Dermatomal Pattern Research Articles

An Ambiguous Rash in an 11-Year-Old Boy

The varicella zoster virus is known for two distinct disease states, the primary varicella zoster virus and herpes zoster. Children who are vaccinated for varicella have a lower incidence of developing herpes zoster than those who have acquired the varicella virus. Regardless, vaccinated children are still at risk for developing herpes zoster and the diagnosis should be considered in patients with a clinical presentation of vesicular and erythematous lesions. An 11-year-old boy, with no significant past medical history, presented to his primary care physician for a rash on his lower back. A thorough history of possible contact exposures was ruled out and further review showed that the boy was up to date on all vaccines. The combination of his physical symptoms and appearance of the rash prompted a culture to be sent to the lab. These results returned positive for varicella zoster DNA on the corresponding polymerase chain reaction (PCR) and proper treatment was initiated. The manifestation of herpes zoster can vary in appearance and does not always present in a standard dermatomal pattern. When clinical diagnosis seems vague, pattern recognition of the distinct vesicular rash shared with a high index of suspicion due to associated symptoms should prompt the culturing of a vesicle for diagnosis of herpes zoster via DNA PCR. Early detection will help hasten appropriate treatment and education to reduce further spread of the virus. Int J Clin Pediatr. 2019;8(1):19-21 doi: https://doi.org/10.14740/ijcp334

A Rare Presentation of Zosteriform Pattern of Cutaneous Metastases from Lung Cancer: A Case Report and Literature Review on Cutaneous Metastases in Non-Small Cell Lung Cancer

Background: Lung cancer typically metastasizes to the brain, bone, liver and adrenal glands but can rarely metastasize to the skin. It has been reported in only 1-12% of lung cancer cases and can be an initial finding in newly diagnosed lung cancer patients. These rare findings can be the first indication of a quiescent lung cancer. Case presentation: This is a case report on a former smoker that initially presented with skin metastases in a zosteriform pattern that was found to be from primary lung adenocarcinoma. He first developed swelling in his left upper extremity and then a rash that was later became vesicular and in ad dermatomal pattern. A subsequent biopsy later revealed this to be from primary adenocarcinoma of the lung. Conclusion: This case highlights the importance of recognizing skin manifestations in high risk patients with smoking history of lung cancer diagnoses and the need for further research on the mechanism of this etiology and treatment options.

A comparative study between McKenzie technique and neural mobilization in chronic low back pain patients with radiculopathy

Purpose: To study the effectiveness of McKenzie Technique and Neural Mobilization in chronic low back with radiculopathy on pain, spinal mobility and disability. Relevance: Radiculopathy also known as nerve root pain which arise from disc herniation or spinal stenosis or post-operative scarring, it radiates down the leg in a dermatomal pattern, the unilateral leg pain is often described by the patient as worse than the back pain. McKenzie technique and neural mobilization techniques are the forms of manual therapy that are used in an effort to reduce radiating pain and improve range of motion. Efficient and effective management of acute low back pain is necessary hence to study the effectiveness of either technique in managing chronic low back with radiculopathy was the objective of this research report. Participants: 30 subjects with chronic low back with radiculopathy were recruited from Nandha College of Physiotherapy, Erode, Government Head Quarters Hospital, Erode L.K.M Hospital, Erode. Methods: Subjects were randomly grouped into 2 group´s viz. Group A (TENS with traction and McKenzie technique) & Group B (TENS with traction and neural mobilization technique). The outcome measures were visual analogue scale (VAS) and disability level in terms of Modified Oswestry Disability Questionnaire (MODQ). Results: Within group's comparison showed significant result for Pain and MODQ score and between group's comparison showed significant result for Pain MODQ score respectively indicating effectiveness of McKenzie technique Conclusions: The results of this study showed that along with TENS + Traction, McKenzie Technique is significant in decreasing pain, improving functional ability and increasing spinal extension in chronic low back with radiculopathy.

