Objective To validate the technique and to establish the reference values of triple stimulation technique(TST)in healthy Chinese adults.Methods One hundred healthy subjects were recruited to undergo TST from April 2010 to February 2011 in both abductor digiti minimi.The TST combines transcranial magnetic stimulation(TMS)of the motor cortex with peripheral collision studies.Three stimuli were given,leading to two collisions.A first magnetic stimulus was applied to the scalp overlying the motor cortex.After a delay,an electric stimulus was applied over the ulnar nerve at the wrist.The delay was chosen so that the action potentials descending from the cortex collided with the antidromic action potentials evoked at the wrist,with the collision site at the wrist and above.After another delay,another electrical stimulus was applied to Erb' s point.This delay was chosen so that ascending antidromic action potentials evoked by wrist stimulation collided at or distal to Erb' s point.At the same time,TST test curves were recorded.The TST test curve was compared with a TST control curve in which the first stimulus was applied to Erb' s point and the other two stimulus sites were the same as the test curve.Control stimuli were thus applied successively to Erb' s point,the wrist,Erb' s point.TST quantifies the number of conducting central motor neurons(expressed by the TST amplitude ratio).The values were compared among genders,age groups,arm length and sides respectively.Results The TST amplitude ratio(TSTteat/TSTcontrol)was 85.0％ ± 6.7％.There were no difference among genders,age groups,arm length and sides respectively.The TST amplitude ratio were 85.0％ ± 2.6％ and 85.0％ ± 8.7％,respectively in subjects with arm length 61-70 cm and 71-80 cm.Conclusion TST could be examined precisely and the normative value could be got.

AIM: To evaluate the efficacy and safety of neurotropin in the treatment of neuropathic pain.METHODS: A systematic literature search was performed in biomedical database including MEDLINE,EMBASE, Cochrane Central Register of Controlled Trials, CBM and CNKI. All studies focused on the clinical controlled trials, especially randomized controlled trials (RCTs) . The outcome measures included efficacy,life quality, cost of the treatment and adverse reactions. Quality assessments of clinical trials were evaluated with Jadad Score. Meta-analysis of included studies was performed with Revman software. RESULTS: Twenty-six clinical trials were included. Jadad Score of 24 trials was less than 3, which indicated the poor quality of the trials. None of the clinical trials evaluated the changes in life quality and cost related to neurotropin treatment.Meta analysis of 11 trials indicated neurotropin was more effective than placebo or blank, and the odds ratio of efficacy was 3.84 [2.68, 5.50] . The combining effect of 6 RCTs showed that neurotropin decreased the pain scores measured by Visual Analog Scale significantly compared with placebo or blank, the weighted mean difference (WMD) was -1.76 [-2.31, -1.21] . The pooled effects of the trials comparing neurotropin with other pain relieving drugs such as earbamazepine or NSAIDs also showed positive effect favored neurotropin.Neurotropin had no more adverse reactions than placebo, carbamazepine or NSAIDs, and the pooled risk difference was -0.01 [-0.04, 0.02] . CONCLUSION: According to present evidence, neurotropin may be effective and safe in the treatment of neuropathic pain. However, the poor quality of the studies decreases the persuasion of the results. Large-scale and well-designed RCTs with enough follow-ups should be carried out to provide further evidence for the use of neurotropin in neuropathie pain.

In this paper, issues of acupuncture using target points and depth of needling were discussed based on the theory of traditional Chinese medicine acupoints and combined with anatomical and neurological research of Western medicine. The theoretical evidence of acupuncture on nerve foramen and ganglion and the reasons for being nonstandard operating on acupoints were analyzed. This study summarized the method of using acupuncture at Xiaguan (ST7), Cuanzhu (BL2), Sibai (ST2) and Jiachengjiang acupoints to align with the spheno-palatine ganglion and additional nerve foramen (supraorbital, infraorbital and mental foramina) to treat primary trigeminal neuralgia. This study adhered to the Standards for Reporting Interventions in Clinical Trials of Acupuncture and helped in development of study standardization for acupuncture processes. The authors hoped that should help in significantly diminishing risk and improving therapeutic efficacy in clinic.

