VERTIGO or DIZZINESS or GIDDINESS

VERTIGO

What is vertigo?

Vertigo is a common symptom in patients presenting to neurology outpatient department. It is described as a sense of rotation (rotation of self or of the surroundings). Other terms to describe the same sensation are dizziness, giddiness, chakkar (in Hindi), tala tiragadam (in Telugu), etc.

What are the common symptoms in a patient with vertigo?

The most common feeling is a sense of rotation or imbalance. This feeling becomes more prominent while walking or moving. In some cases, even head or neck movements (such as getting up from lying down position or bending down to pick something) can aggravate the symptoms of dizziness. Other symptoms may include:

·      Nausea,

·      Vomiting,

·      Imbalance while walking,

·      Blurred vision,

·      Poor concentration.

What are the common causes of vertigo?

Vertigo can be caused by a variety of reasons. The more important of them include:

BPPV- benign paroxysmal positional vertigo

·      In this condition, there is a problem in the inner ear. Calcium crystals get deposited in one of the semicircular canals.

·      It can occur in all ages, and is common in adults and in older people. It affects 2.4% of population sometime in their lifetime.

·      It is a benign condition, which means it is not life-threatening and it does not get worse over time,

·      Symptoms are made worse with head or neck movements (positional symptoms),

·      Symptoms occur intermittently,

·      People may get better in 1-2 days, however, in some, it may last for a few months also,

·      Head injury, concussion, migraine, etc may bring on the symptoms of BPPV

·      Diagnosis is made on the basis of history and clinical examination. Hearing and vestibular tests may be helpful.

·      Treatment consists of symptomatic treatment with antihistaminic medications such as betahistine tablets.

·      Canal repositioning procedures done in office are helpful and can cure the condition, however, these procedures should be done by trained doctors,

·      Vestibular adaptation exercises help in prevention of recurrent episodes of vertigo.

·      In refractory cases, there may be a role for ear surgery. 

2

Posterior circulation stroke (Brain stroke)

·      This refers to reduction in blood supply to the back of brain, mainly cerebellum and brain stem.

·      This is more common in people with risk factors for stroke, such as high blood pressure, diabetes, high cholesterol, smoking, etc.

·      Patients often have additional symptoms such as double vision, slurred speech, difficulty in swallowing, imbalance while walking, etc. Isolated symptoms of vertigo without any additional symptoms, seldom/rarely occur due to brain stroke.

·      The diagnosis can be confirmed by doing an MRI scan of brain.

·      Treatment is done as for brain stroke (refer to my earlier blog articles on brain stroke management).

 Cervical vertigo

·      This is an uncommon cause of vertigo,

·      Occurs in the setting of severe cervical spondylosis and disc disease in the cervical (neck) region,

·      Cervical vertigo is also more common in older people.

·      Treatment is as for disc disease (refer to my earlier article on disc disease)

 Miscellaneous causes of vertigo

In addition to the above listed main causes of vertigo, we should also look for other causes. These include low blood pressure, anemia (low haemoglobin), general weakness, low blood sugars, etc. 

Who should we consult for vertigo?

Initially, a primary care physician may be consulted. If there is a doubt in exact diagnosis, the patient should be evaluated by a neurologist. 

An ENT opinion may be taken if an ear-related cause is suspected.

What is the outcome in cases of vertigo?

Most people with vertigo recover well and they do so in a few days. However, a minority of patients continue to suffer for several months. It is uncommon for the symptoms to last for more than three months.

Vertigo may be disabling in the first few days of illness, however, after that period, most people are able to normally function.

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)

Senior Consultant Neurologist

Apollo Hospitals, Jubilee Hills, Hyderabad

Email: drsudhirkumar@yahoo.com

Phone (for appointment): 0091-40-23607777, extension 6634/3011

Online consultation: http://bit.ly/Dr-Sudhir-kumar

DISC DISEASE OR SLIPPED DISC

CERVICAL AND LUMBAR DISC DISEASE

Introduction

Disc is the soft tissue located in between the vertebral bodies.

A picture showing different types of disc problems. 

Disc problems are common in cervical (neck) and lumbar (lower back) regions. Earlier, it was common in older people, due to more degeneration of discs in them. However, now-a-days, we see several younger people, even in their 20s and 30s, who come with disc problems. This is because of sedentary life style, lack of exercises, prolonged sitting (on account of job, computer use, etc), and sports injuries. 

What are the common symptoms of disc diseases?

