Prolonged Motor Research Articles

Ropivacaine-loaded, hydroxypropyl chitin thermo-sensitive hydrogel combined with hyaluronan: an injectable, sustained-release system for providing long-lasting local anesthesia in rats

Background and objectiveRopivacaine hydrochloride is a commonly used local anesthetic in clinics. However, local injection or continuous infusion of ropivacaine has been associated with several disadvantages. Accordingly, it is important...

Role of Descending Serotonergic Fibers in the Development of Pathophysiology after Spinal Cord Injury (SCI): Contribution to Chronic Pain, Spasticity, and Autonomic Dysreflexia.

Simple SummaryFiber pathways that descend from the brain to the spinal cord drive motor behavior and modulate incoming sensory signals and the capacity to change (plasticity). A subset of these fibers release the neurotransmitter serotonin (5-HT), which can affect spinal cord function in alternative ways depending upon the region innervated and the receptor type engaged. The present paper examines the dampening (inhibitory) effect of serotonin and how a disruption in this process contributes to pathophysiology after spinal cord injury (SCI). After briefly reviewing the underlying anatomy and receptor types, we discuss how damage to serotonergic fibers can enable a state of over-excitation that interferes with adaptive learning and contributes to the development of pain, spasticity, and the dysregulation of autonomic function (autonomic dysreflexia). Recent work has shown that these effects arise, in part, because there is a shift in how the neurotransmitter gamma-aminobutyric acid (GABA) affects neural transmission within the spinal cord, a modification that lessens its inhibitory effect. Clinical implications of these results are discussed.As the nervous system develops, nerve fibers from the brain form descending tracts that regulate the execution of motor behavior within the spinal cord, incoming sensory signals, and capacity to change (plasticity). How these fibers affect function depends upon the transmitter released, the receptor system engaged, and the pattern of neural innervation. The current review focuses upon the neurotransmitter serotonin (5-HT) and its capacity to dampen (inhibit) neural excitation. A brief review of key anatomical details, receptor types, and pharmacology is provided. The paper then considers how damage to descending serotonergic fibers contributes to pathophysiology after spinal cord injury (SCI). The loss of serotonergic fibers removes an inhibitory brake that enables plasticity and neural excitation. In this state, noxious stimulation can induce a form of over-excitation that sensitizes pain (nociceptive) circuits, a modification that can contribute to the development of chronic pain. Over time, the loss of serotonergic fibers allows prolonged motor drive (spasticity) to develop and removes a regulatory brake on autonomic function, which enables bouts of unregulated sympathetic activity (autonomic dysreflexia). Recent research has shown that the loss of descending serotonergic activity is accompanied by a shift in how the neurotransmitter GABA affects neural activity, reducing its inhibitory effect. Treatments that target the loss of inhibition could have therapeutic benefit.

Rehabilitation of a young girl with acute transverse myelitis and prolonged lower motor neuron features: a longitudinal case report over 12 months

BackgroundThis report describes an effective rehabilitation programme for a 13-year-old girl, diagnosed with acute transverse myelitis, as an example of best clinical practice.Case descriptionMiss A was admitted to the National Institute of Neurosciences and Hospital in Dhaka, where she was diagnosed with acute transverse myelitis, in September 2018. She was discharged and referred for intensive rehabilitation over 3 months as an outpatient at the Centre for the Rehabilitation of the Paralysed in Bangladesh. The therapy team conducted a baseline assessment before starting treatment, which included the following outcome measures: the International Standards for Neurological Classification of Spinal Cord Injury Scale; Spinal Cord Independence Measure; and the Spinal Cord Injury Functional Ambulation Inventory. After 3 months, Miss A was discharged home to continue with a home exercise programme supported by her parents. Outcome measurements were repeated at 3-, 6- and 12-month time points.ResultsMiss A regained muscle power in her legs and normal sensation in S4/5 dermatomes, in addition to regaining voluntary anal muscle contraction. Her mobility and transfers improved so that she was able to transfer in and out of her wheelchair independently and use two elbow crutches to walk short distances outdoors.ConclusionsThis report shows that it is possible for a child who had been severely disabled by acute transverse myelitis to make substantial physical improvements up to 12 months after diagnosis when provided with effective rehabilitation. It also identifies that rehabilitation can provide multiple benefits and value for the individual patient, family, community and society.

