Life can be worth living in locked-in syndrome.

The locked-in syndrome (LIS) describes patients who are awake and conscious but severely deefferented leaving the patient in a state of almost complete immobility and loss of verbal communication. The etiology ranges from acute (e.g., brainstem stroke, which is the most frequent cause of LIS) to chronic causes (e.g., amyotrophic lateral sclerosis; ALS). In this article we review and present new data on the psychosocial adjustment to LIS. We refer to quality of life (QoL) and the degree of depressive symptoms as a measure of psychosocial adjustment. Various studies suggest that despite their extreme motor impairment, a significant number of LIS patients maintain a good QoL that seems unrelated to their state of physical functioning. Likewise, depression is not predicted by the physical state of the patients. A successful psychological adjustment to the disease was shown to be related to problem-oriented coping strategies, like seeking for information, and emotional coping strategies like denial--the latter may, nevertheless, vary with disease stage. Perceived social support seems to be the strongest predictor of psychosocial adjustment. QoL in LIS patients is often in the same range as in age-matched healthy individuals. Interestingly, there is evidence that significant others, like primary caregivers or spouses, rate LIS patients' QoL significantly lower than the patients themselves. With regard to depressed mood, ALS patients without symptoms focus significantly more often on internal factors that can be retained in the course of the disease contrary to patients with depressive symptoms who preferably name external factors as very important, such as health, which will degrade in the course of the disease. Typically, ALS patients with a higher degree of depressive symptoms experience significantly less "very pleasant" situations. The herein presented data strongly question the assumption among doctors, health-care workers, lay persons, and politicians that severe motor disability necessarily is intolerable and leads to end-of-life decisions or euthanasia. Existing evidence supports that biased clinicians provide less-aggressive medical treatment in LIS patients. Thus, psychological treatment for depression, effective strategies for coping with the disease, and support concerning the maintenance of the social network are needed to cope with the disease. Novel communication devices and assistive technology now offers an increasing number of LIS patients to resume a meaningful life and an active role in society.

[Life with Locked-In syndrome]. / Quelle vie après le Locked-In syndrome?

The Locked-In Syndrome (LIS) is classically caused by an anterior pontine vascular lesion and characterized by quadriplegia and anarthria with preserved consciousness and intellectual functioning. We here review the definition, etiologies, diagnosis and prognosis of LIS patients and briefly discuss the few studies on their quality of life and the challenging end-of-life decisions that can be encountered. Some clinicians may consider that LIS is worse than being in a vegetative or in a minimally conscious state. However, preliminary data from chronic LIS survivors show a surprisingly preserved self-scored quality of life and requests of treatment withdrawal or euthanasia, though not absent, are infrequent.

[Blink and you live: the locked-in syndrome]. / Le Locked-In Syndrome: la conscience emmurée.

INTRODUCTION: The Locked-In syndrome (LIS) is defined by: (i) the presence of sustained eye opening (bilateral ptosis should be ruled out as a complicating factor); (ii) preserved awareness; (iii) aphonia or hypophonia; (iv) quadriplegia or quadriparesis; and (v) a primary mode of communication that uses vertical or lateral eye movement or blinking. Acute ventral pontine lesions are its most common cause. Following such brainstem lesions patients may remain comatose for some time and then gradually awaken, remaining paralyzed and voiceless, superficially resembling the vegetative state. BACKGROUND: It has been shown that more than half of the time physicians fail to recognize early signs of awareness in LIS. Given appropriate medical care, life expectancy may be several decades but the chances of good motor recovery remain small. Eye-controlled computer technology now allows LIS patients to communicate and control their environment. Recent studies show that most LIS patients self-report meaningful quality of life and the demand for euthanasia is infrequent. CONCLUSION: Patients suffering from LIS should not be denied the right to die--and to die with dignity--but also they should not be denied the right to live--and to live with dignity and the best possible pain and symptom management and revalidation.

[Peripheral neurolytic blocks and spasticity]. / Spasticité: intérêt du testing par anesthésie locorégionale et blocs thérapeutiques.

Peripheral nerve blockade is one of the therapeutic possibilities to treat spasticity of various muscles. Percutaneous nerve stimulation allows accurate location of nerves and neurolysis can be performed using intraneural injection of 65% ethanol or 5 to 12% phenol. Spastic contraction of various muscle groups is a common source of pain and disability which prevents from having efficient rehabilitation. Test-blocks as well as neurolytic blocks are possible in most of motor nerves of the upper and lower limbs and main indications are spastic sequelae of stroke and spinal trauma but also of multiple sclerosis, cerebral palsy and chronic coma. The use of percutaneous nerve stimulation allows accurate location and four nerves are more frequently treated: pectoral nerve loop, median, obturator and tibial nerves. In patients with spasticity of the adductor thigh muscles, nerve blocks are performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. No complications occurred and minor side effects are transient painful phenomena during injection. These approaches proved to be accurate, fast, simple, highly successful and reproducible. Percutaneous neurolytic procedures should be done as early as possible, as soon as spasticity becomes painful and disabling in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neuron.

