Sensory function after cavernous haemangioma: a case report of thermal hypersensitivity at and below an incomplete spinal cord injury.

STUDY DESIGN: Case report of a 42-year-old woman with non-evoked pain diagnosed with a cavernous C7-Th6 spinal haemangioma. OBJECTIVES: To assess the effect of intramedullary haemorrhage (IH) on nociception and neuropathic pain (NP) at and below an incomplete spinal cord injury (SCI). SETTING: Sensorimotor Function Group, Hospital Nacional de Parapléjicos de Toledo (HNPT). METHODS: T2*-susceptibility weighted image (SWI) magnetic resonance imaging (MRI) of spinal haemosiderin and a complete pain history were performed 8 months following initial dysaesthesia complaint. Thermal pain thresholds were assessed with short 1 s stimuli, while evidence for central sensitization was obtained with psychophysical electronic Visual Analogue Scale rating of tonic 10 s 3 °C and 48 °C stimuli, applied at and below the IH. Control data were obtained from 10 healthy volunteers recruited from the HNPT. RESULTS: Non-evoked pain was present within the Th6 dermatome and lower legs. T2*-SWI MRI imaging detected extensive haemosiderin-rich IH (C7-Th5/6 spinal level). Cold allodynia was detected below the IH (left L5 dermatome) with short thermal stimuli. Tonic thermal stimuli applied to the Th6, Th10 and C7 dermatomes revealed widespread heat and cold allodynia. CONCLUSION: NP was diagnosed following IH, corroborated by an increase in below-level cold pain threshold with at- and below-level cold and heat allodynia. Psychophysical evidence for at- and below-level SCI central sensitization was obtained with tonic thermal stimuli. Early detection of IH could lead to better management of specific NP symptoms, an appreciation of the role of haemorrhage as an aggravating SCI physical factor, and the identification of specific spinal pathophysiological pain mechanisms.

Oxcarbazepine monotherapy in carbamazepine-unresponsive trigeminal neuralgia.

The objective of this prospective open-label study was to evaluate the efficacy and tolerability of oxcarbazepine in trigeminal neuralgia (TN) unresponsive to treatment with the standard antiepileptic drug, carbamazepine. Thirty-five patients with idiopathic TN, who underwent treatment with oxcarbazepine monotherapy for at least 12 weeks, were studied. Pain was assessed using mean pain frequency, responder rate, pain-free patients and clinical global impression. The mean maintenance dose was 773.7 mg/day. There was a significant decrease in the mean of the main scores following 12 weeks of treatment (p<0.05) compared with baseline. Oxcarbazepine was effective from the first month of treatment. There was a significant reduction in pain frequency, leading to improvements in patient satisfaction. In general, oxcarbazepine was well tolerated. Oxcarbazepine appears to be an important alternative therapeutic approach for patients affected by TN. This study adds to the existing literature arriving at the same findings.

[Neuroimaging in fibromyalgia]. / Neuroimagen en fibromialgia.

INTRODUCTION: Most current research suggests that fibromyalgia is a disease produced by an alteration in the processing of pain signals in the central nervous system. In recent years, advances in non- or minimally-invasive brain imaging techniques have made it possible to discover how different areas of the nervous system are involved in the aetiopathogenesis of diseases that up until now have been considered as having a functional profile. AIM: To describe the objectified functional and the structural changes that take place in the brains of patients with fibro-myalgia by means of the currently available neuroimaging techniques. DEVELOPMENT: This work reviews the clinical studies, both anatomical and molecular, that have been conducted to date in the field of fibromyalgia using different brain imaging techniques. CONCLUSIONS: Different, but related, areas of the central nervous system have been described as altering not only the functional but also the structural form, in patients with fibromyalgia. These involved areas extend beyond the pain circuits, which would explain the variety of symptoms in patients, in addition to the characteristic pain reported by them.

