Perioral Paresthesia, Generalize Muscle Cramps, and Rhabdomyolysis After a Socotra Island Blue Baboon Tarantula (Monocentropus Balfouri) Bite

BACKGROUND

Literature on systemic envenomation caused by tarantula bites, particularly from the Theraphosidae family, is relatively scarce. This case report provides a formal description of the first known instance of systemic envenomation caused by the Socotra Island Blue Baboon Tarantula (Monocentropus balfouri).

CASE REPORT

In this case, a 23-year-old employee of an exotic pet shop suffered from perioral paresthesia, generalized muscle cramps, and rhabdomyolysis because of a Monocentropus balfouri bite. His symptoms were successfully relieved with oral benzodiazepines. EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the potential for serious complications resulting from the bite of Monocentropus balfouri, a species gaining popularity among global exotic pet collectors.

Residual Paresthesia After Surgery for Degenerative Cervical Myelopathy: Incidence and Impact on Clinical Outcomes and Satisfaction

STUDY DESIGN

Multicenter, prospective cohort study.

OBJECTIVE

The current study aimed to identify the incidence of residual paresthesias after surgery for degenerative cervical myelopathy (DCM), and to demonstrate the impact of these symptoms on clinical outcomes and patient satisfaction.

SUMMARY OF BACKGROUND DATA

Surgery for DCM aims to improve and/or prevent further deterioration of physical function and quality-of-life (QOL) in the setting of DCM. However, patients are often not satisfied with their treatment for myelopathy when they have severe residual paresthesias, even when physical function and QOL are improved after surgery.

MATERIALS AND METHODS

The authors included 187 patients who underwent laminoplasty for DCM. All patients were divided into two groups based on their visual analog scale score for paresthesia of the upper extremities at one year postoperatively (>40 vs. ≤40 mm). Preoperative factors, changes in clinical scores and radiographic factors, and satisfaction scales at one year postoperatively were compared between groups. The authors used mixed-effect linear and logistic regression modeling to adjust for confounders.

RESULTS

Overall, 86 of 187 patients had severe residual paresthesia at one year postoperatively. Preoperative patient-oriented pain scale scores were significantly associated with postoperative residual paresthesia ( P =0.032). A mixed-effect model demonstrated that patients with severe postoperative residual paresthesia showed significantly smaller improvements in QOL ( P =0.046) and myelopathy ( P =0.037) than patients with no/mild residual paresthesia. Logistic regression analysis identified that residual paresthesia was significantly associated with lower treatment satisfaction, independent of improvements in myelopathy and QOL (adjusted odds ratio: 2.5, P =0.010).

CONCLUSION

In total, 45% of patients with DCM demonstrated severe residual paresthesia at one year postoperatively. These patients showed significantly worse treatment satisfaction, even after accounting for improvements in myelopathy and QOL. As such, in patients who experience higher preoperative pain, multidisciplinary approaches for residual paresthesia, including medications for neuropathic pain, might lead to greater clinical satisfaction.

LEVEL OF EVIDENCE

3.

Sun pain and solar dysesthesia: A new challenge in clinical practice

BACKGROUND

A few patients report intense pain and other unpleasant sensations, such as burning, dysesthesia and hyperalgesia, after even brief exposure to the sun and in the absence of any skin lesion. Sometimes they also develop systemic symptoms, such as mild fever, fatigue, faintness and fainting. As a result, these patients carefully avoid even short-term sun exposure with a consequent severe negative impact on their lives.

METHODS

We have reviewed the clinical findings and the results of photobiological investigations of 10 patients who presented this clinical picture. Six of these patients were previously described by our group with the diagnosis of sun pain. We have reviewed the similarities with other previously described disorders such as solar dysesthesia and PUVA pain and have evaluated possible pathogenetic mechanisms.

RESULTS

During phototesting our patients experienced intense pain in the exposed area and in the surrounding skin, without any visible lesion, even with very low sub-erythemal doses. At follow-up, five patients were diagnosed with fibromyalgia, three with a major depressive disorder, one with bipolar syndrome and one with a conversion disorder. The pathogenesis remains unclear, but the use of a psychopharmacological treatment with antidepressants improved both the neuropsychiatric symptoms and sensitivity to the sun in most subjects.

CONCLUSION

For patients with pain and other severe symptoms in the absence of skin lesions and clinical and laboratory manifestations of known photodermatoses, a neuropsychiatric evaluation should be suggested.

Does high-frequency stimulation of sensory axons break the causal link between pain relief and paresthesia?

Neurostimulation produces unnatural cutaneous sensations with potent analgesic effects in pain syndromes. In this issue of Neuron, Sagalajev et al.1 demonstrate that these sensations are an epiphenomenon and explain how high-frequency stimulation can provide analgesia without these unnecessary sensations.

Investigation of the efficacy of two different laser types in the treatment of lower lip paresthesia after sagittal split ramus osteotomy

Orthognathic surgery involves invasive and major surgical procedures commonly used to correct maxillofacial deformities. Bilateral sagittal split ramus osteotomy (BSSO) is often used to treat dentofacial anomalies related to the mandible, but it can result in various complications, the most common of which is inferior alveolar nerve damage. Nerve damage-induced paresthesia of the lower lip significantly affects patient comfort. Medical treatments such as steroids and vitamin B, low-level laser therapy (LLLT), and platelet-rich fibrin (PRF) can be used as supportive therapies for nerve regeneration after damage. This study aimed to investigate the effectiveness of two different types of lasers in treating lower lip paresthesia after BSSO. This clinical trial was a controlled, single-center, prospective, single-blind, randomized study. Thirty patients were included in the study and randomly assigned to three groups: Group I (laser GRR, n = 10) received transcutaneous and transmucosal GRR laser treatment, Group II (Epic10 laser, n = 10) received transmucosal and transcutaneous Epic10 laser treatment, and Group III (vitamin B, n = 10) received B-complex vitamin tablets orally once a day. Two-point and brush tests were performed six times at specific intervals, and a visual analog scale was used to evaluate pain and sensitivity. Both vitamin B and laser therapies accelerated nerve regeneration. The contribution of the laser groups to the healing rate was better than that of the vitamin B group. Although there was no statistically significant difference between the two laser groups, clinical observations indicated better results in the GRR laser group.

Postural Changes in Spinal Cord Stimulation Thresholds: Current and Voltage Sources

OBJECTIVE

Spinal cord stimulation (SCS) thresholds are known to change with body position; however, these changes have not been fully characterized for both "constant-voltage" and "constant-current" pulse generators. This study aimed to evaluate and quantify changes in psychophysical thresholds resulting from postural changes that may affect both conventional paresthesia-based SCS and novel paresthesia-free SCS technologies.

MATERIALS AND METHODS

We measured perceptual, usage, and discomfort thresholds in four body positions (prone, supine, sitting, standing) in 149 consecutive patients, with temporary lower thoracic percutaneous epidural electrodes placed for treating persistent low back and leg pain. We trialed 119 patients with constant-voltage stimulators and 30 patients with constant-current stimulators.

