Hyperbaric treatment deviations for U.S. Navy divers: Spinal DCS.

Introduction: The United States Navy (USN) developed and refined standardized oxygen treatment tables for diving injuries, but USN tables may not address all situations of spinal decompression sickness (DCS). We describe a detailed recompression treatment regimen that deviated from standard USN protocol for an active-duty USN diver with a severe, delayed presentation of spinal cord DCS. Case Report: A USN diver surfaced from his second of three dives on a standard Navy 'no-Decompression' Air SCUBA dive (Max depth 101 fsw utilizing a Navy Dive Computer) and developed mid-thoracic back pain, intense nausea, paresthesias of bilateral feet, and penile erection. Either not recognizing the con- stellation of symptoms as DCS and after resolution of the aforementioned symptoms, he completed the third planned dive (essentially an in-water recompression). Several hours later, he developed paresthesias and numbness of bilateral feet and legs and bowel incontinence. He presented for hyperbaric treatment twenty hours after surfacing from the final dive and was diagnosed with severe spinal DCS. Based on the severity of clinical presentation and delay to treatment, the initial and follow-on treatments were modified from standard USN protocol. MRI of the spine four days after initial presentation demonstrated a 2.2 cm lesion at the T4 vertebral level extending caudally. Follow-up examinations over two years demonstrated almost complete return of motor and sensory function; however, the patient continued to suffer fecal incontinence and demonstrated an abnormal post-void residual urinary volume. An atypical presenting symptom, a discussion of MRI findings, and clinical correlations to the syndrome of spinal DCS are discussed throughout treatment and long-term recovery of the patient.

Brachioradial Pruritus: An Etiologic Review and Treatment Summary.

Brachioradial pruritus (BRP) is a relatively uncommon neuropathic dysesthesia localized to the dorsolateral arms that causes unrelenting itching, burning, tingling, or stinging sensations. There is no identifiable cause of BRP to date, though it is thought to be secondary to either cervical spine pathology or exposure to UV radiation (UVR). Gold-standard treatment of BRP remains unknown. This article reviews previously trialed conservative management options, including chiropractic manipulation, acupuncture, physiotherapy, and photoprotection, as well as medical management options that have been utilized to treat BRP, such as medications, interventional pain management procedures, and surgery. We compiled an updated comprehensive list of possible treatment strategies to be utilized by future providers.

Should we Oppose or Combine Waveforms for Spinal Cord Stimulation in PSPS-T2 Patients? A Prospective Randomized Crossover Trial (MULTIWAVE Study).

Refractory persistent spinal pain syndrome after surgery (PSPS-T2) can be successfully addressed by spinal cord stimulation (SCS). While conventional stimulation generates paresthesia, recent systems enable the delivery of paresthesia-free stimulation. Studies have claimed non-inferiority/superiority of selected paresthesia-free stimulation compared with paresthesia-based stimulation, but the comparative efficacy between different waveforms still needs to be determined in a given patient. We designed a randomized controlled 3-month crossover trial to compare pain relief of paresthesia-based stimulation versus high frequency versus burst in 28 PSPS-T2 patients implanted with multiwave SCS systems. Our secondary objectives were to determine the efficacy of these 3 waveforms on pain surface, quality of life, functional capacity, psychological distress, and validated composite multidimensional clinical response index to provide holistic comparisons at 3-, 6-, 9-, and 15-month post-randomization. The preferred stimulation modality was documented during the follow-up periods. No difference between the waveforms was observed in this study (P = .08). SCS led to significant pain relief, quality of life improvement, improvement of multidimensional clinical response index, and of all other clinical outcomes at all follow-up visits. Forty-four percent of the patients chose to keep the paresthesia-based stimulation modality after the 15-month follow-up period. By giving the possibility to switch and/or to combine several waveforms, the overall rate of SCS responders further increased with 25%. In this study, high frequency or burst do not appear superior to paresthesia-based stimulation, wherefore paresthesia-based stimulation should still be considered as a valid option. However, combining paresthesia-based stimulation with paresthesia-free stimulation, through personalized multiwave therapy, might significantly improve SCS responses. PERSPECTIVE: This article assesses clinical SCS efficacy on pain relief, by comparing paresthesia-based stimulation and paresthesia-free stimulation (including high frequency and burst) modalities in patient presenting with PSPS-T2. Switching and/or combining waveforms contribute to increasing the global SCS responders rate.

