Muscle Spasms after Spinal Cord Injury Stem from Changes in Motoneuron Excitability and Synaptic Inhibition, Not Synaptic Excitation.

Muscle spasms are common in chronic spinal cord injury (SCI), posing challenges to rehabilitation and daily activities. Pharmacological management of spasms mostly targets suppression of excitatory inputs, an approach known to hinder motor recovery. To identify better targets, we investigated changes in inhibitory and excitatory synaptic inputs to motoneurons as well as motoneuron excitability in chronic SCI. We induced either a complete or incomplete SCI in adult mice of either sex and divided those with incomplete injury into low or high functional recovery groups. Their sacrocaudal spinal cords were then extracted and used to study plasticity below injury, with tissue from naive animals as a control. Electrical stimulation of the dorsal roots elicited spasm-like activity in preparations of chronic severe SCI but not in the control. To evaluate overall synaptic inhibition activated by sensory stimulation, we measured the rate-dependent depression of spinal root reflexes. We found inhibitory inputs to be impaired in chronic injury models. When synaptic inhibition was blocked pharmacologically, all preparations became clearly spastic, even the control. However, preparations with chronic injuries generated longer spasms than control. We then measured excitatory postsynaptic currents (EPSCs) in motoneurons during sensory-evoked spasms. The data showed no difference in the amplitude of EPSCs or their conductance among animal groups. Nonetheless, we found that motoneuron persistent inward currents activated by the EPSCs were increased in chronic SCI. These findings suggest that changes in motoneuron excitability and synaptic inhibition, rather than excitation, contribute to spasms and are better suited for more effective therapeutic interventions.Significance Statement Neural plasticity following spinal cord injury is crucial for recovery of motor function. Unfortunately, this process is blemished by maladaptive changes that can cause muscle spasms. Pharmacological alleviation of spasms without compromising the recovery of motor function has proven to be challenging. Here, we investigated changes in fundamental spinal mechanisms that can cause spasms post-injury. Our data suggest that the current management strategy for spasms is misdirected toward suppressing excitatory inputs, a mechanism that we found unaltered after injury, which can lead to further motor weakness. Instead, this study shows that more promising approaches might involve restoring synaptic inhibition or modulating motoneuron excitability.

Double longitudinal myotomy in gender-affirming colovaginoplasty: an innovative surgical technique to prevent and treat neovaginal spasms.

BACKGROUND: Gender-affirming colovaginoplasty (GACv) presents excellent postoperative results. However, neovaginal spasms, reported as painful cramps, can affect the sexual life of patients. AIM: The study sought to describe an innovative surgical technique and evaluate its impact on the prevention and treatment of neovaginal spasms. METHODS: This was a single-center prospective observational study with 2 series of patients: (1) patients who underwent GACv with double myotomy (DM) for spasm prevention (series A), in which longitudinal myotomies were performed across the defunctionalized colon, transecting the taenias, and resecting 2 strips of the intestinal muscle layer of approximately 1- to 2-mm wide and tall, leaving intact colonic tissue between strips; and (2) patients who reported neovaginal spasms in whom intravaginal-DM was performed as treatment surgery (series B), in which the posterior wall of the neovagina was dissected from the rectum and transected by longitudinal myotomies, resecting 2 strips of endoluminal mucosa and submucosal muscle of approximately 1- to 2-mm wide and tall, and the colonic mucosa was subsequently closed. OUTCOMES: Patient-reported outcomes and neovaginal examination were performed following standardized protocols. RESULTS: In series A, 177 patients underwent GACv with the DM technique and were prospectively followed for a median time of 18 months (interquartile range, 13-60 months). No patients reported neovaginal spasms. In series B, 18 patients who reported neovaginal spasms after GACv were treated with intravaginal DM. After a median time of 35 months (interquartile range, 26-45 months), 83% (n = 15 of 18) reported remission of symptoms. CLINICAL IMPLICATIONS: Double longitudinal myotomy performed on the derived portion of the colon in colovaginoplasty is an easy-to-perform and safe technique that may prevent and treat postoperative neovaginal spasms. STRENGTHS AND LIMITATIONS: Our results presented certain limitations, mainly associated with a low prevalence of neovaginal spasms, which, being of personal perception, can be underdiagnosed. To the same extent, the fact that it is a monocentric experience limits the possibility of extrapolating it to other centers. Moreover, a more trained surgical team may be the cause of fewer postoperative complications. On the other hand, the fact of being a reference center for gender-affirming surgery, having our procedures protocolized, and the prospective nature of the study allowed us to obtain a certain homogeneity and granularity of the results. CONCLUSION: DM is a safe procedure and appears to be highly effective for the prevention and treatment of neovaginal spasms after GACv. Routine use of this technique does not increase the operating time or postoperative complications. Multicenter, prospective studies are required to validate our results.

