Dank an Prof. Buchner

Prof. Dr. med. Helmut Buchner war seit 2014 Herausgeber der Zeitschrift Klinische Neurophysiologie und übernahm im Jahr 2016 das Amt der Schriftleitung. Herausgeber und Mitglieder des Beirats haben reichlich Gründe, sich für seine hervorragende Arbeit für die Zeitschrift – und damit auch für die Klinische Neurophysiologie selbst – zu bedanken.

Myo-Neurografie 1990–2020 entlang der „Wissenspunkte für die EMG-Prüfung“ der DGKN

Die „Wissenspunkte für die EMG-Prüfung“ der DGKN (https://dgkn.de/images/richtlinien/RL18_EMG_Wissenpunkte.pdf) sind zuletzt vor 10 Jahren bearbeitet worden. Diese letzte Aktualisierung hatte nur zu geringen Änderungen geführt. Fast alle dieser Punkte sind so im Wesentlichen unverändert aufgelistet, seit der Autor dieser Zeilen EMG betreibt, also seit mehr als 30 Jahren. Hier soll der Versuch unternommen werden, anhand dieser Punkte aufzuzeigen, was sich in dieser Zeit verändert hat, was neu ist, aber auch, was weggefallen ist – oder wegfallen sollte.

Toward the validation of a new method (MUNIX) for motor unit number assessment

INTRODUCTION

This prospectively designed study analyzed the correlation of a new, non-invasive neurophysiological method (Motor Unit Number Index - MUNIX) with two established Motor Unit Number Estimation (MUNE) methods.

METHODS

MUNIX and incremental stimulation MUNE (IS-MUNE) were done in the abductor digiti minimi muscle (ADM), while MUNIX and spike-triggered averaging MUNE (STA-MUNE) were tested in the trapezius muscle. Twenty healthy subjects and 17 patients with amyotrophic lateral sclerosis (ALS) were examined.

RESULTS

MUNIX and MUNE values correlated significantly (ADM: n=108; Spearman-Rho; r=0.88; p<0.01; trapezius muscle: n=49; Spearman-Rho; r=0.46; p<0.01).

DISCUSSION

MUNIX indeed reflects the number of motor units in a muscle, and may sensibly be recorded from the trapezius muscle. With MUNIX being both much more patient friendly and much more rapid to assess than MUNE, the results support the use of MUNIX when motor unit number assessment is desired.

[Common and not so common nerve entrapment syndromes: diagnostics, clinical aspects and therapy]

Altogether, nerve entrapment syndromes have a very high incidence. Neurological deficits attributable to a focal peripheral nerve lesion lead to the clinical diagnosis. Frequently, pain is the dominant symptom but is often not confined to the nerve supply area. Electroneurography, electromyography, and more recently also neurosonography are the most important diagnostic tools. In most patients surgical therapy is necessary, which should be carried out in a timely manner. The entrapment syndromes discussed are suprascapular nerve entrapment, carpal tunnel syndrome, cubital tunnel syndrome, meralgia paraesthetica, thoracic outlet syndrome and anterior interosseous nerve syndrome.

Differentiation between uniform and non-uniform motor nerve conduction slowing

OBJECTIVE

Demyelination may cause a uniform reduction of the conduction velocity of all fibres of a peripheral nerve segment, or may affect only certain nerve fibres in a non-uniform way while sparing others. This study was done to improve the detection of non-uniform conduction slowing by using the high-frequency attenuation (HFA) method.

METHODS

Nerve conduction data from patients with early inflammatory demyelinating neuropathy (non-uniform demyelination, n=20), hereditary neuropathy (uniform demyelination, n=9), motor neuron disease (axon loss, n=20), and from healthy control subjects (n=20) were analysed.

RESULTS

HFA, compound muscle action potential (CMAP) amplitude decay, and F-wave chronodispersion correlated significantly. Among these variables both HFA and amplitude decay most sensitively identified non-uniform demyelination (35%). In the patients with uniform demyelination, the most frequent finding was a reduced nerve conduction velocity (NCV) (100%). The most specific marker of non-uniform demyelination was HFA. For uniform demyelination it was NCV.

CONCLUSIONS

The pattern of correlations between the variables studied confirms that NCV and F-min are indicators of uniform conduction slowing. HFA, amplitude decay, and F-wave chronodispersion indicate non-uniform conduction slowing, for which HFA is both sensitive and specific.

SIGNIFICANCE

The HFA method improves both the diagnostic sensitivity and specificity of nerve conduction studies in patients with non-uniform demyelination.

