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P4.20 Pain response to repeated administration of intravenous immunoglobulin in a patient with diabetic lumbosacral radiculoplexus neuropathy. Evidence for proinflammatory cytokine activation
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Poster presentations: Poster session 4. EMG, nerve conduction, peripheral neuropathies
1
before. At baseline and after 9 months of Dianural® all pts completed questionnaires for pain (McGill Pain Questionnaire and VAS scale) bowel (Wexner Score), bladder (voiding diary), International Index of Erectile Dysfunction (IIEF-5) and Female Sexual Function Index and underwent a thorough neurophysiologic evaluation of pelvic floor (Somatosensory Evoked Potentials and Electroneurography of Pudendal nerves, Sacral Reflexes, Electromyography of perineal muscles, Sympathetic Skin Response). Results: Neurophysiologic assessment of the pelvic floor is able to reveal the PTPN without compression at Alcoc’s canal and to relate it to the trauma; after 9 months of treatment with Dianural® for all the pts there was a statistically improvement either on electrodiagnostic tests, questionnaires and pain scale. PTPN should be recognised as a source of chronic perineal pain and pelvic dysfunction, and treated as peripheral neuropathy, thus sparing the patient from years of suffering and need of consultations.
measures) and in multivariate analysis (predictors: demographic and clinical variables). Results: Ulnar sensory measures were smaller in CTS patients and were correlated to median neurographic measures. The new findings were: (1) the correlation between ulnar and median neurographic measures was also found in controls; (2) the correlation was larger in controls vs. patients and in milder vs. more severe CTS; (3) CTS severity was positive instead of negative predictor of ulnar nerve sensory measures (i.e.: the more severe the CTS, the higher the positive effect on ulnar sensory measures) and other factors (sex, age) contributed to ulnar nerve sensory potentials amplitude; (4) radial nerve sensory measures behaved much in the same way as ulnar ones. Conclusions: Other factors instead of raised carpal tunnel pressure are the major causes of ulnar nerve conduction findings in CTS. Subtle neurographic changes are neither specific to ulnar nerve nor to CTS. Ulnar nerve changes do not appear to contribute to extramedian symptoms.
P4.20 Pain response to repeated administration of intravenous immunoglobulin in a patient with diabetic lumbosacral radiculoplexus neuropathy. Evidence for proinflammatory cytokine activation
P4.22 Monopolar needle antidromic sensory conduction studies of medial plantar nerve distal digital branches: a novel method to detect early diabetic sensory axonal polyneuropathy
S. Tamburin1 , F. Magrinelli1 , M.L. Praitano2 , A. Fiaschi1 , G. Zanette2 1 Department of Neurological, Neuropsychological, Morphological and Movement Sciences, University of Verona, Verona, Italy, 2 Section of Neurology, Pederzoli Hospital, Peschiera del Garda (VR), Italy
G. Squintani1 , L. Ferigo1 , A. Segatti1 , G. Zoppini2 , E. Bonora2 , G. Moretto1 , A. Morini3 1 Neurology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy, 2 Medicine Department, Section of Endocrinology and Metabolism Diseases, Azienda Ospedaliera Universitaria Integrata, Verona, Italy, 3 Neurology Unit, Laboratorio di Neurofisiologia, Ospedale Santa Chiara, Trento, Italy
Introduction: Anecdotal reports and a recent randomized clinical trial suggest that intravenous immunoglobulin (IVIG) may reduce pain intensity in different neuropathic pain (NP) syndromes. These evidences are in accordance with the suggested role for the immune system in the pathophysiology of NP. Objective: To reinforce the growing body of evidence that proinflammatory cytokines are involved in initiating and/or maintaining NP. Methods: A 67-year-old man with diabetic lumbosacral radiculoplexus neuropathy (DLRPN), who did not respond to analgesic therapy, NP drugs and corticosteroids, underwent IVIG therapy (0.4 g/kg/day for 5 days) six times in six years for recurrent episodes of DLRPN worsening. Outcome measures were pain intensity with visual analogue scale (VAS), lower limb muscle strength assessed with the Medical Research Council (MRC) scale and walking distance before and after each treatment. Serum levels of proinflammatory cytokines were measured during an episode of DLRPN worsening. Results: Consistent improvements of VAS and walking distance were obtained after each IVIG treatment in our patient. Time to onset and duration of pain improvement were in accordance with the pharmacokinetics of the IVIG (i.e.: the patient ameliorated 15 20 days after treatment and began to worse 6 10 months afterwards). On one occasion of pain worsening, serum proinflammatory cytokines dosage documented tumour necrosis factor alpha (TNF-alpha) elevation (10.4 ng/L; n.v.: <8.1 ng/L). Conclusions: The present case strengthens the hypothesis that proinflammatory cytokines, in particular TNF-alpha, play