Difference between revisions of "7° Clinical case: Brainstem neoplasm in Orofacial pain"

7° Clinical case: Brainstem neoplasm in Orofacial pain (view source)

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-== Abstract ==
-[[File:Capsaicina.jpg|left|300x300px]]
-The chapter begins by critiquing the traditional Efidence Based in Medicine (EBM) approach, which relies heavily on established scientific knowledge (denoted as <math>KB</math>). It argues that EBM's reliance on compatible and dependent variables is insufficient for capturing the full spectrum of clinical realities, especially in complex cases where quantum variables — which are independent and incompatible — play a crucial role. This critique is illustrated through the introduction of Masticationpedia, a platform intended to refine diagnostic processes in orofacial pain and temporomandibular disorders (TMDs) by integrating these new diagnostic paradigms.
-The patient, referred to as 'Capsaicin', presented with bilateral diffuse orofacial pain affecting the temporal and occipital regions and burning mouth syndrome (BMS), persisting for over a decade. Despite long-standing dental treatments, including the use of a night guard, her pain persisted, leading to her classification under atypical orofacial pain (AOP) and TMD according to the Research Diagnostic Criteria (RDC). However, traditional diagnostic tools such as axiography and electromyography showed no abnormalities, suggesting that her symptoms might not be dental in origin.
-Using the Masticationpedia protocol, the case was analyzed through various "contexts" — dental and neurological. Each context used specific diagnostic assertions (<math>\delta_n</math> for dental and <math>\gamma_n</math> for neurological), which were quantified and analyzed. Both contexts returned values indicating normality (<math>\delta_n = 0</math> and <math>\gamma_n = 0</math>), which contradicted the patient's ongoing pain and symptoms, suggesting a gap in the traditional diagnostic model.
-The chapter introduces the concept of the Coherence Demarcator (. 2003;362(9398):), a tool designed to weigh the clinical assertions more accurately within their respective contexts. In Capsaicin's case, r T. Neuroanatomy helped identify that the severity and implications of her symptoms were not adequately captured by traditional diagnostic categories, pointing towards a more serious underlying condition.
-Faced with contradictory findings and persistent symptoms, further investigations were urged, leading to the discovery of a brainstem schwannoma via MRI — a finding that aligned with her symptoms but had been overlooked by standard diagnostic protocols. This case underscores the necessity of integrating advanced imaging and holistic diagnostic approaches when standard evaluations fail to explain severe symptoms.
-The chapter concludes with reflections on the need for a paradigm shift in medical diagnostics, particularly in orofacial pain. It argues for the integration of quantum models that consider independent and incompatible variables, which can better account for the complexities of human pathology not adequately addressed by EBM.
-The Masticationpedia initiative is positioned as a revolutionary step towards incorporating these new models into everyday clinical practice, aiming to improve diagnostic accuracy and patient outcomes in orofacial medicine. This approach not only challenges existing medical paradigms but also encourages a more nuanced understanding and treatment of conditions that transcend conventional medical categories.
-{{ArtBy|autore=Gianni Frisardi}}
 === Introduction ===
 The brain stem is the caudal portion of the brain that connects the diencephalon to the spinal cord and cerebellum.<ref>Hurley RA, Flashman LA, Chow TW, Taber KH. The brainstem: anatomy, assessment, and clinical syndromes. J Neuropsychiatry Clin Neurosci. 2010;22(1):iv. doi: 10.1176/jnp.2010.22.1.iv. </ref> The brainstem mediates the sensory and motor pathways between the spinal cord and the brain and contains the nuclei of the cranial nerves, the ascending reticular activating system (ARAS), and the autonomic nuclei. It controls brainstem reflexes and the sleep-wake cycle and is responsible for autonomous control of the cardiovascular, respiratory, digestive and immune systems. Brainstem dysfunction can result from various acute or chronic insults, including stroke, infectious, cancer, inflammatory, and neurodegenerative diseases. In the context of critical illness, the brain stem can be susceptible to various insults that can be classified as structural and non-structural in origin. Brainstem dysfunction can therefore contribute to impaired consciousness, cardiocirculatory and respiratory insufficiency and therefore to increased mortality <ref>Annane D, Trabold F, Sharshar T, Jarrin I, Blanc AS, Raphael JC, et al. [https://www.atsjournals.org/doi/10.1164/ajrccm.160.2.9810073?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed Inappropriate sympathetic activation at onset of septic shock: a spectral analysis approach.] Am J Respir Crit Care Med août. 1999;160(2):458–465. doi: 10.1164/ajrccm.160.2.9810073.</ref><ref>Sharshar T, Porcher R, Siami S, Rohaut B, Bailly-Salin J, Hopkinson NS, et al. Brainstem responses can predict death and delirium in sedated patients in intensive care unit. Crit Care Med août. 2011;39(8):1960–1967. doi: 10.1097/CCM.0b013e31821b843b.</ref><ref>Sharshar T, Gray F, Lorin de la Grandmaison G, Hopkinson NS, Ross E, Dorandeu A, et al. Apoptosis of neurons in cardiovascular autonomic centres triggered by inducible nitric oxide synthase after death from septic shock. Lancet Lond Engl. 2003;362(9398):1799–1805. doi: 10.1016/S0140-6736(03)14899-4. </ref><ref>Mazeraud A, Pascal Q, Verdonk F, Heming N, Chrétien F, Sharshar T. Neuroanatomy and physiology of brain dysfunction in sepsis. Clin Chest Med. 2016;37(2):333–345. doi: 10.1016/j.ccm.2016.01.013.</ref> and especially manifest as orofacial pain (OP).[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945639/ Brainstem dysfunction in critically ill patients]: