[Effect of electroacupuncture combined with cervical plexus block on stress responses in patients undergoing thyroid surgery]

OBJECTIVE

To observe the effect of electroacupuncture (EA) combined with cervical plexus block (CPB) on the stress response of patients undergoing thyroid surgery.

METHODS

Forty thyroidectomy patients were randomly divided into sham EA plus CPB group (sham group) and EA+CPB group (20 cases in each group). For patients of the sham group, deep cervical plexus block (25% ropivacaine hydrochloride + 1% lidocaine hydrochloride) was performed first, followed by inserting acupuncture needles into bilateral Hegu (LI 4) and Neiguan (PC 6) separately without needle manipulation and then connecting the output wires of the EA therapeutic instrument to the handles of the acupuncture needles but without electric current output. For patients of the EA+CPB group, deep cervical plexus block was performed first followed by EA stimulation [10 Hz, (6 +/- 2) mA] of the bilateral LI 4 and PC 6 for 20 min. Systolic blood pressure (SBP), heart rate (HR) and breathing frequency were detected using a multipurpose monitor. Plasma adrenocorticotropic hormone (ACTH) and cortisol (Cor) contents were determined using chemiluminescence method, plasma epinephrine (E) level was detected by enzyme-linked immunosorbent assay, glucose (Glu) assayed by oxidase method, and plasma C-reactive protein (CRP) level detected using immumofluorescence technique.

RESULTS

(1) During surgery, the patients' SBP and HR of both sham and EA groups were increased significantly compared with their basic values (P < 0.05), but the levels of the increased SBP and HR of the EA group were obviously lower than those of the sham group (P < 0.05). (2) The levels of plasma ACTH during surgery and at the immediate time after surgery, Cor level at the immediate time after surgery, plasma E and Glu contents during surgery, at the immediate time and on day 1 after surgery, and plasma CRP at the immediate time, and on day 1 and 3 after surgery in the sham group were upregulated considerably (P < 0.05), while the levels of plasma ACTH, Cor, E, Glu and CRP in the above-mentioned time-points of the EA group were all remarkably lower than those of the sham group (P < 0.05).

CONCLUSION

EA combined with cervical plexus block significantly reduces peri-operative cardiovascular stress responses and inhibits abnormal increases of plasma stress hormones and inflammatory reaction in patients undergoing thyroid surgery.

[The effect of the cervical plexus block on anti-nociceptive protection during surgeries on the interior carotid arteries]

MATERIALS AND METHODS

77 anaesthesia protocols during a. carotis interna (ACI) operations were analyzed. All the patients were divided into 3 groups. In the 1-st group a total intravenous anaesthesia - TIV4 (propofol and fentanyl) was used. In the 2nd and 3rd groups was used combined anaesthesia: in the 2nd - TIVA + superficial CPB, in the 3rd - combined anesthesia (sevortane+fentanyl+CPB). When analyzing the results, BP, BIS data, anaesthetic doses and the need for opioid analgesics were evaluated. Assessment of the postoperative pain quality was conducted within 48 hours of the postoperative period on a verbal assessment scale (VAS).

RESULTS

The need for fentanyl was considerably higher in the 1st group. The analysis of the BP data dynamics showed better stability in the 2nd and 3rd groups.

CONCLUSIONS

TIVA + CPB provides better analgesia and reduces the need for opioid analgesics; greater stability of hemodynamic parameters during operation stages, as well as the best brain perfusion during a. carotis interna occlusion; postoperative analgesia and allows to avoid the early appointment of systemic analgesics.

