Improvement in Lasegue's sign: An early predictor of recovery in childhood Guillain-barre syndrome
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《美国医学杂志》
1 Department of Pediatrics, B.P. Koirala Institute of Health Sciences, Dharan, India
2 Government Medical College and Hospital, Chandigarh, India
Lasegue's sign (painful limitation of straight-leg raising) is a feature of radiculopathy and is commonly reported in childhood Guillain-Barre Syndrome (GBS).[1] Improvement in limitation of straight-leg raising (SLR) has been used to monitor clinical recovery in lumbar disc herniation,[2],[3] however, the same has not been evaluated in respect to GBS. We present 3 patients of GBS, in whom improvement in SLR heralded the disease recovery before any other quantitatively demonstrable sign.
Nine patients of childhood GBS were managed in Pediatric Intensive Care Unit of a tertiary care center over 3 years period (Sept'2000 to June'03). Three patients (age, 4 -6 years) had Lasegue's sign at admission. All the three had progressive ascending symmetrical hypotonic hyporeflexic motor weakness, which developed over 3-7 days. Motor power varied from 1/5 to 3/5. All had intercostal muscle weakness, neck rigidity, leg pains, positive Kernig's sign and 1 had backache. Angles of SLR in third patient were 0o and 30o in right and left legs respectively. He also had autonomic instability in the form of varying heart rate (100-124/min) and blood pressure (90/60-110/70 mmHg) during first 36 hours. EKG was normal. None had had dog bite, immunization or viral illness in recent past, or cranial nerve involvement. Routine investigations were normal in 2 patients. One had hypokalemia (serum potassium 3.2 mEq/L) and compensated respiratory acidosis (pH 7.42, PaCO 2 47.7 torr, HCO 3- 30.6 mEq/L); limb and intercostal weakness persisted despite correction of hypokalemia. Cerebrospinal fluid examination was performed in 2 patients (on day 6 and day 7) and was normal. Neurophysiologic studies could be obtained in 1 on day 7 of illness, which revealed normal nerve conduction velocity (45.2 - 46.9 m/sec), decreased amplitude (left ulnar nerve, 0.12 mV; left posterior tibial nerve, 0.73 mV) and increased latency (left ulnar nerve, 5.04 msec left posterior tibial nerve, 8.04 msec) in motor nerves. Stool cultures for polioviruses were negative. Patients were diagnosed as Guillain-Barre Syndrome based on Asbury's modified clinical criteria[4] with grade 4 disability.[5]
Patients underwent double-volume exchange transfusion[6] (with 120 ml/Kg blood) on day 2 for respiratory involvement and progressive motor weakness, as neither plasmapheresis nor intravenous immunoglobulins was available to us. After therapy, Lasegue's sign had improved in 2 patients on the very next day, while in one on day 3. In the third patient, angles of SLR improved to 30o (right) and 45o (left) on day 3, which improved further to 75o (right) and 60o (left) by day 5. Improvement in Lasegue's sign was followed by consistent and continued motor recovery in all 3 patients. Improvement in motor power by at least 1 grade in at least 1 limb was demonstrated for the first time on day 5, 4 and 5 of exchange transfusion respectively. They were discharged after 7-12 days of hospitalization. At 4-6 months follow-up, all patients made complete motor recovery.
Radiculopathy is an early and prominent feature of GBS[7]; and thus Lasegue's sign, a neurodynamic test for radiculopathy, is reported to present in majority (83%) of childhood cases[1]. Though intensity of radicular pain syndromes was not found to correlate with motor disability and may precede or follow the motor weakness,[8] improvement in Lasegue's sign, if present, may occur along with recovery in radiculopathy. Among signs of radiculopathy, Lasegue's sign is the only clinical tool that can be quantified objectively. Improvement in SLR was observed in initial two patients, followed by motor recovery 3-4 days after. Having realized the potential prognostic value of improvement in SLR, its quantitative monitoring was performed in the third one. In this patient, SLR improved by 15 osub -30 osub within 24 hours of therapy, while motor power improved only after 5 days. Till date, only motor signs, viz. halt in progression of motor weakness, number of days required to improve two disability grades, need and duration of ventilatory support and degree of maximum weakness on day 10 have been used to prognosticate outcome and to compare efficacy of various therapeutic modalities.[9],[10] These motor signs may not be helpful as early prognostic predictors, for motor improvement is usually slow. Improvement in SLR as a measure of recovery in radiculopathy may be an alternative which is already being used as an early prognostic indicator in patients with nerve root involvement in lumbar disc herniation.[2],[3] Patients in the present study demonstrated significantly earlier response in SLR as compared to motor power.