Unlocking tracheoesophageal speech from pharyngoesophageal spasm: preliminary results of a videofluoroscopic-guided botulinum toxin A injection technique.

PURPOSE: The tracheoesophageal puncture for the voice prosthesis (VP) placement is the recognized gold standard in post-laryngectomy voice rehabilitation. Despite the development of specific intraoperative techniques, a subset of patients will suffer from poor functional outcomes due to pharyngoesophageal spasms (PES). This paper evaluates the functional outcomes after transcutaneous botulinum toxin type A (BTX-A) infiltration for PES with a videofluoroscopy-guided technique. METHODS: Since 2022, eight consecutive patients with VP and affected by PES were treated with BTX-A injection by a standard videofluoroscopic guided technique at the European Institute of Oncology, IRCCS (IEO) in Milan. A lidocaine test was performed pre-operatively to evaluate the potential effect of chemical neurectomy. All patients with positive lidocaine tests were injected with 50 IU of BTX-A (Allergan, Irvine, CA) according to the sites marked during the videofluoroscopy. Reported symptoms (VHI, SECEL), perceptual (INFVo), aerodynamic (MPT) and manometric parameters were collected before and after treatment. RESULTS: In all cases, BTX-A was performed as an outpatient procedure without complications. For seven patients, only one BTX-A injection was needed, while one patient required a re-injection. Subjective and perceptive improvement after BTX-A was significant for VHI, SECEL and INFVo. MPT showed significant improvement after a chemical neurectomy. After a mean follow-up of 6 months, all patients maintained a good TES quality. CONCLUSION: The videofluoroscopic guided BTX-A injection of the pharyngoesophageal tract showed to be a feasible and reproducible technique in all cases. The pharyngoesophageal videofluoroscopy allows defining of patients' anatomical landmarks that help the surgeon to perform a homogeneous injection, empowered by post-injection massage.

A nomogram model for the occurrence of bladder spasm after TURP in patients with prostate enlargement based on serum prostacyclin and 5-hydroxytryptamine and clinical characteristics.

OBJECTIVE: With the development of analytical methods, mathematical models based on humoral biomarkers have become more widely used in the medical field. This study aims to investigate the risk factors associated with the occurrence of bladder spasm after transurethral resection of the prostate (TURP) in patients with prostate enlargement, and then construct a nomogram model. MATERIALS AND METHODS: Two hundred and forty-two patients with prostate enlargement who underwent TURP were included. Patients were divided into Spasm group (n=65) and non-spasm group (n=177) according to whether they had bladder spasm after surgery. Serum prostacyclin (PGI2) and 5-hydroxytryptamine (5-HT) levels were measured by enzyme-linked immunoassay. Univariate and multivariate logistic regression were used to analyze the risk factors. RESULTS: Postoperative serum PGI2 and 5-HT levels were higher in patients in the Spasm group compared with the Non-spasm group (P<0.05). Preoperative anxiety, drainage tube obstruction, and elevated postoperative levels of PGI2 and 5-HT were independent risk factors for bladder spasm after TURP (P<0.05). The C-index of the model was 0.978 (0.959-0.997), with a χ2 = 4.438 (p = 0.816) for Hosmer-Lemeshow goodness-of-fit test. The ROC curve to assess the discrimination of the nomogram model showed an AUC of 0.978 (0.959-0.997). CONCLUSION: Preoperative anxiety, drainage tube obstruction, and elevated postoperative serum PGI2 and 5-HT levels are independent risk factors for bladder spasm after TURP. The nomogram model based on the aforementioned independent risk factors had good discrimination and predictive abilities, which may provide a high guidance value for predicting the occurrence of bladder spasm in clinical practice.