TITLE: Neuroimagen en fibromialgia.Introduccion. La mayoria de las investigaciones actuales sugiere que la fibromialgia es una enfermedad producida por una alteracion en el procesamiento de la señal dolorosa en el sistema nervioso central. En los ultimos años, gracias al avance de las tecnicas de imagen cerebral no invasivas o minimamente invasivas, se ha podido averiguar como participan las diferentes areas del sistema nervioso en la etiopatogenia de enfermedades consideradas hasta ahora como de perfil funcional. Objetivo. Describir los cambios objetivados, tanto funcionales como estructurales, que ocurren en el cerebro de pacientes con fibromialgia a traves de las tecnicas de neuroimagen disponibles en la actualidad. Desarrollo. Se revisan los estudios clinicos, tanto anatomicos como moleculares, que se han realizado hasta ahora, con las diferentes tecnicas de imagen cerebral, en el campo de la fibromialgia. Conclusiones. Se han descrito diferentes areas del sistema nervioso central, relacionadas entre si, que se alteran no solo de forma funcional, sino tambien estructural, en los pacientes con fibromialgia. Estas areas involucradas se extienden mas alla de los circuitos de dolor, lo que explicaria la variada sintomatologia de los pacientes y el dolor caracteristico referido por ellos.

Effects of baclofen on temperature perception in humans.

The aim of this study was to evaluate the effect of chronic consumption of the GABAB agonist baclofen on temperature perception in humans. We investigated temperature perception thresholds to detect warm and cold stimuli in a group of 21 patients with spinal cord injury, who were chronically consuming oral baclofen at different daily doses to treat spasticity. Temperature perception thresholds were assessed above the level of the lesion, using a psychophysical approach based on the ability of the subjects to perceive precisely quantified sensory stimuli (quantitative sensory testing, QST). The data were compared with a control group of healthy subjects, not receiving baclofen. We found that chronic baclofen consumption increased temperature perception thresholds for both cold and warm stimuli in a dose-dependent manner. Temperature perception thresholds did not depend on the level of the lesion nor on the duration of baclofen treatment, suggesting that our finding represent normal GABAB-mediated modulation in spared nervous structures. We conclude that GABAB therefore plays a role in temperature perception in humans.

[Topiramate in comorbid disorders: epilepsy and migraine]. / Topiramato en enfermedades comórbidas: epilepsia y migraña.

INTRODUCTION: With relative frequency epilepsy and migraine are associated in a same patient. Some times it is difficult to distinguish an attack of others. Reason why it would be of utility to have a treatment effective in both pathologies. It is tried to study in patients with this comorbidity, how of effective it is a drug indicated in the two pathologies, as it is topiramate. PATIENTS AND METHODS: An observational, longitudinal and prospective study is made, where 15 patients are recruited with this association, and which they were treated with topiramate. They are revaluated at three and six months of treatment. RESULTS: Significant differences are obtained (p < 0.05) in all the studied variables (severity and duration of the migraine attacks and frequency of the migraine and epileptic attacks), with a medium dose of 100 mg/day of topiramate, at the end of the study. Not serious adverse effects were observed. CONCLUSIONS: Topiramate in monotherapy seems to be a suitable treatment in patients who undergo epileptic and migrainous attacks jointly.

[Worsening of migraine symptoms due to giant pineal cyst apoplexy]. / Agravamiento de un cuadro migrañoso por apoplejía de un quiste pineal gigante.

INTRODUCTION: Although the association between headaches and pineal gland cysts has been suggested on a number of occasions, no precise evidence of exactly what this relation involves has been produced to date. It is known, however, that a cyst in the pineal gland can bring on or worsen headaches, especially if it is large or there has been bleeding, due to obstructive compromise in the third ventricle and the resulting hydrocephalus that is produced. CASE REPORT: A 15 years-old male who had suffered from migraine from the age of 6 years and who suddenly experienced a worsening of his headaches, both as regards their frequency and their intensity, over the previous days; no known precipitating factor appeared to be involved. Magnetic resonance imaging of the brain revealed the presence of a giant cyst in the pineal gland, with a notable amount of blood inside it, which was producing an obstructive hydrocephalus. The decision was made to resort to surgical treatment, with resection of the cyst and placement of a shunt valve. As a result the patient's headaches improved greatly and this improvement continued throughout a six-month follow-up. CONCLUSIONS: Worsening of a headache, in this case migraine, for no apparent cause must make us consider secondary processes, although they may be as rare as the one described here.

[Acute transverse myelitis: a clinical review and algorithm for diagnostic intervention]. / Mielitis transversa aguda: revisión clínica y algoritmo de actuación diagnóstica.

