Secondary Parkinsonism due to Extrapontine Myelinolysis without Central Pontine Myelinolysis: A case report

Parkinsonism is characterized by clinical symptoms of rigidity, bradykinesia, tremor, and gait disturbance. There are many causes of secondary parkinsonism. The present report discusses a secondary parkinsonism of extrapontine myelinolysis (EPM) without central pontine myelinolysis (CPM) after rapid correction of hyponatremia. EPM is a demyelinating process of the brain. EPM with CPM is relatively common, but EMP without CPM is rare. A 57- year-old woman with Tsutsugamushi disease had a subacuteonset of parkinsonism on the fourteenth day after a rapid correction of severe hyponatremia. Magnetic resonance imaging of the bilateral basal ganglia showed a high signal intensity on T2-weighted images, and a low signal on T1- weighted images. She was started on levodopa, and parkinsonian features slowly improved. We report an unusual case of EPM without CPM, that presented with parkinsonism.

Anatomic Motor Point Localization of the Biceps Brachii and Brachialis Muscles

Injection of the neurolytic agents into motor points of the biceps brachii or brachialis muscles is an effective treatment of spasticity of the elbow flexors in many stroke survivors. Accurate localization of the motor points of each muscle is necessary for enhancing the efficacy of motor point blocks. To identify the precise locations of the motor points (terminal nerve endings) of the biceps brachii and brachialis muscles in relation to anatomic surface landmarks for motor point blocks, we dissected 23 limbs from 12 cadavers. A reference line was defined as a line connecting the coracoid process with the lateral epicondyle of the humerus. The location of the motor points of the biceps brachii and brachialis muscles was identified in reference to the reference line. The motor point of the biceps brachii muscle was found to be approximately half of the reference line. In the brachialis muscle, the location of the motor point was 70% of the reference line from the coracoid process and 2 cm medial to the line. The results are expected to facilitate effective localization of the motor point block of these muscles in selective motor nerve block.

Effect of Bilateral Contraction of Proximal Arm Muscle on Electromyographic Activity in Hemiplegic Patients

OBJECTIVE: Reaction time is known to be longer for bilateral activities than for unilateral ones. However, bilateral isometric training is a common technique for motor recovery in relatively early stage of recovery following stroke. Moreover, few studies elucidated the response time of proximal arm muscle. This study was designed to investigate the effects of bilateral shoulder abduction on electromyographic (EMG) timing in hemiplegic subjects. METHOD: EMG signal of 18 subjects with hemiplegia was recorded during isometric contraction of shoulder abductor along the audible beep. Each subject performed three sets of contraction: unilateral contraction of each side and simultaneous bilateral contraction. EMG parameters included initiation delay, termination delay, and root mean square (RMS). RESULTS: When subjects performed bilateral contraction simultaneously, initiation and termination delays and RMS of paretic arm significantly increased in the affected arm than nonaffected side. Compared with unilateral contraction, initiation and termination delays did not differ significantly although RMS was significantly reduced. In addition, side-to-side difference of termination delay significantly decreased. CONCLUSION: These results demonstrated that bilateral isometric training of proximal arm muscle could be performed for motor recovery after stroke with no compromise of movement timing. Furthermore, movement control would be expected to be enhanced.

Histological Changes after Intradiscal Steroid Injection to the Intervertebral Disc in Disc Injury Rabbit Model

OBJECTIVE: To evaluate the degeneration changes of disc injury rabbit model produced by needle puncture to intervertebral disc and to observe the histological changes of the degenerated disc treated with intradiscal steroid. METHOD: The subjects were composed of 10 L4-5 intervertebral discs (study group) and 10 L3-4 intervertebral discs (control group) of Newzealand white rabbits. The rabbits' discs were exposed by anterior approach and degeneration was elicited by 21 G needle puncture. After 4 weeks, the study group was injected with 0.2 ml triamcinolone acetonide (Tamcetone 40 mg/ml) and the control group was injected with 0.2 ml normal saline, intradiscally. The discs were extracted on 4 weeks after degeneration and stained with Hematoxylin-Eosin and investigated by light microscopy. RESULTS: Degenerative changes, including fissuring and focal fibrosis, were elicited in the all groups, but there were no significant histological differences between the two groups. CONCLUSION: We concluded that the degenerative changes are well observed in disc injury rabbit model. The mollification of discogenic pain following intradiscal steroid injection in practice may not be explained from light microscopic histological changes of the disc. Further biochemical or electromicroscopic study will be necessary to clarify the mechanism of alleviation of discogenic pain by intradiscal steroid.