Spinal cord stimulation for the symptomatic treatment of rigidity and painful spasm in a case of stiff person syndrome.

BACKGROUND: Stiff person syndrome (SPS) is a rare neuroimmunological disorder characterized by rigidity and painful spasm primarily affecting the truncal and paraspinal musculature due to autoimmune-mediated neuronal hyperexcitability. Spinal cord stimulation (SCS) is an approved therapy for managing painful neuropathic conditions, including diabetic peripheral neuropathy and refractory angina pectoris. We describe the novel use of SCS for the treatment of spasm and rigidity in a 49-year-old man with seropositive stiff person syndrome (SPS). The patient was treated with intravenous immunoglobulin (IVIG) and oral medications over a 13-month period with minimal improvement, prompting consideration of SCS. To our knowledge, this is the first report of the successful use of SCS in SPS with the demonstration of multifaceted clinical improvement. METHODS: Following a successful temporary SCS trial, permanent implantation was performed. Spasm/stiffness (Distribution of Stiffness Index; Heightened Sensitivity Scale; Penn Spasm Frequency Scale, PSFS), disability (Oswestry Disability Index, ODI; Pain Disability Index, PDI), depression (Patient Health Questionnaire-9, PHQ-9), sleep (Pittsburgh Sleep Quality Index, PSQI), fatigue (Fatigue Severity Scale, FSS), pain (Numerical Pain Rating Scale, NPRS), quality of life (EuroQoL 5 Dimension 5 Level, EQ-5D-5L), and medication usage were assessed at baseline, 6-month, and 10-month postimplantation. RESULTS: ODI, PHQ-9, FSS, NPRS, PSQI, and EQ-5D-5L scores showed a notable change from baseline and surpassed the defined minimal clinically important difference (MCID) at 6-month and 10-month follow-up. Oral medication dosages were reduced. CONCLUSIONS: The novel use of SCS therapy in seropositive SPS resulted in functional improvement and attenuation of symptoms. We present possible mechanisms by which SCS may produce clinical response in patients with SPS and aim to demonstrate proof-of-concept for a future comprehensive pilot study evaluating SCS-mediated response in SPS.

Effect of randomized prophylactic nitroglycerin on radial artery spasm during transradial catheterization: An analysis based on operator experience.

One limitation to transradial access (TRA) is the occurrence of spasms (RAS), for which the use of prophylactic medications is recommended. Improvement in TRA material combined with the increase in operators' expertise, might mitigate this benefit. We assess the effect of preventive nitroglycerin on RAS during TRA, evaluating the role of the operator's experience. Patients received 500 µg nitroglycerin or placebo. The operator's expertise was classified as: inexperienced (I), intermediate (M), and experienced (E). 2040 patients were included. Prophylactic use of nitroglycerin did not reduce RAS (10.8% vs. 13.4% (placebo), p = 0.07). RAS incidence was 14.5% in I, 12.5% in M, and 9.7% in E (p = 0.01). In group I, nitroglycerin reduced RAS (17.4% vs. 11.1%, p = 0.04), which was not observed in other groups. Overall, nitroglycerin does not prevent RAS, which is more common among inexperienced operators. More experienced operators could abolish preventive nitroglycerin use.

Clinical predictors and management for radial artery spasm: an Australian cross-sectional study.

