Paraesthesia

Yesterday our days were melted in the sun, Bled of their life stuff and essences into Gutters and sewers; and being nothing More than a sun-streaked afternoon, We should call it the last sighting Of the shadow of a shadow of a cloud, Sweeping past the hillside and the snow, Trickling from the weathered rock and cracking, Forming torrent-streams on mountain slopes, And tearing with tiny fingers At the tree roots in the land Merging valleys..

Transverse tripolar spinal cord stimulation: Theoretical performance of a dual channel system

A new approach to spinal cord stimulation is presented, by which several serious problems of conventional methods can be solved. A transverse tripolar electrode with a dual-channel voltage stimulator is evaluated theoretically by means of a volume conductor model, combined with nerve fibre models. The simulations predict that a high degree of freedom in the control of activation of dorsal spinal pathways may be obtained with the described system. This implies an easier control of paraesthesia coverage of skin areas and the possibility to correct undesired paraesthesia patterns, caused by lead migration, tissue growth, or anatomical asymmetries, for example, without surgical intervention. It will also be possible to preferentially activate either dorsal column or dorsal root fibres, which has some important clinical advantages. Compared to conventional stimulation systems, the new system has a relatively high current drain

Assessment and diagnosis of acute limb compartment syndrome: A literature review

Background: Compartment syndrome is a collection of symptoms that signal increased pressure in the muscle compartment and results in compromised tissue perfusion. Failure to diagnose and treat the condition can result in permanent neurovascular deficit, tissue ischaemia, limb amputation and rhabdomyolysis. Aims: The aim of the review was to determine the strength of the evidence regarding risk reduction and early detection of ALCS and to identify the gaps in the evidence. Methods: Following a systematic search, literature about patient risk, risk reduction, clinical observation and compartment monitoring was identified and the methodological quality of studies was considered. Findings: Diaphyseal fractures of the tibia are the most significant risk factor for compartment syndrome followed by fracture of the distal radius. The anterior compartment of the leg and the flexor compartment of the forearm are most affected. Other factors include calcaneal fractures, male gender, age <35 years, high energy trauma, soft tissue injuries (especially in patients with bleeding disorders), open fracture, limb compression due to traction, padding and casts and surgical management of fractures. Males aged below 35 years who sustain a fracture of the lower leg or forearm should be monitored most carefully. Clinical observations, together with compartment pressure monitoring, in patients at risk appears to be the best method of diagnosing the condition. Pain out of proportion to the injury and pain on passive muscle stretch are the most effective clinical observation in conscious patients. Paresis/paralysis, parasthesia and pallor may help in diagnosis but are late signs. The sensitivity and specificity of these symptoms in diagnosing ALCS is unclear and the approach to pain assessment is not considered in detail

International Society of Sports Nutrition position stand: beta-alanine

Position statement: The International Society of Sports Nutrition (ISSN) provides an objective and critical review of the mechanisms and use of beta-alanine supplementation. Based on the current available literature, the conclusions of the ISSN are as follows: 1) Four weeks of beta-alanine supplementation (4–6 g daily) significantly augments muscle carnosine concentrations, thereby acting as an intracellular pH buffer; 2) Beta-alanine supplementation currently appears to be safe in healthy populations at recommended doses; 3) The only reported side effect is paraesthesia (tingling), but studies indicate this can be attenuated by using divided lower doses (1.6 g) or using a sustained-release formula; 4) Daily supplementation with 4 to 6 g of beta-alanine for at least 2 to 4 weeks has been shown to improve exercise performance, with more pronounced effects in open end-point tasks/time trials lasting 1 to 4 min in duration; 5) Beta-alanine attenuates neuromuscular fatigue, particularly in older subjects, and preliminary evidence indicates that beta-alanine may improve tactical performance; 6) Combining beta-alanine with other single or multi-ingredient supplements may be advantageous when supplementation of beta-alanine is high enough (4–6 g daily) and long enough (minimum 4 weeks); 7) More research is needed to determine the effects of beta-alanine on strength, endurance performance beyond 25 min in duration, and other health-related benefits associated with carnosine

Posterior fossa craniectomy and C1/C2 laminectomy for Arnold-Chiari II decompression of syrinx

