Uso do laser de baixa potência para o tratamento de parestesia: uma revisão de literatura / Use of low-level laser to treat paresthesia: a literature review

Introdução: A parestesia é uma neuropatia que afeta a função sensorial. O Laser de Baixa Potência (LBP), por sua vez, apresenta propriedades analgésicas, bioestimuladoras e reparadoras. Objetivo: Realizar um levantamento na literatura científica sobre os aspectos gerais e benefícios do LBP no manejo terapêutico da parestesia, além de identificar a classificação e métodos de obtenção do diagnóstico desta condição. Materiais e Métodos: Tratou-se de uma revisão narrativa da literatura através da busca nas plataformas PubMed, SciELO, LILACS e Google Schoolar. Após o cruzamento dos descritores com os operadores booleanos e aplicação dos critérios de inclusão/exclusão, 26 estudos foram incluídos. Resultados: A parestesia pode ser classificada em neuropraxia, axonotmese e neurotmese, subdivididas em Grau I ao V. Seu diagnóstico pode ser executado através de testes subjetivos e objetivos. O LBP compreende em um dispositivo tecnológico com efeitos analgésico, anti-inflamatório e fotobiomodulador, que estimula o reparo neural. Os estudos mostram que a dosimetria nos comprimentos de onda vermelho e infravermelho, aplicação intra e extra oral, e com mais de uma sessão semanal exerce efeito modulatório positivo do reparo neural, com retorno progressivo da atividade sensitiva. Além disso, os estudos trazem uma ampla variação no número de pontos de aplicação, bem como no tempo de irradiação e quantidade de sessões, em virtude da extensão e tempo de diagnóstico da parestesia. Considerações finais: Apesar da alta complexidade da parestesia, o LBP exerce efeitos benéficos através do retorno da sensibilidade parcial ou total, além de ser um dispositivo bem tolerado pelo organismo e minimamente invasivo.

Introduction: Paresthesia is a neuropathy that affects sensory function. The Low-Level Laser (LLL), in turn, has analgesic, biostimulating and reparative properties. Purpose: Carry out a survey at the scientific literature on the general aspects and benefits of LLL in the therapeutic management of paresthesia in addition to identifying the classification and methods for obtaining a diagnosis of this condition. Materials and Methods: It was a narrative literature review through search in platforms PubMed, SciELO, LILACS and Google Schoolar. After crossing the descriptors with boolean operators and applying the inclusion/exclusion criteria, 26 articles were included in this study. Results: Paresthesia can be classified into neuropraxia, axonotmesis and neurotmesis, subdivided into Grades I to V. Its diagnostic can be carried out through subjective and objective tests. The LLL consists in a technological device with analgesic, anti-inflammatory and photobiomodulatory effects, which stimulates neural repair. Studies show that LLL in dosimetry at red and infrared wavelengths with intra and extra oral application and with more than one-week use exerts a positive modulatory effect on neural repair, with a progressive return of sensory activity. Furthermore, the studies show a wide variation in the number of application points, as well as the irradiation time and number of sessions, due to the extent and time of diagnosis of paresthesia. Final Considerations: Despite the high complexity of paresthesia, the LLL has beneficial effects through the return of partial or total sensitivity in addition being a device well tolerated by the body and minimally invasive.

Síndrome de persona rígida: presentación de caso clínico y abordaje terapéutico / Stiff man Syndrome Clinical case presentation and therapeutic approach

Introducción: El síndrome del hombre rígido representa una rara enfermedad neuromuscular caracterizada por rigidez muscular progresiva y espasmos musculares dolorosos que afecta a 1 persona por cada millón de habitantes por año en el mundo. En la mayoría de los pacientes se encuentran niveles elevados de anticuerpos descarboxilasa del ácido glutámico. En Colombia solo se han publicado alrededor de 3 casos, lo que motiva la presentación de un nuevo informe que aporte a la discusión actual en el campo de la neurología clínica. Caso clínico: Paciente de sexo femenino de 35 años con cuadro clínico progresivo de varios años, caracterizado por contracciones paroxísticas dolorosas, parestesias y pérdida de fuerza. Se documentó la presencia de anticuerpos anti-GAD compatibles con el síndrome del hombre rígido. Tras un tratamiento integral, que incluyó la infusión farmacológicamente intratecal con baclofeno, se obtuvo mejoría clínica en el índice de Barthel. Conclusiones: El síndrome del hombre rígido es una condición infradiagnosticada que se asocia a un deterioro de la calidad de vida de quienes lo padecen.

Introduction: Stiff man syndrome represents a rare neuromuscular disease characterized by progressive muscle rigidity and painful muscle spasms that affects 1 person for every million habitants per year in the world. High levels of glutamic acid antibodies decarboxylase are found in most patients. In Colombia, only around 3 cases have been published, which motivates the presentation of a new report that contributes to the current discussion in the field of clinical neurology. Clinical Case: 35-year-old female patient with a progressive clinical picture of several years, characterized by painful paroxysmal contractions, paresthesias and loss of strength. The presence of anti-GAD antibodies was documented, compatible with Stiff man syndrome. After comprehensive treatment, which included pharmacologically intrathecal infusion with baclofen, clinical improvement was obtained in the Barthel index. Conclusions: Stiff man syndrome is an underdiagnosed condition which is associated with a deterioration in the quality of life for those who suffer from it.

