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онкология

рак

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лечение рака

онкология лекции

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проктология

прием проктолога

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здоровый образ жизни

00:02:13

Good afternoon, I am glad to welcome you all

00:02:16

to the first lexa of the marathon on

00:02:18

neuromuscular diseases as an

00:02:21

announcement for the course on non-muscular

00:02:24

diseases Overcoming difficulties in

00:02:27

diagnosis and treatment,

00:02:29

the duration of the webinar will be 1 hour

00:02:34

notice, the

00:02:35

recording will be available for 24 hours, so you

00:02:39

still have time to watch those who did not have time

00:02:41

connect

00:02:42

please take notepads and a pen to

00:02:45

write down And you

00:02:48

can send any questions you are interested in to the chat

00:02:51

The structure of the marathon of these three days

00:02:53

will not be three lectures on the first day

00:02:56

a variety of nerve lesions that I

00:02:59

will read I will read on the second day

00:03:01

primary muscular diseases that are a

00:03:03

miscalculation Elizaveta Erokhina and on the third

00:03:06

day there will be autoimmune neuromuscular

00:03:08

diseases that Evgeniy Melnik will read

00:03:13

every day during the webinar we will

00:03:16

give one code word that you will

00:03:19

need to remember. It’s better to

00:03:21

write it down at the end of the mini-course at the last

00:03:24

webinar we will draw a prize for participation in the

00:03:27

full course it is clear that diseases

00:03:30

for two participants who

00:03:32

will fill out the form with code

00:03:34

words correctly and quickly the first will receive a gift for the full

00:03:37

course at the easier rate the second will receive a

00:03:40

gift for the full course at the Light rate

00:03:43

breakfast for each participant we will give

00:03:45

a little homework the

00:03:47

first five participants who

00:03:50

complete it correctly and quickly will receive a gift this is a

00:03:53

book on clinical electromyography

00:03:56

for practicing doctors killer whale

00:04:01

Let's get acquainted Write to the chat Who is from

00:04:03

which city For what purpose did you come to the

00:04:05

webinar and at the end Give us

00:04:08

feedback what was most interesting for you to

00:04:10

hear

00:04:11

My name is Shamtieva Kamil Vitalievna I am a

00:04:14

neurologist at the clinic of the diagnostic

00:04:16

department of the

00:04:18

medical scientific educational

00:04:20

center at Moscow State University

00:04:24

We will wait All of you in the full course on

00:04:28

neuromuscular diseases and pathology of the

00:04:30

peripheral nervous system,

00:04:33

you can find out more about the full course by clicking on the

00:04:35

button under the lectures,

00:04:41

so let’s move on to our topic: the biophysical

00:04:44

nervous system is a conventionally distinguished

00:04:47

part that includes structures

00:04:49

associated with the spinal cord and brain.

00:04:52

the trunk that innervates the

00:04:55

trunk of the limbs internal organs

00:04:59

These include the roots and trunks and branches

00:05:02

of the cerebral nerves as well as the plexus of

00:05:04

sensory and autonomic ganglia,

00:05:07

usually to the peripheral nervous system, which

00:05:10

also includes the neuromotor apparatus as a whole,

00:05:14

which even enters the Inferior Motor

00:05:17

Neuron, which is located in the anterior

00:05:19

horn of the spinal cord neuromuscular

00:05:21

synapses and the muscles directly.

00:05:26

The topic of our today's lecture will be

00:05:28

the pathology of peripheral nerves, among

00:05:31

which we can distinguish radiculopathy

00:05:34

corresponding to lesions plexus

00:05:37

Roots

00:05:38

lexopathy which corresponds to the

00:05:40

expression of plexuses

00:05:42

mononeuropathy lesions directly to the

00:05:44

nerves and polyneuropathy which

00:05:47

corresponds to the diffuse expression of

00:05:49

nerve fibers

00:05:52

What is the most common symptom of damage to

00:05:54

peripheral nerves is numbness Pain

00:05:57

is the assessment of these symptoms already at the

00:06:01

appointment helps to determine in many ways the

00:06:03

level of damage. Therefore, when approaching a

00:06:06

patient with

00:06:08

sensory disorders in the hands,

00:06:10

it is necessary to immediately identify a specific

00:06:14

zone of discomfort; it can be only

00:06:17

the little finger or little finger and half of the

00:06:19

ring finger. Perhaps even three

00:06:23

fingers

00:06:25

for pain in a particular finger and

00:06:30

its

00:06:31

arthrosis or trigger finger, which

00:06:34

is already an area of interest for hand

00:06:37

surgeons, such characteristics of its

00:06:40

field syndrome does it spread

00:06:42

from the hand to the forearm to the shoulder? Does

00:06:46

it have any connection with certain

00:06:47

movements or position?

00:06:49

It is worth examining the hand for areas of

00:06:53

atrophy which are characteristic of damage to

00:06:55

certain nerves or deformation

00:06:59

due to endinitis of the flexor tendons of

00:07:01

the fingers or arthrosis of small

00:07:03

joints, the patient may describe to you a

00:07:06

pain syndrome in the area of the palmar

00:07:09

part of the hand due to the

00:07:14

tension from the forming

00:07:16

contracture of dipetrene, which is only appearing, and as a result,

00:07:19

decompression of the spinal nerve will be directed

00:07:21

instead of section aponeurosis is the

00:07:26

first thing that is usually carried out as a

00:07:28

differential diagnosis. The diagnosis is

00:07:30

radiculopathy,

00:07:31

which is

00:07:34

not yet characteristic of prosthesia;

00:07:36

the latter is the result

00:07:38

of damage to the roots of the spinal

00:07:41

nerves. The main reason for which

00:07:43

is compression from the

00:07:45

protruding intervertebral discs of

00:07:47

osteophytes or space-occupying processes in the

00:07:50

intervertebral foramina

00:07:55

when exiting the spinal canal, the

00:07:58

nerves form us weaving roots a

00:08:01

weave is then formed, then the composition of

00:08:03

various nerves enters therefore,

00:08:06

despite the fact that patients often

00:08:09

complain of weakness of the limb, it is worth

00:08:12

distinguishing it from limitations in mobility

00:08:16

due to pain because

00:08:18

a couple of times and muscle trophies occur

00:08:20

on the deposit much later than with

00:08:22

damage to the nerves directly due to the

00:08:25

fact that the fact that the muscles are not exactly nerved,

00:08:28

the composition of which includes several roots,

00:08:30

and even if one root is damaged or destroyed, the

00:08:33

neighboring ones can take on the

00:08:42

diagnostic function; the most optimal for

00:08:44

verifying compression of nerves is shown on the slide:

