Anatomical Locations of the Motor Points of the Biceps Brachii and Brachialis Muscles

OBJECTIVE: To identify the range of the precise locations of the motor points of biceps brachii and brachialis muscles in relation to bony landmarks. METHOD: Nine upper limbs of five male cadavers were dissected. The number and location of the motor points from the musculocutaneous nerve to biceps brachii and brachialis muscles were identified in relation to the bony landmarks. Bony landmarks were coracoid process and lateral epicondyle of the humerus. The length of the arm was defined as the distance from the apex of the coracoid process to the lateral epicondyle of humerus. The locations of the motor points were expressed as the percentage ratio of the length from the coracoid process to the motor points in relation to the length of the arm. RESULTS: First proximal motor points of the long head, short head of biceps brachii, and brachialis were located in 47.5 5.6%, 53.0 4.6%, 64.3 3.4% and second proximal points of them were 51.8 2.9%, 57.7 3.5%, 68.5 4.4% respectively. CONCLUSION: The identification of the locations of motor points related to the bony landmarks would increase the accuracy and ease of the motor point blocks to elbow flexors such as biceps brachii and brachialis muscles.

Comparison of the Spinal Level Assumption by Palpation of the Iliac Crest and Posterior Superior Iliac Spine

OBJECTIVE: To compare the clinical usefulness of the posterior superior iliac spine (PSIS) with that of iliac crest (IC) for identifying the lumbar vertebral level. METHOD: Lumbar spine level was identified by the line connecting bilateral upper margin of iliac crests in the antero-posterior lumbar X-rays of 120 patients. Assumed IC level and assumed PSIS level were compared by 3 examiners' palpation in 60 patients. A marker was taped on assumed IC level and assumed PSIS level by 4 examiners and the postero-anterior lumbar X-rays was taken in randomly distributed 50 patients. RESULTS: IC intersection line was ranged from the L4 spinous process to the L5-S1 interspinous process in all patients. Inter- examiner agreement of palpation was significantly greater in PSIS than IC level (p<0.05). The marker indicating assumed IC level was higher than true IC level in all patients and was higher than L3-4 interspinous process in 8%. CONCLUSION: We may use PSIS level for assumption of the lumbar vertebral level to compensate for the limitation of iliac crest palpation, but at the same time keep in the mind the variarity of the PSIS level.

Gabapentin Therapy for Acute Sensory Neuronopathy: A case report

Sensory neuronopathy (sensory ganglionitis), believed to be caused by an autoimmune attack against the dorsal root ganglia, has been recently linked with antiganglioside antibodies (anti-GD 1b). We present a case of idiopathic sensory neuronopathy with a positive anti-GD 1b IgG. The patient showed functional improvement with the use of gabapentin and immediately showed a resumption of symptoms when its use was stopped. Currently there is no proven therapy for sensory neuronopathy and the effect of immunosuppressive and intra venous immunoglobulin has been reported with mixed results. Also, there has been no research yet on the use and effect of gabapentin in sensory neuronopathy. This case shows that gabapentin alleviated neuropathic pain and tingling sensation in sensory neuronopathy. The authors believe that gabapentin modulated the voltage dependent calcium channels in the dorsal root ganglion and that this led to overall clinical and functional improvement. The curative or relieving effect of gabapentin in sensory neuronopathy still needs more research in the future.

Comparison of Skin Temperature between Supine and Prone Position during Application of Hot Packs on the Back

OBJECTIVE: To compare the skin temperature change between supine and prone position during application of hot pack on the back. METHOD: 15 healthy adults were recruited as subjects. We applied two hot packs to the lumbar region for two consecutive days. On the first day, the body part was on the top of hot pack and on the second day, the hot pack was placed over the body part. We measured peak skin temperature, skin temperature elevation, time required to peak skin temperature, skin temperature after 20 minutes and visual analogue scale(VAS) of subjective feeling of heat (hot). RESULTS: In the peak skin temperature, the means were 44.4+/-0.70degrees C and 42.7+/-0.99degrees C in the supine and prone position, respectively. In the skin temperature elevation, the means were 11.2+/-1.1degrees C and 9.5+/-1.6degrees C, respectively. In the time required to peak skin temperature elevation, the means were 6'49"+/-15" and 10'33"+/-15", respectively. In the skin temperature after 20 minutes, the means were 42.4+/-0.7degrees C and 41.6+/-0.8degrees C, respectively. In the VAS of subjective feeling of heat (hot), the means were 8.66+/-1.11 and 5.72+/-1.48, respectively. CONCLUSION: The patient's position is one of the important factors in determining temperature elevation. Therefore, it should be considered during application of the hot pack.