Objective To examine the technique of multiple point stimulation for motor unit number estimation (MUNE) and to establish the normative value range in Chinese.Methods Surface-recorded motor unit action potentials were measured in 80 healthy subjects.The compound muscle action potential (CMAP) amplitude measured by maximum baseline to negative peak was recorded.The stimuli sites included the wrist, 6 cm above the wrist, elbow and 6 cm above the elbow along median nerve and ulnar nerve.Individual motor unit responses were obtained by adjusting location of the stimulate electrode and isolating threshold responses with distinct morphologies.Then, stimulus intensity was increased gradually to detect single motor unit action potentials (SMUPs).SMUPs were recorded three times.Stimulating was increase again to record another SMUPs set.Total of 12 SMUPs were recorded.Repeat the whole procedure for two times.Results MUNE was 230.0±35.7 in abductor pollieis brevis muscle, and 242.5±30.2 in aductor digiti minimi muscle for multiple point stimulation.Test-retest correlation coefficients and coefficients of variation for mean of two MUNE were 0.88-0.91 and 13.20%-15.24%.Conclusions The multiple point stimulation is a useful and replicable method to asses the MUNE.

Objective To evaluate the application of upper trapezins muscle electromyography (EMG) in the diagnosis of lower motor neuron damage in bulbar region in amyotrophic lateral sclerosis (ALS). Methods Standard EMG was recorded over upper trapezius muscle in 100 patients with ALS, 80 patients with cervical spondylotic myelopathy (CSM) and 100 normal controls. In groups of ALS and CSM,EMG was also recorded over sternocleidomastoid, rectus abdominis, first dorsal intercostals muscle and tibialis anterior muscles. Among those CSM patients, 43 patients had operations and the EMG on their trapezius muscle was examined at pre-operation and at 3 months post-operation. The parameters of EMG were analyzed between the groups. Results In ALS patients, spontaneous activity in upper trapezius EMG was detected more frequently in patients with disease duration equal to or less than 8 months than the others (21/30(70%) vs 28/70(40%), X~2=7.56, P=0.004). There was no difference in neurogenic EMG changes including abnormal spontaneous potentials and motor unit action petentials (MUAP) between trapezius and sternocleidomastoid in patients with ALS. Significant differences in MUAP were noted between ALS patients((1086.9±152.6)μV, (17.2±6.5) ms,23.6%±3.4%) and controls ((606.7± 82.7)μV,(11.6±1.8) ms,12. 8%±2.2%;q=9.27, 4.57, 4.12, all P<0.01), and between patients with ALS and patients with CSM ((615.7±90.3) μV,(12.1±2.0) ms,13.5%±2.4%,q=8.32,4. 25, 4. 23, all P < 0. 01). Few spontaneous activities in trapezius EMG were detected in post-operation CSM patients. Conclusion EMG in upper trapezius can assist in assessment of clinical and subclinical involvement of bulbar lower motor neurons in patients with ALS, especially at earlier stage.

Objective To investigate cervical spinal upper motor neuron (UMN) dysfunction in patients with frail arm syndrome (FAS) by physical examination,triple stimulation technique (TST) and pectoralis tendon reflex tests.Methods Sixty-seven FAS patients,coming from Peking University Third Hospital from June 2013 to June 2016,underwent physical examination and routine electrophysiological tests.The pyramid signs,the results of pectoralis tendon reflex and TST were collected to estimate the function of cervical spinal UMN.Results On the time of diagnosis,weakness of bilateral proximal upper limbs was found in 61 patients,while weakness of unilateral proximal upper limb was found in six patients.There were 25 patients with tendon hyperreflexia,20 patients with tendon hyporeflexia and 22 patients with tendon areflexia.All the patients were pectoral muscle tendon hyperreflexia except one.UMN score of cervical region was 2.0 ± 0.5.Lower motor neuron score of cervical region was 2.0 ± O.2.The amplitude ratio of TSTtest/TSTcontrol was 78.31％ ± 6.52％.The latency and amplitude of quantitative detection of pectoralis tendon reflex was (7.80 ± 1.22) ms and (1.23 ± 0.14) mV,respectively.In the follow-up study,the tendon reflexes and the UMN score declined,the amplitude ratio of TSTtest/TSTcontrol decreased,while the lower motor neuron score increased and the latency of quantitative detection of pectoralis tendon reflex remained almost unchanged.Conclusion The results showed that there was cervical spinal UMN dysfunction in patients with FAS,and the pyramid signs were often concealed by muscle atrophy with progression of the disease.

