Cervical electrostimulation in some vestibular diseases

Vestibular disorders may be treated by means of drugs, surgical tools or rehabilitation. Cervical electrostimulation may be regarded as physical therapy and its activity is connected to neural pathways between cervical receptors and vestibular nuclei. In present study electrodes were placed lateral to cervical column on the opposite side of vestibular deficit as pointed by electronystagmography; stimulus duration was 18 msec and frequency 100 Hz. Every stimulation lasts for 30 minutes and were repeated twice a week for a total number of 10. The ability to adjust vestibulo-ocular reflex was evaluated by means of a Compensatory Index. The following materials were enrolled in the study: 20 normal subjects were observed before and after a cycle of stimulations: 24 patients suffering from acute labyrinthitis or neuritis, 48 cervical vertigo, 8 cervical traumatic injures and 3 patients operated for acoustical neuroma. All these groups were coupled with control groups composed of the same pathology and the same number of subjects. Statistical treatment of reports was evaluated by t-student test before therapy after one month and after 3 months. Results point out good effects of electrostimulation on vestibulo-ocular reflex compensation, especially in cervical vertigo and labyrinthitis or neuritis with respect to control groups. No important results were obtained in neuroma group and in normal subjects. Electrostimulation may act on vestibular nuclei by direct spino-vestibular pathway but also by repeated decompensations mainly mediated via the cerebellum or spino-reticular connections.     

Microbial dehalogenases: enzymes recruited to convert xenobiotic substrates

Ocular torsion was measured in five subjects during sinusoidal lateral tilt (amplitude 25 degrees, 0.2 Hz). The cervical contribution to ocular torsion was best visible as the difference between the signals obtained in conditions with only head tilt and conditions with whole body tilt. Contribution of the neck did not affect the slow component, but produced an anticompensatory modulation of the beating field offset by means of saccades (analogous to gaze shift). Static tilt conditions (25 degrees tilt) of the trunk only, the head only or the whole body showed similar data, although of smaller amplitude. The results from patients suffering from post-whiplash syndrome were similar to those of healthy subjects, showing large intersubject variability. The reduced tolerance to head tilt of whiplash patients restricts useful implementation of this sort of test in the clinic.     

Evaluation of the posture of patients before and after orthodontic surgery

INTRODUCTION AND AIMS: The term "craniomandibular disorder" is used to describe a series of symptoms and signs that directly affect the stomatognathic apparatus with possible repercussions on the otovestibular and oculomotor apparatus and on the cervical spine that may condition the entire body posture. The aim of this study was to evaluate a series of parameters correlated to the occlusal situation and to verify how these factors are affected by a change following the correction of occulusal ratios. METHODS: The paper reports a series of 15 patients suffering from facial dysmorphia treated surgically in the Division of Maxillofacial Surgery of S. Giovanni Battista Hospital in Turin in which an evaluation was made of posture and symptoms linked to craniomandibular disorders before surgery and six months after. At the preoperative evaluation a high incidence of this type of symptoms and signs was observed, and in particular a high percentage of patients with postural imbalance and asymmetry of the frontal body segments. RESULTS AND CONCLUSIONS: From the results obtained it emerges that the surgical re-adaptation of occlusion is followed by esthetic improvement and also by a good recovery of frontal postural symmetry in conformity with the reduced frequency and intensity of symptoms classified as craniomandibular disorders.     

