Comparative Post-operative Outcomes between Positive and Negative Electromyography (EMG) in Patient with Tunnel Syndrome: A Retrospective Study

Category: Other Introduction/Purpose: Tarsal tunnel syndrome can be established using combination of physical examination and electrodiagnostic study including tenderness along tibial nerve in tarsal tunnel area, Tinel sign positive, and positive EMG. However, it has been reported that the sensitivity of the electrodiagnostic study is only 52% for diagnosis of tarsal tunnel syndrome. Therefore, although EMG is negative, some surgeons prefer to make a diagnosis base on physical examination. Conservative treatment is the first line of treatment and when this fails, surgical treatment is indicated. The purpose of this study was to compare post-operative outcomes following tarsal tunnel release in patients who had tarsal tunnel syndrome with positive and negative electrodiagnostic study. Methods: The retrospective chart review of 34 consecutive patients who had underwent tarsal tunnel release between 2015 and 2019 were enrolled in this study. The patients were classified into 2 groups based on results of electrodiagnostic study (negative EMG 15 patients and positive EMG 18 patients). All patients had been treated with conservative treatment for at least 6 months including modified inserted and shoe wear, activities modifications, NSAIDs, and gabapentin. The primary outcome was pain level using Visual Analogue Scale (VAS) while the secondary outcomes were SF-36, FAAM, recovery times (time to return to ADL, work, and sports), and complications. A paired sample t-test was used to assess statistical differences between pre- and post- operative functional outcomes (VAS, SF-36, and FAAM) in the same group of both negative and positive EMG while an independent t-test was used to compare functional outcomes (VAS, SF-36, and FAAM) between the negative and positive EMG. Results: There were 33 patients (15 male and 18 female) with mean age of 49.2 years (range, 25-71 years), mean BMI of 24.7 kg/m2 (range, 17.6-33.2 kg/m2), and mean follow-up of 17.9 months (range, 12-36 months). The mean duration of symptom before the surgery was 8.7 months and 10.2 months for EMG negative and positive respectively. Both groups demonstrated significant improvement of all functional outcomes (FAAM, SF-36, and VAS (p<0.001 all)) compared to pre-operative status; however, there was no significant difference between the two groups, (p>0.05 all). The recovery time were to return to daily activities (3.5 vs 3.6 weeks), time to return to work (5.4 vs 5.6 weeks), and time to return to sport (16.4 vs 17.1 weeks). There were no complications in both groups Conclusion: Tarsal tunnel release demonstrated significantly improvement of functional outcomes in both negative and positive electrodiagnostic study in patients as measured with VAS, SF-36, and FAAM. However, negative EMG did not demonstrate negative impact on functional outcomes after tarsal tunnel release. When clinical and physical examination suspects tarsal tunnel syndrome, tarsal tunnel release should be considered even thought there is negative on electrodiagnostic study.

Isolated Oropharyngeal Dysphagia as the Initial Presentation of Anti-SRP Immune-Mediated Necrotizing Myopathy

A 51-year-old male initially presented with a progressive course of isolated oropharyngeal dysphagia prior to the clinical course of painful symmetrical proximal muscle weakness without sensory deficit which rendered him to wheelchairbound status within 5 months. The physical examination revealed symmetrical proximal muscle weakness without sensory symptoms. The initial serum creatine kinase was extremely high and the electrodiagnostic study revealed a myopathic pattern. A muscle biopsy of the left biceps suggested a diagnosis of immune-mediated necrotizing myopathy (IMNM) and the serum anti-signal recognition particle (SRP) autoantibody was finally detected. This case presented a rare form of anti-SRP IMNM in which isolated oropharyngeal dysphagia preceded the onset of proximal muscle weakness.

Unilateral tongue mass after iatrogenic lingual nerve injury: A case report

Backgroud: This is the first report of hemangioma as a long-term complication of iatrogenic lingual nerve injury during submandibular gland extirpation. Case presentation: A 69-year-old woman presented with a tongue mass, which had grown slowly over 20 years. Submandibular gland (SMG) extirpation performed 40 years prior. MRI and CT revealed evidence of SMG extirpation. In addition, MRI and CT also revealed several enhancing lesions (hemangiomas) in the right sublingual space, as well as in the right anterior part of the tongue. An electrodiagnostic study showed right-sided lingual neuropathy. Psychosensory taste test showed taste disturbance in the affected side tongue. Conclusions: It should be considered to the lingual nerve preservation during the sublingual gland extirpation. It might cause the secondary traumatic pathology.

Analysis of Sonographic Measurement by Anatomical Area in Carpal Tunnel Syndrome and Correlation the Measurement with Electrodiagnostic Study

Purpose: To evaluate effectiveness of ultrasonographic measurement of carpal tunnel by anatomical area and correlation with electrodiagnostic study in diagnosis of carpal tunnel syndrome.Methods: From September 2018 to March 2019, we performed the ultrasonography for 30 cases with carpal tunnel syndrome diagnosed with electrodiagnosis and 30 cases as control group. We measured median nerve diameter, cross-sectional area (CSA), and flattening ratio (FR) by area of carpal tunnel. We analyzed the difference of measurement between two groups and correlate the measurement with electrodiagnosis findings.Results: There was significant statistically differences in sonographic measurement between two groups by independent t-test (CSA zone 1, p=0.01; FR zone 2, p=0.000; FR zone 3; p=0.001). With Pearson correlation test, there was correlation between sonographic measurement and electrodiagnostic findings (terminal latency and nerve conduction velocity) statistically, but the Pearson coefficient was low (r<0.4). Conclusion: By anatomical area, the available value of sonographic measurement was different. But, as the values were has low power to diagnose the carpal tunnel syndrome, ultrasonography is proper to use as a complementary tool in diagnosis of carpal tunnel syndrome.

A Case of Severe Early-Onset Neuropathy Caused by a Compound Heterozygous Deletion of the PMP22 Gene: Clinical and Neurographic Aspects

Heterozygous deletions of the gene PMP22 are associated to hereditary neuropathy with liability to pressure palsies (HNPP), a demyelinating neuromuscular disease causing variable transitory focal muscles weakness. Deletions involving both copies of PMP22 cause more severe phenotypes, with early-onset neuropathy and impairment in motor development. We report a patient with a severe early-onset demyelinating neuropathy, caused by two different inherited deletions of PMP22, whose parents had an HNPP. The patient showed neurological signs and delay in motor development but normal intellective abilities. A motor and sensitive conduction study showed severe signs of demyelination, suggestive for Dejerine Sottas Syndrome (DSS). The patient's father had a typical HNPP caused by a heterozygous 17p11.2 deletion, encompassing PMP22. The patient's mother reported no neuropathic symptoms, but in a nerve conduction studies, parents and several relatives showed signs of sensory–motor deficit with focal slowing of conduction at common sites of entrapment. Quantitative analysis of PMP22, performed in our patient by multiplex ligation-dependent probe amplification, revealed a compound heterozygous status with the same deletion of the father and a deletion of PMP22 exon 5, after proved to be inherited from the mother. Therefore, when we face an early-onset, severe form of neuropathy, we have to consider rare forms of hereditary neuropathy caused by homozygous or compound heterozygous mutations in PMP22, even if parents are asymptomatic; an exhaustive family history and an electrodiagnostic study are essential to guide genetic tests and to make a diagnosis.