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BACKGROUND AND OBJECTIVES: Selective spinal nerve infiltration blocks are used diagnostically in patients with chronic low back pain radiating into the leg. Generally, a segmental nerve block is considered successful if the pain is reduced substantially. Hypesthesia and elicited paresthesias coinciding with the presumed segmental level are used as controls. The interpretation depends on a standard dermatomal map. However, it is not clear if this interpretation is reliable enough, because standard dermatomal maps do not show the overlap of neighboring dermatomes. The goal of the present study is to establish if dissimilarities exist between areas of hypesthesia, spontaneous pain reported by the patient, pain reduction by local anesthetics, and paresthesias elicited by sensory electrostimulation. A secondary goal is to determine to what extent the interpretation is improved when the overlaps of neighboring dermatomes are taken into account. METHODS: Patients suffering from chronic low back pain with pain radiating into the leg underwent lumbosacral segmental nerve root blocks at subsequent levels on separate days. Lidocaine (2%, 0.5 mL) mixed with radiopaque fluid (0.25 mL) was injected after verifying the target location using sensory and motor electrostimulation. Sensory changes (pinprick method), paresthesias (reported by the patient), and pain reduction (Numeric Rating Scale) were reported. Hypesthesia and paresthesias were registered in a standard dermatomal map and in an adapted map which included overlap of neighboring dermatomes. The relationships between spinal level of injection, extent of hypesthesia, location of paresthesias, and corresponding dermatome were assessed quantitatively. Comparison of the results between both dermatomal maps was done by paired t-tests. RESULTS: After inclusion, data were processed for 40 segmental nerve blocks (L2-S1) performed in 29 patients. Pain reduction was achieved in 43%. Hypesthetic areas showed a large variability in size and location, and also in comparison to paresthesias. Mean hypesthetic area amounted 2.7 +/- 1.4 (+/- SD: range, 0 to 6; standard map) and 3.6 +/- 1.8 (0 to 6; adapted map; P <.001) dermatomes. In these cases, hypesthesia in the corresponding dermatome was found in 80% (standard map) and 88% of the cases (adapted map, not significant). Paresthesias occurring in the corresponding dermatome were found in 80% (standard map) compared with 98% (adapted map, P <.001). In 85% (standard map) and 88% (adapted map), spontaneous pain was present in the dermatome corresponding to the level of local anesthetic injection. In 55% (standard map) versus 75% (adapted map, P <.005), a combination of spontaneous pain, hypesthesia, and paresthesias was found in the corresponding dermatome. CONCLUSIONS: Hypesthetic areas determined after lumbosacral segmental nerve blocks show a large variability in size and location compared with elicited paresthesias. Confirmation of an adequately performed segmental nerve block, determined by coexistence of hypesthesia, elicited paresthesias and pain in the presumed dermatome, is more reliable when the overlap of neighboring dermatomes is taken into account.
OBJECT: Nonfunctioning pituitary adenomas comprise approximately 30% of all pituitary tumors. The purpose of this retrospective study is to evaluate the efficacy and role of gamma knife radiosurgery (GKS) in the management of residual or recurrent nonfunctioning pituitary adenomas. METHODS: A review was conducted of the data obtained in 42 patients who underwent adjuvant GKS at the University of Pittsburgh between 1987 and 2001. Prior treatments included transsphenoidal resection, craniotomy and resection, or conventional radiotherapy. Endocrinological, ophthalmological, and radiological responses were evaluated. The duration of follow-up review varied from 6 to 102 months (mean 31.2 months). Fifteen patients were observed for more than 40 months. The mean radiation dose to the tumor margin was 16 Gy. Conformal radiosurgery planning was used to restrict the dose to the optic nerve and chiasm. Tumor control after GKS was achieved in 100% of patients with microadenomas and 97% of patients with macroadenomas. Gamma knife radiosurgery was equally effective in controlling adenomas with cavernous sinus invasion and suprasellar extension. No patient developed a new endocrinological deficiency following GKS. One patient's tumor enlarged with an associated decline in visual function. Another patient experienced a deterioration of visual fields despite a decrease in tumor size. CONCLUSIONS: Gamma knife radiosurgery can achieve tumor control in virtually all residual or recurrent nonfunctioning pituitary adenomas. Dose sparing facilitates tumor management even when the adenoma is close to the optic apparatus or invades the cavernous sinus.
