Hand Clumsiness Research Articles

Contribution of changes in the spinal cord and brain to the onset and progression of hand clumsiness symptoms in cervical spondylotic myelopathy.

Cervical spondylotic myelopathy (CSM) stands as the most prevalent form of spinal cord injury, frequently prompting various changes in both the brain and spinal cord. However, the precise nature of these changes within the brains and spinal cords of CSM patients experiencing hand clumsiness (HCL) symptoms has remained elusive. The authors aimed to scrutinize these alterations and explore potential links between these changes and the onset of HCL symptoms. Using the modified Japanese Orthopaedic Association (mJOA) scale, the authors classified CSM patients into two groups: those without HCL and those with HCL. The authors performed voxel-wise z-score transformation amplitude of low-frequency fluctuations (zALFF) and resting-state functional connectivity (FC) evaluations in the brain. Additionally, they used the Spinal Cord Toolbox to calculate the fractional anisotropy (FA) of spinal cord tracts. The analysis also encompassed an examination of the correlation of these measures with improvements in mJOA scores. Significant disparities in zALFF values surfaced in the right calcarine, right cuneus, right precuneus, right middle occipital gyrus (MOG), right superior occipital gyrus (SOG), and right superior parietal gyrus (SPG) between healthy controls (HC), patients without HCL, and patients with HCL, primarily within the visual cortex. In the patient group, patients with HCL displayed reduced FC between the right calcarine, right MOG, right SOG, right SPG, right SFG, bilateral MFG, and left median cingulate and paracingulate gyri when compared with patients without HCL. Moreover, significant differences in FA values of the corticospinal tract (CST) and reticulospinal tract (REST) at the C2 level emerged among HC, patients without HCL, and patients with HCL. Notably, zALFF, FC, and FA values in specific brain regions and spinal cord tracts exhibited correlations with mJOA upper-extremity scores. Additionally, FA values of the CST and REST correlated with zALFF values in the right calcarine, right MOG, right SOG, and right SPG. Alterations within brain regions associated with the visual cortex, the fronto-parietal-occipital attention network, and spinal cord pathways appear to play a substantial role in the emergence and progression of HCL symptoms. Furthermore, the existence of a potential connection between the spinal cord and the brain suggests that this link might be related to the clinical symptoms of CSM.

Clinico-Radiological Profile and Outcome of Isolated Paramedian Hemipontine Infarcts

Objective: To study the clinico- radiological profile and outcome of isolated paramedian hemipontine infarcts. Materials and Methods: This is a prospective cross- sectional study. 50 consecutive patients admitted between January 2019 and December 2020 with a diagnosis of isolated paramedian hemipontine stroke were included. The locations of the infarcts were classified as follows- caudal; middle; rostral; dorsomedian; caudal and middle; and middle and rostral pons. The clinico- radiological profiles were studied and the outcomes were assessed using NIHSS (National Institutes of Health Stroke Scale) and mRS (modified Rankin score). Data was analysed using SPSS 22 version software. Paired t-test was used as a test of significance to identify the mean differences between the two quantitative variables. Results: Majority of the subjects were 51- 60 years (34%). The most common risk factors were hypertension and type 2 diabetes mellitus. The most common clinical features were hemiparesis and speech disturbances. Pure motor hemiparesis (PMH) is the common syndrome seen in paramedian hemipontine strokes with infarcts located in caudal; middle; caudal and middle; and middle and rostral pons. In ataxic hemiparesis, infarcts were located in dorsomedian pons. In dysarthria clumsy hand syndrome, infarcts were located at rostral pons. 44% of the subjects had left vertebral artery abnormality. There was a statistically significant difference in the mean NIHSS and mRS when compared at admission/ discharge and at 3 months. Conclusion: Isolated paramedian hemipontine stroke syndromes have good topographical correlation with patients usually having a good functional outcome at the end of three months.

Deep Learning-Enhanced Hand Grip and Release Test for Degenerative Cervical Myelopathy: Shortening Assessment Duration to 6 Seconds.

