Kenan Akgun

Winged scapula caused by a dorsal scapular nerve lesion: a case report.

Dorsal scapular nerve lesions are quite rare. A case of a 51-year-old man who had right shoulder pain, weakness of right arm elevation, and prominence of right scapula for 6 months is presented. The condition had been abruptly developed after lifting a heavy box overhead on which he felt a sharp pain in the right shoulder. On clinical examination, there was a prominence of the lower medial border and inferior angle of the right scapula compared with the left. In addition, the right scapula was located more lateral. Magnetic resonance imaging of the thorax revealed the presence of a thinner rhomboid major muscle with a pathologic signal compared with the other side. Needle electromyography of the right rhomboid muscle revealed a long duration, polyphasic motor unit potential with reinnervation potentials, and spontaneous activity. According to these findings, the patient was diagnosed as having a winged scapula because of dorsal scapular nerve lesion.

Conservative treatment for late-diagnosed spinal accessory nerve injury.

Akgun K, Aktas I, Uluc K: Conservative treatment for late-diagnosed spinal accessory nerve injury. Am J Phys Med Rehabil 2008;87:1015–1021. Objective:Spinal accessory nerve (SAN) injuries cause considerable shoulder joint dysfunction and pain, but are often underdiagnosed or diagnosed late. The aim of this study was to present the clinical and electrophysiological features and response to conservative treatment of the patients with late-diagnosed SAN injury. Design:Nine patients diagnosed with SAN injury based on clinical and electrophysiological examinations were evaluated. All patients were treated with a standard physical therapy and rehabilitation program and then received home exercise program. Shoulder pain during rest and activity and pain causing sleep disturbances were evaluated using a visual analog scale. Constant scale investigated shoulder function. Shoulder disability questionnaire evaluated daily living activities. Results were assessed before treatment, after one month of treatment, and years after treatment. Results:According to the electrophysiological studies, seven patients had partial and two patients had total axonal SAN injuries. The delay from the time of injury to diagnosis ranged between 12 and 84 mo (median 14 mo). When compared with the baseline values, visual analog scale, Constant scale, and shoulder disability questionnaire scores were significantly improved in all of the patients. Conclusions:For patients with late-diagnosed SAN injury, conservative treatment seems to be an effective treatment option.

Risk of falls in patients with ankylosing spondylitis.

BackgroundRisk of vertebral fractures is increased in patients with ankylosing spondylitis (AS). The underlying mechanisms for the elevated fracture risk might be associated with bone and fall-related risks. The aims of this study were to evaluate the risk of falls and to determine the factors that increase the risk of falls in AS patients. MethodsEighty-nine women, 217 men, a total of 306 AS patients with a mean age of 40.1 ± 11.5 years from 9 different centers in Turkey were included in the study. Patients were questioned regarding history of falls within the last 1 year. Their demographics, disease characteristics including Bath AS Disease Activity Index, Bath AS Metrology Index (BASMI), Bath AS Functional Index (BASFI), and risk factors for falls were recorded. The Short Physical Performance Battery (SPPB) test was used for evaluation of static and dynamic balance. Erythrocyte sedimentation rate, C-reactive protein, and 25-hydroxyvitamin D levels were measured. ResultsForty of 306 patients reported at least 1 fall in the recent 1 year. The patients with history of falls had higher mean age and longer disease duration than did nonfallers (P = 0.001). In addition, these patients’ BASMI and BASFI values were higher than those of nonfallers (P = 0.002; P = 0.000, respectively). We found that the patients with history of falls had lower SPPB scores (P = 0.000). We also found that the number of falls increased with longer disease duration and older age (R = 0.117 [P = 0.041] and R = 0.160 [P = 0.005]). Our results show that decreased SPPB scores were associated with increased number of falls (R = 0.183, P = 0.006). Statistically significant correlations were found between number of falls and AS-related lost job (R = 0.140, P = 0.014), fear of falling (R = 0.316, P = 0.000), hip involvement (R = 0.112, P = 0.05), BASMI (R =0.234, P = 0.000), and BASFI (R = 0.244, P = 0.000). ConclusionsAssessment of pain, stiffness, fatigue, and lower-extremity involvement as well as asking for a history of falls will highlight those at high risk for further falls. In addition to the general exercise program adopted for all patients, we suggest that a balance rehabilitation program should be valuable for the patients with risk factors for fall. Exercise may improve fear of falling and BASFI and BASMI scores. However, further study is needed to investigate these hypotheses. We believe that clinicians should train and support the patients via reducing fear of falls and maintaining good posture and functional capacity.

