Lower motoneuron dysfunction impacts spontaneous motor recovery in acute cervical spinal cord injury

Paresis after spinal cord injury is caused by damage to upper and lower motoneurons and may differentially impact neurological recovery. This prospective monocentric longitudinal observational study investigated the extent and severity of lower motoneuron dysfunction and its impact on upper extremity motor recovery after acute cervical spinal cord injury. Pathological spontaneous activity at rest and/or increased discharge rates of motor unit action potentials recorded by needle electromyography (EMG) were taken as parameters for lower motoneuron dysfunction and its relation to the extent of myelopathy in the first available spine MRI was determined. Motor recovery was assessed by standardized neurological examination within the first 4 weeks (acute stage) and up to 1 year (chronic stage) after injury. Eighty-five muscles of 17 individuals with cervical spinal cord injury (neurological level of injury from C1 to C7) and a median age of 54 (28-59) were examined. The results showed that muscles with signs of lower motoneuron dysfunction peaked at the lesion center (Χ²[2,n=85]=6.6, p=0.04) and that the severity of lower motoneuron dysfunction correlated with T2-weighted hyperintense MRI signal changes in routine spine MRI at the lesion site (spearman ρ=0.31, p=0.01). Muscles exhibiting signs of lower motoneuron dysfunction, as indicated by pathological spontaneous activity at rest and/or increased discharge rates of motor unit action potentials, were associated with more severe paresis in both the acute and chronic stages after spinal cord injury (spearman ρ acute=-0.22, p=0.04 and chronic=-0.31, p=0.004). Moreover, the severity of lower motoneuron dysfunction in the acute stage was also associated with a greater degree of paresis (spearman ρ acute=-0.24, p=0.03 and chronic=-0.35, p=0.001). While both muscles with and without signs of lower motoneuron dysfunction were capable of regaining strength over time, those without lower motoneuron dysfunctions had a higher potential to reach full strength. Muscles with signs of lower motoneuron dysfunction in the acute stage displayed increased amplitudes of motor unit action potentials with chronic-stage needle EMG, indicating reinnervation through peripheral collateral sprouting as compensatory mechanism (Χ²[1,n=72]=4.3, p=0.04). Thus, lower motoneuron dysfunction represents a relevant factor contributing to motor impairment and recovery in acute cervical spinal cord injury. Defined recovery mechanisms (peripheral reinnervation) may at least partially underlie spontaneous recovery in respective muscles. Therefore, assessment of lower motoneuron dysfunction could help refine prediction of motor recovery following spinal cord injury.

EMG und Neurografie – ein Update

Elektromyografie (EMG) und Elektroneurografie (ENG) gelten als bewährte Methoden, deren Anfänge aber schon Jahrzehnte zurückliegen. In dieser Arbeit werden jüngere Entwicklungen beschrieben und die Rolle von EMG und ENG in wichtigen Situationen diskutiert, nämlich bei traumatische Nervenläsionen, Nervenkompressionssyndromen, Polyneuropathien, Motoneuronerkrankungen, Myopathien, neuromuskulären Transmissionsstörungen und bei muskulärer Überaktivität.

The Prevention of Positioning Injuries During Gynecologic Surgery. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/077, October 2020)

Purpose Positioning injuries are relatively common, forensically highly relevant complications of gynecologic surgery. The aim of this official AWMF S2k-guideline is to provide statements and recommendations on how to prevent positioning injuries using the currently available literature. The literature was evaluated by an interdisciplinary group of experts from professional medical societies. The consensus on recommendations and statements was achieved in a structured consensus process. Method The current guideline is based on the expired S1-guideline, which was updated by a systematic search of the literature and a review of relevant publications issued between February 2014 and March 2019. Statements were compiled and voted on by a panel of experts. Recommendations The guideline provides general and specific recommendations on the prevention, diagnosis and treatment of positioning injuries.

