Role of urologist in diagnosis of multiple sclerosis

This report presents 7 patients with confirmed cases of multiple sclerosis (MS) in whom the diagnosis of MS was first suspected by the urologist. Review of these 7 cases identifies three factors that increased the suspicion of MS at the time of urologic evaluation: a history of neurologic symptoms, abnormalities on a brief neurologic examination, and abnormal basic urodynamic evaluation. Urologists attuned to the possible diagnosis of MS in patients who present with symptoms of voiding dysfunction can facilitate the proper diagnosis with a basic office evaluation.     

Evidence for early lower urinary tract dysfunction in clinically silent multiple sclerosis

The occurrence of micturition complaints as late sequelae of multiple sclerosis is well studied and documented. However, no reports exist on urologically asymptomatic patients with a relatively short disease duration. In a prospective study of 40 patients with definite multiple sclerosis (mean disease duration 5 years), urodynamic investigations (cystometry and pressure-flow study) were combined with neuro-urophysiological measurements (cortical evoked potentials and sacral reflex latencies). Patients with (13) and without (27) micturition complaints were investigated. Neurourodynamic abnormalities were seen in 35 of 40 patients (88%). The lower urinary tract proved to be afflicted by multiple sclerosis at an early stage of the disease. Early neurourodynamic investigations had clinical implications. All of the complaining and half of the noncomplaining patients showed urodynamic abnormalities upon which the need for further followup and eventual therapeutic intervention was based. We conclude that neurourodynamic testing of a urinary functional system can be worthwhile as part of the initial diagnostic evaluation in patients with proved multiple sclerosis.     

Intractable vertigo--when not to operate

Patients with episodic vertigo--or one severe episode of vertigo--may respond to vestibulosuppressive medications or operations on the labyrinth. In patients with constant incapacitating vertigo or disequilibrium, the clinician should suspect nonlabyrinthine disease. A careful history and physical and neurologic examinations will provide clues to underlying disease and direct the selection of further objective tests.     

Clinical application of evoked potentials

Visual, brainstem and somatosensory evoked potentials have added new dimensions to electrophysiological studies. Signal averaging has made it possible to record low-amplitude electrical potentials in the nervous system in response to external stimuli. Clinical abnormalities are indicated by latency prolongations, furnishing objective evidence for suspected or subclinical disease. The tests are most extensively used for the diagnosis of multiple sclerosis. Other indications include hearing and visual evaluation, especially in neonates, diagnosis of brainstem and cerebellopontine angle tumours, monitoring the integrity of sensory function during surgery for scoliosis or neurosurgical procedures and differentiating toxic or metabolic causes of coma from irreversible structural lesions. The tests are non-invasive and considered in conjunction with the clinical data provide useful electrodiagnostic tools.     

Cortical evoked potentials of the dorsal nerve of the clitoris and female sexual dysfunction in multiple sclerosis

PURPOSE: We evaluated whether disrupting genital central nervous system pathways is associated with subjective reports of sexual dysfunction in women with multiple sclerosis. MATERIALS AND METHODS: We performed pudendal somatosensory evoked potential testing in and had sexual questionnaires completed by 14 women with a mean age of 47 years who had multiple sclerosis. RESULTS: The mean expanded disability status score was 5. All but 1 woman reported the desire for sexual intercourse. There was a high rate of dissatisfaction with their sex life and all study participants had concomitant bladder and bowel function problems. The most common sexual complaint was difficult or no orgasm, which was statistically associated with abnormalities or absence of 1 or both pudendal cortical evoked potentials. Fatigue and arousal disorders were also common. CONCLUSIONS: Women with multiple sclerosis have a high self-reported rate of sexual dysfunction, which decreases quality of life. Electrodiagnostic data imply that pudendal somatosensory innervation is necessary for normal female orgasmic function. More study is needed to confirm these findings.     

