Epley's Manoeuvre: A Single Line Treatment for Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo (BPPV) is the commonest cause of peripheral vertigo. Displaced free floating otoconia in the semicircular canals are responsible for brief attacks of vertigo and nystagmus. Epley's manoeuvre relocates these particles into the utricle. Here we studied the efficacy of Epley's manoeuvre in posterior semicircular canal BPPV without labyrinthine sedatives. 120 patients presented with positional vertigo were included in the study based on positive Dix- hallpike test from August 2018 to July 2019. These patients were treated with only the Epley's manoeuvre and followed up for 6 months. Patients who were previously on labyrinthine sedatives were advised to stop them and treated with only the Epley's manoeuvre. In our study of 120 patients, mean age was 43.5 yrs. Females (52.5%) were commonly affected. Left side posterior semicircular involvement was more than the right side. Epley's manoeuvre had 90% efficacy at 1st week and 100% efficacy at 4th week. Duration of vertigo had significant association (p < 0.01) with the number of sessions required. There was significant improvement in the duration of vertigo attack (p < 0.0001) and frequency of attack (p < 0.0001) before and after the manoeuvre. Epley's manoeuvre lead to significant (p < 0.001) improvement in the quality of life of affected patients measured by DHI scoring. In our 6 months follow up, 10 recurrences occurred having significant (p < 0.01) association with the duration of vertigo attack. Only Epley's manoeuvre without any labyrinthine sedatives is an effective treatment for posterior semicircular canal BPPV patients. It also improves the quality of life of affected patients.

Evaluation of the implantation of transpedicular screws in spinal instrumentation with free-hand technique and navigation-assisted with intraoperative computed tomography: An analytical-positional study

BACKGROUND

Spinal instrumentation using transpedicular screws has been used for decades to stabilize the spine. In October 2018, an intraoperative CT system was acquired in the Neurosurgery service of the University Hospital Complex of Vigo, this being the first model of these characteristics in the Spanish Public Health System, so we began a study from January 2015 to December 2019 to assess the precision of the transpedicular screws implanted with this system compared with a control group performed with the classical technique and final fluoroscopic control.

METHODS

The study was carried out in patients who required transpedicular instrumentation surgery, in total 655 screws were placed, 339 using the free-hand technique (Group A) and 316 assisted with intraoperative CT navigation (Group B) (p>0.05). Demographic characteristics, related to surgery and the screw implantation grades were assessed using the Gertzbein-Robbins classification.

RESULTS

92 patients were evaluated, between 12 and 86 years (average: 57.1 years). 161 thoracic screws (24.6%) and 494 lumbo-sacral screws (75.4%) were implanted. Of the thoracic screws, 33 produced a pedicle rupture. For the lumbo-sacral screws, 71 have had pedicle violation. The overall correct positioning rate for the free-hand group was 72.6% and for the CT group it was 96.5% (p<0.05).

CONCLUSION

The accuracy rate is higher in thoracic-lumbar instrumentation in the navigation group versus free-hand group with fluoroscopic control.

Position-dependent obstructive sleep apnea and its influence on treatment success of mandibular advancement devices

PURPOSE

Depending on the severity of pre-treatment obstructive sleep apnea (OSA) and the criteria used to define treatment success, the efficacy of mandibular advancement devices (MADs) ranges from 30 to 69%. Identifying suitable candidates is the key to increasing the efficacy of a MAD. Positive predictors include a low body mass index, a low apnea-hypopnea index (AHI), and low age. Another consideration is whether or not a patient's OSA is position dependent. To evaluate the effect of such dependency on MAD treatment success, we studied the following: treatment success across the patient's total AHI and in the supine and non-supine sleeping positions; the influence of pre-treatment position dependency on MAD treatment success; and the effect of MAD treatment on post-treatment shifts in position dependency.

METHODS

This is a single-center retrospective study of patients with OSA. Patients were diagnosed through an overnight polysomnography and treated with a MAD between February 2015 and January 2018. They were defined as being positional if the AHI in supine sleeping position was at least twice as high as in the non-supine position.