Postoperative sensory changes (i.e., hypesthesias) that occur after suction-assisted lipoplasty (SAL) are expected clinical sequelae. These disturbances usually return to normal within several weeks to months postoperatively. The presumed mechanism of injury is direct trauma to the peripheral nerves from the suction cannula. In addition, the potential for demyelination of peripheral nerves secondary to cavitation during ultrasound-assisted liposuction (UAL) is well known. Quantitative data describing hypesthesia after both procedures are limited. The purpose of this study was to objectively evaluate the severity and duration of postoperative hypesthesia after liposuction to better educate patients preoperatively. Furthermore, the authors use the three-stage UAL technique and wanted to determine whether a clinical difference in sensory return existed between suction- and ultrasound-treated areas. A total of 21 patients underwent liposuction performed by the senior author (RJ.R.). The abdomen, flanks, thighs, and medial knees were tested for objective sensation with the Pressure Specified Sensory Device preoperatively and at 2, 6, and 10 weeks postoperatively. A total of 102 sites were tested. On average, the SAL-treated areas improved to normal sensation by 6 weeks, whereas the UAL-treated areas took, on average, 10 weeks to recover. The severity of the hypesthesia was not correlated with larger aspiration volumes or longer UAL exposure time per site. At 10 weeks, 90 percent of UAL-treated patients and 89 percent of liposuction patients overall had recovered normal sensation. This study provides the body-contouring surgeon with good, objective data with which to educate patients regarding sensory return after liposuction.
PURPOSE: To examine the effect of modifying the interval between administration of saline used during the loss of resistance (LOR) method and local anesthetic on epidural anesthetic level and its quality. METHODS: Seventy-three patients who received thoracic epidural anesthesia were randomly allocated into three groups; the 2, 5 and 10 min groups, according to the interval between the administration of saline and 8 ml mepivacaine 1.5%. Fifteen minutes after the mepivacaine injection, the dermatome level of hypesthesia was determined by an individual blinded to the interval. RESULTS: When the saline-anesthetic interval was prolonged, the hypesthetic levels for coldness and pinprick were decreased. The number of spinal segments with hypesthesia for coldness were 15 [12-20]#, 12.5 [10.5-22.5]## and 10.5 [6.5-15.5]### in the 2, 5 and 10 min groups, respectively (median [range], # P < 0.05 vs the 5 min group, ## P < 0.05 vs the 10 min group, ### P < 0.05 vs the 2 min group). The number of spinal segments with hypesthesia for pinprick were 13.5 [11-18]#, 11 [7.5-20.5]## and 10 [5.5-13]### in the 2, 5 and 10 min groups, respectively. There were differences in all groups between the number of segments with hypesthesia for coldness and pinprick elicited. CONCLUSION: The interval between the administration of saline and local anesthetic alters the anesthetic level and quality of epidural analgesia.
