Comparison of the Effects of Ultrasound-Guided Interfascial Pulsed Radiofrequency and Ultrasound-Guided Interfascial Injection on Myofascial Pain Syndrome of the Gastrocnemius

OBJECTIVE: To investigate the comparative treatment effects of ultrasound-guided pulsed radiofrequency treatment (UG-PRF) in the gastrocnemius interfascial space and ultrasound-guided interfascial injection (UG-INJ) on myofascial pain syndrome. METHODS: Forty consecutive patients with myofascial pain syndrome of the gastrocnemius were enrolled and were allocated to one of the two groups. Twenty patients were treated by UG-PRF delivered to the gastrocnemius interfascial space (UG-PRF group) and the other 20 patients were treated by interfascial injection (UG-INJ group). The primary outcome measure was the numeric rating score (NRS) for pain on pressing the tender point in the gastrocnemius, and the secondary outcome measure was health-related quality of life as determined by the Short Form-36 questionnaire (SF-36). NRSs were obtained at the first visit, immediately after treatment, and at 2 and 4 weeks post-treatment, and physical component summary scores (PCS) and mental component summary scores (MCS) of the SF-36 questionnaire were measured at the first visit and at 4 weeks post-treatment. RESULTS: Immediately after treatments, mean NRS in the UG-PRF group was significantly higher than that in the UG-INJ group (p<0.0001). However, at 2 and 4 weeks post-treatment, the mean NRS was significantly lower in the UG-PRF group (both p<0.0001). Similarly, at 4 weeks post-treatment, mean PCS and MCS were significantly higher in the UG-PRF group (p<0.0001 and p=0.002, respectively). CONCLUSION: Based on these results, the authors conclude that ultrasound-guided gastrocnemius interfascial PRF provides an attractive treatment for myofascial pain syndrome of the gastrocnemius.

Short-Term Effect of Percutaneous Bipolar Continuous Radiofrequency on Sacral Nerves in Patients Treated for Neurogenic Detrusor Overactivity After Spinal Cord Injury: A Randomized Controlled Feasibility Study

OBJECTIVE: To investigate the short-term effects of bipolar radiofrequency applied to sacral nerves to treat neurogenic detrusor overactivity in patients with spinal cord injury. METHODS: Ten patients with spinal cord injury with neurogenic detrusor overactivity were recruited. These subjects were randomized to two groups: intervention (n=5) and control (n=5), members of which received conventional treatment. Voiding diary, International Consultation on Incontinence Questionnaire (ICIQ) and the urinary incontinence quality of life scale (IQOL) data were obtained and an urodynamic study (UDS) was performed before and after intervention. In the intervention group, percutaneous bipolar continuous radiofrequency (CRF) was performed on both the S2 and S3 nerves in each patient. RESULTS: In a comparison of daily frequency and number of urinary incontinence and ICIQ and IQOL scores at baseline and at 1 and 3 months after intervention, all variables achieved a significant effect for time (p0.05). CONCLUSION: Percutaneous bipolar CRF applied to sacral nerves might be an effective therapy for neurogenic overactive bladder that reduces urinary incontinence and improves quality of life.

Changes in the Expressions of Iba1 and Calcitonin Gene-Related Peptide in Adjacent Lumbar Spinal Segments after Lumbar Disc Herniation in a Rat Model

Lumbar disc herniation is commonly encountered in clinical practice and can induce sciatica due to mechanical and/or chemical irritation and the release of proinflammatory cytokines. However, symptoms are not confined to the affected spinal cord segment. The purpose of this study was to determine whether multisegmental molecular changes exist between adjacent lumbar spinal segments using a rat model of lumbar disc herniation. Twenty-nine male Sprague-Dawley rats were randomly assigned to either a sham-operated group (n=10) or a nucleus pulposus (NP)-exposed group (n=19). Rats in the NP-exposed group were further subdivided into a significant pain subgroup (n=12) and a no significant pain subgroup (n=7) using mechanical pain thresholds determined von Frey filaments. Immunohistochemical stainings of microglia (ionized calcium-binding adapter molecule 1; Iba1), astrocytes (glial fibrillary acidic protein; GFAP), calcitonin gene-related peptide (CGRP), and transient receptor potential vanilloid 1 (TRPV1) was performed in spinal dorsal horns and dorsal root ganglions (DRGs) at 10 days after surgery. It was found immunoreactivity for Iba1-positive microglia was higher in the L5 (P=0.004) dorsal horn and in the ipsilateral L4 (P=0.009), L6 (P=0.002), and S1 (P=0.002) dorsal horns in the NP-exposed group than in the sham-operated group. The expression of CGRP was also significantly higher in ipsilateral L3, L4, L6, and S1 segments and in L5 DRGs at 10 days after surgery in the NP-exposed group than in the sham-operated group (P<0.001). Our results indicate that lumbar disc herniation upregulates microglial activity and CGRP expression in many adjacent and ipsilateral lumbar spinal segments.

Activations of Deep Lumbar Stabilizing Muscles by Transcutaneous Neuromuscular Electrical Stimulation of Lumbar Paraspinal Regions

OBJECTIVE: To investigate changes in lumbar multifidus (LM) and deep lumbar stabilizing abdominal muscles (transverse abdominis [TrA] and obliquus internus [OI]) during transcutaneous neuromuscular electrical stimulation (NMES) of lumbar paraspinal L4-L5 regions using real-time ultrasound imaging (RUSI). METHODS: Lumbar paraspinal regions of 20 healthy physically active male volunteers were stimulated at 20, 50, and 80 Hz. Ultrasound images of the LM, TrA, OI, and obliquus externus (OE) were captured during stimulation at each frequency. RESULTS: The thicknesses of superficial LM and deep LM as measured by RUSI were greater during NMES than at rest for all three frequencies (p<0.05). The thicknesses in TrA, OI, and OE were also significantly greater during NMES of lumbar paraspinal regions than at rest (p<0.05). CONCLUSION: The studied transcutaneous NMES of the lumbar paraspinal region significantly activated deep spinal stabilizing muscle (LM) and the abdominal lumbar stabilizing muscles TrA and OI as evidenced by RUSI. The findings of this study suggested that transcutaneous NMES might be useful for improving spinal stability and strength in patients having difficulty initiating contraction of these muscles.

Effects of Abdominal Hollowing During Stair Climbing on the Activations of Local Trunk Stabilizing Muscles: A Cross-Sectional Study

OBJECTIVE: To examine using surface electromyography whether stair climbing with abdominal hollowing (AH) is better at facilitating local trunk muscle activity than stair climbing without AH. METHODS: Twenty healthy men with no history of low back pain participated in the study. Surface electrodes were attached to the multifidus (MF), lumbar erector spinae, thoracic erector spinae, transverse abdominus - internal oblique abdominals (TrA-IO), external oblique abdominals (EO), and the rectus abdominis. Amplitudes of electromyographic signals were measured during stair climbing. Study participants performed maximal voluntary contractions (MVC) for each muscle in various positions to normalize the surface electromyography data. RESULTS: AH during stair climbing resulted in significant increases in normalized MVCs in both MFs and TrA-IOs (p<0.05). Local trunk muscle/global trunk muscle ratios were higher during stair climbing with AH as compared with stair climbing without AH. Especially, right TrA-IO/EO and left TrA-IO/EO were significantly increased (p<0.05). CONCLUSION: Stair climbing with AH activates local trunk stabilizing muscles better than stair climbing without AH. The findings suggest that AH during stair climbing contributes to trunk muscle activation and trunk stabilization.

