title: Implications of ALS focality: rostral-caudal distribution of lower motor neuron loss postmortem.
abstract: BACKGROUND
  Because motor manifestations of ALS begin focally and progress contiguously, the anatomic distribution of underlying lower motor neuron and upper motor neuron degeneration should correlate to onset.
  
  
  OBJECTIVE
  To assess the rostral-caudal distribution of lower motor neuron loss in relation to the region of clinical onset.
  
  
  METHODS
  We evaluated 19 ALS postmortem nervous systems from patients whose motor manifestations had begun in different body regions. In each, we looked at four neuraxis levels: hypoglossal nucleus and cervical, thoracic, and lumbar spinal cord. We used light microscopy and devised a technique of particle counting that indexed lower motor neuron loss.
  
  
  RESULTS
  The average overall loss of lower motor neurons in ALS nervous systems was 55%, and the range of loss had a normal distribution that ranged between 8% and 90%. The distribution of lower motor neuron loss was graded within the nervous system relative to onset (p = 0.02 by analysis of variance). In 14 of the 19 nervous systems, the regional lower motor neuron loss within the nervous systems was graded radially away from the region of onset. In 1, radial degeneration seemed likely but did not meet significance. In 2, radial degeneration was apparent but loss was greatest in a region different than that identified as the region of onset. In the remaining 2, lower motor neuron loss was minimal and not graded (both from patients whose motor manifestations had been predominantly upper motor neuron).
  
  
  CONCLUSIONS
  Lower motor neuron degeneration in ALS is a focal process that advances contiguously, summates over time, and creates graded loss. Stage of degeneration in the nervous system is a function of anatomic location.
authors.affiliation: Neurogenomics Laboratory, Benaroya Research Institute at Virginia Mason, Seattle, WA 98101, USA. jravits@benaroyaresearch.org
authors.forename: John
authors.initials: J
authors.lastname: Ravits
authors.forename: Patrick
authors.initials: P
authors.lastname: Laurie
authors.forename: Yuxin
authors.initials: Y
authors.lastname: Fan
authors.forename: Dan H
authors.initials: DH
authors.lastname: Moore
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000690:Amyotrophic Lateral Sclerosis / Q000473:pathology* / Q000503:physiopathology; D016923:Cell Death / Q000502:physiology; D002574:Cervical Vertebrae; D003933:Diagnosis; D018450:Disease Progression; D005260:Female; D006801:Humans; D007002:Hypoglossal Nerve / Q000473:pathology / Q000503:physiopathology; D008159:Lumbar Vertebrae; D008297:Male; D008526:Medulla Oblongata / Q000473:pathology* / Q000503:physiopathology; D008875:Middle Aged; D009046:Motor Neurons / Q000473:pathology*; D009410:Nerve Degeneration / Q000473:pathology* / Q000503:physiopathology; D013116:Spinal Cord / Q000473:pathology* / Q000503:physiopathology; D013904:Thoracic Vertebrae; D013997:Time Factors