Obturator Nerve Block Using Ultrasound-guided Intraneural Alcohol Injection in Patient with Hip Adductor Spasticity

OBJECTIVE: To investigate the effects of obturator nerve blocks with ultrasound guided intraneural alcohol injection. METHOD: Nine quadriplegic patients suffering hip adductor spasticity were included in this study. The obturator nerve was identified at just below inguinal ligament area on anteromedial surface of upper leg at supine position. An 23 G needle was inserted into anterior branch of obturator nerve under real time ultrasonography. The 50% alcohol solution was injected 3~5 ml at a time within the epineurium of the anterior branch of obturator nerve until the expanding nerve was visualized. We examed modified Ashworth scale (MAS) of hip adductor and passive range of movement of hip abduction at supine position at study entry, 1, 4, and 12 weeks after ultrasound guided intraneural injection. RESULTS: There were statistically significant improvement was seen in MAS of hip adductors and hip abduction angle at 1, 4, and 12 weeks after ultrasound guided intraneural injection, compared with parameters measured at previous injection (p<0.05). CONCLUSION: Ultrasound guided intraneural alcohol injection into anterior branch of obturator nerve for treatment of hip adductor spasticity in patients with quadriplegia is an effective and safe procedure for relieving localized spasticity of the hip adductors.

The Additive Effects of Hyaluronidase in Subacromial Bursa Injections Administered to Patients with Peri-Articular Shoulder Disorder

OBJECTIVE: To evaluate the additive effects of hyaluronidase combined with steroids in patients with peri-articular shoulder disorder. METHOD: Thirty patients with peri-articular shoulder disorder were given subacromial bursa injections once a week for three consecutive weeks. Fifteen patients (Group A) underwent subacromial bursa injections with hyaluronidase 1,500 IU, triamcinolone 40 mg and 0.5% lidocaine (total 6 ml). Another fifteen patients (Group B) underwent the same injections with triamcinolone 40 mg and 0.5% lidocaine (total 6 ml). We examined the active range of motion (AROM) in the shoulder, used a visual analogue scale (VAS) for measurement, and administered a shoulder disability questionnaire (SDQ) at the commencement of the study and then every week until one week after the third injection. RESULTS: There were no significant difference between group A and B before the injections took place (p>0.05). Statistically significant improvement was seen in the VAS, SDQ, and AROM of flexion, abduction, internal rotation at one week after the first and second injections compared with the parameters measured at previous visits in both groups (p0.05). Improvement in all parameters measured at one week after the third injection compared with the measurement values at one week after the second injection were not statistically significant in both groups (p>0.05). However, group A (the hyaluronidase group) showed significantly greater improvements than group B in terms of their SDQ and AROM of internal rotation scores one week after the three injections had taken place (p<0.05). CONCLUSION: Peri-articular shoulder disorder patients who underwent subacromial bursa injections using hyaluronidase and steroids showed greater functional improvements than those who were given only steroid injections.

Effects of Botulinum Toxin A Injection into Salivary Glands of Patients with Brain Lesion Suffering from Posterior Drooling

OBJECTIVE: The aim of the study was to evaluate the effectiveness of ultrasouond-guided salivary gland injection of botulinum toxin A (BTX-A) for posterior drooling. METHOD: 11 patients with brain lesion (9 cerebral palsy, 1 hypoxic ischemic encephalopathy and 1 mental retardation) with posterior drooling (an initial PDAS score greater than 2) and related pulmonary problems were recruited. Drooling severity was measured at baseline, 4 weeks, 3 months and 6 months after botulinum toxin A injection, by using Teacher Drooling Scale (TDS), Visual Analogue Scales (VAS), Drooling Score System (DSS)-severity, frequency and Posterior Drooling/Aspiration System (PDAS). RESULTS: The TDS, DSS-severity, DSS-frequency, VAS, PDAS were significantly reduced at 4 weeks and 3 months after BTX-A injection into salivary glands compared to pre-injection (p<0.05). However, there were no significant changes at 6 months compared to pre-injection level. CONCLUSION: BTX-A injection into salivary glands may improve anterior drooling in patients with brain lesions. Furthermore BTX-A injection into salivary glands may also decrease the posterior drooling which might related to respiratory symptoms in aspiration pneumonia.

Effect of Botulinum Toxin Type A on Morphology of Salivary Glands in Patients with Cerebral Palsy

OBJECTIVE: To investigate the effect of botulinum toxin type A (BTXA) on drooling and the morphologic change of the salivary gland in patients with cerebral palsy. METHOD: Eight cerebral palsy patients suffering from severe drooling participated in this study. BTXA was injected into both submandibular and parotid glands under intravenous sedation and with ultrasound guidance (1 unit/gland/kg: maximum 100 units) in an outpatient or inpatient procedure. The severity of drooling was measured before injection and 3 weeks after injection using the Teacher Drooling Scale, the Drooling Score-severity, frequency and the Visual Analog Scale. To investigate the morphologic change of the salivary glands, the size of salivary glands were measured before injection and 3 weeks after injection using computed tomography of the neck. The measurement values were analyzed by Wilcoxon signed rank test. RESULTS: Statistically significant improvements were shown in all three parameters for assessing the severity of drooling after BTXA injections (p<0.05). Size of the salivary glands were significantly decreased at 3 weeks after BTXA injection (p<0.05). CONCLUSION: Salivary gland injection with BTXA could be a useful treatment method to reduce drooling in patients with cerebral palsy and decreased size of salivary glands may partially explain the mechanism.