00:08:49

x-ray computed tomography and

00:08:51

magnetic resonance imaging of the

00:08:54

same level

00:08:55

x-ray research methods

00:08:57

will evaluate mainly bone structures, it

00:09:00

is clearly seen that the most optimal

00:09:03

study for assessing the condition of the

00:09:05

vertebral discs that relate to the

00:09:08

articular ligamentous apparatus of

00:09:09

the spine is

00:09:11

magnetic resonance imaging, but

00:09:14

certainly in general When it comes to an

00:09:16

older patient, the possibility of

00:09:18

contraindications to this examination,

00:09:20

taking into account the standards of compulsory

00:09:23

health insurance, can be cited

00:09:25

computed tomography but not x-rays, and

00:09:29

in any case, the neurologist must

00:09:31

evaluate the native neuroimaging data with his own eyes.

00:09:36

However, a single sagittal image is

00:09:39

often not enough to confirm

00:09:41

that there is a protrusion or hernia. In

00:09:44

patients, the

00:09:47

causes of root pressure and the development of

00:09:50

radicalopathy are necessary to evaluate

00:09:53

axial sections from which one can

00:09:55

see

00:09:57

if there is a narrowing

00:09:59

intervertebral foramen

00:10:02

because the protrusion of the

00:10:04

intervertebral disc can have a

00:10:06

central lesion and lead to

00:10:09

compression of the neural structures

00:10:13

the patties include the composition of the plexuses, the

00:10:15

lesions of which

00:10:17

are called plexopathies,

00:10:20

there are two main types of flexopathy

00:10:23

depending on the location of the lesion,

00:10:25

this is the brachial lumbosacral,

00:10:27

the most common causes of

00:10:30

plexus lesions are trauma, not

00:10:32

traumatic our causes include

00:10:34

diabetes mellitus infectious processes of

00:10:37

malignancy and radiation

00:10:40

therapy

00:10:41

more than half of cancer patients

00:10:44

receive radiation therapy as part of their

00:10:47

treatment.

00:10:48

A patient who has received training in the

00:10:51

neck, chest, axilla,

00:10:54

abdomen and pelvis has an

00:10:59

increased risk of developing after which

00:11:01

lexopathy, which develops on average

00:11:04

from 3 to tens of years after the

00:11:06

treatment,

00:11:07

plexus lesions can also be of an

00:11:10

idiopathic inflammatory nature, and

00:11:13

in this case, the innovation of

00:11:15

Turner's character syndrome

00:11:18

for the brachial plexus exists. A

00:11:20

special form of flexopathy that is associated

00:11:24

with superior thoracic outlet syndrome is

00:11:30

most often encountered in practice,

00:11:33

lesions of the brachial plexus rather than the

00:11:35

lumbosacral but Do not confuse

00:11:38

shoulder flexopathy with simple pain in the

00:11:40

shoulder, which can lead to

00:11:42

limited mobility due to

00:11:45

pathology of the shoulder

00:11:47

joint itself and thus lead to

00:11:49

false cuts; for this, there is a

00:11:52

set of simple tests that can be

00:11:54

performed at an outpatient appointment

00:11:56

in just a few minutes; flexopathy is already

00:12:01

characterized by the presence of objective

00:12:02

sensory disorders, paresis and

00:12:05

muscle atrophy, while

00:12:08

they do not have limited mobility in the joints;

00:12:15

in general, the

00:12:16

food plexus has a rather

00:12:18

complex structure; the roots are intertwined

00:12:20

first into trunks, then bundles and branches;

00:12:24

such a complex device allows the

00:12:26

function of the hand to be protected as much as possible; the

00:12:31

most typical options are

00:12:33

damage to the upper fascicle or paralysis

00:12:36

Jenner airba With the development of

00:12:38

sensory disturbances, weakness of muscles in the

00:12:41

shoulder area and damage to the lower fascicle

00:12:45

or paralysis of the hook With the development of the same

00:12:48

symptoms but in the area of the hand,

00:12:52

these two pathologies

00:12:54

are best known due to obstetric trauma with

00:12:57

weaving, which nowadays, thank

00:12:59

God, is much less common but

00:13:01

absolutely the same The same phenotype is also observed in

00:13:04

adult patients with trauma to the plexus of the

00:13:11

upper thoracic outlet syndrome; this is a

00:13:14

group of pathologies in which the results

00:13:16

from the pressure of the vascular-nervous bundle of the

00:13:18

upper extremities cause discomfort

00:13:21

and pain in the shoulder, arm and neck, but possible and the

00:13:25

development of a full-fledged

00:13:27

flexopathy clinic with damage to the lower

00:13:30

bundle as a

00:13:31

cause such compression is the

00:13:33

pinching of these structures in the

00:13:35

intermuscular and interosseous spaces

00:13:37

at the exit from the chest of such

00:13:41

anatomical narrowing spaces 3 the

00:13:44

first is in the interpersonal

00:13:47

space between the anterior and middle

00:13:49

extra monthly muscles, the

00:13:51

second is the rib-subclavian

00:13:53

space between the clavicle and the first or

00:13:56

accessory rib and the third is behind the minor of the

00:14:00

pectoral muscle, to clarify the diagnosis, an

00:14:03

x-ray of the neck is performed to

00:14:05

exclude an additional rib or is it a

00:14:07

neural graph, the value of which is sharply

00:14:10

limited for this zoology in the

00:14:13

initial stages, but now an

00:14:16

ultrasound

00:14:18

examination of the plexus with

00:14:20

functional rights has also become available, it is better to start

00:14:23

with this study. But you need to

00:14:25

be sure that An

00:14:28

ultrasound diagnostic specialist has

00:14:30

some experience in working with this

00:14:33

pathology; treatment can be

00:14:35

conservative or surgical,

00:14:37

depending on the cause of compression and the

00:14:40

severity of clinical symptoms;

00:14:43

Turner syndrome, also

00:14:46

known as neurological mytrophy

00:14:48

or idiopathic.

