numeric Rating Scale, The Western Ontario and McMaster Universities Osteoarthritis Index.
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March 2019

Effectiveness of lumbar epidural injection in patients with chronic spinal stenosis accompanying redundant nerve roots.

Medicine (Baltimore) 2019 Mar;98(9):e14490

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine.

Redundant nerve root syndrome (RNRS) is a phenomenon characterized by the presence of elongated, enlarged, tortuous nerve roots in the lumbar subarachnoid space. It is unclear whether RNRS is caused by spinal stenosis or causes these symptoms.This study evaluated the effects of lumbar epidural steroid injection (LESI) on patients with RNRS and assessed factors associated with RNRS. This retrospective observational cohort study was conducted at a single pain clinic of a university hospital.The medical records of 172 outpatients presenting with low back and/or leg pain from July to December 2014 were analyzed. Pain intensity (numeric rating scale [NRS]) and functional status were assessed at baseline and 2, 4, and 12 weeks after the LESI. Patients were considered moderate responders if they showed a 3-point or >30% reduction in baseline NRS, or said "better than 30%," "a little better," or "I feel an effect." Patients were considered substantial responders if they showed a 5-point or >50% reduction in baseline NRS, or said "better than 50%," "very good," or "much better." Generalized estimating equation (GEE) analysis was performed to identify the factors associated with moderate response to LESI. Factors associated with RNRS were also determined by logistic regression analysis.The proportions of both moderate and substantial responders at 2, 4, and 12 weeks were significantly lower in patients with than without RNRS. GEE analysis showed that RNRS were the only factor significantly associated with moderate response to LESI (OR = 0.400; 95% CI, 0.253-0.632; P < .001). The distance from the conus medullaris to the closest level of stenosis was shorter in patients with than without RNRS (P < .001) and was the only independent factor associated with RNRS on multivariate logistic regression analysis (OR = 0.972; P < .001).LESI was less effective in patients with than without RNRS. The only independent factor significantly associated with RNRS was the distance from the conus medullaris to the nearest moderate stenosis.
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http://dx.doi.org/10.1097/MD.0000000000014490DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831256PMC
March 2019

Impact of educational levels on survival rate: A cohort study of 2007 living donor liver transplant recipients at a single large center.

Medicine (Baltimore) 2019 Feb;98(5):e13979

Department of Anesthesiology and Pain Medicine, Asan Medical Center.

Among living donor liver transplantation recipients, the impact of educational levels on survival has rarely explored. Thus, the purpose of study is to analyze the survival rate differences across educational levels among recipients who underwent living donor liver transplantation.We retrospectively analyzed 2007 adult recipients who underwent living donor liver transplantation in a single large center. The educational level was divided into three categories: middle school or lower, high school, and college or higher. The primary outcome was all-cause mortality after living donor liver transplantation. Stratified log-rank test and Cox proportional hazard model were employed for statistical analysis.The incidence rates of all-cause mortality were 23.85, 20.19, and 18.75 per 1000 person-year in recipients with middle school or lower, high school, and college or higher education groups, respectively. However, the gender-stratified log-rank test has not shown a statistically significant difference (P = .3107). In the unadjusted model, hazard ratio (HR) was 1.02 [95% confidence interval (CI) = 0.79-1.33] in high school and 1.23 (95% CI = 0.93-1.64) and in middle school or lower educational level, respectively; In the full adjusted model, the HR of high school was 0.98 (95% CI = 0.75-1.28) and the HR of middle school or lower was 1.01 (95% CI = 0.74-1.37).Although study population of this study is large, we could not find significant survival rate differences by the levels of education. Social selection and high compliance rate might contribute to this result.
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http://dx.doi.org/10.1097/MD.0000000000013979DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380783PMC
February 2019

Percutaneous Epidural Adhesiolysis Using Inflatable Balloon Catheter and Balloon-less Catheter in Central Lumbar Spinal Stenosis with Neurogenic Claudication: A Randomized Controlled Trial.

