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To assess the predictive variables after sonographically guided corticosteroid injection in carpal tunnel syndrome.
A prospective, observational study was carried out on 25 wrists of 20 consecutive patients with carpal tunnel syndrome, confirmed by the American Association of Neuromuscular and Electrodiagnostic Medicine criteria, which includes clinical history, symptoms, and evidence of slowing of distal median nerve conduction. Visual analogue scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) were asked to the patients before and 4 weeks after the procedure. On a basis of VAS difference before and after the procedure, we divided the patients into two groups: more than 50% of VAS improving (good response group) and less than 50% of VAS improving (poor response group). Also, nerve conduction studies and ultrasound evaluations were performed prior to sonographically guided corticosteroid injection and at 4 weeks after the procedure. The cross-sectional area (CSA) of median nerve at maximal swelling point around wrist was measured by manual tracing using ultrasonography. With assessments mentioned above, we tried to assess predictive variables for prognosis after sonographically guided corticosteroid injection in carpal tunnel syndrome.
The CSA of median nerve at wrist measured before the procedure was significantly larger in good response group than in poor response group. Furthermore, the CSA of median nerve at wrist, symptom severity scale of BCTQ, motor/sensory latency and sensory amplitude were correlated with VAS improving.
The CSA of median nerve at wrist is the strongest predictive value for sonographically guided corticosteroid injection in mild-to-moderate carpal tunnel syndrome.
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To investigate the diagnostic value of cross-sectional area (CSA) and wrist to forearm ratio (WFR) in patients with electro-diagnosed carpal tunnel syndrome (CTS) with or without diabetes mellitus (DM).
We retrospectively studied 256 CTS wrists and 77 healthy wrists in a single center between January 1, 2008 and January 1, 2013. The CSA and WFR were calculated for each wrist. Patients were classified into four groups according to the presence of DM and CTS: group 1, non-DM and non-CTS patients; group 2, non-DM and CTS patients; group 3, DM and non-CTS patients; and group 4, DM and CTS patients. To determine the optimal cut-off value, receiver operating characteristic (ROC) curve analysis was performed.
The CSA and WFR were significantly different among the groups (p<0.001). The ROC curve analysis of non-DM patients revealed CSA ≥10.0 mm2 and WFR ≥1.52 as the most powerful diagnostic values of CTS. The ROC curve analysis revealed CSA ≥12.5 mm2 and WFR ≥1.87 as the most powerful diagnostic values of CTS.
Ultrasonographic assessment for the diagnosis of CTS requires a particular cut-off value for diabetic patients. Based on the ROC analysis results, improved accurate diagnosis is possible if WFR can be applied regardless of presence or absence of DM.
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To observe the contrast spread in superoposterior transforaminal epidural steroid injection (SP TFESI) and investigate the correlation between spread patterns and efficacy.
Thirty-one patients with lumbosacral radiculopathy underwent single-level TFESI under fluoroscopy. The final needle tip position was targeted toward the SP quadrant of the intervertebral foramen. To observe the spread, 1 mL of contrast material was injected, followed by a steroid injection. The contrast spread was graded anteroposteriorly and vertically in the epidural space. The effect of SP TFESI was evaluated by proportional pain score reduction.
Levels injected were L4-5 (n=20) and L5-S1 (n=11). Seventeen cases were lateral, and 14 were central herniated disc (HD). Baseline mean visual analog scale score was 6.23. Contrast dispersed dorsally in all the cases, and 45.2% cases showed a concurrent ventral spread. The proportion of the pain reduction after 2 weeks showed no difference between the two groups. In vertical spreading analysis, mean cephalic/caudal grades were 1.40/1.55 at L4-5 level and 1.73/1.64 at L5-S1 level. The HD location had no effect on contrast dispersion.
In SP TFESI, ventral contrast spread did not guarantee a better effect; however, the extent of cephalic flow in ventral expansion group correlated with the proportion of pain reduction.
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To investigate the relationship between urinary retention and short-term functional recovery in subacute stage after stroke.
The medical records of 94 patients admitted to the rehabilitation unit of Korea University Guro Hospital were reviewed retrospectively. The postvoid residual urine (PVR) was measured at least once a day using a bladder scan, and urinary retention (UR) was defined when the daily PVR volume consistently checked more than 100 mL. Clinical data and functional outcomes of patients in the rehabilitation ward were collected. Functional outcomes were measured using the Mini-Mental State Examination (MMSE), Berg Balance Scale (BBS), Functional Ambulation Category (FAC) level, Fugl-Meyer Assessment (FMA), and Modified Barthel Index (MBI) at admission (or transfer) and discharge. The data of patients with and without urinary retention were compared and analyzed.
