Surgical Treatment for Spasticity: Selective Dorsal Rhizotomy ­ Technique and Literature Review

Spasticity is amotor disorder that leads to a resistance to passive jointmovement. Cerebral palsy is the most important cause of spasticity and can be caused by several factors, including multiple gestations, alcoholism, infections, hemorrhages, drowning, and traumatic brain injuries, among others. There aremany scales that help tomeasure andmonitor the degree of impairment of these patients. The initial treatment should focus on the causal factor, such as tumors, inflammation, degenerative diseases, hydrocephalus, etc. Subsequently, the treatment of spastic musculature includes oral or intrathecal myorelaxants, spinal cord electrostimulation, neurotomies, Lissauer tract lesion, dentatotomy and selective dorsal rhizotomy. The latter is a safetechnique, possibleto beperformed inmost centers with neurosurgical support, and it is effective in the treatment of severe spasticity. In this article, the authors describe the surgical technique and conduct a review the literature.

Malignant hyperthermia in a child after magnetic resonance imaging: a case report / Hipertermia maligna em criança após exame de ressonância magnética: relato de caso

ABSTRACT Objective: To report on a case of malignant hyperthermia in a child after a magnetic resonance imaging of the skull was performed using sevoflurane anesthesia. Case description: A 3-year-old boy admitted to the pediatric intensive care unit after presenting clinical and laboratory findings consistent with unspecified viral meningoencephalitis. While the patient was sedated, a magnetic resonance imaging of the skul was performed using propofol followed by the administration of sevoflurane through a laryngeal mask in order to continue anesthesia. Approximately three hours after the start of the procedure, the patient presented persistent tachycardia, tachypnea, generalized muscular stiffness and hyperthermia. With a diagnostic hypothesis of malignant hyperthermia, dantrolene was then administered, which immediately induced muscle stiffness, tachycardia, tachypnea and reduced body temperature. Comments: Malignant hyperthermia is a rare pharmacogenetic syndrome characterized by a severe hypermetabolic reaction after the administration of halogenated inhalational anesthetics or depolarizing muscle relaxants such as succinylcholine, or both. Although it is a potentially fatal disease, the rapid administration of continued doses dantrolene has drastically reduced the morbidity and mortality of the disease.

RESUMO Objetivo: Relatar um caso de hipertermia maligna em criança após exame de ressonância magnética de crânio realizada sob efeito anestésico de sevoflurano. Descrição do caso: Menino de três anos de idade, admitido na Unidade de Terapia Intensiva Pediátrica (UTIP) após apresentar quadros clínico e laboratorial compatíveis com meningoencefalite viral não especificada. Foi realizado um exame de ressonância magnética de crânio com sedação utilizando, na indução anestésica, o propofol seguido pela administração de sevoflurano por meio de máscara laríngea para manutenção anestésica. Aproximadamente três horas após o início do procedimento, o paciente apresentou taquicardia, taquipneia, rigidez muscular generalizada e hipertermia persistentes. Com hipótese diagnóstica de hipertermia maligna, foi então administrado dantrolene, que fez ceder de forma imediata a rigidez muscular, a taquicardia, a taquipneia e reduziu a temperatura corporal. Comentários: A hipertermia maligna é uma síndrome farmacogenética rara, que se caracteriza por reação hipermetabólica grave após administração de anestésicos inalatórios halogenados e/ou relaxantes musculares despolarizantes, como a succinilcolina. Apesar de ser uma doença potencialmente fatal, a rápida administração de dantrolene, junto às doses de manutenção, tem reduzido drasticamente a morbimortalidade da doença.

Belching (Eructation) / 대한소화기학회지

Belching is a normal physiological function that may occur when ingested air accumulated in the stomach is expelled or when food containing air and gas produced in the gastrointestinal tract is expelled. Excessive belching can cause patients to complain of abdominal discomfort, disturbed daily life activities, decreased quality of life and may be related to various gastrointestinal disorders such as gastroesophageal reflux disease, functional dyspepsia, aerophagia and rumination syndrome. Belching disorders can be classified into aerophagia and unspecified belching disorder according to the Rome III criteria. Since the introduction of multichannel intraluminal impedance monitoring, efforts are being made to elucidate the types and pathogenic mechanisms of belching disorders. Treatment modalities such as behavioral therapy, speech therapy, baclofen, tranquilizers and proton pump inhibitors can be attempted, but further investigations on the effective treatment of belching disorders are warranted.

