| Part Ⅰ The bulbocavernosus reflex Characteristics in Multiple System Atrophy Objective:This study was designed to investigate the characteristics of BCR,SSEP in MSA patients,as well as the association with their clinical manifestations,which can help diagnosis of MSA.Methods1.ParticipantsThirty one patients with MSA(27 males and 24 females)were enrolled in the study,from May 2013 to November 2015.The mean age of the MSA group was 54.79±9.19,ranging from 45 to 85.The mean disease duration was 3.07±3.21 years,ranging from 6 months to 15 years.twenty eight patients were diagnosed as MSA-P,and twenty three patients were diagnosed as MSA-C.All the autonomic failure symptoms in MSA patients were recorded.30 healthy participants(14 males and 16females)were recruited as the control group.The mean age of the control group was 57.16±7.25ranging from 31 to 83.The BCR,SSEP tests were used in the two groups,and comparisons of the electrophysiological parameters were analyzed.2.Electrophysiological studyKeypoint EMG/EP system(Dantec Company,Denmark)was used in all the electrophysiological tests.The temperature was kept between 22-24℃ inside the room during the examination and no noise was allowed.The skin temperature was kept above 32℃,and all the subjects were told to be relaxed.1)BCR test:Subjects were examined in the lithotomy position with a ground electrode attached to the ankle.A saddle-shaped surface electrode was attached to the pubic symphysis as a stimulating electrode.A concentric needle electrode was inserted into the left and right bulbocavernosus muscles in turn.The electrode impedance was<5KΩ,and the frequency of the square wave was 1.9pulses/s.The stimulating intensity was 7 times the individual s sensory threshold.The scanning time was 5ms,persistence time was 0.1s,and the bandwidth was 10Hz to 2KHz.20 reflection waves were recorded,and the average value of the latencies and peak to peak amplitudes were calculated.2)SSEP:The stimulating electrodes of SSEP in the same with the BCR.The recordingelectrode was put on Cz-2 and the reference electrode on Fz,stimulating intensity was3 times of sensory threshold,the frequency of the square wave was 5 pulses persecond,analysised by 100 ms.Then the SSEP P4 1 wave was detected.The mainpurpose of this examination is to assess the sensory central conduction of the pudendal nerve.3)Scale assessment:a retrospective review of symptoms of autonomic dysfunction in each group3.data collection1)According to international diagnostic criteria,we should strictly select eligible patients with multiple system atrophy as objects of study.2)The purpose,significance and specific operation methods of this study are explained in detail,so that it can understand the testing process,cooperate with various operations,and sign the informed consent after obtaining the consent.3)The subjects were numbered sequentially,asking for detailed medical history and neurological examination,and keeping records.ResultsThe clinical manifestations of autonomic nervous dysfunction in MSA group included urinary dysfunction,defecation dysfunction and neutral dysfunction in male patients with orthostatic hypotension.Urination disorders and male sexual dysfunction are most common.the latency of BCR in MSA group was significantly longer than that in the control group,the difference was statistically significant.The amplitude of BCR in group MSA was significantly lower than that in control group,and the difference was statistically significant.There was no significant difference in latency of SSEP between MSA group and control groupMSA there was no significant difference in BCR latency,amplitude,abnormal rate and undetected rate between the old and the young group.There was no significant difference between MSA-C subtype and MSA-P subtype in BCR latency,amplitude,abnormal rate and non-extraction rate.The mean BCR latency of MSA patients with duration>2 years was higher than that of MSA patients with duration<2 years,and the mean BCR amplitude of MSA patients with duration>2 years was lower than that of MSA patients with duration<2 years.The BCR abnormal rate and the unextraction rate of MSA patients in the course of>2 were all higher than those of MSA patients whose course of disease was less than 2 years.The abnormal rate of BCR in MSA with urinary dysfunction group was significantly higher than that in non-urinary dysfunction group.The abnormal rate of BCR in MSA with sexual dysfunction group was significantly higher than that in non-sexual dysfunction group.The abnormal rate of BCR in MSA with Defecation disorder group was higher than that in non-dysuria group.The abnormal rate of BCR in MSA with postural hypotension group was higher than that in MSA without Defecation disorder group.The abnormal rate of BCR in MSA patients with orthostatic hypotension was higher than that in patients without orthostatic hypotension,and the difference was not statistically significantThere was significant difference in SSR latency among the three groups(P<0.05).There was no significant difference in SSR latency between MSA-P group and PD group(P>0.05).ConclusionsThe abnormal BCR in MSA patients showed prolonged latency and decreased amplitude.With the prolonged course of disease,the amplitude and latency of SSEP in MSA patients with progressive dysfunction of autonomic nerve were normal.BCR can more sensitively reflect whether MSA patients have voiding dysfunction or male sexual dysfunction.BCR can be used to evaluate autonomic dysfunction in MSA patients of different ages and subtypes.Part II The value of BCR in differential diagnosis of Parkinson’s disease and parkinsonism dominant multiple system atrophyObjective:In this study,the characteristics of autonomic nervous dysfunction,BCR and SSEP in patients with PD and MSA-P were observed,and the value of differential diagnosis was determined.Methods1.ParticipantsA total of 70 outpatients and inpatients in the Department of Neurology of the First Affiliated Hospital of Wenzhou Medical University from May 2013 to October 2016 were collected.Among them,32 cases were Parkinson’s disease(PD)and 38 