Efficacy of Adding a Distal Level Block to a C2 Level Greater Occipital Nerve Block under Ultrasound Guidance in Chronic Migraine.

Objective: To investigate the benefit of adding a distal level greater occipital nerve (GON) block to the proximal level GON block under ultrasound guidance in patients with chronic migraine (CM) with cutaneous allodynia (CA). Methods: Seventy-eight patients with CM were included. A single US-guided GON block was performed at proximal and distal levels in patients with CM with CA and only at the proximal level in patients with CM without CA. Thirty (38.5%) patients with bilateral pain received bilateral GON blocks, and 48 (61.5%) with unilateral pain received unilateral GON blocks. The patients were evaluated using Numeric Rating Scale (NRS) scores before treatment and 1 and 4 weeks after treatment and through Headache Impact Test-6 (HIT-6) scores before treatment and 4 weeks after treatment. Results: The NRS scores significantly decreased at first and fourth weeks, and the HIT-6 scores significantly decreased at fourth week (p < 0.001) compared with preintervention scores in all groups. No significant difference was found between the groups regarding the postinterventional first and fourth week when the decreases of NRS and HIT-6 scores were compared (p = 0.599). There were no significant differences in the effectiveness of unilateral and bilateral GON blocks (p > 0.001). Conclusion: A single US-guided GON block is an effective and safe treatment option in patients with CM, providing a positive effect on pain and quality of life for 4 weeks. The addition of a distal level GON block to the proximal level GON block provides no extra benefit to patients with CM with CA.

An alternative treatment option in older adults with knee osteoarthritis : Genicular nerve pulsed radiofrequency.

Osteoarthritis (OA), including knee OA (KOA), is an important cause of morbidity and disability in older adults. Pain management plays a major role in the treatment of KOA for pain relief and knee function improvement. Ultrasound-guided genicular nerve pulsed radiofrequency therapy is an effective, safe, nonradiative, and easily applicable treatment modality in older adults with KOA. It has a positive effect on geriatric syndromes, especially polypharmacy.

Evaluation of the Efficacy of Ultrasound-Guided Dry Needling Therapy and Exercise in Piriformis Muscle Syndrome.

BACKGROUND:  Piriformis muscle syndrome (PMS) is characterized by symptoms of buttock pain and numbness radiating to the back of the thigh due to irritation of the sciatic nerve. This study aimed to evaluate the efficacy of dry needling (DN) therapy and exercise programs on pain, neuropathic pain, physical function, and disability in patients with PMS. METHODS:  Forty-four patients with PMS were included in the study. Patients were divided into two groups, those who were treated with DN three times once per week under ultrasound guidance and those who had an exercise program for three weeks. To identify the outcomes of the treatment modalities, pre-treatment and post-treatment first-month and third-month visual analog scale (VAS), Oswestry Disability Index (ODI) questionnaire, Lower Extremity Functional Scale (LEFS), and Douleur Neuropathique 4 (DN4) questionnaire scores were used. RESULTS:  There was no statistically significant difference between the groups in baseline scores of VAS (p = 0.548), DN4 (p = 0.446), and LEFS (p = 0.880), but in the DN group, baseline ODI scores were significantly higher than in the exercise group (p = 0.001). The group comparisons showed no statistically significant differences in decreasing pain, reducing disability, and increasing functional status scores among the groups at post-treatment first-month and third-month assessments (p > 0.05). CONCLUSION: Both treatment modalities are beneficial in reducing pain and disability, and increasing the functional status of the patients with PMS in three months of follow-up. In patients who cannot adapt to exercise programs, DN treatment under ultrasound guidance should be kept in mind as a minimally invasive treatment modality with no adverse effects.

Efficacy of ultrasound-guided greater occipital nerve pulsed radiofrequency therapy in chronic refractory migraine.

OBJECTIVE: Ultrasound (US) guided pulsed radiofrequency (PRF) therapy can be used on the greater occipital nerve (GON) in patients with chronic migraine (CM) who are unresponsive to conservative treatments. We aimed to demonstrate the change in pain intensity, duration of migraine episodes, frequency of attacks, migraine disability, depression, and sleep disturbance scores before and after treatment in patients with CM who underwent US-guided GON PRF and the effectiveness of treatment. PATIENTS AND METHODS: According to the International Classification of Headache Disorders III beta version diagnostic criteria, 25 of 43 patients with CM whom treated with GON PRF were included in the study. The Migraine Disability Assessment Scale (MIDAS), Beck Depression Inventory (BDI), Pittsburgh Sleep Quality Index (PSQI), and a visual analog scale (VAS) were used on patients before GON PRF treatment and at post treatment months 1 and 3. RESULTS: The median duration and number of migraine episodes in the post-interventional 1st month and 3rd month were significantly shorter and fewer compared with the pre-intervention period (p < 0.001). In the comparison with the pre-intervention values, all of the scoring concepts, namely the MIDAS, VAS, BDI, and PSQI, revealed a significant drop in the postintervention 1st and 3rd month (p < 0.001). CONCLUSION: In this study, we observed that US-guided GON PRF therapy applied at the proximal (C2) level was a safe and effective treatment option. With GON PRF, we observed a decrease in pain intensity, pain frequency, and duration of episodes, and an improvement in depression symptoms, migraine disability, and sleep disorder scores accompanying chronic migraine.

