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Apparent motor neuron disease following the use of pneumatic tools.

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6. Shapiro AK, Shapiro ES, Bruun RD, Sweet RD: Gilles de la
Tourette Syndrome. New York, Raven Press, 1978
7. Ziegler DK. Tourette's syndrome and essential tremor in a septuagenarian. Arch Neurol 39:132, 1982
Apparent Motor Neuron
Disease Following the Use
of Pneumatic Tools
John P. Gallagher, MD," and Murray Sanders, MDT
The report by Alpers and Farmer [ 1] of 2 cases of amyotrophic lateral sclerosis following the use of pneumatic drills
focused interest on the possible role of vibratory tools in
motor neuron disease. From 1972 to 1981 over 1,100 patients with clinically confirmed motor neuron disease sought
treatment at the Sanders Medical Research Foundation.
Complete records were received on all patients. Among
them were 85 male adults whose symptoms had started before the age of 4 5 years. Questionnaires were sent to these 85
men or their survivors asking for information on previous
trauma, prior athletic activities, and whether the subjects had
ever used pneumatic tools. Fifty replies were received.
Among the 50 respondents, 12 (24%) reported having
used an air-driven hammer or drill prior to the onset of their
disease (Table 1).T h e data on the diagnosis and course of the
disease in these 12 men are given in Table 2. In most cases
the initial diagnosis was made by a local neurologist and later
confirmed by specialists at one or more medical centers or
university clinics. Appropriate testing was done in all cases.
All these men exhibited fasciculations of the muscles of the
extremities or trunk, or both, followed by atrophy and weakness of the involved muscle groups. Pyramidal signs preceded
or eventually followed the signs of lower motor neuron disease noted in the involved muscles.
In 7 patients the earliest symptoms were restricted to
the cervical cord, in 3 others the first symptoms were
hemiparetic, and in 2 patients one or both lower extremities
were affected. No patient had bulbar symptoms. In all patients the disease was progressive; it was fatal in 5 . Remarkably for a disease of such severity, some of the men have
survived for rather long periods, i.e., 7, 9, and 14 years.
There seemed to be no clear relation between the degree of
exposure to vibrations from thc air-driven tools and the severity of the disease.
Felmus and colleagues 121 found a history of pneumatic
drill use in 8 of 16 male patients with amyotrophic lateral
sclerosis. Their patients were from a region of extensive oil
exploration where pneumatic drills are commonly used, and
the average age of the patients was 5 1 years. By contrast the
patients reported here were from a broad geographic area,
and all were younger than 45 years of age when the first
symptoms occurred.
Prior observations of the clinical effects of vibration from
heavy air-driven tools have been limited to the well-known
vasospastic condition of the hands, similar to Raynaud's disease, called zibratiotz-induced whztejinger or uhzte band 131. I n
1974 the National Institute of Occupational Safety and
Health concluded that about 2.5 million construction workers and 110,000 underground miners were exposed to vibration from heavy air-driven tools 141. Statistics from the
United States Bureau of Labor numbered the 1974 work
force at about 92 million; assuming that about 6 0 9 of all
workers are men, the incidence of exposure to pneumatic
tools in the male working population is estimated roughly a t
Table 1 Octuputinnd Hzrtoqi and Presenting Symptoms of 12 Men uvth Motor Neuron Dtreusr Dezehptng b t f ~45~ Years of Age
Pneumatic Tool Use
Patient
No.
Age at
Onset (yr)
Occupation
Tool
Years
of Use
Frequency of Use
Presenting Symptoms
Farming/
ranching
Construction
Jackh;unmer
5
Occasional
Paresis, hand
Large drill
1
Occasional
Machine operation
Gasline construction
Construction
Construction
Mining
Construction
Construction
Oil field
drilling
Construction
Road construction
Light hammer
9
Frequent
Paresis, fingers
and arms
Tremors, deltoids
75 ib drill
4
Frequent
Paresis, leg
75 Ib drill
Jackhammer
Drill
Jackhammer
Jackhammer
Jackhammer
< 1
12
10 (!)
8
10 (?)
