Accuracy of Ultrasound-Guided and Non-guided Botulinum Toxin Injection Into Neck Muscles Involved in Cervical Dystonia: A Cadaveric Study

Objective@#To compare the accuracy of ultrasound-guided and non-guided botulinum toxin injections into the neck muscles involved in cervical dystonia. @*Methods@#Two physicians examined six muscles (sternocleidomastoid, upper trapezius, levator scapulae, splenius capitis, scalenus anterior, and scalenus medius) from six fresh cadavers. Each physician injected ultrasound-guided and non-guided injections to each side of the cadaver’s neck muscles, respectively. Each physician then dissected the other physician’s injected muscle to identify the injection results. For each injection technique, different colored dyes were used. Dissection was performed to identify the results of the injections. The muscles were divided into two groups based on the difficulty of access: sternocleidomastoid and upper trapezius muscles (group A) and the levator scapulae, splenius capitis, scalenus anterior, and scalenus medius muscles (group B). @*Results@#The ultrasound-guided and non-guided injection accuracies of the group B muscles were 95.8% and 54.2%, respectively (p<0.001), while the ultrasound-guided and non-guided injection accuracies of the group A muscles were 100% and 79.2%, respectively (p<0.05). @*Conclusion@#Ultrasound-guided botulinum toxin injections into inaccessible neck muscles provide a higher degree of accuracy than non-guided injections. It may also be desirable to consider performing ultrasound-guided injections into accessible neck muscles.

Reference Value for Infrapatellar Branch of Saphenous Nerve Conduction Study: Cadaveric and Clinical Study

OBJECTIVE: To determine the optimal stimulation and recording site for infrapatellar branch of saphenous nerve (IPBSN) conduction studies by a cadaveric study, and to confirm that obtained location is practically applicable to healthy adults. METHODS: Twelve lower limbs from six cadavers were studied. We defined the optimal stimulation site as the point IPBSN exits the sartorius muscle and the distance or ratio were measured on the X- and Y-axis based on the line connecting the medial and lateral poles of the patella. We defined the optimal recording site as the point where the terminal branch met the line connecting inferior pole of patella and tibial tuberosity, and measured the distance from the inferior pole. Also, nerve conduction studies were performed with obtained location in healthy adults. RESULTS: In optimal stimulation site, the mean value of X-coordinate was 55.50±6.10 mm, and the ratio of the Y-coordinate to the thigh length was 25.53%±5.40%. The optimal recording site was located 15.92±1.83 mm below the inferior pole of patella. In our sensory nerve conduction studies through this location, mean peak latency was 4.11±0.30 ms and mean amplitude was 4.16±1.49 µV. CONCLUSION: The optimal stimulation site was located 5.0–6.0 cm medial to medial pole of the patella and 25% of thigh length proximal to the X-axis. The optimal recording site was located 1.5–2.0 cm below inferior pole of patella. We have also confirmed that this location is clinically applicable.

Phrenic Nerve Clipping in a Stroke Patient with Intractable Hiccup: a Case Report

Hiccup is an intermittent, involuntary and erratic contraction of the diaphragm, immediately followed by a laryngeal closure. Persistent and intractable hiccups are rare but severe, keeping a person from doing daily activities; these can result in depression, fatigue, impaired sleep, dehydration, weight loss, malnutrition, and aspiration. Therefore, proper treatments are necessary. We present a case with intractable hiccup treated with an unusual treatment. A 61-year-old man presented with intractable hiccups, which started 6 years ago after subarachnoid and intraventricular hemorrhage. Conventional pharmacologic treatments including metoclopramide, gabapentin, and baclofen were unsuccessful. Cooperating with cardiothoracic surgeons, phrenic nerve clipping operation was done under intraoperative electrophysiologic monitoring. This method was successful that the symptoms were relieved. Reversible clipping done under intraoperative electrophysiologic monitoring can be a promising therapeutic method for persistent and intractable hiccups in patients with stroke.

Spinal Accessory Nerve Injury Induced by Manipulation Therapy: A Case Report

Spinal accessory nerve (SAN) injury mostly occurs during surgical procedures. SAN injury caused by manipulation therapy has been rarely reported. We present a rare case of SAN injury associated with manipulation therapy showing scapular winging and droopy shoulder. A 42-year-old woman visited our outpatient clinic complaining of pain and limited active range of motion (ROM) in right shoulder and scapular winging after manipulation therapy. Needle electromyography and nerve conduction study suggested SAN injury. Physical therapy (PT) three times a week for 2 weeks were prescribed. After a total of 6 sessions of PT and modality, the patient reported that the pain was gradually relieved during shoulder flexion and abduction with improved active ROM of shoulder. Over the course of 2 months follow-up, the patient reported almost recovered shoulder ROM and strength as before. She did not complain of shoulder pain any more.

