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Premature birth is a public health problem in the world, particularly in economically developed countries with a rate varying between 7% and 12% of births. The diagnosis of the risk of premature labor is difficult to make and the tools at our disposal have changed little in recent years. Uterine contraction is a direct consequence of electrical activity at the level of the myometrium. The type of contraction is related to the importance of cell excitability and its diffusion to the entire myometrium. The analysis of this electrical activity by surface electrodes is currently the only non-invasive way to study the mechanisms that are at the origin of the contraction. The recording of the uterine electromyogram or electrohysterogram (EHG) is therefore promising for the diagnosis and surveillance of women at risk of preterm birth. In this thesis work 3 clinical studies have been carried out. In the first clinical study, different surface electrodes to record electrical signals were tested. I propose at the end of this first part a system of electrodes to allow at the same time a recording of quality and an easy pose compatible with a clinical application. In the second study , the automatic detection of contractions by the El-IG was studied with encouraging results for the clinical application and especially in ambulatory. Finally, in the third clinical experiment, I studied the prediction of the risk of premature delivery by the analysis of electrical parameters extracted from the EHG. The results obtained make it possible to improve the prediction of the risk of premature delivery compared to the tools used routinely.; L’accouchement prématuré est un problème de santé publique dans le monde et notamment dans les pays économiquement développés avec un taux variant entre 7 et 12 % des naissances. Le diagnostic du risque d’accouchement prématuré est difficile à faire et les outils à notre disposition ont peu évolué ces dernières années. La contraction utérine est la conséquence directe de l’activité électrique au niveau du myomètre. Le type de contraction est lié à l’importance de l’excitabilité cellulaire et de sa diffusion à l’ensemble du myomètre. Le recueil et l’analyse de cette activité électrique par des électrodes de surface est aujourd’hui le seul moyen non invasif d’étudier, pendant la grossesse, les mécanismes qui sont à l’origine de la contraction. L’enregistrement de l’électromyogramme utérin ou électrohystérogramme (EHG) est donc prometteur pour réaliser un diagnostic et une surveillance des femmes à risque d’accouchement prématuré. Dans ce travail de thèse 3 études cliniques ont été réalisées. Dans la première, j’ai étudié différentes électrodes de surface permettant d’enregistrer les signaux électriques. Je propose à la fin de cette première partie un système d’électrodes pour permettre à la fois un enregistrement de qualité et une pose aisée compatible avec une application clinique. Dans la deuxième étude j’ai étudié la détection automatique des contractions par l’EHG avec des résultats encourageants pour l’application clinique et notamment en ambulatoire. Enfin dans la troisième étude j’ai étudié la prédiction du risque d’accouchement prématuré par l’analyse de paramètres électriques issus de l’EHG. Les résultats obtenus permettent d’améliorer la prédiction du risque d’accouchement prématuré par rapport aux outils utilisés en routine.

Premature birth is a public health problem in the world, particularly in economically developed countries with a rate varying between 7% and 12% of births. The diagnosis of the risk of premature labor is difficult to make and the tools at our disposal have changed little in recent years. Uterine contraction is a direct consequence of electrical activity at the level of the myometrium. The type of contraction is related to the importance of cell excitability and its diffusion to the entire myometrium. The analysis of this electrical activity by surface electrodes is currently the only non-invasive way to study the mechanisms that are at the origin of the contraction. The recording of the uterine electromyogram or electrohysterogram (EHG) is therefore promising for the diagnosis and surveillance of women at risk of preterm birth. In this thesis work 3 clinical studies have been carried out. In the first clinical study, different surface electrodes to record electrical signals were tested. I propose at the end of this first part a system of electrodes to allow at the same time a recording of quality and an easy pose compatible with a clinical application. In the second study , the automatic detection of contractions by the El-IG was studied with encouraging results for the clinical application and especially in ambulatory. Finally, in the third clinical experiment, I studied the prediction of the risk of premature delivery by the analysis of electrical parameters extracted from the EHG. The results obtained make it possible to improve the prediction of the risk of premature delivery compared to the tools used routinely.; L’accouchement prématuré est un problème de santé publique dans le monde et notamment dans les pays économiquement développés avec un taux variant entre 7 et 12 % des naissances. Le diagnostic du risque d’accouchement prématuré est difficile à faire et les outils à notre disposition ont peu évolué ces dernières années. La contraction utérine est la conséquence directe de l’activité électrique au niveau du myomètre. Le type de contraction est lié à l’importance de l’excitabilité cellulaire et de sa diffusion à l’ensemble du myomètre. Le recueil et l’analyse de cette activité électrique par des électrodes de surface est aujourd’hui le seul moyen non invasif d’étudier, pendant la grossesse, les mécanismes qui sont à l’origine de la contraction. L’enregistrement de l’électromyogramme utérin ou électrohystérogramme (EHG) est donc prometteur pour réaliser un diagnostic et une surveillance des femmes à risque d’accouchement prématuré. Dans ce travail de thèse 3 études cliniques ont été réalisées. Dans la première, j’ai étudié différentes électrodes de surface permettant d’enregistrer les signaux électriques. Je propose à la fin de cette première partie un système d’électrodes pour permettre à la fois un enregistrement de qualité et une pose aisée compatible avec une application clinique. Dans la deuxième étude j’ai étudié la détection automatique des contractions par l’EHG avec des résultats encourageants pour l’application clinique et notamment en ambulatoire. Enfin dans la troisième étude j’ai étudié la prédiction du risque d’accouchement prématuré par l’analyse de paramètres électriques issus de l’EHG. Les résultats obtenus permettent d’améliorer la prédiction du risque d’accouchement prématuré par rapport aux outils utilisés en routine.

