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Neuromuscular recovery after parathyroidectomy in primary hyperparathyroidism
Neuromuscular recovery after parathyroidectomy in primary hyperparathyroidism Fong-Fu Chou, MD, Shyr-Ming Sheen-Chert, MD and Chau-Peng Leong, MD, Kaohsiung Hsien, Taiwan, Republic of China Background. Primary hyperparathyroidism today is diagnosed in the asymptomatic phase because of the inclusion of serum calcium in sequential multichannel analysis. The purpose of present study was to test for neuromuscular abnormalities in asymptomatic patients and to test the improvement of neuromuscular performance after parathyroidectomy. Methods. Nine patients with primary hyperparathyroidism and nine patients with nodular goiter were enrolled in this study. Neuromuscular recovery including muscle power, sensation, and fine motor movement was studied before operation and 1 week and 4 weeks after operation. The muscle power was measured as grip power, palm pinch, lateral pinch, and three-chuck pinch. The sensation was measured as touch sensation and two-point discrimination. The fine motor movement was measured with the Purdue Pegboard Test and the Minnesota Manual Dexterity Test. Results. Four weeks after the operation the patients with hyperparathyroidism had increased their muscle strength and had improved fine motor movement but no change was noted in two-point and touch sensation. When the postoperative muscle recovery was compared, there was a reversible correlation (r = -0.62," p < 0.05) with the preoperative muscle strength and no correlation with the preoperative serum calcium, phosphate, alkaline phosphatase, and intact parathyroid hormone levels. No such improvement was detectable among the control subjects. Conclusions. Surgery can improve muscle strength and fine motor movement but does not affect sensation in asymptomatic patients. (SURGERY 1995; 117."18-25.) From the Division of General Surgery, Department of Surgery, and Department of Rehabilitation, Chang Gung Memorial Hospital at Kaohsiung, Chang Gung Medical College, Kaohsiung Hsien, Taiwan, Republic of China
OBJECTIVE ASSESSMENTOF MUSCULARfunction before and after operation in patients with hyperparathyroidism has confirmed the clinical impression of postoperative improvement of muscular capacity. 1"5 The neuromuscular syndrome of primary hyperparathyroidism as originally described is rarely seen today. The inclusion of serum calcium as a part of multichannel chemical analysis has resulted in the diagnosis of this condition before the classic neuromuscular symptoms and signs develop. Although the disorder is clinically asymptomatic, whether neuromuscular dysfunction is present in a subclinical form and can be improved after surgical therapy is important to know. Nine patients admitted for surgical management of hyperparathyroidism were the subjects of this study. Accepted for publicationApril 27, 1994. Reprint requests: Fong-Fu Chou, MD, Department of Surgery, Chang Gung Memorial Hospital, 123 Ta-Pei Rd., Niao-Sung Hsiang, KaohsiungHsien, Taiwan, R.O.C. Copyright | 1995 by Mosby-Year Book, Inc. 0039-6060/95/$3.00 + 0 11/56/57013 18
SURGERY
PATIENTS AND METHODS Nine patients (six women, three men; median age, 55 years) who were admitted for parathyroidectomy were studied. All patients were free from known neuromuscular disorders, diabetes mellitus, previous wrist fractures, trauma, and uremia. Preoperative clinical manifestations, biochemical data, and grip power, and grip power 4 weeks after operation in patients with primary hyperparathyroidism are presented in Table I. Seven patients underwent resection of an adenoma, and two patients underwent total parathyroidectomy with forearm autotransplantation as mentioned by Wells et al. 6 Muscle power was checked with a grip dynamometer (Jamar, Jackson, Mich.) and a Preston pinch gauge (Jamar, Jackson, Mich.)] Hand strength was measured with the patient in sitting position, with the shoulder adducted and neutrally rotated, the elbow flexed at 90 degrees, the forearm in neutral position, and the wrist positioned at 0 to 30 degrees dorsiflexion and between 0 and 15 degrees of ulnar deviation. The maximal voluntary grip power, palm pinch, lateral pinch, and three-chuck pinch were measured in kilograms.
Surgery Volume 117, Number 7
Chou, Sheen-Chen, Leong
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14
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Fig. 1. Serum calcium and phosPhate levels before operation and 1 day, 1 week, and 4 weeks after operation in nine patients with primary hyperparathyroidism and in nine patients with nodular goiter. Values expressed as mean 4- SD.