Motor Recovery Effect of Minocycline in Spinal Cord Injured Rats

OBJECTIVE: To observe motor recovery after spinal cord injury (SCI) by time and impact strength in minocycline administration rat. METHOD: Forty Sprague-Dawley rats were divided into four groups according to minocycline administration and damage heights. Rats in first group were damaged in 2.5 cm heights, and injected with minocycline. In second group, minocycline was not injected. Rats in third group were damaged in 5 cm heights, and injected with minocycline. In fourth group, rats were damaged in 5 cm and minocycline was not injected. Rats received injury by the force-calibrated weight drop device and first and third groups injected minocycline 90 mg/kg immediately after injury and injected 45 mg/kg every 12 hours. Motor recovery was determined by the Basso-Beattie-Bresnahan (BBB) locomotor rating scale at 1st, 7th, 14th, 21st, and 28th day after injury. RESULTS: The BBB scores were significantly higher in first and third groups as compared to second and fourth groups after injury. There was significant change of BBB scores in first group as compared to third. CONCLUSION: After injury, BBB scores were significantly higher in minocycline treated rats as compared to the control. Minocycline might have beneficial effects on the recovery cascade after SCI.

Repetitive Stimulation Test after Sciatic Nerve Section in the Rat

OBJECTIVE: To evaluate changes of the parameters of the compound muscle action potentials (CMAPs) in repetitive stimulation test of the distal segment after section of the rat sciatic nerve. METHOD: Twenty rats (Sprague-Dawley, 400~450 gm) were used. Under anesthesia, one side of sciatic nerve at the 1 cm distal to the ischial tuberosity was sectioned. Following section the proximal end of the distal segment of the nerve was fixed to adjacent muscle by suture. An active stimulating wire electrode was placed at 1 cm distal to the proximal end of the distal segment. Recording electrodes were mounted at the soleus subcutaneously. Recordings of the repetitive stimulation of the sciatic nerve from the soleus were obtained at 4-hours intervals until complete conduction absence. RESULTS: Mean time of complete absence of the CMAPs in the distal segment after section of the sciatic nerve was 70.0 +/-12.5 hours. There was no significant change in the amplitude or area of the CMAPs in low rate or high rate repetitive stimulation. CONCLUSION: Our results suggested that sufficient amount of acetylcholine was released in response to repetitive stimulation after nerve section in the rat.

Effects of Amantadine Therapy on Seizure Development in the Patients with Brain Injury and Stroke

OBJECTIVE: The objective of this study was to evaluate incidence and risk factors of seizure development during amantadine therapy for the patients with brain injury and stroke. METHOD: Thirty subjects (15 subjects with traumatic brain injuries and 15 subjects with strokes) who received a 4-week trial of amantadine from 100 mg/day to 400 mg/day were included. Control group, 40 patients (20 subjects with traumatic brain injuries and 20 subjects with strokes), did not take any brain stimulant. There were no differences in number, age, lesion area, and cognitive levels between two groups. Incidence of seizure in two groups was evaluated. RESULTS: Seizure occurred in 9 subjects in therapy group (30%) and in 1 subject in control group (2.5%). There was higher incidence of seizure in the group treated with amantadine than in the control group. In therapy group, most of the seizures occurred in high dose of 400 mg/day. CONCLUSION: Amantadine in high dose appeared to be associated with higher incidence of seizure. This study suggested that administration of amantadine in high dose in management of brain injury and stroke should be accompanied with careful monitoring of seizure.

Pain Provocation and Disc Degeneration in Lumbar Discography

OBJECTIVE: To determine the relationship between pain provocation and level and disc degeneration in lumbar discography. METHOD: Seventy-one patients with lumbar discogenic pain and total 109 discography were studied. During contrast mediun injection, the patient's pain response was reported. The patients were invited to choose among the following options: 'no pain or only pressure feeling', 'dissimilar', 'similar', and 'exact'. And pain location was chosen among the followings: 'low back', 'buttock', 'anterior thigh', 'posterior thigh', and 'lateral thigh'. Correlation between degeneration and provocation response was analyzed. And discography level and provocation area were evaluated. RESULTS: Low back and buttock area was the most common provocation pain site, but it was not specific by disc level. And provocation pain frequently appeared in irregular and fissured types, but the existence of provocation pain was significantly low in ruptured type. CONCLUSION: There was no correlation between provocation pain area and discography level. And existence rate of provocation pain in ruptured disc was very low. It might be due to low mechanical compression with little stimulation of nociceptor. We suggested that if patients have a ruptured disc with chemical irritation, provocation pain was not a good indicator of diagnosis of discogenic back pain.

