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• Re:The article by Zanette et al (2014;14:351-353). T
  Stefano Tamburin MD
  Published on: 5 November 2014
• The article by Zanette et al (2014;14:351-353). T
  Richard J Davenport DM FRCP Edin
  Published on: 25 September 2014

• Published on: 5 November 2014

  Re:The article by Zanette et al (2014;14:351-353). T

  • Stefano Tamburin MD
  • Other Contributors:
    • Giampietro Zanette MD, Francesca Magrinelli MD,

  We thank Dr. Davenport for his interest in our case report [1] and the opportunity to better explain our clinical reasoning. In his e-letter Dr. Davenport argues that there is a discrepancy between the distribution of the pain, which appeared more suggestive of L2 and perhaps a contribution of L1 and L3, and the involvement of L4 root as documented by clinical neurophysiology and neuroimaging. The patient was asked to d...

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  We thank Dr. Davenport for his interest in our case report [1] and the opportunity to better explain our clinical reasoning. In his e-letter Dr. Davenport argues that there is a discrepancy between the distribution of the pain, which appeared more suggestive of L2 and perhaps a contribution of L1 and L3, and the involvement of L4 root as documented by clinical neurophysiology and neuroimaging. The patient was asked to draw the distribution of pain on a body diagram with no suggestion from any of us,[2] and some degree of inaccuracy in drawing pain distribution cannot be completely ruled out. However, the most likely explanation for the discrepancy between the reported pain distribution and the anatomical dermatome charts is the presence of referred pain and central sensitization, two phenomena that are known to contribute to the presence of non-anatomical and/or enlarged distribution of neuropathic pain.[3] A pain duration longer than 2 years, as in our case, strongly supports the view of central sensitization. The second point raised by Dr. Davenport concerns the notion that a depressed knee jerk mainly suggests L3 instead of L4 damage. The knee jerk is mediated by the L3 and L4 roots, and its depression, as in the present case, might be secondary to L4 radiculopathy.[4]

  With best regards, Giampietro Zanette MD, Francesca Magrinelli MD, Stefano Tamburin MD

  References 1. Zanette G, Magrinelli F, Tamburin S. Periodic thigh pain from radicular endometriosis. Pract Neurol 2014;14:351-3. 2. Magrinelli F, Zanette G, Tamburin S. Neuropathic pain: diagnosis and treatment. Pract Neurol 2013;13:292-307. 3. Zanette G, Cacciatori C, Tamburin S. Central sensitization in carpal tunnel syndrome with extraterritorial spread of sensory symptoms. Pain 2010;148:227-36. 4. Mumenthaler M. Neurologic Differential Diagnosis; translated and annotated by Otto Appenzeller, 2nd ed. New York, NY: Thieme Publishing Group. 1992:26-27.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
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• Published on: 25 September 2014

  The article by Zanette et al (2014;14:351-353). T

  • Richard J Davenport DM FRCP Edin, Consultant Neurologist

  I thoroughly enjoyed the article by Zanette et al (2014;14:351-353). The authors are to be congratulated for their skilful history taking skills, specifically the key observation that the pain coincided with menses, suggesting the diagnosis, and thus confirming that a neurology opinion, far from being "the last resort", should have been the "first resort". I am troubled by the distribution of the pain however; the autho...

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  I thoroughly enjoyed the article by Zanette et al (2014;14:351-353). The authors are to be congratulated for their skilful history taking skills, specifically the key observation that the pain coincided with menses, suggesting the diagnosis, and thus confirming that a neurology opinion, far from being "the last resort", should have been the "first resort". I am troubled by the distribution of the pain however; the authors' thesis, elegantly supported by the neurophysiology and exquisite imaging, is that the pain was due to endometriosis affecting the left L4 root. However, the distribution of the pain appears more suggestive of mainly L2, and perhaps a contribution from L1 and L3 - they also mentioned a depressed knee jerk, which is mainly L3. Most of us regard the L4 dermatome as being below the knee and medial. Whilst I do not dispute the diagnosis of endometriosis, I am intrigued by this, and wonder how the authors explain the dermatomal discrepancy?

  With kind regards Richard J Davenport DM FRCP Edin Consultant Neurologist rjd@skull.dcn.ed.ac.uk Voicemail: 0131 537 3590 NHS PRACTICE Department of Clinical Neurosciences Western General Hospital Edinburgh EH4 2XU Secretary telephone: 0131 537 2072 Fax: 0131 537 1132 Royal Infirmary of Edinburgh MOPD 2 51 Little France Crescent Old Dalkeith Road Edinburgh EH16 4SA Secretary telephone: 0131 242 1487 PRIVATE PRACTICE Spire Murrayfield Hospital 122 Costorphine Road EDINBURGH EH12 6UD Telephone: 0131 334 0363 Spire Shawfair Park Hospital 10 Easter Shawfair Edinburgh EH22 1FE Telephone: 0131 654 5600

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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