The Effect of Exercises after Local Steroid Injection on the Rabbit Achilles Tendon

OBJECTIVE: To evaluate the effects of exercises after local steroid injection on the rabbit Achilles tendon. METHOD: Twenty-one rabbits were received local injection of triamcinolone acetonide in the Achilles tendons. Group I rabbits were exercised passively on the ankle for three consecutive days immediately after injection. Group II were left to rest for three days after the injections, and then exercised for three days. Group III were left to rest without exercise. Triamcinolone was injected intratendinously in the right Achilles tendons (subgroup a), and injected in the paratendinous tissue of the left Achilles tendons (subgroup b). The Achilles tendons were dissected at 7 days after injection. RESULTS: Collagen concentration of group Ia was significantly lower than group IIa or IIIa. Collagen concentration of group Ib was significantly lower than group IIb. Collagen concentration of group Ia was significantly lower than group Ib. In tendons of group Ia, partial necrotic tissues with fragmented tendon fiber bundles were seen in light microscopic examinations. CONCLUSION: These results demonstrate that intratendinous injection of triamcinolone and immediate exercise of injected tendon, regardless of the routes of the injection, may cause damage to the rabbit Achilles tendon.

Pelizaeus-Merzbacher Disease: A case report

Pelizaeus-Merzbacher disease (PMD) is an X-linked recessive disorder characterized by dysmyelination of the central nervous system (CNS) caused by mutations in the proteolipid protein (PLP) gene. PLP is located at Xq22 and its mutation result in abnormal expression or production of PLP, the most abundant protein in CNS myelin. We present a case of PMD in the 7-year-old boy with nystagmus, ataxia, spastic quadriplegia and severe psychomotor delay. His brain MRI revealed totally dysmyelinated white matter involving entire supratentorial region, atrophic change, and overaccumulation of the iron in both basal ganglia. He also showed soft-tissue contractures of the hip adductors, associated hip dislocations and equinovarus foot deformities due to severe spasticity of lower extremities. Orthopaedic surgery was performed on both hips. Antispastic medication and physical therapy were maintained for reduction of spasticity. We report this case with the review of literatures.

MRI Findings of Adhesive Capsulitis of Shoulder

OBJECTIVE: MRI findings of adhesive capsulitis (AC) have been rarely documented even though the disease is a rather common disorder. To find reliable MRI parameters, we studied MRI findings of the patients with arthrographically-proven AC. METHOD: Eighteen patients with AC (patient group) and eight subjects without AC (control group) were enrolled. Mean age of the former was 55.1 years and that of the latter was 41.4 years. Mean duration of the diseases in patient group was 5.9 months. Oblique coronal and axial MRI images of the shoulder were measured for the thickness of capsule and synovium around the axillary fold (TAF), volume of axillary recess (VAR), and volume of biceps tendon sheath (VBTS), which were compared in both groups using unpaired t-test. RESULTS: TAF was significantly increased in patient group (p<0.0001), and the thickened axillary fold greater than 5.1 mm was a useful MRI criterion for the diagnosis of AC with sensitivity of 93% and with specificity of 100%. VBTS was also significantly diminished in patient group (p<0.05), whereas there was no significant difference in VAR between two groups. CONCLUSION: TAF, especially greater than 5.1 mm, and decreased VBTS are useful MRI parameters for the diagnosis of AC of shoulder.

Functional Recovery of Patients with Traumatic Central Cord Syndrome

OBJECTIVE: The aim of this study was to identify factors influencing the degree of neurological injury, show the natural course of recovery, and evaluate the relationship between degree of neurological injury and functional recovery from traumatic central cord syndrome. METHOD: We reviewed 15 patients retrospectively and investigated their demographic and treatment data. Initial ASIA motor scales and functional recovery at 4 weeks and 8 weeks after injury were analyzed. RESULTS: The age of patients showed significant correlation with degree of neurological injury (r= 0.55145, p<0.05) while mechanism of injury, surgical intervention and gender difference showed no correlation. Only 2 patients (13.3%) ambulated independently at initial period but subsequently 13 patients (86.7%) at 8 weeks. The number of patients who independently voided increased from 2 (13.3%) to 11 (73.3%) during the 8 weeks. Early ASIA motor score differed significantly according to the degree of functional recovery of bladder and ambulation in 4 weeks, 8 weeks after injury (p<0.05). CONCLUSION: Only the age of patients related to the initial neurologic severity. Most patients regained their bladder and ambulatory functions considerably within 8 weeks, and the degree of early neurological injury by ASIA motor scale reflected the degree of functional recovery in 4 and 8 weeks after injury.