Idiopathic peripheral facial palsy, also named Bell's palsy, is the most common cause of peripheral facial palsy in adults. Although it is considered as a benign condition, its social and psychological impact can be dramatic, especially in the case of incomplete recovery. The main pathophysiological hypothesis is the reactivation of HSV 1 virus in the geniculate ganglia, leading to nerve edema and its compression through the petrosal bone. Patients experience an acute (less than 24 hours) motor deficit involving ipsilateral muscles of the upper and lower face and reaching its peak within the first three days. Frequently, symptoms are preceded or accompanied by retro-auricular pain and/or ipsilateral face numbness. Diagnosis is usually clinical but one should look for negative signs to eliminate central facial palsy or peripheral facial palsy secondary to infectious, neoplastic or autoimmune diseases. About 75% of the patients will experience spontaneous full recovery, this rate can be improved with oral corticotherapy when introduced within the first 72 hours. To date, no benefit has been demonstrated by adding an antiviral treatment. Hemifacial spasms (involuntary muscles contractions of the hemiface) or syncinesia (involuntary muscles contractions elicited by voluntary ones, due to aberrant reinnervation) may complicate the disease's course. Electroneuromyography can be useful at different stages: it can first reveal the early conduction bloc, then estimate the axonal loss, then bring evidence of the reinnervation process and, lastly, help for the diagnosis of complications.

Deep brain stimulation (DBS) requires the surgical implantation of a system including brain electrodes and impulsion generator(s). The nuclei targeted by the stereotaxic implantation methodology have to be visualized at best by high resolution imaging. The surgical procedure for implanting the electrodes is performed if possible under local anaesthesia to make electro-physiological measurements and to test intra-operatively the effect of the stimulation, in order to optimize the position of the definitive electrode. In a second step, the impulsion generator(s) are implanted under general anaesthesia. DBS for movement disorders has a very good efficacy and a low albeit non-zero risk of serious complications. Complications related to the material are the most common.

Historical study of electrodiagnosis indicates that nerve conduction block is an old notion, used as early as the second century by Galien and then early in the 19th by physiologists such as Müller and Mateucci. Although introduced into the field of human pathology by Mitchell in 1872, who used it to study nerve injuries, and then by Erb in 1874 to study radial palsy, the contribution of nerve conduction blocks to electrodiagnosis was not exploited until the 1980s. At that time, attempts to improve early diagnosis of Guillain-Barré syndrome showed that among the electrophysiological consequences of demyelination, conduction block was the most appropriate to account for the paralysis. At the same time, descriptions of neuropathies characterized by conduction blocks led to considering conduction block as a major electrophysiological sign. Why was it so difficult for this sign to be retained for electrodiagnosis? Since the notion is not always associated with anatomical lesions, it doesn't fit easily into anatomoclinical reasoning, but has to be thought of in functional terms. Understanding how an uninjured axon could fail to conduct action potentials leads to an examination of the intimate consequences of demyelinations and axonal dysfunctions. But some of the difficulty encountered in adding this new old sign to the armamentarium of electrophysiological diagnosis was related to the technical precautions required to individualize a block. Several pitfalls have to be avoided if a conduction block is to be afforded real diagnostic value. Similar precautions and discussions are also needed to establish an opposing sign, the "excitability block" or "inverse block".

