Adem Yildirim

The Diagnostic and Grading Value of Diffusion Tensor Imaging in Patients with Carpal Tunnel Syndrome

RATIONALE AND OBJECTIVES In this study, we investigated the diagnostic and grading value of diffusion tensor imaging (DTI) in patients with carpal tunnel syndrome (CTS). MATERIALS AND METHODS Of the 120 subjects included in the present study, 72 were in the CTS group and 48 were in the healthy control group. In addition, the patients with CTS were further divided into three subgroups based on severity (mild, moderate, and severe) according to electrophysiological studies (EPS). DTI-derived parameters (fractional anisotropy [FA] and apparent diffusion coefficient [ADC]) were evaluated at four median nerve levels. The mean FA and ADC values of the CTS groups and healthy controls were compared separately. Correlations and possible relationships between DTI parameters and EPS results were analyzed. Receiver operating characteristics analysis was used to calculate the FA and ADC cutoff values for CTS diagnosis and grading. RESULTS Statistically significant differences were observed in mean FA and ADC between the normal and mild, mild and moderate, and moderate and severe subgroups. Significant correlations were found between DTI parameters and EPS measurements based on severity. FA and ADC threshold values, as well as the sensitivity and specificity levels, for diagnosing and grading CTS were determined. CONCLUSIONS DTI parameters can provide helpful information for CTS. The correlations of FA and ADC measurements versus EPS measurements based on severity were significant. Moreover, FA and ADC threshold values were sufficient for the diagnosis and grading of CTS.

The relationship between white matter abnormalities and cognitive functions in new-onset juvenile myoclonic epilepsy

Diffusion tensor imaging (DTI) has revealed evidence of subcortical white matter abnormalities in the frontal area in juvenile myoclonic epilepsy (JME). Decreased fractional anisotropy (FA) and increased mean diffusivity (MD) in the corticothalamic pathway have been detected in adult patients with JME. It has been demonstrated that, in adult patients with JME, frontal dysfunction is related to subcortical white matter damage and decreased volume in frontal cortical gray matter and the thalamus. Many studies have focused on adult patients. Twenty-four patients and 28 controls were evaluated. The group with JME had significantly worse results for the word fluency, trail-B, and Stroop tests that assessed executive functions. A significant decrease in FA values in the dorsolateral prefrontal cortex (DLPFC), the supplementary motor area (SMA), the right thalamus, the posterior cingulate, the corpus callosum anterior, the corona radiata, and the middle frontal white matter (MFWM) and an increase in ADC values in patients with JME were detected. The correlation between FA values in DLPFC and the letter fluency test results was positive, and the correlation with the Stroop and trail-B test results was negative. We found a negative correlation between SMA, anterior thalamus, and MFWM FA values and the trail-B test results and a positive correlation between the SMA, anterior thalamus, and MFWM FA values and the letter fluency test results. We detected white matter and gray matter abnormalities in patients with new-onset JME using DTI. In addition, we determined the relationship between cognitive deficit and microstructural abnormalities by evaluating the correlation between the neuropsychological test battery results and DTI parameters. We evaluated newly diagnosed patients with JME in our study. That leads us to believe that microstructural abnormalities exist from the very beginning of the disease and that they result from the genetic basis of the disease.

False-negative diffusion-weighted imaging in acute stroke and its frequency in anterior and posterior circulation ischemia.

Objective We aimed to investigate the location and size of ischemic stroke lesions that were frequently overlooked by diffusion-weighted imaging (DWI). Materials and Methods We retrospectively reviewed the medical records of 162 patients who had symptoms suggesting ischemic stroke. National Institutes of Health Stroke Scale and Modified Rankin Scale scores, lesion size, magnetic resonance imaging (MRI) findings, delay between onset of symptoms and initial MRI (MRI latency), and vascular distribution of the stroke lesions were analyzed in patients with false-negative DWI findings. Results Of the 116 patients with a final diagnosis of acute ischemic stroke, 11 patients (9.48%) had false-negative DWI findings in the initial period. The mean (SD) MRI latency was 4.3 (1.2) hours. There was no statistically significant difference in point of lesion size, the National Institutes of Health Stroke Scale, and the Modified Rankin Scales scores. Conclusions False-negative DWI findings in acute stroke can be observed both in association with the posterior circulation/small lesions and the anterior circulation/large lesions.

