Comparison of second lumbrical interosseous median and ulnar motor conduction study in population of subjects with idiopathic carpal tunnel syndrome and non-CTS hands-a cross-sectional study

Background: Second lumbrical interosseous (2L-I) median-ulnar motor conduction study across wrist is pivotal in electrodiagnosis of carpal tunnel syndrome (CTS) in different grades of severity. 2L-I Median versus ulnar distal motor latency (DML) difference more than 0.5 milliseconds is used to diagnose median neuropathy at wrist. Other variables of study, namely, 2L DML, compound muscle action potential (CMAP) amplitude, CMAP duration, and conduction velocity (CV) remain less explored with few studies pressing for its role to substantiate CTS diagnosis. Aims and Objectives: Current cross-sectional study aimed to explore role of 2L-I DML, amplitude, duration, and CV in diagnosis of median neuropathy at wrist. Materials and Methods: Total 70, 37 clinically suspected CTS hands and 33 age, height, and weight matched non-CTS hands underwent 2L-I Median Ulnar motor conduction study. Results: Statistically significant difference (P < 0.05) in 2L median DML, CMAP amplitude, duration and CV between CTS and non-CTS hands along with 2L-I Median versus Ulnar DML difference. 2L DML and 2L-I DML difference variables showed better specificity and sensitivity: 83.78 and 93.91, respectively, in diagnosing CTS. Conclusion: We concluded that apart from 2L-I DML difference other variables such as DML, amplitude, duration, and CV may also play substantial role in evaluation of CTS and may be included as part of electrodiagnostic protocol.

Neuropathic pain in peroneal nerve entrapment at the fibular head / Dor neuropática no aprisionamento do nervo fibular na cabeça da fíbula

Abstract Background Peroneal neuropathy at the fibular head (PNFH) is a mononeuropathy that typically presents with drop foot and sensory abnormalities over the skin area innervated by the peroneal nerve. Objective The aim of the present study was to evaluate neuropathic pain in patients with PNFH. Methods Patients with clinical and electrodiagnostic features consistent with PNFH associated with weight loss, leg postures, or prolonged sleep were included in the present retrospective cohort study. Nerve conduction studies were performed in the bilateral lower extremities of all patients. The Leeds assessment of neuropathic symptoms and signs scale (LANSS) was applied to all patients. Results Thirty-two PNFH patients (78% males) were included in the study. The LANSS score in the majority of patients was lower than 12. There was 1 patient with a LANSS score of 12. The electrodiagnostic features of 16 patients were compatible with axonal degeneration. The mean LANSS scores of PNFH patients with and without axonal degeneration were 4.3 ± 3.7 and 5.2 ± 2.9, respectively (p = 0.255). Conclusion The present study showed that neuropathic pain is a rare symptom in patients with PNFH associated with weight loss, leg postures, or prolonged sleep.

Resumo Antecedentes A neuropatia fibular na cabeça da fíbula (PNFH) é uma mononeuropatia que normalmente se apresenta com pé caído e anormalidades sensoriais sobre a área da pele inervada pelo nervo fibular. Objetivo O objetivo do presente estudo foi avaliar a dor neuropática em pacientes com PNFH. Métodos Pacientes com características clínicas e eletrodiagnósticas consistentes com PNFH associada a perda de peso, postura das pernas ou sono prolongado foram incluídos neste estudo de coorte retrospectivo. Estudos de condução nervosa foram realizados nas extremidades inferiores bilaterais de todos os pacientes. A escala de avaliação de sintomas e sinais neuropáticos de Leeds (LANSS) foi aplicada a todos os pacientes. Resultados Trinta e dois pacientes com PNFH (78%) foram incluídos no estudo. A pontuação LANSS em outros pacientes foi menor que 12. Houve 1 paciente com pontuação LANSS de 12. As características eletrodiagnósticas de 16 pacientes foram compatíveis com degeneração axonal. Os escores médios do LANSS de pacientes com PNFH com e sem degeneração axonal foram 4,3 ± 3,7 e 5,2 ± 2,9, respectivamente (p = 0,255). Conclusão O presente estudo mostrou que a dor neuropática é um sintoma raro em pacientes com PNFH associada à perda de peso, postura das pernas ou sono prolongado.

Projection of fatigue and neuromuscular changes caused by different excises / Projeção da fadiga e as alterações neuromusculares provocadas em distintas atividades físicas / Proyección de la fatiga y los cambios neuromusculares provocados en diferentes actividades físicas

ABSTRACT Introduction: Athletes' muscles can be weakened by fatigue caused by excessive activity. This limitation compromises their functional capacity and professional performance. The competition's performance correlates positively with muscular quality of function. The changes analysis caused by different athletic activities in muscle contraction by noninvasive tensiomyography reflects the functional state of the muscles. Still, no experiments are adapted to verify the fatigue risk level. Objective: Verify the possible relationship between exercise and neuromuscular fatigue using noninvasive tensiomyography. Methods: 90 athletes were randomly selected in weightlifting, badminton, and athletics sports. Maximum radial displacement, contraction, delay, duration, and relaxation time indices were collected. Muscle fatigue detection was based on the empirical mode decomposition modeling method with the Rogers sensitivity fluctuation rate. All values were collected in the rectus femoris muscle before and after the exercises. They were statistically treated and compared (P<0.05). Results: All athletes showed a decline in maximum radial displacement values after exercise. It reveals that their muscles are in a considerable state of tension, especially in the track and field group (from 8.57±3.42mm to 5.43±2.14mm). However, the slightest change in delay time was observed in the weightlifting group (16.21±4.15ms initial versus 18.34±3.27ms final). Conclusion: Through tensiomyography technology, it is possible to obtain a relationship between exercise and neuromuscular fatigue, analyzing the physical activity effects in a noninvasive way. Evidence Level II; Therapeutic Studies - Investigating the result.

