Ultrasound-Guided Lower Cervical Nerve Root Injectate Volumes Associated With Dorsal Root Ganglion and Epidural Spread.

OBJECTIVES: We aimed to estimate the spread of injections for ultrasound-guided cervical nerve root blocks and to determine the optimal injectate volume required in this procedure. METHODS: A total of 32 ultrasound-guided injections (C5-C8) were made in 4 fresh cadavers. The target on each cervical root was the space between the posterior tubercle and the cervical root at the most proximal location possible on the sonogram. After ultrasound-guided needle insertion, 0.5 mL of a contrast medium was injected 4 times. The dye flow patterns were confirmed with fluoroscopy each time, and we recorded whether the contrast medium reached the dorsal root ganglion level or the epidural space. After the injections, the needle tip location was determined by computed tomography and image reconstruction. RESULTS: All injections produced typical neurograms. The contrast medium reached the dorsal root ganglion in 29 of 32 (90.6%) injections (mean ± SD, 0.84 ± 0.42 mL of contrast medium) and the epidural space in 10 of 32 (31.3%) injections (1.30 ± 0.54 mL of contrast medium). The mean distance between the needle tip and neural foramen was 9.64 ± 3.68 mm, and this distance correlated positively with the volume of contrast medium necessary to reach the dorsal root ganglion or the epidural space. CONCLUSIONS: Ultrasound-guided cervical nerve root blocks show potential utility for targeting an anesthetic into the cervical root area. This study may be helpful for deciding the most appropriate volume for the procedure.

Investigation of the Diagnostic Value of Ultrasonography for Radial Neuropathy Located at the Spiral Groove.

OBJECTIVE: To determine a diagnostic cut-off value for the cross-sectional area (CSA) of the radial nerve using ultrasonography for radial neuropathy located at the spiral groove (SG). METHODS: Seventeen patients with electrodiagnostic evidence of radial neuropathy at the SG and 30 healthy controls underwent ultrasonography of the radial nerve at the SG . The CSAs at the SG were compared in the patient and control groups. The CSA at the SG between the symptomatic and asymptomatic sides (ΔSx-Asx and Sx/Asx, respectively) were analyzed to obtain the optimal cut-off value. The relationship between the electrophysiological severity of radial neuropathy and CSA was also evaluated. RESULTS: Among the variables examined, there were statistically significant differences in the CSA between the patient and control groups, ΔSx-Asx, and Sx/Asx at the SG. In a receiver operating characteristics analysis, the cut-off CSA was 5.75 mm2 at the SG (sensitivity 52.9%, specificity 90%), 1.75 mm2 for ΔSx-Asx (sensitivity 58.8%, specificity 100%), and 1.22 mm2 for Sx/Asx (sensitivity 70.6%, specificity 93.3%) in diagnosing radial neuropathy at the SG. There was no significant correlation between CSA and electrophysiological severity score for either patient group. CONCLUSION: The reference value obtained for CSA of the radial nerve at the SG may facilitate investigation of radial nerve pathologies at the SG.

Effect of Fascia Penetration on Sensory Nerve Conduction in the Superficial Radial Nerve.

PURPOSE: The aim of this study was to identify the effects of fascia penetration on superficial radial sensory nerve action potential amplitude. METHODS: The penetration point (PP) at which the nerve penetrated the brachioradialis fascia and became superficial was observed using ultrasonography. The sensory nerve action potential amplitude was measured at five points: the penetration point, 2 and 4 cm proximal to the PP, and 2 and 4 cm distal to the PP. RESULTS: The sensory nerve action potential amplitude at the penetration point and at 2 and 4 cm distal to the PP was significantly larger than that at 2 and 4 cm proximal to the PP. The largest amplitude was obtained 2 cm distal to the PP. CONCLUSIONS: The sensory nerve action potential of the superficial radial nerve changes significantly around the fascia penetration point.

Interexaminer reliability and accuracy of posterior superior iliac spine and iliac crest palpation for spinal level estimations.

OBJECTIVE: The purpose of this study was to compare the posterior superior iliac spine (PSIS) and the iliac crest as accurate anatomical landmarks for identifying spinal level. METHODS: This study was conducted in 2 stages. First, 4 examiners examined 60 patients and blindly identified iliac crest and PSIS levels, and the interexaminer reliability of PSIS and iliac crest palpation were then analyzed. Second, 4 examiners attached a radio opaque marker at presumed PSIS and iliac crest levels in 72 patients, and posteroanterior lumbar radiographs were then taken. Four examiners then confirmed PSIS and iliac crest levels after radiographically identifying the marker levels and checked the spinal level at which the spinous process or interspace was crossed by drawing a horizontal line drawn between radio opaque markers. RESULTS: The interexaminer reliability of palpation was significantly greater for PSIS level than for the iliac crest (P < .05). Spinal levels of estimated PSISs identified by palpation ranged from the L5-S1 interspace to the S2 spinous process, and the spinal levels of estimated iliac crest ranged from the L2-3 interspace to the L5 spinous process. CONCLUSIONS: Although PSIS palpation showed statistically higher interexaminer reliability than iliac crest level, clinicians should be cautious when applying this method as a measurement tool because estimated spinal level by palpation can be influenced inadvertently by examiner skill and anatomical variations.

