Nerve root anomalies detected intra-operatively technical nuances towards achieving a successful surgical outcome: our experience of three case reports at a tertiary level centre

Objective: Analysis of three case reports of nerve root anomalies detected intra-operatively and its implications.

Design: Data collected during one year prospective non-randomised study using hospital records.

Setting: Single tertiary care centre.

Subjects: 3 patients in one year period.     

Promoting physical activity in hospitalized patients with mild ischemic stroke: a pilot study

Background: Patients with acute stroke spend most of their hospital day inactive. However, a method to promote physical activity (PA) in stroke has not been established.

Objective: To evaluate the effectiveness of promoting PA by enhancing self-efficacy in hospitalized patients with mild ischemic stroke.

Design: Pre–post interventional study.

Methods: Hospitalized patients with mild ischemic stroke who could walk without assistance were recruited. We measured the daily number of steps taken as the index of daily hospitalized PA using an accelerometer. At the baseline measurement, patients did not receive accelerometer-based feedback. To promote hospitalized PA, a physical therapist provided instruction on the self-monitoring approach and discussed PA targets, encouraged the patients to walk more, and instructed them on the importance of PA after stroke. We also measured self-efficacy for PA using an assessment tool at the baseline and during the intervention.

Results: Twenty-two patients (62.5 years old, 68.2% men) were included. PA during the intervention was higher than that at the baseline measurement (5709.4 ± 2236.1 vs. 2813.9 ± 1511.9 steps/day, p < 0.001). Self-efficacy for PA during the intervention was also higher than that at the baseline measurement (76.4 ± 18.8 vs. 58.9 ± 29.0 points, p < 0.001).

Conclusions: Promoting PA by enhancing self-efficacy may increase PA and self-efficacy for PA in hospitalized patients with mild ischemic stroke. The present results might provide new strategies of PA promotion in these hospitalized patients.     

Comparison of the Mini-Balance Evaluations Systems Test with the Berg Balance Scale in relationship to walking speed and motor recovery post stroke*

Background: The Mini-BESTest is a recently developed balance assessment tool that incorporates challenging dynamic balance tasks. Few studies have compared the psychometric properties of the Mini-BESTest to the commonly used Berg Balance Scale (BBS). However, the utility of these scales in relationship to post stroke walking speeds has not been explored.

Objectives: The purpose of this study was to compare the sensitivity and specificity of the Mini-BESTest and BBS to evaluate walking speeds in individuals with stroke.

Design: A retrospective exploratory design.

Methods: Forty-one individuals with chronic stroke were evaluated with the Mini-BESTest, BBS, and 10-meter self-selected walk test (10MWT). Based on their self-selected gait speeds (below or above 0.8 m/s), participants were classified as slow and fast walkers.

Results: Significant linear correlations were observed between the Mini-BESTest vs. BBS (r = 0.72, p ≤ 0.001), Mini-BESTest vs. 10MWT (r = 0.58, p ≤ 0.001), and BBS vs. 10MWT (r = 0.30, p = 0.05). Independent t-tests comparing the balance scores for the slow and fast walkers revealed significant group differences for the Mini-BESTest (p = 0.003), but not for the BBS (p = 0.09). The Mini-BESTest demonstrated higher sensitivity (93%) and specificity (64%) compared to the BBS (sensitivity 81%, specificity 56%) for discriminating participants into slow and fast walkers.

Conclusions: The Mini-BESTest has a greater discriminative ability than the BBS to categorize individuals with stroke into slow and fast walkers.     

Sonographic assessment of optic nerve and ophthalmic vessels in patients with idiopathic intracranial hypertension

Background: Early diagnosis and proper monitoring of intracranial pressure (ICP) in idiopathic intracranial hypertension (IIH) could reduce morbidity.

Objectives: The objective was to explore and monitor reflection of raised ICP in IIH on optic nerve sheath diameter (ONSD), papillary height and ophthalmic vessels hemodynamics, using transorbital sonography (TOS).

