A Novel Application of an Adjustable Catheter in Acute Radicular Pain Management.

INTRODUCTION: Acute lumbosacral radicular syndrome is often a medical disorder of difficult management. Epidural steroid injection is a useful approach for the herniated disc and radiculitis. The transforaminal approach is usually considered more effective and target-specific, but it can be associated with permanent lower extremity paralysis. A caudal approach with an adjustable catheter has been widely used in adhesiolysis in chronic low back pain, but there are no reports of its application in acute radicular pain. The aim of this study is to assess the clinical effectiveness of epidural steroid injection by caudal approach with an adjustable catheter in patients with severe acute radicular pain. METHODS: Fifty-five patients with severe acute radiculopathy were treated with epidural steroid injection by an epidural catheter whose tip can be directed laterally on the selected site. Numerical rating scale (NRS), pain relief, and analgesic consumption were observed after 1, 3, 6, and 12 months. Analgesic consumption (AC) and functional recovery (FR) have been considered secondary outcomes. RESULTS: We observed a significant reduction of NRS score that was constant every 12 months. Pain relief was good after 1 month and improved further after 3 months. Only a few patients perceived poor pain relief and only three patients relapsed. More than 70% of the patients were drug-free at the 12th month. CONCLUSIONS: The caudal approach with adjustable catheter showed similar but more lasting effects on the acute severe radicular pain when compared to other epidural injections techniques; it is extremely target-specific and thus allows the use of small doses of corticosteroids; moreover, the adjustable catheter makes the procedure free from the risk of major complications. FUNDING: No funding or sponsorship was received for this study. Sponsorship for article publication fees were funded by TSS Medical SRL.

Cognitive and Neurophysiological Effects of Non-invasive Brain Stimulation in Stroke Patients after Motor Rehabilitation.

The primary aim of this study was to evaluate and compare the effectiveness of two specific Non-Invasive Brain Stimulation (NIBS) paradigms, the repetitive Transcranial Magnetic Stimulation (rTMS), and transcranial Direct Current Stimulation (tDCS), in the upper limb rehabilitation of patients with stroke. Short and long term outcomes (after 3 and 6 months, respectively) were evaluated. We measured, at multiple time points, the manual dexterity using a validated clinical scale (ARAT), electroencephalography auditory event related potentials, and neuropsychological performances in patients with chronic stroke of middle severity. Thirty four patients were enrolled and randomized. The intervention group was treated with a NIBS protocol longer than usual, applying a second cycle of stimulation, after a washout period, using different techniques in the two cycles (rTMS/tDCS). We compared the results with a control group treated with sham stimulation. We split the data analysis into three studies. In this first study we examined if a cumulative effect was clinically visible. In the second study we compared the effects of the two techniques. In the third study we explored if patients with minor cognitive impairment have most benefit from the treatment and if cognitive and motor outcomes were correlated. We found that the impairment in some cognitive domains cannot be considered an exclusion criterion for rehabilitation with NIBS. ERP improved, related to cognitive and attentional processes after stimulation on the motor cortex, but transitorily. This effect could be linked to the restoration of hemispheric balance or by the effects of distant connections. In our study the effects of the two NIBS were comparable, with some advantages using tDCS vs. rTMS in stroke rehabilitation. Finally we found that more than one cycle (2-4 weeks), spaced out by washout periods, should be used, only in responder patients, to obtain clinical relevant results.

Paroxysmal non-kinesigenic dyskinesia, post-streptococcal syndromes and psychogenic movement disorders: a diagnostic challenge.

We report a case of a 15-year-old boy presenting with sudden attacks of hyperkinetic movements of the limbs, trunk and neck. Clinical features were suggestive of paroxysmal non-kinesigenic dyskinesia, but the elevated antistreptolysin O antibody titre and history of recurrent upper airways infection led us to consider a post-streptococcal syndrome as a possible diagnosis. The patient started therapy with benzathine penicillin, sodium valproate and clonazepam without any significant improvement. A successive psychiatric assessment revealed the presence of a psychogenic movement disorder. Psychodynamic psychotherapy and individual counselling were started with progressive improvement of psychological symptoms and gradual resolution of hyperkinetic episodes, without any recurrence recorded during the follow-up (10 months).

Sexual behaviors during sleep associated with polysomnographically confirmed parasomnia overlap disorder.

Parasomnia overlap disorder (POD) refers to a sleep disorder characterized by the association of REM sleep behavior disorder (RBD) with NREM sleep parasomnia in the same patient. Sexual behaviors during sleep (SBS) can include most wakeful sexual activities and are classified in the ICSD-2 as a variant of confusional arousals and sleepwalking, both NREM parasomnias. A case of SBS associated with sleepwalking and possible RBD has been previously described, but it was not confirmed by polysomnography (PSG). We report two patients with SBS associated with POD documented by PSG. In one patient (60-year-old female) SBS was video-polysomnographically demonstrated: a few minute episode of masturbation occurring during slow-wave sleep (SWS) and preceded by hypersynchronous delta pattern. During the episode, the EEG pattern showed the persistence of delta rhythms with increasing alpha activity. When awoken by technicians, the patient was not aware of her sexual behavior and did not report any dream. The other patient, a 41-year-old male with a history of sleepwalking and RBD, was legally charged with repeatedly sexually fondling a young girl during the night. The POD was documented by PSG. The parasomnia defense, including sleepsex, was accepted by the Court and the patient was acquitted. This is an unprecedented report of SBS in patients with PSG-confirmed POD and of SBS documented during video-PSG.