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PubMed1988

Amelioration of vincristine neurotoxicity by glutamic acid.

Neurotoxicity is the principal limiting side effect of the widely used antitumor agent, vincristine. Following evaluation of glutamic acid as a potential modifier of vincristine toxicity in preclinical studies in mice and a preliminary clinical trial, a prospective, double-blind, placebo-controlled, randomized trial was conducted by the Piedmont Oncology Association. Of 87 patients entered into the study, 84 were evaluable, including 42 patients who were randomly assigned to receive vincristine 1.0 mg/m2 weekly for six doses and 42 patients who were assigned to receive glutamic acid 500 mg orally three times daily plus vincristine. The following neurotoxic signs and symptoms were evaluated before each dose of vincristine: reflex changes, paresthesias, constipation, strength, and mental changes. Loss of the Achilles tendon reflex, an objective parameter, was noted in 19 percent of patients receiving glutamic acid and 42 percent of control subjects (p = 0.03). Development of moderate to severe paresthesias, a subjective parameter, occurred in 19 percent of the glutamic acid group and 36 percent of the placebo group (p = 0.09). Overall moderate neurotoxicity (6 units or more), determined by adding the grade of each neurotoxic parameter for the weekly clinic visit in which maximum neurotoxicity occurred, was observed in 21 percent of patients receiving glutamic acid and 43 percent of those in the control group (p = 0.04). Hematologic and gastrointestinal side effects occurred with similar frequency in the two groups. The administration of glutamic acid has decreased vincristine-induced neurotoxicity without any attendant side effects.

Adult↗
PubMed1985

Nortriptyline and fluphenazine in the symptomatic treatment of diabetic neuropathy. A double-blind cross-over study.

A controlled clinical trial on the efficacy of a nortriptyline-fluphenazine combination was carried out in patients with painful diabetic polyneuropathy. A visual analog scale was used to evaluate the relief of pain or paresthesia. Significant relief of both pain and paresthesia was obtained with this combination. The differences were statistically significant. Side effects were frequent but not usually severe enough to lead to cessation of these medications.

Adult↗
PubMed2006

The effect of injection of two vs 10 mL saline on the subsequent spread and quality of epidural analgesia in parturients.

OBJECTIVE: To determine whether two vs 10 mL of saline injected into the epidural space affects the subsequent spread and quality of epidural analgesia in parturients. DESIGN: Randomized, double-blinded, placebo-controlled study. SETTING: Delivery room. PATIENTS: 105 ASA physical status I and II parturients requesting epidural analgesia. INTERVENTIONS: After identification of the epidural space by the loss-of-resistance technique using normal saline, two mL of saline was then injected into the epidural space in the 2-mL group (n = 53) and 10 mL in the 10-mL group (n = 52). Five minutes after the test dose, patients received 10 mL of bupivacaine (0.1%) with fentanyl two microg mL(-1). MEASUREMENTS: 25 minutes after the initial bolus of bupivacaine and fentanyl, spread of block, subsequent pain relief, and influence of the volume of the injected saline on the ease of epidural catheter insertion and on the incidence of blood vessel trauma and paresthesia were evaluated. RESULTS: The total number of dermatomes blocked for cold and pinprick sensation in the 10-mL group was significantly more than in the 2-mL group (19 [6-29] vs 15 [4-27] for cold sensation, P = 0.000; and 15 [3-29] vs 11.5 [3-26] for pinprick sensation, P = 0.001). However, the visual analog pain scale and need for supplemental analgesia were similar between the two groups. The epidural catheter was easily inserted in 94.2% of the 2-mL group and 100% of the 10-mL group. The incidence of blood vessel trauma was low and the incidence of paresthesia was high without any significant difference between the two groups. CONCLUSIONS: 10 mL saline was associated with a higher total number of dermatomes blocked for both cold and pinprick sensation than the two mL saline. However, the pain relief was adequate in both groups, and two mL saline was as effective as the 10 mL in the ease of catheter insertion and prevention of intravascular cannulation.

