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2.
Neurology ; 78(8): 585-9, 2012 Feb 21.
Article in English | MEDLINE | ID: mdl-22351796

ABSTRACT

OBJECTIVE: To evaluate whether spinal cord intraoperative monitoring (IOM) with somatosensory and transcranial electrical motor evoked potentials (EPs) predicts adverse surgical outcomes. METHODS: A panel of experts reviewed the results of a comprehensive literature search and identified published studies relevant to the clinical question. These studies were classified according to the evidence-based methodology of the American Academy of Neurology. Objective outcomes of postoperative onset of paraparesis, paraplegia, and quadriplegia were used because no randomized or masked studies were available. RESULTS AND RECOMMENDATIONS: Four Class I and 8 Class II studies met inclusion criteria for analysis. The 4 Class I studies and 7 of the 8 Class II studies reached significance in showing that paraparesis, paraplegia, and quadriplegia occurred in the IOM patients with EP changes compared with the IOM group without EP changes. All studies were consistent in showing all occurrences of paraparesis, paraplegia, and quadriplegia in the IOM patients with EP changes, with no occurrences of paraparesis, paraplegia, and quadriplegia in patients without EP changes. In the Class I studies, 16%-40% of the IOM patients with EP changes developed postoperative-onset paraparesis, paraplegia, or quadriplegia. IOM is established as effective to predict an increased risk of the adverse outcomes of paraparesis, paraplegia, and quadriplegia in spinal surgery (4 Class I and 7 Class II studies). Surgeons and other members of the operating team should be alerted to the increased risk of severe adverse neurologic outcomes in patients with important IOM changes (Level A).


Subject(s)
Evoked Potentials, Motor/physiology , Evoked Potentials, Somatosensory/physiology , Monitoring, Intraoperative/methods , Spinal Cord/physiology , Spine/surgery , Evidence-Based Medicine , Humans , Spinal Cord/surgery
3.
Neurology ; 77(24): 2128-34, 2011 Dec 13.
Article in English | MEDLINE | ID: mdl-22156988

ABSTRACT

OBJECTIVE: To assess the evidence for diagnostic tests and therapies for transverse myelitis (TM) and make evidence-based recommendations. METHODS: A review of the published literature from 1966 to March 2009 was performed, with evidence-based classification of relevant articles. RECOMMENDATIONS: Level B recommendations: neuromyelitis optica (NMO)-immunoglobulin G (IgG) antibodies should be considered useful to determine TM cause in patients presenting with clinical acute complete transverse myelitis (ACTM) features. The presence of NMO-IgG antibodies (aquaporin-4-specific antibodies) should be considered useful in determining increased TM recurrence risk. Level C recommendations: in suspected TM, distinction between ACTM or acute partial transverse myelitis may be considered useful to determine TM etiology and risk for relapse (more common with APTM). Age and gender may be considered useful to determine etiology in patients presenting with TM syndrome, with spinal infarcts seen more often in older patients and more female than male patients having TM due to multiple sclerosis (MS). Brain MRI characteristics consistent with those of MS may be considered useful to predict conversion to MS after a first partial TM episode. Longer spinal lesions extending over >3 vertebral segments may be considered useful in determining NMO vs MS. CSF examination for cells and oligoclonal bands may be considered useful to determine the cause of the TM syndrome. Plasma exchange may be considered in patients with TM who fail to improve after corticosteroid treatment. Rituximab may be considered in patients with TM due to NMO to decrease the number of relapses. Level U recommendations: there is insufficient evidence to support or refute the efficacy of other TM therapies or the usefulness of ethnicity to determine the cause of a subacute myelopathy.


