Difference between revisions of "Encrypted code: Bilateral Motor Evoked Potentials of trigeminal root"

Encrypted code: Bilateral Motor Evoked Potentials of trigeminal root (view source)

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 [[File:Meningioma 3 by Gianni Frisardi.jpeg|link=link=Special:FilePath/Meningioma_3_by_Gianni_Frisardi.jpg|alt=|left|frameless]]
- In this last chapter referring to the correlation between dental malocclusion and postural disorders we can perceive how the axioms sometimes hastily generated from a limited basic knowledge in the field of trigeminal neurophysiopathology can cause serious damage from a diagnostic point of view. The patient 'Balancer' presented in the previous chapters had been suffering for more than 10 years from a meningioma at the base of the skull which, due to its progressively growing volume, compressed and simultaneously stretched the sensory and motor fibers of the trigeminal system as well as damaging the midbrain centers adjacent to the tumor. The term used by the patient in reporting the disturbance in verbal language, was 'chewing difficulty' but in machine language it should have been decrypted in 'lack of the masticatory stereognosic effect' due to proprioceptive sensory deficit. The absence of the jaw jerk on the right side, in fact, demonstrates the real extent of the damage. The <sub>b</sub>Root-MEPs confirm the organic damage and the latency asymmetry of the electrical silent period concludes the clinical diagnosis. MRI shows the severe neurological complication of brainstem displacement. It should be noted that a meningioma of this size increases in volume until it reaches, as in our case, a diameter of 8 cm, with a ten-year time latency. The question is the following: in the early stages of the volumetric increase where only masticatory-type disturbances reported to dental colleagues were appreciable, would it have been possible to make an electrophysiological diagnosis of organic trigeminal damage? Of course yes, because, perhaps we would not have witnessed an absence of reflexes both in latency and in amplitude but we would certainly have noticed a significant asymmetry and a latency delay of the silent period as well as an initial amplitude anomaly in the <sub>b</sub>Root-MEPs. In conclusion, the correlation between the vestibular and trigeminal system, although present from an anatomical and neurophysiopathological point of view, should not be considered by masticatory rehabilitation clinical procedures because an error in the differential diagnosis is too high and dangerous.
+This detailed summary examines the complex interrelationships between dental malocclusion, postural disorders, and trigeminal neurophysiopathology through the clinical case of a patient known as 'Balancer.' The patient's decade-long suffering from a meningioma at the base of the skull illustrates the challenges and potential misdiagnoses that can occur when traditional dental perspectives are applied without considering deeper neurophysiological issues. The text integrates a broad range of medical insights to argue for a more nuanced approach to diagnosing and treating conditions that straddle neurology and dentistry.
-{{ArtBy|
+Introduction
+The chapter opens by highlighting the limitations of axiomatic assumptions in medical diagnoses, particularly in the complex interplay between dental health and neurological conditions. It introduces the case of 'Balancer,' whose symptoms were initially interpreted within a dental framework but later understood to be indicative of significant neurological pathology.
+Trigeminal Neurophysiopathology and Misdiagnosis
+The narrative delves into the specifics of trigeminal neurophysiopathology, explaining how the patient's meningioma exerted physical effects on both sensory and motor fibers of the trigeminal nerve system, leading to severe symptoms that were initially misinterpreted as dental issues. The discussion underscores the importance of considering neurophysiological data in dental diagnoses, particularly when patients present with atypical or severe symptoms that do not align with common dental disorders.
+Diagnostic Challenges and Electrophysiological Insights
+The summary critically evaluates the diagnostic process, emphasizing the role of electrophysiological tests such as the <sub>b</sub>Root-MEPs and assessments of the jaw jerk reflex. These tests revealed the extent of the damage more accurately than dental evaluations and highlighted the need for medical imaging to confirm the presence and impact of the meningioma.
+MRI Findings and Neurological Complications
+MRI results confirmed the severe implications of the meningioma, showing brainstem displacement and raising urgent questions about the initial stages of the tumor's development. This section reflects on whether earlier detection of the tumor through targeted electrophysiological testing could have altered the patient's treatment trajectory.
+Misleading Symptoms and the Importance of Accurate Diagnosis
+The patient's case is used to illustrate how symptoms like 'chewing difficulty' can be misleading. The narrative argues for a more integrated diagnostic approach that combines dental and neurological expertise to avoid oversimplified conclusions that may lead to inadequate treatments.
+Cognitive Neural Network (CNN) Diagnostic Model
+The use of a Cognitive Neural Network (CNN) in diagnosing 'Balancer's' condition is discussed, showcasing how advanced data analysis techniques can aid in distinguishing between symptoms related to dental malocclusions and those stemming from serious neurological conditions. This section details the sequential steps taken through the CNN to refine the diagnosis and better understand the underlying causes of the patient's symptoms.
