Subscapularis function after total shoulder arthroplasty: electromyography, ultrasound, and clinical correlation.

BACKGROUND: The literature lacks electromyographic (EMG) examination of subscapularis function in the postoperative period after total shoulder arthroplasty (TSA). The primary purpose of this study was to document EMG activity of the subscapularis after TSA and to correlate it with clinical and ultrasound findings. METHODS: The study included 30 patients who were at least 1 year (average, 2.1 years) from surgery, status post TSA approached through a standard subscapularis tenotomy. Patients returned for a physical examination, ultrasound evaluation, and EMG evaluation. Patients also completed postoperative surveys: the American Shoulder and Elbow Surgeons questionnaire, the Simple Shoulder Test, and the 12-Item Short Form Health Survey. RESULTS: The American Shoulder and Elbow Surgeons, Simple Shoulder Test, and physical 12-Item Short Form Health Survey scores improved from preoperatively to postoperatively, respectively, 45.3 to 76.8 (P = .0002), 3.9 to 9.0 (P < .0001), and 33.9 to 42.8 (P = .017). Six patients had a positive lift-off test result, and the belly-press test result was negative in all patients. Two patients had a subscapularis rupture on ultrasound. The postoperative EMG finding was normal in 15 patients; in the other 15 patients, there was evidence of chronic denervation with reinnervation changes: 30% subscapularis, 27% infraspinatus, 20% supraspinatus, 20% teres minor, and 13% rhomboids. CONCLUSIONS: This is the first study using a comparison EMG evaluation to document subscapularis function after TSA. EMG evaluation showed that active denervation of the subscapularis was not evident in any patient at least 1 year after TSA. However, in half of the patients, there was evidence of chronicdenervation and reinnervation changes across 5 muscle groups. We theorize that surgical exposure, traction, and the use of interscalene regional anesthesia may contribute to these unexpected EMG results.

Anatomy integration blueprint: A fourth-year musculoskeletal anatomy elective model.

Current undergraduate medical school curricular trends focus on both vertical integration of clinical knowledge into the traditionally basic science-dedicated curricula and increasing basic science education in the clinical years. This latter type of integration is more difficult and less reported on than the former. Here, we present an outline of a course wherein the primary learning and teaching objective is to integrate basic science anatomy knowledge with clinical education. The course was developed through collaboration by a multi-specialist course development team (composed of both basic scientists and physicians) and was founded in current adult learning theories. The course was designed to be widely applicable to multiple future specialties, using current published reports regarding the topics and clinical care areas relying heavily on anatomical knowledge regardless of specialist focus. To this end, the course focuses on the role of anatomy in the diagnosis and treatment of frequently encountered musculoskeletal conditions. Our iterative implementation and action research approach to this course development has yielded a curricular template for anatomy integration into clinical years. Key components for successful implementation of these types of courses, including content topic sequence, the faculty development team, learning approaches, and hidden curricula, were developed. We also report preliminary feedback from course stakeholders and lessons learned through the process. The purpose of this report is to enhance the current literature regarding basic science integration in the clinical years of medical school.

Electrodiagnosis of ulnar neuropathy at the elbow (Une): a Bayesian approach.

INTRODUCTION: In ulnar neuropathy at the elbow (UNE), we determined how electrodiagnostic cutoffs [across-elbow ulnar motor conduction velocity slowing (AECV-slowing), drop in across-elbow vs. forearm CV (AECV-drop)] depend on pretest probability (PreTP). METHODS: Fifty clinically defined UNE patients and 50 controls underwent ulnar conduction testing recording abductor digiti minimi (ADM) and first dorsal interosseous (FDI), stimulating wrist, below-elbow, and 6-, 8-, and 10-cm more proximally. For various PreTPs of UNE, the cutoffs required to confirm UNE (defined as posttest probability = 95%) were determined with receiver operator characteristic (ROC) curves and Bayes Theorem. RESULTS: On ROC and Bayesian analyses, the ADM 10-cm montage was optimal. For PreTP = 0.25, the confirmatory cutoffs were >23 m/s (AECV-drop), and <38 m/s (AECV-slowing); for PreTP = 0.75, they were much less conservative: >14 m/s, and <47 m/s, respectively. CONCLUSIONS: (1) In UNE, electrodiagnostic cutoffs are critically dependent on PreTP; rigid cutoffs are problematic. (2) AE distances should be standardized and at least 10 cm.

Incorporating simulation technology into a neurology clerkship.

