Finger trembling improvement after surgery in Hirayama disease: a case report.

INTRODUCTION: Finger trembling is a characteristic physical finding in Hirayama disease. Although conservative treatment is recommended to stop disease progression, surgery is optional in some cases. However, the postoperative recovery of finger trembling is scarcely reported. CASE PRESENTATION: A 26-year-old Japanese female patient whose chief complaint was left finger trembling with active finger extension presented at our hospital. Hand weakness without muscle atrophy of the left arm was observed. MRI showed left-side oriented intramedullary signal change with concomitant cord atrophy at C4-5 and C5-6. The CT myelogram (CTM) on flexion showed anterior cord compression and anterior shift of posterior dura matter from C4 to C6. And CTM on extension showed the resolution of both findings. Electrophysiological studies showed active and chronic neuronal damage and preserved motor neuron pool of hand muscle. Since she had exhibited a gradual aggravation of symptoms over a period of 5 years, she underwent anterior cervical discectomy and fusion after careful assessment of both conservative and surgical treatment. Finger trembling recovered soon after surgery. DISCUSSION: Finger trembling is an unfamiliar physical finding in terms of postoperative recovery prediction. Anterior horn cell impairment is postulated as a cause of finger trembling. Postural restoration of spinal cord shape and cerebrospinal fluid around the cord with preserved neural function could facilitate functional recovery.

Nerve root morphological and functional changes after degenerative cervical myelopathy surgery: preliminary study using ultrasound and electrophysiology.

STUDY DESIGN: A prospective observational study. OBJECTIVES: To depict morphological and functional changes in the cervical nerve roots before and after spinal cord decompression surgery for degenerative cervical myelopathy (DCM). SETTING: A general hospital in Japan. METHODS: Thirteen DCM patients who underwent posterior spinal cord decompression surgery, laminoplasty or laminectomy, were included in this study. The neural foramen shown on MRI and the cross-sectional area (CSA) of the nerve roots on ultrasound were used to evaluate the C5 and C6 nerve roots. The compound muscle action potentials (CMAPs) of deltoid and biceps muscle were also recorded. RESULTS: All patients showed sensorimotor functional improvement without the postoperative C5 palsy after surgery. Foraminal stenosis and preoperative CSA of the nerve root: C4/5 foramen and C5 nerve root, C5/6 foramen and C6 nerve root, had no significant correlation (P = 0.53 and 0.08). CSA of the C5 nerve root displayed no significant change before and after surgery (P = 0.2), however, that of the C6 nerve root reduced significantly after surgery (P = 0.038). The amplitude of the deltoid and biceps CMAPs displayed no significant change before and after surgery (P = 0.05 and 0.05). CONCLUSION: The C6 nerve root CSA change was observed after spinal cord decompression surgery with functional recovery. However, deltoid and biceps CMAPs amplitude showed no significant change. Independent CSA changes on ultrasound might be useful when conducting a functional evaluation of the postoperative nerve root. SPONSORSHIP: The Grant of Japan Orthopaedics and Traumatology Research Foundation No. 395.

Pyogenic Lumbar Facet Joint Infection with Foot Drop.

Pyogenic facet joint infection (PFJI) is a relatively rare spinal infection. Clinical suspicion of this condition is a key for diagnosis. We report a case of PFJI which required decompression surgery for severe neurological dysfunction. The patient was a 44-year-old woman who had a previous history of orthotic therapy for idiopathic scoliosis. The patient was admitted to our hospital with a history of two days of high fever and severe low back pain. There was no neurologic deficit, and blood tests revealed high levels of inflammatory markers. There was a slight amount of fluid that had collected at L4/5 facet joint in lumbar MRI. She was admitted for examination and treatment of fever of unknown origin and low back pain. Antibiotic treatment started the day after hospitalization since the first report of the blood culture taken upon admission tested positive to gram-positive cocci. As low back pain and fever persisted, an MRI was taken again on the fifth day of hospitalization. Repeated MRI showed fluid extension from the left facet joint to paravertebral muscles and epidural space. She was diagnosed with PFJI, and facet joint puncture was performed. At this time, it became clear that she had foot drop on the right, the contralateral side of the PFJI. She underwent irrigation, debridement, and partial laminectomy. Methicillin-sensitive Staphylococcus aureus (MSSA) was detected in blood cultures at the time of hospitalization, in the puncture fluid and tissue collected during surgery. The patient recovered completely from foot drop after the operation and a three-month course of antibiotics. As the imaging findings may be inadequate in the early stages of onset and PFJI potentially causes neurologic deficit such as foot drop, neurological findings need to be carefully observed even after hospitalization and one should reexamine the MRI if symptoms or clinical findings did not improve or were aggravated.