The effect of triple pelvic osteotomy on the articular contact area of the hip joint in dysplastic dogs: an in vitro experimental study

This study compares the frequency of signs and symptoms from the cervical spine in 24 patients diagnosed with Meniere's disease and 24 control subjects from a population sample. From a previous controlled comparative study concerning signs and symptoms of craniomandibular disorders, 24 patients diagnosed with Meniere's disease (10 males and 14 females) and their 24 matched control subjects participated in this investigation on the state of the cervical spine. Symptoms of cervical spine disorders, such as head and neck/shoulder pain, were all significantly more frequent in the patient group than in the control group. Most of the patients (75%) reported a strong association between head neck movements in the atlanto-occipital and atlanto-axial joints and triggered attacks of vertigo. Also, 29% of the patients could influence their tinnitus by mandibular movements. Signs of cervical spine disorders, such as limitations in side-bending and rotation movements, were significantly more frequent in the patient group than in the control group. Tenderness to palpation of the transverse processes of the atlas and the axis, the upper and middle trapezius, and the levator scapulae muscle were also significantly more frequent in the patient group. The study shows a much higher prevalence of signs and symptoms of cervical spine disorders in patients diagnosed with Meniere's disease compared with control subjects from the general population.     

Modeling vestibulo-ocular reflexes in everyday activities

Fundamental data for the establishment of a new clinical testing procedure for patients suffering from equilibrium disorders were developed. A mathematical model that predicts vestibulo-ocular reflex responses (eye velocities) to three-dimensional head movements was investigated. An experimental set-up permitting the simultaneous recording of the head and eye movements was developed to investigate the vestibulo-ocular reflex (VOR) during everyday activities. The test results show that computer simulation of the VOR occurring during complex movements is indeed possible. The model was able to predict the trend of the experimentally determined eye velocities. It was ascertained that for the further development of the model, the influence of the cervico-ocular reflex (COR) on the resulting eye velocities also has to be taken into account. The proposed method for investigating patients with equilibrium disorders appears suitable enough to make further development to the clinical stage worthwhile. An adaptation of the feedback amplification parameters of the model to take account of the nature of the stimulus and the influence of COR is needed to improve the agreement between the amplitudes of measured and predicted eye velocities. To reliably quantify the feedback amplification parameters, tests need to be carried out in a large number of subjects.     

Cervical lymphatic tuberculosis in the 90's: a case report

The Authors report a clinical case of lymph nodal cervical TBC which led to a retropharyngeal abscess with ossifluent evolution towards the mediastinal region and with fistulation in the dorsal region. A thorough study was carried out on the diffusion of the liquid along the fascial plains of the prevertebral region of the neck and of the mediastinum. With the aid of radiologic tools (CAT scans in particular), and on the basis of topographical anatomy data Authors formulate an hypothesis concerning the mechanics that brought about such a downward development of the abscess. In our opinion this case may well be of interest for otolaryngologists from an epidemic point of view (there is a recrudescence often in atypical manifestations), and because of its surgical peculiarities.     

Simplified preformed chelate protein radiolabeling with technetium-99m mercaptoacetamidoadipoylglycylglycine (N3S-adipate)

The precentral P22/N30 cortical component of the median nerve somatosensory evoked potentials (SEPs) was recorded in 16 patients (11 women and five men) suffering from cervical dystonia before and after botulinum toxin therapy. Cervical dystonia was diagnosed as idiopathic in all patients: 13 patients suffered from right-sided torticollis, and three suffered from left-sided torticollis. The amplitude of the P22/N30 component and the side-to-side ratio of amplitude values were measured. Normal values were obtained by acquiring measurements in two groups of healthy volunteers (n1 = 20 and n2 = 20). The recordings in the first control group were done with the patient's head in a normal position, whereas, in the second control group, the patient kept the head intentionally rotated 60 degrees to the right. Patients were treated with local injections of botulinum toxin A (BTX-A). The mean duration of treatment was 8.3 months, and the mean total amount of BTX injected was 295 U. The P22/N30 precentral component was repeatedly recorded in patients after head posture had been corrected to the normal plane by BTX-A treatment. The recordings showed that the amplitude of the P22/N30 precentral component recorded contralaterally to the direction of head deviation was significantly higher in patients before treatment than after treatment. Contralateral pretreatment amplitudes were also significantly higher (p < 0.01 and p < 0.05, respectively) than amplitudes in both groups of healthy volunteers. The mean side-to-side ratio of precentral P22/N30 component amplitudes was significantly higher in patients before treatment compared with after treatment and also compared with both control groups. These changes in dystonic patients probably reflect the direction of head rotation, the muscle pattern of torticollis, and the change in force of dystonic contraction after the treatment. The changes presumably could be the result of higher excitability of the precentral cortex contralateral to head rotation in patients with cervical dystonia and its change after successful BTX-A treatment.     