F-waves result from the discharge of the motoneurons following their antidromic activation. The F-wave appears, as an indirect (the F-wave latency decreases when the stimulation site moves away from the muscular detection) and late response (occurring after the M response). In practice, the most useful parameter is the F-wave minimal latency, provided that at least seven distinct F-waves are evoked. When the analysis is relative either to the controlateral side, or to a former examination, this parameter is one of most sensitive in electroneuromyography. F-wave evocation implies conduction along the entire peripheral nervous system, and particularly its proximal part, which is not investigated by nervous trunks conduction velocity studies. Thus, F wave study is the most useful in plexopathies and polyradiculonevritis. In the early phase of Guillain-Barré syndrome, their absence may be the unique sign indicative of proximal conduction blocks.

The impact of anosmia or ageusia may be considerable for some occupations. Expert assessment shows how difficult it is to prove the diagnosis. A specialist is usually needed to demonstrate the asserted disorder. Damage compensation is based on the patient's occupation and coverage.

Resume L’objectif de cette etude est d’ameliorer la justesse des systemes d’acquisition de potentiels d’action en ce qui concerne les calculs de Vmax (dV/dtmax) pour rendre de maniere plus fiable cette donnee physiologique importante generalement sous-evaluee. La methode presentee ici permet d’effectuer une correction selon un algorithme adapte a chaque systeme. Nous avons etudie 2 systemes : IOX et DataPac. Nos resultats comparatifs portent sur une etude de 89 fibres de Purkinje de lapin (avant et 30 min apres la superfusion de molecules agissant sur la repolarisation ventriculaire). Il serait critiquable d’utiliser une methode de mesure sans en connaitre l’exactitude dans une gamme de valeurs representatives d’une situation physiologique. Lors d’experiences qui visent a mettre en evidence des effets pharmacologiques ou physiopathologiques (encore plus si cela entraine des consequences therapeutiques), il est essentiel de connaitre auparavant la justesse, la fidelite et la precision de son systeme de mesure au risque de fausser les resultats. Une formule ici presentee pour corriger la Vmax mesuree peut avoir une application pratique en electrophysiologie.

A 0.9 train-of-four ratio, measured at the thumb, is currently considered to reflect adequate recovery of neuromuscular block. Recent studies have documented that a train-of-four ratio0.9 is associated with a decrease in chemoreceptor sensitivity to hypoxia and with a functional impairment of the pharyngeal muscles. These residual effects of neuromuscular blocking agents promote insufficient ventilatory response to hypoxia and regurgitation/aspiration. As a result, the incidence of pulmonary complications have been found to be higher in both early and late postoperative period in patients with residual curarisation. Clinical tests such as the head lift test and visual or tactile evaluation of the response to peripheral nerve stimulation are no longer sufficient to exclude postoperative residual curarisation. Residual curarisation is still present at the time of extubation despite the use of subject if monitoring of neuromuscular function, clinical tests and/or reversal of neuromuscular blocking agents. In contrast, acceleromyographic monitoring provides a valuable tool to avoid residual curarisation and to reduce the related-side effects.

Neuromuscular monitoring and routine use of reversal agents are key elements in the prevention of residual paralysis. According to a nation-wide survey up to 52 % of anaesthesiologists in France apply regularly neuromuscular monitoring after a single intubating dose of a neuromuscular blocking agent and 74 % in case of repetitive administration. However, reversal is rather the exception than routine and, still according to this survey, the risk of residual paralysis largely underestimated. The development of a new class of reversal agents (cyclodextrins) may further modify the management of neuromuscular blockade in clinical practice. The article aims to revise the principles of neuromuscular monitoring and evaluate whether its use is still mandatory when sugammadex is used.