Evaluation of children and young adults with tethered spinal cord syndrome. Utility of spinal and scalp recorded somatosensory evoked potentials

The diagnosis of tethered spinal cord syndrome should be considered in young patients with progressive orthopedic deformities, lower extremity weakness, urinary and fecal incontinence, low back pain, or combinations of these symptoms. Myelographic, computed tomographic, and urodynamic studies are useful for establishing a diagnosis, but contribute little to the evaluation of lower extremity sensory function or to the assessment of electrophysiologic impairment of the spinal cord itself. To determine the diagnostic usefulness of the somatosensory evoked potential after posterior tibial nerve stimulation (posterior tibial nerve somatosensory evoked potential) in tethered spinal cord syndrome, 22 consecutive patients with symptoms of tethered spinal cord syndrome (aged 18 months to 22 years) underwent recording of posterior tibial nerve somatosensory evoked potential; results were correlated with clinical, myelographic, and operative findings. In patients with clinical symptoms but no myelographically demonstrable lesions, posterior tibial nerve somatosensory evoked potentials were within normal limits, suggesting normal physiologic function. In patients with myelographically and operatively confirmed tethering dysraphic lesions, posterior tibial nerve somatosensory evoked potential was predictive of the level and laterality of the lesion. Similarly, ranking the severity of neurological impairment and extent of dysraphism at operation, as well as the extent of abnormality of posterior tibial nerve somatosensory evoked potential, revealed a significant (r = 0.81, p less than 0.001) correlation between clinical severity and posterior tibial nerve somatosensory evoked potential abnormalities. Postoperatively, in 8 patients, posterior tibial nerve somatosensory evoked potential also reflected improved function in relation to the level and type of dysraphic lesion present. These findings indicate that posterior tibial nerve somatosensory evoked potential is a sensitive indicator of neurophysiologic status in patients with tethered spinal cord, and is useful for determining the level of the conus medullaris, degree of spinal cord displacement, and severity of neurological impairment associated with this congenital disturbance of neuraxis formation. Recording of posterior tibial nerve somatosensory evoked potential is noninvasive and offers a more sensitive diagnostic tool than the clinical testing of sensation for detection of the development of neurologic deficits in patients with tethered cord syndrome.     

Efficacy of serologic testing in asymmetric sensorineural hearing loss.

PURPOSE: The goal of this study was to determine the efficacy of a detailed questionnaire, auditory brain stem response testing (ABR), MRI, and an extensive battery of serologic tests in diagnosing asymmetric sensorineural hearing loss (ASNHL). METHODS AND MATERIAL: Patients with audiograms demonstrating ASNHL of 10 dB or greater in 2 consecutive frequencies or 15 dB in any 1 frequency between 250 and 6000 Hz were asked to participate. Patients underwent MRI scanning of the cerebellopontine angle, internal auditory canals, and posterior fossa with gadolinium contrast, ABR, and an extensive battery of tests. The causative diagnosis was made by the individual clinician based on each patient's history, physical examination, and test results. RESULTS: Forty-five patients completed the study. A review of the data confirmed the utility of a detailed history and physical examination, MRI, and fluorescent treponemal antibody test in all cases. Erythrocyte sedimentation rate, glycosylated hemoglobin, Lyme antibody titers, and total hemolytic component (CH50) were helpful in selected cases. Thyroid function testing, complete blood count, Sequential Multiple Analysis-7, prothrombin time/partial thromboplastin time, lipid profile, and ABR were of no value in these patients. CONCLUSION: A careful history and physical examination, MRI, and fluorescent treponemal antibody test should be performed for the evaluation of all patients with ASNHL; however, more extensive serologic testing, including sedimentation rate, glycosylated hemoglobin, Lyme antibody titers, and CH50, should be selectively performed, based on a suggestive history or suspicious physical findings.     

