Degenerative cervical radiculopathy: diagnosis and conservative treatment. A review.

Degenerative cervical radiculopathy: clinical diagnosis and conservative treatment. A review. To provide a state-of-the-art assessment of diagnosis and non-surgical treatment of degenerative cervical radiculopathy a literature search for studies on epidemiology, diagnosis including electrophysiological examination and imaging studies, and different types of conservative treatment was undertaken. The most common causes of cervical root compression are spondylarthrosis and disc herniation. Diagnosis is made mainly on clinical grounds, although there are no well-defined criteria. Provocative tests like the foraminal compression test are widely used but not properly evaluated. The clinical diagnosis of degenerative cervical radiculopathy can be confirmed by magnetic resonance imaging. The role of electromyography is mainly to rule out other conditions. Cervical radiculopathy is initially treated conservatively, although no treatment modality has been evaluated in a randomized controlled trial. Degenerative cervical radiculopathy: diagnosis and conservative treatment. A review.

Clinical value of electrodiagnostic testing following repair of peripheral nerve lesions: a prospective study.

This study prospectively assessed the level of correlation between functional and electrophysiological recovery after median and ulnar nerve lacerations. Motor and sensory recovery were recorded clinically and electrophysiologically every 3 months in 24 patients with 29 complete median or ulnar nerve lacerations. The strength of agreement between the clinical motor score and the electrophysiological score was "fair", but in 41% a discrepancy was identified (kappa factor 0.39). Regeneration was not detected earlier by electrophysiology than by a thoroughly performed clinical evaluation. This suggests that electrophysiologic testing is of value as an adjunct to clinical assessment for evaluating cases in which there is clinical doubt as to the progress of regeneration and secondary surgery is contemplated.

Contrast enhanced color duplex for diagnosis of subtotal stenosis or occlusion of the internal carotid artery.

BACKGROUND AND PURPOSE: We initiated this prospective study to investigate the usefulness of contrast enhancement in combination with color Doppler-assisted duplex imaging (CDDI) for the distinction of subtotal internal carotid artery (ICA) stenosis and ICA occlusion. METHODS: During 1 year all patients with a previously unknown subtotal ICA stenosis (>90%) or ICA occlusion on routine CDDI were included in the study. These patients underwent a CDDI with and without intravenous contrast, Levovist 300 mg/ml. RESULTS: The study group consisted of 32 patients, 15 with subtotal stenosis and high velocity at the ICA stenosis, two with subtotal stenosis and minimal residual color flow and relative low velocity at the ICA stenosis and 15 with ICA occlusion. In all patients the diagnosis by CDDI without and with contrast were the same. Image quality was improved with contrast in 13 of the 17 patients at the subtotal ICA stenosis. There was no significant difference in mean velocities at the subtotal ICA stenoses without and with contrast. CONCLUSION: The usefulness of contrast enhancement with CDDI for differentiating subtotal ICA stenosis and ICA occlusion is limited. Possibly it is useful in patients with moderate image quality of the CCA and ICA and in patients with a subtotal stenosis with minimal residual color flow and relative low velocity at the ICA stenosis.

[Continued driving habits of patients diagnosed with excessive daytime sleepiness]. / Persisterende deelname aan het snelverkeer van patiënten met excessieve slaperigheid overdag.

OBJECTIVE: Description of driving behaviour of patients with excessive daytime sleepiness (EDS) and the influence on their driving of diagnosis, therapy, legal guidelines and advices. DESIGN: Inventory based on questionnaires. SETTING: Centre for Sleep and Wake Disorders, The Hague, the Netherlands. METHODS: All patients with EDS who were in a stable condition for at least 6 months after therapy were sent a questionnaire (n = 138). The questions concerned actual driving behaviour, EDS and the effects of diagnosis, therapy and advice given by the Centre. RESULTS: The response was 67% (n = 92). Eighteen patients had never driven a car. Eighteen of the other 74 patients quit driving or drove less. Fifty-six patients did not change their behaviour or drove even more. There was little effect on driving behaviour of diagnosis, therapy and advice to stop driving. CONCLUSION: Patients with EDS often participate as drivers in modern traffic. Legal guidelines and advice given by physicians have only little influence on this behaviour. As general measures seem to be ineffective, approaches tailored to the individual patient may lead to more acceptable results.

