Oliver Rommel

Quantitative sensory testing, neurophysiological and psychological examination in patients with complex regional pain syndrome and hemisensory deficits

&NA; Based on bed‐side neurological testing, it has recently been shown that 33% of chronic complex regional pain syndrome (CRPS) type I patients exhibit sensory impairments, which extend past the painful area of the affected limb in a hemisensory distribution (Pain, 80 (1999) 95). In the present study, the clinically observed changes in touch and temperature sensations on the side of the body ipsilateral to the affected limb were investigated quantitatively. Neurophysiological and psychological examinations were conducted to detect changes in the peripheral and central nervous system as well as psychopathological abnormalities. In 40 patients with CRPS, a bed‐side neurological examination was performed. Quantitative sensory testing was conducted at five locations on each side of the body. The evaluation of touch thresholds was performed using von Frey filaments (n=40). To measure cool, warm and heat pain thresholds quantitatively, a thermal stimulator using a Peltier‐element was used (n=28). With respect to clinical findings, the initiating trauma and severity of abnormalities on nerve conduction testing, three patients were diagnosed as having a reliable CRPS II (causalgia) and five patients a possible CRPS II. Thirty‐two patients were diagnosed as having a CRPS I. On clinical examination, 15 patients revealed generalized sensory deficits on the side of the body ipsilateral to the affected limb (hemisensory deficit, n=12; sensory impairment in the upper quadrant of the body, n=3). Patients with these generalized sensory deficits had a significantly longer illness duration (P<0.05) and a significantly higher percentage of mechanical allodynia/hyperalgesia than patients with spatially restricted sensory deficits (n=25) (P<0.05). In patients with generalized sensory impairment, thresholds for touch, warm and cold sensations, and for heat pain were significantly increased at all five locations tested ipsilaterally compared with the contralateral body side, except for the cool threshold on the chest and the heat pain threshold distally on the affected limb. In patients with sensory deficits limited to the affected limb, the touch threshold was significantly higher only in the distal part of the affected limb when compared with the contralateral limb. In these patients, thermal testing revealed almost no differences in cool, warm and heat pain thresholds when comparing both sides. Repeated thermal testing conducted in five patients with generalized sensory impairment reproduced the significant differences between both sides for cool, warm and heat pain thresholds. However, the correlation between the results obtained in the first and second examinations was poor. Neurophysiological recordings revealed pathological results in 46% for nerve conduction studies, 24% for somatosensory evoked potentials and 39% for sympathetic skin response. For all methods applied, there was no statistically significant difference in the incidence of pathological results between patients with generalized and patients with spatially restricted sensory abnormalities. Psychological examination using the structured clinical interview on DSM‐IV (SKID) demonstrated a high frequency of affective and anxiety disorders, however, without significant differences between both groups. We conclude that hemisensory impairment in patients with CRPS Type I is probably related to functional disturbances in processing of noxious events in the thalamus and may be a clinical correlate of subcortical brain plasticity in chronic pain.

Hemisensory impairment in patients with complex regional pain syndrome.

The purpose of the present study was to investigate the extent and quality of sensory impairment and their relation to pain characteristics and movement disorders in patients suffering from complex regional pain syndrome (CRPS) type I. Neurological testing was performed independently by two examiners in 24 patients with CRPS type I. In eight patients (33%), a hemisensory impairment with decreased temperature and pinprick sensation ipsilateral to the limb affected by CRPS could be observed. In four patients (17%), a sensory deficit in the upper quadrant of the body could be demonstrated and in eight patients (33%), sensory impairment was limited to the limb affected by CRPS. Mechanical allodynia and mechanical hyperalgesia could be observed in a higher percentage of patients with hemisensory deficit or sensory impairment in the upper quadrant (92%), than in those patients with sensory impairment limited to the affected limb (17%) (P < 0.005). In patients with left-sided CRPS, sensory abnormalities in the upper quadrant or hemisensory impairment were more frequently demonstrated (77%) than in patients with right-sided CRPS (18%) (P < 0.005). There was a high correlation (92%) for the sensory findings between the two examiners, and hemisensory abnormalities were stable over a period of 3-6 months in all six patients with repeated examinations. Motor impairment (contractures, weakness, tremor or difficulties in initiating movement) could be observed in a higher percentage in patients with sensory abnormalities in the upper quadrant or hemisensory impairment (83%) than in patients with sensory impairment limited to the affected limb (42%) (P < 0.05) and was significantly correlated with allodynia/hyperalgesia (P < 0.005). The results demonstrated that sensory deficits in patients with CRPS, frequently extend past the painful area of the affected limb. The increased frequency of mechanical allodynia and movement disorders in patients with hemisensory impairment or sensory deficits in the upper quadrant, might indicate that central mechanisms are involved in the pathogenesis of CRPS in these patients.

