Trigeminal and sphenopalatine ganglion stimulation for intractable craniofacial pain--case series and literature review.

INTRODUCTION: Facial pain is often debilitating and can be characterized by a sharp, stabbing, burning, aching, and dysesthetic sensation. Specifically, trigeminal neuropathic pain (TNP), anesthesia dolorosa, and persistent idiopathic facial pain (PIFP) are difficult diseases to treat, can be quite debilitating and an effective, enduring treatment remains elusive. METHODS: We retrospectively reviewed our early experience with stimulation involving the trigeminal and sphenopalatine ganglion stimulation for TNP, anesthesia dolorosa, and PIFP between 2010-2014 to assess the feasibility of implanting at these ganglionic sites. Seven patients received either trigeminal and/or sphenopalatine ganglion stimulation with or without peripheral nerve stimulation, having failed multiple alternative modalities of treatment. The treatments were tailored on the physical location of pain to ensure regional coverage with the stimulation. RESULTS: Fluoroscopy or frameless stereotaxy was utilized to place the sphenopalatine and/or trigeminal ganglion stimulator. All patients were initially trialed before implantation. Trial leads implanted in the pterygopalatine fossa near the sphenopalatine ganglion were implanted via transpterygoid (lateral-medial, infrazygomatic) approach. Trial leads were implanted in the trigeminal ganglion via percutaneous Hartel approach, all of which resulted in masseter contraction. Patients who developed clinically significant pain improvement underwent implantation. The trigeminal ganglion stimulation permanent implants involved placing a grid electrode over Meckel's cave via subtemporal craniotomy, which offered a greater ability to stimulate subdivisions of the trigeminal nerve, without muscular (V3) side effects. Two of the seven overall patients did not respond well to the trial and were not implanted. Five patients reported pain relief with up to 24-month follow-up. Several of the sphenopalatine ganglion stimulation patients had pain relief without any paresthesias. There were no electrode migrations or post-surgical complications. CONCLUSIONS: Refractory facial pain may respond positively to ganglionic forms of stimulation. It appears safe and durable to implant electrodes in the pterygopalatine fossa via a lateral transpterygoid approach. Also, implantation of an electrode grid overlying Meckel's cave appears to be a feasible alternative to the Hartel approach. Further investigation is needed to evaluate the usefulness of these approaches for various facial pain conditions.

Chronic Fatigue Syndrome: The Current Status and Future Potentials of Emerging Biomarkers.

Chronic fatigue syndrome (CFS) remains an incompletely characterized illness, in part due to controversy regarding its definition, biological basis and diagnosis. Biomarkers are objective measures that may lead to improvements in our understanding of CFS by providing a more coherent and consistent approach to study, diagnosis and treatment of the illness. Such metrics may allow us to distinguish between CFS subtypes - each defined by characteristic biomarkers - currently conflated under the single, heterogeneous condition of CFS. These delineations, in turn, may guide more granular, focused, and targeted treatment strategies based on more precise characterizations of the illness. Here, we review potential CFS biomarkers related to neurological and immunological components of the illness, and discuss how these biomarkers may be used to move the field of CFS forward, emphasizing clinical utility and potential routes of future research.

Novel PI3Kγ mutation in a 44-year-old man with chronic infections and chronic pelvic pain.

A 44-year-old man is presented here with 14 years of chronic purulent sinusitis, a chronic fungal rash of the scrotum, and chronic pelvic pain. Treatment with antifungal therapy resulted in symptom improvement, however he was unable to establish an effective long-term treatment regimen, resulting in debilitating symptoms. He had undergone extensive work-up without identifying a clear underlying etiology, although Candida species were cultured from the prostatic fluid. 100 genes involved in the cellular immune response were sequenced and a missense mutation was identified in the Ras-binding domain of PI3Kγ. PI3Kγ is a crucial signaling element in leukotaxis and other leukocyte functions. We hypothesize that his mutation led to his chronic infections and pelvic pain.

Arthroscopic lysis of adhesions for stiff total knee arthroplasty.

The goal of this study was to evaluate the efficacy of arthroscopic lysis of adhesions after total knee arthroplasty (TKA) in improving range of motion (ROM) and providing an improvement in knee function. The authors retrospectively examined 19 patients who underwent arthroscopic lysis of adhesions following TKA due to poor ROM. The criterion for lysis was the inability to flex to 90° at 3 months. All patients were followed for at least 2 years after lysis. Patient demographics, postoperative and follow-up ROM,number of prior surgeries, Knee Society Scores, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) functional scores were collected. Average ROM increased from 75.37° preoperatively to 98.95° postoperatively. The authors found an association between preoperative knee score and change in ROM between pre-arthroscopic lysis and ROM at final follow-up (P=.0188). When the authors examined the relationship between patient body mass index (BMI) and change in ROM,they found that patients with a BMI higher than 30 kg/m2 had a change of 26.44° compared with patients with a BMI lower than 30 kg/m2, who had a change of only 8.75°. A strong association was found between patient height and change in ROM and final ROM achieved (P=.0062 and .0032, respectively). The authors report a successful outcome among study patients. Furthermore, they found an association between patient height, BMI, and preoperative knee score and the improvement achieved after arthroscopic lysis of adhesions following TKA. The current study's results are comparable with those of published results. The authors recommend arthroscopic lysis of adhesions as a treatment option for stiff knees after TKA that fails after at least 3 months of nonoperative treatment.