The launch on the market of a new compound is always an important event for a specialty, particularly when the mechanism of action is completely new. It is the case with sugammadex, a cyclodextrin able to encapsulate specifically and only nondepolarizing steroidal muscles relaxant, rocuronium or vecuronium. The clinical trials which have been performed for sugammadex approval have demonstrated promising results. Sugammadex is able to rapidly reverse (2-5 min) different levels of neuromuscular blockade: moderate (e.g., T2 recovery), deep (e.g., PTC 1-2 recovery) and also few minutes (3-15) after rocuronium administration. Thus, the sugammadex's onset time is about 10 times more rapid than neostigmine without the need of concomitantly atropine administration. Sugammadex has only been tested in small sample size of patients. Therefore, the exact place in the anesthetic practice, the potential indications, the safety profile on a large-scale, thus remain to determine. In particular, how it will modify our current practices characterized to date by 1) under-use of neuromuscular monitoring, 2) a marginal practice of reversal and 3) a wide use of benzylisoquinolines : atracurium and cis-atracurium? Finally, what will be the medical strategies to justify an additional cost when compared to neostigmine?

Sugammadex, a cyclodextrin, is a novel agent designed to encapsulate selectively steroidal neuromuscular blocking agents such as rocuronium and vecuronium as well. One molecule of sugammadex is able to encapsulate only one molecule of muscle relaxant. This original pharmacological property allows a very rapid reversal of muscle paralysis. After sugammadex injection, a train of four ratio higher than 0.9 is obtained in less than 5 minutes in all the patients whatever the degree of muscle paralysis at the time of reversal and even when anesthesia is maintained with halogenated agents. However, in order to preserve this efficacy, the dose of sugammadex needs to be adjusted to the degree of muscle paralysis at the time of reversal : 2 mg/kg after obtaining 2 responses at the adductor pollicis muscle after a train of four stimulation, 4 mg/kg with a post-tetanic count between 1 and 3 responses, and 12 to 16 mg/kg in case of rescue reversal (3 to 15 minutes after 0.6 to 1.2 mg/kg rocuronium). Even if the original property of sugammadex lets us think that per-operative neuromuscular transmission monitoring would not be furthermore useful, the assessment of the exact degree of muscle paralysis before reversal is mandatory for choosing the right dose of sugammadex.

The clinical picture of hand atrophy related to a cervical rib or elongated C7 transverse process was well described in the modern literature by Gilliatt and Sumner; in 1970, they reported a series of nine patients whose motor status was stabilized following brachial plexus decompression. We report here seven patients suffering from thoracic outlet syndrome (TOS), who developed hand atrophy, sometimes because of diagnostic delay.The patient's charts were analysed retrospectively.The seven patients were all female; the mean age was 43 years. The first complaints were arm pain and paresthesias lasting six months to 5 years. Three patients were treated with C56/C67 discectomy plus disc prosthesis (one patient), ulnar neurolysis at the elbow (the same patient), carpal tunnel release (one patient), and intravenous immunoglobulins (one patient) before TOS diagnosis. Hand atrophy, severe in five patients, was present at presentation. All patients underwent brachial plexus decompression by the anterior (four), posterior (two), or transaxillary (one) approach. This last approach was completed 18 months later by brachial plexus neurolysis via the anterior approach. Postoperatively, motor deficit was improved in two patients and stabilized in five patients.Physicians' unfamiliarity with TOS diagnosis or their reluctance to accept the diagnosis without electrical confirmation can lead to hand atrophy. Brachial plexus decompression at this stage usually stabilizes the deficit.

The anatomic complexity of the brachial plexus makes its electrophysiological exploration difficult. Electrodiagnosis nevertheless plays a crucial role in assessing brachial plexopathies, particularly in the perspective of post-traumatic surgical reconstructions. The evaluation aims to locate as precisely as possible injuries within the plexus, as well as to determine their severity and capacity for recovery. This requires various sensory nerve conduction studies and needle EMG recordings of "marker" muscles. Plexopathies differ from radiculopathies by altered sensory nerve responses and unaltered functional innervation of paracervical muscles. We propose to simplify the exploration of brachial plexopathies by following some practical rules derived from a reanalysis of the brachial plexus anatomic sketch. Two main simplification rules can be deduced from an analysis of the anatomic sketch. First it would be judicious to associate the plexopathies involving a single element of the brachial plexus with distinct etiological and symptomatic patterns according to the altered element, as one does for peripheral nerve and root pathologies. The second proposal relies on the observation that each supraclavicular "truncal" element (upper, middle, or lower) of the brachial plexus results from reunion of cervical root nerves and behaves like a "super-root" for the upper limb, while each infraclavicular "cord" element (posterior, lateral, or medial) is the sum of two or more peripheral nerves and behaves like a "super-nerve". Accordingly, the motor and sensory abnormalities associated with the lesion of a single plexus branch may occupy a clinical and electrophysiological territory that recovers those of its constituants. Except the unaltered paracervical muscles, it is useful to reduce the topographical semiology of truncal lesions to well-known cervical radiculopathies (upper trunk neuropathy to C5 and C6 associated radiculopathies, middle trunk neuropathy to C7 radiculopathy, lower trunk neuropathy to C8 and T1 associated radiculopathies); and that of cord lesions to well-known mononeuropathies of the upper limb (for example, a posterior cord neuropathy may be considered as a full radial mononeuropathy associated with an axillary one). This method of simplification allows to demystify the brachial plexopathies and to facilitate their comprehension and exploration.

