Assessment of Pain During Nerve Conduction Studies in Patients With Carpal Tunnel Syndrome.

Purpose: Patients with suspected carpal tunnel syndrome (CTS) often undergo nerve conduction studies (NCSs). Although patients sometimes complain of NCS-related discomfort, including severe pain, pain evaluations during such NCSs are lacking. We aimed to measure the pain experienced by patients with CTS during NCSs. Methods: This prospective study included 30 patients with CTS who underwent NCSs between April 2018 and March 2019. Pain because of electrical stimulation during NCSs was evaluated using a visual analog scale, and we statistically analyzed pain-related factors such as age, sex, complications, severity grading scale, the intensity of maximum stimulation, and examination time. Results: The mean visual analog scale score for NCSs was 5.2, and the visual analog scale score increased as the intensity of maximum stimulation and examination time increased. Conclusions: We measured the pain because of electrical stimulation experienced by patients with CTS during NCSs. Our findings indicate that medical staff must be mindful of the potential pain experienced by patients during NCSs and educate patients regarding the necessity of the examination and its procedures. Type of study/level of evidence: Diagnostic Ⅳ.

Assessment of thoracic spinal cord electrophysiological activity through magnetoneurography.

OBJECTIVE: Noninvasive and detailed visualization of electrophysiological activity in the thoracic spinal cord through magnetoneurography. METHODS: In five healthy volunteers, magnetic fields around current flowing in the thoracic spinal cord after alternating unilateral and synchronized bilateral sciatic nerve stimulation were measured using a magnetoneurograph system with superconductive quantum interference device biomagnetometers. The current distribution was obtained from the magnetic data by spatial filtering and visualized by superimposing it on the X-ray image. Conduction velocity was calculated using the peak latency of the current waveforms. RESULTS: A sufficiently high magnetic signal intensity and signal-to-noise ratio were obtained in all participants after synchronized bilateral sciatic nerve stimulation. Leading and trailing components along the spinal canal and inward components flowing into the depolarization site ascended to the upper thoracic spine. Conduction velocity of the inward current in the whole thoracic spine was 42.4 m/s. CONCLUSIONS: Visualization of electrophysiological activity in the thoracic spinal cord was achieved through magnetoneurography and a new method for synchronized bilateral sciatic nerve stimulation. Magnetoneurography is expected to be a useful modality in functional assessment of thoracic myelopathy. SIGNIFICANCE: This is the first report to use magnetoneurography to noninvasively visualize electrophysiological activity in the thoracic spinal cord in detail.

Remote rehabilitation for patients with COVID-19.

OBJECTIVE: To describe the effectiveness and risk management of remote rehabilitation for coronavirus disease (COVID-19) patients. DESIGN: Single-centre, retrospective, observational study. PATIENTS: COVID-19 patients undergoing rehabilitation (24 April to 24 May 2020). METHODS: All COVID-19 inpatients undergoing rehabilitation in the general ward were assessed. Data were collected on age, sex, physical ability, rehabilitation modality (remote/direct), need for intubation or extracorporeal membrane oxygenation, degree of pneumonia, oxygen therapy from the start of rehabilitation, D-dimer and C-reactive protein levels, and rehabilitation-related complications. Activities of daily living were measured using the Barthel Index. RESULTS: Out of a total of 43 patients, 14 were initially provided with remote rehabilitation and 29 with direct rehabilitation. Four patients were switched from direct to remote rehabilitation during the study, thus at the end of the study there were 18 in the remote rehabilitation group and 25 in the direct rehabilitation group. Patients in remote rehabilitation were significantly younger than those in direct rehabilitation. Of 12 patients who required intubation, 3 were given remote rehabilitation. One extracorporeal membrane oxygenation survivor underwent direct rehabilitation. All patients on remote rehabilitation were discharged home or to a hotel. Twelve out of 29 patients were transferred to a rehabilitation hospital due to delayed recovery of activities of daily living. No serious adverse events occurred. CONCLUSION: Effective and safe remote rehabilitation was performed in 41.9% of COVID-19 patients in this study, which resulted in improved rehabilitation in COVID-19 zones.

Assessment of grip-motion characteristics in carpal tunnel syndrome patients using a novel finger grip dynamometer system.

BACKGROUND: Grip strength measurement is widely used in daily medical practice, and it has been reported that the grip strength decreases in patients with carpal tunnel syndrome (CTS). However, conventional grip dynamometers evaluate only the maximum power of total grip strength and cannot measure the time course of grip motion. In this report, we aimed to determine the grip characteristics of CTS patients by measuring the time course of each finger's grip motion and to analyze the relationship between finger grip strength and subjective symptoms using this new grip system. METHODS: The grip strength of each finger was measured using the new grip system that has four pressure sensors on the grip parts of each finger of the Smedley grip dynamometer. We analyzed the time course of grip motion and relationship between finger grip strength and subjective symptoms in 104 volunteer and 51 CTS hands. The Japanese Society for Surgery of the Hand version of the Carpal Tunnel Syndrome Instrument (CTSI-JSSH) and the Disability of Arm, Shoulder, and Hand questionnaire (DASH) were used as subjective evaluation scores. RESULTS: In the CTS group, the grip time with the index, middle, and ring fingers was longer, and the time at which strength was lost after reaching the maximum was earlier. Patients with severe subjective symptoms tended to not use the index and middle fingers during grip motion. CONCLUSIONS: This new system that measures each finger's grip strength at one time and record the time course of grip motion could quantify a patient's symptoms easily and objectively, which may contribute to the evaluation of hand function.

