Numbness & Weakness (Face/Arms/Legs)

Bell's Palsy

Bell's Palsy is an idiopathic " viral " attack on the facial nerve occurringin approximately 4 persons out of 10,000. The virus most responsible for this attack is probably the Herpes Simplex-1 Virus ( known as HS1). Recent studies presented at the VIII International Symposium of the Facial Nerve in Matsuyama Japan in April 1997 showed strong clinical evidence that HS1 is the primary cause of previously known idiopathic Bell's Palsy, with nearly 85% of all Bell's patients studies were found to have this virus present.

Other " causes " of facial paralysis include:

  • Herpes Zoster or Shingles Virus
  • Post surgical paralysis following removal of Brain Tumor (Acoustic Neuroma) or other tumors, i.e. parotid, glomus jugulare, facial, etc.
  • Post Trauma following automobile or other injurious trauma
  • Lymes Disease

The paralysis is usually unilateral ( one-side of the face) but is it not uncommon for bilateral patients to appear (both sides of the face) Most paralyses are a once in a lifetime event, but every clinician has seen many patients with a long history of multiple attacks. The residual problems associated with Bell's Palsy/ Facial Paralysis are many, including, but not limited to:

  • Asymmetrical Smile
  • Synkinesis ( involuntary movement associated with a voluntary movement )
  • Tearing
  • Inability to whistle or pucker lips
  • Frozen nasalis muscle in area of nostrils
  • Buccinator paralysis (food caught in cheek of paralyzed side)
  • Drooling of liquids from corner of paralyzed mouth
  • Inability to close eye
  • Abnormal Blink
  • Hyperacussis (perceiving sounds as unduly loud)
  • Excessive perspiration
  • Weakened facial musculature
  • Dry eye
  • Lack of wrinkling on forehead of paralyzed side
  • Affected taste
  • Affected speech
  • Tightness / swelling of facial muscle
  • Facial / acoustic pain

The symptoms ( or residuals ) usually appear severe immediately following attack. Many patients fear stroke due to unilateral paralysis and rush to the emergency room. They usually receive a dose of steroids to reduce swelling and pain, but from that point' forward there has been very little offered to the sufferer to assist in the recovery of his/her face.

Recovery & Residual Cases

Statistics have shown that about 50% of all sufferers have COMPLETE SPONTANEOUS RECOVERY within the first 30 days WITHOUT ANY TREATMENTS OR INTERVENTIONS. Another 20% recover between months 1 and 3, another 5-10% between months 4 and 6.

While there has been some reported recovery after six months, is has rarely been complete and patients residual after 6 months usually remain residual with any serious further spontaneous corrections.

Patients with moderate or severe problems after month 6 are usually considered " residual "and generally will require some form of facial muscle rehabilitation in order to affect some recovery.

Lumbar Radiculopathy

Radiculopathy refers to the fact that the spinal nerve roots are affected. Lumbar radiculopathy indicates that the nerve roots in the lower back are involved. This condition is also sometimes also referred to as sciatica.

Most commonly it involves irritation of the nerve root at or between the L5 and S1 (the 5th lumbar vertebrae and the sacrum). This is often the result of herniated, or ruptured, disk material compressing and irritating the nerve root. Because the irritation is both compression-related and chemical (material in the disc is irritating to the nerve root), treatment should address both concerns.

Causes of Lumbar Radiculopathy?

Most frequently a slipped or herniated (ruptured) disk is the cause of lumbar radiculopathy, but there are other causes as well. The disks are soft gelatinous-filled pieces of cartilage that provide cushioning as well as spacing between the vertebrae. Disks may rupture due to strenuous physical activity, congenital defect, or other injury. When some of the gelatinous material in the disk leaks out, it can compress the nerve root that exits the spinal column at that point. Because the material is also irritating to the surface of the nerve, even material that is not directly causing compression can cause radiculopathy by inflaming the nerve root surface.

Symptoms of Lumbar Radiculopathy?

Symptoms usually begin abruptly, sometimes in connection with general low back pain. The characteristic pain is sharp and severe, traveling quickly down the back of the leg, sometimes to the ankle or foot. It may be brought on by a coughing or sneezing fit, or may simply attack while sitting.

Muscle weakness or spasm may also be present, either during the attack of pain or afterwards. Numbness or tingling may be felt in the legs, ankles or feet, depending on which nerve root is involved.