Carotid and Vertebral Artery Injury following Severe Head or Cervical Spine Trauma

In order to determine the frequency of neck vessel injuries, Doppler investigations were performed in 60 patients following either severe head injury (n = 29), cervical spine injury (n = 26), or combined head and cervical spine injury (n = 5). The majority of patients were referred to our hospital for early rehabilitation; before admission Doppler investigations had been performed in only 2 patients. Clinically, 3 patients sustained severe cerebral ischemia due to neck vessel trauma: 1 patient with left-sided ICA dissection after head trauma revealed Doppler abnormalities only in the early phase of the disease; the second patient demonstrated persistent Doppler abnormalities due to traumatic right-sided ICA and VA occlusion. The third patient sustained a fatal vertebral and basilar artery thrombosis following cervical spine injury. In 57 patients without clinical signs suspicious of neck vessel trauma, sonography revealed abnormali- ties in 3 patients (11%) with severe head injury and in 6 patients (20%) with cervical spine or combined head and spine injury, in both groups mainly related to the vertebrobasilar system. Neck vessel injury is probably an underdiagnosed complication of severe head or cervical spine trauma. Although interpretation of Doppler findings may be difficult, particularly in the vertebrobasilar system, Doppler investigations can be recommended as a screening method to exclude neck vessel injuries.

Sympathetic skin response in patients with reflex sympathetic dystrophy

The sympathetic skin response (SSR) originates from synchronized activation of the sweat glands as a response to a volley discharge in efferent sympathetic nerve fibres. The aim of the study was to verify the diagnostic value of SSR in patients with reflex sympathetic dystrophy (RSD). SSR was recorded in 20 normal subjects and in 24 patients with predominantly chronic RSD. In normal subjects inter- and intra-individually different mono-, bi- and triphasic potentials could be recorded without difference of the waveform from side to side. SSR abnormalities were found in 15 patients and correlated with the severity of the disease. In patients with slight dystrophies, SSR was predominantly normal. In intermediate dystrophies, mainly differences of the SSR waveform between sides could be recorded, indicating unilateral sudomotor dysfunction. In severe dystrophies abnormalities of SSR amplitude or latency were found, indicating more serious disturbance of sudomotor activity, possibly due to a lesion of sympathetic fibres. The SSR provides useful information on sudomotor dysfunction in patients with RSD. However, as there is no consensus in the literature for the clinical criteria to diagnose RSD, it is not yet possible to determine the final diagnostic value of SSR for the diagnoses of RSD.

Muscle pain in myophosphorylase deficiency (McArdle's disease): the role of gender, genotype, and pain-related coping.

Abstract Pain characteristics were examined in 24 patients with myophosphorylase deficiency (McArdle’s disease). Pain parameters were related to mutation analyses as well as psychosocial data using a pain questionnaire including an assessment of psychosocial distress and coping measures (Beck Depression Inventory BDI; Kiel Pain Inventory KPI, Multidimensional Fatique Inventory MFI). Twenty‐three patients complained of pain, which was intermittent and exercise‐induced in 15 patients. Eight patients complained of permanent pain, which was superimposed by exercise‐induced pain in 7 patients. Patients reported 3–7 different pain characters and various localisations. Patients with permanent pain were significantly more frequently female, experienced higher impact on general activities and sleep as well as higher scores on the MFI. Furthermore, these patients revealed higher scores regarding several psychosocial risk factors including avoidance behavior whereas patients with intermittent pain predominantly showed endurance coping. There was no correlation between age or disease duration, pain intensity as well as mutation type and development of permanent or intermittent pain. In addition, severity of the clinical phenotype did not correlate with ACE polymorphism. Although McArdle’s disease is a muscle glycogenosis with marked biochemical homogeneity, the clinical presentation can be quite heterogeneous. A substantial number of patients revealed permanent pain as a major clinical symptom. As permanent pain is not related to age or disease duration, it might be a clinically important subgroup of McArdle’s disease. Gender‐related genetic factors as well as maladaptive pain‐related coping may contribute to the development of such a chronic pain symptom.