Relação da exodontia de terceiros molares e a ocorrência de parestesia do nervo alveolar inferior: uma revisão narrativa / Relationship of third molar extraction and occurrence of lower alveolar nerve paresthesia: a narrative review

Terceiros molares inferiores podem apresentar uma estreita relação com o nervo alveolar inferior, aumentando as chances de lesão durante o ato cirúrgico. Objetivo: descrever a relação entre a exodontia de terceiros molares e a ocorrência da parestesia do nervo alveolar inferior. Revisão de literatura: cirurgia para exodontia de dentes terceiros molares é o procedimento mais frequentemente realizado entre as cirurgias bucais e, como todo tipo de cirurgia, possui riscos e acidentes e/ou complicações que podem acometer os pacientes tal como a parestesia. Esta é uma condição que altera a sensibilidade de determinada área e pode ocorrer em consequência de traumas diretos ao nervo ou pela compressão deste, devido a hematoma e edema, levando a desconforto e incômodo. Considerações finais: é importante o profissional cirurgião-dentista atentar para o planejamento correto, criterioso e fazer uso de exames complementares, a fim de precaver possíveis complicações durante o ato cirúrgico. Caso a parestesia aconteça, podem ser utilizados tratamentos medicamentosos, a laser ou cirúrgicos, com resultados em longo prazo positivos e reversão do caso.(AU)

Lower third molars may present a close relation with the inferior alveolar nerve increasing the chances of injury during the surgical act. In view of this, this literature review aims to describe the relationship between the extraction of molars third and the occurrence of inferior alveolar nerve paresthesia. Paresthesia is a condition that alters the sensitivity of a certain area and can occur as a result of direct trauma to the nerve or compression of the nerve due to hematoma and edema. It leads to discomfort and discomfort, and it is important for the professional to attend to the correct, judicious planning and to make use of complementary exams. If paraesthesia occurs, medical, laser or surgical treatments are used, with positive long- -term results and reversal of the case. (AU)

Foot drop: an iatrogenic complication of spinal anesthesia / Pé caído: uma complicação iatrogênica da anestesia espinhal

Abstract Background and objectives Foot drop in postoperative period is very rare after spinal anesthesia. Early clinical assessment and diagnostic interventions is of prime importance to establish the etiology and to start appropriate management. Close follow-up is warranted in early postoperative period in cases when patient complain paresthesia or pain during needle insertion or drug injection. Case report A 22-year-old male was undergone lower limb orthopedic surgery in spinal anesthesia. During shifting from postoperative ward footdrop was suspected during routine assessment of regression of spinal level. Immediately the patient was referred to a neurologist and magnetic resonance imaging was done, which was inconclusive. Conservative management was started and nerve conduction study was done on the 4th postoperative day that confirmed pure motor neuropathy of right peroneal nerve. Patient was discharged with ankle splint and physiotherapy after slight improvement in motor power (2/5). Conclusions Foot drop is very rare after spinal anesthesia. Any suspected patient must undergo emergent neurological consultation and magnetic resonance imaging to exclude major finding and need for early surgical intervention.

Resumo Justificativa e objetivos Pé caído no período pós-operatório é muito raro após a anestesia espinhal. Avaliação clínica e intervenções diagnósticas precoces são de primordial importância para estabelecer a etiologia e iniciar o tratamento adequado. Um acompanhamento atento é justificado no pós-operatório imediato nos casos em que o paciente se queixa de parestesia ou dor durante a inserção da agulha ou da injeção de fármacos. Relato de caso Paciente do sexo masculino, 22 anos, submetido a cirurgia ortopédica de membros inferiores sob anestesia espinhal. Durante a transferência para a sala de recuperação pós-operatória, houve suspeita de pé caído durante a avaliação rotineira da regressão do nível espinhal. O paciente foi imediatamente enviado ao neurologista e uma ressonância magnética foi feita, mas não foi conclusiva. O manejo conservador foi iniciado e o estudo de condução nervosa foi feito no 4° dia de pós-operatório, o que confirmou a neuropatia motora pura do nervo fibular direito. O paciente foi dispensado com imobilizador de tornozelo e fisioterapia após ligeira melhoria da força motora (2/5). Conclusões Pé caído é muito raro após a anestesia espinhal. Qualquer paciente suspeito deve ser submetido à consulta neurológica de emergência e ressonância magnética para excluir o principal achado e a necessidade de intervenção cirúrgica precoce.

Evidence Gaps in the Use of Spinal Cord Stimulation for Treating Chronic Spine Conditions.

