Parameters of Stimulatio nelectroneuromyography in patients with primary hypothyroidism Текст научной статьи по специальности «Клиническая медицина»

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International Journal of Endocrinology

Орипнальж AOOAÏAKeHHq

/Original Researches/

UDC 616.833-06:616.441-008.64 DOI: 10.22141/2224-0721.14.3.2018.136416

I.I. Bilous

Higher State Educational Institution of Ukraine "Bukovinian State Medical University", Chernivtsi, Ukraine

Parameters of stimulation electroneuromyography in patients with primary hypothyroidism

For cite: Miznarodnij endokrinologicnij zurnal. 2018;14(3):224-228. doi: 10.22141/2224-0721.14.3.2018.136416

Abstract. Background. The purpose of the work is to identify the parameters of stimulation electroneuromyography (ENMG) in patients with primary hypothyroidism against the background of autoimmune thyroiditis and postoperative hypothyroidism. Materials and methods. The study involved 56 patients with hypothyroidism as a result of autoimmune thyroiditis and 19 patients with postoperative hypothyroidism. The control group consisted of 20 apparently healthy persons. Fifty seven (76 %) patients received substitution therapy using synthetic derivatives of L-thyroxine, and 18 (24 %) patients had subclinical hypothyroidism. Patients were examined using clinical-neurological and electrophysiological methods. The electroneuromyography was carried out on the computerized software complex M-TEST (DX-systems, Kharkiv, Ukraine). Integrated ENMG examination was conducted using standard program package in a specially equipped laboratory. ENMG helped evaluate the parameters of the maximum amplitude of the motor M-response of the limb muscles, the reduction of which is a diagnostic criterion for axon injury, and determine the nerve conduction velocity by the motor fibers of the distal parts of the limb nerves. Reduction of nerve conduction velocity is observed with demyelination of nerve fibers. Results. In case of autoimmune thyroiditis, the sensory nerves of the lower extremities (superficial peroneal and sural ones) were damaged by the mixed type. Signs of axo-nopathy manifested by a decrease in the action potential amplitude of the superficial peroneal nerve by 32.7 °% (p < 0.05) and the sural one by 27.5 % (p < 0.05) compared with the control group, and there was a reduction of nerve conduction velocity of peroneal nerves by 21.9 % (p < 0.05) indicating a damage to the myelin sheath. Patients with postoperative hypothyroidism had mostly signs of axonopathy as evidenced by a decrease in the action potential amplitude of the superficial peroneal nerve by 27.9 % (p < 0.05). While studying the function of the motor fibers of the peripheral nerves (median, peroneal and tibial), we found that the injury to motor fibers was demyelinating in 78.8 % of cases, in the remaining patients (22.2 %) polyneuropathy was mixed (with signs of injury to the myelin sheath and axons). Damage to the ulnar and tibial nerves was obligate, whereas the signs of median nerve injury were observed in 72.8 % of cases. The demyelination of the fast conducting fibers of the peroneal and tibial nerves manifested as prolongation of residual latency by 31.7 % (p < 0.05) and 31.6 %, respectively (p < 0.05), a decrease in nerve conduction velocity during peroneal nerve test by 21.5 % (p < 0.05) and by 19.4 % at the examination of the tibial nerves. 22.2 % of patients with autoimmune thyroiditis had signs of combined myelin lesion and axonal injury, when, in addition to reducing the nerve conduction velocity by the motor fibers of the tibial and peroneal nerves and some prolongation of the residual latency, there was a reliable decrease in the M-response amplitude by 15.6 and 14.8 %, respectively. The patients with postoperative hypothyroidism had the signs of myelinopathy only. Conclusions. ENMG allowed revealing the demyelinating and mixed nature of motor fiber injury and the axonal nature of the peripheral nerve injury, with more pronounced changes observed in autoimmune thyroiditis than in polyneuropathy against the background of postoperative hypothyroidism.

