Narrowing of the dural sac cross-sectional area (DSCSA) and spinal canal cross-sectional area (SCCSA) have been considered major causes of lumbar central canal spinal stenosis (LCCSS). DSCSA and SCCSA were previously correlated with subjective walking distance before claudication occurs, aging, and disc degeneration. DSCSA and SCCSA have been ideal morphological parameters for evaluating LCCSS. However, the comparative value of these parameters is unknown and no studies have evaluated the clinical optimal cut-off values of DSCSA and SCCSA. This study assessed which parameter is more sensitive. Both DSCSA and SCCSA samples were collected from 135 patients with LCCSS, and from 130 control subjects who underwent lumbar magnetic resonance imaging (MRI) as part of a medical examination. Axial T2-weighted MRI scans were acquired at the level of facet joint from each subject. DSCSA and SCCSA were measured at the L4-L5 intervertebral level on MRI using a picture archiving and communications system. The average DSCSA value was 151.67 ± 53.59 mm² in the control group and 80.04 ± 35.36 mm² in the LCCSS group. The corresponding average SCCSA values were 199.95 ± 60.96 and 119.17 ± 49.41 mm². LCCSS patients had significantly lower DSCSA and SCCSA (both P < .001). Regarding the validity of both DSCSA and SCCSA as predictors of LCCSS, Receiver operating characteristic curve analysis revealed an optimal cut-off value for DSCSA of 111.09 mm², with 80.0% sensitivity, 80.8% specificity, and an area under the curve (AUC) of 0.87 (95% confidence interval, 0.83–0.92). The best cut off-point of SCCSA was 147.12 mm², with 74.8% sensitivity, 78.5% specificity, and AUC of 0.85 (95% confidence interval, 0.81–0.89). DSCSA and SCCSA were both significantly associated with LCCSS, with DSCSA being a more sensitive measurement parameter. Thus, to evaluate LCCSS patients, pain specialists should more carefully investigate the DSCSA than SCCSA.

Sooho Lee, Hyung Rae Cho, Jun Sung Yoo, and Young Uk Kim. Korean J Pain 2020;33:54-9. https://doi.org/10.3344/kjp.2020.33.1.54

Ankle syndesmotic injuries occasionally require long-term therapy for recovery and can result in tendon injury. Posterior tibial tendon dysfunction (PTTD) is an acquired deformity that can cause flatfoot deformity. The current nonoperative management of PTTD includes nonsteroidal antiinflammatory drugs (NSAIDs), orthopedic devices. Although various treatment options have been attempted, optimal treatments for each stage of the condition are debated. Polydeoxyribonucleotide (PDRN) is effective in healing of chronic wounds associated with tissue damage by attracting tissue growth factors. A 67-year-old woman who presented at our pain clinic with pain on the inside of ankle. She had a syndesmotic screw fixation 3 years prior. Her ankle pain had persisted after the removal of screws and edema for about 1 month resulting from long-term NSAIDs administration. The origin of the pain was possibly tibialis posterior muscle and posterior tibial tendon and she was diagnosed as PTTD after syndesmosis surgery. Sono guided prolotherapy with PDRN was carried out. Patient showed improvement in the arch of the foot, experienced pain relief, and was able to wear regular shoes without any orthopedic device. This case report highlights that PDRN prolotherapy is a safe and efficient therapeutic option for the treatment of PTTD.

A hypertrophied posterior tibial tendon (PTT) has been considered to be an important morphologic parameter of PTT dysfunction (PTTD). Previous research has demonstrated that the PTT thickness (PTTT) is correlated with early signs of PTTD. However, the thickness is different from hypertrophy. Thus, we devised the PTT cross-sectional area (PTTCSA) as a new predictive parameter for diagnosing the PTTD. The PTT data were acquired from 14 patients with PTTD and from 20 normal individuals who underwent ankle magnetic resonance imaging. We measured the PTTT and PTTCSA at the PTT on the ankle magnetic resonance imaging. The mean PTTT was 2.43 ± 0.39 mm in the normal group and 3.40 ± 0.42 mm in the PTTD group. The average PTTCSA was 16.10 ± 4.27 mm² in the normal group and 26.93 ± 4.38 mm² in the PTTD group. The receiver operator characteristic analysis curve demonstrated that the highest predictive value of the PTTT was 3.07 mm, with 85.7% sensitivity, 85.0% specificity. The highest predictive value of the PTTCSA was 22.54 mm ² , with 92.9% sensitivity, 90.0% specificity. Our findings suggest that the PTTCSA was a more valid predictor of PTTD, even though the PTTT and PTTCSA were both significantly associated with PTTD.

Cho HR, et al. J Korean Med Sci. 2020 Feb;35(15):e99. https://doi.org/10.3346/jkms.2020.35.e99