Cryoglobulinemic neuropathies caused by hepatitis C virus are frequent and may have severe clinical outcomes. The aim of this study was to clarify the clinical and anatomical correlations of these neuropathies.Between 1992 and 2007, 22 consecutive patients with cryoglobulinemic neuropathies caused by hepatitis C virus were retrospectively included. Patients were evaluated clinically, electrophysiologically and underwent a neuromuscular biopsy. The group of patients with vasculitis on nerve biopsy was compared with the group without vasculitis.All the neuropathies were axonal with 11 polyneuropathies and 11 mononeuropathies multiplex. The seven patients with medium-sized vasculitis on the nerve biopsy presented an acute sensorimotor mononeuropathy multiplex in six cases (85%), with ischemic conduction block in three cases (42%) and wallerian degeneration in four cases (57%). Among the four patients with small-sized vasculitis, two had a mononeuropathy multiplex (50%) without conduction block (0%) and with wallerian degeneration in one case (25%). The 11 patients without vasculitis (nine lymphocytic perivascular infiltrates and two non inflammatory biopsies) had a polyneuropathy in eight cases (72%) without conduction block and wallerian degeneration (0%). The type of neuropathy was different in the group of patients with vasculitis compared with the group without vasculitis. The neuropathies with vasculitis were significantly different with more frequent mononeuropathies multiplex (p0.05), acute early stage (p0.01), disability (p0.05) and wallerian degeneration (p=0.01).Among hepatitis C patients with cryoglobulinemia, neuropathies with small-sized vasculitis show a pattern between severe mononeuropathies multiplex with medium-sized vasculitis and moderate polyneuropathies with lymphocytic perivascular infiltrates. In cryoglobulinemic vasculitis with hepatitis C, the severity of the neuropathy depends on the nature of the cellular inflammation and the size of the vessel involvement.

The pudendal is the king of the perineum. Most often originating in the S3 root, it is responsible for the teguments of the perineum (glans penis, clitoris, scrotum, and the labia majora, the skin of the central fibrous perineal body, anus), but also the erector muscles and the striated sphincters. The social nerve, it controls erection and the voluntary sphincters. It is also the nerve of the beginnings of sexual sensation and masturbation. Its injury is expressed in perineal pain, which, when positional, suggests a tunnel syndrome. The compression points have become well known: ligament pinching between the sacrotuberous and sacrospinous ligaments, the falciform process and the pudendal canal (Alcock canal). The data from questioning the patient, the results of the neurological exam, and the at least momentary response to infiltration define the Nantes criteria, which confirm the diagnosis. Treatment is medical, physical therapy, infiltration, and, as a last resort, surgery. The results have improved because of new technical norms, with 75% of operated patients benefiting from surgery. This disorder has become well known and should be remembered, thus sparing the patient from years of suffering and needless consultations for patients who do not present with organ disease, too often implicated instead of a true canal neuropathy, whose clinical manifestation and treatment have now been validated.