Hand clumsiness and reduced hand dexterity can signal early signs of degenerative cervical myelopathy (DCM). While the 10-second grip and release (10-s G&R) test is a common clinical tool for evaluating hand function, a more accessible method is warranted. This study explores the use of deep learning-enhanced hand grip and release test (DL-HGRT) for predicting DCM and evaluates its capability to reduce the duration of the 10-s G&R test. The retrospective study included 508 DCM patients and 1,194 control subjects. Propensity score matching (PSM) was utilized to minimize the confounding effects related to age and sex. Videos of the 10-s G&R test were captured using a smartphone application. The 3D-MobileNetV2 was utilized for analysis, generating a series of parameters. Additionally, receiver operating characteristic curves were employed to assess the performance of the 10-s G&R test in predicting DCM and to evaluate the effectiveness of a shortened testing duration. Patients with DCM exhibited impairments in most 10-s G&R test parameters. Before PSM, the number of cycles achieved the best diagnostic performance (area under the curve [AUC], 0.85; sensitivity, 80.12%; specificity, 74.29% at 20 cycles), followed by average grip time. Following PSM for age and gender, the AUC remained above 0.80. The average grip time achieved the highest AUC of 0.83 after 6 seconds, plateauing with no significant improvement in extending the duration to 10 seconds, indicating that 6 seconds is an adequate timeframe to efficiently evaluate hand motor dysfunction in DCM based on DL-HGRT. DL-HGRT demonstrates potential as a promising supplementary tool for predicting DCM. Notably, a testing duration of 6 seconds appears to be sufficient for accurate assessment, enhancing the test more feasible and practical without compromising diagnostic performance.

Comparison Between Distal Trans-radial Access and Conventional Trans-radial Access for Coronary Angiography.

Background Compared with a conventional wrist puncture for radial artery catheterization, a distal radial artery puncture has the advantage of reducing the incidence of radial artery occlusion (RAO). Aim The present study was designed to evaluate the feasibility of distal trans-radial access compared with conventional trans-radial access for coronary angiography. Methods A prospective, randomized, single-blinded, comparative study was conducted at a tertiary care center in India between December 2018 and November 2020. A total of 420 patients (aged >18 years) with signs and symptoms suggestive of coronary artery disease (CAD) and with a palpable radial artery in anatomical snuffbox were randomized into two groups. Group A comprised patients accessed at the distal trans-radial site, and Group B consisted of patients accessed at the conventional trans-radial site for coronary angiography. Baseline demographics, clinical history, and risk factors for CAD were documented. Procedural-related parameters and complications were compared between the two groups. Results The procedural success rate was non-significant between Group A and Group B (96% vs. 98%; p=0.38). Puncture in a single attempt was higher in Group B compared to Group A (92% vs. 78%; p<0.001). There was no significant difference between Group A and Group B for operation time (p=0.207), fluoroscopy time (p=0.183), and contrast volume (p=0.345). The rate of RAO was higher in Group B compared to Group A (13% vs. 2%; p<0.001). Radial artery hematoma/swelling at the puncture site between Group A (10%) and Group B (8%) was not significant (p=0.61). Post-procedural hemostasis time in Group A was 28 ± 7.86 minutes, and in Group B was 24 ± 6.23 minutes. Both post-procedural persistence of pain (p<0.001) and hand clumsiness (p<0.001) were significantly higher in Group B compared to Group A. Conclusion For coronary angiography, the distal trans-radial access site is a reliable and secure alternate access site.

Intrafamilial Heterogeneity in Spinocerebellar Ataxia Type 21 (P8-11.015)

<h3>Objective:</h3> To emphasize the variability of clinical presentations of genetic movement disorders as depicted by a family with SCA21. <h3>Background:</h3> Spinocerebellar ataxia type 21 (SCA21) is a rare autosomal dominant condition that can have a variety of motor, cognitive, or behavioral manifestations. This clinical variability is seen both between and within families with the same mutation. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 51-year-old woman presented to clinic for evaluation of lifelong worsening balance impairment and hand clumsiness. Her physical exam noted marked ataxia and dysmetria in the extremities, ataxic gait, and spastic extremities, and neuropsychiatric testing was remarkable for mild impairments. Following further workup, a family history of neurologic complaints was taken, which revealed that one of her three children had tremors. When brought to clinic, the patient’s daughter revealed a lifelong history of bilateral hand tremors with worsening over the previous two years. She further noted a slowness in her thinking that required special education courses, as well as other mild motor difficulties. Given the potential for a genetic condition, an ataxia panel was ordered, which revealed a c.509C&gt;Tp.P170L mutation in the TMEM240 gene in the patient and her daughter. <h3>Conclusions:</h3> This case emphasizes the importance of recognizing intrafamilial clinical heterogeneity in the diagnosis of genetic movement disorders. It highlights the potential benefits of an investigation into a family history notable for neurological disorders, which may provide the opportunity for appropriate testing and diagnosis. The variable presentations of spinocerebellar ataxias within families have been explored in a limited number of case reports. The identification of a possible unknown factor driving these differences in presentation could have potential therapeutic implications. While all reported cases of SCA21 have some degree of gait and limb ataxia, only one case has reported tremor onset followed by ataxia and dystonia, as seen in this case. <b>Disclosure:</b> Emma *Use 368242 Wetmore has nothing to disclose. Dr. Decker has nothing to disclose. Maysen Mesaros has nothing to disclose. An immediate family member of Dr. Rodriguez-Porcel has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Anmeal. Dr. Rodriguez-Porcel has received publishing royalties from a publication relating to health care.

