Correction: Nerve Conduction Study of the Distal Branches of the Superficial Radial Nerve

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Correction: Idiopathic Retroperitoneal Fibrosis With Myofascial Pain Syndrome: A Case Report

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Idiopathic Retroperitoneal Fibrosis with Myofascial Pain Syndrome: A case report

Idiopathic retroperitoneal fibrosis (IRF) is a rare condition in which a mass of fibrous tissue encompasses the abdominal aorta and the common iliac arteries. Although the histologic findings of IRF are mostly benign, its diagnosis is often delayed, leading to significant physiologic deteriorations, namely renal insufficiency, and poor treatment prognosis. Back pain, which is a common presenting symptom, may lead to confusion in determining the diagnosis of IRF. This report presents a patient with retroperitoneal fibrosis whose diagnosis was delayed due to the concomitant presence of myofascial pain syndrome and lumbar intervertebral disc herniation.

Correlation of Pain Drawing Patterns with Electrophysiological Findings in Carpal Tunnel Syndrome

OBJECTIVE: To evaluate the association between neuralgic pain distribution and the severity of carpal tunnel syndrome (CTS). METHOD: Pain drawings using computerized pain chart system were collected from 131 patients (213 hands) with CTS. The presence and severity of CTS were determined by means of median motor and sensory nerve conduction studies. The severity was divided into 3 classes on the basis of electrophysiological findings: mild (93 hands), moderate (70 hands) and severe (50 hands). The similarities between pain drawing patterns and median nerve dermatome in the hands were evaluated. The pain distributions of the palmar and dorsal sides of each five fingers, palm and dorsum of hand were also evaluated. RESULTS: There were no significant differences in similarity values of pain distribution among the groups of CTS hands divided by severity: similarity values were 0.22+/-0.14 in mild CTS patients, 0.24+/-0.16 in moderate CTS patients and 0.27+/-0.14 in severe CTS patients. In the CTS patients, the pain drawings showed relatively frequent distributions in the palmar side of 2nd to 4th fingers. CONCLUSION: There was no significant correlation between pain drawing patterns and severity of CTS. The pain drawings of patients with CTS indicate distribution to be most frequent in the palmar side of 2nd to 4th fingers.

Nerve Conduction Study of the Distal Branches of the Superficial Radial Nerve

OBJECTIVE: To acquire normal values of nerve conduction study of the superficial radial sensory nerve (SRN) distal branches to the second web space (2 WEB) and second digit (2 DIG) and compare them with the results of the conventional method. METHOD: Forty-three healthy adult subjects (25 males, 18 females) were included. Nerve conduction study was performed in both hands. Superficial radial sensory responses were obtained with 2 recording montages: 1) antidromic stimulation, recording electrode placed between the 2nd and 3rd metacarpals with stimulation 10 cm proximally on the lateral forearm (2 WEB); 2) orthodromic stimulation, stimulation at the second digit with recording 10 cm proximally at the snuff box (2 DIG). Each stimulation was performed twice, and onset latency, peak latency, and sensory nerve action potential (SNAP) amplitude (baseline-to- peak) were measured. Correlations between the values and body mass index (BMI), sex, and finger circumference were tested statistically. RESULTS: The age of the subjects was 36.0+/-10.4 years (range, 23~64 years), and the BMI was 22.6+/-2.8 kg/m2. The onset latency, peak latency and SNAP amplitude of the 2 WEB response were 1.7+/-0.1 ms, 2.2+/-0.2 ms, and 24.6+/- 8.2 micro V, respectively. The onset latency, peak latency and SNAP amplitude of the 2 DIG response were 1.6+/-0.2 ms, 2.2+/-0.2 ms, and 15.2+/-6.0 micro V, respectively. A statistically significant difference was observed between male and female subjects for both 2 WEB and 2 DIG responses. Weak correlations were found between the nerve conduction values and BMI, sex, and finger circumference. CONCLUSION: Sensory nerve action potentials can be successfully obtained from the distal branches of the superficial radial nerve.

