Usefulness of Ultrasonography to Predict Response to Injection Therapy in Carpal Tunnel Syndrome

OBJECTIVE: To verify the feasibility of initial parameters of ultrasonography or electromyography for the prediction of effect after steroid injection therapy in a carpal tunnel syndrome (CTS) patient. METHOD: We recruited individuals with clinical and electrodiagnostic evidence of CTS. Results from the Boston self-assessment questionnaire, median motor and sensory nerve conduction studies, and median nerve ultrasonography were evaluated at baseline, 1 month, and 6 months after injection. Evaluation of median nerve ultrasonography parameters included measurements taken at the maximal swelling point (MS), 2 cm proximal from MS (2MS), and 12 cm proximal from MS (12MS), and its ratio (MS/12MS, 2MS/12MS) was calculated. The correlation between improvement of the symptom score after treatment and baseline parameters was estimated. RESULTS: Fourteen individuals (14 women, mean age 53.8 years) with 22 affected wrists were enrolled. After steroid injection therapy, clinical and electromyographic parameters showed significant improvements at 1 month or 6 months after injection, and ultrasonographic parameters showed significant changes in maximal area and area ratio (MS/12MS) of the median nerve. Symptom score improvement showed a positive correlation in the initial 2MS and ratio of 2MS/12MS after 6 months (p<0.05). CONCLUSION: Most of the improvements occurred during the first month after injection and lasted up to 6 months. The initial median nerve swelling and its ratio may be a useful predictor of response after steroid injection.

Bilateral Hypertrophic Olivary Degeneration with Oculopalatal Tremor after Brainstem Hemorrhage: A case report

Hypertrophic olivary degeneration is a form of transynaptic degeneration, which is caused by a lesion in the dentate-rubro-olivary pathway. Commonly described lesions were brainstem stroke, neoplasm, demyelination, and trauma. It's clinical presentations are Holmes tremor, and palatal tremor. This case was a 49-year-old man who was diagnosed as bilateral brainstem hemorrhage. About 2 months later, he had developed bilateral Holmes tremor of upper extremities and oculopalatal termor. Brain MRI was performed at 13 months after onset. MRI showed hyperintense and hypertrophied lesion on T2-weighted image in both inferior olivary nuclei.

Feasibility of Ultrasonographic Area Ratio of Median Nerve in the Diagnosis of Carpal Tunnel Syndrome in Korea

OBJECTIVE: To examine the usefulness of ratio of maximal swelling to normal cross sectional area (CSA) of median nerve with ultrasound in patients with carpal tunnel syndrome (CTS) and healthy controls. METHOD: Patients with electrodiagnostically proven CTS underwent ultrasonography of the median nerve. The median nerve area was measured at three points (maximal swelling site, 2 cm proximal to maximal swelling site, 12 cm proximal to maximal swelling site) and compared to values from asymptomatic volunteers. RESULTS: The ratio of maximal swelling site to 12 cm proximal was 1.34+/-0.14 in asymptomatic volunteers and 2.31+/-0.43 in patients presenting with CTS. The ratio of maximal swelling site to 12 cm proximal gave 73.7% sensitivity and 90.0% specificity. While using only median nerve area at the wrist resulted in 81.6% sensitivity and 70.0% specificity, depending on the cutoff value used. CONCLUSION: The ratio of maximal swelling site to proximal in patients with CTS is elevated as compared to asymptomatic controls. The ratio of maximal swelling site to 12 cm proximal has higher specificity to diagnose CTS, and may be superior to measuring median nerve area at the wrist alone.

Identification of Proteolipid Protein 1 Gene Duplication by Multiplex Ligation-Dependent Probe Amplification: First Report of Genetically Confirmed Family of Pelizaeus-Merzbacher Disease in Korea

Pelizaeus-Merzbacher disease (PMD) is a rare X-linked recessive disorder with a prototype of a dysmyelinating leukodystrophy that is caused by a mutation in the proteolipid protein 1 (PLP1) gene on the long arm of the X chromosome in band Xq22. This mutation results in abnormal expression or production of PLP. We here present a Korean boy with spastic quadriplegia, horizontal nystagmus, saccadic gaze, intentional tremor, head titubation, ataxia, and developmental delay. The brain magnetic resonance imaging (MRI) showed abnormally high signal intensities in the white matter tract, including a subcortical U fiber on the T2-weighted and fluid attenuated inversion recovery (FLAIR) image. The chromosomal analysis was normal; however, duplication of the PLP1 gene in chromosome Xq22 was detected when the multiplex ligation-dependent probe amplification (MLPA) method was used. We also investigated the pedigree for a genetic study related to PMD. This case suggests that the duplication mutation of the PLP1 gene in patients with PMD results in a mild clinical form of the disorder that mimics the spastic quadriplegia of cerebral palsy.