The Case Files

The Case Files

Selective Radiofrequency Stimulation of the Dorsal Root Ganglion (DRG) as a Method for Predicting Targets for Neuromodulation in Patients With Post Amputation Pain: A Case Series

While spinal cord stimulation (SCS) has established itself as an accepted and validated treatment for neuropathic pain, there are a number of conditions where it has experienced less, long-term success: post amputee pain (PAP) being one of them. Dorsal root ganglion (DRG) stimulation has shown great promise, particularly in conditions where traditional SCS has fallen short. One major difference between DRG stimulation and traditional SCS is the ability to provide focal stimulation over targeted areas. While this may be a contributing factor to its superiority, it can also be a limitation insofar stimulating the wrong DRG(s) can lead to failure. This is particularly relevant in conditions like PAP where neuroplastic maladaptation occurs causing the pain to deviate from expected patterns, thus creating uncertainty and variability in predicting targets for stimulation. We propose selective radiofrequency (RF) stimulation of the DRG as a method for preoperatively predicting targets for neuromodulation in patients with PAP. We present four patients with PAP of the lower extremities. RF stimulation was used to selectively stimulate individual DRG's, creating areas of paresthesias to see which most closely correlated/overlapped with the painful area(s). RF stimulation to the DRG's that resulted in the desirable paresthesia coverage in the residual or the missing limb(s) was recorded as "positive." Trial DRG leads were placed based on the positive RF stimulation findings. In each patient, stimulating one or more DRG(s) produced paresthesias patterns that were contradictory to know dermatomal patterns. Upon completion of a one-week trial all four patients reported 60-90% pain relief, with coverage over the painful areas, and opted for permanent implant. Mapping the DRG via RF stimulation appears to provide improved accuracy for determining lead placement in the setting of PAP where pain patterns are known to deviate from conventional dermatomal mapping.

Segmental Neurofibromatosis

ABSTRACT Segmental neurofibromatosis is a rare condition that most commonly affects women and presents as neurofibromas, café au lait spots, and freckling. The neurofibromas usually occur in a dermatomal pattern, whereas the café au lait spots may follow Blaschko’s lines. There is often no family history. The etiology is due to a postzygotic mutation in the gene encoding neurofibromin. Histopathology reveals a tumor with haphazardly arranged spindle cells and a pale myxoid stroma from mucin deposition and fibroplasia. There have been few reported cases of segmental neurofibromatosis. In this case report, we will discuss the clinical features, histopathology, differential diagnosis, and management of segmental neurofibromatosis.

Neuroembryology of the Acupuncture Principal Meridians: Part 1. The Extremities

Abstract Background: There is accumulating evidence from anatomical, physiologic, and neuroimaging research that demonstrate Classical acupuncture points stimulate nerve trunks or their branches in the head, trunk, and extremities. Objective: The aim of this research is to present novel graphic evidence that the embryologic development of the human nervous system in the extremities provides evidence that the distributions of the acupuncture Principal meridians correspond closely to those of the major nerves of the arms and legs, suggesting that the Principal meridians are representations of the human peripheral nervous system in those places. Materials and Methods: Using Adobe Photoshop software, anterior and posterior perspective diagrams of the adult human dermatomal patterns were modified to position the upper and lower extremities into their embryonic positions at 6 weeks' postconception. Dermatomes, major peripheral nerves, limb acupuncture points, and extremity Principal meridians were applied as se...

Post Herpetic Neuralgia After Acyclovir Treatment

Post Herpetic Neuralgia (PHN) is often diagnosed when pain persists in a dermatomal pattern weeks after the herpes zoster vesicular eruption has healed. There is a definite tendency for PHN to improve with time. There is no way of predicting who will recover. However, some reported that as many as 40% of patients with PHN will continue to have long-term problems because of incomplete or no pain despite the best treatments given. This retrospective series discussed the outcome of treatment of 3 patients with PHN, using acyclovir, Gabapentin and analgesics. Patients were treated by a single pain specialist in a conventional community pain practice. Therapies were given twice-monthly for 1-2 months, then less frequently until pain relief was optimized. Patients received a median of 7 treatments (range 4 - 11). Median baseline allodynia levels were reduced from 9 /10 (range 8 to 10) to 0/10 (range 0 to 6), intermittent shooting pain from 9/10 (range 8 to 10) to 0/10 (range 0 to 6). 1 of 3 patients (30%) was able to be weaned off pain medications. These data showed that there is variation in the response to treatment in patients suffering from PHN. The response ranged from a complete cure to unresponsive at all to the treatment given. There is no way of predicting who will fully recover.