Use of botulinum toxin A in adult neurological disorders: efficacy, tolerability and safety

The protein botulinum neurotoxin A (BoNT/A) is one of seven distinct neurotoxins produced by Clostridium botulinum. BoNT/A blocks cholinergic synapses with an extremely high specificity and potency. Appropriately purified and diluted, BoNT/A serves as a reliable and well tolerated drug that is applied by local injection.The efficacy of BoNT/A is evident in the symptomatic therapy of disorders in which muscular hyperactivity plays a prominent role, such as focal dystonias and hemifacial spasm; in these disorders, BoNT/A is considered first-line therapy. BoNT/A is also beneficial in the treatment of both adults and children with spasticity of various causes. The pain that frequently accompanies these conditions is effectively reduced by BoNT/A. A genuine analgesic effect for BoNT/A unrelated to skeletal muscle spasmolysis has been suggested on the basis of in vitro and in vivo (animal) data. However, studies in humans designed to detect such an effect were negative, as were controlled studies of BoNT/A in patients with primary headache disorders.BoNT/A also acts on cholinergic synapses of the autonomic nervous system, and injection of BoNT/A into salivary glands significantly decreases the production of saliva. This may be beneficial for patients with Parkinson's disease, in whom the excessive production of saliva may be problematic.Overall, BoNT/A has been confirmed as an efficacious, predictable and well tolerated drug in an ever-increasing number of neurological disorders.

Low-Frequency Short-Time Nociceptive Stimulation of the Greater Occipital Nerve does not Modulate the Trigeminal System

Occipital stimulation in a small group of refractory chronic migraine and cluster headache patients has been suggested as a novel therapeutic approach with promising results. In an earlier study we have shown that a drug-induced block of the greater occipital nerve (GON) inhibits the nociceptive blink reflex (nBR). Now, we sought to examine the effects of low-frequency (3 Hz) short-time nociceptive stimulation of the GON on the trigeminal system. We recorded the nBR responses before and after stimulation in 34 healthy subjects. Selectivity of GON stimulation was confirmed by eliciting somatosensory evoked potentials of the GON upon stimulation. In contrast to an anaesthetic block of the occipital nerve, no significant changes of the R2-latencies and R2-response areas of the nBR can be elicited following GON stimulation. Various modes of electrical stimulation exist with differences in frequency, stimulus intensity, duration of stimulation and pulse width. One explanation for a missing modulatory effect in our study is the relatively short duration of the stimulation.

Evidence based medicine on the use of botulinum toxin for headache disorders

Botulinum toxin blocks the release of acetylcholine from motor nerve terminals and other cholinergic synapses. In animal studies botulinum toxin also reduces the release of neuropeptides involved in pain perception. The implications of these observations are not clear. Based on the personal experiences of headache therapists, botulinum toxin injections have been studied in patients with primary headaches, namely tension-type headache (TTH), chronic migraine (CM) and chronic daily headache (CDH). So far, the results of randomized, double-blind, placebo controlled trials on botulinum toxin in a total of 1117 patients with CDH, 1495 patients with CM, and 533 patients with TTH have been published. Botulinum toxin and placebo injections have been equally effective in these studies. In some of the studies, the magnitude of this effect was similar to that of established oral pharmacotherapy. This finding may help to explain the enthusiasm that followed the first open-label use of botulinum toxin in patients with headache. However, research is continuing to determine the efficacy of botulinum toxin in certain subgroups of patients with CM or CDH.

Botulinum toxin A does not alter capsaicin-induced pain perception in human skin

A genuine peripheral antinociceptive and anti-inflammatory effect of Botulinum neurotoxin type A (BoNT/A) has been proposed but could not be demonstrated in humans so far. Therefore, 100 mouse units of Botulinum toxin A (Dysport) and placebo were injected in a double blind paradigm in defined skin areas of 50 subjects. At baseline and after 4 and 8 weeks allodynia was induced in the skin areas with capsaicin ointment. Heat and cold pain threshold temperatures were measured with quantitative sensory testing, and threshold intensities upon electrical stimulation with a pain specific surface electrode were determined. No BoNT/A related differences in pain perception were found at any quality. There is neither a direct peripheral antinociceptive effect nor a significant effect against neurogenic inflammation of BoNT/A in humans.

