Scapular Winging following Sports-Related Injury in a Rugby Player.

The most common cause of medial scapular winging is long thoracic nerve palsy (LTN) and subsequent serratus anterior muscle dysfunction. A 16-year-old right-handed male high-school rugby player developed severe right-sided neck and shoulder pain after tackling an opponent while playing rugby. Six weeks after initial injury, the patient observed shoulder muscle weakness when performing his daily activities. On physical examination, limited active elevation of the right shoulder in the scapular plane and scapular winging was observed. Magnetic resonance imaging revealed atrophy of both the SA and subclavius muscles on the right side, and we initially suspected an LTN injury sustained. However, while detailing his history, the patient explained that he also had noted difficulty sucking high viscosity drinks such as shakes and smoothies since childhood. In addition, physical examination showed weakness of the orbicularis oculi muscle. Considering the facial muscle weakness, facioscapulohumeral dystrophy (FSHD) was also suspected, and genetic testing showed chromosome 4q35 deletion with restriction fragments 17 kb and 3 tandem repeated DNA confirming the diagnosis of FSHD. Clinicians should be aware that FSHD could be one of the differential diagnoses of scapular winging after sports injury, and surgeons should rule out the diagnosis of FSHD before performing any surgical treatment for SA palsy.

Spontaneous Pneumomediastinum in an Adolescent Soccer Player.

Spontaneous pneumomediastinum (SPM) is an uncommon and usually benign self-limiting clinical disorder found in young people, often without apparent precipitating factors or diseases. A pressure gradient exists between the peripheral pulmonary alveoli and the hilum, and increased intra-alveolar pressure causes rupture of the terminal alveoli. We present the case of a 15-year-old male soccer player who presented with a complaint of anterior chest pain and dysphagia after stopping the strong ball with his chest. His symptom gradually progressed over hours. We can make the diagnosis of SPM using by chest X-ray and computed tomography (CT) scanning. His symptoms were gradually resolved over the course of approximately one week with no exercise and careful observation. We believe that our case provides very useful information to alert clinicians and coaches regarding this rare disease that may occur in anyone including adolescent soccer players.

CTGF/CCN2 facilitates LRP4-mediated formation of the embryonic neuromuscular junction.

At the neuromuscular junction (NMJ), lipoprotein-related receptor 4 (LRP4) mediates agrin-induced MuSK phosphorylation that leads to clustering of acetylcholine receptors (AChRs) in the postsynaptic region of the skeletal muscle. Additionally, the ectodomain of LRP4 is necessary for differentiation of the presynaptic nerve terminal. However, the molecules regulating LRP4 have not been fully elucidated yet. Here, we show that the CT domain of connective tissue growth factor (CTGF/CCN2) directly binds to the third beta-propeller domain of LRP4. CTGF/CCN2 enhances the binding of LRP4 to MuSK and facilitates the localization of LRP4 on the plasma membrane. CTGF/CCN2 enhances agrin-induced MuSK phosphorylation and AChR clustering in cultured myotubes. Ctgf-deficient mouse embryos (Ctgf-/- ) have small AChR clusters and abnormal dispersion of synaptic vesicles along the motor axon. Ultrastructurally, the presynaptic nerve terminals have reduced numbers of active zones and mitochondria. Functionally, Ctgf-/- embryos exhibit impaired NMJ signal transmission. These results indicate that CTGF/CCN2 interacts with LRP4 to facilitate clustering of AChRs at the motor endplate and the maturation of the nerve terminal.

Evaluation of sagittal alignment and range of motion of the cervical spine using multi-detector- row computed tomography in asymptomatic subjects.

To evaluate the sagittal alignment and range of motion (ROM) of the cervical spine during cervical flexion and extension ,using multi-detector-row-computed tomography (MDCT) in asymptomatic subjects.Understanding the normal alignment and range of motion of the cervical spine is very important while evaluating patients with cervical spine instability and abnormal alignment. Several reports using plain radiographic data have assessed the alignment and ROM of the cervical spine during flexion and extension. However, there has been no such report using MDCT. Ninety-eight subjects who did not have cervical spine-related symptoms were enrolled. After myelography, all subjects underwent cervical MDCT in cervical flexion and extension. Sagittal alignment and ROM between C2 and C7 were measured.The sagittal alignment between C2 and C7 was -11.7°±8.3° (mean ± standard deviation) in flexion and 26.5°± 12.9° in extension. The C5/6 level showed maximum kyphosis in flexion. The C6/C7 level demonstrated maximum lordosis in extension. ROM between C2 and C7 was 37.9°±11.2°. The C2/3 level showed the lowest ROM and the C5/C6 level showed the highest ROM among the intervertebral levels evaluated.The sagittal alignment and ROM of the cervical spine during flexion and extension in asymptomatic subjects were measured using MDCT. Each level between C2 and C7 could be evaluated in detail without any influence due to degenerative changes in the spine or soft tissues of the shoulder. MDCT generated a more precise understanding of the dynamic changes at each evaluated intervertebral level in the cervical spine. Level of Evidence : Level II.

Range of motion determined by multidetector-row computed tomography in patients with cervical ossification of the posterior longitudinal ligament.

