Effects of rTMS and tDCS on neuropathic pain after brachial plexus injury: a randomized placebo-controlled pilot study.

Neuropathic pain after brachial plexus injury (NPBPI) is a highly disabling clinical condition and is increasingly prevalent due to increased motorcycle accidents. Currently, no randomized controlled trials have evaluated the effectiveness of non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct-current stimulation (tDCS) in patients suffering from NPBPI. In this study, we directly compare the efficacy of 10-Hz rTMS and anodal 2 mA tDCS techniques applied over the motor cortex (5 daily consecutive sessions) in 20 patients with NPBPI, allocated into 2 parallel groups (active or sham). The order of the sessions was randomised for each of these treatment groups according to a crossover design and separated by a 30-day interval. Scores for "continuous" and "paroxysmal" pain (primary outcome) were tabulated after the last stimulation day and 30 days after. Secondary outcomes included the improvement in multidimensional aspects of pain, anxiety state and quality of life from a qualitative and quantitative approach. Active rTMS and tDCS were both superior to sham in reducing continuous (p < 0.001) and paroxysmal (p = 0.002; p = 0.02) pain as well as in multidimensional aspects of pain (p = 0.001; p = 0.002) and anxiety state (p = < 0.001; p = 0.005). Our results suggest rTMS and tDCS are able to treat NPBPI with little distinction in pain and anxiety state, which may promote the use of tDCS in brachial plexus injury pain management, as it constitutes an easier and more available technique.Clinical Trial Registration: http://www.ensaiosclinicos.gov.br/, RBR-5xnjbc - Sep 3, 2018.

Schistosomal Cervical Myelopathy

Schistosomiasis is an infectious disease caused by trematode platyhelminths of the genus Schistosoma. The involvement of the cervical spinal cord is rare, with few cases reported in the literature. The management of such patients is particularly challenging, since clinical and radiological findings may be confounded with other inflammatory diseases and/ or spinal cord tumors. We describe a 20-year old male with a history of swimming outdoors. He first presented pain in the back of the neck extending to shoulders and upper limbs paresis associated with four limbs hyperreflexia. The magnetic resonance imaging (MRI) showed a hypointense T1-weighted lesion in the cervical spinal cord, which was hyperintense on T2 images. The serologic testing was negative for schistosomiasis. A cervical cord biopsy at the C5-C6 level showed Schistosoma eggs in the histopathological examination. The treatment was performed using a single dose of praziquantel 50 mg/kg, with prednisone 40 mg/day for 3 weeks. On the follow-up, 1 year later, the patient presented mild reduction of the vibratory sensitivity in the distal third of both legs. Our illustrative case strengthens that, in endemic regions, Schistosoma mansoni infestation should be included in the differential diagnosis of intramedullary expansive lesions.

A esquistossomose é uma doença infecciosa causada por platelmintos trematódeos do gênero Schistosoma. O acometimento da medula espinhal cervical é raro, com poucos casos apresentados na literatura. O manejo desses pacientes é particularmente difícil, uma vez que os achados clínicos e radiológicos podem ser confundidos com outras doenças inflamatórias e/ou tumores da medula espinhal. Descrevemos um homem de 20 anos de idade com história de natação ao ar livre. Primeiramente, ele apresentou cervicalgia que se estendeu até os ombros e paresia dos membros superiores, associada à hiperreflexia de quatro membros. A ressonância magnética (RM) mostrou lesão hipointensa em T1 na medula espinhal cervical, a qual foi hiperintensa nas imagens em T2. O teste sorológico foi negativo para esquistossomose. Uma biópsia da medula cervical ao nível C5-C6 evidenciou ovos de Schistosoma no exame histopatológico. O tratamento foi realizado com dose única de praziquantel 50 mg/ kg, com prednisona 40 mg/dia por 3 semanas. No seguimento de 1 ano, o paciente apresentou discreta redução da sensibilidade vibratória no terço distal de ambas as pernas. Nosso caso ilustrativo reforça que, em regiões endêmicas, a infestação pelo Schistosoma mansoni deve ser incluída no diagnóstico diferencial de lesões expansivas intramedulares.