Botulinum toxin therapy of migraine and tension-type headache: comparing different botulinum toxin preparations

Most of the initial reports on botulinum toxin in tension-type headache (TTH) and in migraine were positive. Unfortunately, these results were not reproduced in well-designed, randomized controlled trials. So far, doses from 20 U (Botox) to 500 U (Dysport) have been studied in patients with chronic TTH, and doses from 16 to 200 U (Botox) in patients with migraine. Overall, there is no evidence for a beneficial effect of botulinum toxin, although trends favoring botulinum toxin were reported. Experience with botulinum toxin type B (Myobloc/NeuroBloc) is limited and similar to the experience with the type A. Thus, a widespread use of botulinum toxin therapy in headache can currently not be recommended.

Botulinum toxin therapy of migraine and tension-type headache: comparing different botulinum toxin preparations

Most of the initial reports on botulinum toxin in tension-type headache (TTH) and in migraine were positive. Unfortunately, these results were not reproduced in well-designed, randomized controlled trials. So far, doses from 20 U (Botox) to 500 U (Dysport) have been studied in patients with chronic TTH, and doses from 16 to 200 U (Botox) in patients with migraine. Overall, there is no evidence for a beneficial effect of botulinum toxin, although trends favoring botulinum toxin were reported. Experience with botulinum toxin type B (Myobloc/NeuroBloc) is limited and similar to the experience with the type A. Thus, a widespread use of botulinum toxin therapy in headache can currently not be recommended.

Immune-mediated rippling muscle disease

The authors report a 44-year-old man with rippling muscle disease (RMD) who does not have a mutation in the caveolin-3 gene. Immunohistochemistry of the muscle biopsy revealed a marked reduction of caveolin-3 and a mosaic pattern of dysferlin immunostaining. Ultrastructural studies showed a loss of caveolae and alterations of the triad. Autoantibodies were directed against the sarcolemma, triad, and several unknown muscle proteins.

Treatment of chronic tension-type headache with botulinum toxin A: a randomized, double-blind, placebo-controlled multicenter study

A beneficial effect of botulinum toxin on tension-type headache was reported in open-label studies but scientifically rigorous clinical studies are lacking. Therefore we conducted a prospective, multicenter, randomized, double-blind, placebo-controlled trial. Multiple pericranial muscles of 112 patients with chronic tension-type headache were treated either with 500 mouse units of botulinum toxin (Dysport) or with placebo. The diagnoses were made strictly following the International Headache Society criteria. Co-existence of migraine was an exclusion criterion. Injections were made following a fixed scheme and not adjusted to the patient's symptoms. Patients kept a headache diary that was used to calculate the area under the headache curve of 6 weeks before and 12 weeks after the treatment as the main effect measure. Secondary effect measures were the number of days with headache, the number of days with intake of analgesics, the duration of the nocturnal sleep, and the Beck Depression Inventory score. There were no significant differences between the verum group and the placebo group in any of these variables. Seven patients of the verum group had transient weakness of the eyelids, the neck, or both, indicating that a higher dose than used in this study does not seem sensible for the treatment of headache. The statistical power of the study was high enough to warrant the conclusion that there is no clinically significant effect of botulinum toxin A on chronic tension-type headache.

Increased metabolic muscle fatigue is caused by some but not all mitochondrial mutations

CONTEXT

Excessive muscle fatigue occurs in patients with a mitochondrial encephalomyopathy (MEM), but it is also a frequent problem in patients with other neuromuscular disorders (ONMD).

OBJECTIVE

To determine whether, and to what extent, metabolic muscle fatigue specifically occurs in patients with an MEM.

DESIGN

Metabolic muscle fatigue was assessed in a series of 21 patients with an MEM, including 13 patients with chronic progressive external ophthalmoplegia and 8 patients with various mitochondrial point mutations; 27 patients with ONMD; and 25 healthy controls. Isometric twitch force of the ankle dorsiflexors was measured after supramaximal stimulation of peroneal nerves. Six trains of stimuli (of 1 minute's duration with rates from 0.2 to 5 stimuli per second) were given to each subject.

RESULTS

An abnormal decrement of the twitch amplitude that occurred during a stimulation train was found in patients with MEM and in those with ONMD. The decrement of the twitch amplitude of controls and of patients with ONMD was strongly influenced by their muscle force (P<.001). After subtraction of the influence of the muscle force, specific fatigue was notably higher in patients with chronic progressive external ophthalmoplegia than in patients with ONMD and in controls, and it correlated well with elevations of serum lactate. Specific fatigue was also abnormal in a patient with a mitochondrial G7497A mutation, but normal in patients with an A3243G or a G11778A mutation. The heteroplasmy of mitochondrial DNA in muscle correlated neither with the force measures nor with the serum lactate levels.

