Cervical Spinal Cord Stimulation for Failed Neck Surgery Syndrome.

PURPOSE OF REVIEW: Cervical spine pain with or without radicular symptoms is a common condition leading to high utilization of the healthcare system with over 10 million medical visits per year. Many patients undergo surgical interventions and unfortunately are still left with neck and upper extremity pain, sometimes referred to as "Failed Neck Surgery Syndrome." When these options fail, cervical spinal cord stimulation can be a useful tool to decrease pain and suffering as well as reduce prescription medication use. RECENT FINDINGS: Spinal cord stimulation is a well-established therapy for chronic back and leg pain and is becoming more popular for neck and upper extremity pain. Recent studies have explored cervical spinal cord stimulation with successful outcomes regarding improved pain scores, functional outcomes, and reduction of prescription medication use. Continued research into cervical spinal cord stimulation is essential for maximizing its therapeutic potential for patients with chronic neck and upper extremity pain. This review highlights the importance of cervical spinal cord stimulation as an option for patients with failed neck surgery syndrome.

Radiofrequency Ablation of the Superior Cluneal Nerve: A Novel Minimally Invasive Approach Adopting Recent Anatomic and Neurosurgical Data.

OBJECTIVES/INTRODUCTION: Superior cluneal neuralgia (SCN) is a distinct cause of lower back and/or leg pain related to pathology of the superior cluneal nerve (SCn). SCN has been termed pseudo-sciatica and is an overlooked differential diagnosis when patients are otherwise presenting with low back and/or radicular pain. Radiofrequency ablation (RFA) is commonly used for denervation of the medial branches of the dorsal root for facet joint syndrome for sacroiliac joint; however, RFA has not been described to ablate the SCn for SCN. Herein, we present a novel interventional minimally invasive approach using RFA of the SCn for SCN in a series of 46 patients. METHODS: Institutional review board approved retrospective chart review was used to collect data for all SCn RFA cases from January 1, 2018, to February 8, 2021. Fluoroscopically guided SCn ablations were performed for patients with a positive "iliac crest point sign," reproductive of their back and leg pain during physical examination. Sensory stimulation was utilized to confirm RF cannula-probe placement adjacent to the SCn, and motor testing was used to confirm no distal motor response prior to monopolar RF ablation with a Halyard RF Generator (100 mm curved 22G 10 mm active tip RF cannulae). Charts were reviewed for time of analgesia follow-up, duration and degree of analgesia, improvements in patients' functional capacity, and changes in medication. RESULTS: Data were reviewed for 51 patients who underwent Scn RFA, 5 of which were lost to follow-up. The remaining 46 patients consisted of 29 women and 17 men with a mean age of 59.4 years; 78.3% (n = 36) had ongoing relief at a mean of 92.1 days follow-up, ranging from 13 to 308 days, with a mean of 92.3% analgesia (SD 15.0%). At a mean of 111.2 days of follow-up, ranging from 42-201 days, 21.7% (n = 10) of patients reported that their pain had returned and had 95% analgesia during that time period (SD 6.7%); 41.3% (n = 19) reported improved activity/gait, 17.4% reported improved mood (n = 8), and 8.7% reported decreased medication use (n = 4). Five patients had minor complications including bruising (1), 2-3 days of soreness on site (2), myofascial pain (1), and quadratus lumborus muscle spasm relieved with trigger point injection (1). CONCLUSIONS: This is the first report of both technique and outcomes for radiofrequency ablation of superior cluneal neuralgia. This series suggests that RFA of the SCn is a suitable intervention for the treatment of SCN; 21.7% of patients reported a mean of 95% analgesia for a mean duration of 111.2 days, and the remaining 78.3% of patients reported ongoing relief with a mean of 92.3% analgesia at last follow-up (mean 92.1 days). There were no serious adverse events.

A randomized controlled study to assess patients' understanding of and consenting for clinical trials using two different consent form presentations.

