Perioral Paresthesia, Generalize Muscle Cramps, and Rhabdomyolysis After a Socotra Island Blue Baboon Tarantula (Monocentropus Balfouri) Bite.

BACKGROUND: Literature on systemic envenomation caused by tarantula bites, particularly from the Theraphosidae family, is relatively scarce. This case report provides a formal description of the first known instance of systemic envenomation caused by the Socotra Island Blue Baboon Tarantula (Monocentropus balfouri). CASE REPORT: In this case, a 23-year-old employee of an exotic pet shop suffered from perioral paresthesia, generalized muscle cramps, and rhabdomyolysis because of a Monocentropus balfouri bite. His symptoms were successfully relieved with oral benzodiazepines. EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the potential for serious complications resulting from the bite of Monocentropus balfouri, a species gaining popularity among global exotic pet collectors.

Sun pain and solar dysesthesia: A new challenge in clinical practice.

BACKGROUND: A few patients report intense pain and other unpleasant sensations, such as burning, dysesthesia and hyperalgesia, after even brief exposure to the sun and in the absence of any skin lesion. Sometimes they also develop systemic symptoms, such as mild fever, fatigue, faintness and fainting. As a result, these patients carefully avoid even short-term sun exposure with a consequent severe negative impact on their lives. METHODS: We have reviewed the clinical findings and the results of photobiological investigations of 10 patients who presented this clinical picture. Six of these patients were previously described by our group with the diagnosis of sun pain. We have reviewed the similarities with other previously described disorders such as solar dysesthesia and PUVA pain and have evaluated possible pathogenetic mechanisms. RESULTS: During phototesting our patients experienced intense pain in the exposed area and in the surrounding skin, without any visible lesion, even with very low sub-erythemal doses. At follow-up, five patients were diagnosed with fibromyalgia, three with a major depressive disorder, one with bipolar syndrome and one with a conversion disorder. The pathogenesis remains unclear, but the use of a psychopharmacological treatment with antidepressants improved both the neuropsychiatric symptoms and sensitivity to the sun in most subjects. CONCLUSION: For patients with pain and other severe symptoms in the absence of skin lesions and clinical and laboratory manifestations of known photodermatoses, a neuropsychiatric evaluation should be suggested.

Does high-frequency stimulation of sensory axons break the causal link between pain relief and paresthesia?

Neurostimulation produces unnatural cutaneous sensations with potent analgesic effects in pain syndromes. In this issue of Neuron, Sagalajev et al.1 demonstrate that these sensations are an epiphenomenon and explain how high-frequency stimulation can provide analgesia without these unnecessary sensations.

Investigation of the efficacy of two different laser types in the treatment of lower lip paresthesia after sagittal split ramus osteotomy.

Orthognathic surgery involves invasive and major surgical procedures commonly used to correct maxillofacial deformities. Bilateral sagittal split ramus osteotomy (BSSO) is often used to treat dentofacial anomalies related to the mandible, but it can result in various complications, the most common of which is inferior alveolar nerve damage. Nerve damage-induced paresthesia of the lower lip significantly affects patient comfort. Medical treatments such as steroids and vitamin B, low-level laser therapy (LLLT), and platelet-rich fibrin (PRF) can be used as supportive therapies for nerve regeneration after damage. This study aimed to investigate the effectiveness of two different types of lasers in treating lower lip paresthesia after BSSO. This clinical trial was a controlled, single-center, prospective, single-blind, randomized study. Thirty patients were included in the study and randomly assigned to three groups: Group I (laser GRR, n = 10) received transcutaneous and transmucosal GRR laser treatment, Group II (Epic10 laser, n = 10) received transmucosal and transcutaneous Epic10 laser treatment, and Group III (vitamin B, n = 10) received B-complex vitamin tablets orally once a day. Two-point and brush tests were performed six times at specific intervals, and a visual analog scale was used to evaluate pain and sensitivity. Both vitamin B and laser therapies accelerated nerve regeneration. The contribution of the laser groups to the healing rate was better than that of the vitamin B group. Although there was no statistically significant difference between the two laser groups, clinical observations indicated better results in the GRR laser group.

