Comparison of sustained-release and rapid-release ß-alanine formulations on changes in skeletal muscle carnosine and histidine content and isometric performance following a muscle-damaging protocol.

ß-alanine supplementation increases muscle carnosine content and improves anaerobic exercise performance by enhancing intracellular buffering capacity. ß-alanine ingestion in its traditional rapid-release formulation (RR) is associated with the symptoms of paresthesia. A sustained-release formulation (SR) of ß-alanine has been shown to circumvent paresthesia and extend the period of supply to muscle for carnosine synthesis. The purpose of this investigation was to compare 28 days of SR and RR formulations of ß-alanine (6 g day-1) on changes in carnosine content of the vastus lateralis and muscle fatigue. Thirty-nine recreationally active men and women were assigned to one of the three groups: SR, RR, or placebo (PLA). Participants supplementing with SR and RR formulations increased muscle carnosine content by 50.1% (3.87 mmol kg-1ww) and 37.9% (2.62 mmol kg-1ww), respectively. The change in muscle carnosine content in participants consuming SR was significantly different (p = 0.010) from those consuming PLA, but no significant difference was noted between RR and PLA (p = 0.077). Although participants ingesting SR experienced a 16.4% greater increase in muscle carnosine than RR, fatigue during maximal voluntary isometric contractions was significantly attenuated in both SR and RR compared to PLA (p = 0.002 and 0.024, respectively). Symptoms of paresthesia were significantly more frequent in RR compared to SR, the latter of which did not differ from PLA. Results of this study demonstrated that only participants consuming the SR formulation experienced a significant increase in muscle carnosine. Differences in the muscle carnosine response between these formulations may have practical significance for athletic populations in which small changes may have important implications on performance.

Intradiscal Expandable Balloon Distraction During Transforaminal Decompression for Lumbar Foraminal and Lateral Recess Stenosis.

Advanced videoendoscopic equipment (such as motorized drills, chisels, and rongeurs) facilitates the use of modern decompression tools through the inner working channel of the spinal endoscope using the transforaminal approach. Postoperative dysesthetic leg pain, however, is common because of irritation of the dorsal root ganglion. This article presents a novel surgical technique employing an expandable balloon placed into the hollow intervertebral space in patients without any functional disc tissue to distract the stenotic motion segment. This approach improves visualization, facilitates removal of bone during the decompression, and minimizes intraoperative manipulation of the exiting and traversing nerve roots. In a study of 52 targeted patients with symptomatic spinal stenosis at 60 levels (L2/3-1, L3/4-9, L4/5-28, and L5/S1-22) due to advanced degenerative changes of the intervertebral disc and facet joint complex contributing to both foraminal and lateral recess stenosis, only 2 of the 52 patients complained of postoperative dysesthetic leg pain (3.85%) after undergoing this novel procedure. At the final 2-year follow-up, 80.9% of patients showed Excellent and Good outcomes according to modified Macnab criteria.

Digital Relief of the Mental Foramen for a CAD/CAM-Fabricated Mandibular Denture.

Relief of the intaglio surface of a denture base is conventionally performed using thin wax and soft metal foil attached to the master cast. The following report highlights a new relief procedure for the mental foramen using a CT double scan technique on the CAD/CAM dentures fabricated for the patient with paresthesia of the left lower lip and chin during mastication.

Is 2 mm a safe distance from the inferior alveolar canal to avoid neurosensory complications in implant surgery?

AIM: The aim of the present study was to compare the neurosensory complications related to implants inserted closer than 2 mm to the inferior alveolar canal (IAC) with those inserted further than 2 mm. MATERIALS AND METHODS: A total of 474 implants in 314 patients placed posterior to mental foramen area were evaluated retrospectively on panoramic radiographs. Patients were divided into two groups regarding implant proximity to the IAC (Group 1, distance ≤2 mm, Group 2, distance >2 mm). Postoperative neurosensory complications (pain and paresthesia) were recorded. Chi-square test was used for statistical comparison and P ≤ 0.05 was considered significant. RESULTS: One hundred and fifty-three implants (32.2%) were inserted closer than 2 mm to the IAC whereas 321 implants (67.8%) were inserted further than 2 mm. Three implants which had a distance of 0 mm to the IAC (0.63%) caused paresthesia after surgery. Implant distance to IAC did not show a significant difference regarding pain and paresthesia (P = 0.06 and P = 0.08, respectively). CONCLUSION: When 2 mm is considered as a safety distance, the distance of the implants to the IAC did not yield any statistical difference regarding postoperative neurosensory complications.