The Case Files: The Back Pain Edition

Figure: CT and MRI images showing vertebral disc lesion at T2 & T3.FigureFigureFigureFigureFigureA 65-year-old Caucasian man was brought to the ED via ambulance complaining of worsening upper back pain for one week. His primary care physician had recently prescribed him NSAIDs and muscle relaxants, which failed to provide relief. The newest symptoms were numbness and weakness over his left arm and leg. The patient reported no history of trauma to his back nor did he have any chronic illnesses. Physical exam showed paresthesia in the left upper extremity in a dermatomal distribution pattern that suggested further evaluation in determining the underlying cause of this atypical back pain. A laboratory workup was ordered including CBC, CMP, TSH, PSA, blood glucose, and urine analysis in addition to a CT scan of the thoracic and lumbar spine. The laboratory results were within normal limits. The CT report of the thoracic spine scan revealed a soft tissue mass associated with a pathologic fracture containing lytic lesions of the T2 and T3 vertebral bodies. An MRI confirmed CT findings alongside additional spinal cord displacement at the level of T2. A differential diagnosis of a single thoracic spinal tumor was made. The patient was admitted for futher investigation. A full-body bone scan was performed to rule out other lytic lesions. A fine needle aspiration biopsy of the tumor was performed revealing numerous plasma cells consistent with solitary bone plasmacytoma. Plasma cells within the bone marrow normally produce large volumes of antibodies. (Blood 2003;101[5]:1715.) Born from precursor B cells, the antibodies are released into the blood and lymph with a function to attach to and aid in antigen eradication. Plasma cells play a very important role in the development of several diseases. A plasmacytoma is a localized collection of malignant plasma cells without any proof of a systemic plasma cell disorder. (Blood 2000;96[6]:2037.) Diagnostic criteria for solitary plasmacytoma of the bone (SPB) include a single area of bone destruction due to clonal plasma cells; normal marrow without clonal disease; normal results on a skeletal survey and MRI of the spine, pelvis, proximal femora, and humeri; no anemia, hypercalcemia, or renal impairment attributable to myeloma; and absent or low serum or urinary level of monoclonal protein and preserved levels of uninvolved immunoglobulins. (Blood 2000;96[6]:2037.) A study by Hirano (2002) has implicated the overexpression of interleukin-6 in severe autoimmune reactions as well as plasmacytosis with progression to plasmacytoma and multiple myeloma. (Proc Jpn Acad Ser B Phys Biol Sci 2010;86[7]:717.) Moreover, it should be noted that studies have shown progression to multiple myeloma from the initial SPB lesion within two to four years. (Hematology Am Soc Hematol Educ Program 2005:373.) Bones of active hematopoiesis are the most commonly involved structures of solitary plasmacytoma of the bone. (“Diagnosis and Management of Solitary Plasmacytoma of Bone.” In: UpToDate, Waltham, MA. Accessed March 1, 2016.) Rarely, SPB can extend into surrounding soft tissue. More specifically, bone sites most commonly affected (in descending order) are the vertebrae, pelvis, ribs, upper extremities, face, skull, femur, and sternum. Thoracic vertebrae have higher incidence than lumbar, sacral, or cervical spine vertebrae. Multiple myeloma cannot be ruled out in patients with SPB because of possible undetected immunoglobulin or active focal sites. In fact, M protein is present in 30-75 percent of all cases of SPB. If present, patients have a 50 percent higher risk of developing multiple myeloma and have an overall survival of 10 years. This M protein will not disappear after treatment. Approximately 450 new cases of SPB are diagnosed each year (0.15 cases/100,000 persons per year; Hematology Am Soc Hematol Educ Program 2005:373), with the highest demographic being blacks, making this case an anomaly. Men are diagnosed almost twice as much as women with median ages ranging from 55 to 65. This patient's family history was unknown, but the condition does have a genetic aspect. An increased risk of plasma cell dyscrasia is observed in patients who have a first-degree relative with monoclonal gammopathy of undetermined significance or multiple myeloma. (“Diagnosis and Management of Solitary Plasmacytoma of Bone.” In: UpToDate, Waltham, MA. Accessed March 1, 2016.) A full week of diagnostic testing ultimately discovered something far more exceptional than a benign case of back pain. Very little is known about this cancer diagnosis. Advancements in medicine will better characterize and identify medical anomalies such as SPB sooner. The patient is being currently treated with radiation therapy, and is expected to recover successfully. Special thanks to Manjeet Chawla, MD, of Thorek Memorial Hospital for his contributions to this article.

