The Effect and Safety of Steroid Injection in Lumbar Spinal Stenosis: With or Without Local Anesthetics

OBJECTIVE: To compare the long-term effect and safety of an epidural steroid injection in spinal stenosis patients, with or without local anesthetics. METHODS: Twenty-nine patients diagnosed with spinal stenosis were included and randomly divided into two groups. Translaminar epidural and selective nerve root spinal injection procedures were performed using steroids mixed with local anesthetics or normal saline. The effects of spinal injection procedures were measured with visual analogue scale (VAS) and functional rate index (FRI). These measurements were performed before injection, at 1 month after injection and at 3 months after injection. The occurrence of side effects was investigated each time. RESULTS: The VAS and FRI scores were significantly reduced in both the local anesthetics group and normal saline group at 1 and 3 months after the injection. However, there was no significant difference in VAS and FRI score reduction between the two groups each time. Side effects are not noted in both groups. CONCLUSION: The spinal injection procedures using steroids mixed either with local anesthetics or normal saline have an effect in reducing pain and improving functional activities. However, there was no significant difference between the two groups in relation to side effects and the long-term effects of pain and function.

Leg Weakness Caused by Bilateral Piriformis Syndrome: A Case Report

Piriformis syndrome (PS) is an uncommon neuromuscular disorder caused by the piriformis muscle (PM) compressing the sciatic nerve (SN). The main symptom of PS is sciatica, which worsens with certain triggering conditions. Because the pathophysiology is poorly understood, there are no definite diagnostic and therapeutic choices for PS. This case report presents a young woman who mainly complained of bilateral leg weakness. Electromyography revealed bilateral sciatic neuropathy and magnetic resonance imaging confirmed structural lesions causing entrapment of the bilateral SNs. After a laborious diagnosis of bilateral PS, she underwent PM releasing surgery. Few PS cases present with bilateral symptoms and leg weakness. Therefore, in such cases, a high level of suspicion is necessary for accurate and prompt diagnosis and treatment.

Chest Wall Pain as the Presenting Symptom of Leptomeningeal Carcinomatosis

Leptomeningeal metastasis (LMM), also referred to as leptomeningeal carcinomatosis, results from diffuse infiltration of the leptomeninges by malignant cells originating from extra-meningeal primary tumors. It occurs in approximately 5%-10% of patients with solid tumor. Among solid tumors, the most common types leading to infiltration of the leptomeninges are breast cancer, lung cancer, and melanoma. Patients with LMM may present various signs and symptoms. Herein, we report a rare case with initial presentation of isolated chest wall pain. Computed tomography of the chest with contrast revealed a 2.5-cm nodule over the left upper lung. Biopsy confirmed the diagnosis of adenocarcinoma. Later, cerebrospinal fluid cytology exam also confirmed leptomeningeal seeding. It is rare for leptomeningeal carcinomatosis patients to present with chest wall pain. Therefore, a high index of suspicion is mandatory for accurate and prompt diagnosis.

Usefulness of the Computed Tomography Venography for Evaluation of Leg Edema Including Deep Vein Thrombosis in Rehabilitation Patients

OBJECTIVE: To investigate the usefulness of computed tomography venography (CTV) for evaluation of leg swelling, especially deep vein thrombosis (DVT), in rehabilitation patients. METHODS: A hundred twenty-three patients, who had performed CTV performed because of suspected DVT in our clinic, were enrolled. We performed chart reviews retrospectively and categorized CTV findings as follows: DVT distal to inguinal ligament and no compression lesion; DVT proximal to inguinal ligament and no compression lesion; DVT distal to inguinal ligament and anatomical variant (for example, May-Thurner syndrome); DVT due to compression of mass (cancer or cyst); DVT and other incidental abnormal finding; and no DVT and other possible causes of leg swelling. RESULTS: DVTs were found in 65 (53%) patients. DVTs were found at distal level (thigh or lower leg) to inguinal ligament in 47 patients. DVTs were found at proximal to inguinal ligament, usually undetectable with duplex ultrasonography, in 6 patients. DVTs caused by external compression, such as femoral vein and cancer mass, were found in 12 patients (10%), which are also not easily detected with duplex ultrasonography. Other various causes of leg edema without DVT were found in 22 (18%) patients. CONCLUSION: CTV can evaluate more extensively venous problems in the pelvis and abdomen and detect other possible causes of leg swelling. Therefore, CTV can be a useful tool not only for easy detection of DVT but also for evaluating differential diagnosis of leg edema in rehabilitation patients.