The Temporary Mental Nerve Paresthesia as an Outcome of Dentigerous Cyst Removal during Preparation for Dental Implant Placement: A Case Report.

The usage of xenograft material is widely used in almost all oral cavity bone defects for regenerative and reconstructive purposes. The presented xenograft usage in the following care report enabled good bone defect healing and enabled the preservation of affected premolars. It is quite common to use any possible variations of bone materials to ensure bone defect improved healing. In some cases, the scope of surgeries requires the removal of each cyst within close proximity to various nerves and vessels. The inferior alveolar, infraorbital, lingual, and mental nerves are those most commonly adjacent to most operating sites in jaw bones. The usage of some additional materials such as collagen sponges, bone substitutes, resorbable membranes, or other additional materials are useful in each bone defect reconstruction but should be handled with care, as described in the following case. Before planning their usage, it is important to perform each surgery with close cone beam computed tomography imaging, which is very helpful to establish the scope of each lesion and the proximity of vital structures. There are a lot of factors that might influence any possible nerve damage, especially the different nerve anatomical variations. Even factors including the subperiosteal preparation and compression of adjacent tissues might influence later nerve function. When the lesion is expanding through the buccal cortical plate and when soft tissue fluctuation is present, some special care is needed. Similar to the presented case, a limitation in crushing, blowing, or any irritation of nerve fibers improves later postoperative outcomes. When the wound and surrounding tissues are handled with care, a limited possibility of any damage or paresthesia can occur. When the nerve itself is damaged or cut, loss of function can be permanent. Immediately after or even prophylactic prescription 1-2 days before the surgery of Vitamin B with NSAIDs (Non-steroidal anti-inflammatory drugs) (or other additional supplementary medicaments can improve nerve function in time. Possible nerve damage can be divided into many etiological factors. A quite different situation arises when the nerve is pulled in by the cyst growth into the cyst wall. The presented case report describes the outcomes of a cyst removal from the mandibular basis and treatment modalities.

Lateral cerebellothalamic tract activation underlies DBS therapy for Essential Tremor.

BACKGROUND: While deep brain stimulation (DBS) therapy can be effective at suppressing tremor in individuals with medication-refractory Essential Tremor, patient outcome variability remains a significant challenge across centers. Proximity of active electrodes to the cerebellothalamic tract (CTT) is likely important in suppressing tremor, but how tremor control and side effects relate to targeting parcellations within the CTT and other pathways in and around the ventral intermediate (VIM) nucleus of thalamus remain unclear. METHODS: Using ultra-high field (7T) MRI, we developed high-dimensional, subject-specific pathway activation models for 23 directional DBS leads. Modeled pathway activations were compared with post-hoc analysis of clinician-optimized DBS settings, paresthesia thresholds, and dysarthria thresholds. Mixed-effect models were utilized to determine how the six parcellated regions of the CTT and how six other pathways in and around the VIM contributed to tremor suppression and induction of side effects. RESULTS: The lateral portion of the CTT had the highest activation at clinical settings (p < 0.05) and a significant effect on tremor suppression (p < 0.001). Activation of the medial lemniscus and posterior-medial CTT was significantly associated with severity of paresthesias (p < 0.001). Activation of the anterior-medial CTT had a significant association with dysarthria (p < 0.05). CONCLUSIONS: This study provides a detailed understanding of the fiber pathways responsible for therapy and side effects of DBS for Essential Tremor, and suggests a model-based programming approach will enable more selective activation of lateral fibers within the CTT.

Combined Short-Pulse and Directional Deep Brain Stimulation of the Thalamic Ventral Intermediate Area for Essential Tremor.