Comparison of Perioperative Complications in Anterior Decompression With Fusion and Posterior Decompression With Fusion for Cervical Ossification of the Posterior Longitudinal Ligament: Propensity Score Matching Analysis Using a Nation-Wide Inpatient Database.

STUDY DESIGN: A retrospective comparative study. OBJECTIVE: To compare the perioperative complications and costs of anterior decompression with fusion (ADF) and posterior decompression with fusion (PDF) for patients with cervical ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA: Surgical treatment of cervical OPLL has a high risk of various complications. ADF and PDF are effective for the treatment of cervical OPLL; however, few studies have compared the two procedures in terms of the perioperative surgical complications. METHODS: Patients undergoing ADF and PDF for cervical OPLL from 2010 to 2016 were identified in a nation-wide inpatient database. We investigated systemic and local complications, length of hospital stay, costs for hospitalization, reoperation, and mortality. Propensity score was calculated from patients' characteristics and preoperative comorbidities, and one to one matching was performed. RESULTS: Propensity score-matching produced 854 pairs of patients who underwent ADF and PDF. The rate of at least one systemic complication was significantly higher in the ADF group (P = 0.004). The incidence rates of postoperative respiratory failure (P = 0.034) and dysphagia (P = 0.008) were significantly higher in the ADF group. The rates of pneumonia (P = 0.06) and hoarseness (P = 0.08) also tended to be higher in the ADF group. However, no difference was found in the mortality rate (P = 0.22). In the local complications, spinal fluid leakage was significantly higher in the ADF group (P < 0.001). However, blood transfusion rate was significantly higher in the PDF group (P = 0.001). Hospital stay was significantly longer in the PDF group (P < 0.001) and the cost for hospitalization was greater in the PDF group (P < 0.001). CONCLUSION: The present study demonstrated that perioperative complications, such as respiratory failure, dysphagia, and spinal fluid leakage, were more common in the ADF group. However, hospital stay was longer in the PDF group, and the cost for hospitalization was greater in the PDF group. LEVEL OF EVIDENCE: 3.

Location of atypical femoral fracture can be determined by tensile stress distribution influenced by femoral bowing and neck-shaft angle: a CT-based nonlinear finite element analysis model for the assessment of femoral shaft loading stress.

INTRODUCTION: Loading stress due to individual variations in femoral morphology is thought to be strongly associated with the pathogenesis of atypical femoral fracture (AFF). In Japan, studies on AFF regarding pathogenesis in the mid-shaft are well-documented and a key factor in the injury is thought to be femoral shaft bowing deformity. Thus, we developed a CT-based finite element analysis (CT/FEA) model to assess distribution of loading stress in the femoral shaft. PATIENTS AND METHODS: A multicenter prospective study was performed at 12 hospitals in Japan from August 2015 to February 2017. We assembled three study groups-the mid-shaft AFF group (n=12), the subtrochanteric AFF group (n=10), and the control group (n=11)-and analyzed femoral morphology and loading stress in the femoral shaft by nonlinear CT/FEA. RESULTS: Femoral bowing in the mid-shaft AFF group was significantly greater (lateral bowing, p<0.0001; anterior bowing, p<0.01). Femoral neck-shaft angle in the subtrochanteric AFF group was significantly smaller (p<0.001). On CT/FEA, both the mid-shaft and subtrochanteric AFF group showed maximum tensile stress located adjacent to the fracture site. Quantitatively, there was a correlation between femoral bowing and the ratio of tensile stress, which was calculated between the mid-shaft and subtrochanteric region (lateral bowing, r=0.6373, p<0.0001; anterior bowing, r=-0.5825, p<0.001). CONCLUSIONS: CT/FEA demonstrated that tensile stress by loading stress can cause AFF. The location of AFF injury could be determined by individual stress distribution influenced by femoral bowing and neck-shaft angle.

Values and risks of second opinion in Japan's universal health-care system.

BACKGROUND: Second opinion (SO) is widely recognized in Japan, but we do not know how patients view and use SO. OBJECTIVES: To investigate optimum seeking of SO in Japan's universal health-care system. DESIGN, PARTICIPANTS, AND METHODS: Survey of patients at Tokyo Medical and Dental University Hospital. Of 365 responses, 67 had experienced SO with standardized protocol at SO Clinic; 82 had obtained SO elsewhere without instruction; 216 had never sought SO. MAIN OUTCOME MEASURES: Views of values and risks of SO. RESULTS: Second opinion patients with standardized protocol better understood their illness, treatment options, individualized plan, and uncertainty in medicine, and also reported improved decision making compared with SO patients without the protocol (P < 0.05). However, more than half of respondents misunderstood SO as a way to change doctors or treatment. Second opinion respondents (n = 149) had a propensity to request treatment changes (P < 0.1) and more than one-third (n = 82) did not tell SO doctor they were being treated by another doctor. The absolute majority of non-SO patients would seek SO for a serious illness but would hesitate to tell their doctors. DISCUSSION AND CONCLUSION: Respondents recognized value of SO to improve understanding and decision making. This study also found risks in SO misuse which may be reinforced by Japan's cultural tendencies and universal health-care system. Our findings suggest steps to increase the benefit of SO: ensure involvement of original doctor, instruct patients about SO and help them organize their thinking before SO and facilitate patients' return to the treating doctor for discussion and decision making.