The purpose of this study was to measure range of motion (ROM) in patients with cervical ossification of posterior longitudinal ligament (C-OPLL) by multidetector-row computed tomography (MDCT), and to investigate the influence of dynamic factors. The study included 101 patients with C-OPLL and 99 normal control patients. Preoperative MDCT were taken in all subjects in maximum neck flexion and extension. ROM at each disc level between C2/3 and C7/T1 in sagittal view was measured. Ossification morphology at each disc segment was divided into 6 groups: covered disc, covered vertebra, unconnected vertebra, connected vertebra (continuous), connected vertebra (localized), and others. The relationship between ROM and the group of ossification morphology was also investigated. ROM of adjacent intervertebral disc in connected vertebrae (continuous and localized) and those of others were investigated for each group. The average ROM of covered disc group was significantly higher than that of connected vertebra (continuous, localized). The average ROM of connected vertebra (continuous) group was significantly lower than that of covered disc group, others group, and normal control. There was no significant difference between ROM of adjacent intervertebral disc in connected vertebrae and others, but the average ROM of the connected vertebra group was significantly lower than that of the covered disc group and normal control group. Dynamic factor was reduced at continuous segment, but it was not increased in adjacent intervertebral disc.

Risk factors for poor outcome of cervical laminoplasty for cervical spondylotic myelopathy in patients with diabetes.

BACKGROUND: Diabetes is one of the most frequent comorbidities in patients with cervical spondylotic myelopathy. The purpose of this study was to characterize the risk factors for poor treatment outcome following cervical laminoplasty for cervical spondylotic myelopathy in patients with diabetes. METHODS: A total of 105 consecutive patients with diabetes and cervical spondylotic myelopathy who underwent double-door laminoplasty were included in this study; there were sixty-five male patients and forty female patients with a mean age of 68.2 years (range, forty-three to eighty-three years). All patients were followed for twelve months or more after surgery, with a mean follow-up time (and standard deviation) of 25.7 ± 14.2 months. All patients had palliative controlled blood glucose levels in the immediate term during the perioperative period. We evaluated the recovery rate on the basis of the Japanese Orthopaedic Association score. Logistic regression analyses (univariate analysis and multivariate analysis) were performed to identify the risk factors for poor outcome. Poor outcome was defined as a postoperative recovery rate of <50%, and good outcome was defined as a postoperative recovery rate of ≥ 50%. RESULTS: Univariate logistic regression analysis showed that a patient age of sixty-five years or older (odds ratio, 3.111; p = 0.0085) and a duration of cervical spondylotic myelopathy symptoms for twelve months or more (odds ratio, 3.940; p = 0.0012) were associated with an increased risk of poor surgical outcome. High glycated hemoglobin levels of ≥ 6.5% (odds ratio, 2.591; p = 0.0193) and a duration of diabetes for ten years or more (odds ratio, 2.245; p = 0.0321) were significant risk factors for poor surgical outcome. Multivariate logistic regression analysis determined that glycated hemoglobin levels of ≥ 6.5% (odds ratio, 2.822; p = 0.0441) and a duration of diabetes for ten years or more (odds ratio, 2.240; p = 0.0410) were significant risk factors for poor treatment outcome. Fasting blood glucose levels did not affect treatment outcomes. CONCLUSIONS: Diabetes with advanced age and long-term cervical spondylotic myelopathy symptoms adversely affected cervical laminoplasty outcomes. High preoperative glycated hemoglobin levels and long-term diabetes are risk factors for poor cervical laminoplasty outcomes in patients with diabetes and cervical spondylotic myelopathy.

Impact of diabetes on the outcomes of cervical laminoplasty: a prospective cohort study of more than 500 patients with cervical spondylotic myelopathy.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: This study aimed to compare the outcome of cervical laminoplasty between diabetic patients and nondiabetic patients with cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: A few retrospective studies have investigated the outcomes of cervical myelopathy in diabetic patients; therefore, our large-scale cohort study was designed to assess these outcomes in cervical spondylotic myelopathy. METHODS: In total, 505 consecutive patients with cervical spondylotic myelopathy (311 males, 194 females; mean age, 66.6 yr; range, 41-91 yr) who underwent double-door laminoplasty were prospectively enrolled. They were followed up for more than 12 months after surgery (mean follow-up period, 25.6 ± 12.6 mo). The patients were divided on the basis of diabetic criteria for glucose intolerance into 2 groups: the diabetic group (n = 105) and nondiabetic group (n = 400). We evaluated differences in pre- and postoperative Japanese Orthopaedic Association (JOA) scores, recovery rate, achieved JOA scores (postoperative JOA score - preoperative JOA score), and complications between both groups. RESULTS: The mean JOA scores in the diabetic and nondiabetic groups were 10.1 and 10.8 points before surgery and 13.1 and 13.9 points after surgery, respectively. The diabetic group showed significantly low pre- and postoperative JOA scores and low recovery rate of JOA scores compared with the nondiabetic group (47.3% vs. 53.6%, P < 0.05). However, mean achieved JOA scores in the diabetic and nondiabetic groups were 3.0 and 3.1 points respectively, with no significant difference between both groups (P = 0.343). The groups showed no significant difference in the postoperative complication rate. CONCLUSION: Pre- and postoperative JOA scores and recovery rates were lower in the diabetic group than the nondiabetic group. However, the achieved JOA scores were not significantly different between both groups. Diabetic and nondiabetic patients experienced similar benefits from laminoplasty. LEVEL OF EVIDENCE: 3.