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Abstract
Skin biopsy for epidermal nerve fiber analysis provides an important objective test for the diagnosis of peripheral neuropathy, particularly small fiber sensory neuropathy (SFSN). The determination of epidermal nerve fiber density (ENFD) is reliable, with high diagnostic specificity and good sensitivity. Because of false negatives, biopsy results must be interpreted in conjunction with neurologic findings and laboratory results, including objective tests of sensory and autonomic function. SFSN most commonly is length dependent and is idiopathic in about half the patients. Biopsy of a proximal site (thigh) and a distal site (calf) typically shows greater abnormality of ENFD distally than proximally. More severe abnormality of ENFD in the thigh than in the calf raises the possibility of a non-length-dependent SFSN. The causes of this type of neuropathy, such as Sjögren's syndrome, sarcoidosis, and celiac disease, may be treatable.
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Petersen KL, Rice FL, Farhadi M, Reda H, Rowbotham MC. Natural history of cutaneous innervation following herpes zoster. Pain 2010; 150:75-82. [DOI: 10.1016/j.pain.2010.04.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 03/01/2010] [Accepted: 04/05/2010] [Indexed: 12/26/2022]
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Mandel SA, Morelli M, Halperin I, Korczyn AD. Biomarkers for prediction and targeted prevention of Alzheimer's and Parkinson's diseases: evaluation of drug clinical efficacy. EPMA J 2010. [PMID: 23199065 PMCID: PMC3405324 DOI: 10.1007/s13167-010-0036-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Neurodegenerative diseases like Parkinson’s disease (PD) and Alzheimer’s disease (AD) are considered disorders of multifactorial origin, inevitably progressive and having a long preclinical period. Therefore, the availability of biological markers or biomarkers (BMs) for early disease diagnosis will impact the management of AD and PD in several dimensions; it will 1) help to capture high-risk individuals before symptoms develop, a stage where prevention efforts might be expected to have their greatest impact; 2) provide a measure of disease progression that can be evaluated objectively, while clinical measures are much less accurate; 3) help to discriminate between true AD or PD and other causes of a similar clinical syndrome; 4) delineate pathophysiological processes responsible for the disease; 5) determine the clinical efficacy of novel, disease-modifying (neuroprotective) strategies. In the long run the availability of reliable BMs will significantly advance the research and therapeutics of AD and PD.
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Affiliation(s)
- Silvia A. Mandel
- Eve Topf Center for Neurodegenerative Diseases Research and Department of Molecular Pharmacology, Faculty of Medicine, Technion, Haifa, Israel
| | - Micaela Morelli
- Department of Toxicology and Centre of Excellence for Neurobiology of Dependence, University of Cagliari, Cagliari, Italy
| | - Ilan Halperin
- The Israeli Psycological Association, Beersheba, Israel
| | - Amos D. Korczyn
- Tel-Aviv University Medical School Sieratzki Chair of Neurology, Ramat-Aviv, Israel
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Cruccu G, Sommer C, Anand P, Attal N, Baron R, Garcia-Larrea L, Haanpaa M, Jensen TS, Serra J, Treede RD. EFNS guidelines on neuropathic pain assessment: revised 2009. Eur J Neurol 2010; 17:1010-8. [DOI: 10.1111/j.1468-1331.2010.02969.x] [Citation(s) in RCA: 391] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gemignani F, Brindani F, Vitetta F, Marbini A. Restless legs syndrome and painful neuropathy-retrospective study. A role for nociceptive deafferentation? PAIN MEDICINE 2010; 10:1481-6. [PMID: 20021603 DOI: 10.1111/j.1526-4637.2009.00732.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Restless legs syndrome (RLS) occurs in polyneuropathy with small fiber involvement, possibly as a peculiar form of neuropathic pain; however, the relationship between pain and RLS has been poorly investigated in polyneuropathy. DESIGN, SETTING, AND PATIENTS We evaluated retrospectively the occurrence of RLS in 102 consecutive patients with polyneuropathy manifesting with neuropathic pain or dysesthesia, referred to the Neuromuscular Center, using the National Institutes of Health criteria for RLS. The patients were classified in subgroups characterized respectively by allodynia (hyperphenomena), with reported unpleasant sensations evoked by tactile stimuli, and hypoalgesia (hypophenomena), with absent pain sensation to pinprick, according to putative mechanisms of pain. RESULTS RLS was present in 41/102 patients (40.2%). It was significantly more frequent in the "hypoalgesia" (23/37) than in the "allodynia" subgroup (9/31; P = 0.008) and in the not classifiable cases (9/34; P = 0.004). CONCLUSIONS RLS is frequent in painful polyneuropathy and is significantly associated with decreased small fiber input, thus nociceptive deafferentation may represent a factor interacting with RLS "generators," possibly at spinal level. We suggest that overactivity of the spinal structures implicated in RLS may be triggered by nociceptive deafferentation in a subgroup of patients with painful polyneuropathy. Our findings, prompting a mechanistic characterization of RLS associated with painful polyneuropathy, have to be confirmed in a prospective study.