CONCLUSIONS

Generally, metabolic muscle fatigue accompanies muscular weakness. Specifically, some but not all mitochondrial mutations cause excessive metabolic muscle fatigue.

Botulinum toxin A and the cutaneous nociception in humans: a prospective, double-blind, placebo-controlled, randomized study

Aside from temporary chemodenervation of skeletal muscle and potential anti-inflammatory effects, a genuine peripheral antinociceptive effect of Botulinum Neurotoxin Type A (BoNT/A) has been suspected. To evaluate the effect of BoNT/A on cutaneous nociception in humans, 50 healthy volunteers received subcutaneous injections of 100 mouse units (MU) BoNT/A (Dysport) and placebo. Both forearms of each subject were treated in a double-blind fashion, one with verum, one with placebo. Heat and cold pain thresholds within the treated skin areas were measured with quantitative sensory testing (QST) and pain thresholds were evaluated with local electrical stimulation (ES). The tests were done before treatment, and after 4 and 8 weeks. No major side effects were noted. All participants completed the study. Heat and cold pain thresholds increased from baseline to week 4 by 1.4 degrees C for verum and by 1.1 degrees C for placebo. From baseline to week 8, the thresholds increased by 2.7 degrees C for verum and by 1.2 degrees C for placebo. Electrically induced pain thresholds shifted from baseline to week 4 by -0.07 mA for verum and by 0.01 mA for placebo. From baseline to week 8, the thresholds increased by 0.10 mA for verum and by 0.11 mA for placebo. None of these differences was statistically significant. The study shows that there is no direct peripheral antinociceptive effect of BoNT/A in humans. The efficacy of BoNT/A in various pain syndromes must be explained by other pathways such as chemodenervation or anti-inflammatory effects.

Cruciate paralysis or man-in-the-barrel syndrome? Report of a case of brachial diplegia

A patient who developed isolated brachial diplegia following cardiac surgery is described. The underlying cerebral lesion could not be localized using magnetic resonance imaging (MRI). Evoked potentials disclosed normal findings, while pathological latencies were seen on cortical magnetic stimulation. Their marked improvement over the following year was accompanied by almost complete clinical recovery. The preserved arm reflexes, together with the observed slow firing motor units in electromyography argued against bilateral lesions of the brachial plexus. We attribute the observed diplegia to a medullary lesion at the level of the pyramidal decussation, presumably caused by an intraoperative embolic occlusion of the anterior spinal artery. Cruciate paralysis and man-in-barrel-syndrome (MIBS) both are terms used to describe brachial diplegia; cruciate paralysis when caused by medullary lesions, MIBS when caused either by supratentorial or by medullary lesions. Exclusive use of the term MIBS for bilateral frontal lobe lesions, as in the original description, would provide more clarity in terminology.

Doppler microembolic signals in patients with two different types of bileaflet valves

OBJECTIVES

This study was performed to evaluate the prevalence and counts of Doppler microembolic signals in patients with St Jude Medical valves (St Jude Medical, Inc, St Paul, Minn) and patients with ATS valves (ATS Medical, Inc, Minneapolis, Minn) and their relation to clinical parameters.

METHODS

A total of 179 outpatients of the department of cardiothoracic surgery were examined. They included 98 men and 81 women, aged 61 +/- 11 years, with ATS (n = 91) or St Jude Medical (n = 88) valves in the aortic (n = 110), mitral (n = 39), or both positions (n = 30). Neurologic examination was followed by transcranial Doppler monitoring for microembolic signals. Monitoring was performed bilaterally over the middle cerebral arteries for 1 hour per session.

RESULTS

Microembolic signal counts and prevalence were significantly higher in patients with St Jude Medical as compared with ATS valves. Valve type and presence of diabetes mellitus were the only predictors of microembolic signal prevalence on multivariate analysis. No influence of microembolic signals on cerebral embolic complications was established. Additionally, patients with a postoperative history of cerebral embolic complications did not have a higher number of microembolic signals than remaining patients. Interobserver variability was satisfactory.

CONCLUSIONS

Patients with St Jude Medical valves were shown to have significantly higher microembolic signal counts than patients with ATS valves. However, our results suggest that microembolic signal counts cannot be used to predict cerebral embolic complications. Their relation to neuropsychologic deficits remains to be evaluated.