00:17:13

Please excuse the technical

00:17:15

interruption, please check if everything is ok

00:17:18

with the sound on our side, everything seems to be in

00:17:20

order.

00:17:23

Apparently I’m waiting for feedback

00:17:25

in the chat about

00:17:29

whether everyone can hear me

00:17:31

well, thank you very much,

00:17:33

I’m answering the question right away, it’s very difficult

00:17:35

to break down diseases of the peripheral

00:17:37

nervous system into, let’s say, only

00:17:40

traumatic, only compression and

00:17:42

autoimmune,

00:17:44

this will be in more detail broken down into a

00:17:48

course of non-uniform diseases, but

00:17:49

now the task is to

00:17:51

familiarize you a little with the levels of damage.

00:17:53

What are the variants of the course and for nerves

00:17:55

in general, inflammatory damage is

00:17:58

quite a common occurrence, while

00:18:01

trauma is already a rarer thing. So,

00:18:04

Turner character syndrome or

00:18:07

neurological metaphysics or

00:18:08

lymphatic speech flexopathy

00:18:10

According to etymology, it happens in

00:18:14

about one and a half cases per 100 thousand

00:18:16

population per year, there is a

00:18:18

hereditary variant associated with the

00:18:20

mutation Evgeniy Sept 9 when such

00:18:23

attacks appear

00:18:25

several times And after this there is a period of

00:18:28

incomplete recovery

00:18:31

in general, the ideology is not fully studied,

00:18:33

which means a classic description of the pain

00:18:36

syndrome includes the sudden appearance of

00:18:37

severe pain, one-sided in the shoulder,

00:18:42

which can radiate to the neck and hand, is

00:18:46

not even of a positional nature and

00:18:49

intensifies at night, the

00:18:54

pain syndrome usually

00:18:56

continues for several weeks, during which time

00:18:58

sensory and

00:19:00

motor

00:19:02

disturbances may develop, even muscle wasting

00:19:06

may affect the lumbar weaving

00:19:08

weaving But this is much less often felt in

00:19:11

practice

00:19:12

when there is a lesion,

00:19:14

you need to think first of all about other

00:19:16

reasons,

00:19:17

the diagnosis is established on the basis of the

00:19:19

clinical picture and the use of

00:19:22

electroneuromyographic studies with

00:19:24

which we confirm the level of the

00:19:26

lesion and we can also assess the

00:19:28

activity of the process since

00:19:31

Turner syndrome is characterized by

00:19:34

current denervation in a muscle that is

00:19:38

affected by viruses with nerves. It is

00:19:40

also now more common in practice,

00:19:45

which is just necessary. If you

00:19:47

suspect a

00:19:48

lumbar press form that can

00:19:52

reveal inflammatory edema not in

00:19:55

real structures, therapy is

00:19:57

symptomatic in nature; the greatest

00:20:00

energetic effect is indicated for

00:20:02

glucocorticosteroids and in the future

00:20:05

the patient is sent to rehabilitation, the

00:20:08

prognosis for functional recovery in

00:20:11

most cases is favorable, but

00:20:13

according to the literature, the period of damage to individual nerves is sometimes

00:20:15

up to three years.

00:20:20

How many large nerves does a person have,

00:20:23

about a hundred, probably if we take

00:20:26

small branches, we will probably get

00:20:28

several hundred and each of them has the

00:20:31

right to isolated damage

00:20:33

By forming a unique clinical

00:20:35

picture, a whole Arsenal of

00:20:38

diagnostic methods is now available to determine the

00:20:40

nature and level of nerve damage, this includes

00:20:43

electromyography and ultrasound,

00:20:46

and even

00:20:48

magnetic resonance imaging is carried out. What are the

00:20:51

main causes of damage to

00:20:52

peripheral nerves,

00:20:57

of course, for both the above

00:21:00

departments, these are injuries as well as

00:21:02

neoplasms characteristic of nerves

00:21:04

are suture nomas and neurofibromas, and for

00:21:07

peripheral nerves there is a

00:21:09

special form of damage, the so-called

00:21:12

tunnel neuropathy, tunnel

00:21:15

syndromes or compression neuropathy,

00:21:17

this is a group of diseases whose causes

00:21:19

are

00:21:21

local compression of nerves in the muscular

00:21:24

fibrous and bone canals, the most

00:21:27

common neuropathy is tunnel

00:21:30

cranial nerves, this was paralysis or

00:21:33

acute neuropathy facial nerve

00:21:36

prevalence is approximately

00:21:37

up to 20 cases per 100 thousand population. I

00:21:42

think that every neurologist who

00:21:43

works on an outpatient basis encounters

00:21:45

such patients several times a year, especially

00:21:47

in the spring,

00:21:49

the pathogen may be infectious in

00:21:52

nature, occur after a herpes viral

00:21:54

infection, may have autoimmune

00:21:57

kines, but in the vast majority of cases

00:21:59

so it is not established The reasons

00:22:02

why this happened

00:22:04

usually compresses for no more than 72 hours

00:22:07

But it can take up to a week, rarely up to two without

00:22:11

treatment, the muscle function is completely

00:22:13

restored in about 70

00:22:15

percent of cases In patients with

00:22:19

complete treatment and up to 94 percent In

00:22:23

patients with incomplete treatment, help

00:22:26

definition prognosis can also be provided by an

00:22:28

electroneuromyographic study.

00:22:30

But it is not required to establish a diagnosis.

