[Guillain-Barrè syndrome and inadequate antidiuretic hormone secretion syndrome]. / Guillain-Barré-Syndrom und Syndrom der inadäquaten Adiuretinsekretion.

Several neurologic disorders including Guillain-Barré syndrome (GBS) are associated with hyponatremia. Hyponatremia and its overly fast correction have major implications to the course of the underlying neurologic disease. We report a case of GBS complicated by hyponatremia secondary to the development of inadequate antidiuretic hormone secretion syndrome. Differential diagnosis, pathophysiology, and therapeutic approach of hyponatremia in association with GBS are discussed.

[Neurogenic pain after deafferentation through trauma. Little-known pain syndrome following amputation, brachial plexus injury and nerve root avulsion]. / Neurogene Schmerzen nach Deafferenzierung durch Traumen. Wenig bekannte Schmerzsyndrome nach Amputation, Armplexusverletzung und Wurzelausriss.

Amputations may be followed by such phenomena as phantom-limb pain, and pain and involuntary movements of the stump. The sequelae of brachial plexus injuries or cervical root avulsion--the second large group of deafferentiation lesions associated with neurogenic pain--are less varied, and most of these cases involve damage to the substantia gelatinosa of the spinal cord. The two groups of deafferentiation lesions are described on the basis of our own experience and reports in the literature. A generally applicable effective form of treatment is not known, and possible therapeutic approaches, which need to be adapted individually, are discussed.

[Migraine with aura as early symptom of neurosyphilis]. / Neurosyphilis unter dem Bild einer "Migräne mit Aura"

CASE: On the basis of a case report the often difficult classification of migraine with aura and exclusion of symptomatic origin is discussed. In spring 1996 a 34-years old patient started to suffer from attacks of a migraine like headache with focal aura several times a week. While clinical examination was inconspicuous the electroencephalogram showed a general slowing of background activity with intermittent rhythmic delta-activity. NMR was normal. During treatment with flunarizine intensity and frequency of the attacks decreased, but within half a year he developed an increasing psychomotor slowing and cognitive deficit. Now cerebrospinal fluid showed a pleocytosis and highly positive treponema pallidum specific antibody index making the diagnosis of neurosyphilis reliable. Parenteral penicillin caused a delayed normalisation of mental abilities and CSF. DISCUSSION: Headache, especially with the characteristics of migraine, is one of the most frequent symptoms of neurosyphilis and--if untreated--may be followed by transient ischemic attacks or strokes even month later. To detect this kind of symptomatic headache a careful neurological follow-up examination and early CSF-analysis are essentially necessary, because pathological electroencephalograms are not rare in migraine with aura and NMR cannot exclude an inflammatory process.

[Anticonvulsive drugs in therapy of chronic pain--metaanalysis]. / Antikonvulsiva zur Therapie chronischer Schmerzen. Metaanalyse.

Anticonvulsive drugs provide good analgesic effect in the treatment of chronic neuropathic pain syndromes as well as in certain types of headache. Moreover these drugs may also be considered helpful for cases of non-neuropathic pain, especially if non-opioid analgesics are not effective. The optimal anticonvulsive drug for neuropathic pain is carbamazepine, while for headache prophylaxis valproic acid is recommended.

[The "Freiburg Migraine Study". Results of the psychological therapy.]. / Die "Freiburger Migränestudie" : Ergebnisse der psychologischen Therapie.