INTRODUCTION: The transradial approach for coronary artery catheterisation has increased in popularity compared to the transfemoral approach for patients undergoing percutaneous coronary interventions. However, radial artery spasm continues to be a major complication of the procedure. Current management strategies vary concerning radial artery spasm and there is limited evidence of practice in the Australian context. AIM: To identify the predictors of radial artery spasm and the medications used for its prevention and management. METHODS: A descriptive cross-sectional study was carried out over a three-month period in two tertiary hospitals in NSW, Australia. A self-administered pre-procedural survey was completed by patients undergoing coronary artery catheterisation. This survey collected socio-demographic data and assessed anxiety using the Spielberger State-Trait Anxiety Inventory. Procedural data, including length of procedure, equipment used, occurrence of radial artery spasm, and medications given, were collected post-procedure by the interventionalist. RESULTS: Of the 169 participants, over half were male (59.8%) and aged 66 years or older (56.8%). Radial artery spasm was reported in 24 (14.2%) participants. Rates of spasm were significantly higher among females (66.6%, p = 0.004), those aged under 65 years (62.5%, p = 0.001) and those who reported a medical history of anxiety (33.3%, p = 0.0004). There were no significant differences in State and Trait anxiety scores among those who had RAS and those who did not. Logistic regression identified younger age as the only statistically significant predictor of RAS (OR 0.536; 95% CI 0.171-1.684; p = 0.005). To prevent radial artery spasm most patients received midazolam (n = 158; 93.5%), nitrates (n = 133; 78.7%) and/or fentanyl (n = 124; 73.4%) prophylactically. Nitrates were the most frequently administered medication to treat radial artery spasm (78.7%). CONCLUSION: This study highlights that there is a need to develop a clearer understanding of the predictors of RAS, as identifying patients at risk can ensure prophylactic measures are implemented. This study identified nitrates as the preferred vasodilator as a preventative measure along with the use of sedation.

Topical Lidocaine And Or/ Intravenous Midazolam Before Radial Coronary Angiography To Prevent Radial Artery Spasm.

Objectives: To investigate the possible advantage of topical lidocaine and intravenous midazolam in preventing spasm and pain related to the radial artery. Method: The prospective, comparative study was conducted at the catheterization laboratory of the cardiology department Kafrelsheikh University Hospital, Egypt, from January 2021 to January 2022, and comprised adult patients of either gender who were due to undergo coronary angiography and/or percutaneous coronary intervention for different indications. The patients were randomised control group I which was administered a cocktail of nitroglycerine, verapamil and heparin, intervention group II which was administered the control cocktail plustopical lidocaine, group III which was administered the control cocktail plus midazolam intravenously, and group IV which was administered the control cocktail plus topical lidocaine and intravenous midazolam. The groups were compared for frequency of radial artery spasm, accesssite cross-over and the difference in occurrence as well as procedure events, including the puncture number, time and complications. Data was analysed using SPSS 25. RESULTS: Of the 120 patients, there were 30(25%) in each of the 4 groups. Overall, there were 72(60%) males and 48(40%) females. Gender and mean age were not significantly different among the groups (p>0.05). Spasm of the radial artery occurred in 22(18.3%) patients, with higher incidence in the group I 12(40%). The median visual analogue scale score was higher in patients with radial artery spasm patients (p<0.001). The groups showed no significant differences in terms of frequency related to ad hoc percutaneous coronary intervention, contrast volume and fluoroscopy time (p>0.05), while they showed a significant difference in puncture time (p<0.05). Significant differences were noted among the groups in the incidence of radial artery spasm, visual analogue scale scores, requirement of multiple punctures, and the number of indicated punctures (p<0.05). Access site cross-over was more in the group I, while age, complication rates, visual analogue scale score, incidence of multiple punctures, and puncture time were significantly higher in patients with radial artery spasm (p<0.05). CONCLUSIONS: Cutaneous analgesia and procedural sedation before transradial access for coronary interventions were found to be associated with a substantial reduction in radial artery spasm and procedure-related discomfort.

Status of epileptic spasms: A study of 21 children.

