Philippe Hanson

Acute corticosteroid myopathy in intensive care patients.

Several recent studies have attributed the occurrence of acute myopathy in intensive care unit patients to the combination of corticosteroids and neuromuscular junction blocking agents (NMBAs) used for mechanical ventilation. We present 4 patients who developed acute myopathy after administration of high doses of glucocorticoids during sedation with propofol without any NMBAs. All patients had elevated creatine kinase levels. Electrophysiological studies indicated normal motor and sensory nerve conduction velocities but reduced motor nerve response amplitudes. Needle electromyography identified abnormal spontaneous activity; motor unit potentials were polyphasic of low amplitude and short duration, characteristic of a myopathic process. Muscle biopsy demonstrated a prominent acute necrotizing myopathy in all 4 patients with a loss of thick filaments. Our observations support glucocorticoids rather than NMBAs as the main offending drug in acute corticosteroid myopathy. The predisposing factor should be the hypersensitivity of paralyzed muscles to corticosteroids regardless of the drug inducing paralysis: NMBAs or propofol.

Treatment of genu recurvatum in hemiparetic adult patients: A systematic literature review

INTRODUCTION AND METHODS We carried out a systematic review of the literature on treatment of genu recurvatum in hemiparetic adult patients by searching the PubMed, Pedro, Trip Database and Science Direct databases. The following keywords were used: (recurvatum or hyperextension or knee) and (hemiplegia or hemiparesis). RESULTS Nine articles met our selection criteria. Four assessed retraining methods (functional electric stimulation or electrogoniometric feedback), two assessed orthopaedic or neurosurgical treatments and three articles focused on orthoses. DISCUSSION AND CONCLUSION Even though all the various treatments produced encouraging results, most of the reviewed studies presented methodological limitations. Moreover, none of the selected articles suggested a treatment strategy which takes account of the various aetiologies in genu recurvatum. On the basis of some of the reviewed articles and our own clinical experience, we propose an aetiology-specific treatment strategy for genu recurvatum patients. In a broad patient population, this categorization could form the basis for testing the specificity of each treatment method as a function of the cause of genu recurvatum. This approach could help confirm the clinical indications and identify the most appropriate treatment for each patient.

Selective blocks of the motor nerve branches to the soleus and tibialis posterior muscles in the management of the spastic equinovarus foot

OBJECTIVE To identify the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor nerve blocks in the management of the spastic equinovarus foot. DESIGN Descriptive study by computed tomography (CT) scan of 12 hemiplegic legs. SETTING Spasticity group at a university hospital. PARTICIPANTS Twelve patients with hemiplegia (6 men, 6 women) with spastic equinovarus foot. INTERVENTION Three-dimensional location of the motor nerve branches to the soleus and tibialis posterior muscles with CT scan, followed by selective motor branch blocks with anesthetics. MAIN OUTCOME MEASURES Vertical, horizontal, and deep coordinates determined by CT scan in relation to anatomic surface landmarks (upper extremity of the fibula and vertical metallic element). Soleus and tibialis posterior spasticity (Ashworth Scale), soleus H-wave maximum (Hmax)/M-wave maximum (Mmax) ratio, and sensory testing before and after the blocks. RESULTS The mean coordinates +/- standard deviation for the soleus motor branch were 10+/-5 mm (vertical), 17+/-9 mm (horizontal), and 30+/-4 mm (deep); for the tibialis posterior motor branch they were 45+/-6mm (vertical), 17+/-8mm (horizontal), and 47+/-4 mm (deep). Spasticity and Hmax/Mmax ratio decreased after the blocks, confirming their efficiency. No subjects experienced additional sensory deficit. CONCLUSION Our study determined the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor branch blocks and neurolytic procedures. These coordinates allow us to perform selective motor blocks without CT scan.

The influence of skin temperature on latency and amplitude of the sympathetic skin response in normal subjects.

The influence of skin temperature on latency and amplitude of the sympathetic skin response (SSR) was studied in 10 normal subjects. SSRs were elicited in all four limbs of each subject by electrical stimulation after cooling of the right arm and after cooling of the right hand only. At low skin temperature, the latency was prolonged and the amplitude decreased. Latency and amplitude were linearly correlated with skin temperature of the right arm. There were no changes in the left arm and the legs, which basically excludes involvement of central pathways in these response parameters. With regard to the skin temperature of the arm, a temperature correction factor of 0.088 s/°C was calculated for latency. With regard to the skin temperature of the hand, latency prolongation was significantly greater after cooling of the whole arm. This suggests that not only the neuroglandular junction, but also the postganglionic sympathetic C fibers were responsible for latency modifications. In contrast, amplitude was reduced similarly after cooling of the whole arm and the hand only, suggesting that mainly the neuroglandular junction is responsible for amplitude modifications. We conclude that skin temperature is a mandatory measurement in the study of the SSR.

Evaluation of somatic and autonomic small fibers neuropathy in diabetes.