The effects of upper extremity progressive resistance and endurance exercises in patients with spinal cord injury

BACKGROUND AND OBJECTIVES Exercises aiming to strengthen the upper extremities are recommended to increase activities of daily living (ADLs) in patients with spinal cord injury (SCI). The aim of this study was to compare the effects of upper extremity progressive resistance exercises (PRE) and endurance exercises (EE) performed with an arm ergometer in patients with paraplegia due to SCI. MATERIALS AND METHODS A total of 19 SCI patients were included in the study, and randomly divided into two groups. The first group performed PRE while the second group performed arm EE. The functional independence measurement (FIM) was used on each patient at the beginning and at the end of the study. The elbow flexion and extension muscle strengths of each patient were determined with the computerized isokinetic dynamometer at the beginning and end of the study. RESULTS Post-training increased the FIM scores in both PRE (p=0.005) and EE groups (p=0.008). There were increases in the extension peak torque (PT) and total work (TW) at 180°/sec and 60°/sec angular velocity in the PRE group compared to the EE group (all p<0.05). CONCLUSION There were improvement in post-training muscle strength values in both the PRE (found to be more effective) and EE groups. LEVEL OF EVIDENCE Randomized trial (Level I).

Use of diffusion tensor imaging for nonsurgical treatments of carpal tunnel syndrome

Introduction: This study evaluated the applicability of diffusion tensor imaging (DTI) of therapeutic ultrasound (US) and wrist splints in addition to clinical and electrophysiological assessments of patients with carpal tunnel syndrome (CTS). Methods: This prospective study analyzed 41 patients (30 women, 11 men; 56 wrists) with CTS. Therapeutic US and wrist splints were performed for 3 and 4 weeks, respectively. Fractional anisotropy and the apparent diffusion coefficient (ADC) were evaluated in addition to a visual analog scale (VAS), symptom severity scale (SSS), functional status scale (FSS), and electrodiagnostic studies (EDX) before and after treatment. Results: There were significant decreases in the mean ADC, VAS, SSS, FSS, and EDX after treatment. Conclusions: This study suggests that DTI parameters provide helpful information that complements clinical and electrophysiological assessments for evaluating the efficacy of nonsurgical treatment of patients with CTS. Muscle Nerve 50: 950–955, 2014

Comparative results of standard open and mini open, KnifeLight instrument-assisted carpal tunnel release.

PURPOSE The purpose of our study was to compare the results of standard open and mini open (approximately 1.5-cm incision), KnifeLight instrument (Stryker Instruments, Kalamazoo, Michigan, USA) assisted carpal tunnel release (CTR) concerning symptomatic, functional, and electrophysiological aspects, as well as complications during early and late postoperative follow-up. PATIENTS AND METHOD Seventy-five patients who did not improve with nonsurgical methods and were planned to undergo surgery were separated into two groups. Patients in the first group (n = 37) underwent surgery with standard open CTR (Group A); patients in the second group (n = 38) underwent surgery with mini open KnifeLight instrument assisted CTR (Group B). Preoperative and 6-month postoperative electrophysiological values and functional utilization of the operated hand of both groups were compared. Nerve conduction studies were used for electrophysiological evaluation, visual analog scale (VAS) was used for pain evaluation, symptom severity scale (SSS) was used for symptomatic evaluation, and functional status scale (FSS) was used to evaluate hand functions that are the part of the Boston Carpal Tunnel Questionnaire. All evaluations were done preoperatively and repeated at postoperative month 6. Also, to determine early effects of surgical procedures, SSS and FSS scales were repeated at postoperative week 2 and month 3. Groups were also compared for complications and need for reoperation. RESULTS No significant difference was detected between the two groups at postoperative month 6 on VAS and electrophysiological values. Postoperative week 2 FSS and SSS scores of Group B were significantly lower than Group A. Although scores were lower in Group B at month 3, there was no statistically significant difference. Six months after surgery, no significant difference was detected between the two groups in mean SSS and FSS scores. Postoperative complications and reoperation rates were lower in Group B but the difference was not statistically significant. CONCLUSION After 6 months the results of both techniques for CTR are comparable. Mini open KnifeLight instrument assisted CTR is easy to perform and is superior to standard open CTR in the early post-operative period.