[Onabotulinumtoxin A in the treatment of chronic migraine]

INTRODUCTION. Chronic migraine is the most frequent complication of migraine. Its management is complex and difficult, and is based essentially on preventive measures. AIM. To analyse the development of the use of Onabotulinumtoxin A (OnabotA) in migraine, especially in its chronic form, the method of administration, its mechanism of action, its safety profile and its possible indications in clinical practice. DEVELOPMENT. The study conducts a thorough review of all the clinical trials in the literature that have used OnabotA in the prevention of migraine, both in its episodic and its chronic forms, and the outcomes in the chronic form are analysed in detail. CONCLUSIONS. In studies in phase III, OnabotA has proved to be effective in the treatment of patients with chronic migraine, with significant reductions in the mean frequency of days with headaches, the number of headache episodes, the days with migraine or the proportion of patients with severe disability, in addition to other parameters. It is also effective in the subgroup of patients with symptomatic headache due to medication abuse. OnabotA has proved to be safe and well tolerated in this indication, with foreseeable, usually mild or moderate, transitory side effects. In sum, OnabotA is a safe, well-tolerated alternative in the preventive treatment of chronic migraine.

Deep cervical plexus block for the treatment of cervicogenic headache

BACKGROUND

Cervicogenic headache descriptors include its unilateral nature, "signs and symptoms linking it to the neck," and trauma of the neck. Since the pain often occurs over the C2 or C3 nerve root, we used a modification of the deep cervical block technique for treatment of this refractory type headache.

OBJECTIVE

To determine the efficacy of a modified deep cervical block for treatment of cervicogenic headache.

DESIGN

Prospective case study.

METHODS

Thirty-nine patients referred to our pain clinic participated in this study. All patients had undergone extensive screening/diagnostic testing. The blocks were performed unilaterally, without inducing a risk of invading the neural foramen, and repeat injection of the contra-lateral side occurred at >1 week after initial injection. Patients were followed for a 6-month period using a pain diary and questionnaire. Pain was assessed pre- and post-injection and 3 and 6 months post treatments.

RESULTS

The mean treatment period was 59 +/- 61 days. The mean values for pre- and post-injection series pain scores (0-10 pain scale) were 9.54 +/- 1.53 and 6.75 +/- 3.23 respectively (p <0.001). Thirty-three percent (33%) of the patients reported pain scores of < or = 4 on the 0-10 pain scale after their last treatment. Effectiveness of the therapy following the injection procedure was rated to be 42% effective for all first injections and 40% effective for last injections (p =NS). Six months evaluations showed that return of moderate to severe pain took 6.62 +/- 8.1 weeks. At the 3 and 6 months follow up evaluations, mean pain scores had returned to 8.41 +/- 2.96 and 8.83 +/- 2.78, respectively. Ten patients (24%) had pain scores < or = 4 at the 3-month evaluation while 7 of the patients (18%) had pain scores < or = 4 at the 6-month evaluation.

CONCLUSIONS

These results showed that for some patients this series of blocks provided effective pain relief for 3 months post treatment but by 6 months the pain had returned to pre-treatment levels. This block technique significantly diminished pain after the initial as well as the last treatment. These clinically significant changes in pain relief suggest that more aggressive selective therapy targeting these nerve routes might provide longer lasting relief.

[Percutaneous electrical nerve stimulation of peripheral nerve for the intractable occipital neuralgia]

Occipital neuralgia is characterized by pain paroxysm occurring within distribution of the greater or lesser occipital nerves. The pain may radiates from the rear head toward the ipso-lateral frontal or retro-orbital regions of head. Though known causes include head injuries, direct occipital nerve trauma, neuroma formation or upper cervical root compression, most people have no demonstrable lesion.

METHOD AND MATERIALS

A sample of 8 patients (5 females, 3 males) aging 63,5 years on the average with occipital neuralgia has been recruited. The occipital neuralgic pain had presented since 4, 6 years and they had been treated by pharmacological therapy without benefit. Some result has been obtained by blocking of the grand occipital nerve so that the patients seemed to be suitable for subcutaneous peripheral neurostimulation. The pain was evaluated by VAS and SVR scales before treatment (TO) and after three and twelve months (T1, T2).