The cervical spine in the skeletal dysplasias and associated disorders

The cervical spine is an especially important area, not only for the diagnosis of the skeletal dysplasias, but also for the management of the patient. By the "cervical spine" I refer not only to the vertebral bodies and posterior elements of this region, but also to the neural elements contained within, especially the cervical cord. The spine is supported by a group of ligaments both anteriorly and posteriorly, with special fixation of the odontoid and C2 by a ligament which normally affixes it firmly to C1. Multiple things may go wrong with the development of the cervical spine. There may be abnormal development of the "vertebrae" in this region, ranging from hypoplasia to developmental failure and/or abnormal ossification of the cervical vertebrae; associated or unassociated odontoid hypoplasia; poor ligamental fixation of C2 resulting in C1-2 subluxation; abnormal development of the posterior processes; abnormal ligamental development or laxity with abnormal cervical kyphosis or lordosis; and, in the case of more fragile/brittle bone development (osteoporosis or increased bone density), fractures can lead to cervical spine problems. The skeletal dysplasias that involve cervical spine problems constitute about 35 of the 150 well-described disorders. These include certain families of disorders like the type II collagenopathies, as well as many individual disorders. It is very important for the clinician to be able to pilot patients through the various appropriate imaging modalities - conventional radiographs of the cervical spine; lateral flexion/extension views; CT; MRI - so that proper management and therapy will result.     

Duodenum preserving resection of the head of the pancreas: a standard procedure in chronic pancreatitis

Duodenum-preserving resection of the head of the pancreas was developed 25 years ago by Beger. This procedure is indicated in patients suffering from chronic pain in combination with inflammation of the head of the pancreas, common bile duct obstruction, pancreatic duct obstruction and/or obstruction of the retropancreatic vessels. At the Inselspital in Berne, 74 patients underwent this operation between 1993 and 1996. The median length of the operation was 380 min, with the need for transfusion in a median of 0 units (0-6). There was no postoperative mortality. Total postoperative morbidity was 13%. One patient needed relaparotomy on day 17 for small bowel obstruction. Median length of hospital stay was 11 days. Postoperatively, two patients developed diabetes. Duodenum-preserving resection of the head of the pancreas represents an organ-preserving principle of surgery. This procedure treats the complications of chronic pancreatitis and provides long-term pain relief in more than 80% of patients.     

The relationship of biased test responses to psychopathology.

Groups of Ss differing in personality factors are given the Perceptual Reaction Test, a test which requires only an affective response to abstract designs, to determine if there is a difference in response set characteristic of personality. Scale development and validation employs 1,700 normal persons and 546 psychiatric patients and the reliability study utilizes an additional 159 persons. "Differences in response set were discovered between the groups from the general population and such clinical groups as heterogeneous abnormals, psychotics, and schizophrenics for both males and females. For males alone, differences in the response set were discovered between normals, and a group of males suffering from character disorders, and between male psychotics and males with character disorders." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Symptoms of the cervical spine in temporomandibular and cervical spine disorders