Quantitative monitoring of improvement in Lasegue's sign, if present, may be a good clinical tool for early prognostication and for comparing short-term effects of various therapeutic modalities. A study on larger number of patients will be required to document the prognostic value of this sign in patients with GBS.
References
1. Nguyen DK, Agenarioti-Belanger S, Vanasse M. Pain and the Guillain-Barre syndrome in children under 6 years old. J Pediatr 1999; 134: 773-776.
2. Graham GE. Intraoperative straight-leg raising during laminectomy and disk excision for sciatica. Clin Orthop 1981; 154: 343-434.
3. Vroomen PC, de Krom MC, Knottnerus JA. Predicting the outcome of sciatica at short-term follow-up. Br J Gen Pract 2002; 52: 119-123.
4. Asbury AK, Cornblath DR. Assessment of current diagnostic criteria for the diagnosis of Guillain-Barre Syndrome. Ann Neurol 1990; 27(Suppl): S21.
5. Guillain-Barre Syndrome Study Group. Plasmapheresis and acute Guillain-Barre Syndrome. Neurology 1985; 35: 1096.
6. Singh S, Singhi S. Recovery from respiratory paralysis caused by Guillain-Barre Syndrome in an infant after repeated exchange transfusions. Clin Pediatr 1989; 28: 480-481.
7. Lebrun C, Ghetau G, Candito M, Chatel M. Acute polyradiculoneuritis and dysautonomia: contribution of assaying catecholamines and their methoxylated metabolites. Rev Neurol (Paris) 2001; 157: 304-308.
8. Moulin DE, Hagen N, Feasby TE, Amireh R, Hahn A. Pain in Guillain-Barre syndrome. Neurology 1997; 48: 328-331.
9. Shanbag P, Amirtharaj C, Pathak A. Intravenous immunoglobulins in severe Guillain-Barre Syndrome in childhood. Indian J Pediatr 2003; 70: 541-543.
10. Ortiz Corredor F, Mieth Alviar KW. Prognostic factors for walking in childhood Guillain-Barre Syndrome. Rev Neurol 2003; 36 : 1113-1120.(Baranwal Arun K, Mandal R)
2 Government Medical College and Hospital, Chandigarh, India
Lasegue's sign (painful limitation of straight-leg raising) is a feature of radiculopathy and is commonly reported in childhood Guillain-Barre Syndrome (GBS).[1] Improvement in limitation of straight-leg raising (SLR) has been used to monitor clinical recovery in lumbar disc herniation,[2],[3] however, the same has not been evaluated in respect to GBS. We present 3 patients of GBS, in whom improvement in SLR heralded the disease recovery before any other quantitatively demonstrable sign.
Nine patients of childhood GBS were managed in Pediatric Intensive Care Unit of a tertiary care center over 3 years period (Sept'2000 to June'03). Three patients (age, 4 -6 years) had Lasegue's sign at admission. All the three had progressive ascending symmetrical hypotonic hyporeflexic motor weakness, which developed over 3-7 days. Motor power varied from 1/5 to 3/5. All had intercostal muscle weakness, neck rigidity, leg pains, positive Kernig's sign and 1 had backache. Angles of SLR in third patient were 0o and 30o in right and left legs respectively. He also had autonomic instability in the form of varying heart rate (100-124/min) and blood pressure (90/60-110/70 mmHg) during first 36 hours. EKG was normal. None had had dog bite, immunization or viral illness in recent past, or cranial nerve involvement. Routine investigations were normal in 2 patients. One had hypokalemia (serum potassium 3.2 mEq/L) and compensated respiratory acidosis (pH 7.42, PaCO 2 47.7 torr, HCO 3- 30.6 mEq/L); limb and intercostal weakness persisted despite correction of hypokalemia. Cerebrospinal fluid examination was performed in 2 patients (on day 6 and day 7) and was normal. Neurophysiologic studies could be obtained in 1 on day 7 of illness, which revealed normal nerve conduction velocity (45.2 - 46.9 m/sec), decreased amplitude (left ulnar nerve, 0.12 mV; left posterior tibial nerve, 0.73 mV) and increased latency (left ulnar nerve, 5.04 msec left posterior tibial nerve, 8.04 msec) in motor nerves. Stool cultures for polioviruses were negative. Patients were diagnosed as Guillain-Barre Syndrome based on Asbury's modified clinical criteria[4] with grade 4 disability.[5]
Patients underwent double-volume exchange transfusion[6] (with 120 ml/Kg blood) on day 2 for respiratory involvement and progressive motor weakness, as neither plasmapheresis nor intravenous immunoglobulins was available to us. After therapy, Lasegue's sign had improved in 2 patients on the very next day, while in one on day 3. In the third patient, angles of SLR improved to 30o (right) and 45o (left) on day 3, which improved further to 75o (right) and 60o (left) by day 5. Improvement in Lasegue's sign was followed by consistent and continued motor recovery in all 3 patients. Improvement in motor power by at least 1 grade in at least 1 limb was demonstrated for the first time on day 5, 4 and 5 of exchange transfusion respectively. They were discharged after 7-12 days of hospitalization. At 4-6 months follow-up, all patients made complete motor recovery.