INTRODUCTION: Under the term of acute transverse myelitis (ATM), there are included a heterogeneous group of diseases, with the nexus common to produce an inflammatory focal injury of the spinal cord, of acute form. In order to try to group all the etiologies that can provoke this affectation, it is nowadays tried to define several groups of pathologies with a common nexus: those ATM associated to some process, or at least predisposed of the ATM, like are certain infections, immunological systemic and/or multifocal processes, and inclusive tumors, but when we did not get to know this triggering factor, then calling them idiopathic ATM. AIM: To know the different classes from existing ATM, creating an algorithm diagnosis that helps to this classification of ordinate form, simplifying the work to the clinicians that faces a ATM, exposing its differential diagnosis, prognosis and possible treatment. DEVELOPMENT: For it we consulted the last guides and works published related to the ATM, mainly from the diagnostic and therapeutic point of view. CONCLUSIONS: Our knowledge of the ATM is being constantly modified with the coming of new diagnostic techniques and theories that try to explain their origin, probably immunological. Unfortunately, the treatment, and therefore the prognosis, has not varied in the same proportion to the knowledge that we are acquiring in the other areas. Without a doubt, it is a way important to walk, but the next future can teach to us more on this disease.

[Spinal cord involvement by tuberculosis]. / Afectación de la médula espinal por tuberculosis.

INTRODUCTION: We are observing an increase of patients with tuberculosis in Spain. Within the forms of extrapulmonary presentation, the involvement of the central nervous system by the bacillus that cause this disease is a relatively frequent location. Although sometimes is affected the spinal cord of secondary form, rarely is observed isolated involvement. DEVELOPMENT AND CONCLUSIONS: We describe the diverse forms of spinal cord tuberculosis presentation, attending of its location within the spinal cord or adjacent annexes, in order that the clinician knows and remembers this infrequent but possible infection of the spinal cord, because their knowledge and prompt treatment modifies clearly their final prognosis. We analyze the treatment rules for each case according to the last recommendations, and finally, the differences in two groups of population, immunodepressant patients, like human immunodeficiency virus infected patients, as well as in paediatric age patients, because both groups have more possibility of tuberculosis infection generally, and therefore spinal cord involvement, with a differential clinical and therapeutic behaviour.

[Acute transverse myelitis in seven patients with systemic lupus erythematosus]. / Mielitis transversa aguda en siete pacientes con lupus eritematoso sistémico.

INTRODUCTION: Although the association between transverse myelitis and systemic lupus erythematosus is rather infrequent, it is important to take this form of clinical presentation into account because it is a serious complication, which can potentially be treated but even when dealt with in the early stages does not always have a good prognosis. PATIENTS AND METHODS: We conducted a retrospective review over the past 13 years of the cases that have been admitted to our specific centre for the treatment of spinal cord injuries that were diagnosed as suffering from myelitis associated with disseminated lupus erythematosus. Demographic and clinical data, together with data about acute phase and maintenance treatments, as well as the patients' progress and sequelae are described. RESULTS: The case reports of seven patients, all of whom were young females, are studied. In two cases, myelitis was the initial presentation of lupus. The main disorder was at the dorsal, followed by the cervical, levels. Only two patients had a favourable long-term progression from the neurological point of view (both managed to walk) despite acute treatment with high doses of intravenous corticoids, and regardless of the fact that cyclophosphamide was later used. CONCLUSIONS: Myelitis associated to lupus is a rare manifestation but, owing to its important functional repercussions, it must be taken into account when faced with an acute clinical picture involving the spinal cord; this is particularly the case when it occurs in young females, with or without a previous diagnosis of autoimmune disease.

Prevalencia de síntomas neurológicos asociados a la fibromialgia / Prevalence of neurological symptoms associated with fibromyalgia