00:22:33

However, an MRI of the brain

00:22:36

should be brought in to exclude a

00:22:38

local lesion and like

00:22:42

either the nerve itself in the area of its exit from the

00:22:46

brain stem;

00:22:48

treatment includes the prescription of

00:22:51

glucocorticosteroids and acyclovir after the

00:22:54

end of the acute period physiotherapy

00:22:57

gymnastics massage, taking into account the social

00:23:00

significance of facial expressions,

00:23:04

it is worth allocating a sufficient amount of

00:23:07

time for the rehabilitation of a patient with neuropathy of his nerve, depending on the dynamics of

00:23:09

recovery, certain procedures

00:23:12

can be introduced and withdrawn and a

00:23:14

treatment regimen in order to reduce the risk of

00:23:16

development and contractures that can

00:23:19

become complications after this

00:23:22

diseases and, in general, to obtain

00:23:23

maximum effectiveness from the

00:23:25

procedures performed, the

00:23:28

most common tunnel

00:23:30

neuropathies of the upper extremities

00:23:32

are the Carpathians and capital

00:23:35

tunnel syndromes; damage to the median

00:23:38

and ulnar nerve can occur at

00:23:40

other levels. But this is much less common;

00:23:42

often in practice,

00:23:45

damage to the radial nerve in the region of the

00:23:49

spiral canal and axillary depressions

00:23:52

which are called Saturday

00:23:55

night palsy and crutch palsy, respectively,

00:23:58

the main compression neuropathies of the

00:24:00

lower extremities are figurative and

00:24:03

tarsal tunnel syndromes, I also

00:24:06

think that many practice

00:24:08

rota disease is neuropathy of the lateral

00:24:10

cutaneous nerve Peter,

00:24:13

the patient has the right to have

00:24:15

several

00:24:16

neuropathies at once, especially if he has

00:24:19

these are predisposing factors, such as

00:24:21

diabetes mellitus or hypothyroidism,

00:24:25

and a specific type of

00:24:29

activity. However, the presence of

00:24:32

recurrent tunnel patties in the

00:24:34

area of both the upper and lower extremities, as

00:24:37

well as their combination with criminal

00:24:39

neuropathies, requires caution

00:24:42

regarding the carriage of a mutation in the

00:24:44

pmp22 gene, which is characteristic of neuropathy

00:24:47

with a tendency to paralysis from pressure,

00:24:50

this analysis is currently available

00:24:53

in many independent laboratories, has a

00:24:55

low cost, and clarifying the presence of

00:24:58

this mutation will allow the patient to give

00:25:00

rational recommendations regarding

00:25:03

lifestyle and sometimes make a decision

00:25:06

regarding the

00:25:07

need for surgical compression of

00:25:10

nerves; the

00:25:12

clinical picture and treatment approaches

00:25:14

depend on the affected nerve. So,

00:25:17

pain syndrome is especially of a burning

00:25:19

nature occurs in precorporeal and

00:25:22

tarsal tunnel syndromes, it is

00:25:24

for these nerves that in practice it is possible to

00:25:27

carry out

00:25:28

intracanal posters

00:25:30

with glucocorticosteroids and analgesics,

00:25:32

after which the symptoms can begin to be

00:25:35

observed. Or let’s say an abyss for a

00:25:37

whole year or even more; for other

00:25:39

neuropathies it is not indicated;

00:25:43

for all types of tunnel nerves,

00:25:46

numbness is characteristic. Although patients with

00:25:49

syndrome and figure-tonal syndrome

00:25:52

usually do not pay attention to at least

00:25:55

consult a doctor already at the stage of development of

00:25:57

weakness in the leg, which will limit their

00:26:00

social activity.