Keywords: autoimmune thyroiditis; postoperative hypothyroidism; polyneuropathy

© «Ммнародний ендокринолопчний журнал» / «Международный эндокринологический журнал» / «International Journal of Endocrinology» («Miznarodnij endokrinologicnij zurnal»), 2018 © Видавець Заславський О.Ю. / Издатель Заславский А.Ю. / Publisher Zaslavsky O.Yu., 2018

Для кореспонденци: Бшоус I.I., Вищий державний навчальний заклад УкраТни «Буковинський державний медичний ушверситет», пл. Театральна, 2, м. Чершвщ, 58002, УкраТна; е-mail: iryna.bilous2017@gmail.com

For correspondence: I.I. Bilous, State Higher Education Institution of Ukraine "Bukovinian State Medical University'; Teatralna sq., 2, Chernivtsi, 58002, Ukraine; е-mail: iryna.bilous2017@gmail.com

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Introduction

Neurological disorders in patients with pathology of the internal secretion glands are not rare, and problems with the management of such patients often occur [1, 2]. Significant prevalence of combined neuroendocrine pathology in the structure of general morbidity led to the emergence of a new field of modern medicine — neuro-endocrinology, which studies clinical and pathogenetic aspects of neurological complications in endocrine pathology and improvement of treatment methods. Among the pathological states of the nervous system that arise from the imbalance and diseases of the endocrine glands, neurological disorders with hypothyroid conditions of different origin have a special place [3, 4]. This is due to the severity and the incidence of such disorders. In Ukraine and in other countries, there is a significant increase in the incidence of primary hypothyroidism, which brought it to the fore in the structure of endocrine diseases [5]. The increase in the incidence of thyroid pathology is determined by the influence of unfavorable environmental factors, the deterioration of the socio-economic situation in the country, the consequences of the Chornobyl disaster, classifying some regions of Ukraine as those with iodine deficiency.

The most informative method for diagnosing lesions of the peripheral nervous system is electroneuromyog-raphy (ENMG) — the recording of electrical potential oscillations in the skeletal muscles, which allows examining objectively the state of damage to the peripheral neuromotor apparatus. For instance, when using this method, the frequency of detecting peripheral nerves lesions increases to 70—90 % [6—10].

The purpose of the study: to identify the parameters of stimulation electroneuromyography in patients with primary hypothyroidism against the background of autoimmune thyroiditis and postoperative hypothyroidism.

Materials and methods

The study involved 56 patients with hypothyroidism as a result of autoimmune thyroiditis (AIT) and 19 patients with postoperative hypothyroidism. The control group consisted of 20 apparently healthy persons. 58 (76 %) patients received substitution therapy using synthetic derivatives of L-thyroxin, and 18 (24 %) persons had subclinical hypothyroidism. We used clinical-neurological and electrophysiological methods to examine patients. The electroneuromyography was carried out on the computerized software complex M-TEST (DX-systems, Ukraine). Integrated ENMG examination was conducted on electromyograph with standard program package in a specially equipped laboratory. ENMG helped evaluate the parameters of the maximum amplitude of the motor M-response of the limb muscles, the reduction of which is a diagnostic criterion for the axon injury, and determine the nerve conduction velocity (NCV) by the motor fibers of the distal parts of the limb nerves. Reduction of NCV is observed with demyelination of nerve fibers.

Results

Using ENMG methods in the diagnostic complex is quite promising for the earliest possible diagnosis of functional changes in the fibers of the peripheral nervous

OpuriHOAbHi AOCA¡AweHHfl /Original Researches/

system and for the development of adequate treatment methods that would provide sustainable, long-term results in preventing the damage to peripheral nerves. In this regard, early detection of lesions of the peripheral nervous system in primary hypothyroidism is relevant for the treatment and prevention of their further progression.

It is known that the pathogenesis of polyneuropathy is based on the progressive loss of myelin fibers that is on segmental demyelinization and axonal degeneration, which results in impaired nerve fiber conduction. Due to demyelinization, the myelin sheath, which has a small capacity and high resistance, is injured or lost. Thus, when the potential of demyelinated zone decreases, the current density per unit area of the membrane reduces along with the decrease in resistance. According to the ENMG data, already in case of subclinical hypothyroi-dism, a part of the patients has dysfunction of peripheral nerves, which is observed in more than 80 % of cases in clinical hypothyroidism.