English

OBJECTIVES: 1. To find out the incidence of zoster in patients attending the dermatology and venereology clinic. 2. To determine the distribution of herpes zoster in relation to age, sex, religion, season, socio-economic status and rural urban background. 3. To study the various clinical features like site of occurrence, initial presentation and course of the disease. MATERIALS AND METHODS: A total of 100 patients of herpes zoster attending outpatient Department of Dermatology and Venereology were included in the study. Detailed history, thorough physical examination and relevant investigations were done. RESULTS: No seasonal variation was found. Out of the 100 patients of herpes zoster majority of the patients belonged to the age group 21-40 years (42%). The male to female ratio was 1.8:1. Most of the patients were from low socio-economic group. 65 patients were literate and 35 patients were illiterate. Prodromal symptoms occurred in 61% of patients. Post-herpetic neuralgia was common in elderly and immunosuppressed patients. Commonest segment involved was the thoracic segment (46%). Majority of patients had single dermatomal involvement (87%). Multidermatomal involvement was seen in 13 patients (13%), out of which majority had immunosuppression like HIV and Diabetes Mellitus. INTRODUCTION: `Herpes zoster' is a localized disease characterized by unilateral radicular pain and a vesicular eruption that is generally limited to the dermatome innervated by a single spinal or cranial sensory ganglion.1 the words are derived from Greek Herpes - Meaning to creep or to spread and 'Zoster' meaning 'Girdle' or 'Zone'. 2 Zoster is characterized by a prodromal stage characterized by fever, headache, burning pain, followed by an acute stage, with appearance of crops of vesicles on an erythematous base in a dermatomal pattern and an intractable neuropathic pain in chronic stage. Zoster is a common infection among the elderly. Chicken pox and herpes zoster (Shingles) are usually benign but are associated with morbidity and mortality especially in immuno compromised hosts. The distinction between the natural history and manifestation of these clinical syndromes caused by VZV is essential for understanding the potential value of antiviral therapy. zoster usually involves one or more dermatomes and occurs at one particular site. 3 many complications like cutaneous, visceral, ocular and neurologic can occur. Post herpetic neuralgia (PHN) is the most feared and debilitating complication of zoster. The risk for PHN is increased in patients over 60 years of age. Recurrent herpes zoster is listed as one of the AIDS defining illness. In HIV infected there are many atypical manifestations like ulceration, necrosis, ecthymatic lesions, hyperkeratotic papules and many neurological, cutaneous, ophthalmic complications. The thoracic dermatomes are the most commonly affected (56%) followed by cervical (17%), lumbar (10%), sacral (5%) and the trigeminal nerve was infected in 12%.4 the management of PHN remains a challenge, with various modalities of treatment having a modest success. Laboratory studies for herpes zoster includes, serological tests, PCR, Tzanck smear, biopsy and viral tissue culture. The drugs used for the treatment of herpes zoster are Acyclovir, Valacyclovir and Famcyclovir, Desiclovir, Penciclovir and Foscarnet.

Chiropractic and rehabilitation management of a patient with extraforaminal entrapment of L4 nerve with balance problem.

Disc herniation is one of the most common causes of low back pain with radicular pain. Among various types of disc herniation, the extraforaminal disc herniation is a rare cause of lumbar radiculopathy. The aim of presenting this case study is to demonstrate the benefits of Chiropractic care including spine and extremity manipulation and rehabilitation in the treatment of a rare case of extraforaminal L4 nerve entrapment causing severe L4 radiculopathy and chronic mild low back pain (LBP). The aim of presenting this case study is to demonstrate the benefits of Chiropractic care including spine and extremity manipulation and rehabilitation in treatment of rare case of extraforaminal L4 nerve entrapment which caused severe L4 radiculopathy and chronic mild low back pain (LBP). A 45-year old female patient arrived at the clinic with chronic mild low back pain and right buttock pain, all of which had presented for two years' duration. During the preceding month, the radicular pain initiated in medium to high intensity, radiating to her right leg following the L4 dermatomal pattern with a periodic tingling sensation in her right foot. A neuro exam demonstrated a proprioception deficit in her right leg. A Romberg test was positive. The patient was treated by low amplitude high velocity spinal and extremity manipulation for 10 consecutive sessions (2 weeks), followed by rehabilitation and exercise therapy including advanced myofascial release therapy for an additional 12 sessions (4 weeks). After treatment, the patient reported a significant improvement in her low back pain and radiculopathy. In addition, she achieved some improvement in balance. It seems that Chiropractic care and rehabilitation therapy may be a safe and effective modality in treatment of an L4 radiculopathy in a patient with an extraforaminal L4 nerve entrapment. Although it is rare, an L4 extraforaminal disc herniation should be considered as a possible cause of symptoms in patients with chronic mild low back pain and severe L4 radiculopathy.

