High-frequency unilateral thalamic stimulation in the treatment of essential and parkinsonian tremor

Pharmacologic treatment for essential tremor and the tremor of Parkinson's disease is often inadequate. Stereotaxic surgery, such as thalamotomy, can effectively reduce tremors. We performed a multicenter trial of unilateral high-frequency stimulation of the ventral intermedius nucleus of the thalamus in 29 patients with essential tremor and 24 patients with Parkinson's disease, using a blinded assessment at 3 months after surgery to compare clinical rating of tremor with stimulation ON with stimulation OFF and baseline and a 1-year follow-up. Six patients were not implanted because of lack of intraoperative tremor suppression (2 patients), hemorrhage (2 patients), withdrawal of consent (1 patient), and persistent microthalamotomy effect (1 patient). A significant reduction in both essential and parkinsonian tremor occurred contralaterally with stimulation. Patients reported a significant reduction in disability. Measures of function were significantly improved in patients with essential tremor. Complications related to surgery in implanted patients were few. Stimulation was commonly associated with transient paresthesias. Other adverse effects were mild and well tolerated. Efficacy was not reduced at 1 year. Chronic high-frequency stimulation is safe and highly effective in ameliorating essential and parkinsonian tremor.

[Neurological presentation of non-Hodgkin lymphoma: a diagnostic problem]

In two patients, men aged 69 and 38 years, neurological signs were the first presenting symptoms of systemic non-Hodgkin's lymphoma (NHL). This presentation is uncommon. The patients had focal neurological deficit and elevated serum lactate dehydrogenase (LDH) activity. Neurological manifestations of NHL may be caused by extradural lymphoma or by diffuse leptomeningeal metastasis (meningitis lymphomatosa). A third patient, a woman of 48, had a third form of nervous system involvement, primary cerebral NHL, which is not a metastatic sequel to systemic NHL. Primary neurological presentation of NHL may be difficult to diagnose, particularly in case of prior treatment with corticosteroids.

[Diagnosis of centronuclear myopathy in adults]

INTRODUCTION

Centro-nuclear myopathy is a congenital myopathy characterized by the presence of central nuclei on muscle biopsy. Three clinical forms have been distinguished. Classification depends on the type inherited, age of onset and degree of muscle involvement.

CLINICAL CASE

We describe the case of a female patient in whom the diagnosis of centro-nuclear myopathy was made at the age of 53. The patient had not been studied previously, but was sent to us by the Department of Anaesthesia. The clinical features had first appeared in infancy. There was no family history of this disorder. Apparently this was a sporadic case.

CONCLUSIONS

In the differential diagnosis of adult patients with girdle paresthesias centro-nuclear myopathy should be included. This unusual muscle disorder may be need to be considered if anaesthesia is required.

[The effect of short-term hyperventilation on the concentration of ionized serum calcium]

BACKGROUND AND OBJECTIVE

Paraesthesias and carpopedal spasms on hyperventilation are explained by a reduction in ionised serum calcium (ISC). We tested whether 5-minute hyperventilation changes the concentration of ISC.

SUBJECTS AND METHOD

Arterial blood samples were obtained via a small plastic catheter introduced into the femoral artery of ten healthy male volunteers (mean age 33 years) before, during and after 5 minutes of hyperventilation, which was achieved by deep and rapid breathing and considered adequate when the end-expiratory pCO2 had fallen to 2.5 kPA within the first minute and remained below this level during the remaining 4 minutes. These criteria were met in nine of the ten patients. The ISC concentration was measured with an ion-selective electrode, the pH, paCO2 and bicarbonate levels with an autoanalyser.

RESULTS

Paraesthesias of the fingers and hand occurred in nine of the volunteers, carpopedal spasms in seven. Despite a definite rise in pH from 7.39 +/- 0.02 to 7.75 +/- 0.045, the concentration of ISC did not change significantly during the hyperventilation.

CONCLUSION

Paraesthesias and carpopedal spasms which occur during hyperventilation are not caused by a fall in ionised serum calcium in arterial blood.

