Oral dysaesthesia: a special focus on aetiopathogenesis, clinical diagnostics and treatment modalities.

Oral dysaesthesia is a condition characterised by persistent alteration to oral sensation, perceived by the patient to be abnormal and/or unpleasant, in the absence of any mucosal pathology. The condition can be difficult to detect and diagnose. A possible peripheral or central neuropathic aetiology has been proposed. Burning mouth syndrome (BMS) is the most common idiopathic oral dysesthesia in which long-term suffering is often reported by patients. Recent efforts from professional organisations and study groups have provided a consensus on BMS disease definition and diagnostic criteria. Large-scale epidemiological studies are required to provide an accurate estimate for prevalence and incidence of the condition. Meticulous diagnostic investigations which may require interdisciplinary teamwork are often warranted to reach an accurate diagnosis. A combination of interventional modalities, with a holistic approach, is key for successful management and improvement in patients' quality of life.

Round ligament management during minimally invasive groin hernia repair in women: a systematic review and meta-analysis.

BACKGROUND: Female sex has been associated with worse outcomes after groin hernia repair (GHR), including a higher rate of chronic pain and recurrence. Most of the studies in GHR are performed in males, and the recommendations for females extrapolate from these studies, even though females have anatomy intricacies. The round ligament of the uterus (RLU) is associated with pelvic stabilization and plays a role in sensory function. Transection of the RLU during GHR is controversial as it can allow easier mesh placement but can favor genitourinary complications and chronic pain. As no previous meta-analysis compared preserving versus transecting the RLU during minimally invasive (MIS) GHR, we aim to perform a systematic review and meta-analysis evaluating surgical outcomes comparing the approaches. METHODS: Cochrane Central, Embase, and PubMed databases were systematically searched for studies comparing transection versus preservation of the RLU in MIS groin hernia surgeries. Outcomes assessed were operative time, bleeding, surgical site events, hospital stay, chronic pain, paresthesia, recurrence rates, and genital prolapse rates. Statistical analysis was performed using RevMan 5.4.1. Heterogeneity was assessed with I2 statistics. A review protocol for this meta-analysis was registered at PROSPERO (CRD 42023467146). RESULTS: 1738 studies were screened. A total of six studies, comprising 1131 women, were included, of whom 652 (57.6%) had preservation of the RLU during MIS groin hernia repair. We found no statistical difference regarding chronic pain, paresthesia, recurrence rates, and postoperative complications. We found a longer operative time for the preservation group (MD 6.84 min; 95% CI 3.0-10.68; P = 0.0005; I2 = 74%). CONCLUSION: Transecting the RLU reduces the operative time during MIS GHR with no difference regarding postoperative complication rates. Although transection appears safe, further prospective randomized studies with long-term follow-up and patient-reported outcomes are necessary to define the optimal management of RLU during MIS GHR.

Not a Laughing Matter: When Nitrous Oxide Causes Functional Vitamin B12 Deficiency.

Subacute combined degeneration (SCD) is an acquired neurologic complication from prolonged vitamin B12 deficiency. As a result of dorsal and lateral spinal cord column degeneration, patients present with a range of neurological symptoms, including paresthesias, ataxia, and muscle weakness. Without prompt treatment, irreversible nerve damage occurs. Here we present a young man who developed progressive ascending paresthesias and lower extremity weakness after escalated nitrous oxide use. This case highlights the importance of considering SCD from nitrous oxide toxicity when patients present with progressive ataxia, paresthesia, and lower extremity weakness.

Use of oral devices in the management of oral dysesthesia: case reports and literature review.