Adherence to migraine treatment does not depend on the number of prescribed medications / A adesão ao tratamento da migrânea não depende do número de medicações prescritas

To compare the adherence between monotherapy and politherapy in prophylactic migraine treatment. Five hundred consecutive patients with migraine from a tertiary center were retrospectively studied as to the number of preventive medications prescribed during the first visit. Adherence, defined as returning for the next consultation after 4 to 6 weeks and following the prescribed regimens, were also evaluated and compared between patients. 71.8% were women, and 6% of the patients did not receive any preventive medication, 11.4% received one drug, 22.2% two drugs, 41.4% three drugs, and 19% four drugs for the prevention of migraine. The overall adherence was 79.6%. Respectively, 73.7, 71.8, 82.6 and 86.3% of those who received the prescription of one, two, three and four drugs returned, complying with the treatment. There is no difference in adherence to monotherapy or politherapy (one to four drugs) for the prophylaxis of migraine. .

Comparar a adesão entre monoterapia e politerapia no tratamento profilático da migrânea. Foram analisados retrospec-tivamente 500 pacientes com migrânea de um centro terciário, com vistas ao número de medicações preventivas prescritas na primeira consulta e adesão ao tratamento após 4 a 6 semanas. 71,8% da amostra era composta de mulheres. Em relação ao tratamento preventivo da migrânea, 6% não receberam medicação preventiva; 11,4% receberam uma droga; 22,2% duas drogas; 41,4% três drogas e 19% quatro drogas. A adesão média foi de 79,6%. Em relação à prescrição de uma, duas, três ou quatro drogas, essa adesão foi respectiva-mente de 73,7, 71,8, 82,6 e 86,3%. Não houve diferenças na adesão à prescrição de medicações em monoterapia ou politerapia (uma a quatro drogas) para o tratamento preventivo da migrânea. .

Trismus in cephalic tetanus from a foot injury

No abstract available.

Analgesic efficacy of diazepam and placebo in patients with temporomandibular disorders: A double blind randomized clinical trial.

Aim: The aim of the study was to evaluate and compare the analgesic efficacy of placebo and diazepam in patients with temporomandibular disorder. Materials and Methods: Thirty-five patients were recruited with a diagnosis of temporomandibular disorder based on standard clinical diagnostic criteria for temporomandibular disorder. The patients were put in to one of the two groups: placebo or diazepam at random. The average pain intensity was recorded with visual analog scale (VAS) at pretreatment, at weekly interval till the completion of a three-week trial and at post-treatment visit on the eighth week from baseline. The secondary outcome measures were changes in masticatory muscle tenderness, viz. massater muscle, lateral pterygoid muscle, medial pterygoid muscle and temporalis muscle and changes in mouth opening. Statistical Analysis: Intra-group comparison for analgesic efficacy and mouth opening was carried out by Wilcoxon's signed ranked test. Inter-group comparison for analgesic efficacy was also carried out using Mann-Whitney's test. Results: A statistically significant (P<0.01) decrease in temporomandibular disorder pain in the placebo group (65%) and statistically highly significant (P<0.001) decrease in the diazepam group (72%) were observed on VAS after three weeks of treatment. The inter-group comparison demonstrated no statistically significant difference between the groups. Conclusion: This study suggests that the placebo can give near similar results as diazepam can. So the role of placebo should also be considered as one of the important management strategies. In the short term, reduction in the masticatory muscle tenderness and significant improvement in the mouth opening in both the groups were observed.

Guidelines for the Treatment of Gastroesophageal Reflux Disease / 대한소화기학회지

Gastroesophageal reflux disease (GERD) is defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. In the last decade, GERD has been increasing in Korea. Seventeen consensus statements for the treatment of GERD were developed using the modified Delphi approach. Acid suppression treatments, such as proton pump inhibitors (PPIs), histmine-2 receptor antagonists and antacids are effective in the control of GERD-related symptoms. Among them, PPIs are the most effective medication. Standard dose PPI is recommended as the initial treatment of erosive esophagitis (for 8 weeks) and non-erosive reflux disease (at least for 4 weeks). Long-term continuous PPI or on-demand therapy is required for the majority of GERD patients after the initial treatment. Anti-reflux surgery can be considered in well selected patients. Prokinetic agents and mucosal protective drugs have limited roles. Twice daily PPI therapy can be tried to control extra-esophageal symptoms of GERD. For symptomatic patients with Barrett's esophagus, long-term treatment with PPI is required. Further studies are strongly needed to develop better treatment strategies for Korean patients with GERD.

Autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS): typical clinical and neuroimaging features in a Brazilian family / Ataxia espástica autossômica recessiva de Charlevoix-Saguenay (ARSACS): aspectos clínicos e de neuroimagem típicos em uma família brasileira

Autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS) is a neurodegenerative disorder characterized by late-infantile onset spastic ataxia and other neurological features. ARSACS has a high prevalence in northeastern Quebec, Canada. Several ARSACS cases have been reported outside Canada in recent decades. This is the first report of typical clinical and neuroimaging features in a Brazilian family with probable diagnosis of ARSACS.