STUDY DESIGN: A review of literature. OBJECTIVE: The aim of this study was to define and explore the current evidence gaps in the use of spinal cord stimulation (SCS) for treating chronic spine conditions. SUMMARY OF BACKGROUND DATA: Although over the last 40 years SCS therapy has undergone significant technological advancements, evidence gaps still exist. METHODS: A literature review was conducted to define current evidence gaps for the use of SCS. Areas of focus included 1) treatment of cervical spine conditions, 2) treatment of lumbar spine conditions, 3) technological advancement and device selection, 4) appropriate patient selection, 5) the ability to curb pharmacological treatment, and 6) methods to prolong efficacy over time. New SCS strategies using advanced waveforms are explored. RESULTS: The efficacy, safety, and cost-effectiveness of traditional SCS for chronic pain conditions are well-established. Evidence gaps do exist. Recently, advancement in waveforms and programming parameters have allowed for paresthesia-reduced/free stimulation that in specific clinical areas may improve clinical outcomes. New waveforms such as 10-kHz high-frequency have resulted in an improvement in back coverage. To date, clinical efficacy data are more prevalent for the treatment of painful conditions originating from the lumbar spine in comparison to the cervical spine. CONCLUSION: Evidence gaps still exist that require appropriate study designs with long-term follow-up to better define and improve the use of this therapy for the treatment of chronic spine pain in both the cervical and lumbar regions. LEVEL OF EVIDENCE: N/A.

Triggering of Carpal Tunnel Syndrome Symptoms in Patients Using Urban Public Transportation.

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy found in clinical practice. Recent studies evaluated which external factors could be involved in the CTS symptoms, including prolonged exposure to vibration, especially in the upper limb. This study investigated signs and symptoms in patients with CTS after using urban transport on (1) both upper limbs, (2) how long before these symptoms appear, and (3) the hands position or body reaction during the act of pressing the safety bars. Methods: The study was conducted from July 2012 to April 2013. A total of 205 (178 women and 27 men) patients were evaluated. CTS was diagnosed in 285 hands. All participants answered a questionnaire formulated by the authors. The questionnaire was applied by researchers who were single-blinded and not involved in the research. Results: Most of the participants (87%) were women, but there was no statistical significance in age between groups (women = 51.24 ± 8.47 years, men = 51.10 ± 6.52 years, P > .05). The symptoms appeared significantly in the first 15 minutes after boarding when compared with patients who had no symptoms during the journey. There was no difference between hands position along the journey and the onset of symptoms. Conclusions: The onset of symptoms in patients with CTS using urban public transportation most commonly occurred in the first 15 minutes after boarding. Public transport vibration seems to be, at least in part, directly related to the development of symptoms. Questionnaires for the assessment of paresthesia symptoms during the use of public transport may be useful for CTS diagnosis.

Indenização por danos estéticos e morais decorrentes de fratura mandibular ocasionada por acidente de trabalho - relato de perícia odontológica trabalhista / Indemnity for aesthetic and moral damages resulting mandibular fracture for work accident - reporting dental labor expertise

Introdução: a perícia trabalhista odontológica visa verificar e quantificar as lesões no aparelho estomatognático, e suas repercussões, decorrentes de trauma produzidos durante a atividade laborativa. Nos casos onde as lesões geram danos estéticos e/ou funcionais, cabe ao expert reportar a presença dasmesmas, seu aspecto estático e dinâmico, e as consequências para o trabalhador. Objetivo: relatar um caso de perícia odontológica trabalhista em que mesmo havendo trauma facial com sequela estética de pequena monta, houve condenação do empregador para pagamento de danos morais e estéticos. Relatode Caso: um trabalhador foi soterrado durante a sua atividade laboral e, em decorrência do trauma,fraturou a mandíbula (fratura não exposta) e ficou com parestesia nesta região. Em primeira instância, foideterminada uma avaliação médica, onde o perito médico não verificou lesões e/ou sequelas que inviabilizassem o exercício da atividade do reclamante e/ou que fosse digno de reparação. Após orecurso, foi anulada a sentença inicial e determinada uma nova perícia, porém, nomeou-se um expertespecialista em Odontologia Legal que encontrou evidências da referida parestesia, bem como, que amesma era de caráter permanente e irreversível, caracterizando-se nexo causal, o que levou o magistrado a sentenciar o pagamento de danos estéticos e morais. Conclusão: conclui-se com o referidorelato de caso pericial que uma alteração estética de pequena monta na face, decorrente de fratura mandibular não exposta, associada a prejuízos funcionais e sensoriais no complexo maxilomandibular pode resultar em danos estéticos indenizáveis, cabendo ao perito judicial expor adequadamente estasalterações para que o magistrado possa julgar e fazer justiça em cada caso.

Introduction: labor dental expertise aims to verify and quantify injuries and impacts on stomatognathicsystem resulting from trauma suffered at work. In cases where injuries cause aesthetic and/or functionaldamages, the expert must report them as well as their static and dynamic aspect and the consequencesfor the worker. Objective: to report a case of labor dental expertise in which even having facial trauma withslight aesthetic sequel, there was employer condemnation for payment of moral and aesthetic damages.Case Report: a worker was buried during his labor activity, and as a result of trauma, he fractured hismandible (unexposed fracture) staying with paresthesia in this region. In the first instance, it was made amedical evaluation and the medical expert found no injuries and/or sequels that made it impossible toexercise the claimant's activity and/or it was worthy of indemnity. After the appeal, the initial sentence wasoverturned and another expertise determined, but with a new expert, a specialist in forensic dentistry, whofound evidence of permanent and irreversible paresthesia, establishing causal link and leading themagistrate to sentence the payment of aesthetic and moral damages. Conclusion: it is concluded that aslight facial aesthetic alteration resulting from unexposed mandibular fracture, associated with functionaland sensory impairments of maxilomandibular complex, can result in compensable aesthetic damages,falling to the court expert to properly expose these alterations so that the magistrate can judge and dojustice in each case.