Wernicke's Encephalopathy and Peripheral Polyneuropathy Developed during Long Term Metronidazole Therapy in a Patient with a Brain Abscess: A Case Report

Metronidazole can induce serious neurologic problems including peripheral neuropathy, seizures, and encephalopathy. We examined a patient with acute Wernicke's encephalopathy and peripheral polyneuropathy that had developed after prolonged metronidazole therapy without a history of chronic alcoholism or poor nutritional intake. The 68-year-old man had been hospitalized for a brain abscess and was treated for 10 weeks with metronidazole (2 grams per day). This patient, who showed symptoms of numbness and tingling in the legs, was referred for electromyography (EMG) and was diagnosed with peripheral polyneuropathy. A few days later, he developed sudden ataxia, dizziness, and diplopia. The neurologic examination revealed nystagmus and ophthalmoplegia, and the FLAIR brain MRI showed symmetrical high signal intensity lesions in the cerebellar dentate nucleus, midbrain, tegmentum around the periaqueductal gray matter, and tectum. After administering intravenous thiamine and stopping the metronidazole therapy, he recovered from the ophthalmoplegia and ataxia. Brain MR showed complete recovery within 3 weeks; however the EMG remained abnormal for a further 6 months, although the symptoms were almost completely resolved by this time.

New Method and Usefulness of Study on Sensory Nerve Conduction of Lateral Sural Cutaneous Nerve

OBJECTIVE: To find a new method and usefulness of study on sensory nerve conduction of lateral sural cutaneous nerve (LSCN). METHOD: The 60 extremities of 30 adults without peripheral neuropathy were placed in a prone position. Next, each subject was administered with an antidromic stimulation at a point 3 cm lateral from the center of the popliteal fossa. With the aid of active electrodes, the sensory nerve action potentials (SNAPs) were recorded at points 10 cm inferior and 1 cm lateral to the stimulation site. The method of sensory nerve conduction study suggested by Campagnolo et al. was performed simultaneously, to compare of the frequency of SNAPs and the amplitudes. RESULTS: For the sensory nerve conduction study of the LSCN suggested in this report, SNAPs were obtained in 49 extremities, with a revelation rate of 81.7%. The mean amplitude was 11.91+/-3.68micronV. In the results of the tests suggested by Campagnolo et al., the SNAPs were obtained in 29 extremities, with a revelation rate of 48.3%. The mean amplitude was 8.37+/-5.21micronV. Significance testing of the electrodiagnostic method recommended in this study revealed that many SNAPs were observed for the LSCN, with statistically significant action potential amplitudes. CONCLUSION: This study presents the new method and reference values of sensory nerve conduction for LSCN, which is thought to be useful in electrodiagnostic studies to diagnose entrapment neuropathy.

Efficacy of Translaminar Epidural Steroid Injection versus Combined Translaminar Epidural Steroid Injection with Selective Nerve Root Injection in Spinal Stenosis

OBJECTIVE: To compare treatment effects of translaminar epidural steroid injections (TLESIs) only and selective nerve root injections (SNRIs) with TLESIs in lumbosacral spinal stenosis. METHOD: Thirty-four patients diagnosed with magnetic resonance imaging (MRI), somatosensory evoked potential (SEP) and electromyography (EMG) were included. 16 patients who had somatosensory pathway dysfunction or abnormal spontaneous activity received combined SNRIs with TLESIs and 20 patients received only TLESIs. The visual analogue scale (VAS) and functional rating index (FRI) were measured before injection, 1 week and 3 months after 3 times injection. RESULTS: The mean values of VAS before injection, 1 week and 3 months after 3 times injection were 7.55, 3.22, 3.61 in only TLESIs and 7.37, 2.06, 2.31 in SNRIs with TLESIs. The mean values of FRI before injection, 1 week and 3 months after 3 times injection were 25.16, 16.00, 15.83 in only TLESIs and 22.50, 8.37, 8.31 in SNRIs with TLESIs. In the mean values of VAS and FRI were significantly lower SNRIs with TLESIs than only TLESIs (p<0.05). CONCLUSION: Combined SNRIs with TLESIs were more effective treatment for reduction of pain and improvement of function than only TLESIs in lumbosacral spinal stenosis.

