Palma Ciaramitaro

Traumatic peripheral nerve injuries: epidemiological findings, neuropathic pain and quality of life in 158 patients

The objectives of this study were (1) epidemiological analysis of traumatic peripheral nerve injuries; (2) assessment of neuropathic pain and quality of life in patients affected by traumatic neuropathies. All consecutive patients with a diagnosis of traumatic neuropathies from four Italian centres were enrolled. Electromyography confirmed clinical level and site diagnosis of peripheral nerve injury. All patients were evaluated by disability scales, pain screening tools, and quality of life tests. 158 consecutive patients for a total of 211 traumatic neuropathies were analysed. The brachial plexus was a frequent site of traumatic injury (36%) and the radial, ulnar, and peroneal were the most commonly involved nerves with 15% of iatrogenic injuries. Seventy‐two percent of the traumatic neuropathies were painful. Pain was present in 66% and neuropathic pain in 50% of all patients. Patients had worse quality of life scores than did the healthy Italian population. Moreover, there was a strong correlation between the quality of life and the severity of the pain, particularly neuropathic pain (Short Form‐36 [SF‐36] p < 0.005; Beck Depression Inventory [BDI] p < 0.0001). Traumatic neuropathies were more frequent in young males after road accidents, mainly in the upper limbs. Severe neuropathic pain and not only disability contributed to worsening the quality of life in patients with traumatic neuropathies.

Electrophysiological findings of peripheral neuropathy in newly diagnosed type II diabetes mellitus.

Abstract  This study was aimed at assessing the electrophysiological signs of peripheral neuropathy in diabetes mellitus (DM) type II patients at diagnosis. Nerve conduction studies (NCS) of median, ulnar, peroneal, tibial and sural nerves were performed in 39 newly diagnosed DM subjects and compared to those of 40 healthy controls. Metabolic indices were also investigated. Electrophysiological alterations were found in 32 (82%) of the DM patients, and more than half of them (62.2%) showed multiple (two to five) abnormal parameters. Because most of the subjects (84.4%) had from two to five nerves involved, these alterations were widespread in the seven nerves evaluated. Forty‐two percent of the patients had NCS alterations suggestive of distal median mononeuropathy, implying that metabolic factors in DM make the median nerve more susceptible to focal entrapment. A reduced sensory nerve action potential (SNAP) amplitude was observed in the median nerve in 70% of the patients, in the ulnar in 69% and in the sural nerve only in 22%. In the presence of a decrease in the SNAP amplitude of the ulnar or median nerve, the SNAP amplitude of the sural nerve was normal in 82 or 80% of the subjects, respectively. This finding may be in keeping with a distal involvement of the sensory fibres, as explored by routine median or ulnar NCS. No correlation was found between metabolic indices and NCS parameters. In conclusion, a high percentage of newly diagnosed DM patients show signs of neuropathy, and upper limb nerve sensory NCS seem to be more sensitive in detecting it than lower limb NCS.