RESULTS

Moving from supine to the sitting, standing, or prone positions caused all three thresholds (perceptual, usage, and discomfort) to increase by 22% to 34% for constant-voltage stimulators and by 44% to 82% for constant-current stimulators. Changing from a seated to a supine position caused stimulation to exceed discomfort threshold significantly more often for constant-current (87%) than for constant-voltage (63%) stimulators (p = 0.01).

CONCLUSIONS

Posture-induced changes in SCS thresholds occurred consistently as patients moved from lying (supine or prone) to upright (standing or sitting) positions. These changes were more pronounced for constant-current than for constant-voltage pulse generators and more often led to stimulation-evoked discomfort. These observations are consistent with postural changes in spinal cord position measured in imaging studies, and with computer model predictions of neural recruitment for these different spinal cord positions. These observations have implications for the design, implantation, and clinical application of spinal cord stimulators, not only for conventional paresthesia-based SCS but also for paresthesia-free SCS.

Defining the Boundaries of Patient Perception in Spinal Cord Stimulation Programming

OBJECTIVES

Recent developments in spinal cord stimulation (SCS) programming have initiated new modalities of imperceptible stimulation. However, the boundaries of sensory perception are not well defined. The BEnchtop NEuromodulation Following endIng of Trial study aimed to create a map of perceptual threshold responses across a broad range of SCS parameters and programming to inform subperception therapy design.

MATERIALS AND METHODS

This multicenter study was conducted at seven US sites. A total of 43 patients with low back and/or leg pain who completed a percutaneous commercial SCS trial were enrolled. Test stimulation was delivered through trial leads for approximately 90 minutes before removal. SCS parameters, including amplitude, frequency, pulse width (PW), electrode configuration, cycling, and multifrequency stimulation were varied during testing. Paresthesia threshold (PT), comfort level (CL), perceptual coverage area, and paresthesia quality (through patient selection of keywords) were collected. Differences were evaluated with analysis of variance followed by post hoc multiple comparisons using t-tests with Bonferroni correction.

RESULTS

PT was primarily determined by PW and was insensitive to frequency for constant frequency stimulation (range: 20 Hz-10 kHz; F(1284) = 69.58, p < 0.0001). For all tests, CL was approximately 25% higher than PT. The dominant variable that influenced paresthesia quality was frequency. Sensations described as comfortable and tingling were most common for frequencies between 60 Hz and 2.4 kHz; unpleasant sensations were generally more common outside this range. Increasing distance between active electrodes from 7 mm to 14 mm, or cycling the SCS waveform at 1 Hz, decreased PT (p < 0.0001). Finally, PT for a low-frequency stimulus (ie, 60 Hz) was unaffected by mixing with a sub-PT high-frequency stimulus.

CONCLUSIONS

In contrast to previous work investigating narrower ranges, PW primarily influenced PT, independently of frequency. Paresthesia quality was primarily influenced by pulse frequency. These findings advance our understanding of SCS therapy and may be used to improve future novel neuromodulation paradigms.

Combined Short-Pulse and Directional Deep Brain Stimulation of the Thalamic Ventral Intermediate Area for Essential Tremor

OBJECTIVE

Novel deep brain stimulation (DBS) systems allow directional and short-pulse stimulation to potentially improve symptoms and reduce side effects. The aim of this study was to investigate the effect of short-pulse and directional stimulation, in addition to a combination of both, in the ventral intermediate thalamus (VIM)/posterior subthalamic area (PSA) on tremor and stimulation-induced side effects in patients with essential tremor.

MATERIALS AND METHODS

We recruited 11 patients with essential tremor and VIM/PSA-DBS. Tremor severity (Fahn-Tolosa-Marin), ataxia (International Cooperative Ataxia Rating Scale), and paresthesia (visual analog scale) were assessed with conventional omnidirectional and directional stimulation with pulse width of 60 μs and 30 μs.

RESULTS

All stimulation conditions reduced tremor. The best directional stimulation with 60 μs reduced more tremor than did most other stimulation settings. The best directional stimulation, regardless of pulse width, effectively reduced stimulation-induced ataxia compared with the conventional stimulation (ring 60 μs) or worst directional stimulation with 60 μs. All new stimulation modes reduced occurrence of paresthesia, but only the best directional stimulation with 30 μs attenuated paresthesia compared with the conventional stimulation (ring 60 μs) or worst directional stimulation with 60 μs. The best directional stimulation with 30 μs reduced tremor, ataxia, and paresthesia compared with conventional stimulation in most patients. Correlation analyses indicated that more anterior stimulation sites are associated with stronger ataxia reduction with directional 30 μs than with conventional 60 μs stimulation.

CONCLUSION

Directional and short-pulse stimulation, and a combination of both, revealed beneficial effects on stimulation-induced adverse effects.

Approach to diagnosis, evaluation, and treatment of generalized and nonlocal dysesthesia: A review

Dysesthesia is an abnormal sensation in the skin that occurs in the absence of any extraordinary stimulus or other primary cutaneous disorders, excluding any delusions or tactile hallucinations. Clinicians have characterized dysesthesias to include sensations such as burning, tingling, pruritus, allodynia, hyperesthesia, or anesthesia. The etiology and pathogenesis of various generalized dysesthesias is largely unknown, though many dysesthesias have been associated with systemic pathologies including malignancy, infection, autoimmune disorders, and neuropathies. Dermatologists are often the first-line clinicians for patients presenting with such cutaneous findings, thus it is crucial for these physicians to be able to methodically work-up generalized dysesthesias to build a working differential diagnosis, follow up with key labs and/or imaging, and offer patients evidence-based treatment to relieve their symptoms. This broad literature review is an attempt to centralize key studies, cases, and series to help guide dermatologists in their assessment and evaluation of complaints of abnormal cutaneous sensations.

Should we Oppose or Combine Waveforms for Spinal Cord Stimulation in PSPS-T2 Patients? A Prospective Randomized Crossover Trial (MULTIWAVE Study)

Refractory persistent spinal pain syndrome after surgery (PSPS-T2) can be successfully addressed by spinal cord stimulation (SCS). While conventional stimulation generates paresthesia, recent systems enable the delivery of paresthesia-free stimulation. Studies have claimed non-inferiority/superiority of selected paresthesia-free stimulation compared with paresthesia-based stimulation, but the comparative efficacy between different waveforms still needs to be determined in a given patient. We designed a randomized controlled 3-month crossover trial to compare pain relief of paresthesia-based stimulation versus high frequency versus burst in 28 PSPS-T2 patients implanted with multiwave SCS systems. Our secondary objectives were to determine the efficacy of these 3 waveforms on pain surface, quality of life, functional capacity, psychological distress, and validated composite multidimensional clinical response index to provide holistic comparisons at 3-, 6-, 9-, and 15-month post-randomization. The preferred stimulation modality was documented during the follow-up periods. No difference between the waveforms was observed in this study (P = .08). SCS led to significant pain relief, quality of life improvement, improvement of multidimensional clinical response index, and of all other clinical outcomes at all follow-up visits. Forty-four percent of the patients chose to keep the paresthesia-based stimulation modality after the 15-month follow-up period. By giving the possibility to switch and/or to combine several waveforms, the overall rate of SCS responders further increased with 25%. In this study, high frequency or burst do not appear superior to paresthesia-based stimulation, wherefore paresthesia-based stimulation should still be considered as a valid option. However, combining paresthesia-based stimulation with paresthesia-free stimulation, through personalized multiwave therapy, might significantly improve SCS responses. PERSPECTIVE: This article assesses clinical SCS efficacy on pain relief, by comparing paresthesia-based stimulation and paresthesia-free stimulation (including high frequency and burst) modalities in patient presenting with PSPS-T2. Switching and/or combining waveforms contribute to increasing the global SCS responders rate.