Oral dysesthesia (OD) is a diagnosis of exclusion that manifests as an unpleasant and abnormal sensation of the oral mucosa without any noticeable oral lesions. Burning sensation is one of the manifestations of OD which may advocate for similar pharmacotherapeutic options to burning mouth syndrome (BMS), resulting in possible adverse events. The aim of these case reports was to illustrate the significance and rationale for the use of oral devices as a mechanical/physical barrier and a safe approach in the management of OD, without experiencing any antagonistic effects from pharmacotherapeutic agents. Two patients with spontaneous and evoked (following dental procedures) OD symptoms in the right posterior mandibular quadrant and anterior hard palatal areas were evaluated. Additionally, their OD symptoms were associated with hyposalivation and taste changes. A thorough history and complete head and neck examination, with the exclusion of oral lesions and systemic conditions, were performed. These patients were previously prescribed topical clonazepam rinses. An in-office trial, with application of orthodontic wax to the affected area, was performed as a preliminary test in order to justify the fabrication of an oral device for possible symptomatic relief. Conclusion: The case reports demonstrated significant improvement of OD symptoms and amelioration of pain following fabrication of oral devices in two patients with no undesirable effects from pharmacotherapy. Additionally, the oral devices aided as a mechanical/physical barrier, potentially exerting a placebo effect while facilitating an improved quality of life. Furthermore, the cost-effectiveness and ease of fabricating the oral device has been advantageous over other systemic medications. This encourages the need for a detailed prospective study.

Botulinum toxin type A improves pain in numb chin syndrome.

Numb chin syndrome is a rare pain disorder characterized by decreased sensation and paresthesia in the territory of the mental nerve. Neuropathic pain is sometimes described in this setting, and the most common treatments include oral analgesics, gabapentinoids, and carbamazepine; however, botulinum toxin type A has never been used in this setting. We describe a case of bilateral numb chin syndrome, secondary to Burkitt lymphoma, associated with refractory and persistent burning neuropathic pain, effectively treated twelve times with subcutaneous Botulinum toxin type A (BoNT/A) injections. The procedure was well tolerated, but the patient reported incomplete mouth closure of minimal entity. BoNT/A could be a safe and effective therapy for neuropathic pain associated with numb chin syndrome.

Mental and Lingual Nerve Paresthesia Following Infiltration Anesthesia for Dental Implant Placement in a Patient With Guillain-Barré Syndrome.

Guillain-Barré syndrome (GBS) is a rare rapid onset autoimmune peripheral polyneuropathy, most commonly characterized by inflammatory demyelination of peripheral nerves. Patients with GBS are considered higher risk for anesthetic-induced neurotoxicity caused by demyelination. In the present report, a case is described of a 56-year-old man with GBS who experienced mental and lingual nerve paresthesia following infiltration anesthesia for dental implant placement in the posterior mandible. The pareshesia lasted 5 months postoperatively and subsided spontaneously without any intervention. The patient was successfully restored with fixed partial dental prosthesis without any other complication. This is considered the first report of such complication in patient with GBS after local anesthesia in the oral and maxillofacial region. Possible pathogenic mechanism of the complication and clinical implications are discussed.

Peripheral Nerve Safety of Nerve Growth Factor Inhibition by Tanezumab: Pooled Analyses of Phase III Clinical Studies in Over 5000 Patients with Osteoarthritis.

BACKGROUND: Tanezumab, a humanized anti-nerve growth factor antibody, was developed for the treatment of pain associated with osteoarthritis. Due to its mechanism of action, peripheral nerve safety was assessed in all clinical studies. OBJECTIVES: To summarize the neurological safety of intravenous (IV) and subcutaneous (SC) tanezumab versus placebo in patients with osteoarthritis. METHODS: Data were pooled from 3389 patients across seven studies that investigated IV administration, and from 1840 patients across three studies that investigated SC administration. The treatment period of each study ranged from 16 to 24 weeks, and follow-up periods ranged from 8 to 24 weeks. Neurological safety evaluations focused on adverse events (AEs) of abnormal peripheral sensation (APS), neurologic examinations, and consultations. RESULTS: Across datasets, the incidence of AEs of APS was higher in tanezumab groups versus placebo. Paresthesia and hypoesthesia were the most frequently reported AEs in tanezumab-treated patients, compared with placebo. In both datasets, most AEs were of mild severity, resolved, and rarely resulted in discontinuation. In all treatment groups in both IV and SC studies, over 90% of patients had no new or worsened neurological examination abnormalities at the last study visit. Across datasets, mononeuropathy was diagnosed more frequently in tanezumab groups compared with placebo. Polyneuropathy was diagnosed in ≤ 0.9% of patients in tanezumab and placebo groups. CONCLUSIONS: Tanezumab IV or SC had an increased incidence of AEs of APS, such as paresthesia and hypoesthesia, and diagnoses of mononeuropathy compared with placebo. However, tanezumab was not associated with generalized peripheral neuropathy. GOV IDENTIFIERS: NCT00733902, NCT00744471, NCT00830063, NCT00863304, NCT00863772, NCT01089725, NCT00985621, NCT02697773, and NCT02709486.