Attenuation of Spinal Cord Injury-Induced Astroglial and Microglial Activation by Repetitive Transcranial Magnetic Stimulation in Rats

Spinal cord injury (SCI) causes not only loss of sensory and motor function below the level of injury but also chronic pain, which is difficult and challenging of the treatment. Repetitive transcranial magnetic stimulation (rTMS) to the motor cortex, of non-invasive therapeutic methods, has the motor and sensory consequences and modulates pain in SCI-patients. In the present study, we studied the effectiveness of rTMS and the relationship between the modulation of pain and the changes of neuroglial expression in the spinal cord using a rat SCI-induced pain model. Elevated expressions of Iba1 and GFAP, specific microglial and astrocyte markers, was respectively observed in dorsal and ventral horns at the L4 and L5 levels in SCI rats. But in SCI rats treated with 25 Hz rTMS for 8 weeks, these expressions were significantly reduced by about 30%. Our finding suggests that this attenuation of activation by rTMS is related to pain modulation after SCI. Therefore, rTMS might provide an alternative means of attenuating neuropathic pain below the level of SCI.

Effect of Intradiscal Monopolar Pulsed Radiofrequency on Chronic Discogenic Back Pain Diagnosed by Pressure-Controlled Provocative Discography: A One Year Prospective Study

OBJECTIVE: To investigate the efficacy and safety of percutaneous intradiscal monopolar pulsed radiofrequency (PRF) in patients with chronic disabling discogenic back pain. METHOD: Twenty-six subjects (7 males; mean age 43.2 years) with chronic back pain refractory to active rehabilitative management were recruited. All subjects underwent MRI for evaluation of Modic changes, and monopolar PRF (20 min at 60 V) at the center of target lumbar intervertebral disc confirmed by pressure-controlled provocative discography. Clinical outcomes were measured by the visual analogue scale (VAS), Oswestry disability index (ODI), and sitting tolerance time (ST) for 12 months after treatment. Successful clinical outcome was described as a minimum of 2 point reduction in VAS compared with the baseline at each follow-up period. RESULTS: The mean VAS for low back pain reduced significantly from 6.4+/-1.1 at pre-treatment to 4.4+/-1.9 at 12 months (p<0.05). The mean ODI score was 47.3+/-15.4 points at pre-treatment and 36.7+/-19.5 at 12 months (p<0.001). The ST was 27.8+/-20.4 minutes at pre-treatment and 71.5+/-42.2 at 12 months (p<0.001). However, successful clinical outcome was achieved at 58%, 50%, and 42%, measured at 3, 6, and 12 months post-treatment. There were no significant relationship between the clinical outcome and Modic changes; no adverse events were recorded. CONCLUSION: The results demonstrated that the application of intradiscal monopolar PRF might be relatively effective but limited; successful intervention for chronic refractory discogenic back pain is needed. To achieve the optimal outcome through intradiscal PRF, we suggested further studies about stimulation duration, mode, and intensity of PRF.

Effect of Intradiscal Methylene Blue Injection for the Chronic Discogenic Low Back Pain: One Year Prospective Follow-up Study

OBJECTIVE: To evaluate the efficacy of intradiscal methylene blue (MB) injection in patients with chronic discogenic low back pain. METHOD: Twenty patients with discogenic low back pain (4 males, 16 females; mean age 45.6 years) refractory to conservative management were recruited. All subjects underwent MB injection in target lumbar intervertebral discs confirmed by provocative discography. The clinical outcome was assessed by visual analog scale (VAS) and Oswestry disability index (ODI) at baseline and 1, 3, 6 and 12 months after treatment. Successful outcome was described as minimum of 2 points reduction in pain intensity compared with the baseline. RESULTS: VAS and ODI significantly decreased after one injection. The average VAS and ODI were reduced significantly from 5.1 and 38.0 at baseline to 3.2 and 27.4 at 3 months after injection (p<0.05). However, the mean score of VAS at 12 month follow-up was 4.5 and we could not observe any difference between 12 months after injection and pretreatment. Eleven of twenty patients (55%) reported successful outcomes after intradiscal MB injection at 3 month follow up and the average VAS was reduced by 3.3+/-1.1 (p<0.05). At the time of 12 month follow up, pain had relapsed in 6 patients who have had satisfactory effect at 3 month follow up. Successful outcome was maintained in only 5 patients (20%) for 1 year. CONCLUSION: The intradiscal MB injection is a short-term effective minimally invasive treatment indicated for discogenic back pain but it may lose its effectiveness long-term.