Pain relief is sometimes found by drawing the knees close to the chest, thereby providing some increased space in the spinal canal as well as stretching the lower back muscles, relieving any spasm that has begun. One test your doctor may do to determine whether you are experiencing lumbar radiculopathy is to have you lie on your back and raise your straightened leg. Pain down the leg during this test indicates radiculopathy.

Other diagnostic tests include x-rays to rule out other conditions that may cause the same type of symptoms. Because a herniated disk will not be apparent from x-rays, however, other tests may be necessary to confirm the diagnosis. Contrast myelography where the contrast is inserted through a needle into the spinal canal is of great help in localizing the affected nerve root. MRI (magnetic resonance imaging) and CT (computerized tomography) scans may be used to verify that extruded disk material is responsible for compression on the spinal canal, and pinpoint the location. Because MRI scans use magnetic waves to “slice” through the body, they are better able to show the complete picture of the affected spinal area.

Because the nerve roots in different areas ultimately travel to different parts of the body, the level of the nerve root involved will have an effect on the symptoms felt. The most common location of lumbar radiculopathy is at the S1 level, or at the Sacrum. Other levels will produce the following symptoms:

  • Irritation of the disk between L3 and L4 (L4 root) will typically produce pain through the thigh, with muscle weakness and numbness in the shin and ankle. This is not as common as the other two levels.
  • Irritation of the disk between L4 and L5 (L5 root) will typically produce pain through the back of the thigh and calf muscle, as well as muscle weakness along the top of the foot and big toe. This is the most common occurrence of lumbar radiculopathy.
  • Irritation of the disk between L5 and S1 (S1 root) will typically produce pain in the calf, with numbness in the foot, and weakness of the ankle reflex.
Treatment of Lumbar Radiculopathy?

Pain management is important, particularly in the initial stages. Initial bed rest may be necessary for a few days until pain and inflammation begins to subside. Sitting should be minimized as it only aggravates the condition. Non-steroidal anti-inflammatory drugs (NSAIDs) or other non-narcotic medications may be used short-term to control pain and irritation. Muscle relaxants may be used initially to relieve muscle spasms, but are typically not used in older adults, as they may cause confusion.

Physical therapy modalities such as ice, heat packs, neck rotation, relaxation exercise, gentle cervical traction or massage may also be prescribed to help to relieve pain and muscle spasms.

More severe cases of disk ruptures may require surgery to remove part or all of a protruding or ruptured disk. The most common type of surgery is called a laminectomy, because the portion of bone called the lamina must be removed in order to remove pressure and to reach the disk material. The most severe cases may require surgical fusion to stabilize the bones.

Another type of treatment called chemonucleolysis is sometimes used to dissolve the disk material that has leaked. An enzyme is used that will dissolve only the disk material.

Braces may be used either following injury or surgery, until the muscles are strengthened enough to provide support.

Once the area is healed, strengthening exercises should be implemented to increase the strength of the back and abdominal muscles, as well as increase flexibility and range of motion. This will provide increased stability for the lower back, and reduce the chances of injury. Treatment should be effective in improving pain after a few months, though for a small number of people, pain remains for years. Activity may need to be adjusted if it is stressful to the back.

Neuralgia

Definition

Neuralgia is defined as an intense burning or stabbing pain caused by irritation of or damage to a nerve. The pain is usually brief but may be severe. It often feels as if it is shooting along the course of the affected nerve.

Description

Different types of neuralgia occur depending on the reason the nerve has been irritated. Neuralgia can be triggered by a variety of causes, including tooth decay, eye strain, or shingles(an infection caused by the herpes zoster virus). Pain is usually felt in the part of the body that is supplied by the irritated nerve.

Causes & Symptoms

Neuralgia is caused by irritation or nerve damage from systemic disease, inflammation, infection, and compression or physical irritation of a nerve. The location of the pain depends on the underlying condition that is irritating the nerve or the location of the particular nerve that is being irritated.

Neuralgia can result from tooth decay, poor diet, eye strain, nose infections, or exposure to damp and cold. Postherpetic neuralgia is an intense debilitating pain felt at the site of a previous attack of shingles. Trigeminal neuralgia (also called tic douloureux, the most common type of neuralgia), causes a brief, searing pain along the trigeminal nerve, which supplies sensation to the face. The facial pain of migraine neuralgia lasts between 30 minutes and an hour and occurs at the same time on successive days. The cause is not known.