Clinical Reasoning: A Young Woman With Rapidly Progressive Weakness and Paresthesia

A 24-year-old Middle Eastern woman presented with a 2-month history of rapidly progressive asymmetric weakness and paresthesia that began in her left lower extremity and progressed to involve both legs and arms. It was associated with overflow urinary incontinence and significant weight loss. In addition, she complained of a constant occipital headache that worsened in the supine position and was associated with photophobia, tinnitus, nausea, vomiting, and horizontal binocular diplopia. She also had signs of meningismus, decreased left facial sensation, and right sensorineural hearing loss. Because multifocal localization suggests a wide variety of possible differential diagnoses, this study expands on the differential of a subacute multifocal process while highlighting the importance of identifying appropriate risk factors and performing a relevant yet focused diagnostic workup.

Epidural Laterality and Pain Relief With Burst Spinal Cord Stimulation

INTRODUCTION

Burst spinal cord stimulation (SCS) can achieve excellent clinical reduction of pain, alongside improvements in function, quality of life, and related outcomes. Good outcomes likely depend on good lead placement, thereby enabling recruitment of the relevant neural targets. Several competing approaches exist for lead implantation, such as the use of single vs bilateral leads and leads lateralized vs placed at midline. The objective of this study was to examine the relationship between paresthesia locations and pain relief with burst SCS in a prospective double-blind crossover design.

MATERIALS AND METHODS

All participants had bilateral back and leg pain, with more intense pain experienced on one side of the body. A trial SCS system was placed, during which brief intraoperative mapping with conventional stimulation was used to characterize paresthesia locations. Two programs for subperception burst SCS treatment were then applied for two days each, in random order: bilateral paresthesia coverage vs unilateral paresthesia coverage contralateral to the side of the body with more intense pain. Pain ratings (visual analog scale [VAS]) and pain reductions (scaling pain relief [SPR]) were reported for each.

RESULTS

Of the 30 participants who completed the study, 24 (80%) had good pain relief with at least one program. A baseline VAS score of 8.75 was reduced to 5.98 with contralateral stimulation and to 2.88 with bilateral stimulation; with SPR, this equated to 31.25% and 67.50% improvement, respectively. The incremental benefit of bilateral stimulation over contralateral stimulation was statistically significant (p < 0.001). Of the 24 participants, 87.5% preferred bilateral stimulation, whereas 12.5% preferred unilateral stimulation. The six participants who failed the trial had no preference.

DISCUSSION

When burst stimulation is delivered to spinal targets that can generate paresthesias contralateral to the side of worst pain, suboptimal therapy is achieved. Thus, attention to laterality and pain coverage is critical for successful therapy, and it may be important to carefully consider lead implantation techniques.

Persistent post-COVID-19 neuromuscular symptoms

Neuromuscular symptoms may develop or persist after resolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Besides residual sensorimotor symptoms associated with acute neuromuscular complications of coronavirus disease-2019 (COVID-19), such as Guillain-Barré syndrome, critical illness neuromyopathy, and rhabdomyolysis, patients may report persistent autonomic symptoms, sensory symptoms, and muscle symptoms in the absence of these acute complications, including palpitations, orthostatic dizziness and intolerance, paresthesia, myalgia, and fatigue. These symptoms may be associated with long COVID, also known as post-COVID-19 conditions or postacute sequelae of SARS-CoV-2 infection, which may significantly impact quality of life. Managing these symptoms represents a challenge for health-care providers. Recent advances have identified small-fiber neuropathy as a potential etiology that may underlie autonomic dysfunction and paresthesia in some long COVID patients. The pathogenic mechanisms underlying myalgia and fatigue remain elusive and need to be investigated. Herein we review the current state of knowledge regarding the evaluation and management of patients with persistent post-COVID-19 neuromuscular symptoms.

Evaluating the influence of the mandibular canal trajectory on the duration of postoperative paraesthesia in patients undergoing inferior alveolar nerve lateralisation: a prospective cohort study

This prospective cohort study aims to evaluate the influence of the mandibular canal trajectory on the duration of postoperative paraesthesia in patients undergoing inferior alveolar nerve lateralisation (IANL). Twenty patients received a total of 50 dental implants, and their postoperative paraesthesia duration, implant success rate, and anatomical variables were assessed. All patients experienced temporary neurosensory disturbances postoperatively during the first week, but none reported permanent issues at the 12-month follow up. The median paraesthesia duration was 120 days, and no significant differences were detected between genders, anaesthesia types, or patient satisfaction. No significant association was found between the mandibular canal trajectory and postoperative paraesthesia duration. The implant success rate was 100%, with all implants integrating successfully. Our findings suggest that IANL is a safe and effective method for dental implant placement in atrophic mandibles.

Brachioradial Pruritus: An Etiologic Review and Treatment Summary

Brachioradial pruritus (BRP) is a relatively uncommon neuropathic dysesthesia localized to the dorsolateral arms that causes unrelenting itching, burning, tingling, or stinging sensations. There is no identifiable cause of BRP to date, though it is thought to be secondary to either cervical spine pathology or exposure to UV radiation (UVR). Gold-standard treatment of BRP remains unknown. This article reviews previously trialed conservative management options, including chiropractic manipulation, acupuncture, physiotherapy, and photoprotection, as well as medical management options that have been utilized to treat BRP, such as medications, interventional pain management procedures, and surgery. We compiled an updated comprehensive list of possible treatment strategies to be utilized by future providers.

Meralgia paresthetica mimic after Moderna COVID‑19 vaccine

This report describes the case of a 56-year-old male who developed unilateral right anterior thigh numbness which began 16 hours after receiving his second Moderna COVID-19 vaccine in the left deltoid. The numbness persisted and after one week a circular, raised, painless area with a red border appeared in the center of the anterior thigh which resolved after 2 weeks spontaneously. There was no clinical history or risk factors consistent with meralgia paresthetica. At his 6 month follow up the patient reported that his symptoms spontaneously resolved. While many other non-specific neurologic side effects of COVID-19 vaccines have been documented, this is the first case of meralgia paresthetica documented after a vaccine without any other risk factors for the syndrome. COVID vaccines should be considered as a potential cause of very localized peripheral neuropathy.

