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PubMed1999

Convergence of meningeal and facial afferents onto trigeminal brainstem neurons: an electrophysiological study in rat and man.

Headache is often accompanied by referred pain in the face. This phenomenon is probably due to a convergence of afferent inputs from the meninges and the face onto central trigeminal neurons within the medullary dorsal horn (MDH). The possible existence and extent of this convergence was examined in rat and man. MDH neurons activated by stimulation of the parietal meninges were tested for convergent tactile and noxious mechanical input from all three facial branches of the trigeminal nerve. All 21 units with meningeal input could also be activated by facial stimuli. Brush stimuli applied to the supraorbital nerve area activated 86%, to the infraorbital nerve area 29%, and to the mental nerve area none of the units. Pinch stimuli applied to the supraorbital nerve area activated 95%, to the infraorbital nerve area 86%, and to the mental nerve area 52% of the units. The results suggest convergence of meningeal and facial inputs concentrated on the supraorbital nerve in rat. In man convergence was examined by probing neuronal excitability of MDH applying the blink reflex (BR) during Valsalva maneuver which probably increases intracranial pressure. The BR evoked by supraorbital nerve stimulation remained unchanged, while the BR evoked by mental nerve stimulation was significantly facilitated. This facilitation may be due to convergence of meningeal and facial inputs onto trigeminal neurons in man.

Adult↗

PubMed2004

The neck and headaches.

Referred pain from disorders of the cervical spine can be perceived as headache. The mechanism is convergence between trigeminal afferents and afferents of the upper three cervical nerves in the trigeminocervical nucleus. Cervicogenic headache cannot be diagnosed on clinical grounds alone. The definitive criterion is complete relief of pain after controlled diagnostic blocks of cervical structures or their nerve supply. The most rigorously studied example of cervicogenic headache is third occipital headache.

Headache↗

PubMed2000

Ultrasound of the adult hip.

The adult hip is a new and challenging site for evaluation with ultrasound (US). Clinically, diseases involving the hip region may be difficult to diagnose without the help of imaging. The hip region is a crossroad for numerous vascular, nervous, and muscular structures that pass between the trunk and the lower extremity. Thus, inflammatory processes and neoplasms may spread to and from the hip, buttock, thigh, pelvis, and retroperitoneum, and trauma may also effect the adjacent areas of the trunk and thigh. Because it is a crossroad, many conditions that are not specific to the hip occur in this area, including inguinal lymphadenopathy, pathology from the abdomen or the genitalia (intestinal hernia, inflammation, and infection), and even referred pain from spinal disorders. The goals of US imaging are the detection and localization of these pathological processes, the differentiation of intra-articular andextra-articular pathology, and the performance of diagnostic and therapeutic interventional procedures. This article reviews the hip anatomy, followed up by a discussion of the US evaluation and differential diagnosis of common pathology occurring in the hip area. This includes joint effusion, arthritis, loose bodies, bursitis, pseudoaneurysm, muscle and tendon diseases, as well as tumor and tumor-like lesions such as hematoma, abscess, and lymphadenopathy.

Abscess↗

PubMed1987

Clinical aspects of pseudodysphagia.

Pseudodysphagia is the description of the sensation of a feeling of a lump in the throat--commonly known as the globus symptom. A prospective analysis of 145 consecutive patients with this symptom seen by an Otolaryngologist has provided confirmation that a high proportion of these patients have a treatable basis for their complaints and that most can be successfully managed without time-consuming and expensive investigations--provided clinical evaluation includes thorough visualisation of the oropharynx and supraglottis. The explanation for the symptomatology in patients who suffer from reflux oesophagitis is probably referred pain from the region of the lower oesophageal sphincter rather than spasm of the upper sphincter. The expression globus hystericus is outdated and should be discarded, and we recommended describing the symptoms as primary globus pharyngeus when there is no evident cause and secondary globus pharyngeus when the aetiology is detectable.

Adolescent↗

PubMed1995

Atypical carcinoid tumour of the larynx.

