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Rosenberg A, Pruitt R, Saba S, Silverstein JW, D'Amico RS. Isolating the Superficial Peroneal Nerve Motor Branch to the Peroneus Longus Muscle with Concentric Stimulation during Diagnostic Motor Nerve Biopsy. Neurodiagn J 2022; 62:26-36. [PMID: 35226832 DOI: 10.1080/21646821.2022.2034342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 01/21/2022] [Indexed: 06/14/2023]
Abstract
Motor nerve biopsies are performed in the workup of neuropathies of unknown origin when motor neuron disease is suspected. Biopsy of a motor branch of the superficial peroneal nerve innervating the peroneus longus muscle has been described as a convenient alternative to other commonly biopsied motor nerves. To date, neuromonitoring techniques have not been described for this procedure. We describe the surgical neurophysiology techniques necessary for preservation of motor function and associated data during muscle biopsy of a motor branch of the superficial peroneal nerve innervating the peroneus longus muscle. We present a case of a patient who underwent uncomplicated biopsy of the motor branch of the superficial peroneal nerve innervating the peroneus longus muscle during workup for suspected motor neuropathy. The surgical neurophysiology techniques and data are presented in detail. No postsurgical sensory or motor deficit was related to the procedure. Surgical neurophysiology is critical to confirm the appropriate motor branch to the peroneus longus muscle and facilitates safe and accurate motor nerve biopsy.
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Affiliation(s)
- Ashley Rosenberg
- Department of Neurological Surgery Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Rachel Pruitt
- Department of Neurological Surgery Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Sami Saba
- Department of Neurology Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Justin W Silverstein
- Department of Neurology Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
- Neuro Protective Solutions, New York, New York
| | - Randy S D'Amico
- Department of Neurological Surgery Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
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Sahi N, Ghasemi M, Rajabally YA. Autoantibodies in the diagnostic work-up of neuropathy: clinically useful or purely academic? Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32730155 DOI: 10.12968/hmed.2020.0085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The search for autoantibodies in patients with acute and chronic neuropathies has become widespread in neurological practice. These tests are more routinely available and therefore are more commonly requested in larger hospitals with neuroscience centres, although they are now also regularly requested from district general hospital settings, including by non-neurologists. However, the clinical value of these frequently expensive tests is often unclear and their impact on management not always obviously beneficial. This article reviews the main immunological tests used to search for specific autoantibodies in the setting of neuropathy and discusses their potential diagnostic importance, together with the eventual therapeutic implications of results obtained.
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Affiliation(s)
- Nitin Sahi
- Regional Neuromuscular Service, Queen Elizabeth Hospital, University Hospitals Birmingham, UK
| | - Majid Ghasemi
- Regional Neuromuscular Service, Queen Elizabeth Hospital, University Hospitals Birmingham, UK
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Queen Elizabeth Hospital, University Hospitals Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
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Diagnostic Biopsy of a Motor Branch of the Superficial Peroneal Nerve to the Peroneus Longus: A Convenient Alternative for Motor Nerve Biopsy. World Neurosurg 2017; 103:526-530. [DOI: 10.1016/j.wneu.2017.04.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 04/06/2017] [Accepted: 04/07/2017] [Indexed: 12/11/2022]
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Hu MY, Stathopoulos P, O'connor KC, Pittock SJ, Nowak RJ. Current and future immunotherapy targets in autoimmune neurology. HANDBOOK OF CLINICAL NEUROLOGY 2016; 133:511-36. [PMID: 27112694 DOI: 10.1016/b978-0-444-63432-0.00027-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Randomized controlled treatment trials of autoimmune neurologic disorders are generally lacking and data pertaining to treatment are mostly derived from expert opinion, large case series, and anecdotal reports. The treatment of autoimmune neurologic disorders comprises oncologic therapy (where appropriate) and immunotherapy. In this chapter, we first describe the standard acute and chronic immunotherapies and provide a practical overview of their use in the clinic (mechanisms of action, dosing, monitoring, and side effects). Novel approaches to treatment of autoimmune neurologic disorders, through new drug discovery or repurposing, are dependent on improved mechanistic understanding of immunopathology. Such approaches, with emphasis on monoclonal antibodies, are discussed using the paradigm of three autoimmune neurologic disorders whose immunopathogenesis is better understood, specifically myasthenia gravis, neuromyelitis optica, and chronic inflammatory demyelinating polyradiculoneuropathy. It is important to realize that the treatment strategy and management plan must be individualized for each patient. In general these are influenced by the following: clinical severity, antibody type, presence or absence of cancer, and prior treatment response, if known.