+Clinical Implications and Future Directions
+The chapter concludes by discussing the broader clinical implications of the case for both dentistry and neurology. It calls for heightened awareness of the potential for neurological conditions to manifest through symptoms typically associated with dental issues and recommends more interdisciplinary approaches in medical training and practice to prevent similar diagnostic errors.
+Summary
+This summary not only provides a detailed recount of 'Balancer's' medical journey but also serves as a cautionary tale about the risks of compartmentalized medical thinking. It advocates for a holistic approach to patient care that respects the complex interconnections between different bodily systems and emphasizes the critical importance of accurate, comprehensive diagnostic practices in ensuring effective treatment outcomes.<blockquote>
+== Keywords ==
+'''Trigeminal Neurophysiopathology''' - Refers to the study of diseases that affect the trigeminal nerve, highlighting the nerve's role in conveying sensory information from the face to the brain. This term is crucial for medical content discussing neurological impacts on facial sensation and motor functions.
+'''Dental Malocclusion''' - Describes the misalignment of teeth and how they fit together when the jaws are closed. This keyword is key for dental health content, focusing on how teeth alignment affects overall oral health and potentially other bodily functions.
+'''Postural Disorders''' - Pertains to conditions that affect the posture or the way the body is positioned when standing or sitting. This term is particularly relevant in discussions about how spinal and muscular health can be influenced by neurological and dental health.
+'''Meningioma''' - A type of brain tumor that forms from the meninges, the layers of tissue covering the brain and spinal cord. This keyword is critical for content on brain tumors, discussing symptoms, diagnosis, and treatment options.
+'''Electrophysiological Tests''' - Refers to diagnostic tests that measure electrical activity in the body, such as nerve impulses. These tests are crucial in neurology content, especially in diagnosing and understanding the extent of nerve damage.
+'''Jaw Jerk Reflex''' - A reflex that helps diagnose disorders of the trigeminal nerve by tapping the jaw and observing the response. This keyword is relevant for neurological examination content, focusing on reflex testing.
+'''Cognitive Neural Network (CNN) in Diagnosis''' - Discusses the application of advanced data analysis techniques in medical diagnostics, especially for integrating and analyzing patient data for better diagnostic accuracy. This term is significant for content on medical technology and innovations in diagnostics.
+'''MRI Findings in Neurology''' - MRI (Magnetic Resonance Imaging) findings that provide insights into brain and nerve conditions, essential for content related to medical imaging techniques and their applications in diagnosing neurological disorders.
+'''Motor Evoked Potentials (MEPs)''' - A diagnostic measure of the electrical activity in response to stimulation of the motor cortex, used to assess the functionality of motor pathways, particularly relevant for neurophysiological testing content.
+'''Neurological and Dental Integration''' - Focuses on the interdisciplinary approach between neurology and dentistry to tackle complex cases that exhibit symptoms affecting both the neurological and dental systems, crucial for content on comprehensive patient care and diagnostic strategies.</blockquote>{{ArtBy|
 | autore = Gianni Frisardi
 | autore2 = Giorgio Cruccu
@@ Line 18: / Line 60: @@
 <math>CNN=\sum ( </math> [https://pubmed.ncbi.nlm.nih.gov/?term=%27gait+%27&filter=datesearch.y_10&size=200 Gait] (45.300), [https://pubmed.ncbi.nlm.nih.gov/?term=%27gait+AND+motor+evoked+potentials+%27&filter=datesearch.y_10&size=200 motor evoked potentials]  (231),[https://pubmed.ncbi.nlm.nih.gov/?term=%27gait+AND+motor+evoked+potentials+AND+reflex%27&filter=datesearch.y_10&size=200 reflex] (36), [https://pubmed.ncbi.nlm.nih.gov/29696497/ jaw](1) <math>\longrightarrow</math> 'Cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS) with chronic cough and preserved muscle stretch reflexes: evidence for selective sparing of afferent Ia fibres'</blockquote>
-===Diagnostic sequence===
+===Diagnostic sequence ===
-====1st Step: CNN Sequence====
+====1st Step: CNN Sequence ====
-* '''''<math>\tau</math>''' Coherence Demarcator:'' As we have previously described for the other clinical cases, the first step is an initialization command of the Cognitive Neural Network 'CNN' which derives, in fact, from a previous cognitive elaboration on the assertions in the dental and neurological context in which the ' Demarcator of Consistency' gave a prevailing weight. The dental context has already been eliminated from the Consistency Demarcator. From what emerges from the neurological statements, the 'State' of the Trigeminal Nervous System' appears to be strongly damaged. The initialization command will therefore be 'Gait'.