This patient was diagnosed shortly after birth with right-sided facial palsy as a result of lower motor neuron facial nerve involvement, together with spinal abnormalities and hearing impairment (patient currently uses hearing aids). He also has 13 ribs on his left side and 11 ribs on the right, hemi-vertebra at T2/T3 and T8/T9 and fused vertebral bodies at C2/C3 and C6/C7. As a result, clinically he has a short neck with restriction of all neck movements, particularly rotation. Patient is also known to have situs inversus. From the MRI, it showed he had an Arnold-Chiari malformation. Therefore, the cerebellar tonsils herniated through the foramen magnum which resulted in disruption of the CSF flow. This lead to the formation of a syrinx within the spinal cord, the condition being known as Syringomyelia. The syrinx can expand and elongate over time, destroying part of the spinal cord so that the damage will cause the symptoms felt by the patient. Symptoms vary between patients and also depending on the location of the syrinx; in this case, the patient experienced the gait disturbances, balance problems, paraesthesia, pain and bowel control issues. His symptoms suggest a cape-like distribution of paraesthesia and sensory disturbance attributable to syringomyelia.peer-reviewe

Prevention of neurological injuries during mandibular third molar surgery: technical notes

Surgery to the mandibular third molar is common, and injuries to the inferior alveolar nerve and the lingual nerve are well-recognized complications of this procedure. The aim of these technical notes is to describe operative measures for reducing neurological complications during mandibular third molar surgery. The following procedure should be used to prevent damage to the inferior alveolar nerve: a well-designed mucoperiosteal flap, to obtain appropriate access to the surgical area; a conservative ostectomy on the distal and distal-lingual side; tooth sectioning, to facilitate its removal by decreasing the retention zones; tooth dislocation in the path of withdrawal imposed by the curvature of the root apex; and careful socket debridement, when the roots of the extracted tooth are in intimate contact with the mandibular canal. To prevent injury to the lingual nerve, it is important (I) to assess the integrity of the mandibular inner cortex and exclude the presence of fenestration, which could cause the dislocation of the tooth or its fragment into the sublingual or submandibular space; (II) to avoid inappropriate or excessive dislocation proceedings, in order to prevent lingual cortex fracture; (III) to perform horizontal mesial-distal crown sectioning of the lingually inclined tooth; (IV) to protect the lingual flap with a retractor showing the cortical ridge; and (V) to pass the suture not too apically and from the inner side in a buccal-lingual direction in the retromolar are

Carotid endarterectomy : the Maltese experience

Introduction: Carotid endarterectomy significantly reduces the risk of cerebrovascular events in both symptomatic and asymptomatic patients with significant carotid stenosis. The recent American Heart Association/American College of Cardiology guidelines advise that carotid endarterectomy is only beneficial when the perioperative stroke or mortality rate is below 6%. The aim of this study was to review the results of carotid endarterectomy performed in Malta by one vascular surgeon. Methods: All patients undergoing carotid endarterectomy between July 2007 and June 2011 were included in the study. Data was entered prospectively into a vascular database. Retrospective review of the case notes of all patients undergoing carotid endarterectomy was also performed. Demographics of the patient cohort as well as information about perioperative mortality, cerebrovascular events, cardiac events as well as any other complications were recorded. Information was also collected about any deaths and cerebrovascular events during the follow up period. Results: 51 patients underwent carotid endarterectomy during the study period. 94% were symptomatic (65% CVA; 15% TIA; 10% amaurosis fugax; 4% TIA and amaurosis) and 6% asymptomatic. 46% had an internal carotid artery stenosis of 90% or more while the rest had a stenosis of 70% or more. 31% of patients also had significant contralateral carotid stenosis or occlusion. There was one postoperative mortality (1.9%) and one patient sustained a postoperative lacunar stroke (1.9%). There were no cranial nerve injuries and no bleeding requiring return to theatre. The combined perioperative mortality and stroke rate in this cohort was 3.9%. Conclusions: The combined perioperative mortality and stroke rate in this sutdy is better than that reported in the major randomised controlled trials. The perioperative death and stroke rate is well below the threshold level advised by the AHA/ACC.peer-reviewe