The validity of the Dutch Sleep Disorders Questionnaire (SDQ).

The Sleep Disorders Questionnaire (SDQ) is a 176-item questionnaire designed to diagnose the presence of common sleep disorders. This study set out to assess the validity of a Dutch translation of the SDQ. Scores on 145 questionnaires were analyzed. A cluster analysis of these scores revealed the following clusters: healthy, depression, insomnia, narcolepsy, and apnea. The cluster classification proved correct for 67% of the subjects, as determined on the basis of polysomnography. These results show that the Dutch SDQ is a reasonably valid instrument for diagnosing sleep disorders.

Fatal cerebral oedema associated with primary dengue infection.

Encephalopathy associated with dengue fever is considered to be a rare condition in adults. We describe a patient with a primary dengue infection who, in the absence of overt signs of dengue shock syndrome, died due to progressive cerebral oedema. Autopsy findings demonstrated loss of integrity of cerebral vascular endothelium and involvement of complement activation.

Coactivation of the ulnar nerve in motor tests for carpal tunnel syndrome.

Coactivation of the ulnar nerve at the wrist can be a source of error in tests for carpal tunnel syndrome (CTS). We compared the effects of coactivation in two tests for CTS: the abductor pollicis brevis-distal motor latency (APB-DML) and lumbrical-interosseus-distal motor latency difference (2LI-DML). We studied 33 hands of 25 consecutive patients referred for suspected CTS. In severe CTS, when selective supramaximal stimulation of the median nerve was impossible, all APB-compound muscle action potentials (CMAP) showed abnormalities, indicating volume conduction of ulnar muscle activation. 2LI-DML in these hands led to falsely normal test results, as two identical CMAP were obtained after median and ulnar stimulation. In less severe CTS, warning signs indicating coactivation were observed in APB-DML virtually as often as in 2LI-DML. Undetected coactivation was more likely to be associated with false normal test results in 2LI-DML than in APB-DML.

The diagnostic yield of a second EEG after partial sleep deprivation: a prospective study in children with newly diagnosed seizures.

PURPOSE: To assess the diagnostic yield of a repeated EEG (REPEEG) after partial sleep deprivation (SD) in children and adolescents with one or more seizures who previously had had a standard EEG (STDEEG) without epileptiform abnormalities (EAs). In the literature, 32-75% of such REPEEGs after SD were reported to show EA. METHODS: In a prospective, multicentred study, we selected children aged 1 month to 16 years with one or more idiopathic or remote symptomatic newly diagnosed seizures. A REPEEG was recorded in children without EAs in their STDEEG. RESULTS: Of 552 children and adolescents who entered the study, 243 (44%) had a STDEEG without EAs. In 177 (73% of eligible children), REPEEGs were recorded after SD. We found EAs in 61 (34.5%) REPEEGs and new nonepileptiform abnormalities in five (1%). In 552 children in the total cohort, the REPEEG thus added 11% with EAs to the 56% with EAs in the STDEEG. Of REPEEGs, 81% included sleep compared with 20% of STDEEGs. In about half the REPEEGs, EAs occurred during sleep only. One child had tonic-clonic seizures probably related to the SD. CONCLUSIONS: One third of REPEEGs yielded new diagnostic information. Partial, age-dependent SD was highly effective in inducing sleep, which is important because in many cases EAs were found only during EEG recording in sleep. The procedure was safe and convenient.

Cortical somatosensory evoked potentials from lumbosacral dermatomes: airpuff versus electrical stimulation.

Cortical potentials were elicited by airpuff stimulation of the L5 and S1 dermatome in a group of 24 healthy volunteers. The results were compared with the SEPs obtained by conventional electrical stimulation. Both stimulus modalities produce stable and good reproducible cortical responses of similar waveform. The most stable second negative peak, labeled N2, was used in this study. Mean latencies (in msec) were: N2 L5 air = 67.1 +/- 3.3, N2 L5 electr. = 55.7 +/- 3.7 N2 S1 air = 67.2 +/- 3.9, and N2 S1 electr. = 55.1 +/- 2.9 The maximum R/L difference (mean + 3 SD) was 5.7 msec, 5.9 msec, 7.2 msec and 7.2 msec for respectively N2 L5 air, N2 L5 electrical, N2 S1 air and N2 S1 electrical. Single regression analysis showed a significant influence of height, but not age upon all latencies. Multiple regression analysis with height and age as independent variables showed a significant influence of height and age together upon the latencies of the electrical SEP (both L5 and S1). For the airpuff SEP only height was significant. Gender had no effect on the cortical components. The amplitude of peak N2 after electrical stimulation of the S1 dermatome was significant higher than after airpuff stimulation, 2.9 and 1.7 microvolt respectively. For the L5 dermatome both types of stimuli produced responses of nearly equal amplitude, 2.5 and 2.1 microvolt for electrical and airpuff stimulation respectively. Airpuff SEPs may provide a good alternative for electrical stimulation.