Psychische Veränderungen bei Patienten mit komplexem regionalem Schmerzsyndrom (CRPS)

ZusammenfassungFragestellungTreten bei komplexem regionalem Schmerzsyndrom (CRPS) komorbide psychische Störungen, Störungen der Schmerzverarbeitung sowie der psychosozialen Schmerzbewältigung auf und zeigt sich ein Zusammenhang zwischen klinischen und psychischen Auffälligkeiten?MethodikBei chronischem CRPS wurden neben Anamneseerhebung und klinisch-neurologischer Untersuchung das strukturierte klinische Interview (SKID), die Schmerzempfindungsskala (SES) und das Kieler Schmerzinventar (KSI) eingesetzt.ErgebnisseBei 65% der CRPS-Patienten fanden sich im SKID Hinweise auf eine depressive Episode. Die Schmerzempfindung ist ähnlich wie bei neuropathischen Schmerzsyndromen und prämorbide zeigen sich etwas häufiger Angststörungen und affektive Störungen als in der Normalbevölkerung. Signifikant häufiger zeigte sich bei rechtsseitigem CRPS ein depressives Syndrom, sonst fanden sich keine signifikanten Korrelationen zwischen Anamnese, klinischer Untersuchung und der Häufigkeit psychischer Erkrankungen. Klinisch zeigte sich aber eine besondere psychische Belastung bei Patienten mit Allodynie.SchlussfolgerungBeim chronischen CRPS tritt gehäuft ein depressives Syndrom auf, eine psychologische Mitbehandlung dieser Patienten ist empfehlenswert.AbstractQuestionDo comorbid psychological disorders, dysfunctional pain processing, and psychosocial pain coping occur with complex regional pain syndrome (CRPS) and is a connection between clinical and psychological manifestations apparent?MethodsIn addition to securing information on case histories and performing clinical neurological examinations of chronic CRPS patients, the structured clinical interview (SCID), pain perception scale, and the Kiel Pain Inventory were employed.ResultsThe structured clinical interview revealed evidence of a depressive episode in 65% of CRPS patients. Pain perception is similar to neuropathic pain syndromes and patient history revealed a slightly increased frequency of anxiety and affective disorders. Depressive syndrome occurred significantly more often in right-sided CRPS; otherwise, there were no significant correlations between medical history, clinical examination, and frequency of psychological disorders. However, CRPS patients with allodynia manifest clinical signs of special psychological distress.ConclusionIn chronic CRPS depressive syndrome frequently develops and psychological treatment can be recommended.

„Frontalhirnsyndrom” nach Schädel-Hirn-Trauma oder zerebrovaskulären Erkrankungen

ZusammenfassungDer klinisch gebräuchliche Terminus des „Frontalhirnsyndroms” beschreibt eine heterogene Symptomatik, welche nicht nur nach Schädigung des präfrontalen Kortex, sondern auch bei Läsionen von tieferliegenden, mit dem präfrontalen Kortex in Verbindung stehenden Strukturen beobachtet werden kann. Nach den im Vordergrund stehenden klinischen Merkmalen und unter Berücksichtigung der dabei geschädigten anatomischen Strukturen können Schädigungen des präfrontalen Kortex in 3 Untergruppen unterteilt werden: 1. das desorganisierte Syndrom, welchem eine Schädigung der dorsolateralen Konvexität und ihrer Verbindungen zugrunde liegt; 2. das enthemmte Syndrom, welches durch Läsionen des orbitofrontalen Kortex und seiner Verbindungen verursacht wird und 3. das apathische Syndrom infolge mittelliniennaher Läsionen mit Schädigung der Verbindungen zwischen Gyrus cinguli und supplementär-motorischem Areal. Da intrazerebrale Läsionen nur selten auf die beschriebenen Regionen beschränkt sind finden sich häufig Mischbilder mit bisweilen bizzarren psychopathologischen Auffälligkeiten. Anhand von 4 Fallbeispielen von Patienten mit Schädel-Hirn-Trauma (n=2) oder zerebrovaskulärer Erkrankung (n=2) werden die klinische Problematik veranschaulicht und diagnostische sowie therapeutische Maßnahmen besprochen.SummaryThe term „frontal lobe syndrome” comprises a variety of different clinical syndromes produced by focal lesions involving the prefrontal cortex. However, similar syndromes can be observed after lesions involving subcortical structures connected with the prefrontal cortex in neuronal networks. With respect to the different clinical pictures and underlying brain lesions, prefrontal lobe dysfunction may be divided into a disorganized type, caused by lesion of the dorsolateral prefrontal lobe and its connections, a disinhibited type that can be observed following lesions of the orbitofrontal cortex, and an apathetic type following lesions affecting the functional balance between the cingulum and the supplementary motor area. As intracerebral lesions are rarely limited to the brain regions described, in the majority of patients various degrees of behavioural dysfunction can be observed. The case reports of four patients illustrating the three major prefrontal syndroms following severe head injury (n=2) or cerebrovascular disease (n=2) are presented and diagnostic implications as well as possible treatment strategies are discussed.