Late whiplash syndrome: correlation of brain SPECT with neuropsychological tests and P300 event-related potential

BACKGROUND: The acceleration forces infringing the cervical spine in whiplash injury are frequently associated with multiple cerebral symptoms. The purpose of this study was to determine whether there is a correlation between cerebral perfusion findings, P300 recording (an electrophysiologic marker of cognitive ability), and neuropsychological tests in patients with whiplash injury. METHODS: Twenty patients with chronic whiplash injury underwent extensive clinical evaluation and neuropsychological testing. A brain single-photon emission computed tomography (SPECT) study using 99mTc-HMPAO was performed in all patients within 24 hours of neuropsychological evaluation. P300 event-related potentials were performed in 15 patients and in 9 normal volunteers. RESULTS: Thirteen of 20 patients had brain perfusion abnormalities on the SPECT studies, in one or more regions. Eight of 15 patients had abnormal P300 studies. Seven of eight patients with abnormal P300 had also an abnormal SPECT study. Seven of 15 patients had normal P300 results, 6 of them with a normal SPECT and 1 with SPECT abnormalities. There was no significant correlation between the SPECT findings or the P300 results and the scores of attention and working memory. There was, however, close agreement between the SPECT and P300. CONCLUSION: SPECT perfusion abnormalities in patients with chronic whiplash syndrome correlate well with P300 recording. The combination of these studies with neurocognitive and neurobehavioral tests may be useful in identifying a subgroup of patients having organic brain lesions.     

Clinical hip tests and a functional squat test in patients with knee osteoarthritis: reliability, prevalence of positive test findings, and short-term response to hip mobilization

STUDY DESIGN: One group pretest-posttest exploratory design. OBJECTIVES: Primary purposes of this study were to examine the short-term effect of hip mobilizations on pain and range of motion (ROM) measurements in patients with knee osteoarthritis (OA) and to determine the prevalence of painful hip and squat test findings in both patients with knee OA and asymptomatic subjects. The secondary purposes were to assess intrarater reliability and to determine whether fewer subjects experienced painful test findings following hip mobilization. BACKGROUND: Conservative intervention, including manual physical therapy applied to the lower extremity, has been shown to reduce impairments associated with knee OA. METHODS AND MEASURES: One rater pair administered 4 clinical hip tests to 22 patients with knee OA (mean age, 61.2 years; SD, 6.1 years) and 17 subjects without lower extremity symptoms or known pathology (mean age, 64.0 years; SD, 7.9 years). Intrarater reliability was examined for each clinical test. Patients with knee OA and painful-hip and squat test findings received hip mobilizations. Pain and ROM responses for each test were dependent variables. RESULTS: Intraclass correlation coefficients for all tests were greater than 0.87. Composite and individual test pain scores and ROM scores improved significantly following hip mobilization. All clinical test findings were more frequent in the group with knee OA, except for those of the FABER test, and the number of subjects with painful test findings following hip mobilization was reduced for all tests except the hip flexion test. CONCLUSIONS: Patients experienced increases in ROM, decreased pain, and fewer subjects had painful test findings immediately following a single session of hip mobilizations. Examination and intervention of the hip may be indicated in patients with knee OA.     

Usefulness of a brief assessment battery for early detection of Charcot foot deformity in patients with diabetes

Charcot neuroarthropathy is a significant limb-threatening complication that develops in some patients with long-term diabetes mellitus. Early diagnosis is vital to secondary prevention of the destructive process and avoidance of consequent deformity and, ultimately, amputation. The purpose of this study was to determine which historical and physical findings would be more accurate risk factor indicators in those diabetics with and without Charcot foot deformity. A controlled series of tests, historical findings, and physical examinations were performed on 41 patients with diabetes who were Charcot-free and 18 patients with diabetes with known chronic CD of the foot by using inexpensive hand-held instruments in a clinical setting. Physical examination included evaluation of vascular and neurologic characteristics. Historical findings consisted of those normally elicited from systems review or past medical history. The results indicate that simple neurologic testing combined with a thorough patient history were the most beneficial tools to determine diabetics with a higher probability of developing CD. Specifically, history of retinopathy (P <.02), nephropathy (P <.003), and previous foot ulcer (P <.01) were found to be predictive. The neurologic findings of vibratory sensation (P <.001), deep tendon reflexes (P <.05), and the 5.07 (10 g) Semmes-Weinstein monofilament test (P <.001) were also highly correlative for the development of Charcot foot deformity. Vascular examinations were found to differentiate poorly between groups. The application of this data may provide for earlier detection of Charcot arthropathy based on the predictive capabilities.     

