Editor, Editors, USER, admin, Bureaucrats, Check users, dev, editor, founder, Interface administrators, member, oversight, Suppressors, Administrators, translator
11,493
edits
Difference between revisions of "1° Clinical case: Hemimasticatory spasm"
1° Clinical case: Hemimasticatory spasm (view source)
Revision as of 17:45, 19 October 2024
, 9 months agono edit summary
m (Gianni moved page 1° Clinical case: Hemimasticatory spasm - en to 1° Clinical case: Hemimasticatory spasm) |
|||
| (8 intermediate revisions by the same user not shown) | |||
| Line 1: | Line 1: | ||
{{ | {{main menu}} | ||
'''Abstract''': This chapter, part of a series on medical diagnostics, focuses on the challenging diagnosis and treatment of "Hemimasticatory Spasm" in Mary Poppins. After enduring ten years of uncertainty and numerous tests across various disciplines, including dentistry and neurology, her case highlights the need for refined diagnostic approaches that integrate mathematical models and advanced neurophysiological understanding. | |||
The narrative emphasizes the limitations of conventional diagnostic frameworks, often hindered by deterministic thinking that fails to capture the nuances of human physiology. The chapter advocates for integrating quantum probability and fuzzy logic into medical diagnostics, proposing a shift toward a more probabilistic interpretation of patient symptoms and test results. This approach reflects the complex nature of many medical conditions and promotes more accurate and individualized patient care. | |||
Mary Poppins' diagnosis was complicated by overlapping symptoms and the unclear boundary between dental and neurological issues. Traditional diagnostic methods fell short, leading to prolonged suffering. The introduction of the "ephaptic transmission" concept—a nuanced understanding of nerve communication—highlights the importance of sophisticated diagnostic tools and models to differentiate similar symptoms caused by different conditions. | |||
The chapter critiques outdated medical paradigms that compartmentalize conditions into narrowly defined categories, often ignoring the broader systemic nature of many disorders. By invoking Thomas Kuhn's theory of scientific revolutions, the text challenges the medical community to reconsider existing models and adopt approaches that address human health complexities. | |||
Moreover, the chapter discusses the role of "fuzzy logic" in diagnostics, allowing for a range of possibilities rather than binary outcomes. This is particularly relevant for neurological disorders, where symptoms can be transient or vary in intensity. | |||
Mary Poppins' journey through the medical system, marked by misdiagnoses and partial treatments, exemplifies the consequences of inadequate diagnostic models. Her eventual correct diagnosis, facilitated by understanding "ephaptic transmission" within her trigeminal system, underscores the potential for improved outcomes with innovative, interdisciplinary approaches. | |||
In conclusion, the chapter calls for a paradigm shift in medical diagnostics. It argues for moving away from mechanical interpretations of diseases like malocclusions to a holistic, system-oriented view incorporating neurophysiology and quantum mechanics. This shift promises better diagnostic accuracy and aligns more closely with the complex reality of human biology, potentially revolutionizing healthcare. | |||
The chapter concludes by emphasizing continuous education and openness to new ideas among medical professionals, suggesting that integrating diverse scientific insights and emerging technologies into clinical practice is crucial for effective treatment. | |||
{{ArtBy| | |||
| autore = Gianni Frisardi | | autore = Gianni Frisardi | ||
| autore2 = Giorgio Cruccu | | autore2 = Giorgio Cruccu | ||
| Line 14: | Line 25: | ||
| autore6 = | | autore6 = | ||
| }} | | }} | ||
==Introduction== | |||
From what has been exposed in the previous chapters from the 'Introduction' to the '[[Logic of medic language]]' chapters, beyond the complexity of the arguments and the vagueness of the verbal language, we found ourselves faced with a dilemma that of the context in which the patient is referred and in these cases for our poor Mary Poppins it seems to dominate the dental context, given the positive assertions reported by the clinical and laboratory tests performed on the patient. | From what has been exposed in the previous chapters from the 'Introduction' to the '[[Logic of medic language]]' chapters, beyond the complexity of the arguments and the vagueness of the verbal language, we found ourselves faced with a dilemma that of the context in which the patient is referred and in these cases for our poor Mary Poppins it seems to dominate the dental context, given the positive assertions reported by the clinical and laboratory tests performed on the patient. | ||
| Line 29: | Line 40: | ||