a role in the pathogenesis of NP in humans. Our data support the use of IVIG in those NP patients with evidence of cytokine activation. P4.21 The association of ulnar nerve conduction changes with carpal tunnel syndrome. A multivariate analysis study S. Tamburin1 , C. Cazzarolli1 , M.F. Lauriola2 , M.L. Praitano2 , C. Foscato2 , A. Maier1 , A. Fiaschi1 , G. Zanette1 1 Department of Neurological, Neuropsychological, Morphological and Movement Sciences, University of Verona, Verona, Italy, 2 Section of Neurology, Pederzoli Hospital, Peschiera del Garda (VR), Italy Introduction: Extramedian symptoms are very frequent in patients with carpal tunnel syndrome (CTS). Previous studies suggested that ulnar nerve changes are common in CTS and are responsible for extramedian symptoms. Objective: To explore whether CTS is associated with ulnar nerve abnormalities, the specificity of ulnar changes and their possible role in extramedian symptoms. Methods: We recruited 350 CTS patients and 150 controls. Radial and ulnar neurographic measures were explored in univariate analysis (independent variables: group, CTS severity and median neurographic
Introduction: Distal sensory axonal polyneuropathy represents the most common form of diabetic neuropathy, affecting about 70% of patients. Sensory Neurography (SN) of more distal foot nerve trunks (medial plantar and dorsal sural nerves) have been reported as more sensitive than standard nerve SN (sural and superficial peroneal nerve at the ankle) to reveal neuropathy. Objective: To study medial plantar nerve distal digital nerve segments with a ‘new’ antidromic technique in healthy and diabetics; to compare standard nerve SN with these non-conventional foot SN; to assess their different sensitivity in symptomatic and asymptomatic diabetics. Methods: We studied 14 controls (mean age 62, range 50 70), 18 diabetic patients (mean age 66, range 50 70), 10 with sensory impairment symptoms and 8 asymptomatic. All subjects underwent standard neurophysiology (peroneal and posterior tibial nerve motor conduction, sural and peroneal superficial SN). Moreover we investigated more distal foot nerves (dorsal sural, medial plantar nerves with classical near-nerve orthodromic technique) and proper digital nerves (distal branches of interdigital nerves) antidromically, stimulating at foot sole and recording at digits I and II by monopolar needles. T-test was used for statistics. Results: All SAPs were detectable in 100% of controls. Conventional SN did not differ between controls and diabetics. SAP amplitudes of dorsal sural, orthodromic medial plantar and antidromic I and II digital nerves were significantly reduced in diabetics. In diabetic patients, dorsal sural and orthodromic medial plantar SAPs were not detectable in 40% and 37% respectively; antidromic distal medial plantar SAPs were absent in 74% (digit I) and 77% (digit II). This latter technique showed a 80% (digit I) and 78% (digit II) sensitivity in patients with sensory complaints. Conclusions: Medial plantar nerve distal digital segment antidromic SN is a new reliable technique which might be the most sensitive tool to detect early diabetic neuropathy. P4.23 Control mechanisms of finger reaching during perturbed two-dimensional target displacements R. Budai1 , R. Pozzo2 , R. Blanco3 , P.B. Pascolo4 1 Azienda Ospedaliera S. Maria, Udine, Italy, 2 Scienze Motorie Universit` a Tor Vergata, Rome, Italy, 3 Azienda Ospedaliera S. Anna, Ferrara, Italy, 4 Uinversit` a di Udine, Udine, Italy Introduction and Objectives: The aim of this study was to investigate the control mechanisms during goal-directed finger pointing movements (maximal speed and precision). Methods: A visual target was located on the center of a monitor 45 cm away from the right hand lying on an electronic button connected to a timer circuit. The target appearance elicited subject’s response. After the onset of finger motion, target’s position was randomly changed to
Poster presentations: Poster session 4. EMG, nerve conduction, peripheral neuropathies
1
before. At baseline and after 9 months of Dianural® all pts completed questionnaires for pain (McGill Pain Questionnaire and VAS scale) bowel (Wexner Score), bladder (voiding diary), International Index of Erectile Dysfunction (IIEF-5) and Female Sexual Function Index and underwent a thorough neurophysiologic evaluation of pelvic floor (Somatosensory Evoked Potentials and Electroneurography of Pudendal nerves, Sacral Reflexes, Electromyography of perineal muscles, Sympathetic Skin Response). Results: Neurophysiologic assessment of the pelvic floor is able to reveal the PTPN without compression at Alcoc’s canal and to relate it to the trauma; after 9 months of treatment with Dianural® for all the pts there was a statistically improvement either on electrodiagnostic tests, questionnaires and pain scale. PTPN should be recognised as a source of chronic perineal pain and pelvic dysfunction, and treated as peripheral neuropathy, thus sparing the patient from years of suffering and need of consultations.