Pain Physician 2018 11;21(6):593-606

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: When conventional interventional procedures fail, percutaneous epidural adhesiolysis (PEA), which has moderate evidence for successful treatment of lumbar spinal stenosis (LSS), has been recommended over surgical treatments. In a previous study, we demonstrated the efficacy of a newly developed inflatable balloon catheter for overcoming the access limitations of pre-existing catheters for patients with severe stenosis or adhesions.

Objectives: This study compared the treatment response of combined PEA with balloon decompression and PEA only in patients with central LSS over 6 months of follow-up.

Study Design: This study used a randomized, single-blinded, active-controlled trial design.

Setting: This study took place in a single-center, academic, outpatient interventional pain management clinic.

Methods: This randomized controlled study included 60 patients with refractory central LSS who suffered from chronic lower back pain and/or lumbar radicular pain. Patients failed to maintain improvement for > 1 month with epidural steroid injection or PEA using a balloon-less catheter. Patients were randomly assigned to one of 2 interventions: balloon-less (n = 30) and inflatable balloon catheter (n = 30). The Numeric Rating Scale (NRS-11), Oswestry Disability Index (ODI), Global Perceived Effect of Satisfaction (GPES), and Medication Quantification Scale III were each measured at 1, 3, and 6 months after PEA.

Results: There was a significant difference between groups in NRS-11 reduction ≥ 50% (or 4 points), ODI reduction ≥ 30% (or 10 points), GPES ≥ 6 and ≥ 4 points at 6 months, and NRS-11 reduction ≥ 50% (or 4 points) at 3 months after PEA (P < .03). The proportion of successful responders was higher in the balloon group than in the balloon-less group throughout the total follow-up period. Furthermore, there was a statistically significant difference between groups at 6 months after PEA (P = .035).

Limitations: The results may vary according to the definition of successful response. Follow-up loss in the present study seemed to be high.

Conclusion: PEA using the inflatable balloon catheter leads to significant pain reduction and functional improvement compared to PEA using the balloon-less catheter in patients with central LSS.The study protocol was approved by our institutional review board (2012-0235), and written informed consent was obtained from all patients. The trial was registered with the Clinical Research Information Service (KCT 0002093).

Key Words: Balloon decompression, central, chronic pain, epidural adhesiolysis, lumbar, percutaneous, radiculopathy, spinal stenosis.
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November 2018

Effect of Total Intravenous Anesthesia vs Volatile Induction With Maintenance Anesthesia on Emergence Agitation After Nasal Surgery: A Randomized Clinical Trial.

JAMA Otolaryngol Head Neck Surg 2019 02;145(2):117-123

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Importance: Emergence agitation is common after nasal surgery under general anesthesia and may lead to serious consequences for the patient, including an increased risk of injury, pain, hemorrhage, and self-extubation. Despite decades of research, studies on the incidence, risk factors, and prevention of emergence agitation in adult patients are ongoing, and opinions differ on the different effects of inhalation and intravenous anesthesia.

Objective: To investigate the effect of anesthetic method on the occurrence of emergence agitation after nasal surgery.

Design, Setting, And Participants: This prospective, randomized, single-blind, clinical trial included 80 patients undergoing open rhinoplasty, septoplasty, turbinoplasty, endoscopic sinus surgery, and functional endoscopic sinus surgery under general anesthesia who were randomized to receive total intravenous anesthesia (TIVA) with remifentanil hydrochloride and propofol (n = 40) or volatile induction and maintenance of anesthesia (VIMA) with sevoflurane and nitrous oxide (n = 40) in Asan Medical Center, a tertiary referral center in Seoul, Republic of Korea. Data were collected from August 24 through October 14, 2016, and analyzed from October 26, 2016, through September 14, 2017.

Main Outcomes And Measures: The occurrence of emergence agitation defined by the following 2 individual criteria: a Richmond Agitation-Sedation Scale score of at least 1 and a Riker Sedation-Agitation Scale score of at least 5 immediately after extubation.