OBJECTIVE: Novel deep brain stimulation (DBS) systems allow directional and short-pulse stimulation to potentially improve symptoms and reduce side effects. The aim of this study was to investigate the effect of short-pulse and directional stimulation, in addition to a combination of both, in the ventral intermediate thalamus (VIM)/posterior subthalamic area (PSA) on tremor and stimulation-induced side effects in patients with essential tremor. MATERIALS AND METHODS: We recruited 11 patients with essential tremor and VIM/PSA-DBS. Tremor severity (Fahn-Tolosa-Marin), ataxia (International Cooperative Ataxia Rating Scale), and paresthesia (visual analog scale) were assessed with conventional omnidirectional and directional stimulation with pulse width of 60 µs and 30 µs. RESULTS: All stimulation conditions reduced tremor. The best directional stimulation with 60 µs reduced more tremor than did most other stimulation settings. The best directional stimulation, regardless of pulse width, effectively reduced stimulation-induced ataxia compared with the conventional stimulation (ring 60 µs) or worst directional stimulation with 60 µs. All new stimulation modes reduced occurrence of paresthesia, but only the best directional stimulation with 30 µs attenuated paresthesia compared with the conventional stimulation (ring 60 µs) or worst directional stimulation with 60 µs. The best directional stimulation with 30 µs reduced tremor, ataxia, and paresthesia compared with conventional stimulation in most patients. Correlation analyses indicated that more anterior stimulation sites are associated with stronger ataxia reduction with directional 30 µs than with conventional 60 µs stimulation. CONCLUSION: Directional and short-pulse stimulation, and a combination of both, revealed beneficial effects on stimulation-induced adverse effects.

Neuroanatomical considerations for optimizing thalamic deep brain stimulation in Tourette syndrome.

OBJECTIVE: Deep brain stimulation (DBS) of the centromedian thalamic nucleus has been reportedly used to treat severe Tourette syndrome, yielding promising outcomes. However, it remains unclear how DBS electrode position and stimulation parameters modulate the specific area and related networks. The authors aimed to evaluate the relationships between the anatomical location of stimulation fields and clinical responses, including therapeutic and side effects. METHODS: The authors collected data from 8 patients with Tourette syndrome who were treated with DBS. The authors selected the active contact following threshold tests of acute side effects and gradually increased the stimulation intensity within the therapeutic window such that acute and chronic side effects could be avoided at each programming session. The patients were carefully interviewed, and stimulation-induced side effects were recorded. Clinical outcomes were evaluated using the Yale Global Tic Severity Scale, the Yale-Brown Obsessive-Compulsive Scale, and the Hamilton Depression Rating Scale. The DBS lead location was evaluated in the normalized brain space by using a 3D atlas. The volume of tissue activated was determined, and the associated normative connective analyses were performed to link the stimulation field with the therapeutic and side effects. RESULTS: The mean follow-up period was 10.9 ± 3.9 months. All clinical scales showed significant improvement. Whereas the volume of tissue activated associated with therapeutic effects covers the centromedian and ventrolateral nuclei and showed an association with motor networks, those associated with paresthesia and dizziness were associated with stimulation of the ventralis caudalis and red nucleus, respectively. Depressed mood was associated with the spread of stimulation current to the mediodorsal nucleus and showed an association with limbic networks. CONCLUSIONS: This study addresses the importance of accurate implantation of DBS electrodes for obtaining standardized clinical outcomes and suggests that meticulous programming with careful monitoring of clinical symptoms may improve outcomes.

Effectiveness of Laser Therapy and Laser Acupuncture on Treating Paraesthesia After Extraction of Lower Third Molars.

Objective: This randomized clinical trial evaluated the sensitive return of the lower alveolar nerve (LAN) using two photobiomodulation therapy (PBMT) techniques, after the extraction of lower third molars or implant surgery. Materials and methods: Sixty participants with sensory impairment of LAN were randomly divided into three groups (n = 20): group C-systemic medication (control-ETNA®, 01 capsule, 8/8 h, 30 days); group laser therapy (LT) (808 nm, 100 mW, 40 sec/point, 4 J/point, intra/extraoral, irradiation following nerve path); group laser acupuncture (LA) (same parameters as the LT group, applied at six acupuncture points on the affected side (ST 4 [Dicang], M-HN-18 [Jiachengjiang], CV 24 [Chengjiang], ST 5 [Daying], ST 6 [Jiache], and point A1 [YNSA]). The following evaluations were performed, at predetermined times: general perception of paresthesia, thermal perception, vibratory mechanical perception, two-point discrimination, pain perception, and tactile perception. Data were analyzed by two-way analysis of variance (ANOVA), followed by the Tukey, except for the two-point discrimination, which was analyzed using the chi-square test. Results: In general and thermal perception, both PBMTs had better results than control; regarding cold perception, only the LT group was statistically superior to control. LA presented inferior results of neural regeneration for tests of perception of pain and tactile at the lip, and of tactile perception at the chin. In the other tests, there was no statistical difference among the groups. Conclusions: LT and the conventional drug treatment had the same effectiveness and both were superior to LA for the treatment of paresthesia of the LAN after oral surgeries.