Neurological manifestations of systemic lupus erythematosus are frequent and polymorphic. In 40% of cases, lupus can be revealed by neurological symptoms. Cerebral nervous system complications predominate and can be a negative factor for prognosis. Peripheral features are rare and various and can compromise functional prognosis, sometimes with fatal outcome.We report the case of a 30-year-old woman who presented a cerebral venous thrombosis of the superior longitudinal sinus. Outcome was favorable with antibiotics and anticoagulants. Four months later, she developed an acute polyradiculoneuritis associated with an inflammatory syndrome and positive tests for antinuclear antibody and antinuclear anti-DNA. The diagnosis of neurolupus was retained on the basis of four criteria of the American college of Rheumatology. The patient was given steroid therapy associated with a course of intravenous immunoglobulin. She has fully recovered her deficit.Cerebral venous thrombosis and acute polyradiculonévrites are rare events in systemic lupus erythematosus. Early diagnosis and management are crucial.

Percutaneous radiofrequency (RF) thermorhizotomy of the trigeminal nerve is an effective treatment for trigeminal neuralgia. Long-term efficacy is proportional to the degree of postoperative hypoesthesia. The advantage is the topographic selectivity of the thermolesion, provided the electrode tip is placed accurately. This requires precise x-ray guidance and neurophysiological testing. In addition to the indication in idiopathic trigeminal neuralgia, especially for elderly patients with precarious conditions, thermorhizotomy is particularly useful for treating patients with trigeminal neuralgia due to multiple sclerosis. It can also be applied to symptomatic neuralgias, but only when the main components are of the paroxysmal and/or the allodynic types ; the thermorhizotomy method could aggravate permanent components, especially when burning pain predominates; it could also increase preexisting trophic disturbances, particularly keratitis.

Paraneoplastic movement disorders are rare. Reported cases frequently describe association with anti-CV2/CRMP5 antibodies.We report a case of an 80-year-old man who developed sensorial neuronopathy, following by movement disorders mimicking chorea and obsessive-compulsive and behavioral disorders. These manifestations were first considered to be associated with a prostatic adenocarcinoma but PET and surgical biopsy revealed a mediastinal small cell lung carcinoma classically associated with anti-CV2/CRMP5 antibodies.This case demonstrates that in a context of paraneoplastic neurological syndrome, search for a classically associated cancer is necessary in order to institute adapted treatment early, even if another tumor is obvious.

International audience; The diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) requires a careful clinical and neurophysiological evaluation, often completed by CSF analysis. In numerous cases, this diagnosis is straightforward and leads to rapid initiation of an immunomodulatory treatment. However, some patients are not diagnosed because of atypical clinical and/or neurophysiological features, and do not benefit from a potentially effective treatment. In this context, a working group was composed with the task of establishing recommendations on diagnostic strategies for CIDP in the main clinical situations where this diagnosis may be suspected. We have summarized these recommendations and tried to present them in the form of a decision-making algorithm.

The compressive neuropathies often lead to segmental demyelination injury. These injuries can be detected using speed motor conduction and sensitivity conduction. The corresponding abnormalities are localized conduction abnormalities, presenting as deceleration or as a conductive block. Segmentary deceleration is perfectly well observed, such as in cases of carpal tunnel syndrome. The detection examination, recording motor unit potentials, can distinguish between a peripheral injury and a central injury as well as between a neurogenic injury and a myogenous injury. The precise study of the sensitivity potentials makes it possible to distinguish between a radicular injury, in which the sensitivity potentials are normal, and a plexus injury, in which the sensitivity potentials are altered because of a postganglionic injury.

The usual technique of parasacral sciatic nerve block seems an approach easily achieved, however, the ischial tuberosity is difficult to palpate. [1] The purpose of the study was to propose new skin landmarks improved by an anatomical and clinical study.Three cadaver dissections made previously have shown that our skin landmarks appeared correct. Twenty consenting patients, ASA I to III, proposed for lower limb surgery, were included in this descriptive and prospective study. The patient was positioned in the Sim position. A line was drawn between the anterior superior iliac spine (ASIS) and the sacral hiatus (HS). A second line was drawn from the posterior superior iliac spine (PSIS) and perpendicular to the 1st line. The puncture site (P) was the intersection of these two lines. At point P, the needle was inserted perpendicularly to the skin. Twenty milliliters of a mixture of lidocaine 2% and bupivacaine 0.5% were injected after obtaining an appropriate motor response. Sensory block was assessed 30 minutes after performing block in the territories of the tibial nerve, peroneal and posterior cutaneous of thigh. Parasacral block success was defined by the extension of sensory block in the territories of the tibial and fibular nerves. Complications were noted. An independent observer recorded: the time to perform blocks, the depth of the sciatic nerve, the number of needle redirections, the quality of nerve block of patient, and patient satisfaction.The success rate was 95% (19 of 20 cases). Seventy-five percent of blocks were performed by residents on training. The point P was determined at the first attempt. The time required to perform the block was 3 + or - 1.7 min and depth of the sciatic nerve was 81 + or - 17 mm. The rate of patient satisfaction was 85%. One vascular puncture was observed. We have not noted other complications.Access to the sciatic foramen appears to be facilitated by these new surface landmarks, which are simple and reliable. Our new skin landmarks seemed valid for all morphotypes.