Clinical characteristics of osteoporotic second hip fracture: From the data of Clinical Pathway with Regional Alliance in rural region in Japan.

BACKGROUND: Second osteoporotic fracture of the hip is a serious comorbidity that can directly cause mortality. Preventing its occurrence is particularly important in Japan, given its rapidly aging society. Here, the clinical characteristics of such recurrence were evaluated using the data of the Clinical Pathway with Regional Alliance (CPRA). METHODS: CPRA for hip fracture started in 2007 and has allowed intranet-based data sharing since July 2011. Data from this alliance, such as number of second cases, duration from initial fracture, Functional Impairment Measure (FIM), revised Hasegawa Dementia Scale (HDS-R) score, muscle force and range of motion of hip joint, and gait status (GS) were collected and statistically evaluated. RESULTS: Overall, 45 of 1118 cases (2.68/100 person-years) developed a second fracture. The mean interval from initial to second fracture was 13.3 months. Thirty of these cases (66.7%, 1.79/100 person-years) occurred within 1 year from initial fracture (G < 1Y). The second fracture tended to be associated with worse parameter values than initial fracture, especially for GS. FIM score for cognitive function, HDS-R score, and GS at acute fracture in the G < 1Y group were significantly lower than in the initial fracture patient group (Initial). The withdrawal rate was also significantly higher than for Initial, whereas deaths and serious comorbidities were also much more numerous. CONCLUSIONS: Osteoporotic second hip fracture is a severe issue, and its prognosis is remarkably poor. The majority of these cases may occur within 1 year from the initial fracture. Dementia severity correlates with such recurrence within 1 year.

Relationship between dementia degree and gait ability after surgery of proximal femoral fracture: Review from Clinical Pathway with Regional Alliance data of rural region in Japan.

BACKGROUND: Proximal femoral fracture (PFF) is one of the most serious injury-related problems in developed countries. Functional prognosis after operation for PFF is unsatisfactory, as a considerable number of patients cannot perform similar gait function before fracture. Postoperative gait function is a key in performing activities of daily living (ADL). It is well known that PFF patients with dementia result in worse prognosis compared to without dementia. It is believed that dementia affects gait function after operation. However, it is still unclear whether lost function recovers after dementia level improves. METHODS: Relationship between ADL and dementia of PFF patients after surgery was investigated using data of Clinical Pathway with Regional Alliance system. Functional Independence Measurement (FIM), revised version of Hasegawa's Dementia Scale (HDS-R), motivation for rehabilitation (MR), and gait status (GS) measured in acute and recovery institute (A-I and R-I) of 266 patients were analyzed with linear regression analysis. Degrees of patients' dementia were classified into three groups with HDS-R for ten points increment partition, and their average FIM and GS in R-I for groups were compared statistically with ANOVA. FIM gain and GS gain from A-I to R-I were compared statistically with chi-square test. RESULTS: FIM and HDS-R demonstrated significant regression with each of all other parameters (p < 0.01) for both A-I and R-I. The group with lowest HDS-R score demonstrated significant lower FIM gain and lower GS gain than groups with higher scores (p < 0.01). However, patients who demonstrated improvement in HDS-R at R-I demonstrated significant better GS gain (p < 0.05) even in the group with lowest HDS-R at A-I. CONCLUSIONS: These results show that there is a very close correlation between patients' gait function and dementia and that it is necessary to control a patient's status not only for physical condition but also for mental status after PFF operation.