Recurrent Acute Disseminated Encephalomyelitis Presenting as Conus Medullaris Syndrome: A Case Report.

Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disorder that typically follows an infection or recent vaccination. Symptoms such as encephalopathy and focal neurological deficits appear weeks after the initial illness, leading to swift and progressive neurological decline. While ADEM in the brain has been well documented, reports of ADEM, specifically in the spinal cord, are relatively limited. A 58-year-old male presented with rapidly progressive bilateral lower extremity tingling, numbness, and mild gait disturbance approximately two days prior to visiting the emergency room. Spinal magnetic resonance imaging revealed a diffuse, longitudinal, high-signal lesion with mild enlargement of the conus and proximal cauda equina. The lesions were predominantly localized in the distal conus and cauda equina, and serial electrodiagnostic studies showed that the lesions progressed toward the proximal conus in tandem with symptom evolution and lacked clear lateralization. The patient was subsequently treated with high-dose steroids for seven days (intravenous methylprednisolone, 1 mg/kg). The patient's lower extremity weakness gradually improved and he was able to walk independently under supervision three weeks after symptom onset. In this case of spinal ADEM in a middle-aged adult, high-dose steroid treatment led to outstanding neurological recovery from both the initial occurrence and subsequent attacks.

Safe Approach for Flexor Digitorum Profundus I and II Using the Palmaris Longus Tendon.

OBJECTIVE: To investigate a safe and accurate approach to achieve needle insertion for electromyography (EMG) of the flexor digitorum profundus (FDP) I and II muscles by identifying the anatomic relationship between the palmaris longus (PL) tendon, FDP muscle, and neurovascular bundle using ultrasonography. DESIGN: Descriptive study SETTING: Department of physical medicine and rehabilitation. PARTICIPANTS: Healthy individuals (age, 20-70y) without any diseases (N=29; 15 men, 14 women; 58 forearms). INTERVENTIONS: Ultrasonography. MAIN OUTCOME MEASURES: The FDP I and II muscles were transversely scanned on the volar aspect of the forearm at the junction of the middle and distal third between the medial epicondyle and ulnar styloid process. The distances and angles from the medial border of the PL tendon to FDP I, FDP II, and median nerve were measured. RESULTS: The probability of damage to the neurovascular structures and the accuracy of entering the FDP I and II muscles were calculated for 3 imaginary needle insertion angles (61.7°, 100.6°, and 90°). When the needle was inserted at an angle of 61.7°, it reached FDP I with an accuracy of 91.4%. Upon needle insertions at 90° and 100.6°, the needle reached FDP II with accuracies of 90% and 89.6%, respectively. In all 3 cases (61.7°, 90°, and 100.6°), there was no chance of penetrating the blood vessels or nerves. CONCLUSION: EMG of FDP I and II can be performed precisely and safely with the anterior approach at the distal one-third between the medial epicondyle and ulnar styloid process using the PL tendon.

Comparison of Cervical Biportal Endoscopic Spine Surgery and Anterior Cervical Discectomy and Fusion in Patients with Symptomatic Cervical Disc Herniation.

Background: We aimed to analyze the clinical outcomes and effectiveness of cervical biportal endoscopic spine surgery (C-BESS) and anterior cervical discectomy and fusion (ACDF) in patients with symptomatic cervical disc herniation. Methods: This study was a retrospective chart review of four-year clinical data involving 318 cases of symptomatic cervical disc herniation, with 156 patients undergoing the ACDF and 162 patients receiving the C-BESS. Preoperative and postoperative one-year data were collected. Results: The numeric rating scale and neck disability index showed statistically significant improvement for both ACDF and C-BESS groups. While showing a longer operation time and more blood loss during surgery compared to the ACDF group, the C-BESS group demonstrated a learning effect as the surgeon's proficiency increased with more cases. There was no significant difference in the postoperative length of hospitalization between the two methods. The subgroup with predominant arm pain revealed the statistical difference in arm pain intensity changes between the two groups (p < 0.001). The rates of complication were 2.6% for the ACDF group and 1.9% for the C-BESS group. Conclusions: C-BESS and ACDF are effective surgical treatments for patients with symptomatic single-level cervical disc herniation in relieving relevant pain intensities and pain-related disabilities.

Short-Term Impact of Low-Intensity Exercise with Blood Flow Restriction on Mild Knee Osteoarthritis in Older Adults: A Pilot Study.

