The assessment of trigeminal sensory nerve paraesthesia after bilateral sagittal split osteotomy: modified somatosensory evoked potentials recording method

Trigeminal neurosensory impairment is frequently observed following orthognathic surgery. The purpose of the present study is to visualize the degree of trigeminal nerve impairment following bilateral sagittal split osteotomy (BSSO). Twenty patients who underwent BSSO were in the present study. To record the modified somatosensory evoked potentials (SEP), two electrostimulation clips were applied. One clip was placed on the mucous surface of the lower lip and the other was placed on the skin surface. Each contact surface contained a separate 2 mm diameter silver anode and cathode attached to a 5 x 15 mm basement plate. The results obtained using this method revealed that complete recovery from neural impairment was observed in 7 cases (36.8%) on the right operative side and 4 (20.0%) on the left side at 6 months postoperatively. A definite delay in latency was observed on the left operative side at all the examination periods. The recovery period evaluated by the SEP method was longer than that of the objective two-point discrimination thresholds. Clinical records obtained showed considerable implications for trigeminal nerve function after BSSO.

Solitary fibrous tumor presenting as a symptomatic intraspinal mass: case report

OBJECTIVE AND IMPORTANCE

Mesenchymal, nonmeningeal tumors of the central and peripheral nervous systems are rare. Specifically, the solitary fibrous tumor, which occurs in both benign and malignant forms, was first described in the pleura and more recently in a number of sites, including the mediastinum, abdomen, upper respiratory tract, nasopharynx, and orbit. It has not, however, previously been known to involve the spine or to induce cord compression.

CLINICAL PRESENTATION

We describe the case of a 33-year-old man who presented with back pain, progressive myelopathy, and lower extremity dysesthesias. Imaging studies demonstrated an intradural extramedullary mass at T7-T8.

INTERVENTION

At surgery, the lesion was found to be firm, fibrous, intimately apposed to the T8 sensory nerve root but emanating from neither root nor dura. Histologically, the tumor was composed of spindle cells in a storiform pattern with extensive collagen deposition in the intercellular matrix. Immunohistochemistry showed diffuse positive staining of tumor cells for CD34 antigen but negative staining for S100 and EMA, a profile that is consistent with a histopathological diagnosis of solitary fibrous tumor and that effectively rules out meningioma and nerve sheath tumor.

CONCLUSION

This is the first report of an intraspinal solitary fibrous tumor, a rare entity that should be included in the differential diagnosis of intradural extramedullary spinal neoplasms.

Intermittent mental paraesthesia in an edentulous mandible

A patient presenting with bilateral intermittent mental paraesthesia on wearing a lower denture on a very atrophic ridge was treated with an implant-retained overdenture which resolved her symptoms.

MMPI profiles in post-lumbar puncture headache

From the original material of 300 patients, of whom 37.3% had experienced a post-lumbar puncture headache (PPH), a total of 20 males and 50 females were evaluated with the Minnesota Multiple Personality Inventory (MMPI). The test was administered on average 33 months after the lumbar puncture (range 13-51), at a time when anxiety and depression related to the original investigation for a possible organic neurologic disease were expected to affect the results minimally. In the present material PPH was experienced by 45.7% of the patients, 40% of the males, and 48% of the females. Patients without PPH were used as controls. The selected material was a representative sample of the original material both as to distribution of age, proportion of organic diagnoses, and frequency of PPH. The MMPI disclosed no statistically significant differences between PPH patients and controls regarding personality traits.

Non-Hodgkin's lymphoma of the oral cavity as the first manifestation of AIDS

A case of oral non-Hodgkin's lymphoma as the first manifestation of AIDS is described. The clinical presentation was that of a periodontal lesion and mental nerve paraesthesia, which may have lead to initial confusion in diagnosis and management.

Temporary paresthesia of the lower lip: a complication of orthodontic treatment. A case report

Temporary mental paresthesia of the lower lip as a result of orthodontic treatment is extremely rare. Only two cases seem to have been reported earlier, a further case is described and discussed. The cause of this uncommon complication in the present case is obviously the close relationship between the distal root of the lower left second permanent molar and the mandibular canal.