Evolution and Analysis of 445 Cases of Lumbar Discal Hernia Treated with Hemilaminoforaminotomy and Discectomy

Introduction The purpose of this study is to show the good results, we can obtain by making hemilaminectomy with foraminotomy and discectomy for herniated lumbar disc disease. Lumbar disc disease is a common affliction. Surgical intervention provides excellent results in carefully selected patients. Discectomy with hemilaminoforaminotomy through a small incision with surgery loupes or microscope permits an accurate decompression of the root with results from good to excellent. Methods The surgical records of 445 patients, who underwent surgical intervention for herniated lumbar disc disease in an 18.5-year period between March 1996 and September 2014, were checked. A total 202 were women and 243 men. The range age was 14 to 83 years with an average of 48.5 years. All the patients had root pain in a dermatome pattern because of herniated lumbar disc disease with or without foramen stenosis and they were evaluated with imaging studies as: MRI and some of them with CT. Patients older than 60 years (128 patients) had foramen stenosis and they had the same procedure. They were treated with hemilaminoforaminotomy and discectomy through a small incision: 236 patients were operated on one level, 169 were operated on two levels and the other 40 patients were underwent more than two levels. The outcome results were collected at a range from 2 months to 18 years. Over 293 patients have a 10-year follow-up. The procedure was hemilaminectomy with foraminotomy and discectomy using microscope or surgery loupes. Hospitalization was from 12 to 24 hours. Results The results were defined according to Macnab scale as excellent 84, good 10, regular 4, and poor 2% (Fig. 1). Conclusion The results of these series indicate that most patients do well after hemilaminoforaminotomy with discectomy and root decompression. It is safe and it does not have destabilization risk. With this procedure, the outcomes are from good to excellent, although the patients had to be well selected by examination and radiological findings. This kind of minimal invasion surgery allows patients to have a fast recovery with low cost, it enables a quick reincorporate to work and esthetically pleasant.

Efficacy of Nucleo-Annuloplasty Using Disc-Fx in Lumbar Disc Herniation

Background: Lumbar radicular pain may be caused by lumbar disc herniation, spinal stenosis, or degenerative spondylolisthesis. It is most often caused by lumbar disc herniation and presents as pain radiating from the back into the leg, usually in a dermatomal pattern corresponding to the compressed nerve root. In patients whose pain does not respond to epidural steroid injections, other treatment modalities can be considered. Minimally invasive disc decompression procedures have been developed to treat radicular pain caused by disc herniation. The Disc-FX system combines percutaneous manual discectomy using forceps, nuclear ablation, and annular modification using radiofrequency equipment. To our knowledge, no reports of a correlation between response to Disc-FX and type of lumbar disc herniation have been published. The aim of this study was to determine patients’ responses to and shortterm outcomes of Disc-FX procedures. Methods: This single-center study enrolled 43 patients and followed them for 6 months. Disc-FX procedures were performed in the operating room using local anesthesia. Outcome measures were obtained with a numeric rating scale at 1 and 6 months post-treatment. Results: Patients’ mean pain scores were significantly lower 1 and 6 months after treatment than before treatment. The percentage of patients who experienced pain relief (numeric rating scale scores less than 50% of baseline scores) was 55.8% at 1 month and 56.1% at 6 months after the procedure. There were no statistically significant correlations between pain relief and type of herniation, pain location (lower back and/or leg pain), pain duration, or presence of an annular tear. Conclusion: Our results suggest that the Disc-FX procedure is a reasonable treatment option for carefully selected patients with lower back and radicular pain of discogenic origin.

Progressive cribriform and zosteriform hyperpigmentation: Need for change in nomenclature

Progressive cribriform and zosteriform hyperpigmentation is a distinct clinical entity presenting with cribriform macules present in a dermatomal pattern. Much conflict is present in the literature regarding the nomenclature of this disorder. A plethora of pigmentary anomalies have been described in the literature, which demand proper classification. This article provides an insight into the conflict, which surround these entities.