Anatomical Considerations of Lateral and Medial Antebrachial Cutaneous Nerves

OBJECTIVE: To evaluate the anatomic course of the lateral antebrachial cutaneous nerve (LABCN) and medial antebrachial cutaneous nerve (MABCN) in the forearm. METHOD: We dissected 29 upper extremities of 16 cadavers for LABCN and 20 upper extremities of 15 cadavers for the MABCN. We measured the distance (BT_L) between the biceps tendon (BT) and LABCN on the intercondylar line. The BT is the point at which biceps tendon crosses intercondylar line. The distance (L12) between LABCN and the point of 12 cm distal to BT on the line between BT and radial artery at wrist was measured. The distance (ME_M) between MABCN and medial epicondyle on the intercondylar line was measured. M8 and M10 are the distances between MABCN and the points 8 cm and 10 cm distal to BT on the line from BT to mid-point of flexor carpi radialis and palmaris longus at the wrist respectively. RESULTS: BT_L and L12 were 1.4+/-3.7 mm and 4.4+/-3.7 mm respectively. ME_M, M8 and M10 were 28.6+/-6.9 mm, 18.9+/-8.9 mm and 18.3+/-8.2 mm respectively. The thickness of LABCN and MABCN was 19.1+/-4.9 mm and 13.2+/-4.2 mm respectively. CONCLUSION: The LABCN was emerge just lateral to biceps tendon at the elbow and ran down to radial artery. The anatomic course of MABCN was variable at the elbow and forearm.

Vascular Thoracic Outlet Syndrome with Arterial Occlusion: A case report

The diagnosis of thoracic outlet syndrome (TOS) is sometimes confused by its nonspecific symptoms and various etiologies. Moreover, the paths of involving nerves and arteries are highly diverse. We report a 35 year-old man who had numbness and coldness in his left upper extremity with no improvement to medical therapy. The electrophysiologic studies were normal. Radial artery pulse was absent and the thermography revealed markedly reduced temperature below the left mid-forearm. The arteriography showed compression of the left subclavian artery between the clavicle and the 1st rib with aneurysmal change proximal to the compression. Occlusion of the left brachial artery and collateral arteries were also observed. Under the diagnosis of vascular TOS, 1st rib resection was performed and his symptoms were relieved. Vascular TOS may be considered in cases of upper limb paresthesia.

Reliability Test of Korean Version of Berg Balance Scale

OBJECTIVE: The purpose of this study is to translate the Berg Balance Scale (BBS) to the Korean version (K-BBS) and to evaluate its reliability. METHOD: With the agreement of Katherine Berg, the original editor of the BBS, two physiatrists and three physical therapists had translated the English version of BBS into Korean (K-BBS). This was back-translated into English by a Korean-American physiatrist fluent in English. After a 2- hour K-BBS education course, the video recorded K-BBS of 18 stroke patients were reviewed by nine examiners (four physiatrists and five physical therapists) to assess the inter- rater and the intra-rater reliability. Kendall's correlation coefficient and Pearson's correlation coefficient were computed to assess the intra-rater and test-retest reliability, respectively. RESULTS: The inter-rater reliability was 0.97 at 2 separate evaluations with an interval of 10 days (p<0.05). The intra- rater reliability was 0.95 (p<0.05) in the physiatrist group and 0.97 (p<0.05) in the physical therapist group. CONCLUSION: We recommend that the Korean version of the Berg balance scale is a reliable instrument to be used in balance assessment of stroke patients.

A Weight Loading Device as a Method for Assessment of Unilateral Knee Pain

OBJECTIVE: To identify the effectiveness of a weight loading device as a method for assessment of unilateral knee pain. METHOD: Twenty-five patients with unilateral knee pain and 25 pain-free controls participated in this study. Patients with a score of 2 or more on modified Kellgren-Lawrence scale based on the radiologic findings were diagnosed as degenerative arthritis. We constructed a device of segmental foot plates with strain gauge weight sensors to measure the weight load of each leg during self-selected walking speed. Using this device, we obtained the ratio of symptomatic side to asymptomatic side of weight load (RATIO) for each patient. The degree of pain according to visual analogue scale (VAS), abnormalities in radiologic findings, and weight load ratio were compared with each other. RESULTS: The RATIO was 1.00+/-0.03 in the control group, and 0.92+/-0.08 in the patient group (p<0.05). In the patient group, there was a significant correlation between RATIO and the VAS score (r=-0.44, p=0.03). In the patient group with degenerative arthritis, the RATIO (p=0.75) and VAS (p=0.94) were not different from those in patient group without degenerative arthritis. CONCLUSION: The foot plate weight loading device may be an effective tool for convenient measurements of knee pain.