Sequential Changes of CX3CR1 in Dorsal Root Ganglion in a Rat Model of Lumbar Disc Herniation

OBJECTIVE: To investigate the pain-related behaviors and the changes of CX3CR1 expression in the dorsal root ganglion (DRG) in a rat model of lumbar disc herniation. METHOD: A total of 90 male Sprague-Dawley rats were used. A laminectomy was performed to expose left L5 nerve roots and corresponding DRG. Autologous nucleus puplosus was implanted on the left L5 nerve root proximal to the DRG without mechanical compression. Sham operation was also done with the same procedure as mentioned above. Thermal hyperalgesia and mechanical allodynia were assessed at 1, 5, 10, 20 and 30 days after surgery. Real time PCR and immunohistochemistry after behavioral test were performed. RESULTS: In the lumbar disc herniation rats, significant reduction of thermal withdrawal latency indicating thermal hyperalgesia was shown on the ipsilateral hindpaw on postoperative day 1 (p<0.01) and peaked on day 10 (p<0.05) and maintained throughout day 30 (p<0.05). The reduction of mechanical allodynia threshold, indicating mechanical allodynia, was observed on the ipsilateral hindpaw on postoperative day 1 (p<0.01) and continued throughout day 30 (p<0.01). Real time PCR showed the decrease in mRNA expression of CX3CR1 in the ipsilateral DRG on day 1 (p<0.05) and the significant increase on day 20 (p<0.05). The immunoreactivity for CX3CR1 was also increased in ipsilateral DRG on day 10 and 20. CONCLUSION: These data suggest that lumbar disc herniation induces thermal hyperalgesia and mechanical allodynia and upregulates the expression of CX3CR1 in dorsal root ganglion. Expression of CX3CR1 might be associated with subacute neuropathic pain after intervertebral disc herniation.

Short-Term Effects of Pulsed Radiofrequency on Chronic Refractory Cervical Radicular Pain

OBJECTIVE: To evaluate the short-term effectiveness of pulsed radiofrequency on the dorsal root ganglion (DRG) in patients with chronic refractory cervical radicular pain. METHOD: Fifteen patients (13 males, 2 females; mean age, 55.9 years) with chronic radicular pain due to cervical disc herniation or foraminal stenosis refractory to active rehabilitative management, including transforaminal cervical epidural steroid injection and exercise, were selected. All patients received pulsed radiofrequency on the symptomatic cervical dorsal root ganglion and were carefully evaluated for neurologic deficits and side effects. The clinical outcomes were measured using a visual analogue scale (VAS) and a neck disability index (NDI) before treatment, one and three months after treatment. Successful pain relief was defined as a 50% or greater reduction in the VAS score as compared with the pre-treatment score. After three months, we categorized the patients' satisfaction. RESULTS: The average VAS for radicular pain was reduced significantly from 5.3 at pretreatment to 2.5 at 3 months post-treatment (p<0.05). Eleven of 15 patients (77.3%) after cervical pulsed RF stimulation reported pain relief of 50% or more at the 3 month follow-up. The average NDI was significantly reduced from 44.0% at pretreatment to 35.8% 3 months post-treatment (p<0.05). At 3 months post-treatment, eleven of fifteen patients (73.3%) were satisfied with their status. No adverse effects were observed. CONCLUSION: The results demonstrate that the application of pulsed radiofrequency on DRG might be an effective short-term intervention for chronic refractory cervical radicular pain. Further studies, including a randomized controlled trial with long-term follow-up, are now needed.