OBJECTIVE: We studied cases with long-lasting epileptic spasms (ES) considered as a spasm status analyzing type of epilepsy, epileptic syndrome, etiology, treatment, and outcome in 21 patients. METHODS: We evaluated the charts of 21 patients seen between June 2006 and July 2017 who met the electroclinical diagnostic criteria of a spasm status. The spasm status was defined as continuous ES lasting 30 min or longer. RESULTS: The type of ES was mixed in nine patients, flexion in seven, and extension in five. Epileptic spasms were asymmetric in three patients and unilateral in two. They occurred on awakening in all patients, while during sleep they decreased in all and disappeared in three cases. The duration of the spasm status ranged from 40 min to 15 days according to the seizure diaries of patients and video-EEG recordings. Two well-defined subgroups of patients were recognized; the first included patients with West syndrome (WS) and the second other types of severe non-West epilepsy syndromes. The spasm status responded well to oral vigabatrin (VGB) in four patients, oral topiramate (TPM) in three, oral corticosteroids in one, and cannabidiol in another patient. A good response was observed with benzodiazepines in six patients, with phenytoin (PH) in two, and with phenobarbital (PB) in one. Adrenocorticotropic hormone (ACTH) was effective in one patient and the ketogenic diet in two. Prognosis depends on the etiology. CONCLUSION: In this study we identified patients with WS and other types of severe non-West epilepsy syndromes who had a particular type of long-lasting ES that, in spite of its long duration does not strictly meet the criteria of the International League against Epilepsy (ILAE) classification of status epilepticus, may be considered a spasm status.

Bladder spasms following ambulatory urologic procedures.

INTRODUCTION: Bladder spasm are common complications following cystoscopic urologic procedures. This study aims to determine the incidence and risk factors for bladder spasm after ambulatory cystoscopic urologic procedures. MATERIALS AND METHODS: Medical records of adult patients who underwent urologic procedures in our ambulatory center from May 1st, 2018 through December 30th, 2020, were reviewed. Bladder spasm was identified from the administration of antispasmodic therapy (e.g. oxybutynin) during anesthesia recovery. Multivariable analyses were performed to assess the association between bladder spasm and clinical factors. RESULTS: Included were 2,671 patients, of which 917 (34.3%) developed postoperative bladder spasm, yielding an incidence of 343 (95%CI 325-361) per 1,000 procedures. Risk factors associated with bladder spasm were younger adult age (< 60 years), longer (> 45 minutes) and more complex procedures. Compared to cystoscopy the risk of spasm following transurethral resection of the bladder tumor was OR 4.35 (95%CI 3.22, 5.87) and for transurethral resection of the prostate OR 3.25 (95% CI 2.24, 4.71). Spasm prophylaxis with belladonna and opium suppositories (B&O) was used in 1,158 patients and 384 (33.2%) developed spasms. The use of B&O was not associated with reduction of bladder spasm, OR 0.91 (95%CI 0.75, 1.1, p = 0.318). Postoperative outcomes did not differ between patients who did or did not develop spasms. CONCLUSION: Bladder spasms are common following ambulatory urologic procedures, more so with more extensive procedures. Prophylaxis with B&O was not significantly associated with a lower rate of bladder spasms.

Palmaris brevis spasm syndrome in manual workers using vibratory tools.

Palmaris brevis spasm syndrome (PBSS) appears to reflect benign muscle hyperactivity, with unprovoked recurrent spasm of the muscle and consequent dimpling of the hypothenar eminence. Two cases are reported, being the first known report of the condition among manual workers or those using vibratory tools. Each was diagnosed during routine health surveillance for hand-arm vibration syndrome. With hand cramps being a frequent report among vibration-exposed workers, this condition should be considered in such cases, although the lack of reports means that the frequency of the condition is unknown. One of the employees described more frequent episodes of spasm during periods of increased manual work. Diagnosis is possible by witnessing the characteristic spasm, or by viewing photographs of it. Functional impairment is not usual, except for the brief duration of an attack. There is no consensus regarding appropriate treatment.

Disparate treatment outcomes according to presence of pathogenic mutations in West syndrome.

