RU2163461C2 - Method for diagnosing functional state of extrapyramidal paths - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves applying magnetic stimulation of two points one of which is above occipital region of the brain and the other one is at the lumbar segment level of the spinal cord. Latent periods of motor responses of the tibial muscle are recorded. Difference between latent periods of the tibial muscle motor responses is determined in performing magnetic stimulation of the occipital region of the brain and lumbar segment the spinal cord. Then, excitation propagation velocity in the extrapyramidal paths is determined. The velocity being found to drop down to 14.3 ± 0.7 m/s and lower, disturbed excitation propagation capacity is diagnosed on the side the velocity is reduced. EFFECT: quantitative differential evaluation of extrapyramidal path conditions. 2 cl, 3 dwg, 1 tbl

Description

 The invention relates to medicine, namely to neurology, and can be used in the diagnosis of extrapyramidal lesions, for example, tractus rubrospinatus, tractus tectospinalis, tractus reticulospinalis, tractus olivospinalis, tractus vestibulospinalis.

 A known method for the study of extrapyramidal pathways, including the electromyographic study of various muscles using needle electrodes, subsequent registration and analysis of the obtained electromyograms. At the same time, according to the electromyogram in the form of resting activity, represented by the interference curve, parkinsonian disorders of the parkinson type are determined. In the presence of tremor, the electromyogram acquires the character of rhythmic groups of interference activity with a frequency of 4-7 per second, spindle-shaped in amplitude. With chorea and myoclonus, outbreaks of short, rapidly breaking off volleys of phase-type activity are observed. In case of athetosis and torsion dystonia, prolonged discharges of electromyography are observed, corresponding to slow strains in the muscles involved in hyperkinesis [Zenkov L. R., Ronkin M. A. Functional diagnosis of nervous diseases. - M .: Medicine, 1991. - p. 610, 528].

The research method of extrapyramidal pathways has the following disadvantages:
- low accuracy and insufficient reliability of the study of extrapyramidal pathways, since the described electromyographic changes are nonspecific and can be observed not only with disorders of the extrapyramidal system, but also with a number of pathological conditions, for example, at various stages of the denervation-reinnervation process occurring at the muscle level ;
- invasiveness due to the study using needle electrodes penetrating the patient’s body.

 Closest to the proposed invention by technical nature and the result (prototype) is a method for studying the functional state of the pyramidal tract, including magnetic stimulation (MS) of the motor cortex, cervical and lumbar spinal cord, subsequent registration of latent periods of motor responses of the tibial muscle (m tibialis anterior) in response to MS of the motor cortex of the brain and lumbar spinal cord, as well as the muscles of the thumb of the hand (m. adductor pollicis b revis) in response to MS of the cervical spinal cord, determination and analysis of the difference in latent periods of motor responses of the tibial muscle in MS of the motor cortex and in MS of the lumbar spinal cord, as well as the difference in latent periods of motor responses of the muscle leading to the thumb, MS of the cervical spinal cord. The study of the difference in the latent periods of motor responses that occur during MS of the motor cortex of the brain, cervical or lumbar spinal cord, allows you to determine the time of the central motor conduction of the impulse at the levels of the cortex - cervical segment and cortex - lumbar segment [Wayne AM, Sadekov R. A., Danilov A.B., Kupershmidt L.A. The use of magnetic stimulation in organic and psychogenic diseases // Journal of Neuropathology and Psychiatry. S.S. Korsakova - 1994. - N 4. - S. 60 - 61].

However, the research method of the pyramidal tract, selected as a prototype, has the following disadvantages:
- the lack of quantitative assessment of the functional state of extrapyramidal pathways, since in the case of MS of the motor cortex of the brain and spinal cord, pyramidal rather than extrapyramidal pathways are violated;
- the inability to establish the localization of damage to the nervous system at the level of extrapyramidal paths, for example, tractus rubrospinatus, tractus tectospinalis, tractus reticulospinalis, tractus olivospinalis, tractus vestibulospinalis, since the described method allows to determine the localization of damage to the nervous system only of the pyramidal tract according to the time of the central motor conduction of the pulse the use of MS of the motor cortex of the brain and spinal cord;
- low accuracy and insufficient reliability, since the study of the functional state of the pyramidal tract in the described way is aimed only at analyzing the difference in latent periods of motor responses of the tibial muscle in MS of the motor cortex of the brain and in MS of the lumbar spinal cord, as well as the difference in latent periods of motor responses of the muscle, adducting thumb, with MS of the motor cortex and with MS of the cervical spinal cord. This does not take into account the distance between the points of implementation of the MS, which has a significant impact on the latent period. For example, in individuals of high and short stature, children and adults with the same latency, the length of the spinal column varies significantly, which is the basis for insufficiently accurate and reliable assessment of the functional state of the pyramidal paths, namely, for hypo- or overdiagnosis;
- the lack of the ability to establish dynamic control of the treatment results and the development of pathological processes in cases of extrapyramidal pathways of various genesis injuries, as well as the lack of the ability to conduct an expert assessment of disability and prognosis of the disease in cases of extrapyramidal pathways, since the functional state of extrapyramidal pathways cannot be estimated using the totality of operations of the described method.