Simulation-based medical education is growing in use and popularity in various settings and specialties. A literature review yields scant information about the use of simulation-based medical education in neurology, however. The specialty of neurology presents an interesting challenge to the field of simulation-based medical education because of the inability of even the most advanced mannequins to mimic a focal neurologic deficit. The authors present simulator protocols for status epilepticus and acute stroke that use a high-fidelity mannequin despite its inability to mimic a focal neurologic deficit. These protocols are used in the training of third- and fourth-year medical students during their neurology clerkship at Penn State College of Medicine. The authors also provide a review of the pertinent literature.

Rehabilitation of brachial plexus and peripheral nerve disorders.

Peripheral nerve lesions are common and can present in a variety of ways. Peripheral nerve injury can result from a broad spectrum of causes. For the majority of patients, rehabilitation is generally indicated regardless of etiology. Evaluation and treatment by a multidisciplinary team including neurologists, psychiatrists, surgeons, occupational and physical therapists, and therapists with specialized training in orthotics maximizes the potential for recovery. This chapter will focus on those upper and lower extremity neuropathies that are most commonly seen in clinical practice. In addition, we discuss various rehabilitative strategies designed to improve function and quality of life.

Recovery of neurologic dysfunction with early intervention of vitamin B12.

A patient developed numbness and tingling in distal extremities with subsequent weakness. Evaluation revealed B12 deficiency. She had evidence of myelopathy on imaging studies and polyneuropathy on electrodiagnostic testing. Treatment with B12 caused remittance of symptoms and resolution/improvement of abnormalities found on the imaging and electrodiagnostic studies. This case demonstrates that early intervention with B12 supplementation can cause reversal of both central and peripheral nervous system dysfunction.

Familial Creutzfeldt-Jakob disease presenting as epilepsia partialis continua.

Creutzfeldt-Jakob disease (CJD) is a rare disorder caused by prions that can affect any part of the central nervous system. It is characterized by a long incubation period, but once symptoms start there is a progressive neurological decline. Clinical features include dementia, ataxia and myoclonus (startle), among others. We report a biopsy-proven case of familial CJD (fCJD) presenting with continuous focal seizures, epilepsia partialis continua (EPC), as the initial presentation. CJD is an unusual neurological disorder with an incidence of approximately one case per million population (Prusiner 2001). The disorder is due to neuronal degeneration resulting from the accumulation of a pathological isoform (PrP) of the prion protein (PrPc). Patients with fCJD have mutations in the gene encoding PrPc (PRNP) (Vercueil 2006, Collins et al. 2004). This fCJD represents 10-15% of CJD cases making the sporadic form more common 85-95% (Parry et al. 2001). During the course of the disease myoclonus has been reported in 88% of cases, and epileptic seizures (partial seizures, generalized status epilepticus) in 8% (Vercueil 2006). Periodic sharp wave complexes (PSWC) are uncommon in fCJD and occur in about 10% of patients (Wieser et al. 2006).

Hereditary neuropathies.

Hereditary neuropathies represent a clinically diverse group of disorders. Patients can present in a variety of ways-most typically, with slowly progressive distal and symmetric muscle weakness, atrophy, and sensory loss. This article outlines the basic clinical and electrodiagnostic characteristics, pathophysiology, genetics, and diagnostic approach to these conditions.

Evaluating the patient with peripheral nervous system complaints.

Patients commonly seek care from their family physicians for symptoms that are suggestive of peripheral nervous system (PNS) dysfunction. At some point in active practice, virtually all family physicians will be required to conduct at least an initial evaluation of a patient with PNS. The authors outline and describe common themes found in the symptoms and diagnoses of PNS dysfunctions. These themes may be useful to physicians when performing initial evaluations of patients with PNS dysfunctions. The authors also discuss diagnostic methods and effective therapeutic interventions for this population.

Mononeuritis multiplex secondary to sarcoidosis.

Peripheral nerve involvement is a rare, yet treatable neurological manifestation of sarcoidosis. Most patients respond well to corticosteroids, but relapses are common and the long-term prognosis remains unpredictable. We present a patient with an asymmetrical neurological presentation of previously undiagnosed sarcoidosis. She presented with paresthesias and predominantly distal extremity weakness. Other possible causes of neuropathy were ruled out and she was found to have an elevated serum ACE level. A nerve/lip biopsy demonstrated non-caseating granulomas consistent with sarcoid. Her clinical outcome was favorable after initiating treatment with high dose oral prednisone.

Parotid gland injections of botulinum toxin a are effective in treating sialorrhea in amyotrophic lateral sclerosis.