Introducción: La fibromialgia se puede considerar un síndrome del que el síntoma más frecuente, y de hecho único criterio diagnóstico, es el dolor. Sin embargo, como cuadro sindrómico que es, engloba muchos otros síntomas y signos, posiblemente igualmente importantes y, a veces, tan incapacitantes como el propio dolor. Dentro de todos ellos, los relacionados con la esfera neurológica pueden ser fundamentales para comprender el estado general que padecen los pacientes. Material y métodos: Se diseñó y realizó una encuesta a pacientes con diagnóstico previo de fibromialgia, interrogando de forma específica por síntomas o signos neuropsicológicos asociados a su enfermedad, así como la posibilidad de estar recibiendo tratamiento para ellos. Además, indagamos por los posibles determinantes del origen de la enfermedad y, por último, también por la opinión de los pacientes acerca del posible origen de su problema, la fibromialgia. Resultados: Recogimos encuestas hasta completar un total de 100 pacientes. Se observó un alto porcentaje de síntomas relacionados con el sistema nervioso en estos pacientes, y la mayoría de los síntomas por los que se preguntó en el momento de la encuesta, se encontraba por encima del 50% de los pacientes. Por otro lado, casi dos terceras partes de los pacientes relacionaron el origen de su enfermedad con algún factor estresante o desencadenante. Sobre el origen de la fibromialgia, la respuesta más repetida por los pacientes fue de causa desconocida, seguido del posible origen reumatológico y, en tercer lugar, el neurológico. Conclusiones: Diversos síntomas neurológicos se asocian con alta frecuencia a su enfermedad, según los propios pacientes. Todos los clínicos involucrados en el estudio y tratamiento de este cuadro deberían tener en cuenta la participación de estos síntomas relacionados con la esfera neurológica, por su alta proporción y trascendencia, según lo refieren los pacientes con fibromialgia (AU)

Introduction: Fibromyalgia can be considered a syndrome. The most frequent symptom and, in fact, the only diagnostic criterion is pain. Nevertheless, as a syndromic picture, fibromyalgia includes many other symptoms and signs, which are equally important and possibly sometimes as disabling as pain. Among all of these symptoms and signs, those related to the neurological sphere may be fundamental to understanding patients’ general state. Material and methods: We designed and performed a survey of patients with a prior diagnosis of fibromyalgia with specific items on neuropsychological signs or symptoms associated with this disease, as well as the possibility of receiving treatment for these manifestations. In addition, we enquired about the possible triggering factors of the disease, and the patient’s opinion on the possible cause of the fibromyalgia. Results: One hundred surveys were completed. A high percentage of the symptoms were related to the nervous system and, at the time of the survey, these symptoms were reported by over 50% of the patients. Almost two-thirds of the patients related the onset of their disease with a stress or triggering factor. On the cause of the fibromyalgia, the most frequent response was that the fibromyalgia was of unknown cause, followed by a possible rheumatologic origin, and thirdly, of a neurological origin. Conclusions: Patients with fibromyalgia reported a high frequency of associated neurological symptoms. Consequently, all clinicians involved in the study and treatment of fibromyalgia should bear in mind the role of neurological symptoms in this syndrome (AU)

Leucoencefalopatía posterior reversible en un paciente con lesión medular / Reversible posterior leucoencephalopathy in a patient with spinal cord injury

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Documento de Consenso interdisciplinar para el tratamiento de la fibromialgia / Interdisciplinary Consensus Document for the treatment of fibromyalgia

Antecedentes. La elevada prevalencia y enorme impacto clínico y social de la fibromialgia, junto a la complejidad de su tratamiento, exigen consensos de actuación que sirvan de guía a los profesionales de la salud. Aunque existían algunos documentos similares en nuestro idioma, la mayoría habían sido realizados desde la perspectiva de una única disciplina. Objetivo. Desarrollar un consenso sobre el tratamiento de la fibromialgia realizado por representantes seleccionados y avalados por las principales sociedades médicas que intervienen en su tratamiento (reumatología, neurología, psiquiatría, rehabilitación y medicina de familia), así como representantes de las asociaciones de pacientes. Por otra parte, se enfatizó la comprensión de la enfermedad no como un trastorno homogéneo, sino como la suma de diferentes subtipos clínicos, con características sintomáticas específicas y necesidades terapéuticas distintas. Este abordaje representaba una necesidad percibida por los clínicos y una novedad respecto a consensos previos. Método. Se revisaron las diferentes clasificaciones clínicas que se han propuesto en fibromialgia, así como la evidencia científica de los tratamientos utilizados en esta enfermedad. Para la selección de la clasificación empleada y para la realización de las recomendaciones terapéutica, se emplearon algunas de las técnicas habituales para realizarlos consensos (grupo nominal y brainstorming). Conclusión. La clasificación de Giesecke de la fibromialgia en 3 subgrupos parece ser la que cuenta con mayor evidencia científica y la más útil para el clínico. La guía ofrece una serie de recomendaciones generales para todos los pacientes con fibromialgia. Pero, además, para cada subgrupo existen una serie de recomendaciones específicas de tipo farmacológico, psicológico y de modificación del entorno, que permitirán un abordaje personalizado del paciente con fibromialgia en dependencia de sus características clínicas individuales (dolor, depresión, niveles de catastrofización, etc) (AU)