Chronic electrical stimulation of the gasserian ganglion for the relief of pain in a series of 34 patients

The use of an implanted system for chronic electrical stimulation of the gasserian ganglion for relief of facial pain was described in 1980 by Meyerson and Håkansson. Between 1982 and 1995, the senior author (R.R.T.) performed gasserian ganglion stimulation in 34 patients for the relief of chronic medically intractable facial pain. The etiology of pain was peripheral damage to the trigeminal nerve in 22 patients (65%), central (stroke) damage in seven (21%), postherpetic neuralgia in four (12%), and unclassifiable cause in one (3%). All patients received a trial of transcutaneous stimulation (Stage 1). Successful trials in 19 patients (56%) were followed by implantation of a permanent system (Stage II). Trial and postimplantation stimulation were deemed successful when there was a reduction of pain by at least 50% whenever the stimulator was on. Success rates varied from five (71%) of seven patients for central pain to five (23%) of 22 for peripheral pain and none (0%) of four for postherpetic neuralgia. The median follow-up duration in successful cases was 22.5 months. Infections occurred in seven patients, all of whom had undergone Stage II treatment. Infections were more frequent when the stimulating electrode from Stage I was left in place for Stage II (six [43%] of 14) than when completely new hardware was used and prophylactic antibiotic drugs were administered (one [20%] of five). Other complications included iatrogenic injury to the trigeminal nerve or ganglion in three cases (9%), transient diplopia in two (6%), increased pain in two (6%), and various technical problems in 10 (29%). It is concluded that pain of central origin (stroke) is the type most likely to be relieved by this procedure. This finding is new, as the few other clinical series reported to date contain no patients with this type of pain. The risk of infection seems to be lower when completely new hardware is used for Stage II and prophylactic antibiotic drugs are administered.

Modified intraoral maxillo-malar osteotomy: long-term results in 16 consecutive cases

The authors report their experience with sixteen consecutive cases of maxillo-malar osteotomy via an intraoral approach. Some technical expedients and modifications to the original technique are described here. This procedure was associated in all cases with bilateral sagittal splitting of the mandible and in two cases with vertical reduction of the chin. Results from this series confirm the reliability of this technique and the stability of functional and aesthetic results.

[Retrosternal luxation of the clavicle. Apropos of 4 cases surgically treated using a temporary screwed anterior plate and review of the literature]

The authors report 4 new cases of retrosternal dislocation of the clavicle operated by capsular and ligament restoration, and temporary stabilization by anterior plating. The 4 patients were men with a mean age of 17.5 years. The lesion was caused by a sports injury (football, rugby) in 3 out of 4 cases and was related to an indirect mechanism. Clinical examination allowed the diagnosis, was related to based on painful palpation of a dip over the joint, supported by radiology and computed tomography. CT did not reveal the epiphyseal separation present in two cases. Complications were frequent: 1 case of tracheal compression, 2 cases of temporary paresthesia of the upper limb, 2 cases of venous compression with one case of subclavian and medial jugularis venous thrombosis, 1 hemopneumothorax. Surgical reduction was performed in all 4 cases after 2 failures of attempted orthopedic treatment under general anesthesia. All patients recovered a full range of movement, a painless shoulder and no recurrence has been observed. All complications resolved after reduction. Venous thrombosis responded favourably after 6 months of anticoagulant therapy. One plate breakage was observed with no clinical implications. On the basis of an extensive review of the literature, the authors discuss the epidemiology, pathology and the importance of associated injuries, which are frequent and sometimes serious, justifying urgent reduction. Computed tomography is the most useful radiologic modality, both for diagnosis and for investigation of complications. Orthopedic treatment must be attempted first (especially in children) according to a well systematized technique. One third of attempts fail, and cases of delayed diagnosis and serious vascular complications, then require surgical treatment. The costoclavicular ligament is repaired either by Burrows's ligamentoplasty or by bone suture; the clavicle is stabilized by bone suture or by anterior plating. The authors do not advocate either joint fixation by Kirschner wire, or resection of the medial end of the clavicle.

Neurologic and visual symptoms in essential thrombocythemia: efficacy of low-dose aspirin

Neurologic and visual symptoms frequently occurred in 56 reported patients with essential thrombocythemia (ET). They may either precede or follow the well-known microcirculatory complications of ET of acroparesthesias, erythromelalgia, and acrocyanosis or ischemia of one or more toes. In comparison with transient ischemic attacks in patients with vascular risk factors, the usual neurologic presentation of ET consists of brief attacks of sudden cerebral or visual dysfunction, which can be either well localized or diffuse and entirely nonspecific. A dull and throbby headache usually lasting for several hours frequently accompanies the neurologic symptoms. Visual symptoms are less frequent and include transient monocular blindness and global symptoms such as scintillating scotomas and attacks of blurred vision. Neurologic and visual symptoms may leave minor sequelae but are generally nondisabling. The striking similarity to migraine, together with the absence of vascular risk factors and the striking efficacy of aspirin treatment supports the hypothesis that the ischemic neurologic and visual symptoms in ET are caused by shear rate-induced intravascular activation and aggregation of platelets with subsequent transient sludging or occlusion of the cerebral arterial microvasculature. Available data show that both the erythromelalgic distress and the ischemic neurologic attacks in ET are completely abolished by control of platelet function with low dose aspirin alone or reduction of platelet counts to normal as well as by the combination of platelet reducing therapy and low-dose aspirin. Early recognition and appropriate treatment of neurologic symptoms in patients with ET is therefore of great clinical relevance.