Lateral Pectoral Nerve Injury Mimicking Cervical Radiculopathy.

Abstract:The lateral pectoral nerve (LPN) is commonly injured along with the brachial plexus, but its isolated lesions are rare. Here, we present a case of an isolated LPN lesion confused with cervical radiculopathy. A 41-year-old man was admitted to our clinic because of weakness in his right arm. Previous magnetic resonance imaging (MRI) examination revealed right posterolateral protrusion at the C6-7 level. At the initial assessment, atrophy of the right pectoralis major muscle was evident, and mild weakness of the right shoulder adductor, internal rotator, and flexor muscles was observed. Therefore, electrodiagnostic evaluation was performed, and a diagnosis of isolated LPN injury was made. Nerve injury was thought to have been caused by weightlifting exercises and traction injury. Lateral pectoral nerve injury can mimic cervical radiculopathy, and MRI examination alone may lead to misdiagnosis. Repeated physical examinations during the evaluation and treatment phase will identify the muscle atrophy that occurs 1 or more months after the injury.

The clinical importance of the thyroid nodules during anti-tumor necrosis factor therapy in patients with axial spondyloarthritis

The clinical importance of the thyroid nodules in patients with axial spondyloarthritis (ax-SpA) rests with the need to exclude thyroid malignancy. The aim of this study is to assess the risk of thyroid malignancy in ax-SpA patients receiving anti-TNF therapy. From September 2015 until December 2015, 70 patients diagnosed with ax-SpA were included in the research. Forty of the patients had received anti-TNF therapy, and 30 of the patients were anti-TNF naive. All cases were screened for the presence of nodules in the thyroid gland with ultrasound. Of the patients that received anti-TNF therapy, 15 (37.5%); and of the anti-TNF naive patients, 11 (36.7%) had thyroid nodule(s). Four patients from the anti-TNF group underwent fine needle aspiration biopsy of the nodules, and two of them were diagnosed with papillary thyroid carcinoma. None of the nodules in anti-TNF naive patients required biopsy. When compared to the normal population, the standardized incidence ratio (SIR) was found to be increased in both male (SIR 2.03, 95% CI 1.9 to 18) and female (SIR 2.7, 95% CI 2.6 to 24) cases. It is not yet established whether the development of cancer during the treatment process is the effect of the treatment or if it is a part of the natural course of the disease or if it is coincidental. We saw a mild increase in thyroid malignancies in ax-SpA patients who received anti-TNF therapy. Therefore, we believe that the thyroid gland should also be taken into consideration while screening for malignancy before anti-TNF therapy.