Length dependence of variables associated with temporal dispersion in human motor nerves

Temporal dispersion in motor nerves is associated with changes of amplitude, area, duration, and Fourier spectra of compound muscle action potentials (CMAPs) when comparing responses to proximal and distal stimulation. These changes depend on the length of the nerve segment. To quantitatively assess this dependence, motor conduction studies of nerve segments of various lengths were performed in the median, ulnar, and tibial nerves of 86 test subjects, aged 4 to 73 years. Amplitude, area, duration, and spectral energy above 49 Hz of CMAPs were measured. Values after distal and proximal stimulation of each nerve segment were compared to determine amplitude decay, area decay, protraction, and high-frequency attenuation. A significant length dependence of amplitude decay was found in the tibial and ulnar nerves, of area decay in the median and ulnar nerves, and of CMAP duration in the ulnar and tibial nerves. The length dependence of the high-frequency attenuation was significant in all nerves studied. This report provides normative data for variables associated with temporal dispersion.

Discharge patterns of spontaneous activity and motor units on concentric needle electromyography

We analyzed discharge patterns in electromyograms of 6 patients with complete nerve lesions and of 26 healthy subjects, in order to better differentiate between pathological and physiological spontaneous electromyographic (EMG) activity. Within 1639 trains of action potentials, the intervals between at least five successive discharges were measured. Discharge regularity was evaluated with three different algorithms. At 99% specificity, an abnormal discharge pattern was identified with 91 to 95% sensitivity, depending on the algorithm used. Analysis of as few as four successive interdischarge intervals allowed reliable differentiation between normal and pathological spontaneous EMG activity.

Relation between maximum discharge rates on electromyography and motor unit number estimates

To improve quantitative assessment of motor unit recruitment by standard concentric needle electromyography (CNEMG), hypothenar muscles of 22 healthy subjects, 18 with denervation, and 10 with a myopathy were studied. Discharge rates of motor units were measured in CNEMG recordings comprising action potentials of, at most, 4 motor units. Motor unit number estimation (MUNE) was done using the manual incremental method. In controls, the upper 95% limit of the discharge rate was 16.2/s. In all subjects, a strong nonlinear correlation between the number of motor units and the maximal discharge rate was found (r = 0.88, P < 0.0001). Increased discharge rates were found in all but one of the paretic muscles with denervation, but in none of the myopathic muscles. Measurement of the discharge rate is a simple and reliable procedure. If the discharge rate is high in a hypothenar muscle, loss of motor units can be inferred. Moreover, the discharge rate value gives an estimate of the number of motor units in that muscle. Thus, we suggest that maximal discharge rate be included in electromyographic reports.

Transcranial magnetic stimulation compared with upper motor neuron signs in patients with amyotrophic lateral sclerosis

If patients with amyotrophic lateral sclerosis (ALS) present without upper motor neuron signs (UMNS) they do not meet current ALS research criteria. To compare how sensitively degeneration of upper motor neurons is detected clinically and by transcranial magnetic stimulation, 35 patients with ALS were studied. Nineteen patients had definite UMNS, nine patients had probable UMNS, and seven patients had no UMNS. Cortex, cervical nerve roots, and lumbar plexus were stimulated with a magnetic stimulator. Compound muscle action potentials from abductor digiti minimi and from anterior tibial muscles were recorded with surface electrodes. Responses to transcranial magnetic stimulation were considered abnormal if central motor conduction time was above the 99% upper limits or if there was no response to cortical but to peripheral stimulation. In all patients with definite UMNS central motor conduction was abnormal. In patients with probable UMNS it was abnormal in 67%, and in patients without UMNS it was abnormal in 71%. Abnormality of central motor conduction was neither correlated with the duration nor with the severity of the disease. The high rate of abnormalities of central motor conduction found in patients with ALS but without definite UMNS suggests that, in these patients, the diagnosis of ALS can be made more reliably if transcranial magnetic stimulation studies are performed.

Treatment of tension-type headache with botulinum toxin: a pilot study

We studied if injections of botulinum toxin into multiple pericranial muscles reduce pain of patients with tension-type headache. Nine patients with tension-type headache not sufficiently responding to physical therapy or to amitriptyline were studied. Patients kept a headache diary that was used to calculate the area under the headache curve (AUC) of 4 weeks before and after treatment. After a run-in phase of 4 weeks equal doses of 25 units (0.25ml) of botulinum toxin type A (Dysport) were injected into both frontal, temporal, occipital, and sternocleidomastoid muscles. Mean AUC of the 8 patients who completed the study was significantly reduced from 404 to 196 (p = 0.039). No major side effects were reported by the patients. These results justify further studies of botulinum toxin therapy in patients with tension type headache. The presented scheme for injections of botulinum toxin into multiple pericranial muscles is a rational basis for the design of such studies.