Comparison of Levobupivacaine with dexmedetomidine in Infraumbilical surgeries

Introduction: Due to decreased cardiovascular and central nervous system toxicity, levobupivacaine is a good alternative for spinal anesthesia. Dexmedetomidine when used intrathecally is associated with prolonged motor and sensory block, hemodynamic stability, and less requirement of rescue analgesia in 24 h. Materials and Methods: We assumed that sevoflurane will provide clinically acceptable conditions for endotracheal intubation comparable to propofol-suxamethonium in children. All patients received diazepam 0.2 mg/kg orally, the night before surgery. The patients were preloaded with Lactated Ringer's solution 15 mL/kg. They were monitored with automated noninvasive blood pressure, pulse oximetry, and electrocardiogram. Results: In Group LD, increase in VAS was observed at 210 min and the first dose of rescue analgesia was given at 5th h postoperatively. The second dose of recue analgesia was given at 12th h and the third dose was given at 21st h. Postoperative VAS scores at different time intervals were significantly lower in Group LD than Group L, thus indicating superior analgesia. The time of request of the first dose of rescue analgesia was delayed in Group LD as it was demanded at 309.93 ± 23.19 min and in Group L was at 168.30 ± 12.32 min. The difference in the two groups was highly significant (P< 0.001). Conclusion: Sevoflurane provides clinically acceptable intubating conditions and can be a suitable alternative to propofol-suxamethonium for endotracheal intubation in children.

Clinical and long-term characteristics of the subtypes of chronic inflammatory demyelinating polyneuropathy

To clarify the clinical and long-term characteristic of each subtype of chronic inflammatory demyelinating polyneuropathy (CIDP). We evaluated data from 30 consecutive CIDP patients who met the criteria proposed by the European Federation of Neurological Societies and the Peripheral Nerve Society. Patients were classified as having typical CIDP (t-‍CIDP) (10/30, 33%), multifocal acquired demyelinating sensory and motor (MADSAM) (12/30, 40%), DADS (4/30, 13%), sensory CIDP (3/30, 10%) or motor CIDP (1/30, 3%). Nerve conduction studies showed more prolonged distal motor latencies/F-wave latencies and slower motor nerve conduction in the typical CIDP group than in the MADSAM group. Intravenous immunoglobulin (IVIg) was effective in 80% (8/10) of t-‍CIDP, 100% (12/12) of MADSAM, 100% (4/4) of DADS, and 100% (3/3) of sensory CIDP cases. Maintenance therapy with immunoglobulin was administered in patients with t-‍CIDP (5/10, 50%), MADSAM (9/12, 75%), DADS (1/4, 25%), and sensory CIDP (2/3, 67%). There were no patients with CIDP, in whom CIDP subtype was transformed from the initial diagnosis during five years of follow-up. Percentage of MADSAM was the most common phenotype in our cohort of CIDP patients, and IVIg/immunoglobulin maintenance was effective for MADSAM as well as t-‍CIDP in contrast to findings from the previous reports.

Axonal Excitability Findings in Acute Inflammatory Demyelinating Polyneuropathy Related to SARS-CoV-2

Guillain–Barré syndrome (GBS) is a disorder of the peripheral nervous system characterized by acute-onset ascendance paresis. We present a patient who was diagnosed as having facial-onset acute inflammatory demyelinating polyneuropathy after being infected with SARS-CoV-2. A 51-year-old man presented to the emergency department with facial diplegia. He then developed bilateral ascendance paralysis. He had noticed that for 1 month, he had smell and taste disturbances. SARS-CoV-2 infection was suspected. Nasopharyngeal swab polymerase chain reaction test was negative, but anti-SARS-CoV-2 antibody was found to be positive. A nerve conduction study showed prolonged motor distal and F wave latencies with decreased motor and sensory compound muscle action potential amplitudes. Lumbar puncture revealed albuminocytologic dissociation. According to the neurologic examination and laboratory findings, the patient was diagnosed as having acute inflammatory demyelinating polyneuropathy. An axonal excitability study revealed fanning in pattern with prolonged refractoriness, which indicates nodal sodium channel disturbances. Facial-onset SARS-CoV-2–related GBS has been rarely reported; however, facial involvement seems to be one of the features of the neurologic findings.