[EXPERIENCE OF TOTALLY TRANSCUTANEOUS ENDOPROSTHESIS OF THE INFRARENAL AORTA АNEURYSM].

Endovascular endoprosthesis infrarenal aorta constitutes a miniinvasive highly technological method of treatment of a life-thretening pathology. Experience of transcutaneous endoprosthesis of infrarenal aorta in 6 patients was presented. Possibility of a common femoral artery (CFA) suturing, using Prostar XL apparatus, was estimated on a stage of the endoprosthesis dimensions calculation in accordance to a CT and duplex US scanning data and recommendations of manufacturer. In transcutaneous CFA suturing the complications were absent. Absence of a sectional access to CFA have permitted to avoid such complications, as neuralgia, paresthesia, seroma, suppuration of operative wound. In bilateral suturing of CFA a duration of the patients stationary state have reduced.

Recent advances in spinal cord stimulation for pain treatment.

Traditional (40-50 Hz) spinal column stimulation is an efficacious and widely accepted treatment for chronic neuropathic pain conditions. However, there are major challenges including its ineffectiveness for axial back pain, the burden of paresthesia-related discomfort and difficulties producing indisputable research. Recently, there have been the major technological innovations of high-frequency and burst stimulation. Studies have shown these to provide improved analgesia even for axial pain without the problems associated with paresthesia. Dorsal root ganglion stimulation may be useful in certain subsets of patients with dermatomal distribution of pain. Other scientific data and technological improvements such as recent research on cost-effectiveness, MRI compatibility and very recent advances in spinal column stimulation are appraised.

The Role of Conservative Management in Incidental Os Odontoideum.

BACKGROUND: Os odontoideum is a relatively rare but significant condition of the cervical spine that has potentially life-threatening complications, including vertebral artery dissection, leading to permanent neurologic disability and even death. Unfortunately, the literature is not clear as to the best management approach for os odontoideum. As such, clinicians and their patients are still left with difficult and uncertain treatment decisions in the absence of a clinical consensus. CASE DESCRIPTION: A 20-year-old male was brought in after an assault and found to have os odontoideum on routine investigation. He was informed of management options and elected to undergo a conservative management approach with radiologic surveillance. The patient subsequently became symptomatic and required surgical fixation. CONCLUSIONS: This case illustrates that in the event an asymptomatic case of os odontoideum with radiological instability is managed conservatively, careful clinical and radiologic follow-up is essential as such cases can become symptomatic.

Load Carriage-Related Paresthesias: Part 1: Rucksack Palsy and Digitalgia Paresthetica.

This is the first of a two-part article discussing loadcarriage- related paresthesias, including brachial plexus lesions (rucksack palsy), digitalgia paresthetica, and meralgia paresthetica. Paresthesias are sensations of numbness, burning, and/or tingling, usually experienced as a result of nerve injury, compression, traction, or irritation. Rucksack palsy is a traction or compression injury to the brachial plexus, caused by the shoulder straps of the rucksack. The patient presents with paresthesia, paralysis, cramping with pain, and muscle weakness of the upper limb. Muscle-strength losses appear to be greater in those carrying heavier loads. Hypothetical risk factors for rucksack palsy include improper load distribution, longer carriage distances, and load weight. Nerve traction, compression, and symptoms may be reduced by use of a rucksack hip belt; wider, better-padded, and proper adjustment of the shoulder straps; reduction of weight in the rucksack; a more symmetric distribution of the load; and resistance training to improve the strength and hypertrophy of the shoulder muscles. Assessment and neck joint and nerve mobilization may relieve brachial plexus tension and reduce symptoms. Another load-carriage-related disorder is digitalgia paresthetica, likely caused by compression of the sensory digital nerves in the foot during load carriage. Patients have paresthesia in the toes. Although no studies have demonstrated effective prevention measures for digitalgia paresthetica, reducing loads and march distances may help by decreasing the forces and repetitive stress on the foot and lower leg. Specialty evaluations by a physical therapist, podiatrist, or other healthcare provider are important to rule out entrapment neuropathies such as tarsal tunnel syndrome. Part 2 of this article will discuss meralgia paresthetica.

Comparison of Conventional and Kilohertz Frequency Epidural Stimulation in Patients Undergoing Trialing for Spinal Cord Stimulation: Clinical Considerations.

