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Hanly JG, Li Q, Su L, Urowitz MB, Gordon C, Bae SC, Romero-Diaz J, Sanchez-Guerrero J, Bernatsky S, Clarke AE, Wallace DJ, Isenberg DA, Rahman A, Merrill JT, Fortin PR, Gladman DD, Bruce IN, Petri M, Ginzler EM, Dooley MA, Steinsson K, Ramsey-Goldman R, Zoma AA, Manzi S, Nived O, Jonsen A, Khamashta MA, Alarcón GS, Svenungsson E, van Vollenhoven RF, Aranow C, Mackay M, Ruiz-Irastorza G, Ramos-Casals M, Lim SS, Inanc M, Kalunian KC, Jacobsen S, Peschken CA, Kamen DL, Askanase A, Theriault C, Farewell V. Peripheral Nervous System Disease in Systemic Lupus Erythematosus: Results From an International Inception Cohort Study. Arthritis Rheumatol 2020; 72:67-77. [PMID: 31390162 PMCID: PMC6935421 DOI: 10.1002/art.41070] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the frequency, clinical characteristics, associations, and outcomes of different types of peripheral nervous system (PNS) disease in a multiethnic/multiracial, prospective inception cohort of systemic lupus erythematosus (SLE) patients. METHODS Patients were evaluated annually for 19 neuropsychiatric (NP) events including 7 types of PNS disease. SLE disease activity, organ damage, autoantibodies, and patient and physician assessment of outcome were measured. Time to event and linear regressions were used as appropriate. RESULTS Of 1,827 SLE patients, 88.8% were female, and 48.8% were white. The mean ± SD age was 35.1 ± 13.3 years, disease duration at enrollment was 5.6 ± 4.2 months, and follow-up was 7.6 ± 4.6 years. There were 161 PNS events in 139 (7.6%) of 1,827 patients. The predominant events were peripheral neuropathy (66 of 161 [41.0%]), mononeuropathy (44 of 161 [27.3%]), and cranial neuropathy (39 of 161 [24.2%]), and the majority were attributed to SLE. Multivariate Cox regressions suggested longer time to resolution in patients with a history of neuropathy, older age at SLE diagnosis, higher SLE Disease Activity Index 2000 scores, and for peripheral neuropathy versus other neuropathies. Neuropathy was associated with significantly lower Short Form 36 (SF-36) physical and mental component summary scores versus no NP events. According to physician assessment, the majority of neuropathies resolved or improved over time, which was associated with improvements in SF-36 summary scores for peripheral neuropathy and mononeuropathy. CONCLUSION PNS disease is an important component of total NPSLE and has a significant negative impact on health-related quality of life. The outcome is favorable for most patients, but our findings indicate that several factors are associated with longer time to resolution.
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Affiliation(s)
- John G Hanly
- Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Qiuju Li
- University of Cambridge, Cambridge, UK
| | - Li Su
- University of Cambridge, Cambridge, UK
| | - Murray B Urowitz
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Caroline Gordon
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | | | | | | | - Ann E Clarke
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Daniel J Wallace
- Cedars-Sinai and University of California, Los Angeles School of Medicine
| | | | | | | | - Paul R Fortin
- CHU de Québec and Université Laval, Québec City, Québec, Canada
| | - Dafna D Gladman
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Ian N Bruce
- Arthritis Research UK Epidemiology Unit, University of Manchester, NIHR Manchester Musculoskeletal Biomedical Research Centre, and Manchester University NHS Foundation Trust, Manchester, UK
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - M A Dooley
- University of North Carolina, Chapel Hill, North Carolina
| | | | | | | | - Susan Manzi
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | | | - Munther A Khamashta
- St. Thomas' Hospital and King's College London School of Medicine, London, UK
| | | | | | | | - Cynthia Aranow
- Feinstein Institute for Medical Research, Manhasset, New York
| | - Meggan Mackay
- Feinstein Institute for Medical Research, Manhasset, New York
| | | | - Manuel Ramos-Casals
- Institut d'Investigacions Biomèdiques August Pi i Sunyer and Hospital Clínic de Barcelona, Barcelona, Spain
| | - S Sam Lim
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Soren Jacobsen
- Rigshospitalet and Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | | | - Chris Theriault
- Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada
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Abstract
Most cases of scapular winging (SW) are attributed to either long thoracic or spinal accessory nerve lesions. Dorsal scapular nerve lesions are quite rare and the literature contains very few case reports of SW secondary to rhomboid paralysis. We are reporting the unusual case of a young patient who developed right-side scapular winging due to dorsal scapular neuropathy and rhomboids palsy, and we highlight the role of conservative treatment and rehabilitation for cases of mild/medium injury to the dorsal scapular nerve or to the rhomboid muscles. For those cases, physiotherapy is recommended, and this is mainly aimed at strengthening the trapezius in order to compensate for rhomboids weakness.
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Tanaka K, Nakayasu H, Suto Y, Takahashi S, Konishi Y, Nishimura H, Ueno R, Kusunoki S, Nakashima K. Acute Motor-dominant Polyneuropathy as Guillain-Barré Syndrome and Multiple Mononeuropathies in a Patient with Sjögren's Syndrome. Intern Med 2016; 55:2717-22. [PMID: 27629974 DOI: 10.2169/internalmedicine.55.6881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A patient with xerostomia and xerophthalmia due to Sjögren's syndrome presented with acute motor-dominant polyneuropathy and multiple mononeuropathy with antiganglioside antibodies. Nerve conduction studies and a sural nerve biopsy revealed the neuropathy as a mixture of segmental demyelination and axonal degeneration. Positive results were obtained for several antiganglioside antibodies. Corticosteroid treatment proved effective. The neuropathy was considered to represent a mixture of polyneuropathy as Guillain-Barré syndrome and multiple mononeuropathy via Sjögren's syndrome. We speculate that Guillain-Barré syndrome occurred in the patient and Guillain-Barré syndrome itself activated multiple mononeuropathy via Sjögren's syndrome.
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Affiliation(s)
- Kenichiro Tanaka
- Department of Neurology, Tottori Prefectural Central Hospital, Japan
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Jardim MR, Vital R, Hacker MA, Nascimento M, Balassiano SL, Sarno EN, Illarramendi X. Leprosy neuropathy evaluated by NCS is independent of the patient's infectious state. Clin Neurol Neurosurg 2015; 131:5-10. [PMID: 25655301 DOI: 10.1016/j.clineuro.2015.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 01/02/2015] [Accepted: 01/03/2015] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Leprosy causes nerve injury, which mimics clinical and neurophysiological conditions, rendering it an excellent model of peripheral neuropathy. METHODS A retrospective study including 822 nerve conduction studies (NCS) of 509 patients was developed to appraise the electrophysiological pattern of leprosy neuropathy. NCS of motor and sensory nerves performed before, during, and after multidrug therapy (MDT) were analyzed. RESULTS During the three periods of MDT, while NCS alterations were similar regarding extension, topography, damage severity, and type of lesion, NCS showed that sensory was more frequent (sural nerve) (92-96%) than motor impairment (70-77%) (ulnar nerve). CONCLUSION Once axonal loss has been installed, nerve function is little affected by inflammatory, immune and/or bacterial events since chronic neuropathy has been established, inevitably leading to the well-known leprosy sequelae occurring at any time before and/or after leprosy diagnosis.
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Affiliation(s)
- M R Jardim
- Leprosy Laboratory, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil; Department of Neurology, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
| | - R Vital
- Leprosy Laboratory, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil; Department of Neurology, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - M A Hacker
- Leprosy Laboratory, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil
| | - M Nascimento
- Leprosy Laboratory, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil
| | - S L Balassiano
- Department of Neurology, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - E N Sarno
- Leprosy Laboratory, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil
| | - X Illarramendi
- Leprosy Laboratory, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil
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5
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Tamam Y, Tamam C, Tamam B, Ustundag M, Orak M, Tasdemir N. Peripheral neuropathy after burn injury. Eur Rev Med Pharmacol Sci 2013; 17 Suppl 1:107-111. [PMID: 23436672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Peripheral neuropathy is a well-documented disabling sequela of major burn injury. These lesions are associated with both thermal and electrical injuries that may be frequently undiagnosed or overlooked in clinical settings. The purpose of this study was to evaluate the prevalence of burn-related neuropathy in our database and to investigate the clinical correlates for both mononeuropathy and generalized peripheral polyneuropathy. PATIENTS AND METHODS Out of 648 burn patients, admitted to our clinic forty-seven burn patients with the diagnosis of peripheral neuropathy were evaluated retrospectively. The demographic and clinical data collected were gender, age, degree, site and percent surface area of burn, type of burn, and the results of electrodiagnostic examination, including electromyography and nerve conduction assessments and associated pathology if existed. RESULTS Peripheral neuropathy is the most frequent disabling neuromuscular complication of burn, that may be undiagnosed or overlooked. In current study, peripheral neuropathy associated with burn all of our patients were identified by electrodiagnostic study. After treatment in Burn Unit, clinical and electrodiagnostic studies were applied. Motor and sensory distal latencies were prolonged and sensory nerve action potentials reduced in amplitude. CONCLUSIONS The findings of our study have shown that polyneuropathies and axonal neuropathy were more frequent than mononeuropathy and demyelination.