Modeling and Bioinformatics Identify Responders to G-CSF in Patients With Amyotrophic Lateral Sclerosis

Objective: Developing an integrative approach to early treatment response classification using survival modeling and bioinformatics with various biomarkers for early assessment of filgrastim (granulocyte colony stimulating factor) treatment effects in amyotrophic lateral sclerosis (ALS) patients. Filgrastim, a hematopoietic growth factor with excellent safety, routinely applied in oncology and stem cell mobilization, had shown preliminary efficacy in ALS. Methods: We conducted individualized long-term filgrastim treatment in 36 ALS patients. The PRO-ACT database, with outcome data from 23 international clinical ALS trials, served as historical control and mathematical reference for survival modeling. Imaging data as well as cytokine and cellular data from stem cell analysis were processed as biomarkers in a non-linear principal component analysis (NLPCA) to identify individual response. Results: Cox proportional hazard and matched-pair analyses revealed a significant survival benefit for filgrastim-treated patients over PRO-ACT comparators. We generated a model for survival estimation based on patients in the PRO-ACT database and then applied the model to filgrastim-treated patients. Model-identified filgrastim responders displayed less functional decline and impressively longer survival than non-responders. Multimodal biomarkers were then analyzed by PCA in the context of model-defined treatment response, allowing identification of subsequent treatment response as early as within 3 months of therapy. Strong treatment response with a median survival of 3.8 years after start of therapy was associated with younger age, increased hematopoietic stem cell mobilization, less aggressive inflammatory cytokine plasma profiles, and preserved pattern of fractional anisotropy as determined by magnetic resonance diffusion tensor imaging (DTI-MRI). Conclusion: Long-term filgrastim is safe, is well-tolerated, and has significant positive effects on disease progression and survival in a small cohort of ALS patients. Developing and applying a model-based biomarker response classification allows use of multimodal biomarker patterns in full potential. This can identify strong individual treatment responders (here: filgrastim) at a very early stage of therapy and may pave the way to an effective individualized treatment option.

Chance or challenge, spoilt for choice? New recommendations on diagnostic and therapeutic considerations in hereditary transthyretin amyloidosis with polyneuropathy: the German/Austrian position and review of the literature

Hereditary transthyretin amyloidosis is caused by pathogenic variants (ATTR_v) in the TTR gene. Alongside cardiac dysfunction, the disease typically manifests with a severely progressive sensorimotor and autonomic polyneuropathy. Three different drugs, tafamidis, patisiran, and inotersen, are approved in several countries, including the European Union and the United States of America. By stabilizing the TTR protein or degrading its mRNA, all types of treatment aim at preventing amyloid deposition and stopping the otherwise fatal course. Therefore, it is of utmost importance to recognize both onset and progression of neuropathy as early as possible. To establish recommendations for diagnostic and therapeutic procedures in the follow-up of both pre-symptomatic mutation carriers and patients with manifest ATTR_v amyloidosis with polyneuropathy, German and Austrian experts elaborated a harmonized position. This paper is further based on a systematic review of the literature. Potential challenges in the early recognition of disease onset and progression are the clinical heterogeneity and the subjectivity of sensory and autonomic symptoms. Progression cannot be defined by a single test or score alone but has to be evaluated considering various disease aspects and their dynamics over time. The first-line therapy should be chosen based on individual symptom constellations and contra-indications. If symptoms worsen, this should promptly implicate to consider optimizing treatment. Due to the rareness and variability of ATTR_v amyloidosis, the clinical course is most importantly directive in doubtful cases. Therefore, a systematic follow-up at an experienced center is crucial to identify progression and reassure patients and carriers.

Magnetic Measurement of Electrically Evoked Muscle Responses With Optically Pumped Magnetometers

OBJECTIVE

Electroneurography has been an essential method for assessing peripheral nerve disorders for decades. During this procedure, a nerve is briefly electrically excited, and nerve conduction properties are identified by indirect means from the behavior of the innervated muscle. The magnetic field of the resulting muscle response can also be recorded by novel, uncooled magnetometers, which have become very attractive for different medical applications over recent years. These highly sensitive magnetometers are called optically pumped magnetometers.

