Neuromagnetic treatment of pain in refractory carpal tunnel syndrome: An electrophysiological and placebo analysis.

UNLABELLED: {\it OBJECTIVE: } To evaluate the neurobiological effect of constant, subthreshold magnetic field exposure on symptomatic median nerve compression symptoms, neurophysiology and assess the role of placebo. {\it BACKGROUND: } Conservative treatment of moderate and severe CTS has been variable and often results in surgical decompression at the wrist. {\it DESIGN/METHODS: } Eight moderately symptomatic and intractable CTS hands constantly wore identical Elastomag wrist support wraps (unmagnetized vs. magnetized 350 gauss) for one month intervals. Identical wraps were then switched at the second month. Baseline assessments included the neurological exam, VAS scores for burning, numbness and tingling twice a day on a 10 point ordinal scale. CMAP/SNAP was determined at baseline and monthly intervals. Clinical follow-up at end of fourth and eighth weeks was compared to baseline. {\it RESULTS: } The mean pain scores improved in four patients (57%) which also correlated with clinical benefit. Improvement in Tinel and Phalen sign as well as sensory changes was similarly noted. Placebo effect was detected in one patient (13%). Electrophysiological improvement in distal latencies in 5/8 hands using magnetic treatment was noted compared to no change or worsening in all placebo cases. {\it CONCLUSIONS: } Percutaneous magnetic stimulation induced palliative pain relief, presumably via modulation of the unmyelinated C-fibers. Prior studies have suggested an influence on K+ inward rectification excitability. These observations suggest that wearing magnetized wrist wraps appears to be a novel therapeutic agent. However, the underlying neuropathology tends to be progressive.

Expert witness testimony: An update.

This update provides an overview of the current state of expert witness testimony regarding malpractice cases. Many trials are reduced to a battle of the experts and many physicians advertise their credentials and expertise in hopes of attracting lucrative cases. This article focuses on what constitutes an expert witness, medical organizations oversight, the peer review process, and physician immunity.

Documentation and informed consent.

Documentation remains the key factor that leads to success or failure of a claim in a significant number of cases. Since the time of a trial is often years later, an accurate memory can only be reflected by the records kept by the physician in question. This article focuses on developing good habits of documentation in areas such as medical record maintenance, handwriting, informed consent, and record tampering. Guidelines for improved record keeping are also presented in this article.

Cerebral hemodynamic changes induced by simulated tracheal intubation: a possible role in perioperative stroke? Magnetic resonance angiography and flow analysis in 160 cases.

BACKGROUND AND PURPOSE: Perioperative stroke is a rare complication of generalized surgery (1% to 6%). Unexpected difficulties with tracheal intubation (TI), as well as the hyperextended position, may predispose a patient to or play a role in stroke. We sought to identify blood flow changes in carotid and vertebral arterial circulation during simulated TI and develop profile models for stroke risk before possible generalized surgery. METHODS: One hundred sixty consecutive patients with suspected cerebral vascular disease or pending surgery underwent MR angiography with flow analysis. Simulated TI position was maintained for 3 to 4 minutes per acquisition. RESULTS: The cohort consisted of 89 females (56%) and 71 males (44%) with a mean age of 66 years (range, 17 to 89 years). Hypoplastic vertebral arteries with flow less than 50 mL/s were present in 40 patients (25%). Profound alteration in basilar artery flow was noted in this group with increased frequency of microinfarctions on MRI (77% versus 38%). Unsuspected carotid occlusion (n=6) and vertebral artery occlusion (n=2) were associated with significant basilar artery flow changes. Flow reversal was present in five cases. Carotid arterial changes were not significant with simulated TI. No overt ischemic symptoms developed during these maneuvers. CONCLUSIONS: Simulated TI is safe yet induces distinct and potentially detrimental flow abnormalities. Individuals identified with the biological markers of hypoplasia, carotid and vertebral occlusion, severe stenosis, or prior ischemic vascular disease should receive special attention to neck position not only during surgery but also in the postoperative period. Sustained neck hyperextension greater than 12 minutes appears to be a neglected potential hemodynamic factor that may play a pivotal role in the pathogenesis of perioperative stroke.

Medicolegal aspects of iatrogenic injuries.

There is often a fine line between medical malpractice and maloccurrance. Physicians need to develop techniques and skills that enhance the patient-physician relationship based on honesty and informed consent. Documentation and proper maintenance of medical records is demanded by the current legal and health care systems. Failure to follow programs which maintain the integrity of patients' records often has negative consequences. The cases discussed illustrate areas in which the neurologist has come into conflict with the legal system.

Noninvasive laser neurolysis in carpal tunnel syndrome.

The peripheral nervous system is photosensitive providing the scientific rationale for this study, which determines the efficacy and safety of laser light exposure in 30 cases with CTS. Nine joules of energy over five points (7-15 treatments) reversed CTS in 77% of cases with three-fold normalization of CMAP. A photobiologic response was seen in 80% of nerves. This unique and novel approach is cost-effective and will play a role in future management of CTS.