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Affiliation(s)
- Franco Gemignani
- Department of Neurosciences, Section of Neurology, University of Parma, Parma, Italy
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Liao MF, Lee M, Hsieh MJ, Cheng MY, Lee JD, Weng HH, Ro LS. Evaluation of the pathophysiology of classical trigeminal neuralgia by blink reflex study and current perception threshold testing. J Headache Pain 2010; 11:241-6. [PMID: 20186560 PMCID: PMC3451913 DOI: 10.1007/s10194-010-0198-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 02/02/2010] [Indexed: 01/21/2023] Open
Abstract
We recruited 49 patients with classical trigeminal neuralgia (TN) according to the latest guidelines of the International Classification of Headache Disorders, and divided them into an acute (≤30 days onset; 13 patients) and a chronic (>30 days onset; 36 patients) group. We used blink reflex study and current perception threshold (CPT) testing to evaluate the painful facial areas and contralateral non-painful areas of patients with classical TN. CPT 5 Hz examinations, which correlate with unmyelinated fiber function, showed significantly decreased CPTs in the acute stage (11.62 ± 6.99 vs. 18.69 ± 9.66, P = 0.025), but significantly increased CPTs in the chronic stage (26.67 ± 18.65 vs. 19.69 ± 13.70, P = 0.010) on the painful side when compared with the contralateral non-painful side. However, CPTs at 250 Hz (Aδ) and 2000 Hz (Aβ) examinations did not show significant differences between the painful and non-painful sides. In contrast, only three (3/49) patients showed an abnormal trigeminal nerve stimulation on the ipsilateral painful side by blink reflex study. The findings suggest that classical TN is not a simple large-myelinated nerve fiber dysfunction but a more complex process with a main dysfunction of unmyelinated nerve fibers.
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Affiliation(s)
- Ming Feng Liao
- Department of Neurology, Linkou Headquarters, Chang Gung Memorial Hospital and College of Medicine, Chang-Gung University, 199, Tung Hwa North Road, Taipei, Taiwan
| | - Meng Lee
- Department of Neurology, Chiayi Branch, Chang Gung Memorial Hospital and College of Medicine, Chang-Gung University, Taipei, Taiwan
| | - Mei Jen Hsieh
- Department of Neurology, Kaohsiung Branch, Chang Gung Memorial Hospital and College of Medicine, Chang-Gung University, Taipei, Taiwan
| | - Mei Yun Cheng
- Department of Neurology, Linkou Headquarters, Chang Gung Memorial Hospital and College of Medicine, Chang-Gung University, 199, Tung Hwa North Road, Taipei, Taiwan
| | - Jiann Der Lee
- Department of Neurology, Chiayi Branch, Chang Gung Memorial Hospital and College of Medicine, Chang-Gung University, Taipei, Taiwan
| | - Hsu Huei Weng
- Diagnostic Radiology, Chiayi Branch, Chang Gung Memorial Hospital and College of Medicine, Chang-Gung University, Taipei, Taiwan
| | - Long Sun Ro
- Department of Neurology, Linkou Headquarters, Chang Gung Memorial Hospital and College of Medicine, Chang-Gung University, 199, Tung Hwa North Road, Taipei, Taiwan
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Abstract
OBJECTIVES Dysaesthesias is a common symptom in patients with neuropathic pain after peripheral nerve injury (PNI). In contrast to neuropathies with comparable symptoms there is little knowledge of the underlying mechanisms in PNI patients. METHODS Quantitative sensory testing according to the German Research Network on Neuropathic Pain protocol, and changes in intraepidermal nerve fiber density were assessed in 15 patients with dysaesthesias after PNI of the lower limb. According to their small-fiber function patients were assigned into 2 subgroups. RESULTS The sensory profiles of PNI patients were characterized predominantly by minus symptoms (significantly increased thresholds for perception of cold, warm, touch and vibration, and significantly increased thresholds for heat and mechanical pain) on the affected compared with the unaffected