Glossopharyngeal neuralgia is an intense pain felt at the back of the tongue, in the throat, and in the ear--all areas served by the glossopharyngeal nerve. The pain may occur spontaneously, or it can be triggered by talking, eating, or swallowing (especially cold foods such as ice cream). Its cause is not known.

Occipital neuralgia is caused by a pinched occipital nerve. There are two occipital nerves, each located at the back of the neck, each supplying feeling to the skin over half of the back of the head. These nerves can be pinched due to factors ranging from arthritis to injury, but the result is the same: numbness, pain, or tingling over half the base of the skull.

Diagnosis

Neuralgia is a symptom of an underlying disorder; its diagnosis depends on finding the cause of the condition creating the pain.

To diagnose occipital neuralgia, a doctor can inject a small amount of anesthetic into the region of the occipital nerve. If the pain temporarily disappears, and there are no other physical reasons for the pain, the doctor may recommend surgery to deal with the pinched nerve.

Treatment

Glossopharyngeal, trigeminal, and postherpetic neuralgias sometimes respond to anticonvulsant drugs, such as carbamazepine or phenytoin, or to painkillers, such as acetaminophen. Trigeminal neuralgia may also be relieved by surgery in which the nerve is cut or decompressed. In some cases, compression neuralgia (including occipital neuralgia) can be relieved by surgery.

People with shingles should see a doctor within three days of developing the rash, since aggressive treatment of the blisters that appear with the rash can ease the severity of the infection and minimize the risk of developing postherpetic neuralgia. However, it is not clear whether the treatment can prevent postherpetic neuralgia.

If postherpetic neuralgia develops, a variety of treatments can be tried, since their effectiveness varies from person-to-person.

  • Antidepressants such as amitriptyline (Elavil)
  • Anticonvulsants (phenytoin, valproate, or carbamazepine)
  • Capsaicin (Xostrix), the only medication approved by the FDA for treatment of postherpetic neuralgia
  • Topical painkillers
  • Desensitization
  • TENS (transcutaneous electrical nerve stimulation)
  • Dorsal root zone (DREZ) surgery (a treatment of last resort).
Alternative treatment

B-complex vitamins, primarily given by intramuscular injection, can be an effective treatment. A whole foods diet with adequate protein, carbohydrates, and fats that also includes yeast, liver, wheat germ, and foods that are high in B vitamins may be helpful. Acupuncture is a very effective treatment, especially for postherpetic neuralgia. Homeopathic treatment can also be very effective when the correct remedy is used. Some botanical medicines may also be useful. For example, black cohosh (Cimicifuga racemosa) appears to have anti-inflammatory properties based on recent research.

Prognosis

The effectiveness of the treatment depends on the cause of the neuralgia, but many cases respond to pain relief.

Trigeminal neuralgia tends to come and go, but successive attacks may be disabling. Although neuralgia is not fatal, the patient's fear of being in pain can seriously interfere with daily life.

Some people with postherpetic neuralgia respond completely to treatment. Most people, however, experience some pain after treatment, and a few receive no relief at all. Some people live with this type of neuralgia for the rest of their lives, but for most, the condition gradually fades away within five years.

Occipital Neuralgia

What is Occipital Neuralgia?

Occipital neuralgia is a chronic pain disorder caused by irritation or injury to the occipital nerve located in the back of the scalp. Individuals with the disorder experience pain originating at the nape of the neck. The pain, often described as throbbing and migraine-like, spreads up and around the forehead and scalp. Occipital neuralgia can result from physical stress, trauma, or repeated contraction of the muscles of the neck.

Is there any treatment?

Treatment is generally symptomatic and includes massage and rest. In some cases, antidepressants may be used when the pain is particularly severe. Other treatments may include local nerve blocks and injections of steroids directly into the affected area.

What is the prognosis?

For most individuals with occipital neuralgia, the pain is eliminated or reduced with treatment and does not interfere with daily activities.

What research is being done?

Within the NINDS research programs, occipital neuralgia is addressed primarily through studies on pain. NINDS vigorously pursues a research program that seeks to find new treatments for pain and nerve damage and to understand the underlying biological processes associated with pain.