[Sensory neuronopathy. Its recognition and early treatment]. / Neuronopatía sensitiva. Su reconocimiento y tratamiento temprano.

Sensory neuronopathies or ganglionopathies, or dorsal root ganglion disorders, represent a subgroup of peripheral nervous system diseases, frequently associated with dysinmune or neoplastic disorders and with toxic agents. A degeneration of both central and peripheral sensory proyections is present. Patients typically show early ataxia, loss of deep tendon reflexes and positive sensory symptoms present both in proximal and distal sites of the body. We retrospectively studied 10 cases with a final diagnosis of sensory neuronopathy. Sensory neuropathy was the presenting symptom and the course was subacute in all cases. Paresthesias in upper limbs were a predominant manifestation (100%). Other manifestations included: hypoesthesia (10/10), gait ataxia (8/10), autonomic symptoms (3/10) and perioral paresthesias (3/10). Electrophysiology showed sensory axonal neuronal pattern, with normal motor responses. Final diagnosis was acquired sensory neuronopathy in all patients, associated with Sjögren's syndrome in 2, with lupus erythematosus in 1, with rheumatoid arthritis in 1, with a cancer in 2 (paraneoplastic) and idiopathic in 4. In paraneoplastic cases, the tumor was small cell lung cancer in 1 (with positive anti-Hu antibodies), and epidermoid lung cancer in the other. Eight patients were treated with immunotherapy, high dose intravenous methylprednisolone and/or intravenous immunoglobulin; with poor response in 4 cases, neurologic improvement in 5, and without any change in 1 patient. The present work shows the typical clinical and electrophysiological pattern of subacute sensory neuronopathy, and the relevance of early treatment.

Neuronopatía sensitiva: Su reconocimiento y tratamiento temprano / Sensory neuronopathy. Its recognition and early treatment

Las neuronopatías o ganglionopatías sensitivas, o enfermedades del ganglio dorsal, representan un subgrupo de enfermedades del sistema nervioso periférico, frecuentemente asociadas a trastornos disinmunes o paraneoplásicos, y a agentes tóxicos. Los pacientes típicamente presentan ataxia temprana, pérdida de los reflejos osteotendinosos y síntomas sensitivos positivos, presentes tanto en partes proximales como distales del cuerpo. Estudiamos retrospectivamente 10 casos con un diagnóstico final de neuronopatía sensitiva. El síntoma de presentación fue el de una neuropatía sensitiva de curso subagudo en todos los casos, con parestesias en el 100% de los casos. Otras manifestaciones fueron: hipoestesia (10/10), ataxia de la marcha (8/10), síntomas autonómicos (3/10) y parestesias periorales (3/10). La electrofisiología mostró un patrón de compromiso sensitivo axonal, con respuestas motoras normales. El diagnóstico final fue neuronopatía sensitiva adquirida en todos, asociada a síndrome de Sjögren en dos, a lupus eritematoso en uno, a artritis reumatoidea en uno, a cáncer en dos (paraneoplásica) e idiopática en cuatro. En los casos paraneoplásicos, los tumores fueron un carcinoma de pulmón de células pequeñas (con anticuerpos anti-Hu positivos) y un carcinoma epidermoide de pulmón. Ocho pacientes fueron tratados con inmunoterapia, con altas dosis de metilprednisolona endovenosa y/o con inmunoglobulina endovenosa; con pobre respuesta en cuatro casos, mejoría neurológica en cinco, y sin cambios en uno. El presente trabajo muestra el patrón clinico y electrofisiológico de las neuronopatías sensitivas subagudas, y la relevancia de un tratamiento temprano.

Sensory neuronopathies or ganglionopathies, or dorsal root ganglion disorders, represent a subgroup of peripheral nervous system diseases, frequently associated with dysinmune or neoplastic disorders and with toxic agents. A degeneration of both central and peripheral sensory proyections is present. Patients typically show early ataxia, loss of deep tendon reflexes and positive sensory symptoms present both in proximal and distal sites of the body. We retrospectively studied 10 cases with a final diagnosis of sensory neuronopathy. Sensory neuropathy was the presenting symptom and the course was subacute in all cases. Paresthesias in upper limbs were a predominant manifestation (100%). Other manifestations included: hypoesthesia (10/10), gait ataxia (8/10), autonomic symptoms (3/10) and perioral paresthesias (3/10). Electrophysiology showed sensory axonal neuronal pattern, with normal motor responses. Final diagnosis was acquired sensory neuronopathy in all patients, associated with Sjögren’s syndrome in 2, with lupus erythematosus in 1, with rheumatoid arthritis in 1, with a cancer in 2 (paraneoplastic) and idiopathic in 4. In paraneoplastic cases, the tumor was small cell lung cancer in 1 (with positive anti-Hu antibodies), and epidermoid lung cancer in the other. Eight patients were treated with immunotherapy, high dose intravenous methylprednisolone and/or intravenous immunoglobulin; with poor response in 4 cases, neurologic improvement in 5, and without any change in 1 patient. The present work shows the typical clinical and electrophysiological pattern of subacute sensory neuronopathy, and the relevance of early treatment.