There are data on the type of nerve fiber lesions in hypothyroidism: some authors adheres to the version of axonopathy (degeneration of the main cylinder with abnormalities of essential element transport from the axon to the plasma, which leads to irreversible degradation of the distal neuronal region) and myelinopathy (focal changes of myelin sheath without damaging the axon with a decrease in the nerve conduction velocity or a mixed type injury).

We have conducted ENMg to study the function of sensory and motor fibers of the limb nerves in order to identify features of ENMG changes in case of primary hypothyroidism.

All patients underwent ENMG of motor (peroneal, tibial, median) and sensory (peroneal, sural) nerves. The following parameters were evaluated while studying the motor nerves: the amplitude (mV) and the duration of the M-response (ms), the area of the M-response to nerve stimulation at the distal and proximal points, the terminal latency (ms), residual latency (m/s), NCV (m/s). While studying the sensor nerves, we checked the action potential amplitude (^V) and NCV (m/s). To evaluate the parameters of the F-wave of the tibial nerves, the minimum latency (m/s), the mean amplitude (^V), the mean NCV and the chronodispersion (ms) were determined.

The analysis of the ENMG parameters of sensory nerves is shown in Table 1. These findings are indicative of the fact that in case of AIT, the sensory nerves of the lower extremities (superficial peroneal and sural ones) were damaged by the mixed type. Axonopathy manifested by a decrease in the action potential amplitude of the superficial peroneal nerve by 32.7 % (p < 0.05) and the sural one by 27.5 % (p < 0.05) compared with the control group, and there was a reduction of NCV of peroneal nerves by 21.9 % (p < 0.05) indicating a damage to the myelin sheath.

Patients with postoperative hypothyroidism had mostly signs of axonopathy as evidenced by a decrease in action potential amplitude of the superficial peroneal nerve by 27.9 % (p < 0.05). NCV of the sensory fibers did not differ reliably from that of the control group.

Discussion

OpumaAbHi gocAigweHHA /Original Researches/

Table 1. Parameters of stimulation electroneuromyography of sensory fibers in patients

with primary hypothyroidism (М ± m)

Parameters Control group, n = 20 Patients with autoimmune thyroiditis, n = 56 Patients with postoperative hypothyroidism, n = 19

Amplitude (mV), n.peroneus 6.96 ± 0.41 4.68 ± 0.28 (p < 0.05) 5.02 ± 0.35 (p < 0.05)

NCV (m/s), n.peroneus 56.02 ± 0.62 43.76 ± 0.43 (p < 0.05) 47.44 ± 0.57 (p > 0.05)

Amplitude (mV), n.suralis 5.62 ± 0.33 4.08 ± 0.85 (p < 0,05) 5.01 ± 0.22 (p > 0.05)

NCV (m/s), n.suralis 45.61 ± 0.72 36.76 ± 0.57 (p > 0.05) 39.08 ± 0.39 (p > 0.05)

Note: p — the probability compared with control group.

Table 2. Parameters of stimulation electroneuromyography of motor fibers in patients with primary hypothyroidism ^ ± m)

Parameters Control group, n = 20 Patients with autoimmune thyroiditis, n = 56 Patients with postoperative hypothyroidism, n = 19

Amplitude (mV), n.medianus 9.80 ± 0.78 8.77 ± 0.47 (p < 0.05) 9.27 ± 0.52 (p > 0.05)

Amplitude (mV), n.peroneus 9.84 ± 0.81 8.30 ± 0.65 (p < 0.05) 9.18 ± 0.72 (p > 0.05)

Amplitude (mV), n.tibialis 9.62 ± 0.89 8.21 ± 0.53 (p < 0.05) 9.19 ± 0.93 (p > 0.05)

Residual latency (m/s), n.medianus 2.31 ± 0.34 2.42 ± 0.24 (p > 0.05) 2.38 ± 0.45 (p > 0.05)

Residual latency (m/s), n.peroneus 2.61 ± 0.41 3.42 ± 0.21 (p < 0.05) 3.16 ± 0.58 (p > 0.05)

Residual latency (m/s), n.tibialis 2.50 ± 0.52 3.29 ± 0.88 (p < 0.05) 2.89 ± 0.43 (p > 0.05)

NCV (m/s), n.medianus 55.11 ± 0.74 46.62 ± 0.82 (p < 0.05) 48.11 ± 0.31 (p > 0.05)

NCV (m/s), n.peroneus 54.63 ± 0.16 42.81 ± 0.65 (p < 0.05) 44.52 ± 0.94 (p < 0.05)

NCV (m/s), n.tibialis 53.81 ± 0.97 42.32 ± 0.89 (p < 0.05) 46.11 ± 0.72 (p < 0.05)

Note: p — the probability compared with control group.

