Investigation of the Diagnostic Value of Ultrasonography for Radial Neuropathy Located at the Spiral Groove

OBJECTIVE: To determine a diagnostic cut-off value for the cross-sectional area (CSA) of the radial nerve using ultrasonography for radial neuropathy located at the spiral groove (SG). METHODS: Seventeen patients with electrodiagnostic evidence of radial neuropathy at the SG and 30 healthy controls underwent ultrasonography of the radial nerve at the SG . The CSAs at the SG were compared in the patient and control groups. The CSA at the SG between the symptomatic and asymptomatic sides (ΔSx–Asx and Sx/Asx, respectively) were analyzed to obtain the optimal cut-off value. The relationship between the electrophysiological severity of radial neuropathy and CSA was also evaluated. RESULTS: Among the variables examined, there were statistically significant differences in the CSA between the patient and control groups, ΔSx–Asx, and Sx/Asx at the SG. In a receiver operating characteristics analysis, the cut-off CSA was 5.75 mm² at the SG (sensitivity 52.9%, specificity 90%), 1.75 mm² for ΔSx–Asx (sensitivity 58.8%, specificity 100%), and 1.22 mm² for Sx/Asx (sensitivity 70.6%, specificity 93.3%) in diagnosing radial neuropathy at the SG. There was no significant correlation between CSA and electrophysiological severity score for either patient group. CONCLUSION: The reference value obtained for CSA of the radial nerve at the SG may facilitate investigation of radial nerve pathologies at the SG.

Diagnostic Cutoff Value for Ultrasonography of the Common Fibular Neuropathy at the Fibular Head

OBJECTIVE: To establish the diagnostic cutoff value of ultrasonographic measurement for common fibular neuropathy (CFN) at the fibular head (FH). METHODS: Twenty patients with electrodiagnostically diagnosed CFN at the FH and 30 healthy controls were included in the study. The cross-sectional area (CSA) of sciatic nerve at mid-thigh level, common fibular nerve at popliteal fossa (PF), and common fibular (CF) nerve at FH were measured. Additionally, the difference of CF nerve CSA at the FH between symptomatic side and asymptomatic side (ΔSx–Asx), the ratio of CF nerve CSA at FH to at PF (FH/PF), and the ratio of CF nerve CSA at the FH symptomatic side to asymptomatic side (Ratio Sx–Asx) were calculated. RESULTS: CSA at the FH, FH/PF, ΔSx–Asx, and Ratio Sx–Asx showed significant differences between the patient and control groups. The cutoff value for diagnosing CFN at the FH was 11.7 mm² for the CSA at the FH (sensitivity 85.0%, specificity 90.0%), 1.70 mm² for the ΔSx–Asx (sensitivity 83.3%, specificity 97.0%), 1.11 for the FH/PF (sensitivity 47.1%, specificity 93.3%), and 1.24 for the Ratio Sx–Asx (sensitivity 72.2%, specificity 96.7%). CONCLUSION: The ultrasonographic measurement and cutoff value could be a valuable reference in diagnosing CFN at the FH and improving diagnostic reliability and efficacy.

Diagnostic Cutoff Value for Ultrasonography in the Ulnar Neuropathy at the Elbow

OBJECTIVE: To determine the diagnostic cutoff values of ultrasonographic measurements in ulnar neuropathy at the elbow (UNE). METHODS: Twenty-five elbows of 23 patients (9 females, 16 males) diagnosed with UNE and 30 elbows of 30 healthy controls (15 females, 15 males) were included in our study. The ulnar nerve cross-sectional area (CSA) was measured at the Guyon canal, midforearm, and maximal swelling point (MS) around the elbow (the cubital tunnel inlet in healthy controls). CSA measurements of the ulnar nerve at each point, the Guyon canal-to-MS ulnar nerve area ratio (MS/G), and the midforearm-to-MS ulnar nerve ratio (MS/F) were calculated. RESULTS: Among the variables, only CSA at MS, MS/G, and MS/F displayed significant differences between the control and patient groups. The cutoff value for diagnosing UNE was 8.95 mm2 for the CSA at MS (sensitivity 93.8%, specificity 88.3%), 1.99 for the MS/G (sensitivity 75.0%, specificity 73.3%), and 1.48 for the MS/F (sensitivity 93.8%, specificity 95.0%). CONCLUSION: These findings may be helpful to diagnose UNE.