Knee Pain: Pain Patterns of Myofascial Pain Syndrome and Degenerative Arthritis

OBJECTIVE: To evaluate the pain patterns of patients with osteoarthritis (OA) of the knee. METHOD: Forty-four patients (mean age 56.1 years) with pain around the knee who met the Simons' criteria for myofascial pain syndrome (MPS). Patients drew in their pain areas on a pain drawing diagram. The pain areas were input into the Pain Chart System (PCS) software program for analysis. Physical examination, trigger point injection, and exercises for knee muscles were performed. Oral analgesics were not prescribed. RESULTS: MPS was clinically diagnosed in all 44 patients. Radiologic examination revealed degenerative changes in 49 knees. Pain patterns detected by the PCS revealed pain patterns compatible with myofascial trigger point in the vastus medialis in 37 cases, rectus femoris in 32 cases, adductor longus in 5 cases, sartorius in 2 cases, vastus lateralis in 1 case, and the popliteus in 1 case. Following treatment, 36 of the 44 patients experienced pain relief. CONCLUSION: Degenerative changes of the joint seem not to be cause of the knee joint pain. Instead, pain relief following MPS treatment indicates the cause of knee pain as MPS. We recommend that the first step in the treatment for knee pain include recognition and treatment of MPS before applying invasive treatment.

Local Botulinum Toxin Type A Injection for the Management of Congenital Muscular Torticollis

OBJECTIVE: To evaluate the effectiveness of local intramuscular botulinum toxin type A injection in patients with congenital muscular torticollis. METHOD: Six patients (mean age, 13.3 months) with congenital muscular torticollis who did not respond to physical therapy were participated with the informed consent of their parents. Twenty-five to fifty Speywood units of Dysport (Beaufour Ipsen, France) were injected into the palpated mass of the sternocleidomastoid muscle. The angle of tilt and range of motion of the neck in sitting position were obtained before and after injection. The size of the mass within the sternocleidomastoid muscle was measured with ultrasonogram. RESULTS: Satisfactory improvement of 3 parameters at post- injection 6-month follow-up was achieved in all patients. The tilting angle and range of motion of the neck to rotation were normalized in 5 patients. The size of the mass within the sternocleidomastoid muscle was decreased significantly with ultrasonographic evaluation. CONCLUSION: Local intramuscular BTA injection might be effective for patients with congenital muscular torticollis who do not respond to conservative management.

Comparison of Sural Nerve Amplitude and Sural/Radial Amplitude Ratio in the Electrodiagnosis of Diabetic Neuropathy

OBJECTIVE: To evaluate the usefulness of the sural/superficial radial sensory nerve action potential amplitude ratio (SRAR) in the electrodiagnosis of diabetic polyneuropathy. METHOD: Nerve conduction study was performed in 80 diabetic patients and 31 normal adults. Standard nerve conduction studies were performed. Sural nerve response was recorded with the active electrode on the posterosuperior margin of the lateral malleolus and stimulation 14 cm proximally. Superficial radial nerve response was recorded with the active on the snuffbox and stimulation 10 cm proximally. Baseline-to-peak sensory nerve action potential(SNAP) amplitudes were measured, and SRAR were obtained. The diabetic group was subdivided into an electro physiologically normal group (DMNL, n=32) and neuro pathy group (DMPN, n=48). SRAR was compared among the control (NORM, n=31), DMNL and DMPN groups. RESULTS: SRAR was 0.344 in NORM, 0.314 in DMNL and 0.145 in DMPN, respectively. SRAR showed 77.1% sensitivity and 93.8% specificity. Sural SNAP amplitude sensitivity was 85.4% and specificity, 88.7%. CONCLUSION: The relatively high specificity of SRAR indicates its usefulness in the diagnosis of diabetic polyneu ropathy. However, as the superficial radial sensory SNAP amplitude decreased significantly in the diabetic groups compared to control, the SRAR is not superior to the sural SNAP amplitude in the diagnosis of diabetic polyneuropathy.