Use of 1064 nm Nd:YAG Laser Biostimulation for Immediate Reversal of a Long-Standing Paresthesia of the Superior Labial Branch of the Infraorbital Nerve Following a Root Coverage Procedure: A Case Report.

INTRODUCTION: Paresthesia is a common cause of dental malpractice litigation. Symptoms range from minimal to severely affecting the quality of life. Effective treatments of post-traumatic paresthesias are scarce. This case report documents the first reported use of laser biostimulation to reverse a long-standing paresthesia of the infraorbital nerve, resulting from a root coverage procedure of the maxillary right canine. CASE PRESENTATION: A coronally repositioned flap with enamel matrix derivative was used to treat gingival recession on the buccal surface of tooth #6 of a 35-year-old Caucasian female. One week later the patient reported lip numbness. The patient declined further treatment, and the paresthesia remained unchanged for the next 13 months. The patient then consented to laser biostimulation with a 1064 nm neodymium:yttrium aluminum garnet laser. A single laser biostimulation treatment resulted in an immediate and dramatic improvement of lip sensation. The patient's symptoms improved over the next 2½ years without further treatment. CONCLUSION: The cause of the paresthesia and the exact mechanism of its reversal remain unknown, although speculated causes and the possible mechanisms of action of low-level laser therapy are discussed. Laser biostimulation for treatment of peripheral nerve injury is noninvasive and may eliminate the need for corticosteroids or other more invasive treatment modalities. It may not be effective in all paresthesia cases, but when used properly, laser therapy offers a safe treatment alternative for an often troubling problem.

Video-assisted thoracoscopic sympathectomy versus modified Wittmoser method in surgical management of primary hyperhidrosis.

PURPOSES: We compared two different surgical methods evaluating the effectiveness of procedures and the quality of life (QoL) of patients. METHODS: From January 2010 to November 2017 we carried out 476 biportal video-assisted thoracoscopic surgery (VATS) approaches of sympathetic chain in 238 patients. One hundred and twenty-nine (54%) patients underwent conventional sympathectomy (CS) while 109 (46%) patients underwent sympathicotomy associated with the division of the rami communicantes (MWT). Quality of Life (QoL) was classified as follows: from 20 to 35 excellent; from 36 to 51 very good; from 52 to 68 good; from 69 to 84 poor; and > 84 very poor. RESULTS: We noticed statistical significant reduction of complications comparing CS with MWT approaches (chest pain from 36.4 to 4.5%; paresthesias from 8.5 to 3.6%; bradycardia from 28.6 to 10%, respectively). The preoperative and postoperative QoL index evaluation revealed a statistically significant improvement after surgery (CS: 86 ± 2 versus 35 ± 1, p = 0.00001; MWT: 85 ± 1 versus 33 ± 2, p = 0.00001), with general satisfaction of the two techniques. CONCLUSION: Modified Wittmoser method seems to be a valid alternative to conventional sympathectomy, minimizing the percentage rate of complications and showing significant effectiveness in the quality of life improvement.

Evaluation of photobiomodulation effects on pain, edema, paresthesia, and bone regeneration after surgically assisted rapid maxillary expansion: Study protocol for a randomized, controlled, and double blind clinical trial.

BACKGROUND: Surgically assisted rapid maxillary expansion (SARME) generates an uncomfortable postoperative period accompanied by pain, edema, and paresthesia. There are few studies on the effect of photobiomodulation (PBM) after SARME and it was not possible to find studies on the efficacy of light emitted by diode (LED) after this type of intervention. The main objective of the study will be to evaluate the efficacy of PBM with LED in the control of pain, facial edema, paresthesia, and bone repair after SARME. METHODS: A randomized, double-blind, placebo-controlled clinical trial involving 72 participants aged from 18 to 45 years, who search the Department of Buccomaxillofacial Surgery and Traumatology of Mandaqui Hospital Complex, will be conducted. Immediately after surgeries, the participant will be inserted into the placebo or LED group. In the LED group, the participants will receive PBM with an extraoral device (660 and 850 nm with 6 J per point) and an intraoral device (660 nm with 2 J per point) and in the control group the person in charge of the application will simulate the irradiation with the devices kept off. The applications will be in the immediate postoperative period, 1, 2, 7, 14, 30, 60, 90, and 120 days after the end of the surgeries, when the evaluations will also be performed. Facial measurements, extra and intraoral sensitivity, pain and bone repair will be evaluated. Secondarily, data regarding the occurrence of headache; otalgia; nausea; bruising; nasolacrimation; epistaxis; dysphagia; systemic and superficial temperature in the operated region; use of analgesics and anti-inflammatories; anxiety and impact of oral health on the participants' quality of life will be computed. DISCUSSION: Since PBM has shown positive effects on postoperative complications of other types of oral surgery and also has a positive effect on bone repair after maxillary disjunction, surgically assisted or not, it seems clear the need to evaluate its performance regarding pain, edema, and paresthesia after these surgeries. TRIAL REGISTRATION: This protocol was registered in Clinical Trials platform (https://clinicaltrials.gov/) with the number NCT03814525, first published and last updated on January 24, 2019.