side. The only plus symptom reported was a significantly reduced pressure pain threshold. The sensory profile of patients with a severe loss of small-fiber function (n=7) showed a thermal and tactile hypoaesthesia and hypoalgesia; this was in contrast to patients with a moderate loss of small-fiber function, who showed a mild thermal and tactile hypoaesthesia associated with an increased mechanical pain sensitivity. Mean intraepidermal nerve fiber density was significantly decreased in the affected compared with unaffected skin [3.50 (4.00) vs. 11.10 (7.60) fibers/mm] and correlated with warm and mechanical detection thresholds (both r=-0.60). DISCUSSION In conclusion, even though patients presented with comparable clinical symptoms, their sensory profiles differed, supporting the concept of different underlying mechanisms leading to chronic pain in PNI patients. Skin biopsies support the validity of quantitative sensory testing.
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Alves de Medeiros M, Startin CM, Jeffery ND. Innervation of canine skin: an immunohistochemical study. Vet Rec 2009; 165:314-8. [DOI: 10.1136/vr.165.11.314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- M. Alves de Medeiros
- Department of Physiological Sciences; Universidade Federal Rural do Rio de Janeiro; BR 465 KM 7 23890 000 Rio de Janeiro Brazil
| | - C. M. Startin
- School of Biomedical Sciences; Institute of Neuroscience; University of Nottingham; Queen's Medical Centre; Nottingham NG7 2UH
| | - N. D. Jeffery
- Department of Veterinary Medicine; University of Cambridge; Madingley Road Cambridge CB3 0ES
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Camdessanché JP, Jousserand G, Ferraud K, Vial C, Petiot P, Honnorat J, Antoine JC. The pattern and diagnostic criteria of sensory neuronopathy: a case-control study. Brain 2009; 132:1723-33. [PMID: 19506068 PMCID: PMC2702838 DOI: 10.1093/brain/awp136] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Acquired sensory neuronopathies encompass a group of paraneoplastic, dysimmune, toxic or idiopathic disorders characterized by degeneration of peripheral sensory neurons in dorsal root ganglia. As dorsal root ganglia cannot easily be explored, the clinical diagnosis of these disorders may be difficult. The question as to whether there exists a common clinical pattern of sensory neuronopathies, allowing the establishment of validated and easy-to-use diagnostic criteria, has not yet been addressed. In this study, logistic regression was used to construct diagnostic criteria on a retrospective study population of 78 patients with sensory neuronopathies and 56 with other sensory neuropathies. For this, sensory neuronopathy was provisionally considered as unambiguous in 44 patients with paraneoplastic disorder or cisplatin treatment and likely in 34 with a dysimmune or idiopathic setting who may theoretically have another form of neuropathy. To test the homogeneity of the sensory neuronopathy population, likely candidates were compared with unambiguous cases and then the whole population was compared with the other sensory neuropathies population. Criteria accuracy was checked on 37 prospective patients referred for diagnosis of sensory neuropathy. In the study population, sensory neuronopathy showed a common clinical and electrophysiological pattern that was independent of the underlying cause, including unusual forms with only patchy sensory loss, mild electrical motor nerve abnormalities and predominant small fibre or isolated lower limb involvement. Logistic regression allowed the construction of a set of criteria that gave fair results with the following combination: ataxia in the lower or upper limbs + asymmetrical distribution + sensory loss not restricted to the lower limbs + at least one sensory action potential absent or three sensory action potentials <30% of the lower limit of normal in the upper limbs + less than two nerves with abnormal motor nerve conduction study in the lower limbs.