The portrait of a stranger: the hypereosinophilic syndrome with cardiac involvement.

INTRODUCTION: Hypereosinophilic syndrome is a rare clinical condition, and cardiac involvement confers a poor prognosis. Hypereosinophilic myocarditis is a medical emergency and targeted treatment should be started promptly even before a definitive diagnosis could be made. CASE PRESENTATION: A 27-year-old female patient is hospitalized for exertional dyspnea, chest pain, and fatigue for the past 2 weeks. She also describes left leg paresthesias. Clinical examination was in normal limits. ECG showed sinus tachycardia, QS pattern in V1-V4, and diffuse flattened T waves. Laboratory tests revealed increased inflammatory markers, hypereosinophilia, elevated cardiac enzymes, high NT-proBNP. Echocardiography revealed LV dysfunction (EF 31%), while cardiac MRI showed diffuse delayed enhancement with predominant subendocardial disposition. The electromyogram was suggestive of left tibial nerve neuropathy. We interpreted the case as eosinophilic myocarditis with an urgent requirement of therapy and initiated high-dose glucocorticoid therapy and the GDMT 4-pillar heart failure treatment. We excluded common infectious, myeloproliferative syndromes, and frequent associated autoimmune diseases. With prednisone, the eosinophil count rapidly normalized and we gradually tapered the dose by 5 mg per week, however continuing with heart failure therapy. At monthly follow-up visits, there was a significant clinical improvement, with normalization of the eosinophilic count, and a near-normalization of myocardial function. The only symptom that persisted was paresthesias linked to left tibial neuropathy. CONCLUSION: The surprisingly rapid and favorable course of the disease offers a high index of suspicion for a toxic or a reactive transitory etiology, however still unidentified. In our case, the cause of eosinophilia remained unknown, although we managed to narrow down the possible etiologies. A surprisingly good clinical response was obtained with non-specific treatment targeting mainly hyperosinophilic myocarditis.

Psychological Treatment of Persistent Genital Arousal Disorder/Genitopelvic Dysesthesia Using an Integrative Approach.

Persistent genital arousal disorder/genitopelvic dysesthesia (PGAD/GPD) is characterized by persistent, unwanted physiological genital arousal (i.e., sensitivity, fullness, and/or swelling) in the absence of sexual excitement or desire which can persist for hours to days and causes significant impairment in psychosocial well-being (e.g., distress) and daily functioning. The etiology and course of PGAD/GPD is still relatively unknown and, unsurprisingly, there are not yet clear evidence-based treatment recommendations for those suffering from PGAD/GPD. We present the case of a 58-year-old woman with acquired persistent genital arousal disorder, which began in March 2020; she believed she developed PGAD/GPD due to a period of significant distress and anxiety related to the COVID-19 pandemic. After seeking medical diagnosis and treatment from multiple healthcare providers and trying a combination of pharmacological and medical treatment modalities, she presented for psychological treatment. An integrative therapy approach (3 assessment sessions, 11 treatment sessions), which included cognitive behavior therapy, distress tolerance and emotion regulation skills from dialectical behavior therapy, and mindfulness practice, was utilized. The patient reported improvements anecdotally (e.g., decreased impact on occupational and social functioning, greater self-compassion, less frequent and shorter duration of PGAD/GPD flare-ups, improved ability to cope with PGAD/GPD symptoms, and decreased need for sleeping medication) and on self-report measures (e.g., lower PGAD/GPD catastrophizing, lower anxiety and depression, and greater overall quality of life).We report the use of an integrative (i.e., psychoeducational, cognitive behavioral, dialectical behavioral, and mindfulness-based) intervention, which may be an effective psychological treatment for PGAD/GPD.

