OBJECT Occipital neuralgia (ON) causes chronic pain in the cutaneous distribution of the greater and lesser occipital nerves. The long-term efficacy of cervical dorsal root rhizotomy (CDR) in the management of ON has not been well described. The authors reviewed their 14-year experience with CDR to assess pain relief and functional outcomes in patients with medically refractory ON. METHODS A retrospective chart review of 75 ON patients who underwent cervical dorsal root rhizotomy, from 1998 to 2012, was performed. Fifty-five patients were included because they met the International Headache Society's (IHS) diagnostic criteria for ON, responded to CT-guided nerve blocks at the C-2 dorsal nerve root, and had at least one follow-up visit. Telephone interviews were additionally used to obtain data on patient satisfaction. RESULTS Forty-two patients (76%) were female, and the average age at surgery was 46 years (range 16-80). Average follow up was 67 months (range 5-150). Etiologies of ON included the following: idiopathic (44%), posttraumatic (27%), postsurgical (22%), post-cerebrovascular accident (4%), postherpetic (2%), and postviral (2%). At last follow-up, 35 patients (64%) reported full pain relief, 11 (20%) partial relief, and 7 (16%) no pain relief. The extent of pain relief after CDR was not significantly associated with ON etiology (p = 0.43). Of 37 patients whose satisfaction-related data were obtained, 25 (68%) reported willingness to undergo repeat surgery for similar pain relief, while 11 (30%) reported no such willingness; a single patient (2%) did not answer this question. Twenty-one individuals (57%) reported that their activity level/functional state improved after surgery, 5 (13%) reported a decline, and 11 (30%) reported no difference. The most common acute postoperative complications were infections in 9% (n = 5) and CSF leaks in 5% (n = 3); chronic complications included neck pain/stiffness in 16% (n = 9) and upper-extremity symptoms in 5% (n = 3) such as trapezius weakness, shoulder pain, and arm paresthesias. CONCLUSIONS Cervical dorsal root rhizotomy provides an efficacious means for pain relief in patients with medically refractory ON. In the appropriately selected patient, it may lead to optimal outcomes with a relatively low risk of complications.

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Long-term outcomes of intradural cervical dorsal root rhizotomy for refractory occipital neuralgia.

Functional electric stimulators that produce near-ideal, charge-balanced biphasic stimulation waveforms with interphase delay are considered safer and more efficacious than conventional stimulators. An indigenously designed, low-cost, portable FES device named InStim is developed. It features a charge-balanced biphasic single channel. The authors present the complete design, mathematical analysis of the circuit and the clinical evaluation of the device. The developed circuit was tested on stroke patients affected by foot drop problems. It was tested both under laboratory conditions and in clinical settings. The key building blocks of this circuit are low dropout regulators, a DC-DC voltage booster and a single high-power current source OP-Amp with current-limiting capabilities. This allows the device to deliver high-voltage, constant current, biphasic pulses without the use of a bulky step-up transformer. The advantages of the proposed design over the currently existing devices include improved safety features (zero DC current, current-limiting mechanism and safe pulses), waveform morphology that causes less muscle fatigue, cost-effectiveness and compact power-efficient circuit design with minimal components. The device is also capable of producing appropriate ankle dorsiflexion in patients having foot drop problems of various Medical Research Council scale grades.

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Design and development of a low-cost biphasic charge-balanced functional electric stimulator and its clinical validation

Objectives: We aimed to investigate whether autonomic dysreflexia (AD) develops during urodynamic investigation in patients with spinal cord injury (SCI) with neurological level below thoracic (T) 6 together with the frequency and related factors for AD development.Study Design: Prospective study.Methods: The systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) of 51 SCI patients with a neurological level below T6 were measured and recorded at the beginning and every two minutes during the filling phase of the urodynamic study. The changes between the SBP, DBP and HR values at the beginning and end of the filling phase were analyzed.Results: Autonomic dysreflexia developed only in one of the 51 patients included into the study. The BP of this patient increased from 105/76 mmHg to 145/102 mmHg and the HR dropped from 88 beats/minute (bpm) to 69 bpm together with development of the AD symptoms. The patient was a 47-year-old male with a neurological level at T8. A significant dif...

Monitoring development of autonomic dysreflexia during urodynamic investigation in patients with spinal cord injury

We describe a case of intracerebral haemorrhage (ICH) following uncontrolled episodes of autonomic dysreflexia (AD) within 24 h of a minor urological procedure. A 33-year-old active paraplegic patient T1 Association Impairment Scale A underwent an elective suprapubic catheter (SPC) placement for bladder management. The surgery was done under general anaesthesia and was uneventful. Four hours after surgery, he developed haematuria and multiple blood clots in the urine, which eventually caused blockage of the SPC and resulted in symptomatic AD. The clots and blockage persisted, which continued to trigger repeated episodes of increased blood pressure (BP) and AD. Despite medical treatment with sublingual nitrate to lower the increased BP, the patient subsequently developed massive left ICH presenting with right upper limb weakness, facial asymmetry and inability to speak. He continued to have fluctuating BP measurements for 11 days post event with severe hypertensive and hypotensive episodes. This presented a challenge in the BP management as well as post-ICH management. He underwent an intensive neurorehabilitation programme as soon as the BP had stabilized. Severe neurological complications of AD are rare. In this case report, we highlight the importance of close monitoring of BP and AD symptoms after an SPC procedure, the challenges in BP management and the subsequent importance of an early rehabilitation programme after ICH secondary to uncontrolled AD.