*A set of {{:F:Im}} sentences, and a <math>n\geq1</math> number of other <math>(\gamma_1,\gamma_2,.....\gamma_n \ )</math> statements they are logically incompatible if, and only if, the union between them <math>\Im\cup\{\gamma_1,\gamma_2.....\gamma_n\}</math> it is inconsistent | *A set of {{:F:Im}} sentences, and a <math>n\geq1</math> number of other <math>(\gamma_1,\gamma_2,.....\gamma_n \ )</math> statements they are logically incompatible if, and only if, the union between them <math>\Im\cup\{\gamma_1,\gamma_2.....\gamma_n\}</math> it is inconsistent | ||
===Significance of the contexts=== | |||
==== The '''dental context''' ==== | |||
Now, for the '''dental context''' we will have the following sentences and assertions to which we give a numerical value to facilitate the treatment and that is <math>\delta_n=[0|1]</math> where <math>\delta_n=0</math> indicates' normality' and <math>\delta_n=1</math> 'abnormality' and therefore positivity of the report: | Now, for the '''dental context''' we will have the following sentences and assertions to which we give a numerical value to facilitate the treatment and that is <math>\delta_n=[0|1]</math> where <math>\delta_n=0</math> indicates' normality' and <math>\delta_n=1</math> 'abnormality' and therefore positivity of the report: | ||
| Line 62: | Line 75: | ||
<math>\Im_n </math> we will have the same rational process:|and it is precisely here that the contexts conflict}} | <math>\Im_n </math> we will have the same rational process:|and it is precisely here that the contexts conflict}} | ||
==== The '''neurological context''' ==== | |||
In the '''neurological context''', therefore, we will have the following sentences and assertions to which we give a numerical value to facilitate the treatment and that is <math>\gamma_n=[0|1]</math> where <math>\gamma_n=0</math> indicates 'normality' and <math>\gamma_n=1</math> 'abnormality' and therefore positivity of the report: | In the '''neurological context''', therefore, we will have the following sentences and assertions to which we give a numerical value to facilitate the treatment and that is <math>\gamma_n=[0|1]</math> where <math>\gamma_n=0</math> indicates 'normality' and <math>\gamma_n=1</math> 'abnormality' and therefore positivity of the report: | ||
| Line 88: | Line 102: | ||
}} | }} | ||
=== Demarcator of coherence <math>\tau</math>=== | |||
The <math>\tau</math> is a representative clinical specific weight, complex to research and fine-tune because it varies from discipline to discipline and for pathologies, essential in order not to make logical assertions collide <math>\Im_o</math> and <math>\Im_n</math> in the diagnostic procedures and essential to initialize the decryption of the logic communication code. Basically it allows you to confirm the consistency of a union <math>\Im\cup\{\delta_1,\delta_2.....\delta_n\}</math> with respect to another <math>\Im\cup\{\gamma_1,\gamma_2.....\gamma_n\}</math> and vice versa, giving greater weight to the severity of the statements and the report in the appropriate context. | The <math>\tau</math> is a representative clinical specific weight, complex to research and fine-tune because it varies from discipline to discipline and for pathologies, essential in order not to make logical assertions collide <math>\Im_o</math> and <math>\Im_n</math> in the diagnostic procedures and essential to initialize the decryption of the logic communication code. Basically it allows you to confirm the consistency of a union <math>\Im\cup\{\delta_1,\delta_2.....\delta_n\}</math> with respect to another <math>\Im\cup\{\gamma_1,\gamma_2.....\gamma_n\}</math> and vice versa, giving greater weight to the severity of the statements and the report in the appropriate context. | ||
| Line 128: | Line 142: | ||
Once we have washed away the myriad of positively reported normative data, which generate conflicts between contexts, thanks to the coherence marker <math>\tau</math> we have a much clearer and more linear picture on which to deepen the analysis of the functionality of the Central Nervous System. Consequently we can concentrate on intercepting the tests necessary to decrypt the machine language code that the SNC sends out converted into verbal language. | Once we have washed away the myriad of positively reported normative data, which generate conflicts between contexts, thanks to the coherence marker <math>\tau</math> we have a much clearer and more linear picture on which to deepen the analysis of the functionality of the Central Nervous System. Consequently we can concentrate on intercepting the tests necessary to decrypt the machine language code that the SNC sends out converted into verbal language. | ||
==Ephaptic transmission== | |||