Short-term effects of upper extremity circuit resistance training on muscle strength and functional independence in patients with paraplegia

BACKGROUND AND OBJECTIVES A number of exercises to strengthen the upper extremities are recommended to increase functional independence and quality of life (QoL) in patients with paraplegia. Circuit resistance training (CRT) is a type of progressive resistive exercise performed repeatedly at fixed mechanical exercise stations. The aim of this study was to investigate the potential benefits of CRT for upper extremity muscle strength, functional independence, and QoL in patients with paraplegia. MATERIALS AND METHODS Twenty-six patients with paraplegia who were participating in a conventional rehabilitation program at a tertiary education and research hospital were enrolled in this study. The participants were randomly assigned to two groups. The exercise group participated in the CRT program, which consisted of repetitive exercises for the upper extremities performed at fixed mechanical stations 5 sessions per week for 6 weeks, in addition to conventional rehabilitation. Participants in the control group received only conventional rehabilitation over the same period. We compared the groups with respect to QoL, as well as isokinetic muscle test outcomes in the upper extremities, using the Functional Independence Measure (FIM) and Borgs scale. RESULTS We observed significant increases in scores on the physical component of the FIM, Borgs scale, and QoL in both the exercise and control groups. Furthermore, the large majority of isokinetic values were significantly more improved in the exercise group compared to the control group. When post-treatment outcomes were compared between the groups, improvements in scores on the physical component of the FIM and in most isokinetic values were significantly greater in the exercise group. CONCLUSIONS This study showed that CRT has positive effects on muscle strength in the upper extremities and the physical disability components of the FIM when added to conventional rehabilitation programs for paraplegic patients. However, we observed no significant improvement in QoL scores after adding CRT to a conventional treatment regime. LEVEL OF EVIDENCE Randomized trial (Level II).

Developmental age and motor function levels in children with cerebral palsy

We determined the developmental level of 107 children (mean age, 66.41 ± 32.92 mo) with cerebral palsy in an inpatient rehabilitation program and assessed both the difference between calendar age and developmental age and the effect of developmental level on motor function improvement. The Denver II test was used to reveal the difference between calendar age and developmental age, and we determined whether there was a statistically significant difference between the admission and discharge motor function measurements of the subjects. The effect of the Denver II developmental levels of language, fine-motor, personal-social, and gross-motor skillson motor function was investigated. Wefound a statisticallysignificant difference between thedevelopmental levelsandcalendar agesof thestudy subjects. Denver II testresultsrevealed astatisticallysignificant difference between the personal-social, gross-motor, and fine-motor levels of the subjects. We found no difference only between personal- social and language levels. Gross-motor development was the most delayed value by calendar age. Regardless of developmental level, there was a statistically significant difference between motor activity levels at admission and discharge as revealed by the Gross-motor Functional Classification System and the Gross-motor Function Measure. The developmental ages of the subjects were much lower than their calendar ages. We concluded that the Denver II language and fine-motor developmental level did not have an effect on functional gains but that the subjects with good personal-social and gross-motor function developmental levels exhibited relatively better motor function gains at the time of discharge.

Hydatid Cyst of Paravertebral Muscle Mimicking Disc Herniation

Study Design. Case report. Objective. To present a case of primary hydatid cyst in the lumbar subcutaneous tissue affecting posterior paravertebral muscle and mimicking disc herniation. Summary of Background Data. Cystic hydatid disease is a rare but significant parasitic disease in endemic areas. Musculoskeletal or soft tissue hydatidosis accounts for about 0.5% to 5% of all echinococcal infections in endemic areas and is almost secondary to the hepatic or pulmonary disease. Primary lumbar subcutaneous hydatid cyst affecting paravertebral muscle and extending to neural foramina is a very rare condition even in endemic areas. Methods. A 25-year-old-female patient was admitted with swelling and pain in the right lumbar region for 3 months. The pain was reflecting in the right gluteal region and the right leg. Lumbar extension and right lateral flexion was painful and straight leg raising test was positive at right side. There was a mild hypoesthesia at L5 dermatome. According to the magnetic resonance image that the clinician obtained for initial diagnosis of lumbar disc herniation, we found multi-cystic masses located at the right paravertebral muscle at the level of L3–L5 which extended to L4–L5 neural foramina and at subcutaneous tissue at the right gluteal region. Results. The patient was operated for the purpose of removal of cysts. Postoperatively, diagnosis of hydatid cyst was confirmed by histopathology. Conclusion. By this case, we emphasize that cystic hydatid disease should be taken into consideration in the differential diagnosis of low back pain and could mimic disc herniation. Level of Evidence: N/A