Teaching Video NeuroImages: Susac syndrome's acute onset callosal disconnection

A 59-year-old right-handed hypertensive diabetic and previously alcoholic man presented acute confusional state followed by apathy, dysexecutive syndrome, clumsy left hand, and apraxic gait. A year later, his wife noticed impaired hearing. Neurologic examination revealed marked callosal apraxia (nondominant limb ideomotor apraxia, disconnection variant) and left stereoagnosis due to callosal disconnection (video). Left hand agraphia was present without aphasia. MRI showed punched out holes through corpus callosum, sparing the calloso-septal interface (figure 1). Audiometry revealed left neurosensorial loss. Fluorescein retinography demonstrated hyperfluorescence of arterial vessel wall (figure 2), confirming the hypothesis of Susac syndrome.1

Study of Functional Outcome of Cervical Laminoplasty with Fixation Versus Cervical Laminoplasty without Fixation for Multiple Levels for Degenerative Cervical Spondylotic Myelopathy with Modified Japanese Orthopedic Association Score

Objective: To determine functional outcome of cervical laminoplasty with fixation versus without fixation for multiple levels of cervical spondylitis myelopathy. Cervical laminectomy is the standard operation for multiple cervical stenosis, which need decompressive surgery, however it is associated with significant number of recurrence and instability if it is not associated with posterior cervical fixation , usually the disease happens as a result go aging in old people mainly and most of the patients are old and fixation need times and expert, this makes the development of laminoplasty which lead to less instability which if it done in proper way it will not need fixation, in this study I review the outcome in patient have laminoplasty and fixation with patient who did not have associated fixation. Materials and Methods: 50 diagnosed cases of multiple level cervical myelopathy at king Abdulazaiz Hospital in Taif between 2012—2013 were retrospectively analyzed at, 1-year using MJOA. Results: 25 patients underwent 4 levels cervical laminoplasty with posterior lateral mass fixation compared to the same number of patients have 4 level cervical laminoplasty without fixation. The correlation between Duration of Symptoms to Preoperative and postoperative MJOA was statistically significant. We noted statistically significant improvement in symptoms of axial neck pain, radicular arm pain, and gait disturbances post operatively at one year in both groups. No difference between the group who had fixation with the group who did not regarding the improvement of symptoms and functional improvement. Conclusion: Functional outcomes in operated patients at 1-year follow up are the same after laminoplasty with or without fixation. But using fixation increases time of surgery. Symptoms of axial neck pain; radicular arm pain, clumsy hand and gait disturbances show significant improvement at one year follow up. While bladder and bowel involvement showed the least recovery. Significant improvement in function occurs 1 year postoperatively.

Integrative Ayurveda approach to manage Degenerative Cervical Myelopathy (DCM)-A Case Report

Cervical myelopathy involves compression of spinal cord caused by degenerative process of cervical vertebrae or due to trauma. Cervical myelopathy is characterized by pain, stiffness in cervical region and tingling sensation in both upper and lower limb, clumsiness of hands, weakness and difficulty in handling small objects. Available treatment modalities are NSAID’s, Steroids, physiotherapy and cervical support for pain management. Surgery is necessary if conservative treatment fails. In Ayurveda some Para surgical modalities are used to treat this condition like Agnikarma and Raktamokshan along with Shaman Aushadhi. In this case study a 39 years old male patient came to outdoor patient department with complaints of neck pain, neck stiffness and tingling sensation in upper limbs while heaviness and weakness in both upper and lower limbs for last 4 months and especially tingling of upper limb during extension of neck. Patient have alleged history of weight fallen on head in flexed position of neck before 4 months. This case was managed with 4 sittings of Agnikarma with 7 days interval between each sitting and 2 sittings of wet cupping with 15 days interval along with Rasna Saptak Kwath, Erandamula Kwatha, Navjivan Rasa, Ashwagandha Arishta, Karpasasthyadi Taila for 3 months. Patient got relief from symptoms as well as improved routine life with increased in spinal canal diameter at C3-C4 level. This single case demonstrates that TCM can be managed by Ayurveda para surgical procedures along with adjuvant drugs.