T a b l e I. Preoperative clinical manifestations, laboratory values, preoperative grip power, and change in grip power 4 weeks after operation in nine patients with p r i m a r y hyperparathyroidism
Grip po~er (kg)
Laboratory values*
Patient Age Clinical Calcium Phosphate Intact PTH AP 4 weeks Change no. Gender (yr) manifestations (mg/dl) (mg/dl) (pg/ml) (units/L) Preoperative after operation (%) 1 2 3 4 5 6 7 8 9
M F M F F F F F M
32 56 68 59 64 48 49 55 37
Kidney stone None None Hypertension Bone pain None None Bone pain None
12.2 10.5 11.8 11.5 10.4 10.8 13.4 12.9 10.7
1.8 2.7 3.8 1.5 2.6 1.8 2.2 3.0 3.0
530.0 86.4 75.6 81.3 1011.0 68.9 159.0 1936.0 886.0
70 6"8 94 69 900 39 195 479 586
25 12 20.3 19.0 13.5 18.7 26 11.3 34.6
26.8 25.8 25 20.3 21 19.7 27 15 38
7.2 115 23.2 6.8 55.6 5.3 3.8 32.7 9.8
*Normalvalues:serumcalcium,7.9-9,9mg/dl;serumphosphorus,2.5-4.5mg/dl; I-PTH, 10-65 pg/ml; AP, 28-94 units/L.
Fine motor movement of upper extremities was checked with the Purdue Pegboard Test (model 32020; Lafayette Instrument Company, Lafayette, Ind.) and T h e Minnesota M a n u a l Dexterity Test ( M M D T ) (model 32023; Lafayette Instrument).7' 8 T h e Purdue pegboard is
equipped with pins, collars, and washers, which are located in four cups at the top of the board. T h e person tested should be seated comfortably at the table. Separate scores are assessed for the right hand, left hand, both hands, and assembly. T h e number of pins inserted in 30
20
Chou, Sheen-Chen, Leong
Surgery January 1995
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Fig. 2. Maximal grip power (right and left hands) before operation and 1 and 4 weeks after operation in nine patients with primary hyperparathyroidism and in nine patients with nodular goiter. Values expressed as mean + SD. seconds are counted and recorded for the right hand, left hand, and both hands to calculate the score. Assembly testing consists of assembling pins, collars, and washers. The number of parts assembled in 30 seconds are counted and recorded to arrive at a score. Values reported are the mean of three consecutive measurements. M M D T comprises the placing test and the turning test. The placing test measures time in seconds to fill the 60-hole board with blocks, and the turning test is the time in seconds to turn the block on the 60-hole board. Both the placing and the turning score are measured by adding the times of four repetitions of the test. Sensation is checked by two-point discrimination in millimeters with a two-point anesthesimeter (Disk-Criminator; MackinnonDellon, Baltimore, Md.), and touch sensation is tested by pencil. Serum calcium, phosphate, intact parathyroid hormone (PTH), and alkaline phosphatase (AP) levels, and neuromuscular tests, were performed before operation. One week and 4 weeks after operation serum calcium and phosphate levels, and neuromuscular tests, were repeated. Daily checks of serum calcium and phosphate were done before patients were discharged and were in the normal range. If a patient's serum cal-
cium level was less than 7.9 mg/dl and symptoms of hypocalcemia developed, calcium carbonate was given four times daily until symptoms were relieved. Serum calcium and phosphate levels, and muscle power, sensation, and fine motor movement were also measured in nine patients with hemithyroidectomy (six women, three men; median age, 49 years), who served as control subjects for the study. Statistical significance was assessed by means of the Student t test for paired and unpaired samples, and correlations were calculated with Pearson's correlation coefficient. RESULTS
The clinical manifestations, muscle weakness, biochemical data, preoperative grip power, and postoperative grip power of the dominant hand in nine patients with primary hyperparathyroidism are shown in Table I. Clinically, one patient had kidney stones, two had bone pain, and one had hypertension. The preoperative grip power was negatively correlated with age of the patients (r = - 0 . 6 5 ; p < 0.05) but did not correlate with the preoperative serum calcium, phosphate, AP, and intact P T H levels. The increment of grip power of
Surgery Volume 117, Number
Chou, Sheen-Chen, Leong
21
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Fig. 3. Maximal palm pinch (right and left hands) before operation and 1 and 4 weeks after operation in nine patients with primary hyperparathyroidism and in nine patients with nodular goiter. Values expressed as mean + SD.
