Examination Of Peripheral Nervous System Research Articles

Evaluation of muscle atrophy after sciatic nerve defect repair – experimental model

Peripheral nerve injuries are one of the most important causes for disability generating considerable costs around the world. Appropriate assessment of the extent of peripheral nerve lesions and the choice of the right therapeutic protocol remain some of the biggest challenges. Non-invasive neuroimaging approaches are suitable in managing peripheral nerve repairs, providing in the same time accuracy details in structural neural detection, with minimal discomfort at a low cost. Medical imaging technology development has led to progress in examination of peripheral nervous system, using a series of tools and methods, such as: ultrasonography (US), positron emission tomography (PET), magnetic resonance imaging (MRI) and magnetic diffusion tensor imaging (DTI). In this study, we evaluated the regeneration process in Wistar rats after sciatic nerve defects repair with 4 different techniques (i.e. nerve graft, rat aorta used as a nerve conduit, rat aorta filled with platelet rich plasma (PRP) and rat aorta filled with stem cells) by using MRI investigation alongside the clinical evaluation. Our results showed that among the 4 batches, the PRP batch had the best results in muscle atrophy condition (both on MRI scan and on gastrocnemius index); on the second place the stem cell batch, then the nerve graft batch and finally the aortic conduit batch. MRI proved to be a reliable non-invasive monitoring method and showed good result in correlation with the footprint test (sciatic functional index) and the gastrocnemius index

52. Not every rheumatologic headache is giant cell arteritis: a case of aseptic meningitis on a background of rheumatoid arthritis

IntroductionA 65-year-old Caucasian lady had a background of longstanding seropositive rheumatoid arthritis (RA) for which multiple disease modifying drugs and biologics had been tried, but then stopped due to either inefficacy or intolerance. She presented with possible vasculitis and was initially treated and investigated for giant cell arteritis (GCA).Case descriptionThis patient presented with temporal headache and right-sided visual field loss, with tenderness over a weakly palpable right temporal artery. No jaw claudication or other cranial nerve abnormality and peripheral nervous system examination was normal. She was commenced on prednisolone and the ophthalmologist decided against temporal artery biopsy. She subsequently developed episodes of tonic-clonic seizure and reduced consciousness, which would be unexplained by GCA.ESR 70 and CRP 28. ANCA and ANA negative, rheumatoid factor positive and anti-CCP antibodies >600.Gadolinium-enhanced MRI brain showed subdural effusions in the left frontal/parietal lobes alongside effacement of the gyri, indicating lepatomeningitis. Lumbar puncture showed increased cerebral spinal fluid (CSF) protein of 1.25g/L (0.1-0.4) and mildly reduced glucose of 2.1mmol/L (2.2-3.9). CSF was negative for acid fast bacilli, lyme disease, cryptococcal antigen, PCR for viruses and TB, culture and extensive immunological screening. Tuberculosis T-Spot test was negative whilst PET-CT demonstrated widespread polyarthropathy but no evidence of an underlying malignancy. The patient was referred for meningeal biopsy; however it was considered too high-risk given her medical co-morbidities.As an inpatient, she developed pneumonia and two myocardial infarctions. For the next four months, she was seizure-free on levetiracetam, but still experienced right-sided facial twitching. She was commenced on a reducing regime of prednisolone on the assumption of rheumatoid meningitis and also given 12-month empirical therapy to cover for possibility of TB meningitis, although this was deemed less likely. Initially she responded to prednisolone but upon dose reduction, she noticed worsening incoordination and unsteadiness, with simultaneous joint flare-up, indicating that immunosuppression was beneficial to her neurological status. Azathioprine was introduced as a steroid-sparing agent but she developed abnormal liver function and hence mycophenolate has been used instead. No side effects have been reported; she has remained seizure-free and reports an improvement in her neurological status. DiscussionInitially it was appropriate to treat as GCA given very typical history. However, the presence of other unexplained symptoms and MRI findings led the decision that the diagnosis was not purely vasculitic in origin. MRI brain and CSF findings were consistent with aseptic meningitis, typically where there is meningeal inflammation with negative Gram stain and culture of CSF, often with pleocytosis. Although predominantly caused by enteroviruses; it can occur secondary to malignancy, drugs and autoimmune disease. These causes were considered, however the presence of active rheumatoid arthritis made a diagnosis of rheumatoid meningitis likely. This uncommon complication of seropositive rheumatoid arthritis was described by Bathon et al as having three hallmark neuropathological findings; rheumatoid nodules, pachymeningitis and vasculitis. A diagnostic challenge is the lack of correlation between synovitis and neurological presentation. Presentation ranges from cranial/peripheral nerve dysfunction to seizures and altered mental state. In the CSF we expect to find high protein and reduced glucose with sporadic pleocytosis. Findings from MRI and CSF analysis can be variable. Ultimately rheumatoid meningitis as described in the literature is diagnosed by histopathology at biopsy, but this is not always available in clinical practice, and sometimes empirical treatment has to be given.Key learning pointsRheumatoid meningitis is a rare complication of RA, but can present with stroke-like episodes or seizures, so this diagnosis should always be considered in RA patients presenting in such a way. Despite high mortality and the lack of any evidence-based guidelines, combinations of steroids alongside cyclophosphamide, azathioprine and methotrexate are reported to have improved prognosis in some patients. The lack of any RCT evidence means the condition has to be managed according to expert opinion, which may require close co-operation between specialties such as neurology, infectious diseases and rheumatology to achieve a good outcome.Conflicts of interestThe authors have declared no conflicts of interest.