OBJECTIVE: It has been known that West syndrome (WS) patients with an unknown etiology have better clinical outcomes than patients with an identified etiology of any kind. However, after the exponential discovery of genes with mutations responsible for developmental and epileptic encephalopathy (DEE), a significant proportion of patients with a previously unknown etiology have been reclassified as having a genetic etiology, requiring reinvestigation of this concept. Therefore, this study investigated clinical outcomes of WS patients with genetic and unknown etiologies. METHODS: Patients diagnosed with WS without structural or metabolic abnormalities were included in this study. The DEE gene panel, comprising 172 genes, was performed for all patients. All patients were treated using the same treatment protocol for vigabatrin and high-dose prednisolone add-on therapy. Favorable responders were defined as patients who were seizure-free and whose electroencephalogram showed Burden of Amplitudes and Epileptiform Discharges scores of 2 or less. RESULTS: Of the 58 patients included in the study, 17 (29.3%) patients had an identified genetic etiology. There was no significant difference in rates of favorable response at 1 and 3 months after treatment, but significantly higher proportions of patients exhibited favorable responses among those with an unknown etiology at long-term follow-up (41.2% vs. 78.0%, p = .006 at 6 months; 29.4% vs. 65.9%, p = .011 at 1 year; 23.5 vs. 65.9%, p = .003 at 2 years). Moreover, the mental, psychomotor, and social age quotients of the patients with an identified genetic etiology were reduced to a significantly greater degree since diagnosis compared with those of the patients with an unknown etiology. SIGNIFICANCE: WS patients with genetic and unknown etiologies did not initially exhibit significantly different response rates to the vigabatrin and high-dose prednisolone add-on treatment. However, patients with a genetic etiology exhibited significantly higher relapse rates and significantly poorer long-term responses.

British Association of Urological Surgeons (BAUS) and Nurses (BAUN) consensus document: management of the complications of long-term indwelling catheters.

OBJECTIVE: To look at best evidence and expert opinion to provide advice in the form of a consensus statement lead by Female, Neurological and Urodynamic Urology (FNUU) section of the British Association of Urological Surgeons (BAUS) in conjunction with the British Association of Urological Nurses (BAUN). METHODS: Initially a literature search was performed with incorporation of aspects of the existing guidance and further informed by UK best practice by core members of the group. The document then underwent reviews by the FNUU Executive Committee members, the BAUN executive committee, a separate experienced urologist and presented at the BAUS annual meeting 2020 to ensure wider feedback was incorporated in the document. RESULTS: Complications of long-term indwelling catheters include catheter-associated urinary tract infections (CAUTI), purple urine bag syndrome, catheter blockages, bladder spasms (causing pain and urinary leakage), loss of bladder capacity, urethral erosion ("catheter hypospadias")/dilatation of bladder outlet and chronic inflammation (metaplasia and cancer risk). CONCLUSIONS: We have provided a list of recommendations and a troubleshooting table to help with the management of the complications of long term catheters.

Oral IBGard™ Before Colonoscopy: A Single-Center Double-Blinded, Randomized, Placebo-Controlled Trial.

BACKGROUND: Peppermint oil is well known to inhibit smooth muscle contractions, and its topical administration during colonoscopy is reported to reduce colonic spasms. AIMS: We aimed to assess whether oral administration of IBGard™, a sustained-release peppermint oil formulation, before colonoscopy reduces spasms and improves adenoma detection rate (ADR).  METHODS: We performed a single-center randomized, double-blinded, placebo-controlled trial. Patients undergoing screening or surveillance colonoscopies were randomized to receive IBGard™ or placebo. The endoscopist graded spasms during insertion, inspection, and polypectomy. Bowel preparation, procedure time, and time of drug administration were documented. Statistical analysis was performed using the Student's t test and Wilcoxon rank-sum test. RESULTS: There was no significant difference in baseline characteristics or dose-timing distribution between IBGard™ and placebo groups. Similarly, there was no difference in ADR (IBGard™ = 47.8%, placebo = 43.1%, p = 0.51), intubation spasm score (1.23 vs 1.2, p = 0.9), withdrawal spasm score (1.3 vs 1.23, p = 0.72), or polypectomy spasm score (0.52 vs 0.46, p = 0.69). Limiting the analysis to patients who received the drug more than 60 min prior to the start of the procedure did not produce any significant differences in these endpoints. CONCLUSIONS: This randomized controlled trial failed to show benefit of orally administered IBGard™ prior to colonoscopy on the presence of colonic spasms or ADR. Because of its low barrier to widespread adoption, the use of appropriately formulated and timed oral peppermint oil warrants further study to determine its efficacy in reducing colonic spasms and improving colonoscopy quality.

