Sensory abnormalities and masticatory function after microvascular decompression or balloon compression for trigeminal neuralgia compared with carbamazepine and healthy controls.

OBJECT: Idiopathic trigeminal neuralgia (iTN) is a neurological condition treated with pharmacotherapy or neurosurgery. There is a lack of comparative papers regarding the outcomes of neurosurgery in patients with iTN. The objective of this study was to investigate sensory thresholds and masticatory function in 78 patients with iTN who underwent microvascular decompression (MVD) or balloon compression (BC), and compare these treatments with carbamazepine and 30 untreated healthy controls. METHODS: The authors conducted a case-controlled longitudinal study. Patients were referred to 1 of 3 groups: MVD, BC, or carbamazepine. All patients were evaluated before and after treatment with a systematic protocol composed of a clinical orofacial questionnaire, Research Diagnostic Criteria for temporomandibular disorders, Helkimo indices, and a quantitative sensory-testing protocol (gustative, olfactory, cold, warm, touch, vibration, superficial, and deep pain thresholds). RESULTS: Both MVD and BC were effective at reducing pain intensity (p = 0.012) and carbamazepine doses (p < 0.001). Myofascial and articular complaints decreased in both groups (p < 0.001), but only the patients in the MVD group showed improvement in Helkimo indices (p < 0.003). Patients who underwent MVD also showed an increase in sweet (p = 0.014) and salty (p = 0.003) thresholds. The sour threshold decreased (p = 0.003) and cold and warm thresholds increased (p < 0.001) in patients after MVD and BC, but only the patients who underwent BC had an increase in touch threshold (p < 0.001). CONCLUSIONS: Microvascular decompression and BC resulted in a reduction in myofascial and jaw articular complaints, and the impact on masticatory function according to Helkimo indices was greater after BC than MVD. MVD resulted in more gustative alterations, and both procedures caused impairment in thermal thresholds (warm and cold). However, only BC also affected touch perception. The sensorial and motor deficits after BC need to be included as targets directly associated with the success of the surgery and need to be assessed and relieved as goals in the treatment of iTN.

Celiac plexus neurolysis for the treatment of upper abdominal cancer pain.

Optimal treatment of oncologic pain is a challenge to all professionals who deal with cancer and its complications. The management of upper abdominal pain is usually difficult and it is often refractory to conservative therapies. In this context, celiac plexus neurolysis (CPN) appears to be an important and indispensable tool because it alleviates pain, gives comfort to patients and is a safe procedure. In this study, the importance of CPN is reviewed by a retrospective study of 74 patients with pain due to upper abdominal cancer. Almost all cases evaluated (94.6%) had an excellent result after CPN and the majority of side effects were transitory.

Clues for previously undiagnosed connective tissue disease in patients with trigeminal neuralgia.

BACKGROUND: Connective tissue diseases (CTD) may be associated with idiopathic trigeminal neuralgia (TN). The prevalence and diagnostic implications of this association are, however, not well established. OBJECTIVES: The objective of this study was to evaluate, in TN patients, if rheumatologic clinical and laboratory findings could contribute to the early diagnosis of rheumatic diseases. METHODS: Forty-six consecutive TN patients, 67% female, mean disease duration 8.78 +/- 7.25 years, and 47 controls were initially interviewed using a standard questionnaire based on common signs/symptoms of systemic lupus erythematosus, Sjögren syndrome, mixed CTD, and systemic sclerosis. Autoantibodies were detected by standard techniques. Those with rheumatologic complaints or positive autoantibodies were referred to the Rheumatology Outpatient Clinic for a more detailed evaluation. Secondary causes of TN were excluded. RESULTS: The frequency of Raynaud phenomenon (P = 0.026) and ANA reactivity (P = 0.04) were significantly higher in TN patients compared with controls. Fourteen TN patients were ANA positive. Seven of them reported concomitant rheumatic complaints, and interestingly, diffuse CTD was diagnosed in 4 (57%) of these patients: 1 systemic lupus erythematosus; 2 Sjögren syndrome; and 1 undifferentiated disease with scleritis and positive parotid scintigraphy. In all cases, TN preceded by at least 10 months the rheumatologic signs/symptoms. Moreover, these 4 TN patients with CTD had a higher frequency of sicca symptoms (P = 0.001) and higher titers of ANA (>or=1:320) (P = 0.006) than the remaining 42 TN patients without CTD diagnoses. Sixteen patients had isolated laboratory or clinical abnormalities, and none of them had CTD diagnoses. CONCLUSIONS: The concomitant presence of sicca symptoms and high titer ANA are clues for the early investigation of rheumatic diseases in TN patients.