Lacunary stroke. Clinical cases

Introduction. Cerebral microangiopathy is the leading cause of vascular cognitive disorders accompined by dementia in the final stages of the disease. Purpose – to study the spectrum of lacunar syndromes in patients with acute cerebrovascular accidents based on our own observations and provide a description of rare clinical variants of the didorders. Materials and methods. We examined 18 patients (10 men and 8 women) aged 33 to 66 years (mean age 52.33 years) in the acute period of lacunar strokes (LS). We studied the neurological status, the data of laboratory-instrumental, speech therapy and neuropsychological testing. The diagnosis of LS was verified using magnetic resonance imaging. Results. Lacunar strokes were more common in patients of mature age (72.22 %) suffering from arterial hypertension (88.89 %) in combination with obesity (44.44 %); patients with atherosclerosis of the coronary and cerebral arteries (27.78 %), type 2 diabetes mellitus (22.22 %) found to have lacunar stroke less often. The sensorimotor hemisyndrome was found to be prevailed (44.44 %). Other classical lacunar syndromes were detected less frequently: with the same frequency (16.67 %) – isolated hemihypesthesia and «hemiballism / hemichorea», as well as «dysarthria – clumsy hand» (11.11 %). The predominant localization of the lesion is the right hemisphere (88.89 %), the internal capsule (66.67 %), rarely the thalamus (27.78 %). Multiple LS were registered in 27.78 % of cases, including the patients with tandem atherostenosis of the cerebral arteries. Descriptions of two clinical cases of LS are presented. Conclusion. Sensorimotor hemisyndrome dominated in clinical scenario. We also observed more rare disorders – bulbar syndrome with anarthria with bilateral damage to the knee of the internal capsule and hyperkinetic syndrome with myoclonus of the respiratory, vocal and articular apparatus. The right-hemispheric lesion predominated with the localization of foci in the internal capsule, the thalamus suffered rarely. Multiple LS were registered in 27.78 % of cases. LSs have unfavorable prognosis for patients with uncontrolled arterial hypertension combined with tandem stenoses of extra- and intracerebral arteries with cognitive disorders that made it difficult to manage patients. The relevance of LS neuroimaging in overweight patients was noted.

Using Electrical Stimulation of the Ulnar Nerve Trunk to Predict Postoperative Improvement in Hand Clumsiness in Patients With Cervical Spondylotic Myelopathy.

A prospective cohort study. To investigate whether the immediate and short-term effects of preoperative electrical peripheral nerve stimulation (ePNS) on performance of the 10-second test could predict the early postoperative outcomes of patients with cervical spondylotic myelopathy (CSM). Previous studies have shown that early clinical improvement in CSM patients may be because of reversal of spinal cord ischemia after spinal cord compression. We conducted a 10-second test before surgery, after ePNS, and at discharge (one week after surgery) in 44 patients with CSM who underwent C3-C7 laminoplasty and evaluated their correlations. The effects of the procedures (ePNS or operation) and sides (stimulated or nonstimulated side) for the 10-second test were analyzed using repeated measures analysis of variance. The Pearson correlation coefficient was used to measure the relationship between the 10-second test values according to the method (after ePNS vs. surgery). In addition, the Bland-Altman method was used to evaluate the degree of agreement between the 10-second test obtained after ePNS versus shortly after surgery. The preoperative 10-second test showed the most improvement immediately after the administration of ePNS, with a gradual decrease for the first 30 minutes after completion. After the initial 30 minutes, performance decreased rapidly, and by 60 minutes performance essentially returned to baseline. The 10-second post-ePNS had a strong positive correlation with the 10-second test in the early postoperative period (at discharge=one week after surgery). These phenomena were observed with the left hand, the side stimulated with ePNS, as well as the right hand, the side not stimulated. Early postoperative outcomes after CSM surgery may be predicted by the results of preoperative ePNS. Level 3.