Trigeminal trophic syndrome, a rare and often overlooked cause of facial ulceration: a case report and literature review.

Trigeminal trophic syndrome (TTS) is an uncommon and relatively unknown cause of facial ulceration that occurs after damage to the trigeminal nerve. It characteristically involves non-healing facial ulceration(s) with accompanying anesthesia, paresthesia, and dysesthesia along the distribution of a trigeminal dermatome. The ulcerations are believed to be self-induced in response to paresthesia. The disease is most common in middle-aged women, manifesting as a unilateral crescent-shaped ulceration on the ala nasi, with sparing of the nasal tip. The diagnosis is clinical and mostly based on exclusion of other possible causes of facial ulcerations, with emphasis on neoplasms, infection-associated vasculitis, and factitial disorders. There are no specific histological or laboratory signs. There is no standard treatment protocol; however, a number of different successful strategies have been reported, including pharmaceutical and surgical interventions, transcutaneous nerve stimulation, and simple occlusion dressings. Due to the self-inflicted nature of this disorder, the cornerstone of management is patient education with behavioral modification. Here, we report a case of TTS following herpes zoster ophthalmicus and review the current literature on this subject.

Sleep Disturbances in Cervical Spondylotic Myelopathy: Prevalence and Postoperative Outcomes-an Analysis From the Quality Outcomes Database.

STUDY DESIGN: Prospective observational study, level of evidence 1 for prognostic investigations. OBJECTIVES: To evaluate the prevalence of sleep impairment and predictors of improved sleep quality 24 months postoperatively in cervical spondylotic myelopathy (CSM) using the quality outcomes database. SUMMARY OF BACKGROUND DATA: Sleep disturbances are a common yet understudied symptom in CSM. MATERIALS AND METHODS: The quality outcomes database was queried for patients with CSM, and sleep quality was assessed through the neck disability index sleep component at baseline and 24 months postoperatively. Multivariable logistic regressions were performed to identify risk factors of failure to improve sleep impairment and symptoms causing lingering sleep dysfunction 24 months after surgery. RESULTS: Among 1135 patients with CSM, 904 (79.5%) had some degree of sleep dysfunction at baseline. At 24 months postoperatively, 72.8% of the patients with baseline sleep symptoms experienced improvement, with 42.5% reporting complete resolution. Patients who did not improve were more like to be smokers [adjusted odds ratio (aOR): 1.85], have osteoarthritis (aOR: 1.72), report baseline radicular paresthesia (aOR: 1.51), and have neck pain of ≥4/10 on a numeric rating scale. Patients with improved sleep noted higher satisfaction with surgery (88.8% vs 72.9%, aOR: 1.66) independent of improvement in other functional areas. In a multivariable analysis including pain scores and several myelopathy-related symptoms, lingering sleep dysfunction at 24 months was associated with neck pain (aOR: 1.47) and upper (aOR: 1.45) and lower (aOR: 1.52) extremity paresthesias. CONCLUSION: The majority of patients presenting with CSM have associated sleep disturbances. Most patients experience sustained improvement after surgery, with almost half reporting complete resolution. Smoking, osteoarthritis, radicular paresthesia, and neck pain ≥4/10 numeric rating scale score are baseline risk factors of failure to improve sleep dysfunction. Improvement in sleep symptoms is a major driver of patient-reported satisfaction. Incomplete resolution of sleep impairment is likely due to neck pain and extremity paresthesia.

[Waldenström macroglobulinemia complicated by peripheral neuropathy due to neural infiltration].