Diagnosis With Manometry and Treatment With Repetitive Transcranial Magnetic Stimulation in Dysphagia

Videofluoroscopic swallowing study (VFSS) used for the diagnosis of dysphagia has limitations in objectively assessing the contractility of the pharyngeal muscle or the degree of the upper esophageal sphincter relaxation. With a manometer, however, it is possible to objectively assess the pressure changes in the pharynx caused by pharyngeal muscle contraction during swallowing or upper esophageal sphincter relaxation, hence remedying the limitations of VFSS. The following case report describes a patient diagnosed with lateral medullar infarction presenting a 52-year-old male who had dysphagia. We suggested that the manometer could be used to assess the specific site of dysfunction in patients with dysphagia complementing the limitations of VFSS. We also found that repetitive transcranial magnetic stimulation was effective in treating patients refractory to traditional dysphagia rehabilitation.

Feasibility of Ultrasound Guided Atlanto-occipital Joint Injection

OBJECTIVE: To evaluate the feasibility of ultrasound guided atlanto-occipital joint injection. METHOD: Six atlanto-occipital joints of three cadavers were examined. Cadavers were placed in prone position with their head slightly rotated towards the contra-lateral side. The atlanto-occipital joint was initially identified with a longitudinal ultrasound scan at the midline between occipital protuberance and mastoid process. Contrast media 0.5cc was injected into the atlanto-occipital joint using an in-plane needle approach under ultrasound guide. The location of the needle tip and spreading pattern of the contrast was confirmed by fluoroscopic evaluation. RESULTS: After ultrasound guided atlanto-occipital joint injection, spreading of the contrast media into the joint was seen in all the injected joints in the anterior-posterior fluoroscopic view. CONCLUSION: The ultrasound guided atlanto-occipital injection is feasible. The ultrasound guided injection by Doppler examination can provide a safer approach to the atlanto-occipital joint.

Sonographic Measurement of the Tibialis Posterior Tendon Diameters and Cross Sectional Area in Normal Korean Adults

OBJECTIVE: To provide normal reference values of the sonographic diameters and cross sectional area (CSA) of the posterior tibialis tendon (PTT) in Korean adults for early diagnosis and treatment of PTT dysfunction. METHOD: 240 feet from 120 healthy volunteers (63 males; 57 females, mean age: 36.40+/-11.37) were included in this study. Those with a previous history of surgery or trauma to the lower extremities and systemic disease, such as, hypertension, diabetes, or rheumatoid arthritis were excluded. PTT was examined through ultrasonograhy with the patient placed in the prone oblique position, with the knee extended, and ankle dorsiflexed to neutral angle. We evaluated the anterioposterior (AP) and transverse diameter and CSA of the PTT along the line that connected from the posteroinferior angle of the medial malleolus to the heel. RESULTS: The AP diameter of PTT measured by sonography was 3.42+/-0.03 mm and the transverse diameter of the PTT was 9.20+/-0.08 mm. The CSA was 21.46+/-0.26 mm2. Differences in diameters and CSA related to sidedness, sex did not show statistical significance (p>0.05). There was weak linear relationship in AP and transverse diameter and CSA with weight, height, leg and foot length. CONCLUSION: The normal Korean reference values of the PTT diameter and CSA that we obtained from ultrasonography can be used as useful reference data in diagnosing early pathologic conditions of PTT dysfunction.