Midline mandibular osteotomy: an analysis of functional outcomes

Although the oncologic validity and perioperative complications of midline mandibular osteotomy are well described, little attention has been directed toward the long-term functional problems that may be associated with its use. Thirty-one patients who had undergone this procedure were examined to assess postoperative sensation, temporomandibular joint (TMJ) function, occlusion, and cosmesis. The majority (27 of 31) patients had some sequelae but these were minor in nature. Twenty of 31 patients had abnormal sensation, 24 of 31 noted a changed occlusion, and 15 of 31 had signs or symptoms of TMJ myofascial pain. Although patients should be advised of the potential for functional problems with this procedure, they can be reassured that these are likely to be relatively minor in significance. If technically feasible and if an exact restoration of occlusion is a priority, a prefabricated lingual splint should be used.

Infection-related mental and inferior alveolar nerve paresthesia: literature review and presentation of two cases

A review of the literature on infection-related mental and inferior alveolar nerve paresthesia is given. This is followed by 2 case reports. The first case is of a mandibular left second molar in which a chloropercha overfill puff occurred in the vicinity of the inferior alveolar canal. The tooth remained asymptomatic until 2 and 1/2 yr later, when the periapical lesion enlarged and swelling, pain, and paresthesia developed. The paresthesia resolved 2 weeks following periapical surgery. The second case is of a mandibular right first premolar in which paresthesia began 1 day after the initial endodontic treatment. The intracanal medication was formocresol on a cotton pellet that was squeezed dry. The paresthesia was treated by irrigation, antibiotics, and dexamethasone. The paresthesia lasted 7 weeks, and when it resolved the root canal was filled with gutta-percha/eucapercha. Almost 9 months later, the tooth remained asymptomatic.

Influence of local vibration on finger functions of forest workers

We physically examined of forest workers in the northern part of Fukushima District, Japan. The main purpose of this study was to survey the state of finger functions, especially the differences between the functions of right and left fingers of forest workers. This physical examination was conducted in winter. The items of the physical examination were hand grip strength, finger skin temperature, vibration sensation threshold, nail pressure test of the finger. Subjects were classified into A and B groups on the base of the results of the physical examination. A group is normal or slight disorder, and B group is disorder or illness. Hand grip strength was measured five times at five-second intervals. The decrease ratio of the left hand grip strength was greater than that of the right hand grip strength. Although there were significant differences among each finger of A and B groups, there were no big differences in the skin temperatures of the fingers in each group. Vibration sensation threshold was measured for II, III and IV fingers. The vibration sensation threshold of the index finger was the most sensitive and that of IV finger was the least sensitive. The vibration sensation threshold of the right fingers was more sensitive than that of the left fingers. The reaction times of the nail pressure test of the right fingers were generally faster than those of the left fingers. Forestry workers in Japan become elderly. There are big differences among the physical reactions or strengths of elderly people. Standard values for the measuring items for ageing are needed.

[Quantitative determination of the function of thin nerve fibers]

Quantitative assessment of thermal and pain sensitivity (Marstock method on a SOMEDIC Thermotest, Somedic AB Stockholm, Schweden) was made and the function of autonomic nervous system (sympathetic skin response and R-R interval variation) indicating the function of small nerve fibres (A-delta and C) was determined in 44 patients with symptoms of the presumed sensory neuropathy. The function of the large nerve fibres was evaluated by the classic nerve conduction study. The methods of small nerve fibres evaluation exhibited greater sensitivity as the classic nerve conduction study. The dysfunction of small nerve fibre function was morphologically proved by sural nerve biopsy.

Adventitial cystic disease of the popliteal artery: percutaneous US-guided aspiration

PURPOSE

To evaluate percutaneous ultrasound (US)-guided aspiration as an alternative therapy for adventitial cystic disease.

MATERIALS AND METHODS

Between September 1993 and June 1996, seven patients (six men, one woman; age range, 42-62 years; mean age, 48 years) presented with symptomatic adventitial cystic disease of the popliteal artery (one patient with subacute foot paresthesia, six patients with chronic calf claudication). Color Doppler sonography showed stenosis due to eccentric cysts. Five of the patients also underwent digital subtraction angiography, and four patients underwent magnetic resonance imaging. With real-time sonographic guidance, a 14-gauge needle was forwarded percutaneously into the cysts for aspiration. The aspiration procedure was performed on an outpatient basis with local anesthetics.

