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Diabetic Neuropathy
Published in Jahangir Moini, Matthew Adams, Anthony LoGalbo, Complications of Diabetes Mellitus, 2022
Jahangir Moini, Matthew Adams, Anthony LoGalbo
Diagnostic examination may reveal loss of cold perception and decreased pinprick sensation. Electromyography and nerve conduction studies are normal. The best test is a skin biopsy, to compare epidermal nerve fiber density samples to control values, matched for biopsy location and patient age. Sudomotor testing include sweat gland density in skin biopsies and tests to evaluate sweating function.
Peripheral Autonomic Neuropathies
Published in David Robertson, Italo Biaggioni, Disorders of the Autonomic Nervous System, 2019
In diabetic patients, the degree of involvement of the autonomic nervous system is often uneven and tests of autonomic function must, therefore, include many systems to show autonomic deficits that might not be symptomatic. Of all tests, the assessment of thermoregulatory sweating has been neglected because of the cumbersomeness of the procedures. In a comprehensive study of abnormal patterns of sweating in patients with diabetes, Fealey et al. (1989) showed that damage to the autonomic innervation of sweat glands is similar to damage to somatic innervation in diabetes. A pattern of length-dependent damage producing distal hypo- or anhidrosis or focal, multifocal or regional lesions of nerves that show restricted areas of sudomotor dysfunction.
SBA Answers and Explanations
Published in Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury, SBAs for the MRCS Part A, 2018
Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury
There are 12 pairs of cranial nerves and 31 pairs of spinal nerves. The central nervous system comprises the brain and spinal cord. A peripheral nerve is a mixed nerve containing motor, sensory, and autonomic (parasympathetic, sympathetic) elements. Parasympathetic outflow arises from the ‘craniosacral’ region; that is, from certain cranial nerves and sacral roots S2–4. Cranial nerves III (occulomotor), VII (facial), IX (glossopharyngeal), and X (vagus) carry parasympathetic fibres whose function is primarily secretomotor (e.g., salivary secretions in the case of cranial nerve VII) and ciliary motor (pupillary reflexes and accommodation in the case of cranial nerve III), while cranial nerves IX and X play an integral role in blood pressure regulation. Sympathetic outflow is principally ‘thoracolumbar’ (i.e., from spinal segments T1 through to L2). The sympathetic nervous system serves vasomotor (vascular tone), sudomotor (sweating), and pilomotor functions, in addition to controlling smooth muscle and sphincter tone and playing a key role in cardiovascular homeostasis.
Chameleons, red herrings, and false localizing signs in neurocritical care
Published in British Journal of Neurosurgery, 2022
Boyi Li, Tolga Sursal, Christian Bowers, Chad Cole, Chirag Gandhi, Meic Schmidt, Stephan Mayer, Fawaz Al-Mufti
Cervical disc herniation (CDH) typically results in ipsilateral neck and arm pain corresponding to the level of the lesion.73 However, false localizing CDH can present with contralaterally radiating neck pain and contralateral upper and lower extremity pain. Diagnosis can be confirmed on MRI. It is hypothesized that this FLS results from cord compression of the lateral spinothalamic tract.73 The symptoms can be completely resolved by surgical discectomy and fusion, further confirming the false localizing nature of the condition.73 CDH as a FLS can also present as hemifacial hyperhidrosis with no facial flushing, anisocoria or blepharoptosis, compensating for anhidrosis/hypohydrosis on the ipsilateral side below the lesion.74 Useful diagnostic tools include the Minor test, quantitative sudomotor function tests, and microneurography of sudomotor nerve activity.74 Tests showing no intramedullary signal abnormalities on MRI suggest that the pathophysiology may be impairment of premotor neuron from the hypothalamus to the intermediolateral nucleus by the disc herniation.74 The ipsilateral anhidrosis or hypohydrosis can directly be attributed to the disc herniation myelopathy.74 Of note, crossed hypohydrosis can occur ipisilateral but above the hyperhidrosis.74 Thus, when patients present with hemihydrosis, the Minor test should be done to determine the anhidrotic and hyperhidrotic areas, and thermography to determine the localization of the potential CDH to be investigated further.74
The effect of subthalamic deep brain stimulation on autonomic dysfunction in Parkinson’s disease: clinical and electrophysiological evaluation
Published in Neurological Research, 2021
Nese Gungor Yavasoglu, S. Selcuk Comoglu
The effect of DBS treatment on autonomic functions in addition to primary motor symptoms has been investigated. Sudomotor dysfunction, most commonly hyperhidrosis, is quite common in PD patients. Although hyperhidrosis is associated with more motor fluctuations and plasma levodopa level fluctuations in PD patients, it has been shown to be attenuated by STN DBS [6]. In 2007, Witjas et al. observed excessive sweating decreased in 34 of 35 PD patients in the postoperative first year after STN DBS [7]. Sanghera et al. showed that a patient with excessive sweating improved after STN DBS was applied and that sweating returned 4 hours after stimulation was turned off [8]. In the study of Trachani et al., a decrease in hyperhidrosis was observed after implantation in four of the nineteen PD patients who underwent STN DBS, and an improvement was observed in hypohydrosis in two patients [9]. In a study of PD patients with STN DBS, it was observed that sudomotor dysfunction in three patients with early-onset PD completely resolved, while the other eight patients with late-onset PD did not show any improvement in their dysautonomia.
Correlation of neurological level and sweating level of injury in persons with spinal cord injury
Published in The Journal of Spinal Cord Medicine, 2021
Michelle Trbovich, Ashley Ford, Yubo Wu, Wouter Koek, Jill Wecht, Dean Kellogg
Measurement of sudomotor activity in past investigations has been captured via whole-body sweat rates, sweat capsules, and skin temperature as a surrogate SR index, i.e. sweating decreases skin temperature. The majority of previous studies measured evaporative cooling are primarily small pilot studies (N = 1–10) in persons with SCI with varying injury characteristics under protocols that employed a myriad of heat stressors (e.g. passive vs. exercise induced).12,13 While the general statements that sweating is impaired “below the lesion” or in “insensate areas” were commonly made,21,22 only one prior study had the specific objective of correlating NLOI with a sweating level using visual detection of water droplets over large skin surface areas under a plastic sheet.12 Using this technique, Normell found “dissociation between areas with loss of cutaneous thermoregulatory sudomotor responses and areas of loss of somatic sensibility.”33 He also reported that in most of individuals “the dissociation between sudomotor responses and somatic sensation was only a few centimeters or … the width of one or more somato-sensory dermatomes.”33 Thus, data suggests that the sensory and sweating level are not always equivalent, which parallels the anatomic arrangement of the sympathetic sudomotor versus sensorimotor tracts.