Management of Muscle Spasms in Adult Patients with Cerebral Palsy.

As medical care advances, there is a growing number of adult patients with cerebral palsy. The spastic form is characterized by muscle hypertonicity, hyperreflexia, and spasticity, which are associated with worse quality of life, poor functionality, and pain. This literature review attempts to explore the existing treatments for spasticity in cerebral palsy to provide insight into potential treatments in the adult population. The types of treatments are broadly categorized into physical therapy, pharmacologic treatments, botulinum toxin, surgical treatments, and alternative options.

Botulinum toxin A (Botox) injection into muscles of pelvic floor as a treatment for persistent pelvic pain secondary to pelvic floor muscular spasm: A pilot study.

BACKGROUND: Persistent pelvic pain (PPP) remains an important cause of morbidity. Pelvic floor muscle spasm is an important contributor to PPP. AIMS: The study's primary aim was to assess if botulinum toxin (BoNT) injection to pelvic floor muscles altered pain scores or quality of life (QoL) at six, 12 and 26 weeks. Secondary aims included investigating the impact of BoNT on opiate usage, examining the role of pain catastrophising, and assessing for complications. MATERIALS AND METHODS: A single-centre prospective cohort study enrolled 21 patients with PPP who had failed physiotherapy techniques. Each participant underwent BoNT injection to muscles of the pelvic floor and pudendal nerve block. Questionnaires and digital vaginal examinations were conducted at baseline, six, 12 and 26 weeks. Pain score quantification used visual analogue scales (VAS) and numerical rating scales (NRS). Other outcome assessments included The World Health Organization Quality of Life instrument (WHOQoL-BREF), Pain Catastrophising Scale (PCS), and modified Australian Pelvic Floor Questionnaire (APFQ). ACTRN12620000067976. RESULTS: Following BoNT injection, median VAS scores decreased for all domains at six and 12 weeks, with VAS for dyspareunia significant at six weeks (P = 0.026). Scores returned to baseline by 26 weeks. Opiate usage was significantly less following BoNT injection, with a percentage reduction of 23.8% (95% CI -48.3 to 0.7, P = 0.06). Sexual function improved significantly (P < 0.01), and at six months, four previously apareunic participants reported successful penetrative vaginal intercourse. Health-related QoL and PCS demonstrated sustained improvement (P = 0.02-0.05). NRS for muscle tenderness decreased for all assessed muscle groups (P < 0.001). CONCLUSIONS: BoNT requires further assessment as a treatment modality for select women with PPP.

Hirayama disease causing hand tremor on neck flexion.

A 21-year-old man presented with right-hand intrinsic muscle wasting and right-hand tremor on neck flexion. MR scan of cervical spine was normal in the neutral position, but on neck flexion showed anterior shift and flattening of the cervical cord, with prominent posterior epidural space and engorged epidural venous plexus. We diagnosed Hirayama disease and his condition stabilised with a neck collar and physiotherapy.

New insights in phenomenology and treatment of epilepsy in CDKL5 encephalopathy.

Eight patients, seven girls and one boy, had CDKL5 gene mutation, duplication, or deletion. Epileptic spasms started at a mean age of 3.5 months (range = 4 weeks-8 months). In five cases, tonic seizures preceded spasms at a median age of 6 weeks. In one patient who started at 8 months, spasms had a component of terror on awakening, reminding sleep terror. In two patients, electroencephalogram polygraphy of a so-called tonic seizure revealed that the tonic phase was followed by an overlooked clonic phase and then by a cluster of spasms during which each spasm was preceded by a brief clonic jerk revealed by electromyography. This sequence is rather particular and can be an early diagnostic clue. Progressive transition from this seizure type to epileptic spasms in clusters seems to result from increasing expression of the CDKL5 gene, as the child grows older. Five patients responded to the combination of vigabatrin and zonisamide.