Avaliação pós-cirúrgica da sensibilidade facial e estomatognática de pacientes submetidos à cirurgia ortognática / Evaluation of stomathognatic and facial sensibility of patients submitted to orthognathic surgery

Dentro da Odontologia, a cirurgia ortognática é um procedimento complexo. O objetivo desse estudo foi avaliar a condição sensitiva e motora facial e estomatognática de pacientes que foram submetidos à cirurgia ortognática. Trata-se de uma pesquisa quali-quantitativa do tipo descritiva e exploratória, com procedimentos teóricos bibliográficos e técnica de observação direta extensiva através da aplicação de um formulário. O estudo possui caráter censitário, sendo a população composta por 18 indivíduos de uma clínica particular submetidos à cirurgia ortognática entre 2009 e 2012. Na análise dos dados foi utilizado o SPSS na versão 17.0. Com relação aos resultados, observou-se: 50% eram homens e 50% mulheres; a maioria eram adultos jovens, entre 25 e 30 anos; sendo (27,8%) tendo mais de 6 meses e menos de 1 ano da realização da cirurgia; 33,3% com o principal objetivo cirúrgico o recuo de mandíbula e avanço de maxila; 66,7% sentiram uma melhora na respiração e na dicção após realizada a cirurgia; 38,9% relataram ter ronco antes da cirurgia, porém esse número caiu para 5,5% quando perguntados se sofriam de ronco atualmente; 11,1% apresentaram parestesia em pelo menos 1 quadrante facial e 16,3% apontaram diminuição na intensidade dos toques positivos aos testes táteis e térmicos. Apesar da utilização da técnica cirúrgica correta ainda existe a possibilidade de ocorrerem danos temporários devido ao envolvimento de estruturas nobres e da complexidade cirúrgica.

Within Dentistry, orthognathic surgery is a complex procedure. Thus, in view of the complexity of the surgery, the aim of this study was to evaluate sensibility and motor condition of both the face and stomatognathic system of patients who underwent orthognathic surgery. This is an exploratory descriptive study of quali-quantitative nature, with literature research and direct observation technique by form application. The study sample was composed of 18 individuals from a private clinic who underwent orthognathic surgery between 2009 and 2012. For data analysis the SPSS version 17.0 was used. The results showed that 50% of the patients were men and 50% women, most of them were young adults, between 25 and 30 years; 27.8% had surgery in a period of at least 6 months and no longer that 1 year before this study was conducted; 33.3% had as primary surgical objective the mandibular retreat and maxillary advancement; 66.7% felt an improvement in breathing and diction after surgery; 38.9% reported suffering from snoring before surgery, but this number dropped to 5.5% when asked if they suffered from snoring today; 11.1% had paresthesia in at least one facial quadrant and 16.3% showed decrease in intensity of positive touch to tactile and thermal tests. In spite of using proper surgical technique temporary damages may occur due to engagement of noble structures and the complexity of the surgery.

Morbidity after conventional dissection of axillary lymph nodes in breast cancer patients.

BACKGROUND: Conventional axillary lymph node dissection (ALND) has recently become less radical. The treatment morbidity effects of reduced ALND aggressiveness are unknown. This article investigates the prevalence of the main complications of ALND: lymphedema, range-of-motion restriction, and arm paresthesia and pain. METHODS: This cross-sectional study included 200 women with invasive breast cancer who underwent breast-conserving surgery (82.5%, n = 165) or mastectomy (17.5%, n = 35) with ALND from 2007 to 2011. Arm perimetry was used to assess lymphedema, defined as a difference >2 cm in the upper arm circumference between the nonsurgical and surgical arms. Range-of-motion restriction was assessed by evaluating the degree of arm abduction. Paresthesia was measured in the inner and proximal arm regions. Arm pain was assessed by directly questioning the patients and defined as either present or absent. RESULTS: The average (±SD) time between ALND and morbidity evaluation was 35 ± 18 months (range, 7-60 months). The average dissected lymph node number per patient was 14 ± 4 (range, 6-30 lymph nodes). Only 3.5% (n = 7) of the patients presented with lymphedema. Single-incision approaches to breast tumor and ALND (P = 0.04) and the presence of a postoperative seroma (P = 0.02) were associated with lymphedema in univariate analysis. Paresthesia was the most frequent side effect observed (53% of patients, n = 106). This complication was associated with increased age (P < 0.0001) and a larger dissected lymph node number (P = 0.01) in univariate and multivariate analysis. Additionally, 24% (n = 48) of patients had noticeable limited arm abduction. Among the patients, 27.5% (n = 55) experienced sporadic arm pain corresponding to the surgically treated armpit. In multivariate analysis, the pain risk was 1.9-fold higher in patients who underwent ALND corresponding to their dominant arm (95% CI, 1.0-3.7, P = 0.04). CONCLUSION: Conventional ALND in breast cancer patients can result in unwanted complications. However, the current lymphedema prevalence is lower than that of the other analyzed side effects.

Prospective study of postoperative sensory disturbances after surgical treatment of mandibular fractures.

