Jorge Díaz-Ruiz

Natural evolution of carpal tunnel syndrome in untreated patients.

OBJECTIVE To describe the clinical and electrophysiological evolution of a group of patients diagnosed with carpal tunnel syndrome (CTS) who have not undergone any type of treatment (injections, braces or surgery). METHODS Clinical and electrophysiological monitoring was done consecutively in a series of patients who were admitted with a diagnosis of CTS. The average time for follow-up was 2 years. The Historic and objective Classification scale (HiOb) was used to establish the severity of the disease in the test group, and neuro conductions were done to determine the electrophysiological classification. RESULTS A total of 132 patients were monitored. In 31 patients (23.4% of the cases), the HiOb classification deteriorated, 28.8% remained stable, and 47.6% showed recovery. In the nerve conduction studies, 10 cases (7.6%) exhibited electrophysiological deterioration, 67.4% remained constant and 25% improved. CONCLUSIONS A significant percentage of patients with carpal tunnel syndrome had no change in their clinical and electrophysiological condition, while some improved spontaneously without treatment. SIGNIFICANCE Given that most patients diagnosed with CTS remain stable or even improve over time, a conservative treatment may be all that is needed in a selection of patients with this disorder.

Factor analysis of Carpal Tunnel Syndrome Questionnaire in relation to nerve conduction studies

OBJECTIVE This study aims to assess the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) structure and its relation to nerve conduction studies (NCS). METHODS A total of 403 patients with clinical and/or electrophysiological definition of CTS were evaluated with the instrument. The structure of the questionnaire was assessed by means of factor analysis. Factors obtained were compared with NCS. RESULTS Factor analysis showed that three factors represented nearly 60% of the variance of the instrument. Factor one is related to all the function domain questions and to the weakness and difficulty in grasping questions of the symptom domain; factor two to questions that assess numbness and tingling, and to the pain-awakening question of the symptom domain; and factor three, to pain questions of the symptom domain. Factor two had a stronger correlation with latencies of NCS and with the neurophysiological scale than the other two factors. CONCLUSIONS BCTQ assesses function and symptoms in patients with CTS by means of questions related to numbness and tingling sensation, pain and functional status. Questions related to numbness and tingling (factor two) better reflected the pathophysiology of the median nerve. SIGNIFICANCE Factor-2 sensory-related questions of BCTQ may be more useful in diagnosis, follow-up and assessing therapeutic outcome in CTS.

Motor recovery after Guillain-Barré syndrome in childhood

Purpose. To determine the clinical factors that modify the recovery time for gait after Guillain-Barré syndrome (GBS) in childhood. Method. Medical records of patients admitted to Instituto de Ortopedia Infantil Roosevelt (IOIR) between years 1991 and 2001, were reviewed. Age, sex, cranial nerve impairment, requirement of assisted ventilation, number of days of assisted ventilation, muscular strength at day 10 of the disease, presence of quadriplegia, intravenous infusion of human gamma globulins (IVIG), were taken as independent variables. The number of needed days to reach Hughes State III was taken as the major outcome. First, univariate analysis was performed and with the factors that showed a statistically significant association with recovery time, multiple linear regression analysis and Cox regression were also performed. Results. Data of 332 children under 15 years old was collected. (Mean age: 7.1 years). A sample of 215 children was gathered for the study, all of them were regarded as functional states IV or V. Acute Motor Axonal Neuropathy (AMAN) was found in 30% of all cases. In the univariate analysis Cranial nerve impairment, requirement of assisted ventilation, presence of quadriplegia and presence of non-excitable motor nerves were associated with delayed motor recovery time. Patients who received IVIG reached Hughes state III faster than those who received only support treatment. This finding, that was more important in the presence of Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP), lost its value in the Cox regression analysis. In the multivariate analysis, muscular strength, assessed at day 10 of the disease was the most important predictor to determine motor recovery. The presence of quadriplegia was strongly associated with a delayed recovery time. Relative risk: 3.3 (95% Confidence Interval 2.1 – 5.2). Conclusions. Muscular strength at day 10 of the disease is the most useful clinical factor to determine prognosis of motor recovery in children who have suffered Guillain-Barré syndrome.

EMG and duration of ventilatory support in children with Guillain–Barre syndrome

RationalePredicting length of stay in the intensive care unit (ICU) in children with Guillain–Barre syndrome may help decision-making at admission.Materials and methodsBetween 1996 and 2003, we attended to 30 children with Guillain–Barre syndrome who required ventilatory support in ICU. We prospectively collected different variables that could potentially predict prolonged length of stay and ventilatory support in ICU.ConclusionUsing Cox proportional hazard analysis we found that lack of electrical excitability was the best predictor.