Scapular winging in Poland syndrome

Poland syndrome (PS), which was first described in 1841 by Sir Alfred Poland, is characterized by the unilateral absence of the sternal head of the pectoralis major muscle, hypoplasia of the rib cage and upper extremities, breast and nipple hypoplasia or aplasia, and scoliosis.1 The majority of the reported cases are sporadic; however, the disease may be inherited as an autosomal dominant trait.2 This disease tends to occur more frequently in males and most often involves the right side of the body.3 Scapular winging is a rare but potentially debilitating condition that impairs a persons ability to perform his or her activities of daily living.4 Postural deformities can also negatively impact ones quality of life during childhood and adulthood.5 The current work presents the case study of an 18-year-old youth with scapular winging that was associated with PS. In this work, we also describe the pain that was associated with PS, which is rarely mentioned in cases of PS. Case Report An 18-year-old youth with no history of trauma presented with complaints of pain and limited left shoulder activity over the previous two years. Upon physical examination, the left nipple and areola were observed to be hypoplastic and lightly pigmented (Fig. 1). In addition, thoracic vertebral scoliosis and an elevated scapula were observed (Fig. 2). Active myofascial trigger points were detected in the left upper trapezius, levator scapula, and infraspinatus muscles. The left shoulder exhibited a limited range of motion and was painful during flexion and abduction when compared to the right shoulder. Open in a separate window Figure 1 The absence of the pectoralis muscles and nipple hypoplasia on the left side. Also note the hypoplasia of the left serratus anterior muscle.

Letter to the editor involving the article ‘Piriformis muscle syndrome: A cross-sectional imaging study in 116 patients and evaluation of therapeutic outcome’

Key Points• Lack of use of local injection test to confirm the diagnosis may lead to miss the diagnosis of PMS of myofascial origin.• Piriformis muscle syndrome should be diagnosed on the basis of clinical symptoms, specific physical examinations, and positive response to local injection.• Sciatic nerve entrapment is not a must in the diagnosis of PMS and PMS is mostly myofascial in origin.

Ultrasound‐Guided Diagnosis and Injection of the Lateral Femoral Cutaneous Nerve with an Anatomical Variation

Meralgia paresthetica (MP) is an entrapment neuropathy of the lateral femoral cutaneous nerve (LFCN). There are many variations in the course of the LFCN. A 55‐year‐old woman presented with pain and tingling sensations on the anterolateral aspect of her left thigh. Physical examination revealed hypoesthesia of the proximal anterolateral thigh on the left side. During the electrodiagnostic study, sensory nerve action potential of the LFCN could not be obtained on both sides. Through those clinical and electrophysiological findings, we prediagnosed the case as MP and planned to perform diagnostic nerve block. For the injection to perform, ultrasonography was used. During the ultrasonographic evaluation, the left LFCN was visualized lateral to the anterior superior iliac spine (ASIS). Then ultrasound‐guided nerve block with 2 cc lidocaine 2% for diagnostic purpose was performed in this region. Immediately after the injection, the patients complaints relieved completely, and hence the patient was diagnosed as having MP with an LFCN anatomical variation. Two months later her complaints persisted, and ultrasound‐guided LFCN injection with 2 mL of lidocaine 2% + 1 cc of betametazone was performed. One month after the second injection, her complaints were relieved markedly and she resumed her daily activities. In conclusion, the course of the LFCN is quite variable. We present a relatively rare anatomical variation of the LFCN, crossing lateral to the ASIS, diagnosed with ultrasonography. Ultrasonography can be performed to visualize the LFCN, especially a nerve with an anatomical variation.

Reliability and validity of the Turkish version of the fibromyalgia rapid screening tool (FiRST)

[Purpose] An easy-to-use, psychometrically validated screening tool for fibromyalgia is needed. This study aims to evaluate the reliability and validity of the Turkish version of the Fibromyalgia Rapid Screening Tool by correlating it with 2013 American College of Rheumatology alternative diagnostic criteria and the Hospital Anxiety and Depression Scale. [Subjects and Methods] Subjects were 269 Physical Medicine and Rehabilitation clinic outpatients. Patients completed a questionnaire including the Fibromyalgia Rapid Screening Tool (twice), 2013 American College of Rheumatology alternative diagnostic criteria, and the Hospital Anxiety and Depression Scale. Scale reliability was examined by test-retest. The 2013 American College of Rheumatology alternative diagnostic criteria was used for comparison to determine criterion validity. The sensitivity, specificity, and positive and negative likelihood ratios were calculated according to 2013 American College of Rheumatology alternative diagnostic criteria. Logistic regression analysis was conducted to find the confounding effect of the Hospital Anxiety and Depression Scale on Fibromyalgia Rapid Screening Tool to distinguish patients with fibromyalgia syndrome. [Results] The Fibromyalgia Rapid Screening Tool was similar to the 2013 American College of Rheumatology alternative diagnostic criteria in defining patients with fibromyalgia syndrome. Fibromyalgia Rapid Screening Tool score was correlated with 2013 American College of Rheumatology alternative diagnostic criteria subscores. Each point increase in Fibromyalgia Rapid Screening Tool global score meant 10 times greater odds of experiencing fibromyalgia syndrome. [Conclusion] The Turkish version of the Fibromyalgia Rapid Screening Tool is reliable for identifying patients with fibromyalgia.