INTRODUCTION: This present study's purpose is to evaluate the degree of paresthesia and recovery of inferior alveolar nerve in patients with mandible fractures who underwent surgical treatment. MATERIAL AND METHODS: Nineteen patients were evaluated (27 hemimandibles) at six different times: preoperative (T1), postoperative 1 week (T2), postoperative 1 month (T3), postoperative 3 months (T4), postoperative 6 months (T5), and postoperative 1 year (T6). Subjective and objective methods were used for this evaluation. RESULTS: The results were analyzed using likelihood ratio chi-square test for the hypothesis of no association between indicators of sensitivity and responses to the questionnaire, and the Cochran-Mantel-Haenszel test for equality hypothesis. All objective tests showed a statistically significant worsening in sensitivity at T2 (p < 0.0001) and a significant improvement after T4 (α < 0.05). The subjective tests showed an association with the objectives tests, and improvement in sensitivity after T4 (p < 0.0001) was noted. DISCUSSION: The first postoperative week is the period in which there are major changes with respect to sensitivity, and after 3 months postoperatively, the recovery reaches its apex with little difference observed after this period. In this research 100 % of the patients analyzed recovered all sensibility until T6.

Protocolo de regressão de parestesia após cirurgia de lateralização de nervo alveolar inferior / Surgical protocol for regression of paresthesia after inferior alveolar nerve lateralization

Objetivo: A cirurgia de lateralização do nervo alveolar inferior é pouco difundida devido ao dano neurossensor denominado pa restesia , causado pelo trauma ao feixe nervoso ocasionado pela manipulação cirúrgica. Este trabalho objetiva descrever um protocolo clínico com finalidade de regressão mais rápida da parestesia em pacientes atendidos no curso de especialização em Implantodontia da Unicastelo submetidos à cirurgia de lateralização do nervo alveolar inferior para a instalação de implantes odontológicos, aumentando a previsibilidade clínica da técnica. Materiais e métodos: neste estudo foi utilizado o aparelho de piezocirurgia para o acesso cirúrgico, soft laser para a bioestimulação e um composto polivitamínico para a regeneração tecidual. Resultados: Com a utilização do protocolo obteve-se uma expressiva redução da parestesia local, com retorno da sensibilidade nervosa em média de 20 dias. Dentro deste estudo, o melhor resultado de recuperação sensitiva foi obtido em oito dias pós-cirurgia, enquanto o mais lento ocorreu após seis meses e 21 dias devido a intercorrência de rompimento do feixe nervoso. Como dado comparativo, há 12 anos os pacientes submetidos à técnica cirúrgica apresentavam um quadro estatístico de retorno sensitivo com dois anos de espera. Conclusões: O protocolo de lateralização do nervo alveolar inferior adotado tem reduzido consideravelmente a incidência de parestesia. A utilização de piezocirurgia, "softlaser" e do composto polivitamínico associados a um bom conhecimento de anatomia e domínio da técnica cirúrgica são determinantes para o êxito do tratamento

Objective: The surgery of the inferior alveolar nerve lateralization has a restricted use because of the neurosensitive damage to the nerve bundle called paresthesia, caused by trauma during manipulation of the nerve for implant insertion. This paper aims to describe a clinical protocol with the purpose of the regression of paresthesia in patients enrolled in the specialization course of Implantology at University Unicastelo undergoing surgery of lateralization of the inferior alveolar nerve for dental implant place- ment, increasing the predictability of the clinical technique. Materiais and methods: In this work the piezoelectric device for the surgical approach, soft laser for biostimulation and a multivitamin compound for tissue regeneration were used to obtain a faster recovery of sensation. Results: Using the protocol we obtained a reduction of paresthesia, with consequent return of sensitivity to an average of 20 days, compared 12 years ago when the group began using the technique, where the average incidence of paresthesia was two vears The faster recovery of the area paresthesia in the study group was 8 days and longe r was 6 months and 21 days with the complication of rupture of the nerve bundle. Conclusions: The protocol adopted for inferior alveolar nerve lateralization has considerably reduced the incidence of paresthesia. The use of piezosurgery, softlaser and multivitamin compound associated with a good kno- wledge of anatomy and masterv of surgical technique are essential to the success of treatment

Lhermitte's sign and vitamin B12 deficiency: case report.

CONTEXT AND OBJECTIVE: Lhermitte's sign, a classical neurological sign, is a rare manifestation of vitamin B12 deficiency. The aim here was to report on a case of an elderly patient with vitamin B12 deficiency whose first clinical manifestation was the presence of Lhermitte's sign. CASE REPORT: We describe an elderly patient with vitamin B12 deficiency who presented cognitive dysfunction, peripheral polyneuropathy and sensory ataxia, and whose first clinical manifestation was the presence of Lhermitte's sign. This sign is one of the rarest manifestations of vitamin B12 deficiency.

Analysis of MR imaging of wrists in female patients with carpal tunnel syndrome and healthy controls / Análisis de imágenes de RM de las muñecas en pacientes mujeres con síndrome del túnel carpiano y controles sanos

The objective of this study was to evaluate morphological changes of the median nerve in patients with carpal tunnel syndrome (CTS) and healthy controls, to correlate the MRI findings of wrists. This study compared not only morphological changes of the median nerve and also displayed descriptively structures in carpal tunnel between patients diagnosed with idopathic CTS and healthy controls. Our study involved 60 hand, 30 of hand were evaluated diagnosed with idiopathic CTS and 30 hand as healthy controls bilaterally. Two provocative tests (Phalen's and Tinel's test) were performed on each hand for both the patient group (60 wrist) and the control group (60 wrist). With regard to Phalen and Tinel's test results, 24 and 26 wrists were excluded from patient and control groups respectively. Totally 70 wrists were evaluated, and in terms of cross-sectional area of median nerve at the level of distal radio-ulnar joint, pisiform bone and the hook of hamate bone by MRI in the patient and control groups. In addition to evaluation of cross-sectional area of median nerve, we determined signal intensity of wrists and different localization of the median nerve in the carpal tunnel. Cross-sectional area of the median nerve measured by wrist magnetic resonance at the level of metacarpal bones and signal intensity of wrists may be considered as a valuable indicator to determine patients referred with idiopathic CTS.