Double Fascicular Nerve Transfer to Restore Elbow Flexion Following Neuralgic Amyotrophy: A Case Report

Double fascicular nerve transfer (DFNT) involves transferring fascicles from the median and ulnar nerves to the musculocutaneous nerve to restore elbow flexion. We performed this procedure on a patient who was diagnosed with neuralgic amyotrophy (NA) 2 years previously. We aimed to investigate the short-term outcomes and feasibility of DFNT applied to non-traumatic neuropathy. A 63-year-old, right-handed man presented to us with persistent right elbow flexion weakness 24 months after receiving the diagnosis of NA. On examination, biceps strength was 0/5, and shoulder abduction strength was 3/5. Magnetic resonance neurography demonstrated muscle atrophy in the upper trunk. DFNT was considered to restore elbow flexion. The donor and recipient fascicles were then coapted (flexor digitorum superficialis to biceps brachii, flexor carpi ulnaris to brachialis). Postoperatively, paresthesia was reported in the area of ulnar innervation, and the patient complained of hand clumsiness. From postoperative day 10 onward, biceps muscle contracture was identified and on the 14th day, grade 3 elbow flexion strength was observed. We suggest that DFNT may be a safe and effective method to restore elbow flexion in patients with NA.

164. Critical analysis of the presence of spinal cord dysfunction among adult cervical deformity at presentation and the effect of corrective surgery on resolution of symptoms

BACKGROUND CONTEXT Patients with both adult degenerative and myelopathic conditions of the upper spine, along with progressive symptoms, are often eligible for corrective surgery. The impact and prevalence of myelopathy due to spinal cord dysfunction in adult cervical deformity (CD) surgery remains understudied. PURPOSE To investigate the rates of neurological deficits and improvements among patients with severe deformity and by morphotype breakdown. STUDY DESIGN/SETTING Retrospective cohort study of a prospective adult cervical deformity (CD) database. PATIENT SAMPLE A total of 280 CD patients. OUTCOME MEASURES Neurological symptoms, neurological improvements. METHODS CD patients 18 years old with complete baseline (BL) and 3M postoperative HRQL and radiographic data. Patient baseline and post-operative myelopathy signs and symptoms were assessed. Mild myelopathy was defined as mJOA 15-17, Moderate 12-14, and Severe <12. Means comparison tests assessed baseline clinical, radiographic, and demographic factors between patients with severe and mild/moderate myelopathy. RESULTS A total of 170 CD patients met inclusion criteria. Of these, 24% had mild myelopathy, 39% had moderate myelopathy, and 30% had severe myelopathy. Patients with severe myelopathy had a greater degree of frailty (.2 vs .26), greater comorbidity burden (CCI: 1.2 vs .7), disability (NDI: 63 vs 54) with a substantially lower mJOA (9.8 vs 14.5, all p< .05). Severe myelopathy patients also had a longer LOS (6.6 vs 4.8 days) and developed DJF at greater rates (14% vs 5%). Overall, 113 (67%) patients had BL neuro symptoms: 10% bladder incontinence, 6% bowel incontinence, 27% gait instability, 37% hand clumsiness, 60% hand numbness, 7% Lhermitte's sign, 45% bilateral paresthesia and 56% weakness. After surgical intervention, 39% improved in degree of myelopathy. Postoperative myelopathy was 13% mild, 14% moderate and 10% severe. Patients with severe BL myelopathy showed improvements in NDI (63 to 51), mJOA (9.8 to 12.5) and NSR Neck (7.8 to 5.2, all p < .001). However, compared to mild/moderate myelopathy patients, severely myelopathic patients maintained a greater postoperative disability (51 vs 41), and worse degree of myelopathy (12.5 vs 14.3), when compared to mild/moderate patients p<.05. CONCLUSIONS Surgical correction shows substantial efficacy in resolution of myelopathy and improvements in functional status among adult cervical deformity patients. Severely myelopathic patients present with a greater degree of morbidity, frailty and disability, and despite improving post-operatively, maintained a substantially greater disability and neurological impairment postoperatively. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Patients with both adult degenerative and myelopathic conditions of the upper spine, along with progressive symptoms, are often eligible for corrective surgery. The impact and prevalence of myelopathy due to spinal cord dysfunction in adult cervical deformity (CD) surgery remains understudied. To investigate the rates of neurological deficits and improvements among patients with severe deformity and by morphotype breakdown. Retrospective cohort study of a prospective adult cervical deformity (CD) database. A total of 280 CD patients. Neurological symptoms, neurological improvements. CD patients 18 years old with complete baseline (BL) and 3M postoperative HRQL and radiographic data. Patient baseline and post-operative myelopathy signs and symptoms were assessed. Mild myelopathy was defined as mJOA 15-17, Moderate 12-14, and Severe <12. Means comparison tests assessed baseline clinical, radiographic, and demographic factors between patients with severe and mild/moderate myelopathy. A total of 170 CD patients met inclusion criteria. Of these, 24% had mild myelopathy, 39% had moderate myelopathy, and 30% had severe myelopathy. Patients with severe myelopathy had a greater degree of frailty (.2 vs .26), greater comorbidity burden (CCI: 1.2 vs .7), disability (NDI: 63 vs 54) with a substantially lower mJOA (9.8 vs 14.5, all p< .05). Severe myelopathy patients also had a longer LOS (6.6 vs 4.8 days) and developed DJF at greater rates (14% vs 5%). Overall, 113 (67%) patients had BL neuro symptoms: 10% bladder incontinence, 6% bowel incontinence, 27% gait instability, 37% hand clumsiness, 60% hand numbness, 7% Lhermitte's sign, 45% bilateral paresthesia and 56% weakness. After surgical intervention, 39% improved in degree of myelopathy. Postoperative myelopathy was 13% mild, 14% moderate and 10% severe. Patients with severe BL myelopathy showed improvements in NDI (63 to 51), mJOA (9.8 to 12.5) and NSR Neck (7.8 to 5.2, all p < .001). However, compared to mild/moderate myelopathy patients, severely myelopathic patients maintained a greater postoperative disability (51 vs 41), and worse degree of myelopathy (12.5 vs 14.3), when compared to mild/moderate patients p<.05. Surgical correction shows substantial efficacy in resolution of myelopathy and improvements in functional status among adult cervical deformity patients. Severely myelopathic patients present with a greater degree of morbidity, frailty and disability, and despite improving post-operatively, maintained a substantially greater disability and neurological impairment postoperatively.