The beneficial effect of intravenous zoledronic acid therapy following an acute stroke in rats.

PURPOSE: Changes of bone metabolism begin from the initial stages of stroke; therefore, early prevention of these changes has become important. The most appropriate target for preventive therapy is to restrict the profound increase in osteoclastic bone resorption that occur soon after stroke. Oral bisphosphonates, which selectively target osteoclasts and their precursors, are appropriate drugs, but dysphagia or drowsiness after acute stroke can make it difficult to easily administer these compounds to stroke patients. The intravenous (IV) administration of bisphosphonates is an alternative method that can overcome these limitations. In order to determine the effect of IV bisphosphonates at the initial stages of stroke for preventing bone loss, an experiment using ischemic stroke rats was conducted. METHODS: Female Sprague-Dawley rats (n = 100) were randomly divided into four separate groups; sham surgery and vehicle-treated group (sham-vehicle), stroke and vehicle-treated group (stroke-vehicle), stroke with low-dose zoledronic acid treatment group (stroke-low) and stroke with high-dose zoledronic acid treatment group (stroke-high). Permanent occlusion of the left middle cerebral artery was performed, resulting in right hemiplegia. The bone mineral density (BMD) of the 4th and 5th lumbar vertebrae and the femur on the stroke side were measured in vivo on the day before stroke and on the 10th and 21st day after stroke. The osteocalcin and carboxy-terminal telopeptide blood levels were measured on the 10th and 21st day after stroke. The BMD of the excised proximal tibia and the maximum load of femoral neck were measured on the 21st day after stroke. RESULTS: After 21 days of stroke, the BMD of the lumbar vertebrae, femur, and excised tibia and the maximum load of the femoral neck in the sham-vehicle, stroke-low, and stroke-high groups were significantly higher than those in the stroke-vehicle group (P < 0.05). The carboxy-terminal telopeptide levels in the sham-vehicle and stroke-high groups were significantly lower than those in the stroke-vehicle group (P < 0.05). CONCLUSION: The results suggest that IV zoledronic acid treatment might prevent bone loss during the initial stages of stroke.

Diagnostic Cutoff Value for Ultrasonography of the Common Fibular Neuropathy at the Fibular Head.

OBJECTIVE: To establish the diagnostic cutoff value of ultrasonographic measurement for common fibular neuropathy (CFN) at the fibular head (FH). METHODS: Twenty patients with electrodiagnostically diagnosed CFN at the FH and 30 healthy controls were included in the study. The cross-sectional area (CSA) of sciatic nerve at mid-thigh level, common fibular nerve at popliteal fossa (PF), and common fibular (CF) nerve at FH were measured. Additionally, the difference of CF nerve CSA at the FH between symptomatic side and asymptomatic side (ΔSx-Asx), the ratio of CF nerve CSA at FH to at PF (FH/PF), and the ratio of CF nerve CSA at the FH symptomatic side to asymptomatic side (Ratio Sx-Asx) were calculated. RESULTS: CSA at the FH, FH/PF, ΔSx-Asx, and Ratio Sx-Asx showed significant differences between the patient and control groups. The cutoff value for diagnosing CFN at the FH was 11.7 mm2 for the CSA at the FH (sensitivity 85.0%, specificity 90.0%), 1.70 mm2 for the ΔSx-Asx (sensitivity 83.3%, specificity 97.0%), 1.11 for the FH/PF (sensitivity 47.1%, specificity 93.3%), and 1.24 for the Ratio Sx-Asx (sensitivity 72.2%, specificity 96.7%). CONCLUSION: The ultrasonographic measurement and cutoff value could be a valuable reference in diagnosing CFN at the FH and improving diagnostic reliability and efficacy.

Diagnostic cutoff value for ultrasonography in the ulnar neuropathy at the elbow.