Subject(s)
Myelitis, Transverse/diagnosis , Myelitis, Transverse/drug therapy , Neuromyelitis Optica/diagnosis , Neuromyelitis Optica/drug therapy , Aquaporin 4/immunology , Autoantibodies/immunology , Diagnosis, Differential , Evidence-Based Medicine , Female , Humans , Male , Multiple Sclerosis/diagnosis , Multiple Sclerosis/drug therapy , Multiple Sclerosis/immunology , Myelitis, Transverse/immunology , Neuromyelitis Optica/immunology , Spinal Cord/immunology , Spinal Cord/pathology
4.
Neurology ; 77(19): 1752-5, 2011 Nov 08.
Article in English | MEDLINE | ID: mdl-22013182

ABSTRACT

BACKGROUND: This evidence-based guideline is an update of the 2005 American Academy of Neurology practice parameter on the treatment of essential tremor (ET). METHODS: A literature review using MEDLINE, EMBASE, Science Citation Index, and CINAHL was performed to identify clinical trials in patients with ET published between 2004 and April 2010. RESULTS AND RECOMMENDATIONS: Conclusions and recommendations for the use of propranolol, primidone (Level A, established as effective); alprazolam, atenolol, gabapentin (monotherapy), sotalol, topiramate (Level B, probably effective); nadolol, nimodipine, clonazepam, botulinum toxin A, deep brain stimulation, thalamotomy (Level C, possibly effective); and gamma knife thalamotomy (Level U, insufficient evidence) are unchanged from the previous guideline. Changes to conclusions and recommendations from the previous guideline include the following: 1) levetiracetam and 3,4-diaminopyridine probably do not reduce limb tremor in ET and should not be considered (Level B); 2) flunarizine possibly has no effect in treating limb tremor in ET and may not be considered (Level C); and 3) there is insufficient evidence to support or refute the use of pregabalin, zonisamide, or clozapine as treatment for ET (Level U).


Subject(s)
Academies and Institutes/standards , Essential Tremor/therapy , Evidence-Based Medicine/standards , Neurology/standards , Research Report/standards , Academies and Institutes/trends , Clinical Trials as Topic/standards , Essential Tremor/diagnosis , Essential Tremor/drug therapy , Evidence-Based Medicine/trends , Humans , Neurology/trends , Research Report/trends , United States
6.
Neurology ; 74(16): 1316-24, 2010 Apr 20.
Article in English | MEDLINE | ID: mdl-20385882

ABSTRACT

OBJECTIVE: To review the evidence regarding the usefulness of patient demographic characteristics, driving history, and cognitive testing in predicting driving capability among patients with dementia and to determine the efficacy of driving risk reduction strategies. METHODS: Systematic review of the literature using the American Academy of Neurology's evidence-based methods. RECOMMENDATIONS: For patients with dementia, consider the following characteristics useful for identifying patients at increased risk for unsafe driving: the Clinical Dementia Rating scale (Level A), a caregiver's rating of a patient's driving ability as marginal or unsafe (Level B), a history of crashes or traffic citations (Level C), reduced driving mileage or self-reported situational avoidance (Level C), Mini-Mental State Examination scores of 24 or less (Level C), and aggressive or impulsive personality characteristics (Level C). Consider the following characteristics not useful for identifying patients at increased risk for unsafe driving: a patient's self-rating of safe driving ability (Level A) and lack of situational avoidance (Level C). There is insufficient evidence to support or refute the benefit of neuropsychological testing, after controlling for the presence and severity of dementia, or interventional strategies for drivers with dementia (Level U).


Subject(s)
Automobile Driver Examination/psychology , Automobile Driving/psychology , Automobile Driving/standards , Cognition Disorders/diagnosis , Dementia/diagnosis , Disability Evaluation , Automobile Driver Examination/legislation & jurisprudence , Caregivers , Cognition Disorders/psychology , Dementia/psychology , Humans , Neuropsychological Tests/standards , Personality Disorders/diagnosis , Personality Disorders/etiology , Psychomotor Performance/physiology , Risk Assessment
7.
Neurology ; 74(11): 924-31, 2010 Mar 16.
Article in English | MEDLINE | ID: mdl-20231670