UNLABELLED: This study was designed to evaluate the efficacy of different strategies for migraine prophylaxis over a fairly long period. Metoprolol alone was compared with psychotherapy alone and with a combination of metoprolol and psychotherapy. The psychological programme was planned for future use in preventive treatment. In this paper only the results of the psychological therapy are described. PATIENTS AND METHODS: Criteria for inclusion of patients were: migraine without aura or with short aura for at least 2 years, and 2-10 attacks per month. In all, 63 patients (11 men and 52 women) were each randomized for participation one of the three kinds of treatment. All patients declared their willingness to participate in all three different therapies. After neurological and psychological diagnosis the baseline phase of 2 months was started, followed by the intensive therapy phase lasting 3 months. The end of the intensive therapy is followed by a first 2-month follow-up period. A second follow-up of 2 months was started 6 months after the end of intensive therapy. Psychological diagnosis involved the following elements: a migraine questionnaire, a list of patient's complaints, a depression scale and a psychological exploration. All patients kept a diary during all phases of the study with daily descriptions of their headaches, the therapy and their mood. The psychological programme lasted for 12 sessions of 2 hours each. A psychologist worked with small groups of up to 5 patients This programme was composed of progressive relaxation techniques (Jacobson) and techniques aimed at overcoming pain and stress. The data on diagnosis, the baseline phase, the intensive therapy phase and the two follow-up phases were analysed by conventional statistics (comparison of mean values,t-test, variance analysis, non-parametric tests) and by time series analysis. The parameters analysed were: frequency of attacks, mean headache intensity, duration of headache and migraine, consumption of analgesic drugs and mood. Analysis of the questionnaires and the different diagnostic data revealed no significant differences between the three different groups of therapy. RESULTS: A significant improvement in one or at least two measured parameters is shown in Table 1. The results, with 62.5% responders for one parameter in the first follow-up phase are rather positive. If two variables are required to improve significantly the results become worse. Over the different phases the results improve slightly, probably due to the effect of training. In the time series analysis the percentage of responders was calculated to show the number of responders for a particular variable (Table 3). For the different parameters the percentage of responders varied between 0 and 31.3%. CONCLUSIONS: According to the results, the efficacy of the psychological treatment increases only gradually, as it has also been demonstrated for biofeedback and relaxation training [9]. Subjectively, patients rate the results of psychotherapy higher than those demonstrated by statistics. This may depend on the selection of patients, but also on the fact that subjective criteria of improvement are not contained in statistical evaluation. Responders and non-responders had initial differences regarding vegetative, hormonal and psychological factors. Responders had a more stable circulatory status, suffered more rarely from menstrual migraine and normally took significantly fewer analgesic drugs. On the whole, this psychological programme has proved quite effective.

[Pain and functional disturbances of the lumbar spine in lumbar herniated discs.]. / Schmerzen und Funktionsstörungen der Lendenwirbelsäule bei lumbalen Bandscheibenvorfällen.

In this study we attempted to explore the correlation between lumbar disc herniation and functional disorders of the lumbar spine. Fifty patients with lumbar disc herniation proven by computed tomography underwent a comprehensive functional, neurological and radiological examination. All patients were compared to a control group consisting of 16 healthy subjects of comparable age. Only patients without signs of bone or soft tissue alterations or pregnancy at the time of examination were included into the study. Herniations of the L4-5 disc showed a dysfunction in the same segment in 64% of the cases. There was also a correlation between this segmental dysfunction and pain in the sacrotuberal and iliolumbar ligaments. All patients with segmental dysfunction felt pain in the dorsal ligaments. If there was no segmental dysfunction pain in the dorsal ligaments was encountered just as often as in the control group. Herniations of the L5-S1 disc had a dysfunction in the same segment in only 12% of the cases, but in 35% there was dysfunction of the L4-5 motion segment. In this group pain in the dorsal ligaments did not correlate with segmental movements. Frequency of ligamental pain in L4-5 herniations was equal to that in L5-S1 herniations. With increasing size of the disc herniation, the frequency of segmental dysfunction, paralysis and loss of reflexes also increased, but the pain in the dorsal ligament decreased.Segmental dysfunction is explained by increased muscular tone being provoked by irritation of the sinuvertebral nerve. The differences between L4-5 and L5-S1 movements are probably due to the different functional anatomy of these segments. Ligamental pain may be explained by the fact that these ligaments have the same insertion and the muscles have increased in tone.

