Neurological complications of the rheumatic diseases

Peripheral neuropathies in rheumatic diseases: More diverse and frequent than expected. A cross-sectional study

BACKGROUND/OBJECTIVE

Peripheral neuropathies (PN) are heterogeneous nerve disorders; frequently rheumatic patients have neuropathic symptoms. In some rheumatic diseases (RD) PN are secondary to nerve compression while others are related to metabolic abnormalities, inflammation or vasculitis. Our aim was to explore the frequency of neuropathic symptoms with three neuropathy questionnaires (NQ) and nerve conduction studies (NCS) in RD.

METHODS

This is a cross-sectional study in patients with any RD attending for the first time to a rheumatology outpatient clinic. We included all patients who accepted to participate and who answered three NQ and received a physical evaluation. Twenty patients were randomly selected to perform NCS and 10 healthy subjects were included as controls. The topographic diagnoses were: mononeuropathy, multiplex mononeuropathy, and/or polyneuropathy.

STATISTICAL ANALYSIS

descriptive statistics (mean, median, standard deviation, interquartile range and frequency, odds ratios and Pearson correlation test).

RESULTS

One hundred patients and 10 healthy subjects were included. Sixty-nine were female, mean age 40.6 ± 15.7 years. Rheumatic diagnoses were: systemic lupus erythematosus (26%), rheumatoid arthritis (16%), gout (14%), and osteoarthritis (11%). Fifty-two patients had neuropathic signs during physical examination and 67% had positive questionnaires with variable scores among several RD. Abnormal NCS was reported in 14 patients (70%): 6 (42.8%) median nerve mononeuropathies, 4 (28.5%) multiplex mononeuropathies and 4 (28.5%) polyneuropathies. None of the healthy subjects had neuropathy (NQ, physical evaluation, or NCS). Risk of being NCS positive is higher when the patients were NQ positive.

CONCLUSION

PN has variable distribution and high frequency in patients with RD; NQ+ increases the risk of presenting NCS+ for PN.

Radiographic cervical spine osteoarthritis progression rates: a longitudinal assessment

Relative to other sites, the cervical spine has received little attention in the osteoarthritis (OA) literature. Using data from a longitudinal study, we provide age-specific progression rates of radiographic cervical spine OA, by gender. Data from cohort subjects (ages 40+) from the Clearwater Osteoarthritis Study were analyzed (N = 707). All study subjects' demonstrated radiographic cervical spine OA at baseline (2+). Lateral cervical spine radiographs were taken biennially. The study outcome was radiographic disease progression. A grade increase of 1, or more, by the Lawrence and Kellgren ordinal scale was considered progression. Incidence rates were calculated as per 100 person-years of observation. We show that the progression rates for cervical spine OA increase with age. For all ages combined, men demonstrated higher rates of progression compared with women. However, among subjects in their forties and fifties, women were more likely to experience worsening of their disease when compared with men. Progression rates were similar for men and women in their sixties (8.2 and 8.0, respectively). Among subjects in their seventies, men demonstrated a significantly higher rate of progression compared with women (12.5 and 8.6, respectively). As the baby-boomer population continues to increase, cervical spine OA progression assessment can be a useful tool for health-care resource planning. Cervical spine OA research offers an abundance of opportunities. Instability as a precursor to the development of cervical spine OA warrants further research. Epidemiological studies addressing demographic differences (e.g., gender, age) in the incidence of cervical spine OA will contribute to the current knowledge base.

Role of ancillary procedures in surgical management of carpal tunnel syndrome: epineurotomy, internal neurolysis, tenosynovectomy, and tendon transfers

The role of ancillary procedures in the treatment of carpal tunnel syndrome is controversial, especially with regard to internal neurolysis and epineurotomy. At present, there are little to no data to support their routine use in the treatment of primary carpal tunnel syndrome. Similarly, the use of tenosynovectomy in carpal tunnel surgery should be limited to those patients with clear underlying rheumatologic or inflammatory risk factors, or with gross synovitis incidentally noted at surgery. The Camitz transfer is uniquely suited to treating the thenar wasting seen in advanced carpal tunnel syndrome. It can be performed concurrently with open carpal tunnel release with minimal additional dissection and morbidity.

Clinical evaluation and management of work-related carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a clinical entity characterized by pain, paresthesias, and numbness in the distribution of the median nerve with weakness and atrophy of the thenar muscles in advanced cases. It is universally accepted that CTS is the clinical concomitant of compression of the median nerve as it passes through the carpal canal. It is reported to be the most common of the entrapment neuropathies. Increasing evidence suggests that occupational factors, including forceful use of the hands, repetitive use of the hands, and hand-arm vibration, are etiologic for CTS. When occurring as a result of occupational exposures, the term "work-related carpal tunnel syndrome" is applied. Clinical approaches to the diagnosis and treatment of work-related CTS are described in this paper. Particular attention is paid to the clinical features and pathophysiology of CTS, the epidemiology of work-related CTS, ascertainment of work-relatedness in the clinical setting, treatment including both work and non-work interventions, and control of occupational ergonomic risk factors that may contribute to the illness.

Cervical ankylosis with acute spinal cord injury

Twenty-three cases of acute spinal cord injury in persons with cervical ankylosis are presented. Certain characteristics of major sub-groups are described: ankylosing spondylitis (N = 8), degenerative spondylosis (N = 9) and congenital fusion (congenital non-segmentation) (N = 6). The ankylosing spondylitic group presented a grim prognosis for survival (death rate 50 per cent within 60 days) and for loss of neurological function. Five out of eight cases had permanent neurological loss subsequent to their injuries. Both the ankylosing spondylitic and degenerative spondylotic groups presented problems in diagnosis and medical management. The basic principle is immobilisation of the fracture and mobilisation of the patient. The halo is the technique of choice for fracture immobilisation. An integrated intensive respiratory management programme is essential. Patients with ankylosed spines, particularly those with ankylosing spondylitis, should be educated in simple measures to prevent fracture of their spines.

Spinal cord compression by a rheumatoid nodule

A case, believed to be unique, is reported of spinal cord compression due to an extradural rheumatoid nodule.