MENINGO-ENCEPHALITIS WITH NEUROPATHY; BICKERSTAFF/FISHER SYNDROME AN UNDER RECOGNISED ENTITY

A 69-year-old patient who had mild URTI a week ago presented with back pain, nausea and progressive weakness of the limbs. Examination revealed mild confusion and subtle eye closure weakness....

Programmed Learning Module: Radiculopathy Versus Peripheral Neuropathy Localization—2 Cases

OPEN ACCESSNovember 9, 2010Programmed Learning Module: Radiculopathy Versus Peripheral Neuropathy Localization—2 Cases Nethra Ankam, MD, John Norbury, MD Nethra Ankam, MD Sidney Kimmel Medical College at Thomas Jefferson University Google Scholar More articles by this author , John Norbury, MD Sidney Kimmel Medical College at Thomas Jefferson University Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.8166 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractThis resource is a programmed learning module designed to stimulate thinking about how the peripheral nervous system physical exam can be structured to differentiate between a radiculopathy and peripheral nerve lesion. The module consists of an upper limb and a lower limb case. Students at our institution took this module after a 2-hour hands-on skills workshop on peripheral nervous system examination with some emphasis on localization and use of the examination as part of a fourth-year required rotation in rehabilitation medicine. At our institution, these cases are hosted on our learning management system using the test feature so that students can input responses to the questions before seeing the correct answer. However, these cases can be used in paper format as well. Of those students who have taken the lower limb localization case, 71.5% strongly agreed and 21% agreed that the module was a valuable use of their time. For the upper limb case, 73.4% strongly agreed and 19% agreed that the module was a valuable use of their time. Most of the written comments about the module were overwhelmingly positive. Comments focused on how the material solidified concepts for students and how it was good practice for the test. This module is important as it reinforces the significance of the physical examination of the peripheral nervous system. It is also important for students to practice these concepts at home, and this module allows them to do this. Educational Objectives By the end of this module, learners will be able to: Describe how to distinguish a radiculopathy from a peripheral nerve injury using physical examination techniques.Distinguish an L5-S1 radiculopathy from a peripheral nerve injury.Distinguish carpal tunnel syndrome from a C6-C7 radiculopathy. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Instructor's Guide.doc Figure 1 Cutaneous Innervation of the hand.pdf Programmed Learning Module Radiculopathy.doc To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. CitationAnkam N, Norbury J. Programmed Learning Module: Radiculopathy Versus Peripheral Neuropathy Localization—2 Cases. MedEdPORTAL. 2010;6:8166. https://doi.org/10.15766/mep_2374-8265.8166 Copyright & Permissions© 2010 Ankam and Norbury. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsNerve LesionsCarpal Tunnel SyndromeNeuropathyPeripheral Nervous SystemRadiculopathy Disclosures None to report. Funding/Support None to report. Loading ...