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Vega JA, García-Suárez O, Montaño JA, Pardo B, Cobo JM. The Meissner and Pacinian sensory corpuscles revisited new data from the last decade. Microsc Res Tech 2009; 72:299-309. [PMID: 19012318 DOI: 10.1002/jemt.20651] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This article reviews the biochemical, physiological, and experimental data cumulated during the last decade on the Meissner and Pacinian corpuscles. It includes information about (i) the localization of molecules recently detected in sensory corpuscles; (ii) the unsolved problem of the accessory fibers in sensory corpuscles and the occurrence of myelin within them; (iii) the development of sensory corpuscles, especially their neuronal and growth factor dependency; (iv) the composition and functional significance of the extracellular matrix as an essential part of the mechanisms involved in the genesis of the stimuli generated in sensory corpuscles; (v) the molecular basis of mechanotransduction; (vi) a miscellaneous section containing sparse new data on the protein composition of sensory corpuscles, as well as in the proteins involved in live-death cell decisions; (vii) the changes in sensory corpuscles as a consequence of aging, the central, or peripheral nervous system injury; and finally, (viii) the special interest of Meissner corpuscles and Pacinian corpuscles for pathologists for the diagnosis of some peripheral neuropathies and neurodegenerative diseases.
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Affiliation(s)
- José A Vega
- Departamento de Morfología y Biología Celular, Universidad de Oviedo, Oviedo, Spain.
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63
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Wilder-Smith EP, Guo Y, Chow A. Stimulated skin wrinkling for predicting intraepidermal nerve fibre density. Clin Neurophysiol 2009; 120:953-8. [DOI: 10.1016/j.clinph.2009.03.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Revised: 03/18/2009] [Accepted: 03/19/2009] [Indexed: 10/20/2022]
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Wöpking S, Scherens A, Haussleiter IS, Richter H, Schüning J, Klauenberg S, Maier C. Significant difference between three observers in the assessment of intraepidermal nerve fiber density in skin biopsy. BMC Neurol 2009; 9:13. [PMID: 19335896 PMCID: PMC2672925 DOI: 10.1186/1471-2377-9-13] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Accepted: 03/31/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The determination of Intraepidermal Nerve Fiber Density (IENFD) in skin biopsy is a useful method for the evaluation of different types of peripheral neuropathies. To allow a reliable use of the method it is necessary to determine interobserver reliability. Previous studies dealing with this topic used limited suitable statistical methods. METHODS In the present study three observers determined the IENFD and estimated the staining quality of the basement membrane for an adequate quantity of 120 skin biopsies (stained with indirect immunofluorescence technique) from 68 patients. More adequate statistical methods like intraclass correlation coefficient and Bland Altman Plot were chosen to estimate interobserver reliability. RESULTS We found an unexpected significant difference in IENFD between the observers (p < 0.05) and so the results of this study are not in line with the high interobserver reliability reported before (intraclass correlation coefficient: 0.73). The Bland Altmann Plot showed a variance growing with rising mean. The difference in IENFD between the observers and the resulting low interobserver reliability is likely caused by different interpretations of the standard counting rules. There was no significant difference in IENFD between observers for biopsies with a well-defined basement membrane. Thus skin biopsies with an inexactly defined basement membrane should not be used diagnostically for the determination of IENFD. CONCLUSION These results emphasise that standardisation of the method is extremely important and at least two observers should analyse skin biopsies with critical IENFD near the cut-off values.
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Affiliation(s)
- Sigrid Wöpking
- Department of Pain Management, Ruhr-University Bochum, BG-Kliniken Bergmannsheil, Bürkle-de-la-Camp-Platz 1, D-44789 Bochum, Germany.