Cardiovascular response during trigeminal ganglion compression for trigeminal neuralgia according to the use of local anesthetics.

OBJECTIVES: There are controversies about the use of local anesthetics during balloon compression for trigeminal neuralgia (TN) as a protective factor for cardiovascular events. The objective of this study was to investigate cardiovascular parameters (blood pressure and heart rate [HR]) of patients that underwent trigeminal balloon compression with local anesthetics compared to a control group (placebo). METHODS: This is a randomized controlled study; 55 patients were randomized into two groups: study (deep sedation and trigeminal block with 0.8-mL lidocaine 2%) and control group (deep sedation and trigeminal injection of 0.8-mL saline). Blood pressure and HR were measured in five distinct moments: preoperative, during puncture for local anesthesia/placebo, during puncture with the catheter, during balloon compression, and final evaluation. Statistical analysis was performed with Pearson's chi (2) and McNemar tests and the analysis of variance for repetitive measures. RESULTS: The means of systolic and diastolic blood pressures (SBP and DBP, respectively) were higher in the control group when compared to the study group at the evaluation during puncture with the catheter (p < 0.001) and balloon compression (p < 0.001 and p = 0.018 for DBP and SBP, respectively). There was an increase in the HR in the control group during the procedure (p = 0.017). CONCLUSION: The use of local anesthetics during the trigeminal balloon compression for TN can have a preventive role for the risk of cardiovascular events.

Perfil epidemiológico dos pacientes com lesão medular e siringomielia pós-traumática da AACD / Epidemiology of spinal cord injury and posttraumatic syringomyelia in the AACD

A siringomielia pode ser uma complicação grave nos pacientes com lesão medular (LM) de etiologia traumática. O conhecimento do perfil dos doentes com maior risco de desenvolver a siringomielia pode facilitar o seu rastreamento. O objetivo deste estudo é descrever o perfil epidemiológico dos pacientes com lesão medular de origem traumática que evoluíram com piora neurológica e que tiveram o diagnóstico de siringomielia confirmado por ressonância magnética, atendidos na Associação de Assistência à Criança Deficiente (AACD), no período entre janeiro de 2004 a abril de 2008. Foi realizado um estudo retrospectivo a partir da análise de prontuários. Doze doentes foram incluídos no estudo. Todos eram do sexo masculino e apresentaram média de idade de 46,7 anos. O acidente de trânsito foi a causa mais frequente da LM e a metade dos pacientes havia sido submetida ao tratamento cirúrgico na fase aguda. 75% dos pacientes apresentaram lesão completa. A média de tempo decorrido entre a LM e o diagnóstico da siringomielia foi de 5,6 anos. Parestesia nos membros superiores e na região cervical, dor e da diminuição da força foram as queixas mais frequentes. Em 83,3% dos casos a cavidade siringomiélica comprometia o nível da lesão medular e extendia-se cranialmente. Sete pacientes foram submetidos à drenagem da cavidade, destes, dois apresentaram melhora. Quatro dos 12 pacientes (33,3%) evoluíram com piora funcional.

Diferential diagnosis in atypical facial pain: a clinical study.

OBJECTIVE: To evaluate a sample of patients with atypical facial pain (AFP) in comparison to patients with symptomatic facial pain (SFP). METHOD: 41 patients with previous diagnostic of AFP were submitted to a standardized evaluation protocol, by a multidisciplinary pain team. RESULTS: 21 (51.2%) were considered AFP and 20 (48.8%) (SFP) received the following diagnosis: 8 (40.0%) had temporomandibular disorders (TMD); 3 (15.0%) had TMD associated to systemic disease (fibromyalgia, systemic erythematosus lupus); 4 (20.0%) had neuropathy after ear, nose and throat (ENT) surgery for petroclival tumor; 2 (10.0%) had Wallenberg syndrome; 1 (5.0%) had intracranial tumor; 1 (5.0%) had oral cancer (epidermoid carcinoma), and 1 (5.0%) had burning mouth syndrome (BMS) associated to fibromyalgia. Spontaneous descriptors of pain were not different between AFP and SFP groups (p=0.82). Allodynia was frequent in SFP (p=0.05) and emotion was the triggering factor most prevalent in AFP (p=0.06). AFP patients had more traumatic events previously to pain (p=0.001). CONCLUSION: AFP patients had more: a) traumatic events previously to pain onset, and b) emotions as a triggering factor for pain. These data support the need of trained health professionals in multidisciplinary groups for the accurate diagnosis and treatment of these patients.

