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Background: Cervical epidural block (CEB) is an effective intervention for managing cervical radicular pain. This study aimed to investigate the current status of performing CEB in South Korea. Methods: Pain physicians affiliated with the Korean Pain Society were asked to complete anonymous questionnaires regarding CEB between September and October 2022. The questionnaire consisted of 24 questions assessing the current status and methods of CEB in detail. Results: Of the 198 surveys collected, 171 physicians (86.4%) reported performing CEB. Among those, the majority (94.7%) used fluoroscopy during the procedure. The paramedian interlaminar (IL) approach was the most preferred method (50.3%). Respondents performing fluoroscopic-guided IL CEB were categorized into two groups based on clinical experience: those with ≤10 years of experience (≤10-year group, n = 91) and those with >10 years of experience (>10-year group, n = 71). The proportion of physicians obtaining informed consent in the ≤10-year group and >10-year group was 50.5% and 56.3%, respectively. When entering the epidural space during IL CEB, the contralateral oblique view was the second most frequently used in both groups (≤10-year group, 42.9%; >10-year group, 29.6%). In targeting the upper cervical lesions (C3--4), the proportion of respondents who used an IL space higher than C6--7 was 17.6% in the ≤10-year group and 29.5% in the >10-year experience group. Conclusions: This study demonstrated variability in the CEB technique used by pain physicians in South Korea. The findings highlight the need for education on informed consent and techniques to enhance safety. [ABSTRACT FROM AUTHOR]

Background: This study aimed to identify exact anatomical landmarks and ideal injection volumes for safe adductor canal blocks (ACB). Methods: Fifty thighs from 25 embalmed adult Korean cadavers were used. The measurement baseline was the line connecting the anterior superior iliac spine (ASIS) to the midpoint of the patellar base. All target points were measured perpendicular to the baseline. The relevant cadaveric structures were observed using ultrasound (US) and confirmed in living individuals. US-guided dye injection was performed to determine the ideal volume. Results: The apex of the femoral triangle was 25.3 ± 2.2 cm distal to the ASIS on the baseline and 5.3 ± 1.0 cm perpendicular to that point. The midpoint of the superior border of the vasto-adductor membrane (VAM) was 27.4 ± 2.0 cm distal to the ASIS on the baseline and 5.0 ± 1.1 cm perpendicular to that point. The VAM had a trapezoidal shape and was connected as an aponeurosis between the medial edge of the vastus medialis muscle and lateral edge of the adductor magnus muscle. The nerve to the vastus medialis penetrated the muscle proximal to the superior border of the VAM in 70% of specimens. The VAM appeared on US as a hyperechoic area connecting the vastus medialis and adductor magnus muscles between the sartorius muscle and femoral artery. Conclusions: Confirming the crucial landmark, the VAM, is beneficial when performing ACB. It is advisable to insert the needle obliquely below the superior VAM border, and a 5 mL injection is considered sufficient. [ABSTRACT FROM AUTHOR]

Background: The rise in national health care costs has emerged as a global problem given the ever-aging population and rapid development of medical technology. The utilization of interventional pain management has, similarly, shown a continued rise worldwide. This study evaluates the differences in the medical costs in the field of interventional pain treatment (IPT) between two countries: Korea and Japan. Methods: Korean medical insurance costs for 2019 related to pain management focused on IPT were compared to those of Japan. Purchasing power parity (PPP) was used to adjust the exchange rate differences and to compare prices in consideration of the respective societies' economic power. Results: The cost of trigger point injections in Japan was 1.06 times higher than that of Korea, whereas the perineural and intraarticular injection prices were lower in Japan. The cost of epidural blocks was higher in Japan compared to Korea in both cervical/thoracic and lumbar regions. As for blocks of peripheral branches of spinal nerves, the cost of scapular nerve blocks in Japan was lower than that in Korea, given a PPP ratio 0.09. For nerve blocks in which fluoroscopy guidance is mandatory, the costs of epidurography in Japan were greater than those in Korea, given a PPP ratio 1.04. Conclusions: This is the first comparative study focusing on the medical costs related to IPT between Korea and Japan, which reveals that the costs differed along various categories. Further comparisons reflecting more diverse countries and socio-economic aspects will be required. [ABSTRACT FROM AUTHOR]