Subacromial Bursa Injection of Hyaluronate with Steroid in Patients with Peri-articular Shoulder Disorders

OBJECTIVE: To investigate the additive effect of sono-guided subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders. METHOD: This prospective randomized controlled trial involved 26 patients who had shoulder pain. Group A, consisting of 13 patients, was treated with a sono-guided subacromial bursa injection containing a mixture of 0.5% lidocaine (5 ml) and triamcinolone 40 mg (1 ml), followed by injection with sodium hyaluronate (2 ml) once a week for 3 weeks. The other 13 patients (Group B) were treated with a sono-guided subacromial bursa injection containing a mixture of 0.5% lidocaine (5 ml) and triamcinolone 40 mg (1 ml) once a week for 3 weeks. The effects were assessed using a visual analogue scale (VAS) of shoulder pain, active range of motion (AROM), shoulder function assessment scale (SFA), shoulder disability questionnaire (SDQ) at study entry and every week from first injection until 4 weeks after the 1st injection (= 2 weeks after 3rd injection). RESULTS: (1) Demographic features and all parameters measured before injection did not show a significant difference between the 2 groups. (2) Statistically significant improvements were shown in VAS, SFA, SDQ during the 1st, 2nd, and 4th week after the first injection in both groups (p<0.05). (3) SFA showed significant improvement at 1 week after injection only in group A (p<0.05). (4) AROM of internal rotation showed significant improvement at week 4 after the 1st injection only in group A (p<0.05). CONCLUSION: Subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders has additive effects on functional improvement of the affected shoulder, including the AROM of internal rotation.

Leg Length Discrepancy Induced by Arterio-Venous Fistula Due to Repetitive Vascular Punctures: A case report

The causes of leg length discrepancy in childhood include neurologic, musculoskeletal, tumor and vascular diseases. It may contribute secondary complications such as gait disturbance, scoliosis, hip joint arthritis or cosmetic problem etc. Acquired arteriovenous fistula is a rare cause of leg length discrepancy. Multiple vascular punctures in the neonates, especially in prematures, can result in iatrogenic arteriovenous fistula formation. We report two cases of arteriovenous fistula secondary to vascular punctures, diagnosed by color doppler ultrasonography and CT angiography. The lesions were explored and treated surgically.

Case Reports of Peduncular Hallucinosis in Patients with Pontine Hemorrhage : Two cases report

Peduncular hallucinosis that rarely reported in patients with brain stem lesion has several characteristics. The hallucination tends to be vivid, nonstereotypical images of person or animal. All the patients are aware that the hallucination is not part of reality. One of the suggested mechanisms of peduncular hallucinosis is imbalance among the cholinergic, serotonergic and other transmitting systems in the brain stem. We report two cases with typical features of peduncular hallucinosis which appeared about 30 and 12 months after pontine hemorrhage, respectively. We chose antipsychotics and selective serotonergic reuptake inhibitors for their medications, and their hallucinations disappeared about 2 months and 3 weeks after the medication, respectively. We suggest that peduncular hallucinosis should be considered in the patients with pontine hemorrhage if they complain of typical visual hallucinations.

Electrodiagnostic Methods for Carpal Tunnel Syndrome Combined with Diabetic Polyneuropathy

OBJECTIVE: To find out the most useful method among three electrodiagnostic tests for carpal tunnel syndrome (CTS) in patients with diabetic peripheral polyneuropathy (PPN). METHOD: Eighty-three hands out of seventy-four patients who had diabetic PPN and tingling sensation in their hands were included in this study. They were divided into two groups: Group A, PPN with CTS; Group B, PPN only. Fifty-four hands with CTS in patients without diabetes were included as a control group (Group C). Another forty normal hands were also included as a healthy control group (Group D). Clinical and electrophysiologic information was gathered from those subjects. Sensitivity, specificity and receiver operating characteristic (ROC) curves of the three electrodiagnostic tests, namely, the difference between the median nerve latency to the second lumbrical muscle and the ulnar nerve latency to the second interosseous muscle (L-I difference), ratio of distoproximal latency in median sensory nerve (MW ratio), and difference of distoproximal latency in median sensory nerve (MW difference) to diagnose clinical CTS were obtained. RESULTS: The specificity of L-I difference as a diagnostic test for CTS was highest (87.0%). The area of ROC curve of L-I difference was also highest (0.949) among three different electrodiagnostic tests of CTS with diabetic PPN. CONCLUSION: We suggest that L-I difference as the most useful test with highest specificity for the diagnosis of CTS in the patients with diabetic PPN.