METHODS

We performed unaveraged and averaged magnetic signal detection of electrically evoked muscle responses using optically pumped magnetometers. We then discussed the suitability of this procedure for clinical applications in the context of diagnostic value and in direct comparison with the current electrical gold standard.

RESULTS

The magnetic detection of muscle responses is possible using optically pumped magnetometers. Our magnetic results (averaged and unaveraged) closely match those from electrical measurements.

CONCLUSION

Optically pumped magnetometers provide an alternative, contactless technology for electrode-based motor studies, but they are currently not ready for routine clinical use. This costly technology requires additional earth magnetic shielding because this is a prerequisite for proper operation. Currently, there are no diagnostic advantages over electrical measurements. Additionally, the required measurement setup and procedure are much more complicated.

SIGNIFICANCE

In contrast to already published proof-of-principle studies for magnetomyography, we report in detail the results of the magnetic measurements of electrically evoked muscle responses in a shielded environment by applying supramaximal stimulation and finally validate our findings with electroneurography data as a reference.

Signal Modeling and Simulation of Temporal Dispersion and Conduction Block in Motor Nerves

OBJECTIVE

Electroneurography is a well-established diagnostic test for supporting the diagnosis of disorders of myelinated peripheral nerves. Neurophysiological quantities are automatically calculated and are used to determine the pathology of the nerve (axonal damage) or its sheath (myelin damage). Specific differential diagnostic criteria are derived from time-domain normative data, which result primarily from a computer simulation in the early 1990s based on animal data, namely rats. However, the rat signals studied differ significantly from those of humans because of anatomical differences.

METHODS

We present a model-based simulation of nerve conduction in healthy and pathological motor nerves. In contrast to earlier simulations, the present model is based on motor unit action potentials extracted from real human measurements facilitating the generation of realistic signals, starting from a conduction velocity distribution. In addition to the modeling of healthy nerves, we model a hereditary peripheral nerve disease as well as an acute and a chronic inflammatory demyelinating condition.

RESULTS

Quantitative signal differences based on standard variables in the time-domain are presented. The findings for the demyelinating conditions demonstrate amplitude reductions of 71% and 65% between the distal and proximal responses, which result from an increase in the variance of the nerve fiber conduction velocities.

CONCLUSION

The simulation results closely match those of empirical measurements, indicating that the signal model captures relevant pathological mechanisms. An amplitude reduction of more than 50% in demyelinating conditions is in accordance with routine measurements and shows that temporal dispersion is quite well-modeled compared to previous simulation models.

SIGNIFICANCE

The simulation outcomes can serve as the basis for an improved pathophysiological understanding of peripheral nerve disorders and should aid neurophysiologists to refine their diagnostic armamentarium resulting in a more precise differential diagnosis.

SOP Kompressionssyndrome peripherer Nerven

Nervenkompressionssyndrome gehören zu den häufigsten neurologischen Störungen. Für die wichtigsten Kompressionssyndrome an Armen und Beinen werden typische Beschwerden und klinische Befunde sowie das standardisierte elektrophysiologische Vorgehen beschrieben. Neben den Mindestanforderungen und den dabei zu erwartenden pathologischen Befunden wird besonderer Wert darauf gelegt, die technischen Probleme und differenzialdiagnostischen Schwierigkeiten darzustellen.

Neurografie

Bildgebende Verfahren machen der Elektroneurografie scheinbar Konkurrenz, scheinen sie manchenorts in den Hintergrund zu verdrängen. Dies ist zum Schaden der Patienten, da beide Methoden einander vortrefflich ergänzen. Besonders hilfreich ist die Elektroneurografie auch „heute noch“ zum Nachweis und zur Lokalisation von neurogenen Prozessen oder Nervenverletzungen, Nachweis von Demyelinisierung, bei der Ermittlung der Art einer Nervenläsion, Beurteilung des zeitlichen Verlaufs nach einer Nervenläsion, Objektivierung von Läsionen, Diagnostik neuromuskulärer Transmissionsstörungen.