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Affiliation(s)
- Y Tamam
- Department of Neurology, Dicle University School of Medicine, Diyarbakir, Turkey.
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Abstract
A thorough history and physical examination are vital to the assessment of upper extremity compressive neuropathies. This article summarizes relevant anatomy and physical examination findings associated with upper extremity compressive neuropathies.
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Affiliation(s)
- Samuel P Popinchalk
- Department of Orthopaedic Surgery and Sports Medicine, Temple University, Philadelphia, PA 19140, USA
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Loizides A, Peer S, Plaikner M, Djurdjevic T, Gruber H. Punched nerve syndrome: ultrasonographic appearance of functional vascular nerve impairment. Ultraschall Med 2012; 33:352-356. [PMID: 22161613 DOI: 10.1055/s-0031-1281831] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
PURPOSE The mechanical impact of a neighboring vessel on a "punched" nerve segment is thought to be one possible cause of compression neuropathy but has not been proven definitively. We report on 9 subjects with unclear clinical mononeuropathies in whom we could clearly define peripheral nerve impairment by such vessels on real-time high-resolution ultrasound (HRUS). MATERIALS AND METHODS Nine subjects with unclear mononeuropathy based on clinical neurological examination were referred to our department for HRUS assessment. The shape, inner and outer echotexture, size and diameter, and overall integrity of these nerves were assessed including an exact analysis of the surrounding soft tissues to search for potentially extraneural pathology. This included duplex imaging to identify even tiny atypical vascular structures. RESULTS In all patients duplex HRUS showed the pulsatile and "punching" character of the relevant vessels and the direct mechanical impact of these vessel. The involved nerve segments appeared enlarged with a hypoechoic change of echotexture including at least partial masking of their inner fascicular texture. CONCLUSION Although rare, a "punching" vessel can be the cause of a compression neuropathy. Therefore, duplex HRUS must be included in every HRUS examination of patients with otherwise unclear mononeuropathy.
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Affiliation(s)
- A Loizides
- Department of Radiology, Medical University Innsbruck.
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8
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Abstract
Upper extremity mononeuropathies are some of the common disorders seen in neurophysiology laboratories. Electrophysiologic studies rely on accurate localization based on knowledge of applicable anatomy and features of history and physical examination. Careful electrodiagnostic studies provide an accurate diagnosis, help localize the lesion site, exclude alternate diagnoses, reveal unsuspected diagnoses, determine pathophysiology of lesions, and assess severity, timeframe, and prognosis of lesions. This article discusses the electrodiagnostic approach to ulnar neuropathy, proximal median neuropathy, radial neuropathy, musculocutaneous neuropathy, axillary neuropathy, suprascapular neuropathy, and long thoracic neuropathy. Pertinent aspects of the history and physical examination, nerve conduction studies, and electromyography are presented.
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Affiliation(s)
- Elliot L Dimberg
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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9
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Pardal-Fernández JM, Sáez-Méndez L, Rodríguez-Vázquez M, Godes-Medrano B, Iñíguez-De Onzoño L. [Multiple mononeuritis and eosinophilic fasciitis in a patient with idiopathic hypereosinophilic syndrome]. Rev Neurol 2012; 54:100-104. [PMID: 22234568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Hypereosinophilic syndrome is produced by what is usually a multiple infiltration of eosinophils into tissues, and may be secondary or idiopathic, depending on whether it is related to a specific aetiology or not. It is not uncommon for it to include nerve disease, but it is unusual for it to do so in the form of multineuritis. Exceptionally, pathogenesis into multiple mononeuritis appears to be related with neurotoxicity due to products derived from eosinophils rather than with infiltrating or inflammatory phenomena. This study describes the case of a female patient with hypereosinophilic syndrome with no verifiable cause, multineuritis and eosinophilic fasciitis. CASE REPORT A 30-year-old female with no relevant history who visited because of some painless inguinal nodules that had appeared several weeks before. At almost the same time, she presented painful sensitive symptoms in her legs with a significant functional incapacity. An important degree of hypereosinophilia, eosinophilic fasciitis and non-neoplastic eosinophilic infiltration of the bone marrow was found, together with multiple mononeuritis. Treatment with oral corticoids improved the dermatological and haematological clinical features, and associating it with gabapentin improved the neuropathic symptoms. CONCLUSIONS The patient, in accordance with current criteria, presented idiopathic hypereosinophilic syndrome with an undetermined subtype. To our knowledge, the association with eosinophilic fasciitis and multineuritis has not been reported to date. There is no proven infiltrating mechanism in multiple mononeuritis, which corroborates the poor control of the neuropathic clinical symptoms with oral corticoid therapy. Association with gabapentin, which stabilises the axonal membrane, also backs up the neurotoxic pathogenetic hypothesis.
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10
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Pardal-Fernandez JM, Godes-Medrano B, Sánchez-Ayaso P, Rodríguez-Vázquez M, Iñíguez-De Onzoño L. [Multiple mononeuritis in a patient with Churg-Strauss syndrome. Pseudo conduction block as an early electroclinical expression]. Rev Neurol 2011; 53:22-26. [PMID: 21678321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Multiple mononeuritis is one of the most frequent manifestations of Churg-Strauss syndrome. CASE REPORT We describe a case of acute sensory-motor multiple mononeuritis in all four limbs of a 53-year-old male with Churg-Strauss syndrome. Electrodiagnosis performed within the first seven days revealed conduction blocks in several nerves. Follow-up studies showed diffuse bilateral sensory-motor axonal polyneuropathy with symmetries, but without blocks. Electrophysiological and histological analyses, together with experimental studies, showed it to be an axonopathy secondary to acute ischaemia. CONCLUSIONS In only a few cases, such as this one and in a small number of incipient studies, have there been reports of conduction blocks that, owing to the fact that they are commonly related with demyelination, give rise to confusion when it comes to diagnoses and prognoses. The condition usually displays axonopathy due to Wallerian degeneration. It therefore seems recommendable in these cases to proceed with caution and to perform neurophysiological studies in the following weeks in order to prevent inappropriate diagnostic and prognostic judgements from being formed.
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11
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Mauermann ML, Ryan ML, Moon JS, Klein CJ. Case of mononeuritis multiplex onset with rituximab therapy for Waldenström's macroglobulinemia. J Neurol Sci 2007; 260:240-3. [PMID: 17537458 DOI: 10.1016/j.jns.2007.04.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Revised: 03/28/2007] [Accepted: 04/02/2007] [Indexed: 11/21/2022]
Abstract
Waldenström's macroglobulinemia (WM) is a lymphoplasmacytic disorder with associated monoclonal gammopathy. A wide variety of neuropathies can be associated with WM, but most commonly it is a mild length-dependent sensory neuropathy of unclear etiology. Rituximab is a monoclonal antibody which suppresses mature B-cell populations. It has increasingly been used in wide applications including WM, especially in those cases with severe neuropathy. The highlighted case provides an example of rituximab treatment complication in a WM patient with mild sensory neuropathy that evolved to multiple mononeuropathies with features of systemic vasculitis and unusual conversion of type I to type II cryoglobulinemia.
