Medical Research Council Scale Grade Research Articles

Comparison of prognosis in two methods for the lingual nerve repair: direct suture with vein graft cuff and collagen allograft method

BackgroundNo studies have compared the outcomes of direct perineurial suture with vein graft cuff repair and indirect collagen allograft repair of the lingual nerve following an injury. Therefore, we evaluated and compared the outcomes of each over a 1-year observation period. We retrospectively assessed 20 patients who had undergone microneurosurgical repair of unilateral lingual nerve injuries at the Wakayama Medical University Hospital between May 2015 and March 2019. We utilized two different methods for lingual nerve repair, i.e., direct perineurial repair with a vein graft cuff and interpositional collagen allograft repair. Sensory and taste function in the lingual nerve were preoperatively evaluated using a static two-point discrimination test, superficial pain/tactile sensation test, tests for the pressure pain threshold (Semmens-Weinstein monofilament), test for thermal discrimination hot and cold sensation, and a taste discrimination test. These tests were performed again at 6 and 12 months postoperatively.ResultsCompared to the preoperative conditions, all patients showed improved sensory reactions. Functional sensory recovery outcomes were defined by Pogrel’s criteria, Medical Research Council Scale grades, and functional sensory recovery. In each group, all patients improved after the operation. However, the operation time was significantly shorter for an interpositional collagen allograft repair as compared to that for a direct perineurial repair with a vein graft cuff.ConclusionsThere were no statistically significant differences between the two repair Methods, except for the operation time. Both methods led to satisfactory results for all criteria. From an economic point of view, direct perineurial repair with a vein graft cuff is meaningful; however, the esthetic effect on the donor site should be considered. Conversely, interpositional collagen allograft repair has the advantage of a greatly shortened operation time.

A Modified Posterior Approach for Decompression of a Multiloculated Atlanto-axial Cyst With Myelopathy.

Case report. To describe a modified posterior approach for decompression and excision of a multiloculated atlanto-axial cyst. Atlanto-axial cyst with myelopathy is rare. A direct decompression through anterior approach or an indirect decompression through posterior approach has been proposed. We report a rare multiloculated large C1-C2 cyst extending down to C3 body with myelopathy that created a dilemma in choice of approach. A modified posterior approach was adopted for decompression. A 72-year-old lady, known case of Rheumatoid arthritis, presented with cervical myelopathy which was rapidly progressive since 2 months being her to wheel chair bound. She had clumsiness of gait and bilateral grip weakness. Both upper and lower extremities had nonfunctional power (medical research council scale grade 2). Deep tendon reflexes were exaggerated. Sensation was reduced in trunk and both extremities. Magnetic resonance imaging and computed tomography scan showed a large multiloculated cyst compressing spinal cord. Here author used modified posterior approach from the right side to access the cyst. The C2 ganglion excision, vertebral artery isolation, and resection of the pars allowed an approach similar to transforaminal decompression in the lumbar spine. A large antero-lateral epidural part of the cyst was excised. The retro-dental cyst was decompressed by puncturing cyst. Biopsy confirmed a synovial cyst. The patient showed rapid neurological recovery after surgery. Postoperative magnetic resonance imaging at 3 months showed complete resolution of cyst. At 2-year follow-up, there was a complete neurological recovery with residual spasticity. A customized posterior approach allowed near total excision of a rare multiloculated large C1-2 cyst extending to the C3 body. This allowed visualisation anterior to the spinal cord without undue retraction that saved an additional anterior decompression. 5.

Design and development of a low-cost biphasic charge-balanced functional electric stimulator and its clinical validation.

Functional electric stimulators that produce near-ideal, charge-balanced biphasic stimulation waveforms with interphase delay are considered safer and more efficacious than conventional stimulators. An indigenously designed, low-cost, portable FES device named InStim is developed. It features a charge-balanced biphasic single channel. The authors present the complete design, mathematical analysis of the circuit and the clinical evaluation of the device. The developed circuit was tested on stroke patients affected by foot drop problems. It was tested both under laboratory conditions and in clinical settings. The key building blocks of this circuit are low dropout regulators, a DC-DC voltage booster and a single high-power current source OP-Amp with current-limiting capabilities. This allows the device to deliver high-voltage, constant current, biphasic pulses without the use of a bulky step-up transformer. The advantages of the proposed design over the currently existing devices include improved safety features (zero DC current, current-limiting mechanism and safe pulses), waveform morphology that causes less muscle fatigue, cost-effectiveness and compact power-efficient circuit design with minimal components. The device is also capable of producing appropriate ankle dorsiflexion in patients having foot drop problems of various Medical Research Council scale grades.