Exploring the Use of the Current Perception Threshold in Pharyngeal Paresthesia Patients

To explore pharyngeal sensory function by current perception threshold (CPT) measurement in paresthetic pharynx. In total, 58 healthy participants and 66 patients with pharyngeal paresthetic symptoms underwent CPT evaluation. Pharyngeal paresthesia (n = 66) was classified into three categories based on aetiologies: six cases with pain in pharynx; 34 neuropathic patients with glossopharyngeal nerve and/or vagus nerve or recurrent laryngeal nerve injury; and 26 patients with globus pharyngeus. CPT measurements were obtained from bilateral palatoglossal arch and tongue base at 2000, 250 and 5 Hz stimulation frequencies. Ranked from high to low, the CPT values for the bilateral palatoglossal arches and tongue bases were: lower cranial neuropathic patients, globus pharyngeus, healthy participants and patients with pain. The CPT values for neuropathic patients on the injured side were significantly higher than those on the healthy side (P < 0.05). The CPT values for patients with pain in pharynx were significantly lower than those of healthy participants (P < 0.05) when the bilateral tongue bases were stimulated. The CPT measurement is a reliable method for quantitatively assessing pharyngeal sensory function and able to differentiate pharyngeal paresthesia between lower cranial neuropathic and subjective discomfort. Pharyngeal sensory function is more sensitive in patients with pain in pharynx. Pharyngeal sensory function is significantly reduced in lower cranial neuropathic patients, especially on the injured side. Patients with globus pharyngeus have pharyngeal hyposensitivity.

Dorsal arachnoid web: A rare cause of syringomyelia and myelopathy

Dorsal arachnoidal webs are condensations of arachnoidal tissue densely adherent to the pial surface of the posterior aspect of the dorsal spinal cord. Infrequently described in literature they disrupt the flow of CSF in the spinal subarachnoid space leading to syringomyelia and myelopathy. While there are several theories on their origin, the "scalpel sign" on magnetic resonance imaging is considered to be pathognomonic of this condition. An illustrative case of a 58 year old man with syringomyelia and dorsal cord indentation who presented with spastic paraparesis, gait instability, parasthesias and bilateral non radicular upper limb pain that resolved following excision of the web is described to highlight the importance of considering this diagnosis when cases of so called "idiopathic" syringomyelia are encountered.

Spinal cord stimulation to treat meralgia paresthetica. Is it feasible? A case report

Meralgia paresthetica is a neurological disorder caused by a neuropathy of the lateral femoral cutaneous nerve. Its aetiology can be spontaneous or iatrogenic. It is characterized by pain, paresthesia, and numbness in the anterolateral aspect of the thigh. Diagnosis is based on clinical examination, although image and neurophysiological tests can be useful as well. Despite conservative measures use to be effective in most of patients, refractory cases can benefit from alternative treatments. Available surgical procedures are: nerve decompression (neurolysis) or section (neurectomy) and radiofrequency ablation. We present a case of refractory meralgia paresthetica where spinal cord stimulation was used as a possible effective technique in pain relief and to avoid the neurectomy of the lateral femoral cutaneous nerve.

Loss of Taste as an Initial Symptom of a "Facial Diplegia and Paresthesia" Variant of Guillain-Barré Syndrome

Loss of taste is a relatively common symptom of coronavirus disease 2019 (COVID-19) and has also been considered a rare Guillain-Barré syndrome (GBS) symptom. We herein report a case of a facial diplegia and paresthesia (FDP) variant of GBS that initially presented as a loss of taste occurring two weeks after COVID-19 mRNA vaccination. The patient recovered completely after intravenous immunoglobulin therapy. Clinicians should consider the possibility of post-vaccination FDP manifesting as facial palsy and should be aware that GBS, including the FDP variant, can initially present as an isolated loss of taste.

Management of Patients with Cervicofacial Edema and Paresthesia during Perioperative Period of Transoral Endoscopic Thyroidectomy

Objective

To analyze the clinical intervention effect of transoral endoscopic thyroidectomy on the neck and face during perioperative period.

Method

From January 2019 to January 2020, 60 patients included in this study were randomly divided into observation group and control group according to the ratio of 1 : 1, with 30 cases in each group. Both groups underwent rapid surgical intervention during the perioperative period. The patients in the observation group received neck and face management. The degree of jaw swelling, the degree of facial microexpression completion, and the changes in jaw and neck sensation were compared between the two groups.

Results

There was no significant difference in neck and face swelling, pain, facial microexpression, and feeling between the two groups before operation. Patients with facial I/II swelling degree in the observation group were significantly more than in the control group, and the patients with III swelling degree were less than in the control group. There was significant difference for facial swelling between the two groups in the three intervention periods after the operation, and the difference was statistically significant (P < 0.05). The scores of facial microexpression in the observation group were higher than those in the control group during the three postoperative intervention periods, with statistical significance (P < 0.05). There was no significant difference in the pain score of the first day after surgery between the two groups (P = 0.298). In the other two postoperative intervention periods, the pain score of the observation group was lower than that of the control group, with a statistically significant difference, and the difference was statistically significant (P < 0.05). The threshold of chin and neck sensory pressure in the two groups was statistically significant (P < 0.05) except that the "cheek in area 4" (P = 0.290).

Conclusion

The results showed that these interventions, such as the elevation of bed after operation, 24-hour intermittent cryotherapy, ice cubes in mouth, and the "meter" functional training, have good clinical effects on the symptoms of facial swelling and abnormal sensation of neck and face. It can accelerate the speed of edema dissipation, improve the patients' postoperative comfort, and improve the satisfaction and quality of life of patients with the effect of surgery and beauty.

61-year-old woman • nausea • paresthesia • cold allodynia • Dx?

► Nausea ►Paresthesia ► Cold allodynia.

Comparison of Paresthesia Mapping With Anatomic Placement in Burst Spinal Cord Stimulation: Long-Term Results of the Prospective, Multicenter, Randomized, Double-Blind, Crossover CRISP Study

OBJECTIVES

Spinal cord stimulation (SCS) is an effective therapy for chronic intractable pain. Conventional SCS involves electrode placement based on intraoperative paresthesia mapping; however, newer paradigms like burst may allow for anatomic placement of leads. Here, for the first time, we report the one-year safety and efficacy of burst SCS delivered using a lead placed with conventional, paresthesia mapping, or anatomic placement approach in subjects with chronic low back pain (CLBP).

MATERIALS AND METHODS

Subjects with CLBP were implanted with two leads. The first lead was placed to cross the T8/T9 disc and active contacts for this lead were chosen through paresthesia mapping. The second lead was placed at the T9/T10 spinal anatomic landmark. Subjects initially underwent a four-week, double-blinded, crossover trial with a two-week testing period with burst SCS delivered through each lead in a random order. At the end of trial period, subjects expressed their preference for one of the two leads. Subsequently, subjects received burst SCS with the preferred lead and were followed up at 3, 6, and 12 months. Pain intensity (visual analog scale), quality-of-life (EuroQol-5D instrument), and disability (Oswestry Disability Index) were evaluated at baseline and follow-up.

