A Diffuse Leptomeningeal Glioneural Tumor Case Producing Hydrocephalus and Polyradiculopathy

The present report describes the case of a male 17-year-old patient who progressively developed a hydrocephalus and polyradiculopathy due to involvement of central nervous system (CNS) by a diffuse leptomeningeal glioneuronal tumor (DLGNT). The tumor had partial remission in response to the treatment with radiotherapy plus procarbazine, lomustine, and vincristine (PCV) chemotherapy, and the patient had improvement in function and pain levels. The current knowledge about DLGNT, including its clinical manifestations, imaging findings, histological characteristics, and treatment are revised and discussed in the present paper.

The Evidence for Nonoperative Treatment of Lumbar Spinal Diseases / 대한척추외과학회지

STUDY DESIGN: Review article.OBJECTIVES: To assess the evidence for nonoperative treatment of various degenerative spinal degenerative diseases.SUMMARY OF LITERATURE REVIEW: No study has yet evaluated the evidence for preoperative nonoperative treatment of lumbar spinal diseases.METHODS: The evidence regarding nonoperative treatment for each disease was reviewed through NASS guidelines, and the treatment effect compared to surgical treatment was reviewed through the SPORT series. The efficacy of nonoperative treatment according to disease severity and certain special conditions was investigated through corresponding individual articles.RESULTS: No kind of nonoperative treatment could change the fundamental progression of degenerative spinal disease. The natural course of lumbar disc herniation is favorable regardless of treatment. More than 70% of routine cases improve within 6 weeks. However, it does not take a full 6 weeks to decide whether to perform surgery or not. The evidence for transforaminal epidural steroid injections for short-term pain control is grade A. There is grade B evidence for nonoperative treatment with the goal of mid- to long-term pain control. However, we cannot say that those outcomes are better than the natural course of the disease itself. In cases of radicular weakness, the degree of weakness is correlated with the final outcomes, but it is not evident whether the duration of weakness is correlated with surgical outcomes. Early surgery is usually necessary due to intolerable pain, rather than stable motor weakness. The social cost of herniated discs arises from the loss of patients’ productivity, rather than from direct medical expenses. The natural course of spinal stenosis involves provoked pain and the need for palliative care. Unlike disc herniation, rapid deterioration and marked improvement do not occur. The symptoms of mild to moderate lumbar stenosis are unchanged in 70% of cases, improve in 15%, and worsen in 15%. No study has compared nonoperative treatment with the natural course of the disease. There is no evidence for nonoperative treatment of severe stenosis. Epidural spinal injections are effective for controlling short-term pain. Spontaneous recovery of radicular weakness does not occur, and urgent surgery is necessary in such cases. There is no evidence regarding the natural course and nonoperative treatment of degenerative spondylolisthesis. The working group consensus recommends that it should follow the pattern of nonoperative treatment of spinal stenosis when radicular stenosis symptoms are predominant. Overall, 40%–66% of cases of adult bilateral isthmic spondylolysis progress to symptomatic spondylolisthesis. No studies have investigated nonoperative treatment except physical exercise.CONCLUSIONS: Although short-term symptom amelioration can be achieved by nonoperative treatment, the fundamental progression of the disease is not affected. For conditions excluded from most studies, such as prior spine surgery, cauda equina syndrome, progressive neurological deficit, and uncontrollable severe pain associated with instability, deformity, or vertebral fractures, there were not enough studies to reach informed conclusions. Our review found no evidence regarding nonoperative treatment for such conditions. Furthermore, the treatment methods for each disease are not clearly distinguished from each other, and the techniques used for disc herniation have been applied to other diseases without any evidence.

Cauda Equina Syndrome Occurred by Adhesive Arachnoiditis of the Lumbar Spine with an Unknown Cause / 대한정형외과학회잡지

Spinal adhesive arachnoiditis is an inflammation and fibrosis of the subarachnoid space and pia mater caused by infection, trauma, spinal vascular anomalies, and iatrogenic (surgery and/or puncture). Adhesive arachnoiditis develops various symptoms and signs (gait disturbances, radiating pain, paralysis, and incontinence). On the other hand, adhesive arachnoiditis associated with cauda equina syndrome has not been reported in Korea until now. The authors experienced cauda equina syndrome caused by adhesive arachnoiditis of the lumbar spine with satisfactory results following decompression. We report this case with a review of the relevant literature.