With a little effort and patience on the part of passionate readers who have followed the entire logical path, sometimes apparently off topic, we have reached a clinical picture in which the code to be decrypted is inherent in neuromotor damage. Consequently, the access keys to the code, the one that figuratively corresponds to the exact decryption algorithm, would correspond to the right choice of the neuromotor damage detector test. | With a little effort and patience on the part of passionate readers who have followed the entire logical path, sometimes apparently off topic, we have reached a clinical picture in which the code to be decrypted is inherent in neuromotor damage. Consequently, the access keys to the code, the one that figuratively corresponds to the exact decryption algorithm, would correspond to the right choice of the neuromotor damage detector test. | ||
| Line 171: | Line 185: | ||
}}</ref> | }}</ref> | ||
===M-wave=== | |||
The right masseter nerve was electrically stimulated in the infratemporal fossa (see clinical procedure chapter: [[Encrypted code: Ephaptic transmission]]) with a technique similar to that described by Macaluso & De Laat (1995).<ref>Macaluso G, De Laat A. [https://pubmed.ncbi.nlm.nih.gov/8773249/ H-reflexes in masseter and temporalis muscle in man. Experimental] Brain Research. 1995;107:315–320. [PubMed] [Google Scholar] [Ref list]</ref> Square cathode pulses (0.1 ms) generated by an electrical stimulator (Neuropack X1, Nihon Kohden Corporation, Tokyo, Japan) were delivered through a Teflon-coated monopolar needle electrode (TECA 902-DMG25, 53534) with a tip non-isolated (diameter 0.36 mm; area 0.28 mm2) inserted 1.5 cm through the skin below the zygomatic arch and anterior to the temporomandibular joint in the infratemporal fossa with electrical shocks of 0.5 - 5 mA, and 0.1 ms. The anode was a surface non-polarizable Ag-AgCl disc electrode (OD 9.0 mm) positioned over the ipsilateral ear lobe. Electrical stimulation of the masseter nerve never produced pain, and the subjects only perceived muscle contraction. The correct position of the stimulation electrodes was monitored throughout the experimental session by checking online the size of the M wave in the masseter muscle. The signals were recorded by placing surface electrodes on the masseter and temporal muscles and filtered at 10-2000Hz and by concentric needle electrodes inserted into the anterior temporal muscle. | The right masseter nerve was electrically stimulated in the infratemporal fossa (see clinical procedure chapter: [[Encrypted code: Ephaptic transmission]]) with a technique similar to that described by Macaluso & De Laat (1995).<ref>Macaluso G, De Laat A. [https://pubmed.ncbi.nlm.nih.gov/8773249/ H-reflexes in masseter and temporalis muscle in man. Experimental] Brain Research. 1995;107:315–320. [PubMed] [Google Scholar] [Ref list]</ref> Square cathode pulses (0.1 ms) generated by an electrical stimulator (Neuropack X1, Nihon Kohden Corporation, Tokyo, Japan) were delivered through a Teflon-coated monopolar needle electrode (TECA 902-DMG25, 53534) with a tip non-isolated (diameter 0.36 mm; area 0.28 mm2) inserted 1.5 cm through the skin below the zygomatic arch and anterior to the temporomandibular joint in the infratemporal fossa with electrical shocks of 0.5 - 5 mA, and 0.1 ms. The anode was a surface non-polarizable Ag-AgCl disc electrode (OD 9.0 mm) positioned over the ipsilateral ear lobe. Electrical stimulation of the masseter nerve never produced pain, and the subjects only perceived muscle contraction. The correct position of the stimulation electrodes was monitored throughout the experimental session by checking online the size of the M wave in the masseter muscle. The signals were recorded by placing surface electrodes on the masseter and temporal muscles and filtered at 10-2000Hz and by concentric needle electrodes inserted into the anterior temporal muscle. | ||
{{Q2|The response in the right masseter was clearly delayed but relatively symmetrical in amplitude between sides. (Fig. 9)}} | {{Q2|The response in the right masseter was clearly delayed but relatively symmetrical in amplitude between sides. (Fig. 9)}} | ||
===<sub>b</sub>Root-MEPs=== | |||
The trigeminal root was stimulated transcrally through high voltage, low impedance through an electrical stimulator (Neuropack X1, Nihon Kohden Corporation, Tokyo, Japan)) with the anode electrode positioned at the apex and the cathode approximately 10 cm laterally from the apex along a line vertex acoustic meatus. The electric field is believed to excite the trigeminal motor nerve fibers via the trancranial route, near their exit from the skull.<ref name="fris1992" /><ref>G Frisardi, P Ravazzani, G Tognola, F Grandori. [https://pubmed.ncbi.nlm.nih.gov/9467995/ Electric versus magnetic transcranial stimulation of the trigeminal system in healthy subjects. Clinical applications in gnathology.] J Oral Rehab.1997 Dec;24(12):920-8.doi: 10.1046/j.1365-2842.1997.00577.x.</ref> Also in this case, the response in the right masseter was markedly delayed (3.5 ms on the right side 2 ms on the left and dispersed. amplitude of the M-wave. | The trigeminal root was stimulated transcrally through high voltage, low impedance through an electrical stimulator (Neuropack X1, Nihon Kohden Corporation, Tokyo, Japan)) with the anode electrode positioned at the apex and the cathode approximately 10 cm laterally from the apex along a line vertex acoustic meatus. The electric field is believed to excite the trigeminal motor nerve fibers via the trancranial route, near their exit from the skull.<ref name="fris1992" /><ref>G Frisardi, P Ravazzani, G Tognola, F Grandori. [https://pubmed.ncbi.nlm.nih.gov/9467995/ Electric versus magnetic transcranial stimulation of the trigeminal system in healthy subjects. Clinical applications in gnathology.] J Oral Rehab.1997 Dec;24(12):920-8.doi: 10.1046/j.1365-2842.1997.00577.x.</ref> Also in this case, the response in the right masseter was markedly delayed (3.5 ms on the right side 2 ms on the left and dispersed. amplitude of the M-wave. | ||