Daytime sleep in myotonic dystrophy is not caused by sleep apnoea.

Daytime sleepiness is common in myotonic dystrophy and might be attributed to disturbed nocturnal breathing. Seventeen out of 22 patients complained of excessive daytime sleepiness, resembling "idiopathic hypersomnolence". Sleep apnoea might have contributed to daytime sleepiness in only three of 17 patients. Treatment with the central stimulant methylphenidate produced sustained benefit in seven out of 11 patients tested. Daytime sleepiness in myotonic dystrophy is usually caused by dysfunction of central sleep regulation and not by disturbed nocturnal breathing.

Value of the electroencephalogram in adult patients with untreated idiopathic first seizures.

We prospectively studied the reliability and accuracy of the electroencephalogram as a predictor of the risk of recurrence within 2 years in 157 patients with untreated idiopathic first seizures. In all patients, a standard electroencephalogram and, if necessary, an electroencephalogram after partial sleep deprivation were obtained. All electroencephalograms were scored by one observer according to a fixed protocol. The finding of epileptic discharges was associated with a risk of recurrence of 83% (95% confidence interval, 69% to 97%) vs 41% (95% confidence interval, 29% to 53%) in patients with nonepileptic abnormalities and 12% (95% confidence interval, 3% to 21%) in patients in whom both electroencephalograms were normal. The sensitivity proved to be 48%. Interobserver agreement among four neurologists, who independently read 50 electroencephalograms, was found to be moderate. Predictive value for each observer, however, was good. We conclude that electroencephalogram findings may play a role in the decision to initiate or delay treatment after an idiopathic first seizure.

Idiopathic first seizure in adult life: who should be treated?

OBJECTIVE: To assess the accuracy of the diagnosis, recurrence rate, and fate after the first recurrence in adult patients with an untreated idiopathic first seizure. DESIGN: Hospital based follow up study. SETTING: One university hospital and three general hospitals in The Netherlands. PATIENTS: 165 patients aged 15 years or more with a clinically presumed idiopathic seizure; diagnosis was based on a description of the episode according to prespecified diagnostic criteria. MAIN OUTCOME MEASURES: Results of additional investigations and follow up regarding the accuracy of the diagnosis; first recurrence; and response to treatment after the first recurrence. RESULTS: Computed tomography showed major abnormalities in 5.5% of the patients and follow up led to doubts about the initial clinical diagnosis in another 6%. Cumulative risk of recurrence was 40% at two years. The cumulative risk of recurrence at two years was 81% (95% confidence interval 66% to 97%) in patients with epileptic discharges on a standard or partial sleep deprivation electroencephalogram, 39% (27% to 51%) in patients with other electroencephalographic abnormalities, and 12% (3% to 21%) in patients with normal electroencephalograms. Treatment was initiated in most patients who had one or more recurrences; 40 (70%) patients were completely controlled, eight (14%) had sporadic seizures, and nine (16%) did not become free of seizures within one year despite treatment. CONCLUSIONS: The decision to initiate or delay treatment should be based on electroencephalographic findings.

Usefulness of an aura for classification of a first generalized seizure.

In 67 of 149 patients with a generalized first seizure, the occurrence of some kind of sensation immediately preceding the loss of consciousness was the only clue that possibly indicated focal onset of the seizure. We studied the interobserver agreement between six neurologists regarding the interpretation of these preceding feelings as either a nonspecific symptom or an aura implicating a focal onset of the seizure. The observers also classified the seizures as generalized from onset, undetermined, or partial secondarily generalized. To assess the accuracy of the classification, we obtained a standard EEG, an EEG after partial sleep deprivation, a computed tomography (CT) scan, and a follow-up report after 1 year. The subclassification on clinical grounds of a generalized first seizure is too unreliable and probably too invalid as well to be useful in clinical practice or in epidemiologic research.