Biportal Endoscopic Spinal Surgery for Lumbar Intervertebral Disc Herniation / 대한정형외과학회잡지

Herniation of the intervertebral disc is a medical disease manifesting as a bulging out of the nucleus pulposus or annulus fibrosis beyond the normal position. Most lumbar disc herniation cases have a favorable natural course. On the other hand, surgical intervention is reserved for patients with severe neurological symptoms or signs, progressive neurological symptoms, cauda equina syndrome, and those who are non-responsive to conservative treatment. Numerous surgical methods have been introduced, ranging from conventional open, microscope assisted, tubular retractor assisted, and endoscopic surgery. Among them, microscopic discectomy is currently the standard method. Biportal endoscopic spinal surgery (BESS) has several merits over other surgical techniques, including separate and free handling of endoscopy and surgical instruments, wide view of the surgical field with small skin incisions, absence of the procedure of removing fog from the endoscope, and lower infection rate by continuous saline irrigation. In addition, existing arthroscopic instruments for the extremities and conventional spinal instruments can be used for this technique and surgery for recurred disc herniation is applicable because delicate surgical procedures are performed under a brightness of 2,700 to 6,700 lux and a magnification of 28 to 35 times. Therefore, due to such advantages, BESS is a novel technique for the surgical treatment of lumbar disc herniation.

Does the Surgical Timing and Decompression Alone or Fusion Surgery in Lumbar Stenosis Influence Outcome in Cauda Equina Syndrome?

STUDY DESIGN: A retrospective comparative analysis of 64 patients with cauda equina syndrome (CES), who underwent either decompression alone (NF) or fusion (F) surgery. PURPOSE: We compared the outcomes and timing effects. OVERVIEW OF LITERATURE: CES can cause loss of autonomic control of vesicular function and lower limb neurological deficits. Prompt diagnosis and emergency surgery markedly improve outcome. Although decompression only is a mainstream technique, there is guarded recovery of vesicular dysfunction. Decompression ventrally in a narrow window requires manipulation of neural tissue in an already jeopardised critical canal and may accentuate irreversible damages. In F surgery, the adequate exposure leads to a lower neural manipulation. METHODS: Until January 2008, we treated CES with decompression (laminectomy and/or discectomy). However, from that month forward, all our single-level CES patients have received a fusion operation. In this study, characteristic categorical variables and outcomes were analysed. RESULTS: In a retrospective analysis of 64 patients, NF (n=37) and F (n=27) who received treatment, we found that both groups improved significantly on follow-up in all objective parameters. Although, the comparison of clinical and functional outcome data between the two groups was statistically insignificant, the average value of objective outcome such as vesicular function, low back pain (LBP), and complications was better for patients in F group compared with NF group. However, the patient satisfaction for the F group was also lower, in view of their residual symptoms and disabilities. Contrary to common perceptions, we found that the timing of surgery does not influence the recovery rate for either approach. CONCLUSIONS: Although both the techniques appear to be equally effective, the fusion approach overall showed a definite edge over non-fusion, with respect to reduced incidence of iatrogenic dural tears, LBP, and overall outcome, even despite the lower patient satisfaction.

Síndrome de Guillain-Barre. Reporte de un caso / Guillaim Barre Syndrome. Case Report

Antecedentes. El Síndrome de Guillian-Barré (SGB) es una polirradiculopatía aguda, frecuentemente grave, de evolución fulminante sin la asistencia médica oportuna, de origen autoinmunitario. Que es precedida de un antecedente de infección gastrointestinal o respiratoria comúnmente. Se caracteriza por parálisis motora ascendente arrelexica de evolución rápida, con disociación albuminocitológica en líquido cefalorraquídeo. Las principales complicaciones se desarrollan en el 60% de pacientes intubados. Caso Clínico: masculino de 42 años de edad con parestesias en miembros inferiores de cuatro días de evolución, posteriormente a paresias que asciende rápidamente a miembros superiores. Como antecedente enfermedad gastrointestinal aguda hace 4 semanas. A la exploración clínica presentaba tetraparesia, arrelexia, ausencia de relejo tusígeno, y parálisis bulbar con posterior intubación orotraqueal y apoyo ventilatorio. Se realizó punción lumbar con disociación albuminocitológica. Se dio manejo con inmunoglobulina intravenosa (IgIV) por 5 días, siendo la insuiciencia respiratoria, neumonía nosocomial, sepsis y disautónomias como complicaciones más frecuente. Conclusión: el SGB es una entidad de pronóstico grave, que requiere de medidas de soportes esenciales para evitar complicaciones que puedan comprometer la vida del paciente...(AU)