[What is the place of diphosphonates in the treatment of complex regional pain syndrome I?]. / Quelle est la place des biphosphonates dans le traitement de l'algodystrophie sympathique réflexe? Analyse critique de la littérature.

OBJECTIVES: To evaluate the efficacy of biphosphonates (BPs) in complex regional pain syndrome I or reflex sympathetic dystrophy and to specify their place in this chronic painful syndrome. METHODS: A literature review of Medline and Embase with use of a combination of 3 key words: biphosphonates therapy, reflex sympathetic dystrophy, complex regional pain syndrome I, controlled study. Each article was classified by 2 independent reviewers according to Aguilar's method into high, middle or low quality. RESULTS: Three second-generation BPs were tested in the treatment of reflex sympathetic dystrophy: pamidronate, alendronate and clodronate. Many open studies investigated pamidronate, but only 2 were randomised and controlled: a low-quality trial comparing pamidronate with placebo and a middle-quality trial comparing pamidronate with calcitonine. Two high-quality trials were performed, 1 with alendronate and 1 with clodronate. Middle-quality trial and high-quality trials reported positive effects on pain with BPs in recent reflex sympathetic dystrophy (disease duration less than eight months). Side effects (fever, asymptomatic hypocalcemia) were observed frequently but disappeared quickly. CONCLUSION: BPs can be used in recent reflex sympathetic dystrophy when calcitonin is inefficient or when calcitonin injections are not well tolerated.

[Alcohol neurolytic blocks for pain and muscle spasticity]. / Les traitements locaux de la spasticité: blocs périphériques des membres pour alcoolisation ou phénolisation neurolytique.

Peripheral nerve blockade is one of the therapeutic options for spasticity of various muscles. Percutaneous nerve stimulation allows accurate location of nerves and neurolysis can be performed using intraneural injection of 65% ethanol or 5 to 12% phenol. Spastic contraction of various muscle groups is a common source of pain and disability which prevents efficient rehabilitation. Neurolytic blocks are possible in most of motor nerves of the upper and lower limbs and main indications are spastic sequelae of stroke and spinal trauma but also of multiple sclerosis, cerebral palsy and chronic coma. The use of percutaneous nerve stimulation allows accurate location and four nerves are more frequently treated: pectoral nerve loop, median, obturator and tibial nerves. In patients with spasticity of the adductor thigh muscles, nerve blocks are performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. No complications occur and minor side effects are transient painful phenomena during injection. These approaches have proved to be accurate, fast, simple, highly successful and reproducible. Percutaneous neurolytic procedures, should be performed as early as possible, as soon as spasticity becomes painful and disabling in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurons.

Serotoninergic, noradrenergic, and peptidergic innervation of Onuf's nucleus of normal and transected spinal cords of baboons (Papio papio).

We have investigated with light and electron microscope immunocytochemistry the aminergic and peptidergic innervation of Onuf's nucleus in adult baboons. This nucleus, located in the ventrolateral part of the sacral spinal cord (S2 and S3), is considered to control urethral and anal sphincters and penile muscles. By comparison of intact and transected spinal cords, we have found that serotoninergic innervation has two origins: first, supraspinal, innervating the whole nucleus, with a possible predominance in the dorsal half; and second, intraspinal, corresponding to the ventral half of the nucleus. Thyrotropin-releasing hormone innervation appears largely coincident with serotonin, both in intact and transected spinal cords. Noradrenaline is exclusively of supraspinal origin, as attested by its disappearance below the level of the section. Substance P, calcitonin gene-related peptide, and Leu- and Met-enkephalin, which profusely innervate Onuf's nucleus, are on the contrary not affected by the transection. They most likely originate from the cord itself or the dorsal root ganglia. Thus, Onuf's nucleus innervation in the baboon arises both from supraspinal and intraspinal sources. The present study provides an anatomical basis for both voluntary and reflex controls of excretory and sexual functions in a primate. The same neurotransmitter (serotonin) according to its cell origin and discrete topography could exert different influences upon the same effector system.

Effects of neonatal removal of superior cervical ganglion on serotonin and thyrotropin-releasing hormone immunoreactivity in the intermediolateral cell column of the rat spinal cord.

In this study, we investigated the effects of the neonatal removal of the right superior cervical ganglion on the serotonin-like and thyrotropin-releasing-hormone-like immunoreactivities (5-HT-LI and TRH-LI) in the intermediolateral cell column (IML) of the spinal cord by quantitative image analysis. Two weeks after the lesion, we observed a 60% reduction in 5-HT-LI, while TRH-LI was not significantly reduced, in the right IML (lesioned side) at T1-2 levels. One month after the lesion, 5-HT-LI and TRH-LI were significantly reduced by 60% in the right IML at T1-2 levels. After 3 months, this decrease persisted at this level. In addition, we observed a 30% loss of the 5-HT-LI in the right IML at T3-4 levels, whereas TRH-LI did not decrease significantly at T3-4 levels. These findings are discussed and compared with those of other experimental studies on serotonergic reorganization in the rat spinal cord.