Multimodal Pain Management for Parsonage-Turner Syndrome in the Acute Rehabilitation Setting: A Case Report.

Parsonage-Turner syndrome (PTS) is a rare neurological condition characterized by acute shoulder pain and novel neuromuscular weakness in the distribution of the brachial plexus. We present a case report highlighting the difficulties in the diagnosis and management of this condition. A multidisciplinary approach is often required to control this unique type of pain, consisting of neuropathic medications, non-steroidal anti-inflammatory drugs (NSAIDs) to control neuromuscular pain, and modalities provided by experienced physical therapists. Finally, a comprehensive, structured rehabilitation program focusing on the range of motion, neuromuscular re-education, and strengthening is imperative to regain function, reduce symptoms, and improve recovery.

Pain Management Interventions in Lumbar Spinal Stenosis: A Literature Review.

Lumbar spinal stenosis (LSS) occurs due to the narrowing of the space within the vertebral canal and or intervertebral foramina. This results in the compression of the spinal cord and possibly the roots of the spinal nerves. Lower back pain and neurogenic claudication (NC) are major symptoms of spinal stenosis. This is a literature review that summarizes the important findings pertaining to pain management of spinal stenosis. Twenty-four original articles were assessed. Pain can be treated through non-invasive or surgical methods. Conservative techniques include physical exercises, epidural corticosteroid injection, local anesthetic injection therapy, and oral analgesics. Surgical intervention deals with the decompression of the affected spinal region, with or without vertebral fusion surgery. Other novel surgical techniques include implantation of specific equipment, known as interspinous spacer devices and minimally invasive lumbar decompression (MILD). Most studies offering a comparative analysis have demonstrated that surgical intervention is more efficacious than non-surgical interventions to manage pain associated with spinal stenosis.

Diaphragm Pacing: A Safety, Appropriateness, Financial Neutrality, and Efficacy Analysis of Treating Chronic Respiratory Insufficiency.

OBJECTIVES: This study aimed to evaluate the safety and applicability of treating chronic respiratory insufficiency with diaphragm pacing relative to mechanical ventilation. MATERIALS AND METHODS: A literature review and analysis were conducted using the safety, appropriateness, financial neutrality, and efficacy principles. RESULTS: Although mechanical ventilation is clearly indicated in acute respiratory failure, diaphragm pacing improves life expectancy, increases quality of life, and reduces complications in patients with chronic respiratory insufficiency. CONCLUSION: Diaphragm pacing should be given more consideration in appropriately selected patients with chronic respiratory insufficiency.

A Multicenter Retrospective Analysis on the Etiology of Bradycardia in COVID-19 Patients.

Introduction Bradycardia has been reported in the setting of SARS-CoV2 (COVID-19) and appears to be an important cardiac manifestation with an association of mortality. However, the etiology of bradycardia in COVID-19 remains unclear. Therefore, this study aims to retrospectively investigate the potential causes of bradycardia in COVID-19 patients. Method The multicenter retrospective analysis consisted of 1,116 COVID-19 positive patients from March 2020 to March 2021. Bradycardia and severe bradycardia were defined as a sustained heart rate of <60 BPM and <50 BPM, respectively, on two separate occasions, a minimum of four hours apart during the hospitalization. End-of-life bradycardia was excluded from the study. Data were retrieved using a structured query language (SQL) program through the EMR, and data were analyzed using IBM SPSS 27.0 (IBM Corp., Armonk, NY). Logistic regression was used to study the bradycardic event and its association with remdesivir, beta-blockers, or steroids use during the patient's hospital stay. Result In the multivariate analysis, bradycardia was significantly associated with length of hospital stay (p<0.001), mortality (p=0.022), ventilator use (p=0.001), and steroid use (p=0.001). However, there was no significant association between bradycardia and remdesivir use (p=0.066) or beta-blocker use (p=0.789). Conclusion Our study showed that steroid use was protective against developing bradycardia in COVID-19 patients. Furthermore, remdesivir and the use of beta-blockers were not associated with bradycardia in COVID-19 patients. However, bradycardia was associated with both increased mortality and length of stay in the hospital. Therefore, future studies should focus on the mechanism of bradycardia in COVID-19 patients and the effect of bradycardia on patient outcomes.

Septic Portal Vein Thrombosis, Clinical Presentation, and Management.

Pylephlebitis, otherwise known as septic portal vein thrombosis, is an infective suppurative thrombosis of the portal vein and/or its intra-hepatic branches. It is a diagnosis that is frequently missed but easily treated with antibiotics. Therefore, it should be considered early on in any patient presenting with fever, abdominal pain, leukocytosis, and evidence of portal vein thrombosis on a CT scan. In this case report, we discuss a case of pylephlebitis as well as the etiologies, diagnosis, and treatment of septic portal vein thrombosis.

Elevated Adrenocorticotropic Hormone, Hypercortisolism, and Marked Hypernatremia.

We present a case of refractory hypernatremia in a patient with elevated adrenocorticotropic hormone (ACTH) and hypercortisolism. Cortisol's effect in tissues results in various outcomes, from maintaining blood pressure to increasing serum glucose levels. In addition, cortisol, cortisone, and aldosterone activate mineralocorticoid receptors with the same affinity; therefore, the activation of mineralocorticoid receptors by elevated cortisol levels leads to increased sodium reabsorption, increased potassium secretion, and metabolic alkalosis. Hypernatremia in our patient was initially refractory to fluid replacement but was eventually corrected with intravenous fluid and desmopressin. Overall, we suggest that hypercortisolism should be considered a differential diagnosis in hypernatremia refractory to fluids replacement.

Epidural hematomas after removal of percutaneous spinal cord stimulator trial leads: two case reports.

OBJECTIVE: We report 2 cases of spinal epidural hematoma formation after the removal of percutaneous spinal cord stimulator trial leads and discuss the possible etiologies of these complications. CASE REPORT: Two patients developed spinal epidural hematomas shortly after removal of their percutaneous trial leads and required multilevel laminectomies for evacuation of the hematoma. Patient 1 reported taking aspirin the morning that his leads were pulled, whereas patient 2 had not taken aspirin in the 7 days before commencing his trial. There were 2 days between identification and evacuation of patient 1's hematoma, and he did not fully recover from the injury to his spinal cord. Patient 2 underwent surgery immediately with complete resolution of his symptoms. CONCLUSIONS: Currently, the neuromodulation community ascribes to the American Society of Regional Anesthesia and Pain Medicine guidelines, which state that nonsteroidal anti-inflammatory drugs do not significantly increase the risk for epidural hematoma with neuraxial anesthesia and, therefore, there is no need to discontinue these drugs before epidural or spinal anesthesia. We suggest that these guidelines may not be appropriate for neuromodulatory techniques that likely subject the surrounding vasculature to more trauma than neuraxial anesthesia. We recommend discontinuing nonsteroidal anti-inflammatory drugs, particularly aspirin, before neuromodulation procedures. Further investigation will establish a timeframe for holding these drugs to optimize patient safety.