Lingual Nerve Repair: To Graft or Not to Graft?

Since no studies have compared direct and graft repair of the lingual nerve, we examined the subjective and objective outcomes of lingual nerve repair by direct epineurial repair and indirect graft repair, assessed the effect of other confounding variables, and compared the outcomes of autograft and allograft repairs. All patients who had undergone microneurosurgical repair of the lingual nerve from 2000 to 2012 by 1 surgeon (M.M.) were asked to complete an online questionnaire regarding their current neurosensory status at least 2 years after nerve repair. A direct comparison was made between patients who had undergone direct epineurial repair and those who had undergone interpositional nerve graft repair. Student's t test and χ(2) test were used to determine whether a significant difference existed in the success between the 2 techniques and whether age, gender, race, delay from injury to repair, or degree of initial nerve deficit influenced the success of nerve repair. Of the 72 patients identified, 43, who had undergone 47 nerve repairs (18 direct, 29 indirect graft repairs [4 bilateral]; 28 female and 19 male patients; mean age 28.3 years), were interviewed. The objective results of functional sensory recovery, defined by a Medical Research Council Scale grade of S3, S3+, or S4, was 89% for the graft repairs and 85% for the direct repairs (P = .01). The subjective patient satisfaction score (0 to 10 scale) was 8.9 for the graft repairs and 8.1 for the direct repairs (P = .02). The autograft and allograft repairs performed comparably, and the other variables (ie, age, gender, race, delay from injury to nerve repair, gap length, and initial Sunderland grade injury) were not found to be significant (P > .05). Graft repair of the lingual nerve provides superior long-term (>2 years) objective and subjective outcomes compared with direct repair. This might be because of the lack of tension at the repair site, more freedom with nerve stump preparation, and the addition of neurotropic and neurotrophic factors from the donor nerve graft at the site of injury to augment neurosensory recovery.

Can Motor Evoked Potentials Be an Objective Parameter to Assess Extremity Function at the Acute or Subacute Stroke Stage?

ObjectiveTo investigate whether motor evoked potential (MEP) amplitude ratio measurements are sufficiently objective to assess functional activities of the extremities. We also delineated the distribution between the presence or absence of MEPs and the Medical Research Council (MRC) scale for muscle strength of the extremities.MethodsWe enrolled 183 patients with first-ever unilateral hemiplegia after stroke. The MEP parameters were amplitude ratio (amplitude of affected side/amplitude of unaffected side) recorded at the first dorsal interosseous (FDI) and tibialis anterior (TA) muscles. We performed frequency analyses using the MRC scale for muscle strength and the presence or absence of evoked MEPs. Change on the MRC scale, hand function tests (HFTs), and the Modified Barthel Index (MBI) subscore were compared between the evoked MEP and absent MEP groups using the independent t-test. Receiver operating characteristic curves were used to determine the optimal cutoff scores for the MEP amplitude ratio using the HFT results and MBI subscores. Correlations between the MEP amplitude ratio and the MRC scale, HFTs, and MBI subscore were analyzed.ResultsAbout 10% of patients with MRC scale grades 0-2 showed evoked MEPs at the FDI muscle, and 4% of patients with MRC scale grades 3-5 did not show MEPs. About 18% of patients with MRC scale grades 0-2 showed evoked MEPs at the TA muscle, and 4% of patients with MRC scale grades 3-5 did not show MEPs. MEP amplitude increased with increasing MRC scale grade. The evoked MEP group had more significant changes on the MRC scale, HFT, and the climbing stair score on the MBI than those in the group without MEPs. Larger MEP amplitude ratios were observed in patients who had more difficulty with the HFTs and ambulation. The MEP amplitude ratio was significantly correlated with the MRC scale, HFT, and MBI subscore.ConclusionWe conclude that the MEP amplitude ratio may be useful to predict functional status of the extremities in patients who suffered stroke.