OBJECTIVE: Compare therapeutic response of patients to conventional versus high-frequency spinal cord stimulation (SCS). METHODS: Twelve patients with back and leg pain who met standard clinical criteria for a trial of conventional SCS (low-frequency stimulation [LFS]) participated in a half-day session of high-frequency stimulation (HFS) during their weeklong conventional trial. HFS consisted of frequencies ranging from 50 Hz to 4 kHz, or 100 Hz to10 kHz, at constant voltage settings increasing from 0.5 V to 10 V. Visual Analog Scale scores from 0 to10 were recorded, along with notes of any clinical discomfort and open patient comments. RESULTS: Two of 12 patients had no benefit from either LFS or HFS. In the remaining 10 patients, paresthesias were significantly altered by HFS, and four experienced complete elimination of paresthesias. Five patients preferred HFS to LFS, with an additional three preferring both equally. Abrupt sensation to the onset of HFS was described in six patients, and in ten patients, HFS allowed maximum voltage stimulation of 10 V without discomfort. The four patients who did not have a successful trial of stimulation had significantly longer duration of pain compared to the eight patients who went on to permanent implant (11.2 vs. 4.3 years, P = 0.04). CONCLUSIONS: HFS significantly altered the feeling of paresthesias in the majority of patients (ten of 12), was preferred to LFS in five of 12 patients, and non-inferior to LFS in eight of 12 patients. Both 4 kHz and 10 kHz stimulation allowed patients to benefit from HFS. HFS allowed maximum voltage stimulation without discomfort.

Can pregabalin prevent paclitaxel-associated neuropathy?--An ACCRU pilot trial.

PURPOSE: Paclitaxel can cause an acute pain syndrome (P-APS), considered to be an acute form of neuropathy and chronic chemotherapy-induced peripheral neuropathy (CIPN). Anecdotal reports suggested that gabapentin may be helpful in the prevention of these toxicities. The purpose of this pilot study was to obtain data to support or refute the utility of pregabalin for the prevention of P-APS and CIPN. METHODS: Patients scheduled to receive weekly paclitaxel (80 mg/m(2)/dose) were randomized 1:1 to receive pregabalin 75 mg or a placebo, twice daily, during the 12 weeks of chemotherapy. Patients completed the European Organization of Research and Treatment of Cancer Quality of Life (EORTC QLQ) CIPN20 questionnaire at baseline, prior to each dose of paclitaxel and monthly for 6 months post-treatment. Patients completed a post-paclitaxel questionnaire for 6 days after each dose of paclitaxel and an acute pain syndrome symptom questionnaire on day 8. The primary end point was to determine the effect of pregabalin on the maximum of the worst acute pain scores for the week following paclitaxel administration for cycle 1. RESULTS: Forty-six patients were randomly assigned to the treatment or placebo arm. There was no suggestion of a difference between the two study arms with regard to P-APS measures. While there was a suggestion that pregabalin decreased numbness, there was no suggestion that it decreased tingling, pain, or the EORTC QLQ-CIPN20 subscale scores. There were no evident toxicity differences between the two study arms. CONCLUSIONS: The results of this pilot trial do not support that pregabalin is helpful for preventing P-APS or paclitaxel-associated CIPN.

Transverse small skin incision for carotid endarterectomy.

BACKGROUND: The purpose of this report is to determine the feasibility of short transverse skin incision (STI < 4 cm) for eversion (EEA) and patch (PEA) endarterectomy with or without shunt by comparing it with the outcomes after long transverse skin incision (LTI 4-8 cm). METHODS: Of 164 elective consecutive patients (71 ± 2.73% symptomatic) operated at one institution over 24 months, 81 were treated with STI, while 83 patients received LTI. The LTI and STI groups did not differ in terms of age, symptoms, or risk factors. EEA or PEA under locoregional (LRA) or general (GA) anesthesia were performed. RESULTS: STI was associated with shorter operation times (75.19 ± 15.33 vs. 94.87 ± 41 and 99.4 ± 27.36 vs. 132.66 ± 51.32, respectively, P < 0.01) and similar clamping times (26.05 ± 5.71 vs. 26.07 ± 7.14 and 34.04 ± 9.49 vs. 42.5 ± 20.8, respectively) in the EEA and PEA groups that did not receive shunts compared with the corresponding LTI groups, and the operating room stays of the STI patients operated on GA were shorter than that of the corresponding LTI patients (181.11 ± 39.16 vs. 212.5 ± 64, P < 0.001). Nonsignificant differences were found between the corresponding STI and LTI shunt groups. No perioperative deaths occurred. STI was associated with less perioperative complications than LTI. Macroscopically nondistinguishable scar was present in 85% in the STI and 52% in the LTI groups (P < 0.001). Postoperative local irritation and paresthesia occurred similarly in the STI (11%) and LTI (14%) groups. CONCLUSIONS: STIs are feasible for PEA and EEA. STIs produce significantly better cosmetic outcomes and shorter operation times than LTI and have similar rates of complication and similar incidences of local discomfort. Although no neurological consequences of using STIs for PEAs with shunts were revealed, STI should be applied with caution until sufficient patch length and long-term patency of this procedure are demonstrated.