The Effectiveness of Sympathetic Skin Response Studies for Patients with Primary Palmar Hyperhidrosis and Who Undergo Thoracic Sympathicotomy / 대한흉부외과학회지

BACKGROUND: There is no standardized tool and parameter that can accurately assess the sympathetic function before and after performing sympathectomy in patients with primary palmar hyperhidrosis. We examined the effectiveness of the sympathetic skin response (SSR) study for documenting the change of sympathetic denervation before and after performing selective thoracic sympathicotomy. MATERIAL AND METHOD: We prospectively investigated the SSR from 12 healthy subjects who were diagnosed with primary hyperhidrosis. Each SSR was recorded on the right palm or sole with electrical stimuli applied to the skin at the left wrist and foot and vice versa for the controlateral side. This test was performed before, 2 weeks and 1 year after selective thoracic sympathicotomy. The data was corrected for the onset latency and the amplitude of the SSR (n=24). RESULT: The mean age of the 12 patients was 24.6+/-0.4 years (range: 19~36) and the gender ratio was 1:0.7. The mean values of the preoperative, postoperative 2 weeks and postoperative 1 year onset latency and amplitude of the palmar side (n=24) were 1.46+/-0.24 msec and 6,043+/-2,339micronV, 1.63+/-0.42 msec and 823+/-638micronV, and 1.44+/-0.39 msec and 2,412+/-1,546micronV, respectively. The mean values of the plantar side (n=38) were 1.83+/-0.42 msec and 2,816+/-1,694micronV, 2.16+/-0.39 msec and 1,445+/-1,281micronV and 1.95+/-0.25 msec and 1,622+/-865micronV, respectively. Among the documented parameters, only the palmar amplitude (p=0.002) showed statistical significance in recording the change of the sympathetic system within the same individual for the pre and postoperative period. CONCLUSION: The SSR amplitude ratio may be a useful parameter for documenting the efficacy of sympathetic denervation after selective sympathicotomy.

Anatomic Study of Injection Point of Piriformis Muscle on Cadaver Study

OBJECTIVE: To identify the optimal site for piriformis muscle injection, using easily detectable sacroiliac joint as a landmark, under fluoroscopic guidance. METHOD: We examined the anatomic relationships of the sciatic nerve, piriformis muscle and sacroiliac joint in 18 buttocks from 9 cadavers. The distance from the inferior margin of the sacroiliac joint to the piriformis muscle at the crossing point with the sciatic nerve, and the width of the sciatic nerve at that point were measured. We assessed the depth of the piriformis muscle and the sciatic nerve using ultrasonography in asymptomatic controls. RESULTS: The mean distance from the inferior margin of the sacroiliac joint to the piriformis muscle at the crossing point with the sciatic nerve was 15.7+/-3.4 (12~22) mm laterally and 16.5+/-4.1 (10~25) mm caudally. The mean width of the sciatic nerve at that point was 15.4+/-3.7 (12~22) mm. Ultrasonographic findings revealed the mean distance as 4.48+/-0.49 cm from the skin to the surface of the piriformis muscle and as 5.68+/-0.62 from the skin to the surface of the sciatic nerve. CONCLUSION: The most optimal injection site for piriformis syndrome was located 15.6+/-3.4 (12~22) mm laterally and 16.5+/-4.1 (10~25) mm caudally from the inferior margin of the sacroiliac joint.

Prevalence of Denervation Potentials from Foot Intrinsic and Lumbosacral Paraspinal Muscles in Asymptomatic Persons in Korea

OBJECTIVE: To determine the prevalence of denervation potentials from the foot intrinsic and the lumbosacral paraspinal muscles in asymptomatic persons in Korea. METHOD: Nerve conduction studies were performed in 80 asymptomatic persons at sural, peroneal and tibial nerves. We excluded 15 persons with abnormal values of nerve conduction studies. In our study, 36 males and 29 females participated and the mean age of subjects was 52.9 years. We checked denervation potentials from unilateral lumbosacral paraspinal (L4-S1) and foot intrinsic muscles (abductor hallucis and extensor digitorum brevis muscle) by needle EMG. RESULTS: The prevalence of denervation potentials from foot intrinsic muscles was 3% (2 cases out of 65 asymptomatic subjects). Denervation potentials consisting of a positive sharp wave were seen from the abductor hallucis muscle. No subjects showed any denervation potentials from the lumbosacral paraspinal muscles in our study. Abnormal X-ray findings were seen in subjects who had denervation potentials from the foot intrinsic muscles. CONCLUSION: The prevalence of denervation potentials from the foot intrinsic and the lumbosacral paraspinal muscles in asymptomatic person was not as high as previously reported