The authors report one case of primary hepatic neuroendocrine carcinoma associated with multiple liver metastases. A patient was a 41-year-old female. In 2010, B-ultrasound examination revealed that there were multiple space-occupying lesions in the liver, and hepatic hemangiomas was considered to be the diagnosis. Then, the patient was followed up regularly. In Aug. 2013, B-ultrasound examination indicated that the hepatic lesions were significantly enlarged. Multi-detector CT scanning and MRI examination were performed, and still the diagnosis of multiple hepatic hemangiomas was suggested. On CT and MRI the lesion presented as a well-circumscribed hypervascular tumor with “fast-in and slow-out” enhancement pattern. On MRI, the lesion was characterized by multiple nodules. Needle biopsy was carried out, and the pathological and immunohistochemical diagnosis was metastatic neuroendocrine tumor. Systemic examination did not find the primary lesion. Therefore, primary hepatic neuroendocrine carcinoma associated with intra- hepatic metastases was diagnosed. The patient was treated with transcatheter arterial chemoembolization. The drugs used were 100 mg Oxaliplatin+one bottle of gelatin sponge particles(300-500μm)+10 ml iodized oil, and micro-pump infusion of 100 mg oxaliplatin(99 mg/h) through catheter was also employed. Clinically, primary hepatic neuroendocrine carcinoma is extremely rare. In combination with the medical literatures, the authors attempt to make a preliminary discussion on the clinical characteristics, differential diagnosis, treatment and prognosis of primary hepatic neuroendocrine carcinoma.

Objective To investigate the clinical and electrophysiological characteristics of upper motor neuron-dominant amyotrophic lateral sclerosis (UMN-D ALS ).Methods The clinical and electrophysiological characteristics were analyzed retrospectively in 76 patients with UMN-D ALS and 19 patients with primary lateral sclerosis (PLS).Electrophysiological study included the examination of median nerve,ulnar nerve,tibial nerve,peroneal nerve and sural nerve except for the electromyogram of bulbar region,cervical region,thoracic region and lumbosacral region.Results The diagnosis in 8 PLS patients were changed to UMN-D ALS after detailed review.In UMN-D ALS patients,there were more females in age group of older than 40 (male:female =1∶1.37) and 32 patients (38.1％) had onset with bulbar dysfunction.UMN-D ALS patients showed electromyograph evidence of denervation at 30 months (median)after onset,and clinical lower motor neuron (LMN) signs 6 months later.Seventy-seven patients (91.6％)developed LMN sign by 4 years from symptom onset.ALS functional rating score-revised changed from 40 ±3 to 32 ±4 in 4 years in U MN-D ALS patients (t =1.83,P ＜ 0.05 ).The amplitude of motor unit action potential (MUAP) on the first interosseus dorsalis was higher (( 1003.7 ± 25.2) μV vs (353.5 ±21.5) μV,t=2.34,P ＜0.05) and the duration of MUAP was longer ((19.8 ±2.3) ms vs (9.6 ±1.3) ms,t =1.85,P ＜0.05 ) in UMN-D ALS patients than in PLS patients.Conclusions UMN-D ALS occurs more in female cases,with more bulbar onset and with faster progression than PLS does.It also presents focal denervation in electromyograph.

Objective To analyze the results of treatment of complicated tibial plateau fractures with open reduction and internal fixation with bilateral plates .Methods 29 elder patients with C type tibial platform fractures underwent internal fixation with bilat-eral plates and bone grafting .Fixation with bilateral plates was performed during operation with dynamic compression plate or 1/3 Tubular steel plate placed medially and the dissection plate or LISS system ones inserted laterally after the underlying separation . Meanwhile ,sufficient bone grafting during operation could effectively support reduction of articular surface .Results All patients were followed up of an average of 13 .8 ± 2 .43 months .According to Rasmussen score standard ,the excellent and good rate was 82 .7% .There was significant difference of TPA and PA between postoperation and postoperation one year later .Conclusion It is a simple and effective method to treat complicated elder tibial platform fractures with bilateral plates .It will improve the effect and re-duce complications significantly to perform sufficient bone grafting intraoperatively ,and make the drainage unobstructed and do the early functional exercises postoperatively .

Objective To explore the possible causes and treatment of nonunion of fractures of diaphysis of radius and ulna. Methods According to different personal conditions and results of X gram, 73 cases of the nonunion fractures of diaphysis of radius and ulna were treated with different internal fixations, autologus spongy bone transplantation, release of scar and interosseous membrane, or local skin flap transposition. All had early functional mobilization of the forearm after operation. Results The patients were followed up for 12 to 29 months. All the cases had bony union, and 64 cases(87.7% ) obtained satisfactory functional rehabilitation. Conclusion The major causes that may lead to the nonunion of the diaphysis of radius and ulna are conditions of local soft tissue, site and severity of the fracture, security of internal fixation, and improper early movement, rather than infection. Proper internal fixation, autologus spongy bone transplantation, and release of scar and interosseous membrane are effective in treatment of the nonunion of the fracture and in the functional rehabilitation of the forearms.