Intrathecal Midazolam: A Review on the Drug's Pharmacological Features, as Well as Its Therapeutic Efficacy and Side Effects

Introduction: Spinal anaesthesia with lignocaine was highly popular earlier for short surgical procedures as it had a predictable onset and provided dense sensory and motor blockade of moderate duration. Unfortunately, some reports of neurotoxicity had cast doubts on the intrathecal use of lignocaine. Post operative pain relief is an unresolved issue. One of the methods of providing postoperative analgesia is by prolonging the duration of intrathecal hyperbaric bupivacaine (0.5%) by adding various drugs such as opioids, midazolam, clonidine, ketamine, neostigmine etc. Discovery of benzodiazepine receptors in the spinal cord triggered the use of intrathecal midazolam for analgesia.&#x0D; Methodology: This review article was prepared after a thorough study of the literature using data search engine such as ‘Pubmed’. This article referred to prior Randomized Controlled Trial (RCT) on Intrathecal Midazolam.&#x0D; Review Findings: Midazolam is a potent short acting benzodiazepine that has been shown to have anti-nociceptive effects when administered intrathecally both in laboratory animals and in humans. Preservative free midazolam is also being used in recent times. As an additive to intrathecal hyperbaric bupivacaine to prolong the quality and duration of analgesia. It is said to be associated with less side effects compared to neuraxial opioids.&#x0D; Conclusion: Intrathecal midazolam can be used for postoperative pain relief. It can prolong the duration of analgesia and prolonged motor and sensory block without any significant hemodynamic compromise.

Reversal of Bupivacaine 0.5% Epidural Anesthesia Using Epidural Saline Washout

Background: Prolonged motor and sensory block following epidural anesthesia has been associated with patient dissatisfaction. Administration of epidural crystalloids in patient who had received bupivacaine 0.75% and lidocaine 2% epidural anesthesia. However, bupivacaine 0.5% is commonly used in our institutional and the effectiveness of bolus of NS in non-obstetrical patients undergoing 0.5% bupivacaine epidural anesthesia has not been investigated. The objective of this study was to determine the relationship of normal saline (NS) epidural flush volume to the recovery of motor and sensory block and its hemodynamic stability (blood pressure and heart rate) in non-obstetrical patients undergoing epidural anesthesia using 0.5% bupivacaine. Methods: Following surgery, subjects with T6 dermatome level of sensory, were randomized to 2 treatment groups. Group 1 (control, n = 11) received 1-mL epidural normal saline (NS). Group 2 (experimental, n = 11) received an epidural bolus of 30-mL NS. Assesment of motor and sensory block was performed at 15-minute intervals until complete motor and sensory recovery. Hemodynamic stability (blood pressure and heart rate) between two groups were also monitor every 15-minutes and determined. Results: Times to full motor recovery were significantly faster in the epidural bolus of 30-mL groups than in the control group (69 ± 19.66 vs 95 ± 11.83; p = 0.0017).). Conclusions: A more rapid recovery of motor block in patients undergoing 0.5% bupivacaine epidural anesthesia can be achieved with the use of 30-mL NS epidural washout, with hemodynamic stability.

Influence of Catheter–Incision Congruency in Epidural Analgesia on Postcesarean Pain Management: A Single-Blinded Randomized Controlled Trial

Patient-controlled epidural analgesia (PCEA) or epidural morphine may alleviate postcesarean pain; however, conventional lumbar epidural insertion is catheter–incision incongruent for cesarean delivery. Methods: In total, 189 women who underwent cesarean delivery were randomly divided into four groups (low thoracic PCEA, lumbar PCEA, low thoracic morphine, and lumbar morphine groups) for postcesarean pain management. Pain intensities, including static pain, dynamic pain, and uterine cramp, were measured using a 100 mm visual analog scale (VAS). The proportion of participants who experienced dynamic wound pain with a VAS score of >33 mm was evaluated as the primary outcome. Adverse effects, including lower extremity blockade, pruritus, postoperative nausea and vomiting, sedation, and time of first passage of flatulence, were evaluated. Results: The low thoracic PCEA group had the lowest proportion of participants reporting dynamic pain at 6 h after spinal anesthesia (low thoracic PCEA, 28.8%; lumbar PCEA, 69.4%; low thoracic morphine, 67.3%; lumbar morphine group, 73.9%; p < 0.001). The aforementioned group also reported the most favorable VAS scores for static, dynamic, and uterine cramp pain during the first 24 h after surgery. Adverse effect profiles were similar among the four groups, but a higher proportion of participants in the lumbar PCEA group (approximately 20% more than in the other three groups) reported prolonged postoperative lower extremity motor blockade (p = 0.005). In addition, the first passage of flatulence after surgery reported by the low thoracic PCEA group was approximately 8 h earlier than that of the two morphine groups (p < 0.001). Conclusions: Epidural congruency is essential to PCEA for postcesarean pain. Low thoracic PCEA achieves favorable analgesic effects and may promote postoperative gastrointestinal recovery without additional adverse effects.