Brucella: A Cause of Peripheral Neuropathy

Brucellosis is a common infectious disease in Mediterranean countries. We evaluated the peripheral nerve involvement in patients with brucellosis. Thirty-eight patients with brucellosis were examined. Four of them were excluded because of B₁₂ deficiency and diabetes mellitus. Thirty-four patients were included. The average age was 43.08 ± 15.3 years. Patients were divided into two groups according to the abnormality in their peripheral nervous system (PNS) examination. All patients underwent nerve conduction and needle electromyography EMG studies. Twenty normal healthy subjects were used as a control group. Axonal sensorimotor neuropathy was determined in 12 patients who also had abnormality in PNS examination. After 6 months of treatment, nerve conduction studies were nearly normal in these patients. The EMG findings of the remaining 22 patients were normal, as well as the clinical examination. However, the motor conduction velocities of median (p < 0.001), peroneal (p < 0.001), and ulnar (p < 0.05) nerves were decreased, F wave latencies were prolonged in the posterior tibial and peroneal nerve, and distal latency was also prolonged in the posterior tibial nerve (p < 0.05) when compared to healthy subjects. Sensory conduction velocities of the median (p < 0.001), ulnar and sural (p < 0.05) nerve were also decreased. Brucellosis may be considered as a cause of clinical or subclinical peripheral neuropathy and should be evaluated especially in endemic areas.

Hemiplegic migraine associated with interscalene block and general anaesthesia

We report a case of new onset hemiplegic migraine following general anaesthesia and an interscalene block, the first reported case in the literature. A middle-aged man underwent manipulation of the left shoulder under anaesthesia. An awake left interscalene block under sedation was performed. The plexus was located easily with a 25 Stimiplex needle and 30 ml 0.5% levobupivicaine injected at an end point of 0.4 mA (biceps twitch) uneventfully. General anaesthesia was then induced with 50 μg fentanyl and 200 mg propofol. A laryngeal mask airway was placed and the patient ventilated spontaneously with oxygen, air and sevoflurane. The patient was positioned in the right decubitus position. There were no adverse events during the 40 min procedure. In recovery he was unable to move or feel the left side of his body and had difficulty responding to questions with slurred speech. Cranial nerve examination revealed reduced sensation of the left cheek, flaccid paresis of the left cheek, and left hypoglossal nerve impairment. A dense left-sided hemiplegia and hemisensory loss was found on peripheral nervous system examination. Symptoms resolved gradually. Within 4 h he was able to move his foot but sensation was still impaired on the left side of his body. Cranial nerve assessment at this time showed tongue movement and speech back to normal. At 15 h upper limb movement had partially recovered, he was able to lift the arm, but still unable to move the fingertips. By 24 h the upper limb signs had almost completely resolved, and the leg weakness appeared to be resolving. Cranial nerve examination demonstrated ongoing numbness of the left side of the tongue. He notes having very slight generalised weakness thereafter which lasted for a further 3 days. Immediate MRI of the cervical spinal cord was normal. Carotid duplex scans and cranial MRI performed later revealed no abnormality. Since the initial episode he had six further attacks of left-sided weakness. Severe stabbing pains in the head followed by mild to moderate headache have preceded each episode. Both his left arm and leg are affected. Symptoms resolve after 3 days. A diagnosis of hemiplegic migraine was made following neurological consultation. Propranolol was commenced and he was reviewed after 3 months. At this stage he reports suffering headaches every 2 weeks which were more tolerable. He had no further attacks of associated left-sided weakness or numbness. EEG undertaken was normal. Our case highlights the diagnostic dilemma posed by a neurological deficit following anaesthesia with interscalene block. A number of central and peripheral diagnoses should be considered. A left interscalene block could lead to left-sided neurology if injected directly into the substance of the spinal cord. A total spinal is likely to have occurred simultaneously. Literature describing this complication describes predominantly upper limb neurological loss, all being in individuals where interscalene block was performed under general anaesthesia [1]. Spontaneous right-sided stroke under anaesthesia is a possible differential diagnosis, but no radiology supported this, and the recurrent nature of the symptoms confirmed this. General anaesthesia is known to precipitate migraine in sufferers. Ten per cent of migraine sufferers have neurological deficits and in 4% this persists beyond the duration of the headache. Hemiplegia associated with migraine post general anaesthesia has to date only been reported in individuals with a prior history of the condition or a known strong family history of hemiplegic migraine [2]. Hemiplegic migraine is a rare disorder characterised by attacks of transient hemiparesis followed by migraine headache. Classically there is an aura, followed by development of neurological signs lasting a mean of 60 min followed by headache lasting 30 min to 5 days. Motor signs occur unilaterally in approximately 60% of cases and are never isolated – most commonly associated with sensory signs and language disturbance, and least commonly with visual disturbances – in contrast to classic migraine. Triggers for the development of migraine in these individuals are commonly minor stressful events, which is the postulated mechanism in this gentleman [3]. This case highlights that hemiplegic migraine should be considered as a possible differential when faced with neurological deficit postoperatively.