Spinal manipulation for patients with lumbar herniated disks attending a private practice

The natural history of sciatica in acute lumbar disc herniation (LDH) patients is quite favorable, with 36% reporting major improvement after 2 weeks and up to 73% having resolution of their leg pain by 12 weeks.1 The use of spinal manipulation therapy (SMT) to treat LDH has been contra-indicated3 and there is only moderate evidence in the literature to support this form of therapy.2 The purpose of this study was to document outcomes of patients with magnetic resonance imaging (MRI) confirmed, symptomatic with low back pain (LBP) and sciatica who were specifically treated with side posture high-velocity, low-amplitude, SMT to the level of the LDH. 171 patients were recruited in a single private chiropractic practice in Switzerland. They were 18-65 years old, experiencing LBP and moderate to severe leg pain in dermatomal pattern, and at least one of the following: (a) decreased straight leg raise test, (b) deficit in detection of cold, (c) reduced response to pinprick, (d) decreased muscle strength in a corresponding myotome, (e) decreased or absent deep tendon reflex corresponding to the involved segment. MRI-proven LDH at the corresponding symptomatic spinal segment was also required. The specific lumbar SMT procedures were high-velocity, low-amplitude side posture thrusts and dependent upon whether the LDH was intraforaminal or paramedian as seen on the MRI.

Mimickers of Cervical Radiculopathy.

Degenerative changes of the cervical spine are the primary cause of nerve root compression leading to symptomatic radiculopathy. Genetic and age-related changes, including loss of intervertebral disc height, as well as facet and uncovertebral joint hypertrophy, produce narrowing of the neural foramen. A herniated nucleus pulposus may cause acute foraminal stenosis. Symptomatic nerve root compression may ensue, leading to pain radiating from the neck into the shoulder, arm, forearm, and/or hand, with or without accompanying numbness and paresthesias. Several musculoskeletal and nonmusculoskeletal entities have a presentation similar to that of cervical radiculopathy and can be easily overlooked if the diagnosis of radiculopathy is assumed (Table I). Therefore, the clinician should be familiar with the classic signs and symptoms of cervical radiculopathy as well as a spectrum of differential diagnoses that may mimic it. View this table: TABLE I Mimickers of Cervical Radiculopathy by Nerve Root Patients with cervical radiculopathy may report antecedent trauma, but the typical onset is more insidious. Acute, severe pain in a dermatomal distribution typically results from cervical disc herniation, whereas subacute, chronic, or intermittent radicular pain tends to be secondary to a chronically herniated disc or degenerative foraminal stenosis. Henderson et al.1, in a report on >700 patients who had been diagnosed with cervical radiculopathy, noted upper extremity pain in 99.4% of the patients, sensory changes to pinprick in 85.2%, neck pain in 79.7%, diminished reflexes in 71.2%, and diminished strength in 68%. Nearly 54% of the patients experienced pain or paresthesias in a dermatomal pattern, …

(105) Horner's Syndrome secondary to a T1 radiculopathy: a case report

Horner's Syndrome is typically characterized by the classic triad of miosis (constricted pupil), partial ptosis, and loss of hemifacial sweating (anhidrosis). The most common causes of Horner's Syndrome include brainstem lesions, brachial plexopathies, Pancoast tumors, and other lesion of the primary neurons or postganglionic neurons. Nerve root irritation secondary to lower cervical or upper thoracic radiculopathies normally results in pain, parasthesias, and weakness in specific dermatomal or myotomal patterns depending on the level that is affected; however, the sympathetic nerve fibers are usually not involved. Then again, an inflamed T1 nerve root has the potential to affect some sympathetic fibers since the second-order preganglionic pupillomotor fibers exit the spinal cord at the level of T1 as they enter the cervical sympathetic chain. We present an interesting case of acute cervical and thoracic spine pain followed by upper extremity pain, weakness, parasthesias and visual disturbances in a 46 year-old male. During initial presentation, the patient complained of left sided visual disturbances, miosis of his left pupil, ptosis, neck/upper back pain and little finger weakness/numbness. Due to the suspicion of Horner's Syndrome, the differential diagnoses expanded to include the possibility of Pancoast Tumor and Brachial Plexopathy in addition to radiculopathy. MRI of the brachial plexus and Chest X-Ray did not reveal any signs of tumor. MRI of the cervical spine demonstrated a T1-2 disc extrusion with impingement of the T1 nerve root which was confirmed by EMG/NCS. The patient's Horner's Syndrome, pain and weakness improved after completion of a Medrol Dose Pak and he is currently pending Neurosurgical Evaluation. This case shows the potential of an upper thoracic radiculopathy to manifest sympathetic symptomology of a Horner’s Syndrome along with the classic clinical presentation of pain, parasthesias and weakness.