THU0387 The clinical importance of the thyroid nodules during tumor necrosis factor-alpha inhibitor therapy in patients with axial spondyloarthritis

Background TNF is a pivotal regulator of inflammation and the cytokine system. Besides this, there is no doubt that TNF has a major role in cancer biology. TNF has a dual defensive and offensive role in carcinogenesis (1). TNF-blocking treatment has led to improvements in the management of inflammatory diseases.Even though their efficacy as anti-inflammatory drugs is well-proven, there are some concerns about the adverse effects of anti-TNF therapy (2). Basic research suggests that the evaluation of infections and malignancy as major adverse effects should be performed effectively (3). However, some studies conducted so far have dubious notions that anti-TNF therapy increases the risk of cancer (3,4). Objectives Objective: The clinical importance of the thyroid nodules in patients with axial spondyloarthritis (ax-SpA) rests with the need to exclude thyroid malignancy. The aim of this study is to assess the risk of thyroid malignancy in ax-SpA patients receiving anti-TNF therapy. Methods From September 2015 until December 2015, 70 patients diagnosed with ax-SpA according to ASAS criteria, were included in the research. Forty of the patients had received anti-TNF therapy, and 30 of the patients were anti-TNF naive. A clinician from the Physical Medicine and Rehabilitation clinic performed ultrasonography on all patients to screen for thyroid nodule(s). If thyroid ultrasonography revealed an abnormal finding, the patient was referred to a radiologist. Results The mean (SD) age was 38±9.87 years; % 75.7 of the patients were male. None of the demographic differences between the groups were statistically significant. Fifteen of the forty patients that received anti-TNF therapy and eleven of the thirty anti-TNF naive patients had thyroid nodule(s). Four patients from the anti-TNF group underwent fine needle aspiration biopsy, and two of them were diagnosed with papillary thyroid carcinoma. None of the nodules in anti-TNF naive patients required biopsy. When compared to the normal population, the standardized incidence ratio (SIR) was found to be increased in both male (SIR: 2.03% 95 CI: 1.9 to 18) and female (SIR: 2.7% 95 CI: 2.6 to 24) cases. Conclusions We see a mild increase in thyroid malignancies in ax-SpA patients that received anti-TNF therapy. Consequently, the thyroid gland should also be taken into consideration while screening for malignancy before anti-TNF therapy. References Wajant, Harald. The role of TNF in cancer. Death Receptors and Cognate Ligands in Cancer. Springer Berlin Heidelberg, 2009. 1–15. Dixon, W. G., et al. Influence of anti-tumor necrosis factor therapy on cancer incidence in patients with rheumatoid arthritis who have had a prior malignancy: results from the British Society for Rheumatology Biologics Register. Arthritis care & research 62.6 (2010): 755–63. Bongartz, Tim, et al. Anti-TNF antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systematic review and meta-analysis of rare harmful effects in randomized controlled trials. Jama 295.19 (2006): 2275–85. Askling, Johan, et al. Risks of solid cancers in patients with rheumatoid arthritis and after treatment with tumour necrosis factor antagonists. Annals of the rheumatic diseases 2005;64:1421–6. Disclosure of Interest None declared