dominant hand 4 weeks after operation was reversibly correlated with preoperative grip power (r = - 0 . 6 2 ; p < 0.05) but not with serum calcium, phosphate, AP, and intact P T H levels. In nine patients with primary hyperparathyroidism the serum calcium level was 11.6 + 1.1 mg/dl (mean _+ SD), phosphate level was 2.5 _+ 0.7 mg/dl, AP level was 277.8 _+ 306.4 units/L, and intact P T H level was 537.1 + 641.2 ng/ml. One day after operation the serum calcium level was 8.7 + 1.3 mg/dl and phosphate level was 2.6 + 0.7 mg/dl. One week after operation the serum calcium level was 8.1 _+ 1.5 mg/dl and phosphate level was 2.9 + 0.8 mg/dl. Four weeks later the serum calcium level was 8.6 + 0.7 and phosphate level was 2.8 + 0.7 mg/dl (Fig. 1). Because of hypocalcemia, three patients took calcium carbonate for an average of 2 weeks. Normal serum calcium levels were present 3 weeks after operation in all patients. Before operation the mean serum calcium level in nine control subjects was 8.4 + 0.4 mg/dl and phosphate level was 3.5 +_ 1.0 mg/dl. One day after operation the serum calcium level was 8.0 + 0.3 mg/dl and phosphate level was 3.8 + 0.7 mg/dl. One week after operation the serum calcium level was 7.9 _+ 0.3 mg/dl and phosphate level was 3.2 + 0.9 mg/dl. At 4 weeks the serum cal-
cium level was 8.3 _+ 0.5 mg/dl and phosphate level was 3.5 + 0.8 mg/dl. After operation neither calcium nor phosphate had changed (Fig. 1). The individual results in nine patients with hyperparathyroidism as to grip power, palm pinch, lateral pinch, and three-chuck pinch are shown in Figs. 2 to 5. The grip power of right hand and the left hand, respectively, in the parathyroidectomy group was 20 _+ 7.5 kg and 18.1 + 7:9 kg before operation, 19.8 + 7.6 kg and 15.9 + 5.7 kg 1 week later, and 24.2 + 6.5 kg and 21.8 _+ 8.0 kg 4 weeks later. There was an increase of grip power in both hands 4 weeks later as compared with preoperative values (paired t test, p < 0.01). The grip power of the right hand and left hand, respectively, in the control group was 32.3 + 6.9 kg and 29 +_ 13 kg before operation, 30.1 + 6.5 kg and 27.5 + 8.0 kg 1 week later, and 32.8 _+ 7.9 kg and 32 -+ 8.5 kg 4 weeks later. The change was not significant. The palm pinch results of the right hand and the left hand, respectively, in the parathyroidectomy group were 4.0 _+ 1.4 kg and 3.9 _+ 0.8 kg before operation, 4.0 + 1.1 kg and 3.7 + 0.6 kg 1 week later, and 5.3 + 1.1 kg and 5.2 + 1.2 kg 4 weeks later. There was an increase of palm pinch on both hand 4 weeks later as compared with preoperative levels (p < 0.01). The palm pinch results
22
Chou, Sheen-Chen, Leong
Surgery January 1995
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Fig. 4. Maximal lateral pinch (right and left hands) before operation and 1 and 4 weeks after operation in nine patients with primary hyperparathyroidism and in nine patients with nodular goiter. Values expressed as mean _+ SD.
of the right hand and the left hand, respectively in the control gruop were 6.4 + 2.1 kg and 5.0 _+ 1.8 kg before operation, 6.3 + 2.0 kg and 4.9 + 1.5 kg 1 week later, and 6.5 + 2.1 kg and 5.4 + 1.3 kg 4 weeks later. The change was not significant. T h e lateral pinch results of the right and left hands, respectively, in the parathyroidectomy group were 5.4 + 2.1 kg and 4.8 _+ 1.5 kg before operation, 5.2 + 1.9 kg and 4.9_+ 1.4 kg 1 week later, and 6.7 + 2.1 kg and 6.2 + 1.8 kg 4 weeks later. There was an increase in lateral pinch in both hands 4 weeks later as compared with preoperative levels (p < 0.01). The lateral pinch results of the right and left hands, respectively, the control group were 7.0 + 3.2 kg and 6.8 + 2.2 kg before operation, 7.0 _+ 3.0 kg and 6.0 + 2.0 kg 1 week later, and 7.5 _+ 3.4 kg and 7.0 _+ 2.2 kg 4 weeks later. The change was not significant. The three-chuck pinch results of the right and left hands, respectively, in the parathyroidectomy group were 5.2 + 1.8 kg and 4.9 + 1.4 kg before operation, 5.6 + 1.6 kg and 5.0 _+ 1.0 kg 1 week later, and 6.9 _+ 2.0 kg and 6.2 _+ 1.8 kg 4 weeks later. There was an increase in three-chuck pinch in both hands 4 weeks later as compared with preoperative levels (p < 0.01). The three-chuck pinch results of the right and left hands, respectively, in the control group were 8.2 + 1.7 kg and 7.6 + 3.0 kg before operation,
8.4_+ 2.0 kg and 6.7_+ 2.8 kg 1 week later, and 7.9 + 1.0 kg and 7 + 2.5 kg 4 weeks later. T h e change was not significant. Neither the parathyroidectomy group nor the control group had any change in 2-point discrimination and touch sensation before or after operation. The Purdue test scores of the right and left hands, respectively, were 12.4 _+ 2.6 and 11.5 _+ 2.4 before operation, 12.9 _+ 2.0 and 11.4 _+ 2.2 1 week later, and 14.2 _+ 2.0 and 13 + 2.6 4 weeks later (Fig. 6). There was an increase in Purdue test scores for right and left hands 4 weeks later as compared with preoperative levels (p < 0.01). The Purdue test scores of both hands and assembly scores, respectively, were 9.3 + 2.4 and 27.2 _+ 11.8beforeoperation, 9.8 _ 1.6and28.1 _+ 7.5 1 week later, and 11.0 + 1.7 and 31.9 + 8.4 4 weeks later (Fig. 7). There was an increase in Purdue test scores in both hands and assembly scores 4 weeks later as compared with preoperative levels (p < 0.01). The Purdue test scores for right hand, left hand, and both hands, and assembly scores, in the control group, respectively, were 15.7 + 0.7, 13.9 _+ 0.7, 10.7 + 1.5, and 31.2 + 5.8 before operation; 15.3 + 0.6, 13.2 + 0.6, 10.5 + 0.8, and 30.2 _+ 5.4 1 week later; an15.9 + 0.7, 13.9 + 1.4, 11.1 + 0.6, and 34 + 7.7 4 weeks later. There was no significant change between
Surgery Volume 117, Number I
Chou, Sheen-Chen, Leong
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23
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Chou, Sheen-Chen, Leorzg
Surgery January 1995
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Fig. 8. M M D T times (placing and turning) before operation and 1 and 4 weeks after operation in nine patients with primary hyperparathyroidism and in nine patients with nodular goiter. Values expressed as mean + SD.