One-port videothoracoscopic surgical intervention.

BACKGROUND: One-port video-assisted thoracic surgery (VATS) has recently been proposed as an alternative to conventional 3-port VATS. To reduce pain, chest wall paresthesia, and hospital stay, lesser ports are the current direction. MATERIALS AND METHODS: From 2007 to 2010, 98 patients underwent 1-port VATS procedure. The charts were retrospectively evaluated. A 2.5 cm long incision was made at the sixth intercostal space in the median axillary line. A single flexible port was used. Both the camera and the endoinstruments were introduced through the port. Patient characteristics, visual analog score, and postoperative paresthesia scores were evaluated. RESULTS: The study enrolled 38 women and 60 men with the mean age of 49.1±1.5 years (range, 19 to 75 y). Thirty-one patients (28.6%) were diagnosed with malignant pleural effusion. Perioperative pleurodesis with talc was performed in 81% of them. One-port VATS approach was used for pleura biopsies in 77 (78.6%), wedge resection in 4 (3.8%), pleurectomy in 13 (12.4%), and biopsy with talc chemical pleurodesis in 4 (3.8%) instances. The mean operation time was 24.4 minutes (range, 15 to 50 min). No major cardiorespiratory or surgical complications were noted. The median observation time was 60 months (range, 36±81 mo). Among benign pathology patients, 56 (82.3%) of them did not complain about any pain; however, 12 patients had prolonged discomfort (2 pinprick, 6 numbness, and 4 pruritus). CONCLUSIONS: One-port VATS in selected patients are feasible and seems to be safe in thoracic surgical interventions instead of conventional 3 ports that was presented in this series.

Lhermitte's phenomenon and platinum, beware of latency.

BACKGROUND: Lhermitte's sign (LS) is characterized by electric shock-like sensations, spreading along the spine in a cervico-caudal direction and into the arms and legs. It is felt upon flexion of the neck and reflects a myelopathy resulting from damage to sensory axons at the dorsal columns of the cervical spinal cord. In patients with cancer, LS can occur due to direct tumour involvement of the spine or in relation to radiotherapy. Chemotherapy-related LS has only rarely been reported. CASE REPORT: We present the case of a 44-year-old patient treated with platinum- and etoposide-based chemotherapy for metastatic seminoma, who subsequently developed severe disabling LS. The severity and duration of LS in this case exceeds prior reports. We review the literature on chemotherapy-related LS and discuss the practice implications. CONCLUSION: Neuropathy and LS related to cisplatin-based chemotherapy can result in significant adverse effects. Raised awareness of this complication could aid sub-phenotyping of the population most at risk and assist strategies to avert discomfort and disability post chemotherapy.

Puede el paciente advertir cercanía al nervio dentario inferior bajo anestesia infiltrativa?: presentación de un caso clínico / Can the patient notice the proximity to mental nerve under local anesthesia?: report of a clinical case

Cuando se colocan implantes dentales en el sector posterior de la mandíbula, el profesional debe decidir si utilizar la técnica troncular o la infiltrativa. Algunos estudios afirmaron que bajo anestesia infiltrativa el paciente podría advertir al profesional a través de su dolor, la cercanía del fresado o la colocación del implante al nervio dentario inferior. En contra posición, el objetivo de esta presentación de un caso clínico es evidenciar a través de tomografías pre y post quirúrgicas,que bajo anestesia infiltrativa la paciente no refirió dolor a pesar que el implante fue colocado íntimamente en relación al conducto dentario inferior.

How fast pain, numbness, and paresthesia resolves after lumbar nerve root decompression: a retrospective study of patient's self-reported computerized pain drawing.