RESUMO Introdução: A musculatura do atleta pode ser debilitada com a fadiga ocasionada pelo excesso de atividade. Essa limitação compromete sua capacidade funcional e desempenho profissional. O desempenho nas competições correlaciona-se positivamente com a qualidade da função muscular. A análise das alterações provocadas por distintas atividades atléticas na contração muscular pela tensiomiografia não invasiva reflete o estado funcional dos músculos, porém não há experimentos adaptados para verificar o grau de risco de fadiga. Objetivo: Verificar a possível relação entre exercício e fadiga neuromuscular utilizando tensiomiografia não invasiva. Métodos: 90 atletas foram selecionados aleatoriamente nos esportes de halterofilismo, badminton e atletismo. Foram coletados os índices de deslocamento radial máximo, tempo de contração, tempo de atraso, duração e tempo de relaxamento. A detecção de fadiga muscular foi baseada no método de modelagem da decomposição do modo empírico com o conceito de taxa de flutuação de sensibilidade de Rogers. Os valores dos três grupos foram coletados no músculo reto femoral antes e depois dos exercícios. Foram tratados estatisticamente e comparados(P<0,05). Resultados: Todos os grupos de atletas apresentaram um declínio nos valores de deslocamento radial máximo após o exercício. Isso revela que seus músculos estão em grande estado de tensão, especialmente no grupo de atletismo (de 8.57±3.42mm para 5.43±2.14mm). A menor alteração no tempo de atraso, porém, foi observada no grupo de halterofilismo (16.21±4.15ms iniciais contra 18.34±3.27ms finais). Conclusão: Através da tecnologia de tensiomiografia foi possível obter a relação entre exercício e fadiga neuromuscular analisando os efeitos da atividade física de forma não invasiva. Nível de evidência II; Estudos Terapêuticos - Investigação de Resultados.

RESUMEN Introducción: La musculatura del deportista puede estar debilitada por la fatiga causada por una actividad excesiva. Esta limitación compromete su capacidad funcional y su rendimiento profesional. El rendimiento en las competiciones se correlaciona positivamente con la calidad de la función muscular. El análisis de los cambios provocados por las diferentes actividades deportivas en la contracción muscular mediante la tensiomiografía no invasiva refleja el estado funcional de los músculos, pero no existen experimentos adaptados para verificar el grado de riesgo de fatiga. Objetivo: Verificar la posible relación entre el ejercicio y la fatiga neuromuscular mediante una tensiomografía no invasiva. Métodos: Se seleccionaron al azar 90 atletas de los deportes de halterofilia, bádminton y atletismo. Se recogieron los índices de desplazamiento radial máximo, tiempo de contracción, tiempo de retardo, duración y tiempo de relajación. La detección de la fatiga muscular se basó en el método de modelado de descomposición modal empírica con el concepto de tasa de fluctuación de la sensibilidad propuesto por Rogers. Se recogieron los valores de los tres grupos en el músculo recto femoral antes y después de los ejercicios. Se trataron y compararon estadísticamente (P<0,05). Resultados: Todos los grupos de atletas mostraron un descenso en los valores del desplazamiento radial máximo después del ejercicio. Esto revela que sus músculos están en un gran estado de tensión, especialmente en el grupo de atletismo (de 8,57±3,42mm a 5,43±2,14mm). Sin embargo, el menor cambio en el tiempo de retraso se observó en el grupo de levantamiento de pesas (16,21±4,15ms iniciales frente a 18,34±3,27ms finales). Conclusión: A través de la tecnología de la tensiomografía fue posible obtener la relación entre el ejercicio y la fatiga neuromuscular analizando los efectos de la actividad física de forma no invasiva. Nivel de evidencia II; Estudios terapéuticos - Investigación de resultados.

Valores de referencia de estudios de electromiografía de los músculos masetero y temporal

los músculos masetero y temporal tienen mucha relevancia en el proceso de masticación; además, suelen verse afectados con enfermedades mioarticulares, neurológicas, entre otras. El objetivo de este estudio es presentar los resultados de electromiografía con electrodo de aguja de los músculos masetero y temporal al momento de la masticación, evaluando los parámetros en amplitud y duración de los potenciales obtenidos. Se tomaron veintiséis individuos con previa valoración de odontología que descartaba alteraciones congénitas, defectos de la masticación y con dinamometría normal en momento de mayor oclusión, a los cuales se les realizó electromiografía de aguja en los músculos masetero y temporal en la máxima oclusión; los resultados fueron analizados bajo el estudio de los valores de amplitud máxima y mínima, así como duración ubicando en percentiles y cuadriles, buscando determinar valores que puedan considerarse normales en esta muestra. Al estudiar el músculo temporal se encontró que la duración normal se encuentra entre 4,75 y 6,487 mseg, mientras que la amplitud se encontraría entre 1572,05 uV y 1038,03 uV; en el caso del músculo masetero, se evidenció que la duración normal se encuentra entre 4,03 y 6,767 mseg, mientras que la amplitud se encontraría entre 2838,43 uV y 1864,635 uV. Este estudio da a conocer valores propios para nuestra población en lo que respecta a duración y amplitud de los potenciales de acción de unidad motora de los músculos temporal y masetero, los cuales concuerdan con los establecidos previamente como normales. En estudios previos realizados en otras partes del mundo, se encontró que la duración es menor que en las extremidades, pero la amplitud es similar, aunque con tendencia a valores inferiores al promedio.