Accuracy of Ultrasound-Guided and Non-ultrasound-Guided Botulinum Toxin Injection Into Cadaver Salivary Glands

OBJECTIVE: To compare the accuracy of ultrasound (US)-guided and non-US-guided botulinum toxin (BTX) injection into the salivary glands (parotid and submandibular glands) of cadavers. METHODS: Two rehabilitation physician injected dye into three sites in the salivary glands (two sites in the parotid gland and one site in the submandibular gland) on one side of each cadaver (one was injected on the right side, while the other was injected on the left side), using either a non-US-guided injection procedure based on superficial landmarks or a US-guided procedure. Orange dye was used for the US-guided procedure, and green dye was used for the blind procedure. Two physicians uninvolved with the injection procedures and who were blinded to the method of injection dissected the cadavers to identify whether the dye was accurately injected into each target site. RESULTS: The accuracies of the blind and US-guided injections into the parotid gland were 79.17% and 95.83%, respectively. In the submandibular gland, the accuracies of the blind and US-guided injections were 50.00% and 91.67%, respectively. The difference in accuracy between the two procedures was statistically significant only in the submandibular gland (p=0.025). There were no significant differences in the accuracy of US-guided and non-US-guided injections between the two physicians for the two sites in the parotid gland (p=0.278 and p=0.146, respectively). CONCLUSION: US-guided BTX injection into the submandibular gland offers significantly greater accuracy over blind injection. For the treatment of drooling by injecting BTX into the submandibular gland, clinicians should consider using US guidance for improved accuracy.

Musculoskeletal Problems in Lower Extremity after Stroke

Stroke is a leading cause of disability in the elderly. Among complications of stroke, musculoskeletal problems are common, thereby causing improper gait biomechanics, development of pain, and limitation in performing activities of daily living. Post-stroke hip fractures and greater trochanteric pain syndrome are common complication near hip joint. Knee osteoarthritis can be accelerated by altered biomechanics of post-stroke period, that is associated with ambulation levels. Stiff knee gait and genu recurvatum can be developed after stroke and usually contribute to abnormal gait patterns, due to weakness or spasticity of various muscles, and they need to control or compensate affected muscle activities. In case of ankle and foot problems, foot varus deformity is caused by imbalance between muscles that control ankle movement, while claw toes and the persistent extension of the great toe are mainly due to overactivity of muscles that moves toes, and mainstay of treatment is to control inappropriate activities of affected muscles. It is important to make the exact therapeutic decision and establish the rehabilitation plan through the early evaluation of lower extremity musculoskeletal problems that affect the mobility and ambulation.

Ultrasound Dimensions of the Rotator Cuff and Other Associated Structures in Korean Healthy Adults

In evaluating patients complaining of shoulder pain, ultrasonography is an emerging imaging tool due to convenience, low cost, high sensitivity and specificity. However, normative values of ultrasound dimensions of the shoulder to be compared with pathologic findings in Korean adults are not provided yet. We evaluated the ultrasound dimensions of the rotator cuff, long head of biceps tendon, deltoid muscle and acromioclavicular joint in Korean healthy adults. Shoulder ultrasonography was performed on 200 shoulders from 100 healthy adults. The dimensions of the thickness of rotator cuff (supraspinatus, infraspinatus, subscapularis tendon), deltoid muscle, long head of biceps tendon, subacromial subdeltoid bursa, and acromioclavicular joint interval were measured in a standardized manner. Differences in measurements among sex, age, and dominant arms were compared. The thickness of rotator cuff tendons (supraspinatus, infraspinatus, subscapularis) and deltoid muscle were significantly different between men and women. The thickness of subacromial subdeltoid bursa was significantly different between men and women for non-dominant side. In rotator cuff tendon measurements, the differences between dominant and non-dominant shoulders were not significant, which means the asymptomatic contralateral shoulder can be used to estimate the normal reference values. When stratified by age divided by 10 years, the measurements of supraspinatus, subscapularis and deltoid thickness showed tendency of increase with the age. The acromioclavicular joint interval, on the other hand, revealed decreasing tendency. This report suggests normative values of ultrasound dimensions of healthy Korean population with varying age, and can be useful as reference values in evaluating shoulder pathology, especially in rotator cuff tendon pathology.

