Janne Ludwig

Effects of subthalamic nucleus stimulation and levodopa on the autonomic nervous system in Parkinson’s disease

Dysfunctions of the autonomic nervous system (ANS) are common in Parkinson’s disease (PD). Regarding motor disability, deep brain stimulation of the subthalamic nucleus (STN) is an effective treatment option in long lasting PD. The aims of this study were to examine whether STN stimulation has an influence on functions of the ANS and to compare these effects to those induced by levodopa. Blood pressure (BP) and heart rate (HR) during rest and orthostatic conditions, HR variability (HRV) and breathing-induced cutaneous sympathetic vasoconstriction (CVC) were tested in 14 PD patients treated with STN stimulation during “ON” and “OFF” condition of the stimulator. The effects of a single dose of levodopa on ANS were tested in 15 PD patients without DBS. STN stimulation had no influence on cardiovascular ANS functions, whereas CVC was significantly increased. In contrast, levodopa significantly lowered BP and HR at rest and enhanced orthostatic hypotension. Further, HRV, skin perfusion and temperature increased after administration of levodopa. Our results suggest that in contrast to levodopa, STN stimulation has only minor effects on autonomic functions. Since less pharmacotherapy is needed after STN stimulation, reduced levodopa intake results in relative improvement of autonomic function in deep brain stimulated PD patients.

Harlequin syndrome - one face of many etiologies

Background A 55-year-old woman presented to hospital with a 3-month history of asymmetric facial flushing of the skin during exertion, and an 18-month history of left-sided ptosis and miosis. Detailed medical history analysis revealed that a palpable node measuring 0.8 × 1.2 × 1.2 cm (volume 1.1 ml) had been discovered 2 years previously, within the left lobe of an otherwise uncomplicated goiter that had been successfully managed for 20 years. Otherwise, the patient was healthy.Investigations Neurological examination, autonomic testing, duplex ultrasonography, scintigraphy and MRI.Diagnosis Harlequin syndrome following a lesion of the preganglionic sympathetic efferents, caused by neurovascular compression of the sympathetic chain between the stellate and superior cervical ganglion brought about by an elongated inferior thyroid artery.Management Explanation of pathophysiology and benign nature of the condition.

Cytokine expression in serum and cerebrospinal fluid in non-inflammatory polyneuropathies

Background: Pain is a common symptom in polyneuropathies (PNPs), although it is still not known why some PNPs are painful and others are painless. Increased pro-inflammatory cytokines have been found in conditions resulting in exaggerated pain states in animal studies. Recently, elevated pro-inflammatory cytokine levels have also been found in the cerebrospinal fluid (CSF) of patients suffering from complex regional pain syndrome. Pro-inflammatory cytokines have been shown to induce or increase inflammatory or neuropathic pain. Methods: Using chemiluminescent enzyme immunometric assays, cytokine levels in 36 patients with painful and painless non-inflammatory PNPs in serum and CSF were investigated. The severity of PNPs was measured with electroneurography (ENG). In subjects with normal results using conventional ENG, quantitative thermo-testing was performed to investigate small-nerve-fibre function. Results: Interleukin (IL)-6 and tumour necrosis factor (TNF)-α in serum or CSF did not differ between patients with (n = 18) or without (n = 18) painful PNPs, whereas patients with mechanical allodynia (n = 5) had elevated serum TNF-α levels compared to those without allodynia. TNF-α and IL-6 serum levels were higher in patients with severe (n = 21) compared to those with mild neuropathy (n = 15), and showed a positive correlation with severity of neuropathy. Conclusions: Results suggest that nerve fibre degeneration and presence of mechanical allodynia in peripheral non-inflammatory neuropathy determine cytokine expression in serum.

Behavioral and sensory changes after direct ischemia-reperfusion injury in rats.

Complex regional pain syndromes (CRPS) are disabling pain syndromes that can develop after trauma or minor tissue injury affecting a limb. Characteristics of CRPS are sensory signs and symptoms, autonomic abnormalities, trophic changes and an impaired motor function. Pathophysiological mechanisms for the development of CRPS are still a matter of investigation. Based on clinical data and investigations of CRPS patients it is hypothesized that tissue hypoxia and inflammation are important for the development of CRPS. The aim of the current study was therefore to examine if direct ischemia‐reperfusion injury can induce behavior in rats with symptoms present in patients with CRPS.

