Arq. NeuroPsiquiatr. vol.50 número3

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C L I N I C A L A N D M O R P H O L O G I C A L S T U D Y O F C A L F

E N L A R G E M E N T F O L L O W I N G S - l R A D I C U L O P A T H Y

OSVALDO J. M. NASCIMENTO * — MARCOS R. G. DE FREITAS *

MYRIAN D. HAHN ** — ABELARDO Q. C. ARAÚJO *

S U M M A R Y — Calf enlargement following sciatica is a rare condition. It is reported the

case of a 28-year-old woman who complained of repeated episodes of lower back pain

radiating into the left buttock and foot. One year after the beginning of her symptoms,

she noticed enlargement of her left calf. X - r a y studies disclosed 1 ^ - 9 , disk degeneration.

E M G showed muscle denervation with normal motor conduction velocity. Open biopsies of

the gastrocnemius muscles were performed. T h e left gastrocnemius muscle showed

hyper-trophic type 2 fibers in comparison with the right gastrocnemius. Electron microscopy showed

mildly increased number of mitochondria in these fibers. A satisfactory explanation for

denervation hypertrophy has yet to be provided.

K E Y W O R D S : Muscle hypertrophy, calf enlargement, radiculopathy, muscular biopsy,

electron microscopy.

Estudo clínico e morfológico da hipertrofia de panturrilha no curso de radiculopatia

R E S U M O — A hipertrofia da panturrilha no curso de ciática é raramente observada. É

relatado o caso de uma paciente com 28 anos de idade que apresentou episódios repetidos de

dor lombar irradiada para nádega e pé esquerdos. Um ano após o início dos sintomas, notou

aumento da panturrilha esquerdia. Estudos radiográficos revelaram degeneração do disco de

**L * - S . O exame eletromiográfico mostrou desnervação muscular com velocidade de condução**

5 1

motora normal. Foram realizadas biópsias dos músculos gastrocnêmios. No esquerdo notou-se

hipertrofia das fibras tipo 2, em comparação ao gastrocnêmio direito. A microscopia

ele-trônica revelou aumento do número de mitocôndrias nas fibras hipertrofiadas. Explicação

satisfatória para a hipertrofia muscular na vigência de desnervação ainda não foi definida.

P A L A V R A S - C H A V E : hipertrofia muscular, aumento da panturrilha, radiculopatia,

mi-croscopia eletrônica.

Hypertrophy of the calf associated with sciatica is a rare condition

1 4

_.

Muscle hypertrophy following denervation has been studied in cases of traumatic

lesion of peripheral nerve

7,

chronic spinal atrophies

3,12,16,

postpoliomyelitis

syn-dromes, and polyneuropathies

4,5,15.

Lhermitte and AlbessardS were the first to

report a case of hypertrophy of the calf during the course of sciatica. Lapresle et

al.s, in 1973, described the first muscle biopsy study in a similar case. Other

morphological studies were later performed io,i3 showing hypertrophy of both

fiber types, specially type 1 fibers.

We describe clinical and biopsy findings (light and electron microscopy) in

a patient with calf muscular hypertrophy following a S

x

radiculopathy.

Departments of «Clinicai Medicine (Neurology) and Rathology (Neuropathology), H o s**

-pital Universitário Antonio Pedro, Universidade Federal Fluminense ( U F F ) .

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P A T I E N T A N D M E T H O D

N C S , a 8 2 - y e a r - o l d r i g h t - h a n d e d w o m a n h a d c o m p l a i n e d o f r e p e a t e d e p i s o d e s o f l o w b a c k p a i n r a d i a t i n g i n t o t h e l e f t b u t t o c k a n d f o o t s i n c e F e b r u a r y 1988. O n e y e a r l a t h e r s h e n o t i c e d a s l o w e n l a r g e m e n t o f h e r l e f t calf. P a i n f u l c r a m p s o c c a s i o n a l l y o c u r r e d . N o p r e c e d i n g p h y s i c a l t r a i n i n g w a s r e p o r t e d . F a m i l y h i s t o r y f o r n e u r o m u s c u l a r d i s e a s e w a s n e g a t i v e . T h e n e u r o l o g i c a l e x a m i n a t i o n r e v e a l e d d i m i n i s h e d l e f t p l a n t a r f l e x i o n ( g r a d e 4 / 5 M R C ) a n d e v e r s i o n o f t h e f o o t ( g r a d e 4 / 5 M R C ) o n t h i s s i d e . T h e s t r e n g h t i n o t h e r m u s c l e g r o u p s w a s n o r m a l . T h e a n k l e j e r k w a s a b s e n t o n t h e left. T h e calf o n t h a t s i d e w a s — e n l a r g e d w i t h a c i r c u m -f e r e n c e o -f 4 0 c m ; o n t h e o p p o s i t e1