This pilot study aimed to investigate the immediate impact of low-intensity exercises with blood flow restriction (BFR) on older adults with knee osteoarthritis (KOA). Fifteen patients with KOA who were over 50 years old, participated and underwent low-intensity resistance knee exercises at 30% of their one-repetition maximum with BFR three times/week for two weeks. Pre- and post-exercise assessments included pain levels, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, isokinetic knee strength, lower extremity muscle volume (via leg circumference and muscle thickness), functional performance tests (timed up-and-go [TUG] and sit-to-stand [STS]), skeletal muscle index (SMI) using bioelectrical impedance analysis, and handgrip strength (HGS). Post-exercise, there was a significant reduction in pain. WOMAC scores showed significant improvements across all three domains: pain, stiffness, and physical function. In the TUG and STS tests, completion times were significantly reduced. Thigh and calf circumferences, as well as thigh muscle thickness significantly increased after exercise. Post-exercise SMI and HGS also significantly increased. However, isokinetic knee strength did not show significant changes. In conclusion, low-intensity BFR exercises provide immediate benefits in symptoms and physical performance for patients with KOA, potentially inducing local and systemic muscle mass increase, even after a short-term intervention.

Intraneural ganglion cyst of the peroneal nerve occurring after coronavirus disease-19 vaccination: A case report.

Ganglion cysts are relatively common, but intraneural ganglion cysts (INGCs) within peripheral nerves are rare and poorly understood. We present the case of a 58-year-old woman who presented with acute right-foot drop. She experienced acute knee pain radiating from the lateral leg to the dorsal foot two days after the first coronavirus disease-19 (COVID-19) vaccination (BNT162b2, Pfizer-BioNTech). She had no history of trauma or medication use. Two weeks after the onset of symptoms, she developed a dorsiflexor weakness of the right foot (Medical Research Council grade, poor). The weakness worsened to a "trace" grade despite providing conservative management for one month. Ultrasonography revealed a fusiform echolucent structure within the course of the right common peroneal nerve around the fibular head. Magnetic resonance imaging revealed multiple intraneural cysts within the right common peroneal nerve. Nerve conduction and electromyographic studies revealed multiphasic motor unit action potentials accompanied by abnormal spontaneous activities in the innervated muscles, along with axonal degeneration of the deep peroneal nerves. Surgical removal of the cyst was performed, and the patient's symptoms gradually improved. Pathological examination revealed a cystic structure containing mucinous or gelatinous fluid and lined with flattened or cuboidal cells. The clinical course and sequential electromyographic findings relevant to this symptomatic cyst were temporally related to the vaccination date. The present case suggests that INGC-induced peroneal palsy is a possible complication after COVID-19 vaccination.

Lumbosacral Interbody Fusion Using a Biportal Endoscopic Technique for Patients with Multilevel Severe Degenerative Lumbosacral Spondylosis: Technical Note and Case Presentations.

BACKGROUND: Open decompression and posterior interbody fusion are standard surgical interventions for multilevel degenerative lumbosacral spondylosis (DLS). Despite their clinical efficacy, intraoperative and postoperative complications have led to the demand for a minimally invasive approach. A biportal endoscopic approach is an advanced minimally invasive surgical option. METHODS: The data of two patients with multilevel DLS who had undergone biportal endoscopic spine surgery (BESS) were retrospectively analyzed. Parameters such as surgical difficulty, duration of operation, blood loss, length of hospital stay, and postoperative complications were reviewed. Pain and functionality were assessed using the visual analog scale (VAS) and the Oswestry Disability Index (ODI), respectively. RESULTS: Both patients were women and aged 75 and 73 years; they complained of back pain, claudication, pain and weakness in the lower extremities, and gait disturbance. The symptoms lasted 5 and 8 years, respectively. The multilevel BESS approach was applied bilaterally. Dissection, laminofacetectomy, decompression, excision, cage insertion, and screw implantation were performed. The operation durations were 170 and 160 minutes with blood loss of 500 and 650 mL, respectively. Back pain, leg pain, and ODI scores significantly improved; no pseudoarthrosis or additional neurologic deficits were noted on follow-up. CONCLUSIONS: The presented BESS technique is a minimally invasive treatment option for patients with multilevel DLS, which typically requires a complicated surgical approach. Randomized controlled studies with larger sample sizes and longer follow-up periods are needed to verify the superiority of this operation.

Assessment of a Discogenic Pain Animal Model Induced by Applying Continuous Shear Force to Intervertebral Discs.