00:26:02

However, the same was 8 grams, which is

00:26:06

also not typical for these two

00:26:07

tunnel neuropathies, sometimes

00:26:10

different situations can occur

00:26:12

including, let’s say, in recent

00:26:15

months, a girl came in for an appointment with a

00:26:18

pronounced neuropathic

00:26:19

pain syndrome in the area of the

00:26:22

ulnar nerve, which is rare,

00:26:26

this was due to the fact that she had

00:26:29

hypermobility of the nerves at the level of the

00:26:32

elbow joint, it was palpable, it was

00:26:34

displaced, it was all is associated with

00:26:36

pain

00:26:41

at the same time when a

00:26:45

patient comes for an electromyography, let’s say with a referral

00:26:47

from a doctor with a figure tonal syndrome and

00:26:50

he only has a pain syndrome just below the

00:26:53

knee in the shin area and there are no

00:26:55

objective sensory and

00:26:56

motor disorders, it is immediately clear that

00:26:59

this patient will be full during the study Is it

00:27:01

normal

00:27:03

for treatment to be indicated for all

00:27:07

patients with neuropathies? Usually this is

00:27:09

immobilization in the acute period, as well as

00:27:12

some types of physical treatment and

00:27:14

medical rehabilitation; indications for

00:27:17

surgical treatment are determined taking into

00:27:19

account not only the clinical picture but

00:27:21

also electromyographic and

00:27:23

ultrasound examinations. Let's

00:27:27

move on to planiropathy; this is diffuse

00:27:31

damage to the

00:27:32

nerves of the nerve fibers most common

00:27:36

causes in developing

00:27:38

countries are diabetes mellitus and

00:27:41

alcohol abuse. However, the list of

00:27:44

other causes is extremely long, which often

00:27:47

requires special training of

00:27:48

neurologists to work with a patient with

00:27:52

these conditions. It is important to

00:27:55

establish a diagnosis as early as possible, on which

00:27:58

treatment tactics and prognosis will depend,

00:28:00

but in reality how is shown in the diagram and

00:28:04

this is now relevant, up to a

00:28:06

quarter of patients find the cause of

00:28:08

damage to the physical nerves even

00:28:12

after a full-scale and

00:28:14

expensive examination,

00:28:17

it is worth warning the patient about this in advance and at the

00:28:20

First appointment, if the reason is not yet obvious,

00:28:23

keep this in mind as part of the first

00:28:27

appointment. general

00:28:29

biochemical blood tests are prescribed, a blood test for

00:28:31

core hemoglobin, thyroid-stimulating hormone,

00:28:33

and also for vitamin B12 can ideally be

00:28:38

prescribed to the head transcobolamine is the

00:28:40

active form of vitamin B12 but is

00:28:43

not available in standard compulsory medical insurance but is already

00:28:46

available in some

00:28:48

private laboratories it is an

00:28:52

earlier marker of nerve damage

00:28:54

due to a deficiency of this vitamin

00:28:58

further tests should already be

00:29:01

prescribed After the lecture,

00:29:03

which will allow us to clarify the type and

00:29:07

nature of nerve damage,

00:29:10

depending on which nerve

00:29:13

fibers are more involved in the

00:29:14

pathological process,

00:29:17

sensitive symptoms arise; this is numbness,

00:29:19

prosthesia and pain sensations of the slide do not

00:29:23

change; it is written that

00:29:31

paresis may develop; muscle loss

00:29:35

and vegetative symptoms with polyropathy,

00:29:38

either an isolated

00:29:39

lesion of a certain type of nerve

00:29:41

fiber or a combination of them can occur. What leads to the

00:29:44

appearance of a variety of clinical

00:29:46

pictures from the pathophysiology side is of

00:29:49

critical importance. Which specific

00:29:51

part of the nerve is affected and whether it is the core

00:29:55

or the sheath, which is established using an

00:29:58

electron beam examination

00:30:00

when we receive a conclusion from a neurophysiologist

00:30:03

primarily we are primary

00:30:06

axonal or primarily demonizing

00:30:08

type of damage to nerve fibers,

00:30:12

the type of damage to nerve fibers is the

00:30:15

most valuable information for us, so with the

00:30:18

help we can plan a further

00:30:20

examination plan to find the causes. It is

00:30:24

also important to pay attention to the

00:30:26

speed of development of symptoms

00:30:30

since the acute development of symptoms of

00:30:33

polyneuropathy in the overwhelming case is

00:30:35

characteristic of underground inflammatory

00:30:38

polyneuropathy that requires

00:30:40

specific treatment as early as possible

00:30:42

When we talk about the island development of

00:30:46

symptoms We usually mean

00:30:47

a period of up to 4 weeks, while usually the

00:30:51

course is monophasic, it is important to

00:30:55

understand this because if polyropathy,

00:30:57

according to the diagnostic method,

00:31:01

is still inflammatory And this is more likely

00:31:04

demonizing to polish according to

00:31:07

electromyography data and the patient,

00:31:09

let’s say, has protein-cell

00:31:11

dissociation

00:31:12

and the symptoms have been increasing for

00:31:15

more than 4-8 weeks. Then we are most likely talking

00:31:18

about chronic variants of

00:31:21

diesel polyneuropathy for which

00:31:23

the treatment is completely different;

00:31:27

the most common acute Crazy

00:31:29

polyneuropathy is Gene

00:31:31

Barre syndrome according to epidemiological data,

00:31:35

the disease occurs in one to two

00:31:38

cases per 100 thousand population,

00:31:41

there is a characteristic staged

00:31:45

appearance of symptoms: first, up to 4

00:31:48

weeks, we have an increase in clinical

00:31:51

symptoms, then we develop a

00:31:53

plateau phase, which also lasts 4 weeks, and

00:31:56

after that the patient enters the

00:31:59

recovery period which can

00:32:00

last up to a year,

00:32:01

Barrett's syndrome is generally a fairly

00:32:04

heterogeneous clinical condition.

00:32:06

However, in the vast majority of cases,

00:32:09

it is still flaccid tetraparesis, and

00:32:13

is characterized by an increase in the distal

00:32:15

limbs of the legs in an ascending

00:32:18

manner to the hips, then to the pelvic girdle,

00:32:22

torso, arms, shoulder girdle, as well as

00:32:27

very facial and boulevard

00:32:28

muscles Which leads to impaired

00:32:30

swallowing and breathing, depending on the

00:32:34

form, sensory disturbances may be present or

00:32:35

absent; the

00:32:38

main forms of the disease that

00:32:40

should be mentioned. As a result, the clinical

00:32:43

diagnosis is acute inflammatory

00:32:46

demelting polyuropathy; acute

00:32:49

motor axonal polyneuropathy; and

00:32:52

acute motor-sensory axonal

00:32:54

polyneuropathy; there are many other

00:32:56

options let's say there is a purely

00:33:00

sensory option, which is quite

00:33:01

common, currently

00:33:03

patients come after a coronavirus

00:33:06

infection and say that they

00:33:08

have developed No less than in the feet and hands

00:33:11

which, let's say, gradually then went away.

00:33:14

It cannot be ruled out that these patients

00:33:16

suffered, let's say, a fairly mild

00:33:18

form of Barre syndrome,

00:33:21

but it's always worth remembering the fact that any,

00:33:24

even the mildest, form can quickly

00:33:26

develop into a full-fledged clinical

00:33:28

picture and the patient may require

00:33:31

respiratory support and stay in

00:33:33

intensive care, therefore,

00:33:35

any suspected patient

00:33:38

should be hospitalized in a hospital

00:33:40

when timely

00:33:44

pathogenetic therapy is carried out, the period of

00:33:46

increase in symptoms stops and

00:33:49

formation begins, treatment

00:33:52

helps to minimize

00:33:54

neurological deficiency

00:33:59

and among chronic dysemonic

00:34:01

planeropathies, they directly distinguish

00:34:03

chronic inflammatory

00:34:05

demyelizing polyropathy, which

00:34:07

is characterized by damage to both sensory and

00:34:10

motor fibers, and multiple

00:34:12

motor neuropathy, which is

00:34:15

characterized by damage only to motor

00:34:17

fibers by the formation of blocks of

00:34:20

excitation conduction along them in places not typical

00:34:23

for compression of nerves, especially in the region of the

00:34:25

brachial plexus

00:34:27

and a lumbar chair is not available.

