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Kim SY, Jang JN, Choi YS, Park S, Yi J, Song Y, Kim JW, Kang KN, Kim YU. The cervical ligamentum flavum area: A new sensitive morphological parameter for identifying the cervical spinal stenosis. Medicine (Baltimore) 2023; 102:e36259. [PMID: 38013374 PMCID: PMC10681602 DOI: 10.1097/md.0000000000036259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/01/2023] [Indexed: 11/29/2023] Open
Abstract
Thickening of the cervical ligamentum flavum (CLF) has been considered as a main cause of cervical spinal stenosis (CSS). A previous study reported that cervical ligamentum flavum thickness (CLFT) is correlated with CSS. However, the whole hypertrophy is different from focal thickness. Therefore, to analyze hypertrophy of the CLF, we created a new morphological parameter, called the cervical ligamentum flavum area (CLFA). We hypothesized that the CLFA is an important morphological parameter in the diagnosis of CSS. CLF samples were acquired from 83 patients with CSS, and from 84 controls who underwent cervical magnetic resonance imaging (C-MRI). T2-weighted axial C-MRI images were acquired. We measured the CLFA and CLFT at the C6-C7 intervertebral level on C-MRI using appropriate image analysis software. The CLFA was measured as the cross-sectional area of the entire CLF at the level of C6-C7 stenosis. The CLFT was measured by drawing a straight line along the ligament side towards the spinal canal at the C6-C7 level. Mean CLFA was 25.24 ± 6.43 mm2 in the control group and 45.34 ± 9.09 mm2 in the CSS group. The average CLFT was 1.48 ± 0.28 mm in the control group and 2.09 ± 0.35 mm in the CSS group. CSS patients had significantly higher CLFA (P < .01) and CLFT (P < .01). For the validity of both CLFA and CLFT as predictors of CSS, a receiver operating characteristic curve analysis revealed an optimal cutoff point for the CLFA was 31.66 mm2, a sensitivity of 92.8%, specificity of 88.4%, and an area under the curve of 0.97 (95% CI, 0.94-0.99). The optimal cut off-point of the CLFT was 1.79 mm, with a sensitivity of 83.5%, specificity of 84.5%, and an area under the curve of 0.92 (95% CI, 0.87-0.96). Both CLFT and CLFA were significantly related to CSS, but CLFA was the more sensitive measurement parameter. Therefore, to evaluate patients with CSS, treating physicians should test for CLFA.
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Affiliation(s)
- So Yeon Kim
- Department of Neurosurgery, Catholic Kwandong University of Korea College of Medicine, International St. Mary’s Hospital, Incheon, Republic of Korea
| | - Jae Ni Jang
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary’s Hospital, Incheon, Republic of Korea
| | - Young-Soon Choi
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary’s Hospital, Incheon, Republic of Korea
| | - Sukhee Park
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary’s Hospital, Incheon, Republic of Korea
| | - Jungmin Yi
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary’s Hospital, Incheon, Republic of Korea
| | - Yumin Song
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary’s Hospital, Incheon, Republic of Korea
| | - Jae Won Kim
- Catholic Kwandong University of Korea College of Medicine, Gangneung, Republic of Korea
| | - Keum Nae Kang
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Republic of Korea
| | - Young Uk Kim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary’s Hospital, Incheon, Republic of Korea
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Nahm FS. Receiver operating characteristic curve: overview and practical use for clinicians. Korean J Anesthesiol 2022; 75:25-36. [PMID: 35124947 PMCID: PMC8831439 DOI: 10.4097/kja.21209] [Citation(s) in RCA: 251] [Impact Index Per Article: 125.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 11/05/2021] [Indexed: 11/10/2022] Open
Abstract
Using diagnostic testing to determine the presence or absence of a disease is essential in clinical practice. In many cases, test results are obtained as continuous values and require a process of conversion and interpretation and into a dichotomous form to determine the presence of a disease. The primary method used for this process is the receiver operating characteristic (ROC) curve. The ROC curve is used to assess the overall diagnostic performance of a test and to compare the performance of two or more diagnostic tests. It is also used to select an optimal cut-off value for determining the presence or absence of a disease. Although clinicians who do not have expertise in statistics do not need to understand both the complex mathematical equation and the analytic process of ROC curves, understanding the core concepts of the ROC curve analysis is a prerequisite for the proper use and interpretation of the ROC curve. This review describes the basic concepts for the correct use and interpretation of the ROC curve, including parametric/nonparametric ROC curves, the meaning of the area under the ROC curve (AUC), the partial AUC, methods for selecting the best cut-off value, and the statistical software to use for ROC curve analyses.