Pathophysiological changes of the central auditory pathway after blunt trauma of the head

It is the aim of the present paper to correlate clinical symptoms of auditory dysfunction (tinnitus, hyperacusis, hearing loss) one year on average after a blunt trauma of the head with objective audiological test results (otoacoustic emission and auditory brainstem response testing, impedance audiometry) and to compare these findings to controls without history of head trauma. Thirty-one patients (24-56 years) were included. They were largely female (n = 26). The clinical and otolaryngological examination (including otoscopy) of all patients revealed no pathological abnormalities. Pure-tone audiograms were normal with one exception (pre-existing noise-induced hearing loss) as well as tympanograms. The main auditory symptoms were tinnitus (n = 9), hyperacusis (n = 2) and a reported transient hearing loss immediately after the trauma (n = 16) (which had improved at the time of examination). The results of testing the central auditory pathway showed that the transiently evoked otoacoustic emissions (otoemissions) revealed statistically significant differences between amplitude differences of all patients as well as patients with tinnitus and controls in the linear, but not in the non-linear stimulation mode. A complete loss of stapedial reflex responses was found in 12 of the patients and a partial (irregular) loss (in at least more than two frequencies) in four additional patients. Auditory brainstem responses (ABR) were normal in all patients, but 76% had lowered loudness discomfort levels (LDL). Blunt trauma of the head can lead to auditory dyfunction, probably as a result of diffuse axonal injury of the central auditory pathway. An initial sensorineural hearing loss after the trauma (as a result of the inner ear fluid concussion) was transiently reported only. Auditory symptoms play a minor role in the so-called "postconcussive syndrome," but should be considered and evaluated fully.     

Cystometry I. Introduction

Cystometry, a clinical test for assessment of detrusor function, may be used as a supplement to history and physical examination in patients with neurologic dysfunction of the urinary bladder. The test is based on the implicit assumption that the detrusor reflex response is a necessary prerequisite to efficient voiding. Since some patients may void by straining, cystometry should be supplemented by urodynamic and neurologic procedures for evaluation of micturition.     

Value of the preoperative history as an indicator of hemostatic disorders.

Eighty-three general surgical patients completed the standardized bleeding history questionnaire, and screening tests of platelet counts, prothrombin times, partial thromboplastin times, and Ivy bleeding times were done on these patients. Fifty-two per cent had undergone previous operation; 25% described symptoms of potential hemostatic disorders and seven per cent had positive family histories. Laboratory results indicated abnormalities in five patients (6%). The bleeding history is an important part of the preoperative evaluation of a patient, but it can have serious false-negative results. This history should guide the selection of laboratory tests. Such testing can yield an unexpectedly high rate of abnormalities. When identified, these abnormalities require further investigation.     

A methodical approach to the evaluation of neurologic conditions affecting the lower extremity

This article has attempted to demonstrate a methodical approach in identifying and evaluating neuropathy affecting the lower extremity. Patients with neurologic symptoms present in a multitude of ways, with a variety of possible etiologies. Logical progression through the history and physical examination, classification schemes, knowledge of etiology, reinforcement by diagnostic tests and differential diagnosis, is the only road the physician can follow that will lead to an effective treatment regimen, with optimum prognosis. The following articles discuss specific neurologic disease in more detail. A methodical approach to each pathology will hopefully enable the podiatric physician to extract the information from the pages and into everyday clinical practice.     