Low-level laser therapy and anesthetic infiltration for orofacial pain in patients with fibromyalgia: a randomized clinical trial

Background: To compare the analgesic effect of anesthetic infiltration of lidocaine 2% and low-level laser therapy (LLLT) by GaAlAs into tender points of patients with orofacial pain and fibromyalgia (FM). Material and Methods: A randomized clinical trial was performed with adults (N=66) that were allocated into two groups (1:1): Group A received LLLT irradiation by Diode Laser GaAlAs (780nm) with expositions twice a week during six weeks and Group B was treated with anesthetic infiltration of lidocaine 2% without vasoconstrictor once a week for four weeks. The pain assessment included the Visual Analogic Scale (VAS) and tenderness to palpation. Results: No dropout and adverse effect was observed during the study. The pain decreased significantly in each group after the treatment (p=0.0001, β=1.0), even though no statistical difference was found between both treatments (p=0.46, β= 0.82). The presence of tender points decreased after both treatments, with responsively in some types of masticatory muscles (p<0.05) except posterior temporalis muscle. The patients' perception showed that both treatments were effective and a few patients reported that the treatment did not improve welfare. Conclusions: The LLLT by GaAlAs and anesthetic infiltration of lidocaine 2% were equally effective to control orofacial pain in FM individuals (AU)

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[Surgical treatment of meralgia paresthetica: case report]. / Tratamento cirúrgico da meralgia parestésica: relato de caso.

Meralgia paresthetica is characterized by pain, paresthesias or burning, and decreased touch and pain sensation on the anterolateral aspect of the thigh. It is due to neuropathy of the lateral femoral cutaneous nerve (LFCN). Conservative treatment is usually successful in relieving the symptoms in most of the patients. We describe a case of a woman, 37 years old, who required surgical treatment for intractable symptoms. Although neurolysis with transposition is the most common procedure, we preferred neurectomy with excision of a portion of the LFCN for its very low recurrence rate as opposed to neurolysis. The area of anesthesia generated by this procedure in the distribution of the LFCN tends to shrink with time. This patient achieved excellent outcome following this surgical technique.

Tratamento cirúrgico da meralgia parestésica: relato de caso / Surgical treatment of meralgia paresthetica: case report

Meralgia parestésica é caracterizada por dor, parestesia ou queimação e diminuição da sensibilidade táctil e dolorosa na face antero- lateral da coxa. Isto ocorre por uma neuropatia do nervo cutâneo femural lateral (NCFL). O tratamento conservador é frequentemente bem sucedido aliviando os sintomas na maioria dos pacientes. Descrevemos o caso de uma paciente de 37 anos de idade que necessitou de tratamento cirúrgico pelos sintomas intratáveis. Apesar da neurólise com transposição ser o procedimento mais comum, preferimos a neurectomia com remoção de parte do NCFL por ser sua taxa de recorrência baixa em oposição a neurólise. A áárea de anestesia que ocorre pelo procedimento no trajeto do NCFL tende a reduzir com o tempo. A paciente teve uma evolução excelente com o emprego desta técnica.

Ruptura de cisto aracnóideo intracraniano causando higroma e hemiplegia súbita / Subdural higroma and acute hemiplegia due to non traumatic rupture of arachnoid cyst

Os autores relatam dois casos de ruptura de cisto aracnóideo, sem história de trauma craniano, com formação de higroma, manifestando-se com quadro clínico de síndrome de hipertensão intracraniana e evoluindo com hemiplegia súbita. São discutidos a etiologia, as manifestações clínicas, o mecanismo de ruptura do cisto e as imagens radiológicas que traduziram a evolução do evento.