We reported clinical and neuropathological observations of a 41-year-old man with Degos disease. He first noted painless skin lesions over the upper extremities in January, 1982. Three years later he was diagnosed as Degos disease by skin biopsy, and treatment with aspirin was started. In September, 1985, he complained of paresthesia on his right arm, followed by a series of new neurological manifestations suggesting multifocal spinal cord lesions. On October 28, examination of admission showed papules with central umblication over the whole body except the head, face, palms, soles and scrotum. Neurological examination revealed no weakness, diminished right biceps reflex, exaggerated patellar reflexes and Achilles reflexes, left extensor plantar reflex, hypesthesia and hypalgesia to the level of Th8, mild left spastic gait, and retention of urine. In November, he had paraparesis, loss of vibration sense of lower extremities, hypesthesia and hypalgesia to the level of TH4, and weakness of right upper extremity. In December, he showed tetraplegia, left-sided facial palsy, and hypesthesia and hypalgesia to the level of C5. In January, 1986, he showed right facial palsy, left facial hypesthesia, pseudobulbar palsy. In February, he had bilateral abducens nerve palsy and hiccups. On February 18, he died of intracranial hemorrhages. He had episodic abdominal pain several times during admission. His condition deteriorated progressively in four months after the first manifestation of neurological symptoms, despite the therapy with heparin, urokinase, ticlopidine, dipyridamole, and prednisolone. Laboratory studies showed gradual increase of CSF proteins (from 156 mg/dl to 602 mg/dl) and extremely increased platelet aggregation.(ABSTRACT TRUNCATED AT 250 WORDS)
To test the hypothesis that the acute temporomandibular joint pain-dysfunction syndrome might represent a variant of acute benign cranial polyneuritis, a prospective study was designed using neuro-otologic examination and electromyography. Seven consecutive patients with cardinal symptoms of the temporomandibular joint pain-dysfunction syndrome (pain, tenderness, clicking, and limitation of jaw movement) were examined within one week after the onset of their acute symptoms. Another three with chronic symptoms were tested for comparison to the acute cases. All seven patients with the acute condition had asymptomatic hypesthesia of all three divisions of the trigeminal nerve and decreased volitional muscle action potentials in the masseter and temporalis muscles. At the end of three weeks the hypesthesia resolved in all seven patients, and the muscle action potentials returned to normal in six of the seven. Electromyographic testing of the single patient with persistent decreased muscle action potentials and three patients with chronic symptoms showed fibrillations, decreased polyphasic regeneration potentials, and spontaneous fasciculations with clinical atrophy and spasm of the affected masseter and temporalis muscles. Other acute cranial nerve findings included unilateral hypesthesia of the glossopharyngeal and second cervical nerves, motor paralysis of the superior laryngeal branch of the vagus nerve, and increased facial nerve latency. These findings suggest an organic neuromuscular, rather than a psychophysiologic, cause for the temporomandibular joint pain-dysfunction syndrome.
PURPOSE: To present the results of orbital decompression in patients with thyroid-associated ophthalmopathy (TAO). METHODS: Transantral orbital decompression was performed in 63 patients with TAO. In 40 patients (63%) the operation was made because of progressive ophthalmopathy not responding to medical therapy, and in 23 patients (37%) the operation was made for rehabilitative reasons. The long-term hypesthesia engaging the infraorbital nerve was assessed with a questionnaire using a Visual Analogue Scale (VAS). RESULTS: The mean proptosis reduction was 3.2 mm (range 0-8 mm). Twenty-one patients had impaired visual acuity preoperatively, and 20 improved. Altogether 30 patients (40%) had worsened ocular motility postoperatively. Forty-three patients did not have diplopia in the primary position preoperatively, and new diplopia developed in 22 of these (51%). Hypesthesia in the infraorbital nerve area was reported for half of the operated sides, but was a major cause of distress (VAS-scoring >5) to eleven patients. CONCLUSIONS: Transantral orbital decompression is indicated in patients with progressive TAO or in patients with prominent exophthalmos, and results in a good proptosis reduction, but the risk of postoperative diplopia is significant. Postoperative hypesthesia is common but often not a major problem.
The presence of cortical spreading depression is typically inferred from the presence of hypesthesia. The electrocorticogram and slow-potential change were recorded during cortical spreading depression and it was found that hypesthesia remained long after the cortex recovered from neural depression. Hypesthesia, therefore, is an unreliable indicant of cortical spreading depression; if cortical spreading depression is used as a research tool, neural activity must be monitored. These data offer a special problem for memory transfer studies.