An unexpected cause of palmar paraesthesia in a soldier : a case report

Athletes presenting with neurological symptoms merit thorough assessments that in most cases will include investigations with one or more imaging modality. Imaging is especially useful in atypical presentations of neurological pathology (both acute and chronic) as was the instance in the presented case report. The case of a 22-year-old male soldier is presented who presented with a two week history of paraesthesia involving his right hand. After being assessed by the military medical officer, a presumptive diagnosis of cervical radiculopathy was made and appropriate treatment was prescribed. Symptoms persisted despite treatment and following an inconclusive cervical X-Ray, a magnetic resonance scan was booked that confirmed the diagnosis of multiple sclerosis. The patient was admitted to hospital and started on intravenous methylprednisolone and beta-interferon therapy with resolution of his symptoms. This case highlights the usefulness of imaging in confirming diagnosis, especially in atypical presentations of pathology afflicting the neurological system. Atypical symptoms, lack of response to standard therapy and inconclusive initial radiological investigations, should prompt the physician to carry out further detailed imaging modalities. The choice of the latter will need to reflect the working differential diagnoses. With reference to the presented case, imaging plays a role not only in diagnosis but also in assessing response to treatment and disease progression.peer-reviewe

Shoulder posture and median nerve sliding

Background: Patients with upper limb pain often have a slumped sitting position and poorshoulder posture. Pain could be due to poor posture causing mechanical changes (stretch; localpressure) that in turn affect the function of major limb nerves (e.g. median nerve). This studyexamines (1) whether the individual components of slumped sitting (forward head position, trunkflexion and shoulder protraction) cause median nerve stretch and (2) whether shoulderprotraction restricts normal nerve movements.Methods: Longitudinal nerve movement was measured using frame-by-frame cross-correlationanalysis from high frequency ultrasound images during individual components of slumped sitting.The effects of protraction on nerve movement through the shoulder region were investigated byexamining nerve movement in the arm in response to contralateral neck side flexion.Results: Neither moving the head forward or trunk flexion caused significant movement of themedian nerve. In contrast, 4.3 mm of movement, adding 0.7% strain, occurred in the forearm duringshoulder protraction. A delay in movement at the start of protraction and straightening of thenerve trunk provided evidence of unloading with the shoulder flexed and elbow extended and thescapulothoracic joint in neutral. There was a 60% reduction in nerve movement in the arm duringcontralateral neck side flexion when the shoulder was protracted compared to scapulothoracicneutral.Conclusion: Slumped sitting is unlikely to increase nerve strain sufficient to cause changes tonerve function. However, shoulder protraction may place the median nerve at risk of injury, sincenerve movement is reduced through the shoulder region when the shoulder is protracted andother joints are moved. Both altered nerve dynamics in response to moving other joints and localchanges to blood supply may adversely affect nerve function and increase the risk of developingupper quadrant pain

A six year retrospective review of occipital nerve stimulation practice--controversies and challenges of an emerging technique for treating refractory headache syndromes

BACKGROUND: A retrospective review of patients treated with Occipital Nerve Stimulation (ONS) at two large tertiary referral centres has been audited in order to optimise future treatment pathways. METHODS: Patient's medical records were retrospectively reviewed, and each patient was contacted by a trained headache expert to confirm clinical diagnosis and system efficacy. Results were compared to reported outcomes in current literature on ONS for primary headaches. RESULTS: Twenty-five patients underwent a trial of ONS between January 2007 and December 2012, and 23 patients went on to have permanent implantation of ONS. All 23 patients reached one-year follow/up, and 14 of them (61%) exceeded two years of follow-up. Seventeen of the 23 had refractory chronic migraine (rCM), and 3 refractory occipital neuralgia (ON). 11 of the 19 rCM patients had been referred with an incorrect headache diagnosis. Nine of the rCM patients (53%) reported 50% or more reduction in headache pain intensity and or frequency at long term follow-up (11-77 months). All 3 ON patients reported more than 50% reduction in pain intensity and/or frequency at 28-31 months. Ten (43%) subjects underwent surgical revision after an average of 11 ± 7 months from permanent implantation - in 90% of cases due to lead problems. Seven patients attended a specifically designed, multi-disciplinary, two-week pre-implant programme and showed improved scores across all measured psychological and functional parameters independent of response to subsequent ONS. CONCLUSIONS: Our retrospective review: 1) confirms the long-term ONS success rate in refractory chronic headaches, consistent with previously published studies; 2) suggests that some headaches types may respond better to ONS than others (ON vs CM); 3) calls into question the role of trial stimulation in ONS; 4) confirms the high rate of complications related to the equipment not originally designed for ONS; 5) emphasises the need for specialist multidisciplinary care in these patients