Efficacy of Transforaminal Epidural Steroid Injections According to Nerve Root Enhancement

OBJECTIVE: To determine the efficacy of transforaminal epidural steroid injections according to nerve root enhancement in lumbar disc herniations. METHOD: Twenty seven patients who had extruded or seques tered lumbar disc herniations on enhanced MR imaging were investigated: fifteen patients with corresponding nerve root enhancement (enhanced group), and twelve patients without enhancement (non-enhanced group). All patients received transforaminal epidural steroid injection. Clinical outcomes were measured by visual analogue scale (VAS) for back and radicular pain, Oswestry disability index (ODI) before treatment and one month after injection. RESULTS: The averages of VAS for lower extremity and back pain in both groups one month after injection significantly reduced compared to that of pretreatment, respectively (p<0.001). The amount of decrease in pain in enhanced group was larger than that of non-enhanced group (p<0.05). The averages of ODI in both group one month after injection significantly reduced compared to that of pretreatment (p<0.0001), however, there was no difference between the two groups. CONCLUSION: The nerve root enhancement on contrast-enhanced MR imaging indicates the presence of severe inflammatory reaction of nerve root, which means well-responsiveness to anti-inflammatory treatment such as transforaminal epidural steroid injection, even if patients' symptom is very severe.

Effects of Continuous Repetitive Transcranial Magnetic Stimulation on Pain Response in Spinal Cord Injured Rat

OBJECTIVE: To investigate the effects of continuous repetitive transcranial magnetic stimulation (rTMS) on pain response in spinal cord injured rat. METHOD: Forty Sprague-Dawley rats (200~250 grams, female) were used. Thoracic spinal cord (T9) was contused using New York University (NYU) spinal cord impactor. Ten gram weight rod was dropped from a height of 25 mm to produce spinal cord contusion model with moderate injury. The animals were randomly assigned to two groups: one exposed to real magnetic stimulation (real-rTMS group) and the other not exposed to magnetic stimulation (sham-rTMS group). rTMS was applied for 8 weeks. To assess the effect of continuous rTMS on below-level pain responses after spinal cord injury (SCI), the hindpaw withdrawal response for thermal stimuli, cold stimuli and mechanical stimuli were compared between two groups. RESULTS: Behavioral response for pain showed that hindpaw withdrawal response for cold stimuli was reduced significantly from 4 weeks after SCI in real-rTMS group compared with sham group (p<0.05). CONCLUSION: These results suggest that continuous rTMS may have beneficial effects on attenuation of cold allodynia after SCI, and it might be an additional non-invasive therapeutic method in patients with chronic neuropathic pain after SCI.

The Long-Lasting Pattern of the Neuropathic Radicular Pain in An Autologous Nucleus Pulposus Model of Rat

OBJECTIVE: To observe the long-lasting changes of pain progression with time course in an autologous nucleus pulposus model of rat. METHOD: The subjects were 25 Sprague-Dawley (Sprague- Dawley, 250 gm) male rats. They were randomly assigned into either the sham or experimental group. In the experimental group (n=15), autologous nucleus pulposus was harvested from the coccygeal intervertebral disc of the rat and this was grafted on the left L5 dorsal root ganglion. In the sham group (n=10), the left L4 and L5 nerve roots were exposed by laminectomy, but the nucleus pulposus was not grafted. All the rats were evaluated for mechanical allodynia and thermal hyperalgesia at 2 days before surgery, and on days 1, 5, 10, 20, 30, 40 and 50 after surgery. The morphological changes of the spinal nerves were assessed by toluidine blue staining on days 5 after surgery. RESULTS: In the ipsilateral hindpaw of the experimental group, there was a dramatic drop of the mechanical withdrawal threshold and the thermal withdrawal latency on day 1 after surgery, which was maintained at day 50 after surgery. In morphological study, pathological findings such as swelling of the myelin sheath, demyelination, swelling and degeneration of the axoplasm were observed in the spinal nerve at day 5 after surgery. CONCLUSION: The long-lasting pattern of neuropathic radicular pain shown in a rat model of lumbar disc herniations is helpful to understand the natural history of neuropathic radicular pain due to ruptured nucleus pulposus.