Of the 94 participants, 25 patients were classified to the UR group and 69 were classified to the non-UR group. At the initial stage of rehabilitation, the scores of MMSE, BBS, FAC, MBI were significantly worse in the UR group (p<0.05). Both groups showed significant improvements of all functional outcomes after rehabilitation (p<0.05). The non-UR group showed more prominent recovery of BBS, FAC, MBI scores (p<0.05).
Urinary retention in post-stroke patients is significantly related to the poor functional status at initial stage of rehabilitation, and also to poor recovery after rehabilitation.
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To evaluate the risk of phrenic nerve injury during ultrasound-guided stellate ganglion block (US-SGB) according to sonoanatomy of the phrenic nerve, and determine a safer posture for needle insertion by assessing its relationship with surrounding structure according to positional change.
Twenty-nine healthy volunteers were recruited and underwent ultrasound in two postures, i.e., supine position with the neck extension and head rotation, and lateral decubitus position. The transducer was placed at the anterior tubercle of the C6 level to identify phrenic nerve. The cross-sectional area (CSA), depth from skin, distance between phrenic nerve and anterior tubercle of C6 transverse process, and the angle formed by anterior tubercle, posterior tubercle and phrenic nerve were measured.
The phrenic nerve was clearly identified in the intermuscular fascia layer between the anterior scalene and sternocleidomastoid muscles. The distance between the phrenic nerve and anterior tubercle was 10.33±3.20 mm with the supine position and 9.20±3.31 mm with the lateral decubitus position, respectively. The mean CSA and skin depth of phrenic nerve were not statistically different between the two positions. The angle with the supine position was 48.37°±27.43°, and 58.89°±30.02° with the lateral decubitus position. The difference of angle between the two positions was statistically significant.
Ultrasound is a useful tool for assessing the phrenic nerve and its anatomical relation with other cervical structures. In addition, lateral decubitus position seems to be safer by providing wider angle for needle insertion than the supine position in US-SGB.
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To verify the utility of the lateral femoral cutaneous nerve (LFCN) ultrasound-guided conduction technique compared to that of the conventional nerve conduction technique.
Fifty-eight legs of 29 healthy participants (18 males and 11 females; mean age, 42.7±14.9 years) were recruited. The conventional technique was performed bilaterally. The LFCN was localized by ultrasound. Cross-sectional area (CSA) of the LFCN and the distance between the anterior superior iliac spine (ASIS) and the LFCN was measured. The nerve conduction study was repeated with the corrected cathode location. Sensory nerve action potential (SNAP) amplitudes of the LFCN were recorded and compared between the ultrasound-guided and conventional techniques.
Mean body mass index of the participants was 23.7±3.5 kg/m2, CSA was 4.2±1.9 mm2, and the distance between the ASIS and LFCN was 5.6±1.7 mm. The mean amplitude values were 6.07±0.52 µV and 6.66±0.54 µV using the conventional and ultrasound-guided techniques, respectively. The SNAP amplitude of the LFCN using the ultrasound-guided technique was significantly larger than that recorded using the conventional technique.
Correcting the stimulation position using the ultrasound-guided technique helped obtain increased SNAP amplitude.
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To investigate the correlation of the ultrasonographic wrist-to-forearm median nerve area ratio (WFR) and cross sectional area of median nerve at the wrist (CSA-W) to the electrophysiologic severity in patients with carpal tunnel syndrome (CTS).
One hundred and ten wrists electrophysiologically graded as mild, moderate, and severe CTS and 38 healthy controls underwent ultrasonography of median nerve at the distal wrist crease and mid-forearm. WFR and CSA-W were analyzed according to the severity of CTS.
WFR was 1.12±0.14, 1.91±0.33, 2.27±0.47 and 3.02±0.97 and the CSAs-W was 7.23±1.67 mm2, 13.51±3.72 mm2, 14.67±2.93 mm2, and 18.74±6.01 mm2 in controls, mild (n=28), moderate (n=46), and severe (n=36) CTS, respectively. CSA-W displayed significant differences between the control and the mild CTS, moderate CTS and severe CTS groups. However, there was no significant difference between mild CTS and moderate CTS groups. WFR revealed significant difference between all groups. The sensitivity and specificity of the WFR in grading the severity of CTS were higher than those of the CSA-W.
Ultrasonography is a useful complementary tool for the evaluation of CTS. Both WFR and CSA-W are highly correlated with severity grade of CTS. However, WFR is superior to CSA-W for diagnosis and grading of the severity of CTS.
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