BACKGROUND: Chronic discogenic pain includes degeneration-driven changes under the mechanical macroenvironment of an internal disc, which leads to the progressive changes of biochemical microenvironment that induce abnormal ingrowth of the nociceptor. The propriety of the animal model reflecting the pathologic natural history has not been assessed. OBJECTIVES: This study investigated the biochemical evidence of chronic discogenic pain by employing a discogenic pain animal model induced by shear force. STUDY DESIGN: Animal study utilizing rats in vivo model of a shear force device. METHODS: Fifteen rats were divided into 3 groups (n = 5/group) according to the period for which sustained dorsoventral shear force was applied (1 week or 2 weeks); the control group received the spinous attachment unit, without a spring. Pain data were collected using von Frey hairs on the hind paws. Growth factor and cytokine abundance was analyzed in the dorsal root ganglion (DRG) and plasma. RESULTS: After the shear force devices were installed, the significant variables were found to markedly increase in the DRG tissues of the 2-week group; however, they were not altered in the 1-week group. Specifically, interleukin (IL)-6, neurogrowth factor (NGF), transforming growth factor (TGF)-alpha, platelet-derived growth factor (PDGF)-beta, and vascular endothelial growth factor (VEGF) were increased. Meanwhile, the plasma levels of tumor necrosis factor-alpha, IL-1beta, IL-5, IL-6, IL-12, and NGF were increased in the 1-week group; whereas, TGF-alpha, PDGF-beta, and VEGF were increased in the 2-week group. LIMITATIONS: The limitations include the general limitations of quadrupedal animals, the poor precision and flexural deformation of shear force devices, inaccuracies regarding the evaluation of histological denaturation, and short intervention and observational periods. CONCLUSIONS: This animal model effectively generated biochemical responses to shear loading with evidence of neurological changes induced without direct macrodamage to the outer annulus fibrosus. Chemical internals were induced by mechanical externals among the contributing factors of chronic discogenic pain.

Biportal endoscopic spine surgery for cervical disk herniation: A technical notes and preliminary report.

Biportal endoscopic spine surgery (BESS) for cervical disk herniation (CDH) has been rarely reported. The aim of the article is to describe a novel BESS as a posterior approach for CDH and report the preliminary outcomes and complications. This single-centered retrospective chart review included 109 consecutive patients who underwent BESS for symptomatic single-level CDH. Working and viewing portals were created in each unilateral paravertebral area at the target disk level. Endoscopic exploration allowed for effective and minimally invasive decompression via safe access to the medial foramen with minimal laminectomy and facetectomy. Clinical outcomes, including the visual analog scale, neck disability index, Macnab criteria, and the motor function of the involved arm, were evaluated at 4, 8, 12, and 24 postoperative weeks. Visual analog scale and neck disability index improved significantly at 24 weeks postoperatively (P < .01). According to the Macnab criteria, "excellent," "good," and "fair" results were obtained for 55.9%, 30.3%, and 13.8% of patients, respectively. The post 24-week distribution of the involved upper extremity strength grade was significantly improved compared to the initial value (P = .02). One patient had a motor weakness with a decreased grade over 4 weeks from excessive irrigation. The posterior approach of BESS was efficient and feasible for the treatment of CDH.

Estimation of Functional Reserve in Patients with Hospital-Associated Deconditioning.

BACKGROUND: This study aimed to analyze the applicability of sit-to-stand (STS) muscle power tests for evaluating functional reserve in patients with hospital-associated deconditioning (HAD). METHODS: This study is a single group preliminary observational study. STS tests were performed in the early stages of comprehensive rehabilitation treatment, and the interval changes in the clinical indicators were assessed after four weeks of clinical observation. A STS capacity ratio was estimated by the time duration of five STS repetitions (5r-STS) and the maximum number of STS repetitions over 30 s (30s-STS); the activities were measured using a three-dimension motion capture system and force plate. RESULTS: After 4 weeks of comprehensive rehabilitation, the 10 m gait speed (p = 0.004), hand grip power (p = 0.022), hip extensor power (p = 0.002), Berg balance scale (p < 0.001), and modified Barthel index (MBI) (p = 0.001), respectively, were significantly improved. The force plate-derived (FPD) 30s-STS power and the number of repeats in the FPD 30s-STS showed a positive correlation with improvements in the hand grip power (Spearman's Rho = 0.477, p = 0.045), hip extensor power (Spearman's Rho = 0.482, p = 0.043), and MAI (Spearman's Rho = 0.481, p = 0.043), respectively. The STS capacity ratio was correlated with higher improvements in the 10 m gait speed (Spearman's Rho = 0.503, p = 0.034), hip extensor power (Spearman's Rho = 0.494, p = 0.037), and MBI (Spearman's Rho = 0.595, p = 0.009). Despite individual variability in the differences between the FPD and estimated STS power, the results for the correlation between the STS capacity ratio and clinical outcomes were consistent. CONCLUSIONS: The STS capacity ratio showed a positive correlation with the clinical outcomes, including gait speed, and may reflect a part of the functional reserve excluding the individual variability of performance.