00:34:31

Unfortunately, when examining a patient,

00:34:33

the options present him with

00:34:35

indirect damage to the nerves,

00:34:38

the basis of phytogenesis of which

00:34:41

currently remains incompletely studied. The

00:34:43

key aspects in making a

00:34:46

diagnosis are an examination by a neurologist and an

00:34:49

electronic graphic

00:34:51

study, on the basis of which the

00:34:53

compliance of the

00:34:56

data obtained with the criterion is assessed developed by the

00:34:58

European neurological community

00:35:00

for each specific zoology, it is worth

00:35:03

noting that the identification of a patient with

00:35:05

deminizing planiropathy should be

00:35:08

followed by urine testing for protein secretion,

00:35:12

which is increased, which is characteristic of

00:35:15

paranomic states. However, it

00:35:19

may not be the first time, well,

00:35:23

the only thing is that certainly not every

00:35:24

patient is sent for this study

00:35:26

only those who have features of the

00:35:28

clinical picture,

00:35:31

depending on the established form,

00:35:34

various approaches

00:35:36

to therapy are suggested in the case of Genn Bore syndrome,

00:35:40

high-volume

00:35:42

plasmapheresis is indicated, this is approximately 200-250

00:35:45

milliliters per

00:35:47

kilogram of weight. That is, if we are talking

00:35:50

about a man of 80 kilograms, this is approximately 20

00:35:54

liters per course

00:35:56

for

00:35:57

7-10 days That is, this is at least 2,

00:36:01

better than 3 liters Per day

00:36:04

or with the help of human

00:36:06

immunoglobulin in a dosage of 2 grams per

00:36:09

kilogram per course, which will be 160 grams of the

00:36:14

same 80-kilogram

00:36:16

man, the cost of which will be about a

00:36:19

million rubles

00:36:22

or less it is known whether this is carried out

00:36:24

somewhere in Moscow under compulsory medical insurance and it is unlikely that you will be

00:36:27

able to obtain

00:36:29

residence quickly, but there is the possibility of

00:36:32

bringing some books to clinics; it

00:36:36

varies depending on the year,

00:36:39

but still it must contain 95

00:36:45

percent of class G immunoglobulin

00:36:48

and the combined use of both approaches,

00:36:51

that is, plasmaference And after that, it has

00:36:53

not yet shown its

00:36:55

advantage in many studies;

00:36:58

glucocorticosteroids are ineffective in these patients.

00:37:00

Therefore, if you do not have

00:37:03

plasma globulins, there is no point in infusing

00:37:05

patients with asteroids; she just wait

00:37:08

until he moves from the phase of increasing

00:37:10

symptoms to the phase, then and further to

00:37:13

recovery. Previously, this is how patients were

00:37:15

observed. they were just on

00:37:17

respiratory support until they

00:37:18

came off it on their own;

00:37:23

antiviral drugs are not indicated for

00:37:25

these patients; in the case of multiple

00:37:28

motor neuropathy, the

00:37:29

use of only human

00:37:31

immunoglobulin is effective; they do

00:37:34

not work as well as we would like; and if they are

00:37:37

ineffective,

00:37:39

static drugs are already used for

00:37:43

chronic

00:37:45

inflammatory-demelizing

00:37:46

polyneuropathy; usually the first lines

00:37:49

of therapy are corticosteroids at a dose of

00:37:51

one milligram per kilogram of weight

00:37:57

with insufficient effectiveness, you can

00:37:59

look at all the data on the lines of therapy for

00:38:03

some forms of this disease, they even

00:38:04

show the advantage of using

00:38:06

some types of static drugs

00:38:10

over other lines of therapy, hematologists are involved in the treatment of

00:38:13

facial expression passports

00:38:18

and, finally, investigative polyneuropathy

00:38:20

is a heterogeneous group of diseases

00:38:23

which is accompanied by damage to both

00:38:26

motor and sensory and

00:38:27

autonomic nerve fibers, often

00:38:30

combined with other neurological and

00:38:33

Ecstasy neural manifestations, an already

00:38:36

defined field of hundreds of genes that are

00:38:38

responsible for the development of various forms of

00:38:40

hereditary polyneuropathy, their number

00:38:42

continues to increase, how can a doctor

00:38:45

suspect a hereditary

00:38:48

variant of palmyropathy in a patient, you need to undress him

00:38:51

and look at his legs,

00:38:53

since the latter can claim

00:38:56

that the weakness in the legs was divorced literally

00:38:58

two months ago, since the symptoms

00:39:00

grow very slowly and sometimes it

00:39:03

can last a lifetime, then they

00:39:05

seek help already at the stage of development of

00:39:08

pronounced cuts,

00:39:09

and if the patient then experiences something

00:39:12

like this How is the deformation of the feet put on the slide?

00:39:14

This is of the PSC type, that

00:39:18

is, hollow feet

00:39:19

which are characterized by an increase in the

00:39:22

arch of the foot, as well as

00:39:25

hammer-shaped deformities of the toes, and

00:39:28

sometimes we twist the ankle joint

00:39:30

inward, which occurs due to an imbalance in the

00:39:33

tone of the own muscles of the foot and the thick leg. It is

00:39:36

assumed that patients are

00:39:38

all it is a hereditary form of

00:39:40

polyropathy, however, this is not a

00:39:43

harmonious sign of this disease; the

00:39:46

patient may have a normal foot;

00:39:49

it is worth remembering that a hereditary

00:39:52

disease is possible for you and in

00:39:54

adulthood, even after 50 years, the

00:39:56

patient may have no family

00:39:59

history due to a recessive or

00:40:01

expansive type of inheritance; there may

00:40:04

be no family of symptomatic symptoms

00:40:07

of carriers Therefore, strictly speaking, from the

00:40:10

anamnesis, we will not determine anything at the

00:40:12

present time; a developed

00:40:14

examination algorithm, including collecting an anamnesis and

00:40:17

additional examination, including an

00:40:19

electromyographic examination and

00:40:22

ultrasound examination; examination at the

00:40:24

present time, which also allows

00:40:27

some proportions of cases to wait. What

00:40:30

specific genetic defect

00:40:32

lies at the basis of our formation pathology and

00:40:36

refer the patient to the

00:40:38

study of a specific Gene or already

00:40:41

on a neuromuscular panel which,

00:40:44

using new generation scanning technology,

00:40:46

can simultaneously

00:40:47

view hundreds of genes and is

00:40:50

currently available in the mediagenic

00:40:52

research center and in some

00:40:54

commercial laboratories,

00:40:56

which helps work with patients already for

00:40:58

rational planning of their future

00:41:01

life

00:41:04

our code word today the place is not me

00:41:07

Thank you all very much for your attention

00:41:11

in 40 minutes of course It is impossible

00:41:14

to tell all the diseases of the

00:41:16

peripheral nervous system

00:41:18

because there are a huge number of them, sometimes

00:41:21

the courses covered there are only tunnel

00:41:23

neuropathies only inflammatory

00:41:24

polymerpathies

00:41:25

Therefore, we will be glad to see everyone already on

00:41:29

the course where we will try to devote a little more

00:41:31

detail to each level of

00:41:34

damage, more time I

00:41:36

hope you found it interesting today I will be

00:41:38

glad to see feedback Now I

00:41:41

will try to answer the questions

00:41:47

and tomorrow you will have the next

00:41:50

lecture I can answer yes So now I

00:42:09

was here organizational questions first

00:42:11

[music]