[Pain and functional disturbances in the sacroiliac joint in disc herniation of the lower lumbar spine.]. / Schmerzen und Funktionsstörungen des Iliosakralgelenks bei Bandscheibenvorfällen der unteren Lendenwirbelsäule.

Back and leg pain in patients with lumbar disc herniation can be caused by various mechanisms. In addition to nerve root compression, functional alterations in the sacroiliac joint, facet joint or the iliolumbar and sacrotuberal ligaments can produce "pseudoradicular" lower back syndrome. The following study attempts to show whether or not pain and functional alterations in the sacroiliac joint (SIJ) correlate with herniations revealed by computed tomography (CT). The study also attempts to determine the correlation between pain and functional changes of the SIJ and the size and level of the disc herniation. Fifty patients with monosegmental disc herniations revealed by CT who showed no signs of bone or soft tissue alterations were included in this study. The average duration of the patients' complaints of leg or back pain was 5.7 years. Ninety-six percent of these patients had received conservative treatment before admission to our hospital. All patients were compared to a control group consisting of 16 healthy subjects of comparable age. All patients underwent a comprehensive functional, neurologic and radiologic examination. The CTs were analyzed by a standardized three-dimensional method. All of the 50 patients had sciatica complaints and a disc herniation revealed by CT. In two cases hemiation of the L3-4 disc was demonstrated, in 14 cases L4-5 disc herniation and in 34 cases a L5-S1 disc herniation. In contrast to the control group of 15 healthy subjects, the patients showed a significant number of functional disorders upon examination. In 84% of all patients, movement of the SIJ was restricted. Painful palpation of the symphysis was demonstrated in 46% of all cases. Thirty-five percent of patients with herniation of L4-5 disc demonstrated SIJ tenderness as opposed to 65% of the patients with herniation of the L5-S1 disc. This SIJ tenderness did not correlate with motion of the SIJ. In addition, SIJ motion and frequency of sensory dysfunction showed no correlation with the size of the disc herniation. Paralysis and loss of reflexes showed a positive correlation with the increasing size of the disc herniation. SIJ tenderness decreased as the size of the herniation increased. Dysfunction of the ipsilateral SIJ is explained by increased muscular tone caused by irritation of the n. sinuvertebralis and its lumbar coupling. Frequency of SIJ tenderness is significantly higher in patients with herniations between L5 and S1. Since the SIJ is innervated by the r. dorsalis of the sacral roots, the increased tenderness can be explained by the change in neurovegetative innervation of the SIJ. Due to the high correlation between lumbar disc herniation and SIJ dysfunction, disc herniation should be considered as a possible cause of sacroiliac-joint syndrome.

[Not Available]. / Medikamentöse Schmerztherapie bei rheumatischen Erkrankungen : Bericht über ein symposium bei der 16. Jahrestagung der Deutschen Gesellschaft zum Studium des Schmerzes e.V., Berlin, 24.-27. Oktober 1991.

Different therapeutic modalities are available for the treatment of rheumatic pain. The most important one, besides physiotherapy, is medication with analgesics and adjuvant drugs. Analgesics are given orally and by a stepwise approach in keeping with the principles of cancer pain therapy. In the first step nonopioid analgesics are prescribed, especially non-steroid anti-inflammatory drugs (NSAID) if pain is caused by inflammation. Other nonopioid analgesics, which can be used as alternatives for patients with non-inflammatory pain, are metamizol and paracetamol. Weak or even strong opioids must be administered to patients with rheumatic diseases when pain relief is insufficient or side-effects occur during medication with non-opioids. Long-term treatment of rheumatic pain even with strong opioids such as oral morphine involves only a small risk of severe side-effects such as respiratory depression or the development of tolerance and drug abuse. Patients often suffer from constipation, nausea and vomiting, but these side-effects can be treated with laxatives and antiemetic drugs. There is no reason to differentiate between opioid medication in a cancer patient with pain and in a patient with "non-malignant" rheumatic pain. Centrally acting muscle relaxants may be helpful as adjuvant medication in patients with myalgia for example, and tricyclic antidepressants can also be beneficial, especially in neuropathic pain and for patients with psychiatric distress associated with pain.