Postural Changes in Spinal Cord Stimulation Thresholds: Current and Voltage Sources.

OBJECTIVE: Spinal cord stimulation (SCS) thresholds are known to change with body position; however, these changes have not been fully characterized for both "constant-voltage" and "constant-current" pulse generators. This study aimed to evaluate and quantify changes in psychophysical thresholds resulting from postural changes that may affect both conventional paresthesia-based SCS and novel paresthesia-free SCS technologies. MATERIALS AND METHODS: We measured perceptual, usage, and discomfort thresholds in four body positions (prone, supine, sitting, standing) in 149 consecutive patients, with temporary lower thoracic percutaneous epidural electrodes placed for treating persistent low back and leg pain. We trialed 119 patients with constant-voltage stimulators and 30 patients with constant-current stimulators. RESULTS: Moving from supine to the sitting, standing, or prone positions caused all three thresholds (perceptual, usage, and discomfort) to increase by 22% to 34% for constant-voltage stimulators and by 44% to 82% for constant-current stimulators. Changing from a seated to a supine position caused stimulation to exceed discomfort threshold significantly more often for constant-current (87%) than for constant-voltage (63%) stimulators (p = 0.01). CONCLUSIONS: Posture-induced changes in SCS thresholds occurred consistently as patients moved from lying (supine or prone) to upright (standing or sitting) positions. These changes were more pronounced for constant-current than for constant-voltage pulse generators and more often led to stimulation-evoked discomfort. These observations are consistent with postural changes in spinal cord position measured in imaging studies, and with computer model predictions of neural recruitment for these different spinal cord positions. These observations have implications for the design, implantation, and clinical application of spinal cord stimulators, not only for conventional paresthesia-based SCS but also for paresthesia-free SCS.

Defining the Boundaries of Patient Perception in Spinal Cord Stimulation Programming.

OBJECTIVES: Recent developments in spinal cord stimulation (SCS) programming have initiated new modalities of imperceptible stimulation. However, the boundaries of sensory perception are not well defined. The BEnchtop NEuromodulation Following endIng of Trial study aimed to create a map of perceptual threshold responses across a broad range of SCS parameters and programming to inform subperception therapy design. MATERIALS AND METHODS: This multicenter study was conducted at seven US sites. A total of 43 patients with low back and/or leg pain who completed a percutaneous commercial SCS trial were enrolled. Test stimulation was delivered through trial leads for approximately 90 minutes before removal. SCS parameters, including amplitude, frequency, pulse width (PW), electrode configuration, cycling, and multifrequency stimulation were varied during testing. Paresthesia threshold (PT), comfort level (CL), perceptual coverage area, and paresthesia quality (through patient selection of keywords) were collected. Differences were evaluated with analysis of variance followed by post hoc multiple comparisons using t-tests with Bonferroni correction. RESULTS: PT was primarily determined by PW and was insensitive to frequency for constant frequency stimulation (range: 20 Hz-10 kHz; F(1284) = 69.58, p < 0.0001). For all tests, CL was approximately 25% higher than PT. The dominant variable that influenced paresthesia quality was frequency. Sensations described as comfortable and tingling were most common for frequencies between 60 Hz and 2.4 kHz; unpleasant sensations were generally more common outside this range. Increasing distance between active electrodes from 7 mm to 14 mm, or cycling the SCS waveform at 1 Hz, decreased PT (p < 0.0001). Finally, PT for a low-frequency stimulus (ie, 60 Hz) was unaffected by mixing with a sub-PT high-frequency stimulus. CONCLUSIONS: In contrast to previous work investigating narrower ranges, PW primarily influenced PT, independently of frequency. Paresthesia quality was primarily influenced by pulse frequency. These findings advance our understanding of SCS therapy and may be used to improve future novel neuromodulation paradigms.