Multifocal motor neuropathy during treatment with infliximab

Dear Editor, Infliximab (Remicade ) is a chimeric human/murine immunoglobulin G1 (IgG1) anti-tumour necrosis factor-a (TNF) antibody. Although TNF antagonists are among the most potent and rapidly effective treatments for rheumatoid arthritis (RA) (Olsen and Stein, 2004), a number of adverse effects, including induction or worsening of demyelinating central nervous system diseases, have been reported (Mohan et al., 2001; Sicotte and Voskuhl, 2001). Three cases of motor neuropathy with conduction blocks (Singer et al., 2004; Rodriguez-Escalera et al., 2005) have been reported in patients on infliximab; two of these patients had Crohn’s disease and seronegative arthritis, while one had polyarthritis and Hepatitis C with mixed cryoglobulinaemia. Herein, we report yet another patient with onset of multifocal motor neuropathy (MMN) and conduction blocks during infliximab treatment. A 40-year-old woman with a 10-year history of RA was started on infliximab treatment in January 2003 (3 mg/kg intravenous every 8 weeks) with a satisfactory response in the months that followed. However, she developed asymmetric progressive weakness of right forearm flexion and of intrinsic muscles of right hand in October 2003. Neurological evaluation (January 2004) disclosed the presence of severe weakness of the right biceps brachii (0/5 according to Medical Research Scale Score), the right extensor carpi radialis, extensor digitorum communis, extensor indicis, abductor pollicis brevis, abductor digiti minimi, and interossei (3/5) and moderate weakness of the left deltoid, extensor digitorum communis, extensor index, interossei, left tibialis anterior, and gastrocnemius (4/5). Tendon reflexes were normal apart from the absence of response in the right biceps. There was no detectable sensory loss. The neurological examination was otherwise unremarkable. Nerve conduction studies showed the presence of definite conduction block in both median and ulnar nerves, right radial, left peroneus, and tibial nerves. A significant decrease in motor conduction velocity was evident in both the median nerves. Sensory conduction studies of the bilateral median, radial, ulnar and sural nerves were unremarkable. Brain and spinal cord magnetic resonance imaging and cerebrospinal fluid examination were normal. DNA analysis was negative for the presence of the 1.5-Mb deletion in chromosome 17p11.2 associated with hereditary neuropathy with liability to pressure palsy. Routine screening tests for thyroid pathologies, hepatitis, cryoglobulinaemia and vasculitis were negative. IgM anti-GM1 antibodies were positive at high titre (1 : 640) (Antigen Coated Membrane Strips Euroimmun). The patient satisfied the diagnostic criteria for MMN established by Olney (Olney et al., 2003). Infliximab treatment was stopped in March 2004, and the patient was treated with intravenous immunoglobulins (1 g/kg/day for 2 days monthly), and muscle strength progressively improved. At the last follow up, in February 2005, there was a marked increase in the muscle strength, with only residual moderate weakness (4/5) affecting only the biceps, extensors carpi radialis and interossei muscles. Nerve conduction studies demonstrated a reduction in the number of blocks. The timing of the onset of neuropathy reported in literature varies greatly, i.e., after 2 years of infliximab therapy in one case, 3 months in another (Singer et al., 2004), 14 weeks in a case reported by RodriguezEscalera et al. (2005) and after 9 months in our case. The therapeutic schedule also varied in all cases. A spontaneous remission of the neuropathy was observed in the two cases reported by Singer, after suspension of the treatment. Whilst in our case and that of RodriguezEscalera, a therapy with immunoglobulins was administered in both cases with a positive outcome. Lastly, in both our cases and the case reported by RodriguezEscalera, there was a positivity to antiganglioside antibodies. MMN was not a neurologic complication of RA (Nobile-Orazio et al., 2005), and the onset of MMN Address correspondence to: Dr. Dario Cocito, MD, U.O. Neurofisiologia Clinica, Dipartimento di Neuroscienze, Università di Torino, Via Cherasco 15, 10126 Torino, Italy, Tel: þ39-0116-335243; Fax: þ39-0116-963487; E-mail: dariococito@yahoo.it Journal of the Peripheral Nervous System 10:386–387 (2005)

Validation of the Italian version of the Neuropathic Pain Symptom Inventory in peripheral nervous system diseases

The aim of this study was to validate the Italian version of the Neuropathic Pain Symptom Inventory (NPSI) in patients with neuropathic pain due to peripheral nerve diseases, and also to evaluate the validity of a new NPSI score: a frequency weighted NPSI score (NPSI-FW). First, the original version of the NPSI was translated into Italian. Then the validity and reliability of the Italian NPSI (I-NPSI) were tested in 392 Italian patients consecutively referred to 16 Italian outpatient services for peripheral nerve diseases, by correlating the I-NPSI scores with other pain scales. The repeatability and responsiveness were assessed. A significant correlation between the I-NPSI scores and all the other pain measures was seen. Reproducibility and responsiveness were good. Our study shows the validity of the I-NPSI and demonstrates its reliability for assessing neuropathic pain in patients with peripheral nerve diseases. The I-NPSI scores represent reliable measurements to assess neuropathic symptoms and effectiveness of treatment on them.

Pain affects the quality of life of neuropathic patients

The aim of this study was to verify the extent to which the presence of pain affects the quality of life (QoL) of neuropathic patients. The patients were selected in our Department of Peripheral Nervous System Diseases. We enrolled 120 consecutive patients with chronic polyneuropathy who had not received continuous pain therapy during the two months preceding study entry, and administered them the Total Neuropathy Score (TNS), the official Italian version of the SF-36 and the Italian Pain Questionnaire (QUID). Our main finding was that the QoL is affected not only by the presence of neuropathy, but also by the presence and intensity of pain: the physical aspect of the QoL correlated only weakly with the TNS, but pain was closely related to a worsening in this parameter; moreover, the mental domains of the SF-36 were only correlated with pain. Pain per se worsens the QoL of neuropathic patients, regardless of disease severity.