Acute carpal tunnel syndrome: Clinical, electromyographic, and ultrasound features in 25 patients

BackgroundThe acute presentation of carpal tunnel syndrome (CTS) is rare. When symptoms start acutely with no obvious causes, ultrasound (US) imaging may provide clues to the etiology. ObjectiveThis study describes the clinical, electromyographic, and US findings in 25 patients presenting with acute CTS (ACTS). MethodsIn this analysis, of the patients referred for electrodiagnostic confirmation of CTS over the past decade, 25 had an acute onset of symptoms. All patients underwent EMG/NCV and US of the median nerve at the carpal tunnel and forearm. ResultsOf the 25 cases with ACTS, 5 (20%) had bilateral involvement leading to the total hands studied to 30. In 14 (56%) patients, an inciting event was identified as a possible cause of ACTS. In 11 (44%) patients without an antecedent event, 7 (64%) had a persistent median artery (PMA) detected by US. Electrodiagnostic studies showed prolonged distal motor latency with normal motor conduction velocity proximal to the carpal tunnel in 24 (80%) of 30 hands, 6 (20%) hands showed absent compound muscle action potentials over the abductor pollicis brevis (APB), and 22 (73%) hands had absent sensory potentials. Denervation changes were seen in the APB in 13 (43%) hands, and motor unit potentials were absent in 6 (20%) hands. Sixteen (64%) patients underwent a carpal tunnel release for severe symptoms. ConclusionCTS may present acutely without a clinically identifiable cause. US complements electrodiagnostic studies and is particularly useful when electrodiagnostic tests are non-diagnostic (due to absent compound muscle and sensory action potentials). US may also provide clues to the underlying cause.

Feasibility and Challenges of Performing Magnetoencephalography Experiments in Children With Arthrogryposis Multiplex Congenita.

Arthrogryposis multiplex congenita (AMC) has recently drawn substantial attention from researchers and clinicians. New effective surgical and physiotherapeutic methods have been developed to improve the quality of life of patients with AMC. While it is clear that all these interventions should strongly rely on the plastic reorganization of the central nervous system, almost no studies have investigated this topic. The present study demonstrates the feasibility of using magnetoencephalography (MEG) to investigate brain activity in young AMC patients. We also outlined the general challenges and limitations of electrophysiological investigations on patients with arthrogryposis. We conducted MEG recordings using a 306-channel Elekta Neuromag VectorView system during a cued motor task performance in four patients with arthrogryposis, five normally developed children, and five control adults. Following the voice command of the experimenter, each subject was asked to bring their hand toward their mouth to imitate the self-feeding process. Two patients had latissimus dorsi transferred to the biceps brachii position, one patient had a pectoralis major transferred to the biceps brachii position, and one patient had no elbow flexion restoration surgery before the MEG investigation. Three patients who had undergone autotransplantation prior to the MEG investigation demonstrated activation in the sensorimotor area contralateral to the elbow flexion movement similar to the healthy controls. One patient who was recorded before the surgery demonstrated subjectively weak distributed bilateral activation during both left and right elbow flexion. Visual inspection of MEG data suggested that neural activity associated with motor performance was less pronounced and more widely distributed across the cortical areas of patients than of healthy control subjects. In general, our results could serve as a proof of principle in terms of the application of MEG in studies on cortical activity in patients with AMC. Reported trends might be consistent with the idea that prolonged motor deficits are associated with more difficult neuronal recruitment and the spatial heterogeneity of neuronal sources, most likely reflecting compensatory neuronal mechanisms. On the practical side, MEG could be a valuable technique for investigating the neurodynamics of patients with AMC as a function of postoperative abilitation.