+*'''''<math>\tau</math>''' Coherence Demarcator:'' As we have previously described for the other clinical cases, the first step is an initialization command of the Cognitive Neural Network 'CNN' which derives, in fact, from a previous cognitive elaboration on the assertions in the dental and neurological context in which the ' Demarcator of Consistency' gave a prevailing weight. The dental context has already been eliminated from the Consistency Demarcator. From what emerges from the neurological statements, the 'State' of the Trigeminal Nervous System' appears to be strongly damaged. The initialization command will therefore be 'Gait'.
 * 1st loop open: The first result of the 'CNN' for the keyword '[https://pubmed.ncbi.nlm.nih.gov/?term=%27gait++%27&filter=datesearch.y_10&ac=yes&cauthor_id=None&user_filter=&schema=none&page=1&whatsnew=None&show_snippets=on&format=summary&sort=relevance&sort_order=desc&size=200 Gait]' returns 45,300 results, obviously, too vast to be exhaustive but having ascertained in the context analysis phase a serious trigeminal electrophysiological situation with marked structural anomalies and functional, we can safely enter a correlated key such as ' Motor Evoked Potentials' without specifying the trigeminal district which could encroach on the identified set.
-* 2st loop open: To this second query '[https://pubmed.ncbi.nlm.nih.gov/?term=%27gait+AND+motor+evoked+potentials+%27&filter=datesearch.y_10&size=200 Motor Evoked Potentials]'  the database replies with 231 results that are still too vast as an answer and therefore we are looking for a key more similar to the clinical case presented. Since the most anomalous results in the neurological context have emerged from the latency and amplitude alterations of the trigeminal reflexes, an appropriate access key could be, in fact, 'Reflex' also without specifying 'trigeminal' for the same anticipated reasons.
+*2st loop open: To this second query '[https://pubmed.ncbi.nlm.nih.gov/?term=%27gait+AND+motor+evoked+potentials+%27&filter=datesearch.y_10&size=200 Motor Evoked Potentials]'  the database replies with 231 results that are still too vast as an answer and therefore we are looking for a key more similar to the clinical case presented. Since the most anomalous results in the neurological context have emerged from the latency and amplitude alterations of the trigeminal reflexes, an appropriate access key could be, in fact, 'Reflex' also without specifying 'trigeminal' for the same anticipated reasons.
-* 3st loop open: To the '[https://pubmed.ncbi.nlm.nih.gov/?term=%27gait+AND+motor+evoked+potentials+AND+reflex%27&filter=datesearch.y_10&size=200 Reflex]'request, the response was 36 results which narrowed the field of analysis for the diagnosis of our patient 'Balancer'. Only at this level of the CNN can one attempt to close the loop with a more specific request such as 'Jaw'. In this way we have not lost contact with the whole considered and we have remained in the field of electrophysiology.
+*3st loop open: To the '[https://pubmed.ncbi.nlm.nih.gov/?term=%27gait+AND+motor+evoked+potentials+AND+reflex%27&filter=datesearch.y_10&size=200 Reflex]'request, the response was 36 results which narrowed the field of analysis for the diagnosis of our patient 'Balancer'. Only at this level of the CNN can one attempt to close the loop with a more specific request such as 'Jaw'. In this way we have not lost contact with the whole considered and we have remained in the field of electrophysiology.
-* 4st loop open: The request '[https://pubmed.ncbi.nlm.nih.gov/29696497/ jaw]' in fact in the 36 results it is possible to intercept an article in which some electrophysiological parameters are reported which correspond to a clinical situation of cerebellar ataxia, a pathology in which postural and gait instability is a clinical sign impressive and important.
+*4st loop open: The request '[https://pubmed.ncbi.nlm.nih.gov/29696497/ jaw]' in fact in the 36 results it is possible to intercept an article in which some electrophysiological parameters are reported which correspond to a clinical situation of cerebellar ataxia, a pathology in which postural and gait instability is a clinical sign impressive and important.
 <nowiki/><nowiki/>
-=====2st Step: CNN analysis=====
+=====2st Step: CNN analysis =====
 The 'CNN' loop closure analy of course is based on the terminal article which basically describe five patients with cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS) with chronic cough and lower limb muscle stretch reflexes preserve yourself.<ref name=":0">Jon Infante, Antonio García, Karla M Serrano-Cárdenas, Rocío González-Aguado, José Gazulla, Enrique M de Lucas, José Berciano. Cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS) with chronic cough and preserved muscle stretch reflexes: evidence for selective sparing of afferent Ia fibres.J Neurol . 2018 Jun;265(6):1454-1462. doi: 10.1007/s00415-018-8872-1.Epub 2018 Apr 25.