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Affiliation(s)
- Michelle L Mauermann
- Department of Neurology, Section of Peripheral Nerve, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905, United States
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12
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Megalopoulos A, Vasiliadis K, Siminas S, Givissis P, Vargiami E, Zafeiriou D, Botsios D, Betsis D. Pseudoaneurysm of the popliteal artery complicated by peroneal mononeuropathy in a 4-year-old child: report of a case. Surg Today 2007; 37:798-801. [PMID: 17713737 DOI: 10.1007/s00595-007-3514-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2006] [Accepted: 01/03/2007] [Indexed: 11/29/2022]
Abstract
Pseudoaneurysms of the popliteal artery (PPA) rarely occur in children. In fact, we found only 10 cases reported in the medical literature. We report the case of a 4-year-old boy who presented with a painful palpable mass in the right popliteal fossa. He also had mild, painless right foot-drop and difficulty toe-walking on the same side. The diagnosis of a PPA was based on the findings of triplex ultrasound and computed tomographic-angiography. We attributed the cause of the lesion to blunt trauma, which he had suffered 2 years earlier. Thorough preoperative evaluation excluded the possibility of a self-immune process or a bone tumor in the region. Neurological examination demonstrated a mild, isolated, peripheral mononeuropathy of the right peroneal nerve. Thus, we performed surgical repair using an autologous reversed great saphenous vein graft. The patient had an uneventful postoperative course and his peripheral neuropathy and foot-drop resolved completely within 1 month after surgery. Now, after 3 years of follow-up, the patient has a patent graft and a fully functioning limb. PPAs are rare, especially in children, and trauma is the predominating underlying cause. PPAs should be treated immediately after diagnosis because their complications are associated with high rates of functional impairment and even limb loss.
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Affiliation(s)
- Angelos Megalopoulos
- Fourth Surgical Department, Aristotle University of Thessaloniki, General Regional Hospital G. Papanikolaou, Exohi 570-10, Thessaloniki, Greece
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13
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Affiliation(s)
- Mark Sisco
- Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 675 North St. Clair Street, Suite 19-250, Chicago, IL 60611, USA
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Abstract
Instrumental musicians often seek medical consultation for symptoms suggestive of nerve entrapment. About 20% of those seen in the author's performing artists' clinic were diagnosed with a focal neuropathy. In general, neuropathies that are most common in the overall population tend also to be most common among musicians, although some expectations exist, including, for example, localized peri-oral sensory syndromes associated with playing a brass instrument, and, possibly, ulnar neuropathies related to the playing position of bowed string players. The diagnosis is made, as always, by careful clinical assessment, including observation of the instrumentalist playing, with ancillary procedures such as nerve conduction studies and needle electromyography adding to the accuracy of the diagnosis. Treatment is similar to that used in nonmusicians, but certain factors, including the musician's requirement for extraordinary neuromuscular dexterity, may influence the therapeutic decisions. Very limited long-term outcome results are available, and additional studies in musicians would be helpful in determining the most appropriate therapeutic approaches. Virtually no longitudinal studies have been performed to look at methods for preventing these disorders.
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Affiliation(s)
- Richard J Lederman
- Department of Neurology and Medical Center for Performing Artists, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Birnbaum J. Infliximab-associated neuropathy in RA patients—the importance of considering the diagnosis of mononeuritis multiplex. Clin Rheumatol 2006; 26:281-2. [PMID: 17063281 DOI: 10.1007/s10067-006-0436-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Accepted: 08/31/2006] [Indexed: 11/30/2022]
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Abstract
Mononeuropathy multiplex is a syndrome of diverse causes, the most common of which is nerve ischemia due to microangiopathy associated with diabetes or the collagen-vascular diseases. The acquired inflammatory demyelinating neuropathies invariably are multifocal, although the clinical manifestations of these and other multifocal neuropathies may appear symmetrical. The identification of multifocal neuropathies is important because of the frequent therapeutic implications. A case of mononeuropathy multiplex associated with polyarteritis nodosa is described.
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Affiliation(s)
- G J Parry
- Department of Neurology, University of California San Francisco, CA, USA
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Santoro L, Manganelli F, Briani C, Giannini F, Benedetti L, Vitelli E, Mazzeo A, Beghi E. Prevalence and characteristics of peripheral neuropathy in hepatitis C virus population. J Neurol Neurosurg Psychiatry 2006; 77:626-9. [PMID: 16464900 PMCID: PMC2117469 DOI: 10.1136/jnnp.2005.081570] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the prevalence of peripheral neuropathy (PN) and its correlation with cryoglobulinemia (CG) in an unselected, untreated referral hepatitis C virus (HCV) population. PATIENTS AND METHODS Two hundred and thirty four patients (120 women and 114 men) with untreated HCV infection were consecutively enrolled by seven Italian centres. Clinical neuropathy was diagnosed when symptoms and signs of peripheral sensory or motor involvement were present. Median, ulnar, peroneal, and sural nerves were explored in all patients and distal symmetric polyneuropathy was diagnosed when all explored nerves or both lower limb nerves were affected. Mononeuropathy and mononeuropathy multiplex were diagnosed when one nerve or two non-contiguous nerves with asymmetrical distribution were affected. Screening for CG was done in 191 unselected patients. RESULTS Clinical signs of PN were observed in 25 of the 234 patients (10.6%). Electrophysiological PN was found in 36 (15.3%). CG was present in 56/191 patients (29.3%). The prevalence of CG increased significantly with age (p<0.001) and disease duration (p<0.05). PN was present in 12/56 (21%) patients with CG and 18/135 (13%) without CG (p=NS). PN increased significantly with age (p<0.001) and logistic regression analysis confirmed age as the only independent predictor of PN (OR 1.10 for each year; 95% CI 1.04 to 1.15; p<0.001). CONCLUSIONS Electrophysiological examination detected subclinical neuropathy in 11 patients (4.7%). Statistical analysis showed that CG was not a risk factor for PN whereas PN prevalence increased significantly with age.
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Affiliation(s)
- L Santoro
- Dipartimento di Scienze Neurologiche, Università degli Studi di Napoli Federico II, Via Sergio Pansini 5, 80131 Napoli, and Department of Neurology, Hospital Maggiore, Lodi, Italy.
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18
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Abstract
PURPOSES Neuropathies are defined as dysfunction of peripheral nerves, which may show motor, sensory and autonomic symptoms. Although most neuropathies are symmetric, it is important to distinguish a polyneuropathy from a mononeuropathy, a multiple mononeuropathy or a polyradiculoneuropathy. Electrophysiological procedures are helpful in determining the pathological process which may be either an axonopathy, a myelinopathy or a neuronopathy. MAIN POINTS Major progresses have been made in the ten past years in the management and diagnostic approaches of peripheral neuropathy. The history and the physical examination are the first steps to the evaluation of patients with peripheral neuropathy. Electrodiagnostic studies and then laboratory tests are the next step in the diagnostic procedures of peripheral neuropathies. These will lead to a proper identification of the cause of neuropathy, allowing to develop a specific treatment for the patient. However, even after a careful work-up of a patient with neuropathy, 25 to 40% of patients with polyneuropathies remain undiagnosed. PERSPECTIVES Further development are focused in better understanding the pathogenesis and molecular mechanisms of peripheral nerve diseases in order to provide a specific and adequate treatment for each neuropathy.
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Affiliation(s)
- T Stojkovic
- Clinique Neurologique, Service du Professeur Vermersch, Hôpital Roger-Salengro, CHRU de Lille, 59037 Lille cedex, France.
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19
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Abstract
The author reviewed 34 years of personal experience with inpatients in a large municipal hospital to analyze the seats and causes of involvement of single pairs of cranial nerves. Among 578 cases, the sixth (n = 234) and second (211) nerves predominated, followed by the fourth (48), seventh (30), third (27), and eighth (18) cranial nerves. Trauma (99), infection (94), tumor (92), increased intracranial pressure (85), vascular disease (74), and demyelination (66) were common causes.
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Affiliation(s)
- James R Keane
- Department of Neurology, University of Southern California Medical School, Los Angeles, CA, USA
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20
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Kashiwagi FT, Resende LAL, Bertotti MFZ, Souza MTM, Fonseca RG. Mononeuropathy of the suprascapular nerve: study of 3 South American cases. Electromyogr Clin Neurophysiol 2005; 45:219-21. [PMID: 16083144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
In this work 3 new cases of suprascapular nerve mononeuropathy are described. ENMG diagnosis criteria were: a) normal sensory conduction studies of the ipsolateral ulnar, median and radial nerves; b) bilateral suprascapular nerve latencies with bilateral compound muscle action potential, obtained from the infraspinatus muscle with symmetrical techniques; and c) abnormal neurogenic infraspinatus muscle electromyographic findings, coexisting with normal electromyographical data of the ipsolateral deltoideus and supraspinatus muscles. These 3 cases of suprascapular mononeurpathy were found in 6,080 ENMG exams from our University Hospital. For us this mononeuropathy is rare with a 0.05% occurrence.