The effectiveness of acupuncture or TENS for phantom limb syndrome. II: A narrative review of case studies

IntroductionPhantom limb pain and phantom limb sensation are extremely prevalent, affecting up to 85% of amputees, but with limited positive solutions available. Previous systematic reviews of complementary therapies suggested the use of acupuncture and transcutaneous electrical nerve stimulation. However, there is a lack of randomized controlled trials and inadequate information to guide clinical practice and future definitive research. This narrative review aims to provide guidance for using acupuncture or TENS and to identify potential outcome measures and optimum treatment protocols for clinical practice and future research. MethodsCase studies identified in a previous systematic review were included, with clinical characteristics extracted to provide narrative description. ResultsThirty-six case studies (257 individuals) were included. Acupuncture usually involved body needling and was most frequently reported on the contralateral limb. Chinese papers tended to use body and scalp acupuncture together; studies reported in English language journals tended to use one style. Acupoints along Yang Ming meridians, Liv 3, and LI 4 were commonly used. Needle retention time varied but was usually 30–40min. Most Chinese studies reported daily treatment for 10–30 sessions, English studies tended to treat less frequently (weekly) and provide a smaller number of treatments (4–7 treatments). Contralateral stimulation in the upper fifth and middle 2/5 of sensory area were frequently used to activate lower limbs and body with scalp acupuncture. TENS treatment tended to be administered at the stump, the contralateral side and in relation to dermatomal pain patterns and innervating peripheral nerves. High frequency TENS was the most frequently used treatment, usually administered more than once daily. Both acupuncture and TENS recorded positive outcomes. Visual analogue scales, numerical pain rating scales, pain rating indices and present pain intensity were common outcome measures. ConclusionTreatment protocols can be drawn from the case studies for clinical practice but information is variable. Differences in clinical practice between studies published in Chinese and English may be due to different educational background, qualifications, cultural expectations, and differences in healthcare systems and policy. Further studies are recommended to develop standard treatment protocols for further randomized controlled trials.

Risk Factors for First Time Incidence Sciatica: A Systematic Review

Characteristically, sciatica involves radiating leg pain that follows a dermatomal pattern along the distribution of the sciatic nerve. To our knowledge, there are no studies that have investigated risk factors associated with first time incidence sciatica. The purpose of the systematic review was to identify the longitudinal risk factors associated with first time incidence sciatica and to report incidence rates for the condition. For the purposes of this review, first time incidence sciatica was defined as either of the following: 1) no prior history of sciatica or 2) transition from a pain-free state to sciatica. Studies included subjects of any age from longitudinal, observational, cohort designs. The study was a systematic review. Eight of the 239 articles identified by electronic search strategies met the inclusion criteria. Risk factors and their respective effect estimates were reported using descriptive analysis and the preferred reporting items for systematic reviews and meta-analyses guidelines. Modifiable risk factors included smoking, obesity, occupational factors and health status. Non-modifiable factors included age, gender and social class. Incidence rates varied among the included studies, in part reflecting the variability in the operationalized definition of sciatica but ranged from <1% to 37%. A majority of the identified risk factors associated with first time sciatica are modifiable, suggesting the potential benefits of primary prevention. In addition, those risk factors are also associated with unhealthy lifestyles, which may function concomitantly toward the development of sciatica. Sciatica as a diagnosis is inconsistently defined among studies.

A case of linear lichen planus: Using the accurate nomenclature

Linear lichen planus (LLP) is a rare variant of lichen planus that is characterized by lichenoid, pruritic, violaceous papules, arranging in a linear pattern. When lichen planus is localized in a dermatomal pattern or Blaschcoid lines, incorrect nomenclature has been used and mistakes have been made in terminology. It should be known that there is not a dermatomal arrangement; however, Blaschko lines have been followed in the definition of linear lichen planus. We should avoid the zosteriform term when there is not a previous story of herpes zoster infection. Here we present a case of 40-year-old man that has lesions in two different Blaschko lines and investigate this complexity in terminology. J Clin Exp Invest 2013; 4 (4): 529-531