Adult↗
PubMed2004

The amelioration of symptoms in cervical spinal stenosis with spinal cord deformation through specific chiropractic manipulation: a case report with long-term follow-up.

OBJECTIVE: To describe the chiropractic management of a patient with paresthesia on the entire left side of her body and magnetic resonance imaging (MRI)-documented cervical spinal cord deformation secondary to cervical spinal stenosis. CLINICAL FEATURES: A 70-year-old special education teacher had neck pain, headaches, and burning paresthesia on the entire left side of her body. These symptoms developed within hours of being injured in a side-impact motor vehicle accident. Prior to her visit, she had been misdiagnosed with a cerebrovascular accident. INTERVENTION AND OUTCOMES: Additional diagnostic studies revealed that the patient was suffering from cervical spinal stenosis with spinal cord deformation. Two manipulative technique systems (Advanced Biostructural Therapy and Atlas Coccygeal Technique) unique to the chiropractic profession and based on the theory of relief of adverse mechanical neural tension were administered to the patient. This intervention provided complete relief of the patient's complaints. The patient remained symptom-free at long-term follow-up, 1 year postaccident. CONCLUSION: There is a paucity of published reports describing the treatment of cervical spinal stenosis through manipulative methods. Existing reports of the manipulative management of cervical spondylosis suggest that traditional manual therapy is ineffective or even contraindicated. This case reports the excellent short-term and long-term response of a 70-year-old patient with MRI-documented cervical spinal stenosis and spinal cord deformation to less traditional, uniquely chiropractic manipulative techniques. This appears to be the first case (reported in the indexed literature) that describes the successful amelioration of the symptoms of cervical spinal stenosis through chiropractic manipulation. More research into the less traditional chiropractic systems of spinal manipulation should be undertaken.

Accidents, Traffic↗
PubMed2006

Clinical presentation, quantitative sensory testing, and therapy of 2 patients with fourth thoracic syndrome.

OBJECTIVE: The aim of the study was to describe 2 representative cases of patients presenting to an osteopathic pain practice with signs and symptoms consistent with the fourth thoracic (T4) syndrome. In addition, this article reports the application of quantitative thermosensory testing and dynamometer strength testing to confirm associated sensory and motor strength changes. Nonmanipulative therapeutic interventions are reported for the first time. CLINICAL FEATURES: Two patients experienced paresthesias in all digits of the hands, glove-like numbness of the hands and forearm, weakness (unable to open jars), hand clumsiness, upper extremity coldness, fullness or tightness, deep aching pain, and other signs and symptoms consistent with T4 syndrome. The patients were evaluated using quantitative thermosensory testing and handgrip dynamometry before and after treatment. INTERVENTION AND OUTCOME: Relief of bilateral arm pain, numbness, and paresthesias occurred after intramuscular injections of 1 to 2 mL of 0.5% bupivacaine at the fourth thoracic paraspinal level. Additional therapy for associated signs and symptoms was provided using an anticonvulsant (gabapentin). CONCLUSION: The clinical presentation of the patients reported in this article provides a description and additional information regarding T4 syndrome.

Adult↗
PubMed2004

Neurosensory changes after liquid nitrogen cryotherapy.

PURPOSE: The study goal was to evaluate neurosensory changes after liquid nitrogen cryotherapy in the management of mandibular lesions in close proximity to the inferior alveolar nerve. PATIENTS AND METHODS: The design of the study was a retrospective review. Sixteen patients with posterior mandibular lesions (15 odontogenic keratocysts and 1 fibromyxoma) in close proximity to the inferior alveolar nerve were treated with a standardized enucleation and cryotherapy technique. Postoperative evaluation included patients report of symptoms and formal neurosensory testing. RESULTS: All patients had altered sensation in the distribution of the inferior alveolar nerve immediately after cryotherapy. Two patients experienced anesthesia, and the remaining 14 patients showed paresthesia. The average time for return or improvement in sensation was 91 days (range, 6 to 235 days). The average time of follow-up was 2.6 years (range, 0.5 to 7.3 years). At the time of last follow-up, no patients had anesthesia or dysesthesia. Four patients had full return of sensation and 12 patients had paresthesia. No patients reported significant difficulty from abnormal nerve function. All 16 patients experienced some return of sensation; 9 patients had full or near full return of sensation. CONCLUSIONS: Based on these results, the combination of enucleation and liquid nitrogen cryotherapy produces minimal alteration of inferior alveolar nerve function.