Evaluation of the galvanic vestibulo-ocular response recorded with a modified electronystagmographic technique.

Previously, a simple method for recording galvanic nystagmus (GN) using conventional electronystagmography (ENG) was demonstrated. The present study reports on investigations made to examine the applicability of that technique. During a standard stimulus over 20 s, amplitudes and rate of saccades show no tendency to diminish. In a series of 10 repeated standard stimuli over 16 min, a parabolic relationship is observed between time on one side and on the other, the mean amplitude, the mean rate of saccades and the sum of amplitudes per stimulus duration. The threshold of GN was 1.29 mA and that of induced tilting sensation 3.64 mA. In a series of 8 repeated threshold stimuli, thresholds of GN and tilting sensation linearly increase (p less than 0.001). During the slow increase of the current, the amplitudes and frequency of saccades and the slow-phase velocity linearly increase (p less than 0.01). The direction of per- and poststimulatory galvanic nystagmus and tilting sensation were investigated. Several autonomic reactions and psychophysical sensations during stimulation were noted. In conclusion, it is thought that the modified ENG technique is a valid method for further clinical use and basic research and its applicability has proven to be good.

A modified method of electronystagmography for recording eye movement during the galvanic vestibular test.

This study demonstrates a new technique for recording galvanic nystagmus using conventional electrooculography: a first pair of electrodes is placed at the nasal and lateral orbital margin of the left eye. An additional pair of electrodes is placed near the left angle of the mouth. This latter pair of electrodes picks up voltage variations induced by heart beat but only a minimal part of voltage variations caused by eye movements during bipolar, binaural electric stimulation. Electronic subtraction of the voltage variations near the angle of the mouth from the voltage variations at the equilateral eye cancels the cardiac interference and allows a pure recording of horizontal eye movements. 35 of 40 subjects could be examined successfully.

The vestibulo-ocular response during transient arousal shifts in man.

Horizontal vestibulo-ocular response (VOR) evoked by continuous sinusoidal rotation (0.1 Hz, +/- 90 degrees) was recorded in 20 young and healthy volunteers by DC oculography (EOG). Arousal was assessed by EEG and by reaction time measurement. While alert subject showed the characteristic VOR with vestibular nystagmus, the quick repositioning flicks disappeared during light sleep and changed to largely compensatory smooth eye deviations. This state of reduced arousal was also characterized by EEG attenuation and slow reaction times. Furthermore, we observed brief states with complete extinction of the vestibular response but without significant EEG change. The results demonstrate the high variability of VOR with shifting arousal. The polysynaptic system in the reticular formation which generates the fast phase of the nystagmus beat is far more modifiable than the three-neuronal reflex arc of the slow nystagmus component.

[Trauma-triggered migraine attacks. Review of the literature.]. / Traumatisch ausgelöste Migräneattacken (TAMA) Eine Literaturübersicht.

In children and young adults migraine attacks can be triggered by mild head injury. The literature on this syndrome was surveyed and 50 case reports found to meet the latest criteria of classification requiring at least two similar attacks for diagnosis of migraine (except for common migraine which was excluded from review). 33 subjects had at least one trauma-triggered attack and one identical or similar spontaneous attack, 17 cases at least two similar or identical trauma triggered attacks. An analysis of all cases showed the following features: The symptoms of migraine mostly start with a latency between one and thirty minutes after the injury and dissolve within one day. First attacks without mention of headache were mainly found in children younger than 8 years. Trauma-triggered migraine attacks are well documented for familial hemiplegic migraine, migraine attacks with hemispheric symptoms and attacks with disturbances of consciousness, while the view that posttraumatic transient cortical blindness and transient global amnesia are migraine attacks is insufficiently supported. A hereditary predisposition for a traumatic trigger mechanism seems to be present at least in familial hemiplegic migraine. Nosologic relations to syndromes of secondary neurological deterioration after mild head injury in childhood are discussed.