Mandibular lymphomas are rare and most often revealed by painless swelling. The authors report the case of a mandibular lymphoma revealed by an isolated lesion of the inferior alveolar nerve evolving for eight months.A 41-year-old male patient was followed for left mandibular pain, with progressive hypoesthesia of the left inferior alveolar nerve. The radiological assessments remained normal during eight months. Then a vestibular tumor developed in front of tooth 34. The biopsy revealed a B-cell lymphoma. No other localization was found. The patient was in complete remission two years after polychemotherapy.Our observation is unusual in its clinical presentation. Mandibular lymphomas most often present as a painless swelling, sometimes ulcerated in the mouth. They are very rarely diagnosed after an isolated hypoesthesia of V3. Lymphomas are the second most frequent head and neck lymphomas after epidermoid carcinomas, but the frequency seems to be increasing. In almost all the cases, they present as B-cell tumours of the DLBCL subtype in the WHO classification. Mandibular localizations account for only 0.6% of the cases. They are often misdiagnosed as a dental problem. The complete remission rate after chemotherapy ranges from 60 to 80% at one year. Nevertheless, the prognosis remains bad with a survival rate of only 50% at five years.

Lambert-Eaton myasthenic syndrome (LEMS) is a rare presynaptic disorder of the neuromuscular junction. Electrodiagnosis is characterized by compound muscle action potentials of small amplitude at rest, normalizing immediately after brief exercise or high-rate nerve stimulation. Needle electromyographic (EMG) activity is classically described as normal or myogenic.We report the case of a young patient with a non-paraneoplastic LEMS in whom the initial electroneuromyographic examination showed neurogenic changes in needle EMG concomitant with typical features of presynaptic neuromuscular junction disorder at single and repetitive nerve stimulation.Neurogenic EMG abnormalities were not previously described in patients with LEMS and could result from "functional" reversible denervation, depending on the presence of anti-calcium channel antibodies at axon terminals.Neurogenic features in needle EMG examination in case of subacute motor deficiency should not eliminate the possibility of a presynaptic neuromuscular junction disorder, such as LEMS.

Primo-infection by varicella-zoster virus (VZV) may be associated with several neurologic complications. Bilateral facial palsy is a rather uncommon manifestation.We report the case of a 38-year-old woman who developed bilateral facial diplegia and paresthesia affecting all four limbs with subacute onset several days after varicella virus primoinfection. Ancillary tests showed hyperproteinorachia and signs of demyelinating polyneuropathy in nerve conduction tests. The diagnosis of Guillain-Barré syndrome was retained and a treatment with intravenous immunoglobulines was started, leading to progressive improvement.Immunotherapy is a possible therapeutic approach in the context of neurologic postinfectious complications after VZV infection where an underlying mechanism is probable.

As part of a quality assurance in the anaesthesia department, this study was designed to enhance the rate of neuromuscular blockade monitoring for patients receiving muscle relaxant during anaesthesia.After approval of our local ethical committee, we assessed 200 computerized anaesthesia records in which neuromuscular relaxants were used. The following data were collected: demographic characteristics, durations of anaesthesia and surgery, use of neuromuscular monitoring, reversal agents and the quality of neuromuscular monitoring. The results were discussed with all anaesthesia providers of the department and an internal guideline was elaborated with the endpoint that all patients having muscle relaxants should have quantitative neuromuscular monitoring. Six months later, another assessment of 200 consecutive records collected the same data to check the efficiency of the elaborated guideline.The monitoring rate was of 67% at the first assessment and increased to 94% (p0.05). The reversal rate was at 48% in the first assessment and was stable at the second assessment (50%). The rate of patients not monitored and not reversed decreased from 5 to 2% (p0.05).This study shows that as part of a quality assurance program systematic quantitative monitoring of neuromuscular blockade can be significantly increased.

