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Poster 109 An Uncommon Cause of Compressive Peroneal Nerve Palsy
1062
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Poster 109 "An Uncommon Cause of Compressive Peroneal Nerve Palsy." F. Marlene Perez, MD (The New York HospitaI-Cornell Medical Center, New York, NY); Elisabeth A. Lachmann, MD; Richard S. Tunkel, MD. One of several unusual etiologies of peroneal nerve palsy is compression by a ganglion cyst. Although synovial cysts are relatively common entities, they rarely involve peripheral nerves. Two cases are presented in which the common peroneal nerve is compressed by a post-traumatic ganglion cyst in the proximal tibiofibular joint. In the first case, compression occurred several months after blunt trauma to this region, and although the symptoms resolved following surgical excision of the cyst and rehabilitation treatment, the cyst reoccurred. In the second case, compression of the common peroneal nerve by a synovial cyst occurred after years of repetitive trauma to this patient's feet from ballet. Magnetic resonance imaging and electrodiagnostic studies confirmed compression of the common peroneal nerve by a ganglion cyst. The pathogenesis of ganglion cyst formation and the mechanism of compression are delineated.
Poster 110 "Clinical Outcomes of Patients after Conservative Management for Cervical Radiculopathy." Banwari Ladha, MD (Sinai Hospital, Detroit, MI); Parmod K. Mukhi, MD; Maury Ellenberg, MD; Amy Indenbaum, MD; Joseph C. Honet, MD. We retrospectively studied 46 patients with cervical radiculopathy to determine the outcome with nonsurgical treatment. We reviewed 200 patient charts seen in an outpatient physiatric referral practice between June 1991 and September 1994. The ICD-9 code (723.4) for cervical radiculopathy was used to separate out the initial patient group. To assure definite cervical radiculopathy was present, patients included in the study had to have at least 2 major criteria; 1 major and 2 minor criteria; or 3 minor criteria. Major criteria were a positive Spurling maneuver and positive EMG; minor criteria included radicular pain, muscle weakness and absent or decreased reflexes. Patients who did not fulfill these criteria were excluded from the study. Outcomes were recorded as excellent, good, fair, or poor. Excellent consisted of the presence of no residual symptoms, return to baseline work and activities. Good consisted of greater than 80% improvement in pain with returnto-work, baseline activities, and minimal residual complaints. Fair consisted of the return to most baseline activities with the presence of pain complaints requiring pain medication. Poor consisted of either no change or worsening of symptoms or requiting surgical intervention. Forty-six patients met the inclusion criteria. There were 33 men and 13 women; mean age was 53 years with a range of 31 to 96. Patients were followed for a mean time frame of 29 weeks, with a range of 1 to 101 weeks. Two patients were lost to follow-up. Thirty-four patients (73.9%) had a C7 radiculopathy; 2 patients (4.3%) had a C8 radiculopathy; and 1 patient (2.2%) had a C6 radiculopathy. Nine patients (19.6%) had indeterminate levels of radiculopathy (ie, C5 or C6, C7, or C8). Twenty patients (43.5%) had an excellent outcome; 12 (26.1%) a good outcome; 7 (15.2%) a fair outcome; and 5 patients (10.9%) had a poor outcome. Of the 5 patients, 2 had epidural steroids followed by surgical intervention yielding an excellent outcome, whereas 1 had acupuncture resulting in a good outcome. Of the 46 patients examined, a total of 39 patients (84.8%) had a fair to excellent outcome using nonsurgical management. When this data is statistically applied to the general population, 74.4% to 95.2% of patients would fit these outcomes at the 95% confidence level. This suggests that the majority of patients with cervical radiculopathy seen in an outpatient referral practice would resolve their radiculopathy and pain, and return to normal activities with nonsurgical management.