[A patient with perfectly aligned itching papules of the back after hijama therapy]. / Een patiënte met huidafwijkingen na hijama-therapie.

A 31-year-old woman was seen at our clinic with itching papules of the back after hijama treatments. Hijama treatments consist of superficially cutting the skin followed by cupping and are applied for a diversity of complaints, including pain. Our patient initially presented with sensitive and burning sensations at the cutting sites, but recently, the cutting sites started to itch as well. At physical examination, we saw perfectly aligned papules with a sign of Wickham's striae on her back where the skin had been cut. Further examination revealed comparable, solitary papules on the inside of her wrist, flank and chest. A skin biopsy confirmed the diagnosis lichen planus. The patient was prescribed betamethasone cream and we advised against further hijama treatments.

Dissociable Contributions of Precuneus and Cerebellum to Subjective and Objective Neuropathy in HIV.

Neuropathy, typically diagnosed by the presence of either symptoms or signs of peripheral nerve dysfunction, remains a frequently reported complication in the antiretroviral (ART)-treated HIV population. This study was conducted in 109 healthy controls and 57 HIV-infected individuals to investigate CNS regions associated with neuropathy. An index of objective neuropathy was computed based on 4 measures: deep tendon ankle reflex, vibration sense (great toes), position sense (great toes), and 2-point discrimination (feet). Subjective neuropathy (self-report of pain, aching, or burning; pins and needles; or numbness in legs or feet) was also evaluated. Structural MRI data were available for 126/166 cases. The HIV relative to the healthy control group was impaired on all 4 signs of neuropathy. Within the HIV group, an objective neuropathy index of 1 (bilateral impairment on 1 measure) or 2 (bilateral impairment on at least 2/4 measures) was associated with older age and a smaller volume of the cerebellar vermis. Moderate to severe symptoms of neuropathy were associated with more depressive symptoms, reduced quality of life, and a smaller volume of the parietal precuneus. This study is consistent with the recent contention that ART-treated HIV-related neuropathy has a CNS component. Distinguishing subjective symptoms from objective signs of neuropathy allowed for a dissociation between the precuneus, a brain region involved in conscious information processing and the vermis, involved in fine tuning of limb movements. Graphical Abstract In HIV patients, objective signs of neuropathy correlated with smaller cerebellar vermis (red) volumes whereas subjective symptoms of neuropathy were associated with smaller precuneus (blue) volumes.

Telogen Effluvium With Dysesthesia (TED) Has Lower B12 Levels and May Respond to B12 Supplementation

We investigated a subtype of Telogen Effluvium associated with Dysesthesia, (TED) which was defined as the presence of Telogen Effluvium with severe itch, pain, soreness, burning, or formication in the absence of any inflammatory scalp disorder or medication associated with Telogen Effluvium or Dysesthesia. These are patients who present with a "burning" scalp or other dysesthesia associated with increased telogen hair shedding. Telogen Effluvium is not typically associated with any scalp symptoms.3 Other scalp dysesthesia studies have mentioned occasional patients in their study that were also diagnosed with Telogen Effluvium,1,2 but the clinical association of Scalp Dysesthesia and Telogen Effluvium has never been made as a distinct entity.

Concurrent notalgia paresthetica and brachioradial pruritus associated with cervical degenerative disc disease.