Background: Percutaneous radiofrequency thermocoagulation (RFTC) has been widely utilized in the management of trigeminal neuralgia. Despite using image guidance, accurate needle positioning into the target area still remains a critical element for achieving a successful outcome. This study was performed to precisely clarify the anatomical information required to ensure that the electrode tip is placed on the sensory component of the mandibular nerve (MN) at the foramen ovale (FO) level. Methods: The study used 50 hemi-half heads from 26 South Korean adult cadavers. Results: The cross-sectioned anterior and posterior divisions of the MN at the FO level could be distinguished based on an irregular boundary and color difference. The anterior division was clearly brighter than the posterior one. The anterior division of the MN at the FO level was located at the whole anterior (38.0%), anteromedial (6.0%), anterior center (8.0%), and anterolateral (22.0%) parts. The posterior division was often located at the whole posterior or posterolateral parts of the MN at the FO level. The anterior divisions covered the whole MN except for the medial half of the posterolateral part in the overwrapped images of the cross-sectional areas of the MN at the FO level. The cross-sectional areas of the anterior divisions were similar in males and females, whereas those of the posterior divisions were significantly larger in males (P = 0.004). Conclusions: The obtained anatomical information is expected to help physicians reduce unwanted side effects after percutaneous RFTC within the FO for the MN. [ABSTRACT FROM AUTHOR]

Background: Fibromyalgia (FM) is a complex disorder characterized by widespread chronic pain and tenderness in the muscles, ligaments, and soft tissues. It is a chronic pain condition often accompanied by other symptoms and comorbidities. To effectively manage FM, it is crucial to obtain fundamental epidemiological data pertaining to the target population. Therefore, this study was conducted to elucidate the epidemiological characteristics of FM in the Korean population. Methods: Population-based medical data of 51,276,314 subscribers to the National Health Insurance Service of Korea from 2014 to 2018 were used in this study. Results: The overall incidence of FM ranged from 441 (2014) to 541 (2018) cases per 100,000 person-years, with a higher prevalence observed among female patients compared to male patients. The incidence gradually increased until middle age, followed by a decrease. The highest incidence rates were observed in the fifth decade of life for females and the sixth decade of life for males. When categorizing the affected parts of the body, the shoulder region was observed to be the most frequently affected. A comparison of the drug prescriptions based on medical specialty showed that antidepressants were the most commonly prescribed medications. The management of FM leads to consistent increases in medical expenses, regional disparities, and variations in prescription patterns across different medical specialties. Conclusions: The findings of this study will not only contribute to the understanding of FM characteristics but also provide a vital foundation for efficient management of FM in Korea. [ABSTRACT FROM AUTHOR]

The article discusses the necessity of professional medical illustration in increasing the value of medical journals. Medical illustrations are visual representations that convey medical information and are commonly used in surgical records, medical journals, and patient instructions. Accurate and intuitive illustrations are effective in conveying information in various medical disciplines. The article suggests that the Korean Pain Society should consider supporting and utilizing professional medical illustrators to enhance the quality and impact of their publications. [Extracted from the article]

Coccydynia is a debilitating pain disorder. However, its pathophysiology is not well understood. When approaching coccydynia, the exact underlying cause of pain must be identified to develop an appropriate treatment plan. The specific approach to coccydynia can vary depending on an individual's condition and the underlying cause. Thorough evaluation by a pain physician is essential to determine the most appropriate course of treatment. The purpose of this review is to examine the various causes contributing to coccygeal pain and specifically focus on the exact anatomical neurostructures, such as the anococcygeal nerve, perforating cutaneous nerve, and ganglion impar. We also reviewed the relevant clinical outcomes and suggested recommendations for each anatomical structure. [ABSTRACT FROM AUTHOR]