BACKGROUND: Informed consent is the ethical basis for clinical research. The physical appearance of the consent document may influence patients' willingness to carefully read the consent document. We therefore tested the hypothesis that presentation of consent documents in an enhanced format improves patients' attention, understanding and therefore willingness to consent for clinical research. METHODS: Patients being asked to participate in three large clinical trials were randomly assigned to enhanced or routine presentation. The enhanced document was printed on 20-pound, cream-colored bond paper and presented in a blue folio. In contrast, patients assigned to routine presentation were given an otherwise identical stapled set of photocopied pages. The primary outcome was the effect of the enhanced format on the proportion of patients consenting; the major secondary outcome was patient's understanding of the presented procedures and risks. RESULTS: A total of 189 of 251 (75%) patients approached with standard format consenting documents consented for an underlying study, whereas 164 of 248 (66%) approached with enhanced format documents consented; the adjusted odds ratio (95% confidence interval) for consenting (comparing enhanced to standard formats) was 0.64 (0.43, 0.95), P=0.03. About 90% of the patients in each group correctly identified the major study intervention and major associated risk. Neither patients' characteristics nor understanding affected the consenting rate for the presented clinical research. CONCLUSION: Consent forms in an enhanced format (i.e., printed on fine paper and presented in a folio) did not improve patients' understanding or willingness to consent to participate in clinical trials.

WITHDRAWN Coronary artery spasm associated with blood brain barrier disruption induced by carotid sinus stimulation.

Ahead of Print article withdrawn by publisher Blood brain barrier disruption (BBBD) is a novel technique for treating central nervous system lymphoma. This technique depends on the disruption of the tight junctions between endothelial cells (which represent the blood brain barrier) by intra-arterial injection of mannitol. The most common complications of blood brain barrier disruption are seizures and brain edema. Here, the authors present a rare complication of coronary artery spasm manifested by elevation of the ST segment and bradycardia due to carotid sinus stimulation in a 33 year-old-male during blood brain barrier disruption. To the authors' knowledge, this is the first report of a coronary artery spasm complicating blood brain barrier disruption.

Hepatitis C virus infection among paediatric patients attending University of Assiut Hospital, Egypt.

Few studies have evaluated the epidemiology and risk factors of hepatitis C virus (HCV) infection in children in Egypt. This study of 465 children attending Assiut University Hospital measured the rates of anti-HCV positivity by 3rd-generation ELISA test and of HCV-RNA positivity by PCR, with analysis of some relevant risk factors. The rate of HCV-RNA positivity among ELISA-positive cases (n = 121) was 72.2% overall: 100% in the subgroup with hepatitis, 70.8% in those with a history of multiple transfusions and 58.3% in those without hepatitis or multiple transfusions. History of blood transfusions, frequent injections, hospitalization or surgical procedures were significant risk factors for anti-HCV positivity by ELISA.

Lesional skin vascular endothelial growth factor levels correlate with clinical severity in patients with cement allergic contact dermatitis.

Allergic contact dermatitis to cement is a delayed-type hypersensitivity reaction in which cytokines interferon-gamma (IEN-y) and vascular endothelial growth factor(VEGF) may be involved in persisting erythema and oedema. VEGF and IFN-gamma levels in serum and skin lesions were measured in 32 Egyptian building workers with chronic allergic contact dermatitis due to occupational exposure to cement and 20 healthy controls. Dermatitis patients had significantly higher levels of serum and lesional skin VEGF and IFN-gamma than controls. A significant positive correlation was found between tissue VEGF and the eczema area and severity index (EASI) score in dermatitis patients (r = 0.86). VEGF and IFN-gamma may play a role in the pathogenesis of cement allergic contact dermatitis.

Cigarette smoking, hypertension and diabetes mellitus as risk factors for erectile dysfunction in upper Egypt.