Methods: The study included 24 IIH patients and 30 controls. Patients were compared to controls (phase I) then reassessed twice; 1 week and 4 weeks later (phase II). Both groups underwent clinical evaluation and TOS to measure ONSD, papillary elevation, and color Doppler indices of the ophthalmic vessels. Patients underwent lumbar puncture (LP) to measure cerebrospinal fluid (CSF) pressure.

Results: ONSD was significantly higher in patients compared to controls (p < 0.001). The cut-off value was 6.2 mm. Papillary elevation (p = 0.006) and ONSD (p = 0.006) were significantly reduced 4 weeks following LP. Baseline color Doppler indices of the ophthalmic vessels were comparable between both groups and the changes observed during the follow-up visits in the patients were insignificant.

Conclusion: Reflected ICP changes on ONSD and papilla, measured by TOS, could be a valuable noninvasive additional tool to diagnose and monitor IIH patients. IIH insignificantly influences ophthalmic vessels hemodynamics.

Abbreviation BMI: Body mass index. CSF: Cerebrospinal fluid. EDV: End diastolic velocity. ICP: Intracranial pressure. IH:intracranial hypertension. IIH: Idiopathic intracranial hypertension. LP: Lumbar puncture. MI: Mechanical index. MRI: Magnetic resonance imaging. MRV: Magnetic resonance venography. OA: Ophthalmic artery OND: Optic nerve diameter. ONSD: Optic nerve sheath diameter. OV: Ophthalmic vein. PIs: Pulsatility indices. PSV: Peak systolic velocity. ROC: Receiver operator characteristic. TOS: Trans-orbital sonography.     

Levodopa,placebo and rotigotine change biomarker levels for oxidative stress

Introduction: Homocysteine increase and glutathione derivative cysteinyl-glycine fall are indirect biomarkers for oxidative stress, for instance due to dopamine D₁ receptor stimulation.

Objectives: To investigate the influence of the D₁ receptor agonists levodopa and rotigotine compared with placebo on homocysteine and cysteinyl-glycine in plasma of patients with Parkinson’s disease.

Methods: Patients received 100 mg levodopa, 4 mg rotigotine or placebo. Cysteinyl-glycine and homocysteine were measured every 30 min over three hours.

Results: Homocysteine rose during levodopa- and placebo administration. Rotigotine had no effect. Cysteine-glycine only increased after placebo- but not after levodopa- or rotigotine.

Discussion: Homocysteine elevation results from hepatic and gastrointestinal methylation processes. Transdermal rotigotine circumvents these methylation locations. Turnover of segregated alkyl residuals from rotigotine serves as methyl group donors, which counteract homocysteine increment. The placebo-related cysteinyl-glycine increase results from reduced free radical exposure. Low levodopa dosing and antioxidants in the rotigotine patch matrix prevented cysteinyl-glycine fall.     

Skeletal muscle changes following stroke: a systematic review and comparison to healthy individuals

Background: Despite extensive study of the impact of stroke on muscle and functional performance, questions remain regarding the extent to which changes are due to the neurological injury vs. age-related loss of morphology and force production.

Objectives: To synthesize available evidence describing post-stroke changes in lower extremity muscle size and strength compared to healthy adults.

Methods: Scientific literature was searched up to April 2016 to identify studies that included lower extremity muscle size and strength measures in individuals with chronic stroke. Lower extremity muscle size and strength data from healthy controls were sought for comparison. Relative differences were calculated between paretic, nonparetic, and control limbs.

Results: Fifteen studies with 375 participants (61% male; age = 62 ± 5 years; time since stroke = 60 ± 42 months) were included. The paretic limb exhibited deficits of ~13% in thigh muscle size, ~5% in lower leg muscle size, and ~8% in lean leg mass compared to the nonparetic limb. Paretic plantarflexor and knee extensor strength were 52 and 36% lower, respectively, compared to the nonparetic limb. When compared to age-matched control data, both paretic and nonparetic limbs showed deficits in muscle size and strength.

Conclusions: Age-related differences support the impact of stroke-related sarcopenia as a contributor to hemiparetic muscle dysfunction. Understanding these muscular changes is necessary for designing appropriate exercise interventions aimed at restoring muscle function.     