The masseter and temporalis muscles are very relevant in the process of mastication. mastication process; they are also often affected by myoarticular and neurological diseases, among others. This study aims to present the results of electromyography with needle electrodes of the masseter and temporalis muscles at the time of mastication, evaluating the parameters in amplitude and duration of the potentials obtained. Twenty-six individuals were taken with a previous dental evaluation that ruled out congenital alterations, masticatory defects, and with normal dynamometry at the moment of maximum occlusion, to whom needle electromyography was performed in the masseter and temporalis muscles at maximum occlusion; the results were analyzed under the study of the maximum and minimum amplitude values, as well as duration located in percentiles and quadrilles, seeking to determine values that could be considered normal in this sample. When studying the temporal muscle, it was found that the normal duration is between 4.75 and 6.487 msec, while the amplitude would be between 1572.05 uV and 1038.03 uV; in the case of the masseter muscle, it was evidenced that the normal duration is between 4.03 and 6.767 msec, while the amplitude would be between 2838.43 uV and 1864.635 uV. This study reveals values specific to our population in terms of duration and amplitude of the motor unit action potentials of the temporalis and masseter muscles, which agree with those previously established as normal. In previous studies performed in other parts of the world, it was found that the duration is shorter than in the extremities. Still, the amplitude is similar, although with a tendency to lower valuesthan the average.

os músculos masseter e temporal são muito importantes no processo de mastigação. Além disso, eles são frequentemente afetados por doenças mioarticulares, neurológicas e outras. O objetivo deste estudo é apresentar os resultados da eletromiografia com eletrodos de agulha dos músculos masseter e temporal no momento da mastigação, avaliando os parâmetros de amplitude e duração dos potenciais obtidos. Foram tomados 26 indivíduos com avaliação odontológica previa que descartou alterações congênitas, defeitos de mastigação e com dinamometria normal quando da oclusão máxima, nos quais foi realizada a eletromiografia de agulha dos músculos masseter e temporal em oclusão máxima; os resultados foram analisados sob o estudo dos valores máximos e mínimos de amplitude, bem como de duração, colocando-os em percentis e quartis, buscando determinar valores que pudessem ser considerados normais nessa amostra. Ao estudar o músculo temporal, verificou-se que a duração normal está entre 4,75 e 6,487 mseg, enquanto a amplitude estaria entre 1572,05 uV e 1038,03 uV; no caso do músculo masseter, verificou-se que a duração normal está entre 4,03 e 6,767 mseg, enquanto a amplitude estaria entre 2838,43 uV e 1864,635 uV. Este estudo revela valores próprios para nossa população em termos de duração e amplitude dos potenciais de ação da unidade motora dos músculos temporal e masseter, que estão de acordo comos valores previamente estabelecidos como normais. Em estudos anteriores realizados em otros lugares, verificou-se que a duração é mais curta do que nas extremidades, mas a amplitude é semelhante, embora com uma tendência a valores mais baixos do que a média.

Determining the utility of minimum F-wave latency alterations in the electrodiagnosis of ulnar neuropathy at the elbow / Determinação da utilidade das alterações mínimas da latência da onda F no eletrodiagnóstico da neuropatia ulnar do cotovelo

ABSTRACT Background: Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy. There is little information about the application of F-wave studies for evaluation of UNE. Objective: The aim of this study was to evaluate the diagnostic value of minimum F-wave (F-min) latency alterations by comparing this with nerve conduction analyses in UNE-suspected patients. Methods: Ninety-four UNE-suspected patients were admitted to this study. Sensory and motor nerve conduction and F-wave analyses on the median and ulnar nerves were performed on both upper extremities. Results: A total of 188 upper extremities of 94 patients were examined. Their mean age was 41.4±12.9 years, and 69 patients were female (73.4%). The mean ulnar-nerve across-elbow motor conduction velocity (MCV) in the affected arms was significantly slower than the velocity in healthy arms. The mean ulnar-nerve F-min latencies were significantly longer in the affected arms. Fifty-one patients were electrophysiologically diagnosed as presenting UNE (54.2%). Significantly slower mean ulnar-nerve across-elbow MCV, longer mean ulnar-nerve F-min latency and longer distal onset latency were detected in UNE-positive arms. Lastly, patients who were symptomatic but had normal nerve conduction were evaluated separately. Only the mean ulnar F-min latency was significantly longer in this group, compared with the healthy arms. Conclusion: Our study confirmed the utility of F-min latency measurements in the electrodiagnosis of UNE. F-wave latency differences can help in making an early diagnosis to provide better treatment options.