Surgery Volume 117, Number 1 scores before operation and 4 weeks later (Figs. 6 and
7). The M M D T times for placing and turning, respectively, were 352 + 56 seconds and 405 + 102 seconds before operating, 325 + 49 seconds and 373 +- 77 seconds 1 week later, and 300 _+ 27 seconds and 332 + 39 seconds 4 weeks later (Fig. 8). M M D T times for placing and turning decreased 4 weeks later as compared with the preoperative times (p < 0.01). The M M D T times for placing and turning in the control group, respectively, were 296 _+ 7 seconds and 317 _+ 18 seconds before operation 312 +_ 9 seconds and 315 _+ 15 1 week later, and 291 _+ 8 seconds and 305 _+ 13 seconds 4 weeks later. There was also no significant change before operation and 4 weeks later (Fig. 8).
Chou, Sheen-Chen, Leong
25
trol group, the improvement in muscle strength and fine motor movement is not due to the learning process. Improved muscle strength, increased Purdue test scores, and decreased M M D T times in patients who have undergone parathyroidectomy may improve their quality of life and work efficiency. Hypercaleemia frequently manifests as pronounced fatigue with psychiatric symptoms, which are reversible after operation. 9 Most of the patients in this study did not have subjective muscle symptoms, but the degree of improvement correlated with the reduced muscle strength noted before operation. There was no correlation between the preoperative serum calcium level and the degree of improvement after operation, which is a finding similar to that of others 2' 4, 5 but contrary to those in two recent reports. 3' 10
DISCUSSION
The neuromuscular syndrome of primary hyperparathyroidism as originally described in patients does not fit the modern presentation. Only two patients among nine in this series had subjective symptoms of bone pain. We recognize that patients with primary hyperparathyroidism have milder disease and are frequently asymptomatic. During the past decade objective and quantitative attempt s have been made to show that muscle function improves after correction of hypercalcemia, 1-5 especially the muscle strength of knee extension and flexion) Although most patients in this study did not have general weakness, muscle power (grip, palm pinch, lateral pinch, and three-chuck pinch) increased significantly 4 weeks after parathyroidectomy. T w o patients who were surgically treated with total thyroidectomy and autotransplantation and one patient who was surgically treated by removal of an adenoma had hypocalcemia lasting 2 to 3 weeks. The improvement was not evident 1 week after operation, possibly because of unstable calcemia at that time (three patients were taking oral calcium carbonate). However, normocalcemia was noted in all our patients 4 weeks later. The Purdue test and the M M D T have not been previously applied in patients with hyperparathyroidism after operation in the literature. These two tests are ideal for semiskilled operations such as wrapping, packing, stuffing envelopes, and filling containers with pharmaceutical pills and capsules. We found 4 weeks after operation that fine motor movement had significantly improved according to both tests. Compared with improvement in the con-
We are grateful for the assistance of Mr. Reh-Kun Chang and colleagues, of the rehabilitation department. REFERENCES 1. Hedman I, Grimby G, Tisell LE. Improvement of muscle strength after treatment for hyperparathyroidism. Acta Chit Scand 1984;150:521-4. 2. Wersall-Robertson E, Hamberger B, Ehren H, Eriksson E, Granberg PO. Increase in muscular strength followingsurgery for primary hyperparathyroidism. Acta Med Scand 1986; 220:233-5. 3. Joborn C, Joborn H, Rasrad J, Akerstrom G, Ljunghall S. Maximal isokinetic musde strength in patients with primary hyperparathyroidism before and after parathyroid surgery. Br J Surg 1988;75:77-80. 4. Kristoffersson A, Bjerle P, Stjernberg N, Jarhult J. Pre- and postoperative respiratorymuscle strength in primary hyperparathyroidism. Acta Chit Scand 1988;154:415-8. 5. KristofferssonA, BostromA, Soderberg T. Muscle strength is improvedafter parathyroidectomyin patients with primary hyperparathyroidism. Br J Surg 1992;79:165-9. 6. Wells SA, Ellis GJ, Gunnells JC, Schneider AB, Sherwood LM. Parathyroid autotransplantation in primary parathyroid hyperplasia. N Engl J Med 1976;295:57-62. 7. Hunter JM, ed. Rehabilitation of the hand. 2nd ed. St Louis: CV Mosby, 1984:3%41, 91-4. 8. Jacobs K, ed. Occupationtherapy: work-related programs and assessments. 2nd ed. Boston: Little, Brown, 1991:38-9. 9. Joborn C, Hetta J, Lind L, Rastad J, Akerstrom G, Ljunghall S. Self-rated psychiatric symptomsin patients operated on because of primary hyperparathyroidism and in patients with longstanding mild hypercalcemia. SURGERY1989;105:72-8. 10. Delbridge LW, Marshman D, Reeve TS, Crummer P, Posen S. Neuromuscularsymptomsin elderly patients with hyperparathyroidism: improvement with parathyroid surgery. Med J Aust 1988;149:74-6.