The relationship between somatic and autonomic neuropathy was assessed in the feet of 30 diabetic patients. Somatic small fiber function was evaluated by the thermal threshold test for cold (A5 fibers) and warmth (C fibers). Telethermography and transcutaneous oxygen tension were used to investigate the autonomic control of peripheral circulation. Autonomic neuropathy caused the opening of arteriovenous anastomosis, which was revealed through an elevation of the feets temperature and a low transcutaneous oxygen tension. The association of the opening of the arteriovenous anastomosis and the perturbation of the thermal threshold test established a relationship between the dysfunction of the autonomic and the somatic fibers.

Skin potential recordings during cystometry in spinal cord injured patients

In order to investigate autonomic mechanisms associated with bladder filling and bladder contraction, skin potentials from the hands and the feet of 32 spinal cord injured patients were recorded during cystometry. All had a complete clinical loss of motor and sensory function below the lesion, but in 3 patients, the autonomic lesion was electrophysiologically assessed as incomplete. In patients with a complete autonomic lesion, any rise in intravesical pressure associated with bladder hyperreflexia induced SP responses below the level of the lesion. SP responses were never obtained during bladder filling, as the intravesical pressure remained low. These results tend to confirm those of Guttmann and Whitteridge, but differ in so far as SP responses at the foot were a regular finding in all paraplegic and in most tetraplegic patients. Furthermore, bladder contraction failed to elicit SP responses below the level of the lesion in patients with an incomplete autonomic lesion. This study emphasises the importance of assessing the integrity of the autonomic nervous pathways when dealing with autonomic mechanisms in spinal cord injured patients. The possible relation between SP responses and bladder neck dysfunction is further discussed.

Selective tibial neurotomy in the treatment of spastic equinovarus foot: a 2-year follow-up of three cases.

Deltombe T, Detrembleur C, Hanson P, Gustin T: Selective tibial neurotomy in the treatment of spastic equinovarus foot: A 2-year follow-up of three cases. Am J Phys Med Rehabil 2006;85:82–88. Objective:To objectively assess the decrease in spasticity and the improvement in gait after tibial nerve neurotomy performed to treat spastic equinovarus foot. Design:Before–after trial with a 2-yr follow-up. Three hemiplegic patients with spastic equinovarus foot were treated with a selective peripheral neurotomy of the tibial motor nerve branches (soleus, lateral and medial gastrocnemius and tibialis posterior nerves). Evaluation included clinical assessment of spasticity (Ashworth scale), maximal Hoffmann reflex (Hmax)/compound muscle action potential (Mmax) ratio measurement, gait analysis, and muscle stiffness evaluation performed before and 2 mos, 1 yr, and 2 yrs after the neurotomy. Results:Spasticity, muscle stiffness, and Hmax/Mmax ratio decreased after neurotomy. The kinematic (ankle dorsal flexion and knee recurvatum) and kinetic variables (maximum ankle muscle moment and external work) of the gait were permanently improved after neurotomy. Interestingly, kinetic variables seemed to gradually improve with time after the neurotomy. Conclusion:Tibial neurotomy is an effective and durable treatment for spastic equinovarus foot.

Sacral reflex latencies in tethered cord syndrome.

We performed electrophysiologic evaluation in three adult patients with diagnosis of tethered cord syndrome confirmed by magnetic resonance imaging. In addition to lower motor neuron lesion signs in the lumbar and sacral myomeres we noticed shortened latencies for the H and bulbocavernosus reflexes. H reflex latencies ranged from 23.3 to 26.0 ms; bulbocavernosus reflex latencies ranged from 18.2 to 20.2 ms. The low location of the conus medullaris accounts for the shortening of the monosynaptic H reflex and for a part of the shortening of the polysynaptic bulbocavernosus reflex, anoxia of the conus being probably another important factor. In the absence of previous description of alternative pathology accountable for such a shortening, our observations suggest that shortened sacral reflex latencies might be specific of the tethered cord syndrome.

Abdominal wall weakness and lumboabdominal pain revealing neuroborreliosis: a report of three cases.

Abstract: The authors report three cases of thoracic radiculoneuropathy disclosing neuroborreliosis. All three patients had low back and abdominal pain and two had marked abdominal wall paresis. EMG confirmed a motor involvement of the lower thoracic roots and CSF analysis revealed a lymphocytic meningitis in all three cases. Antibodies against Borrelia burgdorferi were present in both the serum and the CSF. A favourable outcome was obtained in all three patients with appropriate antibiotherapy. The differential diagnosis of this misleading presentation is discussed.

Cervical spinal cord injury in sapho syndrome.

Cervical spinal fracture and pseudarthrosis are previously described causes of spinal cord injury (SCI) in patients with spondylarthropathy. SAPHO (Synovitis Acne Pustulosis Hyperostosis Osteitis) syndrome is a recently recognized rheumatic condition characterized by hyperostosis and arthro-osteitis of the upper anterior chest wall, spinal involvement similar to spondylarthropathies and skin manifestations including palmoplantar pustulosis and pustular psoriasis. We report the first case of SAPHO syndrome disclosed by SCI related to cervical spine ankylosis.