Clinical neurological examination vs electrophysiological studies:Reflections from experiences in occupational medicine

Seventy-five percent of upper limb disorders that are related to work are regarded as diagnostically unclassifiable and therefore challenging to the clinician.Therefore it has been generally less successfully toprevent and treat these common and frequently disabling disorders.To reach a diagnosis requires the identification of the responsible pathology and the involved tissues and structures.Consequently,improved diagnostic approaches are needed.This editorial discusses the potentials of using the clinical neurologic examination in patients with upper limb complaints related to work.It is argued that a simple but systematic physical approach permits the examiner to frequently identify patterns of neurological findings that suggest nerve afflictions and their locations,and that electrophysiological studies are less likely to identify pathology.A diagnostic algorithm for the physical assessment is provided to assist the clinician.Failure to include representative neurological items in the physical examination may result in patients being misinterpreted,misdiagnosed and mistreated.

Compressive Myelopathy, Spinal Shock, and a Complicated Neurological Exam

The neurological examination, developed and tested since the 1800s has provided physicians with a vital tool to rapidly assess and provide clues to many of the pathological processes lurking inside the brain and spinal cord. With the advent of magnetic resonance imaging, physicians are able to visualize the precise location of the abscess before surgical intervention. In this case report, we present a 51-year-old male with an epidural abscess with multifocal compressive myelopathy, resulting in a complicated neurological examination, making localization a diagnostic challenge. With this case, we would like to stress that complicated multifocal lesions of the cord may present with a large variation in examination findings. This patient’s neurological exam was complicated secondary to a ventrally as well as dorsally located epidural abscess with superimposed spinal shock sequelae. We would like to highlight the importance of a thorough history and the neurological examination but also mention some of its limitations. It is crucial to use clinical judgement to navigate the patient’s history, presentation, and examination to accurately diagnose and treat, particularly so in cases involving compressive myelopathies of the spinal cord.

Repeat cranial tomography in patients with mild head injury and stable neurological examination - a perspective from a developing country

Objective： To determine the frequency of altered findings on repeat cranial tomography （CT） in patients with mild head injury along with stable neurological examination at tertiary care hospital.Methods： Cross-sectional study was done in the Department of Radiology, Liaquat National Hospital, Karachi from January 2008 to September 2010. All patients with mild head injury in terms of Glasgow Coma Scale （GCS） who underwent repeat scan without clinical or neurological deterioration in the emergency department of a tertiary care centre were included. The collected data were accordingly entered and analyzed by the principal investigator using Statistical Package for Social Sciences （SPSS） version 16.0.Results： In all 275 patients, only 17 （6%） of the patients were found worseing on repeat CT, 120 （43.63%）scans improved, 138 （50.18%） unchanged and 17 （6.18%）worsened. None of these patients showed signs of clinical deterioration.Conclusion： Our results suggest that for patients with mild head injury and stable neurological examination, only 6% of them show deterioration on repeat CT, especially when patients＇ GCS is below 13.

Challenges in developing therapeutic strategies for mild neonatal encephalopathy

There is increasing evidence that infants with mild neonatal encephalopathy(NE) have significant risks of mortality, brain injury and adverse neurodevelopmental outcomes. In the era of therapeutic hypothermia, infants need to be diagnosed within 6 hours of birth, corresponding with the window of opportunity for treatment of moderate to severe NE, compared to the retrospective grading over 2 to 3 days, typically with imaging and formal electroencephalographic assessment in the pre-hypothermia era. This shift in diagnosis may have increased the apparent prevalence of brain damage and poor neurological outcomes seen in infants with mild NE in the era of hypothermia. Abnormal short term outcomes observed in infants with mild NE include seizures, abnormal neurologic examination at discharge, abnormal brain magnetic resonance imaging and difficulty feeding. At 2 to 3 years of age, mild NE has been associated with an increased risk of autism, language and cognitive deficits. There are no approved treatment strategies for these infants as they were not included in the initial randomized controlled trials for therapeutic hypothermia. However, there is already therapeutic creep, with many centers treating infants with mild NE despite the limited evidence for its safety and efficacy. The optimal duration of treatment and therapeutic window of opportunity for effective treatment need to be specifically established for mild NE as the evolution of injury is likely to be slower, based on preclinical data. Randomized controlled trials of therapeutic hypothermia for infants with mild NE are urgently required to establish the safety and efficacy of treatment. This review will examine the evidence for adverse outcomes after mild NE and dissect some of the challenges in developing therapeutic strategies for mild NE, before analyzing the evidence for therapeutic hypothermia and other strategies for treatment of these infants.