RESULTS

During the follow up period 7 patients have been monitored for a whole year while one patient was followed only for 3 months in that some complications have presented. In the other 7 patients pain paroxysms have interrupted and trigger point disappeared with a VAS and SVR reduction of about 71% and 60%, respectively.

CONCLUSIONS

Our experience demonstrates a sound efficacy of such a technique for patients having occipital neuralgia resistant to pharmacological therapies even if action mechanisms have not yet clearly explained. Some hypothesis exist and we think it might negatively affect the neurogenic inflammation that surely acts in pain maintaining.

Plexopathies

The neural plexuses are intricate networks of nerve fibers interposed between the spinal cord or anterior primary rami proximally and the most proximal portions of peripheral nerves distally. If the lumbar and sacral plexuses are considered as a single entity, then they constitute the largest peripheral nervous system structure. Each of the plexuses varies substantially from the others in its overall vulnerability to injury, the specific types of trauma or disease that most often affects it, and the ease with which it is assessed by the two laboratory diagnostic procedures in current use for doing so: neuroimaging studies and electrodiagnostic examinations.

The involvement of the peripheral nervous system in biopsy proven active giant cell arteritis

BACKGROUND

Peripheral nervous system (PNS) affection is an uncommon, sometimes life-threatening manifestation of giant cell arteritis (GCA).

OBJECTIVE

To describe characteristics of neurological abnormalities of the PNS in GCA patients.

METHODS

Eighty consecutive cases of biopsy proven GCA were studied.

RESULTS

Three patients presented with subacute sensorimotor deficits abnormalities in the distribution of the arm plexus. In all cases PNS affection was the leading clinical symptom in addition to a typical clinical syndrome of cranial arteriitis. In one case MRI demonstrated diffuse signal abnormalities surrounding the brachial nerve plexus. In another patient, who died from pulmonary embolism 10 weeks after beginning of therapy, autopsy demonstrated residual arteritis in an artery supplying the brachial nerve plexus.

CONCLUSIONS

Involvement of the PNS is more uncommon than cerebral ischemia and neuroophthalmological complications in patients suffering from GCA. Severe PNS involvement has an affinity to the midcervical nerve roots and the brachial nerve plexus.

Electromyographic Findings After Different Selective Neck Dissections

OBJECTIVES

The objective was to compare electrophysiologic investigations of the upper trapezius muscle (UT) after different selective neck dissections (SND) and analyze the differences between types of SND and the preservation and excision of the cervical nerves (the C2-4 rami of the cervical plexus).

STUDY DESIGN

Retrospective study of 54 patients (average age, 65.1 +/- 9.6 yr, 45 males) with 70 SND.

METHODS

Patients underwent needle electromyography (EMG) of the UT by 4 months after surgery. The findings were rated according to the 5 point EMG scale system from 1 (total denervation: positive sharp wave or fibrillation potential at rest and electrical silence at voluntary contraction) to 5 (normal pattern).

RESULTS

The average EMG scale was 1.7 +/- 1.1, 58.6% for score 1 and only 5.7% for score 5. There was not a significant difference in the EMG scale between the types of SND, whereas the group in which the cervical nerves were excised was significantly lower than in that in which it was preserved. The average EMG scales in the former and latter were 1.5 +/- 0.8 and 2.0 +/- 1.3, 68.8%.

CONCLUSIONS

The study data confirm that complete or incomplete denervation of the UT was caused by axonal injury of the spinal accessory nerve, even though it was spared, because of traction of the nerve during neck dissection. Second, the excision of the C2 to 4 rami of the cervical plexus caused worse damage of the UT. It is suggested that it is important to preserve the cervical nerves to avoid denervation of the UT.

[Effect of electroacupuncture on bispectral index of electroencephalography in patients undergoing subtotal thyroidectomy]

OBJECTIVE

To investigate the effects of electroacupuncture on bispectral index (BIS) of electroencephalography in patients undergoing subtotal thyroidectomy.