Notalgia paresthetica (NP) is a common, often refractory sensory neuropathic syndrome with the hallmark symptoms of localized pruritus and dysesthesia of the unilateral infrascapular region. Brachioradial pruritus (BRP) is similarly classified as a localized pruritus syndrome but of the upper extremities, typically one or both forearms. Notalgia paresthetica and BRP are both generally chronic, nonlethal, incurable conditions with intermittent remissions and exacerbation. Often described as dermatologic syndromes, both diseases are typically considered to be multifactorial in etiology with an uncertain etiology. However, recent literature suggests that it is highly probable that NP in many, if not nearly all cases, has an association with underlying cervical disease at the C5-C6 levels. This elucidation has resulted in a paradigm shift in evaluation and treatment of NP as cervical disease with referred skin manifestations to the mid back. Notalgia paresthetica and BRP may occur concurrently in the same patients. To determine possible underlying cervical spine disease, it is vital to examine the neck and consider radiographic studies of the spine. Collaborative multispecialty evaluation may be indicated in primary management of these two conditions. For cases of NP and BRP that are associated with cervical disease, the first-line therapy may include nondermatologic spinal treatments. Many cases of NP and BRP are most likely dermatologic signs of underlying degenerative spine, disc, and muscle disease.

Deep Decompression of the Lateral Femoral Cutaneous Nerve Under Local Anesthesia.

OBJECTIVE: Meralgia paresthetica is a mononeuropathy of the lateral femoral cutaneous nerve (LFCN) caused by compression around the inguinal ligament. We report a surgical alternative for the treatment of meralgia paresthetica under local anesthesia and its outcomes. METHODS: We operated on 12 patients with unilateral meralgia paresthetica whose age at surgery ranged from 62 to 75 years. The mean postoperative follow-up period was 19 months. Microsurgical deep decompression of LFCN was performed with the patient under local anesthesia. Clinical outcomes of surgical treatment were assessed based on the patient's most recent follow-up visit and were classified into 3 categories: complete, partial, or no relief of symptoms. Symptoms of pain or numbness in the anterolateral part of the thigh were evaluated, using a visual analog scale, before surgery and after surgery, i.e., at the most recent follow-up visit. RESULTS: All patients reported symptom improvement: complete relief in 9 patients (75%) and partial relief in 3 patients (25%). In the 3 patients with partial relief, the remaining symptoms did not affect their daily living. Overall, the visual analog scale scores were significantly improved in all patients (P < 0.05), and no patient experienced postoperative recurrence of their symptoms at the time of the last follow-up visit. CONCLUSIONS: Symptoms of meralgia paresthetica can resemble those of a lumbosacral disorder. Microsurgical deep decompression under local anesthesia produces good surgical outcomes. The use of local anesthesia contributes not only to reduction of pain during surgery but also eliminates excessive surgical procedures and reduces the duration of hospital stay.

A Prospective Analysis of Neuromonitoring for Confirmation of Lead Placement in Dorsal Root Ganglion Stimulation.

BACKGROUND: Dorsal root ganglion stimulation is a neuromodulation therapy used for chronic neuropathic pain. Typically, patients are awakened intraoperatively to confirm adequate placement. OBJECTIVE: To determine whether neuromonitoring can confirm placement in an asleep patient. METHODS: This is a prospective analysis of 12 leads placed in 6 patients. Lead confirmation was confirmed by awake intraoperative testing, as well as asleep testing utilizing neuromonitoring. Patients were used as their own control. Sensory and motor thresholds for each patient with awake and asleep neuromonitoring testing were recorded. Intraoperative impedance and postoperative programming were also recorded. RESULTS: In each patient, paresthesias were generated prior to motor contractions in the awake patient. For each patient, somatosensory evoked potential responses were present after lowering below the dropout threshold of electromyogram responses with neuromonitoring. There were varying degrees of separation in the thresholds that did not appear to be consistent across level or diagnosis. Smaller degrees of separation between thresholds during awake testing also held true in the asleep patient. This was further confirmed with postoperative programming. Impedances did not alter the separation in thresholds or amount of stimulation required for responses. One patient was combative during awake testing, and therefore motor thresholds were not obtained. This same patient was determined to have a ventral placement, confirmed with awake and asleep neuromonitoring testing. CONCLUSION: This series demonstrates that the proposed neuromonitoring protocol can be used in an asleep patient to assure proper positioning of the dorsal root ganglion electrode in the dorsal foramen by generating somatosensory evoked potential responses in the absence of electromyogram responses.

Perspectives of Medieval Persian Medicine on Multiple Sclerosis.