RESULTS

Complete treatment success was achieved in 32% of study population (n = 96) and partial success in 54%. Complete treatment success was significantly higher (p = 0.004) when a patient was sleeping in the non-supine position. Treatment success did not differ significantly between patients who were position dependent and those who were not. When treated with a MAD, patients did not spend significantly more time in supine position. Neither did we find any post-treatment shifts in position dependency.

CONCLUSION

A MAD is an effective treatment modality that may significantly reduce the total AHI, supine, and non-supine AHI. Since position dependency has no impact on MAD treatment success, it does not determine whether or not a patient is a suitable candidate for MAD treatment.

Evaluation of the implantation of transpedicular screws in spinal instrumentation with free-hand technique and navigation-assisted with intraoperative computed tomography: An analytical-positional study

BACKGROUND

Spinal instrumentation using transpedicular screws has been used for decades to stabilize the spine. In October 2018, an intraoperative CT system was acquired in the Neurosurgery service of the University Hospital Complex of Vigo, this being the first model of these characteristics in the Spanish Public Health System, so we began a study from January 2015 to December 2019 to assess the precision of the transpedicular screws implanted with this system compared with a control group performed with the classical technique and final fluoroscopic control.

METHODS

The study was carried out in patients who required transpedicular instrumentation surgery, in total 655 screws were placed, 339 using the free-hand technique (Group A) and 316 assisted with intraoperative CT navigation (Group B) (p>0.05). Demographic characteristics, related to surgery and the screw implantation grades were assessed using the Gertzbein-Robbins classification.

RESULTS

92 patients were evaluated, between 12 and 86 years (average: 57.1 years). 161 thoracic screws (24.6%) and 494 lumbo-sacral screws (75.4%) were implanted. Of the thoracic screws, 33 produced a pedicle rupture. For the lumbo-sacral screws, 71 have had pedicle violation. The overall correct positioning rate for the free-hand group was 72.6% and for the CT group it was 96.5% (p<0.05).

CONCLUSION

The accuracy rate is higher in thoracic-lumbar instrumentation in the navigation group versus free-hand group with fluoroscopic control.

Standardized framework to report on the role of sleeping position in sleep apnea patients

PURPOSE

Sleep apnea is a multifactorial illness which can be differentiated in various physiological phenotypes as a result of both anatomical and non-anatomical contributors (e.g., low respiratory arousal threshold, high loop gain). In addition, the frequency and duration of apneas, in the majority of patients with OSA, are influenced by sleeping position. Differences in characteristics between non-positional patients (NPP) and positional patients (PP) suggest another crucial phenotype distinction, a clinical phenotype focusing on the role of sleeping position on sleep apnea. Since this clinical phenotype distinction has therapeutic implications, further research is necessary to better understand the pathophysiology behind this phenotypic trait and to improve management of PP. Therefore, we suggest a standardized framework that emphasizes the role of sleeping position when reporting clinical and research data on sleep apnea.

METHODS

We identified 5 key topics whereby a standardized framework to report on the role of sleeping position would be of added value: (1) sleep study data, (2) anatomical, morphological and physiological factors, (3) drug-induced sleep endoscopy (DISE) findings, (4) sleep apnea management, and (5) effectiveness versus efficacy of positional therapy in sleep apnea management. We performed a literature search to identify evidence to describe and support the rationale behind these 5 main recommendations.

RESULTS

In this paper, we present the rationale behind this construct and present specific recommendations such as reporting sleep study indices (disease severity) and sleep time spent in various sleeping positions. The same is suggested for DISE findings and effect of treatment. Sleep study indices (disease severity), anatomical, morphological, and physiological factors in sleep apnea patients should be reported separately for PP and NPP.

CONCLUSION

Applying these suggestions in future research will improve patient care, assist in better understanding of this dominant phenotype, and will enhance accurate comparisons across studies and future investigations.

Functional positional eye and eyelid movements

BACKGROUND

Positional manoeuvres are an important part of the neurological examination, particularly in patients with vertigo where the presence and characteristics of provoked nystagmus can help differentiate central from peripheral neurological disorders.

METHODS

Case series of functional positional eye and eyelid movements.

RESULTS

We report four patients with functional eye and eyelid movements provoked during positional manoeuvres. The range of abnormalities observed included positional convergence spasm, brief functional saccadic oscillations, and excessive positional blinking mimicking upbeat nystagmus. The functional movements described were present on a background of pre-existing peripheral or central nystagmus, or positional vertigo.