METHODS

Sixty patients were equally randomized into group A given electroacupuncture combined with cervical plexus block (CPB) and group B given CPB alone. After needling sensation was reached in bilateral "Hegu" and "Neiguan" acupoints, 5 min of high frequency electrical stimulation by electrical stimulation device followed with CPB was applied to group A, while only CPB was performed in group B. Visual analog scale (VAS) and verbal stress scale (VSS) were monitored, complication and adverse reaction were observed and BIS, mean arterial pressure (MAP), heart rate (HR) and arterial oxygen saturation (SaO2) were monitored continuously in the perioperative period.

RESULTS

HR increased and BIS decreased in group A, both were lower significantly than those in group B (P < 0.01); MAP, the complementary dosage of fentanyl and lidocaine used and scores of VAS and VSS were also lower in group A than those in group B (P < 0.01).

CONCLUSION

Electroacupuncture could enhance the anesthetic effect of CPB, lower the BIS value during subtotal thyroidectomy.

Cervicogenic Headache in Patients With Presumed Migraine: Missed Diagnosis or Misdiagnosis?

The differential diagnosis of headache is often challenging, with significant clinical and socioeconomic consequences of incomplete or inaccurate diagnosis. Overlapping symptoms contribute to the diagnostic challenge. Four female patients, ages 26 to 69 with standing diagnoses of migraine, were evaluated and treated for complaints of chronic, severe headaches. All had obtained limited relief from migraine therapies. On physical examination, all had occipital nerve tenderness or positive Tinel sign over the occipital nerve. All responded well to occipital nerve blocks with local anesthetic, achieving complete or substantial pain relief lasting up to 2 months. We conclude that accurate diagnosis of occipital neuralgia or cervicogenic headache as contributing factors can lead to substantial headache relief through occipital nerve blocks in patients with coexisting or misdiagnosed migraine.

PERSPECTIVE

The pathophysiology of many types of chronic headaches is not well understood. Mixed mechanisms such as neurovascular, neuropathic, myofascial, and cervicogenic may all contribute. Our four patients with chronic headaches responded well to occipital nerve blocks. The neuroanatomical relationship between the trigeminocervical nucleus and occipital nerve may serve as the basis of efficacy for these blocks.

Palsies of the fifth cervical nerve root after cervical decompression: prevention using continuous intraoperative electromyography monitoring

OBJECT

A desire to prevent complications resulting from spinal surgery led to the development of intraoperative monitoring. Intraoperative electromyography (EMG) provides useful diagnostic information regarding nerve root function during spinal and peripheral nerve surgeries. The C-5 nerve root is considered particularly vulnerable to injury during cervical surgery. Despite advances in techniques, the incidence of postoperative C-5 palsy has not changed.

METHODS

The authors reviewed prospectively collected data obtained in 161 patients who underwent 171 cervical procedures. In 116 procedures, operative monitoring was modified to include continuous C-5 EMG from the deltoid muscle. In cases in which spontaneous C-5 activity occurred, an appropriate change in operative manipulation was made. A historical control group consisted of a retrospective review of 55 procedures that were monitored using conventional techniques. In the retrospective cohort, four (7.3%) of 55 patients presented after undergoing surgery for C-5 nerve root palsy. In each patient conventional monitoring revealed unremarkable findings. In the prospective cohort, intraoperative spontaneous EMG activity necessitated a change in either positioning or operative technique in three cases. Only one patient (0.9%) experienced postoperative C-5 palsy. Postoperative C-5 palsy occurred in no patient in whom there was no intra-operative evidence of root irritation (p < 0.03, chi-square test).

CONCLUSIONS

The incidence of postoperative C-5 palsies was reduced from 7.3% to 0.9% due to intraoperative continuous EMG monitoring. No patient suffered a postoperative C-5 palsy when intraoperative evidence of root irritation was absent.