OBJECTIVE ASSESSMENTOF MUSCULARfunction before and after operation in patients with hyperparathyroidism has confirmed the clinical impression of postoperative improvement of muscular capacity. 1"5 The neuromuscular syndrome of primary hyperparathyroidism as originally described is rarely seen today. The inclusion of serum calcium as a part of multichannel chemical analysis has resulted in the diagnosis of this condition before the classic neuromuscular symptoms and signs develop. Although the disorder is clinically asymptomatic, whether neuromuscular dysfunction is present in a subclinical form and can be improved after surgical therapy is important to know. Nine patients admitted for surgical management of hyperparathyroidism were the subjects of this study. Accepted for publicationApril 27, 1994. Reprint requests: Fong-Fu Chou, MD, Department of Surgery, Chang Gung Memorial Hospital, 123 Ta-Pei Rd., Niao-Sung Hsiang, KaohsiungHsien, Taiwan, R.O.C. Copyright | 1995 by Mosby-Year Book, Inc. 0039-6060/95/$3.00 + 0 11/56/57013 18
SURGERY
PATIENTS AND METHODS Nine patients (six women, three men; median age, 55 years) who were admitted for parathyroidectomy were studied. All patients were free from known neuromuscular disorders, diabetes mellitus, previous wrist fractures, trauma, and uremia. Preoperative clinical manifestations, biochemical data, and grip power, and grip power 4 weeks after operation in patients with primary hyperparathyroidism are presented in Table I. Seven patients underwent resection of an adenoma, and two patients underwent total parathyroidectomy with forearm autotransplantation as mentioned by Wells et al. 6 Muscle power was checked with a grip dynamometer (Jamar, Jackson, Mich.) and a Preston pinch gauge (Jamar, Jackson, Mich.)] Hand strength was measured with the patient in sitting position, with the shoulder adducted and neutrally rotated, the elbow flexed at 90 degrees, the forearm in neutral position, and the wrist positioned at 0 to 30 degrees dorsiflexion and between 0 and 15 degrees of ulnar deviation. The maximal voluntary grip power, palm pinch, lateral pinch, and three-chuck pinch were measured in kilograms.
Surgery Volume 117, Number 7
Chou, Sheen-Chen, Leong
19
14
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Fig. 1. Serum calcium and phosPhate levels before operation and 1 day, 1 week, and 4 weeks after operation in nine patients with primary hyperparathyroidism and in nine patients with nodular goiter. Values expressed as mean 4- SD.
T a b l e I. Preoperative clinical manifestations, laboratory values, preoperative grip power, and change in grip power 4 weeks after operation in nine patients with p r i m a r y hyperparathyroidism
Grip po~er (kg)
Laboratory values*
Patient Age Clinical Calcium Phosphate Intact PTH AP 4 weeks Change no. Gender (yr) manifestations (mg/dl) (mg/dl) (pg/ml) (units/L) Preoperative after operation (%) 1 2 3 4 5 6 7 8 9
M F M F F F F F M
32 56 68 59 64 48 49 55 37
Kidney stone None None Hypertension Bone pain None None Bone pain None
12.2 10.5 11.8 11.5 10.4 10.8 13.4 12.9 10.7
1.8 2.7 3.8 1.5 2.6 1.8 2.2 3.0 3.0
530.0 86.4 75.6 81.3 1011.0 68.9 159.0 1936.0 886.0
70 6"8 94 69 900 39 195 479 586
25 12 20.3 19.0 13.5 18.7 26 11.3 34.6
26.8 25.8 25 20.3 21 19.7 27 15 38
7.2 115 23.2 6.8 55.6 5.3 3.8 32.7 9.8
*Normalvalues:serumcalcium,7.9-9,9mg/dl;serumphosphorus,2.5-4.5mg/dl; I-PTH, 10-65 pg/ml; AP, 28-94 units/L.