CONCLUSION

Functional positional eye and eyelid movements may co-exist with organic nystagmus that renders an accurate interpretation of the manoeuvre more challenging. A thorough understanding of the clinical features that differentiate these two categories of eye/eyelid movements makes the analysis easier, thus preventing misdiagnosis and avoiding unnecessary investigations.

Prediction of school-age IQ, academic achievement, and motor skills in children with positional plagiocephaly

Introduction

Children with positional plagiocephaly and/or brachycephaly (PPB) are at risk of early developmental delay, but little is known about early life factors associated with school-age neurodevelopment. This study examined associations of demographic characteristics, prenatal risk factors and early neurodevelopment assessment with school-age IQ, academic performance, and motor development in children with PPB.

Methods

The study sample consisted of 235 school-age children with PPB followed since infancy. Outcome measures included IQ using the Differential Ability Scales-Second Edition, academic achievement as measured by the Wechsler Individualized Achievement Tests-Third Edition), and motor function using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition. Linear regression was used to examine the incremental improvement of model fit of demographics, prenatal and early life characteristics, severity of PPB, and neurodevelopment at ages 7, 18, and 36 months as measured by the Bayley-3 on school-age scores.

Results

Mean age at school-age assessment was 9.0 years. Adjusted r² for demographic, prenatal, and early life risk factors ranged from 0.10 to 0.22. Addition of PPB severity and Bayley-3 measures at ages 7 and 18 months did not meaningfully change model fit. Adjusted r² after inclusion of Bayley-3 at 36 months ranged from 0.35 to 0.41.

Conclusion

This study suggests that PPB severity and very early life neurodevelopment have little association with school-age neurodevelopment above and beyond demographic and early life risk factors. However, preschool-age neurodevelopmental assessment may still be useful in identifying children with PPB at risk for delay and who may benefit from early intervention.

Positional transient loss of consciousness and hemispheric deficits in the setting of severe four-vessel extracranial cerebrovascular disease

Carotid artery stenosis typically causes hemispheric neurologic effects by atheroembolism. Nonhemispheric symptoms, such as syncope, are generally not attributable to extracranial carotid disease. This report describes a 62-year-old woman with severe bilateral carotid artery stenosis, right vertebral artery occlusion, and severe left vertebral artery stenosis who presented with transient loss of consciousness and unilateral weakness when upright. Her symptoms resolved after right carotid endarterectomy. Whereas vertebrobasilar insufficiency alone can cause syncope, in the case of severe multivessel cerebrovascular disease, unilateral carotid revascularization was successful in treating the patient's transient loss of consciousness, suggesting global cerebral hypoperfusion as the cause.

Direction-Changing and Direction-Fixed Positional Nystagmus in Patients With Vestibular Neuritis and Meniere Disease

Objectives

Direction-changing positional nystagmus (PN) was considered to indicate the presence of benign paroxysmal positional vertigo involving lateral semicircular canal in most cases. We investigated the incidence of PN on the supine head-roll test and compared the characteristics of nystagmus in patients with vestibular neuritis (VN) and Meniere disease (MD).

Methods

A retrospective review of patients, who were diagnosed with unilateral VN or unilateral definite MD between September 2005 and November 2011, was conducted. Sixty-five VN patients and 65 MD patients were enrolled. Eye movements were recorded for 30–60 seconds at the positions of sitting, head roll to the right, and head roll to the left, and maximum slow-phase eye velocity was calculated. PN was classified as direction-fixed (paretic or recovery) and direction-changing (geotropic or apogeotropic).

Results

Spontaneous nystagmus was observed in 57 patients (87%, the slow-phase eye velocity of 7°/sec±5°/sec) with acute VN, 39 (60%, 2°/sec±1°/sec) with follow-up VN, and 32 (49%, 2°/sec±2°/sec) with MD. Direction-fixed PN was the most common type. Direction-fixed paretic type was most common in acute VN (80%) and follow-up VN (42%), and direction-fixed recovery type was most common in MD (31%). Paretic type was significantly more common in acute VN (80%) than in follow-up VN (42%) and MD (26%), and the recovery type was significantly more common in MD (31%) than in acute VN (3%) and follow-up VN (14%). Direction-changing PN was more common in MD (22%), followed by follow-up VN (14%) and acute VN (9%).