Determination of Injection Site in Flexor Digitorum Longus for Effective and Safe Botulinum Toxin Injection

OBJECTIVE: To determine the optimal injection site in the flexor digitorum longus (FDL) muscle for effective botulinum toxin injection. METHODS: Fourteen specimens from eight adult Korean cadavers were used in this study. The most proximal medial point of the tibia plateau was defined as the proximal reference point; the most distal tip of the medial malleolus was defined as the distal reference point. The distance of a line connecting the proximal and distal reference points was defined as the reference length. The X-coordinate was the distance from the proximal reference point to the intramuscular motor endpoint (IME), or motor entry point (MEP) on the reference line, and the Y-coordinate was the distance from the nearest point from MEP on the medial border of the tibia to the MEP. IME and MEP distances from the proximal reference point were evaluated using the raw value and the X-coordinate to reference length ratio was determined as a percentage. RESULTS: The majority of IMEs were located within 30%-60% of the reference length from the proximal reference point. The majority of the MEPs were located within 40%-60% of the reference length from the proximal reference point. CONCLUSION: We recommend the anatomical site for a botulinum toxin injection in the FDL to be within a region 30%-60% of the reference length from the proximal reference point.

Inexplicable Abdominal Pain due to Thoracic Spinal Cord Tumor

Chronic, refractory abdominal pain without a metabolic or structural gastroenterological etiology can be challenging for diagnosis and management. Even though it is rare, it has been reported that such a recurrent abdominal pain associated with radicular pattern can be derived from structural neurologic lesion like spinal cord tumor. We experienced an unusual case of chronic recurrent abdominal pain that lasted for two years without definite neurologic deficits in a patient, who has been harboring thoracic spinal cord tumor. During an extensive gastroenterological workup for the abdominal pain, the spinal cord tumor had been found and was resected through surgery. Since then, the inexplicable pain sustained over a long period of time eventually resolved. This case highlights the importance of taking into consideration the possibility of spinal cord tumor in differential diagnosis when a patient complains of chronic and recurrent abdominal pain without other medical abnormalities.

Management of Severe Bilateral Ptosis in a Patient With Midbrain Infarction: A Case Report

Ptosis could be caused by oculomotor nerve palsy in the midbrain infarction. Bilateral ptosis has been reported in several reports, which focused on clinical characteristics of midbrain infarction. Little research attention has been paid to the treatment of patients with bilateral ptosis in midbrain infarction. We experienced a case of severe bilateral ptosis occurring after midbrain infarction. The patient could not open her eyes, perform basic activities or achieve effective rehabilitation. Neurogenic ptosis can improved after the underlying cause is treated. However, in this case, bilateral ptosis was not improved after conservative care for 6 months and the patient remained limited in activities of daily living and mobility. Surgical correction of bilateral ptosis was done by the resection of both Muller's muscles. After surgical correction, the bilateral ptosis was much improved and the effect persisted for at least 6 months.

Intractable Abdominal Pain in a Patient With Spinal Cord Injury: A Case Report

Patients with spinal cord injury (SCI) may experience several types of chronic pains. Abdominal pain in patients with SCI has gained limited attention and little is yet known about its characteristics and mechanisms. It often has been regarded as visceral pain associated with constipation and distention. Neuropathic pains localized in the abdomen have rarely been reported. We experience a case of intractable abdominal pain in a patient with SCI, neither of visceral pathology nor of musculoskeletal origin. The nature of pain fulfilled the diagnostic criteria for neuropathic pains. The pain was therefore regarded as neuropathic and managed accordingly. The first- and second-line oral drugs available were being performed, unfortunately, adequate pain control was not achieved. We tried an intrathecal lidocaine injection as another treatment option, and the injection had considerable effects.

Ischemic Stroke in Rats Enhances Bone Resorption in Vitro

We hypothesized that the formation and differentialtion of osteoclasts are accelerated and the potential of bone resorption is increased in the hemiplegic bone marrow in the early stage of stroke. We randomly divided white female Sprague-Dawley (SD) rats (n = 30) into two groups, stroke (n = 15) and sham group (n = 15). On the 7th day after stroke, after cutting away the epiphyses of the femurs and tibias, diaphyseal channels were flushed using alpha-minimum essential medium (alpha-MEM) and bone marrow cells were collected. Bone marrow stem cells, which were extracted from the femur and tibia, were cultured on the 7th day after middle cerebral artery occlusion. We then estimated the ratio of non-adherent cells to total bone marrow cells that included osteoclast precursor cells. After culturing these cells separately, cells that tested positive on the tartrate resistant acid phosphatase (TRAP) were counted and bone resorption was evaluated by using the OAAS(TM) plate. In comparison to the control group, the stroke group showed a higher increase of non-adherent cells in the hemiplegic side bone marrow. In addition, after the primary culture, the stroke group showed an increased number of TRAP positive cells and a higher degree of bone resorption estimated by OAAS(TM) plate. As a result, osteoclastogenesis and osteoclast differentiation are accelerated and the potential of bone resorption is increased in the hemiplegic bone marrow and these changes are detected as early as within the first week after middle cerebral artery occlusion in SD rats.