Fine motor movement of upper extremities was checked with the Purdue Pegboard Test (model 32020; Lafayette Instrument Company, Lafayette, Ind.) and T h e Minnesota M a n u a l Dexterity Test ( M M D T ) (model 32023; Lafayette Instrument).7' 8 T h e Purdue pegboard is
equipped with pins, collars, and washers, which are located in four cups at the top of the board. T h e person tested should be seated comfortably at the table. Separate scores are assessed for the right hand, left hand, both hands, and assembly. T h e number of pins inserted in 30
20
Chou, Sheen-Chen, Leong
Surgery January 1995
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SD =standard deviation Preop= preoperative, Postop= postoperative 1 week Late= postoperative 4 weeks, P with paired t test
Fig. 2. Maximal grip power (right and left hands) before operation and 1 and 4 weeks after operation in nine patients with primary hyperparathyroidism and in nine patients with nodular goiter. Values expressed as mean + SD. seconds are counted and recorded for the right hand, left hand, and both hands to calculate the score. Assembly testing consists of assembling pins, collars, and washers. The number of parts assembled in 30 seconds are counted and recorded to arrive at a score. Values reported are the mean of three consecutive measurements. M M D T comprises the placing test and the turning test. The placing test measures time in seconds to fill the 60-hole board with blocks, and the turning test is the time in seconds to turn the block on the 60-hole board. Both the placing and the turning score are measured by adding the times of four repetitions of the test. Sensation is checked by two-point discrimination in millimeters with a two-point anesthesimeter (Disk-Criminator; MackinnonDellon, Baltimore, Md.), and touch sensation is tested by pencil. Serum calcium, phosphate, intact parathyroid hormone (PTH), and alkaline phosphatase (AP) levels, and neuromuscular tests, were performed before operation. One week and 4 weeks after operation serum calcium and phosphate levels, and neuromuscular tests, were repeated. Daily checks of serum calcium and phosphate were done before patients were discharged and were in the normal range. If a patient's serum cal-
cium level was less than 7.9 mg/dl and symptoms of hypocalcemia developed, calcium carbonate was given four times daily until symptoms were relieved. Serum calcium and phosphate levels, and muscle power, sensation, and fine motor movement were also measured in nine patients with hemithyroidectomy (six women, three men; median age, 49 years), who served as control subjects for the study. Statistical significance was assessed by means of the Student t test for paired and unpaired samples, and correlations were calculated with Pearson's correlation coefficient. RESULTS
The clinical manifestations, muscle weakness, biochemical data, preoperative grip power, and postoperative grip power of the dominant hand in nine patients with primary hyperparathyroidism are shown in Table I. Clinically, one patient had kidney stones, two had bone pain, and one had hypertension. The preoperative grip power was negatively correlated with age of the patients (r = - 0 . 6 5 ; p < 0.05) but did not correlate with the preoperative serum calcium, phosphate, AP, and intact P T H levels. The increment of grip power of
Surgery Volume 117, Number
Chou, Sheen-Chen, Leong
21
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Fig. 3. Maximal palm pinch (right and left hands) before operation and 1 and 4 weeks after operation in nine patients with primary hyperparathyroidism and in nine patients with nodular goiter. Values expressed as mean + SD.
dominant hand 4 weeks after operation was reversibly correlated with preoperative grip power (r = - 0 . 6 2 ; p < 0.05) but not with serum calcium, phosphate, AP, and intact P T H levels. In nine patients with primary hyperparathyroidism the serum calcium level was 11.6 + 1.1 mg/dl (mean _+ SD), phosphate level was 2.5 _+ 0.7 mg/dl, AP level was 277.8 _+ 306.4 units/L, and intact P T H level was 537.1 + 641.2 ng/ml. One day after operation the serum calcium level was 8.7 + 1.3 mg/dl and phosphate level was 2.6 + 0.7 mg/dl. One week after operation the serum calcium level was 8.1 _+ 1.5 mg/dl and phosphate level was 2.9 + 0.8 mg/dl. Four weeks later the serum calcium level was 8.6 + 0.7 and phosphate level was 2.8 + 0.7 mg/dl (Fig. 1). Because of hypocalcemia, three patients took calcium carbonate for an average of 2 weeks. Normal serum calcium levels were present 3 weeks after operation in all patients. Before operation the mean serum calcium level in nine control subjects was 8.4 + 0.4 mg/dl and phosphate level was 3.5 +_ 1.0 mg/dl. One day after operation the serum calcium level was 8.0 + 0.3 mg/dl and phosphate level was 3.8 + 0.7 mg/dl. One week after operation the serum calcium level was 7.9 _+ 0.3 mg/dl and phosphate level was 3.2 + 0.9 mg/dl. At 4 weeks the serum cal-
cium level was 8.3 _+ 0.5 mg/dl and phosphate level was 3.5 + 0.8 mg/dl. After operation neither calcium nor phosphate had changed (Fig. 1). The individual results in nine patients with hyperparathyroidism as to grip power, palm pinch, lateral pinch, and three-chuck pinch are shown in Figs. 2 to 5. The grip power of right hand and the left hand, respectively, in the parathyroidectomy group was 20 _+ 7.5 kg and 18.1 + 7:9 kg before operation, 19.8 + 7.6 kg and 15.9 + 5.7 kg 1 week later, and 24.2 + 6.5 kg and 21.8 _+ 8.0 kg 4 weeks later. There was an increase of grip power in both hands 4 weeks later as compared with preoperative values (paired t test, p < 0.01). The grip power of the right hand and left hand, respectively, in the control group was 32.3 + 6.9 kg and 29 +_ 13 kg before operation, 30.1 + 6.5 kg and 27.5 + 8.0 kg 1 week later, and 32.8 _+ 7.9 kg and 32 -+ 8.5 kg 4 weeks later. The change was not significant. The palm pinch results of the right hand and the left hand, respectively, in the parathyroidectomy group were 4.0 _+ 1.4 kg and 3.9 _+ 0.8 kg before operation, 4.0 + 1.1 kg and 3.7 + 0.6 kg 1 week later, and 5.3 + 1.1 kg and 5.2 + 1.2 kg 4 weeks later. There was an increase of palm pinch on both hand 4 weeks later as compared with preoperative levels (p < 0.01). The palm pinch results
22
Chou, Sheen-Chen, Leong
Surgery January 1995
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Fig. 4. Maximal lateral pinch (right and left hands) before operation and 1 and 4 weeks after operation in nine patients with primary hyperparathyroidism and in nine patients with nodular goiter. Values expressed as mean _+ SD.