COVID-19 Case Tracking System in Quarantine Policy: Focus on the Privacy Shift Concept and Application in South Korea.

This study analyzed how Korea's quarantine policy manages personal information to prevent and control COVID-19. Korea effectively halted the spread of COVID-19 through epidemiological investigations and cell-broadcast systems. In this process, the route of infection is presented without identifying the patient, and the necessary participants are selected only through authentication. We found a correlation between the number of emergency text messages sent by the Ministry of Interior and Safety in 2020 and the number of confirmed cases (R2 = 0.465, p < 0.001). Based on Korea's case, we propose a new concept for solving the personal information problems that might arise during a pandemic response.

Effect of direct vibration on the activity of deep trunk muscles of patients with non-specific chronic low back pain.

BACKGROUND: Vibration training is an adjuvant to muscle-strengthening exercises. OBJECTIVE: To investigate the short-term effects of direct vibration on the deep trunk muscles of patients with non-specific chronic low back pain (CLBP). METHODS: Participants with non-specific CLBP were randomly placed into two groups: the vibration-plus stabilization exercise (VSE) group (n= 31) and the conventional stabilization exercise (CSE) group (n= 31). The groups underwent 12 sessions of an exercise program. The thickness and activity of the trunk muscles were measured using ultrasonography and surface electromyography. RESULTS: Ultrasonography revealed that the ratio of muscle thickness to contraction and relaxation was statistically increased after exercise in the bilateral transversus abdominis (TrA) and lumbar multifidus (LM) muscles in the CSE group (p= 0.031), and in the bilateral TrA, LM, and internal oblique (IO) muscles in the VSE group (p< 0.001). The LM/lumbar erector spinae (LES) ratio in the CSE group (p= 0.037), and the IO/rectus abdominis (RA), TrA/RA, and LM/LES ratios in the VSE group (p= 0.019) were statistically increased. Multiple regression analysis showed that symptom improvement was related to increased activity of the deep trunk muscles in the VSE group (p< 0.001). CONCLUSION: Direct vibration can increase the selective activity of contracting deep trunk muscles.

Immediate effects of static and proprioceptive neuromuscular facilitation stretching of hamstring muscles on straight leg raise, craniovertebral angle, and cervical spine range of motion in neck pain patients with hamstring tightness: A prospective randomized controlled trial.

BACKGROUND: The cranio-cervical flexion exercise and sub-occipital muscle inhibition technique have been used to improve a forward head posture among neck pain patients with straight leg raise (SLR) limitation. However, little is known about the cranio-vertebral angle (CVA) and cervical spine range of motion (CROM) after applying stretching methods to the hamstring muscle. OBJECTIVE: To compare the immediate effects of static stretching and proprioceptive neuromuscular facilitation stretching on SLR, CVA, and CROM in neck pain patients with hamstring tightness. METHODS: 64 subjects were randomly allocated to the static stretching (n1= 32) or proprioceptive neuromuscular facilitation (n2= 32) stretching group. The SLR test was performed to measure the hamstring muscle's flexibility and tightness between the two groups, with CROM and CVA also being measured. The paired t-test was used to compare all the variables within each group before and after the intervention. The independent t-test was used to compare the two groups before and after the stretching exercise. RESULTS: There were no between-group effects for any outcome variables (P> 0.05). However, all SLR, CVA, and CROM outcome variables were significantly improved within-group (P< 0.05). CONCLUSIONS: There were no between-group effects for any outcome variable; however, SLR, CVA, and CROM significantly improved within-group after the one-session intervention in neck pain patients with hamstring tightness.

Percutaneous Unilateral Biportal Endoscopic Spine Surgery Using a 30-Degree Arthroscope in Patients With Severe Lumbar Spinal Stenosis: A Technical Note.