A 51-year-old man with the chief complaint of glove- and stocking-type dysesthesia for >3 years was diagnosed with Waldenström's macroglobulinemia (WM) based on IgM-type M-proteinemia, bone marrow infiltration of plasmacytoid B cells, multiple lymphadenopathies, and splenomegaly. A nerve conduction examination suggested demyelinating neuropathy. Serum anti-myelin-associated glycoprotein antibody was negative. Sural nerve biopsy showed myelin thinning, suggesting demyelination. Axonal damage and tumor cell infiltration in the intrafascicular epineurium were also observed. After chemotherapies with rituximab and bendamustine, M-proteinemia and lymphadenopathies disappeared. However, abnormalities in the nerve conduction examination and dysesthesia were only slightly alleviated. As articles describing patients with WM with peripheral nerve infiltration are limited, we report this case with a literature review.

Lumbar endoscopic spine surgery for persistent genital arousal disorder/genitopelvic dysesthesia resulting from lumbosacral annular tear-induced sacral radiculopathy.

BACKGROUND: Persistent genital arousal disorder/genitopelvic dysesthesia (PGAD/GPD) is characterized by distressing, abnormal genitopelvic sensations, especially unwanted arousal. In a subgroup of patients with PGAD/GPD, cauda equina Tarlov cyst-induced sacral radiculopathy has been reported to trigger the disorder. In our evaluation of lumbosacral magnetic resonance images in patients with PGAD/GPD and suspected sacral radiculopathy, some had no Tarlov cysts but showed lumbosacral disc annular tear pathology. AIM: The aims were 2-fold: (1) to utilize a novel multidisciplinary step-care management algorithm designed to identify a subgroup of patients with PGAD/GPD and lumbosacral annular tear-induced sacral radiculopathy who could benefit from lumbar endoscopic spine surgery (LESS) and (2) to evaluate long-term safety and efficacy of LESS. METHODS: Clinical data were collected on patients with PGAD/GPD who underwent LESS between 2016 and 2020 with at least 1-year follow-up. LESS was indicated because all had lumbosacral annular tear-induced sacral radiculopathy confirmed by our multidisciplinary management algorithm that included the following: step A, a detailed psychosocial and medical history; step B, noninvasive assessments for sacral radiculopathy; step C, targeted diagnostic transforaminal epidural spinal injections resulting in a temporary, clinically significant reduction of PGAD/GPD symptoms; and step D, surgical intervention with LESS and postoperative follow-up. OUTCOMES: Treatment outcome was based on the validated Patient Global Impression of Improvement, measured at postoperative intervals. RESULTS: Our cohort included 15 cisgendered women and 5 cisgendered men (mean ± SD age, 40.3 ± 16.8 years) with PGAD/GPD who fulfilled the criteria of lumbosacral annular tear-induced sacral radiculopathy based on our multidisciplinary management algorithm. Patients were followed for an average of 20 months (range, 12-37) post-LESS. Lumbosacral annular tear pathology was identified at multiple levels, the most common being L4-L5 and L5-S1. Twenty-two LESS procedures were performed in 20 patients. Overall, 80% (16/20) reported improvement on the Patient Global Impression of Improvement; 65% (13/20) reported improvement as much better or very much better. All patients were discharged the same day. There were no surgical complications. CLINICAL IMPLICATIONS: Among the many recognized triggers for PGAD/GPD, this subgroup exhibited lumbosacral annular tear-induced sacral radiculopathy and experienced long-term alleviation of symptoms by LESS. STRENGTHS AND LIMITATIONS: Strengths include long-term post-surgical follow-up and demonstration that LESS effectively treats patients with PGAD/GPD who have lumbosacral annular tear-induced sacral radiculopathy, as established by a multidisciplinary step-care management algorithm. Limitations include the small study cohort and the unavailability of a clinical measure specific for PGAD/GPD. CONCLUSION: LESS is safe and effective in treating patients with PGAD/GPD who are diagnosed with lumbosacral annular tear-induced sacral radiculopathy.

Rates of Postoperative Complications and Approach-related Neurological Symptoms After L4-L5 Lateral Transpsoas Lumbar Interbody Fusion Compared With Upper Lumbar Levels.