RESULTS

Forty-three subjects successfully completed the trial. Twenty-one preferred the paresthesia mapping lead and 21 preferred the anatomic placement lead. Anatomic placement lead was activated in one subject who had no preference. The pain scores (for back and leg) significantly improved from baseline for both lead placement groups at all follow-up time points, with no significant between-group differences.

CONCLUSIONS

This study demonstrated that equivalent clinical benefits could be achieved with burst SCS using either paresthesia mapping or anatomic landmark-based approaches for lead placement. Nonparesthesia-based approaches, such as anatomic landmark-based lead placement investigated here, have the potential to simplify implantation of SCS and improve current surgical practice.

Mandibular nerve schwannoma: a case report

Benign schwannomas are uncommon and their intraosseous location is even rarer counting for less than 1% of all benign primary bone tumors. They exceptionally occur in the oral cavity with the tongue being the most common site of involvement. We report here a case of intramandibular schwannoma derived from the inferior alveolar nerve, in a 57-year-old patient with a 3 months history of inferior left lip paresthesia. The oral examination showed a firm, painless and non-pulsatile swelling located in the inferior vestibule. The panoramic X-ray revealed a circumscribed and homogeneous radiolucent image. Treatment consisted of total excision of the tumor with preservation of the nerve bundles. The histological examination confirmed the diagnosis of schwannoma. The patient recovered a normal sensory function 6 months post-operatively without any recurrence up to 2 years after surgery. The treatment of intramandibular schwannoma is basically surgical with the conservative approach being the most advocated by majority of authors.

Notalgia paresthetica: An underdiagnosed condition in primary care

ABSTRACT

Notalgia paresthetica is a perplexing diagnosis in the primary care setting. Chronic itching, paresthesia, or pain causes discomfort in patients who suffer with notalgia paresthetica and it is thought to be a common but underdiagnosed condition. Recognition of this dermatologic condition can lead to reassurance and relief for affected patients.

Paresthesia Predicts Increased Risk of Distal Neuropathic Pain in Older People with HIV-Associated Sensory Polyneuropathy

OBJECTIVE

Distal sensory polyneuropathy (DSP) is a disabling consequence of human immunodeficiency virus (HIV), leading to poor quality of life and more frequent falls in older age. Neuropathic pain and paresthesia are prevalent symptoms; however, there are currently no known curative treatments and the longitudinal course of pain in HIV-associated DSP is poorly characterized.

METHODS

This was a prospective longitudinal study of 265 people with HIV (PWH) enrolled in the CNS HIV Antiretroviral Therapy Effects Research (CHARTER) study with baseline and 12-year follow-up evaluations. Since pain and paresthesia are highly correlated, statistical decomposition was used to separate the two symptoms at baseline. Multivariable logistic regression analyses of decomposed variables were used to determine the effects of neuropathy symptoms at baseline on presence and worsening of distal neuropathic pain at 12-year follow-up, adjusted for covariates.

RESULTS

Mean age was 56 ± 8 years, and 21% were female at follow-up. Nearly the entire cohort (96%) was on antiretroviral therapy (ART), and 82% had suppressed (≤50 copies/mL) plasma viral loads at follow-up. Of those with pain at follow-up (n = 100), 23% had paresthesia at the initial visit. Decomposed paresthesia at baseline increased the risk of pain at follow-up (odds ratio [OR] 1.56; 95% confidence interval [CI] 1.18, 2.07), and decomposed pain at baseline predicted a higher frequency of pain at follow-up (OR 1.96 [95% CI 1.51, 2.58]).

CONCLUSIONS

Paresthesias are a clinically significant predictor of incident pain at follow-up among aging PWH with DSP. Development of new therapies to encourage neuroregeneration might take advantage of this finding to choose individuals likely to benefit from treatment preventing incident pain.

Comparison Between Cyanoacrylate Embolization and Radiofrequency Ablation for Superficial Venous Incompetence: A Systematic Review and Meta-analysis

BACKGROUND

Chronic venous disease is a debilitating condition involving great saphenous vein (GSV) incompetence.

OBJECTIVE

To investigate the efficacy and effectiveness of cyanoacrylate embolization (CAE) versus radiofrequency ablation (RFA) in patients with incompetent GSVs.

MATERIALS AND METHODS

PubMed, Embase, and the Cochrane library were searched. The primary outcomes were the Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ), closure rate, and visual analog scale (VAS) for pain.

RESULTS

This meta-analysis included 378 and 590 patients who underwent CAE and RFA, respectively. Cyanoacrylate embolization was comparable with RFA in VCSS (weighted mean difference [WMD] = -0.03, 95% confidence interval [CI]: -0.18 to 0.12, p = .686), AVVQ (WMD = -0.08, 95% CI: -0.38 to 0.21, p = .570), closure rate (odds ratio [OR] = 0.61, 95% CI: 0.18-2.01, p = .414), and VAS (standardized mean difference [SMD] = 0.24, 95% CI: -0.59 to 1.06, p = .523). There were no significant differences between CAE and RFA regarding the occurrence of phlebitis (OR = 1.22, 95% CI: 0.70-2.13, p = .479) and pigmentation (OR = 0.48, 95% CI: 0.18-1.31, p = .153), but CAE had a lower risk of ecchymosis (OR = 0.45, 95% CI: 0.25-0.81, p = .007) and paresthesia (OR = 0.16, 95% CI: 0.03-0.99, p = .049).

CONCLUSION

Cyanoacrylate embolization and RFA demonstrated no significant differences in VCSS, AVVQ, closure rate, and pain score for patients with incompetent GSVs. Patients in the CAE group had a lower risk of ecchymosis and paresthesia compared with the RFA group.

A 67-Year-Old Woman With Abdominal Pain, Paresthesia, and Rapidly Expanding Lung Nodule

CASE PRESENTATION

A 67-year-old woman with a medical history significant for hypertension, hyperlipidemia, type 2 diabetes mellitus, OSA, and schizophrenia was admitted multiple times the previous 3 months for generalized abdominal pain. Her most recent admission was unique for new onset bilateral upper and lower extremity weakness with paresthesia. Pertinent review of systems included malaise, fever, cough, left lower quadrant pain without weight loss, and rash. Previous evaluation included multiple CT scans of her abdomen that revealed colonic thickening. Ensuing colonoscopy revealed chronic ulcers with cytopathic changes consistent with cytomegalovirus.

Thoracic degenerative spondylolisthesis-associated myelopathy: A case report

RATIONALE

The thoracic spine is stabilized in the anteroposterior direction by the rib cage and the facet joints, thus thoracic degenerative spondylolisthesis is very uncommon. Here, we report a rare case of thoracic degenerative spondylolisthesis in which the lower thoracic region was the only region involved.

PATIENT CONCERNS

We present the case of a 56-year-old Chinese female who suffered from thoracic degenerative spondylolisthesis. She had a 2-year history of gait disturbance and bilateral lower-extremity numbness. The initial imaging examinations revealed Grade I anterior spondylolisthesis and severe cord compression, as well as bilateral facet joint osteoarthritis at T11/12.

DIAGNOSIS

The patient was diagnosed with thoracic degenerative spondylolisthesis-associated myelopathy.

INTERVENTIONS

She underwent a posterior decompression with transforaminal thoracic interbody fusion (TTIF) at T11/12.

OUTCOMES

The patient recovered well after the operation, and MRI at 12-month follow-up revealed that spinal cord compression was relieved and high signal intensity in T2-weighted image was improved.

LESSONS

To the best of our knowledge, this is the first reported case of thoracic degenerative spondylolisthesis in which the lower thoracic region was the only region involved. Disruption of joint capsule, instability with micromotion, and degenerative disc may contribute to this rare disease. Posterior decompression with posterolateral fusion or TTIF were the main treatment modalities, however, TTIF has its unique advantages because of sufficient decompression, immediate stability and high fusion rate.

Metastatic prostate cancer presenting as trigeminal nerve paresthesia in the mandible

Metastatic disease to the oral cavity is rare and often presents with ambiguous symptoms and subtle or no radiographic changes. These factors make diagnosis challenging. This article describes a case of metastatic prostate cancer to the mandible that presented as altered sensation to the gingiva, lips, and chin without radiographic evidence of pathosis noted on standard dental imaging. At the time of presentation, the patient's prostate cancer, diagnosed 9 years previously, was thought to be well-controlled with medical therapy. With additional laboratory testing and medical imaging, widespread metastatic disease was discovered. This case reinforces the importance of including metastatic disease in the differential diagnosis as well as the utility of collaboration with providers outside dentistry.

Safety and surgical outcomes of transoral endoscopic thyroidectomy vestibular approach for papillary thyroid cancer: A two-centre study

OBJECTIVE

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been increasingly used to treat patients with papillary thyroid cancer (PTC) with improved cosmetic outcomes. This study aimed to explore the safety and efficacy of TOETVA in patients with PTC.

MATERIALS AND METHODS

This retrospective study included TOETVA patients from Yantai Yuhuangding and Xiamen Zhongshan Hospitals. Among the 297 patients studied, 84 had benign nodules (28.3%), 208 had PTC (70.0%), and five had follicular thyroid cancer (1.7%).

RESULTS

The incidence of transient and permanent recurrent laryngeal nerve injury was 1.3%, while that of transient hypoparathyroidism was 1.0%. Mental nerve paraesthesia was observed in 241 cases (81.1%), while permanent mental nerve paraesthesia was noted in seven cases (2.4%). Abnormal motor function of the lower lip and chin was observed in 12 cases (4.0%). Ten of the 208 patients with PTC (4.8%) underwent total thyroidectomy (TT) and bilateral central neck dissection (CND). A mean 6.6 ± 4.1 and 10.9 ± 4.0 lymph nodes were removed in the unilateral and bilateral surgeries, respectively, with a metastasis rate of 49.0%; a mean 2.7 ± 2.3 and 3.2 ± 2.6 lymph nodes were metastatic, respectively. The parathyroid gland was inadvertently removed in 6.6% and auto-transplanted in 10.6% of patients with unilateral PTC. The non-stimulated thyroglobulin level in the TT and bilateral CND patients was below 1 ng/mL at the 6-month follow-up.

CONCLUSION

TOETVA is safe in well-selected patients with unilateral PTC. However, its safety remains unclear in patients treated with TT and bilateral CND.

Multidisciplinary approach to Fabry disease: from the eye of a neurologist

Fabry Disease (FD) is an X-linked lysosomal storage disease that emerges as a result of the mutations in the galactosidase A gene encoding alpha-galactosidase. The peripheral nervous system (PNS) involvement manifests itself as acroparesthetic complaints due to the small-fiber involvement. Our goal was to assess the PNS involvement of 14 patients with FD both clinically and electrophysiologically besides the other systemic features. 14 patients (11 female and 3 male) of the same family whose enzyme level and genetic mutation analysis confirmed the FD diagnosis were evaluated retrospectively in terms of systemic and neurological findings of the FD. Neurological examination and nerve conduction studies were performed to evaluate the PNS involvement. PNS involvement was more common in females. Eight of the patients had acroparesthesia. The neurological examinations of all patients were normal. Two patients presented sensory axonal polyneuropathy, one of whom had no acroparesthesia. Other patients with acroparesthesia had normal nerve conduction studies. There was no significant relationship between the presence of acroparesthesia and the results of conduction studies (p > 0.05). Acroparesthetic complaints in patients with normal results were attributed to small-fiber involvement. Since small-diameter nerve fibers cannot be evaluated by routine conduction studies, especially in the early stages of FD, these studies may be normal. Early diagnosis through the symptoms such as acroparesthesia may contribute to the survival of the patient by preventing and/or delaying the development of renal, cardiac, and cerebrovascular diseases, which are the main causes of morbidity and mortality.

Uniportal thoracoscopic surgical management using a suture traction for primary pneumothorax

BACKGROUND

We devised a new strategy using suture traction to facilitate the management of primary spontaneous pneumothorax during uniportal thoracoscopy. To test its validity, we compared the outcomes of our modified technique with those of conventional three-port thoracoscopy.

METHODS

This retrospective study included all 43 consecutive patients with primary spontaneous pneumothorax undergoing thoracoscopy between January 2017 and December 2019. They were divided within two groups: uniportal thoracoscopy using suture traction (n = 21) and conventional 3-port thoracoscopy (n = 22). Postoperative pain, paresthesia, patient satisfaction, and surgical outcomes were compared to test the validity of our technique.

RESULTS

There were no significant differences in operative time (47 ± 4.8 vs. 43 ± 7.9 min), number of staples used (2.5 ± 0.9 vs. 2.3 ± 0.6), postoperative drainage (235 ± 15 vs. 240 ± 19 mL), chest tube drainage time (3.2 ± 0.8 vs. 3.4 ± 1.8 days), and hospital stay (4.2 ± 1.2 vs. 4.3 ± 0.9 days). However, uniportal thoracoscopy was associated with less pain at 24 (p = 0.01), 48 (p = 0.02), and 72 h (p = 0.03) postoperatively, less paresthesia at 24 (p = 0.03), 48 (p = 0.02), and 72 h (p = 0.02) postoperatively, and greater patient satisfaction at 24 (p = 0.04), 48 (p = 0.02), and 72 h (p = 0.02) postoperatively.

CONCLUSIONS

Our technique may facilitate the use of uniportal thoracoscopy for treatment of primary spontaneous pneumothorax, reducing neurological sequelae and improving patient satisfaction compared to the traditional three-port thoracoscopy.