Frequent
Occasional
Frequent
Occasional
Frequent
Occasional
Paresis,
Paresis,
Paresis,
Paresis,
Paresis,
Paresis,
10 (?I
< 1
Frequent
Frequent
Paresis, arm and leg
Paresis. both arms
~~
1
28
2
10
3
31
4
33
5
6
35
35
7
36
8
10
37
38
42
11
12
42
42
3
Jackhammer
Jackhammer
(?)
4
694 Annals of Neurology Vol 14 No 6 December 1983
hand
hand
hand
arm and leg
both legs
arm and leg
Table 2. Diagnosis and Disease Course in 12 Men with Motor Neuron Disease Developing before 45 Years of Age
Diagnosing Neurologist(s)
Testing
Patient
No.
Initial
Confirming
EMG NCS CSF MG Other
1
2
Local
Medical center
University
Medical center (2)
+
+
+
+
+
+
+
+
3
Medical center
Medical center (3)
+
+
+
+
4
Local (2)
Medical center (2)
+
5
Local (2)
Medical center (2)
6
Local
VAMC
Local
Medical center
Local
Medical center
+
+
+
+
+
7
8
+
+
+
+
+
+
+
-
+
9
Local (2)
Medical center
+
-
+
+
10
Local
Local
+
+
+
11
Local
Medical center (2)
+
+
12
Local
Medical center ( 4 )
+
+
+
+
+
+
+
+
-
EMG = elecrromyography; NCS = nerve conduction studies; CSF
negative; VAMC = Veterans Administration Medical Center.
5%. Among the men whom we identified with motor neuron
disease developing before the age of 45, the incidence of
pneumatic tool use was nearly 25%. The use of heavy airdriven tools appears to be greater among men developing
motor neuron disease at a relatively early age than among
men in the general population.
“1544 Burningtree Rd
Charleston. SC 29412
tknders Medical Research Foundation
-33 SE Third St
Boca Raton, FL 3.3432
References
1. Alpers BJ, Farmer RA: Role of repeated trauma by pneumatic
drill in production of amyotrophic lateral sclerosis. Arch Neurol
Psychiatry 62:178-182, 1049
2. Felmus MT, Patten RM, Swanke L Antecedent events in amyotrophic lateral sclerosis. Neurology (Minneap) 26: 167-1 72, 1976
3 . Taylor W, e t al: Raynaud’s phenomenon in a foundryWisconsin. Morbidity Mortality Weekly Rep 30:5 15-516, 52 1,
1981
4. Wasserman DE, Badger DW, Doyle TE, Margolies L: Industrial
vibration-an overview. J Am Soc for Safety Eng 1938-43,
1974
=
+
Disease Course
Pulmonary function
Death after 5 yr
Progression by
5th yr to paresis,
all extremities,
and bulbar signs
Progressive paresis,
Muscle biopsy
all limbs, by
5th yr
Stable, mild disease
Muscle and spinal
at 5th yr
roentgenography
Rapid deterioration,
death in 7th yr
Pneumoencephalograph y Death after 9 yr
Death after 8 yr
Pneumoencephalography Progressive paresis,
bulbar signs
by 2nd yr
Progressive paresis,
all extremities
after 9 yr
Totally disabled,
after 7 yr
Spinal roentgenography, Death after 5 yr
pulmonary function
Spinal roentgenography, Stable after 14 yr
nerve biopsy, pulmonary function
cerebrospinal fluid studies; MG
=
myelography;
+
= positive;
-
=
Temporal Lobe
Astrocytoma with
Infantiie Spasms
Takashi Mimaki, MD, Jiro Ono, MD,
and Hyakuji Yabuuchi, M D
Infantile spasms, an age-specific convulsive disorder of infancy and early childhood, have seldom been associated with
central nervous system neoplasms. We present the case of a
19-month-old boy with normal prenatal, perinatal, and early
postnatal development who had a tonic seizure at 4 weeks of
age. An initial electroencephalogram (EEG) showed a normal
sleep pattern. Seizures became more frequent despite therapeutic doses of phenobarbital, diazepam, valproic acid, and
acetazolamide.
When the patient was 8 months of age, the seizures
changed to infantile spasms consisting of sudden flexion of
the neck and trunk and forward flexion of the arms. Seizures
occurred several times a day in clusters of several minutes of
repeated spasms. Routine laboratory tests showed normal
Notes and Letters
695
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