Ilker Yagci

The utility of lumbar paraspinal mapping in the diagnosis of lumbar spinal stenosis.

Yagci I, Gunduz OH, Ekinci G, Diracoglu D, Us O, Akyuz G: The utility of lumbar paraspinal mapping in the diagnosis of lumbar spinal stenosis. Objective:The aim of this prospective, blinded and controlled study is to evaluate the utility of lumbar paraspinal mapping in the diagnosis of lumbar spinal stenosis. Design:The subjects were assessed and allocated into three groups according to clinical and radiologic features with a standardized assessment protocol. These three groups were clinical and radiologic lumbar spinal stenosis, radiologic lumbar spinal stenosis, and the control group. The measurements of magnetic resonance imaging studies were performed by a blinded radiologist. An electromyographer who was masked to patients’ data performed all the nerve conduction tests, lower-limb needle electromyography, and lumbar paraspinal mapping. The relations of clinical, radiologic, and electrophysiologic findings were investigated. Results:Sixty-two patients were enrolled in the study. Two patients were eliminated because electrophysiologic studies showed polyneuropathy. There were 28, 16, and 16 patients in clinical and radiologic lumbar spinal stenosis, radiologic lumbar spinal stenosis, and control groups, respectively. In the clinical and radiologic lumbar spinal stenosis group, the findings of limb needle electromyography were inconsistent with 50% acute and 46.4% chronic radiculopathy. However, the paraspinal mapping showed that there were fibrillation potentials and positive sharp waves in at least two levels in 92.8% of the patients in clinical and radiologic lumbar spinal stenosis. The mean total paraspinal mapping score was 33.64 ± 21.17, which was significantly higher than the radiologic lumbar spinal stenosis and control groups. In the radiologic lumbar spinal stenosis group, the findings of paraspinal mapping were normal in 93.8% of the patients. Paraspinal mapping technique was found to be better correlated to the clinical findings than magnetic resonance imaging in asymptomatic patients. In the control group, 6 of 14 patients had high total paraspinal mapping scores (range, 0–9). Those patients with higher paraspinal mapping scores in the control group were mostly diagnosed with acute monoradiculopathy caused by disc herniation. Conclusions:Paraspinal mapping technique is a sensitive method in the diagnosis of lumbar spinal stenosis and reflects physiology of nerve roots better than the limb electromyography.

Comparative electrophysiological techniques in the diagnosis of carpal tunnel syndrome in patients with diabetic polyneuropathy

OBJECTIVE To determine utility of comparative electrophysiological techniques in differentiating carpal tunnel syndrome (CTS) in the background of diabetic polyneuropathy (DPN). DESIGN Ninety diabetic patients were classified into three groups: normal, CTS, and DPN according to nerve conduction studies (NCSs). The patients in the DPN group were divided into two subgroups of DPN and DPN-CTS according to clinical criteria. The comparative electrophysiological parameters including median-radial sensory distal latency difference (M-RSLD), median-ulnar sensory distal latency difference (M-USLD) and lumbrical-interosseous median-ulnar distal latency difference (LIMULD) were compared in subgroups of DPN, DPN-CTS and CTS. RESULTS Thirty-five (38.8%), 47 (52.3%), and 8 (8.9%) patients were diagnosed as CTS, DPN, and normal, respectively, according to NCS. After clinical stratification, 25 patients were diagnosed as DPN and 22 patients were diagnosed as DPN-CTS. The mean M-USLD and LIMULD values were similar in CTS and DPN-CTS groups, but larger than DPN statistically (p<0.05 for all). LIMULD, M-RSLD and M-USLD were positive in 88.4, 73 and 54% in the DPN-CTS group, respectively. CONCLUSIONS Electrophysiological abnormalities were common in diabetic patients and LIMULD can identify CTS in diabetic DPN patients better than M-RSLD and M-USLD.

Paraspinal muscle denervation and balance impairment in lumbar spinal stenosis.

Introduction: Denervation of the paraspinal muscles may impair posture and displace the center of gravity. Therefore, we assessed balance impairment in patients with lumbar spinal stenosis (LSS) with and without paraspinal denervation. Methods: Thirty‐two women with LSS (15 symptomatic, 17 asymptomatic), aged 42–78 years, were assessed for disability, pain, and mobility, and underwent masked mini‐paraspinal mapping (mPSM). Berg Balance Scale (BBS) and device‐assisted balance (DAB) tests were used for balance assessment. Results: The symptomatic group had worse balance and higher mPSM scores than the asymptomatic group. Among DAB tests, limit of stability (LOS) had the highest correlations with BBS and mPSM in the symptomatic group. Conclusions: Paraspinal denervation correlated highly with static and dynamic balance in symptomatic patients. We recommend paraspinal mapping, balance assessment, rehabilitation, and follow‐up with the LOS test for symptomatic patients. Muscle Nerve 53: 422–430, 2016

Are extramedian symptoms associated with peripheral causes in patient with carpal tunnel syndrome? Electrodiagnostic and ultrasonographic study