 The essence of the invention lies in the fact that in a method for diagnosing the functional state of extrapyramidal pathways, including MS of the brain and lumbar spinal cord, the subsequent registration of latent periods of motor responses of the tibial muscle, determining the difference in latent periods of motor responses of the tibial muscle in brain MS and lumbar MS spinal cord, produce the MS of the occipital brain, and after determining and analyzing the difference in latent periods of motor responses, more shebertsovoy occipital muscles in MS brain card MC and lumbar spinal cord excitation is set propagation velocity (SRV) for extrapyramidal pathways. Moreover, to reduce the SRV along extrapyramidal paths to 14.3 ± 0.7 m / s or more, a violation of the excitation on the side of lowering this speed is diagnosed.

 In addition, SRV along extrapyramidal paths is established by the ratio of the distance between the points of the MS of the occipital brain and lumbar spinal cord to the difference in latent periods of motor responses of the tibial muscle in the MS of the occipital brain and in the MS of the lumbar spinal cord.

 This method of diagnosing the functional state of extrapyramidal pathways allows us to provide a quantitative assessment of the functional state of extrapyramidal pathways, establishing the localization of nervous system damage at the level of extrapyramidal paths, increased accuracy and reliability, the ability to establish dynamic control of treatment results and the development of pathological processes in cases of extrapyramidal pathways of various genesis, as well as expert assessment of disability and prognosis oia with the defeat of extrapyramidal tracts.

 A quantitative assessment of the functional state of extrapyramidal pathways is achieved by means of the MS of the occipital region of the brain and the subsequent establishment of disturbance of the excitation behavior along extrapyramidal paths on the side of lowering the SRV to 14.3 ± 0.7 m / s or more, which is established by the ratio of the distance between the points of the MS of the occipital region of the head the brain and lumbar spinal cord to the difference in latent periods of motor responses of the tibial muscle in MS of the occipital brain and in MS of the lumbar spinal on the brain.

 The localization of damage to the nervous system at the level of extrapyramidal pathways is carried out to reduce the SRV along extrapyramidal paths to 14.3 ± 0.7 m / s or more with the condition of conducting the MS of the occipital part of the brain. During the implementation of the MS of the occipital region of the brain, subcortical centers are excited, for example, the basal nuclei of the hemispheres, the optic tubercle, the red nucleus, the black substance, the olive kernel, the nuclei of the vestibular nerve, the reticular formation, which are an integral part of the extrapyramidal system and from which extrapyramidal pathways originate e.g. tractus rubrospinatus, tractus tectospinalis, tractus reticulospinalis, tractus olivospinalis, tractus vestibulospinalis.

 The increased accuracy and reliability of the method were established by determining and analyzing the difference in latent periods of motor responses of the tibial muscle in the case of the occipital region of the brain and in the lumbar region of the spinal cord, as well as taking into account the distance between the points of the cerebral region of the occipital region of the brain and lumbar spinal cord taking into account the length of the spinal column of each patient, which is the basis for accurate and reliable determination of SRV by extrapyramidal pathways and diagnosis of the disorder carried out I drive on the extrapyramidal pathways on the side of the speed reduction.

 The possibility of establishing dynamic control of the treatment results and the development of pathological processes in cases of extrapyramidal pathways of various genesis is also carried out by conducting multiple studies of the functional state of extrapyramidal pathways through the MS of the occipital region of the brain and lumbar spinal cord when used for the diagnosis of SRV along extrapyramidal pathways during the development of the disease and tracking changes in these metrics. In this case, SRV indices lower than 14.3 ± 0.7 m / s correspond to disturbance of excitation along extrapyramidal paths, and SRV indices of more than 14.3 ± 0.7 m / s correspond to the absence of disturbance of excitation along extrapyramidal paths.