The case of an atypical carcinoid tumour of the larynx is described in a 65-year-old man. This rare tumour may present diagnostic difficulties, but the diagnosis should be considered in a patient presenting with symptoms of local or referred pain and an apparently small, non-ulcerating supraglottic tumour. Immunocytochemistry has an important role in establishing the diagnosis. A very unusual feature of this case was positive staining for S-100 protein by sustentacular cells. Atypical carcinoid tumours do not respond well to radiotherapy so the primary treatment should be surgical resection.

Aged↗

PubMed1997

Should imaging at stress always be followed by imaging at rest in Tc-99m MIBI SPECT? A proposal for a selective referral and imaging strategy.

OBJECTIVES: We addressed the question whether in patients with cardiac chest pain referred for stress myocardial perfusion scintigraphy, Tc-99m MIBI SPECT stress imaging should always be followed by a rest imaging procedure. BACKGROUND: Using Tc-99m MIBI imaging a stress rest sequence is usually performed implying that the resting study always follows the stress study irrespective of the results of the stress study. As a normal stress study would eliminate a subsequent resting study, it appears desirable to potentially define certain subsets of patients in whom a normal stress study can be expected in order to determine a more selective referral approach to the nuclear medicine department. The consequences of such a more streamlined approach would less impose on the logistics of the department of nuclear medicine, with decrease of investigation time, radiation dose, and costs in a time of retrenchment in the medical sector. METHODS: A consecutive series of 460 patients (mean age 58.2 years) was studied who were stratified to 269 patients without prior myocardial infarction, and to 191 patients with documented evidence of a previously sustained myocardial infarction. All patients underwent Tc-99m MIBI SPECT imaging according to a two-day stress-rest protocol. RESULTS: Patients with and without a previous myocardial infarction showed suboptimal overall predictive accuracies for the exercise electrocardiograms (58% and 60%, respectively). In the total group of 460 patients, 94 (20%) patients showed a normal stress-rest Tc-99m MIBI SPECT; this occurred in 86/269 (32%) patients without a previous myocardial infarction and in only 8/191 (4%) patients with a previous myocardial infarction. CONCLUSIONS: Patients with a stress defect at Tc-99m MIBI SPECT imaging should always undergo a resting SPECT study irrespective of the clinical and stress electrocardiographic findings. As patients without a previous myocardial infarction had a normal stress SPECT study in almost one-third (32%) of patients compared to only 4% in patients with a previously myocardial infarction, it may be useful to employ different referral and imaging strategies i.e., a stress-only versus a stress-rest procedure. To schedule referring patients differently according to the presence or absence of a previously sustained myocardial infarction may be cost-saving, less demanding for the nuclear medicine personnel, and patient-convenient. In addition, a stress-only imaging procedure reduces radiation exposure to the individual patient.

Adult↗

PubMed2001

Peyronie's disease: epidemiology and clinical presentation of 134 cases.

OBJECTIVE: To investigate epidemiological and clinical features of Peyronie's disease in an unselected group of patients not seen by a urologist before. PATIENTS AND METHODS: A series of 134 consecutive cases with Peyronie's disease was evaluated regarding to the age at diagnosis, the symptoms and signs of the disease, and the site and formation of the scar. The medical history which could be possibly related with the onset of the disease was investigated as well. RESULTS: The disease mainly affected middle-aged men. While all men had a palpable scar, only 51 (38%) had noticed the induration. Curvature (mean: 35 degrees) appeared in 87 men (65%) and caused sexual dysfunction due to severe penile deformity in 16 men (11.9%). 53 patients (39.5%) referred painful erections. In 11 men (8.2%) the onset of the disease was noticed after auto-injections of vaso-active drugs for the treatment of previous erectile dysfunction, while 18 (13.4%) had a history of penile trauma during sexual intercourse or manipulation. No specific relation with diabetes mellitus and Duputren's contracture was identified. Scars, like elongated indurations with vague bounds, were mainly formed (77.6%) in the dorsal midline. CONCLUSIONS: The mean age of patients at diagnosis, the site of penile scars, and the activities of the affected men could advocate the hypothesis that trauma is the main causal factor for Peyronie's disease. In 21.6% of the patients, the lesion occurred after a traumatic activity. Sexual dysfunction due to severe penile curvature affected a small proportion of the patients. Thus, due to the diminution of pain spontaneously or after treatment, the patients with Peyronie's disease may have a normal life with satisfactory sexual function. In some selected cases surgery offers an effective result.