Comparison of Fixed Distance Stimulation and Distal Wrist Crease Stimulation in Median Motor Conduction Study

OBJECTIVE: To determine optimal stimulation site for median motor conduction study, we compared fixed distance (7 cm proximal to the recording electrode) stimulation method and distal wrist crease stimulation method. METHOD: Nerve conduction studies were performed in 65 hands of 36 healthy adults without neurologic abnormality. Median motor responses were recorded from abductor pollicis brevis (APB) with the stimulations at the point 7 cm proximal to the recording electrode and at the distal wrist crease. The distal latencies and onset-to-peak amplitudes were measured and compared between two techniques. The distal latencies were also compared to that of ulnar compound muscle action potential (CMAP) obtained with fixed distance stimulation (7 cm proximal to the recording electrode). And we measured median nerve actual length from distal wrist crease to APB muscle motor point by anatomic dissection of 12 hands. RESULTS: The distal latencies of median CMAP to APB with 7 cm fixed distance stimulation and distal wrist crease stimulation were 2.91+/-0.37 ms and, 2.75+/-0.41 ms respectively. The differences were statistically significant. The distal latency of ulnar CMAP was 2.50+/-0.32 ms. Differences in distal latencies between ulnar CMAPs and not only 7 cm fixed distance median stimulation but also distal wrist crease median stimulation were also statistically significant. The mean length of median nerve from distal wrist crease to APB motor point was 5.91+/-0.77 cm. CONCLUSION: We suggest that the median motor nerve conduction study using distal wrist crease stimulation was an easier and more rapid procedure than fixed distance median motor nerve conduction study.

Chronic Inflammatory Demyelinating Polyradiculoneuropathy in Patient with Systemic Lupus Erythematosus: A case report

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) has been reported rarely in systemic lupus erythematosus (SLE). We report a case of a 33 year-old woman who was diagnosed as SLE 2 years ago and presented with both feet and hands tingling sensation over 2 months. She also showed clinical features of areflexia, elevated CSF protein, and demyelination in the nerve conduction study. Her lower limb weakness and ataxic gait gradually progressed. Her symptoms which had shown minimal improvement to immunoglobulin therapy responded to immunosuppressant treatment.

Atlantoaxial Subluxation in Undifferentiated Spondyloarthropathy: A case report

Atlantoaxial subluxation in undifferentiated spondyloarthropathy is extremely rare and has not been reported. We describe a case of 27-year-old man who was diagnosed as undifferentiated spondyloarthropathy with atlantoaxial subluxation with an initial complaint of painful swelling of right 1st metatarsophalangeal joint and posterior neck pain. Roentgenograms showed sclerotic change and increased hazziness in right 1st metatarsophalangeal joint. Magnetic resonance images and roentgenograms of the cervical spine showed inflammation of odontoid process and atlantoaxial subluxation. Bone scan showed hot uptakes in left sacroiliac joint, right 1st & 4th metacarpophalangeal joints and 1st metatarsophalangeal joint. HLA-B27 gene was positive. Spontaneous atlantoaxial subluxation and undifferentiated spondyloarthropathy was diagnosed and conservatively treated with oral medication. Currently, there is no definite neurological sign. Early recognition and awareness of potential clinical complications is important in preventing compressive damage on central nervous system.