Multiple Symmetric Lipomatosis Presenting with Bilateral Brachial Plexopathy.

Dear Editor, Multiple symmetric lipomatosis (MSL), also called Madelung's disease, is a rare disease characterized by the growth of nonencapsulated masses of adipose tissue.1 The disease causes not only cosmetic issues but also various clinical problems depending on the location and extent of the lesion,2 with neuromuscular manifestations such as polyneuropathy, myopathy, and ataxia having been reported.3 Herein we report on a case of bilateral brachial plexopathy caused by extensive lipoma associated with MSL. A 55-year-old man presented with progressive bilateral hand weakness. He first noticed a weak grip with his right hand 2 years before the presentation. The symptom progressed slowly, and his left hand also became weak a few months later. The patient often experienced paresthesia in both arms, but did not complain of proximal arm or leg weakness. He had been drinking about 200 mL of alcohol every day for 30 years. A physical examination revealed excessive soft tissues around his neck, shoulder, and forearm (Fig. 1A). His hand grip, finger abduction, wrist flexion/extension, and elbow extension were extremely weak (Medical Research Council scale grades from 1 to 3) on both sides with muscle atrophy in the first dorsal interossei, hypothenar, and pectoralis major muscles. Deep tendon reflexes were absent in both arms. A nerve conduction study revealed no potentials in the ulnar and radial motor nerves or the medial and lateral antebrachial cutaneous nerves of the left arm. Electromyography revealed positive sharp waves and fibrillation potentials in the first dorsal interosseous, abductor pollicis longus, and extensor carpi radialis of the left arm. Long-duration, high-amplitude motor unit action potentials (MUPs) were present in all muscles of the left arm with reduced recruitment of MUPs. Magnetic resonance images showed extensive fat proliferation and infiltration at the face, neck, shoulder, and axilla that resulted in compression of the brachial plexus (Fig. 1B). He was diagnosed with bilateral brachial plexopathy secondary to MSL, and was operated on to relieve the compression of the brachial plexus. After the surgery, the weaknesses in his hands were slightly improved. Fig. 1 A: Excessive fatty tissues around the neck and shoulder. B: Coronal fat-suppressed T2-weighted MRI reveals the brachial plexus (thick arrow) compressed by lipoma (thin arrow). The incidence of MSL is highest in Mediterranean countries, and it is uncommon in Asia (including Korea). A case-series study of Korean MSL patients found that most patients visited hospital because of a mass lesion and some of them were complicated with peripheral neuropathy.4 The etiology of the disease is not fully understood, but most patients included in previous studies have had a history of chronic excessive alcohol consumption.5 While the exact role of alcohol in the pathophysiology remains elusive, defects in adrenergic stimulated lipolysis or hypertrophy of the brown fat cells have been proposed as an alternative explanation for the pathomechanism.6 The differential diagnosis should include other forms of generalized lipomatosis such as Bannayan-Zonana syndrome, Cowden syndrome, Proteus syndrome, and Dercum disease.7 Familial multiple lipomatosis manifests as multiple encapsulated lipomas with autosomal dominant inheritance, but with relative sparing of the head and shoulders.8 Surgical excision is the treatment of choice. Liposuction can be applied alone9 or in combination with lipectomy.10

Comparison between partial ulnar and intercostal nerve transfers for reconstructing elbow flexion in patients with upper brachial plexus injuries.