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65
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Painful neuropathy in subclinical hypothyroidism: clinical and neuropathological recovery after hormone replacement therapy. Neurol Sci 2009; 30:149-51. [DOI: 10.1007/s10072-009-0026-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Accepted: 12/24/2008] [Indexed: 10/21/2022]
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66
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Acute painful diabetic neuropathy induced by strict glycemic control ("insulin neuritis"): the old enigma is still unsolved. Biomed Pharmacother 2009; 63:249-50. [PMID: 19250797 DOI: 10.1016/j.biopha.2009.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 01/13/2009] [Indexed: 11/22/2022] Open
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67
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Halperin I, Morelli M, Korczyn AD, Youdim MBH, Mandel SA. Biomarkers for evaluation of clinical efficacy of multipotential neuroprotective drugs for Alzheimer's and Parkinson's diseases. Neurotherapeutics 2009; 6:128-40. [PMID: 19110204 PMCID: PMC5084261 DOI: 10.1016/j.nurt.2008.10.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
During the last century, the world population has shown a staggering increase in its proportion of elderly members and thus neurodegenerative diseases like Alzheimer's disease (AD) and Parkinson's disease (PD), respectively, are becoming an increasing burden on society. Among the diverse, significant challenges facing clinicians, is the improvement of diagnostic measures to detect early and subtle symptoms, a phase in which prevention efforts might be expected to have their greatest impact and provide a measure of disease progression that can be evaluated during the course of drug treatment. At present, clinical diagnosis of AD and PD is based on a constellation of symptoms and manifestations, although the disease originated several years earlier. Given the multiple etiological nature of AD and PD, it is reasonable to assume that the initial causative pathobiological processes may differ between the affected individuals. Therefore, the availability of biological markers or biomarkers will help not only early disease diagnosis, but also delineate the pathological mechanisms more definitively and reliably than the traditional cognitive and neurological phenotypes. In the current article, we review the literature on biochemical, genetic, and neuroimaging biomarkers and discuss their predictive value as indicative for disease vulnerability to detect individuals at risk for PD and AD, and to determine the clinical efficacy of novel, disease-modifying (neuroprotective) strategies.
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Affiliation(s)
- Ilan Halperin
- Tel-Aviv Sourasky Medical Center, Department of Neurology, Memory Clinic, 64239 Tel-Aviv, Israel
| | - Micaela Morelli
- grid.7763.50000000417553242Department of Toxicology and Centre of Excellence for Neurobiology of Dependence, University of Cagliari, 09124 Cagliari, Italy
| | - Amos D. Korczyn
- grid.12136.370000000419370546Sieratzki Chair of Neurology, Tel-Aviv University Medical School, 31096 Ramat-Aviv, Israel
| | - Moussa B. H. Youdim
- Eve Topf Center for Neurodegenerative Diseases Research and Dept. of Pharmacology, Faculty of Medicine, Technion, Haifa, Israel, Efron St., P.O.B. 9697, 31096 Haifa, Israel
| | - Silvia A. Mandel
- Eve Topf Center for Neurodegenerative Diseases Research and Dept. of Pharmacology, Faculty of Medicine, Technion, Haifa, Israel, Efron St., P.O.B. 9697, 31096 Haifa, Israel
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Abstract
PURPOSE OF REVIEW To give an overview of recent data on the use of skin biopsy as a diagnostic tool in neuropathies. RECENT FINDINGS The sensitivity and specificity of skin biopsy in detecting small fiber neuropathy is supported by new data. In many patients with small fiber neuropathy, a treatable disorder can be identified if a full workup is done. Skin innervation is affected in neuropathies formerly considered as the large fiber type, such as porphyria and chronic inflammatory demyelinating neuropathy. New methods have been devised to complement histological evaluation of skin innervation by in-vivo microscopy and by neurophysiological assessment of small nerve fibers. Skin biopsies have been used to learn more about the pathophysiology of neuropathies, such as the discovery of reduced vascular endothelial growth factor expression in diabetic neuropathy and the increase in cytokine expression in some painful small fiber neuropathies. Quantification of skin innervation has been used as a measure for treatment success in experimental studies and is presently used for follow-up in clinical trials. SUMMARY Skin biopsy in the diagnosis of neuropathy is moving from a method giving descriptive results to a tool that may be helpful in etiological diagnostics, as a follow-up in clinical trials, and in pathophysiological research.