Thus, in patients with AIT, there was a more significant affection of the sensory nerves of the lower extremities, which combined signs of axonopathy and myelinopathy. In postoperative hypothyroidism, only signs of axonal injury of the superficial peroneal nerve were detected.

While studying the function of motor fibers of the peripheral nerves (median, peroneal and tibial), we found that the injury to motor fibers was demyelina-ting in 78.8 % of cases, in the remaining patients (22.2 %) polyneuropathy was mixed (with signs of injury to the myelin sheath and axons). Damage to the ulnar and tibial nerves was obligate, whereas the signs of median nerve injury were observed in 72.8 % of cases (Table 2).

The demyelination of the fast conducting fibers of the peroneal and tibial nerves manifested as prolongation of the residual latency by 31.7 % (p < 0.05) and 31.6 %, respectively (p < 0.05), as a decrease in NCV by 21.5 % (p < 0.05) when testing peroneal nerves and by 19.4 % at the examination of the tibial nerves.

As to the median nerves, there was a slight decrease in

the amplitude of the distal M-response, an injury of the myelin sheath was evidenced by a statistically false prolongation of the residual latency and a slight decrease in the NCV. 22.2 % of patients with AIT had signs of combined myelin lesion and axonal injury, when, in addition to reduced NCV by the motor fibers of the tibial and peroneal nerves and some prolongation of the residual latency, there was a reliable decrease in the M-response amplitude by 15.6 and 14.8 %, respectively. The patients with postoperative hypothyroidism had signs of myelinopathy only.

Conclusions

ENMG allowed revealing the demyelinating and mixed nature of motor fiber injury and the axonal nature of the peripheral nerve injury, with more pronounced changes observed in AIT than in polyneuropathy against the background of postoperative hypothyroidism.

Conflicts of interests. Author declares no conflicts of interests that might be construed to influence the results or interpretation of their manuscript.

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Оригшальш дoслiджeння /Original Researches/

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6. Radhakrishnan R, Calvin S, Singh JK, Thomas B, Srinivasan

K. Thyroid dysfunction in major psychiatric disorders in a hospital based sample. Indian J Med Res. 2013;138(6):888-893.

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8. Nandi-Munshi D, Taplin CE. Thyroid-related neurological disorders and complications in children. Pediatr Neurol. 2015;52(4):373-82. doi: 10.1016/j.pediatrneurol.2014.12.005.

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Received 03.04.2018 ■

Билоус И.И.

ВГОУ Украины «Буковинский государственный медицинский университет», г. Черновцы, Украина

Показатели стимуляционной электронейромиографии у пациентов с первичным гипотиреозом

Резюме. Цель исследования — выявить электронейро-миографические особенности поражения периферической нервной системы у пациентов с первичным гипотиреозом на фоне аутоиммунного тиреоидита (АИТ) и послеоперационного гипотиреоза путем проведения стимуляционной электронейромиографии (ЭНМГ). Материалы и методы. Обследовано 56 больных гипотиреозом на фоне АИТ и 19 пациентов с послеоперационным гипотиреозом. Контрольную группу составили 20 практически здоровых лиц. Пятьдесят семь (76 %) пациентов получали заместительную терапию синтетическими производными L-тироксина, у 18 (24 %) больных был субклинический гипотиреоз. Проведено комплексное клинико-неврологическое и электрофизиологическое обследование больных, которое включало ЭНМГ-те-стирования моторных (малоберцовые, большеберцовые, срединные) и сенсорных (малоберцовые, икроножные) нервов. При исследовании моторных нервов оценивали следующие показатели: амплитуду и продолжительность М-ответа, площадь М-ответа на стимуляцию нерва в ди-стальной и проксимальной точках, терминальную латен-тность, резидуальную латентность, скорость проведения возбуждения (СПВ), при изучении сенсорных нервов — амплитуду потенциала действия и СПВ. Результаты. При АИТ наблюдалось поражение сенсорных нервов нижних конечностей (поверхностные малоберцовые и икроножные) по смешанному типу. Аксонопатия проявлялась уменьшением амплитуды потенциала действия поверхностного малоберцового нерва на 32,7 % (р < 0,05) и икроножного на 27,5 % (р < 0,05) по сравнению с контрольной группой, также наблюдалось снижение СПВ по малоберцовым нервам на 21,9 % (р < 0,05), что свидетельствует о повреждении миелиновой оболочки. У пациентов с послеоперационным гипотиреозом отмечались преимущественно признаки аксонопатии, о чем свидетельствовало уменьшение амплитуды потенциала действия поверхностного малоберцового нерва на 27,9 %