s i d e c i r c u m f e r e n c e w a s 3 4 c m ( F i g . 1 ) X - r a y s t u d i e s d i s c l o s e d L i - S , d i s k d e g e n e r a t i o n . T h e e l e c t r o m y o g r a m s h o w e d n o r m a l m o t o r c o n d u c t i o n v e l o c i t y , absexice

5 1

o f t h e H r e f l e x l a t e n c y o n t h e l e f t s i d e , p o s i t i v e s h a r p w a v e s a n d f i b r i l l a t i o n i n t h e l e f t g a s t r o c n e m i u s m u s c l e , a n d p o s i t i v e s h a r p w a v e s i n t h e l o w e r l u m b a r l e f t p a r a s p i n a l m u s c l e s . N o p s e u d o m y o t o n i c d i s c h a r g e s w e r e r e g i s t e r e d .

M u s c l e b i o p s i e s o f t h e g a s t r o c n e m i u s m u s c l e w e r e p e r f o r m e d o n b o t h c a l v e s . F o r m a l i n f i x e d a n d p a r a f f i n - e m b e d d e d s p e c i m e n s w e r e s t a i n e d w i t h h a e m a t o x y l i n - e o s i n ( H E ) , G o m o r i t r i c h r o m e , a n d p e r i o d i c a c i d o f S c h i f f ( P A S ) . A s e c o n d s p e c i m e n o f m u s c l e w a s f r o z e n i n l i q u i d n i t r o g e n a n d s t a i n e d f o r m y o f i b r i l l a r a d e n o s i n e t r i p h o s p h a t a s e ( A T P a s e p r e i n c u b a t i o n a t p h 9 . 4 a n d 4 . 6 ) a n d s u c c i n o - d e h y d r o g e n a s e ( S D H ) . A m o d i f i e d G o m o r i t r i c h r o m e a n d H E w e r e a l s o u s e d o n t h e f r o z e n m a t e r i a l . A t h i r d s p e c i m e n w a s p r o c e s s e d f o r e l e c t r o n m i c r o s c o p y .

R E S U L T S

T h e l e f t g a s t r o c n e m i u s m u s c l e s h o w e d g r o u p s o f a t r o p h i e d f i b e r s a n d n o r m a l s i z e d a s weill a s h y p e r t r o p h i e d t y p e 2 f i b e r s , i n c o m p a r i s o n w i t h t h e r i g h t g a s t r o c n e m i u s m u s c l e

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C O M M E N T S

In our patient true hypertrophy of the muscle of one calf developed

pro-gressively following S

x

radiculopathy as described by Lapresle et a l .

6

. There was

hypertrophy of type 2 fibers exclusively with less marked signs indicating

dener-vation. The hypertrophy of the left calf was related to the increased diameter

of type 2 fibers when compared to the fibers of the right side. Previous reports

of muscle biopsy findings in calf hypertrophy after partial nerve lesions

concern-ing Si root revealed enlargement of both fibers type, mainly of type 1

1 0

»

1 4

.

Predominant hypertrophy of type 2 fibers have also been r e p o r t e d

1 1

. The

proximity of atrophic fibers with those with compensatory hypertrophy could

m a k e clear the inequality of muscle fibers s i z e

1 4

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of Bernât and O c h o a

1

only type 2 fibers were hypertrophied. Their patient had a

2 year period of physical exercise. This type 2 fiber hypertrophy could be

un-doutedly regarded as compensatory work-induced i.io. Diversely, our patient had

no exercise program but she mantained her activity.