Selective denervation: reinnervation for the control of adductor spasmodic dysphonia

OBJECTIVES

The objective of this study was to evaluate the efficacy of a new surgical procedure for adductor spasmodic dysphonia (AddSD). This surgery involves the bilateral selective division of the adductor branches of the recurrent laryngeal nerves with immediate reinnervation of the distal nerve trunks with branches of the ansa cervicalis (selective denervation-reinnervation).

METHODS

Our first six patients to undergo this procedure were enrolled in the study. All patients suffered from AddSD and had previously received botulinum toxin A (Botox, Allergen, Markham, ON) therapy. Patients were recorded preoperatively and all underwent the same surgical procedure performed by the same lead surgeon. All patients were surveyed postoperatively and then re-recorded. Expert and untrained judges undertook perceptual evaluation of voice quality. Voice samples were also objectively evaluated for aphonic voice breaks.

RESULTS

No major surgical complications were noted. Patient satisfaction was excellent, and five of the six patients no longer require botulinum toxin therapy. In five of the six patients, the majority of untrained and expert listeners perceived the postoperative voice to be superior. Objectively, the rate of aphonic voice breaks was also reduced in five of the six patients.

Stability of the sternoclavicular joint. A retrospective study

Enlargement of the sternoclavicular joint is a well-documented but little recognised complication of radical neck dissection [AJR 3 (1971) 584]. We examined the stability of the sternoclavicular joint in 61 patients who had had radical neck dissection, functional neck dissection or sternomastoid division in the treatment of torticollis. Our findings support the hypothesis that postoperative stability of the sternoclavicular joint depends on the integrity of the accessory nerve and probably the proprioceptive branches of C3 and C4 of the cervical plexus. We conclude that in patients who require surgical section of the sternomastoid muscle in the treatment of torticollis, or for venous access in microvascular reconstruction, enlargement of the sternoclavicular joint should not occur as a postoperative complication, unlike those patients who have radical neck dissection with resection of the accessory nerve.

The role of temporomandibular disorders and cervical dysfunction in tension-type headache

It has been estimated that 30% to 80% of the population has at least one tension-type headache each year. Tension-type headaches can be located in any region of the head, which can confuse a differential diagnosis with temporomandibular joint disorders and cervical dysfunction. The roles of temporomandibular joint disorders and cervical dysfunction in tension-type headache are evaluated. Definitions, pathophysiology, and treatment considerations for each are discussed.

[Origin of shoulder pain after "neck dissection". Importance of the cervical plexus]

BACKGROUND

The role of sensitive parts of the cervical plexus for the development of neuropathic pain is not yet clear. Our study investigated the correlation between shoulder pain and cervical plexus damage after different types of neck dissection (ND).

MATERIAL AND METHODS

The sensitivity for warm/cold and sharp/blunt was tested in the dermatomes of C2, C3, C4, and the minor occipital nerve. Shoulder pain was measured semiquantitatively by a rating scale.

RESULTS

Motion-dependent shoulder pain was observed 6 months postoperatively in 50% after resection and in 29.2% after preservation of these structures. Pain occurred more frequently following radical ND than after modified radical types 1 and 3 ND.

DISCUSSION

Our investigations showed that the superficial cervical plexus function is assessable by cutaneous sensitivity tests. The minor occipital nerve seemed to be less affected. Fewer pain symptoms in cases with preserved cervical plexus could be demonstrated. We can conclude that preservation of the superficial cervical plexus is important to diminish postoperative shoulder pain.

Obstetric brachial plexus palsy: a comparison of the degree of recovery after repair of a C6 ventral root avulsion in newborn and adult sheep

The C6 motor rootlets were avulsed from the spinal cord in six newborn lambs to simulate a birth lesion of the upper root of the brachial plexus. Six 1-year-old sheep were used for comparison, and treated in a similar manner. The injury was repaired immediately in each group using an autologous coaxial freeze-thawed skeletal muscle graft. The animals were allowed to recover for 1 year after the surgery. The C6 root was then examined electrophysiologically and morphologically. The results were compared with those obtained from a group of untreated intact 1-year-old sheep. The fibre and axon diameters and myelin sheath thickness were significantly different in the group repaired as lambs when compared with the group repaired at the age of 1 year. There was also a significantly increased maximum conduction velocity and a greater range of conduction velocities within the nerve in the lambs. Central motor latency was significantly slower in the sheep than in the lambs. These findings would suggest a greater potential for recovery in the lambs after brachial plexus root avulsion injuries.