A Comparative Study between Intrathecal Fentanyl and Dexmedetomidine as Adjuvants to Hyperbaric Levobupivacaine 0.5% in Patients Undergoing Infra Umbilical Surgeries

Abstract Background Spinal anesthesia is a common technique for lower abdomen and lower limb surgery, but the use of local anesthetics alone may produce unwanted side effects such as prolonged motor and autonomic block, limited duration of action, besides, excessive local anesthetics can cause cardiac toxicity and central nervous system side effects. For these reasons, local anesthetics combined with other drugs, to utilize their synergistic analgesia and to reduce the dose of local anesthetics, has become a new option for anesthesiologists. Objectives This study is designed to assess and compare the effect of intrathecal Fentanyl and Dexmedetomidine as adjuvants to hyperbaric Levobupivacaine 0.5% regarding the onset, duration of sensory and motor block, duration of post operative analgesia and possible side effects in patients undergoing infra umbilical surgeries. Materials and Methods The study was performed at Ain Shams university hospitals. After obtaining ethical committee approval and informed consent from the patients. The study protocol was obtaining an informed consent; 75 patients admitted for infraumbilical surgeries in Ain Shams University hospitals operation theatre, were blindly randomized into three groups, using their medical record number (MRN) and subjected to a comparative study. A for Fentanyl group, group B for Dexmedetomidine group and group C for Levobupivacaine control group in the duration of 6 months from March to August 2019. Results The study showed that the quality of intraoperative analgesia was significantly better with dexmedetomidine than fentanyl group, and the requirement for opioids was significantly lower with dexmedetomidine than fentanyl group. The degree of motor block and postoperative analgesia was significantly denser with dexmedetomidine than fentanyl group. Conclusion From the current study we can conclude that using intrathecal 5 µg dexmedetomidine seems to be a suitable alternative to 25 µg fentanyl as adjuvants to 0.5% hyperbaric levobupivacaine in spinal anaesthesia. Its associated with prolonged motor and sensory block and provides good quality of intraoperative analgesia and extended duration of post operative analgesia as compared to fentanyl.

Prolonged distal motor latency of median nerve does not improve diagnostic accuracy for CIDP

Compression of the median nerve at the carpal tunnel can give demyelinating features and result in distal motor latency (DML) prolongation fulfilling the EFNS/PNS demyelinating criteria for chronic inflammatory demyelinating polyneuropathy (CIDP). Accordingly, being carpal tunnel syndrome (CTS) common in the general population, the EFNS/PNS guidelines recommend excluding the DML of the median nerve when DML prolongation may be consistent with median neuropathy at the wrist from CTS. The main aims of this study were to verify whether the inclusion of DML of the median nerve could improve electrophysiological diagnostic accuracy for CIDP and if the median nerve at the carpal tunnel (CT) was more prone to demyelination.

Effect of intrathecal buprenorphine on the haemodynamic response in patients undergoing laparoscopic appendicectomy under general anaesthesia

: Combined regional and general anaesthesia for laparoscopic appendicectomy offers better intraoperative haemodynamic stability. Buprenorphine is a long acting opioid which can be administered intrathecally and provides excellent analgesia intraoperatively and post operatively while allowing early ambulation without prolonged motor block. The study aimed to compare the haemodynamic response during laparoscopic appendicectomy using combined general anaesthesia with intrathecal buprenorphine and general anaesthesia alone. In this observational study 80 patients who underwent laparoscopic appendicectomy were divided into two groups of 40 each by random sampling. The patients in the GA group received general anaesthesia whereas patients in the GA+SAB group received intrathecal buprenorphine along with general anaesthesia. The heart rate, systolic and diastolic blood pressures and SpOwere noted after induction of general anaesthesia, immediately after endotracheal intubation, after creating pneumoperitonium and post extubation. Student’s t test was used for comparing the haemodynamic variables There were no statistically significant differences between GA and GA+SAB group in the heart rate, systolic and diastolic blood pressure after pneumoperitonium was created. When compared to general anaesthesia alone, addition of intrathecal burenorphine provides little advantage in preventing stress response during laparoscopic appendicectomy.