RESULTS

The procedure was technically and clinically successful in all cases. No complications were noted. Follow-up color duplex sonography performed between 1 and 32 months (mean, 14.8 months) after the procedure showed no relevant recurrent stenosis.

CONCLUSION

Percutaneous US-guided aspiration is an easy, safe, efficacious method for treating adventitial cystic disease. In symptomatic patients who do not have thrombotic occlusion, it may be considered the treatment of choice.

Reverse pedicled lateral arm flap for reconstruction of posterior soft-tissue defects of the elbow

Posterior soft-tissue defects of the elbow are difficult to reconstruct by conventional techniques such as closure by approximation or skin graft. An ideal technique should be an easy and reliable one-stage procedure that provides predictable surgical results with regard to elbow function and cosmesis. This report details our experience in 7 patients who underwent a one-stage procedure for coverage of the posterior elbow employing the reverse pedicled lateral arm flap. All flaps survived and all patients were able to resume full range of motion of the elbow joint at the 6-month follow-up. Complications included forearm paraesthesia in 3 patients and conspicuous scarring in a young female patient. We emphasize two valuable refinements in surgical technique including measuring posterior elbow defect in full flexion and postoperative elbow extension splinting. In trauma-related defects of the posterior elbow, a preoperative angiogram is important before raising this flap.

Mental nerve neuropathy as a result of hepatitis B vaccination

We describe a 20-year-old woman who presented with polyarthralgia and sensory neuropathy, including mental nerve neuropathy. The symptoms were attributed to hepatitis B vaccination. This unusual cause of mental nerve neuropathy has not been previously described. However, as the use of hepatitis B vaccination is growing, adverse side effects, including mental nerve neuropathy, should be observed with an increased frequency.

Local symptoms after open carpal tunnel release. A randomized prospective trial of two incisions

We report a randomized trial of two skin incisions for carpal tunnel decompression, namely a standard incision and an ulnar L incision. We looked particularly at the resolution of local symptoms namely pillar pain and scar sensitivity. There were 47 patients in the trial. No difference was found in pillar pain between the two incisions, but one had a lower incidence of scar sensitivity. These results give a baseline for comparison of local postoperative symptoms following open release with those following endoscopic release.

Protection of the lingual nerve during operations on the mandibular third molar: a simple method

The object of the study was to assess the incidence of lingual nerve sensory loss during removal of impacted mandibular third molar teeth, and the effect of retention of the lingual plate on the incidence. The subjects were 395 patients, of whom 362 completed the study. Removal of 504 impacted wisdom teeth with retention of the lingual plate was performed. Results showed that 381 (76%) of the teeth were partially erupted and the remaining 123 were unerupted. In 497 (99%) bone had to be removed, and of these 376 (76%) required division of the tooth before removal (75% of the entire series). The only complication was transient paraesthesia in one patient which settled within a month. The study concludes that retention of the lingual plate gives optimum protection to the lingual nerve during removal of impacted wisdom teeth.

Dorsal root entry zone lesion performed with Nd:YAG laser

Thermocoagulation of the dorsal root entry zone (DREZ) is the current surgical management of deafferentation pain syndromes. It is usually performed with the assistance of specially designed lesion generators. We report a patient who underwent a DREZ lesion with a Nd:YAG laser as an alternative to standard thermocoagulation technique. A 62-year-old woman with a 5-year history of bilateral dysaesthetic (burning) type of leg pain, after a crush fracture of the fourth thoracic vertebra and complete cord transection, was managed by inducing a bilateral dorsal root entry zone lesion at T2-T5 myelotomes using a Nd:YAG laser, which was used as an alternative to the conventional electrically generated thermocoagulation. A significant reduction of deafferentation type of pain was achieved.

Randomised double-blind placebo-controlled study on adverse effects of rubella immunisation in seronegative women

BACKGROUND

The objective of our study was to investigate the association of adverse clinical musculoskeletal and neurological events in healthy postpartum women with live attenuated (RA27/3 strain) rubella-virus vaccine, and to assess the frequency of acute and recurrent arthralgia and arthritis and associations with acute and recurrent muscle pain (myalgia) and neurological manifestations (paraesthesias).

