Cervical arterial dissection and traumatic myelopathy following yoga: surgical case report.

INTRODUCTION: Cervical spondylosis can predispose patients to central canal stenosis. In this setting, myelopathy through further flattening of the cord from extrinsic compression can be precipitated by relatively minor traumas. Arterial dissection is similarly considered a result of high velocity or momentum during trauma, commonly associated with fractures, cervical hyperflexion, or direct blunt force to the neck. Overall, precautions for both arterial dissection and myelopathy are rarely considered in low-velocity, static activities such as yoga. CASE PRESENTATION: The authors report the case of a 63-year-old man who suffered concurrent cervical myelopathy from multilevel spondylopathy, right vertebral artery dissection, and left cervical carotid artery dissection following a yoga session. Symptomatology consisted of acute onset neck pain, upper extremity sensory paresthesia, worsening gait and balance, and impaired dexterity for several weeks. Cervical MRI was obtained given myelopathic symptoms and revealed spondylosis with compression and T2 signal change at C3-C4. CT angiography of the neck revealed aforementioned dissections without flow limiting stenosis or occlusion. A therapeutic heparin infusion was started preoperatively until the patient underwent C3-C4 anterior cervical discectomy and fusion. Aspirin and Plavix were then started without incidence and the patient had significant but gradual improvement in myelopathic symptoms at 6-week follow-up. DISCUSSION: The static yet intensive poses associated with yoga present a rare etiology for arterial dissection and myelopathy, but patients with persistent and progressive symptoms should be screened with the appropriate imaging modality. Cervical decompression should be expedited before initiating an antiplatelet medication.

Cervicomedullary junction spinal cord stimulation for head and facial pain.

OBJECTIVE: To review our experience with cervicomedullary junction spinal cord stimulation (SCS), to alleviate head and facial pain. BACKGROUND: There is a dearth of literature regarding the use of spinal cord stimulation for treating head and facial pain. DESIGN: We performed a Boolean search of the electronic medical record (1990-2009) and identified 35 patients (9 men, 26 women) for whom the senior author (J.J.M) trialed paddle lead cervicomedullary junction stimulation (CMJ-S) for intractable head or facial pain. Twenty-five patients (71.4%) had a successful trial with subsequent implantation of SCS hardware and 10 patients (28.6%) experienced a failed trial. Pain syndromes were categorized into diagnostic groups: trigeminal deafferentation pain (TDP), trigeminal neuropathic pain (TNP), occipital pain/neuralgia, post-herpetic neuralgia (PHN), and post-stroke facial pain. Follow-up via structured telephone interview was obtained in 25 patients (71.4%). RESULTS: Among the 25 patients available for follow-up, 16 patients (64%) underwent implantation and 9 patients (36%) had a failed trial of CMJ-S. The mean patient age and length of follow-up was 47.3 years old (20-78 years old) and 53.4 months (2-120 months), respectively. On a 0-10 pain intensity scale (0 being no pain and 10 being the worst degree of pain), a mean pretrial pain level of 9.6 (range 7-10) had been reduced to a mean of 4.8 (0-10) at follow-up. Successful trial and subsequent implantation occurred in 7 patients with TDP (70%), 4 patients with TNP (80%), both patients with PHN (100%), and in the single patient with post-stroke facial pain (100%) but in only 2 patients (28.6%) with occipital neuralgia/pain. At the time of telephone interview, 4 of the implanted patents (25%) had their hardware removed because of loss of effectiveness (3) and infection (1). The other 12 implanted patients (75%) continue to use CMJ-S on a daily basis and insist that it has improved their quality of life. Six current users (50%) of CMJ-S have been able to decrease their use of oral pain medications. Complications in the implanted group included infection (1), uncomfortable paresthesias from breakdown of connecting wire insulation (1), and gradual loss of effectiveness (3). CONCLUSIONS: Our preliminary experience suggests that patients suffering from TDP, TNP, and PHN may respond favorably to CMJ-S whereas patients with occipital neuralgia/pain are rarely palliated by this neuromodulatory approach.

Localization of cervical and cervicomedullary stimulation leads for pain treatment using median nerve somatosensory evoked potential collision testing.