Short Segment Conduction Study of Median and Ulnar Nerves in the Diagnosis of Carpal Tunnel Syndrome

OBJECTIVE: To compare the latency difference of median and ulnar sensory nerves through the wrist-palm short segment in patients with carpal tunnel syndrome (CTS). METHOD: Subjects included 68 hands of 36 carpal tunnel syndrome patients and 97 hands of 53 healthy adults with no electrophysiologic evidence of CTS. The median and the ulnar sensory responses were recorded on the third and the fifth digit using bar recording electrode, respectively. Both nerves were stimulated just proximal to the distal wrist crease and 5 cm distal to the proximal stimulation point. The latency differences between the 2 stimulation points were obtained. RESULTS: The transcarpal short segment conduction times in the control group were 1.0+/-0.1 msec and 0.9+/-0.1 msec for the median and ulnar nerves, respectively. The transcarpal short segment conduction times in the patients with CTS were 1.9+/-0.5 msec and 1.0+/-0.3 msec for the median and ulnar nerves, respectively. The transcarpal short segment conduction time difference between the median and ulnar nerves were 0.13+/-0.12 msec in the control group and 0.88+/-0.50 msec in the CTS group. The difference of transcarpal conduction of two nerves was statistically significant in comparison with the two groups. CONCLUSION: Wrist-palm short segment study of median and ulnar sensory nerve may be used adjunctively in diagnosis of mild CTS.

Conduction Block in Carpal Tunnel Syndrome

OBJECTIVE: To demonstrate a conduction block of the median nerve at the flexor retinaculum (FR) in carpal tunnel syndrome (CTS), comparison of potentials obtained with stimulation of median nerve at the wrist and the palm may be required. METHOD: To determine the severity and incidence of conduction block in patients with CTS, seventy hands of neurologically healthy adults (mean age, 48 years) as control, and seventy hands of patients with CTS (mean age, 51 years) were tested. We performed median motor and middle finger recorded antidromic sensory conduction study with stimulation of the wrist and palm of a distance of 5 cm. The negative peak spike duration and baseline to peak amplitude of the compound muscle action potential (CMAP), and sensory nerve action potential (SNAP) with wrist and palm stimulations were measured. From these values, the wrist to palm duration ratio and amplitude ratio were obtained. RESULTS: The criteria of median motor nerve conduction block were a wrist to palm amplitude ratio of less than 0.7 and a wrist to palm duration ratio of less than 1.13. The criteria of median sensory conduction block were a wrist to palm amplitude ratio of less than 0.61 and a wrist to palm duration ratio of less than 1.33. In the patient group, 10 hands (14.3%) showed motor conduction block and 12 hands (17.1%) showed sensory conduction block and 3 hands (4.3%) showed both. The wrist to palm amplitude ratios of CMAP and SNAP in the patient showing conduction block were 0.6+/-0.1, and 0.4+/-0.2, respectively. There was no correlation between palm CMAP or SNAP amplitude and respective wrist to palm ratios. CONCLUSION: Comparison of the amplitude and duration of CMAP or SNAP obtained with stimulation of both wrist and palm may be able to differentiate between conduction block and axonal degeneration. These values may be useful in planning treatment and predicting outcome.

The Relationship between Clinical and Electrodiagnostic Findings in Carpal Tunnel Syndrome

OBJECTIVE: Carpal tunnel syndrome (CTS), a common entrapment neuropathy of the median nerve at the wrist, can be diagnosed clinically and electrophysiologically and treated successfully. The purpose of this study was to determine an association between clinical findings and the electrodiagnostic severity of this syndrome. METHOD: Medical records of 313 patients with CTS which was confirmed based on clinical and electrophysiological findings were reviewed. Clinical symptoms and signs (thenar atrophy, sensory change, positive Tinel sign and Phalen test) and electrodiagnostic values were recorded. CTS severity was determined according to the modified Stevens' criteria. The relationship between electrodiagnostic severity and clinical findings was investigated and statistically analyzed using the ANOVA and chi square tests. RESULTS: The median motor and sensory latencies became prolonged and amplitudes decreased with worsening electrophysiological severity of CTS, and the differences between severity groups were statistically significant. The frequency of symptoms and signs obtained was significantly greater in the more severe CTS groups. CONCLUSION: A positive correlation exists between the frequency of clinical findings and electrophysiological severity of CTS.