STUDY DESIGN: This was a retrospective comparative study. OBJECTIVE: To compare the likelihood of approach-related complications for patients undergoing single-level lateral lumbar interbody fusion (LLIF) at L4-L5 to those undergoing the procedure at upper lumbar levels. SUMMARY OF BACKGROUND DATA: LLIF has been associated with a number of advantages when compared with traditional interbody fusion techniques. However, potential risks with the approach include vascular or visceral injury, thigh dysesthesias, and lumbar plexus injury. There are concerns of a higher risk of these complications at the L4-L5 level compared with upper lumbar levels. MATERIALS AND METHODS: A retrospective cohort review was completed for consecutive patients undergoing single-level LLIF between 2004 and 2019 by a single surgeon. Indication for surgery was symptomatic degenerative lumbar stenosis and/or spondylolisthesis. Patients were divided into 2 cohorts: LLIF at L4-L5 versus a single level between L1 and L4. Baseline characteristics, intraoperative complications, postoperative approach-related neurological symptoms, and patient-reported outcomes were compared and analyzed between the cohorts. RESULTS: A total of 122 were included in analysis, of which 58 underwent LLIF at L4-L5 and 64 underwent LLIF between L1 and L4. There were no visceral or vascular injuries or lumbar plexus injuries in either cohort. There was no significant difference in the rate of postoperative hip pain, anterior thigh dysesthesias, and/or hip flexor weakness between the cohorts (53.5% L4-L5 vs. 37.5% L1-L4; P =0.102). All patients reported complete resolution of these symptoms by 6-month postoperative follow-up. DISCUSSION: LLIF surgery at the L4-L5 level is associated with a similar infrequent likelihood of approach-related complications and postoperative hip pain, thigh dysesthesias, and hip flexor weakness when compared with upper lumbar level LLIF. Careful patient selection, meticulous use of real-time neuromonitoring, and an understanding of the anatomic location of the lumbar plexus to the working corridor are critical to success.

Assessment of Panoramic Radiographic Variables as Predictors of Inferior Alveolar Nerve Injury During Third Molar Extraction

ABSTRACT Objective: To assess the role of radiological predictive markers on orthopantomogram for inferior alveolar nerve (IAN) injury related to the removal of mandibular third molar surgery and the occurrence of post-operative IAN paresthesia. Material and Methods: This prospective observational study was conducted on 60 patients (aged 17-35 years) indicated for extraction and showed one or more of the seven previously known panoramic radiographic risk signs of IAN injury. Variables such as age, sex, tooth angulation, and relationship with the inferior alveolar canal (IAC) were assessed to see their outcome on IAN injury. Data analysis is presented through tables and descriptive methods. Results: Among patients, 26 were male and 34 were female, with a mean age of 26.17 years. Out of seven radiological predictive markers, only six were found in this study, whereas one marker, viz. interruption of white line of the canal was not found. After surgical removal of the lower third molar, only two patients with radiographic signs showing the deflection of roots and darkening of roots continued with sensory deficit 5 weeks post-operatively. Conclusion: The risk of inferior alveolar nerve injury during lower third molar surgery is very low, even in patients with radiological predictive markers.

Point-of-Care Ultrasound in the Diagnosis of Venous Thoracic Outlet Syndrome.

BACKGROUND: Clinicians trained in point-of-care ultrasound (POCUS) use the tool to enhance diagnostic capabilities at the bedside, often excluding or diagnosing conditions that are suspected based on the history and physical examination. Thoracic outlet syndrome (TOS) involves compression of arteries and nerves between the clavicle and first rib causing pain and paresthesia in the affected limbs. To our knowledge, use of POCUS to diagnose TOS in the literature has not been described. CASE REPORT: A 46-year-old man presented with left upper extremity (LUE) edema, pain, and paresthesia, which was progressive over 3 weeks. Examination of the LUE revealed diffuse swelling without erythema and a left radial pulse present on Doppler only. A subsequent POCUS examination of the LUE was performed to exclude a deep vein thrombosis, and enlarged and turbulent veins distal to the internal jugular vein were found, which suggested venous compression external to the veins. Additional imaging confirmed narrowing of the subclavian vein and a diagnosis of venous thoracic outlet syndrome (vTOS) was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Failure to promptly diagnose and treat TOS can lead to long-term chronic upper extremity pain and even permanent disability. Diagnosis of vascular TOS is often made using computed tomography to identify impinged vessels, although color Doppler sonography can be an excellent choice for initial imaging in patients with suspected vTOS. Although POCUS is being used increasingly as a diagnostic tool and for procedural guidance, our case represents a novel application of POCUS in the diagnosis of vTOS.