Transthyretin amyloid-related transitory events (TARTEs): Descriptive analysis of clinical, imagiological, and neurophysiological features

Transthyretin-related familial amyloid polyneuropathy (ATTR-FAP) is a multisystemic disorder inherited as an autosomal dominant trait. Transitory events in ATTR-FAP patients are a feature of this disorder and remain poorly depicted in the literature. We aimed to describe a case series of ATTR-FAP patients who presented to our department with transitory events and document the clinical, neuroimaging and neurophysiological characteristics of the events.We collected data from eight patients carrying the Val30Met ATTR-FAP variant. We registered a total of 23 events. Of the eight patients, seven had been submitted to hepatic transplant.The events were either TIA-like or seizures, often followed by prolonged language, motor or sensory impairment. In 9 (39%) of the events, the patients presented with fever, but an infection was only found in 5 (21%). Cerebrospinal fluid analysis was performed in 5 patients. EEG was abnormal in at least 1 event in 7 of the 8 patients. Brain MRI was performed in 3 patients during the acute stage and showed no acute lesions.Although the etiology of these events remains unclear, brain MRI performed in the acute phase of acute TIA-like events and the EEG abnormalities, argues in favor of regional brain dysfunction due to amyloid deposition. Focal neurological episodes should be considered in long-term duration Val30Met ATTR-FAP patients, who present with acute neurological deficits or seizures.

Comparison of Dexmedetomidine and Fentanyl as Adjuvants to Intrathecal Levobupivacaine in Lower Segment Cesarean Section

Objective: To determine the effectiveness of dexmedetomidine on the spinal anaesthesia as an adjuvant to the hyperbaric levobupivacaine in patients undergoing cesarean section. Study Design: Comparative/Observational Place &amp; Duration: The study was conducted at Anesthesiology/Obstetrics and Gynaecology departments of Mayo hospital, Lahore for duration of six months i.e from 1st November 2020 to 30th April 2021. Methods: This analysis included a total of 120 cases. After the informed consent the patients had received comprehensive demographics. Three equal classes of patients were divided into groups A, B and C. Group I had 40 patients and received 2.5 ml isobaric levobupivacane, group II with 40 patients and received 2.5 ml isobaric levobupivacaine and 5μg dexmedetomidine, and group III received 2.5 ml isobaric levobupivacaine and 25 μg fentanyl intrathecally. The outcomes of these groups were analysed in which sensory and motor blockage period were measured from the time the intrathecal drugs were administered. The full SPSS 26.0 version was used to analyze the results. Results: The mean age of the patients in group I was 27.44 ± 7.64 years with BMI 23.19±8.44, mean age in group II was 27.22 ±7.42 years with BMI 24.44 ± 6.16 and in group III mean age was 26.99 ±9.61 years with BMI 24.72 ±4.34. Duration of sensory and motor blockade was observed and resulted that it was earlier in group III as compared to group I and II. Prolonged duration of sensory and motor blockade was observed in group II as compared to groups I and III with significantly P value&lt; 0.001. Conclusion: We concluded that for an adjuvant of 0.5 percent isobaric levobupivalacaine, Intrathecal dexmedetomidine induces both prolonged motor blockage and post operative analgesia than fentanyl. Key words: Levobupivacaine; Spinal anesthesia, Fentanyl, Intrathecal analgesia, Cesarean section; Dexmedetomidine.

Effects of fadolmidine, an α2 -adrenoceptor agonist, as an adjuvant to spinal bupivacaine on antinociception and motor function in rats and dogs.

α2‐Adrenoceptor agonists such as clonidine and dexmedetomidine are used as adjuvants to local anesthetics in regional anesthesia. Fadolmidine is an α2‐adrenoceptor agonist developed especially as a spinal analgesic. The current studies investigate the effects of intrathecally administered fadolmidine with a local anesthetic, bupivacaine, on antinociception and motor block in conscious rats and dogs. The antinociceptive effects of intrathecal fadolmidine and bupivacaine alone or in combination were tested in the rat tail‐flick and the dog's skin twitch models. The durations of motor block in rats and in dogs were also assessed. In addition, the effects on sedation, mean arterial blood pressure, heart rate, respiratory rate and body temperature were evaluated in telemetrized dogs. Concentrations of fadolmidine in plasma and spinal cord were determined after intrathecal and intravenous administration in rats. Co‐administration of intrathecal fadolmidine with bupivacaine increased the magnitude and duration of the antinociceptive effects and prolonged motor block without hypotension. The interaction of the antinociceptive effect was synergistic in its nature in rats. Concentration of fadolmidine in plasma was very low after intrathecal dosing. Taken together, these studies show that fadolmidine as an adjuvant to intrathecal bupivacaine provides enhanced sensory‐motor block and enables a reduction of the doses of both drugs. The results indicate that co‐administration of fadolmidine with intrathecal bupivacaine was able to achieve an enhanced antinociceptive effect without hypotension and could thus represent a suitable combination for spinal anesthesia.