(р < 0,05). При исследовании функции двигательных волокон периферических нервов (срединный, малоберцовый и большеберцовый) выявлено, что поражение моторных волокон носило демиелинизирующий характер в 78,8 % случаев, у остальных больных (22,2 %) полиней-ропатия была смешанной (с признаками поражения ми-елиновой оболочки и аксонов). Повреждение локтевых и большеберцового нервов было облигатным, в то же время признаки поражения срединного нерва наблюдались в 72,8 % случаев. О демиелинизации быстропроводящих волокон малоберцовых и большеберцовых нервов свидетельствовало повышение резидуальной латентности на 31,7 % (р < 0,05) и 31,6 % соответственно (р < 0,05), снижение СПВ при тестировании малоберцовых нервов на 21,5 % (р < 0,05) и на 19,4 % — при исследовании больше-берцовых нервов. Со стороны срединных нервов отмечалось незначительное снижение амплитуды дистального М-ответа, на поражение миелиновой оболочки указывало статистически недостоверное повышение резиду-альной латентности и незначительное снижение СПВ. У 22,2 % больных с АИТ отмечались признаки сочетан-ного поражения миелиновой оболочки и аксонального повреждения, когда кроме снижения СПВ двигательными волокнами большеберцового и малоберцового нервов на 21,7 и 21,4 % и некоторого удлинения резидуальной латентности наблюдалось достоверное снижение амплитуды М-ответа на 15,6 и 14,8 % соответственно. У пациентов с послеоперационным гипотиреозом отмечались лишь признаки миелинопатии. Выводы. ЭНМГ позволила выявить демиелинизирующий и смешанный характер поражения моторных волокон и аксональный характер поражения сенсорных периферических нервов, причем более выраженные изменения наблюдались при АИТ, чем при полинейропатии на фоне послеоперационного гипотиреоза.

Ключевые слова: аутоиммунный тиреоидит; послеоперационный гипотиреоз; полинейропатия

Opигiнaльнi дocлiджeння /Original Researches/ SH

Блоус I.I.

ВДНЗ Украни «Буковинський державний медичний yHÍBepcmeT», м. 4epHÍBui, Украна

Пoкaзники cтимyляцiйнoï eлeктpoнeйpoмioгpaфiï в na^erniB i3 пepвинним гiпoтиpeoзoм