Thoracic outlet syndrome: a review for the primary care provider.

CONTEXT: Thoracic outlet syndrome (TOS) symptoms are prevalent and often confused with other diagnoses. A PubMed search was undertaken to present a comprehensive article addressing the presentation and treatment for TOS. OBJECTIVES: This article summarizes what is currently published about TOS, its etiologies, common objective findings, and nonsurgical treatment options. METHODS: The PubMed database was conducted for the range of May 2020 to September 2021 utilizing TOS-related Medical Subject Headings (MeSH) terms. A Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) systematic literature review was conducted to identify the most common etiologies, the most objective findings, and the most effective nonsurgical treatment options for TOS. RESULTS: The search identified 1,188 articles. The automated merge feature removed duplicate articles. The remaining 1,078 citations were manually reviewed, with articles published prior to 2010 removed (n=771). Of the remaining 307 articles, duplicate citations not removed by automated means were removed manually (n=3). The other exclusion criteria included: non-English language (n=21); no abstracts available (n=56); and case reports of TOS occurring from complications of fractures, medical or surgical procedures, novel surgical approaches, or abnormal anatomy (n=42). Articles over 5 years old pertaining to therapeutic intervention (mostly surgical) were removed (n=18). Articles pertaining specifically to osteopathic manipulative treatment (OMT) were sparse and all were utilized (n=6). A total of 167 articles remained. The authors added a total of 20 articles that fell outside of the search criteria, as they considered them to be historic in nature with regards to TOS (n=8), were related specifically to OMT (n=4), or were considered sentinel articles relating to specific therapeutic interventions (n=8). A total of 187 articles were utilized in the final preparation of this manuscript. A final search was conducted prior to submission for publication to check for updated articles. Symptoms of hemicranial and/or upper-extremity pain and paresthesias should lead a physician to evaluate for musculoskeletal etiologies that may be contributing to the compression of the brachial plexus. The best initial provocative test to screen for TOS is the upper limb tension test (ULTT) because a negative test suggests against brachial plexus compression. A positive ULTT should be followed up with an elevated arm stress test (EAST) to further support the diagnosis. If TOS is suspected, additional diagnostic testing such as ultrasound, electromyography (EMG), or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) might be utilized to further distinguish the vascular or neurological etiologies of the symptoms. Initial treatment for neurogenic TOS (nTOS) is often conservative. Data are limited, therefore there is no conclusive evidence that any one treatment method or combination is more effective. Surgery in nTOS is considered for refractory cases only. Anticoagulation and surgical decompression remain the treatment of choice for vascular versions of TOS. CONCLUSIONS: The most common form of TOS is neurogenic. The most common symptoms are pain and paresthesias of the head, neck, and upper extremities. Diagnosis of nTOS is clinical, and the best screening test is the ULTT. There is no conclusive evidence that any one treatment method is more effective for nTOS, given limitations in the published data. Surgical decompression remains the treatment of choice for vascular forms of TOS.

Acute transverse myelitis progressing to permanent quadriplegia following COVID-19 infection.