Conclusion

Though direction-fixed paretic PN was most common in VN and MD patients, direction-changing PN could be observed in a few patients (9%–20%) with peripheral vestibular disorders regardless of the duration from the onset of dizziness, suggesting the presence of otolith-related dizziness.

Benign paroxysmal positional vertigo: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society

This article presents operational diagnostic criteria for benign paroxysmal positional vertigo (BPPV), formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society. The classification reflects current knowledge of clinical aspects and pathomechanisms of BPPV and includes both established and emerging syndromes of BPPV. It is anticipated that growing understanding of the disease will lead to further development of this classification.

Dizziness in a Tertiary Care Centre in Sikkim: Our Experience and Limitations

Dizziness is a common symptom and though most of the causes are benign yet some may be potentially life threatening. Diagnosis can be a challenge sometimes due to lack of dedicated vestibular lab and injudicious use of vestibular suppressant medications. A 2 year retrospective study of the hospital records from September 2014 to August 2016 was done to study the causes of dizziness and the limitations and challenges in the diagnosis. 75 complete records of patients presenting with dizziness were accessed and analysed. 54.7% of the patients were males and most patients were young adults. Most of the cases were benign and Benign paroxysmal positional vertigo was the commonest diagnosed case (20%). Potentially life threatening cases diagnosed were cerebellar infarct and posterior fossa space occupying lesion (5.3%). Complete evaluation of a dizzy patient must be done to arrive at a causal diagnosis. Injudicious use of vestibular sedatives should be discouraged. Proper training and education to the primary care physician should be imparted so that they can adopt a practical approach for evaluation and management of a dizzy person.

Recent developments in the diagnosis and treatment of obstructive sleep apnea : English version

Over the past few years, the diagnostic tools and therapeutic approaches for obstructive sleep apnea (OSA) have evolved further. Based on a review of the current literature and the personal experiences of the authors, the most relevant developments are summarized in this article and discussed with regard to their impact on the clinical management of the disease. In the third edition of the International Classification of Sleep Disorders, the classification of sleep-disordered breathing was modified. Notably, additional clinical criteria for the diagnosis of OSA were established and out-of-center sleep testing was introduced as an alternative to polysomnography. Recent technical advancements in diagnostic tools (e. g., peripheral arterial tonometry and pulse wave analysis) have further expanded the diagnostic possibilities. Drug-induced sleep endoscopy allows for a reliable assessment of the level and degree of upper airway obstruction. Whether this gain in diagnostic information leads to an improvement in surgical outcome is, however, still being discussed. The relevance of positional OSA has received increasing attention - the subgroup of patients in whom sleeping position significantly impacts their disease is reported to be above 50 %. For these patients, the introduction of the sleep position trainer offers a new therapeutic option. Further, hypoglossal nerve stimulation (upper airway stimulation) has substantially expanded the surgical spectrum for the treatment of OSA. In regard to the established surgical treatment options, randomized trials with superior methodology have been published, especially for bimaxillary advancement and tonsillectomy with uvulopalatopharyngoplasty. These developments are of particular interest for the otolaryngologist and will influence daily practice.

Phenotypes in obstructive sleep apnea: A definition, examples and evolution of approaches

Obstructive sleep apnea (OSA) is a complex and heterogeneous disorder and the apnea hypopnea index alone can not capture the diverse spectrum of the condition. Enhanced phenotyping can improve prognostication, patient selection for clinical trials, understanding of mechanisms, and personalized treatments. In OSA, multiple condition characteristics have been termed "phenotypes." To help classify patients into relevant prognostic and therapeutic categories, an OSA phenotype can be operationally defined as: "A category of patients with OSA distinguished from others by a single or combination of disease features, in relation to clinically meaningful attributes (symptoms, response to therapy, health outcomes, quality of life)." We review approaches to clinical phenotyping in OSA, citing examples of increasing analytic complexity. Although clinical feature based OSA phenotypes with significant prognostic and treatment implications have been identified (e.g., excessive daytime sleepiness OSA), many current categorizations lack association with meaningful outcomes. Recent work focused on pathophysiologic risk factors for OSA (e.g., arousal threshold, craniofacial morphology, chemoreflex sensitivity) appears to capture heterogeneity in OSA, but requires clinical validation. Lastly, we discuss the use of machine learning as a promising phenotyping strategy that can integrate multiple types of data (genomic, molecular, cellular, clinical) to identify unique, meaningful OSA phenotypes.