Results: Among the 80 patients included in the analysis (68.8% men [n = 55]; mean [SD] age, 41.6 [17.9] years), emergence agitation measured by the Richmond Agitation Sedation Scale occurred in 8 of 40 patients (20.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 17.5 (95% CI, 3.6-31.4). Emergence agitation measured by the Riker Sedation-Agitation Scale score occurred in 10 of 40 patients (25.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 22.5 (95% CI, 7.3-37.7).

Conclusions And Relevance: The occurrence of emergence agitation after nasal surgery under general anesthesia can be significantly reduced by using TIVA rather than VIMA.

Trial Registration: CRIS identifier: KCT0002145.
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http://dx.doi.org/10.1001/jamaoto.2018.3097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6440219PMC
February 2019

Prevalence of fibromyalgia in fourteen Korean tertiary care university hospital pain clinics.

J Pain Res 2018 17;11:2417-2423. Epub 2018 Oct 17.

Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea,

Purpose: We aimed to investigate the prevalence of fibromyalgia (FM) in patients who visited outpatient pain clinics in Korea, using the modified 2010 American College of Rheumatology (ACR) criteria and to evaluate comorbid conditions that may be associated with FM.

Patients And Methods: Outpatients, aged ≥18 years, who first visited pain clinics at any of the 14 tertiary care university hospitals, were recruited for this study. Modified 2010 ACR criteria were used to diagnose FM. Participants' demographic information and eleven comorbid measures (sleep disturbance, fatigue, irritable bowel syndrome, amnesia, hypothyroidism, headache, anxiety, depression, rheumatism, low back pain, and history of traffic accident) were also investigated via additional questionnaires.

Results: We recruited 1,233 outpatients (754 men and 479 women). Based on the modified 2010 ACR criteria, 13.38% (165/1,233 patients, 95% CI: 11.48-15.28) of patients had FM. As participants with a history of FM were excluded, the prevalence of FM was 11.0% (123/1,118 patients). Patients with FM were more likely to have one or more of the eleven predetermined comorbid conditions. Patients who were female and who had a previous history of FM, sleep disturbance, headache, or a history of traffic accident were more likely to have FM.

Conclusion: FM, according to the modified 2010 ACR criteria, appears to be a common disorder among chronic pain patients referred to tertiary care university hospital pain clinics. Therefore, physicians treating pain should consider this prevalence of FM among pain clinic patients.
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http://dx.doi.org/10.2147/JPR.S172221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200436PMC
October 2018

Retrodiscal epidural balloon adhesiolysis through Kambin's triangle in chronic lumbar spinal stenosis: A retrospective analysis and technical considerations.

Medicine (Baltimore) 2018 Oct;97(41):e12791

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

A previous study showed that transforaminal balloon adhesiolysis via the safe triangle was effective in lumbar spinal stenosis. However, retrodiscal pathology is difficult to treat with this method. Therefore we attempted retrodiscal balloon adhesiolysis via Kambin's triangle. The design of our study is a retrospective analysis. The setting of our study is a tertiary, interventional pain management practice, speciality referral center.The primary indication for this procedure is radicular pain arising from ipsilateral retrodiscal pathology. Medical records were reviewed of patients who received retrodiscal decompression with a transforaminal balloon inflatable catheter between January 1, 2016 and July 31, 2017. The intervention was conducted by 2 well-trained pain specialists. The introducer needle was positioned at Kambin's triangle. Adhesiolysis was performed using a balloon filled with radiocontrast media. After balloon adhesiolysis, an agent containing lidocaine and dexamethasone was injected through the introducer sheath. Numeric rating scale pain scores were obtained 1 and 3 months after the procedure.The mean pre-procedure numeric rating scale score was 7.05 ± 1.40. After 1 and 3 months, the mean scores were 3.91 ± 2.20 and 3.77 ± 2.11, respectively. No patient had significant complications. Also, technical considerations were discussed.Chronic pain due to lumbar central stenosis, especially ipsilateral retrodiscal pathology, can be reduced by retrodiscal balloon adhesiolysis through Kambin's triangle. Although this study is limited by its retrospective design, the results suggest that this procedure is a useful treatment due to its ease of performance and cost-effectiveness.
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http://dx.doi.org/10.1097/MD.0000000000012791DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6203470PMC
October 2018