An unusual case of thoracic outlet syndrome associated with long distance running

An amateur marathon runner presented with symptoms of thoracic outlet syndrome after long distance running. He complained of numbness on the C8 and T1 dermatome bilaterally. There were also symptoms of heaviness and discomfort of both upper limbs and shoulder girdles. These symptoms could be relieved temporarily by supporting both upper limbs on a rail or shrugging his shoulders. The symptoms and signs would subside spontaneously on resting. An exercise provocative test and instant relief manoeuvre, which are the main diagnostic tests for this unusual case of "dynamic" thoracic outlet syndrome, were introduced.

Is IgG anti-GT1a antibody associated with pharyngeal-cervical-brachial weakness or oropharyngeal palsy in Guillain-Barré syndrome?

The pharyngeal-cervical-brachial variant (PCB) of Guillain-Barré syndrome (GBS) has clinical features similar to those of botulism and diphtheria. Mizoguchi et al. (1994) [Mizoguchi, K., Hase, A., Obi, T., Matsuoka, H., Takatsu, M., Nishimura, Y., Irie, F., Seyama, Y., Hirabayashi, Y., 1994. Two species of antiganglioside antibodies in a patient with a pharyngeal-cervical-brachial variant of Guillain-Barré syndrome. J. Neurol. Neurosurg. Psychiatry 57, 1121-1123] reported a patient with PCB-like symptoms who had serum IgG anti-GT1a antibodies which did not cross-react with GQ1b. We assumed that PCB is associated with anti-GT1a antibodies that do not have reactivity to GQ1b and made a serological study of a PCB patient. We searched for PCB patients prospectively and found one with PCB. This patient had IgG anti-GT1a antibodies which were not absorbed with GQ1b in an absorption study, whereas IgG anti-GT1a antibodies from Fisher's syndrome patients were. The frequency of positive IgG anti-GT1a antibody did not differ in patients with and without bulbar palsy. Our findings indicate that IgG anti-GT1a antibodies which do not cross-react with GQ1b are specifically detectable in PCB and can be used as a diagnostic marker of PCB.

[Idiopathic cervical plexopathy]

We describe a 26 year-old woman with cervical plexopathy with damage of left superficial or cutaneous branches, and left cervical sensory dorsal rami. Picture began acutely and vanished few days later. We ruled out known etiologies like traumatisms, tumours and surgical and anaesthetic complicated procedures, therefore the patient suffered an idiopathic cervical plexopathy. We hypothesize two possibilities for this clinical picture: an autoimmune reaction or a muscular entrapment.

Utilization of intraoperative electroneurography to understand the innervation of the trapezius muscle

The radical neck dissection is an operation for the management of lymph node metastases from primary sites involving the oral cavity, larynx, and other areas of the head and neck. In this procedure, the spinal accessory nerve is removed along with other structures. In modified neck dissection the spinal accessory nerve is preserved. Patients undergoing the modified neck dissection have had variable functional outcomes from little or no pain or disability, to significant muscle dysfunction. Our group hypothesized that patients with good functional outcomes following modified neck dissection may have had motor contributions from C2, C3, or C4 branches, while those with less favorable outcomes did not. To demonstrate the presence of motor input and its significance both from the spinal accessory nerve and the branches of the cervical plexus, we utilized intraoperative electroneurography. We find that although there is motor contribution from C2, C3, and C4 to the trapezius muscle, it was not consistent or significant.