Disc prolapse or slipped disc can present with several symptoms:

In cervical disc disease, following symptoms are common:

1. Neck pain,

2. Pain in the arm, which may increase on coughing,

3. Tingling or pins and needle sensations in the arm,

4. Numbness in arm,

5. Weakness in the arm.

In lumbar disc disease, the following symptoms may occur:

1. Lower back pain,

2. Pain in the leg, which may radiate from lower back to the leg, also referred to as sciatica,

3. Tingling or numbness in leg,

4. Weakness of leg,

5. Leg pain, numbness or weakness may increase on walking (referred to as claudication), and get relieved on resting. 

How is the diagnosis of disc disease confirmed?

1. Clinical history and examination by a neurologist are useful in suspecting the diagnosis.

2. MRI of spine (cervical or lumbar region, as the case may be) is the confirmatory test for disc disease. 

An MRI scan of lumbar spine showing a prolapsed disc at L5-S1 level

What are the treatment options for disc disease?

Conservative (without surgery): It is useful to note that surgery is not needed in about 90% of cases. 

Several measures are useful in relieving pain in patients with disc prolapse: 

1. Rest- in severe cases, bed rest may be advised. In less severe cases, limited mobility within the house (for toilet and dining purposes) may be permitted.

2. Use of analgesics (such as aceclofenac, etoricoxib) and muscle relaxants (such as mobizox and myospaz forte) may help in relieving pain.

3. Specific medications that help reduce the nerve pain are pregabalin, gabapentin, duloxetine, etc. 

4. Physiotherapy- measures such as IFT, ultrasound, traction, etc help reduce the pain in several people with disc prolapse. 

Surgical options

In 10% of patients, medical treatment fails, then, surgery may be needed. Following are the specific indications for surgery in a patient with slipped disc:

1. Failure of medical treatment to adequately control the pain,

2. Progressive neurological deterioration, such as worsening of weakness or numbness, or bladder/bowel involvement,

Various types of surgeries are:

1. Laminetomy,

2. Discectomy,

3. Spine stabilisation with instrumentation. 

The choice of surgery depends on patient's symptoms, MRI findings and age. 

General advice to patients with disc disease:

1. Avoid forward bending,

2. Avoid lifting heavy weights. 

3. Lose weight, if overweight or obese

What is the prognosis of patients with disc disease?

In general, the outcome of patients with disc prolapse is good and most patients return to normal life after proper treatment. They are able to do their activities of daily living and are gainfully employed.

Surgery is also safe, however, I come across many people who have wrong notions about surgery. They have been mis-informed that after surgery, people get paralysed. In practice, this does not happen. However, if the case for surgery is not correctly chosen, there may not be good relief from pain after surgery also, a condition referred to as "failed back syndrome". 

If you have any further queries, you may get back to me.

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)

Senior Consultant Neurologist,

Apollo Hospitals, Hyderabad, India

Phone- 0091-40-23607777

Email: drsudhirkumar@yahoo.com

Online consultation: http://bit.ly/Dr-Sudhir-kumar

MERALGIA PARESTHETICA

MERALGIA PARESTHETICA

Introduction

Meralgia paresthetica is a condition, characterised by sensations of burning, tingling and pain in the upper outer aspect of thigh.

What is the underlying cause of meralgia paresthetica?

It is caused by entrapment or compression of the nerve that supplies sensation to the upper, outer aspect of thigh. The nerve is commonly called as lateral femoral cutaneous nerve of the thigh.

The condition can get aggravated by sitting in one position for a long time, wearing a tight belt, wearing skinny jeans, or compression of nerve by protruding abdomen in an obese person. 

What are the common symptoms of meralgia paresthetica?

The common symptoms include one or more of the following symptoms, affecting the upper/mid thigh region:

• Numbness,
• Tingling,
• Burning, 
• Pain. 

These symptoms occur more on sitting or standing, and get mildly relieved on lying down down. They may be more severe at night.

The picture (shaded area) below shows the location of symptoms over thigh in meralgia paresthetica.

How is the diagnosis of meralgia paresthetica confirmed?

The diagnosis is made on the basis of clinical symptoms and signs and no tests are often necessary. However, nerve conduction studies of femoral nerve can be done in some cases. In atypical cases, MRI of lumbo-sacral spine may be required to exclude pinching of nerves in the lower back.

How do we treat meralgia paresthetica?

The treatment is with medications such as pregabalin, gabapentin, duloxetine, etc, which are very effective in reducing nerve-related pain, burning and tingling.

In addition, if the person is obese/overweight, then, weight reduction is advised. Prolonged sitting should be avoided.

In 90% of cases, the above treatment would succeed. However, in 10% of cases, symptoms do not improve with medical treatment, and surgery may be required.

The surgical options include decompression of the nerve or division of the nerve. Division of the nerve may leave numbness in the affected region.

What is the outcome of meralgia paresthetica?

Most people do well with treatment and no long-term residual symptoms or disability occurs in patients suffering from this condition.