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Affiliation(s)
- Melody Y Hu
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Kevin C O'connor
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Sean J Pittock
- Departments of Laboratory Medicine/Pathology and Neurology, Mayo Clinic, College of Medicine, Rochester, MN, USA
| | - Richard J Nowak
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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Léger JM, Guimarães-Costa R, Iancu Ferfoglia R. The pathogenesis of multifocal motor neuropathy and an update on current management options. Ther Adv Neurol Disord 2015; 8:109-22. [PMID: 25941538 PMCID: PMC4409549 DOI: 10.1177/1756285615575269] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Multifocal motor neuropathy (MMN) is a rare and disabling disease. Several experimental studies and clinical data are strongly suggestive of an immune-mediated pathogenesis, although underlying mechanisms in MMN seem to be very specific, mainly because of the presence of IgM anti-GM1 serum antibodies and the dramatic response to intravenous immunoglobulins (IVIg). The origin of antiganglioside antibodies and the way in which they act at the molecular level remain unclear. Several studies have demonstrated the key role of complement activation in the underlying mechanisms of MMN, as well as in animal models of acute motor axonal neuropathy (AMAN). Deposition of the membrane attack complex may disrupt the architecture of the nodes of Ranvier and paranodal areas, causing local disruption of nodal sodium-channel clusters. In patients with MMN, muscle weakness is the consequence of conduction blocks (CB), which leads to secondary axonal degeneration, consequently the aim of the treatment is to reverse CB at early stages of the disease. High-dose immunoglobulin is to date the only therapy which has proven efficacy in MMN patients in providing transient improvement of muscle strength, but long-term follow-up studies show a progressive motor decline. Therefore, other therapies are needed to improve the conduction nerve properties in long-term design. The reduction of complement activation and more generally the gain in paranodal stabilization could be directions for future therapeutic strategies.
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Affiliation(s)
- Jean-Marc Léger
- National Referral Center for rare Neuromuscular Diseases, Institut Hospitalo-Universitaire de Neurosciences, University Hospital Pitié-Salpêtrière and University Pierre et Marie Curie (Paris VI), 47 boulevard de l'Hôpital, 75013 Paris, France
| | - Raquel Guimarães-Costa
- National Referral Center for rare Neuromuscular Diseases, Institut Hospitalo-Universitaire de Neurosciences, University Hospital Pitié-Salpêtrière and University Pierre et Marie Curie (Paris VI), Paris, France
| | - Ruxandra Iancu Ferfoglia
- National Referral Center for rare Neuromuscular Diseases, Institut Hospitalo-Universitaire de Neurosciences, University Hospital Pitié-Salpêtrière and University Pierre et Marie Curie (Paris VI), Paris, France
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Abstract
PURPOSE OF REVIEW Multifocal motor neuropathy (MMN) remains a difficult issue for neurologists, as its clinical and electrophysiological presentation may be atypical, and because no alternative treatment to periodic immunoglobulin infusions has been assessed in its long-term management. This review intends to summarize the most recent advances in the diagnosis and treatment of MMN. RECENT FINDINGS Recent reports have focused on atypical onset and unusual clinical presentation. Several sophisticated electrophysiological techniques, as triple stimulation, may help establish the presence of conduction blocks, as well as MRI findings. A recent immunological study focused on the detection of serum IgM binding to NS6S heparin disaccharide. In another research article, it was proposed that the use of combinatorial glycoarray or ELISA may increase the diagnostic sensitivity of antiglycolipid antibody testing. Subcutaneous immunoglobulin may represent an interesting alternative option to intravenous immunoglobulin. Lastly, recently reported open-label clinical trials with complement inhibitors and anti-CD20 monoclonal antibody may constitute a first step for further developments. SUMMARY Diagnostic criteria for MMN are well established, but challenging situations still occur. Progresses in neurophysiologic and other laboratory tests may help in clarifying doubtful diagnoses. Current research into the pathophysiology of MMN is required to determine the future treatment targets.