El objetivo de este estudio fue evaluar los cambios morfológicos del nervio mediano en pacientes con síndrome del túnel carpiano (STC) y controles sanos, para correlacionar los hallazgos de las RM de muñeca. Este estudio comparó no sólo los cambios morfológicos del nervio mediano, también se muestran en forma descriptiva estructuras del túnel carpiano entre los pacientes diagnosticados con STC idiopatico y controles sanos. Nuestro estudio incluyó 60 manos, 30 manos fueron evaluados con diagnóstico de STC idiopático y 30 manos como controles sanos, bilateralmente. Dos pruebas de provocación (prueba de Phalen y prueba de Tinel) se realizaron en cada mano para el grupo de pacientes (60 muñecas) y el grupo control (60 muñecas). En lo que respecta a los resultados de prueba de Phalen y prueba de Tinel, 24 y 26 muñecas fueron excluidas del grupo paciente y grupo control respectivamente. En total 70 muñecas fueron evaluadas, en términos de la sección transversal del área del nervio mediano a nivel de la articulación radio-ulnar distal, el hueso pisiforme y el hamulus del hueso hamate por medio de resonancia magnética en gruposs paciente y control. Además de la evaluación de la sección del área del nervio mediano, se determinó la intensidad de la señal de la muñeca y las diferentes localizaciones del nervio mediano en el túnel carpiano. La sección transversal del área del nervio mediano medida por medio de resonancia magnética de muñeca a nivel de los huesos metacarpianos y la intensidad de la señal de las muñecas pueden ser considerados como un valioso indicador al evaluar pacientes referidos con STC idiopático.

Lhermitte's sign and vitamin B12 deficiency: case report / Sinal de Lhermitte e deficiência de vitamina B12: relato de caso

CONTEXT AND OBJECTIVE: Lhermitte's sign, a classical neurological sign, is a rare manifestation of vitamin B12 deficiency. The aim here was to report on a case of an elderly patient with vitamin B12 deficiency whose first clinical manifestation was the presence of Lhermitte's sign. CASE REPORT: We describe an elderly patient with vitamin B12 deficiency who presented cognitive dysfunction, peripheral polyneuropathy and sensory ataxia, and whose first clinical manifestation was the presence of Lhermitte's sign. This sign is one of the rarest manifestations of vitamin B12 deficiency.

CONTEXTO E OBJETIVO: O sinal de Lhermitte, um sinal neurológico clássico, é uma rara manifestação clínica da deficiência de vitamina B12. O objetivo foi relatar o caso de um paciente idoso com deficiência de vitamina B12, cuja manifestação clínica inicial foi a presença do sinal de Lhermitte. RELATO DO CASO: Paciente idoso com deficiência de vitamina B12, apresentou-se com disfunção cognitiva, polineuropatia periférica e ataxia sensitiva, cuja manifestação clínica inicial foi a presença do sinal de Lhermitte. Este sinal é uma das mais raras manifestações da deficiência de vitamina B12.

Notalgia parestésica / Notalgia paresthetica

La notalgia parestésica es una neuropatía sensorial caracterizada clínicamente por una mancha hiperpigmentada bien circunscrita localizada en la espalda, que afecta las áreas correspondientes a los dermatomos D2 a D6. El prurito es el síntoma más común, aunque algunos pacientes describen otras sensaciones, incluyendo ardor, parestesia, hiperestesia o dolor. Los hallazgos histopatológicos son inespecíficos. Su etiología no ha sido claramente demostrada, pero en algunos casos existe una llamativa correlación con patología de la columna vertebral, incluyendo cambios degenerativos y/o hernias del núcleo pulposo. El diagnóstico diferencial incluye la neurodermitis y la amiloidosis macular. No existe un tratamiento definitivo para la enfermedad. Se han empleado diversas terapias incluyendo capsaicina tópica, bloqueo anestésico para vertebral, oxcarbazepina, gabapentina y toxina botulínica.

Notalgia paresthetica is a sensory neuropathy characterizd clinically by a well-circumscribed hyperpigmented patch located on the back, affecting the areas corresponding to dermatomes D2-D6. Pruritus is its most common symptom, but some patients describe other sensations including burning, paresthesia, hypeesthesia or pain. Histopathological findings are not specific. The etiology of this condition has not be en clearly demonstrated but in some cases there exists a striking correlation with spinal pathology, including degenerative changes or a herniated nucleous pulposus. Differential diagnoses include neurodermitis and maclular amyloidosis There is no definitive treatment for the disease diverse therapies have been employed including topical capsaicin paravertebral local anesthetic block, oxcarbazepine, gabapentir and botulinum toxin type A.

SUMEVA, a new system of climacteric symptom evaluation, and its correlation with FSH and estradiol levels.