Adult↗

PubMed2003

Infection--an underappreciated cause of bone pain in multiple myeloma.

Bone pain, especially back pain, is a common presenting feature of myeloma patients. We report three multiple myeloma patients with exacerbations of back pain and referred shoulder pain resulting from vertebral infections. Two patients were treated with surgery, and one patient had computerized tomography-guided percutaneous needle aspiration for diagnostic purposes. All three patients received a prolonged course of antibiotics. Vertebral infection resolved with this treatment in all three patients without any recurrence. Previous dexamethasone therapy, together with an episode of bacteraemia, appears to be a predisposing factor for vertebral infection. Magnetic resonance imaging enabled the diagnosis in all three patients.

Aged↗

PubMed2003

MRI in greater trochanter pain syndrome.

The greater trochanter pain syndrome refers to pain on the lateral aspect of the hip joint. This is frequently attributed to trochanteric bursitis and distension of the subgluteal bursae. Associated tears of the tendons of gluteus medius and minimus have been described and may result from repetitive frictional trauma to these tendons and their associated bursae secondary to impingement beneath the tensor fascia lata. Occasionally tendinous damage may result from acute local direct trauma or a hyperadductive strain injury. We describe MRI in two patients with chronic lateral hip pain.

Aged↗

PubMed1998

Endoscopic laser foraminoplasty on the lumbar spine--early experience.

Since April 1995 this endoscope assisted laser technique has been used for widening the lumbar exit route foramina. Patient selection included individuals with primarily unilateral sciatica as well as low back pain and referred buttock pain following various operative interventions. Endoscopic laser foraminoplasty (ELF) utilises an endoscope, a uniportal posterolateral approach and a side firing holmium laser probe. Under direct vision and within the protection of saline solution, epidural scarring, extruded and sequestrated disc protrusions and/or osteophytes are removed by holmium laser ablation. The patient is responsive and aware under neurolept analgesia and this ensures the protection and the integrity of the nerve root. A total of 219 such interventions has been performed up to January 1, 1997. The first 48 cases with a follow-up exceeding 12 months have been included in this preliminary review. Initial experience is encouraging. The ELF seems to provide another means of addressing sequelae of primary degenerative disorders as well as the common consequences of conventional spine surgery. ELF provides an alternative to minimal intervention fenestrectomy and open surgical undercutting for predominantly unisegmental and unilateral lateral recess stenosis and in selected cases it may prevent or delay the indication of spinal fusion.

Adult↗

PubMedDate not supplied

[Lipoatrophia semicircularis--an orthopedic diagnosis?].

INTRODUCTION: Lipoatrophia semicircularis (LAS) represents an isolated fatty atrophy usually located at the lower extremity. The atrophy is circular and painless and usually resolves without therapy. The skin modifications occur within a few days or weeks. The etiology is unknown. CASE: In the following we present a case of LAS with a segmental dysfunction of the third ipsilateral lumbal root of a 43-year-old women. It was possible to provoke a referred pain into the area of atrophy by passive motion of the lumbal spine into the plane of resistant. CONCLUSION: LAS is rare and slightly known among orthopedists. Knowledge of the typical morphological modifications will lead to diagnosis. In most of the cases further diagnostic measures are not necessary. We recommend a segmental investigation of the spine in the case of secured diagnosis.

Adipose Tissue↗

PubMed1992

[Lemierre's syndrome with splenic abscesses].