The Assessment of Functional Change in Ischemic Stroke Rat

OBJECTIVE: To investigate and quantify functional deficit in ischemic stroke rat. METHOD: Male Sprague-Dawley rats were divided into sham group and stroke group. Permanent cerebral ischemia was inflicted on the stroke group by occluding the middle cerebral artery (MCAO). The proportion of hind limb weight bearing pressure was also measured. The withdrawal threshold values in the hindpaws were measured by using von-Frey hair for seven days from the day before ischemia. RESULTS: The proportion of paretic hind limb pressure to whole hind limb pressure in stroke group was significantly reduced than sham group (p0.05). Garcia motor score of stroke group was reduced significantly than sham group in whole experimental session after MCAO (p0.05). CONCLUSION: Ischemic stroke in rats can lead to the reduction of pressure at paretic hind limb. The motor test for pressure weight borne on the paretic leg may provide functional information in the future studies with ischemic stroke rat.

The Success Rate of Superior Approach Glenohumeral Injection in Patients with Frozen Shoulder

OBJECTIVE: In treating patients with frozen shoulder, posterior and anterior approach glenohumeral injections are well known methods. But the accuracy of the above injection methods is low. In this study, we introduce the superior approach glenohumeral injection method and evaluate its success rate. METHOD: Twenty six patients who were clinically diagnosed with frozen shoulder were enrolled. Patients received a superior approach glenohumeral injection of 1 cc radiographic contrast (Urografin(R), Schering, Germany). The success of superior approach was determined by radiography study of the shoulder joint taken after the injection. RESULTS: 24 of the 26 procedures (92.3%) were judged to be accurately placed by the radiography study and there was no significant complication after the superior approach intrarticular injection. CONCLUSION: Superior approach glenohumeral injection in frozen shoulder showed the high success rate. We consider this superior approach as a very effective method. If the study for the interrater reliability is added, the superior approach will be considered to be a useful approach.

Neuropathic Arthropathy Induced by Syringomyelia due to Arnold-Chiari I Malformation: A case report

Neuropathic arthropathy is a chronic and progressive disease of bone and joints. One of the most common causes of neuropathic arthropathy is syringomyelia. Syringomyelia associated with Arnold-Chiari I malformation has been well documented in many reports. We report a case of 76 year-old woman presented with the right elbow joint pain and stiffness. Her symptom was caused by neuropathic arthropathy associated with Arnold-Chiari I malformation and syringomyelia. The purpose of this paper is to emphasize that neuropathic arthropathy requires the evaluation of central nervous system to assess for occult causal lesion.

Percutaneous Radiologic Gastrostomy in a Locked-in Syndrome Patient : A case report

Since being introduced by Gauderer et al. in 1980, percutaneous endoscopic gastrostomy (PEG) has proved to be a safe and effective procedure that has become a popular way to establish long term enteral feeding in situations where oral intake is not possible. Indications of PEG are broad, with a few exceptions such as total obstruction of pharynx or esophagus and poor transillumination conditions. In those cases, percutaneous radiologic gastrostomy (PRG) or surgical gastrostomy is feasible. We reported a case of percutaneous radiologic gastrostomy (PRG) in locked-in syndrome patient.

Hemodynamic Change after Half Body Bathing in Patients with Cardiovascular Risk Factor

OBJECTIVE: Nowadays half body bathing (H-bath) became popular with increasing interests of health and well-being. H-bath is expected to be beneficial and safe as well as conventional whole body bathing (W-bath). However, there has been no formal report on the safety and effectiveness of H-bath. Therefore, this study tried to evaluate and compare the cardiovascular response during H-bath and W-bath in patients with or without cardiovascular disease. METHOD: 17 subjects with at least one cardiovascular risk factor and 15 subjects without any cardiovascular risk factor took H-bath while 22 healthy control group without any cardiovascular risk factor took W-bath. Changes of skin and oral temperature as well as hemodynamic responses (systolic blood pressure, diastolic blood pressure, heart rate) were measured. RESULTS: Increasing of systolic blood pressure and heart rate in H-bath was statistically lowered compared to W-bath as time goes by in bathing (p<0.05). There were no significant difference in patients with and without cardiovascular disease. CONCLUSION: Heart rate, temperature, systolic blood pressure showed a more gradual increase during H-bath than during W-bath. We propose that H-bath could be a more safe and compliant method of cardiac rehabilitation in patients with cardiovascular disease.