OBJECTIVE: To evaluate a new climacteric symptom scale (SUMEVA) and to assess its correlation with follicle stimulating hormone (FSH) and estradiol (E2) levels. METHODS: 115 healthy perimenopausal women who were not receiving, nor had received, hormone therapy were studied. They were asked to complete 3 questionnaires concerning climacteric symptoms: (1) Kupperman's index (KI), (2) Green scale (GS), and (3) SUMEVA, which is the sum of symptom evaluations done in an analog visual scale. FSH and E2 determinations were done by chemoluminiscence. STATISTICAL ANALYSIS: The comparison among the groups was done by Student's t test. Pearson correlation analysis was done between FSH and E2 levels and KI, the GS, and SUMEVA. RESULTS: There were 60 women with FSH < or = 30 mIU/mL (group I) and 55 with FSH > 30 mIU/mL (group II). The KI average in the whole group was 13.2 +/- 8.1, the GS 20.6 +/- 13.1, and the SUMEVA 65.6 +/- 44.9. The three scales had a significant correlation between them. CONCLUSIONS: No correlation of KI, GS, or SUMEVA was found with FSH and E2 levels, but the SUMEVA was as effective as the other previously validated, scales for climacteric symptom evaluation.

[Signs and symptoms associated to otoneurologic alterations diagnosed on computerized vestibular exam of patients with multiple sclerosis]. / Sinais e sintomas associados a alterações otoneurológicas diagnoticadas ao exame vestibular computadorizado em pacientes com esclerose múltipla.

OBJECTIVE: To identify main symptoms and signs on computerized vestibular testing in patients diagnosed with multiple sclerosis. METHOD: Thirty patients with the diagnosis of multiple sclerosis were studied. We analyzed data related to presented symptoms and the findings from a computerized vestibular testing realized in the otoneurological ambulatory in Santa Casa de Misericórdia de São Paulo in 2003. RESULTS: Reported symptoms consisted mainly of disequilibrium (60%), tingling of limbs (43.3%), vertigo (40%), headache and anxiety (36.7%), tinnitus (30%), depression (26.7%). In vestibular testing we found alterations in positional nystagmus (6.7%), spontaneous nystagmus with the eyes shut (30%), directional nystagmus (13.3%) and caloric testing (63.3%). In the final conclusion of the exam, the diagnosis of irritative type peripheral vestibular syndrome (60%) and central syndrome (13.4%) prevailed. CONCLUSION: We conclude that the realization of an otoneurological exam has become indispensable in patients with multiple sclerosis. This is due to high prevalence of alterations at computerized vestibular exam and of otoneurological symptoms.

Sinais e sintomas associados a alteraçoes otoneurológicas diagnoticadas ao exame vestibular computadorizado em pacientes com esclerose múltipla / Signs and symptoms associated to otoneurologic alterations diagnosed on computerized vestibular exam of patients with multiple sclerosis

OBJECTIVE: To identify main symptoms and signs on computerized vestibular testing in patients diagnosed with multiple sclerosis. METHOD: Thirty patients with the diagnosis of multiple sclerosis were studied. We analyzed data related to presented symptoms and the findings from a computerized vestibular testing realized in the otoneurological ambulatory in Santa Casa de Misericórdia de São Paulo in 2003. RESULTS: Reported symptoms consisted mainly of disequilibrium (60%), tingling of limbs (43.3%), vertigo (40%), headache and anxiety (36.7%), tinnitus (30%), depression (26.7%). In vestibular testing we found alterations in positional nystagmus (6.7%), spontaneous nystagmus with the eyes shut (30%), directional nystagmus (13.3%) and caloric testing (63.3%). In the final conclusion of the exam, the diagnosis of irritative type peripheral vestibular syndrome (60%) and central syndrome (13.4%) prevailed. CONCLUSION: We conclude that the realization of an otoneurological exam has become indispensable in patients with multiple sclerosis. This is due to high prevalence of alterations at computerized vestibular exam and of otoneurological symptoms.

OBJETIVO: Descrever os principais sintomas e sinais ao exame vestibular computadorizado em pacientes com diagnóstico de esclerose múltipla. MÉTODO:Foram examinados 30 pacientes com diagnóstico de esclerose múltipla. Analisaram-se os dados relativos à sintomatologia e achados ao exame vestibular computadorizado realizado no ambulatório de otoneurologia da Irmandade Santa Casa de Misericórdia de São Paulo, em 2003. RESULTADOS: Em relação aos sintomas relatados, observamos desequilíbrio (60%), formigamento de extremidades (43,3%), vertigem (40%), cefaléia e ansiedade (36,7%), zumbido (30%), depressão (26,7%). Ao exame vestibular encontramos alterações do nistagmo de posicionamento (6,7%), nistagmo espontâneo de olhos fechados (30%), nistagmo semi-espontâneo (13,3%), rastreio pendular (3,3%) e prova calórica (63,3%). Na conclusão do exame tivemos prevalência de síndrome vestibular periférica irritativa (60%) e síndrome central (13,4%). CONCLUSÃO: Concluimos que a realização do exame otoneurológico torna-se imprescindível nos pacientes com esclerose múltipla devido a elevada prevalência de alterações à vectonistagmografia computadorizada e elevada prevalência de sintomas otoneurológicos.