A Nasogastric Tube Inserted into the Gastrocutaneous Fistula

We reported a case in which a nasogastric tube was inserted into the gastrocutaneous fistula, diagnosed by abdominal computed tomography. A 78-year-old man with a history of recurrent cerebral hemorrhage had a percutaneous endoscopic gastrostomy tube due to dysphagia for 2 years. However, soft tissue infection at the gastrostomy site caused the removal of the tube. Immediately, antibiotic agents were infused. For appropriate hydration and medication, a nasogastric tube was inserted. However, there was no significant improvement of the soft tissue infection. Moreover, the amount of bloody exudate increased. Abdominal computed tomography revealed the nasogastric tube placed under the patient's skin via gastrocutaneous fistula. The nasogastric tube was removed, and an antibiotic agents were maintained. After 3 weeks, the signs of infection fully improved, and percutaneous endoscopic gastrostomy was performed again. This case shows necessities of an appropriate interval between removal of the gastrostomy tube and insertion of a nasogastric tube, and suspicion of existence of gastrocutaneous fistula.

The Relationship between Weight of Backpack and Backpain in Primary School Children in Korea

OBJECTIVE: To investigate school children's backpack loads, its association with backpack loads and backpain, school-children's perception of their backpack loads, school conditions, and personal factors that determine backpack loads in Korea. METHOD: We weighed the backpacks of 642 school children in three elementary schools in Suwon city. A validated questionnaire evaluating backpain, features of backpack carrying and subjective perceptions of backpack loads was administered to 450 schoolchildren. The data were divided into two groups, those who had experienced backpain and those who had not. Each group was analyzed according to backpack load, perception of backpack load, school condition and personal factors. RESULTS: The mean weight of the backpack was 2.65 kg, which was 7.85% of mean body weight. The number of children whose backpack loads exceeded 15% of their body weight was 3.3%. 34.5% of children experienced backpain and backpack weight and backpack weight/body weight ratio were significantly higher in the group who experienced backpain. Time spent carrying of backpacks was longer and more students reported heaviness and fatigue when carrying backpacks in the same group. There was a difference in manners of carrying of backpacks and locker usage between the two groups. An improper method of backpack carrying, which is more than 10 cm below the waistline was noted in 85% of the school children. CONCLUSION: Carrying a heavier backpack is related to backpain in schoolchildren and a wide investigation should be performed concerning backpack loads of school children in Korea. Adequate backpack load guidelines should be determined.

Superficial Radial Nerve and Cephalic Vein: An Anatomic Study by Cadaver Dissection

OBJECTIVE: To acquire normal anatomy of superficial radial nerve and cephalic vein and identify the optimal site for venipuncture of cephalic vein at wrist to decrease the damage of superficial radial nerve. METHOD: We examined anatomic relationships of the superficial radial nerve, cephalic vein, and styloid process of radius in 14 hands from 10 cadavers. The distances were measured from the styloid process of radius to the point at which the superficial radial nerve pierced fascia, and to the crossing point of superficial radial nerve with cephalic vein. RESULTS: The mean distance from the styloid process of radius to the point at which the superficial radial nerve pierced fascia was 79.9+/-9.84 (60~93) mm and from the styloid process of radius to the crossing point of superficial radial nerve with cephalic vein was 29.5+/-15.24 (13~55) mm. CONCLUSION: The most optimal injection site for venipuncture of cephalic vein at wrist was located 55 mm more proximal area from styloid process.

A Case of Conversion Disorder Presenting Hemiplegia

Patients with conversion disorder are often presented with critical symptoms or signs which could suggest severe organic disorders. Hysterical hemiparesis is a relatively rare presentation and it is difficult to diagnose because it is displayed as a unilateral motor weakness with or without sensory deficits. A previously healthy 23-years-old woman developed sudden onset of hemiplegia and hemianesthesia with loss of anal tone. Before the onset, she had a traffic accident. A through medical workup including X-rays, MRI, CT scans, EMG, and brain SPECT revealed no organic causes for such neurologic deficits. She gradually regained neurologic function over 2 months from the onset. Conversion disorder should be considered when symptom- related anatomic or physiologic abnormalities could not be proven with appropriate workup. Medical evaluation must be performed in advance to the diagnosis of conversion disorder to avoid misdiagnosis.