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69
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Dellon AL. The Four Medial Ankle Tunnels: A Critical Review of Perceptions of Tarsal Tunnel Syndrome and Neuropathy. Neurosurg Clin N Am 2008; 19:629-48, vii. [PMID: 19010287 DOI: 10.1016/j.nec.2008.07.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A Lee Dellon
- Plastic Surgery and Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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70
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How to assess new drugs for neuropathies: advances in trial design and methodology. Curr Opin Neurol 2008; 21:519-26. [DOI: 10.1097/wco.0b013e32830f1e3b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Current world literature. Curr Opin Neurol 2008; 21:615-24. [PMID: 18769258 DOI: 10.1097/wco.0b013e32830fb782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Devigili G, Tugnoli V, Penza P, Camozzi F, Lombardi R, Melli G, Broglio L, Granieri E, Lauria G. The diagnostic criteria for small fibre neuropathy: from symptoms to neuropathology. Brain 2008; 131:1912-25. [PMID: 18524793 PMCID: PMC2442424 DOI: 10.1093/brain/awn093] [Citation(s) in RCA: 525] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Small fibre neuropathy (SFN), a condition dominated by neuropathic pain, is frequently encountered in clinical practise either as prevalent manifestation of more diffuse neuropathy or distinct nosologic entity. Aetiology of SFN includes pre-diabetes status and immune-mediated diseases, though it remains frequently unknown. Due to their physiologic characteristics, small nerve fibres cannot be investigated by routine electrophysiological tests, making the diagnosis particularly difficult. Quantitative sensory testing (QST) to assess the psychophysical thresholds for cold and warm sensations and skin biopsy with quantification of somatic intraepidermal nerve fibres (IENF) have been used to determine the damage to small nerve fibres. Nevertheless, the diagnostic criteria for SFN have not been defined yet and a 'gold standard' for clinical practise and research is not available. We screened 486 patients referred to our institutions and collected 124 patients with sensory neuropathy. Among them, we identified 67 patients with pure SFN using a new diagnostic 'gold standard', based on the presence of at least two abnormal results at clinical, QST and skin biopsy examination. The diagnosis of SFN was achieved by abnormal clinical and skin biopsy findings in 43.3% of patients, abnormal skin biopsy and QST findings in 37.3% of patients, abnormal clinical and QST findings in 11.9% of patients, whereas 7.5% patients had abnormal results at all the examinations. Skin biopsy showed a diagnostic efficiency of 88.4%, clinical examination of 54.6% and QST of 46.9%. Receiver operating characteristic curve analysis confirmed the significantly higher performance of skin biopsy comparing with QST. However, we found a significant inverse correlation between IENF density and both cold and warm thresholds at the leg. Clinical examination revealed pinprick and thermal hypoesthesia in about 50% patients, and signs of peripheral vascular autonomic dysfunction in about 70% of patients. Spontaneous pain dominated the clinical picture in most SFN patients. Neuropathic pain intensity was more severe in patients with SFN than in patients with large or mixed fibre neuropathy, but there was no significant correlation with IENF density. The aetiology of SFN was initially unknown in 41.8% of patients and at 2-year follow-up a potential cause could be determined in 25% of them. Over the same period, 13% of SFN patients showed the involvement of large nerve fibres, whereas in 45.6% of them the clinical picture did not change. Spontaneous remission of neuropathic pain occurred in 10.9% of SFN patients, while it worsened in 30.4% of them.
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Reinisch CM, Traxler H, Piringer S, Tangl S, Nader A, Tschachler E. Rarefaction of the peripheral nerve network in diabetic patients is associated with a pronounced reduction of terminal Schwann cells. Diabetes Care 2008; 31:1219-21. [PMID: 18332160 DOI: 10.2337/dc07-1832] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Peripheral neuropathy is the most frequent neurological complication in diabetic patients. The diagnosis is established by both clinical neurological examination and demonstration of reduced epidermal nerve fibers in skin biopsies (1). Whereas the decrease of free nerve endings has been extensively studied in diabetic patients (2,3), no data are available on possible changes of terminal Schwann cells. Besides their role as scaffold for peripheral nerves, they also play an important role in supporting survival and function of peripheral nerves (4). RESEARCH DESIGN AND METHODS We analyzed the subepidermal nerve plexus in dermal sheet preparations of deceased diabetic and nondiabetic patients by immunostaining for detection of the neural cell adhesion molecule and quantification of the subepidermal nerve plexus. RESULTS AND CONCLUSIONS The subepidermal nerve plexus, comprising nerve fibers and ensheathing Schwann cells, was significantly reduced in diabetic patients. Whether the reduction in terminal Schwann cells is cause or consequence of the loss of peripheral nerve fibers remains to be investigated.