Posterior Epidural Migration of a Lumbar Intervertebral Disc Fragment Resembling a Spinal Tumor: A Case Report

Posterior epidural migration of a lumbar intervertebral disc fragment (PEMLIF) is uncommon because of anatomical barriers. It is difficult to diagnose PEMLIF definitively because of its relatively rare incidence and the ambiguity of radiological findings resembling spinal tumors. This case report describes a 76-year-old man with sudden-onset weakness and pain in both legs. Electromyography revealed bilateral lumbosacral polyradiculopathy with a mass-like lesion in L2-3 dorsal epidural space on lumbosacral magnetic resonance imaging (MRI). The lesion showed peripheral rim enhancement on T1-weighted MRI with gadolinium administration. The patient underwent decompressive L2-3 central laminectomy, to remove the mass-like lesion. The excised lesion was confirmed as an intervertebral disc. The possibility of PEMLIF should be considered when rim enhancement is observed in the epidural space on MRI scans and electrodiagnostic features of polyradiculopathy with sudden symptoms of cauda equina syndrome.

Intradural Extramedullary Cysticercosis Involving the Thoracolumbar Spinal Canal in a Patient with Cerebral Cysticercosis / 대한정형외과학회잡지

Neurocysticercosis (NCC) by Taenia solium is the most common parasitic infection of the central nervous system involving the cerebrum. However, spinal involvement of NCC is rare. Spinal NCC can cause radiculopathy, myelopathy, cauda equina syndrome, and even paraparesis, depending on its location and size. Spinal NCC may require surgical treatment as a first-line treatment because medical therapy can further aggravate the inflammation due to dead cysts, resulting in clinical deterioration. The current standard therapy for spinal NCC is surgical decompression followed by medical therapy. We experienced a case of widespread thoracolumbar intradural extramedullary cysticercosis involving the spinal canal with cerebral cysticercosis. We report this rare case with literature review.

Neurological Complications of Posterior Spinal Surgery: Incidence and Clinical Features / 대한척추외과학회지

STUDY DESIGN: Retrospective study. OBJECTIVES: To identify clinical features and risk factors helpful for the prevention and early diagnosis of neurological complications. OVERVIEW OF LITERATURE: Previous studies have investigated postoperative complications only for specific disease entities and did not present distinctive clinical features. MATERIALS AND METHODS: This was an observational study of patients who underwent posterior thoracolumbar spinal surgery in the orthopedic department of a single hospital over the course of 19 years (1995-2013). The incidence, cause, onset time, and risk factors of complications were investigated. Neurological deterioration was graded on a 5-point numeric scale: G1, increased leg pain or sensory loss, G2, unilateral motor weakness; G3, bilateral motor weakness; G4, cauda equina syndrome; and G5, complete paraplegia. RESULTS: Sixty-five cases out of 6574 (0.989%) developed neurological complications due to the following causes: epidural hematoma, 0.380%; instrumentation with inadequate decompression, 0.213%; mechanical injury, 0.167%; inadequate discectomy, 0.061%; and unknown cause, 0.167% (p=0.000). The grade of neurological deterioration was G1 in 0.167% of patients, G2 in 0.517%, G3 in 0.228%, G4 in 0.046%, and G5 in 0.030%. Neurological deterioration was most severe in patients who experienced epidural hematoma, followed by those in whom complications occurred due to instrumentation with inadequate decompression, unknown causes, mechanical injury, and inadequate discectomy, in order (p=0.009). Revision surgery was a significant risk factor (p=0.000; odds ratio, 2.741). The time that elapsed until symptom development was as follows, in order: unknown cause, 0.6 hours; epidural hematoma, 5.4 hours; mechanical injury, 6.6 hours; inadequate discectomy, 18.0 hours; and instrumentation with insufficient decompression, 36.0 hours (p=0.001). CONCLUSIONS: The incidence of neurological complications in our cohort was 1%. Revision surgery increased the risk by 3 times. Severe cases (cauda equina syndrome or complete paraplegia) rarely developed, occurring in 0.08% of patients. The major causes of neurological decline were epidural hematoma and instrumentation with inadequate decompression. Close observation in the early period was important for the diagnosis because most patients developed symptoms within 12 hours. Delayed diagnosis was most common in complications caused by instrumentation with inadequate decompression.