Mixed Quadriplegia with Lissencephaly and Dysmyelination

Lissencephaly results from a neuromigrational arrest during first and second trimester of pregnancy and shows hypotonia, marked mental retardation and seizure as predominant features. Myelination is a perinatal process and co-occurence of migrational disorder with myelination disorder is rare. We report a 17-month-old male with mixed quadriplegia and mental retardation with type 1 lissencephaly and dysmyelination of cerebral white matter diagnosed by magnetic resonance imaging.

Effect of Combined Therapy of Cisapride and Lactulose on Neurogenic Bowel Dysfunction in Spinal Cord Injury

OBJECTIVE: To calculate the colonic transit time (CTT) and to evaluate the effect of combined therapy of cisapride and lactulose on neurogenic bowel dysfunction in patients with chronic spinal cord injury. METHOD: This study was prospectively designed. Right (rCTT), left (lCTT), rectosigmoid (rsCTT), and total (tCTT) colonic transit times were measured using the radio-opaque marker technique in twenty patients with spinal cord injury (SCI group), of which mean age was 39 years (range: 13~67 years) and median duration after SCI was 15 months (4-252 months). Ten ambulatory stroke patients (mean age 49 years, median duration, 12 months) were also evaluated as control group. All CTTs in both groups were compared by unpaired Student's t-test. In SCI group, the therapeutic effect of combined administration of cisapride (10 mg p.o. t.i.d) and lactulose (134.0 g/100 ml, 30-45 ml per day p.o.) was statistically analyzed by paired Student's t-test. RESULTS: Total (p<0.0001) and segmental CTT (p<0.01) except right colon were significantly delayed in SCI group when compared to the control group. In SCI group, tCTT of non-ambulatory patients (n=13) and rCTT, lCTT, rsCTT and total CTT of ambulatory patients (n=7) were significantly decreased after the combined drug therapy (p<0.05). In ambulatory SCI patients, duration after injury showed negative correlation with tCTT (Pearson's correlation coefficient r = 0.8407, p=0.0178). CONCLUSION: Combined therapy of cisapride and lactulose can improve tCTT in SCI patients with neurogenic bowel dysfunction.

Aicardi Syndrome: A case report

Aicardi syndrome is defined by the clinical triad infantile spasms, agenesis of the corpus callosum, and pathognomonic chorioretinal lacunae. Infantile spasm begins at early infancy and tends to be controlled poorly. The prognosis is poor in the patient with severe developmental delay and intractable seizures being common. We present a case of Aicardi syndrome in the 9-month-old female infant with infantile spasm, spastic tetraplegia and microcephaly. Her brain MRI revealed corpus callosum agenesis, atrophy of left hemisphere and periventricular heterotopia. She showed bilateral choroidal and optic disc coloboma. We report this case with the review of literatures.

The Effect of Electrical Stimulation on Spasticity in Hemiplegic Patients

OBJECTIVE: To evaluate the immediate effect of neuromuscular electrical stimulation in reducing spasticity and to compare antispastic effect of low frequency electrical stimulation with that of high frequency electrical stimulation. METHOD: The subjects were 10 hemiplegic patients with stroke (n=7) and traumatic brain injury (n=3) and double blind test was used. For three days, one of sham, 30 Hz and 99 Hz electrical stimulation was respectively applied to rectus femoris and hamstring muscles at random order once a day. The evaluation of spasticity was done by using the Modified Ashworth scale, beats of ankle clonus, F/M ratio and relaxation index of knee by pendulum test before and after electrical stimulation. RESULTS: The result of the study revealed statistically significant immediate decrement of spasticity in hemiplegic patients after electrical stimulation, but there was no statistical different effect according to the frequency of electrical stimulation. CONCLUSION: Neuromuscular electrical stimulation is useful in reducing spasticity. Further investigation to assess the long therapeutic effect of low and high frequency electrical stimulation will be needed.