This study was performed to assess the prevalence of signs and symptoms related to cervical spine disorders (CSD) in subgroups of patients with temporomandibular disorders (TMD) and to compare TMD patients and CSD patients with regard to the results of orthopaedic cervical spine tests. One hundred and eleven consecutive patients with TMD and 103 consecutive patients with signs and symptoms of CSD were examined. The results indicated that there is a considerable overlap in the signs and symptoms of patients with TMD and patients with CSD. Signs and symptoms on neck extension occurred more often in CSD patients than in subgroups of TMD patients. No significant differences in upper cervical extension, neck flexion, and shoulder girdle function were found between CSD patients and subgroups of patients with TMD. Patients with CSD reported neck pain during active and passive movements of the neck more often than the subgroups of patients with TMD. TMD patients and CSD patients did not differ with regard to pain on shoulder girdle function and palpation of the shoulder girdle. Logistic regression analyses showed that orthopaedic tests of the cervical spine are of minor importance in discriminating between patients with TMD and patients with CSD. It is concluded that TMD with a myogenous involvement in contrast to TMD with only an arthrogenous involvement should no longer be viewed as a local disorder of the stomatognathic system. The upper quarter, including the stomatognathic system, cervical spine, and shoulder girdle, should be evaluated in patients with more complex or persistent symptoms in the head and neck region.     

Cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury

OBJECTIVE: To investigate cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury. DESIGN: A 2-year review of consecutive patients admitted to the emergency unit after whiplash injury. SETTING: An otorhinolaryngology department. PATIENTS AND SUBJECTS: Twenty-seven consecutive patients with diagnosed whiplash injury (14 men and 13 women, mean age, 33.8yrs [range, 18 to 66yrs]). The controls were healthy subjects without a history of whiplash injury. MAIN OUTCOME MEASURES: Oculomotor function was tested at 2 months and at 2 years after whiplash injury. The ability to appreciate both movement and head position was studied. Active range of cervical motion was measured. Subjective intensity of neck pain and major medical symptoms were recorded. RESULTS: Active head repositioning was significantly less precise in the whiplash subjects than in the control group. Failures in oculomotor functions were observed in 62% of subjects. Significant correlations occurred between smooth pursuit tests and active cervical range of motion. Correlations also were established between the oculomotor test and the kinesthetic sensibility test. CONCLUSION: The results suggest that restricted cervical movements and changes in the quality of proprioceptive information from the cervical spine region affect voluntary eye movements. A flexion/extension injury to the neck may result in dysfunction of the proprioceptive system. Oculomotor dysfunction after neck trauma might be related to cervical afferent input disturbances.     

Aneurysm of the anterior mitral valve in a case of aortic endocarditis in a patient with ulcerative colitis

The use of a semirigid cervical collar has been recommended to prevent further cervical spine injury in the management of trauma patients. These cervical collars are kept on obtunded patients for prolonged periods. We assessed the incidence of cervical collar related decubiti in patients with severe closed head injury (SCHI). We also assessed the utility of fluoroscopy in clearing the cervical spine of patients with SCHI. A retrospective chart review was performed on 52 consecutive patients with SCHI at a community hospital-based Level II trauma center over an 8-month period. Thirteen of 34 patients (38%) who survived >24 hours after admission developed decubiti related to the cervical collar. The patients who developed decubiti had a significantly greater duration of cervical collar placement (21.15 +/- 0.99 days) as compared with patients who did not develop decubiti (4.42 +/- 0.79 days; P = 0.001). Eight patients had their cervical spine assessed for ligamentous injury by bedside fluoroscopy. All eight patients had early collar removal; none of these patients developed decubiti. Patients with SCHI with semirigid cervical collars kept in place for prolonged periods of time are at risk for developing decubiti. Fluoroscopy in addition to standard radiographs may "clear" the cervical spine and allow early removal of these collars.     

Cervical vertigo--reality or fiction?

Neck afferents not only assist the coordination of eye, head, and body, but they also affect spatial orientation and control of posture. This implies that stimulation of, or lesions in, these structures can produce cervical vertigo. In fact, unilateral local anesthesia of the upper dorsal cervical roots induces ataxia and nystagmus in animals, and ataxia without nystagmus in humans. If cervical vertigo exists outside these experimental conditions, it is obviously characterized by ataxia and unsteadiness of gait, and not by a clear rotational or linear vertigo. Neurological, vestibular, and psychosomatic disorders must first be excluded before the dizziness and unsteadiness in cervical pain syndromes can be attributed to a cervical origin. To date, however, the syndrome remains only a theoretical possibility awaiting a reliable clinical test to demonstrate its independent existence.     