Percutaneous Endoscopic Jejunostomy in a Traumatic Brain Injured Patient with Subtotal Gastrectomy; A case report

To present a case of Percutaneous Endoscopic Jejunostomy in traumatic brain injured patient with subtotal gastrectomy. A 54-year-old man who injured a left subdural and intraventricular hemorrage by a falling. The patient had a history of the subtotal gastrectomy and suffered significant gastroesophageal reflux and recurrent aspiration pneumonia during nasogastric tubal feeding. The traditional Percutaneous Endoscopic Gastrostomy was inappropriate procedure for him because of significant alteration of gastric anatomy, insufficient volume of remnant stomach, and continuous gastroesophageal reflux. Direct percutaneous endoscopic placement of a jejunostomy tube was performed and we provide adequate enteral nutritional support in a traumatic brain injured patient with subtotal gastrectomy and gastroesophageal reflux.

Effects of Intradiscal Steroid Injection in Patients with Lumbar Discogenic Pain

OBJECTIVE: To determine the therapeutic effects of intradiscal steroid injection in patients with lumbar discogenic pain. METHOD: Seventeen patients with lumbar discogenic pain who have not received other interventional procedures were studied. After confirmation of needle placement into the discs by C-arm fluoroscopy, discogram was done. And 40 mg of triamcinolone and 0.5 cc of 2% lidocaine were injected into the nucleus. Correlation between degeneration and Visual Analogue Scale (VAS) was analyzed. The effects of steroid injection were evaluated using VAS and limitation of lumbar flexion at pre-injection, 1 week post-injection, 1 month post-injection, and 3 months post-injection. Changes over time were assessed statistically using ANOVA and chi-square. RESULT: Correlation between degeneration and VAS was high (r=0.7). The averages of VAS reduced significantly from 6.1+/-1.6 at pre-injection, to 2.4+/-1.8 at 1 week post- injection, to 1.8+/-1.2 at 3 months post-injection, respectively (p<0.05). The number of group of highly or moderately limited lumbar flexion was decreased from 10 at pre- injection to 4 at 1 day post-injection. Fourteen of 17 patients (82.4%) had a successful outcome reporting at least 50% reduction between pre and 3 months post-injection in VAS. CONCLUSION: Intradiscal steroid injection was an effective treatment for patients with lumbar discogenic pain.

Correlation between Doppler Ultrasonography and Impedance Plethysmography in Lower Extremity Varicose Vein

OBJECTIVE: To investigate the diagnostic validity of doppler ultrasonography (US) and impedance plethysmography (IPG) using photoplethysmography for evaluation of varicose vein of the lower extremities. METHOD: One hundred sixty-six limbs in 83 consecutive patients with varicose vein were included. Venous reflux and deep venous lesions were assessed by doppler US. Venous filling time was evaluated using IPG. Diagnostic capabilities of two methods were analyzed using Receiver Operating Characteristic (ROC) curve. RESULTS: Doppler US identified superficial venous reflux in sixty-nine of 119 limbs with varicose vein and no abnor malities in 34 of 47 normal limbs (sensitivity, 58%; specifi-city, 75%). IPG demonstrated superficial venous insufficiency in 75 of the affected limbs and normal refill time in 38 of the normal limbs (sensitivity, 63%; specificity, 81%). Sensitivity was increased to 82% when both tests were used together. Area under the ROC curve was 0.66 in doppler US, 0.72 in IPG, and 0.76 in both tests. Deep venous lesion was found in 31 limbs using the both tests; 15 limbs with doppler US and 18 limbs with IPG. CONCLUSION: IPG was more superior to doppler US in diagnosing venous insufficiency. The combination of both tests provided more accurate diagnostic information in assessing venous valvular function

Surface Mapping of Motor Points of Gastrocnemius and Soleus Muscles

OBJECTIVE: To identify the relationship between the location of motor points of gastrocnemius and soleus and the skin surface landmarks. METHOD: Compound muscle action potentials (CMAPs) of each lattice of gastrocnemius and soleus in 11 healthy subjects were recorded. Standardized reference lines were made as follows: 1) a horizontal reference line (popliteal crease) and 2) a vertical reference line drawn between mid-points of the horizontal reference line and inter-malleolus connection line. The CMAPs were mapped horizontally and vertically 1cm width to the standardized reference lines. Location of motor points was mapped to the skin surface in the ratio of length of the vertical and horizontal reference lines. RESULTS: The motor point of medial head of gastrocnemius was located at 41.0+/-6.1% distal and 54.6+/-19.2% medial to the mid-point of horizontal reference line. The location of the motor point of the lateral head of gastrocnemius was 35.7+/-5.2% distal and 48.5+/-15.1% lateral, respectively. In the soleus, the motor point was at 68.6+/-8.0% distal and 10.5+/-9.0% lateral, respectively. CONCLUSION: The motor point of the lateral head of gastrocnemius was located more proximally relative to medial head, and the motor point of soleus was located at slightly lateral side of the vertical reference line. The author concluded that mapping of motor points of the gastro-soleus muscles would increase accessibility in performing phenol motor point block or botulinum toxin injection for management of spasticity or abnormal tonicity of the ankle.