Diferential diagnosis in atypical facial pain: a clinical study

OBJETIVE: To evaluate a sample of patients with atypical facial pain (AFP) in comparison to patients with symptomatic facial pain (SFP). METHOD: 41 patients with previous diagnostic of AFP were submitted to a standardized evaluation protocol, by a multidisciplinary pain team. RESULTS: 21 (51.2 percent) were considered AFP and 20 (48.8 percent) (SFP) received the following diagnosis: 8 (40.0 percent) had temporomandibular disorders (TMD); 3 (15.0 percent) had TMD associated to systemic disease (fibromyalgia, systemic erythematosus lupus); 4 (20.0 percent) had neuropathy after ear, nose and throat (ENT) surgery for petroclival tumor; 2 (10.0 percent) had Wallenberg syndrome; 1 (5.0 percent) had intracranial tumor; 1 (5.0 percent) had oral cancer (epidermoid carcinoma), and 1 (5.0 percent) had burning mouth syndrome (BMS) associated to fibromyalgia. Spontaneous descriptors of pain were not different between AFP and SFP groups (p=0.82). Allodynia was frequent in SFP (p=0.05) and emotion was the triggering factor most prevalent in AFP (p=0.06). AFP patients had more traumatic events previously to pain (p=0.001). CONCLUSION: AFP patients had more: a) traumatic events previously to pain onset, and b) emotions as a triggering factor for pain. These data support the need of trained health professionals in multidisciplinary groups for the accurate diagnosis and treatment of these patients.

OBJETIVO: Avaliar uma amostra de pacientes com dor facial atípica (DFA) e compará-la a outra com dor facial sintomática (DFS). MÉTODO: 41 pacientes com diagnóstico prévio de DFA foram submetidos a um protocolo padronizado de avaliação aplicado por uma equipe multidisciplinar. RESULTADOS: 21 (51,2 por cento) foram mantidos com o diagnóstico de DFA e 20 (48,8 por cento) (DFS) receberam os seguintes diagnósticos: 8 (40.0 por cento) tinham disfunções temporomandibulares (DTM); 3 (15,0 por cento) tinham DTM associada a doença sistêmica (fibromialgia, lupus eritematoso sistêmico); 4 (20,0 por cento) tinham neuropatia após cirurgia otorrinolaringológica (ORL) para tumor petroclival; 2 (10,0 por cento) tinham síndrome de Wallenberg; 1 (5,0 por cento) tinha um tumor intracraniano; 1 (5,0 por cento) tinha câncer oral (carcinoma epidermóide), e 1 (5,0 por cento) tinha síndrome da ardência bucal (SAB) associada à fibromialgia. Expressões espontâneas utilizadas para a dor não diferiram entre os 2 grupos (p=0,82). Alodínia foi freqüente nos doentes com DFS (p=0,05) e emoções foi o fator desencadeante mais comum no grupo com DFA (p=0,06). Doentes com DFA apresentaram mais eventos traumáticos anteriores ao início da dor (p=0,001). CONCLUSÃO: Pacientes com DFA apresentaram mais: a) eventos traumáticos anteriores à cirurgia e b) emoções como fator desencadeante de dor. Estes dados realçam a necessidade de profissionais treinados em dor nas equipes multidisciplinares para o diagnóstico preciso e tratamento adequado desses doentes.

Frequency of postoperative complications after balloon compression for idiopathic trigeminal neuralgia: prospective study.

BACKGROUND: Idiopathic trigeminal neuralgia (ITN) is often treated with balloon compression, considered in the literature to be a safer and more efficient procedure than other surgeries, with a high success rate. METHODS: This study evaluated 105 patients with idiopathic trigeminal neuralgia who underwent balloon compression of the trigeminal ganglion, with a follow-up of 210 days, and clinical questionnaires and a systematic physical evaluation used as instruments. RESULTS: There was a significant decrease in the shock-like complaint (P < .001), although 66.3% still experienced pain after 7 days of surgery from other causes; 50.5% presented limitation during jaw activities. Other complaints were hearing, taste and/or smelling loss, and visual difficulties. One patient had a TMJ ankylosis and needed surgical TMJ treatment. CONCLUSIONS: Although neurosurgery in the treatment of severe ITN pain is known to provide relief and its importance is recognized, there may also be severe complications that could compromise habitual tasks to various degrees. Therefore, the patient needs to be alerted about all complaints that he or she might present after the procedure. The professional has a duty to correctly inform and alert every patient under his or her care.