Background: Trigeminal neuralgia (TN) is one of the most painful disorder in the orofacial region, and many patients have suffered from this disease. For the effective management of TN, fundamental epidemiologic data related to the target population group are essential. Thus, this study was performed to clarify the epidemiological characteristics of TN in the Korean population. This is the first national study to investigate the prevalence of TN in Korean patients. Methods: From 2014 to 2018, population-based medical data for 51,276,314 subscribers to the National Health Insurance Service of Korea were used for this study. Results: The incidence of TN was 100.21 per 100,000 person-years in the year of 2018 in Korea, and the male to female ratio was 1:2.14. The age group of 51-59 years had the highest prevalence of TN. Constant increases in medical cost, regional imbalance, and differences in prescription patterns by the medical specialties were showed in the management of TN. Conclusions: The results in this study will not only help to study the characteristics of TN, but also serve as an important basis for the effective management of TN in Korea. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to clarify the topographical relationship between the accessory nerve (AN) and transverse cervical artery (TCA) to provide safe and convenient injection points for AN blockade. Methods: This study included 21 and 30 shoulders of 14 embalmed Korean adult cadavers and 15 patients, respectively, for dissection and ultrasound (US) examination. Results: The courses of the TCA and AN in the scapular region were classified into four types based on their positional relationships. Type A indicated the nerve that was medial to the artery and ran parallel without changing its location (38%). In type B (38%), the nerve was lateral to the artery and ran parallel without changing its location. In type C (19%), the nerve or artery traversed each other only once during the whole course. In type D (5%), the nerve or artery traversed each other more than twice forming a twist. At the levels of lines I-IV, the nerve was relatively close to the artery (approximately 10 mm). TCAs were observed in all specimens around the superior angle of the scapula at the level of line II, whereas they were not found below line VI. In US images of the patients, the TCA was commonly observed at the level of line II (93.3%) where all ANs and TCAs were observed in cadaveric dissection. Conclusions: The results expand the current knowledge of the relation between the AN and TCA, and provide helpful information for selective diagnostic nerve blocks in the scapular region. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to clarify the topographical relationships between the dorsal scapular nerve (DSN) and the dorsal scapular artery (DSA) in the interscapular region to identify safe and convenient injection points related to DSN blockade. Methods: Thirty shoulders of embalmed Korean cadavers and 50 live subjects were used for dissection and ultrasound (US) analysis. Results: The running patterns of the DSA and DSN in the interscapular region were classified into 3 types. Type I was defined as nerves that were medial to the artery and parallel without changing location (80.0% of specimens). In type II (13.3%), the nerve and artery traversed one another only one time over their entire length. In type III (6.7%), the nerve and artery traversed one another, resembling a twist. Above the level of the scapular spine, the nerve was always medial to the artery. Below the scapular spine, the number of arteries was obviously decreased. Most of the arteries were lateral to the medial border of the scapula, except at the level of the superior angle of the scapula artery (SA). The positional tendency of the DSN toward the medial or lateral sides from the medial border of the scapula was similar. In US imaging of live subjects, the DSA was most observed at the level of the SA (94.0%). Conclusions: Results of this study enhance the current knowledge regarding the pathway of the DSN and DSA and provide helpful information for selective diagnostic nerve blocks in the interscapular region. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to clarify the topographical relationships between the dorsal scapular nerve (DSN) and the dorsal scapular artery (DSA) in the interscapular region to identify safe and convenient injection points related to DSN blockade. Methods: Thirty shoulders of embalmed Korean cadavers and 50 live subjects were used for dissection and ultrasound (US) analysis. Results: The running patterns of the DSA and DSN in the interscapular region were classified into 3 types. Type I was defined as nerves that were medial to the artery and parallel without changing location (80.0% of specimens). In type II (13.3%), the nerve and artery traversed one another only one time over their entire length. In type III (6.7%), the nerve and artery traversed one another, resembling a twist. Above the level of the scapular spine, the nerve was always medial to the artery. Below the scapular spine, the number of arteries was obviously decreased. Most of the arteries were lateral to the medial border of the scapula, except at the level of the superior angle of the scapula artery (SA). The positional tendency of the DSN toward the medial or lateral sides from the medial border of the scapula was similar. In US imaging of live subjects, the DSA was most observed at the level of the SA (94.0%). Conclusions: Results of this study enhance the current knowledge regarding the pathway of the DSN and DSA and provide helpful information for selective diagnostic nerve blocks in the interscapular region. [ABSTRACT FROM AUTHOR]

