Faculty Bibliography

BACKGROUND:A previously unreported systemic reaction to Galcanezumab (Emgality) is described. Galcanezumab is a humanized monoclonal antibody designed to bind to calcitonin gene-related peptide, a neuropeptide associated with neurogenic inflammation during migraine attacks. Although clinical trials showed that Galcanezumab had few adverse reactions (injection site related erythema, pruritus, and swelling), no systemic drug reactions have been noted. CASE REPORT/METHODS:A 50-year-old female with chronic migraine, mast cell disorder, Hashimoto's disease, positive antinuclear antibody and positive anti-cyclic citrullinated peptide antibody not on immune modulators received the initial dose of galcanezumab 240 mg after failing multiple migraine treatments. The following day, she developed injection site reaction, malar erythema and flu-like symptoms. Symptoms progressed the second day after injection, and she developed swelling in her lips and throat. Intravenous steroid and antihistamines improved airway symptoms, and the remaining symptoms improved after a course of oral steroids. CONCLUSIONS:Delayed system allergic reaction to Galcanezumab requiring emergency intervention may occur. A history of autoimmune disorder may be a predisposing factor.

Introduction: The morbidity of severe Post Traumatic Stress Disorder (PTSD) is high, particularly in the veteran population. Though several effective treatments exist for PTSD, including psychological and pharmacologic interventions, patients whose disease is both severe and refractory to traditional therapy often face difficult, life-altering decisions. Features of the condition include intrusive symptoms such as recurrent memories, dreams or flashbacks as well as marked impairments in cognition and mood. These can profoundly impair family/social interactions and jeopardize a veteran's ability to return to work. Patients refractory to conventional treatment can undergo Stellate Ganglion Blocks (SGB) with potential significant improvement, though broader data on this intervention is limited and mixed. Here we describe our experience from three PTSD patients who underwent Stellate Ganglion Peripheral Neuromodulation for head and neck pain. Materials / Methods: All three patients were implanted over the Stellate Ganglion using a commercially available temporary peripheral nerve stimulator (SPRINT PNS, SPR Therapeutics, U.S.A.) that is approved for up to 60 days of therapy. Laterality was determined by laterality of effective SGB. During the implantation period we tracked measures of global function, head and neck pain as weekly PCL-5 questionnaires. The PCL-5 is a validated 20 item self-assessment tool that and tracks the 20 DSM-V PTSD symptoms. Notably our patients experienced several periods of "off time". Though unplanned, we took the opportunity to treat these periods of treatment interruption as neurologic off phases and conducted semi-structured interviews to assess treatment offset, withdrawal, washout, and onset with re-initiation. These features help elucidate the role of the SG in the regulation of sympathetic signaling involved in PTSD and allow us to delve into potential therapeutic opportunities as well as the rationale behind them.
Result(s): Our first case is that of a 40-50 year old veteran with debilitating PTSD featuring cognitive impairment, suicidal ideation, and episodes of violent behavior. He experienced significant improvement in global functioning, PTSD symptoms and pain, with immediate worsening during off phases and post-explant which was necessitated due to a superficial lead site infection. Our second two patients are currently still implanted.
Discussion(s): This novel small case series presents us with the unique opportunity to re-evaluate and explore the mechanisms of sympathetic regulation in the Stellate Ganglion relevant to PTSD and discuss therapeutic strategies utilizing Neuromodulation.
Conclusion(s): Neuromodulation holds considerable promise for the treatment of peripheral and central disorders. Our case-series presents a novel application and rationale behind Stellate Ganglion Neuromodulation for PTSD. Learning Objectives: 1. Discuss the pathophysiology of PTSD. 2. Discuss the role of the Stellate Ganglion. 3. Discuss possible mechanisms by which sympathetic regulation can targeted in the treatment of psychiatric and physical distress. Keywords: PTSD, peripheral nerve, Stellate ganglion, Psychology, neuromodulation, Pain
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We report on a 54-year-old male with history of blunt force trauma to left side of his face resulting in a left orbital bone fracture with no surgical intervention. Persistent left facial pain developed on the left upper lip, left nose, and around the left nasal ala. The pain was severe and constant, with exacerbation on touch. A diagnosis of left infraorbital neuralgia was made, and conservative treatment with gabapentin and then carbamazepine was attempted, without improvement in the pain. Three diagnostic left infraorbital nerve blocks were done with significant pain relief. Pulsed radiofrequency ablation of the left infraorbital nerve was done with 100% pain relief that lasted 10 months, with pain gradually returning to baseline at 11 months postprocedure. The ablation was carried out using sensory stimulation of 0.25V to confirm correct needle placement. Settings for the ablation were pulsing for four minutes, pulse width 20 ms, and frequency 2Hz at 42degreeC. Total pulsing of 10 minutes was followed by injection of 1mL of a mixture of 20 mg Kenalog and 1% lidocaine. Advantages of pulsed radiofrequency ablation are due to sparing thermal damage to the target tissue, which minimizes side effects like dysesthesia, hypoesthesia, and anesthesia dolorosa despite shorter duration of effect compared with conventional radiofrequency. Recent studies of pulsed radiofrequency ablation for facial and head pain have shown excellent pain relief at more than six months. Further research to elucidate the ideal settings for pulsed radiofrequency ablation are needed to optimize this treatment modality