OBJECT: Spinal cord stimulation (SCS) is being currently used to treat medically refractory pain syndromes involving the face, trunk, and extremities. Unlike thoracic SCS surgery, during which patients can be awakened from conscious sedation to confirm good lead placement, safe placement of paddle leads in the cervical spine has required general anesthesia. Using intraoperative neurophysiological monitoring, which is routinely performed during these cases at the authors' institution, the authors developed an electrophysiological technique to intraoperatively lateralize lead placement in the cervical epidural space. METHODS: Data from 44 patients undergoing median and tibial nerve somatosensory evoked potential (SSEP) monitoring during cervical laminectomy or hemilaminectomy for placement or replacement of dorsal column stimulators were retrospectively reviewed. Paddle leads were positioned laterally or just off midline and parallel to the axis of the cervical spinal cord to effectively treat what was most commonly a predominant unilateral pain syndrome. During SSEP recording, the spinal cord stimulator was activated at 1.0 V and increased in increments of 1.0 V to a maximum of 6.0 V. A unilateral reduction or abolishment of SSEP amplitude was regarded as an indicator of lateralized placement of the stimulator. A bilateral diminutive effect on SSEPs was interpreted as a midline or near midline lead placement. RESULTS: Epidural stimulation abolished or significantly reduced SSEP amplitudes in all patients undergoing placement for a unilateral pain syndrome. In 15 patients, electrodes were repositioned intraoperatively to achieve the most robust SSEP amplitude reduction or abolishment using the lowest epidural stimulation intensity. In all cases in which a significant unilateral reduction in SSEP was observed, the patient reported postoperative sensory alterations in target locations predicted by intraoperative SSEP changes. Placement of cervical spinal cord stimulators for bilateral pain syndromes often resulted in bilateral but asymmetrical SSEP changes. In no cases were significant SSEP changes, other than those induced using the device to directly stimulate the dorsal surface of the spinal cord, observed. No case of new postoperative neurological deficit was observed. CONCLUSIONS: Somatosensory evoked potentials can be used safely and successfully for predicting the lateralization of cervical spinal cord stimulator placement. Moreover, they can also intraoperatively alert the surgical team to inadvertent displacement of a lead during anchoring. Further studies are needed to determine whether apart from assisting with proper lateralization, SSEP collision testing may help to optimize electrode positioning and improve pain control outcomes.

Simultaneous intrathecal opioid pump and spinal cord stimulation for pain management: analysis of 11 patients with failed back surgery syndrome.

Dual-modality management of failed back surgery syndrome (FBSS) using a combination of an intrathecal opioid pump (IOP) and spinal cord stimulator (SCS) has not been investigated. The authors performed a retrospective review of 11 patients (8 men, 3 women) with FBSS who underwent nonsimultaneous surgical implantation of both an IOP and a thoracic SCS. Chart review and structured phone interviews were performed to obtain follow-up. Of the two modalities, 3 patients (27%) had an IOP placed first and 8 patients (73%) had a SCS implanted initially. Mean follow-up was 41.7 months (3-97 months). All 11 patients (100%) stated that the dual-modality treatment improved their quality of life and all continue to use both an IOP and SCS for pain control. Six patients (55%) felt that the IOP provided superior pain relief as compared to the SCS, 4 patients (36%) felt that IOP and SCS provided a similar degree of pain relief, and 1 patient (9%) said the SCS provided better pain relief than the IOP. Nine patients (82%) claimed that dual-modality treatment improved their activities of daily living. Nine patients (82%) reported that the combination of IOP and SCS treatment had allowed them to significantly decrease their oral pain medication requirements. Seven patients (64%) had hardware-related complications which required surgery; of this group, 2 patients (18%) needed more than one operation. Six patients (55%) had minor postoperative complications, which were managed nonoperatively. Overall, 10 patients (91%) were glad that they had implantation of both an IOP and SCS and would recommend this combined therapy to other patients. Dual neuroaugmentative treatment with an IOP and thoracic SCS can be safely performed and may provide satisfactory pain relief in appropriately selected patients with FBSS.

Exacerbation of electrical storm subsequent to implantation of a right vagal stimulator.

A patient with advanced ischemic cardiomyopathy underwent implantation of a vagal stimulator in an attempt to control recurrent drug refractory ventricular arrhythmia. Electrical storm was exacerbated after the implant and continued after neurostimulation was discontinued. The report aims to provide a cautionary note to application of vagal stimulation for control of cardiac arrhythmia.