Adolescent↗
PubMed2004

Lingual flap retraction for third molar removal.

PURPOSE: Lingual nerve damage following lower third molar surgery remains a clinical problem. The traditional approach in the United States has been a buccal approach avoiding exposure or surgery on the lingual side of the crest of the ridge. An alternative technique is to deliberately expose the lingual tissues and retract the lingual nerve lingually before tooth removal. This study reports a trial of this technique. MATERIALS AND METHODS: Patients had removal of their lower third molars carried out using a technique that raises a lingual flap in addition to a buccal flap and places a specially designed lingual retractor to ensure that the lingual nerve is held out of the surgical field. This technique was used in cases where the crown of the tooth had to be sectioned or when distal bone needed to be removed. RESULTS: Two hundred fifty patients were treated by this method. There were 4 cases of transient lingual paresthesia, presumably caused by traction pressure from the retractor. Three of these cases were mild and resolved within 3 weeks. The fourth case had more profound paresthesia, but still resolved within 2 months. There were no cases of permanent nerve damage, and in many cases removal of the third molar was simplified by the superior access. CONCLUSION: Lingual retraction for third molar removal improves access to the surgical site and can simplify third molar removal. In this prospective study there were no cases of permanent lingual nerve injury.

Alveolectomy↗
PubMedDate not supplied

Nerve blocks at the wrist for carpal tunnel release revisited: the use of sensory-nerve and motor-nerve stimulation techniques.

BACKGROUND AND OBJECTIVES: Because the median nerve at the wrist has mainly sensory endings, the aim of this study was to assess the response of the median nerve to nerve stimulation at the wrist and to evaluate the quality of median nerve block. A control group of patients who received blinded injections was analyzed and compared post hoc. METHODS: One hundred and eleven patients scheduled for ambulatory endoscopic carpal-tunnel release performed under median and ulnar nerve blocks at the wrist were prospectively studied. The blocks were performed with a nerve stimulator. Nerve-stimulation techniques were explained to the patient before the block was performed. The patient was trained to inform the anesthetist of their perception of an electrical paresthesia that was synchronized to the nerve stimulator. The anesthetist recorded the first response of the patient to nerve stimulation: sensory (S), sensory-motor (SM), or motor response (M). When the minimal stimulating current was obtained, an equal volume of 4 mL of 1.5% mepivacaine was injected on median and ulnar nerves. If necessary, a lateral subcutaneous injection of 2 mL of 1.5% mepivacaine was administered at the wrist crease in the musculocutaneous nerve area. Thirty-five patients who received blinded local anesthetics injections were included post hoc. Quality of anesthesia was compared between groups. RESULTS: Responses included 89 S (80.2%), 18 SM (16.2%), and 4 M (3.71%). No differences occurred in time to perform the block, minimal current intensity, and efficacy. More punctures were necessary in the M group compared with the S group and the control group (P < .05). The onset time of sensory blocks increased significantly in control-group patients (P < .05), but the duration of the nerve-block procedure decreased in comparison with the M group. Respectively, 10% and 20% of patients experienced mild or severe pain in the nerve-stimulation group and control group. At 20 minutes, the block was complete for the median and ulnar nerves in 96.4% and 85% of the nerve-stimulation patients and control patients (P < .05). Two patients in the control group experienced painful mechanical paresthesia. Neither permanent nor transient nerve injuries were observed during or after the nerve block or surgery. CONCLUSION: This study describes how infrequently an initial motor response is identified when a nerve stimulator is used on the median nerve at the wrist. A very high success rate of median and ulnar nerve block at the wrist is obtained by use of sensory or sensory-motor-nerve stimulation and less than 10 mL of anesthetic solution.

Anesthetics, Local↗
PubMed2001

Arm complications after radial artery procurement for coronary bypass operation.