Parkinson disease: do we need to improve treatment strategies that focus on nonmotor complications such as pain?

This Practice Point commentary discusses the findings and limitations of a cross-sectional survey by Nègre-Pagès et al. that investigated the prevalence of pain in a large number of patients with Parkinson disease (PD). The authors used a validated definition of chronic pain and included an age-matched and sex-matched control group. The study showed that chronic pain is a frequent but underreported symptom in PD, suggesting that awareness of this problem should be increased. This commentary highlights the issues to consider when interpreting these results, including the use of self-reported questionnaires and the classification of PD-associated pain. Overall, the findings indicate that interventions in patients with PD should go beyond the treatment of motor symptoms only and also target nonmotor symptoms; in particular, the treatment of pain needs to be improved.

So zähmen Sie den Zoster-Schmerz

ZusammenfassungSchmerzen im Zusammenhang mit einer Varizella-Zoster-Infektion können den akuten Zoster viele Monate überdauern. Einschießende Schmerzen, brennender Dauerschmerz und Schmerzen, die durch leichte Berührungen ausgelöst werden, quälen die Patienten. Wichtiges Therapieziel ist eine frühzeitige und ausreichende Schmerztherapie, um einer Schmerzchronifizierung frühestmöglich entgegenzuwirken.

472 ENDOTHELIAL DYSFUNCTION IN COLD TYPE CRPS

Later the intradural tumor (haemangiopericytoma) under C8 root right was diagnosed and removed. Patient No. 3 ([posterior] tibial nerve) and patient No. 4 (common peroneal nerve): Both patients had history of rectal carcinoma. They suffered with problems mimicking peripheral nerve entrapment neuropathy. The metastasis of carcinoma in the pelvis was established later. Conclusions: We have to keep on mind the malignant disease in a patient’s history and exclude malignant origin of his/her problems, especially when it can avoid unnecessary operations.

473 SKIN TEMPERATURE DIFFERENCES IN CRPS AND HEALTHY CONTROLS

Later the intradural tumor (haemangiopericytoma) under C8 root right was diagnosed and removed. Patient No. 3 ([posterior] tibial nerve) and patient No. 4 (common peroneal nerve): Both patients had history of rectal carcinoma. They suffered with problems mimicking peripheral nerve entrapment neuropathy. The metastasis of carcinoma in the pelvis was established later. Conclusions: We have to keep on mind the malignant disease in a patient’s history and exclude malignant origin of his/her problems, especially when it can avoid unnecessary operations.

461 SPECIFIC SENSORY PROFILE IN FABRY PATIENTS WITH NEUROPATHIC PAIN

Background and Aims: Patients with failed back surgery syndrome (FBSS) continue to experience persistent or recurrent pain, disability and reduced quality of life despite anatomically successful lumbosacral spine surgery. The aim of this randomised controlled trial was to evaluate the clinical (and cost-) effectiveness of the addition of spinal cord stimulation (SCS) to conventional medical management (CMM) of patients with FBSS. Methods: 100 patients suffering from persistent neuropathic pain predominantly in the legs were randomised to receive SCS utilising the SynergyTM neurostimulator (Medtronic Inc, Minneapolis) plus CMM or CMM alone. Patients in either group received appropriate adjuvant therapy (excluding spinal surgery or intrathecal drug delivery) and were followed up to 24months, with crossover after the 6-month visit upon patient request. Pain relief (>50% change on VAS), functional capacity (Oswestry), health related quality of life (HRQoL assessed by Short-Form 36), patient satisfaction and adverse effects were assessed at each study visit. Results: In an intention to treat analysis at 6-months, patients randomised to SCS experienced the following improvements when compared to CMM alone: significantly more leg pain relief (P = 0.0001), improved functionality (P = 0.0002), improved HRQoL in 7 out of 8 domains (0.02> P >0.0002) and greater satisfaction in their treatment (P< 0.0004). Fourteen (29%) of the 48 patients who received a stimulator had a complication that required additional surgery. Conclusions: Compared to CMM alone, SCS improves pain relief, healthrelated quality of life and functionality in predominantly neuropathic FBSS patients at 6 months. The 12-month follow up will be completed in July 2006.