[Somesthetic evoked potentials and serial motor evoked potentials in the study of proximal peripheral nerve conduction. Apropos of 7 cases]

The study of proximal motor and sensory nerve conduction in the thoracic outlet syndrome is still difficult and laborious in 1994. However, these conductions can be measured at different levels by means of somaesthetic evoked potentials and motor evoked potentials, when one takes the time to perform them. The study in normal subjects demonstrates that the proximal sensory and motor conduction delays are approximately 3.2 ms and are therefore comparable to that of the median nerve at the wrist. The study of 7 cases related to various diseases shows that these techniques, performed after electromyogram of both upper limbs, an essential prerequisite to their interpretation, are able to clearly demonstrate abnormalities of proximal conduction in patients suffering from of a scalene syndrome, a cervical epiduritis, radiation plexopathy, hereditary sensible to pressure neuropathy, motor neuropathy with persistent multifocal conduction blocks, or, on the contrary, may confirm the normality of conduction, for example in anterior horn disease.

Further regional variants of acute immune polyneuropathy. Bifacial weakness or sixth nerve paresis with paresthesias, lumbar polyradiculopathy, and ataxia with pharyngeal-cervical-brachial weakness

OBJECTIVE

To describe four syndromes of acute regional weakness with clinical, spinal fluid, and electrophysiologic similarities to the acute immune polyneuropathy of Guillain-Barré syndrome.

DESIGN

Case series of personally examined patients.

RESULTS

Seven patients are described: four with facial diplegia and distal limb paresthesias, one with sixth nerve palsy and distal paresthesias, one with bilateral lumbar polyradiculopathy, and one with combined Fisher's syndrome and pharyngeal-cervical-brachial weakness. These self-limited illnesses, which evolved over days or weeks, involved acellular cerebrospinal fluid with raised protein concentration and electrophysiologic findings that were consistent with a demyelinating polyneuropathy.

CONCLUSIONS

The first three regional variants of Guillain-Barré syndrome may cause diagnostic difficulty, particularly at the onset of illness, and the fourth links Fisher's syndrome with the typical syndrome. The consistently bilateral weakness of Guillain-Barré syndrome and its regional variants and the absence of a monoparetic or hemiparetic pattern suggest that the pathologic process occurs in the same single or contiguous groups of nerves on both sides of the sagittal plane but is not randomly distributed in the peripheral nervous system.

Innervation of the trapezius muscle: a study in patients undergoing neck dissections

Twenty-four patients with surgical section of the accessory nerve and/or its cervical contribution(s) were examined from 1 to 156 months after surgery, and compared to twenty controls. Thirteen patients had a classical neck dissection; seven had the whole length of the accessory nerve preserved but not the cervical plexus contributions. Four had the upper half of the accessory nerve sectioned, but with preservation of both the lower half and its cervical contributions. Clinical and electrophysiological studies of the three portions of the trapezius suggested the existence of an undescribed motor nerve supply to the trapezius and of a motor input from the cervical plexus contributions via the accessory nerve. The former is also supported by an anatomical study.

[Peripheral nerve injuries as a rare complication of cervical lymph node excision for diagnostic purposes]

During the last 3 years 263 patients were admitted who underwent diagnostic lymph node biopsy. Complications were observed only in 4 cases. In these cases, following cervical lymph node excision from the supraclavicular region, sectioning the spinal accessory nerve and branches of brachial plexus resulted in the "shoulder syndrome" which is characterized by a weakened, deformed, and often painful shoulder. Attention is called to the possibility of nerve injury during diagnostic excision of cervical lymph nodes. Most often the spinal accessory nerve and branches of brachial plexus are transected with subsequent deformity and decreased range of motion of the shoulder, which could influence deeply the quality of patient's life.