Evidence suggests that many cranial nerve syndromes, such as migraine headache, acute vestibular neuronitis, globus hystericus, carotidynia, acute facial paralysis (Bell's palsy), and Meniere's disease, are caused by the neurotropic herpes simplex virus (HSV). Because transitory cranial nerve dysfunction during acute HSV infection can be asymptomatic but often occurs in conjunction with mucocutaneous vesicles, we tested five subjects with herpes labialis for cranial nerve dysfunction. Four of the subjects had hypesthesia of the trigeminal nerve (which recurred in two); four, hypesthesia of the glossopharyngeal nerve; and two, hypesthesia of the second cervical nerve. Three of the subjects had positional or spontaneous nystagmus (which recurred in one); one of the subjects had a unilateral, decreased caloric response of 50%. Unilateral weakness of the cricothyroid muscle or the palate occurred in three of the subjects (and recurred in one). Volitional electromyograms were normal in all the subjects, but two of the subjects had increased facial nerve latency (which recurred in one). Similar findings of an acute, transitory nature should suggest to the clinician a viral polyganglionitis caused by HSV infection.
PURPOSE: To examine the effects of the volume of saline and the concentration of local anesthetic on the quality of anesthetic level. METHODS: One hundred and fifty two patients received thoracic epidural anesthesia were allocated into two groups; mepivacaine 1% (75 patients) and 1.5% (77 patients). Each group was randomly divided into three subgroups depending on epidural saline volumes of 1 ml, 5 ml, or 10 ml. Fifteen minutes after the injection of 10 ml mepivacaine, the dermatome levels of hypesthesia to cold and pinprick were determined by an individual blinded to the saline volume. RESULTS: The number of spinal segments with hypesthesia to cold in the three subgroups in the mepivacaine 1% group were 12.5 [6-20], 13 [8.5-20.5] and 12.5 [6.5-22], respectively (median [range]). The segments in the mepivacaine 1.5% group were 12 [7-18.5], 14 [8.5-19]* and 15 [6-23]*, respectively (*P < 0.05 vs 1-ml group). The number of spinal segments with hypesthesia for pinprick in the three subgroups in the 1% mepivacaine group were 10.5 [2-22], 10.5 [4-17] and 11 [4-19], respectively. The segments in the mepivacaine 1.5% group were 12 [7.5-16], 12 [7.5-17] and 11.5 [5-22.5], respectively. Saline volume did not alter the anesthetic level of the mepivacaine 1%, although it did affect the anesthetic spread of the mepivacaine 1.5%. In both groups, a differential nerve block was elicited in the 5 ml and 10 ml saline subgroups. CONCLUSION: When a large volume of saline is administered prior to local anesthetic, more differential blockade and a greater extent of anesthesia may be elicited.
BACKGROUND: Surgical treatments for thyroid diseases require skin incisions that can result in prominent scars, complaints resulting from adhesions, hypesthesia, and paresthesia in the neck. We have developed an endoscopic thyroidectomy using an axillary approach. In this article, we compare our original technique with conventional open surgery from the aspects of surgical invasiveness and patients' complaints after surgery. STUDY DESIGN: Each procedure was performed in 20 patients with follicular tumors. The two groups were similar for age, gender, and the mean diameter of the thyroid tumor. No statistically significant difference in the final pathological diagnosis was found between the two groups. Surgical invasiveness and patients' complaints after surgery were compared using results of the operation and a questionnaire. RESULTS: The operating time for open surgery was significantly shorter than that for endoscopic surgery (p < 0.01). In the endoscopic surgery group, the patient questionnaires revealed that 4 patients had severe anterior chest pain on the first postoperative day. The postoperative pain decreased after, and we could not find any difference between the two groups with regard to postoperative pain. Three months after surgery, one patient who had received an endoscopic procedure complained of slight hypesthesia, and none of the patients complained of discomfort while swallowing. Among the patients who underwent open surgery, 13 patients (65%; p < 0.01) complained of hypesthesia or paresthesia and 6 patients (30%; p < 0.05) complained of discomfort while swallowing. All of the patients treated using the endoscopic procedure were satisfied with the cosmetic results, but 15 patients who underwent open surgery complained of unsatisfactory cosmetic results (p < 0.01). CONCLUSIONS: The incidence of postoperative complaints after endoscopic surgery is considerably lower than that after open surgery.