The electrophysiological examinations have shown a muscular hyperactivity

related to the pseudomyotonic pattern in some cases 6 , 1 0 , and absence in others i.

i i , i 4 as occurs in the present report. Recently Mattle et a l .

9

described two patients

with isolated neurogenic hypertrophy of the trapezius muscle due to accessory

nerve injury and a patient with neurogenic hypertrophy of the anterior tibial

muscle due to chronic radicular lesion of L

4

. E M G in these cases showed dense

continuing spontaneous discharges of complex potentials.

The type 1 fibers hypertrophy observed in some reports have been

inter-preted as compensatory, induced by lesions of synergic muscles and/or muscle

compartments 1

4

. Our findings also suggest that compensatory muscle hypertrophy

of both type could appear in partial denervation

1 , 6 , 1 0 , 1 1 .

The mild increase in

the number of mitochondria could express higher oxydative requirements of type

2 fibers on this chronic active denervation. Further studies are necessary for the

full understanding of muscle hypertrophy in the course of neurogenic lesions.

R E F E R E N C E S

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7 . L h e r m i t t e J . H y p e r t r o p h i e d e s m u s c l e s d e l a j a m b e c o n s é c u t i v e à u n e l é s i o n d u n e r f s c i a t i q u e p a r b a l l e . R e v N e u r o l ( P a r i s ) 1918, 3 3 : 5 6 - 5 8 .

8 . L h e r m i t t e J , A l b e s s a r d M . L ' h y p e r t r o p h i e m u s c u l a i r e d e l'a j a m b e d a n s l a n é v r i t e s c i a t i -q u e . R e v N e u r o l ( P a r i s ) 1932, 8 3 : 7 8 - 9 0 .

9 . M a t t l e H P , H e s s C W , L u d i n H - P , M u m e n t h a l e r M . I s o l a t e d m u s c l e h y p e r t r o p h y a s a s i g n o f r a d i c u l a r o r p e r i p h e r a l n e r v e i n j u r y . J N e u r o l N e u r o s u r g P s y c h i a t r y 1991, 5 4 : 3 2 5 -329.

10. M i e l k e U , R i c k e r K , E m s e r W , B o x l e r K . U n i l a t e r a l c a l f e n l a r g e m e n t f o l l o w i n g S_L

r a d i c u l o p a t h y . M u s c l e N e r v e 1982, 5 : 4 3 4 - 4 3 8 .

11. M o n t a g n a P , M a r t i n e l l i P , R a s i F , C i r i g n o t t a F , G o v o n i E , L u g a r e s i E . M u s c u l a r h y -p e r t r o -p h y a f t e r c h r o n i c r a d i c u l o -p a t h y . A r c h N e u r o l 1984, 4 1 : 3 9 7 - 3 9 8 .

12. P e a r n J H , H u d g s o n P . A n t e r i o r - h o r n c e l l d e g e n e r a t i o n a n d g r o s s c a l f h y p e r t r o p h y w i t h a d o l e s c e n t o n s e t . L a n c e t 1978, 1 : 1 0 5 9 - 1 0 6 1 .

13. R i c k e r K , R o h k a m m R , M o x l e y R T . H y p e r t r o p h y o f t h e calf w i t h S r a d i c u l o p a t h y .

A r c h N e u r o l 1988, 4 5 : 6 6 0 - 6 6 4 . 1

14. S e r r a t r i c e G , P e l l i s s i e r J F , M a r i n i J F , V a l e n t i n - L e c c e s e P . U n c a s d e s c i a t i q u e a v e c h y p e r t r o p h i e d u m o l l e t . R e v N e u r o l ( P a r i s ) 1989, 1 4 5 : 4 7 4 - 4 7 7 .

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16. Y a m a d a M , K a n o M , C h i d a K , F u r u k a w a T , T s u k a g o s h i H . A s y m p t o m a t i c b e n i g n f a m i l i a l s p i n a l m u s c u l a r a t r o p h y w i t h h y p e r t r o p h y o f t h e c a l v e s a n d h i g h c r e a t i n e k i n a s e l e v e l s . J N e u r o l N e u r o s u r g P s y c h i a t r y 1988, 5 1 : 4 5 2 - 4 5 3 .