Tritiated thymidine autoradiographic study on the influence of sensory and sympathetic innervation on periodontal wound healing in the rat

Understanding of wound healing mechanisms is important in designing preventive and therapeutic approaches to inflammatory periodontal diseases, which are a major cause of dental morbidity. In this study, cell proliferation was assessed after an experimental gingival wound; this was preceded by either resection of 3 mm of the inferior alveolar nerve, total extirpation of the superior cervical ganglion, trauma to those structures or sham operations. At different times, animals were pulsed with 0.5 microCi/g body weight of tritiated thymidine; histological sections were processed for quantitative autoradiography of different compartments of the periodontium. Wounding led to a significant increase in cell proliferation in the epithelial layer, the fibroblast compartment and the periodontal ligament, but not in the alveolar crest compartment. Sympathetic denervation significantly enhanced this response in the epithelial layer, the fibroblast compartment and the alveolar crest, whereas sensory denervation only modified the response in the fibroblast layer. Thus it appears that sympathetic innervation plays an important role in the regulation of cell proliferation in the periodontium and that pharmacological modulation of sympathetic activity should be further studied as a therapeutic approach in periodontal disease.

Headache: classification, mechanism and principles of therapy, with particular reference to migraine

The sensation of pain derived from intracranial and extracranial blood vessels is conveyed to the central nervous system chiefly by the trigeminal nerve, with first order neurones terminating in the nucleus caudalis of the spinal trigeminal tract and an area lateral to the dorsal horn of the spinal cord at the second cervical segment. The evoked discharge of second order neurons can be suppressed by activation of the endogenous pain control system or, in about one third of cases, by the local application of ergot derivatives or the serotonin (5HT1) agonist sumatriptan (GR43175). Stimulation of brainstem structures such as locus ceruleus, raphe nuclei and the trigeminal system induce changes in the cerebral and extracranial circulations of the experimental animal that mimic those of migraine with aura (classical migraine). Clinical and laboratory observations have led to a neural hypothesis for migraine in which changes in hypothalamic function (an 'internal clock') and reactions to stress or excessive afferent stimuli are thought to initiate brainstem activity, causing secondary vascular changes and release of inhibition of the trigeminal pain pathways to cause headache. Painful distension of cranial blood vessels may contribute the throbbing component to migraine headache. Migraine is associated with a lowered level of platelet serotonin that is thought to reflect monoamine depletion in brainstem nuclei. Migraine headache can be precipitated by reserpine, which releases serotonin from body stores, and relieved by the intravenous infusion of serotonin. The new 5HT1 agonist sumatriptan promises to have the beneficial effects of serotonin without the side-effects that limited its clinical use.(ABSTRACT TRUNCATED AT 250 WORDS)

Digital nerve sensory potentials in lesions of cervical roots and brachial plexus

Normal values for the amplitudes of digital sensory nerve action potentials were obtained from 190 control subjects, using an orthodromic surface-recording technique. Lower limits were calculated, taking into account laterality, age and sex; the ratios of amplitudes between different digits were also estimated. The results in control subjects were compared with those of 20 cases of trauma involving root avulsion or extraspinal injury, 38 patients with intraspinal disease, 6 patients with extraspinal disorder and 9 cases of neuralgic amyotrophy. The variability of the dermatomes is discussed and it is concluded that digital sensory potential amplitudes offer a useful method of determining the site of a nerve lesion, provided certain limitations are recognized.

[Cervical-nystagmus as related to vertebral receptors]

Two patients with absent peripheral labyrinthine function are reported, in whome cervical nystagmus could be demonstrated. Return of labyrinthine function with simultaneous disappearance of the cervical nystagmus in one of the patients demonstrates existence of receptors in the upper three vertebral joints and their potential influence on the vestibular system. Pathogenetic as well as diagnostic functions of the sensory afferent systems of the upper cervical region are discussed.

The neurapraxic lesion: a clinical contribution to the study of trophic mechanisms

Four patients with neurapraxic lesions are described; in spite of the absence of impulse activity in muscle fibers no other signs of denervation could be detected. These observations are interpreted as indirect evidence for the role o f a non-impulsive (axoplasmic flow) system in certain trophic phenomena. The relationship of the present findings to the spectrum of neuropathic lesions is considered.