BackgroundThere have been several reports that partial ulnar transfer (PUNT) is preferable for reconstructing elbow flexion in patients with upper brachial plexus injuries (BPIs) compared with intercostal nerve transfer (ICNT). The purpose of this study was to compare the recovery of elbow flexion between patients subjected to PUNT and patients subjected to ICNT.MethodsSixteen patients (13 men and three women) with BPIs for whom PUNT (eight patients) or ICNT (eight patients) had been performed to restore elbow flexion function were studied. The time required in obtaining M1, M3 (Medical Research Council scale grades recovery) for elbow flexion and a full range of elbow joint movement against gravity with the wrist and fingers extended maximally and the outcomes of a manual muscle test (MMT) for elbow flexion were examined in both groups.ResultsThere were no significant differences between the PUNT and ICNT groups in terms of the age of patients at the time of surgery or the interval between injury and surgery. There were significantly more injured nerve roots in the ICNT group (mean 3.6) than in the PUNT group (mean 2.1) (P = 0.0006). The times required to obtain grades M1 and M3 in elbow flexion were significantly shorter in the PUNT group than in the ICNT group (P = 0.04 for M1 and P = 0.002 for M3). However, there was no significant difference between the two groups in the time required to obtain full flexion of the elbow joint with maximally extended fingers and wrist or in the final MMT scores for elbow flexion.ConclusionsPUNT is technically easy, not associated with significant complications, and provides rapid recovery of the elbow flexion. However, separation of elbow flexion from finger and wrist motions needed more time in the PUNT group than in the ICNT group. Although the final mean MMT score for elbow flexion in the PUNT group was greater than in the ICNT group, no statistically significant difference was found between the two groups.

Effect of exercise on the quality of life and pulmonary function in patients with chronic obstructive pulmonary disease

To investigate the effect of exercise therapy on activity of daily living (ADL) and lung function in patients with chronic obstructive pulmonary disease (COPD). A total of 122 patients with moderate to severe COPD received routine treatment.The patients were divided into 2 groups randomly. Sixty-two patients in the experimental group received respiratory training on the basis of respiratory pathophysiology and aerobic exercise for 1 year. Medical research council scale (MRC) score, ADL score, 6-min walking distance, and lung function were measured. The MRC grade after the exercise therapy was lower than that before the exercise therapy in the experimental group (P<0.01) and the control group (P<0.05). The ADL score and 6-min walking distance increased compared with that before the respiratory training (P<0.05).After the respiratory training, the ADL score and 6-min walking distance had significant difference between the experimental group and the control group (P<0.05). Long term and individual exercise therapy can relieve dyspnea, and improve the exercise tolerance and quality of life in COPD patients.

A Comparison of the Level of Dyspnea vs Disease Severity in Indicating the Health-Related Quality of Life of Patients With COPD

To compare categorizations of the level of dyspnea with the staging of disease severity as defined by the FEV(1) in representing how the health-related quality of life (HRQOL) is distributed in patients with COPD. Cross-sectional study. Outpatient clinic at the respiratory department of a university hospital. A total of 194 consecutive male patients with stable, mild-to-severe COPD. The score distributions for the components of the St. George's respiratory questionnaire (SGRQ) were used as disease-specific HRQOL measures, and the scores from the Medical Outcomes Study Short Form 36-item questionnaire (SF-36) were used as generic HRQOL measures. These scores were stratified according to the level of dyspnea, as defined by the Medical Research Council (MRC) dyspnea scale, and the stage of disease severity, as defined by the American Thoracic Society (ATS). Differences in the HRQOL scores among the subgroups were compared by an analysis of variance (ANOVA). Multiple pairwise comparisons were made with Fisher's least significant difference (LSD) method, with the overall alpha-level set at 0.05. In those groups classified according to the level of dyspnea, significant differences were observed for the scores on the SGRQ and SF-36 (ANOVA, p < 0.05). The scores for activity and impact, and the total scores of the SGRQ and all scales, except for bodily pain and general health on the SF-36, were significantly worse for patients with severe dyspnea (MRC scale grades, 3, 4, and 5, respectively) than for those with moderate dyspnea (MRC grade level, 2; Fisher's LSD method, p < 0.05). Significant differences were recognized among the different stages of disease severity with respect to the scores from all scales of the SF-36, except for bodily pain, and all scores from the SGRQ (ANOVA, p < 0.05). However, differences in the scores on the SGRQ and SF-36 between patients with ATS stage II disease (FEV(1), 35 to 49% predicted) and stage III disease (FEV(1), < 35% predicted) were not statistically significant. Using the SGRQ and SF-36, the HRQOL of patients with COPD was more clearly separated by the level of dyspnea than by the ATS disease staging. In addition to the ATS disease staging, categorizations based on the level of dyspnea may be useful to clinicians in terms of the HRQOL of COPD patients.