cases were multiple system atrophy type-P(MSA-P).A total of 30 health examiners were collected from the physical examination center of the First Affiliated Hospital of Wenzhou Medical University.The study was approved by the Ethics Committee of the First Affiliated Hospital of Wenzhou Medical College and all the subjects signed informed consent forms.2.Electrophysiological studyKeypoint EMG/EP system(Dantec Company,Denmark)was used in all the electrophysiological tests.The temperature was kept between 22-24℃ inside the room during the examination and no noise was allowed.The skin temperature was kept above 32℃,and all the subjects were told to be relaxed.1)BCR test:Subjects were examined in the lithotomy position with a ground electrode attached to the ankle.A saddle-shaped surface electrode was attached to the pubic symphysis as a stimulating electrode.A concentric needle electrode was inserted into the left and right bulbocavernosus muscles in turn.The electrode impedance was<5KΩ,and the frequency of the square wave was 1.9pulses/s.The stimulating intensity was 7 times the individual’s sensory threshold.The scanning time was 5ms,persistence time was 0.1s,and the bandwidth was 10Hz to 2KHz.20 reflection waves were recorded,and the average value of the latencies and peak to peak amplitudes were calculated.2)SSEP:The stimulating electrodes of SSEP in the same with the BCR.The recordingelectrode was put on Cz-2 and the reference electrode on Fz,stimulating intensity was3 times of sensory threshold,the frequency of the square wave was 5 pulses persecond,analysised by 100 ms.Then the SSEP P4 1 wave was detected.The mainpurpose of this examination is to assess the sensory central conduction of the pudendal nerve.3)SSR:Keep quiet indoor environment,room temperature 20～25 C,the subjects take supine position,record point skin temperature 32～36 C,ask the subjects to stay awake and relaxed during the inspection process,The stimulation electrode was placed at the median nerve of the wrist.The recording electrode was placed at the center of the hand and foot.The reference electrode was placed at the second interosseous muscle of the dorsum of the hand,about 3 cm from the web of the finger,and the grounding electrode was 15-20 cm above the wrist.Before the start of stimulation,the electrode impedance is checked,and the requirement is less than 5K.The stimulation time was set to 0.1ms at the beginning of 20mA stimulation.Band pass is set to 1-30 Hz,analysis time is set to 5-10 ms,sensitivity is set to 2 mV/cm,continuous stimulation 4 times,each stimulation interval more than 1 minute,given irregular stimulation to avoid habitual effects on the results,measured the average value of the initial incubation period and amplitude,the average value of the incubation period is milliseconds(ms),the unit of amplitude is millivolt.(mV)4)Scale assessment:a retrospective review of symptoms of autonomic dysfunction in each group3.data collection1)According to international diagnostic criteria,we should strictly select eligible patients with multiple system atrophy as objects of study.2)The purpose,significance and specific operation methods of this study are explained in detail,so that it can understand the testing process,cooperate with various operations,and sign the informed consent after obtaining the consent.3)The subjects were numbered sequentially,asking for detailed medical history and neurological examination,and keeping records.Results1.The occurrence rate of autonomic nervous dysfunction in each group1)The clinical manifestations of autonomic nervous dysfunction in PD patients were 14 cases,accounting for 44%of all PD patients.The most prominent symptom is digestive system symptoms,20 cases of stubborn constipation,accounting for 62.5%.Secondly,there were 18 cases of nocturia,56.2%,16 cases of incomplete urination,50%,15 cases of acute urination,15 cases of urinary incontinence,46.9.4%,14 cases of frequent urination,43.8%;25 cases of male sexual dysfunction,29.4%.2)The clinical manifestations of autonomic nervous dysfunction in 29 MSA-P patients accounted for 76.3%of all MSA patients.The most prominent one was male sexual dysfunction in 16 cases,accounting for 94.4%,followed by constipation in 20 cases,accounting for 92.1%of urinary incontinence in 33 cases,accounting for 86.8%,urinary emergencies in 32 cases,accounting for 84.2%,urinary frequency in 29 cases.It accounted for 76.3%,28 cases of urine,73.7%,and 25 cases of nocturnal urine,accounting for 65.8%.Statistical results showed that constipation,urgency,frequency of urination and urinary incontinence,male sexual dysfunction in PD and MSA-P differences were statistically significant.Statistical results showed that constipation,urgency,frequency of urination and urinary incontinence,male sexual dysfunction in PD and MSA-P differences were statistically significant.2.Comparison of BCR and SSEP results in each group1)BCR extraction rate was 95%(30/32)in Parkinson’s disease patients,74%(28/38)in MSA-P patients,and higher in PD group than in MSA-P group.2)The difference of BCR latency among the three groups was statistically significant.The results showed that the latency of MSA-P group was longer than that of PD group(P<0.05)and normal control group(P<0.05).However,there was no significant difference in latency between Parkinson disease group and control group.3)The results showed that the difference of BCR amplitude between the three groups was statistically significant.The amplitude of MSA-P group was significantly lower than that of Parkinson’s disease group(P<0.05).Compared with the healthy control group,the amplitude of the Parkinson’s disease group and MSA-P group decreased(P<0.05).The amplitude of BCR decreased in MSA group>Parkinson’s disease group>healthy control group.4)There was no significant difference in latency and amplitude of SSEP between the three groups.ConclusionsPD does have autonomic neuropathy similar to MSA-P in clinical practice.BCR detection can be used as a reference for differentiating MSA-P from Parkinson’s disease. |
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