 An expert assessment of incapacity for work and a disease prognosis are provided on the basis of extrapyramidal SRV indices obtained by using the MS of the occipital brain and lumbar spinal cord, with the establishment of the difference in latent periods of motor responses of the tibial muscle in the MS of the occipital brain and lumbar spinal cord, and also when fixing the distance between the points of the MS.

 The magnitude of SRV along extrapyramidal paths, up to 14.3 ± 0.7 m / s or less, is optimal for diagnosing disturbances in excitation along extrapyramidal pathways based on the experimental characteristics of excitation along extrapyramidal pathways in healthy and sick people, obtained as a result of studies in in accordance with the claimed method (see table in Fig. 4). The value of SRV along extrapyramidal paths, comprising more than 14.3 ± 0.7 m / s, corresponds to a satisfactory functional state of extrapyramidal paths.

 The invention is illustrated in the drawing, where in FIG. 1 depicts a general scheme for studying the functional state of extrapyramidal pathways, which implements a method for diagnosing the functional state of extrapyramidal pathways; in FIG. 2 - scheme for the study of SRV along extrapyramidal paths; in FIG. 3 shows curves of motor responses of the tibial muscle in MS of the occipital region of the brain and lumbar spinal cord in a patient with multiple sclerosis; in FIG. 4 presents a table in which the characteristics of the excitation along extrapyramidal pathways in healthy and sick people are given.

 In FIG. 2 is additionally indicated: S is the distance between the points of the MS of the occipital brain and lumbar spinal cord; T is the difference in latent periods of motor responses of the tibial muscle in MS at the above points. In FIG. 3 is additionally indicated: line 1 - data on the equipment; line 2 - surname, name, patronymic of the patient, number of the medical history, date and time of printing the curves; right field - standard hardware curve characteristic; 01-02 - curves of motor responses of the tibial muscle in MS of the occipital region of the brain 01 - on the right, 02 - on the left; 03-04 - curves of motor responses of the tibial muscle in MS of the lumbar spinal cord: 03 - on the right, 04 - on the left; abscissa axis - time, division value - 10 ms; the ordinate axis is the response amplitude, the division price is 40 μV. In FIG. 4 is additionally indicated: M - arithmetic mean; m is the standard error; n is the number of patients in groups; C - latent period of the motor response of the tibial muscle in MS of the occipital region of the brain; L is the latent period of the motor response of the tibial muscle in MS of the lumbar spinal cord; LP - latent period; SRV - the speed of propagation of excitation along extrapyramidal paths; asterisk — differences in latent period and SRV values in healthy and sick patients are significant, P <0.01 (P - significance of differences with a group of healthy individuals).

 A method for diagnosing the functional state of extrapyramidal pathways is as follows. MS is produced at two points: above the occipital region of the brain and at the level of the lumbar spinal cord in the region of the LII-LIV vertebrae, latent periods of motor responses of the tibial muscle on the right and left are recorded, the distance between the points of the MS of the occipital region of the brain and lumbar spinal cord is recorded . Then, the difference in latent periods of motor responses of the tibial muscle on each side is determined for MS of the occipital region of the brain and lumbar region of the spinal cord. After this, SRV is established along extrapyramidal paths with respect to the distance between the points of the MS of the occipital brain and lumbar spinal cord to the difference in latent periods of motor responses of the tibial muscle in the MS of the occipital brain and lumbar spinal cord. To reduce the SRV along extrapyramidal paths to 14.3 ± 0.7 m / s or more, a disturbance in the excitation is diagnosed on the side of lowering this speed.

 An example of a specific implementation of the method for diagnosing the functional state of extrapyramidal paths.

 The proposed method for diagnosing the functional state of extrapyramidal pathways is implemented using a complex of equipment (see Fig. 1) containing a magnetic stimulator 1, for example, Magstim-200 from Magstim, Great Britain, electromyograph 2, for example, Sapphire 2M from Medelec, Great Britain. For synchronization, the trigger output of the magnetic stimulator 1 is connected to the trigger input of the electromyograph 2. The power level of the output signal of the magnetic stimulator 1 is visualized on its display as a percentage of the maximum possible power. To obtain the motor response of the tibial muscle in MS, a magnetic impulse of 60-100% of the maximum output power of magnetic stimulator 1 is used. Magnetic stimulator 1 is connected to the inductive coil 3, and the electromyograph 2 is connected to the outlet cup electrodes by active 4 and reference 5. The potential difference of the active electrode 4 and a reference electrode 5 is fed to the input of the amplifier of the electromyograph 2. As an inductive coil 3, for example, a high-power coil with a diameter of 90 mm is used, having the following magnet characteristics th field: on the surface of the coil maximum 2.0 T, at a distance of 1 m from the coil 0.2 mT, magnetic pulse rise time of 100 microseconds, the pulse width 1 ms. Active 4 and reference 5 electrodes are filled with electrode gel.