OBJECTIVE: : The objective of this study was to determine the safety and efficacy of botulinum toxin A in ameliorating refractory sialorrhea and improving quality of life in patients with amyotrophic lateral sclerosis. MATERIALS AND METHODS: : Six patients with bulbar ALS received bilateral parotid gland injections of botulinum toxin A. RESULTS: : No adverse effects occurred. Tissue use decreased in 5 of 7 patients at a dose of 10 units and in 3 of 4 patients at a dose of 20 units. Self-reported quality of life did not change in most. CONCLUSIONS: : Parotid gland injections of botulinum toxin appear safe and may be helpful in some patients with ALS for the treatment of sialorrhea.

Myasthenia gravis.

Myasthenia gravis (MG) is a chronic neuromuscular disorder that can lead to various degrees of neurologic dysfunction. Initial patient presentation may be a diagnostic dilemma to the family physician unfamiliar with testing methods for and the treatment and care of patients with MG. The author focuses on the clinical features, electrodiagnostic testing, and treatment of patients with MG.

Bilateral anterior interosseous neuropathy following surgery: a case report.

The authors present a patient who developed bilateral anterior interosseous neuropathy following an abdominal surgical procedure. This case is of particular interest because while anterior interosseous nerve involvement may be seen with Parsonage-Turner Syndrome, the bilateral involvement is quite rare. The electrodiagnostic findings are presented and the literature reviewed.

The neurologic assessment and treatment of the "difficult to extubate" patient.

Neurologic issues are involved in the patient who is difficult to wean. Assessing the patient and performing a complete neurologic examination are important when developing a successful weaning strategy. The neurologist contributes to this process by providing expertise in the various neurologic conditions and skill in performing a thorough neurologic examination.

Frequency of anxiety in myasthenia gravis.

Symptoms of anxiety are common in many chronic medical conditions. Myasthenia gravis (MG) is a chronic neuromuscular condition characterized by fatigable weakness; few studies to date have examined the occurrence of anxiety in patients with MG and related it to anxiety in other chronic conditions. Sixty-nine patients were given a set of self-administered questionnaires, which included the Beck Anxiety Inventory (BAI). The BAI was scored and showed that 55% of the patients had scores suggestive of anxiety. Forty percent was mildly anxious, 12% were moderately anxious, and 3% were severely anxious. This study suggests that anxiety is at least as common in patients with MG as in patients with other chronic medical conditions. It also suggests that the BAI is a clinically useful tool for assessing anxiety in such a population.

Self-reported Depressive Symptoms in Myasthenia Gravis.

It is well known that patients with a chronic medical illness experience major depression at a higher rate than the general population. The purpose of this study was to determine the frequency of depression among patients with myasthenia gravis (MG) who were referred to a Muscular Dystrophy Association clinic. Forty-five patients with a diagnosis of MG were evaluated with a self-administered survey regarding various typical somatic and psychologic symptoms of depression (the Beck Depression Inventory [BDI]) and then scored according to the BDI guidelines. Thirty-three percent of these patients generated scores suggestive of depression (24% were categorized as mildly depressed, 7% as moderately depressed, and 2% as severely depressed). These results suggest that patients with MG patients experience depression at a higher rate than the general population and at a similar rate as patients with other chronic illnesses.

A comparison of quantitative sensory testing with skin biopsy in small fiber neuropathy.

Patients with a small fiber neuropathy often are difficult to diagnose. They frequently undergo various diagnostic studies including quantitative sensory testing (QST) and skin biopsy. We wanted to determine if there was a correlation between findings on a QST study to that of a skin biopsy. Twenty patients were prospectively studied. Nine had an abnormal skin biopsy. Thirteen patients had an abnormal QST. Seven of the nine patients with an abnormal skin biopsy had an abnormal QST. Assuming that skin biopsy is the gold standard for identification of small fiber neuropathies, the sensitivity of QST for detection of such neuropathies is high, provided that both cold and warm sensation thresholds are studied. However, the specificity of QST for small fiber neuropathies is low (46%).

Use of intravenous immunoglobulin in Lambert-Eaton myasthenic syndrome.

The authors report a case of a 65-year-old woman with small cell lung cancer who had profound, progressive lower extremity weakness, intermittent blurred vision, a dry mouth, and orthostatic hypotension. Results of laboratory and electrodiagnostic studies were consistent with the diagnosis of Lambert-Eaton myasthenic syndrome. The patient was treated with one course of intravenous immunoglobulin and had significant improvement.