OBJECTIVE: To determine the diagnostic cutoff values of ultrasonographic measurements in ulnar neuropathy at the elbow (UNE). METHODS: Twenty-five elbows of 23 patients (9 females, 16 males) diagnosed with UNE and 30 elbows of 30 healthy controls (15 females, 15 males) were included in our study. The ulnar nerve cross-sectional area (CSA) was measured at the Guyon canal, midforearm, and maximal swelling point (MS) around the elbow (the cubital tunnel inlet in healthy controls). CSA measurements of the ulnar nerve at each point, the Guyon canal-to-MS ulnar nerve area ratio (MS/G), and the midforearm-to-MS ulnar nerve ratio (MS/F) were calculated. RESULTS: Among the variables, only CSA at MS, MS/G, and MS/F displayed significant differences between the control and patient groups. The cutoff value for diagnosing UNE was 8.95 mm(2) for the CSA at MS (sensitivity 93.8%, specificity 88.3%), 1.99 for the MS/G (sensitivity 75.0%, specificity 73.3%), and 1.48 for the MS/F (sensitivity 93.8%, specificity 95.0%). CONCLUSION: These findings may be helpful to diagnose UNE.

Diagnosis with manometry and treatment with repetitive transcranial magnetic stimulation in Dysphagia.

Videofluoroscopic swallowing study (VFSS) used for the diagnosis of dysphagia has limitations in objectively assessing the contractility of the pharyngeal muscle or the degree of the upper esophageal sphincter relaxation. With a manometer, however, it is possible to objectively assess the pressure changes in the pharynx caused by pharyngeal muscle contraction during swallowing or upper esophageal sphincter relaxation, hence remedying the limitations of VFSS. The following case report describes a patient diagnosed with lateral medullar infarction presenting a 52-year-old male who had dysphagia. We suggested that the manometer could be used to assess the specific site of dysfunction in patients with dysphagia complementing the limitations of VFSS. We also found that repetitive transcranial magnetic stimulation was effective in treating patients refractory to traditional dysphagia rehabilitation.

Feasibility of Ultrasound Guided Atlanto-occipital Joint Injection.

OBJECTIVE: To evaluate the feasibility of ultrasound guided atlanto-occipital joint injection. METHOD: Six atlanto-occipital joints of three cadavers were examined. Cadavers were placed in prone position with their head slightly rotated towards the contra-lateral side. The atlanto-occipital joint was initially identified with a longitudinal ultrasound scan at the midline between occipital protuberance and mastoid process. Contrast media 0.5cc was injected into the atlanto-occipital joint using an in-plane needle approach under ultrasound guide. The location of the needle tip and spreading pattern of the contrast was confirmed by fluoroscopic evaluation. RESULTS: After ultrasound guided atlanto-occipital joint injection, spreading of the contrast media into the joint was seen in all the injected joints in the anterior-posterior fluoroscopic view. CONCLUSION: The ultrasound guided atlanto-occipital injection is feasible. The ultrasound guided injection by Doppler examination can provide a safer approach to the atlanto-occipital joint.

Accuracy of the glenohumeral injection using the superior approach: a cadaveric study of injection accuracy.

OBJECTIVE: The glenohumeral joint can be accessed by anterior, posterior, or superior approach. Blind shoulder injections using anterior or posterior approach have been often inaccurate and infiltrated untargeted structures. The aim of this study was to investigate the success rate of injections in the glenohumeral joint using the superior approach. DESIGN: Nineteen shoulders from 12 adult cadavers were anatomically dissected after a dye injection had been performed, with cadavers in the supine position. A clinician rated injection confidence scores. The dissectors rated injection accuracy scores and investigated untargeted structures penetrated. RESULTS: The clinician's confidence scores were the highest in 18 of 19 shoulders. Superior glenohumeral injections were successful in 18 of 19 (94.7%) shoulders; however, in 3 of these 18 shoulders, the long heads of biceps tendons were penetrated. CONCLUSIONS: The glenohumeral joint injection using the superior approach is accurate and clinically useful, but caution for the likelihood of penetrating the long head of biceps tendon should be considered.

Comparison of venlafaxine extended release versus paroxetine for treatment of patients with generalized anxiety disorder.

This trial was to evaluate the efficacy and tolerability of venlafaxine extended release (XR) and paroxetine for treatment of patients with generalized anxiety disorder (GAD). Sixty patients who met DSM-IV criteria for GAD were randomly assigned to either venlafaxine XR or paroxetine for 8 weeks. Efficacy was assessed with the Hamilton Rating Scale for Anxiety (HAM-A) and Clinical Global Impression-Severity of Illness (CGI-S) scale at the baseline, week 1, week 4, and week 8. The side-effects were collected with reported adverse events and laboratory tests throughout the study period. Repeated measures analysis of variance (ANOVA) on the HAM-A and CGI-S scores showed a significant decrease over time in both treatment groups without significant group difference or time x group interaction effect. There were no serious adverse events in both groups. This open trial demonstrated that either venlafaxine XR or paroxetine would be effective and tolerable for the treatment of patients with GAD. Double blind, placebo-controlled head-to-head comparison studies are needed to draw a definite conclusion.