Adolescente con inestabilidad lumbosacra por presencia de quiste hidatídico: reporte de caso / An adolescent with lumbosacral instability due to the presence of a hydatid cyst: a case report

RESUMEN La hidatidosis, causada por el Echinococcus granulosus, afecta a la columna vertebral en 0,5-2% del total de casos, siendo la columna sacra una ubicación rara, típica de personas en edad adulta. Se reporta el caso de un varón de 14 años oriundo de Juliaca (Puno, Perú) quien presentó lumbalgia crónica y síndrome de cauda equina. Atendido inicialmente en Juliaca, fue trasladado al Hospital Edgardo Rebagliati Martins (Lima, Perú) con el diagnóstico de tumoración sacra. En la resonancia magnética se mostró una tumoración multiquística con lisis del L5 y S1 e inestabilidad. El tratamiento quirúrgico fue una laminectomía L5-S2 y extracción de múltiples quistes de hidátide más estabilización lumbopélvica con tornillos transpediculares. En el posoperatorio se recetó albendazol (15 mg/kg/d) por el periodo de seis meses. Se debe considerar al quiste hidatídico dentro del diagnóstico diferencial cuando existan lesiones quísticas en la columna vertebral, sobre todo en regiones endémicas como el Perú.

ABSTRACT Hydatidosis, caused by Echinococcus granulosus, affects the spinal column in 0.5-2% of all cases, with the sacral column being a rare location typically observed only in adults. The case is reported of a 14-year-old boy from Juliaca (Puno, Peru) who presented with chronic lower back pain and cauda equina syndrome. He was initially attended to in Juliaca, and then transferred to the Hospital Edgardo Rebagliati Martins (Lima, Peru) with a diagnosis of sacral tumor. In magnetic resonance imaging, a multicystic tumor was seen with L5 and S1 lysis and instability. The surgical treatment was an L5- S2 laminectomy and extraction of multiple hydatid cysts followed by lumbopelvic stabilization with transpedicular screws. Post-operatively, he was prescribed albendazol (15 mg/kg/d) for six months. Hydatid cysts should be considered within the differential diagnosis when there are cystic lesions in the spinal column, particularly in endemic areas such as Peru.

Cauda Equina Syndrome by Facet Synovial Pseudocyst Secondary to Epidural Injection / 대한정형외과학회잡지

A 77-year-old woman presented with bilateral leg weakness, accompanied by severe axial back and radicular pain, after a L4–5 epidural injection. She had been receiving misappropriated epidural injections for the last few months. A contrast-enhanced magnetic resonance image showed rim enhancing, spinal canal compromising cystic lesion at the posterior epidural space of L4–5. During surgery, a severely central compromised non-communicating cystic lesion located at posterior epidural space was resected. A histological report of this lesion confirmed a pseudocyst containing a degenerated synovial tissue. Herein, we report our experience of cauda equine syndrome after epidural injection with successful treatment.

Síndrome de Guillain Barré en pacientes pediátricos: diagnóstico y rehabiblitación. Reporte de Caso / Guillain-Barre Syndrome in Pediatric Patient: Diagnosis and Rehabilitation. Case Report