Cervical myelitis presenting as occipital neuralgia

Aim: Occipital neuralgia is a common form of headache that is characterized by paroxysmal severe lancinating pain in the occipital nerve distribution.

Methods: The exact pathophysiology is still not fully understood and occipital neuralgia often develops spontaneously. There are no specific guidelines for evaluation of patients with occipital neuralgia.

Result: Cervical spine, spinal cord and posterior neck muscle lesions can induce occipital neuralgia. Brain and spine imaging may be necessary in some cases, according to the nature of the headache or response to treatment.

Discussion: We report a case of cervical myelitis presenting as occipital neuralgia.     

Possible error in the Danish version of the WHO Quality of Life (WHOQOL-BREF) Questionnaire

Background: The WHOQOL-BREF is widely used to measure quality of life.

Aims: The goal of the present study was to use the questionnaire in a doctoral study.

Methods: We studied all the instructions provided by the WHO.

Results: In the Danish version of the WHOQOL-BREF there is a discrepancy between the negatively phrased question 9 and both the syntax file and the verbal instructions for coding the data provided by the WHO.

Conclusions: This is a notification of possible error interpretations in projects that use the questionnaire. This could be corrected by manual correction in the coding process or by changing the negatively phrased question 9.     

Social phobia,depression and eating disorders during middle adolescence: longitudinal associations and treatment seeking

Background: Longitudinal associations between social phobia (SP), depression and eating disorders (EDs), and the impact of antecedent SP and depression on subsequent treatment seeking for EDs have rarely been explored in prospective adolescent population studies.

Aim: We aimed to examine these associations in a large-scale follow-up study among middle adolescents.

Method: We surveyed 3278 Finnish adolescents with a mean age of 15 years for these disorders. Two years later, 2070 were reached and again surveyed for psychopathology and treatment seeking. Longitudinal associations between the self-reported disorders and treatment-seeking patterns for self-acknowledged ED symptoms were examined in multivariate analyses, controlling for SP/depression comorbidity and relevant socioeconomic covariates.

Results: Self-reported anorexia nervosa (AN) at age 15 years predicted self-reported depression at age 17 years. Furthermore, self-reported SP at age 15 years predicted not seeking treatment for bulimia nervosa (BN) symptoms, while self-reported depression at age 15 years predicted not seeking treatment for AN symptoms during the follow-up period.

Conclusions: Adolescents with AN should be monitored for subsequent depression. Barriers caused by SP to help seeking for BN, and by depression for AN, should be acknowledged by healthcare professionals who encounter socially anxious and depressive adolescents, especially when they present with eating problems.     

Neurological impairments in hypoxic neonates and lactate levels

Introduction: Metabolic acidosis with increasing lactate concentration develops due to the lack of oxygen in the tissues.

Objectives: The effect of lactic acidosis on neurological development in the first year of life.

Materials and Methods: Our study included 50 newborns with perinatal hypoxia requiring oxygen therapy and 50 healthy newborns. pH, pCO2, pO2, base excess (BE) and lactates from arterialized capillary blood were determined in both groups of newborns, in the first and second hours after birth, and neurological development in the first year of life was estimated.

Results: pH, pCO2, pO2, BE and lactates differed significantly between the groups in the first and second hours after birth p < 0.01. Hypotonia was recorded in 20/50 cases and hypertonia was recorded in 10/50 cases in the first year of life.

Conclusion: Lactate concentration may be an indicator of neurological damage in neonates with perinatal hypoxia.     

Stereological assessment of the total number of hypoglossal neurons after repeated crush injuries to the hypoglossal nerve in adult rats

Objective: Retrograde neuronal cell death does not occur in mature motoneurons following the axonal injury of peripheral nerves. However, a previous study suggested that retrograde neuronal cell death does occur in adult rats after the creation of double lesions on the hypoglossal (XII) nerve based on a substantial decrease in the number of XII neurons. Using stereological methods, we examined neuronal apoptosis in XII neurons and the total number of XII neurons following repeated crush injuries to the XII nerve.