BACKGROUND: Radial arteries are being used frequently for coronary artery bypass conduits, and surgeons are appropriately concerned about the risks of ischemia, infection, and neurologic dysfunction of the "donor" arm. We present our record of donor site complications, with emphasis on the safety of radial usage in patients older than 65 years of age. METHODS: A total of 343 radial arteries were removed from 217 patients, aged 37 to 83 years. Forty-nine (23%) of the patients were women; 126 of the radial arteries were from patients aged 65 years or older. Four patients died. In the remaining 213 patients, 338 donor arms were examined for at least 6 weeks postoperatively for evidence of infection, ischemia, hematoma, seroma, or paresthesia. RESULTS: No donor arms developed symptoms of 'ischemia or motor dysfunction. Two of 338 (0.6%) arms developed hematomas requiring operative drainage. Relatively minor complications of stitch abscesses, skin dehiscence, superficial infection, and small hematomas or seromas affected another 14 arms (4.1%). Cutaneous paresthesias in the radial distribution of the lateral antebrachial cutaneous nerve or superficial branch of the radial nerve were noted postoperatively in 36 arms (10.7%). The risk of any arm complication occurring was 13% in the 65 and older group and 17% in those less than 65 years old (p = NS). CONCLUSIONS: The risk of a major arm complication from radial artery harvesting for coronary bypass is low, even in patients of advanced age.

Adult↗
PubMed1998

Neurotoxicity of isolated limb perfusion with tumor necrosis factor.

Hyperthermic isolated limb perfusion (HILP) with tumor necrosis factor alpha (TNFalpha) is effective for advanced melanoma and sarcoma of the limbs. Ten patients undergoing HILP with TNFalpha were evaluated by neurological examinations, nerve conduction studies (NCS), sympathetic skin responses (SSR) and conventional and quantitative electromyography (EMG), performed before, 7 days and 6 weeks following HILP. Seven patients showed minimal clinical signs of peripheral nerve damage following HILP; in two the injury was evident electrophysiologically: 7 days following HILP five patients had paresthesias and/or hypoesthesia, one had a mild foot drop and one had autonomic disturbances in the affected limb. SSR was low in two patients in the affected limb, sensory nerve action potentials were not elicited in one, with normal motor NCS and EMG. At 6 weeks, four patients continued to have mild paresthesias and one had dysautonomia of the perfused limb. Sensory responses and SSR did not change, motor abnormalities were not found. These findings show that HILP with TNFalpha induces a mild, mainly sensory neuropathy in perfused limbs, not disturbing functionality and improving over time.

Adult↗
PubMed1999

Effects of altering cycling technique on gluteus medius syndrome.

OBJECTIVE: We discuss how altering the cycling technique of a cyclist receiving periodic chiropractic care helped in the management of gluteus medius syndrome. CLINICAL FEATURES: A 24-year-old male amateur cyclist had numbness and tingling localized to a small region on the superior portion of the right buttock. The area involved demonstrated paresthesia to light touch sensory evaluation. The cyclist had received chiropractic adjustments 2 days before the onset of the symptoms. One week earlier, the patient began riding a new bicycle with different gearing than his previous one. Manual-resisted muscle testing created soreness in the lumbosacral area and buttocks. Trigger points were identified in the right gluteus medius. Standing lumbar spine flexion was 70 degrees, limited by tight hamstrings. INTERVENTION AND OUTCOME: Because the patient was already receiving periodic chiropractic care, no passive therapy was used. Patient education regarding the difference in gear selection in bicycles of a higher quality was provided. He was instructed to train in lower gears than he had previously used and to maintain a cadence of 70 to 90 revolutions of the pedals per minute. After 2 days, the paresthesia on the right buttock resolved. The trigger points were only mildly tender with minimal residual soreness of the involved muscles. CONCLUSION: Management of gluteus medius syndrome by altering the cadence and gear development for a bicyclist is discussed. Either frank or cumulative injury to the gluteus medius muscle is the typical etiologic factor for this syndrome. Repetitive strain of the patient's gluteus medius muscle as a result of poor cycling technique appeared to be the cause here. Knowledge of bicycle fitting, training techniques, and bicycle mechanics appeared necessary to resolve the problem.