Poster 111 "Rare Rehabilitation Challenge in a Patient with Hypo-kalemic Periodic Paralysis and Charcot-Marie-Tooth Disease: A Case Report." Joseph P. Laluya, DO (Rush-Presbyterian-St Lukes Medical Center/Rush University, Chicago, IL). Hypokalemic periodic paralysis (HPP) is a rare illness characterized by episodes of low serum potassium followed by paralysis of limb muscles, proximal more than distal, and occasionally bulbar and respiratory involvement, which may prove fatal. Charcot-Marie-Tooth (CMT) is the most common hereditary peripheral neuropathy characterized by
Arch Phys Med Rehabil Vol 76, November 1995
symmetric weakness, distal greater than proximal, as well as significant ankle deformities and sensory deficits. We present a 28-year-old man who was diagnosed with CMT at age 7 and HPP at age 16. CMT resulted in severe pes cavus and equinus deformities requiring bilateral achilles tendon elongation at age 12. Eventually, bilateral foot-drop developed, requiring ankle-foot-orthoses. HPP episodes became more frequent during the patient's twenties, with paresis lasting from 4 to 18 hours. The most recent episode resulted in persistent lower extremity weakness. Other rehabilitation challenges involved medical treatment with potassium replacement, pain management, and psychosocial adjustment for this young man. Functional electrical stimulation, isokinetic exercises, and orthotics were utilized to upgrade strength and range of motion. This case illustrates the unique characteristics seen in patients with HPP and CMT. A detailed rehabilitation course and pertinent literature are discussed.
Poster 112 "Botulinum Toxin Injection Technique of the Lateral Cricoarytenoid in Spastic Dysphonia." Arthur Alfred Rodriquez, MD (University of Wisconsin Medical School, Madison, WI); Chales N. Ford, MD. Spastic dysphonia has been treated with botulinum toxin (botox) injection into the intrinsic laryngeal muscles. Recent studies suggest that unilateral injection of the thyroarytenoid (TA) may be more effective than bilateral injection, and that results are enhanced when botox is injected specifically into the lateral cricoarytenoid (LCA). This study demonstrates the technique for percutaneous injection or electromyography of the LCA. Injection techniques were developed by dissection of four human larynges and have been performed on approximately 20 patients. With the subject supine, the injection needle (covered with teflon, except for the tip which serves as a monopolar EMG electrode) is inserted through the unanesthetized skin just lateral to the midline just above the superior border of the cricoid cartilage. The needle is advanced through the cricothyroid and just over the cricothyroid membrane, and directed 45 ° from the sagittal plane (vs 15° for the TA), and 40 ° from the transverse plane (vs 65 ° for the TA). The subject is asked to phonate sustained/i/, and the electrode is advanced in a submucous location until motor units are observed. Placement into the adductor muscle is confirmed by requesting a gentle valsalva or vocal click maneuver.
Poster 113 "Improvement of Speech Following Stereotactic Thalmotomy in a Multiple Sclerosis Patient: A Case Report." William J. Hwang, MD (The University of Texas Southwestern Medical Center at Dallas, Dallas, TX); Stephanie A. Kesler, M.Ed, CCC/SLP; Denise Frankoff, MA, CCC/SLP; Geetha Pandian, MD; Kevin R. Krafft, MD. Stereotactic thalamotomy is known as an effective surgical treatment for intention tremor among Parkinsonian and multiple sclerosis patients; however, worsening of speech has also been described as a side effect in post-thalamotoy course. Contrary to this finding, we report a case in which the patient had demonstrated improvement in her speech after a thalamotomy procedure. The patient is a 22-year-old woman with multiple sclerosis who underwent stereotactic thalamotomy for her tremor in September, 1994. Preoperatively, the patient had severe mixed dysarthria with hyperkinetic dysarthric features such as exaggerated, involuntary movements of the head, neck and oral musculature; further, difficulty coordinating phonation, respiration, and articulation characterized by bursts of phonation, pitch breaks and lack of pitch control, excessive loudness, and imprecise articulation were also noted. The above symptoms were worsened by patient's involuntary movements of the head, neck, and oral musculature. Postoperatively, in addition to improvement in tremor, her speech pattern also improved to moderate mixed dysarthria. Speech intelligibility was increased by decreased bursts of phonation and less severe pitch breaks due to better control of inhalation and exhalation, decreased volume of speech, increased precision of articulation, and resolution of involuntary movements of the head, neck, and oral musculature. Overall, in our patient, thalamotomy was associated with improved speech. So far, few reports have been made regarding the effectiveness of thalamotomy and speech rehabilitation as means
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Poster 109 "An Uncommon Cause of Compressive Peroneal Nerve Palsy." F. Marlene Perez, MD (The New York HospitaI-Cornell Medical Center, New York, NY); Elisabeth A. Lachmann, MD; Richard S. Tunkel, MD. One of several unusual etiologies of peroneal nerve palsy is compression by a ganglion cyst. Although synovial cysts are relatively common entities, they rarely involve peripheral nerves. Two cases are presented in which the common peroneal nerve is compressed by a post-traumatic ganglion cyst in the proximal tibiofibular joint. In the first case, compression occurred several months after blunt trauma to this region, and although the symptoms resolved following surgical excision of the cyst and rehabilitation treatment, the cyst reoccurred. In the second case, compression of the common peroneal nerve by a synovial cyst occurred after years of repetitive trauma to this patient's feet from ballet. Magnetic resonance imaging and electrodiagnostic studies confirmed compression of the common peroneal nerve by a ganglion cyst. The pathogenesis of ganglion cyst formation and the mechanism of compression are delineated.