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Affiliation(s)
- F T Kashiwagi
- Departament of Neurology and Psychiatry, Botucatu School of Medicine, UNESP, Brazil
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21
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Vissers KC, De Jongh RF, Hoffmann VL, Meert TF. Exogenous interleukin-6 increases cold allodynia in rats with a mononeuropathy. Cytokine 2005; 30:154-9. [PMID: 15863388 DOI: 10.1016/j.cyto.2005.01.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2003] [Revised: 11/09/2004] [Accepted: 01/03/2005] [Indexed: 11/17/2022]
Abstract
Interleukin-6 (IL-6) is a pleiotropic cytokine, signaling intracellularly via its unique membrane-bound receptor IL-6R and gp130. In peripheral nerve injury models, IL-6 and IL-6R are increased at the injured nerve and the respective dorsal root ganglion. IL-6 is increased at the ipsilateral dorsal and ventral horn of the spinal cord. IL-6 is known to affect neuronal survival, differentiation and regeneration. It is involved in synaptic plasticity and hyperexitability and induces the synthesis or release of other substances with known neuroprotective or neuromodulatory effects. In this study, intrathecal administration of recombinant rat IL-6 to rats with a chronic constriction injury of the sciatic nerve, induced a logarithmic dose-dependent increase in cold allodynia with a threshold of 10 pg IL-6 and a maximal effect at 100 ng IL-6. Intrathecal administration of saline or denaturated IL-6 was without effect. In rats with a chronic constriction injury, systemic administered IL-6 did not induce a hyperalgesic effect, illustrating that IL-6 acts at the level of the dorsal root ganglion or the spinal cord. Intraplantar injection of 100 ng IL-6 in the operated hind paw resulted in an increased cold allodynia. This study demonstrates that the sensitivity to exogenous intrathecal or peripheral IL-6 increases in rats with a mononeuropathy.
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Affiliation(s)
- Kris C Vissers
- Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Campus André Dumont, Genk, Belgium.
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22
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Abstract
Diabetes mellitus is associated with a wide spectrum of neuropathy syndromes, ranging from a mild asymptomatic distal sensory neuropathy to a severe disabling radiculoplexus neuropathy. As the pathophysiology of these separate conditions is better understood, classification of the various phenotypes becomes important because of treatment implications. Here we provide a short summary of the history of the classification of diabetic neuropathies and try to describe the most common forms classified according to their presumed pathophysiology. We have tried to include epidemiological data where available, as well as histopathology of nerve in several diabetic neuropathies.
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Affiliation(s)
- Michael Sinnreich
- Department of Neurology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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23
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Abstract
PURPOSE Fecal incontinence caused by a weak or disrupted internal anal sphincter is common but there has been no effective treatment. This prospective study evaluates the medium-term clinical effects of an injectable silicone biomaterial, PTP (Bioplastique), used to augment the internal anal sphincter. METHOD Eighty-two patients (64 females; median age, 66 years) with severe fecal incontinence and a low anal resting pressure caused by internal anal sphincter dysfunction (defect, n = 11; intact, n = 71) were randomized to PTP injection into intersphincteric space and internal anal sphincter with (Group A, n = 42) or without (Group B, n = 40) guidance by endoanal ultrasound. Both groups were similar in terms of age, gender, past anorectal surgery, duration of follow-up (median, 6 months; range, 1-12 months), and baseline continence score. Sixty-two percent of Group A and 55 percent of Group B had prolonged pudendal nerve terminal motor latency. RESULTS There was no significant complication. Two patients in Group A and four patients in Group B noted minor discomfort at injection sites. At one month postprocedure, endoanal ultrasound confirmed retention of silicone biomaterial without migration. In both groups, fecal continence was significantly improved by PTP implants 1 month after injection, but continued to improve significantly for up to 12 months in Group A and 6 months in Group B (P < 0.001). Improvement in fecal continence and maximum anal resting pressure was significantly greater in Group A, in whom injection was guided by endoanal ultrasound, than in Group B. At three months after injection, significantly more Group A patients than Group B patients achieved >50 percent improvement in Wexner's continence score (69 percent vs. 40 percent; P = 0.014). Ninety-three percent of Group A and 92 percent of Group B had >50 percent improvement in global quality of life scores (visual analog scale). At a median follow-up of 6 months, all domains of the fecal incontinence quality of life scale improved significantly in both groups; however, the physical function and mental health scores of Short Form-12 only improved in Group A. A prolonged pudendal nerve terminal motor latency had no effect on functional outcome in either group. CONCLUSION Injection of silicone biomaterial provided a marked improvement in fecal continence and quality of life in patients with internal sphincter dysfunction, despite the presence of pudendal neuropathy.
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Affiliation(s)
- J J Tjandra
- Department of Colorectal Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia.
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24
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de Entrambasaguas-Barretto M, Carratalá-Monfort S, Belenguer-Benavides A. [Mononeuropathy of the anterior interosseous nerve related to a first generalised tonic-clonic seizure]. Rev Neurol 2004; 39:996-7. [PMID: 15573324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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25
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Courteix C, Coudoré-Civiale MA, Privat AM, Pélissier T, Eschalier A, Fialip J. Evidence for an exclusive antinociceptive effect of nociceptin/orphanin FQ, an endogenous ligand for the ORL1 receptor, in two animal models of neuropathic pain. Pain 2004; 110:236-45. [PMID: 15275773 DOI: 10.1016/j.pain.2004.03.037] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2003] [Revised: 03/22/2004] [Accepted: 03/29/2004] [Indexed: 10/26/2022]
Abstract
Nociceptin/orphanin FQ (noci/OFQ), the endogenous ligand for the orphan ORL1 (opioid receptor-like1), has been shown to be anti- or pronociceptive and modify morphine analgesia in rats after central administration. We comparatively examined the effect of noci/OFQ on hyperalgesia and morphine analgesia in two experimental models of neuropathic pain: diabetic (D) and mononeuropathic (MN) rats. Noci/OFQ, when intrathecally (i.t.) injected (0.1, 0.3, or 1, to 10 microg/rat) was ineffective in normal rats, but reduced and suppressed mechanical hyperalgesia (paw-pressure test) in D and MN rats, respectively. This spinal inhibitory effect was suppressed by naloxone (10 microg/rat, i.t.) in both models. Combinations of systemic morphine with spinal noci/OFQ resulted in a strong potentiation of analgesia in D rats. In MN rats, an isobolographic analysis showed that the morphine+noci/OFQ association (i.t.) suppressed mechanical hyperalgesia in a superadditive manner. In summary, the present findings reveal that spinal noci/OFQ produces a differential antinociception in diabetic and traumatic neuropathic pain according to the etiology of neuropathy, an effect possibly mediated by opioid receptors. Moreover, noci/OFQ combined with morphine produces antinociceptive synergy in experimental neuropathy, opening new opportunities in the treatment of neuropathic pain.
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Affiliation(s)
- Christine Courteix
- EMI 9904 INSERM/UdA, Department of Pharmacology, Faculty of Pharmacy, 28 place Henri Dunant, BP 38, 63001 Clermont-Ferrand Cedex 1, France.
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26
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Abstract
Pain is a major symptom of many different diseases. Modern pain research has uncovered important neuronal mechanisms that are underlying clinically relevant pain states, and research goes on to define different types of pains on the basis of their neuronal and molecular mechanisms. This review will briefly outline neuronal mechanisms of pathophysiological nociceptive pain resulting from inflammation and injury, and neuropathic pain resulting from nerve damage. Pain is the sensation that is specifically evoked by potential or actual noxious (i.e. tissue damaging) stimuli or by tissue injury. Pain research has not only explored the neuronal and molecular basis of the "pain system" of the healthy subject but has also provided insights into the function and plasticity of the "pain system" during clinically relevant pains such as post-injury pain, inflammatory pain, postoperative pain, cancer pain and neuropathic pain. This review will briefly describe the "pain system" and then address neuronal mechanisms that are involved in clinical pain states.
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Affiliation(s)
- Hans-Georg Schaible
- Institut für Physiologie, Friedrich-Schiller-Universität Jena, Teichgraben 8, 07740 Jena, Germany.