C1 laminoplasty and posterior atlantoaxial fusion for large retro-odontoid pseudotumor with Instability: A technical note

BackgroundRetro-odontoid pseudotumor (ROPT) is a non-neoplastic pathology of the craniovertebral junction that is usually associated with atlantoaxial instability. The mass compresses the spinal cord, causing cervical myelopathy and potentially resulting in severe disability. Posterior atlantoaxial fixation without laminectomy is a suitable surgical option when the symptoms are mild and the static compression is moderate. In the setting of patients with severe symptoms and large ROPTs, posterior decompression becomes necessary. However, achieving solid posterior atlantoaxial fusion is difficult without a bony surface, namely the C1 posterior arch. Here, we describe a novel technique of C1 laminoplasty to achieve C1 decompression, and posterior atlantoaxial fusion with a modified Goel technique. MethodsAn 83-year-old man was referred to our orthopedic department with quadriplegia due to atlantoaxial instability. His daily life had been affected by severe neck pain, clumsiness of bilateral hands, and gait disturbance for more than 2 years. Preoperative cervical radiograms revealed atlantoaxial instability, and magnetic resonance imaging showed a large pseudotumor compressing to the spinal cord. ResultsThe patient underwent C1 laminoplasty to decompress the spinal cord and retain the posterior arch as a bony surface for grafting and posterior atlantoaxial fusion. The procedure was well tolerated. The patient’s quadriparesis was improved and his Japanese Orthopedic Association score improved from 9/17 to 15/17 and his visual analog scale score for neck pain improved from 75 mm to 28 mm at the 1-year follow-up. ConclusionC1 laminoplasty and posterior atlantoaxial fusion appears useful when C1 decompression and atlantoaxial fusion become necessary.

Case of cortical superficial siderosis presenting with corticobasal syndrome

AbstractA 70‐year‐old man presented with slow gait and a clumsy hand on the right side. Neurological examination revealed dystonia and ideomotor apraxia in the right hand. A mask‐like face, rigidity in the right arm, and shuffling gait were noticed. Treatment with L‐dopa had no effect. He was clinically diagnosed with corticobasal syndrome (CBS). Susceptibility‐weighted images of brain magnetic resonance imaging showed low‐intensity areas on the surface of the cerebral cortex, especially on the left parietal lobe, brain stem, and cerebellum, indicating superficial siderosis (SS). Neuropathological examination revealed diffuse hemosiderin deposition over the surface of the brain, including the left parietal lobe. Cerebellar hemorrhage with rupture to the subarachnoid space was noticed. Cortical SS should, therefore, be included in the differential diagnosis of CBS.