ABSTRACT

OBJECTIVE: Nonmotor symptoms (sleep dysfunction, sensory symptoms, autonomic dysfunction, mood disorders, and cognitive abnormalities) in Parkinson disease (PD) are a major cause of morbidity, yet are often underrecognized. This evidence-based practice parameter evaluates treatment options for the nonmotor symptoms of PD. Articles pertaining to cognitive and mood dysfunction in PD, as well as treatment of sialorrhea with botulinum toxin, were previously reviewed as part of American Academy of Neurology practice parameters and were not included here. METHODS: A literature search of MEDLINE, EMBASE, and Science Citation Index was performed to identify clinical trials in patients with nonmotor symptoms of PD published between 1966 and August 2008. Articles were classified according to a 4-tiered level of evidence scheme and recommendations were based on the level of evidence. RESULTS AND RECOMMENDATIONS: Sildenafil citrate (50 mg) may be considered to treat erectile dysfunction in patients with Parkinson disease (PD) (Level C). Macrogol (polyethylene glycol) may be considered to treat constipation in patients with PD (Level C). The use of levodopa/carbidopa probably decreases the frequency of spontaneous nighttime leg movements, and should be considered to treat periodic limb movements of sleep in patients with PD (Level B). There is insufficient evidence to support or refute specific treatments for urinary incontinence, orthostatic hypotension, and anxiety (Level U). Future research should include concerted and interdisciplinary efforts toward finding treatments for nonmotor symptoms of PD.


Subject(s)
Autonomic Nervous System Diseases/drug therapy , Parkinson Disease/drug therapy , Sleep Wake Disorders/drug therapy , Autonomic Nervous System Diseases/etiology , Clinical Trials as Topic , Evidence-Based Medicine , Humans , Parkinson Disease/complications , Practice Patterns, Physicians' , Sleep Wake Disorders/etiology , United States
8.
PM R ; 1(1): 5-13, 2009 Jan.
Article in English | MEDLINE | ID: mdl-19627867

ABSTRACT

BACKGROUND: Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of laboratory and genetic tests for the assessment of DSP. METHODS: A literature review using MEDLINE, EMBASE, Science Citation Index and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based upon the level of evidence. RESULTS AND CONCLUSIONS: 1. Screening laboratory tests may be considered for all patients with polyneuropathy (Level C). Those tests that provide the highest yield of abnormality are blood glucose, serum B12 with metabolites (methylmalonic acid with or without homocysteine) and serum protein immunofixation electrophoresis (Level C). If there is no definite evidence of diabetes mellitus by routine testing of blood glucose, testing for impaired glucose tolerance may be considered in distal symmetric sensory polyneuropathy (Level C). 2. Genetic testing is established as useful for the accurate diagnosis and classification of hereditary neuropathies (Level A). Genetic testing may be considered in patients with cryptogenic polyneuropathy who exhibit a hereditary neuropathy phenotype (Level C). Initial genetic testing should be guided by the clinical phenotype, inheritance pattern, and electrodiagnostic (EDX) features and should focus on the most common abnormalities which are CMT1A duplication/HNPP deletion, Cx32 (GJB1), and MFN2 mutation screening. There is insufficient evidence to determine the usefulness of routine genetic testing in patients with cryptogenic polyneuropathy who do not exhibit a hereditary neuropathy phenotype (Level U).


Subject(s)
Clinical Laboratory Techniques , Polyneuropathies/diagnosis , Polyneuropathies/genetics , Blood Protein Electrophoresis , DNA Mutational Analysis , Evidence-Based Medicine , Glucose Tolerance Test , Humans , Inheritance Patterns , Polyneuropathies/blood , Vitamin B 12/blood
9.
PM R ; 1(1): 14-22, 2009 Jan.
Article in English | MEDLINE | ID: mdl-19627868

ABSTRACT

BACKGROUND: Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of autonomic testing, nerve biopsy and skin biopsy for the assessment of polyneuropathy. METHODS: A literature review using MEDLINE, EMBASE, Science Citation Index and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based upon the level of evidence. RESULTS AND CONCLUSIONS: 1. Autonomic testing may be considered in the evaluation of patients with polyneuropathy to document autonomic nervous system dysfunction (Level B). Such testing should be considered especially for the evaluation of suspected autonomic neuropathy (Level B) and distal small fiber sensory polyneuropathy (SFSN) (Level C). A battery of validated tests is recommended to achieve the highest diagnostic accuracy (Level B). 2. Nerve biopsy is generally accepted as useful in the evaluation of certain neuropathies as in patients with suspected amyloid neuropathy, mononeuropathy multiplex due to vasculitis, or with atypical forms of chronic inflammatory demyelinating polyneuropathy (CIDP). However, the literature is insufficient to provide a recommendation regarding when a nerve biopsy may be useful in the evaluation of DSP (Level U). 3. Skin biopsy is a validated technique for determining intraepidermal nerve fiber (IENF) density and may be considered for the diagnosis of DSP, particularly SFSN (Level C). There is a need for additional prospective studies to define more exact guidelines for the evaluation of polyneuropathy.