Trigeminal Neuralgia

Trigeminal neuralgia is a disorder of the trigeminal nerve (which is divided into three branches, as illustrated below) that causes episodes of sharp, stabbing pain in the cheek, lips, gums, or chin on one side of the face. The origin of this disorder is not certain, but scientists believe it may be caused by degeneration, pressure, or irritation of the trigeminal nerve.

Description

The trigeminal nerve, which is divided into three branches, is responsible for chewing, for producing saliva and tears, and for sending facial sensations to the brain. When this nerve breaks down for some reason, it can trigger brief but agonizing sizzles of pain on one side of the face.

This condition is unusual in those under age 50 and more often occurs after 70. Women are three times more likely to have the condition than are men. When trigeminal neuralgia does occur in younger people, it is often associated with multiple sclerosis.

The pain, while brief, is so severe that the sufferer often can't do anything else while the attack lasts. People with this pain often wince or twitch, which is where trigeminal neuralgia gets its French nickname tic douloureux, meaning "painful twitch."

Causes & Symptoms

The origin of trigeminal neuralgia is not certain, but scientists believe it may be caused by degeneration, pressure, or irritation of the trigeminal nerve. Some doctors believe the pain may be triggered by pressure from a nearby abnormally-formed artery lying too close to the nerve.

Any part of the three branches of the trigeminal nerve may be affected. Neuralgia of the first branch leads to pain around the eyes and over the forehead; the second branch causes pain in the upper lip, nose and cheek; the third branch causes pain on the side of the tongue and lower lip.

The first episodes are usually fairly mild and brief, and it may be minutes, hours, or weeks before the next attack. However, attacks tend to occur in clumps that may last for weeks at a time. As the sufferer ages, the episodes become more frequent and painful, until the person begins to live in constant fear of the next one.

The momentary bursts of pain usually begin from the same spot on the face each time. The pain can be triggered by touching the area, washing, shaving, eating, drinking, or even talking. Even a cool breeze across the face can set off an attack. Pain is more severe at the ends of the affected nerve, especially over the lip, chin, nostrils, or teeth.

Diagnosis

Diagnosis is usually made by eliminating other problems that could cause similar pain in teeth, jaw, head, or sinuses. Because patients with the condition tend to avoid trigger points, avoiding chewing, shaving, touching or washing their faces can be a clue to diagnosis of trigeminal neuralgia.

Testing

All patients with a new diagnosis of trigeminal neuralgia should undergo magnetic resonance imaging (MRI) of the brain stem with and without gadolinium contrast medium to rule out posterior fossa or brain stem lesions and demyelinating disease. MRI angiography is also useful in confirming vascular compression of the trigeminal nerve by aberrant blood vessels. Additional imaging of the sinuses should be considered if a question of occult or co-existing sinus disease is entertained. If the first division of the trigeminal nerve is affected, ophthalmologic evaluation to measure intraocular pressure and to rule out intraocular pathology is indicated. Screening laboratory testing consisting of complete blood count, erythrocytes, sedimentation rate and automated blood chemistry testing should be performed if the diagnosis of trigeminal neuralgia is in question. A complete blood count will be required as a baseline before starting treatment with carbamazepine or some of the other drug listed in the next section.

Treatment

It is not easy to treat trigeminal neuralgia. Pain can be suppressed by a range of medicines, including the anti-epilepsy medicines carbamazepine (Tegretol), phenytoin (Dilantin), gabapentin (neurontin), baclofen. These drugs slow down the nerve signals at certain nerve terminals, which eases the pain. However, these drugs cause a wide range of side effects, including nausea, dizziness, drowsiness, liver problems, and skin allergies. Some people develop resistance to the drugs or they can't tolerate the high dosage needed to control the discomfort. If the medicines are stopped, the pain usually returns.

If drug treatment fails, surgical treatment to block pain signals from the nerve may be effective. Radio-frequency waves, gamma rays, or glycerol injections can deaden the nerve (and hence the pain). An operation that frees the nerve from whatever is compressing it (blood vessel or tumor) can permanently relieve pain, but this major neurosurgical procedure carries its own risks and complications. Alternatively, a new procedure seeks to place a cushioning sponge between the nerve and a pulsating artery wrapping around it to soothe the irritated nerve.

Prognosis

Although the pain is momentarily incapacitating, it's not life-threatening. As the person ages, the attacks can be expected to occur more and more frequently.