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27
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Wang JZ. Microinjection of neuropeptide Y into periaqueductal grey produces anti-nociception in rats with mononeuropathy. Sheng Li Xue Bao 2004; 56:79-82. [PMID: 14985834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
The present study was carried out to investigate the effects of neuropeptide Y (NPY) in the midbrain periaqueductal grey (PAG) on the nociceptive modulation in mononeuropathic rats. NPY was microinjected into the PAG. The latency of paw withdrawal (PWL), assessed by the hot-plate (52 ) and the Randall Selitto test, was measured. Intra-PAG administration of 0.05, 0.1 and 0.2 nmol of NPY significantly increased the PWLs in a dose-dependent manner. Co-administration of 0.2 nmol of NPY(28-36) and 5.5 nmol of naloxone significantly attenuated the NPY-induced increase in PWLs. The results suggest that Y(1) receptor may mediate NPY-induced anti-nociception, and that the opioid receptors in PAG may also be involved in this process in mononeuropathic rats.
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Affiliation(s)
- Jia-Zhen Wang
- Department of Physiology, Linyi medical college, Linyi 276002, Shangdong Province, China.
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28
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Ryan MM, Tilton A, De Girolami U, Darras BT, Jones HR. Paediatric mononeuritis multiplex: a report of three cases and review of the literature. Neuromuscul Disord 2003; 13:751-6. [PMID: 14561499 DOI: 10.1016/s0960-8966(03)00099-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Mononeuritis multiplex results from disease processes causing multifocal injury to the peripheral nerves, with or without involvement of one or more cranial nerves. Most reported cases of paediatric mononeuritis multiplex have been related to autoimmune disorders. We present clinical and neurophysiologic findings in three cases of multiple mononeuropathy occurring in adolescence, with onset at ages 16, 17 and 13 years. Two of these cases were related to systemic vasculitis, one possibly representing a paediatric case of non-systemic vasculitis. Sural nerve biopsy confirmed the diagnosis of vasculitis in one patient with systemic lupus erythematosus, but was non-diagnostic in another case. Mononeuritis multiplex is an extremely uncommon form of acquired peripheral neuropathy in childhood. We discuss the differential diagnosis and review previous descriptions of this rare condition.
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Affiliation(s)
- Monique M Ryan
- Department of Neurology, Children's Hospital, Boston, MA, USA.
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29
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Abstract
BACKGROUND Methadone, being an N-Methyl-D-Aspartate receptor antagonist, may have a potential role in the treatment of neuropathic pain. OBJECTIVES To evaluate the effect of methadone in the treatment of neuropathic pain and to estimate the possible dose ranges needed for pain control. METHODS Methadone was offered as a treatment option to consecutive cancer and noncancer patients with neuropathic pain. Pain intensity was measured by the visual analogue scale (VAS) (0-10 cm where 0 = no pain and 10 = worst possible pain). Mechanical allodynia and paroxysmal (shooting) pain were assessed clinically. All assessments were collected prospectively before treatment and once a stable dose of methadone was reached. RESULTS A total number of 18 patients met our inclusion criteria. The mean pretreatment VAS +/- SD was 7.7+/-1.5 cm and this dropped significantly to 1.4+/-1.7 cm on a stable dose of methadone (P<0.0001). Nine of 13 patients (70 %) had a complete resolution of mechanical allodynia and all eight patients (100%) with shooting pain reported a complete response. The median stable dose of methadone was 15 mg per day. CONCLUSION Methadone at relatively low doses seems to be useful in the treatment of neuropathic pain.
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Abstract
The aim of the study is to establish if the putative anticonvulsant SPM 927 has an analgesic effect in human neuropathic pain and to assess its tolerability. This is an open label study of 25 adult human subjects with resistant neuropathic pain. Subjects were treated with SPM 927 in a dose-escalating scheme to 600 mg daily, if tolerated. Treatment was continued for 4 weeks then withdrawn without tapering. Pain scores were recorded using a 11-point Likert score and a categorical pain-rating scale. Laboratory parameters and, electrocardiographs (ECGs) were collected; side effects were noted. Of the 25 enrolled subjects, 12 completed the study according to the protocol. The remaining subjects dropped out due to adverse events (n=12) or withdrawn consent. Mean daily pain scores (Likert score) fell by 0.83 (95% CI -1.77, +0.11) at the end of maintenance and rose by 0.58 (95% CI -0.23, +1.40) after withdrawal of SPM 927. Similar changes were seen in the categorical pain-rating scores. There were decreases in the mean scores for shooting pain, paraesthesia, and allodynia, but much less change in the numbness and burning-pain scores. The most common side effects were nausea, dizziness, leukocytosis, and increased ALT. No consistent changes in ECG recordings or haemodynamic variables were observed. SPM 927 may have an analgesic effect in human neuropathic pain and was reasonably well tolerated in this study. These data support the continued clinical development of SPM 927 for neuropathic pain.
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Affiliation(s)
- G McCleane
- Rampark Pain Centre, 2 Rampark, Dromore Road, Lurgan BT66 7HR, Northern Ireland, UK.
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31
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Baliki M, Al-Amin HA, Atweh SF, Jaber M, Hawwa N, Jabbur SJ, Apkarian AV, Saadé NE. Attenuation of neuropathic manifestations by local block of the activities of the ventrolateral orbito-frontal area in the rat. Neuroscience 2003; 120:1093-104. [PMID: 12927214 DOI: 10.1016/s0306-4522(03)00408-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Clinical and recent imaging reports demonstrate the involvement of various cerebral prefrontal areas in the processing of pain. This has received further confirmation from animal experimentation showing an alteration of the threshold of acute nociceptive reflexes by various manipulations in the orbito-frontal cortical areas. The present study investigates the possible involvement of this area in the modulation of neuropathic manifestations in awake rats. Several groups of rats were subjected to mononeuropathy following the spared nerve injury model, known to produce evident tactile and cold allodynia and heat hyperalgesia. The activity of the ventrolateral orbital areas was selectively blocked by using either chronic or acute injection of lidocaine, electrolytic lesion, or chemical lesion with kainic acid or 6-hydroxydopamine (6-OHDA). The effects of these manipulations were compared with those following lesion of the somatic sensorimotor cortical areas. Local injection of lidocaine resulted in a reversible depression of all neuropathic manifestations while electrolytic or chemical lesions elicited transient attenuation affecting mainly the heat hyperalgesia and to a lesser extent the cold allodynia. The magnitude of the observed effects with the different procedures used can be ranked as follows: 6-OHDA<lesion<electrolytic lesion<kainic acid lesion<lidocaine injection. The observed effects were transient despite the permanence of the lesions while lesion of the somatosensorimotor cortices produced sustained reduction of the neuropathic manifestations. Our results correlate well with the established connections of the ventrolateral orbital area with the thalamic nucleus subnucleus involved in the procession of thermal nociception. The transient effects reported following permanent lesions in the orbital areas may reflect its flexible role in pain modulation. This observation provides further evidence on the plasticity of the neural networks involved in the regulation of nociceptive behavior.
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Affiliation(s)
- M Baliki
- Department of Human Morphology and Physiology, American University of Beirut, P.O. Box 110236/41, Riad El Solh, 1107-2020, Beirut, Lebanon
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32
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Jones HR. Mononeuropathies of infancy and childhood. Suppl Clin Neurophysiol 2003; 53:396-408. [PMID: 12741027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Affiliation(s)
- H R Jones
- Department of Neurology, Harvard Medical School, Children's Hospital, Boston, MA, USA.
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33
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Rueter LE, Kohlhaas KL, Curzon P, Surowy CS, Meyer MD. Peripheral and central sites of action for A-85380 in the spinal nerve ligation model of neuropathic pain. Pain 2003; 103:269-276. [PMID: 12791433 DOI: 10.1016/s0304-3959(02)00455-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Neuronal nicotinic receptor (NNR) agonists such as ABT 594 have been shown to be effective in a wide range of preclinical models of acute and neuropathic pain. The present study, using the NNR agonist A-85380, sought to determine if NNR agonists are acting via similar or differing mechanisms to induce anti-nociception and anti-allodynia. A systemic administration of the quaternary NNR antagonist chlorisondamine (0.4 micromol/kg, intraperitoneal (i.p.)) did not alter A-85380-induced (0.75 micromol/kg, i.p.) anti-nociception in the rat paw withdrawal model of acute thermal pain. In contrast, previous studies have demonstrated that blockade of central NNRs by prior administration of chlorisondamine (10 microg i.c.v.) prevents A-85380 induced anti-nociception indicating a predominantly central site of action of NNR agonists in relieving acute pain. In the rat spinal nerve ligation model of neuropathic pain, A-85380 induced a dose-dependent anti-allodynia (0.5-1.0 micromol/kg) that was blocked by pretreatment with mecamylamine (1 micromol/kg). Interestingly, unlike acute pain, both systemic and central administration of chlorisondamine blocked A-85380-induced anti-allodynia, an effect that was determined not to be due to a non-specific effect of chlorisondamine or to chlorisondamine crossing the blood-brain barrier. The peripheral site of action was shown not to be the primary receptive field, since A-85380 had equally potent anti-allodynic effects when it was injected into either the affected or unaffected paw. In contrast, infusion of A-85380 directly onto the L5 dorsal root ganglion on the affected side resulted in a dose-dependent and marked anti-allodynia (10-20 microg) at doses that had no effect when injected systemically. This effect was blocked by pretreatment with chlorisondamine. Together these data further support the idea that different mechanisms underlie different pain states and suggest that the effects of NNR agonists in neuropathic pain may be due in part to peripheral actions of the compounds.