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Jeong HW, Yi J, Lee S, Park S, Kang KN, Lee J, Cho HR, Kim YU. Prognostic value of cervical ligamentum flavum thickness as a morphological parameter to predict cervical stenosis. Medicine (Baltimore) 2021; 100:e27084. [PMID: 34449510 PMCID: PMC8389973 DOI: 10.1097/md.0000000000027084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 08/12/2021] [Indexed: 01/04/2023] Open
Abstract
One of major causes of cervical central stenosis (CCS) is thickened change of cervical ligament flavum (CLF). The association of a morphological parameter called cervical ligament flavum thickness (CLFT) with CCS has not been reported yet. Thus, the purpose of this research was to investigate the relationship between CCS and CFJT.Data were obtained from 88 patients with CCS. A total of 87 normal controls also underwent cervical spine magnetic resonance imaging (CSMRI). All subjects underwent axial T2-weighted CSMRI. Using our picture archiving and communications system, thickness of ligament flavum of the cervical spine at C6/7 level was analyzed.The mean CLFT was 1.41 ± 0.24 mm in normal subjects and 2.09 ± 0.39 mm in patients with CCS. The CCS group was found to have significantly (P < .001) higher rate of CLFT than normal subjects. ROC curves were used to assess the usefulness of CLFT as a predictor of CCS. In the CCS group, the best practical cut off-point of CLFT was 1.71 mm (sensitivity = 90.9%; specificity = 90.8%), with AUC of 0.94 (95% confidence interval: 0.90--0.98).Greater CLFT values were associated with greater possibility of CCS. Thus, treating physician should carefully examine CLFT, as it can help diagnose CCS.
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Affiliation(s)
- Hye-Won Jeong
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International ST. Mary's Hospital, Incheon, Republic of Korea
| | - Jungmin Yi
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International ST. Mary's Hospital, Incheon, Republic of Korea
| | - Sooho Lee
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International ST. Mary's Hospital, Incheon, Republic of Korea
| | - Sukhee Park
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International ST. Mary's Hospital, Incheon, Republic of Korea
| | - Keum Nae Kang
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Republic of Korea
| | - Jonghyuk Lee
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Republic of Korea
| | - Hyung Rae Cho
- Department of Anesthesiology and Pain Medine, Myongji Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Young Uk Kim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International ST. Mary's Hospital, Incheon, Republic of Korea
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Abstract
Background Cervicogenic headache is a distinct type of headache described in 1980s by Sjaastad, a Norwegian neurologist. It is a not so uncommon headache, which is usually under-diagnosed resulting in suboptimal quality-of-life. Objective The aim of this study was to review the current recommendations on diagnosis and management of cervicogenic headache. Methods and Material A PubMed search was done for the recent articles on 'cervicogenic headache' published in English literature with the aim of recognizing the current perspectives on cervicogenic headache. Results The diagnosis of cervicogenic headache is based on clinical criteria mentioned by the International Headache Society (IHS) and Cervicogenic Headache International Study Group (CHISG). Cervical nerve block may confirm the nociceptive source in majority of cases and is included in CHISG criteria. Non-invasive diagnostic methods like echogenicity of muscles, diffusion tensor imaging (DTI) and single-photon emission tomography (SPECT) are proposed by some authors for avoiding complications associated with blocks. Mainstay of management is physical therapy. Surgical interventions for cervical degenerative disease may relief an associated headache but such interventions are not performed solely for cervicogenic headache. Conclusion Headaches with a cervical spine nociceptive source are increasingly being recognized. Current diagnostic criteria and management options are reviewed here.