Subject(s)
Autonomic Nervous System/pathology , Polyneuropathies/diagnosis , Skin/pathology , Autonomic Nervous System/physiopathology , Biopsy , Evidence-Based Medicine , Humans , Neurologic Examination , Polyneuropathies/etiology , Polyneuropathies/pathology , Skin/innervation
10.
Neurology ; 73(2): 126-32, 2009 Jul 14.
Article in English | MEDLINE | ID: mdl-19398682

ABSTRACT

OBJECTIVE: To reassess the evidence for management issues related to the care of women with epilepsy (WWE) during pregnancy, including the risk of pregnancy complications or other medical problems during pregnancy in WWE compared to other women, change in seizure frequency, the risk of status epilepticus, and the rate of remaining seizure-free during pregnancy. METHODS: A 20-member committee including general neurologists, epileptologists, and doctors in pharmacy evaluated the available evidence based on a structured literature review and classification of relevant articles published between 1985 and February 2008. RESULTS: For WWE taking antiepileptic drugs, there is probably no substantially increased risk (greater than two times expected) of cesarean delivery or late pregnancy bleeding, and probably no moderately increased risk (greater than 1.5 times expected) of premature contractions or premature labor and delivery. There is possibly a substantially increased risk of premature contractions and premature labor and delivery during pregnancy for WWE who smoke. Seizure freedom for at least 9 months prior to pregnancy is probably associated with a high likelihood (84%-92%) of remaining seizure-free during pregnancy. RECOMMENDATIONS: Women with epilepsy (WWE) should be counseled that seizure freedom for at least 9 months prior to pregnancy is probably associated with a high rate (84%-92%) of remaining seizure-free during pregnancy (Level B). However, WWE who smoke should be counseled that they possibly have a substantially increased risk of premature contractions and premature labor and delivery during pregnancy (Level C).


Subject(s)
Epilepsy/epidemiology , Pregnancy Complications/epidemiology , Abortion, Spontaneous/epidemiology , Anticonvulsants/therapeutic use , Cesarean Section , Epilepsy/drug therapy , Female , Humans , Hypertension/epidemiology , Obstetric Labor, Premature/epidemiology , Odds Ratio , Pre-Eclampsia/epidemiology , Pregnancy , Pregnancy Complications/drug therapy , Recurrence , Risk , Smoking/epidemiology , Status Epilepticus/drug therapy , Status Epilepticus/epidemiology , Uterine Hemorrhage/epidemiology
11.
Neurology ; 73(2): 133-41, 2009 Jul 14.
Article in English | MEDLINE | ID: mdl-19398681

ABSTRACT

OBJECTIVE: To reassess the evidence for management issues related to the care of women with epilepsy (WWE) during pregnancy. METHODS: Systematic review of relevant articles published between January 1985 and June 2007. RESULTS: It is highly probable that intrauterine first-trimester valproate (VPA) exposure has higher risk of major congenital malformations (MCMs) compared to carbamazepine and possible compared to phenytoin or lamotrigine. Compared to untreated WWE, it is probable that VPA as part of polytherapy and possible that VPA as monotherapy contribute to the development of MCMs. It is probable that antiepileptic drug (AED) polytherapy as compared to monotherapy regimens contributes to the development of MCMs and to reduced cognitive outcomes. For monotherapy, intrauterine exposure to VPA probably reduces cognitive outcomes. Further, monotherapy exposure to phenytoin or phenobarbital possibly reduces cognitive outcomes. Neonates of WWE taking AEDs probably have an increased risk of being small for gestational age and possibly have an increased risk of a 1-minute Apgar score of <7. RECOMMENDATIONS: If possible, avoidance of valproate (VPA) and antiepileptic drug (AED) polytherapy during the first trimester of pregnancy should be considered to decrease the risk of major congenital malformations (Level B). If possible, avoidance of VPA and AED polytherapy throughout pregnancy should be considered to prevent reduced cognitive outcomes (Level B). If possible, avoidance of phenytoin and phenobarbital during pregnancy may be considered to prevent reduced cognitive outcomes (Level C). Pregnancy risk stratification should reflect that the offspring of women with epilepsy taking AEDs are probably at increased risk for being small for gestational age (Level B) and possibly at increased risk of 1-minute Apgar scores of <7 (Level C).