00:42:15

with the onset of pain So the question

00:42:20

about the term Turner's character syndrome is

00:42:21

whether it is limited only to the

00:42:24

proximal nerves. If the

00:42:26

distal nerves are involved in the onset of pain. In

00:42:30

reality, the phenomenon itself of

00:42:34

Turner's character syndrome; its main

00:42:35

clinical signs are the sharp

00:42:38

development of the pain syndrome and this can

00:42:41

be but basically this is the maximum Nerves

00:42:43

But I think that the

00:42:47

distal nerves they start anyway

00:42:49

with the proximal case with plexus 8

00:42:51

lesion of the median nerve, that is, the

00:42:55

detailed part is more likely No, rather it

00:42:57

will be useful throughout, that is, the

00:43:00

distal part of the limb, it

00:43:02

may hurt at first, but after all, there

00:43:06

should not be more throughout the entire arm and so all the

00:43:09

nerves in our body begin to become plexuses,

00:43:10

respectively,

00:43:11

the maximum part of

00:43:15

the age of the stage of Bell's palsy is expressed more often. What type of

00:43:18

physical therapy is preferable any

00:43:20

period There, the first 5-7 days are not

00:43:23

recommended physical treatment after this,

00:43:25

depending on the metro bibliologists who- then

00:43:30

someone uses lasers, in fact, they are not

00:43:33

prescribed in international recommendations

00:43:39

regarding the treatment of Bale's palsy

00:43:42

with dexamethasone, indeed in

00:43:46

foreign recommendations it is

00:43:48

Prednisolone and in Europe, patients are treated on an

00:43:50

outpatient basis, they give out tablets, in

00:43:52

principle, in our clinic too, we have

00:43:54

tablets there, the patient goes home and

00:43:56

has to be treated for some time for

00:43:57

physical treatment,

00:43:58

indeed in Russian publications

00:44:01

there is such a thing and in hospitals there is such a

00:44:04

rule to treat patients with dexamethasone

00:44:07

there, about 16 milligrams per day,

00:44:08

it turns out to be honest, taking into account the

00:44:12

literature data and our personal experience, a patient with

00:44:14

loss of the facial nerve can stop on his own,

00:44:17

therefore, as far as it has been

00:44:19

proven that it is not

00:44:22

installed or restored at all by dexamethasone. I

00:44:24

think it is impossible to answer the question

00:44:26

without large studies, but large

00:44:28

studies only, for example, the

00:44:37

mutation is probably premp22 before this is a very

00:44:41

common mutation of the population, it is

00:44:43

in Invitro and at the end there

00:44:46

will be a recording not yet there on the slide then

00:44:51

PMP 22 I can write in general

00:44:59

all

00:45:05

children the same thing, too, hormones and

00:45:09

antiviral therapy Acyclovir is also

00:45:11

used, it is not shown

00:45:13

separately as a line of therapy, but it

00:45:16

is in a complex

00:45:21

After what period of time can you

00:45:24

check, repeat the blockade of tunnel

00:45:27

tunnel neuropathy is you did not

00:45:29

work the first time Why do it the

00:45:30

second time, that is, it’s one thing that

00:45:33

the blockade was done, it helped, let’s say for two

00:45:36

months, you can do it again for two months,

00:45:38

but there is another question. The blockade helps

00:45:40

only for two months, how

00:45:42

advisable is it to postpone surgical

00:45:44

treatment, which is currently

00:45:46

available, it is carried out using MS without

00:45:48

anesthesia and essentially it’s just a rudimentary ligament being cut,

00:45:51

why put it off?

00:45:57

Russia, this reduction will come in answers in the

00:46:01

middle manner, in principle, in the ulnar

00:46:03

less than three and a half

00:46:07

microamperes, which

00:46:10

indicates that

00:46:12

axonal damage to the nerves is already occurring. When you

00:46:14

just see visually atrophy, then there is no

00:46:17

point in waiting for the atrophy to turn into

00:46:19

complete malnutrition. into complete

00:46:21

atrophy.

00:46:22

Therefore, it is better to recommend

00:46:24

surgical treatment

00:46:37

of axonal polyropathy if the patient

00:46:39

has diabetes mellitus. There, with diabetes

00:46:41

mellitus, there is also an Ax VTB

00:46:43

associated form, that is, in principle. It is

00:46:45

better for a patient with diabetes mellitus to

00:46:47

bring a

00:46:48

study of polypathic complaints

00:46:51

because this, too, often cannot

00:46:53

demonize nerve damage. And so

00:46:56

if you have axonal sensory

00:46:59

motor damage to fibers in diabetes

00:47:01

mellitus, it is not necessary to look for another cause

00:47:03

because essentially

00:47:08

the level is not that high, that is, we can

00:47:10

also check the

00:47:12

blood test for B12 to rule out

00:47:15

a deficiency; his

00:47:18

treatment tactics will change, but in general, I can’t

00:47:23

recall my practice so that in a

00:47:25

patient with diabetes mellitus, if

00:47:27

only some special clinical

00:47:29

features are present, I look for something additionally other

00:47:38

ismunas autoimmunities there is no difference

00:47:40

between these terms,

00:47:49

it seems I answered everything

00:47:55

If it is necessary to do a

00:47:57

study later, in general, nothing either That

00:48:02

is, if on the set on Bor it is

00:48:04

clinically manifested even myography in the

00:48:06

first days, there is no point in doing it because

00:48:07

we have all the nervous psychological

00:48:09

parameters in reserve for about 10-14

00:48:12

days. The patient is simply taken the usual

00:48:15

tests so as not to exclude the possibility that this

00:48:17

may be some variant

00:48:20

that simulates what - something that cannot

00:48:23

be imitated by other couples Well, from

00:48:25

practice only arsenic poisoning But we

00:48:27

must try to find a

00:48:28

patient who was poisoned by lead from

00:48:32

lead But well, the form will show that there are

00:48:34

any changes, if any,

00:48:37

in the general biochemical blood test a

00:48:38

blood test that

00:48:40

confuses us, yes, that is, legends there are no

00:48:42

changes there should not be them, we

00:48:44

can also take any function

00:48:48

because for little sister January there are no

00:48:50

directly expressed changes, then it

00:48:53

could be protein or

00:48:56

cellular proteins dissociation, but if we

00:48:59

see a huge

00:49:00

leukocytosis or lymphocytosis, then of course we

00:49:03

should suspect the debut of some kind of

00:49:06

neurolymph lymphotosis and the like.