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Enhancement of cutaneous nerve regeneration by 4-methylcatechol in resiniferatoxin-induced neuropathy. J Neuropathol Exp Neurol 2008; 67:93-104. [PMID: 18219259 DOI: 10.1097/nen.0b013e3181630bb8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To generate an experimental neuropathy model in which small-diameter sensory nerves are specifically affected and to test a potential treatment, adult mice were given a single injection (50 microg/kg, i.p.) of the capsaicin analog resiniferatoxin (RTX). On Day 7 after RTX treatment, there was a 53% reduction in unmyelinated nerve density in the medial plantar nerve (p = 0.0067) and a 66% reduction in epidermal nerve density of hind paw skin (p = 0.0004) compared with vehicle-treated controls. Substance P-immunoreactive dorsal root ganglion neurons were also markedly depleted (p = 0.0001). These effects were associated with the functional deficit of prolonged withdrawal latencies to heat stimuli (p = 0.0007) on a hot plate test. The potential therapeutic effects of 4-methylcatechol (4MC) on this neuropathy were then tested by daily injections of 4MC (10 microg/kg, i.p.) from Days 7 to 35 after neuropathy induction. On Day 35, 4MC-treated mice had an increase in unmyelinated (p = 0.014) and epidermal nerve (p = 0.0013) densities and a reduction in thermal withdrawal latency (p = 0.0091) compared with RTX-only controls. These results indicate that 4MC promoted regeneration of unmyelinated nerves in experimental RTX-induced neuropathy and enhanced function.
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Argyriou AA, Koltzenburg M, Polychronopoulos P, Papapetropoulos S, Kalofonos HP. Peripheral nerve damage associated with administration of taxanes in patients with cancer. Crit Rev Oncol Hematol 2008; 66:218-28. [PMID: 18329278 DOI: 10.1016/j.critrevonc.2008.01.008] [Citation(s) in RCA: 175] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 01/15/2008] [Accepted: 01/25/2008] [Indexed: 11/17/2022] Open
Abstract
Peripheral neuropathy is a well recognized toxicity of taxanes, usually resulting to dose modification and changes in the treatment plan. Taxanes produce a symmetric, axonal predominantly sensory distal neuropathy with less prominent motor involvement. A "dying back" process starting from distal nerve endings followed by effects on Schwann cells, neuronal body or axonal transport changes and a disturbed cytoplasmatic flow in the affected neurons is the most widely accepted mechanism of taxanes neurotoxicity. The incidence of taxanes-induced peripheral neuropathy is related to causal factors, such as single dose per course and cumulative dose and risk factors including treatment schedule, prior or concomitant administration of platinum compounds or vinca alcaloids, age and pre-existing peripheral neuropathy of other causes. The most reliable method to assess taxanes neurotoxicity is by clinical examination combined with electrophysiological evaluation. There is currently no effective symptomatic treatment for paclitaxel-associated pain, myalgias and arthralgias. Tricyclic antidepressants and anticonvulsants have been used as symptomatic treatment of neurotoxicity with some measure of success. Therefore, new approaches for prophylaxis against taxanes-induced peripheral neuropathy are needed. Several neuroprotective agents including, thiols, neurotrophic factors, and antioxidants hold promise for their ability to prevent neurotoxicity resulting from taxanes exposure. However, further confirmatory trials are warranted on this important clinical topic. This review critically looks at the pathogenesis, incidence, risk factors, diagnosis, characteristics and management of taxanes-induced peripheral neuropathy. We also highlight areas of future research.
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Affiliation(s)
- Andreas A Argyriou
- Department of Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, UCL, Institute for Neurology, Queen Square, London WC1N3BG, UK.
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Rossi A, Giovenali P, Benvenuti M, Di Iorio W, Calabresi P. Skin biopsy: a new diagnostic tool for autonomic dysfunctions in Parkinson's disease? Lancet Neurol 2007; 6:848-9; author reply 849. [PMID: 17884672 DOI: 10.1016/s1474-4422(07)70231-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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