Periodic bursts of rhythmic dyskinesia associated with spinal anesthesia

Restless legs syndrome: Clinical changes in nervous system excitability at the spinal cord level

Restless legs syndrome (RLS) is a complex multifactorial disorder whose aetiology has yet to be fully elucidated. Some of the features of RLS, such as processing of sensations and activation of movement, may result from a dysfunction in spinal processing giving rise to a state of spinal hyperexcitability. In the current article we review studies investigating spinal excitability in RLS patients looking specifically at electrophysiological studies of spinal activity, sensory evaluations, and spinal reflex studies. Increased spinal excitability has been shown in RLS patients based on the combined data from electrophysiological studies. Results from studies assessing sensory evaluations in RLS patients show enhanced spinal processing of nociceptive inputs possibly due to central sensitisation. However, not all sensory modalities demonstrate an increase in sensitivity. An increase in nervous system excitability would result in an increase in reflex responses in RLS patients however the data from reflex analyses in RLS patients has failed to consistently show this expected result. Overall changes to RLS spinal excitability have been demonstrated though these changes might be heterogeneous as not all afferent input appears to be affected in the same manner. There may be phase-dependent and modality-dependent alterations in spinal excitability suggesting that the theory of absolute spinal hyperexcitability in RLS patients' needs to be reconsidered.

[Acute exacerbation of restless legs syndrome during perioperative procedures: case reports and suggested management]

Restless legs syndrome, or Ekbom syndrome, is a common (yet poorly recognized) neurological condition, with sensitive and motor symptoms and a probable genetic vulnerability. The subjects experience an imperious urge to move their legs at rest, possibly associated with paresthesia and pain, which occurs mostly in the evening and night, and is transiently relieved by movements and walking. Severe cases suffer from involuntary leg jerks during quiet wake and severe insomnia. The syndrome is more frequent in middle-aged subjects, in women, and in iron deficient subjects (renal insufficiency, pregnancy, multiparous mothers). We report a series of patients with a severe restless legs syndrome, adequately treated with small doses of dopamine agonist in the evening. They experienced a perioperative, acute exacerbation of their syndrome. The inability to stay still with involuntary jerks in the operating room, the generalized pain followed by suicidal thoughts, and the agitation with akathisia in the recovery room, complicated the surgery procedures and their follow-ups. The prevention of restless legs exacerbation includes: (i) contra-indicating hydroxyzine, droperidol and any other drug blocking the central dopamine transmission before and during anaesthesia; (ii) using intravenous or subcutaneous opioids, and benzodiazepines during and after the surgery procedure; (iii) temporary increasing the dosage of dopamine agents after surgery; (iv) monitoring (and compensating if low) the iron stores after surgery.