Department of Neurosurgery, Mokpo Hankook Hospital, Mokpo-city

1. Hyperosmolar Dextrose Solution Injection Into the Lumbosacral medial branch and Bilateral Sacroiliac Joint for Remnant Buttock Pain after Vertebral Augmentation Procedures Hyeun Sung Kim, Sung Keun Park, Hoon Joy, In Ho Park, Jae KwangRyu, Seok Won Kim, ChangilJu, Kyung Joon Lim, Dae Hyun Jo Department of Neurosurgery, Mokpo Hankook Hospital, Mokpo-city Department of Neurosurgery, Department of Anesthesiology and Pain Medicine, College of Medicine, Chosun University Department of Pain Medicine, College of Medicine, Pochon CHA University

2. Background Osteoporotic Vertebral Compression Fractures(VCFs) in the Elderly Patients • Deteriorates internal organ function • Deteriorates pulmonary function • Restrict the range of motion • Deteriorates quality of life • Death HS Kim : Mokpo Hankook Hospital

3. Background Vertebral Compression Fractures • Vertebral collapse • Induce height loss, spinal instability, facet unarthropathy, and nerve root entrapment • May cause pain in the area above or below the fracture site • Fall down • Induces the asymmetric force of the sacroiliac joint • Residual or persistent pain • More than 10 % patients even after successful vertebral or • sacral augmentation procedures HS Kim : Mokpo Hankook Hospital

4. Material and Methods Indications • Patients who fell down as initial accident • and with factors causing strains on the sacroiliac joint • Excluding snapping or spontaneous fracture patients • Pain only localized into sacroiliac joint referred area • No newly developed osteoporotic vertebral fracture referred pain • No remnant fractured vertebral referred pain • No true lower lumbar radicular pain • Patients without compensation psychologically. HS Kim : Mokpo Hankook Hospital

5. Material and Methods Material • From October 2006 to December 2007 • 36 patients with remnant pain after augmentation procedures of 321 • In their 50s : 3 cases, the 60s : 9 cases, the 70s : 21 cases, older than the 80s : 3 cases Preparation • Solution :15 % glucose/ 0.2 % lidocaine solution • : 3 cc 50 % glucose solution, 1 cc 2 % lidocaine, 6 cc distilled water • Posture : On a radiolucent operative table • : under the guide of C-arm fluoroscopy • : in prone position • : IV sedation • Preparation : the aseptic preparation on the lower lumbar area and the SIJ area. HS Kim : Mokpo Hankook Hospital

6. Methods Procedures : Bilateral medial branch(MB)(L4,5,S1 branch) injection and bilateral SI joint (SIJ) injection • insertion of 2 inch block needles into the synovial portion of both SI joints • assessed whether the bilateral SI joint insertion was accurate (water soluble iopromide (ultravistⓇ)) • approximately 5 – 10 cc solution was injected to both sacroiliac joints • <tears in the SI joint > • => drugs may be flowed to adjacent structures and penetrated adjacent nervous structures • : Does not exceed 10 cc • 1 cc each identical solution was injected in the vicinity of the bilateral L4,5,S1 medial branches. • It is important to insure that the solution is injected into the synovial sac • the solution is more likely to leak out and affect neighboring nerves, giving a false-positive. HS Kim : Mokpo Hankook Hospital

7. Methods Sacroiliac Joint Injection Medial Branch Injection HS Kim : Mokpo Hankook Hospital

8. Methods Evaluations • VAS check • At the time of admission • After performing augmentation procedures • After MB and SIJ injection • 2 days after augmentation procedures and one day after the injection • => to rule out the pain caused by injection and surgery • The patients were injected at 1 week interval. Patients of our study had following pain characteristics • Before Augmentation Procedures • severe restriction of the range of motion • difficult to stand • difficult to take sitting position due to severe pain • After the augmentation procedures • rather present the unilateral or bilateral buttock pain didn’t related with position HS Kim : Mokpo Hankook Hospital