The Evaluation of Neurotoxicity after Intrathecal Restorative Fluid Injection in the Rat

OBJECTIVE: To assess neurotoxicity of intrathecal restorative fluid leakage in the course of the intradiscal restorative fluid injection. METHOD: Twenty male Sprague-Dawley rats, body weight range of 300~350 gm, were divided randomly into four groups. Control group, group A (mixed solution of glucosamine hydrochloride 5%, chondroitin sulfate 5%, and bupivacaine hydrochloride 2%), group B (glucosamine hydrochloride 8%, chondroitin sulfate 2%, and bupivacaine hydrochloride 2%) and group C (glucosamine hydrochloride 16%, chondroitin sulfate 2%, and bupivacaine hydrochloride 2%). The behavioral test for cold allodynia (tail flick test) was conducted 1 day prior to the injection and 7 days postoperatively. Histopathologic evaluation was performed using light microscopy by a neuropathologist. The severity of nerve and cord injury were graded according to injury scoring system. RESULTS: Each group showed no significant difference in sensory function test using tail flick test before and after intrathecal restorative fluid injection. Cold allodynia was not showed statistically significant difference among the group. Histological examination showed statistically significant difference between control group and group B, group C, and between group A and group B, C in both cord and root. CONCLUSION: Intrathecal injection of restorative fluid shows neurotoxic changes in roots and spinal cord in histopathologic studies. Although same ingredients of restorative solution, the different concentration of the ingredients revealed different neurotoxicity.

Comparison of the Ultrasonographic Study and the Electrodiagnostic Study on the Ulnar Neuropathy around the Elbow Region

OBJECTIVE: To evaluate the relationship between the electrophysiologic findings and the ultrasonographic findings of the ulnar neuropathy around the elbow. METHOD: We examed 20 elbows with the ulnar neuropathy around the elbow and 22 healthy elbows. We measured the cross-sectional area (CSA) and the diameters of the long, short axis of the ulnar nerve at the swollen portion and the compressed portion by ultrasonography. RESULTS: The CSA, diameters on the longitudinal and transverse view of the swollen portion of the ulnar nerve of the patients group was larger than that of the control group (p0.05). There was significant correlation between the decrement of the nerve conduction velocity across elbow and the increment of the diameter on the swollen portion on the longitudinal and transverse view (r=0.541, 0.466, p<0.05, respectively). CONCLUSION: The difference of diameter between swollen and compressed portion of the ulnar nerve on the ultrasonography was correlated with the conduction velocity decrement on the electrophysiologic study.

A Long-Term Follow Up Study of Prognostic Factors after Carpal Tunnel Release

OBJECTIVE: The purpose of this study was to examine the factor influencing the improvement of symptoms and change of electrophysiologic findings of patients after carpal tunnel release. METHOD: We examined 16 patients (27 hands) who underwent carpal tunnel release operation after diagnosed with carpal tunnel syndrome by the electrodiagnostic study from March 2000 to February 2001. Nerve conduction tests and visual analogue scale were performed pre-operateively and 1 month and 3 years post-operatively. We also performed a correlation study to measure the improvements of symptoms with the patient's age, duration of symptoms, and severity of works. RESULTS: The improvement of visual analogue scale had no correlation with the age, severity of work and visual analogue scale at pre-operation. However, there was significant relationship between the improvement of visual analogue scale and duration of symptom. CONCLUSION: These findings suggest that the benifits of the carpal tunnel release operation were influenced by the patient's duration of the symptoms. The longer the symptoms were experienced, the improvements of the symptoms were reduced.

Radiographic Evaluation of Foot Deformities in Children with Cerebral Palsy

OBJECTIVE: To evaluate whether 7 radiographic angles make a useful method for analysing foot deformities in children with cerebral palsy, and to assess with changes in angles after 2 years with orthoses or operations. METHOD: The talocalcaneal, talus-first metatarsal, and calcaneus-fifth metatarsal angles on the AP radiographs and the talocalcaneal, tibiotalar, talus-first metatarsal, and talohorizontal angles on the lateral radiographs were measured in 183 cerebral palsied. Seven angles were analyzed according to the clinical types, spasticity, ambulation, and age. One hundred three feet were followed up for 2 years with application of orthoses or operations. RESULTS: The frequencies of higher range in AP talocalcaneal angle were 24.4% in spastic diplegia. The increased frequencies for abnormal range increased as the grade of spasticity. Non-ambulator group had many frequencies of lower range in AP talocalcaneal angle. The age of 8~9 years showed high peak in the frequency of abnormal range. After 2 years, the frequencies of normal range were increased in groups with orthoses or operations. CONCLUSION: The radiographic angles were a useful method for observing feet of the children with cerebral palsy. If the appropriate interventions for feet were applied, the normal frequencies of radiographic angles were increased after 2 years.