METHODS

We used a randomised placebo-controlled, double-blind design in a community setting. 636 women were enrolled and, after 90 women dropped out, 546 healthy women aged 18-41 years, who were rubella seronegative on routine screening were immunised parenterally with either monovalent live attenuated (RA27/3 strain) rubella vaccine (n = 270) or saline placebo (n = 276) in the postpartum period. Outcome measures were the occurrence of acute and persistent or recurrent joint manifestations (arthralgia or arthritis) at 1, 3, 6, 9, and 12 months after immunisation. Occurrence of muscle pain (myalgia), and neurological symptoms (paraesthesia) was also assessed at the same times.

FINDINGS

543 women completed 1-month follow-up. 456 women completed the 12-month assessment. There were no differences at the time of immunisation between rubella vaccine and placebo groups in distribution of age, ethnic origin, parity, time between delivery and immunisation, breastfeeding history, or histories of earlier rubella vaccination or joint complaints. Results indicated a significantly higher incidence (p = 0.006; odds ratio = 1.73 [95% CI = 1.17-2.57]) of acute joint manifestations in rubella-vaccine recipients (30%) than in placebo recipients (20%). Frequency of chronic (recurrent) arthralgia or arthritis was only marginally significant (p = 0.042; 1.58 [1.01-2.45]).

INTERPRETATION

RA27/3 rubella vaccine given to seronegative women during the postpartum period was significantly associated with development of acute arthralgia or arthritis. Although the numbers of women assessed and length of follow-up revealed only marginally significant differences in persistent or recurrent joint manifestations between rubella vaccine and placebo recipients, it is possible that susceptible women who are given rubella vaccination may experience this outcome.

Early excision of heterotopic ossification about the elbow followed by radiation therapy

We reviewed the results, in eight patients, of excision of heterotopic ossification about the elbow performed three to ten months (average, seven months) after the initial injury and followed by radiation therapy to prevent recurrence. The etiology of the heterotopic ossification included a neurological (head or spinal cord) injury in five patients and a local injury (fracture or fracture-dislocation) of the elbow in three patients. The average preoperative arc of motion of the three joints that were capable of motion was 12 degrees (5, 10, and 20 degrees); the remaining five joints were fixed in an average of 56 degrees (range, 10 to 90 degrees) of flexion. All of the patients received a total dose of radiation of 1000 centigray, divided into five fractions. The radiation therapy was instituted on the first postoperative day, and at least three of the remaining four treatments were administered on consecutive days. Radiation therapy was not performed on the weekend, so the five fractions were administered over the course of seven days. At an average of forty-six months (range, twenty-five to seventy-two months), the arc of motion averaged 103 degrees, which compared favorably with the 121-degree arc of motion that had been attained intraoperatively. Two patients who had residual motor deficits in the involved extremity had an arc of motion of 50 and 70 degrees at the latest follow-up evaluation; those who had normal motor function fared considerably better, averaging 118 degrees of motion. There was no substantial recurrence of ossification either radiographically or that limited motion, and no complications attributable to the radiation therapy were noted. On the basis of this experience, it seems that the generally recommended twelve to eighteen-month delay between injury and excision, to allow for maturation of heterotopic bone and thus to lessen the likelihood of recurrence, may be eliminated. Additional studies are needed to define the relative risk of recurrence in the various clinical settings in which heterotopic ossification is seen and to determine whether radiation therapy is necessary to prevent recurrence after early excision in each of these instances.

Lumbar disk disease in pregnancy

BACKGROUND

Lumbar disk herniation is rare in pregnancy. We report on three pregnant women with this disorder seen over 2 years.

CASES

Three women were seen with progressive back pain, paresthesias, and urinary retention. In all three cases, magnetic resonance imaging confirmed the diagnosis. All failed conservative treatment and required surgery. All did well postoperatively, with improvement of symptoms and delivery at or near term.