Biomarker Supervised G-CSF (Filgrastim) Response in ALS Patients

Objective: To evaluate safety, tolerability and feasibility of long-term treatment with Granulocyte-colony stimulating factor (G-CSF), a well-known hematopoietic stem cell factor, guided by assessment of mobilized bone marrow derived stem cells and cytokines in the serum of patients with amyotrophic lateral sclerosis (ALS) treated on a named patient basis.

Methods: 36 ALS patients were treated with subcutaneous injections of G-CSF on a named patient basis and in an outpatient setting. Drug was dosed by individual application schemes (mean 464 Mio IU/month, range 90-2160 Mio IU/month) over a median of 13.7 months (range from 2.7 to 73.8 months). Safety, tolerability, survival and change in ALSFRS-R were observed. Hematopoietic stem cells were monitored by flow cytometry analysis of circulating CD34⁺ and CD34⁺CD38⁻ cells, and peripheral cytokines were assessed by electrochemoluminescence throughout the intervention period. Analysis of immunological and hematological markers was conducted.

Results: Long term and individually adapted treatment with G-CSF was well tolerated and safe. G-CSF led to a significant mobilization of hematopoietic stem cells into the peripheral blood. Higher mobilization capacity was associated with prolonged survival. Initial levels of serum cytokines, such as MDC, TNF-beta, IL-7, IL-16, and Tie-2 were significantly associated with survival. Continued application of G-CSF led to persistent alterations in serum cytokines and ongoing measurements revealed the multifaceted effects of G-CSF.

Conclusions: G-CSF treatment is feasible and safe for ALS patients. It may exert its beneficial effects through neuroprotective and -regenerative activities, mobilization of hematopoietic stem cells and regulation of pro- and anti-inflammatory cytokines as well as angiogenic factors. These cytokines may serve as prognostic markers when measured at the time of diagnosis. Hematopoietic stem cell numbers and cytokine levels are altered by ongoing G-CSF application and may potentially serve as treatment biomarkers for early monitoring of G-CSF treatment efficacy in ALS in future clinical trials.

Transthyretin-Amyloidose (ATTR-Amyloidose): Empfehlungen zum Management in Deutschland und Österreich

Die Transthyretin-Amyloidose (ATTR-Amyloidose) ist eine seltene, rasch verlaufende neurodegenerative Erkrankung, verursacht durch Mutationen im Transthyretin-Gen. Aufgrund der Seltenheit ist sie wenig bekannt mit der Folge, dass die Diagnose in vielen Fällen nicht oder für eine effektive Therapie zu spät gestellt wird. Therapeutisch steht seit Anfang der 1990er-Jahre die Lebertransplantation zur Verfügung, seit 2011 der oral einzunehmende Transthyretinstabilisator Tafamidis. Weitere Substanzen sind in der klinischen Prüfung oder stehen vor der Zulassung. Hierzu zählen die gentherapeutischen Substanzen Inotersen und Patisiran, die auf dem Boden der RNA-Interferenz wirken, für die Behandlung der Polyneuropathie und Tafamidis zur Behandlung der Kardiomyopathie bei ATTR-Amyloidosen. Die vorliegende Arbeit deutschsprachiger Experten gibt Empfehlungen zu Diagnostik, Management und Therapie von ATTR-Amyloidosen und soll helfen, diese erbliche, heute aber gut behandelbare, Erkrankung einem weiteren Kreis von Ärzten bekannt zu machen.