A week after onset of a pharyngo-tonsillitis a previously healthy 23-year-old man developed high fever (41.4 degrees C), leukocytosis (12,200/microliters) with marked shift to the left, thrombocytopenia (86,000/microliters) and increased transaminases (GOT 83 U/l, GPT 113 U/l). Chest x-ray film suggested intrapulmonary abscesses with left-sided pleural effusion. The suspected diagnosis of "post-tonsillitis" septicaemia (Lemierre's syndrome) was confirmed by demonstrating anaerobic, fusiform, gram-negative bacteria (Fusobacterium nucleatum and necrophorum) in several blood cultures. Despite antibacterial treatment (amoxicillin/clavulanic acid, imipenem/cilastatin, clindamycin) he had recurrent pain referred to the kidney region and persisting fever. Repeated ultrasound and radiological examinations revealed new foci in the spleen, which were enlarging. Laparotomy with splenectomy performed on day 17 after the begin of treatment confirmed multiple splenic abscesses, but abscess pus and splenic tissue were sterile. After altogether 6 weeks of antibiotic treatment, finally with chloramphenicol, the patient was discharged in a good general state.

Abscess↗

PubMed1999

Inflammation of the rat urinary bladder is associated with a referred thermal hyperalgesia which is nerve growth factor dependent.

We have assessed whether a referred somatic hyperalgesia to thermal stimulation of the hind limb of rats occurs after inflammation of the urinary bladder. Furthermore, we evaluated whether any such viscero-somatic hyperalgesia (VSH) is dependent on the neurotrophin nerve growth factor (NGF). Limb withdrawal thresholds from thermal stimulation of both fore and hind limbs were assessed simultaneously at baseline and at fixed times for 24 h after various interventions. After plotting curves for the difference in withdrawal time of fore and hind limbs against time, the area under the curve (AUC) was calculated to provide a single measure over the 24-h period. A negative value indicated relative hyperalgesia of the hind limb. With simple catheterization, although there was a trend towards hind limb hyperalgesia, there was no significant difference in this AUC (mean -100.5) compared with naïve control animals (mean AUC +53.6). However, inflammation with 50% turpentine oil was associated with a significant change in AUC (mean -676.8), indicative of relative hyperalgesia of the hind limb. This hyperalgesia was mimicked by intra-vesical instillation of NGF (in place of turpentine) (mean AUC -1418.3 while mean AUC in naïve animals was +439.4). Furthermore, prior administration of an NGF sequestering molecule, trkA-IgG, attenuated turpentine-induced VSH. These findings increase our knowledge of the nature of visceral and referred pain and further implicate NGF in the hyperalgesic response to inflammation of the urinary bladder.

Animals↗

PubMed1998

Convergence of nociceptive and non-nociceptive input onto the medullary dorsal horn in man.

Referred pain arising in orofacial pain states is probably due to convergence of different somatosensory input onto the medullary dorsal horn (MDH). To examine convergence between nociceptive and non-nociceptive input onto the MDH, the blink reflex (BR) was applied. R1- and R2-components can be evoked by innocuous stimuli, but only the R2 is elicited by painful heat. The BR was elicited by innocuous electrical stimuli applied to the supraorbital nerve. A conditioning painful heat pulse which did not evoke any BR was homotopically applied to the left forehead preceding the electrical stimulus by 75 ms. While R1 remained unchanged, the R2 was facilitated by about 30%. This study demonstrates a convergence of low-threshold mechanoreceptive and nociceptive inputs onto interneurons of the MDH in man.

Adult↗

PubMed2001

International Headache Society headache diagnostic patterns in pain facility patients.