The Correlation of Epidural Fibrosis with Epiduroscopic and Radiologic Imaging for Chronic Pain after Back Surgery.

BACKGROUND: Chronic low back pain is observed frequently after lumbar spinal surgery. Epidural fibrosis has been implicated in the etiology of persistent pain after back surgery. The incidence of epidural fibrosis increases as the number and extent of spinal surgery increases. Epidural fibrosis can be detected by conventional radiologic methods [e.g., lumbosacral magnetic resonance imaging (MRI) with gadolinium], but these methods are insufficient to reveal the presence of epidural adhesions. Imaging of the epidural cavity using an epiduroscope is one of the best methods for visualizing the spinal cavity without damaging anatomic structures. OBJECTIVES: To evaluate the correlation between the type and number of surgery and the degree of epidural fibrosis and to compare epidural fibrosis in epiduroscopic and MRI findings in patients with failed back surgery syndrome (FBSS). STUDY DESIGN: A prospective trial. SETTING: A university hospital. METHODS: This study included 61 patients with persistent low back pain and/or radicular pain for at least 6 months, despite lumbar surgery and conservative treatment, and who accepted epiduroscopic imaging. All patients were evaluated in a physical examination using a visual analog scale (VAS) per the elapsed time after surgery. The patients were divided into 3 groups according to the number and type of surgeries. Epidural fibrosis was rated using MRI with gadolinium and epiduroscopy. RESULTS: When the relationship between admission symptoms and epidural fibrosis was evaluated, MRI findings of fibrosis were found to be significantly higher in all patients with both lumbar and radicular pain symptoms at the confidence level of 95% (P = 0.001). The degree of fibrosis detected using epiduroscopy was grade 1 and 2 in almost all patients who presented with low back pain only, only radicular pain, or only distal paresthesia (P = 0.001). In the correlation analysis between the duration of the postoperative period (4.13 ± 2.97 years) and the degree of fibrosis detected using MRI and epiduroscopy, a statistically significant relationship was found at the confidence level of 95% (P < 0.05). As the number and extent of spinal surgeries increased, the incidence of MRI fibrosis increased, which is compatible with the literature (P = 0.001) There was a statistically significant relationship between the degree of fibrosis as detected using MRI and epiduroscopy at the confidence level of 95% (P < 0.05). Differently, we observed that 6 patients had grade 1 fibrosis as diagnosed using epiduroscopy, whereas none had fibrosis on MRI. LIMITATIONS: We did not have a control group. Further studies are required to demonstrate the relevance of these 2 imaging techniques (epiduroscopy and MRI) in terms of detecting epidural fibrosis in patients with FBSS.  CONCLUSIONS: Epiduroscopic imaging seems to be more sensitive than MRI in detecting grade I epidural fibrosis in patients with FBSS. Thus, the possibility of low-grade epidural fibrosis as a source of pain after back surgery, should be kept in mind in normally reported MRIs. Treatment should be planned accordingly.

Contribution of Quantitative EEG to the Diagnosis of Early Cognitive Impairment in Patients With Idiopathic Parkinson's Disease.

Cognitive dysfunction can emerge during the clinical course of Parkinson's disease (PD) even beginning in early stages, which requires extended neuropsychological tests for diagnosis. There is need for rapid, feasible, and practical tests in clinical practice to diagnose and monitor the patients without causing any discomfort. We investigated the utility of quantitative analysis of digital EEG (qEEG) for diagnosing subtle cognitive impairment in PD patients without evident cognitive deficits (ie, "normal cognition"). We enrolled 45 patients with PD and age- matched 39 healthy controls in the study. All participants had Mini-Mental State Examination (MMSE) score greater than 25. qEEG analysis and extensive neuropsychological assessment battery were applied to all participants. Test scores for frontal executive functions, verbal memory processes, attention span, and visuospatial functions were significantly lower than healthy controls ( P < .01). qEEG analysis revealed a significant increase in delta, theta, and beta frequencies, and decrease in alpha frequency band in cerebral bioelectrical activity in patient group. In addition, power spectral ratios ([alpha + beta] / [delta + theta]) in frontal, central, temporal, parietal, and occipital regions were significantly decreased in patients compared with the controls. The slowing in EEG was moderately correlated with MMSE scores ( r = 0.411-0.593; P < .01). However, qEEG analysis and extensive neuropsychological assessment battery were only in weak correlation ( r = 0.230-0.486; P < .05). In conclusion, qEEG analysis could increase the diagnostic power in detecting subtle cognitive impairment in PD patients without evident cognitive deficit, perhaps years before the clinical onset of dementia.