[Limitations of and new options with neurophysiological methods in migraine research and diagnosis : Electroencephalographicmethods.]. / Grenzen und Möglichkeiten neurophysiologischer Methoden in der Erforschung und Diagnostik der Migräne : Elektroenzephalographische Methoden.

In parallel with the development of the various electrophysiological methods now available, the clinical syndrome of migraine has been repeatedly analyzed with the aid of these tools, in attempts to track its course with reference to electrophysiological parameters. A survey of the international literature reveals the following EEG findings. (1) In patients with different forms of headache without structural lesions the distribution of normal and abnormal EEG recordings during headachefree intervals resembles that seen among healthy subjects. (2) In common migraine, nonfocal and nonspecific abnormalities are reflected in up to 65% of all EEG recordings during the migraine-free interval. (3) Focal EEG abnormalities during a migraine attack are relatively rare, generally occurring only during migraines with transient focal neurological disturbances. (4) It is very rare for there to be permanent focal changes that are apparent during both pain-free intervals and migraine attacks. In the presence of such changes very careful diagnosis is necessary to exclude symptomatic lesions. (5) In up to 53% of migraineurs a few minutes' hyperventilation leads to generalized slow, wide-amplitude, sometimes episodic waves in the EEG. Similar changes also occur in healthy subjects, but are less common, less intense and of shorter duration. (6) There is a statistically significant correlation between the occurrence of a migraine and EEG activation by photic stimulation at frequencies over 20 Hz. (7) No unequivocal results obtained in large series of patients with train mapping are yet available.

Tonic cervical stimulation: does it influence eye position and eye movements in man?

In healthy subjects eye movements were analysed during body rotation, during trunk torsion either with the head passively held stationary in space or with the head voluntarily stabilized in space, and during voluntary head movements. Trapezoidal movements around the vertical axis were performed (+/- 40 degrees, plateau 10 s, duration of ramp 1 or 4 s). Moreover the influence of a tonic head deviation up to 40 degrees on optokinetic nystagmus and on vestibulo-ocular reflex during sinusoidal turning was examined. Eye movements were recorded by DC-electrooculography. Saccadic and slow components of eye movements and the shift of eye position during the plateau of the trapezoidal stimulus were analysed. For all modes of stimulation during the plateau no nystagmus occurred. At the end of the dynamic phase of the stimulus relatively frequent eye deviations--mostly in the direction of the head deviation--were observed, not only after turning the trunk with the head stabilized in space (cervical stimulation) but also after turning head and trunk together. The fact that such eye deviations are thus observed even in the absence of any tonic, especially cervical stimulus, supports the assumption that they cannot be attributed to a tonic stimulus but merely to an effect of the preceding phasic stimulus which outlasts them. Also amplitude and direction of eye shifts during the plateau do not depend on a tonic stimulus, but merely on the eye deviation reached at the end of the dynamic phase of stimulation. Optokinetic nystagmus and vestibulo-ocular reflex are not influenced by an additional tonic cervical stimulus.

[CT follow-up studies of conservatively treated lumbar intervertebral disk herniation]. / CT-Verlaufsuntersuchungen bei konservativ behandelten lumbalen Bandscheibenvorfällen.

A CT study was carried out on 43 patients with low back pain and sciatica who were treated conservatively. They were followed up for over 20 months (mean) clinically and monitored by CT before and after treatment. Initially, 38 of them had herniation and 5 had protrusion of the disc. At the time of follow-up only 24 of the initial 40 patients still had neurological deficits. In 76.7% of the patients CT showed an improvement (clear regression in 15 patients, moderate decrease in 18 patients). A favourable tendency towards regression was observed in disc herniation at the L5-S1 level and in cases showing sequestration. The prognosis was unfavourable in herniations at higher levels than L5-S1 and in lateral herniation reaching the intervertebral foramen.