Spinal nerve function in five volunteers experiencing transient neurologic symptoms after lidocaine subarachnoid anesthesia

The etiology of transient neurologic symptoms (TNS) after 5% lidocaine spinal anesthesia remains undetermined. Previous case reports have shown that patients acutely experiencing TNS have no abnormalities on neurologic examination or magnetic resonance imaging. The aim of our study was to determine whether volunteers with TNS would exhibit abnormalities in spinal nerve electrophysiology. Twelve volunteers with no history of back pain or neurologic disease underwent baseline electromyography (EMG), nerve conduction studies, and somatosensory-evoked potential (SSEP) testing. Then, the volunteers were administered 50 mg of 5% hyperbaric lidocaine spinal anesthesia and were placed in a low lithotomy position (legs on four pillows). The next day, all volunteers underwent follow-up EMG, nerve conduction, and SSEP testing and were questioned and examined for the presence of complications including TNS (defined as pain or dysthesia in one or both buttocks or legs occurring within 24 h of spinal anesthesia). Volunteers who had TNS underwent additional EMG testing 4-6 wk later. Five of the 12 volunteers reported TNS. No volunteer had an abnormal EMG, nerve conduction study, or SSEP at 24 h follow up, nor were there any changes in EMG studies at delayed testing in the five volunteers experiencing TNS. On statistical analysis, the right peroneal and the right tibial nerve differed significantly for all volunteers from pre- to postspinal testing. When comparing pre- and postspinal testing of the TNS and non-TNS volunteers, statistically significant changes occurred in the nerve conduction tests of the right peroneal and left tibial nerve. There was no difference in measurements of F response, H reflex latency, amplitude, or velocity for either leg. Multivariate analysis of variance showed no significant difference between TNS and non-TNS volunteers for the changes in the nine nerve conduction tests when considered together (P = 0.4). We conclude that acute TNS after lidocaine spinal anesthesia did not result in consistent abnormalities detectable by EMG, nerve conduction studies, or SSEP in five volunteers. Implications: Electrophysiologic testing in volunteers experiencing transient neurologic symptoms is not abnormal.     

In search of childhood asthma: questionnaire, tests of bronchial hyperresponsiveness, and clinical evaluation

BACKGROUND: The definition or diagnosis of asthma is a challenge for both clinicians and epidemiologists. Symptom history is usually supplemented with tests of bronchial hyperresponsiveness (BHR) in spite of their uncertainty in improving diagnostic accuracy. METHODS: To assess the interrelationship between respiratory symptoms, BHR, and clinical diagnosis of asthma, the respiratory symptoms of 1633 schoolchildren were screened using a questionnaire (response rate 81.2%) and a clinical study was conducted in a subsample of 247 children. Data from a free running test and a methacholine inhalation challenge test were available in 218 children. The diagnosis of asthma was confirmed by a paediatric allergist. RESULTS: Despite their high specificity (>0.97), BHR tests did not significantly improve the diagnostic accuracy after the symptom history: area under the receiver operator characteristic (ROC) curve was 0.90 for a logistic regression model with four symptoms and 0.94 for the symptoms with free running test and methacholine inhalation challenge results. On the other hand, BHR tests had low sensitivity (0.35-0.47), whereas several symptoms had both high specificity (>0.97) and sensitivity (>0.7) in relation to clinical asthma, which makes them a better tool for asthma epidemiology than BHR. CONCLUSIONS: Symptom history still forms the basis for defining asthma in both clinical and epidemiological settings. BHR tests only marginally increased the diagnostic accuracy after symptom history had been taken into account. The diagnosis of childhood asthma should not therefore be overlooked in symptomatic cases with no objective evidence of BHR. Moreover, BHR should not be required for defining asthma in epidemiological studies.     