Weight Bearing Study Using Digital Scales in Hemiplegic Patients

OBJECTIVE: The purpose of this study was to compare and analyze the differences between weight bearing through the plegic and nonplegic lower extremities in hemiplegic patients in various standing conditions. METHOD: We used digital scales to measure weight bearing among 13 hemiplegic patients when they performed comfortable standing, maximal weight shifting to each lower extremity, step standing with each foot on a step, and maximal weight shifting to each lower extremity again. RESULTS: 1) Patients bore significantly more weight on their nonplegic lower extremity than on their plegic one during comfortable standing (p0.05) and the weight bearing of nonplegic lower extremity was insignificantly increased (p>0.05). CONCLUSION: Step standing was a very useful training method of facilitating the weight bearing in hemiplegic lower extremity.

Quantitative Electromyographic Analysis of Scalenus Medius and Upper Trapezius Muscles during Neck Motion

OBJECTIVE: To determine the function of the normal upper trapezius and scalenus medius muscles during neck motion by quantitative eletromyographic analysis. METHOD: Nine subjects were evaluated electromyographically with monopolar fine wire electrodes. The isometric tilting and rotation of neck with manual resistance were performed in the sitting position. The Root Mean Square (RMS) and Mean Rectified Voltage (MRV) were recorded. RESULTS: The RMS and MRV of upper trapezius muscle were significantly higher at each degree of ipsilateral rotation than contralateral rotation. But the RMS and MRV of scalenus medius muscle were significantly higher at each degree of contralateral rotation than ipsilateral rotation. The RMS and MRV of upper trapezius and scalenus medius muscles were significantly higher at ipsilateral tilting than at contralateral tilting. CONCLUSION: Based on these results, we concluded that the upper trapezius muscle acts more in ispilateral rotation, while scalenus medius muscle acts in contralateral rotation, and upper trapezius and scalenus medius muscles act in ipsilateral tilting.

The Healing Effect of Pulsed Ultrasound on Injured Achilles Tendon in Rats

OBJECTIVE: To explore the healing effect of low intensity pulsed ultrasound with three different timing of intervention after tenotomy of Achilles tendon in rats. METHOD: One hundred and thirty-two male rats were divided into experimental and control groups. Both groups were classified according to treatment phase: treatment on inflammatory phase (group I), proliferative phase (group II), and maturation phase (group III). Each groups were divided into 2 subgroups according to tendon excision time: 1 day after 7 consecutive treatment on 3 different phases (I-A, II-A, and III-A) and 30 days after tenotomy (I-B, II-B, and III-B). Three MHz pulsed ultrasound was administered on right tendon for 4 mins at 0.5 W/cm2. The excised tendons of all groups were compared histologically and biochemically as control. RESULTS: The tendons of II-A experimental group revealed increased fibroblasts. The collagen fibers in the neo-tendon of II-B and III-B experimental groups had a tendency to be arrayed more regularly. On I-A group, the neo-tendon showed high immunoreactivity for type I and particularly type III collagen in cytoplasm of fibroblasts and collagen fibers. The imunoreactivity for type III collagen in the neo-tendon of II-A experimental group increased than control. The concentration of collagen of the neo-tendon was significantly increased on I-A and II-A experimental groups compared with control (p<0.05). Collagen concentration of the neo-tendon of II-B experimental group increased significantly compared with control and I-B and III-B experimental groups (p<0.05). CONCLUSION: These results suggest that low intensity pulsed ultrasound therapy on injured Achilles tendon may be of benefit such as increasing collagen synthesis in the early healing process, especially in proliferative phase.

Selective Epidural Steroid Injection in a Patient with Refractory Radicular Leg Pain: A case report

For the management of refractory radicular pain, traditional injection techniques such as transcaudal or translumbar epidural steroid injection may be indicated. This epidural injection, done blindly, may result in improper needle placement. Fluoroscopically guided transforaminal epidural steroid injection and computerized tomography-controlled periganglionic foraminal steroid injection are selective nerve blocks. These procedures are useful for the diagnosis. The advantages of these procedures are precise anatomic location provided by fluoroscope or CT. Intraforaminal or periganglionic steroid injection is useful in the treatment of radicular pain. Thus we introduce a case of selective epidural steroid injection in a patient with refractory radicular pain.

Chiari Type I Malformation in a Child with Syringomyelia and Scoliosis: A case report

The association between pediatric Chiari malformation and the development of syringomyelia has been well documented. Scoliosis in the patient with syringomyelia is thought to be secondary to anterior horn cell damage, which innervate the muscles of trunk, by an asymmetrically expanded syrinx. In pediatric patients, the neurologic signs and symptoms due to Chiari malformation and syringomyelia show much lower frequency but the incidence of scoliosis is very high. Thus, the MRI study for the diagnosis of the underlying syringomyelia and Chiari malfornation is essential in pediatric scoliosis patients, which may otherwise be misdiagnosed for idiopathic scoliosis. We present a case of Chiari type I malformation associated with syringomyelia and scoliosis.