Subject(s)
Abnormalities, Drug-Induced/etiology , Anticonvulsants/adverse effects , Cognition Disorders/chemically induced , Epilepsy/drug therapy , Pregnancy Complications/drug therapy , Anticonvulsants/therapeutic use , Birth Weight/drug effects , Contraindications , Drug Therapy, Combination , Female , Humans , Infant, Newborn , Pregnancy , Prenatal Exposure Delayed Effects , Risk , Valproic Acid/adverse effects , Valproic Acid/therapeutic use
12.
Neurology ; 72(2): 185-92, 2009 Jan 13.
Article in English | MEDLINE | ID: mdl-19056666

ABSTRACT

BACKGROUND: Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of laboratory and genetic tests for the assessment of DSP. METHODS: A literature review using MEDLINE, EMBASE, and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based upon the level of evidence. RESULTS AND RECOMMENDATIONS: 1) Screening laboratory tests may be considered for all patients with polyneuropathy (Level C). Those tests that provide the highest yield of abnormality are blood glucose, serum B12 with metabolites (methylmalonic acid with or without homocysteine), and serum protein immunofixation electrophoresis (Level C). If there is no definite evidence of diabetes mellitus by routine testing of blood glucose, testing for impaired glucose tolerance may be considered in distal symmetric sensory polyneuropathy (Level C). 2) Genetic testing should be conducted for the accurate diagnosis and classification of hereditary neuropathies (Level A). Genetic testing may be considered in patients with cryptogenic polyneuropathy who exhibit a hereditary neuropathy phenotype (Level C). Initial genetic testing should be guided by the clinical phenotype, inheritance pattern, and electrodiagnostic features and should focus on the most common abnormalities which are CMT1A duplication/HNPP deletion, Cx32 (GJB1), and MFN2 mutation screening. There is insufficient evidence to determine the usefulness of routine genetic testing in patients with cryptogenic polyneuropathy who do not exhibit a hereditary neuropathy phenotype (Level U).


Subject(s)
Clinical Laboratory Techniques/standards , Genetic Predisposition to Disease/genetics , Polyneuropathies/diagnosis , Polyneuropathies/genetics , DNA Mutational Analysis/standards , Diabetic Neuropathies/diagnosis , Diabetic Neuropathies/metabolism , Diabetic Neuropathies/physiopathology , Diagnosis, Differential , Genetic Testing/standards , Glucose Tolerance Test/standards , Humans , Inheritance Patterns , Mutation/genetics , Polyneuropathies/physiopathology
13.
Neurology ; 72(2): 177-84, 2009 Jan 13.
Article in English | MEDLINE | ID: mdl-19056667

ABSTRACT

BACKGROUND: Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of autonomic testing, nerve biopsy, and skin biopsy for the assessment of polyneuropathy. METHODS: A literature review using MEDLINE, EMBASE, and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based upon the level of evidence. RESULTS AND RECOMMENDATIONS: 1) Autonomic testing should be considered in the evaluation of patients with polyneuropathy to document autonomic nervous system dysfunction (Level B). Such testing should be considered especially for the evaluation of suspected autonomic neuropathy (Level B) and distal small fiber sensory polyneuropathy (SFSN) (Level C). A battery of validated tests is recommended to achieve the highest diagnostic accuracy (Level B). 2) Nerve biopsy is generally accepted as useful in the evaluation of certain neuropathies as in patients with suspected amyloid neuropathy, mononeuropathy multiplex due to vasculitis, or with atypical forms of chronic inflammatory demyelinating polyneuropathy (CIDP). However, the literature is insufficient to provide a recommendation regarding when a nerve biopsy may be useful in the evaluation of DSP (Level U). 3) Skin biopsy is a validated technique for determining intraepidermal nerve fiber density and may be considered for the diagnosis of DSP, particularly SFSN (Level C). There is a need for additional prospective studies to define more exact guidelines for the evaluation of polyneuropathy.