Adult↗
PubMed2001

Acute ophthalmoparesis (without ataxia) associated with anti-GQ1b IgG antibody: clinical features.

OBJECTIVE: To examine the clinical features of acute ophthalmoparesis (AO) (without ataxia) associated with anti-GQ1b immunoglobulin G (IgG) antibody. DESIGN: Retrospective observational case series. PARTICIPANTS: Twenty-one subjects with AO (without ataxia) who had anti-GQ1b IgG. METHODS: Clinical features of 21 subjects with AO were analyzed. RESULTS: Seventeen had symptoms of antecedent infection. Gaze limitation was bilateral in 16 subjects and unilateral in five, indicative that laterality does not always negate AO. Nine subjects showed abducens paresis, and two limitation of abduction and adduction. Eight, who initially had bilateral abducens palsy, subsequently had impairment of adduction and vertical movement. These showed that bilateral abducens palsy followed by oculomotor nerve involvement is characteristic of AO. Muscle stretch reflexes were normal in nine subjects, hypoactive in eight, absent in three, and brisk in one. Distal paresthesias were present in seven subjects. Acellular cerebrospinal fluid (CSF) associated with raised protein concentration was detected in three. CONCLUSIONS: Antecedent infectious symptoms, characteristic limitation of ocular movement, areflexia, distal paresthesias, and CSF albuminocytologic dissociation are useful markers for diagnosing AO as well as anti-GQ1b IgG. AO can be considered a mild form of Miller Fisher syndrome or a regional variant of Guillain-Barré syndrome.

Abducens Nerve Diseases↗
PubMed1985

Alopecia in meralgia paresthetica.

Meralgia paresthetica has been described as a common affliction of the lateral femoral cutaneous nerve, creating the symptoms of numbness, tingling, and paresthesias in the overlying areas of the lateral and anterior thigh. It is second only to sciatica in peripheral nerve diseases of the lower extremity. We present two patients with classic symptoms of meralgia paresthetica and nonscarring alopecia overlying and demarcating the areas of paresthesias. Meralgia paresthetica should be included in the differential diagnosis of localized alopecia of the anterior or lateral thigh.

Aged↗
PubMed1991

Successful reeducation of functional sensibility after median nerve repair at the wrist.

The effect of sensory reeducation was evaluated in a group of twenty-two adult patients who had a repair of a clean-cut median nerve at the wrist. These results were compared with the sensibility in a group of twenty-four adults with repair of clean-cut median nerve at the wrist who had never received sensory reeducation. The reeducation group were evaluated between one and two years from the time of their median nerve repair. The control patients were retrospectively evaluated between one and sixteen years after their nerve repair. The effect of reeducation on improving the paresthesias that accompany neural regeneration was also evaluated. Sensibility was determined by an object recognition test and by measurement of static and moving two-point discrimination. The results demonstrated that sensory reeducation significantly (p less than 0.01) diminished the severity of postoperative paresthesias. It also gave significantly better improvement in moving two-point discrimination than in static two-point discrimination within the timeframe evaluated (p less than 0.002). Excellent recovery of sensibility, as determined by ability to recognize nine or more objects out of twelve, was significantly greater (p less than 0.005) for the sensory reeducation group than at any time interval beginning after six months after nerve repair. It is concluded that a program of sensory reeducation after median nerve repair at the wrist in adults minimizes discomfort and improves sensibility in the postoperative period.

Adult↗
PubMed1981

Factors related to the outcome of surgically managed compressive ulnar neuropathy at the elbow level.