OBJECTIVE: Treating chronic testicular pain is often challenging, and few treatment options have been reported. We report a case of intractable testicular pain successfully treated with spinal cord stimulation (SCS). CASE: A 59-year-old male with a 40-year history of bilateral testicular pain after ruptured epididymitis presented for consultation after failing multiple medical and surgical treatments. Repeat genitofemoral nerve block gave him temporary relief. SCS trial to target this distribution resulted in complete pain relief, and the patient was referred for implantation. He reported continued relief nine months after implantation. DISCUSSION: This is the third reported case of intractable chronic testicular pain successfully treated with SCS. Although evidence is scarce, SCS appears to be a potential treatment for patients with testicular pain presenting with a clear distribution of pain.

Introduction: We report a case of chronic intractable testicular pain resulting from ruptured tubercular epididymitis that was successfully treated with spinal cord stimulation. Methods: A 59-year-old male presented with a 40-year history of bilateral testicular pain after surgery for ruptured tubercular epididymitis. Since this surgery, he has had constant 7/10 dull and intermittent sharp stabbing pain with radiation to the rectum and inguinal regions. Treatment with gabapentin, ibuprofen and opioids failed to provide adequate analgesia. The patient had undergone numerous previous scrotal injections by multiple urologists, which provided partial pain relief. The patient also underwent a left spermatic cord stripping that resulted in increased left inguinal pain. At our initial evaluation, a bilateral genitofemoral nerve block with steroid and local anesthetic was administered, which provided 2.5 weeks of 80% pain relief. Given the clear genitofemoral distribution of pain, we proceeded with a spinal cord stimulation trial. Results: Two Boston Scientific octrodes (8 lead-array) were placed posteriorly between T12 and L1, and provided complete pain relief with activation of the upper and lower leads. He has since been referred for permanent lead placement. To our knowledge (using a PubMed literature search), this is only the third reported case study of successful treatment of testicular pain with spinal cord stimulation (1, 2). Conclusions: Treatment of testicular pain and other urogenital pain syndromes can be very challenging. In this patient, who demonstrated clear genitofemoral nerve distribution pain by response to local anesthetic block, dorsal column stimulation at the level of the genitofemoral nerve proved effective. In patients with chronic testicular pain who fail conservative treatment, a trial of spinal cord stimulation may be considered before more invasive surgical procedures

Brain injury can lead to impaired cortical inhibition of the hypothalamus, resulting in increased sympathetic nervous system activation. Symptoms of paroxysmal sympathetic hyperactivity may include hyperthermia, tachycardia, tachypnea, vasodilation, and hyperhidrosis. We report the case of a 41-year-old man who suffered from a left middle cerebral artery stroke and subsequently developed central fever, contralateral temperature change, and hyperhidrosis. His symptoms abated with low-dose propranolol and then returned upon discontinuation. Restarting propranolol again stopped his symptoms. This represents the first report of propranolol being used for unilateral dysautonomia after stroke. Propranolol is a lipophilic nonselective beta-blocker which easily crosses the blood-brain barrier and may be used to treat paroxysmal sympathetic hyperactivity.