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Affiliation(s)
- Lynne E Rueter
- Neurological Research, D4N5 AP9A, Abbott Laboratories, 100 Abbott Park Road, Abbott Park, IL 60064-6115, USA
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Wallace VCJ, Cottrell DF, Brophy PJ, Fleetwood-Walker SM. Focal lysolecithin-induced demyelination of peripheral afferents results in neuropathic pain behavior that is attenuated by cannabinoids. J Neurosci 2003; 23:3221-33. [PMID: 12716929 PMCID: PMC6742302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
Demyelinating diseases can be associated with painful sensory phenomena such as tactile allodynia and hyperalgesia. To study the mechanisms underlying demyelination-induced pain, we have characterized a novel model of demyelination of the sciatic or saphenous nerve. Topical lysolecithin application causes focal demyelination of afferent nerve A-fibers without axonal loss, as assessed either by electron and light microscopy or by immunohistochemical analysis of dorsal root ganglia (DRG) for a neuronal injury marker, activating transcription factor 3. Focal demyelination is accompanied by spontaneous action potentials in afferents and increased expression of neuropeptide Y and Na(v)1.3 sodium channels specifically in DRG neurons that coexpress a specific marker of myelinated afferents. In contrast, expression of tetrodotoxin-resistant, Na(v)1.8 sodium channels is specifically decreased in the same subgroup of DRG cells. Central sensitization of somatosensory processing is also induced, with increased behavioral reflex responsiveness to thermal and mechanical stimuli. These changes are reversed by intrathecal administration of an NMDA receptor antagonist or cannabinoid (CB) receptor agonist, but not by a mu-opioid receptor agonist. Recovery of behavioral reflexes occurred approximately 3 weeks after lysolecithin treatment. This is the first time that demyelination of afferent A-fibers has been shown to specifically induce neuropathic pain and indicates that axonal damage is not a prerequisite for development of the pain state. The profile of phenotypic changes in DRG is distinct from other pain models and displays a sensitivity to NMDA and CB receptor agents that may be exploitable therapeutically.
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MESH Headings
- Action Potentials/drug effects
- Animals
- Behavior, Animal/drug effects
- Cannabinoids/pharmacology
- Demyelinating Diseases/chemically induced
- Demyelinating Diseases/complications
- Demyelinating Diseases/physiopathology
- Disease Models, Animal
- Drug Administration Routes
- Excitatory Amino Acid Antagonists/pharmacology
- Ganglia, Spinal/metabolism
- Ganglia, Spinal/pathology
- Immunohistochemistry
- Lysophosphatidylcholines/pharmacology
- Mice
- Mice, Inbred C57BL
- Mononeuropathies/chemically induced
- Mononeuropathies/complications
- Mononeuropathies/pathology
- Mononeuropathies/physiopathology
- Nerve Fibers, Myelinated/drug effects
- Nerve Fibers, Myelinated/pathology
- Neurons, Afferent/drug effects
- Neurons, Afferent/pathology
- Neurons, Afferent/physiology
- Neuropeptide Y/metabolism
- Pain/drug therapy
- Pain/physiopathology
- Peripheral Nerves/drug effects
- Peripheral Nerves/pathology
- Peripheral Nerves/physiopathology
- Receptors, N-Methyl-D-Aspartate/antagonists & inhibitors
- Receptors, Opioid, mu/agonists
- Reflex/drug effects
- Sciatic Nerve/drug effects
- Sciatic Nerve/pathology
- Sciatic Nerve/physiopathology
- Sodium Channels/metabolism
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Affiliation(s)
- Victoria C J Wallace
- Centre for Neuroscience Research, Division of Preclinical Veterinary Sciences, The Royal (Dick) School of Veterinary Studies, The University of Edinburgh, Summerhall, Edinburgh EH9 1QH, United Kingdom
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35
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Abstract
Patients with clinical evidence of ulnar mononeuropathy at the elbow may have normal routine motor and sensory nerve conduction studies, suggesting a low sensitivity for these methods. Other, more specialized techniques may have a higher sensitivity, increasing diagnostic yield, and provide more specific localization of the lesion. We compared the sensitivity and specificity of ulnar segmental nerve conduction studies (SgNCS or "inching") at 2-cm intervals with those of routine ulnar motor and sensory studies. We studied 21 arms with symptoms or signs of ulnar neuropathy and 25 asymptomatic control arms. SgNCS proved significantly more sensitive than more routine studies in diagnosing ulnar neuropathy at the elbow, with a sensitivity of 81%, whereas motor conduction velocity in a longer (10-14 cm) segment across the elbow was the next most sensitive at 24%. Recording from the first dorsal interosseous muscle did not improve sensitivity when compared with recording from the abductor digiti quinti. Short SgNCS significantly improves detection of ulnar mononeuropathy at the elbow and should be considered when routine studies are negative and clinical suspicion remains high.
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Affiliation(s)
- Yevgeny Azrieli
- Department of Neurology, St. Luke's-Roosevelt Hospital Center, New York, New York, USA
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36
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Abstract
One diagnostic criterion for ulnar nerve mononeuropathy at the elbow (UNE) is a decrease in across-elbow nerve conduction velocity (NCV) > 10 m/s compared to the forearm segment. Distance and latency measurement errors are an inherent part of NCV calculations. Twenty electromyographers measured the latencies of stored ulnar compound muscle action potentials and measured the forearm and across-elbow distances along the ulnar nerve. Based on previously published equations, experimental error in NCV was calculated for various NCVs. The mean distances and standard deviations for the forearm and elbow segments were 212.5 +/- 2.1 mm and 86.7 +/- 4.2 mm, respectively. For an NCV of 55 m/s, a difference of 14 m/s between the two segments can occur from measurement error alone. Distance measurements about the elbow are fraught with interobserver errors rendering the resultant NCV of that segment of limited value as a sole criterion for the diagnosis of UNE.
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Affiliation(s)
- Mark E Landau
- Department of Neurology, Walter Reed Army Medical Center, 6900 Georgia Avenue, Washington, DC 20307, USA.
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37
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Raghavendra V, Rutkowski MD, DeLeo JA. The role of spinal neuroimmune activation in morphine tolerance/hyperalgesia in neuropathic and sham-operated rats. J Neurosci 2002; 22:9980-9. [PMID: 12427855 PMCID: PMC6757841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2002] [Revised: 09/03/2002] [Accepted: 09/03/2002] [Indexed: 02/27/2023] Open
Abstract
Hypersensitivity resulting from nerve injury or morphine tolerance/hyperalgesia is predicted to involve similar cellular and molecular mechanisms. One expected but incompletely explored mechanism is the activation of central neuroimmune responses associated with these conditions. To begin to address this, we undertook three separate studies: First, we determined the acute antinociceptive action of morphine, the rate of development of opioid tolerance, and withdrawal-induced hyperalgesia/allodynia in nerve-injured and sham-operated rats using noxious (thermal and mechanical) and non-noxious (mechanical allodynia) behavioral paradigms. Second, we investigated the impact of chronic morphine treatment on spinal glial activation and cytokine expression after L5 spinal nerve transection or sham surgery. Third, we examined the consequences of spinal administration of cytokine inhibitors on the development of morphine tolerance and morphine withdrawal-induced hyperalgesia and allodynia. Results demonstrated that after nerve injury, the antinociceptive effect of acute morphine was significantly decreased, and the rate of development of tolerance and opioid withdrawal-induced hyperalgesia/allodynia was significantly enhanced compared with that after sham surgery. Chronic administration of morphine to sham-operated rats activated spinal glia and upregulated proinflammatory cytokines [interleukin (IL)-1beta, IL-6, and tumor necrosis factor-alpha]. This neuroimmune activation was further enhanced in nerve-injured rats after chronic morphine treatment. Spinal inhibition of proinflammatory cytokines restored acute morphine antinociception in nerve-injured rats and also significantly reversed the development of morphine tolerance and withdrawal-induced hyperalgesia and allodynia in nerve-injured or sham-operated rats. Targeting central cytokine production and glial activation may improve the effectiveness of morphine and reduce the incidence of morphine withdrawal-induced hyperalgesia and allodynia in neuropathic pain conditions.