Cholecysto-biliary fistulas

Out of a total of 910 cholecystectomies performed on patients suffering from biliary calculosis, from January 1980 to December 1994 the Authors observed two cases of cholecysto-biliary fistulas (0.2%), a complication which can rarely affect biliary stones. In the light of the international literature and of their own, however, limited experience, the Authors take into account the pathophysiologic and clinical aspects of this pathology. They agree with the literature data on the lack of specificity of the clinical signs and uselessness of preoperative diagnostic tools, the only exception sometimes being E.R.C.P. The Authors find Csendes' cholecysto-biliary fistulas classification extremely useful as far as the subsequent surgical treatment is concerned. The latter should be electric, i.e. evaluation of each single case depending on the type of fistula, its size, conditions of its edges, dilatation of the main bile duct. Surgery may range from a simple suture of the fistula edges with endoluminal drainage, associated or not to surgery of the papilla, to a biliary digestive anastomosis.     

Eye-head coordination in labyrinthine-defective humans

Eye-head coordination during saccadic gaze shifts normally relies on vestibular information. A vestibulo-saccadic reflex (VSR) is thought to reduce the eye-in-head saccade to account for current head movement, and the vestibulo-ocular reflex (VOR) stabilizes postsaccadic gaze while the head movement is still going on. Acute bilateral loss of vestibular function is known to cause overshoot of gaze saccades and postsaccadic instability. We asked how patients suffering from chronic vestibular loss adapt to this situation. Eye and head movements were recorded from six patients and six normal control subjects. Subjects tracked a random sequence of horizontal target steps, with their heads (1) fixed in primary position, (2) free to move, or (3) preadjusted to different head-to-target offsets (to provoke head movements of different amplitudes). Patients made later and smaller head movements than normals and accepted correspondingly larger eye eccentricities. Targeting accuracy, in terms of the mean of the signed gaze error, was better in patients than in normals. However, unlike in normals, the errors of patients exhibited a large scatter and included many overshoots. These overshoots cannot be attributed to the loss of VSR because they also occurred when the head was not moving and were diminished when large head movements were provoked. Patients' postsaccadic stability was, on average, almost as good as that of normals, but the individual responses again showed a large scatter. Also, there were many cases of inappropriate postsaccadic slow eye movements, e.g., in the absence of concurrent head movements, and correction saccades, e.g., although gaze was already on target. Performance in patients was affected only marginally when large head movements were provoked. Except for the larger lag of the head upon the eye, the temporal coupling of eye and head movements in patients was similar to that in normals. Our findings show that patients with chronic vestibular loss regain the ability to make functionally appropriate gaze saccades. We assume, in line with previous work, three main compensatory mechanisms: a head movement efference copy, an active cervico-ocular reflex (COR), and a preprogrammed backsliding of the eyes. However, the large trial-to-trial variability of targeting accuracy and postsaccadic stability indicates that the saccadic gaze system of patients does not regain the high precision that is observed in normals and which appears to require a vestibular head-in-space signal. Moreover, this variability also permeates their gaze performance in the absence of head movements.     

A task for assessing vertigo elicited by repetitive head movements

OBJECTIVE: We developed a simple, inexpensive test for assessing vertigo in persons with peripheral vestibular disorders. METHOD: The test was administered to 16 asymptomatic adults and 16 patients with chronic vertigo caused by peripheral vestibular disorders. Participants sat in a chair and as rapidly as possible transferred 25 beanbags one at a time from a basket placed on the floor to a basket held .91 m up in the air. The task was timed, and the participants rated the level of vertigo elicited on a 10-point scale. RESULTS: Patients took significantly more time to perform the task and reported significantly greater levels of vertigo than did the asymptomatic adults. Test scores did not differ significantly across test sessions or raters. CONCLUSION: Performance on this task reliably differentiated patients with vestibular disorders from asymptomatic adults. The test is inexpensive, takes less than 1 min to perform, and has minimal technical requirements, making it suitable for a variety of facilities and levels of staff expertise.     