OBJECTIVE: Trigeminal neuromas are rare tumors that may involve any part of the nerve complex, including peripheral divisions of the nerve. These rare lesions are treated primarily surgically. We present our series of 38 patients who were treated surgically since 1981, with special emphasis on surgical approach. METHODS: We have surgically treated 38 patients with 39 trigeminal neuromas since 1981. This series of patients was reviewed with regard to clinical presentation, tumor characteristics, surgical approach, and outcome. RESULTS: Sixteen women and 22 men (mean age, 48 yr) all presented with some abnormality of trigeminal dysfunction. Twenty-eight patients presented with trigeminal hypesthesia, 10 with hypesthesia also had facial pain, 3 presented with only facial pain, and 7 presented with diplopia. Eighteen patients had tumors originating from the ganglion, nine from the posterior fossa nerve root, two from the ophthalmic division, and one from the mandibular division, and nine had tumors involving both posterior and middle fossae (dumbbell type). Eighteen tumors were large (>3 cm), 16 were medium sized (2-3 cm), and 5 were small (<2 cm). Tumor location was the prime determinant of surgical approach. Patients with peripheral and ganglion type lesions were treated via an entirely extradural temporopolar approach. Lesions confined to the posterior fossa were approached via a lateral suboccipital approach. Dumbbell-shaped lesions required a combined petrosal strategy. Total resection of tumor was accomplished in 30 patients. Three patients with subtotal resection displayed malignant histology. Postoperatively, 30 patients remained with some degree of trigeminal hypesthesia, two had facial pain (one persistent and one new), and five were left with total trigeminal anesthesia. Four patients were relieved of diplopia, five were relieved of headache, and two were relieved of ataxia. There were no perioperative deaths. CONCLUSION: Trigeminal neuroma is a surgically treatable disease that may be operated on, in many cases, via an entirely extradural approach. These lesions may be successfully resected with low morbidity and a very low rate of recurrence.
A case of fungal aneurysm associated with presumed Tolosa-Hunt syndrome is reported. A 57-year-old man was admitted to our hospital with complaints of left blepharoptosis, headache and weight loss. Neurological examination revealed left ophthalmoplegia without facial hypesthesia. Visual acuity was normal. Laboratory studies showed raised ESR, 4+ glycosuria, and a blood sugar of 351mg/dl. Computerized tomography (CT) scan and left carotid angiography were considered normal. Left orbital venography showed no filling of the left cavernous sinus. Diabetic ophthalmoplegia was suspected by a neurologist. The patient was treated with insulin therapy, but visual acuity worsened, and hypesthesia was noted in the first and second divisions of the left trigeminal nerve. Subsequent CT scan demonstrated a high density lesion, which was homogeneously enhanced, in the left cavernous portion and the superior orbital fissure. The patient was presumed of Tolosa-Hunt syndrome, and prednine therapy (30mg/day) was started. On the second day after the administration of prednine, hypesthesia of the first and second division of the left trigeminal nerve improved. After 9 days of prednine therapy, the patient suddenly complained of severe headache, and lapsed into a coma. Massive hemorrhage with subarachnoid hemorrhage was recognized on the CT scan, with a marked midline shift to the right. The hematoma was immediately removed. A ruptured cerebral aneurysm was found at the bottom of the hematoma. The aneurysm was located in the distal portion of the left middle cerebral artery. Aneurysm clipping with external decompression and bilateral ventricular drainage was performed.(ABSTRACT TRUNCATED AT 250 WORDS)