A ataxia espástica autossômica recessiva de Charlevoix-Saguenay (ARSACS) é doença degenerativa do sistema nervoso, caracterizada por ataxia associada a espasticidade, entre outras manifestações neurológicas, de início na infância. A doença tem alta prevalência na região de Quebec, no Canadá. Muitos relatos de ARSACS têm sido descritos fora do Canadá nas últimas décadas. Nesse artigo, relatamos a primeira descrição dos aspectos clínicos e de neuroimagem típicos em uma família brasileira com provável diagnóstico de ARSACS.

Soft occlusal splint therapy in the management of myofascial pain dysfunction syndrome: a follow-up study.

BACKGROUND AND OBJECTIVES: Myofascial Pain Dysfunction Syndrome (MPDS) has been recognized as the most common, nontooth-related chronic orofacial pain condition that confronts dentists. A variety of therapies has been described in literature for its management. The present study is a prospective study carried out to evaluate the efficacy of occlusal splint therapy and compare it with pharmacotherapy (using analgesics and muscle relaxants) in the management of Myofascial Pain Dysfunction Syndrome. MATERIALS AND METHODS: Forty patients in the age range of 17-55 years were included in the study and randomly assigned to one of two equally sized groups, A and B. Group A patients received a combination of muscle relaxants and analgesics while Group B patients received soft occlusal splint therapy. All the patients were evaluated for GPI, VAS, maximum comfortable mouth opening, TMJ clicking and tenderness during rest and movement as well as for the number of tender muscles at the time of diagnosis, after the 1 st week of initiation of therapy and every month for three months of follow-up. RESULTS: There was a progressive decrease in GPI scores, number of tender muscles, TMJ clicking and tenderness with various jaw movements and significant improvement in mouth opening in patients on occlusal splint therapy during the follow-up period as compared to the pharmacotherapy group. CONCLUSION: Occlusal splint therapy has better long-term results in reducing the symptoms of MPDS. It has better patient compliance, fewer side effects, and is more cost-effective than pharmacotherapy; hence, it can be chosen for the treatment of patients with MPDS.

Electroconvulsive therapy in drug resistant neuroleptic malignant syndrome.

We report a case of a 20 years female referred to us with a history of a brief psychotic episode for which she was given inj. Haloperidol. The patient presented in an unconscious state with high grade fever. The diagnosis was kept as neuroleptic malignant syndrome after ruling out other possibilities. The patient did not respond to Bromocriptine and Dantrolene. With the recent evidence of electroconvulsive therapy being useful in these patients, we went ahead with the same. We present this case to share our experience of the excellent response of neuroleptic malignant syndrome to electroconvulsive therapy.

Hipertermia maligna: adelantándose a las complicaciones / Malignant hyperthermia: moving forward before the complications

La hipertermia maligna (HTM) es una enfermedad fármaco-genética de carácter autosómico dominante de baja incidencia pero potencialmente mortal, caracterizada por un síndrome hipermetabólico del músculo estriado esquelético, que puede desencadenar la destrucción completa de éste, resultando en aumento de la temperatura corporal, alto consumo de oxígeno, hiperpotasemia, falla renal y arritmias. A continuación se da a conocer el caso de un paciente de 6 años portador de una distrofia muscular de Duchenne con antecedentes familiares de hipertermia maligna y que se sometió a cirugía adenoamigdaliana en la cual se tomaron las medidas anestésicas para prevenir la aparición de una crisis.

Interaccion vecuronio-rocuronio revisada por la comparacion de su potencia relativa / Interaction between vecuronium and rocuronium: revaluation by their relative potencies

Existen varios métodos para el estudio de la interacción entre bloqueadores musculares y otros tantos para elcálculo de la curva dosis respuesta. El presente trabajo analiza la interacción entre el vecuronio y rocuronio comparando las potencias respectivas obtenidas del control con el de las mezclas, calculadas para cada paciente. En primer lugar se concluyó la relación dosis-respuesta con el uso de dosis subparalíticas únicas, administrando vecuronio 10, 20 y 30 ug. Kg-¹ o rocuronio 50, 100 y 200 ug.Kg-¹. Utilizando el máximo efecto se determinaron las dosis efectivas-50 y 95 (DE50 – 95) resolviendo la ecuación de Hill para cada paciente considerando 4,75 como coeficiente. Seguidamente se repitieron los cálculos después de administrar fracciones equipotenciales que representan 0.2, 0.3 y 0.4 x DE50 de ambas drogas. Con ayuda del análisis algebraico se identificó el tipo de interacción: [dv / (DE50-95) v + dr/(DE50-95) r] y que demostró un valor ligeramente menor de uno [1] lo cual indica aditivismo. Todas las cifras que se obtuvieron guardan gran similitud con los provenientes de otros métodos y sugieren que el presente es una herramienta sencilla, confiable y útil para el cálculo de la relación dosis-respuesta en general y para estudiar la interacción entre vecuronio y rocuronio en particular.