Assessment of temporal dispersion in motor nerves with normal conduction velocity

Demyelinated nerves attenuate high-frequency components of propagating action potentials. In order to study if there is diagnostic use of this in motor nerves, the spectral energy above 49 Hz, amplitude, area, and duration of the compound muscle action potentials were measured; values after distal and proximal stimulation of posterior tibial nerves were compared. Normative data were collected in 48 control subjects. The same measurements were made in 20 patients with polyneuropathy and reduced motor nerve conduction velocity, in 21 patients with mild polyneuropathy but normal motor nerve conduction velocity, and in 8 patients with myasthenia gravis. Overall, high-frequency attenuation was closely correlated with amplitude decay (r = 0.63, P<10(-19)) and with increase of action potential duration (r = 0.34, P = 10(-5)). In the group of patients with normal NCV, high-frequency attenuation was abnormal in 9 (43%), amplitude decay was abnormal in two (10%), and area decay was abnormal in one (5%) patient. The action potential duration was normal in all of these patients. High-frequency attenuation was not influenced by stimulus intensity, thus it is not changed by conduction block, and it was not influenced by impaired neuromuscular transmission. Hence, high-frequency attenuation, both sensitively and specifically does indicate abnormal temporal dispersion. In conclusion, the simple measurement of high-frequency attenuation markedly improves detection and characterization of demyelination of human motor fibers.

Focal sensory nerve abnormalities in patients with amyotrophic lateral sclerosis

Slowing of sensory nerve conduction is an unexplained finding in patients with sporadic amyotrophic lateral sclerosis (ALS). To study the frequency of these abnormalities and to study if a predisposition to the development of entrapment neuropathies is causal, 23 patients with definite ALS and 23 age-matched healthy volunteers were investigated prospectively. Antidromic sensory and motor nerve conduction velocities (NCVs) were measured in ulnar and median nerves. Median sensory NCV was abnormally low in three patients if compared with the lower limit of the control group; and median sensory NCV was abnormally low in nine patients (six right, eight left hands) if compared with ipsilateral ulnar sensory NCV. Sensory nerve conduction data did not correlate with clinical findings, such as forearm weakness or usage of canes. Motor nerve conduction data did not correlate with sensory nerve conduction data, with the exception of distal motor latency of right median nerves, which correlated with right median sensory NCV. Our findings show how affection of sensory fibers of distal segments of median nerves can be detected in individual patients with ALS. Nerve entrapment may contribute to this affection, but it is not the only cause. This should be considered in discussions about diagnostic criteria for ALS.

[Proximal myotonic myopathy (PROMM). Clinical variability within a family]

Proximal myotonic myopathy (PROMM) is a newly described autosomal dominant inherited disorder characterized by predominant proximal weakness of the legs, mild clinical myotonia or myotonia on electromyograms (EMG), cataracts and slight elevation of liver enzymes. The trinucleotide (cytosine, thymine, and guanine) repeat size of the myotonic dystrophy (DM) gene is normal. Magnetic resonance imaging of the brain may reveal a peculiar pattern of white matter abnormalities. We describe seven patients in a new family with PROMM. The only symptoms may be subclinical myotonic changes in the EMG or cataracts, but symptoms may also include severe proximal weakness of the legs and painful paraesthesia. PROMM is an important differential diagnosis of myotonic dystrophy; and because of the proximal weakness it is also a differential diagnosis of other muscle diseases such as limb girdle dystrophy, metabolic and endocrine myopathies, and myositis. Because of the variability of the symptoms, for the definite diagnosis of PROMM it may require the examination of other family members.

Autonomic neuropathy in a patient with adrenomyeloneuropathy

Adrenomyeloneuropathy (AMN) is a clinical subtype of X-linked adrenoleukodystrophy (ALD). In ALD, the accumulation of very long chain fatty acids (VLCFA) in the nervous system, adrenal cortex, and testes due to impaired degradation of VLCFA is thought to be pathogenic. Demonstration of abnormally high levels of saturated VLCFA is diagnostic of ALD. The symptoms of AMN include spastic paraparesis, impaired vibration sense in the distal legs, urinary disturbances, and mild peripheral neuropathy. About further involvement of the autonomic nervous system, no data are available. We report an AMN patient with clinically suspected and electrophysiologically verified autonomic neuropathy, supporting the hypothesis that neuropathy in AMN is at least partially caused by primary axonal degeneration.