OBJECTIVE: Previous studies have indicated that many patients with chronic pain (PWCP) referred to pain facilities for the treatment of neck and/or low back pain complain of associated headaches. The purpose of this study was to characterize the nature of these headaches according to International Headache Society (IHS) headache diagnostic criteria. DESIGN: In preparation for this study, a questionnaire that reflected IHS headache diagnostic criteria was developed. All consecutive patients admitted to our pain facility complaining of headache completed this questionnaire and received a physical and neurologic examination focused on key aspects of headache. A headache interview was also conducted, using the questionnaire as a question guide. All questionnaires were entered in a computerized database, and IHS diagnoses were arrived at for each patient. As many IHS diagnoses as possible were assigned to each PWCP as long as IHS criteria were fulfilled. In addition, a frequency distribution for headache precipitants and neck-associated symptoms was developed and evaluated by discriminant analysis to determine the diagnostic value of these factors in relation to each IHS diagnostic group. SETTING: Pain facility (multidisciplinary pain center). PATIENTS: Consecutive PWCP. RESULTS: Of 1,466 PWCP, 154 (10.5%) were identified as suffering from severe headache interfering with function. Of these, 55.8% indicated that their headaches were related to an injury for which they were seeking treatment and 83.7% had neck pain. Migraine headache represented the most common diagnostic group (90.3%), with cervicogenic headache representing the second most common (33.8%). Of the total group, 44.2% had more than one headache diagnosis, that is, there was overlap. Cervicogenic headache patients had the greatest percentage of overlap (94.2%), with migraine patients being second (68.3%). The most frequent headache precipitant was mental stress, followed by neck position and activity/exercise. The migraine and cervicogenic headache groups had a statistically significant greater number of neck-associated symptoms when compared with the remaining patients. Of the total headache group, 74.6% complained that they had a tender point at the back of their neck. Cervicogenic, migraine, and tension PWCP had the greatest frequency of head or neck tender points. The discriminant analysis for neck-associated symptoms yielded the following symptoms as the most common predictors of headache across IHS diagnostic groups: clues to onset were severe headache beginning at the neck or tender point and numbness in arms and legs; headache brought on by neck position and arms overhead; and neck symptoms consisting of a tender point in the neck and feeling severe headache in the neck. CONCLUSIONS: Headache can and should be considered a frequent comorbid condition in PWCP. Because of the overlap data, more precise diagnostic criteria may be required to separate cervicogenic headache from migraine headache. Neck-associated symptoms seem to be important even to those PWCP diagnosed with migraine headache.

Headache↗

PubMed1981

Increased focal uptake of Tc-99m-IDA hepatobiliary agent by a liver metastasis.

A patient with fever and right upper quadrant abdominal pain referred for a hepatobiliary scan. TC-99m-PIPIDA scanning revealed a hypervascular hepatic focus that persisted as a "hot spot" in delayed views. Ga-67-citrate scanning revealed increased uptake in the same hepatic focus. The patient suddenly died. Postmortem examination revealed that this abnormal site represented a necrotic tumor histologically compatible with metastatic breast carcinoma.

Aged↗

PubMed1990

The "warm" sacroiliac joint. A finding in pelvic abscess.

Two patients with pain referable to the low back and sacroiliac regions had bone scans with similar findings. In each, one sacroiliac joint was "warm" (uptake on that side was slightly greater than that in the contralateral area). Ga-67 imaging also demonstrated increased uptake in the same locale. Subsequent CT scanning revealed pelvic abscesses adjacent to the affected joints. Asymmetric uptake of bone imaging agent may have been related to hyperemia and "heating" of the sacroiliac joint. Rapid defervescence with antibiotics and drainage (and no CT evidence of bone involvement) suggested that osteomyelitis was not involved in these cases.

Abscess↗

PubMed1984

Computed tomography of pneumatosis intestinalis.

Four cases of pneumatosis intestinalis detected by computed tomography (CT) are described. Plain abdominal films obtained on the same day as CT failed to show pneumatosis in three of the four cases. The CT appearances characteristic of pneumatosis intestinalis are cystic, linear, or curvilinear gas collections in the periphery of distended, partly fluid-filled loops of bowel. Two of the four cases had underlying bowel infarction. Evidence of pneumatosis should be carefully looked for in patients with acute abdominal pain referred for CT examination. Computed tomography may be a useful modality for the early diagnosis of bowel ischemia when plain abdominal films are noncontributory.

Abdomen, Acute↗