Subject(s)
Peripheral Nerves/pathology , Polyneuropathies/diagnosis , Sensory Receptor Cells/pathology , Autonomic Nervous System Diseases/diagnosis , Autonomic Nervous System Diseases/etiology , Autonomic Nervous System Diseases/physiopathology , Autonomic Pathways/pathology , Autonomic Pathways/physiopathology , Biopsy/methods , Biopsy/standards , Electrodiagnosis/methods , Electrodiagnosis/standards , Evidence-Based Medicine/methods , Evidence-Based Medicine/standards , Humans , Neurologic Examination/methods , Neurologic Examination/standards , Peripheral Nerves/physiopathology , Polyneuropathies/physiopathology , Skin/innervation , Skin/physiopathology
14.
Muscle Nerve ; 39(1): 116-25, 2009 Jan.
Article in English | MEDLINE | ID: mdl-19086068

ABSTRACT

Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of laboratory and genetic tests for the assessment of DSP. A literature review using MEDLINE, EMBASE, Science Citation Index, and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based on the level of evidence. (1) Screening laboratory tests may be considered for all patients with polyneuropathy (Level C). Those tests that provide the highest yield of abnormality are blood glucose, serum B(12) with metabolites (methylmalonic acid with or without homocysteine), and serum protein immunofixation electrophoresis (Level C). If there is no definite evidence of diabetes mellitus by routine testing of blood glucose, testing for impaired glucose tolerance may be considered in distal symmetric sensory polyneuropathy (Level C). (2) Genetic testing is established as useful for the accurate diagnosis and classification of hereditary neuropathies (Level A). Genetic testing may be considered in patients with cryptogenic polyneuropathy who exhibit a hereditary neuropathy phenotype (Level C). Initial genetic testing should be guided by the clinical phenotype, inheritance pattern, and electrodiagnostic (EDX) features and should focus on the most common abnormalities, which are CMT1A duplication/HNPP deletion, Cx32 (GJB1), and MFN2 mutation screening. There is insufficient evidence to determine the usefulness of routine genetic testing in patients with cryptogenic polyneuropathy who do not exhibit a hereditary neuropathy phenotype (Level U).


Subject(s)
Clinical Laboratory Techniques/methods , Genetic Predisposition to Disease/genetics , Peripheral Nerves/physiopathology , Polyneuropathies/diagnosis , Polyneuropathies/genetics , Algorithms , Clinical Laboratory Techniques/standards , DNA Mutational Analysis , Evidence-Based Medicine , Genetic Testing/methods , Genetic Testing/standards , Humans , Inheritance Patterns/genetics , Peripheral Nerves/metabolism , Polyneuropathies/physiopathology , Predictive Value of Tests
15.
Muscle Nerve ; 39(1): 106-15, 2009 Jan.
Article in English | MEDLINE | ID: mdl-19086069

ABSTRACT

Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of autonomic testing, nerve biopsy, and skin biopsy for the assessment of polyneuropathy. A literature review using MEDLINE, EMBASE, Science Citation Index, and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based on the level of evidence. (1) Autonomic testing may be considered in the evaluation of patients with polyneuropathy to document autonomic nervous system dysfunction (Level B). Such testing should be considered especially for the evaluation of suspected autonomic neuropathy (Level B) and distal small fiber sensory polyneuropathy (SFSN) (Level C). A battery of validated tests is recommended to achieve the highest diagnostic accuracy (Level B). (2) Nerve biopsy is generally accepted as useful in the evaluation of certain neuropathies as in patients with suspected amyloid neuropathy, mononeuropathy multiplex due to vasculitis, or with atypical forms of chronic inflammatory demyelinating polyneuropathy (CIDP). However, the literature is insufficient to provide a recommendation regarding when a nerve biopsy may be useful in the evaluation of DSP (Level U). (3) Skin biopsy is a validated technique for determining intraepidermal nerve fiber (IENF) density and may be considered for the diagnosis of DSP, particularly SFSN (Level C). There is a need for additional prospective studies to define more exact guidelines for the evaluation of polyneuropathy.