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Affiliation(s)
- Vasudeva Raghavendra
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA
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38
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Abstract
This study looks at disease diversity, location of lesions, and progression of neuralgic amyotrophy (NA). Forty patients (28 male and 12 female, age range 15 to 70 years) were clinically examined. Muscle atrophy, weakness, and sensory impairment were assessed. Needle EMG and conduction velocities were performed. Careful clinical, electrophysiological, laboratory, and radiological studies excluded other illness. Twenty-two patients were followed for 2 years. Antecedent fever and upper-respiratory tract infection was seen in 22 cases. Pain of sudden onset was always the initial symptom, followed by weakness, mainly in the proximal muscles of shoulder. The affectation was bilateral in 7 cases. Seven cases had a recurrent form of the disease. Clinical and electrophysiological findings suggest axonal lesions of the peripheral nerves, occurring singly (mononeuritis) or in various combinations (mononeuropathy multiplex). Unusual features, such as VII and XI cranial nerves, phrenic nerve, and lateral antebrachial cutaneous nerve affectation, were found. Follow-up showed good function recovery at variable times, even in 1 case with associated myotonic dystrophy (MD). NA is a well-defined entity, with variable clinical expression and data consistent with mononeuropathy or mononeuropathy multiplex, axonal in type. The overall prognosis is good. The progression in a patient with MD suggests that the capability of muscle fiber membrane to accept regenerating nerve sprouts remains in dystrophic muscles.
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Ulugol A, Aslantas A, Ipci Y, Tuncer A, Hakan Karadag C, Dokmeci I. Combined systemic administration of morphine and magnesium sulfate attenuates pain-related behavior in mononeuropathic rats. Brain Res 2002; 943:101-4. [PMID: 12088843 DOI: 10.1016/s0006-8993(02)02618-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The response to opioids is reduced in neuropathic pain states. We examined the effect of the combination of morphine (0.1 mg/kg) and magnesium sulfate (125 mg/kg) on behavioral signs of neuropathic pain in spinal nerve ligated rats. Administered alone, neither drug produced any effect, but the combination exerted a significant anti-allodynic effect, which was partially reversed by naloxone. These results suggest that combining low doses of magnesium sulfate with opiates might be an alternative in treating neuropathic pain, with reduced risk of side effects.
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Affiliation(s)
- Ahmet Ulugol
- Department of Pharmacology, Faculty of Medicine, Trakya University, 22030 Edirne, Turkey.
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40
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Abstract
Upper extremity mononeuropathies are common. Most are due to compression, whereas others occur in the setting of systemic disorders (e.g., diabetes) or with coexistent polyneuropathies. Electrophysiologic studies are essential in most cases, and provide critical information regarding localization, severity, activity, chronicity, and underlying pathophysiological mechanisms. Insights gleaned from the electrodiagnostic report guide clinicians in the optimal management of mononeuropathies of the upper extremity.
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Affiliation(s)
- David N Herrmann
- Department of Neurology, University of Rochester, SMH 601 Elmwood Ave, Box 673, Rochester, NY 14642, USA.
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41
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Abstract
Lower extremity mononeuropathies are less common than those affecting the upper limb. Yet, they are often challenging and more difficult to diagnose. The electrodiagnostic (EDX) studies play a pivotal role in diagnosis. Well planned and executed studies are very useful, although limiting factors such as age, foot swelling or prior lumbar spine surgery may hinder making a definite diagnosis. In this section, the author emphasizes the EDX studies of most lower extremity mononeuropathies and discusses, briefly, their anatomical and clinical aspects.
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Affiliation(s)
- Bashar Katirji
- Department of Neurology, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5098, USA.
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42
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Abstract
A cohort of 106 patients with electrodiagnostically confirmed long thoracic neuropathy (50 patients) or spinal accessory neuropathy (56 patients) seen at the Mayo Clinic over a 22-year period were retrospectively studied to better understand the natural history of these disorders and to determine the role of electrodiagnostic testing in predicting prognosis. Mean follow-up was 48 and 50 months, respectively. Good functional recovery was generally observed regardless of the results of electrodiagnostic studies, but improvement in the amplitude of the spinal accessory compound muscle action potential on serial nerve conduction studies tended to predict a good outcome. No electrodiagnostic findings correlated with poor outcome. Traumatic neuropathies generally did worse than neuropathies of other causes. In spinal accessory neuropathies, involvement of the dominant limb, scapular winging, and impaired arm elevation were associated with a poor outcome. Our data suggest that, contrary to other focal neuropathies, the electrodiagnostic findings do not predict functional outcome in these neuropathies.
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43
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Abstract
Isolated injury of the spinal accessory nerve is a well-recognized complication of surgeries involving the posterior triangle of the neck. The procedures most commonly implicated are lymph node biopsy and carotid endarterectomy. We present a patient with isolated injury to the spinal accessory nerve, localized proximal to the innervation of the sternocleidomastoid muscle, which was noted following suboccipital decompression for an Arnold-Chiari malformation. To our knowledge, this association has not been previously reported.
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Affiliation(s)
- J A Rescigno
- Department of Neurology, University of Connecticut School of Medicine, Farmington, CT 06030, USA
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44
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Abstract
To study causes of obturator neuropathy and to correlate them with outcome, we retrospectively studied patients seen at the Mayo Clinic electromyography (EMG) laboratory from 1975 through 1999 with a diagnosis of obturator neuropathy. Twenty-two patients with obturator neuropathy were identified. The clinical outcome of patients with acute obturator neuropathy treated conservatively was good regardless of etiology or severity.
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Affiliation(s)
- Eric J Sorenson
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA.
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Abstract
A 41-year-old man complained of subacute onset of dyspnea and pain in the neck and chest. He was diagnosed with bilateral diaphragmatic paralysis, based on clinical inspection of the breathing pattern and transdiaphragmatic pressure recording, and was trained to use a portable bi-level positive airway pressure apparatus (BiPAP). Needle electromyography showed profuse fibrillation potentials and positive waves in the diaphragm, more abundant on the right than left side, and no response to phrenic nerve stimulation. Other muscles were not involved. Follow-up examinations, performed at 9 and 12 months after onset of paralysis, demonstrated a slow but progressive improvement of the patient's respiratory function, together with the appearance of reinnervation potentials in the diaphragm, and polyphasic, long-latency responses to phrenic nerve stimulation. The subacute onset of the paralysis associated with local pain, and its subsequent recovery, suggest bilateral proximal lesions in the phrenic nerves. In the absence of traumatic or metabolic causes, these findings suggest that the phrenic nerve can be a target in idiopathic neuritis.
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Affiliation(s)
- Josep Valls-Solé
- Unitat d'EMG, Servei de Neurologia, Hospital Clinic, Facultad de Medicina, Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS),Universitat de Barcelona, Villarroel 170, Barcelona 08036, Spain.
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46
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Abstract
Persistent sensitivity to noxious and innocuous somatic stimuli results from peripheral nerve injury. Following chronic constriction injury (CCI) of the sciatic nerve in the rat, the hind paw ipsilateral to the injury displays significantly decreased response latencies to a noxious heat stimulus (thermal hyperalgesia), compared with the contralateral uninjured paw. The ligated paw also shows increased lifting and duration of lifting from a cooled (4 +/- 1 degrees C) surface. To characterize the peripheral nerve component of increased sensitivity to cold, CCI rats were systemically injected with the potent capsaicin analog resiniferatoxin (RTX). Twenty-four hours following RTX injection response latencies to noxious heat were significantly increased for both the ligated and unligated hind paws. In addition, increased responsiveness of the ligated paw to the cold surface was significantly attenuated. The results demonstrate that the enhanced responsiveness to cold and heat following a CCI are mediated in part by RTX-sensitive primary afferents.