As of January 2022, there have been over 350 million confirmed cases of COVID-19 in the world. The most common symptoms in those infected are fever, cough, malaise, and myalgia, however pulmonary, hematologic, gastrointestinal, renal, and neurologic complications have also been reported. Acute transverse myelitis (ATM) is an uncommon neurological syndrome characterized by acute or subacute spinal cord dysfunction that can lead to paresthesias, sensory and autonomic impairment, and even paralysis. Etiologies are often unclear; however, potential causes include infection, neoplastic, drug or toxin induced, autoimmune, and acquired. Treatment for ATM primarily consists of steroids and plasmapheresis, which often reverses any neurologic symptoms. ATM has rarely been reported as a complication of COVID-19 infections. A 43-year-old female presented to the emergency department for evaluation of progressive numbness and tingling in her legs ten days after developing upper respiratory symptoms from a COVID-19 infection. Physical examination and magnetic resonance imaging confirmed a diagnosis of ATM. During her hospital course, she experienced rapid progression of her paresthesias and developed complete loss of motor function in her upper and lower extremities. Within 48 hours after emergency department arrival, she required intubation due to worsening diaphragmatic and chest wall paralysis. Her treatment included a long-term steroid regimen and plasmapheresis, and unfortunately, she did not have any neurologic recovery. We present a very rare case of ATM progressing to complete quadriplegia following COVID-19 infection.

Broadening the spectrum of the neurological complications in systemic lupus erythematosus: A patient with meningoradiculitis.

BACKGROUND: Neurological complications of systemic lupus erythematosus (SLE) are wide and may rarely involve the peripheral nervous system. However, no case of meningoradiculitis has been well-detailed. METHODS: We report a patient with lupus-associated meningoradiculitis. RESULTS: A 57-year-old woman had SLE without neurological involvement, treated with hydroxychloroquine, methotrexate, and prednisone for 10 years. Six months after the drug discontinuation for SLE, she acutely developed gait instability, paresthesia, and neuropathic pain of the four limbs. The neurological examination and nerve conduction studies were consistent with radiculopathies. Cerebrospinal fluid (CSF) analysis showed lymphocytic meningitis. The spinal magnetic resonance imaging (MRI) revealed thickening and an enhancement of the lumbosacral roots consistent with meningoradiculitis. The extensive investigations did not argue for a differential diagnosis of SLE. The patient dramatically improved upon corticosteroids. At the last follow-up, the patient still reported mild paresthesia but the clinical examination, the CSF, and the spinal MRI were normal. CONCLUSION: This well-detailed case of meningoradiculitis broadens the spectrum of neurological complications in SLE. Early recognition of such complications might lead to efficient immunotherapy.

Perineal and right femoral hydatid cyst in a female with regional paresthesia: a rare case report.

BACKGROUND: Hydatid cyst is a zoonotic disease caused by the parasite Echinococcus granulosus. The tapeworm larvae can create cyst in different areas of the body, especially the liver and lungs; however, the formation of the cyst in the perineal and femoral regions are very rare. The unusual location of the cyst can help us with the differential diagnosis of soft tissue mass(es) in this location, especially in endemic areas. Diagnosis of this disease is crucial because if the cysts are ruptured during surgery, the fluid inside can cause anaphylactic shock. CASE PRESENTATION: Our case is a 55-year-old woman with the chief complaint of a painful mass in the right thigh and perineal area with progressed pain and paresthesia to the right thigh and shin. The patient had no history of fever, abdominal pain, digestive dysfunctions, or chest pain. The vital signs were normal, and there was no family history. Physical examination showed that the skin over the mass had no discoloration, and the size was around 5.7 cm long. The result of the ultrasonography examination showed a cystic mass with suspicion toward the femoral hernia. After a CT scan, the result of secondary workups was a multi-lobular cystic mass with no connection to the abdominal region, which suggested a hydatid cyst. The patient underwent spinal anesthesia and surgery, a cystic mass with ecto- and endocyst, with clinical similarity to a hydatid cyst, was removed with wide margins, and the cyst wall was kept intact. In the next step, the specimen was sent for histological examination that confirmed cystic hydatidosis. The Post-surgical Abdominal and thoracic Ultrasonography screening were used to exclude relapse, and medical therapy was given for 3-6 months. An 18-months follow-up demonstrated no reoccurrence and no newly formed cyst. CONCLUSIONS: Although rare, femoral hydatid cyst can occur in some cases, especially in endemic areas. We highly recommend our colleagues consider ruling out cystic hydatidosis in any patients complaining of regional mass(es), mostly painless, presenting with adjacent tissue compression with or without manifestation of an allergic reaction.