Acute common peroneal neuropathy due to hand positioning in normal labor and delivery.

BACKGROUND: Foot drop has been described as an infrequent complication from common peroneal nerve injury related to external compression and forceful knee flexion while pushing during vaginal delivery. Past recommendations include placing the hands at the posterior thighs rather than the legs to avoid this complication. CASE: A 32-year-old woman developed unilateral foot drop after vaginal delivery. Electromyography was diagnostic for an acute compression neuropathy of the common peroneal nerve above the knee. CONCLUSION: The patient's likely mechanism of injury occurred during delivery from external compression by the patient's dominant hand to the distal posterior thigh while under epidural anesthesia. Labor and delivery teams should be aware that nerve injury is also possible at the distal thigh with excessive external pressure.

Phrenic nerve stimulation in the evaluation of ventilator-dependent individuals with C4- and C5-level spinal cord injury.

Three individuals with C4 or C5 spinal cord injuries (SCI) were seen in follow-up for management of their late complications, which included impaired ventilation. Electrodiagnostic studies were performed on all three as part of the assessment of the function of their phrenic nerves and diaphragm muscles in relation to their need for mechanical ventilator support. Each patient had evidence of lower-motor neuron injury to the phrenic nerves. Two of the patients who initially displayed small-amplitude (<0.1 mV) compound muscle action potentials (CMAP) bilaterally were later reevaluated during the course of their observation in the outpatient rehabilitation clinic. The CMAP amplitude of the diaphragm increased in these two cases during the 3-11 mos after SCI. Evidence of nerve recovery occurred in parallel with improvements in pulmonary function testing and was followed by successful weaning from the ventilator. These individuals both gained ventilator independence after the CMAP amplitude of least one hemidiaphragm was >0.4 mV. In the third case, early failure of ventilator weaning was reported to the patient as a poor prognostic sign. At the time of our first evaluation 11 mos after injury, a CMAP of 1.0 mV was seen on the right, with an absent response on the left. In case 3, the needle electromyogram demonstrated voluntary active motor unit action potentials that provided additional electrophysiologic support for phrenic nerve function. Phrenic nerve-conduction studies can provide useful measures in assessing the recovery of lower-motor neuron diaphragm function in relation to impaired ventilation in individuals with C4- or C5-level SCI.

A novel technique for recording from the serratus anterior.

OBJECTIVE: To design an electrodiagnostic technique by which to accurately record the serratus anterior compound muscle action potential (CMAP). DESIGN: Observational study. SETTING: Academic electromyography laboratory. PARTICIPANTS: Fifteen healthy volunteers. INTERVENTIONS: The long thoracic nerve was stimulated by using a standard bipolar surface electrode in the axilla, just anterior to the midaxillary line. The serratus anterior CMAP was recorded by using a self-adhesive, 8.0 x 0.5 cm, ring electrode as the E1 placed across the serratus anterior interdigitations starting at the nipple level. A self-adhesive, motor (1 x 1 cm) electrode was used as E2 and placed over the seventh rib. A standard self-adhesive ground electrode was placed over the inferior region of the latissimus dorsi. MAIN OUTCOME MEASURES: Distal motor latency (DML), and CMAP amplitude and duration. RESULTS: After removing 2 outliers, the results are reported as the mean +/- 1.96 standard deviations. Right long thoracic DML was 2.2+/-1.0ms and the left was 2.3+/-0.9ms, with a side-to-side mean difference of 0.3+/-0.4ms. The right serratus CMAP amplitude was 3.8+/-3.9mV and the left was 3.9+/-3.7mV, with a side-to-side mean difference of 0.6+/-1.2mV. Statistical analysis did not reveal a significant side-to-side difference for DML or CMAP amplitude. Both sides were combined to form a single set of trials for DML and CMAP amplitude. The mean DML became 2.2+/-0.7ms, and the CMAP amplitude was 3.5+/-1.9mV. The CMAP duration was 14.5+/-4.3ms on the right and 14.5+/-4.1ms on the left. A significant, positive correlation existed between height and DML ( P <.02). The 95% confidence intervals for DML and CMAP amplitudes were 2.1 to 2.5ms and 1.5 to 3.1mV, respectively. CONCLUSIONS: Our latency, side-to-side comparisons and amplitude data were consistent with other motor nerve conduction findings in the literature. Stimulating the long thoracic nerve in the axilla will provide a reliable technique to aid in the diagnosis and treatment of long thoracic neuropathy.

Intrathecal baclofen for spasticity management in Rett syndrome.

Intrathecal baclofen infusions have proven to be effective for management of spasticity during the last two decades. Efficacy of intrathecal baclofen for spasticity of spinal origin has been well established and has shown promise in treatment of spasticity that is not spinal in origin. Rett syndrome is a neurodevelopmental disorder primarily affecting girls and women. Manifested in the advanced stages of this syndrome is increased spasticity leading to functional decline. Presented is a case report of a 32-yr-old white woman with Rett syndrome, diagnosed before the age of 2 yr, and significant spasticity that was successfully managed with intrathecal baclofen. After placement of an intrathecal baclofen pump, the dose was increased slowly during 1 yr to 800 microg/day with good clinical response. There was observed a significant decrease in upper and lower limb Ashworth scores, from an average of 3-4 to 2-3, during this 1-yr period. The decrease in spasticity in this patient eventually led to improved range of motion, positioning, skin care, hygiene, and quality of life. Intrathecal baclofen is an effective option in managing severe spasticity from Rett syndrome.

Detecting and treating shoulder impingement syndrome: the role of scapulothoracic dyskinesis.

The shoulder joint is most appropriately referred to as the "shoulder complex," since its total range of motion depends on four interworking articulations. The scapula is central in proficient shoulder activity, and rotator cuff muscles will not operate optimally if the scapula is poorly positioned. Dynamic scapular stabilization requires coordinated muscular activity, and muscle dysfunction will lead to glenohumeral incongruity during overhead athletic activities. Lack of scapular protraction, upward rotation, and posterior tilting can lead to subacromial impingement. Pain inhibition and fatigue can also provoke altered muscle patterns, but rehabilitation exercises can address biomechanic deficiencies.