Background: Recently, the use of ultrasound (US) techniques in regional anesthesia and pain medicine has increased significantly. However, the current extent of training in the use of US-guided pain management procedures in Korea remains unknown. The purpose of the present study was to assess the current state of US training provided during Korean Pain Society (KPS) pain fellowship programs through the comparative analysis between training hospitals. Methods: We conducted an anonymous survey of 51 pain physicians who had completed KPS fellowships in 2017. Items pertained to current US practices and education, as well as the types of techniques and amount of experience with US-guided pain management procedures. Responses were compared based on the tier of the training hospital. Results: Among the 51 respondents, 14 received training at first- and second-tier hospitals (Group A), while 37 received training at third-tier hospitals (Group B). The mean total duration of pain training during the 1-year fellowship was 7.4 months in Group A and 8.4 months in Group B. Our analysis revealed that 36% and 40% of respondents in Groups A and B received dedicated US training, respectively. Most respondents underwent US training in patient-care settings under the supervision of attending physicians. Cervical root, stellate ganglion, piriformis, and lumbar plexus blocks were more commonly performed by Group B than by Group A (P < 0.05). Conclusions: Instruction regarding US-guided pain management interventions varied among fellowship training hospitals, highlighting the need for the development of educational standards that mandate a minimum number of US-guided nerve blocks or injections during fellowships in interventional pain management.b [ABSTRACT FROM AUTHOR]

Background: Recently, ultrasound has been commonly used. Ultrasound-guided interscalene brachial plexus block (IBPB) by posterior approach is more commonly used because anterior approach has been reported to have the risk of phrenic nerve injury. However, posterior approach also has the risk of causing nerve injury because there are risks of encountering dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Therefore, the aim of this study was to evaluate the risk of encountering DSN and LTN during ultrasound-guided IBPB by posterior approach. Methods: A total of 70 patients who were scheduled for shoulder surgery were enrolled in this study. After deciding insertion site with ultrasound, awake ultrasound-guided IBPB with nerve stimulator by posterior approach was performed. Incidence of muscle twitches (rhomboids, levator scapulae, and serratus anterior muscles) and current intensity immediately before muscle twitches disappeared were recorded. Results: Of the total 70 cases, DSN was encountered in 44 cases (62.8%) and LTN was encountered in 15 cases (21.4%). Both nerves were encountered in 10 cases (14.3%). Neither was encountered in 21 cases (30.4%). The average current measured immediately before the disappearance of muscle twitches was 0.44 mA and 0.50 mA at DSN and LTN, respectively. Conclusions: Physicians should be cautious on the risk of injury related to the anatomical structures of nerves, including DSN and LTN, during ultrasound-guided IBPB by posterior approach. Nerve stimulator could be another option for a safer intervention. Moreover, if there is a motor response, it is recommended to select another way to secure better safety. [ABSTRACT FROM AUTHOR]