Effect of Intensive Conservative Treatment on Extraforaminal Lumbar Disc Herniations - 1 Year Prospective Follow-up Study

OBJECTIVE: To evaluate the outcomes of intensive conservative treatment on extraforaminal lumbar disc herniations. METHOD: Twenty five patients with extraforaminal lumbar disc herniations with symptomatic radicular pain were included. Under fluoroscopic guidance, 40 mg of triamcinolone was infused around the nerve root after provocation of patient's usual radicular pain. Lumbosacral dynamic stabilization exercise, thermal and electrical therapy, and education of posture correction were added. The clinical outcomes were measured by visual analogue scale (VAS) and Oswestry disability index (ODI) before treatment, one, three, six, and twelve months after the treatment. After twelve months, patients' satisfaction was classified to four categories: excellent, good, fair, or poor. Four patients were dropped out. RESULTS: Follow-up VAS and ODI significantly decreased since post-treatment one month (p<0.0001). The average score of VAS for lower extremity and back pain reduced significantly from 6.6, 4.5 at pretreatment to 1.5, 1.9 at 12 months post-treatment, respectively (p<0.0001). The averages of ODI reduced significantly from 65.4% at pretreatment to 25.4% at post-treatment 12 months (p<0.0001). In patients' satisfaction, seventeen patients (81.0%) were recorded as excellent or good after post-treatment 12 months. CONCLUSION: Intensive conservative treatment was effective on patients who underwent extraforaminal lumbar disc herniation. Pain relief and functional improvement sustained for 12 months.

Effects of Functional Magnetic Stimulation on the Functional Recovery in a Rat Model of Spinal Cord Injury

OBJECTIVE: To investigate the effects of functional magnetic stimulation (FMS) on the functional recovery in a rat model of spinal cord injury (SCI). METHOD: Forty-five Sprague-Dawley rats (200~250 grams, female) were used. Rats were laminectomized and the T9 segment of spinal cord was contused using New York University (NYU) spinal impactor. Ten gram weight rod was dropped from a height of 25 mm to produce moderately contused spinal cord injury model. The animals were randomly assigned to 2 groups: one exposed to FMS (FMS group) and the other not exposed to FMS (non-FMS group). Transcranial functional magnetic stimulation was noninvasively applied for 4 weeks. To compare the results between FMS group and non-FMS group, motor functions were evaluated with the Basso, Beattie, and Bresnahan (BBB) locomtor rating scale and inclined plane test, and somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) were also recorded. RESULTS: There was a significant difference in locomotor recovery between FMS group and non-FMS group (p<0.05). Measurement of MEP was also indicated that amplitude of MEP in FMS group is larger than that in non-FMS group. CONCLUSION: These results indicate that FMS may have beneficial effects on motor recovery after spinal cord injury and the benefits of FMS could be an additional non-invasive therapeutic method for clinical trials in patients with spinal cord injury.

Clinical Usefulness of Diffusion Tensor Image Tractography in Stroke Patients: Report of two cases

We report the clinical usefulness of elucidating the state of the corticospinal tract (CST) by the use of diffusion tensor image tractography (DTT) in hemiparetic stroke patients. DTT was performed using 1.5 T magnetic resonance imaging. DTT demonstrated that the CST of the affected hemisphere was preserved in the medial portion of the hematoma in patient 1, but was interrupted by a hematoma in patient 2. DTT seems to be useful for elucidating the status of the CST in hemiparetic stroke patients.

Comparing the Outcome of Conservative Treatment between Soft Herniated Cervical Disc with Radiculopathy and Cervical Spondylotic Radiculopathy

OBJECTIVE: To compare the long-term clinical outcome of conservative treatment between herniated soft cervical disc with radiculopathy (HCD-R) and cervical spondylotic radiculopathy (CSR) METHOD: Clinical outcomes of each twenty patients with foraminal stenosis and with herniated cervical disc in magentic resonance image were evaluated prospectively for one year. All patients received cervical transforaminal epidural steroid injection. Clinical outcomes were measured by visual analogue scale (VAS), Neck Disability Index (NDI) at initial, one, three, six, and twelve months after injection. Twelve months after injection, we categorized patients' satisfaction. RESULTS: All assessements were significantly reduced (p < 0.05). The averages of VAS for upper extremity and neck pain decreased from 6.7, 5.1 to 1.5, 1.2 in the CSR group, and also decreased from 5.6, 6.3 to 1.3, 2.3 in the HCD-R group, respectively. The averages of NDI in the CSR group decreased from 42% to 8%, and in the HCD-R group from 53% to 14%, respectively. 88.8% in the CSR group and 88.1% in the HCD-R group were satisfied at posttreatment 12 months. There was no difference between groups in all comparison. CONCLUSION: CSR responded very well to conservative treatment as well as HCD-R, and the effects sustained for long- term.