RESUMO Introdução: A neuropatia ulnar do cotovelo (NUC) é a segunda neuropatia por encarceramento mais comum. Existem poucas informações sobre a aplicação dos estudos da onda F para avaliação da NUC. Objetivo: O objetivo deste estudo foi avaliar o valor diagnóstico das alterações mínimas de latência da onda F (F-min), comparando-as com análises de condução nervosa em pacientes com suspeita de NUC. Métodos: Noventa e quatro pacientes com suspeita de NUC foram admitidos neste estudo. A condução nervosa sensitiva e motora e as análises da onda F nos nervos mediano e ulnar foram realizadas em ambas as extremidades superiores. Resultados: Um total de 188 membros superiores de 94 pacientes foi examinado. A média de idade foi 41,4±12,9 anos e 69 pacientes eram do sexo feminino (73,4%). A velocidade de condução motora média do nervo ulnar através do cotovelo (VCM) nos braços afetados foi significativamente mais lenta do que a velocidade em braços saudáveis. As latências médias F-min do nervo ulnar foram significativamente mais longas nos braços afetados. Cinquenta e um pacientes foram diagnosticados eletrofisiologicamente como apresentando NUC (54,2%). Pacientes com presença de NUC tiveram, de forma significativa, detecção de VCM mais lenta no nervo ulnar ao nível do cotovelo, presença de latência mais longa da onda F-mínima no nervo ulnar, bem como latência de início distal mais longa. Por fim, os pacientes sintomáticos, e com condução nervosa normal, foram avaliados separadamente. Apenas a latência da onda F mínima média do nervo ulnar foi significativamente maior neste grupo, em comparação com os braços saudáveis. Conclusão: Nosso estudo confirmou a utilidade das medidas de latência da onda F-mínima no eletrodiagnóstico da NUC. As diferenças de latência da onda F podem ajudar a fazer um diagnóstico precoce para fornecer melhores opções de tratamento.

Eletrogastrografia multicanal transcutânea: parâmetros normais em uma população brasileira / Transcutaneous multichannel electrogastrography: normal parameters in a brazilian population

ABSTRACT BACKGROUND: Electrogastrography (EGG) is a noninvasive technique for the assessment of gastric myoelectrical activity using electrodes placed on the abdominal surface. Changes in gastric myoelectrical activity may be associated with diseases such as gastroparesis, functional dyspepsia, nausea, and recurrent vomiting. In Brazil, no studies to date have assessed gastric myoelectrical activity using multichannel EGG in healthy individuals. OBJECTIVE: To establish normal values of transcutaneous multichannel EGG in healthy Brazilian individuals. METHODS: This was a prospective study including 20 healthy individuals who underwent EGG. Recording was performed during two periods: a preprandial recording was performed for 30 minutes, and a postprandial recording was performed for 30 minutes after a soft-solid meal of 400 kcal (20 grams of proteins, 60 grams of carbohydrates, and 9 grams of fat). RESULTS: We assessed dominant frequency (DF) parameters, %DF distribution, the instability coefficient, and the power ratio (PR). A total of 20 individuals (11 women and 9 men) with a mean age of 39.5±7.4 years were included. Mean DF (95%CI) ranged from 2.4 to 3.1 cpm in the resting phase and 2.6 to 3.2 cpm in the postprandial period. The %DF in normogastria range was >70% in all healthy individuals. We identified that only one individual did not present a positive response to the test meal, and the other 19 individuals showed a PR greater than 1. The instability coefficient did not change significantly with meal intake. CONCLUSION: Multichannel EGG may be applied in future studies to evaluate gastric motility disorders in the Brazilian population.

RESUMO CONTEXTO: Eletrogastrografia (EGG) é técnica não invasiva que avalia a atividade miolétrica gástrica utilizando eletrodos localizados na superfície abdominal. Alterações na atividade miolétrica gástrica podem estar associadas a distúrbios como gastroparesia, dispepsia funcional, náuseas e vômitos recorrentes. No Brasil, não há estudos até o momento que tenham avaliado a atividade miolétrica gástrica pela EGG multicanal transcutânea em indivíduos saudáveis. OBJETIVO: Estabelecer valores de normalidade da EGG multicanal transcutânea em indivíduos brasileiros saudáveis. MÉTODOS: Este foi um estudo prospectivo, incluindo 20 indivíduos saudáveis submetidos a EGG. O registro foi realizado em dois períodos: um período pré-prandial foi registrado por 30 minutos, e um período pós-prandial por 30 minutos após a ingesta de uma dieta de prova com consistência sólida e pastosa de 400 kcal (20 gramas de proteínas, 60 gramas de carboidratos e 9 gramas de gordura). RESULTADOS: Foram avaliados os parâmetros de frequência dominante (FD), distribuição da % de FD, coeficiente de instabilidade e "power ratio" (PR). Foram incluídos 20 indivíduos (11 mulheres e 9 homens) com idade média de 39,5 +/- 7,4 anos. A FD média (95%CI) variou de 2,4 a 3,1 cpm no período de basal (pré-prandial) e de 2,6 a 3,2 cpm no período pós-prandial. A % da FD na faixa de normogastria foi >70% em todos os indivíduos saudáveis. Identificamos que apenas um indivíduo não apresentou resposta positiva a refeição de prova, e os outros 19 indivíduos apresentaram PR>1. O coeficiente de instabilidade não mudou significativamente com a ingesta da refeição de prova. CONCLUSÃO: A EGG multicanal transcutânea pode ser aplicada em estudos futuros para a avaliar distúrbios da motilidade gástrica na população brasileira.