measures) and in multivariate analysis (predictors: demographic and clinical variables). Results: Ulnar sensory measures were smaller in CTS patients and were correlated to median neurographic measures. The new findings were: (1) the correlation between ulnar and median neurographic measures was also found in controls; (2) the correlation was larger in controls vs. patients and in milder vs. more severe CTS; (3) CTS severity was positive instead of negative predictor of ulnar nerve sensory measures (i.e.: the more severe the CTS, the higher the positive effect on ulnar sensory measures) and other factors (sex, age) contributed to ulnar nerve sensory potentials amplitude; (4) radial nerve sensory measures behaved much in the same way as ulnar ones. Conclusions: Other factors instead of raised carpal tunnel pressure are the major causes of ulnar nerve conduction findings in CTS. Subtle neurographic changes are neither specific to ulnar nerve nor to CTS. Ulnar nerve changes do not appear to contribute to extramedian symptoms.
P4.20 Pain response to repeated administration of intravenous immunoglobulin in a patient with diabetic lumbosacral radiculoplexus neuropathy. Evidence for proinflammatory cytokine activation
P4.22 Monopolar needle antidromic sensory conduction studies of medial plantar nerve distal digital branches: a novel method to detect early diabetic sensory axonal polyneuropathy
S. Tamburin1 , F. Magrinelli1 , M.L. Praitano2 , A. Fiaschi1 , G. Zanette2 1 Department of Neurological, Neuropsychological, Morphological and Movement Sciences, University of Verona, Verona, Italy, 2 Section of Neurology, Pederzoli Hospital, Peschiera del Garda (VR), Italy
G. Squintani1 , L. Ferigo1 , A. Segatti1 , G. Zoppini2 , E. Bonora2 , G. Moretto1 , A. Morini3 1 Neurology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy, 2 Medicine Department, Section of Endocrinology and Metabolism Diseases, Azienda Ospedaliera Universitaria Integrata, Verona, Italy, 3 Neurology Unit, Laboratorio di Neurofisiologia, Ospedale Santa Chiara, Trento, Italy
Introduction: Anecdotal reports and a recent randomized clinical trial suggest that intravenous immunoglobulin (IVIG) may reduce pain intensity in different neuropathic pain (NP) syndromes. These evidences are in accordance with the suggested role for the immune system in the pathophysiology of NP. Objective: To reinforce the growing body of evidence that proinflammatory cytokines are involved in initiating and/or maintaining NP. Methods: A 67-year-old man with diabetic lumbosacral radiculoplexus neuropathy (DLRPN), who did not respond to analgesic therapy, NP drugs and corticosteroids, underwent IVIG therapy (0.4 g/kg/day for 5 days) six times in six years for recurrent episodes of DLRPN worsening. Outcome measures were pain intensity with visual analogue scale (VAS), lower limb muscle strength assessed with the Medical Research Council (MRC) scale and walking distance before and after each treatment. Serum levels of proinflammatory cytokines were measured during an episode of DLRPN worsening. Results: Consistent improvements of VAS and walking distance were obtained after each IVIG treatment in our patient. Time to onset and duration of pain improvement were in accordance with the pharmacokinetics of the IVIG (i.e.: the patient ameliorated 15 20 days after treatment and began to worse 6 10 months afterwards). On one occasion of pain worsening, serum proinflammatory cytokines dosage documented tumour necrosis factor alpha (TNF-alpha) elevation (10.4 ng/L; n.v.: <8.1 ng/L). Conclusions: The present case strengthens the hypothesis that proinflammatory cytokines, in particular TNF-alpha, play a role in the pathogenesis of NP in humans. Our data support the use of IVIG in those NP patients with evidence of cytokine activation. P4.21 