Etiology of Carpal Tunnel Syndrome in a Large Cohort of Children.

(1) Background: Carpal tunnel syndrome (CTS), a compressive mononeuropathy of the median nerve at the wrist, is rare in childhood and occurs most frequently due to secondary causes. (2) Methods: Medical history, electrodiagnostic findings, and imaging data of patients with CTS from two pediatric neuromuscular centers were analyzed retrospectively. The etiology of CTS was investigated and compared with the literature. (3) Results: We report on a cohort of 38 CTS patients (n = 22 females, n = 29 bilateral, mean age at diagnosis 9.8 years). Electrodiagnostic studies of all patients revealed slowing of the antidromic sensory or orthodromic mixed nerve conduction velocities across the carpal tunnel or lack of the sensory nerve action potential and/or prolonged distal motor latencies. Median nerve ultrasound was diagnostic for CTS and confirmed tumorous and vascular malformations. Etiology was secondary in most patients (n = 29; 76%), and mucopolysaccharidosis was the most frequent underlying condition (n = 14; 37%). Idiopathic CTS was rare in this pediatric cohort (n = 9; 24%). (4) Conclusion: Since CTS in childhood is predominantly caused by an underlying disorder, a thorough evaluation and search for a causative condition is recommended in this age group.

P-PN023. Childhood-onset demyelinating polyneuropathy: Challenges in differentiating acquired from genetic disease

Introduction . Childhood chronic inflammatory demyelinating polyneuropathy (CIDP) can be misdiagnosed for the more common genetic neuropathies such as Charcot-Marie-Tooth (CMT) disease. We present a case of childhood-onset demyelinating polyneuropathy who was initially diagnosed as CMT before a revised diagnosis of CIDP was made. Results . A 14-year-old boy with bilateral pes cavus presented with progressive history of ataxic gait, generalized areflexia and proprioceptive sensory loss. Nerve conduction studies showed demyelinating features including markedly slow motor conduction velocities and prolonged distal motor latencies resembling CMT1. Despite the absence of a family history of genetic neuropathies, a diagnosis of CMT1 was considered most likely. The patient represented two years later with an acute onset of worsening instability and muscle weakness. A detailed history revealed functional improvement following the last presentation along with two separate episodes of exacerbations suggesting a relapsing-remitting form of neuropathy. Cerebrospinal fluid analysis showed cytoalbuminergic dissociation. Nerve ultrasound demonstrated enlarged peripheral nerves, particularly in the proximal and non-entrapment sites. Genetic testing was negative for known mutations in common CMT genes. A course of intravenous immunoglobulin resulted in clinically significant improvement. Conclusion . This report highlights the diagnostic challenges in childhood-onset demyelinating neuropathies and the importance of not missing a potentially treatable immune-mediated neuropathy.

Prolonged distal motor latency of median nerve does not improve diagnostic accuracy for CIDP

Compression of the median nerve at the carpal tunnel can give demyelinating features and result in distal motor latency (DML) prolongation fulfilling the EFNS/PNS demyelinating criteria for chronic inflammatory demyelinating polyneuropathy (CIDP). Accordingly, being carpal tunnel syndrome (CTS) common in the general population, the EFNS/PNS guidelines recommend excluding the DML of the median nerve when DML prolongation may be consistent with median neuropathy at the wrist from CTS. The main aims of this study were to verify whether the inclusion of DML of the median nerve (when consistent with CTS) could improve electrophysiological diagnostic accuracy for CIDP and if the median nerve at the carpal tunnel was more prone to demyelination. We analyzed electrophysiological data from 499 patients included consecutively into the Italian CIDP Database. According to the EFNS/PNS criteria, 352 patients had a definite, 10 a probable, and 57 a possible diagnosis of CIDP, while 80 were not fulfilling the diagnostic criteria. The inclusion of DML prolongation of median nerve did not improve significantly the diagnostic accuracy for CIDP; overall diagnostic class changed in 6 out of 499 patients (1.2%) and electrodiagnostic class of CIDP changed from not fulfilling to possible in only 2 patients (2.5% of not-fulfilling patients). In conclusion, we can infer that excluding DML prolongation of median nerve does not increase the risk of missing a diagnosis of CIDP thus corroborating the current EFNS/PNS criteria.