Methods: The right XII nerve of adult rats was crushed three times at one-week intervals with a brain aneurysm clip. At 4 weeks after the final crush, the total numbers of XII neurons on the injured right and uninjured left sides were estimated stereologically.

Results: After repeated crush injuries, no apoptosis was evident in XII neurons as indicated by immunostaining for cleaved caspase-3. Moreover, immunohistochemistry for the vesicular acetylcholine transporter revealed axonal elongation in the tongue 4 weeks after repeated crush injuries. At 4 weeks, the total numbers of XII neurons were 7800 ± 290 on the injured right side and 8000 ± 230 on the uninjured left side, and no significant difference was evident between the injured and uninjured sides.

Conclusion: Neuronal cell death does not occur in XII neurons and the total number of XII neurons does not decrease after repeated crush injuries of the XII nerve in adult rats.     

Investigation of subdural electrode displacement in invasive epilepsy surgery workup using neuronavigation and intraoperative MRI

Objectives: One of the main obstacles of electrode implantation in epilepsy surgery is the electrode shift between implantation and the day of explantation. We evaluated this possible electrode displacement using intraoperative MRI (iopMRI) data and CT/MRI reconstruction.

Methods: Thirteen patients (nine female, four male, median age 26 ± 9.4 years) suffering from drug-resistant epilepsy were examined. After implantation, the position of subdural electrodes was evaluated by 3.0 T-MRI and thin-slice CCT for 3D reconstruction. Localization of electrodes was performed with the volume-rendering technique. Post-implantation and pre-explantation 1.5 T-iopMRI scans were coregistered with the 3D reconstructions to determine the extent of electrode dislocation.

Results: Intraoperative MRI at the time of explantation revealed a relevant electrode shift in one patient (8%) of 10 mm. Median electrode displacement was 1.7 ± 2.6 mm with a coregistration error of 1.9 ± 0.7 mm. The median accuracy of the neuronavigation system was 2.2 ± 0.9 mm. Six of twelve patients undergoing resective surgery were seizure free (Engel class 1A, median follow-up 37.5 ± 11.8 months).

Conclusion: Comparison of pre-explantation and post-implantation iopMRI scans with CT/MRI data using the volume-rendering technique resulted in an accurate placement of electrodes. In one patient with a considerable electrode dislocation, the surgical approach and extent was changed due to the detected electrode shift.

Abbreviations: ECoG: electrocorticography; EZ: epileptogenic zone; iEEG: invasive EEG; iopMRI: intraoperative MRI; MEG: magnetoencephalography; PET: positron emission tomography; SPECT: single photon emission computed tomography; 3D: three-dimensional.     

The improvement in respiratory function by inspiratory muscle training is due to structural muscle changes in patients with stroke: a randomized controlled pilot trial

Background: The changes effected by the inspiratory muscle training (IMT) on the structure of inspiratory muscles such as on the diaphragm, in patients with stroke, is unclear.

Objective: To investigate the effect of IMT on inspiratory function, diaphragm thickness, walking endurance, and fatigue in patients with stroke.

Methods: A total of 30 patients with stroke were randomized to either the experimental group or the control group. The experimental group (n = 15) underwent inspiratory muscle training with resistance adjusted to 30% of maximal inspiratory pressure, 90 breaths a day, 5 times a week for 6 weeks. Both groups received regular physical therapy for the same amount of time. The primary outcome measure was the diaphragm thickness ratio. The secondary outcomes were inspiratory function; maximal inspiratory pressure and inspiratory muscle endurance; and gait endurance and fatigue.

Results: There were significant differences between the two groups in the thickness ratio on the affected diaphragm thickness (medium effect size), maximal inspiratory pressure (medium effect size), and inspiratory muscle endurance (large effect size; Bonferroni correction p < 0.005). The gait endurance (medium effect size) and fatigue (small effect size) showed no significant differences in the between group comparison.

Conclusion: Inspiratory muscle training was effective in improving respiratory function and inducing structural changes, especially in the affected diaphragm.     

Effect of whole body vibration on spasticity in hemiplegic legs of patients with stroke

Background: Several reports have focused on the effects of whole body vibration (WBV) on spasticity with differing results. Most studies used modified Ashworth scale (MAS) for qualitative measurements, but the effect was small.