There are several methods for the study of the interaction between neuromuscular blockers and as many tocalculate their dose-response curve. The present trial deals with the interaction between vecuronium and rocuronium assessed by comparison of their respective potencies obtained for a control with that of their mixtures, both calculated for each patient. Drug potency was obtained first after the administration of single no paralytic doses: vecuronium 10, 20 and 30 ug. Kg-¹ or rocuronium 50, 100 and 200 ug. Kg-¹. Using maximal effect, 50 and 95 effective doses (ED50 – 95) were determined by solving Hill equation for each subject, considering 4.75 as the coefficient. The same procedure was repeated after the administration of 0.2, 0.3 or 0.4 x ED50 of both drugs. Algebraic analysis was used to identified the type of interaction according to [dv/ (DE50-95) v + dr/ (DE50-95) r] leading to a value less than one [1] indicating additivism. All numerical values actually obtained are in close agreement with that coming from other methods, suggesting that this is an easy, consistent and useful tool for the calculation of the doseresponserelationship in general and for the study of the vecuronium-rocuronium interaction in particular.

Use of intrathecal morphine infusion for spasticity

OBJETIVO: Estudar a eficiência do uso da infusão de morfina intratecal, no tratamento da espasticidade. MÉTODO: Doze pacientes com espasticidade refratária a tratamento clínico foram estudados. Dez eram do sexo masculino e dois do feminino. A idade média foi 34,4 anos (20 a 61 anos). A média inicial da escala de Ashworth foi 4,6. Todos foram submetidos a implante de bomba de infusão para infusão Intratecal de morfina. RESULTADOS: Ao final do tratamento o valor da escala de Ashworth foi 2,2. A dose média de infusão intratecal de morfina foi 0,95 mg, com freqüência de aplicação de 1,8 vezes/dia. Como complicações, quatro pacientes desenvolveram prurido, dois náuseas, dois retenção urinária e todos melhoraram com diminuição da concentração da morfina intratecal. Um paciente foi submetido à revisão da bomba de morfina por extrusão do cateter. CONCLUSAO: O uso de morfina intratecal para o tratamento de espasticidade refratária a tratamento clínico é eficaz e com poucas complicações.

Baclofen in the treatment of intractable hiccups.

Availability of a large number of drugs/remedies for the management of hiccups suggests that all the available drugs are not effective in all the patients. Baclofen was successful in relieving the intractable hiccups where all other known drugs of hiccup were unable to provide relief.

Stiff person syndrome and myasthenia gravis.

Association of stiff person syndrome, an immune related disorder of anterior horn cells and myasthenia gravis an endplate disorder with similar pathogenesis, is rare. This communication documents this association in the Indian literature for the first time.

A Case of Maternal Tetanus in Korea

Tetanus is uncommon in Korea due to the introduction of vaccination programs and advances in public health. A case of maternal tetanus occurred on the 9 day postpartum in a 29-yr-old woman, who had not received a 10-yr-booster of tetanusdiphtheria toxoid after receiving the primary series of tetanus-toxoid-containing vaccine. There has hitherto been no reports on maternal tetanus in Korea. This case illustrates that tetanus remains a medical problem, principally among nonand underimmunized adults. The only way to fully prevent this disease is to ensure adequate immunization in all adults.

Stiff person syndrome.

This communication considers a patient with episodic muscle spasms. Pharmacological intervention and electrophysiological studies provided adequate evidence confirming the diagnosis of stiff person syndrome. Electrophysiological studies in present communication similar to earlier reports, confirmed once again the autonomous state of the anterior horn cell in this disease process.

Post-neonatal tetanus: issues in intensive care management.

Tetanus is an acute neurological disease characterized by muscle rigidity and spasms, autonomic dysfunction and in severe forms requires respiratory and hemodynamic support. Though it is entirely preventable by immunization, it still occurs in developing countries causing significant morbidity and mortality. Intensive care management of tetanus is fraught with problems of ventilator-associated pneumonia, nosocomial sepsis and a variety of other complications. Various treatment protocols have been tried in managing diverse manifestations of severe tetanus but the consensus is yet to emerge. In this review we have discussed the pathophysiology, clinical features and management controversies and suggest on basis of our experience use of high dose diazepam (20-120 mg/kg/day) and vecuronium with mechanical ventilation if required for control of spasms, and early detection of autonomic dysfunction and use of propranolol, in our circumstances.