Hyperacute extensive spinal cord infarction and negative spine magnetic resonance imaging: a case report and review of the literature

RATIONALE

Spinal cord infarction (SCI) accounts for only 1% to 2% of all ischemic strokes and 5% to 8% of acute myelopathies. Magnetic resonance imaging (MRI) holds a role in ruling out non-ischemic etiologies, but the diagnostic accuracy of this procedure may be low in confirming the diagnosis, even when extensive cord lesions are present. Indeed, T2 changes on MRI can develop over hours to days, thus accounting for the low sensitivity in the hyperacute setting (ie, within 6 hours from symptom onset). For these reasons, SCI remains a clinical diagnosis. Despite extensive diagnostic work-up, up to 20% to 40% of SCI cases are classified as cryptogenic. Here, we describe a case of cryptogenic longitudinally extensive transverse myelopathy due to SCI, with negative MRI and diffusion-weighted imaging at 9 hours after symptom onset.

PATIENT CONCERNS

A 51-year-old woman presented to our Emergency Department with acute severe abdominal pain, nausea, vomiting, sudden-onset of bilateral leg weakness with diffuse sensory loss, and paresthesias on the trunk and legs.

DIAGNOSES

On neurological examination, she showed severe paraparesis and a D6 sensory level. A 3T spinal cord MRI with gadolinium performed at 9 hours after symptom onset did not detect spinal cord alterations. Due to the persistence of a clinical picture suggestive of an acute myelopathy, a 3T MRI of the spine was repeated after 72 hours showing a hyperintense "pencil-like" signal mainly involving the grey matter from T1 to T6 on T2 sequence, mildly hypointense on T1 and with restricted diffusion.

INTERVENTIONS

The patient was given salicylic acid (100 mg/d), prophylactic low-molecular-weight heparin, and began neuromotor rehabilitation.

OUTCOMES

Two months later, a follow-up neurological examination revealed a severe spastic paraparesis, no evident sensory level, and poor sphincteric control with distended bladder.

LESSONS

Regardless of its relatively low frequency in the general population, SCI should be suspected in every patient presenting with acute and progressive myelopathic symptoms, even in the absence of vascular risk factors. Thus, a clinical presentation consistent with a potential vascular syndrome involving the spinal cord overrides an initially negative MRI and should not delay timely and appropriate management.

The etiology of notalgia paresthetica: a descriptive study of 117 patients

BACKGROUND

Notalgia paresthetica (NP) is a neuropathic itching condition unilaterally localized in the midscapular area. It is a common but an underdiagnosed disease, and only a few studies investigating NP etiology with a limited number of patients have been reported in the literature.

OBJECTIVE

We aimed to evaluate the demographic, clinical, histopathological, neurological, and radiological findings of NP patients and investigate correlations between them and symptoms of NP to elucidate the etiology of NP.

METHODS

One hundred and seventeen consecutive patients diagnosed with NP were included and assessed in a multidisciplinary and prospective manner. We recorded demographic and clinical data and obtained a skin biopsy from the pruritic or hyperpigmented region. Pruritus severity was assessed by visual analogue scale (VAS). All patients were evaluated neurologically with magnetic resonance imaging.

RESULTS

The mean age of the patients was 47.08 ± 12.28 years. The disease was more common in females (87.2%). Statistical analysis revealed that VAS scores were independent of the age, gender, and skin type of the patient. We found no significant difference in VAS scores between NP patients with or without comorbidities. Vertebral pathologies detected by MRI and amyloid deposition revealed in histopathology were not among the main factors affecting VAS scores.

STUDY LIMITATION

Since consecutive patients enrolled into the study, we could not include equal number of male and female patients.

CONCLUSION

We found no correlation between symptom severity and findings from neurological and histopathological evaluations. Further microneurological studies should be carried out to elucidate the etiology of NP.

[A women with burning pain in her arms after a fall]

BACKGROUND

The central cord syndrome is an incomplete spinal cord injury that can develop after a minor trauma to the cervical spinal column.

CASE DESCRIPTION

A 73-year-old woman presented at our Emergency Department with pyelonephritis accompanied by weakness and a burning feeling in her arms and legs after a fall on her head. The weakness and pain did not improve during her hospital admission. On consultation with a neurologist, the patient was diagnosed with central cord syndrome. As the neurological loss of function did not resolve spontaneously, the patient underwent laminectomy and spondylodesis. Postoperatively her symptoms improved. After 22 days in hospital, the patient was discharged to a rehabilitation clinic.

CONCLUSION

In older patients with pre-existing degenerative cervical spinal stenosis, central cord stenosis resulting from minor trauma can cause severe and invalidating symptoms. The early tracing and treatment of patients with this syndrome is essential in order to increase the chance of neurological and functional recovery.

Pharyngeal dysesthesias as aura in epilepsy localized to the non-dominant frontal operculum misdiagnosed as non-epileptic seizures

The diagnosis of atypical paroxysmal events represents a significant challenge for clinicians when differentiating epileptic from nonepileptic events. The ictal manifestations of pharyngeal dysesthesias are often misdiagnosed and difficult to distinguish clinically, given their subtle features such as pharyngeal discomfort with and without autonomic symptomology. We report a rare case of isolated ictal pharyngeal dysesthesias localizing to the non-dominant frontal operculum lobe misdiagnosed as psychogenic and later confirmed by continuous video-EEG monitoring.

Unrecognized tibial nerve injury in total-ankle arthroplasty: Two case reports

RATIONALE

Tibial nerve injury is a sustainable but rare complication during total-ankle arthroplasty (TAA). We outlined 2 previously unreported cases of tibial nerve injury in TAA, including the prognoses and possible causes.

PATIENT CONCERNS

First, a 63-year-old woman complained of a 5-month history of persistent tingling sensation and numbness on the medial and plantar aspects of her foot after TAA. Second, a 50-year-old woman complained of a 6-month history of tingling sensation and numbness on the plantar surface of her forefoot after TAA.

DIAGNOSIS

Explorations were performed on suspicion of tarsal tunnel syndrome; however, both patients exhibited complete laceration of tibial nerve with neuroma formation.

INTERVENTIONS

In both patients, we excised the neuroma and performed end-to-end nerve repair.

OUTCOMES

The sensory disturbance of the sole considerably improved at long-term follow-up over 8 years after the neurorrhaphy procedures.

LESSONS

Tibial nerve injury is rare following TAA, and is sometimes unrecognized or misdiagnosed. If tibial nerve injury is suspected, prompt surgical exploration should be performed; great precaution must also be taken to prevent injury of the tibial nerve during TAA.

Effects of Kinesio Taping on pain, paresthesia, functional status, and overall health status in patients with symptomatic thoracic outlet syndrome: A single-blind, randomized, placebo-controlled study

OBJECTIVE

This study aimed to assess the effects of kinesio taping (KT) on pain, paresthesia, functional status, and overall health status in patients with symptomatic thoracic outlet syndrome (sTOS).

METHODS

A single-blind placebo-controlled design was employed in this study. The study duration was defined as 12 months. Analyses were performed on 60 patients with sTOS randomly assigned to KT (4 men and 26 women; mean age=33.5 years, range=20-46 years) and control groups (5 men and 25 women; mean age=26 years, range=20-43 years). KT was applied to the KT group three times. The control group received placebo taping. Pain and paresthesia were evaluated using the visual analogue scale (VAS) pain (10 cm) and VAS paresthesia (10 cm). The upper limb function was assessed using the disabilities of the arm, shoulder, and hand (DASH) questionnaire. The overall health status was evaluated based on the Nottingham Health Profile (NHP). Each assessment was carried out at baseline (t0), posttreatment (t1), and 8 weeks after baseline (t2).