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Affiliation(s)
- Aldric T Hama
- Merck Research Laboratories, 3535 General Atomics Court, San Diego, CA 92121, USA
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Montoya G JV, Ariza J, Sutachán JJ, Hurtado H. Relationship between functional deficiencies and the contribution of myelin nerve fibers derived from L-4, L-5, and L-6 spinolumbar branches in adult rat sciatic nerve. Exp Neurol 2002; 173:266-74. [PMID: 11822890 DOI: 10.1006/exnr.2001.7806] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The distribution and relative intrafascicular contribution of myelin fibers derived from spinal segments L-4 to L-6 were analyzed in adult rat sciatic nerve and its main branches, using 200-kDa neurofilament subunit immunodetection in previously injured nerve sections in the L-4 or L-5 spinal branch or both. These branches' functional contribution was evaluated 16 days after the injury, using the method of J. Bain, S. Mackinnon, and D. Hunter (1988, Plast. Reconstr. Surg. 83: 129-136). A common topographic intrafascicular distribution was found in 69% of cases, with notable segregation of L-4 and L-5 fibers and a random distribution for L-6 fibers. At sciatic nerve main branch level, L-4 contributes almost entirely to the peroneal nerve, L-5 to the tibial nerve, and L-6 and other branches to the sural nerve. After injury to L-4, a significant reduction in peroneal nerve functional index (PFI) was observed, as was a reduction in print length (PL). Injury to L-5 caused a significant reduction in the sciatic (SFI) and tibial (TFI) functional nerve indices, an increase in PL, and a reduction in the spread between opposite toes (TS). Finally, transection of both L-4 and L-5 was followed by a significant reduction in all functional indices measured, an increase in PL, and a reduction in intermediate toe (ITS) and opposite toe spread (TS). The results indicate a direct relationship between the distribution and contribution of the spinal nerve fibers forming the sciatic nerve and the alteration in functional indices for sciatic, tibial, and peroneal nerves.
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Affiliation(s)
- José V Montoya G
- Neuroscience Laboratory, National Institute of Health Bogotá, Bogota, Colombia
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Höke A, Gordon T, Zochodne DW, Sulaiman OAR. A decline in glial cell-line-derived neurotrophic factor expression is associated with impaired regeneration after long-term Schwann cell denervation. Exp Neurol 2002; 173:77-85. [PMID: 11771940 DOI: 10.1006/exnr.2001.7826] [Citation(s) in RCA: 199] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In the peripheral nervous system, regeneration of motor and sensory axons into chronically denervated distal nerve segments is impaired compared to regeneration into acutely denervated nerves. In order to find possible causes for this phenomenon we examined the changes in the expression pattern of the glial cell-line-derived neurotrophic factor (GDNF) family of growth factors and their receptors in chronically denervated rat sciatic nerves as a function of time with or without regeneration. Among the GDNF family of growth factors, only GDNF mRNA expression was rapidly upregulated in Schwann cells as early as 48 h after denervation. This upregulation peaked at 1 week and then declined to minimal levels by 6 months of denervation. The changes in the protein expression paralleled the changes in the expression of the GDNF mRNA. The mRNAs for receptors GFRalpha-1 and GFRalpha-2 were upregulated only after maximal GDNF upregulation and remained elevated as late as 6 months. There were no significant changes in the expression of GFRalpha-3 or the tyrosine kinase coreceptor, RET. When we examined the expression of GDNF in a delayed regeneration paradigm, there was no upregulation in the distal chronically denervated tibial nerve even when the freshly axotomized peroneal branch of the sciatic nerve was sutured to the distal tibial nerve. This study suggests that one of the reasons for impaired regeneration into chronically denervated peripheral nerves may be the inability of Schwann cells to maintain important trophic support for both motor and sensory neurons.
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Affiliation(s)
- A Höke
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland 21287, USA.
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Horiuchi I, Ochi H, Murai H, Osoegawa M, Minohara M, Furuya H, Kira J. Th2 shift in mononeuritis multiplex and increase of Th2 cells in chronic inflammatory demyelinating polyneuropathy: an intracellular cytokine analysis. J Neurol Sci 2001; 193:49-52. [PMID: 11718750 DOI: 10.1016/s0022-510x(01)00603-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
To elucidate the T helper 1 (Th1)/T helper 2 (Th2) balance in various inflammatory neuropathies, we measured the ratio of intracellular interferon-gamma (IFN-gamma)-positive to IL-4-positive cells (intracellular IFN-gamma/IL-4 ratio) by flow cytometry in peripheral blood CD4(+) T cells of 14 patients with mononeuritis multiplex (MNM), 12 patients with chronic inflammatory demyelinating polyneuropathy (CIDP), 10 patients with Guillain-Barré syndrome (GBS), 23 patients with neurodegenerative disorders and 36 healthy controls by intracellular labeling. The patients with MNM showed a significantly lower intracellular IFN-gamma/IL-4 ratio (P<0.05) and higher IL-4(+)/IFN-gamma(-) cell percentages (P<0.05) than the controls. The increase of IL-4(+)/IFN-gamma(-) cell percentages was especially prominent in MNM of unknown etiology (P<0.005). The patients with CIDP also showed significantly higher IL-4(+)/IFN-gamma(-) cell percentages (P<0.05) than the controls. The IL-4(+)/IFN-gamma(-) cell percentages were increased in some patients with GBS, but the difference was not significant compared with the controls. Thus, our results suggest that a Th2 shift is a characteristic of MNM and may play an important role in the development of the disease.
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Affiliation(s)
- I Horiuchi
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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50
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Abstract
This review deals with physiological and biological mechanisms of neuropathic pain, that is, pain induced by injury or disease of the nervous system. Animal models of neuropathic pain mostly use injury to a peripheral nerve, therefore, our focus is on results from nerve injury models. To make sure that the nerve injury models are related to pain, the behavior was assessed of animals following nerve injury, i.e. partial/total nerve transection/ligation or chronic nerve constriction. The following behaviors observed in such animals are considered to indicate pain: (a) autotomy, i.e. self-attack, assessed by counting the number of wounds implied, (b) hyperalgesia, i.e. strong withdrawal responses to a moderate heat stimulus, (c) allodynia, i.e. withdrawal in response to non-noxious tactile or cold stimuli. These behavioral parameters have been exploited to study the pharmacology and modulation of neuropathic pain. Nerve fibers develop abnormal ectopic excitability at or near the site of nerve injury. The mechanisms include unusual distributions of Na(+) channels, as well as abnormal responses to endogenous pain producing substances and cytokines such as tumor necrosis factor alpha (TNF-alpha). Persistent abnormal excitability of sensory nerve endings in a neuroma is considered a mechanism of stump pain after amputation. Any local nerve injury tends to spread to distant parts of the peripheral and central nervous system. This includes erratic mechano-sensitivity along the injured nerve including the cell bodies in the dorsal root ganglion (DRG) as well as ongoing activity in the dorsal horn. The spread of pathophysiology includes upregulation of nitric oxide synthase (NOS) in axotomized neurons, deafferentation hypersensitivity of spinal neurons following afferent cell death, long-term potentiation (LTP) of spinal synaptic transmission and attenuation of central pain inhibitory mechanisms. In particular, the efficacy of opioids at the spinal level is much decreased following nerve injury. Repeated or prolonged noxious stimulation and the persistent abnormal input following nerve injury activate a number of intracellular second messenger systems, implying phosphorylation by protein kinases, particularly protein kinase C (PKC). Intracellular signal cascades result in immediate early gene (IEG) induction which is considered as the overture of a widespread change in protein synthesis, a general basis for nervous system plasticity. Although these processes of increasing nervous system excitability may be considered as a strategy to compensate functional deficits following nerve injury, its by-product is widespread nervous system sensitization resulting in pain and hyperalgesia. An important sequela of nerve injury and other nervous system diseases such as virus attack is apoptosis of neurons in the peripheral and central nervous system. Apoptosis seems to induce neuronal sensitization and loss of inhibitory systems, and these irreversible processes might be in common to nervous system damage by brain trauma or ischemia as well as neuropathic pain. The cellular pathobiology including apoptosis suggests future strategies against neuropathic pain that emphasize preventive aspects.
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Affiliation(s)
- M Zimmermann
- Neuroscience and Pain Research Institute, Berliner Strasse 14, 69120 Heidelberg, Germany.
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