Objective: To investigate the effect of WBV on spasticity in hemiplegic legs of patients with stroke using F-wave parameters.

Methods: Sixteen patients with stroke (mean age, 54.7 ± 13.5 years: time after stroke, 28.0 ± 26.3 months) were enrolled in a comparative before-and-after intervention trial. WBV was applied at 30 Hz (4–8 mm amplitude) for 5 min on the hamstrings, gastrocnemius, and soleus muscles in a sitting position. Spasticity was assessed according to the F-wave parameters, MAS, and active and passive range of motion (A-ROM and P-ROM, respectively). These assessments were obtained before, immediately after, and 20 min after each intervention.

Results: The F-wave parameters, MAS score, and P-ROM improved significantly after the WBV and remained below the baseline level, even after 20 min; no such change was noted in the unaffected limb via the F-wave parameters. The WBV also improved volitional movement immediately after intervention, as indicated by the A-ROM.

Conclusions: These results confirmed a significant reduction of motor neuron excitability until 20 min after the WBV, as indicated by F-wave parameters.     

Internal decompression for spinal stenosis (IDSS) for decompression and use of interlaminar dynamic device (CoflexTM) for stabilization in the surgical management of degenerative lumbar canal stenosis with or without mild segmental instability: our initial results

Introduction: Internal decompression of spinal stenosis (IDSS) and Posterior dynamic stabilization (PDS) form a bridge between decompression laminectomy alone and rigid fusion, by attempting to sustain beneficial effects of decompression and stabilization in an attempt to prevent bad effects of relentless degeneration.

Objective: To evaluate the clinical outcome in operated patient of posterior dynamic stabilization.

Design: Data were collected over 1 year in prospective, nonrandomized follow-up study using outcome scales.

Setting: Single surgeon, tertiary care centre in Mumbai, India.

Described here is the operative technique of posterior dynamic stabilization using CoFlex^TM and clinical outcome of 67 consecutive patients using Visual Analogue Scale and Oswestry Disability Score.     

Voxel-based morphometry of disgust sensitivity

Background: Difficulties with the regulation of negative affect have been extensively studied in neuroimaging research. However, dysregulation of a specific emotion, disgust, has hardly been investigated. In the present study, we used voxel-based morphometry to identify whether gray matter volume (GMV) of frontal regions is correlated with personality traits associated with general and disgust-specific emotion regulation difficulties.

Method: We analyzed T1-weighted images of 49 females (mean age = 22.8 years, SD = 3.2). The women rated their disgust sensitivity (DS) (temporally stable tendency to experience disgust as uncontrollable and extremely aversive) as well as general difficulties with emotion regulation.

Results: DS and general emotion regulation deficits were positively associated with a heightened GMV of the orbitofrontal cortex. DS additionally showed a negative association with GMV of the medial prefrontal cortex.

Conclusion: The present study revealed shared and distinct contributions of frontal brain regions to disgust-specific and general emotion regulation difficulties.     

The curious case of processing unaccusative verbs in aphasia

Background: Individuals with agrammatic Broca’s aphasia (IWBA) exhibit a delay in lexical activation in S-V-O word order sentences and delayed lexical reactivation in sentences that contain syntactic dependencies. This pattern is in contrast to neurologically unimpaired individuals who immediately evince lexical reactivation at the gap in sentences that contain syntactic dependencies. However, in the case of sentences that contain unaccusative verbs, neurologically unimpaired individuals also exhibit a delay in lexical reactivation. This delay provides a unique opportunity to further examine lexical delays in IWBA.

Aim: The purpose of the current studies is to investigate the online comprehension of sentences that contain unaccusative verbs in IWBA and in a group of age-matched control (AMC) individuals.

Methods and Procedures: Cross-modal picture priming was used to test for priming of a displaced lexical item (direct object noun) immediately after the unaccusative verb (at the gap) during the ongoing auditory stream and at three additional time points downstream from the verb (500 ms, 750 ms, and 1,250 ms).