The Two Year's Follow Up Study of Symptomatic Hands without Electrodiagnostic Evidence of Carpal Tunnel Syndrome

OBJECTIVE: The purpose of this study was to determine the natural history of symptomatic hands without electrodiagnostic evidence of carpal tunnel syndrome (CTS). METHOD: This study was comprised of 88 hands of 49 subjects with symptoms consistent with CTS without median mononeuropathy who were recruited during a community health examination and followed after two years. 88 hands of 44 people with age and sex-matched healthy controls were followed for comparison. Symptoms and electrodiagnostic findings were compared between the two groups. RESULTS: 62 hands of the symptomatic group had persistent symptoms after 2 years while 16 hands of the control group had symptoms consistent with CTS. Median motor distal latencies were significantly delayed after two years in the symptomatic group (p<0.05). Median sensory latencies were also delayed in the symptomatic group, but this was not statistically significant (p=0.064). The occurrence rate of median mononeuropathy at wrist was significantly higher in the symptomatic group than in the control group (13.6% vs. 2.3%)(p<0.05). CONCLUSION: The results of this study suggested that a significant number of symptomatic hands without electrodiagnostic evidence of CTS may have persistent symptoms and may progress to electrodiagnostically evident CTS.

Prevalence and Risk Factors of Ulnar Neuropathy at the Elbow in a Rural Population

OBJECTIVE: The purpose of this study was to investigate the prevalence and risk factors of ulnar neuropathy at the elbow (UNE) in a rural district in Korea. METHOD: Among the 578 residents in a rural district who participated in the health examination, 450 (116 male, 334 female) adults were randomly selected. A symptom questionnaire and electrodiagnostic studies were used to diagnose UNE. General characteristics, female-related factors, work-related factors and anthropometric measurements were compared between normal and UNE group to identify the risk factors of UNE. RESULTS: Subjects with UNE were 29 (6.4%), symptom without electrodiagnosis findings 23 (5.1%), asymptomatic subjects were 379 (84.2%). Diabetes mellitus, repetitive heavy lifting were risk factors of UNE. CONCLUSION: The prevalence of UNE was 6.4% in a rural district and these data suggest that medical conditions like diabetes mellitus and physical factors like repetitive heavy lifting are risk factors of UNE.

The Correlation of Electrodiagnostic Severity, Severity of Symptom, Functional Status, and Clinical Severity in Patients with Carpal Tunnel Syndrome

OBJECTIVE: To evaluate the correlation of electrodiagnostic severity, severity of symptom, and clinical severity in carpal tunnel syndrome (CTS). METHOD: The sixty eight patients with documented CTS in outpatient clinic from January, 2000 to June, 2001 were included (9 male, 59 female, averaged age 50.0+/-8.8 years). We evaluated the severity of symptom, functional status of ADL with the Levine' questionnaire, and clinical severity with 3 kinds of examination (thenar atrophy, sensory change, and Phalen's test). The electrodiagnostic severity was classified according to Stevens' classification and compared with the severity of symptom, functional status, and clinical severity. RESULTS: The electrodiagnostic severity was classified into three degrees. Five patients (7.4%) were classified into mild degree, 32 patients (47.1%) moderate degree, 31 patients (45.6%) severe degree. The average of severity of symptom scores were 28.4+/-8.5, 31.8+/-7.4, and 31.8+/-9.1 respectively, and there was no significant difference (p>0.05) between the groups. Functional status scales were 14.2+/-6.7, 15.6+/-5.4 and 18.9+/-7.0 respectively and no significant difference (p=0.07) but there was a tendency that the severer was electrodiagnostic severity, the more decreased functional status scale. The clinical severity showed a significant correlation with the electrodiagnostic severity (p<0.05). CONCLUSION: The electrodiagnostic severity has a significant correlation with the clinical severity, but not with the severity of symptom, the functional status in CTS.

Plantar Nerve Injuries Related to Calcaneal Fractures

OBJECTIVE: We investigated plantar nerve injuries associated with calcaneal fracture and severity of disability. METHOD: From July, 2001 to June, 2002, twelve patients who had calcaneal fractures with persistent foot pain and paresthesia were included in our study. We examined electromyography for medial and lateral plantar nerve, inferior calcaneal nerve, also evaluated types of calcaneal fracture and severity of pain and disability with nerve injury. RESULTS: The intraarticular types were 13 cases, extraarticular type was 1 case and communited types were 2 cases. In the electromyographic findings, the 9 cases were diagnosed asneuropathy. In a cases with neuropathy, 8 persons complained over moderate degree of pain and all persons complained over moderate degree of walking disability. However one of three persons without neuropathy complained over moderate degree of walking disability. So disability tended to be more severe in cases with neuropathy. CONCLUSION: We think that neuropathy associated with calcaneal fracture is a cause of aggravation of pain and walking disability, and electromyography for nerves of foot will be needed in the calcaneal fracture.