El Síndrome de Guillain-Barré (SGB) se deine como una polirradiculoneuropatía desmielinizante perifé - rica aguda. En América Latina es la principal causa de parálisis lácida en menores de 15 años con incidencia anual que oscila entre 0.91-1.1 casos por 100,000 habitantes. En Honduras un estudio de cohorte realizado durante 11 años en el Hospital Escuela Univer - sitario (HEU), estimó en la población pediátrica una incidencia de 1.37 casos por cada 100,000 habitantes. Caso clínico: Paciente femenina de 12 años de edad que fue diagnosticada con SGB variante neuropatía axonal motora aguda (AMAN), quien presentó falla ventilatoria y fue tratada con inmunoglobulina y esteroides. Permaneció 4 meses en unidad de cuidados intensivos pediátricos HEU donde se le realizaron exámenes para su diagnóstico y clasiicación, incluyendo citoquímica de líquido cefalorraquídeo que reporto disociación albuminocitológica a los 10 días de iniciado cuadro de debilidad muscular. Adicionalmente, electromiografía informó datos compatibles con SGB variante AMAN. Posteriormente fue referida al Servicio de Rehabilitación del Hospital de Especialidades San Felipe, donde inició terapia rehabilitadora por un lapso de 6 meses, presentando notable aumento de fuerza muscular y mejoría de independencia funcional. Conclusión: La terapia física y un buen aporte nutricional se han considerado factores clave para el manejo de los pacientes con SGB, sobre todo cuando la terapia se inicia de manera oportuna y multidisciplinaria...(AU)

Guillain-Barre syndrome as a differential diagnosis of low back pain syndrome / Síndrome de Guillain-Barré como diagnóstico diferencial de síndrome de dor lombar / El síndrome de Guillain-Barré como diagnóstico diferencial del síndrome de dolor lumbar

ABSTRACT Peripheral neuropathies are diseases of the lower motor neurons of the spinal cord and brainstem it can often mimic symptoms associated with the injuries of compressive radiculopathy. They are manifested by tingling, coldness, numbness, burning, pain, hypersensitivity, weakness, atrophy, postural hypotension, impotence, anhidrosis, and urinary incontinence. Therefore, it is important in the diagnostic strategy to keep in mind this type of pathology, especially when it comes to patients already in the 6th decade of life.

RESUMO As neuropatias periféricas são doenças dos neurônios motores inferiores da medula espinal e do tronco encefálico, cujos sintomas podem mimetizar, muitas vezes, lesões associadas à radiculopatia de origem compressiva. Manifestam-se por formigamento, frigidez, dormência, queimação, dor, hipersensibilidade, fraqueza, atrofias, hipotensão postural, impotência, anidrose e incontinência urinária. Portanto, é importante na estratégia de diagnóstico ter em mente esse tipo de patologia, principalmente quando se trata de doentes já na sexta década de vida.

RESUMEN Las neuropatías periféricas son trastornos de las neuronas motoras inferiores de la médula y del tallo encefálico, cuya sintomatología puede semejar muchas veces lesiones asociadas a una radiculopatía de origen compresiva. Se manifiestan por sensación de hormigueo, frialdad, adormecimiento, quemadura, dolor, hipersensibilidad, debilidad, atrofias, hipotensión arterial postural, impotencia, anhidrosis e incontinencia de esfínteres. Por lo tanto, es importante en la estrategia diagnóstica tener presente este tipo de patologías principalmente cuando se trata de pacientes que pasan la 6ª década de la vida.

Extensive Intradural Epidermoid Cysts with Cauda Equina Syndrome in the Lumbosacral Spine: Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of extensive epidermoid cysts in the lumbosacral spine. SUMMARY OF LITERATURE REVIEW: The intradural epidermoid cyst with extensive involvement is rare, and previous reports have reported only extensive intramedullary epidermoid cysts. MATERIALS AND METHODS: A 75-year-old male presented with progressive motor weakness of both extremities beginning 3 days prior. MRI showed extensive intradural extramedullary epidermoid cysts in the lumbosacral region. We performed total laminectomy from the L1 to the L5 level, and the cystic mass was removed. RESULTS: We confirmed the epidermoid cyst on histopathologic examination. CONCLUSIONS: Extensive extramedullary epidermoid cysts are difficult to remove completely. Attempting complete removal may result in neurological deficit. Therefore, when surgical intervention is planned, the poor postoperative prognosis should be taken into consideration.

Huge Intradural Lumbar Disc Herniation Mimicking an Intradural Spinal Tumor: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a case of cauda equine syndrome due to a lumbar intradural disc herniation. SUMMARY OF LITERATURE REVIEW: IDH is rare but there is a higher incidence of neurologic deficit in IDH. Therefore, it should be treated immediately. MATERIALS AND METHODS: A 34-year-old male patient was presented with cauda equina syndrome due to a lumbar intradural mass and underwent surgical excision. RESULTS: Operative findings and the histologic study revealed an intradural disc herniation. CONCLUSIONS: IDH is very rare lesion but should be considered in a differential diagnosis if preoperative MRI demonstrates an intradural lesion.