Clinical findings in patients with chronic complex regional pain syndrome

PURPOSE What are the clinical findings in patients with chronic complex regional pain syndrome (CRPS)? METHODS Bedside examination was performed in 40 patients with CRPS and a mean illness duration of 43 months. To evaluate motor and autonomic disturbances, rating scales were developed and applied. Quantitative sensory testing (QST) was conducted in 24 patients. RESULTS Clinical examination revealed sensory abnormalities in 93% of patients examined (in 56% limited to the affected limb, in 7% in the upper quadrant of the body, in 30% hemisensory impairment of the ipsilateral body side), and 60% of the patients suffered from mechanical allodynia in the affected limb. Patients with generalized sensory impairment had a significantly longer illness duration, pain intensity and significantly higher frequency of mechanical allodynia/hyperalgesia than patients with sensory deficits limited to the limb affected. In patients with generalized sensory abnormalities, QST revealed significant changes of cold, warm and touch thresholds on the ipsilateral compared to the contralateral body side. Mild/moderate motor abnormalities could be demonstrated in 45% of patients, tremor (50%), impaired joint movements, 45%, and 40% of patients revealed autonomic disturbances. CONCLUSION In chronic CRPS, among clinical symptoms and signs, pain and sensory impairment play a major role. Mechanical allodynia reveals the highest level of subjective disability among all symptoms. With respect to hemisensory impairment, functional disturbances of central pain processing in the nucleus ventralis posterior of the thalamus are postulated.

Klinische Auffälligkeiten bei Patienten mit chronischem komplexen regionalen Schmerzsyndrom (sympathische Reflexdystrophie/Kausalgie)

PURPOSE What are the clinical findings in patients with chronic complex regional pain syndrome (CRPS)? METHODS Bedside examination was performed in 40 patients with CRPS and a mean illness duration of 43 months. To evaluate motor and autonomic disturbances, rating scales were developed and applied. Quantitative sensory testing (QST) was conducted in 24 patients. RESULTS Clinical examination revealed sensory abnormalities in 93% of patients examined (in 56% limited to the affected limb, in 7% in the upper quadrant of the body, in 30% hemisensory impairment of the ipsilateral body side), and 60% of the patients suffered from mechanical allodynia in the affected limb. Patients with generalized sensory impairment had a significantly longer illness duration, pain intensity and significantly higher frequency of mechanical allodynia/hyperalgesia than patients with sensory deficits limited to the limb affected. In patients with generalized sensory abnormalities, QST revealed significant changes of cold, warm and touch thresholds on the ipsilateral compared to the contralateral body side. Mild/moderate motor abnormalities could be demonstrated in 45% of patients, tremor (50%), impaired joint movements, 45%, and 40% of patients revealed autonomic disturbances. CONCLUSION In chronic CRPS, among clinical symptoms and signs, pain and sensory impairment play a major role. Mechanical allodynia reveals the highest level of subjective disability among all symptoms. With respect to hemisensory impairment, functional disturbances of central pain processing in the nucleus ventralis posterior of the thalamus are postulated.

Epidural Hematoma and Hemorrhagic Infarction Mimicking a Left Temporal Meningioma

This 72-year-old man presented with subacute onset of dizziness, disturbed orientation and a mild left-sided hemiparesis because he had trouble seeing objects coming from the left side. Clinically the incomplete hemianopia was the most obvious focal neurological deficit. CCT (fig. 1) and MRI (fig. 2) were followed by an angiography, which surprisingly did not show the supposed meningioma, but only disturbances of autoregulation in the temporo-occipital vessels of the middle cerebral artery (MCA) territory. Follow-up MRI revealed the origin by demonstrating (fig. 3) a subacute hemorrhagic infarction in the temporal MCA complicated by a small epidural hematoma (fig. 4), which was misinterpreted in the early CCT and MRI. The patient had been under aspirin-therapy because of coronary artery disease.