Risk Factors for Hemorrhagic Transformation in Patients with Acute Middle Cerebral Artery Infarction.

INTRODUCTION: Hemorrhagic transformation (HT) after acute ischemic stroke (AIS) can be seen at any time following ischemic stroke. Although HT usually occurs as a complication of antithrombotic, anticoagulant, or thrombolytic treatments, it can also occur spontaneously. We aimed to investigate the occurrence of early HT and its relevant risk factors in patients diagnosed with acute middle cerebral artery (MCA) infarction who were not treated with thrombolytic agents. METHODS: We recruited 171 patients with acute MCA infarction between January 2011 and July 2012 who were not treated with thrombolytic agents and were suitable to our inclusion criteria. Controlled neuroimaging was performed immediately in patients with deterioration, otherwise on day 7 following stroke. All patients were investigated for AIS risk factors and biochemical analyses were performed. Patients with HT in controlled neuroimaging were grouped both clinically (i.e., symptomatic or asymptomatic) and radiologically, according to "European Cooperative Acute Stroke Radiological Study" (ECASS), and risk factors were examined. RESULTS: We enrolled 171 patients [94 men (55%) and 77 women (45%)] in the study. HT developed in 37 patients (21.63%). In terms of risk factor analysis, the most frequent etiological factor was atherosclerosis in AIS patients (50.3%). National Institutes of Health Stroke Scale scores were significantly higher both in sHT patients according to asHT patients and in HT patients on day 7 compared with their initial scores. Serum low-density lipoprotein (LDL-C), triglycerides (TG), and total cholesterol (TC) levels were significantly lower in patients with HT (p<.001). CONCLUSION: HT is a major complication in AIS that considerably increases the morbidity and mortality. To reduce the occurrence of HT, risk factors for each patient population should be determined. Acute thrombolytic therapy should be used cautiously in high-risk patients, and appropriate alternative therapies should be revised in them.

Dural puncture: an overlooked cause of cerebral venous thrombosis.

Cerebral venous thrombosis (CVT) accounts for 0.5-1 % of all strokes. Although dural puncture is proposed as one of the rare risk factors, this association has only been mentioned in anecdotal reports. Headache, i.e., usually the first and the most frequent clinical symptom on admission, is often attributed to the dural puncture itself. We investigated the frequency of CVT following a recent dural puncture in our stroke database, together with the other risk factors. The computerized medical records of patients (n = 10,740) registered in our tertiary-care neurology clinic stroke database were reviewed retrospectively. Patients diagnosed with CVT were reanalyzed. Patients who had a dural puncture in the preceding 7 days were included in the study. A total of 46 patients were diagnosed with CVT. Nine patients (19.6 %) had a recent dural puncture before the onset of the symptoms. Patients were younger than 45 years and had at least one more predisposing condition for thromboembolism other than the dural puncture. All patients have received either spinal anesthesia or intrathecal chemotherapy. Dural puncture seems to trigger CVT particularly in patients with predisposing disorders. Although reported as an extremely rare complication, our data indicate a much higher association. This case series emphasize the importance of reevaluation of patients with persistent/progressive headache following dural puncture. The effect of change in the biochemical composition of CSF due to intrathecal drug administration in pathogenesis is not known. Larger controlled trials are warranted to clarify the causal relationship between lumbar puncture and/or intrathecal drug administration and CVT.

The effects of desflurane on human platelet aggregation in vitro.

In view of the possible antiplatelet effects of general anesthetics, we investigated the in vitro effects of desflurane, a new inhalation agent, on platelet aggregation. For 15 patients who underwent elective operations, blood was sampled with desflurane induction before and after anesthesia but prior to surgery so that platelet aggregation in the drawn blood could be tested before desflurane anesthesia and again after exposure to the anesthetic. Platelet aggregation was measured with a whole-blood aggregometer. Adenosine diphosphate (ADP), collagen, and ristocetin were used as aggregating agents. Our results showed that aggregation in response to ADP, collagen, or ristocetin was not inhibited in patients who received desflurane anesthesia. This study with an in vitro model showed that desflurane had no influence on platelets in clinically relevant doses.