OBJECTIVE To evaluate the relationship between extramedian spreading of sensorial symptoms and median and ulnar nerve cross-sectional area (CSA) and to compare the ultrasonographic and electrophysiological findings in patients with carpal tunnel syndrome (CTS) with or without extramedian sensory symptoms. DESIGN Cross-sectional study. MATERIALS AND METHODS Patients with CTS were divided into two groups as with or without extramedian symptoms and were assessed clinically, electrophysiologically and ultrasonographically by three blind investigators. In electrophysiological tests, median and ulnar nerve conduction studies were performed. Nerve cross-sectional areas were measured at hook of hamate, psiform bone, radio-ulnar joint, one-third distal part of forearm, and medial epicondyle by ultrasonography. FINDINGS The study was completed with 61 patients (108 hands). Extramedian symptoms were present in 31 patients (54 hands). Finger grip strength was lower, pain values evaluated with visual analogue scale were higher in patients with extramedian symptoms (p<0.05). There was no statistically significant difference in electrophysiological and ultrasonographic parameters. CONCLUSION According to our results, extramedian symptoms are not related to nerve conduction studies or nerve ultrasonography, these symptoms may be explained with central sensitization in patient with CTS.

The effect of vitamin D supplementation on pain, quality of life, and nerve conduction studies in women with chronic widespread pain.

The aim of this study was to investigate the effects of vitamin D supplementation on pain, quality of life, and nerve conduction studies (NCSs) in women with chronic widespread pain (CWP) diagnosed with Vitamin D insufficiency. Thirty-three female participants with CWP and vitamin D insufficiency were included in this open-label trial. They were evaluated by routine NCSs in upper and lower limbs, pain scales, and the Nottingham Health Profile before and 8 weeks after starting vitamin D supplementation therapy. The P-value was adjusted to account for the number of comparisons performed in each assessment. After 8 weeks of treatment, participants reported significantly lower pain scores (P=0.000). The total Nottingham Health Profile score and subscores for pain, emotional reactions, and physical activity domains were significantly lower (0.000⩽P⩽0.008). However, no statistically significant changes in NCSs were detected, except trends toward increases in the amplitudes of left median and ulnar sensory nerve potentials and a decrease in the distal latency of the right median sensory potential (0.01⩽P⩽0.04). Vitamin D supplementation therapy decreased pain and increased quality of life without significantly affecting nerve conduction in patients with CWP.

Is ultrasonography useful in the diagnosis of the polyneuropathy in diabetic patients

[Purpose] The aim of this study was to investigate the usefulness of ultrasonography for the diagnosis of polyneuropathy in diabetic patients by examination of the median and ulnar nerves. [Subjects and Methods] Sixty-three diabetic patients and fourteen controls were enrolled in the study. Nerve conduction studies were performed on both upper and lower limbs. Median and ulnar nerve cross-sectional areas were measured at the wrist and forearm levels in 140 hands by ultrasound. [Results] The median nerve cross-sectional area was increased at the hook of hamatum, pisiform bone, and radioulnar joint levels in patients with carpal tunnel syndrome. The ulnar nerve area at the medial epicondyle was significantly increased in the diabetic polyneuropathy (9.2 ± 1.6), diabetic polyneuropathy plus carpal tunnel syndrome (9.3 ± 1.4), and carpal tunnel syndrome (9.2 ± 1.9) groups compared with the control group (7.7 ± 1.1). In receiver operating characteristics analysis, the cutoff value of the ulnar nerve was 8.5 mm2 at ulnar epicondyle with 71.4% specificity and 70.4% sensitivity, corresponding to the highest diagnostic accuracy for diabetic polyneuropathy. [Conclusion] Ultrasonographic examination of the median and ulnar nerves can be an alternative or additional diagnostic modality for the evaluation of neuropathies in diabetic patients.

Is ultrasonographic enthesitis evaluation helpful for diagnosis of non-radiographic axial spondyloarthritis?

The aim of this study is to evaluate the diagnostic utility of ultrasonographic enthesitis assessment in patients with non-radiographic axial spondyloarthritis (nr-axSpA) and to compare different sonographic scoring methods. Patients with nr-axSpA (n = 30) and mechanical back pain (MBP) (n = 30) were enrolled in the study with standardized clinical criteria. For both of the groups, a total of 18 entheses were evaluated in each patient with B mode ultrasound and power Doppler by a sonographer who is blinded to initial clinical and radiological assessments. Glasgow Ultrasound Enthesitis Scoring System (GUESS), Madrid Sonographic Enthesitis Index (MASEI) and D’Agostino grading system were performed. Intra-rater and inter-rater reliability analyses were evaluated with the intraclass correlation coefficient (ICC). There was at least one enthesitis in 96.7% of patients with nr-axSpA. Median values of the number of enthesitis were 5 in nr-axSpA and 0 in MBP. Mean GUESS total scores were 0.9 in MBP and 4.5 in nr-axSpA. Mean MASEI total scores were 2.3 and 10.5, respectively. The sensitivities were 96.7% and 93.3% for GUESS and MASEI while the detected specificities were 80% for both methods. For Intra-rater reliability analysis, ICC was calculated as 0.981 for GUESS and 0.975 for MASEI, while it was calculated as 0.964 and 0.962 for inter-rater reliability analysis. Thus, evaluation of enthesitis with ultrasound is a reliable, helpful tool for the distinction of patients with nr-axSpA from patients with MBP. We favored the use of MASEI because of assessing upper extremity, using power Doppler and having a correlation with disease activity.