Electrodiagnostic Study of Retrograde Degeneration in Carpal Tunnel Syndrome

OBJECTIVE: We investigated the useful electrodiagnostic indicators and the extent of retrograde degeneration (RD) in carpal tunnel syndrome (CTS). METHOD: We measured median mixed nerve action potentials (MMNAP) in 26 CTS and 37 normal hands by recording at the elbow and stimulating 0, 3, 6 and 9 cm proximal to the distal wrist crease. The 3 MMNAP parameters such as amplitude, latency and conduction velocity were compared between CTS and control group. The most useful indicator was compared between subgroups of CTS (mild and severe) and control group. RESULTS: The amplitudes of all MMNAPs in CTS group, except stimulating 9 cm proximal to the wrist (MA9), were significantly smaller than those in control group (p<0.05). MA9 in severe CTS subgroup, not mild subgroup, was significantly smaller than that in control group (p<0.05). CTS and control group were not significantly different in the MMNAP latencies, except stimulating 9 cm proximal to the wrist (p<0.05), and in the MMNAP conduction velocity, except stimulating in 0 cm to 3 cm segment proximal to the wrist. CONCLUSION: The amplitude of MMNAP in forearm can be the most useful indicator of RD in CTS, and the conduction velocity, a less useful indicator. We believe that RD progresses as the severity of CTS increases, and dose beyond 9 cm proximal to the distal wrist crease.

Shoe and Insole Modification for Hallux Valgus and Its Associated Foot Deformities

OBJECTIVE: To evaluate outcomes of treatment of hallux valgus and its associated foot deformities with shoe and insole modification. METHOD: We present the short-term follow-up of 32 symptomatic hallux valgus deformities in 20 patients. The patients were all female and 32 to 77 years in age at the time of modification of shoe and insole. Twenty patients were evaluated on an average of 4 weeks following their shoe and insole modification. Hallux valgus angles and first-second intermetatarsal angle were evaluated as well as the range of motion of the first metatarsophalangeal joint and patient's satisfaction. Outcome was measured using changes in visual analogue scale (VAS) on twenty occasions during 4 weeks. RESULTS: Hallux valgus was commonly associated with the lesser (2nd~5th) toe deformity (21 cases, 65.5%), pes planus (12 cases, 37.5%), Achilles tightness (12 cases, 37.5%) and great toe pronation (10 cases, 31.5%). The result obtained was highly significant (p<0.002), suggesting that the shoe and insole modification were as effective in reducing the level of pain due to hallux valgus and its associated foot deformities. CONCLUSION: The shoe and insole modification can be an effective treatment of reducing pain of hallux valgus and its associated deformities.

Lateral Femoral Cutaneous Nerve Conduction Study

OBJECTIVE: The purpose of this study was to determine the reliability and usefulness of the lateral femoral cutaneous nerve conduction study by comparing the modified Ma's method (method I) with the method proposed by Spevak and Prevec (method II) and to develop a standard value of the Korean normal adult by the method II. METHOD: Twenty-nine healthy adults were examined for the lateral femoral cutaneous nerve conduction by both methods bilaterally. The nerve was stimulated 1 cm medial to anterior superior iliac spine (ASIS) in the method I and 8 cm distal to ASIS in the method II. The sensory nerve action potential was recorded with 8 cm long strip electrodes placed on the thigh 17 cm distal to ASIS in the method I and 33 cm distal to ASIS in the method II. RESULTS: 1) Among 58 extremities, a sensory nerve action potential was detected in 52 extremities (89.7%) by the method I and in 57 extremities (98.3%) by the method II without a significant difference between both methods. 2) The mean distal latency was 3.41 msec by the method I and 4.56 msec by the method II. 3) The mean amplitude was 7.24 microvolt by the method I and 6.63 microvolt by the method II without a significant difference between both methods. 4) The mean conduction velocity was 50.9 m/sec by the method I and 55.2 m/sec by the method II without a significant difference between both methods. CONCLUSION: According to the study, both methods are compatible and reliable for the examination of lateral femoral cutaneous nerve except for a significant difference in a mean conduction velocity.