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Intracerebral haemorrhage following uncontrolled autonomic dysreflexia post suprapubic catheter placement surgery.

Relationship between ankle function and walking ability for children and young adults with cerebral palsy: A systematic review of deficits and targeted interventions

Autonomic dysreflexia is a clinical emergency syndrome of uncontrolled sympathetic output that can occur in patients who have a history of spinal cord injury. Despite its frequency in spinal cord injury patients, central nervous system complications are very rare. We report a man with traumatic high level incomplete spinal cord injury who suffered hypertensive right thalamic hemorrhage secondary to an episode of autonomic dysreflexia. Prompt recognition and removal of the triggering factor, the suprapubic catheter obstruction which led to hypertensive attack, the patient had a favorable functional outcome after the resorption of the hematoma and effective rehabilitation programme.

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Acute Onset of Intracerebral Hemorrhage due to Autonomic Dysreflexia.

Occipital neuralgia (ON) is an uncommon headache disorder characterized by paroxysmal lightening-like sharp headache at the distribution of the greater or lesser occipital nerves or of the third occipital nerve [1]. Tenderness and sometimes diminished sensation or dysesthesia in the distribution of these nerves may accompany to the patient’s complaints. ON is commonly caused by trauma, such as whiplash or surgery. However, anything that irritates or compresses the occipital nerve may cause occipital neuralgia, including tight muscles, arthritic inflammation of the cervical vertebrae, or a tumor. The most common etiology of ON is idiopathic; however, trauma, prior skull base surgery, rheumatoid arthritis, nerve entrapment by hypertrophied atlanto-epistrophic C1–C2 ligament, compression by an anomalous ectatic vertebral artery, or degenerative C1–C2 arthrosis may also be causative factors for ON [2, 3]. Herpes zoster infection (HZI) results from the reactivation of varicella zoster virus (VZV) in the dorsal root ganglia and may cause shortand long-term pain during its course. Here, we report an unusual case of occipital neuralgia as an initial symptom of the HZI of the lesser occipital nerve. Case

Occipital neuralgia as an unusual manifestation of herpes zoster infection of the lesser occipital nerve: a case report.

Objectives The aim of the study was to investigate the effectiveness of electrical stimulation to agonist muscles after injection of Botulinum toxin A (BTX-A) in children with spastic diplegic cerebral palsy (SDCP). Patients and methods Between October 2009 and October 2010, 38 patients with SDCP (19 males, 19 females; mean age 6.3 years; range, 4 to 10 years) were included. The patients were able to walk independently or with minimal assistance by foot equine and had spasticity in the calf muscles between Grades 1+ and 3 according to the Modified Ashworth Scale (MAS). The patients received either BTX-A injection + electrical stimulation (Group 1, n=19) or BTX-A injection alone (Group 2, n=19). All patients were evaluated using the MAS, Penn Spasm Frequency Scale (PSFS), Gross Motor Function Measure-88 (GMFM-88) (Dimensions D and E), and walking velocity. Results A decrease in spasticity was evident for the right, left, and bilateral lower extremities for both groups (p<0.05). There were no statistically significant differences in the MAS, PSFS, GMFM-88 (Dimensions D and E), and walking velocity between the groups. Conclusion Our study results showed that both patient groups benefited from the treatment and the administration of electrical stimulation to the gastrocnemius motor points produced no additional benefit for patients with SDCP.

Effectiveness of electrical stimulation after administration of botulinum toxin in children with spastic diplegic cerebral palsy: A prospective, randomized clinical study.

Correction of drop foot is normally achieved by electrical stimulation of the common peroneal nerve by sending a series of pulses at a given frequency and duration. This article presents the design of a low-cost, programmable, portable, and high performance stimulator, designed at the Near East University. The stimulator, called the NEU-Stim, has been designed to correct the drop foot problems. For this purpose, a foot sensor, microcontroller, and electrodes are used in the design of the stimulator. The frequency, duty cycle, and the amplitude of the output waveform can easily be controlled using switches. The device is currently in experimental stage, and because of its low-cost it should find applications in developing countries after it has been completely assessed. Preliminary results on patients have shown that the device can correct the drop foot, and help patients to walk faster and more comfortably.

Design of a low-cost microcontroller-based functional electronic stimulation device for drop foot correction

Multiple system atrophy (MSA) is a late-onset, sporadic, progressive, neurodegenerative disorder clinically characterized by autonomic failure and either poorly levodopa-responsive parkinsonism or cerebellar ataxia. There isn’t any effective treatment on disease progression. Current therapeutic strategies are primarily based on dopamine replacement and improvement of autonomic failure. Clonazepam, propranolol, baclofen, amantadine, gabapentin, buspirone have also been used for symptomatic treatment of ataxia in MSA patients, but their efficacy known modest and transient. Herein we describe a MSA-C patient with disabling ataxia and sick sinus syndrome who showed distinct improvement in her symptoms after amantadine treatment and cardiac pacemaker implantation.

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Pembe Hare Yigitoglu

Papers

Acute Onset of Intracerebral Hemorrhage due to Autonomic Dysreflexia.

Occipital neuralgia as an unusual manifestation of herpes zoster infection of the lesser occipital nerve: a case report.

Effectiveness of electrical stimulation after administration of botulinum toxin in children with spastic diplegic cerebral palsy: A prospective, randomized clinical study.

Design of a low-cost microcontroller-based functional electronic stimulation device for drop foot correction

Management of balance problems in an elderly with multiple system atrophy with predominant cerebellar ataxia (MSA-C) and sick sinus syndrome