Combinatory Biomarker Use of Cortical Thickness, MUNIX, and ALSFRS-R at Baseline and in Longitudinal Courses of Individual Patients With Amyotrophic Lateral Sclerosis

Objective: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative process affecting upper and lower motor neurons as well as non-motor systems. In this study, precentral and postcentral cortical thinning detected by structural magnetic resonance imaging (MRI) were combined with clinical (ALS-specific functional rating scale revised, ALSFRS-R) and neurophysiological (motor unit number index, MUNIX) biomarkers in both cross-sectional and longitudinal analyses. Methods: The unicenter sample included 20 limb-onset classical ALS patients compared to 30 age-related healthy controls. ALS patients were treated with standard Riluzole and additional long-term G-CSF (Filgrastim) on a named patient basis after written informed consent. Combinatory biomarker use included cortical thickness of atlas-based dorsal and ventral subdivisions of the precentral and postcentral cortex, ALSFRS-R, and MUNIX for the musculus abductor digiti minimi (ADM) bilaterally. Individual cross-sectional analysis investigated individual cortical thinning in ALS patients compared to age-related healthy controls in the context of state of disease at initial MRI scan. Beyond correlation analysis of biomarkers at cross-sectional group level (n = 20), longitudinal monitoring in a subset of slow progressive ALS patients (n = 4) explored within-subject temporal dynamics of repeatedly assessed biomarkers in time courses over at least 18 months. Results: Cross-sectional analysis demonstrated individually variable states of cortical thinning, which was most pronounced in the ventral section of the precentral cortex. Correlations of ALSFRS-R with cortical thickness and MUNIX were detected. Individual longitudinal biomarker monitoring in four slow progressive ALS patients revealed evident differences in individual disease courses and temporal dynamics of the biomarkers. Conclusion: A combinatory use of structural MRI, neurophysiological and clinical biomarkers allows for an appropriate and detailed assessment of clinical state and course of disease of ALS.

Quantitatives EMG und mehr

Es war zunächst geplant, das vorliegende Themenheft mit „quantitatives EMG“ zu überschreiben. Den Lesern der „Klinische Neurophysiologie“ wird klar sein, dass mit diesem Thema jedenfalls dann kein ganzes Heft zu füllen ist, wenn man meint: „quantitatives EMG, das ist doch Sammeln und Ausmessen von Potenzialen von zwanzig verschiedenen motorischen Einheiten“. Ein Ziel dieses Heftes ist es dazu beizutragen, dass dieser Satz nicht mehr so oft zu hören oder zu lesen ist.

Elektromyografie: Analyse von Entladungsfrequenz und -rhythmus

In der diagnostischen Elektromyographie werden Aktionspotenziale von einzelnen Muskelfasern (pathologische Spontanaktivität) oder Potenziale motorischer Einheiten beurteilt. Die diagnostische Reichweite der Methode wird verbessert, wenn Entladungsfrequenz und -Rhythmus der Aktionspotenziale analysiert werden. Damit lässt sich zuverlässig Spontanaktivität als pathologisch erkennen, und zentrale von peripherer Lähmung unterscheiden.

SOP Allgemeine Methodik der Myografie

Die Elektromyografie dient der Untersuchung von Patienten mit neuromuskulären Erkrankungen mittels konzentrischer Nadelelektroden. In dieser SOP wird eine standardisierte Verfahrensweise mit technischen Details vorgestellt. Ein Überblick über die wichtigsten elektromyografischen Befunde bietet Unterstützung bei der Interpretation der Messergebnisse. Abschließend werden Besonderheiten der Einzelfaser-EMG erläutert.

Update – Neurophysiologische Methoden zur Bestimmung der Anzahl motorischer Einheiten in menschlichen Muskeln