 Above the occipital region of the brain, the center 6 of the axisymmetric placement of the inductive coil 3 is indicated for MS of the brain, and above the lumbar region of the spinal cord, the center 7 of the axisymmetric placement of the same coil 3 for MS of the lumbar spinal cord (the location of the center 7 is shown in dashed line in Fig. 1 ) This dual arrangement of the inductive coil 3 corresponds to the motor responses of the tibial muscles 8 and 9 in the case of MS of the occipital part of the brain and for MS of the lumbar spinal cord. The active electrodes 4 are installed on the skin of the patient's tibia above the motor point of the tibial muscle symmetrically on the right and left lower extremities, the reference electrodes 5 - on the skin of the patient's tibia above the bone protrusion of the tibia, symmetrically on the right and left lower extremities. In addition to the inductive coil 3, electrodes 4 and 5, a surface ground electrode (not shown) is installed on the skin above the patient’s ankle joint.

 Before a diagnostic study of the functional state of the extrapyramidal pathways of the patient, an inductive coil 3 is installed in the center 6 above the occipital part of the brain and the same inductive coil 3 in the center 7 above the lumbar spinal cord in the region of the LII-LIV vertebrae, connecting it in both cases with a magnetic stimulator 1. The active electrodes 4 are placed on the shin above the motor point of the tibial muscle symmetrically on the right and left lower extremities 4, symmetrically on the right and above the bone protrusion of the tibia the left lower extremities - reference electrodes 5 connected to the electromyograph 2, on the skin above the ankle joint - a surface ground electrode.

 During the study of the functional state of extrapyramidal tracts, the patient should be in a calm awake state in a sitting position.

 MS for the patient is performed over the occipital region of the brain and over the lumbar region of the spinal cord in the region of the LII-LIV vertebrae by means of an inductive coil 3 connected to the magnetic stimulator 1. As a result, the MS records the motor responses of the tibial muscle, after placing it on the patient’s lower leg above the motor point of this muscle active electrodes 4 symmetrically on the right and left lower extremities and setting reference electrodes symmetrically on the right and left lower extremities over the bone protrusion of the tibia s 5. Fix the distance between the centers of placement 6 of the inductive coil 3. Determine the difference in latent periods of the motor responses of the 8, 9 tibial muscle from the irritation artifact to the beginning of the negative phase of the recorded response from the motor response curves of this muscle in the occipital region of the brain and lumbar region spinal cord obtained using an electromyograph 2 connected by electrodes 4 and 5 (see Fig. 1, 2, 3). Then, SRV is established along extrapyramidal paths by the ratio of the distance S between the points of the MS of the occipital brain and the lumbar spinal cord, that is, between the centers 6 and 7 of the placement of the inductive coil 3, to the difference in latent periods T of the motor responses 8, 9 of the tibial muscle in case of the occipital MS brain and in MS of the lumbar spinal cord, respectively (see Fig. 2). To reduce the SRV along extrapyramidal paths to 14.3 ± 0.7 m / s or more, a disturbance in the excitation is diagnosed on the side of lowering this speed. The indices of SRV along extrapyramidal paths, comprising more than 14.3 ± 0.7 m / s, correspond to a satisfactory functional state of extrapyramidal paths.

Clinical examples
1. Assessment of the functional state of extrapyramidal pathways is normal.

 In accordance with the claimed method, a group of neurologically healthy patients aged 19 to 29 years was investigated. The research results are presented in the table in figure 4. From the table it follows that the value of SRV along extrapyramidal pathways in healthy patients averaged 38.4 ± 0.7 m / s.