Dysphagia associated with Jugular Foramen Syndrome due to Traumatic Brain Injury

OBJECTIVE: To present one case of dysphagia associated with jugular foramen syndrome (Vernet syndrome) by trauma. The jugular foramen syndrome refers to paralysis of the IX, X and XI cranial nerves. Dysphagia due to jugular foramen syndorme without pseudobular palsy is rare in traumatic brain injury. CASE SUMMARY: A 16-year-old boy with the left occipital skull fracture and skull base fracture was not able to take any food by mouth. There was no other significant symptom without dysphagia. Physical examination, laryngoscopic examination and electromyography revealed paralysis of the left IX, X and XI cranial nerves. Videofluoroscopic examination demonstrated atonic ballooned pyriformis sinus and closed upper esophageal sphincter. Brain CT and MRI showed fracture line in the left jugular foramen without brain stem or diffuse cortical lesion. Feeding gastrostomy was performed. CONCLUSION: We report an unusual case of dysphagia due to jugular foramen syndrome in traumatic brain injury patient.

Histological Changes of the Intervertebral Disc with Intradiscal Steroid Injection

OBJECTIVE: To observe histological changes of the intervertebral disc injected with intradiscal steroid and mollification of discogenic pain. METHOD: A study group of 25 Sprague-Dawely rats was divided into five subgroups. A control group of 10 Sprague-Dawely rats was divided into five subgroups. The rats' intervertebral discs were exposed by an anterior surgical approach. For study group, the rats were injected intradiscally methylprednisolone acetate 4 mg (Depomedrol, 40 mg/ml) to the L4-L5 intervertebral disc, methylprednisolone sodium succinate 4 mg (Solumedrol, 40 mg/ml) to the L5-L6 intervertebral disc, and triamcinolone acetonide 4 mg (Triamcinolone, 40 mg/ml) to the L6-S1 intervertebral disc. For control group, the rats were injected intradiscally 0.1 ml of saline to the L5-L6 intervertebral disc and a needle was inserted in the L6-S1 intervertebral disc. The intervertebral discs were extracted after 1 week, 2 weeks, 3 weeks, 4 weeks, and 16 weeks. The extracted intervertebral discs were stained with Hematoxylin-Eosin and examined histomorphometrically. RESULTS: There is no significant histological change in either group until 4 weeks after the different types of steroid were injected. Focal fibrotic change was present in the Solumedrol and Triamcinolone injection subgroups after 16 weeks. CONCLUSION: We concluded that rapid mollification of discogenic pain following intradiscal steroid injection may not result from histological change of the disc. Further biochemical study will be neccessary to clarify mollification mechanism of discogenic pain by intradiscal steroid injection.

Experimental Verification of Drug Interaction between Warfarin and Baclofen

OBJECTIVE: A warfarin-baclofen interaction has been postulated, but has not been documented in the literature. The purpose of this study is to investigate the drug interaction between warfarin and baclofen in rats. METHOD: Twenty Sprague-Dawley rats (250-300 gm), divided into a control and a study group were used. 0.02 mg/day of warfarin was administered intraperitoneally without baclofen for the first three days. Daily blood samples were drawn after six hours of warfarin adminstration for measurement of prothrombin time (PT) and International Normalized Ratio (INR). On the fourth day, the rats in the study group were given 0.02 mg of warfarin and 0.6 mg of baclofen intraperitoneally. For the control group, 0.02 mg of warfarin was administered on all four days. PT and INR measurements were taken at 3 hours, 6 hours, and 24 hours after the administration of warfarin with or without baclofen. RESULTS: Mean INR value was significantly increased by concomitant baclofen administration after 6 hours, resulting in 1.72 for the control group with warfarin alone and 2.74 for the study group with warfarin and baclofen (p<0.05). CONCLUSION: The concomitant administration of warfarin and baclofen affects the anticoagulant effect of warfarin. Physicians should be aware of the risk for increased anticoagulant effect of warfarin when baclofen is also administered.