Резюме. Мета до^дження — виявити електpонейpо-мiогpафiчнi особливостi ypаження пеpифеpичноï Hcp-вовоï системи в пацieнтiв i3 пеpвинним гiпотиpеозом на фонi автоiмyнного тиpеоïдитy (AIT) та пiсляопеpа-цшного гiпотиpеозy шляxом пpоведення стимyляцiйноï електpoнейpомiогpафiï (ЕНМГ). Матерiалu та методы. Обстежено 56 xвоpиx на гiпотиpеоз на фош AIT та 19 па-цieнтiв i3 пiсляопеpацiйним гiпотиpеозом. КОШРОЛЬНУ rpyny становили 20 пpактично здоpовиx осiб. П'ятдесят сiм (76 %) пащенпв отpимyвали замiснy теpапiю синте-тичними поxiдними L-тиpоксинy, y 18 (24 %) xвоpиx був субклшчний гiпотиpеоз. Пpоведено комплексне клшко-невpологiчне та електpофiзiологiчне обстеження xвоpиx, що включало ЕНМГ-тестування мотоpниx (малогомш-ков^ великогомiлковi, сеpединнi) та сенсоpниx (мало-гомiлковi, литковi) неpвiв. Пpи дослщженш мотоpниx неpвiв оцiнювали настyпнi показники: амплиуду та тpи-валiсть М-вщповш, площу М-вiдповiдi на стимyляцiю неpвy в дистальнiй та пpоксимальнiй TO4rax, теpмiналь-ну латентнiсть, pезидyальнy латентшсть, швидкiсть що-ведення збудження (ШПЗ), пpи вивченнi сенсоpниx не-pвiв — амплiтyдy потенцiалy ди та ШПЗ. Результаты. За AIT спостеpiгалось ypаження сенсоpниx неpвiв нижнix кшщвок (повеpxневi малогомiлковi та литковi) за змша-ним типом. Aксонопатiя появлялась y зменшеннi ампль туди потенщалу ди повеpxневого малогом1лкового неpва на 32,7 % (p < 0,05) та литкового на 27,5 % (p < 0,05) по-piвняно з контpольною гpyпою, також вiдмiчали знижен-ня ШПЗ малогомiлковими неpвами на 21,9 % (p < 0,05), що свщчить пpо пошкодження мieлiновоï оболонки. У пацieнтiв iз пiсляопеpацiйним гiпотиpеозом спостеpi-галися пеpеважно ознаки аксонопати, пpо що свщчило зменшення амплiтyди потенцiалy д11 повеpxневого мало-гомiлкового неpва на 27,9 % (p < 0,05). ^и дослщженш

функци pyxовиx волокон пеpифеpичниx неpвiв (сеpе-динний, малогом1лковий та великогомшковий) виявле-но, що ypаження мотоpниx волокон мало демiелiнiзyю-чий xаpактеp y 78,8 % випадыв, y pешти xвоpиx (22,2 %) полiнейpопатiя була змiшаною (з ознаками ypаження мieлiновоï оболонки та аксошв). Пошкодження лштьо-виx та великогомшковж неpвiв було облiгатним, y той же час ознаки ypаження сеpединного неpва спостеpiгалися в 72,8 % випадыв. ^о демieлiнiзацiю швидкопpовiдниx волокон малогомшковж та великогомiлковиx неpвiв свщчило подовження pезидyальноï латентностi на 31,7 % (p < 0,05) та 31,6 % вщповщно (p < 0,05), зниження ШПЗ щи тестуванш малогомiлковиx неpвiв на 21,5 % (p < 0,05) та на 19,4 % — щи дослщженш великогомшковж неpвiв. З боку сеpединниx неpвiв вiдмiчалося незначне зниження амплиуди дистальноï М-вiдповiдi, на ypаження мiелiно-воï оболонки вказувало статистично вipогiдне пщвищен-ня pезидyальноï латентностi та незначне зниження ШПЗ. У 22,2 % xвоpиx з AIT вщ^чалися ознаки поеднаного ypаження мiелiновоï оболонки та аксонального пошкодження, коли ^м зниження ШПЗ pyxовими волокнами великогомшкового та малогомiлкового неpвiв на 21,7 та 21,4 % та деякого пщвищення pезидyальноï латентностi спостеpiгалося вipогiдне зниження амплiтyди М-вiдповiдi на 15,6 та 14,8 % вщповщно. У пащенпв iз пiсляопеpацiй-ним ппотщеозом вiдмiчалися лише ознаки мiелiнопатiï. Висновки. ЕНМГ дозволила виявити демiелiнiзyючий та змiшаний xаpактеp ypаження мотоpниx волокон та аксо-нальний xаpактеp ypаження сенсоpниx пеpифеpичниx не-pвiв, пpичомy б1льш виpаженi змiни спостеpiгалися пpи AIT, нiж пpи полiнейpопатiï на фонi пiсляопеpацiйного гiпотиpеозy.

K™40BÍ слова: автоiмyнний т^ео^и^ пiсляопеpацiй-ний гiпотиpеоз; полiнейpопатiя