STUDY DESIGN: A single-center retrospective study. OBJECTIVE: To compare the speed of recovery of different sensory symptoms, pain, numbness, and paresthesia, after lumbar nerve root decompression. SUMMARY OF BACKGROUND DATA: Lumbar radiculopathy is characterized by different sensory symptoms like pain, numbness, and paresthesia, which may resolve at different rates after surgical decompression. METHODS: Eighty-five cases with predominant lumbar radiculopathy treated surgically were reviewed. Oswestry Disability Index score, 36-Item Short Form Health Survey scores (Physical Component Summary and Mental Component Summary), and pain drawing at preoperative and at 6 weeks, 3 months, 6 months, and 1-year follow-up were reviewed. Recovery rate between different sensory symptoms were compared in all patients, and between the short-term compression (<6 mo) and long-term compression groups. RESULTS: At baseline, 73 (85.8%) patients had pain, 63 (74.1%) had numbness, and 38 (44.7%) had paresthesia; 28 (32.9%) had all these 3 component of sensory symptoms. Mean pain score improved fastest (55.3% at 6 wk); further resolution until 1 year was slow and not significant compared with each previous visit. Both numbness and paresthesia scores showed a trend of faster recovery during the initial 6-week period (20.5% and 24%, respectively); paresthesia recovery reached a plateau at 3 months postoperatively, but numbness continued a slow recovery until 1-year follow-up. Both Oswestry Disability Index score and Physical Component Summary scores (54.02 ± 1.87 and 26.29 ± 0.93, respectively, at baseline) improved significantly compared with each previous visits at 6 weeks and 3 months postoperatively, but further improvement was insignificant. Mental Component Summary showed a similar trend but smaller improvement. The short-term compression group had faster recovery of pain than the long-term compression group. CONCLUSION: In lumbar radiculopathy patients after surgical decompression, pain recovers fastest, in the first 6 weeks postoperatively, followed by paresthesia recovery that plateaus at 3 months postoperatively. Numbness recovers at a slower pace but continues until 1 year. LEVEL OF EVIDENCE: 4.

Imaging features of rhinoplasty.

SUMMARY: Cosmetic rhinoplasty encompasses a diverse group of procedures, including alteration of the radix, nasal dorsum, nasal tip, and nasal base; premaxillary augmentation; septoplasty; and combinations thereof. Similarly, many different types of grafts and alloplastic materials can be used in cosmetic rhinoplasty, such as cartilage, bone, silicone, porous polyethylene, expanded polytetrafluoroethylene, and calcium hydroxylapatite. Complications of rhinoplasty that can be observed on imaging include retained metallic surgical instrument fragments, infection, implant extrusion, nerve impingement by implants, nasal valve collapse, and implant deformity. Knowledge of the basic surgical procedures and potential complications of cosmetic rhinoplasty is important for adequately interpreting postoperative radiologic imaging studies.

Embryonic NOTES thoracic sympathectomy for palmar hyperhidrosis: results of a novel technique and comparison with the conventional VATS procedure.

BACKGROUND: To avoid the disadvantages of chronic pain and chest wall paresthesia associated with video-assisted thoracic surgery (VATS) procedures, we developed a novel surgical technique for performing sympathectomy by embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) with a flexible endoscope. In this study, we compared the outcomes of E-NOTES with conventional VATS thoracic sympathectomy on palmar hyperhidrosis. METHODS: From January 2010 to April 2011, a total of 66 patients with severe palmar hyperhidrosis were treated with thoracic sympathectomy in our department. Thirty-four transumbilical thoracic sympathectomies were performed via a 5-mm umbilicus incision with ultrathin gastroscope, then compared with 32 conventional needlescopic thoracic sympathectomies. Retrospective statistical analysis of a prospectively collected group of patients was performed. RESULTS: There was no significant difference with regard to gender, mean age, body mass index, and length of hospital stay between the two groups. The operative time for E-NOTES thoracic sympathectomy was longer than that of VATS thoracic sympathectomy (56.4 ± 10.8 vs. 40.3 ± 6.5 min, p < 0.01). No mortality, diaphragmatic hernia, or Horner syndrome was observed in either group. Postoperative questionnaires were returned by all treated patients with a mean time from operation to follow-up of 1.4 ± 0.3 years. All 66 patients receiving sympathectomy reported successful treatment of their palmar hyperhidrosis. Compensatory hyperhidrosis was noticed in 7 (20.1 %) and 6 (18.8 %) patients in the E-NOTES and VATS groups, respectively (p > 0.05). Postoperative pain and paresthesia were significantly reduced in the E-NOTES group at each time interval, and the aesthetic effect of the incision was superior in the E-NOTES group. CONCLUSIONS: Transumbilical-diaphragmatic thoracic sympathectomy is a safe and efficacious alternative to the conventional approach. This novel procedure can further reduce postoperative pain and chest wall paresthesia as well as afford maximum cosmetic benefits by hiding the surgical incision in the umbilicus.