BACKGROUND: Unilateral biportal endoscopic surgery (UBESS) for severe lumbar central canal stenosis (LCCS) remains challenging. OBJECTIVE: To describe the use of UBESS with a 30-degree arthroscope in patients with severe LCCS. MATERIALS AND METHODS: Working and viewing portals were created in each unilateral paravertebral area at the target interlaminar level. After ensuring the visual field with a 30-degree arthroscope, effective tissue removal was possible through safe access to the bilateral hypertrophic yellow ligament with minimal osteotomy. The authors evaluated 58 patients and analyzed the clinical outcomes using the visual analog scale, Macnab criteria, and self-predicted walking distance. RESULTS: The visual analog scale scores for low back and leg pains decreased from 7.1 to 1.9 and from 7.9 to 1.6, respectively, at 18 months after the procedure. According to the Macnab criteria, "excellent," "good," and "fair" results were obtained in 51.7%, 41.4%, and 6.9% subjects, respectively. Before surgery, the subjects could walk a mean of 305.8±468.1 m. After surgery, 43.1% of the patients could walk for >1 hour, whereas the remaining patients could walk 1521.8±1831.1 m. CONCLUSION: UBESS using a 30-degree arthroscope can be an efficient and safe intervention in patients with severe LCCS.

Effect of Injectate Viscosity on Epidural Distribution in Lumbar Transforaminal Epidural Steroid Injection.

Introduction: There is no report on the effect of injectate viscosity on epidural distribution for lumbar transforaminal epidural steroid injections (L-TFESIs). The aim of this study was to evaluate the influence of injectate viscosity on the volume needed to reach specific landmarks in L-TFESIs. Methods: A prospective, randomized, comparative human study involving 118 patients undergoing L-TFESIs was conducted. The study subjects were divided into two groups by a random selection method: raw viscosity group (RV, n=58) and low viscosity group (LV, n=60). Contrast volumes were recorded as the contrast flow reached specific anatomical landmarks under fluoroscopic guidance. Results and Discussion: The possibility of delivering the injectate to each landmark showed a positive correlation with the amount and a negative correlation with the viscosity of the injectate. However, for landmarks at the medial aspect of the superior pedicle of the corresponding level of injection and for those beyond the spinous process over the contralateral spinal segment, the influence of viscosity was not statistically significant. Conclusion: The epidural distribution of the contrast agent through the transforaminal approach was most affected by the injectate volume and was also partly affected by the viscosity.

Modification of therapeutic temperature range in cryotherapy could improve clinical efficacy in tension type headache.

BACKGROUND: Cold pack therapy is not used frequently in clinics in spite of its effectiveness in clinical reports. Low compliance due to cold intolerance may be a disturbance factor that hinders patients from using the modality. OBJECTIVE: To demonstrate the improved compliance and clinical efficacy as new devised cold modality with a different composition is applied to target different therapeutic temperature range in tension-type headache (TTH) patients. METHODS: A randomized, controlled, comparative trial involving 53 patients with tension-type headache was conducted. A new cold modality that targets upper normal therapeutic temperature range was devised and applied to one group (n= 27) and ice pack was applied to the other group (n= 26). RESULTS: After application of two modalities for 4 weeks, the amount of analgesics intake, modality use per week, and Likert survey of cold intolerance were significantly different between the two groups. CONCLUSIONS: Rather than focusing on lowering the skin temperature indefinitely, optimizing tolerability by targeting the temperature at the upper therapeutic range could be more effective in cold modality application.

Effects of assisted sit-up exercise compared to core stabilization exercise on patients with non-specific low back pain: A randomized controlled trial.

BACKGROUND: Traditional sit-up exercise is a simple method to strengthen core muscles. However, it can increase the potential of lumbar spine injury during the bending process. OBJECTIVE: To evaluate the effect of assisted sit-up exercise (SUE) using a new training device, HubEX-LEX®, on strengthening core muscles and improving non-specific low back pain (NSLBP) compared to conventional core stabilization exercise (CSE). METHODS: Subjects with chronic NSLBP were randomly divided into two groups: SUE (n= 18) or CSE (n= 18). They participated in 12 sessions of the exercise program. Before and after the training, thickness and activity of core muscles were measured using ultrasonogram and surface electromyography respectively. Pain and disability were assessed using two questionnaires. RESULTS: Thickness ratios (contracted/rest) of rectus abdominis and external oblique in the SUE group and those of transversus abdominis in the CSE group showed statistically significant difference between before and after exercise (p< 0.05). The ratio of activation of internal oblique relative to rectus abdominis and all measurements for pain and disability showed statistically significant improvement in both groups (p< 0.05). CONCLUSIONS: Assisted SUE using new training device can be an effective therapeutic exercise to strengthen dynamic abdominal muscles and improve core muscle activation pattern in NSLBP patients.