Rapid Destructive Arthropathy of the Knee in Parkinson’s Disease with Pisa Syndrome: A Case of Knee-Spine Syndrome

The changes occurring in knee osteoarthritis often cause alterations in the spinal loading condition, which further lead to degenerative changes. This close relationship of the knee and spine has been reported as knee-spine syndrome. A 60-year-old woman with Parkinson’s disease (PD; Hoehn-Yahr stage IV) had severe knee pain with moderate lateral osteoarthritis of the knee (Kellgren-Lawrence classification grade II). Conservative therapy had no effect at all, and the knee developed destructive osteoarthritis rapidly without any traumatic episodes. The radiographic findings progressed to Kellgren-Lawrence grade IV within a month. Magnetic resonance imaging revealed partial depression of the joint surface, including shredded ossicles and substantial amounts of synovial fluid. The imaging findings were considered to be caused by a subchondral insufficiency fracture (SIF). Total knee arthroplasty was performed using a semiconstrained prosthesis. The alignment of her lower extremity improved, and the patient could walk without knee pain. The patient had Pisa syndrome, a lateral flexion of the trunk, which is a postural deformity of the trunk secondary to long-standing PD. The postural deformity in PD is not based on spinal deformity itself but on the loss of postural reflexes and the imbalance of muscle tonus. Her left knee pain appeared 1 month after L1-L4 posterior lumbar interbody fusion (PLIF) as the Pisa syndrome to her left side worsened. The more the trunk tilts to the lateral side, the center of the gravity axis will shift and pass through more lateral points of the knee and result in higher knee load. The stress concentration from the spine to the lateral joint of the knee caused lateral knee osteoarthritis, namely, knee-spine syndrome. When patients undergo correction surgery for adult spinal disorder with impairment of postural reflexes, they need to be followed up carefully regarding not only the spinal alignment but also the lower extremities.

Target Selection for Parkinson Disease With Medication-Refractory Unilateral Resting Tremor

A 67-year-old, right-handed man had a 7-year history of right-dominant, severe medication-refractory resting and action-postural tremor, rigidity, bradykinesia, and impairment of postural reflexes, with his symptoms poorly responsive to oral antiparkinsonian medication. His parkinsonian symptoms with the exception of tremor responded to levodopa infusion. His most bothersome symptom was tremor, and implantation of a left subthalamic nucleus (STN) deep brain stimulation (DBS) lead was pursued with possible posterior subthalamic area (PSA) DBS if the tremor suppression by STN was not intraoperatively sufficient. Ultimately, the STN DBS lead provided reasonable tremor suppression during the operation, and there was no need for PSA DBS. After the surgery, his tremor and other parkinsonian symptoms were well-controlled. This case highlights that unilateral STN DBS is a reasonable indication for medication-refractory parkinsonian tremor with significant laterality of bothersome symptoms, although other options may also be considered.

Ataxic disorders

Ataxia is a feature of disorders of the cerebellum and its connections. It may be found in a large range of neurological conditions, in some of which it is the principal or main feature, but clinical assessment is complicated by the fact that few ataxic patients have disease restricted to the cerebellum alone. The term ataxia derived from the Greek means ‘irregularity’ or ‘disorderliness’. Unsteadiness can result from several causes, including poor vision, impairment of postural reflexes, or due to a deficiency of sensory input (i.e. sensory ataxia). This chapter focuses on the symptoms, signs, and the pathological and clinical features of the disorders of the cerebellum (and its connections).

Pyrazinamide Induced Parkinsonism

“Parkinsonism” refers to a syndrome characterized by the presence of tremor, rigidity and bradykinesia. In addition there is loss of postural reflexes as well as freezing. Drugs rank the second in the causes of parkinsonism. As it is reversible, drug-induced parkinsonism (Rabbit syndrome) should be borne in mind and suspected in any patient receiving drug treatment. We report a case of drug induced parkinsonism, evidently due to pyrazinamide. To the best of our knowledge, this is the first case to be reported in our country.J MEDICINE January 2017; 18 (1) : 42-43