Backgrounds. The elevated prevalence and enormous clinical and social impact of fibromyalgia, together with the complexity of its treatment, require action consensuses that guide health care professionals. Although there are some similar documents in our language, most have been made from the perspective of a single discipline. Objective. To develop a consensus on the treatment of fibromyalgia made by selected representatives and supported by the principal medical associations that intervene in its treatment (rheumatology, neurology, psychiatry, rehabilitation and family medicine) and representatives of the associations of patients. On the other hand, understanding the disease not as a homogenous disorders but also as the sum of different clinical subtypes, having specific symptomatic characteristics and different therapeutic needs is stressed. This approach represented a need perceived by the clinicians and a novelty regarding previous consensuses. Methods. The different clinical classifications proposed in fibromyalgia and the scientific evidence of the treatments used in this disease were reviewed. For the selection of the classification used and performance of the therapeutic recommendations, some of the usual techniques to obtain the consensus (nominal group and brainstorming) were used. Conclusion. The classification of Giesecke of fibromyalgia into 3 subgroups seems to have the greatest scientific evidence and the most useful for the clinician. The guide offers a series of general recommendations for all the patients with fibromyalgia. However, in addition, for each subgroup, there are a series of specific pharmacological and psychological-type recommendations and those of modification of the environment, which will make it possible to have a personalized approach to the patient with fibromyalgia in accordance with their individual clinical characteristics (pain, catastrophizing levels, etc.) (AU)

Agravamiento de un cuadro migrañoso por apoplejía de un quiste pineal gigante / Worsening of migraine symptoms due to giant pineal cyst apoplexy

Introducción. Aunque la asociación entre cefalea y quistes de la glándula pineal se ha postulado en repetidas ocasiones, no se ha podido demostrar de forma precisa en qué consiste dicha relación. Sí es conocido el inicio o empeoramiento de las cefaleas por un quiste de la glándula pineal, sobre todo si éste es de gran tamaño, o ha sangrado, debido a la afectaciónobstructiva en el tercer ventrículo, y la hidrocefalia secundaria producida. Caso clínico. Varón de 15 años, migrañoso desde los 6 años, que en los últimos días sufrió un empeoramiento brusco de sus cefaleas, tanto en frecuencia como en intensidad, sin un desencadenante conocido. Se le realizó una resonancia magnética cerebral, que mostró un quiste gigante de laglándula pineal, con importante contenido hemático en su interior, el cual producía una hidrocefalia obstructiva. Se decidió intervenir quirúrgicamente, con resección del quiste y la colocación de una válvula de derivación. Como resultado, se produjo una importante mejoría de sus cefaleas, que se mantuvo durante un período de seguimiento de seis meses. Conclusión. Anteun agravamiento de una cefalea, en este caso migrañosa, sin causa aparente, se debe pensar en procesos secundarios, aunquepueden ser tan infrecuentes como el presentado

Introduction. Although the association between headaches and pineal gland cysts has been suggested on a numberof occasions, no precise evidence of exactly what this relation involves has been produced to date. It is known, however, that a cyst in the pineal gland can bring on or worsen headaches, especially if it is large or there has been bleeding, due to obstructive compromise in the third ventricle and the resulting hydrocephalus that is produced. Case report. A 15 years-old male who had suffered from migraine from the age of 6 years and who suddenly experienced a worsening of his headaches, both as regards their frequency and their intensity, over the previous days; no known precipitating factor appeared to be involved. Magnetic resonance imaging of the brain revealed the presence of a giant cyst in the pineal gland, with a notableamount of blood inside it, which was producing an obstructive hydrocephalus. The decision was made to resort to surgical treatment, with resection of the cyst and placement of a shunt valve. As a result the patient's headaches improved greatly andthis improvement continued throughout a six-month follow-up. Conclusions. Worsening of a headache, in this case migraine, for no apparent cause must make us consider secondary processes, although they may be as rare as the one described here