P27.07 Pancoast Tumour Presenting as Lower Limb Weakness; Would You Recognise It?

Pancoast tumours were an obscure entity until Henry Pancoast first described them in the 20th century. This tumour typically involves the apical chest wall and thoracic inlet structures. To characterise a lesion as a Pancoast tumour, it must arise from the lung apices and cause neurological dysfunction. It may present as pain in the shoulder girdle and arm (along C8, T1 and T2 dermatomes), weak or atrophied hand muscles and Horner's syndrome, a constellation of symptoms collectively known as Pancoast Syndrome. These tumours that form 5 per cent of all the NSCLC (Non-small cell lung carcinoma) are often not detected early and have a high predilection for metastasis leading to an overall poor prognosis. The following clinical case study accurately describes a Pancoast tumour's signs and symptoms and emphasises the need for its early recognition by retaining a high index of suspicion even in the most routine of circumstances. A 56-year-old man presented to the emergency department with sudden onset of left leg weakness associated with mild sensory loss. Further questioning revealed clumsiness of the left hand. The initial impression was that of a stroke, but the CT head was found to be unremarkable. It was only later that examination revealed a classical Horner's syndrome; miosis, partial ptosis and hemifacial anhidrosis, raising suspicion of an apical pathology. The chest radiograph was deemed normal, and hence a CT scan of the chest was requested, which showed a left-sided Pancoast tumour. A Subsequent MRI revealed cord compression at T2-T3 levels with tumour infiltration into the left brachial plexus. CT guided biopsy confirmed lung adenocarcinoma with distant spread. He underwent five cycles of radiotherapy, during which he developed neuropathic pain, particularly along the left shoulder and upper chest. His left-sided Horner's syndrome improved clinically. The left fingers' clumsiness did not worsen, and he continued to use his left hand despite some residual weakness but permanently lost bilateral leg function due to spinal cord metastasis. This case demonstrates the significance of a thorough medical history (including smoking) and examination while assessing patients with seemingly unrelated symptoms. The presence of "normal" physical and imaging studies should provoke the clinician to think of an alternative possibility. The inability to include Pancoast tumour in the differential diagnosis most commonly causes a delay in diagnosis and management. Early recognition is the key since the prognosis is directly dependent on timely treatment, which affects patients' survival rate with lung adenocarcinoma.

Is the unstable ataxic hand of Alajouanine and Akerman a distinct contribution?

We discuss from a historical perspective whether the 1931 description of the "unstable ataxic hand" by Théophile Alajouanine, the fifth successor of Charcot at la Salpêtrière, and the Brazilian neurologist Abraham Akerman, then studying in France, merits being considered a distinct contribution vis-à-vis the earlier description by Oppenheim of the "useless hand syndrome". The specific object of the article by Alajouanine and Akerman was a semiologic sign, namely a pseudoathetosis localized in the hand, while the original description by Oppenheim of the symptom-complex that came to be known as useless hand syndrome did not include an abnormal movement. Moreover, as a result of the useless hand syndrome originating from a clinical classification of multiple sclerosis based on the localization of the lesions, it involves topographic and etiologic diagnoses specificities. In contrast, the unstable ataxic hand can be observed in the useless hand syndrome and other syndromes involving predominantly sensory symptoms, such as "numb clumsy hands" due to high cervical spondylosis or extramedullary tumor, and the "cortical sensory syndrome" most commonly due to parietal stroke. Because it had not been thoroughly described in the context of a symptom-complex, Alajouanine and Akerman's unstable ataxic hand merits being considered a distinct and valuable contribution.

Epidemiological study of cervical cord compression and its clinical symptoms in community-dwelling residents.