Importance of Sensory Latency Measurement in Early Diabetic Polyneuropathy

OBJECTIVE: To evaluate the correlation between the variables of sensory nerve conduction study of diabetic polyneuropathy patients and the factors that explain variations of multivariate data of sensory nerve conduction study. METHOD: Forty four early diabetic polyneuropathy patients and forty normal control people were included in our study. Early polyneuropathy patients were diagnosed by nerve conduction study. Their sensory nerve conduction meaurement variables were compared with normal control people in terms of correlation between amplitude and latency, and factors that were independent. RESULTS: Age controlled partial correlations between amplitude and latency suggested that early diabetic polyneuropathy patients had more association between amplitude and latency than normal control people. Cannonical correlation also reinforced the above suggestion. Factor analysis revealed degenerative factor, demyelination factor, axonopathy factors that were independent in normal control people and degenerative factors, upper extremity demyelination factor, lower extremity functional factors in the dibetic polyneuropathy patients. CONCLUSION: The latency of sensory nerve conduction study was an important variable in assessing diabetic polyneuropathy patients.

The Comparison of Therapeutic Effect of Shoulder Pain with Simple and Mixed Type in Patients with Adhesive Capsulitis

OBJECTIVE: This study was designed to divide the patients with adhesive capsulitis into two groups by ultrasonographic findings, such as simple capsulitis and mixed capsulitis patients and to compare the improvement of range of motion and shoulder pain in one month. METHOD: We examined 50 patients with adhesive capsulitis diagnosed by physical examination. In accordance to ultrasonographic findings, we divided the patients into two groups such as capsulitis and mixed capsulitis in patients with adhesive capsulitis. We treated shoulder pain by intraarticular injection and medication. We examined the range of motion of shoulder and visual analogue scale at each visiting time in a month. RESULTS: The mean age of patients was 55.3 (range: 39~77) years. There were 26 patients with simple capsulitis and 24 patients with mixed capsulitis. The average duration of pain was 16.1+/-23.9 months. There was meaningful difference of shoulder range of motion and visual analogue scale between pretreatment and posttreatment in patients with simple capsulitis and mixed capsulitis. But, there was no meaningful difference of shoulder range of motion and visual analogue scale between two groups. CONCLUSION: No specific difference was noted between the simple and the complex groups of adhesive capsulitis in the effect of treatment.

Schinzel-Giedion Syndrome and Psychomotor Retardation: A case report

We reported a girl diagnosed Schinzel-Giedion syndrome with severe psychomotor retardation and malformation that was characterized by mid face retraction, scoliosis, skull anomaly, wide cranial fontanels, brain cortical atropy, atrial septal defect, and hydronephrosis. Urinary tract infection, respiratory tract infection, and seizure were common. The neurodevelopment therapy was not effective and developmental stage was not improved. Spasticity was the only findings which was improved.

Strain, Burden and Depression of Caregivers of Hemiplegic Patients

OBJECTIVE: Study was designed preliminarily to observe the accordance of caregivers strain and depression with other factors such as sex of the patient, caregiver, lesion side, Mini Mental Status Examination (MMSE) score and Beck's Depression Index (BDI). METHOD: We composed a questionnaire with BDI, and the Sense of Competence Questionnaire (SCQ) in order to evaluate the amount of stress and depression of caregivers. Evaluation of the patient was done by interviewing them along with reviewing their medical records and obtaining scores such as the MMSE, Functional Inependence Index (FIM) and the Geriatric Depression Scale (GDS). RESULTS: BDI of the caregivers showed a negative correlation with the patients' age. Lesion side nor age, nor the prevalence of hemiplegia of patients did not show statistical relevance with the strain that the caregiver felt. The first subscale of SCQ showed a positive correlation with the caregiving time that the caregiver gave. In accordance to the sex of the caregiver, females showed to spend more time with the patient, showed to be more unsatisfied with the patient but showed a tendency of lesser SCQ score. CONCLUSION: Depression, strain and burden that the caregivers went through showed to have slight correlation with the patient and caregiver factors.