of the right hand and the left hand, respectively in the control gruop were 6.4 + 2.1 kg and 5.0 _+ 1.8 kg before operation, 6.3 + 2.0 kg and 4.9 + 1.5 kg 1 week later, and 6.5 + 2.1 kg and 5.4 + 1.3 kg 4 weeks later. The change was not significant. T h e lateral pinch results of the right and left hands, respectively, in the parathyroidectomy group were 5.4 + 2.1 kg and 4.8 _+ 1.5 kg before operation, 5.2 + 1.9 kg and 4.9_+ 1.4 kg 1 week later, and 6.7 + 2.1 kg and 6.2 + 1.8 kg 4 weeks later. There was an increase in lateral pinch in both hands 4 weeks later as compared with preoperative levels (p < 0.01). The lateral pinch results of the right and left hands, respectively, the control group were 7.0 + 3.2 kg and 6.8 + 2.2 kg before operation, 7.0 _+ 3.0 kg and 6.0 + 2.0 kg 1 week later, and 7.5 _+ 3.4 kg and 7.0 _+ 2.2 kg 4 weeks later. The change was not significant. The three-chuck pinch results of the right and left hands, respectively, in the parathyroidectomy group were 5.2 + 1.8 kg and 4.9 + 1.4 kg before operation, 5.6 + 1.6 kg and 5.0 _+ 1.0 kg 1 week later, and 6.9 _+ 2.0 kg and 6.2 _+ 1.8 kg 4 weeks later. There was an increase in three-chuck pinch in both hands 4 weeks later as compared with preoperative levels (p < 0.01). The three-chuck pinch results of the right and left hands, respectively, in the control group were 8.2 + 1.7 kg and 7.6 + 3.0 kg before operation,
8.4_+ 2.0 kg and 6.7_+ 2.8 kg 1 week later, and 7.9 + 1.0 kg and 7 + 2.5 kg 4 weeks later. T h e change was not significant. Neither the parathyroidectomy group nor the control group had any change in 2-point discrimination and touch sensation before or after operation. The Purdue test scores of the right and left hands, respectively, were 12.4 _+ 2.6 and 11.5 _+ 2.4 before operation, 12.9 _+ 2.0 and 11.4 _+ 2.2 1 week later, and 14.2 _+ 2.0 and 13 + 2.6 4 weeks later (Fig. 6). There was an increase in Purdue test scores for right and left hands 4 weeks later as compared with preoperative levels (p < 0.01). The Purdue test scores of both hands and assembly scores, respectively, were 9.3 + 2.4 and 27.2 _+ 11.8beforeoperation, 9.8 _ 1.6and28.1 _+ 7.5 1 week later, and 11.0 + 1.7 and 31.9 + 8.4 4 weeks later (Fig. 7). There was an increase in Purdue test scores in both hands and assembly scores 4 weeks later as compared with preoperative levels (p < 0.01). The Purdue test scores for right hand, left hand, and both hands, and assembly scores, in the control group, respectively, were 15.7 + 0.7, 13.9 _+ 0.7, 10.7 + 1.5, and 31.2 + 5.8 before operation; 15.3 + 0.6, 13.2 + 0.6, 10.5 + 0.8, and 30.2 _+ 5.4 1 week later; an15.9 + 0.7, 13.9 + 1.4, 11.1 + 0.6, and 34 + 7.7 4 weeks later. There was no significant change between
Surgery Volume 117, Number I
Chou, Sheen-Chen, Leong
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23
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Chou, Sheen-Chen, Leorzg
Surgery January 1995
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Fig. 8. M M D T times (placing and turning) before operation and 1 and 4 weeks after operation in nine patients with primary hyperparathyroidism and in nine patients with nodular goiter. Values expressed as mean + SD.