Die Anzahl funktionstüchtiger motorischer Einheiten stellt nach wie vor das ideale Maß zur Verlaufsbeurteilung bei Erkrankungen mit Verlust motorischer Einheiten dar. Die absolute Zahl motorischer Einheiten (ZME) sowie deren Verlauf über die Zeit erlauben neben der Beschreibung des Krankheitsverlaufes Aussagen über Regenerationsmechanismen wie Reinnervation durch kollaterale Aussprossung oder Reinnervation durch Axonwachstum. Eine exakte Bestimmung der Zahl motorischer Einheiten ist leider auch heute nicht möglich, eine Schätzung funktionstüchtiger motorischer Einheiten hingegen mit elektrophysiologischen Methoden durchführbar. Der apparative und zeitliche Aufwand älterer Methoden zur Schätzung der Anzahl motorischer Einheiten ist außerordentlich hoch und bedarf spezieller Untersucher-Erfahrung. Die 2004 erstbeschriebene Methode MUNIX hingegen ist einfach durchführbar und deutlich weniger zeitaufwendig. MUNIX eignet sich hervorragend zur Verlaufsbeurteilung der ZME bei bekanntem Verlust motorischer Einheiten. Neue Untersuchungen hingegen zeigen, dass MUNIX als diagnostische Methode per se ungeeignet ist.

Misleading bilateral blink reflex loss in a severe tetanus case

Tetanus is rare and often forgotten in the diagnostic workup. The diagnosis is mainly based on typical clinical symptoms, because of missing sensitive paraclinical test. As described in our case, a missing bilateral blink reflex may occur in severe tetanus, which should not lead to the rejection of the diagnosis.

Myopathy in Childhood Muscle-Specific Kinase Myasthenia Gravis

BACKGROUND

Adult and pediatric patients suffering from MuSK (muscle-specific kinase) -antibody positive myasthenia gravis exhibit similar features to individuals with acetylcholine receptor (AChR) antibodies, but they differ in several characteristics such as a predominant bulbar, respiratory and neck weakness, a generally worse disease severity and a tendency to develop muscle atrophy. Muscle atrophy is a rare phenomenon that is usually restricted to the facial muscles.

RESULTS

We describe a girl with MuSK-antibody positive myasthenia gravis who developed a myopathy with severe generalized muscular weakness, muscle atrophy, and myopathic changes on electromyography.

CONCLUSION

This is the first published example of a generalized myopathic syndrome in myasthenia gravis. We review the relevant literature and discuss the hypothesis of a mitochondrial myopathy as a pathogenic mechanism in MuSK-antibody positive myasthenia gravis.

Autonomic and peripheral nervous system function in acute tick-borne encephalitis

OBJECTIVES

Tick-borne encephalitis (TBE) is an emerging flaviviral zoonosis in Central and Eastern Europe. TBE can present as meningitis, meningoencephalitis, or meningoencephalomyelitis. Dysfunction of the autonomic (ANS) and peripheral motoric and sensory nervous system (PNS) might contribute to acute and long-term complications. We aimed to examine, whether the ANS and PNS are affected in acute TBE.

METHODS

Fourteen patients with acute TBE, 17 with diabetic polyneuropathy (d-PNP), and 30 healthy controls (HC) were examined in our single-center, prospective study. ANS and PNS function was assessed by time- and frequency-domain parameters of the heart rate (HR) variability at rest and deep respiration, and by sural and tibial nerve neurography. Primary endpoint was the HR variability at rest measured by root mean square of the successive differences (RMSSD). Autonomic symptoms and quality of life (QoL) were assessed by questionnaires.

RESULTS

Tick-borne encephalitis patients had a lower RMSSD at rest (TBE 13.1 ± 7.0, HC 72.7 ± 48.3; P < 0.001) and deep respiration (TBE 42.8 ± 27.0, HC 109.7 ± 68.8; P < 0.01), an increased low-frequency to high-frequency power component ratio at rest (TBE 4.0 ± 4.0, HC 0.8 ± 0.5; P < 0.001), and a higher minimal heart rate at rest (TBE 85.4 ± 7.0, HC 69.5 ± 8.5; P < 0.001), all similar to patients with d-PNP, indicating sympathovagal imbalance with increased sympathetic activation. Compared to HC, sural and tibial nerve conduction velocities and action potential amplitudes were reduced, ANS symptoms were more frequent, and QoL was lower in patients with TBE.