Poster 110 "Clinical Outcomes of Patients after Conservative Management for Cervical Radiculopathy." Banwari Ladha, MD (Sinai Hospital, Detroit, MI); Parmod K. Mukhi, MD; Maury Ellenberg, MD; Amy Indenbaum, MD; Joseph C. Honet, MD. We retrospectively studied 46 patients with cervical radiculopathy to determine the outcome with nonsurgical treatment. We reviewed 200 patient charts seen in an outpatient physiatric referral practice between June 1991 and September 1994. The ICD-9 code (723.4) for cervical radiculopathy was used to separate out the initial patient group. To assure definite cervical radiculopathy was present, patients included in the study had to have at least 2 major criteria; 1 major and 2 minor criteria; or 3 minor criteria. Major criteria were a positive Spurling maneuver and positive EMG; minor criteria included radicular pain, muscle weakness and absent or decreased reflexes. Patients who did not fulfill these criteria were excluded from the study. Outcomes were recorded as excellent, good, fair, or poor. Excellent consisted of the presence of no residual symptoms, return to baseline work and activities. Good consisted of greater than 80% improvement in pain with returnto-work, baseline activities, and minimal residual complaints. Fair consisted of the return to most baseline activities with the presence of pain complaints requiring pain medication. Poor consisted of either no change or worsening of symptoms or requiting surgical intervention. Forty-six patients met the inclusion criteria. There were 33 men and 13 women; mean age was 53 years with a range of 31 to 96. Patients were followed for a mean time frame of 29 weeks, with a range of 1 to 101 weeks. Two patients were lost to follow-up. Thirty-four patients (73.9%) had a C7 radiculopathy; 2 patients (4.3%) had a C8 radiculopathy; and 1 patient (2.2%) had a C6 radiculopathy. Nine patients (19.6%) had indeterminate levels of radiculopathy (ie, C5 or C6, C7, or C8). Twenty patients (43.5%) had an excellent outcome; 12 (26.1%) a good outcome; 7 (15.2%) a fair outcome; and 5 patients (10.9%) had a poor outcome. Of the 5 patients, 2 had epidural steroids followed by surgical intervention yielding an excellent outcome, whereas 1 had acupuncture resulting in a good outcome. Of the 46 patients examined, a total of 39 patients (84.8%) had a fair to excellent outcome using nonsurgical management. When this data is statistically applied to the general population, 74.4% to 95.2% of patients would fit these outcomes at the 95% confidence level. This suggests that the majority of patients with cervical radiculopathy seen in an outpatient referral practice would resolve their radiculopathy and pain, and return to normal activities with nonsurgical management.