Forty-eight of 59 patients who had undergone initial and no secondary treatment of compressive ulnar neuropathy at the level of the elbow during the period of January, 1968, to December, 1977, were reviewed by personal follow-up examination. Cubital tunnel decompression and anterior subcutaneous transposition of the ulnar nerve gave equal results as to the relief of pain and dysesthesia. However, anterior subcutaneous transposition gave better total relief of paresthesias and better return of intrinsic muscle function than did cubital tunnel decompression. Submuscular transposition was not evaluated in this study. The presence of intraoperative intraneural fibrosis or preoperative intrinsic muscle weakness were factors associated with a poor result. Prolonged duration of symptoms and advanced age were relative factors associated with a poor outcome. The presence of preoperative pain, paresthesias, or a widened two-point discrimination had no association with the eventual outcome.

Adult↗
PubMed1991

Carpal tunnel syndrome in the elderly. "Beware of severe cases".

This study compares the clinical and electrophysiological features of Carpal Tunnel Syndrome (CTS) in elderly (over 70 years of age) and middle age populations (50-60 years of age). Our study shows a severe (95%) electrophysiological motor and sensory denervation of CTS, in 60% of the elderly group and only 18% of the middle aged group (P much much less than 10(-3). Clinically, the presence of thenar wasting was the only reliable sign of significant denervation, Phalen's test, Tinel sign and painful paresthesia being equivocal. Some 18% of the elderly were asymptomatic despite 25% of these patients having severe neurological impairment. It was noted that exclusively diurnal paresthesiae were confined to the elderly group (23%) (P much less than 10(-3)). To avoid permanent disability the elderly should be viewed as a high risk group of severe cases even in the absence of firm clinical evidence and should undergo objective electrophysiological assessment with a view to surgical intervention as a priority.

Aged↗
PubMed2000

Uniport soft-tip, open-ended catheters versus multiport firm-tipped close-ended catheters for epidural labor analgesia: a quality assurance study.

STUDY OBJECTIVE: To compare a multiport, firm-tipped, close-ended, epidural catheter (Portex catheter) with a uniport, open-ended, soft-tipped, wire-reinforced catheter (Arrow catheter) in obstetric patients. STUDY DESIGN: Prospective data collection for intradepartmental quality assurance. SETTING: Obstetric unit in a tertiary care maternity hospital. PATIENTS: 2612 patients requesting labor analgesia. INTERVENTIONS: The Arrow catheter was used in 1,352 women and the Portex catheter in 1,260 women. MEASUREMENTS AND MAIN RESULTS: The incidence of unsatisfactory block were 3.3% and 4.4% with the Arrow and Portex catheters, respectively (p = 0.2). The catheter perforated the dura matter in 0.4% of cases with both catheters. The incidence of epidural venipuncture was 1.1% with the Arrow catheter and 5.7% with the Portex catheter (p = 0.0001). Paresthesias occurred in 6% of cases with the Arrow catheter and 11. 2 % of cases with the Portex catheter (p = 0.0001). Epidural catheter reinsertion was required in fewer patients in the Arrow group than in the Portex group (4.8% vs. 7.1%; p = 0.01). CONCLUSIONS: In obstetric patients, the softer uniport Arrow catheter produces paresthesias and venipunctures less frequently than the firm multiport Portex catheter.

Adult↗
PubMedDate not supplied

"See one, do one, teach one, have one": a novel variation on regional anesthesia training.

INTRODUCTION: Is it possible to determine the number of nerve blocks needed for residents to become competent in regional anesthesia? Several studies have focused on this question, and the Residency Review Committee (RRC) for Anesthesiology has now defined a "minimum clinical experience" for some aspects of regional anesthesia training. In our experience, personally being a regional block recipient can also serve to enhance training. METHODS: Many residents at Virginia Mason Medical Center have received regional anesthetics as volunteers in research projects. We designed questionnaires to define their perceptions in both performing and receiving regional anesthesia. RESULTS: Twenty-one residents were recipients of a total of 72 regional anesthetic procedures. Many residents' comments focused on the discomfort of local anesthesia infiltration, the value of sedation, a better appreciation of the patients' perspectives, and improved preoperative consultation. Residents experiencing paresthesias were more likely to consider paresthesias as bad (P =.0098). CONCLUSION: The lessons learned from personally receiving a regional anesthetic are invaluable and can improve the quality of training, as well as the relationship between anesthesiologist and patient.

Adult↗