Resultado clínico y electrodiagnóstico en pacientes con liberación quirúrgica del síndrome del túnel del carpo / Clinical and electrodiagnosis outcome in patients with carpal tunnel release surgery

Resumen Introducción. La cirugía de síndrome del túnel del carpo (STC) es efectiva, aunque algunos reportes muestran satisfacción de solo el 75% luego de los procedimientos. La escala funcional histórico-objetiva (HiOb) es la que mejor se correlaciona con el estado neurofisiológico del nervio mediano. Objetivo. Determinar los resultados clínicos, funcionales y electrofisiológicos luego de una liberación quirúrgica en pacientes con STC. Materiales y métodos. Estudio analítico y descriptivo de pacientes con STC operados entre 2013 y 2014. Todos los individuos tenían pruebas clínicas y electrofisiológicas pre y post quirúrgicas. Resultados. Se estudiaron 36 pacientes con edad promedio de 49 años; los signos clínicos prequirúrgicos más frecuentes fueron Phalen y elevación de manos (91%). El seguimiento mínimo fue 6 meses. Hubo mejoría del dolor; de los signos de Tinel, de Phalen y de elevación de manos; en la escala HiOb, y en el Cuestionario de Boston, tanto en la función como en los síntomas. Los resultados electrofisiológicos mostraron mejoría en latencia distal motora del nervio mediano, latencia distal sensitiva del nervio mediano y delta sensitivo. Conclusiones. La liberación quirúrgica del STC es un procedimiento eficaz en la mejoría del dolor, los síntomas, las escalas funcionales y los hallazgos electrofisiológicos. El signo de Tinel prequirúrgico se asocia a peores resultados en el cuestionario de Boston.

Abstract Introduction: Carpal tunnel release surgery is effective, although some reports show a satisfaction level of only 75% after surgery. The functional historical-objective scale (HiOb) is the one that best correlates with the neurophysiological state of the median nerve. Objective: To determine clinical, functional and electrophysiological outcomes following surgical release in patients with carpal tunnel syndrome. Materials and methods: Analytical and descriptive study of patients with carpal tunnel syndrome who underwent surgery between 2013 and 2014. All individuals underwent pre- and postoperative clinical and electrophysiological testing. Results: 36 patients with an average age of 49 years were studied; the most frequent preoperative clinical signs were Phalen's test and hand elevation (91%). The minimum follow-up time was 6 months. There was improvement in pain; in the signs of Tinel's, Phalen's and hand elevation; in the HiOb scale, and in the Boston Questionnaire, both in terms of function and symptoms. Electrophysiological results showed improvement in distal motor latency of the median nerve, distal sensory latency of the median nerve, and delta sensory latency. Conclusions: Carpal tunnel release surgery is an effective procedure to improve pain, symptoms, functional scales and electrophysiological findings. Tinel's preoperative sign is associated with worse outcomes in the Boston questionnaire.

Diaphragm quantitative electromyography in difficult-to-treat asthmatic patients / Eletromiografia quantitativa do diafragma em pacientes com asma de difícil controle

ABSTRACT Quantitative electromyography is an important tool to evaluate myopathies, and some difficult-to-treat asthmatic patients may have a subclinical corticosteroid myopathic process, using only inhaled corticosteroid, according to some studies. In this report, diaphragm quantitative electromyography was used to evaluate asthmatic difficult-to-treat patients, comparing them with a control group. Significant differences were obtained in amplitude, duration and size index of motor unit action potentials, with lower parameters in the asthmatic patients, which may indicate a myopathic process.

RESUMO Eletromiografia quantitativa é uma ferramenta importante para a avaliação de miopatias, e alguns pacientes asmáticos de difícil controle podem ter um processo miopático subclínico, mesmo usando apenas corticosteroides inalatórios, de acordo com alguns artigos. Nesse artigo a eletromiografia quantitativa do diafragma foi usada para avaliar os pacientes asmáticos de difícil controle, comparando com um grupo controle. Diferenças significativas nas amplitudes, durações e índices de tamanho dos potenciais de unidades motoras foram encontradas, com parâmetros mais baixos nos pacientes asmáticos, o que pode indicar um processo miopático.

Síndrome de Guillain-Barré simulando muerte cerebral: una presentación inusual / Guillain Barré syndrome simulating brain death: an unusual presentation

RESUMEN El síndrome de Guillain-Barré continúa siendo la causa más importante de parálisis flácida aguda y subaguda en el mundo, con avances notorios en cuanto a diagnóstico, fisiopatología y manejo. Hay variantes típicamente descritas en esta condición clínica; sin embargo, desde hace algunos años se tienen reportes en escenarios clí nicos que se tornan un reto diagnóstico y de particular interés cuando imitan condiciones tan graves desde el punto de vista pronóstico como cuadros de muerte cerebral. Presentamos el caso de un varón de 53 años con un cuadro rápidamente progresivo de síntomas generales, debilidad muscular y progresión temprana a falla ventilatoria que desarrolla signos de compromiso de tallo cerebral y criterios de muerte cerebral y en quien los estudios de electrodiagnóstico permitieron llegar a la conclusión del curso de un síndrome de Guillain Barré imitando una muerte cerebral.

SUMMARY Guillain-Barré syndrome continues to be the most important cause of acute and subacute flaccid paralysis in the world, with notable advances in terms of diagnosis, pathophysiology and management. There are variants typically described in this clinical condition, however, for some years there have been reports in clinical scenarios that become a diagnostic challenge and of particular interest when it imitates such serious conditions from the prognostic point of view as brain death. We present the case of a 53-year-old man with a rapidly progressive picture of general symptoms, muscle weakness and early progression to ventilatory failure who develops signs of brain-length compromise and brain death criteria in whom electrodiagnostic studies allowed to reach the conclusion of the course of a syndrome of Guillain Barré imitating a brain death.

