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Atypical facial pain in multiple sclerosis caused by spinal cord seizures: a case report and review of the literature.

Gupta K, Burchiel KJ - J Med Case Rep (2016)

Bottom Line: This knowledge is also important for the treating neurologists and neurosurgeons.Neurosurgical intervention for trigeminal neuralgia poses considerable surgical risk, and it should be avoided where possible.Identifying the primary pain generator is, therefore, critical for accurate diagnosis and management.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurological Surgery CR-137, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA. guptak@ohsu.edu.

ABSTRACT

Background: Pain is a very commonly reported symptom and often drives patients to seek medical attention; however, it can prove a very difficult diagnostic conundrum and even more challenging to treat effectively. Accurately determining the primary pain generator is key, as certain conditions have efficacious medical and surgical treatments. We present a rare case of a man with multiple sclerosis presenting with spinal cord seizures causing dermatomal pain. While pain has been reported in the context of motor symptoms attributed to spinal cord seizures in a small number of spinal cord conditions, this case represents the first report of pain exclusively associated with spinal cord demyelination in multiple sclerosis.

Case presentation: We present the case of a 60-year-old Caucasian male patient with multiple sclerosis who reported a 5-year history of progressive pain in his left retroauricular region and superior left shoulder. He described this pain as sharp, episodic, and unrelenting and he was referred for consideration for surgical treatment of trigeminal neuralgia. He had no evidence of trigeminal nerve root pathology on magnetic resonance imaging, but did show dorsolateral spinal cord demyelination at the C3-4 level. His symptoms therefore represent an unusual presentation of spinal cord seizures.

Conclusions: Spinal cord seizures are rarely reported in multiple sclerosis and typically present with focal motor seizures. These have been reported to present with cramping dysesthesia and pruritus, though rarely with primary pain. Knowledge of uncommon pain presentations is critical for the increasing number of primary care physicians caring for patients with such chronic neurological diseases as it will guide management and referral patterns. This knowledge is also important for the treating neurologists and neurosurgeons. Neurosurgical intervention for trigeminal neuralgia poses considerable surgical risk, and it should be avoided where possible. Identifying the primary pain generator is, therefore, critical for accurate diagnosis and management.

No MeSH data available.


Related in: MedlinePlus

Magnetic resonance imaging of the brain. a A sagittal fluid attenuation inversion recovery sequence and b axial T2-weighted sequence demonstrate white matter lesions consistent with a diagnosis of multiple sclerosis. c A T2-weighted magnetic resonance image of his cervical spine demonstrates a lesion at the level of C3–4 affecting the left-sided dorsal horn and dorsolateral white matter tracts
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Fig1: Magnetic resonance imaging of the brain. a A sagittal fluid attenuation inversion recovery sequence and b axial T2-weighted sequence demonstrate white matter lesions consistent with a diagnosis of multiple sclerosis. c A T2-weighted magnetic resonance image of his cervical spine demonstrates a lesion at the level of C3–4 affecting the left-sided dorsal horn and dorsolateral white matter tracts

Mentions: On detailed questioning, our patient described episodic rapid-onset pain in his left shoulder that lasted 30 seconds and radiated to his ear and retroauricular region. These episodes did not have a trigger and had been progressively worsening. On a systematic review we noted that he described difficulty coordinating his left arm and leg over the past 5 years as well, corresponding to the duration of his pain. On examination he was alert and oriented, and recalled his history well. He showed no abnormal signs on a cranial nerve examination. Examination of his extremities demonstrated subtle left deltoid muscle wasting and weakness. His fine touch perception showed a left-sided patchy loss in his left C3–5 dermatomes. In his lower extremities he had a positive crossed-adductor response on his left leg, but no clonus was elicited and his reflexes were otherwise normal. An MRI of his brain and cervical spine demonstrated multiple demyelinated plaques in his corpus callosum, particularly prominent in his splenium, and a plaque on his left cervical spinal cord at the level of C3–4 in the dorsolateral column and dorsal horn (Fig. 1). He had no evidence of neurovascular compression or demyelination at his trigeminal nerve root entry zone.Fig. 1


Atypical facial pain in multiple sclerosis caused by spinal cord seizures: a case report and review of the literature.