Variations of End Level of the Dural Sac

OBJECTIVE: To determine the normal variations of end level of the dural sac in Korean subjects by magnetic resonance imaging (MRI). METHOD: The corresponding vertebral level of termination of the dural sac was evaluated by MRIs in two hundred adult Koreans (118 males, 82 females). We excluded the subjects with spine fracture, significant spinal deformity or spinal stenosis. End level of the dural sac was described in terms of their corresponding vertebral level. The vertebral levels were further divided into upper, middle, lower level, and intervertebral disc levels from the L5 to S3 vertebra. RESULTS: The most frequent end level of the dural sac was at the S1-S2 intervertebral disc level (22.5%) which was followed by the upper portion of S2 (21.5%) and the middle portion of S2 (17.0%). There was no significant difference in end level of the dural sac between male and female subjects. CONCLUSION: The dural sac most frequently ended at the S1-S2 intervertebral level and the end level of dural sac were located from the L5-S1 intervertebral level to the mid-point of S3. In a clinical setting, variable levels of the dural sac termination should be considered in an unexpected dural puncture during a caudal anesthesia or injection.

Probable Interaction between Warfarin and Baclofen: A report of two cases

OBJECTIVE: To present two cases of probable warfarin and baclofen interactions which occurred during the concomitant drug administrations. CASE SUMMARY: In the first case, a 55-year-old man with C6 ASIA C receiving 80 mg/day of baclofen was prescribed 5 mg/day of warfarin after heparinization for the treatment of deep vein thrombosis of the left external iliac vein. After the third day of warfarin administration, the patient exhibited cognitive dysfunction. Within one week after initiation of warfarin, the INR increased to 4.4, with increased cognitive dysfunction. After the stop of warfarin, the return of the INR to baseline took six days. In the second case, a 45-year-old man with a spastic right hemiplegia from a stroke and a history of myocardial infarction was on 5 mg/day of warfarin for two years. When forty-five mg of baclofen was added, the patient developed a nausea, fatigue, and confusion after three days. The INR increased to 4.5 at eight days after the baclofen was added, despite the diminished dosage of warfarin. CONCLUSION: These two cases suggest a probable warfarin-baclofen interaction. Attention should be given to the patients who concomitantly use the warfarin and baclofen to protect the patient from harmful drug interactions.

Bladder Volume Measurement Using Portable Ultrasound Instrument in Spinal Cord Injury Patients

A noninvasive measurement of residual urine or bladder volume would reduce number of unnecessary catheterizations and be useful for an intermittent catheterization program in the management of neurogenic bladder. The purpose of this study is to evaluate a portable ultrasound instrument for the measurement of bladder volume and to assess the effect of several factors such as trabeculation or soft tissue thickness on the accuracy of the measurements. Nine patients with neurogenic bladder dysfunction underwent 480 bladder volume measurements using a portable ultrasonographic device(BVI-2500 BladderScan) before 60 intermittent catheterizations. Ultrasonographic measurements of urine volume were compared with catheterized urine volumes. The mean difference was 46.42+/-39.15 cc and the mean percentage error was 23.32+/-19.31%. Mean differences of each bladder capacity were not affected by bladder capacity, and mean percentage errors tend to decrease as the bladder capacity increase. Bladder trabeculation and soft tissue thickness had no effect on the accuracy of the measurements. The ultrasonographic measurements detected the presence of residual urine volumes of > or =100 cc with a sensitivity of 81% and a specificity of 93%. The repeatability(Mean/SD) was 23%. The accuracy had no correlation with the frequency of scanning. We conclude that BVI-2500 bladder scan portable ultrasonographic device is a useful tool for the management of neurogenic bladder dysfunction in spinal cord injured people. Trabeculation and soft tissue thickness has no effect on the accuracy of the measurements.

Peroneal Nerve Entrapment Caused by an Atypical Popliteal Cyst in a Child: A case report

Baker's cyst is commonly associated with intraarticular pathology such as degenerative arthritis. Few cases of neural compression by a Baker's cyst in the popliteal fossa have been reported with intraarticular pathology. We report a case of peroneal nerve compression by an atypical Baker's cyst in a child without intraarticular pathology. A 10-year-old boy had 6-month history of the left foot drop without a known trauma. There was no swelling or pain in the knee. The electrodiagnostic study demonstrated a profound lesion of the deep peroneal nerve and a mild denervation of the superfical peroneal nerve. Magnetic resonance images displayed an atypical Baker's cyst originating from the popliteal fossa and extending to the posterolateral side of the fibular head. Clinical and electrophysiological findings improved after aspiration of the cyst.