Abstracts of the 8th Meeting of the Italian Peripheral Nerve Study Group: 81

Symptomatic neuropathy in young patients with type 1 Diabetes Mellitus (t1DM) is rare but subclinical peripheral alterations can be assessed by electroclinical evaluation. This study aimed to assess prevalence of clinical and subclinical peripheral neuropathy in patients with t1DM. Motor and/or sensory nerve conduction studies of both median, ulnar, peroneal, tibial and sural nerves and standard clinical examination of peripheral nervous system were performed in 83 patients (27 females and 56 males) with diabetes onset since five years. The mean age of patients was 19.89 (range 9–28.3) years, the mean disease duration was 9.61(range 4.4–19.3) and the mean age at the onset of diabetes was 9.02 (range 0.8–23.5). Five patients (6.02 %) had both symptomatic (light clinical abnormalities as paresthesias and mild reduction of vibratory sensibility) and electrophysiologic neuropathy and six (7.2 %) with mild abnormal nerve conduction studies were totally asymptomatic (subclinical neuropathy). The majority of symptoms and electrophysiological alterations were found on the lower limbs. Only two patients had a minimal distal neuropathy of median nerve. No patients showed laboratory evidence of early renal complications or systemic hypertension; 5 (6.02 %) had early diabetic retinal abnormalities as microaneurisms, seen by fundus examination. Analysis of sex, age of onset, duration of diabetes, age at the date of electrophysiologic examination, Hemoglobin A1c (mean level of the last two years), association with retinal abnormalities and clinical assessment was performed (Fisher Exact Test, ANOVA). No correlation was found with the age at the onset, retinal abnormalities and glycaemic control index. Peripheral neuropathy was significantly related with patient age at the date of electrophysiological study and duration of t1DM.

The impact of formal instruction in clinical examination skills on medical student performance -- the example of peripheral nervous system examination.

Peripheral nervous system examination is an essential part of the full medical clerking of a patient. We have investigated the effectiveness of formal instruction in peripheral nervous system examination compared to the traditional bedside ward teaching that our students usually receive. We instructed an unselected group of 22 medical students in peripheral nervous system examination in a clinical skills centre and evaluated them with a 12 item marking schedule before and after instruction. The performance of this group was then compared to the rest of their year (220 students) in an end of year OSCE, which included a neurology station assessing sensory examination of the lower limbs. Students formally instructed in neurology significantly improved their scores after instruction and scored 15% higher marks (90% vs. 75%) than the rest of their year in the end of year neurology OSCE station 2 months later (P < 0.01, Mann Whitney U-test). They did not perform significantly better in the OSCE overall. Formal instruction in neurological examination resulted in a significant increase in the end of year neurology OSCE station score compared to traditional heterogeneous teaching methods.