Clinical features in patients with positional obstructive sleep apnea according to its subtypes

PURPOSE

This study aimed to determine the prevalence of positional obstructive sleep apnea (OSA) and its subtypes in Korean adults with newly diagnosed OSA and document the clinical characteristics of positional OSA and its subtypes compared to non-positional OSA METHODS: In this cross-sectional study, we evaluated 1052 OSA adults. Positional OSA was defined as an overall apnea-hypopnea index (AHI) ≥5 and supine AHI to non-supine AHI ratio of ≥2. Positional OSA was subtyped depending on the degree of AHI while in the non-supine position: subtype I (a non-supine AHI <5/h), subtype II (a non-supine AHI ≥5/h and <15/h), and subtype III (a non-supine AHI ≥15/h). To compare clinical characteristics between patient groups depending on the positional tendency of OSA, statistical analyses were performed.

RESULTS

The prevalence of positional OSA was 75.6 % with 39.9 % having AHI normalized <5/h while in non-supine position. Positional OSA patients had milder OSA, older age, and lower BMI than did non-positional OSA patients. However, having positional OSA did not influence daytime sleepiness, depressive symptoms, anxiety, and health-related quality of life. Unlike the subtype I and II positional OSAs, subtype III did not differ in clinical features from non-positional OSA. There were significant differences in supine sleep time depending on the positional tendency of OSA. Subtype III positional OSA had the shortest supine sleep time whereas subtype I positional OSA and non-positional OSA had the longest supine sleep time.

CONCLUSIONS

Positional OSA subtypes have different clinical characteristics. Subtyping of positional OSA is helpful for developing specific treatment strategies according to positional tendency.

Use of external orthotic helmet therapy in positional plagiocephaly

Positional plagiocephaly is the most common type of cranial asymmetry affecting infants. We aimed to investigate the effectiveness of helmet therapy compared to no helmet therapy in treating positional plagiocephaly in infants under the age of 1year. This retrospective review was conducted in an Australian paediatric hospital and included 171 patients recruited from outpatient clinics. Only 30 patients had positional plagiocephaly scores recorded at first and final consultations while 39 patients had diagonal measurements recorded at both visits. The mean age was 7.38months at initial consultation with a mean follow-up duration of 5.85months. Those who had helmet therapy had a significantly greater reduction in diagonal difference than those who did not use helmets (p=0.011). Therefore, there may be a role for helmet therapy in the treatment of severe positional plagiocephaly.

Evolution of match performance parameters for various playing positions in the English Premier League

This study aimed to investigate position-specific evolution of physical and technical performance parameters in the English Premier League (EPL). Match performance observations (n=14700) were collected using a multiple-camera computerized tracking system across seven seasons (2006-07 to 2012-13). Data were analyzed relative to five playing positions: central defenders (n=3792), full backs (n=3420), central midfielders (n=3200), wide midfielders (n=2136) and attackers (n=2152). High-intensity running distance increased in the final season versus the first season in all playing positions (p<.05, ES: 0.9-1.3) with full backs displaying the greatest increase (∼36% higher in 2012-13). Similar trends were observed for sprint distance with full backs demonstrating the most pronounced increase across the seven seasons (36-63%, p<.001, ES: 0.8-1.3). Central players (central defenders and midfielders) illustrated the most pronounced increases in total passes and pass success rate (p<.05, ES: 0.7-0.9) whilst wide players (full backs and wide midfielders) demonstrated only small-moderate increases in total passes and pass success rate (p<.05, ES: 0.6-0.8). The data demonstrates that evolving tactics in the EPL have impacted on the physical demands of wide players and the technical requirements of central players. These findings could be used for talent identification or position-specific physical and technical training.