Surgery Volume 117, Number 1 scores before operation and 4 weeks later (Figs. 6 and
7). The M M D T times for placing and turning, respectively, were 352 + 56 seconds and 405 + 102 seconds before operating, 325 + 49 seconds and 373 +- 77 seconds 1 week later, and 300 _+ 27 seconds and 332 + 39 seconds 4 weeks later (Fig. 8). M M D T times for placing and turning decreased 4 weeks later as compared with the preoperative times (p < 0.01). The M M D T times for placing and turning in the control group, respectively, were 296 _+ 7 seconds and 317 _+ 18 seconds before operation 312 +_ 9 seconds and 315 _+ 15 1 week later, and 291 _+ 8 seconds and 305 _+ 13 seconds 4 weeks later. There was also no significant change before operation and 4 weeks later (Fig. 8).
Chou, Sheen-Chen, Leong
25
trol group, the improvement in muscle strength and fine motor movement is not due to the learning process. Improved muscle strength, increased Purdue test scores, and decreased M M D T times in patients who have undergone parathyroidectomy may improve their quality of life and work efficiency. Hypercaleemia frequently manifests as pronounced fatigue with psychiatric symptoms, which are reversible after operation. 9 Most of the patients in this study did not have subjective muscle symptoms, but the degree of improvement correlated with the reduced muscle strength noted before operation. There was no correlation between the preoperative serum calcium level and the degree of improvement after operation, which is a finding similar to that of others 2' 4, 5 but contrary to those in two recent reports. 3' 10
DISCUSSION
The neuromuscular syndrome of primary hyperparathyroidism as originally described in patients does not fit the modern presentation. Only two patients among nine in this series had subjective symptoms of bone pain. We recognize that patients with primary hyperparathyroidism have milder disease and are frequently asymptomatic. During the past decade objective and quantitative attempt s have been made to show that muscle function improves after correction of hypercalcemia, 1-5 especially the muscle strength of knee extension and flexion) Although most patients in this study did not have general weakness, muscle power (grip, palm pinch, lateral pinch, and three-chuck pinch) increased significantly 4 weeks after parathyroidectomy. T w o patients who were surgically treated with total thyroidectomy and autotransplantation and one patient who was surgically treated by removal of an adenoma had hypocalcemia lasting 2 to 3 weeks. The improvement was not evident 1 week after operation, possibly because of unstable calcemia at that time (three patients were taking oral calcium carbonate). However, normocalcemia was noted in all our patients 4 weeks later. The Purdue test and the M M D T have not been previously applied in patients with hyperparathyroidism after operation in the literature. These two tests are ideal for semiskilled operations such as wrapping, packing, stuffing envelopes, and filling containers with pharmaceutical pills and capsules. We found 4 weeks after operation that fine motor movement had significantly improved according to both tests. Compared with improvement in the con-
We are grateful for the assistance of Mr. Reh-Kun Chang and colleagues, of the rehabilitation department. REFERENCES 1. Hedman I, Grimby G, Tisell LE. Improvement of muscle strength after treatment for hyperparathyroidism. Acta Chit Scand 1984;150:521-4. 2. Wersall-Robertson E, Hamberger B, Ehren H, Eriksson E, Granberg PO. Increase in muscular strength followingsurgery for primary hyperparathyroidism. Acta Med Scand 1986; 220:233-5. 3. Joborn C, Joborn H, Rasrad J, Akerstrom G, Ljunghall S. Maximal isokinetic musde strength in patients with primary hyperparathyroidism before and after parathyroid surgery. Br J Surg 1988;75:77-80. 4. Kristoffersson A, Bjerle P, Stjernberg N, Jarhult J. Pre- and postoperative respiratorymuscle strength in primary hyperparathyroidism. Acta Chit Scand 1988;154:415-8. 5. KristofferssonA, BostromA, Soderberg T. Muscle strength is improvedafter parathyroidectomyin patients with primary hyperparathyroidism. Br J Surg 1992;79:165-9. 6. Wells SA, Ellis GJ, Gunnells JC, Schneider AB, Sherwood LM. Parathyroid autotransplantation in primary parathyroid hyperplasia. N Engl J Med 1976;295:57-62. 7. Hunter JM, ed. Rehabilitation of the hand. 2nd ed. St Louis: CV Mosby, 1984:3%41, 91-4. 8. Jacobs K, ed. Occupationtherapy: work-related programs and assessments. 2nd ed. Boston: Little, Brown, 1991:38-9. 9. Joborn C, Hetta J, Lind L, Rastad J, Akerstrom G, Ljunghall S. Self-rated psychiatric symptomsin patients operated on because of primary hyperparathyroidism and in patients with longstanding mild hypercalcemia. SURGERY1989;105:72-8. 10. Delbridge LW, Marshman D, Reeve TS, Crummer P, Posen S. Neuromuscularsymptomsin elderly patients with hyperparathyroidism: improvement with parathyroid surgery. Med J Aust 1988;149:74-6.