Multiple sclerosis and gliomas. Clinical remarks on 10 cases and critical review of the literature

The association between multiple sclerosis and tumours of the central nervous system is unusual. The authors analyzed the clinico-pathological elements of the correlation. The pertinent literature on this subject is critically reviewed. Ten cases of patients with an history of multiple sclerosis for more than 15 years and a clinical and radiological evidence of brain tumour were submitted to surgery in order to remove the lesion and/or to chemo- and radiotherapy. The various aspects of the association were studied in detail. A patient with multiple sclerosis, particularly with atypical symptoms, should be evaluated by an annual MRI investigation with intravenous paramagnetic contrast medium. The diagnostic work-up should be: clinical and radiological assessment; MRI in the event of atypical symptoms; Sstereotactic or neuronavigation-aided biopsy in any suspected lesions. Patients with multiple sclerosis and glioma present survival times identical to those observed in patients not suffering from multiple sclerosis. The coexistence of multiple sclerosis and brain tumours does not seem to influence the clinical evolution of either of these pathologies. We believe that it is important to achieve an early diagnosis of brain tumour in such patients with a clinical and neuroradiological follow up, so that they can be treated promptly.     

Urodynamic findings and long-term outcome management of patients with multiple sclerosis-induced lower urinary tract dysfunction

We studied urodynamically 46 patients between 20 and 74 years old with multiple sclerosis and uncomfortable bladder symptoms. The response to treatment was recorded during a followup of 1 to 10 years (mean 3 1/2 years). Lack of response to appropriate therapy predicated on urodynamic testing appeared to be related to progression of multiple sclerosis.     

Symptom-based assessment of the severity of a concussion

OBJECT: Current grading systems of concussion and return-to-play guidelines have little empirical support. The authors therefore examined the relationships of the characteristics and symptoms of concussion and the history of concussion to three indicators of concussion severity-number of immediate symptoms, number of symptoms at the initial follow-up examination, and duration of symptoms--to establish an empirical basis for grading concussions. METHODS: Forty-seven athletes who sustained concussions were administered alternate forms of an Internet-based neurocognitive test until their performances were within normal limits relative to baseline levels. Assessments of observer-reported and self-reported symptoms at the sideline of the playing field on the day of injury, and at follow-up examinations were also obtained as part of a comprehensive concussion management protocol. Although loss of consciousness (LOC) was a useful indicator of the initial severity of the injury, it did not correlate with other indices of concussion severity, including duration of symptoms. Athletes reporting memory problems at follow-up examinations had significantly more symptoms in general, longer durations of those symptoms, and significant decreases in scores on neurocognitive tests administered approximately 48 hours postinjury. This decline of scores on neurocognitive testing was significantly associated with an increased duration of symptoms. A history of concussion was unrelated to the number and duration of symptoms. CONCLUSIONS: This paper represents the first documentation of empirically derived indicators of the clinical course of postconcussion symptom resolution. Self-reported memory problems apparent 24 hours postconcussion were robust indicators of the severity of sports-related concussion and should be a primary consideration in determining an athlete's readiness to return to competition. A decline on neurocognitive testing was the only objective measure significantly related to the duration of symptoms. Neither a brief LOC nor a history of concussion was a useful predictor of the duration of postconcussion symptoms.     

Neuro-otologic evaluation of the patient with acute, severe head injuries: correlations among physical findings, auditory evoked responses, and computerized tomography

Long-term clinical neurologic and otologic sequelae of traumatic head injury are well recognized. In this article, we describe the relationship among neurophysiologic, neuro-otologic, and neuroradiologic findings in a series of fifty patients with acute, severe head injury. Seventy percent of the patients had one or more otologic abnormalities, of which hemotympanum was most common. Outcome of computerized tomography (CT), auditory brainstem response (ABR), and otologic examination findings were not mutually dependent. For example, otologic disease was found in 50% of the patients with normal ABR. All but one patient in the series showed brain damage by CT; yet only 14% of the series had evidence of temporal bone fracture and, unexpectedly, one third of this group yielded normal otologic findings and a normal ABR. We conclude that combined application of otologic examination, CT scanning, and auditory evoked response assessment provides complementary information on structural and functional neuro-otologic status in persons with acute, severe head injury.