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Affiliation(s)
- Satish Verma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Yang S, Kwon S, Chang MC. The Usefulness of Diffusion Tensor Tractography in Diagnosing Neuropathic Pain: A Narrative Review. Front Neurosci 2021; 15:591018. [PMID: 33841069 PMCID: PMC8032899 DOI: 10.3389/fnins.2021.591018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Diffusion tensor tractography (DTT) is derived from diffusion tensor imaging. It has allowed visualization and estimation of neural tract injury, which may be associated with the pathogenesis of neuropathic pain (NP). The aim of the present study was to review DTT studies that demonstrated the relationship between neural injuries and NP and to describe the potential use of DTT in the evaluation of neural injuries that are involved in the pathophysiological process of NP. A PubMed search was conducted for articles published until July 3, 2020, which used DTT to investigate the association between neural injuries and NP. The key search phrase for identifying potentially relevant articles was (diffusion tensor tractography AND pain). The following inclusion criteria were applied for article selection: (1) studies involving patients with NP and (2) studies in which DTT was applied for the evaluation of NP. Review articles were excluded. Altogether, 108 potentially relevant articles were identified. After reading the titles and abstracts and assessment of eligibility based on the full-text articles, 46 publications were finally included in our review. The results of the included studies suggested that DTT may be beneficial in identifying the pathophysiological mechanism of NP of various origins including central pain caused by brain injuries, trigeminal neuralgia, sciatica, and some types of headache. Further studies are needed to validate the efficacy of DTT in investigating the pathophysiology of other types of NP.
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Affiliation(s)
- Seoyon Yang
- Department of Rehabilitation Medicine, Ewha Women's University Seoul Hospital, Ewha Women's University School of Medicine, Seoul, South Korea
| | - SuYeon Kwon
- Department of Rehabilitation Medicine, Ewha Women's University Seoul Hospital, Ewha Women's University School of Medicine, Seoul, South Korea
| | - Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, South Korea
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Won HS, Jang HY, Moon HS, Zhu PB, Kim YD, Kim H. Fluoroscopic Findings of Extra-Cervical Facet Joint Flow and Its Incidence on Cervical Facet Joint Arthrograms. J Clin Med 2020; 9:jcm9123919. [PMID: 33276698 PMCID: PMC7761532 DOI: 10.3390/jcm9123919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 11/24/2020] [Accepted: 12/02/2020] [Indexed: 12/18/2022] Open
Abstract
Cervical facet joint (CFJ) syndrome is a common cause of neck pain. For its diagnosis and treatment, CFJ injection with arthrogram is generally performed. This study aimed to investigate the frequency of extra-CFJ flow on CFJ arthrograms during injections and its differences according to age, sex, and cervical vertebral level. We analyzed 760 CFJ arthrograms administrated to 208 patients diagnosed with CFJ syndrome. Arthrograms at each vertebral level were collected to evaluate the normal CFJ and extra-CFJ flow. The primary and secondary outcomes were frequency of extra-CFJ flow according to cervical vertebral level, age, and sex and according to pairwise cervical levels, respectively. Extra-CFJ flow at the cervical spine occurred during 179 injections, and the overall incidence was 3.3–36.2% at different cervical levels. The incidence of extra-CFJ flow at each cervical vertebral level according to age and sex was not significant. Extra-CFJ flow was the highest at C6 and C7, but there was no statistical significance. Extra-CFJ flow was higher at lower vertebral levels (C5–C7) than at upper levels (C3 and C4). Additional clinical studies and anatomical evaluations are needed to support its clinical value and enable the development of new injection techniques.
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Affiliation(s)
- Hyung-Sun Won
- Department of Anatomy, Wonkwang University School of Medicine, 460 Iksan-daero, Iksan, Jeonbuk 54538, Korea; (H.-S.W.); (P.-B.Z.)
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, 460 Iksan-daero, Iksan, Jeonbuk 54538, Korea
| | - Ho-Yeon Jang
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, 460 Iksan-daero, Iksan, Jeonbuk 54538, Korea;
| | - Hyun-Seog Moon
- Joy of the World, Interventional Pain Management Center, 10 Sinchon-ro 35-gil, Seodaemun-gu, Seoul 03774, Korea;
| | - Peng-Bo Zhu
- Department of Anatomy, Wonkwang University School of Medicine, 460 Iksan-daero, Iksan, Jeonbuk 54538, Korea; (H.-S.W.); (P.-B.Z.)
| | - Yeon-Dong Kim
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, 460 Iksan-daero, Iksan, Jeonbuk 54538, Korea
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, 460 Iksan-daero, Iksan, Jeonbuk 54538, Korea;
- Wonkwang Institute of Science, Wonkwang University School of Medicine, 460 Iksan-daero, Iksan, Jeonbuk 54538, Korea
- Correspondence: (Y.-D.K.); (H.K.); Tel.: +82-63-8591562 (Y.-D.K.); +82-2-30103883 (H.K.)
| | - Hyungtae Kim
- 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
- Correspondence: (Y.-D.K.); (H.K.); Tel.: +82-63-8591562 (Y.-D.K.); +82-2-30103883 (H.K.)
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