Idiopathic trigeminal neuralgia: clinical aspects and dental procedures.

OBJECTIVE: Evaluation of the characteristics and dental treatments in a Brazilian series of idiopathic trigeminal neuralgia (ITN) patients. STUDY DESIGN: Forty-eight subjects with ITN were interviewed and evaluated according to a systematized approach. FINDINGS: (a) location of the trigger zone, intraoral in 64.58%; (b) comorbidities, 18 patients (hypertension in 9); (c) treatment with dental procedures for ITN according to duration of pain (31), 44.44% (during the first year), 50.00% (1-5 years), 80.00% (5-10 years), and 100.00% (>10 years). There was no correlation between trigger zone location and the frequency of previous dental procedures (P=.667). There was significant statistical correlation between the number of patients who underwent dental treatments and the duration of ITN (P=.004). CONCLUSION: (a) Demographic characteristics of this sample are similar to those described in the literature, (b) the dental procedures were not correlated with location of trigger zone, and (c) patients with long-lasting ITN had more number of previous dental procedures.

Movement disorders induced by peripheral trauma.

Movement disorders induced by central nervous system trauma are well recognized. However, over the last few years, attention has been drawn to the role of peripherally induced movement disorders. We describe three patients presenting respectively dystonia, tremor and choreoathetosis associated with tremor and dystonia of the body parts previously exposed to traumatic injuries. Pathophysiological mechanisms underlying these phenomena are not entirely known, but functional changes in afferent neuronal input to the spinal cord and secondary affection of higher brain stem and subcortical centers are probably involved.

Movement disorders induced by peripheral trauma

Movement disorders induced by central nervous system trauma are well recognized. However, over the last few years, attention has been drawn to the role of peripherally induced movement disorders. We describe three patients presenting respectively dystonia, tremor and choreoathetosis associated with tremor and dystonia of the body parts previously exposed to traumatic injuries. Pathophysiological mechanisms underlying these phenomena are not entirely known, but functional changes in afferent neuronal input to the spinal cord and secondary affection of higher brain stem and subcortical centers are probably involved

Dor facial e dor facial sintomática: caracterizaçäo diferencial quanto à apresentaçäo clínica / Atypical facial pain and symptomatic facial pain: differential characterzation as for the clinical presentation

Objetivo: Caracterizar uma amostra de doentes com histórico de dor facial atípica, avaliar comparativamente dados dos históricos de doentes com dor facial atípica e dor facial sintomática e analisar a ocorrência de anormalidades psicológicas em doentes com histórico de dor facial atípica. Método: Identificação e categorização de aspectos da dor, exame clínico e exames laboratoriais e radiológicos (hematológicos, bioquímicos, radiografia do crânio, coluna cervical, mandíbula, articulação têmporo-mandibular, tomografia computadorizada do crânio) de 41 doentes com histórico de DFA. Resultados: o diagnóstico foi DFA em 21 (51,2 por cento) doentes e DFS em 20 (48,8 por cento). Era do sexo feminino 80,0 por cento dos casos de DFS e 57,1 por cento dos de DFA. Disfunção têmporo-mandibular (DTM)desdentado foi o diagnóstico em 25,0 por cento dos casos de DFS, neuropatia iatrogênica em 20,0 por cento, DTMdoença sistêmica em 15,0 por cento, outras DTMs em 15,0 por cento e síndrome de Wallemberg em 10,0 por cento; carcinoma de língua, tumor intracraniano ou ardência bucal foram diagnosticados, respectivamente, em um (5,0 por cento) doente. DFA foi mais prevalente (28,6 por cento) nos doentes com 41 a 50 anos e 61 a 70 anos de idade e DFS nos com 41 a 50 anos (30,0 por cento). Latejamento (76,2 por cento), aperto (57,1 por cento) e ou queimor (52,4 por cento) foram os descritores mais empregados pelos doentes com DFA e latejamento (60,0 por cento), queimor (45,0 por cento) e ou pontada (35,0 por cento) pelos doentes com DFS. A dor localizou-se à esquerda em 42,8 por cento dos casos de DFA e em 50,0 por cento dos de DFS e no território do segundo ramo do nervo trigêmeo em 38,2 por cento doentes com DFA e do terceiro ramo em 25,0 por cento dos com DFS. Foi intensa (EVA >_ 7) em 71,4 por cento doentes com DFA e em 85,0 por cento dos com DFS e apenas constante em 74,9 por cento e 72,8 por cento dos doentes, respectivamente. Lacrimejamento havia sido relatado por 28,6 por cento doentes com DFA e em 25,0 por cento dos com DFS. Em 4,8 por cento dos...(au)