INTRODUCTION: Traditional Persian Medicine (TPM) was the prevailing practice of medicine in the Eurasia region up through the 18th century, a practice of medicine stemming back to Hippocrates and to the 5000 year old civilization of the region. It is a school of medicine which touches on many a delicate points which may seem unimaginable within the realm of modern allopathic medicine. This practice of ancient medicine besides shedding light on various possible theoretical modern day disorders serves as a vast resource for therapeutics. In this paper, we present study of the manuscripts of this ancient medical practice in search of symptom presentations coinciding with presentation of multiple sclerosis (MS). MATERIAL & METHOD: This paper represents a comprehensive search through TPM texts and manuscripts with the intention to seek possible clues on MS from potentially valuable age-old resources. We predominantly focused our search on the works of five eminent physicians of Medieval Persia: Avicenna (980-1037 AD), Haly Abbas (949-982 AD), Rhazes (865-925 AD), Averroes (1126-1198 AD) and Jorjani (1042-1137 AD). RESULTS: In this paper, the authors attempt a theory and conclude with high probability that a conjunction of a series of signs, symptoms found in TPM texts under the terms khadar, isterkha and falej form the symptoms and the disease pattern of modern day MS. This theory draws upon existent similarities in terms of disease pathology, disease patterns and predisposing factors seen between MS and the related morbidities within Persian Medicine. CONCLUSION: We recommend further examinations of such potentially valuable long-standing resources, examining the diagnoses and treatments as set forth by Persian Medicine through international collaboration within the global scientific community.

Safety and Efficacy of Focused Ultrasound Thalamotomy for Patients With Medication-Refractory, Tremor-Dominant Parkinson Disease: A Randomized Clinical Trial.

Importance: Clinical trials have confirmed the efficacy of focused ultrasound (FUS) thalamotomy in essential tremor, but its effectiveness and safety for managing tremor-dominant Parkinson disease (TDPD) is unknown. Objective: To assess safety and efficacy at 12-month follow-up, accounting for placebo response, of unilateral FUS thalamotomy for patients with TDPD. Design, Setting, and Participants: Of the 326 patients identified from an in-house database, 53 patients consented to be screened. Twenty-six were ineligible, and 27 were randomized (2:1) to FUS thalamotomy or a sham procedure at 2 centers from October18, 2012, to January 8, 2015. The most common reasons for disqualification were withdrawal (8 persons [31%]), and not being medication refractory (8 persons [31%]). Data were analyzed using intention-to-treat analysis, and assessments were double-blinded through the primary outcome. Interventions: Twenty patients were randomized to unilateral FUS thalamotomy, and 7 to sham procedure. The sham group was offered open-label treatment after unblinding. Main Outcomes and Measures: The predefined primary outcomes were safety and difference in improvement between groups at 3 months in the on-medication treated hand tremor subscore from the Clinical Rating Scale for Tremor (CRST). Secondary outcomes included descriptive results of Unified Parkinson's Disease Rating Scale (UPDRS) scores and quality of life measures. Results: Of the 27 patients, 26 (96%) were male and the median age was 67.8 years (interquartile range [IQR], 62.1-73.8 years). On-medication median tremor scores improved 62% (IQR, 22%-79%) from a baseline of 17 points (IQR, 10.5-27.5) following FUS thalamotomy and 22% (IQR, -11% to 29%) from a baseline of 23 points (IQR, 14.0-27.0) after sham procedures; the between-group difference was significant (Wilcoxon P = .04). On-medication median UPDRS motor scores improved 8 points (IQR, 0.5-11.0) from a baseline of 23 points (IQR, 15.5-34.0) following FUS thalamotomy and 1 point (IQR, -5.0 to 9.0) from a baseline of 25 points (IQR, 15.0-33.0) after sham procedures. Early in the study, heating of the internal capsule resulted in 2 cases (8%) of mild hemiparesis, which improved and prompted monitoring of an additional axis during magnetic resonance thermometry. Other persistent adverse events were orofacial paresthesia (4 events [20%]), finger paresthesia (1 event [5%]), and ataxia (1 event [5%]). Conclusions and Relevance: Focused ultrasound thalamotomy for patients with TDPD demonstrated improvements in medication-refractory tremor by CRST assessments, even in the setting of a placebo response. Trial Registration: ClinicalTrials.gov identifier NCT01772693.