The present investigation was undertaken to establish the relation between climacteric symptoms, ovarian function, ageing, and psychological factors. The subjects were as follows; 1,270 women who received a screening test for cervical cancer and 247 women following hysterectomy. The methods of investigation were Kupperman menopausal index (K-index), Cornell Medical Index (CMI) and YG character questionnaire (YG test). The following results were obtained: 1) the K-index increased until 39 years of age and was constant after 40 years. Five symptoms (chills, nervousness, melancholia, excitability and vertigo) were not influenced by ageing, and seven symptoms (panting, hypesthesia, insomnia, wakefulness, fatigue, palpitation and formication) increased with age. Hot flushes, perspiration, numbness, shoulder stiffness, lumbago, and headache, occurred at peak frequency in the climacteric period. 2) In hot flushes, perspiration, numbness, hypesthesia, shoulder stiffness, lumbago, and formication, a significant difference was found between the control and those patients who had received bilateral oophorectomy. 3) The K-index and CMI score were significantly correlated, and six symptoms (palpitation, panting, excitability, vertigo, wakefulness and formication) in particular were related to CMI. 4) The K-index was lowest in the patients indicated to be the D type by the YG test, and was highest in the patients of the B.E type. Six symptoms (excitability, palpitation, panting, melanchoria, hypesthesia and formication) were thought to be associated with the character of the patients. Results showed that four symptoms (hot flushes, perspiration, numbness, shoulder stiffness and lumbago) were closely related to ovarian function, and three symptoms (panting, excitability, and palpitation) depended largely on mental factors. The relationship between vasomortor symptoms and gonadotropin was investigated.(ABSTRACT TRUNCATED AT 250 WORDS)
Plasmacytoma often forms an intramedullary mass in the vertebrae with absorption of trabecula and cortex of the bone. However, occasionally, it forms a mass in the extramedullary space of the vertebrae. The authors report such a rare case with plasmacytoma which formed a mass in the thoracic epidural space without evidence of involvement of the adjacent vertebra. On May 22, 1985, a 80-year-old man was admitted to our clinic with chief complaints of gait disturbance and hypesthesia below the umbilical level. Difficulty of walking developed approximately four months prior to admission with gradual aggravation and hypesthesia added thereafter. Neurological examinations at admission showed paraparesis with positive Babinski's and Chaddock's reflexes, hypesthesia and disturbances of vibration and position senses below the 9th thoracic nerve level. Myelography and CT scan using metrizamide indicated a presence of epidural mass at the 8th to 9th thoracic vertebrae. There was no abnormal bony change in the spine on plain X-ray and CT scan. On May 30, 1985, total removal of epidural tumor was performed by removing the laminae from the 7th to 10th vertebrae. Histological examinations including immunological stainings showed a plasmacytoma which produced monoclonal immunoglobulin of IgG-lambda type. Radiation therapy was not carried out. The serum protein fraction, immunoglobulin, immunoelectrophoresis, Bence-Jones protein and CSF immunoglobulin examined after operation, supported a histological diagnosis of plasmacytoma. Also, slight proliferation of plasma cells was noted in the bone marrow and peripheral blood.(ABSTRACT TRUNCATED AT 250 WORDS)
STUDY DESIGN: Pain pattern mapping of the sacroiliac joint in asymptomatic volunteers was investigated. Prospective evaluation of 10 volunteers who received sacroiliac joint injections was performed. The injections consisted of contrast material followed by Xylocaine. OBJECTIVES: To determine the pain referral pattern of the sacroiliac joint in asymptomatic individuals. SUMMARY OF BACKGROUND DATA: All 10 individuals experienced discomfort upon initial injection, with the most significant sensation felt directly around the injection site. Subsequent sensory examination revealed an area of hypesthesia running caudally from the posterior superior iliac spine. METHODS: Volunteers were asked to describe the nature and location of the sensation upon sacroiliac injection. Sensory examination immediately followed the injection to determine referral patterns. RESULTS: Sensory examination immediately after sacroiliac injection revealed an area of buttock hypesthesia extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine. This area of hypesthesia corresponded to the area of maximal pain noted upon injection. CONCLUSION: A pain referral map was successfully generated using provocative injections into the right sacroiliac joint in asymptomatic volunteers.