Poster 111 "Rare Rehabilitation Challenge in a Patient with Hypo-kalemic Periodic Paralysis and Charcot-Marie-Tooth Disease: A Case Report." Joseph P. Laluya, DO (Rush-Presbyterian-St Lukes Medical Center/Rush University, Chicago, IL). Hypokalemic periodic paralysis (HPP) is a rare illness characterized by episodes of low serum potassium followed by paralysis of limb muscles, proximal more than distal, and occasionally bulbar and respiratory involvement, which may prove fatal. Charcot-Marie-Tooth (CMT) is the most common hereditary peripheral neuropathy characterized by
Arch Phys Med Rehabil Vol 76, November 1995
symmetric weakness, distal greater than proximal, as well as significant ankle deformities and sensory deficits. We present a 28-year-old man who was diagnosed with CMT at age 7 and HPP at age 16. CMT resulted in severe pes cavus and equinus deformities requiring bilateral achilles tendon elongation at age 12. Eventually, bilateral foot-drop developed, requiring ankle-foot-orthoses. HPP episodes became more frequent during the patient's twenties, with paresis lasting from 4 to 18 hours. The most recent episode resulted in persistent lower extremity weakness. Other rehabilitation challenges involved medical treatment with potassium replacement, pain management, and psychosocial adjustment for this young man. Functional electrical stimulation, isokinetic exercises, and orthotics were utilized to upgrade strength and range of motion. This case illustrates the unique characteristics seen in patients with HPP and CMT. A detailed rehabilitation course and pertinent literature are discussed.
Poster 112 "Botulinum Toxin Injection Technique of the Lateral Cricoarytenoid in Spastic Dysphonia." Arthur Alfred Rodriquez, MD (University of Wisconsin Medical School, Madison, WI); Chales N. Ford, MD. Spastic dysphonia has been treated with botulinum toxin (botox) injection into the intrinsic laryngeal muscles. Recent studies suggest that unilateral injection of the thyroarytenoid (TA) may be more effective than bilateral injection, and that results are enhanced when botox is injected specifically into the lateral cricoarytenoid (LCA). This study demonstrates the technique for percutaneous injection or electromyography of the LCA. Injection techniques were developed by dissection of four human larynges and have been performed on approximately 20 patients. With the subject supine, the injection needle (covered with teflon, except for the tip which serves as a monopolar EMG electrode) is inserted through the unanesthetized skin just lateral to the midline just above the superior border of the cricoid cartilage. The needle is advanced through the cricothyroid and just over the cricothyroid membrane, and directed 45 ° from the sagittal plane (vs 15° for the TA), and 40 ° from the transverse plane (vs 65 ° for the TA). The subject is asked to phonate sustained/i/, and the electrode is advanced in a submucous location until motor units are observed. Placement into the adductor muscle is confirmed by requesting a gentle valsalva or vocal click maneuver.
Poster 113 "Improvement of Speech Following Stereotactic Thalmotomy in a Multiple Sclerosis Patient: A Case Report." William J. Hwang, MD (The University of Texas Southwestern Medical Center at Dallas, Dallas, TX); Stephanie A. Kesler, M.Ed, CCC/SLP; Denise Frankoff, MA, CCC/SLP; Geetha Pandian, MD; Kevin R. Krafft, MD. Stereotactic thalamotomy is known as an effective surgical treatment for intention tremor among Parkinsonian and multiple sclerosis patients; however, worsening of speech has also been described as a side effect in post-thalamotoy course. Contrary to this finding, we report a case in which the patient had demonstrated improvement in her speech after a thalamotomy procedure. The patient is a 22-year-old woman with multiple sclerosis who underwent stereotactic thalamotomy for her tremor in September, 1994. Preoperatively, the patient had severe mixed dysarthria with hyperkinetic dysarthric features such as exaggerated, involuntary movements of the head, neck and oral musculature; further, difficulty coordinating phonation, respiration, and articulation characterized by bursts of phonation, pitch breaks and lack of pitch control, excessive loudness, and imprecise articulation were also noted. The above symptoms were worsened by patient's involuntary movements of the head, neck, and oral musculature. Postoperatively, in addition to improvement in tremor, her speech pattern also improved to moderate mixed dysarthria. Speech intelligibility was increased by decreased bursts of phonation and less severe pitch breaks due to better control of inhalation and exhalation, decreased volume of speech, increased precision of articulation, and resolution of involuntary movements of the head, neck, and oral musculature. Overall, in our patient, thalamotomy was associated with improved speech. So far, few reports have been made regarding the effectiveness of thalamotomy and speech rehabilitation as means