Sensory Thresholds of Normal Human Feet Using Semmes-Weinstein Monofilament

OBJECTIVE: To obtain the sensory thresholds of the feet from healthy adult using Semmes-Weinstein monofilaments. METHOD: Twenty male and twenty female volunteers aging from 24 to 38 years old were selected. There were no known medical conditions associated with decreased foot sensation and history of previous injury to the foot. The subjects were blindfolded with the leg resting on a chair as 14 plantar and 5 dorsal locations were tested on each foot. Each site on the foot had the Semmes-Weinstein monofilaments applied to it first, in an order of increasing stiffness, then repeated in decreasing order. A positive threshold response was recorded when the subject could feel the filament and could accurately locate where on the foot the stimulus had been applied. RESULTS: The mean sensitivity for all sites was 3.41+/-0.17. Sensation in the plantar surface of greater toe, 5th toe, arch, and dorsal surface of 1st web space, 3rd toe at the metatarsophalangeal joint level, 5th metatarsal head were the most sensitive. The least sensitive regions were the heel pad, lateral plantar midfoot, and medial and lateral heel. CONCLUSION: Normal data of sensory threshold using Semmes-Weinstein monofilament could be used for the early detection of peripheral neuropathy or loss of protective sensation.

Traumatic Knee Contracture after Operation

Traumatic knee contracture is a common complication after an operative procedure. It occurs mainly due to an intraarticular adhesion and results in a significant knee dysfunction and disability. Patients with a contracture have different ways of recovery, however there is no reliable clinical data regarding a recovery to the full range of motion after knee injury. A proper therapeutic plan is needed to the physiatrists during a rehabilitation of the traumatic knee contracture. The purpose of this study was to obtain a clinical insight into the course of recovery to the normal range of motion after a traumatic knee contracture. One hundred and fourty-seven cases of traumatic knee contracture patients who underwent an operative treatment at the Department of Orthopedic Surgery, St. Mary's Hospital between the years of 1992 to 1996, were reviewed. Knee contractures were most frequent in the second and third decades with a traffic accident being the most common cause. A factor that influenced regaining a normal range of motion was the injury type with an earlier recovery in the order of an injury to the meniscus, cruciate ligament, collateral ligament, a complex injury, and a bone fracture. Persistent contracture groups showed a higher incidence of bone fractures around the knee and open surgeries, while there was no discrepancy in sex, age, and operation time. In conclusion, the results of this study are expected to give some insights to clinicians and to help them in treating patients with the traumatic knee contracture after operation.

Analysis of Upper Extremity Motion during Drinking Using Virtual Reality Motion Analysis System(VRMAS)

Currently the evaluations of upper extremity motion have relied on a task-oriented approach to gain an accurate clinical picture of the functional capacities. As it is, an adequate and objective system to estimate upper extremity function is yet to be developed. Authors used the virtual reality motion analysis system(VRMAS) which was developed by us for the purpose of investigating the kinematics of upper extremity motion during drinking a cup of water. Four healthy male adult subjects were recruited from the hospital personnels. After each subject sat down on a chair resting against the backrest in a neutral position, in front of a table he was instructed to drink the content of the cup from the table. The data was analized and showed the following results. While drinking, the hand movements were smooth and linear. There were six distinct stages during drinking a cup of water; a reaching for the cup(stage 1), picking up the cup and carrying the cup to the mouth(stage 2), extending neck and drinking from the cup(stage 3), flexing neck(stage 4), replacing the cup to the table(stage 5), and returning to the start position(stage 6). During the stage 1 and 2, of all joint motions, the shoulder adduction and elbow flexion were most prominent. The stage 3 showed the most complex movements in shoulder flexion, forearm pronation, and wrist extension which were simultaneous. Remaining stages were the reversal of the first three stages. We could observe the ranges of motion of neck, shoulder, elbow, and wrist joint as well as the relationships of these joints at the same time. In conclusion, VRMAS could be a very useful evaluation tool for the upper extremity motion and for obtaining the kinematic data from the upper extremity motion analysis.