Subject(s)
Autonomic Nervous System Diseases/diagnosis , Peripheral Nerves/pathology , Polyneuropathies/diagnosis , Sympathetic Fibers, Postganglionic/pathology , Autonomic Nervous System Diseases/physiopathology , Axons/pathology , Biopsy , Electrodiagnosis , Evidence-Based Medicine , Humans , Neural Conduction/physiology , Peripheral Nerves/physiopathology , Polyneuropathies/physiopathology , Predictive Value of Tests , Sensory Receptor Cells/pathology , Skin/innervation , Skin/pathology , Sympathetic Fibers, Postganglionic/physiopathology
16.
Neurology ; 71(15): 1183-90, 2008 Oct 07.
Article in English | MEDLINE | ID: mdl-18716236

ABSTRACT

BACKGROUND: Trigeminal neuralgia (TN) is a common cause of facial pain. PURPOSE: To answer the following questions: 1) In patients with TN, how often does routine neuroimaging (CT, MRI) identify a cause? 2) Which features identify patients at increased risk for symptomatic TN (STN; i.e., a structural cause such as a tumor)? 3) Does high-resolution MRI accurately identify patients with neurovascular compression? 4) Which drugs effectively treat classic and symptomatic trigeminal neuralgia? 5) When should surgery be offered? 6) Which surgical technique gives the longest pain-free period with the fewest complications and good quality of life? METHODS: Systematic review of the literature by a panel of experts. CONCLUSIONS: In patients with trigeminal neuralgia (TN), routine head imaging identifies structural causes in up to 15% of patients and may be considered useful (Level C). Trigeminal sensory deficits, bilateral involvement of the trigeminal nerve, and abnormal trigeminal reflexes are associated with an increased risk of symptomatic TN (STN) and should be considered useful in distinguishing STN from classic trigeminal neuralgia (Level B). There is insufficient evidence to support or refute the usefulness of MRI to identify neurovascular compression of the trigeminal nerve (Level U). Carbamazepine (Level A) or oxcarbazepine (Level B) should be offered for pain control while baclofen and lamotrigine (Level C) may be considered useful. For patients with TN refractory to medical therapy, Gasserian ganglion percutaneous techniques, gamma knife, and microvascular decompression may be considered (Level C). The role of surgery vs pharmacotherapy in the management of TN in patients with MS remains uncertain.


Subject(s)
Evidence-Based Medicine , Neurology/standards , Trigeminal Neuralgia/diagnosis , Trigeminal Neuralgia/therapy , Europe , Humans , Quality of Health Care , Societies, Medical/standards , United States
17.
Eur J Neurol ; 15(10): 1013-28, 2008 Oct.
Article in English | MEDLINE | ID: mdl-18721143

ABSTRACT

Several issues regarding diagnosis, pharmacological treatment, and surgical treatment of trigeminal neuralgia (TN) are still unsettled. The American Academy of Neurology and the European Federation of Neurological Societies launched a joint Task Force to prepare general guidelines for the management of this condition. After systematic review of the literature the Task Force came to a series of evidence-based recommendations. In patients with TN MRI may be considered to identify patients with structural causes. The presence of trigeminal sensory deficits, bilateral involvement, and abnormal trigeminal reflexes should be considered useful to disclose symptomatic TN, whereas younger age of onset, involvement of the first division, unresponsiveness to treatment and abnormal trigeminal evoked potentials are not useful in distinguishing symptomatic from classic TN. Carbamazepine (stronger evidence) or oxcarbazepine (better tolerability) should be offered as first-line treatment for pain control. For patients with TN refractory to medical therapy early surgical therapy may be considered. Gasserian ganglion percutaneous techniques, gamma knife and microvascular decompression may be considered. Microvascular decompression may be considered over other surgical techniques to provide the longest duration of pain freedom. The role of surgery versus pharmacotherapy in the management of TN in patients with multiple sclerosis remains uncertain.