To assess the clinical and epidemiological characteristics of chronic inflammatory demyelinating polyneuropathy (CIDP) in a French population opinion survey.A national and multicentric metropolitan French opinion survey was conducted by TNS Healthcare Sofres from October to December 2006. Five thousand and thirty three hospital or private practice physicians were contacted by mail. A specific questionnaire (38 questions) was designed for the survey to evaluate epidemiology, diagnosis and treatment of CIDP.Four hundred and forty one responses were obtained, 430 were analyzed, 11 being excluded. Only 172 physicians were caring for patients with CIDP, the others feeling that they were not competent for this management (only 34% of the physicians cared for at least one patient during the study). Treatment was managed by only 28% of the physicians and mainly by neurologists working in public hospitals. The percentage of treated patients was 84%, the others were not treated because the impairment was too mild. IVIg were the first intention treatment for 63.2% of the patients and steroids for 30.8% of them. The choice was mainly based on the good tolerance profile of IVIg, both treatments being considered as efficacious.This survey has shown a higher incidence and prevalence of CIDP than expected but a methodological bias may have led to an overestimation (a same patient being included twice). Treatment complied with recommendations and guidelines while the diagnosis may be improved.

We report the case of a 36-year-old-man who first presented two relapses of chronic inflammatory demyelinating polyneuropathy (CIDP) before a diagnosis of sarcoidosis was made. He subsequently presented two combined relapses of CIDP and sarcoidosis. Each time, the outcome was favorable after treatment with intravenous immunglobulins and steroids. The possible relationship between CIDP and sarcoidosis is discussed.

Diagnostic value of nerve biopsy in the diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) has been widely discussed and indication has markedly decreased since 20 years. Diagnosis of CIDP is usually based on clinical features (progressive or relapsing course, symmetrical motor and sensory neuropathy in arms and legs, hypo or areflexia usually involve all four limbs), raised CSF protein concentration and nerve conduction studies consistent with demyelination. Several electrophysiological criteria for CIDP have been proposed. We presented a case of sensory-motor neuropathy with examination compatible with CIDP. Cerebrospinal fluid protein content has been slightly elevated. Electrophysiological criteria have been lacking due to absence of recorded compound motor action potential or sensory nerve action potential in lower limbs and absence of demyelination features in upper limbs. Sural nerve biopsy has allowed to show significant demyelination on microscopic and teased nerve fibers analysis. A diagnosis of CIDP has been kept and immunomodulatory treatment has been discussed. Intravenous immune globulin treatment has been effective in this patient. Nerve biopsy stay useful for confirmation of CIDP in front of clinical features compatible with the diagnosis but without usual biological and electrophysiological criteria. The confirmation of diagnosis is significant and can lead to effective treatment.

The diagnosis of Chronic idiopathic demyelinating polyneuropathy (CIDP) is based on clinical, biological and electrophysiological data. Besides the easily recognized classic forms, there are many clinical variants, sometimes with paucisymptomatic presentation leading to uncertain diagnosis. Numerous sets of diagnostic criteria have sought to define CIDP, specially electrophysiological criteria. These criteria are more sensible than specific. We report two cases of CIDP. Electrodiagnostic studies did not show evidence of multifocal demyelination. We describe the other examinations available to diagnose CIDP.

Despite a supposed common mechanism with demyelination, dysimmune peripheral neuropathies compose a heterogeneous group in term of symptoms (sensory, motor, autonomic), localization of lesions (focal, multifocal or widely spreaded) as well as evolutions (acute, relapsing or chronic). The lacks of reliable biological or electrophysiological markers of evolution in dysimmune neuropathies require development of clinical scales for therapeutic trials and therapeutic decisions in daily practice. As elaboration of a universal scale is not a realistic goal, several specific measurement tools have been proposed for dysimmune neuropathies this past ten years. Highlighting the interest of functional scales as the ONLS, the European INCAT group made a remarkable effort to validate these scales in dysimmune neuropathies. However, there is a controversy concerning the relative interest of deficit scales versus functional scales. The deficit scales may be more sensitive to progression of the disease whereas the functional scales reflect the impact of neuropathy. The use of composite scales, mixing the evaluation of deficits, electrophysiological data and functional issues, is a promising solution, but the relative value of these parameters still remains to be defined.