Residual Paresthesia After Surgery for Degenerative Cervical Myelopathy: Incidence and Impact on Clinical Outcomes and Satisfaction.

STUDY DESIGN: Multicenter, prospective cohort study. OBJECTIVE: The current study aimed to identify the incidence of residual paresthesias after surgery for degenerative cervical myelopathy (DCM), and to demonstrate the impact of these symptoms on clinical outcomes and patient satisfaction. SUMMARY OF BACKGROUND DATA: Surgery for DCM aims to improve and/or prevent further deterioration of physical function and quality-of-life (QOL) in the setting of DCM. However, patients are often not satisfied with their treatment for myelopathy when they have severe residual paresthesias, even when physical function and QOL are improved after surgery. MATERIALS AND METHODS: The authors included 187 patients who underwent laminoplasty for DCM. All patients were divided into two groups based on their visual analog scale score for paresthesia of the upper extremities at one year postoperatively (>40 vs. ≤40 mm). Preoperative factors, changes in clinical scores and radiographic factors, and satisfaction scales at one year postoperatively were compared between groups. The authors used mixed-effect linear and logistic regression modeling to adjust for confounders. RESULTS: Overall, 86 of 187 patients had severe residual paresthesia at one year postoperatively. Preoperative patient-oriented pain scale scores were significantly associated with postoperative residual paresthesia ( P =0.032). A mixed-effect model demonstrated that patients with severe postoperative residual paresthesia showed significantly smaller improvements in QOL ( P =0.046) and myelopathy ( P =0.037) than patients with no/mild residual paresthesia. Logistic regression analysis identified that residual paresthesia was significantly associated with lower treatment satisfaction, independent of improvements in myelopathy and QOL (adjusted odds ratio: 2.5, P =0.010). CONCLUSION: In total, 45% of patients with DCM demonstrated severe residual paresthesia at one year postoperatively. These patients showed significantly worse treatment satisfaction, even after accounting for improvements in myelopathy and QOL. As such, in patients who experience higher preoperative pain, multidisciplinary approaches for residual paresthesia, including medications for neuropathic pain, might lead to greater clinical satisfaction. LEVEL OF EVIDENCE: 3.

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.

Clinical Reasoning: A Young Woman With Rapidly Progressive Weakness and Paresthesia.

A 24-year-old Middle Eastern woman presented with a 2-month history of rapidly progressive asymmetric weakness and paresthesia that began in her left lower extremity and progressed to involve both legs and arms. It was associated with overflow urinary incontinence and significant weight loss. In addition, she complained of a constant occipital headache that worsened in the supine position and was associated with photophobia, tinnitus, nausea, vomiting, and horizontal binocular diplopia. She also had signs of meningismus, decreased left facial sensation, and right sensorineural hearing loss. Because multifocal localization suggests a wide variety of possible differential diagnoses, this study expands on the differential of a subacute multifocal process while highlighting the importance of identifying appropriate risk factors and performing a relevant yet focused diagnostic workup.

Evaluating the influence of the mandibular canal trajectory on the duration of postoperative paraesthesia in patients undergoing inferior alveolar nerve lateralisation: a prospective cohort study.

This prospective cohort study aims to evaluate the influence of the mandibular canal trajectory on the duration of postoperative paraesthesia in patients undergoing inferior alveolar nerve lateralisation (IANL). Twenty patients received a total of 50 dental implants, and their postoperative paraesthesia duration, implant success rate, and anatomical variables were assessed. All patients experienced temporary neurosensory disturbances postoperatively during the first week, but none reported permanent issues at the 12-month follow up. The median paraesthesia duration was 120 days, and no significant differences were detected between genders, anaesthesia types, or patient satisfaction. No significant association was found between the mandibular canal trajectory and postoperative paraesthesia duration. The implant success rate was 100%, with all implants integrating successfully. Our findings suggest that IANL is a safe and effective method for dental implant placement in atrophic mandibles.