Challenges in the treatment of fibrodysplasia ossificans progressiva

Fibrodysplasia ossificans progressiva (FOP), is a rare autosomal dominant connective tissue disease with a prevalence of 1 in 2 million. It is characterized by congenital foot deformities and multiple heterotopic ossifications in fibrous tissue. It usually starts with painful soft tissue swellings occurring with attacks at the ages of three or four. The attacks develop spontaneously or after minor trauma, and gradually turn into heterotopic ossifications that cause joint limitations, growth defects, skeletal deformities and chronic pain. The average life expectancy is forthy, and most of the patients are lost due to pulmonary complications. FOP is often misdiagnosed as fibromatosis, desmoid tumour or cancer, bunion, myositis, arthritis and rheumatic diseases. After clinical suspicion, confirmatory genetic analysis should be used for the diagnosis. The treatment of FOP is currently supportive. An effective, proven method has not yet been established. Herein, we present an 18-year-old female patient with FOP who underwent different treatment modalities in a 5-year period. This case-based review reveals all available treatment approaches with at least 6-month follow-up for FOP in the literature.

AB1072 The median nerve cross-sectional area may be a parameter of follow- up after treatment in patients with carpal tunnel syndrome?

Objectives Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy in general population. Diagnosis of CTS depends on clinical symptoms, physical examination and electrophysiological findings. In recent years, diagnostic value of median nerve ultrasonography has increased particularly for the CTS. To aim of this study compare the electrophysiological and ultrasonographic findings at CTS patients who treated with splinting at night during three months. Methods The patients, who were diagnosed with mild or moderate CTS, received a fabricated night orthotic which held the wrist in a neutral position during three months. All patients were evaluated clinically, electrophysiologically, and ultrasonographically before treatment and at 3 months by blind physicians. Pain was evaluated using Visual Analogue Scala (VAS) Boston Carpal Tunnel Questionnare was used to evaluated symptom severity and functional capacity. In electrophysiologic evaluation median nerve conduction studies was recorded. Median nerve cross-sectional areas (M-CSA) were measured by ultrasonography at the level of radio-ulnar joint, pisiform bone, and hook of hamate. After treatment, 68 patients were divided into two groups according to whether there was a%50 reduction in VAS. Results: The study was completed with 68 patients and 114 hands. While in group 1, in which VAS reduction was less than%50, there were 38 hands; in group 2, in which VAS reduction wan more than%50, there were 76 hands. There were no differences improvement of symptom severity, nerve conduction studies parameters, M-CSA at the level of radio-ulnar joint between groups. Improvement of functional capacitiy and descrease of M-CSA at the level of pisiform bone and hook of hamate were significantly better in group 2 (p<0.05). Conclusions: After conservative treatment, while M-CSA was consistent with clinical findings, this consistency has not been observed with nerve conduction studies. M-CSA may be used to follow-up after receiving conservative treatment in patient with CTS. Disclosure of Interest: None declared

AB1003 Median and ulnar nerve cross-sectional area in carpal tunnel syndrome with extraterritorial spread of sensory symptoms

Objectives To evaluate the relationship between extramedian spreading of sensorial symptoms and median and ulnar nerve cross-sectional area in patient with carpal tunnel syndrome (CTS), to compare the ultrasonographic and electrophysiological findings in patients with CTS whose sensorial symptoms are extramedian spreading or median distribution only. Methods Patients with CTS were divided into two groups as with and without extramedian symptoms and were assessed clinically, electrophysiologically and ultrasonographically by three blind investigators. In electrophysiological tests, median and ulnar nerve conduction studies were performed. Nerve cross-sectional areas were measured at hamatum hook, psiform bone, radio-ulnar joint, one-third distal part of forearm, and medial epicondyle for median nerve; radio-ulnar joint, psiform bone, one-third distal part of forearm, and medial epicondyle for ulnar nerve by ultrasonography. Results The study was completed with 61 patients (108 hands). Extramedian symptoms were present in 31 patients (54 hands). Finger grip strength was lower, pain values evaluated with visual analogue scale were higher in these patients (p<0.05). There was no statistically significant difference in electrophysiological and ultrasonographic parameters between two groups. Conclusions These results suggest that extramedian spread in CTS patients is more related to central and peripheral sensitization than peripheral causes. Disclosure of Interest None declared