The spectrum of generalised anxiety in clinical practice: the role of short-term, intermittent treatment

BACKGROUND: DSM-IV generalised anxiety disorder (GAD) has a high lifetime prevalence, but subthreshold anxiety states are even more common, particularly in family practice. METHOD: Generalized anxiety is conceptualised as a spectrum of disorders, with transient anxiety at one end and GAD at the other. RESULTS: Based on long-term experience with family practice patients, the authors suggest that most anxious patients, wherever on this continuum they are placed, could be treated with short-term, possibly intermittent, rather than chronic anxiolytic therapy. Data are presented which show that 50% of chronic GAD patients are only in need of such short-term intermittent therapy. CONCLUSIONS: Further clinical research is needed to refine short-term, intermittent treatments for anxiety spectrum disorders, to make effective treatments available to those suffering from anxiety but falling short of diagnostic criteria for GAD, and to target more effectively the different treatment strategies.     

Nerve cell damages in whiplash injuries. Animal experimental studies

Mechanical loading of the cervical spine during car accidents often lead to a number of neck injury symptoms with the common term Whiplash Associated Disorders (WAD). Several of these symptoms could possibly be explained by injuries to the cervical spinal nerve root region. It was hypothesised that the changes in the inner volume of the cervical spinal canal during neck extension-flexion motion would cause transient pressure changes in the CNS as a result of hydro-dynamic effects, and thereby mechanically load the nerve roots and cause tissue damage. To test the hypothesis, anaesthetised pigs were exposed to experimental neck trauma in the extension, flexion and lateral flexion modes. The severity of the trauma was kept below the level where cervical fractures occur. Transient pressure pulses in the cervical spinal canal were duly recorded. Signs of cell membrane dysfunction were found in the nerve cell bodies of the cervical spinal ganglia. Ganglion injuries may explain some of the symptoms associated with soft-tissue neck injuries in car accidents. When the pig's head was pulled rearward relative to its torso to resemble a rear-end collision situation, it was found that ganglion injuries occurred very early on in the neck motion, at the stage where the motion changes from retraction to extension motion. Ganglion injuries did not occur when pigs were exposed to similar static loading of the neck. This indicates that these injuries are a result of dynamic phenomena and thereby further supports the pressure hypothesis. A Neck Injury Criterion (NIC) based on a theoretical model of the pressure effects was developed. It indicated that it was the differential horizontal acceleration and velocity between the head and the upper torso at the point of maximum neck retraction that determined the risk of ganglion injuries.     

Association between tinnitus and somatoform disorders

Pathophysiological mechanisms are often unknown in patients suffering from "idiopathic" tinnitus, and the presence of other unexplained physical symptoms such as those seen in somatoform disorders can be assumed. This study investigates how often tinnitus exists in general medical out-patients with and without somatoform disorders. In an international study initiated by the World Health Organization (WHO), 1275 patients from 12 participating centers located in 11 different countries were examined by means of the WHO Somatoform Disorders Schedule. The overall prevalence of unexplained tinnitus was 11%; however, tinnitus was clearly more frequent among patients with somatization disorder (42%) or hypochondriacal disorder (27%). It was also more frequent than a great number of other symptoms considered to be typical of somatoform disorders. Tinnitus was also related to depression, anxiety, and to symptoms indicating autonomic arousal. Three possible conclusions are discussed: (i) tinnitus may be a somatoform symptom; (ii) the findings may indicate a substantial comorbidity of two different conditions; (iii) tinnitus and somatization may be linked through common mechanisms of arousal and somatic anxiety.