Neuralgia essencial do nervo trigêmeo. Análise de 105 casos / Esential trigeminal neuralgia. Analysis of 105 cases

Os autores analisam seqüencialmente os aspectos clínicos e terapêuticos de 105 doentes em neuralgia do trigêmeo. A média de idades foi de 61,6 anos; 64,8 por cento dos doentes eram do sexo feminino. A dor foi descrita, mais freqüentemente, como choque de curta duração, esteve principalmente localizada no território da segunda divisão do nervo trigêmeo e o mecanismo-gatilho mais comum foi a mastigação. O tratamento medicamentoso em todos os casos constituiu no uso da carbamazepina em doses crescentes. Quando ocorreram efeitos indesejáveis, a fenitoína foi a droga substituta em 7,1 por cento dos casos. Apesar de ter ocorrido melhora inicial na maioria dos casos, 40 (47 por cento) doentes necessitaram de tratamento cirúrgico: a rizotomia percutânea mecânica com balão do nervo trigêmeo foi o único procedimento em 95,9 por cento desses casos; a rizotomia percutânea por radiofreqüência foi necessária em 4,1 por cento dos casos, todos refratários à compressão. Todos os doentes apresentaram melhora significativa da sintomatologia após a execução dos procedimentos operatórios.

Nucleotratotomia trigeminal estereotáxica no tratamento da dor facial atípica / Stereotactic trigeminal nucleotractotomy for treatment of atypical facial pain

As características funcionais e morfológicas da face, aliadas à complexidade do fenômeno doloroso, tornam favorável a existência de inúmeras fontes de dor facial, como procuraram demonstrar as várias classificações existentes a respeito. A nucleotratotomia trigeminal consistena ablação cirúrgica de núcleos trigeminais de segunda ordem e tratos.Dois casos de dor facial atípica refratários ao tratamento medicamentoso ou a outras formas nãooperatórias são discutidos. A intensidade da dor pré e pós-operatória foi avaliada pela Escala Visual Analógica. A técnica operatória é descrita. Os resultados imediatos foram satisfatórios em ambos os casos. Um doente teve recidiva da dor, com menor intensidade, dois meses após o procedimento e o outro estava assintomático oitomeses depois. Um doente apresentou ataxia transitória que regrediu em dois meses; o outro teve meningite bacteriana no pós-operatório. Aspectos terapêuticos e as bases fisiopatológicas da indicação cirúrgica são apresentados.

The functional and morphologic peculiarities of the face justify the occurrence of varied sources of pain. The trigeminal nucleotractotomy consists in a surgical lesion of secundary trigeminal nuclei and tracts.Two cases of atypical facial pain refractory to clinical treatments are discussed. The intensity of pain was evaluated by the Visual Analogic Scale. The surgical technique is described. The immediate results were satisfactory. One patient developed recurrent pain two months later,and the other was asymptomatic for eight months. One patient presented transitory ataxia and the other developed bacterial meningitis. The physiopathological basis of this procedure is discussed.

Dor facial atípica: caracterização de uma amostra / Atypical facial pain: characterization of a sample

As características funcionais e morfológicas da face, aliadas à complexidade do fenômeno doloroso, tornam a face favorável à existência de inúmeras fontes de dor como procuram demonstrar as várias classificaçöes existentes a respeito. No período de janeiro de 19986 a março de 1993, 57 dorntes com dor facial de etiologia incerta foram submetidos a avaliaçöes neurológica, bucomaxilofacial, psiquiátrica, psicológica e de medicina física. Foram também investigados, por procedimentos de imagem do crânio, coluna cervical e exames de laboratório, incluindo o do líquido cefalorraquidiano. A idade média dos doentes foi de 51 anos. Trinta e nove doentes (68 por cento) eram do sexo feminino. O tempo de história da dor variou de 1 mês a 23 anos, com média de 61,8 meses. A dor em queimação foi a mais frequente (43 por cento) seguida de latejante (33 por cento)...