A prospective study of microvascular decompression for trigeminal neuralgia

In a prospective study of 25 patients with trigeminal neuralgia (TN), we examined the results of microvascular decompression (MVD). Initial pain relief was complete in 22 patients and partial in one. There were two primary failures. After a median observation time of 38 months, 20 of the 22 patients still were completely free of pain, and one patient reported then 50% pain relief. A vascular compression of the trigeminal root was found intra-operatively in 23 patients. No serious complications occurred. Minor but bother-some dyaesthesias were reported by two patients (8%). The results were satisfactory when compared to other MVD studies.

Posttraumatic syringomyelia: a review of 21 cases

A retrospective study was conducted on 21 consecutive patients with combined clinical and radiologic evidence of posttraumatic syringomyelia. Medical records and radiologic studies were reviewed to determine the following: age at injury, mechanism of trauma, spinal column injury and resultant neurologic deficit, latency period between injury and clinical manifestations of posttraumatic syringomyelia, clinicoradiologic findings of posttraumatic syringomyelia, and results of treatment. The patients were found uniformly to have sustained significant trauma (gunshot wounds, falls, or vehicular accidents) with marked neurologic dysfunction at the time of injury. Latent periods ranged from 1 month to 23 years. The most commonly presenting symptoms were radicular pain, spasticity, sensory loss, hyperhidrosis, and weakness. The most common physical findings were spasticity, hypesthesia, and weakness. Long term followup was obtained in 17 (81%) of the cases and suggested a higher rate of satisfaction among patients treated with surgical decompression of the syrinx. Radicular pain and sensory disturbance responded most predictably to surgical intervention, whereas spasticity responded least favorably. It is concluded that posttraumatic syringomyelia is a potentially disabling but treatable late complication of spinal injury, warranting a high index of suspicion among physicians who observe patients with such trauma.

[Neurologic signs in Addison-Biermer disease (report of 3 cases)]

The authors report three patients in whom a neurological syndrome was the first manifestation of Addison-Biermer disease. In the first case a paraneoplastic neurological syndrome was suspected, in two other cases the initial tentative diagnosis was multiple sclerosis. The correct diagnosis was reached after a prolonged diagnostic procedure and after ruling out of other diseases. The course of the disease was very serious in all cases leading to death of one patient despite intensive treatment (postmortem examination confirmed the diagnosis). In the second case the neurological syndrome failed to regress completely. The authors stress the necessity of considering this aetiology in neurological syndromes of atypical pattern and course.

Gamma knife radiosurgery for trigeminal neuralgia

Radiosurgery is one of the surgical treatments of trigeminal neuralgia. Through precise irradiation of the proximal trigeminal nerve identified on high-resolution imaging, pain relief can be achieved after a short latency interval. This image-guided approach has been useful for both patients with persistent pain after other surgeries, and as a primary surgical option. A minimum dose of 70 Gy delivered with the gamma knife has been associated with low risk for facial numbness, and no other morbidity. Management of trigeminal neuralgia without an incision, transfacial needle placement or nerve section may prove useful to increasing numbers of patients.

Are postoperative review appointments necessary following uncomplicated minor oral surgery?

This paper reports the results of a postal survey of all current BAOMS Fellows concerning their practice and opinion on the usefulness and desirability of reviewing all patients following uncomplicated minor oral surgery. It also reports the results of a separate postal survey of 500 patients who had recently undergone third molar removal. The overwhelming majority of Fellows routinely review all their patients following third molar removal and apicectomy but not after simple exodontia. There was no excess morbidity in patients who were not offered a follow-up appointment compared to those who had been seen postoperatively after removal of their third molars. Patients not followed up in hospital postoperatively did not seek help from their doctor or dentist more frequently than patients who were followed-up. Despite the lack of evidence showing objective benefit to patients from postoperative follow-up, given the choice the majority of patients wish to be reviewed postoperatively.

Mental nerve paresthesia associated with a non-vital tooth

Apical periodontitis is a common development associated with teeth with necrotic pulp. Although rare, some cases may present further complications, such as neuropathies in areas adjacent to the affected tooth. A case is described in which mental nerve paresthesia was associated with a non-vital mandibular premolar. Endodontic therapy resolved the paresthesia completely without further clinical complications.

Mental paraesthesia: an ominous symptom. Case reports

The sudden onset of paraesthesia in the distribution of the mental nerve should be regarded as an ominous symptom. It is usually related to events such as fractures or dentoalveolar surgery, but in the absence of such history this finding should be regarded with suspicion. Four case studies are presented in which the patient presented with unexplained mental paraesthesia, which were later related to metastatic malignant disease. Careful medical history is required to alert the clinician to appropriate diagnostic procedures and ensure correct management.