The Change of Blood Sugar Level after Steroid Injection in Shoulder Pain with Diabetes Mellitus

OBJECTIVE: This study was designed to investigate the effect of steroid injection on the blood sugar level in shoulder pain patients with diabetes mellitus. METHOD: Fifteen patients with shoulder pain and diagnosed diabetes mellitus were included. The blood sugar, insulin, cortisol and HbA1c level were measured before and twice (at 24 hours and 1 week) following a intraarticular, intratendinous or intrabursal injection containing triamcinolone. Statistical significance was determined by the paired t-test. RESULTS: The blood sugar, insulin and HbA1c levels had no significant difference between before and after steoid injection (p>0.05). But, the cortisol level significantly fell at 24 hours after steroid injection compared with preinjection level and returned to preinjection level by 1 week after steroid injection (p<0.05). CONCLUSION: One time triamcinolone injection resulted in significant suppression of cortisol level, but it returned to preinjection level after a week. The blood level of sugar, insulin and HbA1c showed no significant change after one time steroid injection.

Analysis of Characteristics and Effect of Treatment for Shoulder Pain Patient Classified by Sonographic Findings

OBJECTIVE: This study was designed to observe the general characteristic of patients with shoulder pain, interrelation between the ultrasonographic findings, physical examination and radiological findings, and the effect of treatment of shoulder pain classified by ultrasonographic findings. METHOD: We examined 334 patients (165 male and 169 female) with shoulder pain who had been consulted to us. We examined degenerative changes such as subacromial spur, greater tuberosity sclerosis using radiological method. We classified patients into three categories -capsular, noncapsular and mixed - in accordance to physical examination and ultrasonographic findings. In order to estimate the effect of treatment, VAS change one week after injection, treatment duration, and frequency of injection were checked. RESULTS: The mean age of patients was 54.4 (range: 22~77) years. The average VAS change, duration of treatment, and frequency of injection were 4.68+/-2.93, 6.14 +/- 4.83 weeks, 3.59 +/- 2.70 times. There was meaningful correlation between diagnosis done with physical examination and ultrasonography in cases showing capsular and noncapsular patterns. Although there was meaningful difference of treatment effect classified by ultrasonographic findings, no meaningful difference in treatment effect was ween in patients classified by physical examination. CONCLUSION: Ultrasonography is an useful tool supporting diagnosis based on physical examination. The ultrasonography of shoulder could predict progress and prognosis of patients with shoulder pain.

Experimental Study on the Characteristics of Nerve Injury after Ischemia-Reperfusion and Their Recovery in Rats

OBJECTIVE: To analyze the degree of injury and patterns of recovery according to the severity and degree of ischemia-reperfusion. METHOD: Fifty-three rats were divided into 2 groups by degree of ischemia using ultrasonography. Each group was subdivided into 1 and 3-hours ischemia groups. Baseline recordings were performed, and ligation of the femoral vessels were done. Reperfusion process was done. Nerve conduction study (NCS), Sciatic Function Index (SFI) and histologic study were used. RESULTS: NCS parameters of the less than 3 hours incomplete insult group showed normal value. More than 1 hour of complete insult induced peripheral nerve injury. On first day and week, amplitude of NCS was small in 3-hour group. Muscle fiber diameter was less in 3-hour group. Although NCS parameters did not reach normal values on 4th week, 3-hour group showed smaller amplitudes. SFI returned to normal level at 4th week. Reperfusion injury was observed by electromyography. CONCLUSION: Less than 3 hours of partial ischemia/ reperfusion did not result in any form of injury whereas more than 1 hour of complete insult resulted in peripheral nerve injury with greater injury seen in 3 hour insult group. Neurological recovery was not achieved at 4 th week, and the more severe the ischemia, the poorer was the recovery.

Lumbar Root Injury by the Leakage of Bone Cement after the Percutaneous Vertebroplasty: A case report

Percutaneous vertebroplasty is being increasingly used to treat compression fractures of vertebrae. Although it is said that this technique has minimal risk, we experienced a root injury after percutaneous vertebroplasty. A 62 year old woman suffered from weakness of the right lower extremity immediately after percutaneous vertebroplasty. We observed bone cement leakage into the spinal canal of the second through the fourth lumbar level, resulting in root injury. Weakness of the patient improved after the physical therapy. We should be aware of the neurologic complications of percutaneous vertebroplasty.