Gupta K, Burchiel KJ - J Med Case Rep (2016)

Magnetic resonance imaging of the brain. a A sagittal fluid attenuation inversion recovery sequence and b axial T2-weighted sequence demonstrate white matter lesions consistent with a diagnosis of multiple sclerosis. c A T2-weighted magnetic resonance image of his cervical spine demonstrates a lesion at the level of C3–4 affecting the left-sided dorsal horn and dorsolateral white matter tracts
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4837532&req=5

Fig1: Magnetic resonance imaging of the brain. a A sagittal fluid attenuation inversion recovery sequence and b axial T2-weighted sequence demonstrate white matter lesions consistent with a diagnosis of multiple sclerosis. c A T2-weighted magnetic resonance image of his cervical spine demonstrates a lesion at the level of C3–4 affecting the left-sided dorsal horn and dorsolateral white matter tracts
Mentions: On detailed questioning, our patient described episodic rapid-onset pain in his left shoulder that lasted 30 seconds and radiated to his ear and retroauricular region. These episodes did not have a trigger and had been progressively worsening. On a systematic review we noted that he described difficulty coordinating his left arm and leg over the past 5 years as well, corresponding to the duration of his pain. On examination he was alert and oriented, and recalled his history well. He showed no abnormal signs on a cranial nerve examination. Examination of his extremities demonstrated subtle left deltoid muscle wasting and weakness. His fine touch perception showed a left-sided patchy loss in his left C3–5 dermatomes. In his lower extremities he had a positive crossed-adductor response on his left leg, but no clonus was elicited and his reflexes were otherwise normal. An MRI of his brain and cervical spine demonstrated multiple demyelinated plaques in his corpus callosum, particularly prominent in his splenium, and a plaque on his left cervical spinal cord at the level of C3–4 in the dorsolateral column and dorsal horn (Fig. 1). He had no evidence of neurovascular compression or demyelination at his trigeminal nerve root entry zone.Fig. 1

Bottom Line: This knowledge is also important for the treating neurologists and neurosurgeons.Neurosurgical intervention for trigeminal neuralgia poses considerable surgical risk, and it should be avoided where possible.Identifying the primary pain generator is, therefore, critical for accurate diagnosis and management.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurological Surgery CR-137, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA. guptak@ohsu.edu.

ABSTRACT

Background: Pain is a very commonly reported symptom and often drives patients to seek medical attention; however, it can prove a very difficult diagnostic conundrum and even more challenging to treat effectively. Accurately determining the primary pain generator is key, as certain conditions have efficacious medical and surgical treatments. We present a rare case of a man with multiple sclerosis presenting with spinal cord seizures causing dermatomal pain. While pain has been reported in the context of motor symptoms attributed to spinal cord seizures in a small number of spinal cord conditions, this case represents the first report of pain exclusively associated with spinal cord demyelination in multiple sclerosis.

Case presentation: We present the case of a 60-year-old Caucasian male patient with multiple sclerosis who reported a 5-year history of progressive pain in his left retroauricular region and superior left shoulder. He described this pain as sharp, episodic, and unrelenting and he was referred for consideration for surgical treatment of trigeminal neuralgia. He had no evidence of trigeminal nerve root pathology on magnetic resonance imaging, but did show dorsolateral spinal cord demyelination at the C3-4 level. His symptoms therefore represent an unusual presentation of spinal cord seizures.

Conclusions: Spinal cord seizures are rarely reported in multiple sclerosis and typically present with focal motor seizures. These have been reported to present with cramping dysesthesia and pruritus, though rarely with primary pain. Knowledge of uncommon pain presentations is critical for the increasing number of primary care physicians caring for patients with such chronic neurological diseases as it will guide management and referral patterns. This knowledge is also important for the treating neurologists and neurosurgeons. Neurosurgical intervention for trigeminal neuralgia poses considerable surgical risk, and it should be avoided where possible. Identifying the primary pain generator is, therefore, critical for accurate diagnosis and management.

No MeSH data available.


Related in: MedlinePlus