CONCLUSIONS

The ANS and to a lesser degree the PNS are affected by acute TBE, which could potentially contribute to short- and long-term morbidity.

Occipital Nerve Blockade in Chronic Cluster Headache Patients and Functional Connectivity Between Trigeminal and Occipital Nerves

Headache syndromes often involve occipital and neck symptoms, suggesting a functional connectivity between nociceptive trigeminal and cervical afferents. Although reports regarding effective occipital nerve blockades in cluster headache exist, the reason for the improvement of the clinical symptoms is not known. Using occipital nerve blockade and nociceptive blink reflexes, we were able to demonstrate functional connectivity between trigeminal and occipital nerves in healthy volunteers. The R2 components of the nociceptive blink reflex and the clinical outcome in 15 chronic cluster headache patients were examined before and after unilateral nerve blockade of the greater occipital nerve with 5 ml prilocain (1%) on the headache side. In contrast to recent placebo-controlled studies, only nine of the 15 cluster patients reported some minor improvement in their headache. Six patients did not report any clinical change. Exclusively on the injection side, the R2 response areas decreased and R2 latencies increased significantly after the nerve blockade. These neurophysiological and clinical data provide further evidence for functional connectivity between cervical and trigeminal nerves in humans. The trigeminocervical complex does not seem to be primarily facilitated in cluster headache, suggesting a more centrally located pathology of the disease. However, the significant changes of trigeminal function as a consequence of inhibition of the greater occipital nerve were not mirrored by a significant clinical effect, suggesting that the clinical improvement of occipital nerve blockades is not due to a direct inhibitory effect on trigeminal transmission.

The Prevention of Positioning Injuries during Gynecologic Operations. Guideline of DGGG (S1-Level, AWMF Registry No. 015/077, February 2015)

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Positioning injuries after lengthy gynecological procedures are rare, but the associated complications can be potentially serious for patients. Moreover, such injuries often lead to claims of malpractice and negligence requiring detailed medical investigation. To date, there are no binding evidence-based recommendations for the prevention of such injuries. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. The recommendations cover.

Safety and feasibility of long term administration of recombinant human granulocyte-colony stimulating factor in patients with amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neuronal disease resulting in a loss of the upper and lower motor neurons and subsequent death within three to four years after diagnosis. Mouse models and preliminary human exposure data suggest that the treatment with granulocyte-colony stimulating factor (G-CSF) has neuro-protective effects and may delay ALS progression. As data on long-term administration of G-CSF in patients with normal bone marrow (BM) function are scarce, we initiated a compassionate use program including 6 ALS patients with monthly G-CSF treatment cycles. Here we demonstrate that G-CSF injection was safe and feasible throughout our observation period up to three years. Significant decrease of mobilization efficiency occurred in one patient and a loss of immature erythroid progenitors was observed in all six patients. These data imply that follow-up studies analyzing BM function during long-term G-CSF stimulation are required.

Entrapment syndrome of multiple nerves in graft-versus-host disease

INTRODUCTION

Peripheral nerve entrapment syndromes are associated with hereditary neuropathy with liability to pressure palsies and a variety of rheumatic and endocrinological diseases.

METHODS

We report a patient with entrapment syndromes of multiple nerves associated with chronic graft-versus-host-disease (GVHD) after allogeneic hematopoietic stem cell transplantation. Nerve ultrasound, histology, and ultrastructural changes were assessed.

RESULTS

The 51-year-old man had developed severe deep dermal sclerosis due to chronic GVHD with a progressive polyneuropathy and entrapment syndromes of multiple nerves. Pre-stenotic enlargement was shown by nerve ultrasound. Histology demonstrated fibrosis of the epineurium with scarce infiltration of macrophages. Electron microscopy demonstrated alterations of the myelin sheaths and marked depletion of normal-sized myelinated nerve fibers.

CONCLUSIONS

In addition to polyneuropathy, chronic GVHD can be associated with peripheral nerve entrapment syndromes and should be added to the differential diagnosis of compressive neuropathies.