@@ Line 46: / Line 88: @@
 Jon Infante's article<ref name=":0" /> concludes with a striking statement, i.e. that '''spasmodic cough''' can be an integral part of the clinical picture in CANVAS, anticipating the appearance of postural imbalance by several decades and ''that sparing of muscle spindle afferents (Ia fibers) is probably the pathophysiological basis of normoreflexia.''
- {{Q2|We came to the conclusion that the patient's postural disorder could not be related to the rehabilitative occlusal incongruity but to a neurological damage but the question now is the following:|........is the neurological damage functional or organic?}}
+{{Q2|We came to the conclusion that the patient's postural disorder could not be related to the rehabilitative occlusal incongruity but to a neurological damage but the question now is the following:|........is the neurological damage functional or organic?}}
-===Decryption process===
+=== Decryption process ===
 The diagnostic procedure followed routinely according to the Masticationpedia model has allowed us to eliminate, through the coherence demarcator, the dental context to follow the neurological one and to deepen through the 'Cognitive Neural Network' (CNN) the possible correlations between symptoms and neurophysiological abnormalities in patients with postural and walking disorders due to functional pathologies (labyrinthitis, neuropathies, etc.) from organic ones (tumors, demyelinations, etc.). Now we must try to decrypt the encrypted message of the machine language of the Trigeminal Nervous System.
@@ Line 71: / Line 113: @@
 # Context analysis through dental and neurological laboratory tests
-# Choice of neurological statement filtered by the '''''<math>\tau</math>''''' ''Coherence Demarcator''
+#Choice of neurological statement filtered by the '''''<math>\tau</math>''''' ''Coherence Demarcator''
 # Evaluation of the clinical case in the Cognitive Neural Network (CNN)
-# Closing the CNN loop with Jon Infante's article<ref name=":0" /> and the consideration of the organic/functional damage of our patient's trigeminal sensory-motor structures through the observation of the amplitude asymmetry of the 'bRoot-MEPs'. The logical sequence of the tests carried out with the numbering restored has been ordered in the image gallery.
+#Closing the CNN loop with Jon Infante's article<ref name=":0" /> and the consideration of the organic/functional damage of our patient's trigeminal sensory-motor structures through the observation of the amplitude asymmetry of the 'bRoot-MEPs'. The logical sequence of the tests carried out with the numbering restored has been ordered in the image gallery.
 <Center>
@@ Line 84: / Line 126: @@
 </Center>
-=== Conclusion ===
+===Conclusion===
 We now have evidence of both direct and indirect functional organic correlation between the trigeminal system and the vestibular system, just think of the study of mVEMP (Vestibular Evoked Myogenic Potentials) now recognized as a solid and reliable test for assessing the functional integrity of the reflex pathway vestibulo-masseteric<ref>Sangu Srinivasan Vignesh, Niraj Kumar Singh, Krishna Rajalakshmi. Tone Burst Masseter Vestibular Evoked Myogenic Potentials: Normative Values and Test-Retest Reliability. J Am Acad Audiol. 2021 May;32(5):308-314. doi: 10.1055/s-0041-1728718.Epub 2021 Jun 1.
 </ref> in clinical manifestations with involvement of the trigeminal and vestibular system as in schwannomas<ref>Ashutosh Kumar, Sanjay Behari, Jayesh Sardhara, Prabhaker Mishra, Vivek Singh, Vandan Raiyani, Kamlesh Singh Bhaisora, Arun Kumar Srivastava . Quantitative assessment of brainstem distortion in vestibular schwannoma and its implication in occurrence of hydrocephalus.Br J Neurosurg . 2022 Dec;36(6):686-692. doi: 10.1080/02688697.2022.2047155.Epub 2022 Mar 7.
@@ Line 109: / Line 151: @@
 Needle electromyography (EMG) is the most sensitive electrodiagnostic study for motor axon loss, and low-amplitude motor responses appear with severe injuries. Decrease in motor response amplitude begins around days 2-3 and is complete by day 6. This reflects the fact that neuromuscular junction degeneration precedes axon degeneration and motor responses are dependent on neuromuscular junction transmission.<ref>Ferrante MA. The Assessment and Management of Peripheral Nerve Trauma. Curr Treat Options Neurol. 2018 Jun 01;20(7):25.</ref>
-=== Appendix ===
+===Appendix===