29. Mononeuritis multiplex in leprosy

Introduction: High resolution ultrasound (US) imaging has been widely advocated as a substitute for electrodiagnosis in the evaluation of carpal tunnel syndrome (CTS) but most studies have been carried out in highly selected patient populations. Objectives: To assess the diagnostic performance of US imaging of the median nerve in comparison to electrodiagnosis in unselected patients. Methods: The clinical probability of CTS based on the patient history was quantified using a previously validated symptom questionnaire in 565 patients attending a neurophysiology laboratory for assessment of possible CTS. Subjects had not previously been treated for CTS but no other exclusions were applied. Subjects had conventional electrodiagnostic (EDX) studies for CTS conforming to the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) standards, and high resolution US imaging in both wrists using a Sonosite M-turbo portable US system with a 30 mm linear array 8–14 MHz transducer. Median nerve cross sectional areas just proximal to the carpal tunnel were measured using the method of manual tracing just inside the hyperechoic nerve border. The proportion of normal and abnormal EDX and imaging findings was compared across a range of clinical probabilities of CTS using two alternate cutoff criteria for abnormality in each case. Results: Where the clinical likelihood of CTS was low US imaging was more likely to produce an abnormal result (76%) than nerve conduction studies (NCSs) (54%). As the clinical probability of CTS increased, the likelihood of an abnormal NCS result increased, eventually reaching 98%. A less marked increase in the sensitivity of US was seen, reaching 85%. Conclusion: In unselected patients NCSs have better diagnostic performance than US.

Poster 212 Musculoskeletal Disorders of Upper Limbs Functional Compromise, Evaluator's Perspective

Participants: Men and women (N 38; 25.5 5.4 years; 18% women) playing in the All Florida Tournament, December 2010. Average weekly play was 2.3 1.1 days. Interventions: A deidentified survey was provided to participants of the HBP tournament. Main Outcome Measures: Main outcomes of the survey included number of annual injuries, location, nature and type of injury, helmet use and medical attention sought and received. Results: 42.1% reported no annual injury. Those who reported, experienced 1 major injury; 55.3% of players reported new injuries; 2.6% reported old injuries. The most common injury sites were the lower extremity (48% of all injuries) and the upper extremity (38% of all injuries). Among lower extremity injuries, the most frequent sites were the calf and/or shin (3), the ankle (3), and the knee (2). Upper extremity injuries occurred in the hand (3) and wrist (2), with the remaining locations along the arm to the shoulder. Injury severity ranged from bone fractures (30%) and abrasions and/or cuts (22%); the remaining injuries were composed of muscle strains, hematomas, and various other soft-tissue injuries. Collisions with the ground, with other players, and with equipment were the 3 main causes. Helmet use was confirmed by 28.9% of players when the injury was sustained; 29% of players (6) sought medical attention, 3 cases of which were emergent. Conclusions: Main sites of injury were those in distal locations (calf, ankle, hand). Protective gear for the hand and lower leg may reduce injury rates specific to this sport. Medical providers should be prepared to assess and treat the variety of bone and soft-tissue injuries seen in these athletes.

Poster 121 Encephalomyelopathy With Vitamin B12 Deficiency. A Case Report

Disclosures: J. Diaz-Ruiz, none. Patients or Programs: A 77-year-old man with progressive gait abnormality and behavioral and cognitive abnormalities. Program Description: A 77-year-old man with a history of chronic alcohol abuse and chronic gastritis was referred to the physiatrist due to lower limb weakness. He had paresthesia in his hands and feet of 1 year, with progressive lower limb weakness, gait abnormality, frequent falling, and instability. He also presented with recent memory loss, visual hallucinations, delirium, and irritability. Seven months after onset of symptoms, he became wheelchair bound. On physical examination, he had lower limb spasticity, vibratory and thermal sensory abnormalities, areflexia, and Babinski sign. A Functional Independence Measure of 50 was established. The patient’s history did not reveal preexisting diseases. Cervical and thoracic magnetic resonance imaging showed posterior myelopathy. The N19 latency was significantly prolonged on median somatosensory evoked potentials, and a posterior tibial somatosensory evoked potential had an absent P45. Nerve conduction studies and electromyography were both normal. Laboratory tests showed megaloblastic anemia and low vitamin B12 levels. Cyanocobalamin was started. Setting: A university hospital. Results: Three months after cyanocobalamin administration, improvement in gait was observed. The patient could walk with a cane, and cognitive and psychiatric symptoms improved. The Functional Independence Measure score improved to 106; N19 and P45 also improved. Discussion: This is a typical case of cyanocobalamin deficiency with encephalomyelopathy that markedly improved with vitamin B12 administration despite the severity of symptoms. Conclusions: Cyanocobalamin deficiency is an important cause of myelopathy and of psychiatric and cognitive symptoms in the elderly that produces severe functional impairment and that dramatically improves with the administration of the vitamin.