Aplicação da técnica de eletrodiagnóstico em pacientes críticos: uma revisão sistemática / Application of electrodiagnostic technique in critically ill patients: a systematic review

O ambiente de terapia intensiva está evoluindo em tecnologias para avaliação e tratamento sendo uma das técnicas mais atuais aplicadas neste ambiente o eletrodiagnóstico. Esta é uma revisão sistemática desenvolvida com base nos resultados de pesquisa das principais bases de dados, seguindo o PRISMA. Neste foram incluídos somente artigos observacionais que utilizaram a técnica de eletrodiagnóstico em pacientes críticos, para os mais diferentes objetivos e desfechos. As bases de dados consultadas foram: MEDLINE (acessado via PubMed), Fisioterapia Evidence banco de dados (Pedro), Registro de Ensaios Controlados (CENTRAL Cochrane) e EMBASE além de uma busca manual de referências adicionais. Um total de 10 artigos foram encontrados, sendo que dois apresentaram-se repetidos e outros seis foram excluídos por não contemplarem os critérios de inclusão obtendo-se ao final um total de dois artigos totalizando 33 pacientes. Um dos artigos apresentou resultados seguros, sem lesão muscular e o protocolo foi viável para ser aplicado em terapia intensiva. O outro artigo que após lesão cerebral traumática os pacientes podem apresentar distúrbios eletrofisiológicos, além de atrofia muscular generalizada sendo evidenciados pela técnica de eletrodiagnóstico. (AU)

The intensive care environment is evolving in technologies for evaluation and treatment, and these include a recent technique named electrodiagnosis. This systematic review was based on search results from major databases, following PRISMA guidelines. Only observational studies using the electrodiagnostic technique in critically patients for different objectives and outcomes were included. The following databases were searched: MEDLINE (accessed via PubMed), Physiotherapy Evidence database (Pedro), Controlled Trials Registry (CENTRAL Cochrane) and EMBASE, in addition to a manual search for additional references. Ten articles were found, two of which were repeated and six were excluded because they did not meet the inclusion criteria; thus, two articles were selected, with a total of 33 patients. One of the articles showed safe results, without any muscle injury, and the protocol was applicable in intensive care. The other article demonstrated that, after traumatic brain injury, patients may present with electrophysiological disorders and generalized muscle atrophy, which can be revealed by the electrodiagnostic technique. (AU)

Peripheral Neuropathies in Patients with Rhabdomyolysis: Clinical Characteristics and Electrodiagnostic Findings in the Acute/Subacute Stage

BACKGROUND: Rhabdomyolysis is a syndrome caused by injury to skeletal muscle and characterized by myalgia and swelling of the affected muscles. Peripheral nerve injury rarely occurs in patients with rhabdomyolysis. METHODS: We reviewed the medical records of 8 consecutive patients with peripheral neuropathies associated with rhabdomyolysis. We assessed the clinical characteristics and electrodiagnostic findings of eight patients. RESULTS: In seven patients, rhabdomyolysis occurred after prolonged immobilization. In one patient, blunt trauma was a cause of rhabdomyolysis. All patients presented with weakness and paresthesia in lower extremities and electrodiagnostic tests showed peripheral nerve injury suggesting sciatic neuropathy or lumbosacral plexopathy. Although rhabdomyolysis itself recovered completely in all patients, neurologic deficits from neuropathy recovered partially and slowly. CONCLUSIONS: Sciatic nerve or lumbosacral plexus was injured in all eight patients. Among the various causes of rhabdomyolysis, prolonged immobilization is associated with development of peripheral neuropathy.

Diagnostic Usefulness of Digital Infrared Thermal Image in Carpal Tunnel Syndrome

OBJECTIVE: The purpose of this study is to evaluate the usefulness of infrared thermography in patients with carpal tunnel syndrome by comparing with electrodiagnostic and ultrasonographic findings.METHOD: From January 2014 to October 2017, electrodiagnosis, ultrasound, and digital infrared thermal image (DITI) of unilateral carpal tunnel syndrome diagnosed in a single hospital were retrospectively analyzed. The subjects with bilateral symptoms of carpal tunnel syndrome, peripheral vascular disease, diabetes, thyroid disease, fibromyalgia, rheumatic disease, systemic infection, inflammation, malignant tumor, and other musculoskeletal disorders such as finger osteoarthritis, peripheral neuropathy, cervical radiculopathy, and the previous history of surgery were excluded.RESULTS: Of 53 patients diagnosed with carpal tunnel syndrome, 11 were male and 42 were female. The visual analogue scale was 4.9 ± 1.9, and the duration of symptom was 11.8 ± 12.5 months. There was no statistically significant difference in the body surface temperature between the unaffected and affected sides. The severity of symptoms, electrodiagnostic findings, and cross-sectional area of the median nerve significantly correlates to each other. The temperature difference between the second fingers of the affected and unaffected sides showed a weak correlation with the amplitude of sensory nerve action potential and onset latency of compound muscle action potential, when there was no significant correlation with the other parameters.CONCLUSION: The difference in temperature on the surface of the body, which can be confirmed by DITI, is little diagnostic value when DITI is performed in unilateral carpal tunnel syndrome patients, especially when compared with ultrasonography.

Brachial Plexus Injury after Deep Sleep

Lying on the side while falling asleep deeply after drinking or taking a sleeping pill can cause compressive neuropathy. We report a 70-year-old male patient of medial cord of left brachial plexus injury (BPI) after deep sleep. The mechanism of the injury might be compression and stretching of brachial plexus. The electrodiagnostic study was performed and the medial cord lesion of BPI was suggested. The ultrasonography image of compression site revealed the nerve swelling of medial cord of brachial plexus and median nerve at the mid-arm level. Pharmacologic treatment including oral prednisolone and exercise training were prescribed. On 6 months after initial visit, neurologic symptom and pain were improved but mild sequelae was remained.