Digital nerve somatosensory evoked potentials and flexor carpi radialis H reflexes in cervical disc protrusion and involvement of the sixth or seventh cervical root: relations to clinical and myelographic findings.

Peak latencies of somatosensory evoked potentials (SEPs) from nerves of the first digit (digit 1-SEP), 39 controls, and third digit (digit 3-SEP), 47 controls, and indicated for Erb's point, second cervical vertebra (Cv2) and contralateral cortical hand area correlated significantly with arm length. Single regression analysis for arm length for Erb's potentials and the Cv2 potential in digit 1-SEP, and multiple regression analysis for arm length and age for the Cv2 potential in digit 3-SEP, the cortical potentials and flexor carpi radialis H reflex were used for demonstration of root C6 or C7 pathology. Upper crossing of +3 S.D. was defined as abnormal. The combined examination yielded abnormalities in 81% of our 22 patients operated for compression of root C6 or C7 due to cervical disc protrusion. A minority of the patients showed multiple positive correlations between symptoms and electrophysiologic and myelographic findings. In others only one or the other investigative procedure provided confirmatory information, while, in a notable number (6 patients), these approaches revealed abnormalities when there were no or non-specific symptoms. The presented electrophysiological investigations are useful to determine the presence and severity of root C6 or C7 compression as well as the functional relevance of a myelographic abnormality.

The flexor carpi radialis H-reflex in polyneuropathy: relations to conduction velocities of the median nerve and the soleus H-reflex latency.

In 80 controls latencies of flexor carpi radialis (FCR) and in 94 controls latencies of soleus H-reflexes correlated well with length of the extremity, body height and age. Multiple regression equations using latency as a variable dependent on age and body height can be best used in practice when both reflexes are employed for demonstration of proximal pathology. The majority (69%) of 93 patients with various polyneuropathies showed abnormalities in both reflexes illustrating that proximal nerve segments are frequently involved. Four per cent had abnormal FCR H-reflexes with normal soleus H-reflexes whereas the reverse was found in 19% of the patients. Abnormal FCR H-reflexes occurred with normal motor and sensory conduction velocities in the peripheral part of the median nerve in 14%, whereas the reverse was seen in 12%, indicating that FCR H-reflex examination is a valuable supplement to conventional conduction studies for detection of electrophysiologically existing pathology.

Flunarizine, the vestibular system and migraine.

The vestibular function was extensively investigated in 75 patients suffering from migraine. Pathological findings were present in 62 patients (82.6%). With the exception of position nystagmus, vestibular abnormalities were not related to migraine characteristics. Fifty-six patients were treated with flunarizine 10 mg daily for three months. A favourable effect on headache was obtained in 44 patients (78.5%). Flunarizine therapy influenced significantly gaze nystagmus and position nystagmus. The latter tended to be related to anti-migraine efficacy. Other electronystagmographic parameters were not substantially influenced. The authors assume that the vestibular abnormalities in migraine are side phenomena, the clinical relevance of which, at least during the headache-free phase, is not yet well understood.

The flexor carpi radialis H-reflex in lesions of the sixth and seventh cervical nerve roots.

In 143 normal subjects latencies of H-reflexes of the flexor carpi radialis muscle were well correlated with arm lengths. In 32 patients with injury to cervical roots C5 to C8 it was shown that latencies were only abnormal in lesions of roots C6 or C7. It is suggested that in most instances root C6 or C7 and, probably both roots in some cases are involved in the reflex pathway. Repeat electrophysiological examinations after surgery provided valuable data about the various types of nerve root recovery.

The H-reflex of the flexor carpi radialis muscle; a study in controls and radiation-induced brachial plexus lesions.

H-reflexes of the flexor carpi radialis muscle were studied in 52 controls and 25 cancer patients with radiation-induced brachial plexopathy. It was found that H-reflex conduction velocity (H-RCV) decreased with increasing age. This was not true for H-reflex latency (H-RL) and inter-latency times. There were no H-RCV and latency differences between age-matched male and female subjects. In the affected arm the reflex was absent in nine patients and delayed in 16 patients in whom H-RCV was decreased in 13 patients. Three patients showed large H-RL differences which were also notable features in median nerve disease in the region of the brachial plexus.