The association of ulnar nerve conduction changes with carpal tunnel syndrome. A multivariate analysis study S. Tamburin1 , C. Cazzarolli1 , M.F. Lauriola2 , M.L. Praitano2 , C. Foscato2 , A. Maier1 , A. Fiaschi1 , G. Zanette1 1 Department of Neurological, Neuropsychological, Morphological and Movement Sciences, University of Verona, Verona, Italy, 2 Section of Neurology, Pederzoli Hospital, Peschiera del Garda (VR), Italy Introduction: Extramedian symptoms are very frequent in patients with carpal tunnel syndrome (CTS). Previous studies suggested that ulnar nerve changes are common in CTS and are responsible for extramedian symptoms. Objective: To explore whether CTS is associated with ulnar nerve abnormalities, the specificity of ulnar changes and their possible role in extramedian symptoms. Methods: We recruited 350 CTS patients and 150 controls. Radial and ulnar neurographic measures were explored in univariate analysis (independent variables: group, CTS severity and median neurographic
Introduction: Distal sensory axonal polyneuropathy represents the most common form of diabetic neuropathy, affecting about 70% of patients. Sensory Neurography (SN) of more distal foot nerve trunks (medial plantar and dorsal sural nerves) have been reported as more sensitive than standard nerve SN (sural and superficial peroneal nerve at the ankle) to reveal neuropathy. Objective: To study medial plantar nerve distal digital nerve segments with a ‘new’ antidromic technique in healthy and diabetics; to compare standard nerve SN with these non-conventional foot SN; to assess their different sensitivity in symptomatic and asymptomatic diabetics. Methods: We studied 14 controls (mean age 62, range 50 70), 18 diabetic patients (mean age 66, range 50 70), 10 with sensory impairment symptoms and 8 asymptomatic. All subjects underwent standard neurophysiology (peroneal and posterior tibial nerve motor conduction, sural and peroneal superficial SN). Moreover we investigated more distal foot nerves (dorsal sural, medial plantar nerves with classical near-nerve orthodromic technique) and proper digital nerves (distal branches of interdigital nerves) antidromically, stimulating at foot sole and recording at digits I and II by monopolar needles. T-test was used for statistics. Results: All SAPs were detectable in 100% of controls. Conventional SN did not differ between controls and diabetics. SAP amplitudes of dorsal sural, orthodromic medial plantar and antidromic I and II digital nerves were significantly reduced in diabetics. In diabetic patients, dorsal sural and orthodromic medial plantar SAPs were not detectable in 40% and 37% respectively; antidromic distal medial plantar SAPs were absent in 74% (digit I) and 77% (digit II). This latter technique showed a 80% (digit I) and 78% (digit II) sensitivity in patients with sensory complaints. Conclusions: Medial plantar nerve distal digital segment antidromic SN is a new reliable technique which might be the most sensitive tool to detect early diabetic neuropathy. P4.23 Control mechanisms of finger reaching during perturbed two-dimensional target displacements R. Budai1 , R. Pozzo2 , R. Blanco3 , P.B. Pascolo4 1 Azienda Ospedaliera S. Maria, Udine, Italy, 2 Scienze Motorie Universit` a Tor Vergata, Rome, Italy, 3 Azienda Ospedaliera S. Anna, Ferrara, Italy, 4 Uinversit` a di Udine, Udine, Italy Introduction and Objectives: The aim of this study was to investigate the control mechanisms during goal-directed finger pointing movements (maximal speed and precision). Methods: A visual target was located on the center of a monitor 45 cm away from the right hand lying on an electronic button connected to a timer circuit. The target appearance elicited subject’s response. After the onset of finger motion, target’s position was randomly changed to