Degenerative compressive myelopathy (DCM) is caused by cervical cord compression. The relationship between the magnitude and clinical findings of cervical cord compression has been described in the literature, but the details remain unclear. This study aimed to clarify the relationship between the magnitude and clinical symptoms of cervical cord compression in community-dwelling residents. The present study included 532 subjects. The subjective symptoms and the objective findings of one board-certified spine surgeon were assessed. The subjective symptoms were upper extremity pain and numbness, clumsy hand, fall in the past 1 year, and subjective gait disturbance. The objective findings were: Hoffmann, Trömner, and Wartenberg signs; Babinski's and Chaddock's signs; hyperreflexia of the patellar tendon and Achilles tendon reflexes; ankle clonus; Romberg and modified Romberg tests; grip and release test; finger escape sign; and grip strength. Using midsagittal T2-weighted magnetic resonance imaging, the anterior-posterior (AP) diameters (mm) of the spinal cord at the C2 midvertebral body level (DC2) and at each intervertebral disc level from C2/3 to C7/T1 (DC2/3-C7/T1) were measured. The spinal cord compression ratio (R) for each intervertebral disc level was defined and calculated as DC2/3-C7/T1 divided by DC2. The lowest R (LR) along C2/3 to C7/T1 of each individual was divided into 3 grades by the tertile method. The relationship between LR and clinical symptoms was investigated by trend analysis. The prevalence of subjective gait disturbance increased significantly with the severity of spinal cord compression (p = 0.002812), whereas the other clinical symptoms were not significantly related with the severity of spinal cord compression. The magnitude of cervical cord compression had no relationship with any of the neurologic findings. However, subjective gait disturbance might be a better indicator of the possibility of early stage cervical cord compression.

Teaching Video NeuroImages: Optic Ataxia as the Presenting Sign of the Heidenhain Variant of Creutzfeldt-Jakob Disease.

A 59-year-old woman presented with subacute onset of hand clumsiness followed by memory loss. She reported difficulty reaching for objects, although she could see them. Examination (video) showed optic ataxia, visual acuity of 20/30 OU, intact visual field, and near-normal finger-to-nose test. Hyperintense signals in the left temporo-parieto-occipital cortex in diffusion-weighted MRI, periodic triphasic complexes in EEG (figure), and elevated t-tau in CSF suggested the Heidenhain variant of Creutzfeldt-Jakob disease.1 The patient received supportive care and progressed to akinetic mutism. Optic ataxia—inaccuracy of visually guided arm movements—is a visuomotor disorder associated with lesions involving the posterior parietal cortex.2

Useless hand syndrome: Diagnostic role of electromyography and nerve conduction studies

BackgroundUseless hand syndrome (UHS) refers to clumsiness of complex finger movements and loss of manual dexterity due to cervical cord lesions, often associated with multiple sclerosis (MS). This condition may represent the first demyelinating event in MS or may occur in a patient with pre-existing MS. MethodsWe report 3 patients with UHS, 2 of whom had not been previously diagnosed with MS. The history and physical examinations, EMG/NCV studies of the arms, and radiological findings are presented. ResultsPresenting symptoms in all 3 cases included paresthesia and difficulty with manual dexterity which led the family physician to refer these patients to a hand surgeon. Pre-EMG neurological examination detected myriad abnormalities such as loss of position sense, two-point discrimination, stereognosis, graphesthesia, and difficulty performing rapid alternating movements. EMG/NCV findings were normal in 2 cases and, in the third case, showed abnormalities which did not explain the clinical picture and pointed to involvement of the central somatosensory pathways. Cervical MRIs revealed demyelinating lesions in all patients. ConclusionPatients with acute onset of sensory disturbance and clumsy hands are often first referred for EMG/NCV studies. Absence of significant abnormalities may suggest central somatosensory pathway dysfunction and should alert to the possibility of UHS and underlying MS.

«Dysarthria–clumsy hand syndrome» as lacunar stroke manifestation

A detailed analysis of the neurological disorders of «dysarthria–clumsy hand» syndrome (DCHS) is important for its earlier diagnosis. The purpose of this study was to evaluate the incidence of DCHS and the range of its clinical signs, as well as the degree of hand/arm dysfunctions and its dynamics in patients with the acute lacunar stroke (LS). Material and methods. 139 patients with acute LS were examined. Quantitative assessment of neurological deficits, such as paresis, cerebellar ataxia, and apraxia was performed using the relevant scales. The upper limb function was assessed by Action Research Arm Test and 9-Hole Peg Test. Barthel Index was used for disability evaluation. Results. DCHS was diagnosed in 17% of LS patients (group1) and other clinical variants of LS was detected in 83% of patients (group 2). The cause of «clumsiness» in the hand/arm in DCHS was ataxia (83%), mild paresis (71%) and kinesthetic apraxia (29%), which were present independently or in combination. Hand/arm dysfunction and disability, while performing daily activities, were less severe in group 1 patients compared to group 2. The complete restoration of hand/arm function was observed in 63% of the patients with DCHS in 2 weeks after the onset of LS. Conclusions. Mild paresis, cerebellar ataxia and apraxia are the main causes of «clumsiness» of the hand/arm in patients with DCHS. In general, DCHS has good functional outcomes.