Interpretation of Electrodiagnostic Tests in Chronic Inflammatory Demyelinating Polyneuropathy: Classification Using Nerve Conduction Study / 대한신경근육질환학회지

Electrodiagnostic tests (EDX) is essential for the diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP). EDX could provide information about demyelinating pathology in the peripheral nerves. According to phenotypes, CIDP could be classified several phenotypes, which has different clinical manifestations, EDX could present a different distribution pattern of demyelinating lesions. In addition, EDX could be useful markers for predicting treatment response of prognosis of CIDP.

Isolated musculocutaneous nerve injury following a pedestrian-automobile collision: A case report

@#Isolated musculocutaneous nerve (MCN) lesion is rare and usually associated with direct trauma. Along with the rarity of this condition, other muscles involved in elbow flexion, such as brachioradialis and pronator teres, can mask the weakness induced by the MCN injury and make it difficult to identify it. Here, we report a 17-year-old patient with isolated MCN palsy following a single episode of anterior shoulder contusion. A lack of suspicion for this rare condition delayed diagnosis until 7 months post injury, when atrophy of muscles in the left upper arm became prominent and weakness of the elbow flexors persisted. After 6 months of rehabilitation therapy rather than undergoing surgical exploration, elbow flexor strength was nearly fully recovered but sensory symptoms remained. The mechanism of injury is speculated to be a sudden overloading of the anterior shoulder with extension and external rotation, which overstretched and compressed the MCN within the coracobrachialis muscle where the nerve is relatively fixed. Although isolated peripheral nerve injury is rare, it can be caused by a single episode of vigorous impact. Therefore, even in patients without any external wounds, careful physical examination with suspicion of peripheral nerve injury as one of the differential diagnoses is needed.

Palmar Digital Neuropathy With Anatomical Variation of Median Nerve: Usefulness of Orthodromic Technique: A Case Report

Anatomic variation of palmar digital nerve pathways were reported in several cases. Selective exploration of palmar digital nerves with a nerve conduction study has been challenging, because of technical issues. We report a patient who received bilateral carpal tunnel release operation, complaining of a tingling sensation, and hypoesthesia on the middle and ring fingers. An electrodiagnostic study revealed a sensory neuropathy of palmar digital nerve of the left median nerve, supplying the ulnar side of the middle finger, and radial side of the ring finger. She underwent re-operation of open left carpal tunnel release, and a branching site of common digital nerves of the median nerve was identified not at the palm, but at a far proximal site around the distal wrist crease. Usefulness of an orthodromic sensory conduction study was clarified to eliminate volume conducted response or co-activation of nearby nerves in the patient with selective involvement of palmar digital nerve.

Compresión del nervio mediano en el túnel del carpo en una paciente de 16 años. Reporte de caso / Compression of the median nerve in the carpal tunnel in a 16 year-old: A case report

Introducción El síndrome del túnel del carpo es la patología nerviosa compresiva mas frecuente del miembro superior. En niños es una entidad infrecuente, en la mayoría de las ocasiones esta asociado principalmente a una alteración de origen genético como la mucopolisacaridosis, puede ser de origen idiopático, traumático, infeccioso asociado patologías sistémicas y ocupación del túnel del carpo. Reporte del caso Se trata de una paciente femenina de 16 años de edad con dolor en la mano izquierda de un año de evolución, presenta hipoestesia y parestesia de la punta de los dedos sin evento traumatico previo. El examen físico no es conclusivo, aunque altamente sospecho de patología neurológica compresiva. Mediante electrodiagnóstico e imagenología se realiza el diagnóstico de síndrome del túnel del carpo por secundario a ganglión en el piso del túnel. El tratamiento mas recomendado en este tipo fue la liberación quirúrgica y resección del ganglión. Discusión El diagnóstico del síndrome del túnel del carpo en niños y adolescentes es de difícil diagnóstico dado por la amplia sintomatología, una vez diagnósticado el síndrome del túnel del carpo, el tratamiento más recomendado según esta causa es la liberación quirúrgica del túnel del carpo y resección del ganglión. El síndrome del túnel del carpo es una patología infrecuente en los niños, se debe realizar estudios complementarios para realizar un diagnóstico adecuado y un tratamiento efectivo. Es infrecuente que después de la liberación del túnel del carpo exista persistencia de la sintomatología neurológica distal.

Background Carpal tunnel syndrome is the most frequent nerve compression disorder of the upper limb. It is uncommon in children and in the majority of cases it is mainly associated with an alteration of genetic origin such as mucopolysaccharidosis. It can be of an idiopathic, traumatic, infectious origin, associated with systemic infectious diseases and occupation of the carpal tunnel. Case report The case is presented on a 16 year-old female patient with pain in the left hand for a year, with hypoesthesia and paraesthesia of the fingertips, with no previous traumatic event. The physical examination was not conclusive, although a nerve compression disorder was highly suspected. Using electrodiagnosis and imaging, the diagnosis of carpal tunnel syndrome was made that was secondary to a ganglion identified on the floor of the tunnel. The most recommended treatment in this type of condition is surgical release and resection of the ganglion. Discussion Carpal tunnel syndrome in children and adolescents is difficult to diagnose due to the wide range of symptoms. Once the carpal tunnel syndrome has been diagnosed, the most recommended treatment according to this cause is the surgical release of the carpal tunnel and resection of the ganglion. Carpal tunnel syndrome is an infrequent condition in children. Complementary studies should be performed to make an adequate diagnosis and an effective treatment. After the release of the carpal tunnel it rare for the neurological symptomatology to persist.