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.

Approach to diagnosis, evaluation, and treatment of generalized and nonlocal dysesthesia: A review.

Dysesthesia is an abnormal sensation in the skin that occurs in the absence of any extraordinary stimulus or other primary cutaneous disorders, excluding any delusions or tactile hallucinations. Clinicians have characterized dysesthesias to include sensations such as burning, tingling, pruritus, allodynia, hyperesthesia, or anesthesia. The etiology and pathogenesis of various generalized dysesthesias is largely unknown, though many dysesthesias have been associated with systemic pathologies including malignancy, infection, autoimmune disorders, and neuropathies. Dermatologists are often the first-line clinicians for patients presenting with such cutaneous findings, thus it is crucial for these physicians to be able to methodically work-up generalized dysesthesias to build a working differential diagnosis, follow up with key labs and/or imaging, and offer patients evidence-based treatment to relieve their symptoms. This broad literature review is an attempt to centralize key studies, cases, and series to help guide dermatologists in their assessment and evaluation of complaints of abnormal cutaneous sensations.

Persistent post-COVID-19 neuromuscular symptoms.

Neuromuscular symptoms may develop or persist after resolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Besides residual sensorimotor symptoms associated with acute neuromuscular complications of coronavirus disease-2019 (COVID-19), such as Guillain-Barré syndrome, critical illness neuromyopathy, and rhabdomyolysis, patients may report persistent autonomic symptoms, sensory symptoms, and muscle symptoms in the absence of these acute complications, including palpitations, orthostatic dizziness and intolerance, paresthesia, myalgia, and fatigue. These symptoms may be associated with long COVID, also known as post-COVID-19 conditions or postacute sequelae of SARS-CoV-2 infection, which may significantly impact quality of life. Managing these symptoms represents a challenge for health-care providers. Recent advances have identified small-fiber neuropathy as a potential etiology that may underlie autonomic dysfunction and paresthesia in some long COVID patients. The pathogenic mechanisms underlying myalgia and fatigue remain elusive and need to be investigated. Herein we review the current state of knowledge regarding the evaluation and management of patients with persistent post-COVID-19 neuromuscular symptoms.

Effect of Dexmedetomidine on Perception of Paresthesia during Subthalamic Nucleus Deep Brain Stimulation Surgery for Parkinson's Disease.

Background: Deep brain stimulation (DBS) has become a well-established treatment for the management of Parkinson's disease (PD). The most common method of lead targeting utilizes microelectrode recording (MER) and intraoperative macrostimulation to confirm accurate placement of the lead. This has been significantly aided by the use of dexmedetomidine (DEX) sedation during the procedure. Despite the frequent use of DEX, it has been theorized that DEX may have some effects on the MER during intraoperative testing. The effect on the perception of sensory thresholds during macrostimulation in the form of paresthesia is still unreported. Objectives: To investigate the effect of the sedative DEX on sensory perception thresholds observed in the intraoperative versus postoperative settings for patients undergoing subthalamic nucleus (STN) DBS surgery for PD. Materials and Methods: Adult patients (n = 8) with a diagnosis of PD underwent placement of DBS leads (n = 14) in the STN. Patients were subjected to intraoperative macrostimulation for capsular and sensory thresholds prior to placement of each DBS lead. These were compared to sensory thresholds observed in the postoperative setting during outpatient programming at three depths on each lead (n = 42). Results: In most contacts (22/42) (P = 0.19), sensory thresholds for paresthesia perception were either perceived at a higher voltage or absent during intraoperative testing in comparison to those observed in the postoperative setting. Conclusions: DEX appears to have measurable (though not statistically significant) effect on the perception of paresthesia observed during intraoperative testing.