 2. Diagnosis of the functional state of extrapyramidal pathways in pathology.

 Patient K., 29 years old (medical history N 32547). The patient underwent magnetic resonance imaging of the brain and cervical spine (protocol N 995 2/04/98). Conclusion: a magnetic resonance image is characteristic of the presence of foci of demyelination in the substance of the brain and in the cervical spinal cord. Based on clinical data, taking into account the results of an additional study (magnetic resonance imaging, evoked potentials - auditory, visual, somatosensory, magnetic stimulation of the pyramidal tract), the patient was diagnosed with multiple sclerosis, cerebrospinal form of the course, II severity, hypertonic-hypokinetic syndrome .

 The patient was studied extrapyramidal paths by the present method. As a result, the motor response curves of the tibial muscle were recorded, which are presented in Figure 3. As follows from Figure 3, motor responses of the tibial muscle with a latent period of 52.2 ms on the right and 71.4 ms on the left were recorded in the occipital region of the brain. In MS of the lumbar spine, motor responses of the tibial muscle were recorded with a latency of 23.2 ms on the right and 26.1 ms on the left. By the ratio of the distance between the points of the MS (in this case, 500 mm) to the difference in the latent periods of the motor responses of the tibial muscle (29.0 ms on the right and 45.3 ms on the left), SRV was determined in the spinal cord between the stimulation points for each side. On the right, the SRV value is 17.2 m / s, on the left - 11.0 m / s. When comparing the SRV values with the data obtained from neurologically healthy individuals (see Fig. 4), it turned out that the SRV was reduced by 54.6% on the right and 71.7% on the left. In this case, we diagnose a violation of the excitation along extrapyramidal paths on the right and left.

 We studied a group of patients with a predominance of hypertensive-hypokinetic syndrome in the clinical picture. The group consisted of 15 patients with multiple sclerosis (cerebrospinal form, II-III degree of severity) aged 26 to 32 years. The results of the study of patients are presented in the table in figure 4. In the diagnosis of multiple sclerosis, the known criteria were used [Leonovich A.L. Actual issues of neuropathology. - Minsk, Higher School, 1990. - p. 28-39, 88-103; Clinical criteria for the diagnosis and treatment of multiple sclerosis. Guidelines. - Moscow: Ministry of Health, 1991. - p. 6-11]. When processing the material, only undoubted, typical cases of multiple sclerosis were analyzed.

 An analysis of the results showed that the SRV value of the described group of patients was significantly reduced compared with the group of neurologically healthy individuals. Therefore, using the proposed method, it becomes possible to determine the violation of the excitation along extrapyramidal pathways in patients to reduce the SRV along extrapyramidal paths to 14.3 ± 0.7 m / s or more (see Fig. 4).

 Thus, the application of the invention allows to quantitatively determine the functional state of extrapyramidal pathways, to establish the localization of damage to the nervous system at the level of extrapyramidal paths, to increase the accuracy and reliability of the method, to provide the possibility of dynamic monitoring of the results of treatment and development of pathological processes in the defeat of extrapyramidal pathways of various origins, to carry out expert disability assessment and objective prognosis of the disease.

 A method for diagnosing the functional state of extrapyramidal pathways can be used in neurological hospitals, rehabilitation and aftercare departments, specialized departments, such as neurophysiological laboratories, for the study of patients with cerebellar injuries of various origins. The inventive method for diagnosing the functional state of extrapyramidal paths is simple to use and provides a small investment of time for its implementation.

Claims (2)

 1. A method for diagnosing the functional state of extrapyramidal pathways, including magnetic stimulation of the brain and lumbar spinal cord, subsequent registration of latent periods of motor responses of the tibial muscle, determination and analysis of the difference in latent periods of motor responses of the tibial muscle during magnetic stimulation of the brain with magnetic stimulation of the lumbar spinal cord brain, characterized in that they produce magnetic stimulation of the occipital region of the brain, and after defined The differences in the latent periods of the motor responses of the tibial muscle during magnetic stimulation of the occipital brain and during magnetic stimulation of the lumbar spinal cord determine the speed of excitation propagation along extrapyramidal paths, while reducing the speed of excitation propagation along extrapyramidal paths to 14.3 ± 0.7 m / s and more diagnose a violation of the excitation on the side of reducing this speed.  2. The method according to claim 1, characterized in that the speed of excitation propagation along extrapyramidal paths is established by the ratio of the distance between the points of magnetic stimulation of the occipital brain and lumbar spinal cord to the difference in latent periods of the motor departments of the tibial muscle during magnetic stimulation of the occipital brain and with magnetic stimulation of the lumbar spinal cord.

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