RESULTS

In the KT group, except the social isolation domain of the NHP, all outcome measures showed improvement from t0 to t1. At the second follow-up visit (t2), improvements remained visible compared with baseline. However, none of the variables improved from t1 to t2. Otherwise, all measures deteriorated slightly, and the deteriorations in VAS for pain, NHP pain, NHP sleep, and NHP physical abilities were statistically significant (p=0.041, p=0.048, p=0.013, and p=0.016, respectively). In the control group, only VAS for paresthesia and NHP emotional reaction showed improvement over time (p=0.002 and p=0.044, respectively). When changes in outcome measures between the two groups were compared, except NHP emotional reaction and NHP social isolation, median changes (from t0 to t1) were higher in the KT group than in the control group (p<0.05 for all variables). Regarding VAS pain, VAS paresthesia, DASH, and three NHP domains (energy level, pain, and physical abilities), changes from t0 to t2 were also higher in the KT group (p<0.05 for all variables).

CONCLUSION

KT can provide benefits in terms of relieving pain and paresthesia, as well as improving the upper limb function and quality of life in patients with sTOS.

LEVEL OF EVIDENCE

Level II, Therapeutic study.

Tarsal tunnel syndrome caused by posterior facet talocalcaneal coalition: A case report

RATIONALE

Tarsal tunnel syndrome (TTS) is a compressive neuropathy of the posterior tibial nerve and its branches. Tarsal coalition is defined as a fibrous, cartilaginous, or osseous bridging of 2 or more tarsal bones. TTS with tarsal coalition is uncommon. Here, we present a rare example of successful surgical management of TTS with posterior facet talocalcaneal coalition.

PATIENT CONCERNS

A 74-year-old woman presented with hypoesthesia, numbness, and an intermittent tingling sensation on the plantar area over the right forefoot to the middle foot area. The hypoesthesia and paresthesia of the right foot began 6 years previously and were severe along the lateral plantar aspect. The symptoms were mild at rest and increased during daily activities. Tinel sign was positive along the posteroinferior aspect of the medial malleolus.

DIAGNOSIS

Lateral ankle radiography showed joint-space narrowing and sclerotic bony changes with a deformed C-sign and humpback sign. Oblique coronal and sagittal computed tomography revealed an irregular medial posterior facet, partial coalition, narrowing, and subcortical cyst formation of the posterior subtalar joint. Magnetic resonance imaging showed an abnormal posterior talocalcaneal coalition compressing the posterior tibia nerve. Electromyography and nerve conduction velocity studies were performed, and the findings indicated that there was an incomplete lesion of the right plantar nerve, especially of the lateral plantar nerve, around the ankle level.

INTERVENTIONS

Surgical decompression was performed. Intraoperatively, the lateral plantar nerve exhibited fibrotic changes and tightening below the posterior facet talocalcaneal coalition. The coalition was excised, and the lateral plantar nerve was released with soft-tissue dissection.

OUTCOMES

The patient's symptoms of tingling sensation and hypoesthesia were almost relieved at 4 months postoperatively, but she complained of paresthesia with an itching sensation when the skin of the plantar area was touched. The paresthesia had disappeared almost completely at 8 months after surgery. She had no recurrence of symptoms at the 1-year follow-up.

LESSONS

The TTS with tarsal coalition is rare. Supportive history and physical examination are essential for diagnosis. Plain radiographs and computed tomography or magnetic resonance imaging are helpful to determine the cause of TTS and verify the tarsal coalition. After diagnosis, surgical excision of the coalition may be appropriate for management with a good outcome.

Cornea verticillata and acroparesthesia efficiently discriminate clusters of severity in Fabry disease

BACKGROUD

Fabry disease (OMIM #301 500), the most prevalent lysosomal storage disease, is caused by enzymatic defects in alpha-galactosidase A (GLA gene; Xq22.1). Fabry disease has historically been characterized by progressive renal failure, early stroke and hypertrophic cardiomyopathy, with a diminished life expectancy. A nonclassical phenotype has been described with an almost exclusive cardiac involvement. Specific therapies with enzyme substitution or chaperone molecules are now available depending on the mutation carried. Numerous clinical and fundamental studies have been conducted without stratifying patients by phenotype or severity, despite different prognoses and possible different pathophysiologies. We aimed to identify a simple and clinically relevant way to classify and stratify patients according to their disease severity.

METHODS

Based on data from the French Fabry Biobank and Registry (FFABRY; n = 104; 54 males), we applied unsupervised multivariate statistics to determine clusters of patients and identify clinical criteria that would allow an effective classification of adult patients. Thanks to these criteria and empirical clinical considerations we secondly elaborate a new score that allow the severity stratification of patients.

RESULTS

We observed that the absence of acroparesthesia or cornea verticillata is sufficient to classify males as having the nonclassical phenotype. We did not identify criteria that significantly cluster female patients. The classical phenotype was associated with a higher risk of severe renal (HR = 35.1; p <10-3) and cardiac events (HR = 4.8; p = 0.008) and a trend toward a higher risk of severe neurological events (HR = 7.7; p = 0.08) compared to nonclassical males. Our simple, rapid and clinically-relevant FFABRY score gave concordant results with the validated MSSI.

CONCLUSION

Acroparesthesia and cornea verticillata are simple clinical criteria that efficiently stratify Fabry patients, defining 3 different groups: females and males with nonclassical and classical phenotypes of significantly different severity. The FFABRY score allows severity stratification of Fabry patients.

[Meralgia paraesthetica]

This review summarises the treatment of meralgia paraesthetica. The condition is easy to recognise clinically, and in most cases the effect of conservative treatment is good. In case of persistent symptoms, further work-up is recommended including neurophysiological testing and ultrasound examination. If surgery is decided, we recommend nerve decompression primarily, since this procedure holds a success rate of 60-70%. In case of persistent symptoms, neurectomy should be performed. Ultrasound examination immediately before surgery can be helpful in localising the nerve and shortening procedural time.

Prolonged Weakness and Paresthesia After Revision Total Hip Arthroplasty in a Patient with Sickle Cell Anemia Receiving Spinal Anesthesia: A Case Report

CASE

This report describes a case of prolonged neurologic deficit of primarily the nonoperative lower extremity in a patient with sickle cell disease (SCD) who received spinal anesthesia during revision total hip arthroplasty (THA). The patient initially showed bilateral lower extremity neurologic deficits localized to the L5/S1 nerve root, with the eventual persistence of symptoms in the nonoperative extremity for >1 year.

CONCLUSIONS

This report describes an unusual complication after THA and spinal anesthesia. This case highlights the rare occurrence of nerve root injury after spinal anesthesia and emphasizes the importance of close perioperative monitoring in patients with SCD undergoing orthopaedic surgery.