Subject(s)
Trigeminal Neuralgia/therapy , Adolescent , Adult , Aged , Aged, 80 and over , Analgesics/therapeutic use , Anticonvulsants/therapeutic use , Carbamazepine/analogs & derivatives , Carbamazepine/therapeutic use , Child , Child, Preschool , Combined Modality Therapy , Decompression, Surgical , Diagnostic Imaging , Disease Management , Double-Blind Method , Evidence-Based Medicine , Female , Humans , Male , Middle Aged , Oxcarbazepine , Radiosurgery , Randomized Controlled Trials as Topic/statistics & numerical data , Sensitivity and Specificity , Trigeminal Ganglion/surgery , Trigeminal Neuralgia/diagnosis , Trigeminal Neuralgia/drug therapy , Trigeminal Neuralgia/surgery
19.
Neurology ; 70(19): 1707-14, 2008 May 06.
Article in English | MEDLINE | ID: mdl-18458231

ABSTRACT

OBJECTIVE: To perform an evidence-based review of the safety and efficacy of botulinum neurotoxin (BoNT) in the treatment of autonomic and urologic disorders and low back and head pain. METHODS: A literature search was performed including MEDLINE and Current Contents for therapeutic articles relevant to BoNT and the selected indications. Authors reviewed, abstracted, and classified articles based on the quality of the study (Class I-IV). Conclusions and recommendations were developed based on the highest level of evidence and put into current clinical context. RESULTS: The highest quality literature available for the respective indications was as follows: axillary hyperhidrosis (two Class I studies); palmar hyperhidrosis (two Class II studies); drooling (four Class II studies); gustatory sweating (five Class III studies); neurogenic detrusor overactivity (two Class I studies); sphincter detrusor dyssynergia in spinal cord injury (two Class II studies); chronic low back pain (one Class II study); episodic migraine (two Class I and two Class II studies); chronic daily headache (four Class II studies); and chronic tension-type headache (two Class I studies). RECOMMENDATIONS: Botulinum neurotoxin (BoNT) should be offered as a treatment option for the treatment of axillary hyperhidrosis and detrusor overactivity (Level A), should be considered for palmar hyperhidrosis, drooling, and detrusor sphincter dyssynergia after spinal cord injury (Level B), and may be considered for gustatory sweating and low back pain (Level C). BoNT is probably ineffective in episodic migraine and chronic tension-type headache (Level B). There is presently no consistent or strong evidence to permit drawing conclusions on the efficacy of BoNT in chronic daily headache (mainly transformed migraine) (Level U). While clinicians' practice may suggest stronger recommendations in some of these indications, evidence-based conclusions are limited by the availability of data.


Subject(s)
Autonomic Nervous System Diseases/drug therapy , Botulinum Toxins/administration & dosage , Neuromuscular Blocking Agents/administration & dosage , Pain/drug therapy , Autonomic Nervous System Diseases/physiopathology , Clinical Trials as Topic/statistics & numerical data , Evidence-Based Medicine , Humans , Hyperhidrosis/drug therapy , Low Back Pain/drug therapy , Pain/physiopathology , Urinary Bladder, Neurogenic/drug therapy
20.
Muscle Nerve ; 37(4): 473-6, 2008 Apr.
Article in English | MEDLINE | ID: mdl-18236463

ABSTRACT

We developed a disease-specific, 10-point functional rating scale for patients with inclusion body myositis (IBMFRS). The IBMFRS was utilized as a secondary outcome measure in a multicenter pilot trial of the clinical safety and tolerability of high-dose beta interferon-1a. In this trial, 28 IBM patients completed the IBMFRS at baseline and monthly for 6 months. The IBMFRS showed statistically significant correlations (P < 0.001) with maximal voluntary isometric contraction, manual muscle testing, handgrip dynamometry, and the amyotrophic lateral sclerosis (ALS) functional rating scale (ALSPRS). Compared to these other outcome measures, the IBMFRS was also the most sensitive measure of change over the course of the study.


Subject(s)
Disability Evaluation , Myositis, Inclusion Body/physiopathology , Severity of Illness Index , Activities of Daily Living , Humans , Pilot Projects , Reproducibility of Results , Sensitivity and Specificity
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