背景:落脚综合征(FDS),以脚背屈肌严重无力和萎缩为特征,常见于重度获得性脑损伤(ABI)患者。如果综合症是单方面的,原因通常是腓骨神经病(PN),由于膝盖水平的腓骨颈部神经躯干受压;频率较低,病因是先前或伴随的腰椎神经根病。双侧综合征是由多发性神经病和肌病引起的。主要原因,由于大脑或脊髓损伤,模仿这种综合征,但通常伴有其他症状,如痉挛。危重病多发性神经病(CIP)和肌病(CIM),孤立或合并(危重病多发性神经病,CIPNM),已证明构成ABI患者FDS的重要病因。评估重症康复病房(IRU)中FDS的原因有几个局限性,其中包括电生理测试的复杂性,神经生理学顾问有限,以及患者严重的意识障碍和缺乏合作。
目的:我们试图提出一种简化的电生理筛查,以确定FDS的病因。特别是PN和CIPNM,帮助临床医生认识到IRU入院时严重ABI预后不良的重要临床预测因素。
方法:这种前瞻性,单中心研究包括20名患有FDS的重度ABI患者(11名女性/9名男性,平均年龄55.10+16.26;CRS-R=11.90+6.32;LCF:3.30+1.30;DRS:21.45+3.33),长期康复治疗(≥2个月)。我们应用直接胫骨前肌刺激(DMS)与腓骨神经运动传导评估相关,穿过腓骨头(NCS),鉴定yCIP和/orCIM,并排除脱髓鞘或压迫性单侧PN。
结果:在IRU入学时,简化的电生理筛查报告了四个单侧PN,fourCIP和sixCIM与aCIPNM的总体患病率估计约为50%。两个月后,与没有CIPNM的其他ABI患者相比,CIPNM组的预后明显较差,如实现气管内导管撤机的概率较低(20%对90%)和较低的CRS-R和DRS评分所证明的。由于我们研究的亚急性康复背景,无法评估站立姿势恢复的运动结果,功能性行走和平衡,由于单侧PN的存在而受损。
结论:拟议的简化电生理筛查的实施可能使重度ABI患者的单侧PN或CIPNM的早期识别,从而有助于更好的功能预后在康复设置。
BACKGROUND: Foot drop syndrome (FDS), characterized by severe weakness and atrophy of the dorsiflexion muscles of the feet, is commonly found in patients with severe acquired brain injury (ABI). If the syndrome is unilateral, the cause is often a peroneal neuropathy (PN), due to compression of the nervous trunk on the neck of the fibula at the knee level; less frequently, the cause is a previous or concomitant lumbar radiculopathy. Bilateral syndromes are caused by polyneuropathies and myopathies. Central causes, due to brain or spinal injury, mimic this syndrome but are usually accompanied by other symptoms, such as spasticity. Critical illness polyneuropathy (CIP) and myopathy (CIM), isolated or in combination (critical illness polyneuromyopathy, CIPNM), have been shown to constitute an important cause of FDS in patients with ABI. Assessing the causes of FDS in the intensive rehabilitation unit (IRU) has several limitations, which include the complexity of the electrophysiological tests, limited availability of neurophysiology consultants, and the severe disturbance in consciousness and lack of cooperation from patients.
OBJECTIVE: We sought to propose a simplified electrophysiological screening that identifies FDS causes, particularly PN and CIPNM, to help clinicians to recognize the significant clinical predictors of poor outcomes in severe ABI at admission to IRU.
METHODS: This prospective, single-center study included 20 severe ABI patients with FDS (11 females/9 males, mean age 55.10 + 16.26; CRS-R= 11.90 + 6.32; LCF: 3.30 + 1.30; DRS: 21.45 + 3.33), with prolonged rehabilitation treatment (≥2 months). We applied direct tibialis anterior muscle stimulation (DMS) associated with peroneal nerve motor conduction evaluation, across the fibular head (NCS), to identify CIP and/or CIM and to exclude demyelinating or compressive unilateral PN.
RESULTS: At admission to IRU, simplified electrophysiological screening reported four unilateral PN, four CIP and six CIM with a CIPNM overall prevalence estimate of about 50%. After 2 months, the CIPNM group showed significantly poorer outcomes compared to other ABI patients without CIPNM, as demonstrated by the lower probability of achieving endotracheal-tube weaning (20% versus 90%) and lower CRS-R and DRS scores. Due to the subacute rehabilitation setting of our study, it was not possible to evaluate the motor results of recovery of the standing position, functional walking and balance, impaired by the presence of unilateral PN.
CONCLUSIONS: The implementation of the proposed simplified electrophysiological screening may enable the early identification of unilateral PN or CIPNM in severe ABI patients, thereby contributing to better functional prognosis in rehabilitative settings.