Neurogenic muscle hypertrophy: a case report

Muscular hypertrophy is caused mainly due to myopathic disorder. But, it is also rarely produced by neurogenic disorder. A 74-year-old woman complained of right calf pain with hypertrophy for several years. Recent lumbar spine magnetic resonance imaging (MRI) showed central and lateral canal narrowing at the L4-L5 intervertebral space. Lower extremity MRI revealed fatty change of right medial head of the gastrocnemius and soleus, causing right calf hypertrophy. Electrodiagnostic examinations including electromyography and nerve conduction velocity testing demonstrated 5(th) lumbar and 1(st) sacral polyradiculopathy. Integrating all the results, the diagnosis was neurogenic muscle hypertrophy. Neurogenic muscle hypertrophy is very rare, but we recommend that clinicians consider this problem when a patient complains of lower limb hypertrophy and pain.

Cauda Equina Syndrome due to Lumbar Ossification of the Posterior Longitudinal Ligament: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of cauda equina syndrome due to lumbar ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF LITERATURE REVIEW: Lumbar OPLL with neurologic symptoms is very rare. MATERIALS AND METHODS: A 49-year-old female had experienced weakness in both lower extremities and radiating pain for 1 day prior to presentation. Simple radiography and CT showed OPLL at the L1-L2 level. We performed a total laminectomy and posterolateral fusion at the L1-L2 level using a posterior approach. RESULTS: After treatment, the patient showed improvement of symptoms and is currently living without discomfort. CONCLUSIONS: Cauda equina syndrome due to lumbar OPLL is rare; however, rapid neurologic recovery can be achieved through early diagnosis and surgery.

The Factors That Affect Improvement of Neurogenic Bladder by Severe Lumbar Disc Herniation in Operation

OBJECTIVE: This study analyzed retrospectively the bladder function of patients after early surgery for cauda equina syndrome (CES) performed within 24 or 48 hours, or after 48 hours of the onset of autonomic symptoms. METHODS: We retrospectively reviewed the clinical data of 31 patients after decompression surgery for lumbar disc herniation (LDH) who had been diagnosed with CES between January 2001 and December 2014 at Inha University Hospital. The following factors were assessed to evaluate the influence of time to surgery: bladder function, rectal incontinence, sexual dysfunction, LDH level, and degree of spinal canal compression. RESULTS: After decompression, the outcome group was categorized into normal bladder function and abnormal bladder function. The patients operated on within 48 hours showed an improved postoperative outcome. Among 16 patients operated on within 48 hours, 13 (81%) recovered normal bladder function. In contrast, among 15 patients with decompression after 48 hours, 6 (40%) recovered normal bladder function. Among 21 patients with mild bladder dysfunction at admission, 16 (76%) recovered normal bladder function after decompression. CONCLUSION: Our study suggests that patients who have decompression surgery within 48 hours of the onset of bladder dysfunction, improve their chances of recovering bladder function than those who have a late operation (>48 hours). Also, patients with mild bladder dysfunction are more likely to recover bladder function after decompression, than patients with severe bladder dysfunction.

Painful legs and moving toes syndrome in a 16-year-old girl / 소아과

Painful legs and moving toes (PLMT) syndrome is characterized by spontaneous movements of the digits and pain in one or both lower extremities. Of the reported cases, a majority of the patients was female, and the mean age of onset was 58 years. Only one pediatric case has been reported so far. Herein, we report the first adolescent case of PLMT in Korea. A 16-year-old girl complained of tingling pain in the left leg and involuntary movement of the ipsilateral great toe one month after a second untethering surgery. Three years ago, she had undergone untethering surgery to correct lipomeningomyelocele at the S2 level of the conus medullaris. At that time, she was diagnosed with polyradiculopathy at the left L5 level with axonal involvement. We diagnosed her with PLMT syndrome and prescribed gabapentin. Her symptoms diminished within a day. Complete relief from involuntary movement of the toe was achieved within four months. PLMT is a rare syndrome but it should be considered in the differential diagnosis of children and adolescents with limb pain and spontaneous movement in their toes.