Neuropathic pain in post‐burn hypertrophic scars: A psychophysical and neurophysiological study

Introduction: Pain complicates hypertrophic post‐burn pathologic scars (PPS) Methods: To investigate the possible neuropathic origin of pain, 13 patients with painful PPS involving at least 1 hand underwent clinical examination, including the Douleur Neuropathique en 4 questions (DN4) questionnaire; median, ulnar, and radial nerve conduction studies (NCS); cold‐ (CDT) and heat‐induced pain threshold evaluation by quantitative sensory testing; and cutaneous silent period (CSP) testing of the abductor pollicis brevis. Controls included 9 patients with non‐painful PPS, 52 healthy subjects, and 28 patients with carpal tunnel syndrome (CTS). Results: All patients with painful PPS had possible neuropathic pain (DN4 score ≥4). NCS signs of CTS were similarly present in PPS subjects with or without pain. Hands with painful PPS had lower CDT and CSP duration, more frequent cold‐ and heat‐pain hypesthesia, and more thermal allodynia than controls. Conclusions: In PPS, possible neuropathic pain is associated with psychophysical and neurophysiological abnormalities suggestive of small‐fiber damage. Muscle Nerve 45: 883–890, 2012

Short-Term Efficacy of Ultramicronized Palmitoylethanolamide in Peripheral Neuropathic Pain

Introduction. This study evaluates the efficacy of palmitoylethanolamide ultramicronized (PEA-um) as an add-on treatment in patients with diabetic or traumatic neuropathic pain (NP). Methods. 30 patients with chronic NP were assessed with Visual Analogue Scale (VAS), NP Symptom Inventory (NPSI), and Health Questionnaire Five Dimensions (EQ-5D), both at baseline and after 10 and 40 days of treatment with 1200 mg/die of PEA-um. All other therapies were maintained stable during the follow-up period. Results. VAS mean score significantly improved within the first 10 days, ranging from 8.20 ± 1.53 to 6.40 ± 1.83 (P < 0.002), with a further decrease to 5.80 ± 2.04 (P < 0.001) after 40 days of PEA-um administration. Moreover, NPSI total score improved from 5.2 ± 1.5 to 3.8 ± 2.1 (P: 0.025) and EQ-5D ranged from −0.30 ± 0.65 to 0.5 ± 0.34 (P < 0.001) between T0 and T2. Conclusions. This study reports the prospective short-term efficacy data of oral PEA-um in patients with diabetic or traumatic NP. A significant improvement was observed both in VAS and NPSI scores and in quality of life scales after 40 days of treatment, although some limitations should be considered, including the short followup and the open-label study design.

High prevalence of neuropathies in patients with end-stage liver disease.

Cocito D, Maule S, Paolasso I, Castelli L, Ciaramitaro P, Poglio F, Ottobrelli A, Grimaldi S. High prevalence of neuropathies in patients with end‐stage liver disease.
Acta Neurol Scand: 2010: 122: 36–40.
© 2009 The Authors Journal compilation

Prevalence of Neuropathic Pain in Patients with Traumatic Brachial Plexus Injury: A Multicenter Prospective Hospital-Based Study

Objective Prevalence and clinical characteristics of neuropathic pain due to traumatic brachial plexus injury. Design Observational epidemiological study. Setting Hospital-based multicenter study. Subjects One hundred seven prospectively enrolled patients with brachial plexus injury. Methods All the patients underwent clinical examination and neurophysiological testing for a definitive diagnosis of the brachial plexus lesion. The DN4 questionnaire was used to identify neuropathic pain, and the Neuropathic Pain Symptom Inventory (NPSI) to evaluate the different symptoms of neuropathic pain. The SF36 questionnaire and the Beck Depression Inventory (BDI) were used to assess quality of life and mood disturbances in patients with neuropathic pain. Results Of the 107 enrolled patients, 74 had pain (69%); neuropathic pain, as assessed by means of the DN4, was identified in 60 (56%) of these patients. According to the NPSI, the most frequent and severe pain type was the spontaneous burning pain. Clinical and neurophysiological findings showed that pain is unrelated to age but is associated with the severity of peripheral nerve damage. The SF36 questionnaire and BDI showed that neuropathic pain impairs quality of life and causes depression. Conclusions Our study provides information on the prevalence, characteristics, and variables associated with neuropathic pain due to traumatic brachial plexus injuries that might provide a basis for improving the clinical management of this condition.

Subclinical electrophysiological alterations of phrenic nerve in chronic inflammatory demyelinating polyneuropathy.

Alterations of the phrenic nerve (PN) and pulmonary function tests (PFTs) have been described in patients with chronic inflammatory demyelinating polyneuropathy (CIDP). This study was aimed at assessing the relationship between PN and respiratory function in CIDP patients without clinical signs of respiratory failure. Bilateral PN and right median nerve conduction studies were carried out along with blood gas analysis and PFTs: maximal inspiratory pressure; maximal expiratory pressure; forced vital capacity. The amplitude of the compound muscle action potential of the PN was seen to be altered in 19/24 (79%) patients and latency in 22 (92%). Eighteen patients (75%) showed at least one abnormal PFTs or CO2 partial pressure value. Electrophysiological alterations of the PN were observed in a high percentage of the CIDP patients studied. No statistically significant correlation was observed between PN and PFTs alterations.