9. Results Result • Total injection time : 2.31 times • VAS score change • From 8.78 to 4.33 : augmentation procedures • From 4.33 to 2.67 : the first injection of MB and SIJ • From 2.67 to 1.97 : the 2nd injection of MB and SIJ • Regarding remnant buttock pain : after MB and SIJ injection : decreased to 87.2 %. • Based on cases whose VAS score was decreased more than 50 % after 2 weeks • did not show effective response (reduction of pain less than 50 %) : 5 cases of patients (14 %) • successful responses (reduction of pain more than 50 %) : 31 patients (86 %) HS Kim : Mokpo Hankook Hospital

10. Discussion Augmentation Procedures in Osteoporotic (VCFs) : VP /KP • Decrease the patients pain • Decrease the life threatening complications : pneumonia, urinary tract infection, etc • Increase the quality of life • Increase the span of life • Low risk • Short procedures time • Early mobilization HS Kim : Mokpo Hankook Hospital

11. Discussion 3 Types of Mechanisms of development of Pain in Osteoporotic VCFs • Direct Traumatic Pain • disappears after augmentation procedures in most cases • Referred pain • Induced by a referred mechanism • Epidural inj., intercostal nerve block, TPI, facet joint inj., & RF neurotomy • Direct strain of the sacroiliac joint • due to fall down • when falling down on the hip • shearing force acts on the sacroiliac joint and ligaments • the force is delivered as the vertical direction as the force on the ischialtuberosity • Mechanism • Sacrum : downward(weight)  Fall down force : upper direction(ilium) • shearing force : muscles and ligaments in the vicinity of the sacroiliac joint • lower lumbar vertebrae adjacent to the sacrum : exposed to the identical strain HS Kim : Mokpo Hankook Hospital

12. Discussion Sacroiliac Joint • True joint and it has its inherent motion • Has nerves distributed in a wide area up to the L2-S3 • It is very sensitive to injury • Shows diverse patterns of pain depending on the level and area of injury. • Actually, only by adjacent segment blocks, localized buttock pain could not be resolved in many cases. • The lower part of the SI joint : Synovial part • like a knee joint • has a fluid-filled capsule which allows for smooth (if minor) motion. • The upper part of the SI joint • comprises two fairly rough surfaces attached with numerous ligaments HS Kim : Mokpo Hankook Hospital

13. Discussion Proposed RIT mechanism of action : Complex and Multifaceted • Cellular and extracellular matrix damage induced by mechanical transectionwith the needle stimulates inflammatory cascade, governing release of growth factors. • Compression of cells by relatively large extracellular volume as well as cell expansion or constriction due to osmotic properties of injectate stimulates the release of intracellular growth factors. • Chemomodulation of collagenthrough inflammatory, proliferative, regenerative/reparative response is induced by the chemical properties of the injectates and mediated by cytokines and multiple growth factors. • Chemoneuromodulation of peripheral nociceptorsprovides stabilization of antidromic, orthodromic, sympathetic and axon reflex transmissions. • Modulation of local hemodynamicswith changes in intraosseous pressure leads to reduction of pain. Empirical observations suggest that a dextrose/lidocaine combination has a much more prolonged action than lidocaine alone. • Temporary repetitive stabilization of the painful hypermobile joints, induced by inflammatory response to the injectates, provides a better environment for regeneration and repair of the affected ligaments and tendons. • Additional possible mechanisms of action include the disruption of adhesions by that have been created by the original inflammatory attempts to heal the injury by the large volume of injectate the relatively large volume of chemically non-irritating injectate assumes the role of a space occupying lesion in a relatively tight and slowly equilibrating extracellular compartment of the connective tissue. . Linetsky FS, Manchikanti L. Regenerative injection therapy for axial pain. Tech Reg Anesth Pain Manage. 2005; 9:40-49. Linetsky FS, Derby R, Miguel R, Saberski L, Stanton-Hicks M. Pain management with regenerative injection therapy (RIT). In: Bowell MV, Cole BE, eds. Weiner’s Pain Management: A Practical Guide for Clinicians, 7th ed. Boca Raton, FL: CRC Taylor & Francis Press; 2006:939-965 HS Kim : Mokpo Hankook Hospital

14. Conclusion The hyperosmolar dextrose solution injection into the bilateral lumbosacral medial branch and sacroiliac joint to the patient who has a remnant buttock pain after augmentation procedures in the patients with osteoporotic VCFs is the one of the treatment methods that decreased the symptoms. HS Kim : Mokpo Hankook Hospital