Neuropatía vasculítica no sistémica: revisión de caso / Non-systemic vasculitic neuropathy: case review / Neuropatia vasculítica não sistêmica: revisão de caso

Resumen La neuropatía vasculítica no sistémica es una condición poco común, caracterizada por el compromiso aislado del sistema nervioso periférico a causa de la infiltración celular en el lecho vascular encargado de su irrigación. Es un término acuñado hace poco más de tres décadas y se considera una enfermedad poco descrita y subdiagnósticada. Se presenta el caso clínico de un paciente masculino de mediana edad que debuta con síntomas progresivos de predominio motor en miembros inferiores, quien es sometido a una serie de estudios que permiten concluir el diagnóstico. Es tratado con corticoides sistémicos, agentes citotóxicos y, por último, agentes biológicos con los que se estabilizaron los síntomas.

Summary Non-systemic vasculitic neuropathy is a rare condition characterized by the isolated involvement of the peripheral nervous system caused by cellular infiltration in the vascular bed responsible for its irrigation. It is a term which was coined a little over three decades ago and is considered a poorly described and underdiagnosed disease. Below, we present the clinical case of a middle-aged male patient who began experiencing progressive symptoms of motor predominance in the lower limbs, and who underwent a series of studies in order to conclude a diagnosis. The patient was treated with systemic corticosteroids, cytotoxic agents and, finally, biological agents which stabilized the symptoms.

Resumo A neuropatia vasculítica não sistêmica é uma condição pouco comum, caracterizada pelo compromisso isolado do sistema nervoso periférico a causa da infiltração celular no leito vascular encarregado de sua irrigação. É um termo cunhado há pouco mais de três décadas e se considera uma doença pouco descrita e subdiagnosticada. A seguir, se apresenta o caso clínico de um paciente masculino de meia idade que debuta com sintomas progressivos de predomínio motor em membros inferiores, que é submetido a uma série de estudos que permitem concluir o diagnóstico. É tratado com corticoides sistêmicos, agentes citotóxicos e, por último, agentes biológicos com o que se estabilizaram os sintomas.

Phenotypic expression variability in Best Disease: a purpose of a series of cases / Variabilidade de expressão Fenotípica na Doença de Best: a propósito de uma série de casos

Abstract The objective of the following work is to document the phenotypic expression variability in Best Disease in first-degree relatives. The information was collected by assessing medical notes, interviewing the patient and obtaining photographic record of the diagnostic methods to which the patient was submitted. Data was analyzed along with a thorough review of the literature. A series of cases were reported in which the patient presenting the phenotypic characteristics of the disease has first degree relatives without ophthalmic findings during examination, but present an abnormal pattern on the electro-oculogram (EOG). Our article reveals the importance of electrophysiological exams in the diagnosis of Best vitelliform macular dystrophy, including the prevention of its clinical manifestation (autosomal dominant), providing concrete subsidies for genetic counseling.

Resumo O objetivo do presente trabalho é a documentação da variabilidade de expressão fenotípica da Doença de Best em parentes de primeiro grau. As informações foram obtidas por meio de revisão do prontuário, entrevista com o paciente e registro fotográfico dos métodos diagnósticos aos quais os pacientes foram submetidos. Dados foram analisados junto a uma extensa revisão da literatura. Relatamos uma série de casos, no qual o paciente que apresenta as alterações fenotípicas da doença tem familiares de primeiro grau sem alterações ao exame oftalmológico, porém os mesmos apresentam padrão anormal de eletro-oculograma (EOG). O nosso artigo revela a importância dos exames eletrofisiológicos no diagnóstico da distrofia macular viteliforme de Best, inclusive no que se refere à prevenção de sua manifestação clínica (autossômica dominante), fornecendo subsídios concretos para o aconselhamento genético.

Is phrenic nerve conduction affected in patients with difficult-to-treat asthma? / A neurocondução do nervo frênico está alterada na asma de difícil controle?

ABSTRACT Objective The aim of this study was to obtain data on phrenic neuroconduction and electromyography of the diaphragm muscle in difficult-to-treat asthmatic patients and compare the results to those obtained in controls. Methods The study consisted of 20 difficult-to-treat asthmatic patients compared with 27 controls. Spirometry, maximal inspiratory and expiratory pressure, chest X-ray, phrenic neuroconduction and diaphragm electromyography data were obtained. Results The phrenic compound motor action potential area was reduced, compared with controls, and all the patients had normal diaphragm electromyography. Conclusion It is possible that a reduced phrenic compound motor action potential area, without electromyography abnormalities, could be related to diaphragm muscle fiber abnormalities due to overload activity.

RESUMO Objetivo O objetivo do presente estudo foi obter dados da neurocondução do frênico e exame com agulha do diafragma em pacientes com asma de difícil controlee comparar com um grupo normal. Métodos O estudo consiste em realizar radiografia de tórax, espirometria, pressão máxima inspiratória e expiratória, neurocondução do nervo frênico e eletromiografia do músculo diafragma em 20 pacientes asmáticos de difícil controle e comparar com 27 controles. Resultados Encontramos redução da área do potencial de ação muscular composto do nervo frênico e a eletromiografia do musculo diafragma estava normal em todos os pacientes. Conclusão É possível que a redução da área do potencial de ação muscular composto do nervo frênico nos pacientes com asma de difícil controle associado a eletromiografia normal do músculo diafragma esteja relacionada as alterações da fibra muscular do mesmo devido à sobrecarga de atividade.