Effect of Aggressive Rehabilitative Treatment on Canalicular Sequestered Lumbar Disc Herniations : Long-term Follow-up Study

OBJECTIVE: To assess long term outcomes of aggressive rehabilitative treatment on canalicular sequestered lumbar disc herniations METHOD: Clinical outcomes of twenty four patients with sequestered disc herniation with symptomatic radicular pain were evaluated prospectively and longitudinally for one year. All patients received aggressive rehabilitative treatment including transforaminal epidural steroid injection, pelvic stabilization exercise, physical therapy, and back school. Clinical outcomes were measured by visual analogue scale (VAS) for back and radicular pain, Oswestry Disability Index (ODI) for back pain before treatment, posttreatment one, three, six, and twelve months. After twelve months, we categorized patients' satisfaction. Four patients were dropp RESULTS: The averages of VAS for lower extremity and back pain reduced significantly from 6.6 and 5.8 at pretreatment to 0.7 and 0.9 at 12 months posttreatment, respectively (p<0.001). The averages of ODI reduced significantly from 73.5% at pretreatment to 22.3% at posttreatment 12 months (p<0.001). Sixteen of twenty patients (80.0%) were satisfied with their current status posttreatment 12 months. CONCLUSION: Sequestered disc herniations could be treated successfully by aggressive rehabilitative treatment. Clinical improvement was achieved from posttreatment one month and persisted for twelve months. Operation might be delayed until aggressive rehabilitation treatment fail to treat sequestered disc herniations.

Influence of Lesion Location on Cortical Recovery Pattern in Hemiparetic Stroke Patients

OBJECTIVE: The aim of this study was to elucidate how the location of cerebral infarct influences cortical recovery pattern in hemiparetic stroke patients. METHOD: Forty-three chronic stroke patients and 21 control subjects were recruited for the study. The patients were classified into 4 groups according to infarct locations: cortex (CO), corona radiata (CR), posterior limb of the internal capsule (PL), and brainstem (BS). Functional MRI was performed using the blood oxygen level-dependent technique at 1.5 T with the motor task of hand grasp-release movements. RESULTS: The activation pattern of the primary sensori-motor cortex (SM1) was found to be significantly influenced by the lesion locations, but that of the secondary motor area was not (Pearson's chi-square test, p<0.05). The contralateral' SM1 activation was the major response in the control group (85.7%) and in the BS group (75.0%). On the other hand, the major activation pattern was `peri-lesional' in the CO group (peri-lesional 57.1%, peri-lesional and ipsilateral 42.9%), `bilateral activation' in the CR (85.7%) and the PL group (100.0%). CONCLUSION: Our results suggested that motor recovery mechanisms could be different according to location of cerebral infarct.

The Effect of Selective Tibial Neurotomy and Rehabilitation in a Quadriplegic Patient with Ankle Spasticity Following Traumatic Brain Injury

Ankle spasticity following brain injury leads to abnormal posture and joint contracture; making standing or walking impossible. This study investigates the efficacy of selective tibial neurotomy (STN) and intensive rehabilitation in a patient who suffered ankle spasticity after brain injury. This case describes a 37-year-old man whose traumatic brain injury (TBI) resulted in severe right ankle spasticity and contracture. He was unable to stand due to severe right ankle spasticity and contracture. Intensive rehabilitation and STN allowed him to walk without brace at 6 months and run at 12 months after STN. STN is an effective procedure to resolve localized spasticity of the ankle and it may be considered as a management strategy after local injection to alleviate ankle spasticity and/or contracture prior to orthopaedic surgery.