Poster 72: Validation of Alteration Electrophysiologic Scale in Patient With Lumbosacral Radiculopathy

analysis. The factors obtained were compared with NCS and a neurophysiological grading scale for CTS. Results: Factor analysis showed that 3 factors represented 60% of variance of BCTQ. Factor 1 relates to all the function domain questions and to the weakness and difficult of grasping questions of symptom domain (P .05). Factor 2 relates to numbness and tingling questions and to the pain-awakening question of the symptom domain (P .01). Factor 3 relates to pain questions of the symptom domain (P .05). Factor 2 had a stronger correlation with latencies and latencies differences of NCS, and with the neurophysiological scale than the other 2 factors (Factor 1 and 3) (P .01). Conclusions: BCTQ indeed assesses function and symptoms of patients with CTS by means of questions related to numbness and tingling, pain, and functional status. Among questions of BCTQ, those related to numbness and tingling correlate better with electrophysiologic abnormalities distinctive of CTS and to the neurophysiologic severity of the disease, and better reflect the pathophysiology of median nerve in CTS.

Poster 99: Assessment of Functional Limitation for Musculoskeletal Disorders in Upper Limbs Using Quick DASH Questionnaire: A Transversal Study

Disclosures: G. A. Sowa, None. Objective: Mechanical loading has been shown to affect intervertebral disk matrix homeostasis. We have previously demonstrated that compression results in a time and magnitude dependent alteration in expression of genes involved in matrix homeostasis in vitro. The current study extends this work into an animal model to characterize the effects of chronic cyclic compression on intervertebral disk collagen homeostasis in vivo. Design: Controlled laboratory animal study. Setting: Laboratory. Participants: NA. Interventions: Cyclic axial compression was applied in vivo to a functional spine unit in New Zealand white rabbits via a novel custom designed loading apparatus at 2.5 MPa at 0.5 Hz (low frequency) and 5.0 Hz (high frequency) for 2 h/d, 5 d/wk. Main Outcome Measures: Serum was collected after 18, 24, 28, 34, and 38 weeks of loading and analyzed for CTX-II (a marker of collagen II breakdown). After sacrifice, the annulus fibrosis (AF) and nucleus pulposus (NP) were harvested from the loaded segments. Gene expression analysis was used to compare collagen II expression to unloaded controls. Results: Serum CTX-II levels were higher in the high-frequency animals than low frequency or control animals at all time points. Low-frequency animals demonstrated elevation of CTX-II levels over controls only after 38 weeks of loading. In the AF, gene expression of collagen II was decreased compared with control at 10 weeks in the low-frequency group but elevated in both low and high frequency groups after 30 weeks of loading and in all NP samples. Conclusions: Collagen remodeling appears to become more apparent after increased durations of loading as demonstrated by time dependent increases in collagen II gene expression in the annulus and increased collagen II breakdown, as indicated by increased CTX-II levels. Future histological evaluation will be required to determine the significance of these molecular changes on overall matrix structure.

Poster 71: Structure and Factor Analysis of Boston Carpal Tunnel Syndrome Questionnaire in Relation to Nerve Conduction Studies

Disclosures: A. Morchower, None. Objective: To evaluate whether lidocaine iontophoresis performed before needle electromyography (EMG) will mitigate pain experienced during EMG. Design: This was a prospective, randomized, placebo-controlled, double-blinded study. 14 subjects were randomized to lidocaine (4%) or placebo (normal saline) groups. A research pharmacist provided the blinded medication. Setting: Hospital-based, outpatient EMG clinic. Participants: Subjects were recruited from patients scheduled for bilateral upper extremity EMG. Local institutional review board approval was obtained. Interventions: All subjects provided informed consent. A total of 40 mA.min of iontophoresis was administered over the left opponens policis (OP) with either normal saline (placebo) or lidocaine 4% (active). The right OP was untreated. Bilateral OP muscles were then examined using a monopolar EMG needle. Main Outcome Measures: Immediately after the EMG examination, subjects rated their pain on a 10-cm Visual Analog Scale (VAS) and stated whether or not they preferred the iontophoresis. Results: All 14 subjects completed the study. Paired t tests and Wilcoxon signed rank tests were performed to evaluate group differences. The mean ( SD) VAS score of the untreated side was 6.61 (1.96) and the treated side was 4.63 (2.90). A paired t-test revealed a significant difference between them (P .05). However, there were no significant differences between the untreated and treated sides in either treatment group (lidocaine group: 7.29 1.56 vs 5.63 3.12; P .19 and placebo group: 5.93 2.19 vs 3.63 2.48; P .1), indicating a placebo effect. Comparing the lidocaine and placebo groups on the treated side revealed no significant differences either (P .22). 71% of the subjects preferred to have the iontophoresis treatment. Conclusions: Iontophoresis before needle EMG significantly reduces pain associated with it. However, there is an apparent placebo effect as there were no statistical differences noted between the treated and untreated hands in either the placebo or the lidocaine group. Further studies are needed to determine if lidocaine iontophoresis is beneficial to use in the clinical setting. Poster 70 Nerve Conduction Study for Median Nerve Using Ultrasonography. Sangchul Lee, MD, PhD (Myongji Hospital, Koyang, Kyunggi, Republic of Korea).