Outcomes and Results: Delayed reactivation of the displaced lexical item downstream from the gap (similar to prior reports of delayed reactivation with younger unimpaired listeners) for both the AMCs and the IWBA was found.

Conclusion: These results provide support that IWBA do not evince a delayed time course of lexical reactivation for unaccusative verbs compared to neurologically unimpaired individuals.     

Boston Naming Test norms for the Dominican population

Background: Although neuropsychology is a well-established discipline worldwide, in the Dominican Republic (DR), its practice is relatively new.

Aims: This research was conducted with the aim of adapting and standardising the 2005, 60-item version of the Boston Naming Test (BNT) in the DR, taking into consideration the influence of gender, educational level and age.

Methods & Procedures: The sample consisted of 239 Spanish-speaking, healthy community-dwelling Dominicans between 16 and 80 years of age from each of the country’s major provinces.

Outcomes & Results: Results indicate that, of the demographic variables studied, the educational level alone influences performance on the naming test.

Conclusions: We recommend a change in the presentation order of the original BNT items to respond to the intended increase in difficulty. The use of these norms will facilitate interpretation of the results not only for Dominicans in the DR but also for first-generation Dominicans who live in other countries like the United States, Canada, and Spain, where there are sizeable Dominican communities, helping to adequately classify performances as normal or pathological.     

Analysis of muscle fiber conduction velocity during finger flexion and extension after stroke

Background: Stroke survivors experience greater strength deficits during finger extension than finger flexion. Prior research indicates relatively little observed weakness is directly attributable to muscle atrophy. Changes in other muscle properties, however, may contribute to strength deficits.

Objectives: This study measured muscle fiber conduction velocity (MFCV) in a finger flexor and extensor muscle to infer changes in muscle fiber-type after stroke.

Methods: Conduction velocity was measured using a linear EMG surface electrode array for both extensor digitorum communis and flexor digitorum superficialis in 12 stroke survivors with chronic hand hemiparesis and five control subjects. Measurements were made in both hands for all subjects. Stroke survivors had either severe (n = 5) or moderate (n = 7) hand impairment.

Results: Absolute MFCV was significantly lower in the paretic hand of severely impaired stroke patients compared to moderately impaired patients and healthy control subjects. The relative MFCV between the two hands, however, was quite similar for flexor muscles across all subjects and for extensor muscles for the neurologically intact control subjects. However, MFCV for finger extensors was smaller in the paretic as compared to the nonparetic hand for both groups of stroke survivors.

Conclusions: One explanation for reduced MFCV may be a type-II to type-I muscle fiber, especially in extrinsic extensors. Clinically, therapists may use this information to develop therapeutic exercises targeting loss of type-II fiber in extensor muscles.     

Therapeutic ultrasound after sciatic nerve compression of Wistar rats

Objectives: The present study analyzed the effect of therapy with therapeutic ultrasound on the sciatic nerve after compression injury, comparing two similar doses of SATA.

Methods: In total, 32 Wistar rats were used, divided into the following groups: CG — control; IG — compression injury of the sciatic nerve; IGCU — injury and continuous ultrasound; and IGPU — injury and 20% pulsed ultrasound. The treatment with ultrasound started on the 3rd postoperative day, with a frequency of 1 MHz, 0.4 W/cm² (SATA) for IGCU. IGPU received 2.0 W/cm² (SATP), with 20% of the active cycle, for 3 minutes. The treatment was performed on a daily basis, totaling 15 days of therapy. Evaluations were performed for functional, histological, and morphometric forms.

Results: Both the Sciatic Functional Index and the withdrawal threshold and grip strength failed to show an advantage of using therapeutic ultrasound. For the morphometric evaluations of nerve fiber diameter and axons, myelin sheath thickness, and G quotient and nerve fiber estimates, IGPU values were estimated to be significantly lower. The morphological analysis revealed intense inflammatory response and neovascularization, as well as degeneration of axons and the myelin sheath, for the injury group and IGCU; however, IGPU showed greater tissue disorganization.

Conclusion: There were no significant differences, showing functional or nocicepitive recovery of the treated groups, including with characteristics pointing to the pulsed group with worse results.