Histochemical Findings of Soleus in Relation to the Severity of Injury and Duration of Exercise in Sciatic Nerve Injured Rats

OBJECTIVE: To investigate the histopathological findings of soleus muscle in relation to the severity of injury and the duration of treadmill exercise in rats with sciatic nerve damage. METHOD: Sciatic nerve of seventy rats was compressed with haemostatic forceps. The experimental group was divided into 4 subgroups according to the intensity and duration of injury: group 1, first degree compression for 5 seconds; group 2, first degree for 30 seconds; group 3, third degree for 5 seconds; and group 4, third degree for 30 seconds. Treadmill exercise was done for either 30 minutes or 2 hours a day, 5 days a week for 4 weeks. Histochemical study of soleus was done before nerve compression and 1 week, 4 weeks after compression. RESULTS: The fiber diameter of soleus was larger in the experimental group at 4 weeks (p<0.05). The intensity of injury had greater impact on the recovery of fiber diameter than the duration. Thirty minute exercise was seen to have a earlier recovery of fiber diameter than 2 hours. CONCLUSION: These results may provide the basic data to clarify the neurological recovery in relation to the severity of injury, and to help establishing adequate duration of exercise after nerve damage.

Analysis of the Accessibility and Quality of Information of Arthritis-Related Internet Web Sites in Korea

OBJECTIVE: The purposes of this study were to evaluate the accessibility of the arthritis-related web sites and the quality of the information contained in the sites. METHOD: To assess the status of arthritis-related information on the internet sites in Korea, we searched for Korean words which meant and were related with `arthritis' using the 10 most famous Korean internet search engines. Identified internet site were assessed regarding the quality of content, authorship, design, and functionality. RESULTS: The number of identified web sites ranged from 24 to 214. The average search yielded around 83 web sites listing for `arthritis'. The number of web sites listed for `arthritis' was as many as that for `hypertension', `diabetes', `cancer' or `hepatitis and hepatoma'. The frequency of appearance in a search did not correlate well with the quality of associated web sites. CONCLUSION: The quality of arthritis-related web sites in Korea varied. It is essential to develop a high quality information supplying web sites and to set up an evaluation tool for qualifying the medical information on internet.

Effectiveness of Current Perception Threshold in Follow up of the Patients with Carpal Tunnel Syndrome

OBJECTIVE: To compare the degree of change of current perception threshold (CPT) results with the degree of nerve conduction study (NCS) change and evaluate the effectiveness of the CPT in following up patients who went through operation for carpal tunnel syndrome (CTS). METHOD: Twenty hands with CTS were examined with CPT and NCS, before, 2 weeks after and 2 months after operation. In the CPT, the threshold of the median nerve was measured, in the NCS, amplitude and latency of the median nerve was measured. Subjects were divided into 3 groups according to the severity by NCS results and into 2 groups according to the subjective perception of improvement. RESULTS: The subjects mean age was 51.4. Changes of NCS results in amplitude and latency showed no statistical relevance. CPT study result changes demonstrated to be statistically significant. Improvement of CPT results seen in the period of 2 weeks and 2 months and the initial first 2 weeks showed no difference. Change of CPT results showed correlation not in accordance with the severity of the NCS study, but with the symptomatic improvement of the patients. CONCLUSION: CPT can be an effective tool in evaluating the improvement of symptoms and may be used as a follow up tool in patients with CTS.

Ultrasonographic Finding of the Ulnar Nerve with Change of Elbow Joint

OBJECTIVE: We tried to make real time observation of the ulnar nerve with elbows in an extended and flexed state at 100 degrees. METHOD: We examined 58 elbows of 29 healthy volunteers. The participants were symptomless and showed normal conduction across the elbow. The transducer was applied between the line connecting medial epicondyle and olecranon. We measured the distances between the center of nerve, medial epicondyle, olecranon, skin, and investigated the flattening ratio with elbows extended. Afterwards, we repeated the measurement with the elbows flexed at 100 degrees. We classified the position of the nerves into three groups according to the flexed position. We used the Okamoto classification. RESULTS: The distance between nerve and skin, between nerve and medial epicondyle was 0.57+/-0.11 cm, 0.83+/-0.15 cm, with the elbow extended. But with the elbow flexed, the distance decreased to a value of 0.45+/-0.11 cm, 0.64+/-0.25 cm, respectively. The flattening ratio was 0.52+/-0.13 at extension, and 0.31+/-0.11 at flexion. Subluxation and dislocation of the ulnar nerve were seen in 20.7% and 5.2% respectively. With the elbow flexed, the ulnar nerve moved anteromedially and superficially in the dislocated group. CONCLUSION: With the elbow flexed, the ulnar nerve moves superficially and medially, and the flattening ratio is greater when the elbow is extended.