I hope this article would help patients suffering from this condition, and also enrich the knowledge of readers. I would be pleased to answer any queries related to this condition. My email is drsudhirkumar@yahoo.com 

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)

Senior Consultant Neurologist,

Apollo Health City, Hyderabad

Phone: 0091-40-23607777

email: drsudhirkumar@yahoo.com 

Online consultation: http://members.tripod.com/sudhirkumar_5/neurologist/id6.html

MYASTHENIA GRAVIS

MYASTHENIA GRAVIS

Introduction

Myasthenia gravis is an uncommon auto-immune disease, characterised by muscle weakness.

Common symptoms of Myasthenia Gravis

Myasthenia gravis presents with symptoms due to weakness of various muscles. 

Common presentations of this include:

1. Drooping of one or both eyelids (usually, there is a difference in the degree of eyelid drooping). Drooping of eyelid is also called as ptosis. 

2. Double vision, on looking up, down, left, right or sideways.

3. Slurring of speech or nasal twang in voice,

4. Difficulty in chewing food,

5. Difficulty in swallowing food, or nasal regurgitation of liquids, 

6. Weakness of arms or legs,

7. Breathing difficulty,

8. Difficulty in holding neck straight (tends to droop forwards)

Please note

The sensations are normal in the affected parts of body.

Urinary and bowel control is preserved. 

Please also note

1. Symptoms may vary at different times of day, most often they are worse in evenings,

2. There is fatiguability, symptoms get worse on repeating the same movements,

3. There may be periods (days to weeks) of remission, when all symptoms seem to disappear, only to return back later. 

The following factors may trigger or worsen exacerbations:

• Bright sunlight
• Surgery
• Immunization
• Emotional stress
• Menstruation
• Intercurrent illness (eg, viral infection)
• Medication (eg, aminoglycosides, ciprofloxacin, chloroquine, lithium, phenytoin, beta-blockers, statins)

How do we confirm the diagnosis of myasthenia gravis?

1. Clinical symptoms, as described above make us suspect a diagnosis of MG, 

2. Tensilon test- where tensilon (edrophonium) injection is given, after which there is temporary improvement of symptoms such as ptosis,

3. Repetitive nerve stimulation- This test in done in the electrophysiology laboratory, where the muscle fatigue is shown (by seeing reduced amplitude with repeated stimulation of muscles),

4. Anti-Acetylcholine receptor antibody levels are elevated in about 80% of people. These antibodies are supposed to be released from thymus gland (located behind the upper chest wall in the centre). These antibodies prevent the action of acetylcholine on the muscles, making them weak. 

5. CT scan of chest is done to look for enlargement or tumor in thymus gland. 

6. Other less common antibodies seen in some patients with MG are anti-straited muscle antibody, anti-MuSK antibody, and anti-striational antibody.

What is the medical management of Myasthenia Gravis?

The medical management is classified into two categories:

1. Symptomatic treatment- to improve the symptoms. Pyridostigmine is commonly used.

We usually start a dose of 60 mg two times daily, and the maximum dose can be unto 720 mg per day.

Common side effects include increased salivation, abdominal pain and cramps, diarrhoea, muscle twitchings, etc.

2. Definitive treatment- is used to suppress the antibodies.

Steroids are commonly used. 

Other agents used are azathioprine, mycophenolate, cyclosporine, methotrexate, and cyclophosphamide.

3. In patients with myasthenic crisis (severe disease requiring feeding tube due to swallowing problem), or requiring mechanical ventilation (due to respiratory distress), PLASMAPHERESIS (blood is purified, and antibodies are removed, something similar to dialysis) or IV IMMUNOGLOBULINS (injections are given by drip over five days) are required.

4. THYMECTOMY- the best and permanent treatment for MG is thymectomy operation. In this, the thymus gland located behind the sternum bone (chest wall) is removed by operation. This removes the source of antibodies and the disease gets cured in most people.

What is the outcome of myasthenia gravis after treatment?

Earlier, the disease had a high morbidity and mortality, as treatments were not available. However, now, with good treatments available, more than 95% people do well and are fully cured.

I hope this articles helps people with myasthenia gravis as well as their caregivers. I would be pleased to answer any further queries. 

Please send email at drsudhirkumar@yahoo.com 

If anyone prefers ONLINE CONSULTATION, please visit http://bit.ly/Dr-Sudhir-kumar

DR SUDHIR KUMAR MD (INTERNAL MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HEALTH CITY

Phone (for appointment): 0091-40-23607777 (extension 6634/3011)

Email: drsudhirkumar@yahoo.com 

Online consultation: http://members.tripod.com/sudhirkumar_5/neurologist/id6.html