CONCLUSION

Lumbar disk herniation should be considered in pregnant women presenting with considerable back or leg pain. Magnetic resonance imaging is a useful diagnostic tool. Most patients can be treated conservatively, but those with incapacitating pain, progressive neurologic deficits, or bowel or bladder dysfunction may require surgical treatment.

Lumbosacral plexus neuropathy: a case report and review of the literature

Lumbosacral plexus neuropathy (LSPN) is an idiopathic clinical syndrome characterized by the sudden onset of neuropathic pain, followed by weakness and sometimes sensory disturbances in the distribution of the lumbosacral plexus. Prognosis is usually favourable, although complete recovery may take several months to years. LSPN is the lumbosacral counterpart of the neuralgic amyotrophy syndrome (idiopathic brachial plexus neuropathy). We present a patient who initially was misdiagnosed with a radicular syndrome, but illustrates the typical signs and symptoms of LSPN. We also give clinical and electromyographical criteria for the diagnosis of LSPN and review the literature.

[Compression syndrome of the superficial fibular nerve. Case report]

The case of a female patient complaining of dysaesthesia and paraesthesia on the dorsum of her right foot and digits which failed to respond to conservative treatment is presented. 10 cm above the lateral malleolus, a muscle bulge of 2 cm was detected. Hoffmann-Tinel's sign was positive at this site. The diagnosis of nerve entrapment was confirmed by a conduction velocity block. Through an incision centered over the muscle bulge, the superficial fibular nerve was identified. It was found to be compressed by fascia. Fascial release and epineuriotomy resulted in complete recovery. Entrapment of the sensory superficial fibular nerve in the patient is thought to have been caused by prolonged work-related kneeling and squatting over many years.

Ciguatera fish poisoning following travel to the tropics

A 40-year-old man-as well as 15 more participants of the same meal-suddenly experienced vomiting and watery diarrhea four hours after having eaten a meal of grouper in the Dominican Republic. Symptoms persisted for four hours and were followed by a generalized pruritus and paresthesias of the lips, tongue, palms, and soles of the feet. Physical examination was normal with the exception of a pulse of 45 beats per minute, a blood pressure of 80/50 mmHg, and paradoxical temperature perception. Laboratory values were regular except for the erythrocyte sedimentation rate of 40 mm per hour. 24-hour Holter electrocardiogram showed a normal sinus rhythm with impaired heart rate variability (37-100 beats per minute). Due to the typical history and the clinical findings, ciguatera toxin ingestion was diagnosed. Pruritus decreased slightly with symptomatic therapy, but it took 16 weeks for all symptoms to resolve. Ciguatera fish poisoning is rare in temperate countries. Symptoms of this neurotoxic disease are gastrointestinal, neurologic, and cardiovascular manifestations with paresthesias, paradoxical sensor disturbances, and muscular weakness as well as bradycardia and hypotension. With travel to and from the tropics and increasing imports of tropical fish ciguatera will be of growing importance even in nontropical areas.

Neurologic complications of 603 consecutive continuous spinal anesthetics using macrocatheter and microcatheter techniques. Perioperative Outcomes Group

Recent case reports of cauda equina syndrome after continuous spinal anesthesia have led to a reevaluation of the indications and applications of this regional anesthetic technique. However, few large studies have formally investigated the frequency of neurologic complications using macro- and microcatheter (smaller than 24 gauge) techniques. This retrospective review examines 603 continuous spinal anesthetics, including 127 administered through a 28-gauge microcatheter, performed between June 1987 and May 1992. The surgical procedure was orthopedic in 397 of 476 (83.4%) macrocatheter patients. All microcatheter patients were parturients. Three patients reported pain (persistent paresthesia) postoperatively. In two patients, the symptoms resolved in 4 days; the other patient was discharged 8 days postoperatively with residual foot pain. There was also one patient with aseptic meningitis and one patient with a sensory cauda equina syndrome (still present after 15 mo). There were 58 (9.6%) patients with a postdural puncture headache (PDPH), including 42 of 127 (33.1%) patients in the microcatheter group. An epidural blood patch was performed in 41 (6.8%) patients. The frequency of neurologic complications, excluding PDPH, is similar to those in published reviews. However, PDPH in microcatheter patients is more frequent than previously reported.