00:49:19

Yes, there are algorithms for

00:49:22

polymerpathy. Especially for the wide sea of

00:49:24

mulberries, we just don’t consider them within the framework of this lecture

00:49:30

because they will be discussed in the course.

00:49:31

Because it’s not so easy to say words

00:49:39

drying of the lower leg, atrophy can be with

00:49:42

myopathy with polyneuropathy

00:49:48

sensory

00:49:54

adolescents sensory

00:49:59

under acute sensory polyropathy if

00:50:02

it is definitely necessary to make a remark if on the

00:50:05

axonal

00:50:06

thick it can be a sign of a multi-

00:50:09

systemic disease because under

00:50:11

acute polyropathy this needs to be looked at

00:50:14

if it is demonizing this is one thing this is

00:50:16

dismon to polish this maybe,

00:50:18

including an increase in dependence on

00:50:21

what kind of pathology we are talking about, let’s say a couple

00:50:25

economic condition, there can be

00:50:27

anything if we meet about

00:50:29

axonal under acute,

00:50:31

then we should always think about the fact that

00:50:35

we have vasculitis and systemic manifestations do not immediately

00:50:39

appear, but they

00:50:41

may appear, say, six months later

00:50:44

alts This is the first bell

00:50:54

against viral therapy. I don’t think it

00:50:58

was a mistake not to use it. But here’s

00:51:00

my clinical practice. Somehow, in my

00:51:02

younger years, I didn’t use

00:51:04

antiviral therapy,

00:51:06

and as a result, a few days after

00:51:10

paralysis, my patients herpes popped up

00:51:12

everywhere After that, I started

00:51:14

using it, but again, all the

00:51:16

patients agree to antiviral

00:51:18

therapy because it puts a

00:51:20

certain burden on the liver and many

00:51:23

go through everything fine, this is not a gross

00:51:25

mistake, this is the level of evidence when

00:51:26

used together

00:51:29

with acyclovir asteroids, the

00:51:40

European recommendations say that

00:51:42

that acupuncture was ineffective,

00:51:45

we are carried out

00:51:50

about the place, we will not listen to the report of

00:51:53

Evgeniy Alexander Melnik

00:51:57

on the website that this is used for

00:52:00

about 7 10 days, dosage of 400

00:52:04

milligrams 5 6 times a day, non-

00:52:10

inflammatory bladder, and this probably most

00:52:13

likely refers to damage to the

00:52:15

central nervous system, an

00:52:21

increase in B12 does not mean anything. That is, most

00:52:24

likely the patient took vitamins not so long ago;

00:52:32

the method of treatment depends on the severity of

00:52:34

the symptoms; Upper chest negotiation syndrome;

00:52:37

That is, a situation when the

00:52:39

patient is already developing atrophy; a

00:52:41

pronounced pain syndrome that is

00:52:42

not relieved by anything; it is correct for

00:52:45

the surgeon to remove the additional rib or there

00:52:48

to cut the muscle that compresses the bundle

00:52:51

If we are talking about minimal manifestations,

00:52:54

let’s say a little discomfort, it’s

00:52:56

enough to correct the patient, let’s go to a

00:52:58

massage therapist who once massages the

00:53:00

decimal muscles, you can do Botox,

00:53:09

swelling can be part of the vegetative

00:53:11

manifestations of polyneuropathy,

00:53:19

which means this is an important question about how

00:53:22

often they disagree data from

00:53:23

electronyamography with a clinic

00:53:25

of polyneuropathy there is such a thing as

00:53:28

polyneuropathy of small fibers when the

00:53:30

patient has sensory manifestations and

00:53:32

he has vegetative manifestations,

00:53:35

while the electromagnification will be the norm, it may be

00:53:38

the norm, that is, the absence of changes in the

00:53:41

summer of non-lovingography does not tell us

00:53:43

that the patient is a little

00:53:45

annoying if he has a clinic, it means

00:53:48

he has polyropathy; to evaluate thin

00:53:51

windows, questionnaires are used; there are

00:53:53

some Physiological

00:53:55

examination methods in our country, they are not so

00:53:57

developed; in Europe, let’s say there is a

00:54:00

vessel scan. And in our country, it’s probably

00:54:02

best to evaluate microscopy of thin

00:54:06

fibers that are located in we now have

00:54:08

corneas

00:54:09

from them, we can already roughly say that the

00:54:12

patients are all affected

00:54:24

Dear colleagues Thank you very much for your

00:54:26

participation I am very grateful to you for your

00:54:29

attention because it is the

00:54:32

first time for such a large audience. Usually I

00:54:34

consider it a student or within an institution,

00:54:37

so I am very grateful to everyone for

00:54:39

feedback

00:54:40

I will be glad to see those of you who come

00:54:43

to our course, we will prepare, we promise

00:54:45

clinical examples, a little introduction to

00:54:49

electromyography, since it is quite

00:54:51

difficult for doctors

00:54:53

and I would like you to understand When you

00:54:56

refer patients for research And

00:54:58

when you receive data that they are generally

00:54:59

these habits mean that tomorrow

00:55:03

you will have the next lecture with

00:55:06

Elizaveta Erokhina, a specialist in

00:55:09

diseases especially in children, you can

00:55:12

also ask her many questions

00:55:15

Thank you for your attention

00:55:18

Thank you all very much

Description:

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