Background: Pain medicine often requires medico-legal involvement, even though diagnosis and treatments have improved considerably. Multiple guidelines for pain physicians contain many recommendations regarding interventional treatment. Unfortunately, no definite treatment guidelines exist because there is no complete consensus among individual guidelines. Pain intervention procedures are widely practiced and highly associated with adverse events and complications. However, a comprehensive, systemic review of medical-dispute cases (MDCs) in Korea has not yet been reported. The purpose of this article is to analyze the frequency and type of medical dispute activity undertaken by pain specialists in Korea. Methods: Data on medical disputes cases were collected through the Korea Medical Association mutual aid and through a private medical malpractice liability insurance company. Data regarding the frequency and type of MDCs, along with brief case descriptions, were obtained. Results: Pain in the lumbar region made up a major proportion of MDCs and compensation costs. Infection, nerve injury, and diagnosis related cases were the most major contents of MDCs. Only a small proportion of cases involved patient death or unconsciousness, but compensation costs were the highest. Conclusions: More systemic guidelines and recommendations on interventional pain management are needed, especially those focused on medico-legal cases. Complications arising from pain management procedures and treatments may be avoided by physicians who have the required knowledge and expertise regarding anatomy and pain intervention procedures and know how to recognize procedural aberrations as soon as they occur. [ABSTRACT FROM AUTHOR]

Painful periarticular calcification most commonly occurs within the rotator cuff of the shoulder and rarely around the elbow, hip, foot, and neck. As acute inflammatory reaction develops, severe pain, exquisite tenderness, local swelling, and limitation of motion with pain occur. In case of calcific tendinitis of the shoulder, it can be easily diagnosed according to the symptoms and with x-ray. However, in lesions of the hip, as it is a rare location and usually involves pain in the posterolateral aspect of the thigh, which can simulate radicular pain from a lumbar intervertebral disc, it could be difficult to diagnose. Hence, physicians usually focus on lumbar lesions; therefore, misdiagnosis is common and leads to a delayed management. Here, we report the case of a 30-year-old female patient with calcific tendinitis of the rectus femoris that was successfully managed with ultrasound-guided steroid injection. This study offers knowledge about the rectus femoris calcification. [ABSTRACT FROM AUTHOR]

Background: Epidural steroid injection (ESI) is one of the most common procedures for patients presenting low back pain and radiculopathy. However, there is no clear consensus on what constitutes appropriate steroid use for ESIs. To investigate optimal steroid injection methods for ESIs, surveys were sent to all academic pain centers and selected private practices in Korea via e-mail. Methods: Among 173 pain centers which requested the public health insurance reimbursements for their ESIs and were enrolled in the Korean Pain Society, 122 completed questionnaires were returned, for a rate of 70.5%; also returned were surveys from 39 academic programs and 85 private practices with response rates of 83.0% and 65.9%, respectively. Results: More than half (55%) of Korean pain physicians used dexamethasone for ESIs. The minimum interval of subsequent ESIs at the academic institutions (3.1 weeks) and the private practices (2.1 weeks) were statistically different (P = 0.01). Conclusions: Although there was a wide range of variation, there were no significant differences between the academic institutions and the private practices in terms of the types and single doses of steroids for ESIs, the annual dose of steroids, or the limitations of doses in the event of diabetes, with the exception of the minimum interval before the subsequent ESI. [ABSTRACT FROM AUTHOR]

Several complications are possible after a lumbar epidural block. However pneumocephalus are rare. In this case, we report a case of pneumocephalus. A 68-year-old male patient received lumbar epidural block with the loss of resistance technique using air, and after 35 minutes, apnea, unconsciousness, hypotension, and bradycardia occurred. Immediately, brain CT was done, and we found pneumocephalus. The patient complained of severe occipital headache and itchiness due to pneumocehalus. After conservative treatment, the patient recovered without neurologic complications, and on the seventh day of his hospitalization, he was discharged from the hospital. [ABSTRACT FROM AUTHOR]

Glomus tumors are small vascular tumors that are usually benign and rarely occur. They originate from glomus bodies and present in the reticular dermis. They are clinically distinguished by their small size and their ability to cause extreme pain. Most of these tumors are subungually located. However, atypical locations of the tumors sometimes cause misdiagnosis, particularly when the lesion is rarely reported. Therefore, we report a case of glomus tumor which presented with chronic abdominal pain, found in the abdominal wall that has never been reported before. [ABSTRACT FROM AUTHOR]

A response from the author of the article "Successful Treatment of Abdominal Cutaneous Entrapment Syndrome (ACES) Using Ultrasound Guided Injection" published in a previous issue of the journal is presented.