The Effect of Asymmetric Dynamic and Static Weight-bearing Force on Bone Mineral Density in Hemiplegic Stroke Patients : Preliminary Study

OBJECTIVE: To measure the foot force and contact area distribution between the paretic and nonparetic sides during static and dynamic weight-bearing states, and to determine their relationship with BMD (bone mineral density). METHOD: Sixteen stroke patients (mean age=63.5+/-7.46 years) were included and BMDs of bilateral femurs were evaluated. Foot force and total foot contact areas were measured using the F-scan insole system. All values were expressed in ratio of paretic versus nonparetic sides. RESULTS: The paretic side showed significantly smaller values in BMD, foot force and total contact area than the nonparetic sides (p0.05), or total contact area ratio during both dynamic and static weight-bearing state (r=0.23, r=0.12, p>0.05). Multiple regression analysis showed that dynamic weight-bearing force ratio and time elapsed since stroke were independently related to BMD ratio (t=3.25, p<0.001 and t=-4.89, p<0.001). CONCLUSION: The present study showed that foot force differences in the dynamic weight-bearing state significantly correlated to post-stroke BMD while foot contact area in both the static and dynamic weight-bearing state did not correlate to post-stroke BMD.

Gabapentin Induced Liver Injury : A case report

Gabapentin has been accepted worldwide as a novel antiepileptic drug with a favourable tolerability profile. Although its exact mode of action is not known, it is recently widely used to manage symptomatic treatment of neuropathic pain syndromes. It has few side effect profiles and it is known not to be associated with liver injury. But we experienced a case of liver injury associated with gabapentin. A 44-year-old man was hospitalized because of seizure caused by septic shock. He complained of tingling sensation and burning pain on his both legs. Gabapentin was prescribed to control his symptoms. An increase of serum aminotransferases was detected after gabapentin therapy, and immediately after stopping it, aminotransferase level normalized.

Diagnosis of Speech Disorder and Language Developmental Delay in Korean Preschoolers

OBJECTIVE: This study was designed for evaluating the clinical usefulness of the Korean Denver Developmental Screening Test II (KDDST II) for screening of speech-language delays, for evaluating the co-morbidity of psychiatric disorders and examining the prevalence of hearing impairment in speech-language delays. METHOD: Fifty eight preschoolers whose chief complaints fell into 'late talker', 'dysarticulation' or 'stuttering' performed KDDST II, speech-language evaluation and hearing screening. Psychiatric consultation was performed if the child had any behavioral or emotional red flags. RESULTS: More than 50% were classified as 'language delay only', 25.9% as 'language delay with speech disorder', 22.4% as 'phonological disorder only'. Eleven children (34.4%) with language delay were classified as 'global developmental delay'. Sensitivity of KDDST II as a screening tool of language delay was only 84.4%. Two cases of hearing impairment and 3 cases of complicated otitis media were detected by hearing screening. Seventeen children (29.3%) also had psychiatric disorders such as attention deficit hyperactive disorder, anxiety disorder, and autism spectrum disorder. CONCLUSION: Evaluation of whole spectrums of development and hearing screening were recommended in the children with speech-language delays. Psychiatric consultation should be also considered in a case of any behavioral or emotional concerns.

The Effect of Peripheral Vascular Disease on Diabetic Neuropathy

OBJECTIVE: To evaluate the effect of peripheral vascular disease (PVD) on diabetic neuropathy with the use of Doppler ultrasound and electrodiagnostic study. METHOD: One hundred fifty one patients with diabetes mellitus underwent nerve conduction studies. PVD was diagnosed when ankle-brachial index (ABI) was 0.9 and less and also toe-brachial index (TBI) was 0.7 and less. Electrophysiologically normal group was subdivided into non- PVD group (A1) and PVD group (A2). Diabetic neuropathy group was subdivided into non-PVD group (B1) and PVD group (B2). The frequency of diabetic neuropathy and the difference of amplitude, conduction velocity, and F wave latency within A groups and B groups were investigated. RESULTS: Diabetic neuropathy was significantly correlated with PVD (p<0.05). There was no definite difference of electrophysiologic parameters between A1 and A2 groups. B1 group showed significantly reduced amplitude of sensory nerve action potential (SNAP) in sural nerve compared with B2 group (p<0.05). In all patients, the amplitude of SNAP in sural nerve was related with duration of diabetes and TBI by multiple linear regression analysis. CONCLUSION: This study supports the influence of PVD on diabetic neuropathy and suggests vascular abnormality in patients with diabetic neuropathy may result in predominantly axonal injury rather than demyelinating injury.