| Line 185: | Line 199: | ||
Having highlighted, through the execution of the <math>M-wave</math> and <math>_bRoot-MEPs</math> test, a delay in the conduction speed of the trigeminal nerve fibers generates the suspicion that it is a focal demyelination. This indicates that the problem is to be referred to the nervous component rather than to the muscular one, therefore, our attention should focus on the type of focal demyelination, extent of damage and presumably localization of the damage. The differential diagnosis at this point focuses on the type and area of the demyelinating damage, for example, if it is a damage exclusively referred to the masseterine motor nerve or the motor nerve of the temporal muscle is also involved, important for treatment with botulinum endotoxin. To resolve this doubt it is necessary to evoke a heteronymous <math>H-wave</math> response from recording on the temporal muscle. | Having highlighted, through the execution of the <math>M-wave</math> and <math>_bRoot-MEPs</math> test, a delay in the conduction speed of the trigeminal nerve fibers generates the suspicion that it is a focal demyelination. This indicates that the problem is to be referred to the nervous component rather than to the muscular one, therefore, our attention should focus on the type of focal demyelination, extent of damage and presumably localization of the damage. The differential diagnosis at this point focuses on the type and area of the demyelinating damage, for example, if it is a damage exclusively referred to the masseterine motor nerve or the motor nerve of the temporal muscle is also involved, important for treatment with botulinum endotoxin. To resolve this doubt it is necessary to evoke a heteronymous <math>H-wave</math> response from recording on the temporal muscle. | ||
===H-wave=== | |||
The arrangement is similar to that previously described with regard to the <math>M-wave</math> with the variant that the temporal muscle is recorded simultaneously with the stimulation of the masseterine nerve in the intratemporal fossa by a bipolar needle electrode. The stimulation must be gradually adapted in order to evoke both a <math>M-wave</math> from the masseter that a heteronymous <math>H-wave</math> from the temporal muscle. | The arrangement is similar to that previously described with regard to the <math>M-wave</math> with the variant that the temporal muscle is recorded simultaneously with the stimulation of the masseterine nerve in the intratemporal fossa by a bipolar needle electrode. The stimulation must be gradually adapted in order to evoke both a <math>M-wave</math> from the masseter that a heteronymous <math>H-wave</math> from the temporal muscle. | ||
| Line 195: | Line 209: | ||
[[File:Hephaptic edited.jpeg|center|thumb|600x600px|'''Figure 10:''' On the left side indicated with EMG the recording of the motor unit discharge on the right masseter at the time of the spasm is shown while on the right below indicated with M-wave we can see two motor potentials evoked by the electrical stimulation in infratemporal fossa recorded on the masseter. With H-wave it is possible to note the recording of the heteronomous H-wave on the temporal ipsilateral to the stimulation.]] | |||
=== Conclusions=== | |||
=== Conclusions === | |||
Following this step by step path we have demonstrated a peripheral motor nerve injury as originally proposed by Kaufman.<ref name="kauf">Kaufman MD. [https://pubmed.ncbi.nlm.nih.gov/7436363/ Masticatory spasm in facial hemiatrophy]. Ann Neurol 1980;7:585-7.</ref> Conduction studies have shown a slowing of conduction in the extracranial course of masticatory nerve fibers without a reduction in the amplitude of <math>M-wave</math> and obviously EMG signs of chronic denervation. The temporal muscle biopsy appeared histologically normal. | Following this step by step path we have demonstrated a peripheral motor nerve injury as originally proposed by Kaufman.<ref name="kauf">Kaufman MD. [https://pubmed.ncbi.nlm.nih.gov/7436363/ Masticatory spasm in facial hemiatrophy]. Ann Neurol 1980;7:585-7.</ref> Conduction studies have shown a slowing of conduction in the extracranial course of masticatory nerve fibers without a reduction in the amplitude of <math>M-wave</math> and obviously EMG signs of chronic denervation. The temporal muscle biopsy appeared histologically normal. | ||