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Koski CL. Treatment of Multifocal Motor Neuropathy with Intravenous Immunoglobulin. J Clin Immunol 2014; 34 Suppl 1:S127-31. [DOI: 10.1007/s10875-014-0016-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 03/19/2014] [Indexed: 12/15/2022]
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Hahn AF, Beydoun SR, Lawson V, Oh M, Empson VG, Leibl H, Ngo LY, Gelmont D, Koski CL. A controlled trial of intravenous immunoglobulin in multifocal motor neuropathy. J Peripher Nerv Syst 2013; 18:321-30. [DOI: 10.1111/jns5.12046] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 09/25/2013] [Accepted: 10/18/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Angelika F. Hahn
- Department of Neurology; London Health Sciences Centre; London Ontario Canada
| | - Said R. Beydoun
- Department of Neurology; University of Southern California; Los Angeles CA USA
| | - Victoria Lawson
- Department of Neurology; The Ohio State University; Columbus OH USA
| | - MyungShin Oh
- Clinical Biostatistics; Baxter Healthcare Corporation; Westlake Village CA USA
| | | | - Heinz Leibl
- Clinical Research, BioTherapeutics; Baxter Innovations GmbH; Vienna Austria
| | - Leock Y. Ngo
- Clinical Research, BioTherapeutics; Baxter Healthcare Corporation; Westlake Village CA USA
| | - David Gelmont
- Clinical Research, BioTherapeutics; Baxter Healthcare Corporation; Westlake Village CA USA
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Dy CJ, Lange DJ, Jones KJ, Garg R, DiCarlo EF, Wolfe SW. Diagnostic biopsy of the pronator teres and a motor branch of the median nerve: indications and technique. J Hand Surg Am 2012; 37:2570-5. [PMID: 23174072 DOI: 10.1016/j.jhsa.2012.09.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 09/18/2012] [Accepted: 09/18/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE Biopsy of muscle tissue and motor nerve is helpful in the neurological evaluation of patients who present with upper limb and/or diffuse motor weakness. The procedure is indicated to supplement clinical, serological, and imaging diagnostic work-up of myopathic and neuropathic disorders. We describe a surgical technique and clinical series of biopsy of the pronator teres muscle and a motor branch of the median nerve. METHODS We performed a retrospective review of 20 patients who underwent biopsy of the pronator teres and a motor branch of the median nerve as part of a clinical, serological, and radiographic evaluation for weakness of the upper extremity. All of the biopsies were performed by a single surgeon. The surgical technique is described. Follow-up visits with both the surgeon and the neurologist were reviewed to evaluate preoperative and postoperative neurological function to identify any changes in nerve or muscle function and any postoperative complications. RESULTS Biopsied tissue was sufficient for pathological diagnosis in all 20 patients. Diagnoses included multifocal motor neuropathy in 14 patients, amyotrophic lateral sclerosis in 3 patients (2 sporadic; 1 familial), inclusion body myositis (1 patient), inflammatory myopathy (1 patient), and chronic inflammatory demyelinating polyneuropathy (1 patient). At a mean follow-up of 11 weeks (range, 5-31 wk), there were 6 minor surgical complications, all of which were superficial hematomas that resolved with use of a compressive wrap. CONCLUSIONS Biopsy of the pronator teres and a motor branch of the median nerve was safe and effective. The technique is particularly useful when considering the diagnosis of multifocal motor neuropathy affecting the upper extremity.
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Affiliation(s)
- Christopher J Dy
- Division of Hand and Upper Extremity Surgery, Department of Neurology, Hospital for Special Surgery, New York, NY, USA
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Baig F, Knopp M, Rajabally YA. Diagnosis, epidemiology and treatment of inflammatory neuropathies. Br J Hosp Med (Lond) 2012; 73:380-5. [PMID: 22875431 DOI: 10.12968/hmed.2012.73.7.380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article reviews the main diagnostic, epidemiological and therapeutic issues relating to the three main inflammatory neuropathies: Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy and multifocal motor neuropathy. The current knowledge base and recent developments are described.
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Affiliation(s)
- Fahd Baig
- Department of Neurology, University Hospitals of Leicester, Leicester, UK
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Vlam L, van den Berg LH, Cats EA, Piepers S, van der Pol WL. Immune pathogenesis and treatment of multifocal motor neuropathy. J Clin Immunol 2012; 33 Suppl 1:S38-42. [PMID: 22941513 DOI: 10.1007/s10875-012-9779-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 08/22/2012] [Indexed: 11/24/2022]
Abstract
Multifocal motor neuropathy (MMN) is a rare, probably immune-mediated chronic disorder characterized by asymmetric distal limb weakness and conduction block. The exact pathogenesis of MMN is still unclear, but IgM anti-GM1 antibodies, which can be detected in sera from approximately half of all MMN patients, are thought to play an important role. Treatment with intravenous immunoglobulin (IVIG) is effective in the vast majority of patients, but, despite IVIG maintenance treatment, many patients experience a slowly progressive decline in muscle strength. In this review we will summarize the results from studies on pathogenesis. We will discuss current treatment strategies of MMN and how insight into MMN pathogenesis may translate into novel therapies in the future.
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Affiliation(s)
- Lotte Vlam
- Rudolf Magnus Institute of Neuroscience, Department of Neurology G 03.228, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands
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Vlam L, van der Pol WL, Cats EA, Straver DC, Piepers S, Franssen H, van den Berg LH. Multifocal motor neuropathy: diagnosis, pathogenesis and treatment strategies. Nat Rev Neurol 2011; 8:48-58. [PMID: 22105211 DOI: 10.1038/nrneurol.2011.175] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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