Erectile dysfunction impairs the quality of life of millions of men worldwide. This study aims to determine the relationship between selected clinical risk factors and erectile dysfunction in men residing in upper Egypt. Patients were surveyed with the 5-item International Index of Erectile Function (IIEF-5) and assessed for the presence of hypertension, diabetes and smoking. Of 658 men with erectile dysfunction, 17.3% had hypertension, 21.4% had diabetes and 40.1% were smokers, whereas among 821 age-matched controls without erectile dysfunction, the corresponding figures were 2.8%, 3.7% and 28.7%. Multivariate analysis showed that hypertension (OR = 5.4), diabetes mellitus (OR = 5.4) and smoking (OR = 3.1) were significant risk factors for erectile dysfunction.

Corrected QT dispersion improves diagnostic performance of exercise testing in diagnosing coronary artery disease.

To determine the best combination of parameters that would improve the diagnostic performance of exercise testing, coronary angiography plus exercise testing were done on 112 patients with angina pectoris and normal electrocardiogram. The univariate predictors of coronary artery disease included: age > or = 40 years, male sex, hypertension, smoking, development of exertional chest pain, decrease in systolic blood pressure (BP) > or = 10 mmHg or systolic BP 3 min post-exercise > 90% of peak, heart rate drop < 12 beats/min 1 min postexercise, exercise-induced ST-segment depression > or = 1 mm. Multivariate logistic regression analysis showed that using either ST depression > or = 1 mm or peak exercise QTDc > 70 ms significantly improved sensitivity and negative predictive value of the test without a significant decrease in specificity.

Recurrent lung collapse due to unidentified phrenic nerve injury after cardiac surgery.

Partial or complete recurrent lung collapse after cardiac surgery is one cause of failure to wean from ventilator support, and frequently leads to multiple reintubations and prolonging intensive care unit and hospital stays. A 79-year-old female underwent uneventful coronary artery bypass surgery and was extubated on the first postoperative day (POD). On POD 2, a routine portable chest X-ray (CXR) revealed complete opacification of the left hemithorax. The patient was readmitted to the Cardiovascular Intensive Care Unit (CVICU) and electively intubated, and bronchoscopy revealed a left mainstem bronchus mucous plug. The patient was extubated uneventfully the same day. A CXR on the next day revealed recurrent total collapse of the left lung, which this time was successfully treated non-invasively with intermittent CPAP mask, percussive therapy, and respiratory treatments using acetylcysteine solution. After several days, the left lung collapsed again, necessitating reintubation and repeat bronchoscopy. With Pulmonary medicine present, the patient was subsequently extubated so that bronchoscopy could be performed while the patient was breathing spontaneously. This examination revealed dynamic collapse of the left lower lobe bronchus. A sniff test was performed and revealed an immobile left hemi-diaphragm. The patient gradually became stronger, and as the airway edema subsided, she was able to be managed on the regular nursing floor with intermittent CPAP mask treatments and mucolytics. Although uncommon, one documented cause of failure to wean from mechanical ventilation is diaphragmatic dysfunction. This finding is often delayed because it requires a sniff test in an extubated patient to make the diagnosis.

Pattern and possible contributing factors to dialysis-associated arrhythmia in young patients.

We studied dialysis-associated arrhythmia in 48 uraemic patients < 35 years on chronic haemodialysis (HD) (> 3 months). Holter findings showed only minor arrhythmia; atrial in 42% of patients and ventricular in 38%. ST-segment depression > 1 mm was observed in 58% of patients; 80% had arrhythmia, and 36% experienced anginal pain. HD caused a significant increase in QTc, QTdc and Ca2+ level, while K+ level was significantly decreased. Patients who experienced arrhythmia during HD had higher left ventricular mass and left ventricular mass index, lower post-dialysis K+ level, higher QTc and QTdc both before and after HD. They were more frequently hypertensive. ST-segment depression was significantly related to ventricular arrhythmia.