Phantom pain in a patient with brachial plexus avulsion injury.

OBJECTIVE: Phantom limb pain is a painful sensation perceived in the absent limb following surgical or traumatic amputation. Phantom limb sensations, which are nonpainful, occur in nearly all amputees. Deafferentation can also produce similar symptoms. Here we report the presence of phantom pain in a deafferented limb. DESIGN: Case report. SETTING: Hospital-based outpatient clinic. PATIENT: A 65-year-old man was referred to the pain clinic for management of upper extremity pain secondary to brachial plexus avulsion (BPA) following a motor vehicle accident. Initially he noticed a feeling of growing and shrinking of his arm. Following this, the pain started gradually from his elbow extending to his fingertips covering all dermatomes. He described the pain as continuous, severe, and sharp. He also described the arm as being separate from his existing insensate arm and felt as though the fist was closed with the thumb pointing out. On physical examination, he had no sensation to fine touch or pressure below the elbow. There were no consistent areas of allodynia. He had diffuse muscle wasting in all the muscle groups of his left upper extremity, besides winging of the scapula. Electrodiagnostic studies showed a left brachial plexopathy consistent with multilevel nerve root avulsion sparing the dorsal rami. CONCLUSION: This is a report of phantom limb sensations and phantom pain following BPA in an intact but flaccid and insensate limb.

Targeting myofascial taut bands by ultrasound.

Myofascial pain syndrome (MPS) is a frequent diagnosis in chronic pain and is characterized by tender, taut bands known as trigger points. The trigger points are painful areas in skeletal muscle that are associated with a palpable nodule within a taut band of muscle fibers. Despite the prevalence of myofascial pain syndrome, diagnosis is based on clinical criteria alone. A growing body of evidence that suggests that taut bands are readily visualized under ultrasound-guided exam, especially when results are correlated with elastography, multidimensional imaging, and physical exam findings such as local twitch response. The actual image characteristic in B mode appears to be controversial. Ultrasonography provides an objective modality to assist with diagnosis and treatment of trigger points in the future.

Hyperparathyroidism, hypercalcemia and difficult laryngoscopy: a retrospective review.

BACKGROUND: The incidence of difficulty with intubation in the general population depends upon the definition used but results as high as 37% have been published. Endocrine disorders such as diabetes and hyperthyroidism have been linked to an increased incidence of difficult intubation via laryngoscopy. Hypercalcemia with resulting calcification has been demonstrated to result in neck pain, decreased cervical range of motion, and loss of skin and tendon compliance. We speculated that patients with hyperparathyroidism and resulting hypercalcemia would have an increased incidence of intubation difficulty via laryngoscopy. METHODS: We studied 382 patients presenting for parathyroidectomy in whom direct laryngoscopy was initially attempted compared to 262 patients presenting for abdominal surgery in whom laryngoscopy was initially attempted via retrospective chart review. Difficult laryngoscopy was defined as 3 or greater attempts at direct laryngoscopy or 2 attempts and the use of airway adjunct (Eschmann stylet), flexible fiberoptics, or an indirect laryngoscope (Pentax AWS or Airtraq). Awkward intubation was defined as requiring > 1 attempt at laryngoscopy, intubation requiring a change in laryngoscope blade, the use of an airway adjunct (Eschmann stylet), or a Cormack and Lehane's view on initial laryngoscopy > 2. Hypercalcemia was defined as serum [Ca2+] > 10.2 mg/ dl. Propensity score matching was done to create 88 matched patient sets. McNemar's test was used to evaluate intubation difficulties in patients presenting for parathyroidectomy. The relationship between difficult laryngoscopy and hypercalcemia in parathyroidectomy patients was assessed by simple logistic regression (unadjusted) and multiple logistic regression. RESULTS: There is no difference in the rate of difficult or awkward laryngoscopy or the rate at which laryngoscopy was abandoned in favor of another means of intubation between parathryoidectomy and abdominal surgery patients. Hypercalcemia also does not impact laryngoscopy difficulty. CONCLUSIONS: To our knowledge, this is the first manuscript evaluating the impact of parathryoidectomy surgery and hypercalcemia on ease of intubation via laryngoscopy. Despite the fact that patients presenting for parathyroidecomy have many potential etiologies of increased difficulty with laryngoscopy, they do not appear to be at increased risk of laryngoscopy problems. The same is true of those patients presenting with hypercalcemia. Source(s) of support: There was no source of funding for this study. Presentation at a meeting: Society for Airway Management Annual Meeting 2009 Las Vegas NV and American Society of Anesthesiologists Annual Meeting 2010 San Diego, CA. Conflicting Interest (If present, give more details): With regard to conflict of interest, Dr. Arndt is a paid consultant for Cook Medical and receives royalties based on the sale of products that he invented.