Radiculopathy is an early and prominent feature of GBS[7]; and thus Lasegue's sign, a neurodynamic test for radiculopathy, is reported to present in majority (83%) of childhood cases[1]. Though intensity of radicular pain syndromes was not found to correlate with motor disability and may precede or follow the motor weakness,[8] improvement in Lasegue's sign, if present, may occur along with recovery in radiculopathy. Among signs of radiculopathy, Lasegue's sign is the only clinical tool that can be quantified objectively. Improvement in SLR was observed in initial two patients, followed by motor recovery 3-4 days after. Having realized the potential prognostic value of improvement in SLR, its quantitative monitoring was performed in the third one. In this patient, SLR improved by 15 osub -30 osub within 24 hours of therapy, while motor power improved only after 5 days. Till date, only motor signs, viz. halt in progression of motor weakness, number of days required to improve two disability grades, need and duration of ventilatory support and degree of maximum weakness on day 10 have been used to prognosticate outcome and to compare efficacy of various therapeutic modalities.[9],[10] These motor signs may not be helpful as early prognostic predictors, for motor improvement is usually slow. Improvement in SLR as a measure of recovery in radiculopathy may be an alternative which is already being used as an early prognostic indicator in patients with nerve root involvement in lumbar disc herniation.[2],[3] Patients in the present study demonstrated significantly earlier response in SLR as compared to motor power.
Quantitative monitoring of improvement in Lasegue's sign, if present, may be a good clinical tool for early prognostication and for comparing short-term effects of various therapeutic modalities. A study on larger number of patients will be required to document the prognostic value of this sign in patients with GBS.
References
1. Nguyen DK, Agenarioti-Belanger S, Vanasse M. Pain and the Guillain-Barre syndrome in children under 6 years old. J Pediatr 1999; 134: 773-776.
2. Graham GE. Intraoperative straight-leg raising during laminectomy and disk excision for sciatica. Clin Orthop 1981; 154: 343-434.
3. Vroomen PC, de Krom MC, Knottnerus JA. Predicting the outcome of sciatica at short-term follow-up. Br J Gen Pract 2002; 52: 119-123.
4. Asbury AK, Cornblath DR. Assessment of current diagnostic criteria for the diagnosis of Guillain-Barre Syndrome. Ann Neurol 1990; 27(Suppl): S21.
5. Guillain-Barre Syndrome Study Group. Plasmapheresis and acute Guillain-Barre Syndrome. Neurology 1985; 35: 1096.
6. Singh S, Singhi S. Recovery from respiratory paralysis caused by Guillain-Barre Syndrome in an infant after repeated exchange transfusions. Clin Pediatr 1989; 28: 480-481.
7. Lebrun C, Ghetau G, Candito M, Chatel M. Acute polyradiculoneuritis and dysautonomia: contribution of assaying catecholamines and their methoxylated metabolites. Rev Neurol (Paris) 2001; 157: 304-308.
8. Moulin DE, Hagen N, Feasby TE, Amireh R, Hahn A. Pain in Guillain-Barre syndrome. Neurology 1997; 48: 328-331.
9. Shanbag P, Amirtharaj C, Pathak A. Intravenous immunoglobulins in severe Guillain-Barre Syndrome in childhood. Indian J Pediatr 2003; 70: 541-543.
10. Ortiz Corredor F, Mieth Alviar KW. Prognostic factors for walking in childhood Guillain-Barre Syndrome. Rev Neurol 2003; 36 : 1113-1120.(Baranwal Arun K, Mandal R)