MMPI profiles in post-lumbar puncture headache

From the original material of 300 patients, of whom 37.3% had experienced a post-lumbar puncture headache (PPH), a total of 20 males and 50 females were evaluated with the Minnesota Multiple Personality Inventory (MMPI). The test was administered on average 33 months after the lumbar puncture (range 13-51), at a time when anxiety and depression related to the original investigation for a possible organic neurologic disease were expected to affect the results minimally. In the present material PPH was experienced by 45.7% of the patients, 40% of the males, and 48% of the females. Patients without PPH were used as controls. The selected material was a representative sample of the original material both as to distribution of age, proportion of organic diagnoses, and frequency of PPH. The MMPI disclosed no statistically significant differences between PPH patients and controls regarding personality traits.

Natural evolution of late whiplash syndrome outside the medicolegal context

BACKGROUND

In Lithuania, few car drivers and passengers are covered by insurance and there is little awareness among the general public about the potentially disabling consequences of a whiplash injury. We took this opportunity to study the natural course of head and neck symptoms after rear-end car collisions.

METHODS

In a retrospective questionnaire-based cohort study, 202 individuals (157 men; 45 women) were identified from the records of the traffic police department in Kaunas, Lithuania. These individuals were interviewed 1-3 years after experiencing a rear-end car collision. Neck pain, headache, subjective cognitive dysfunction, psychological disorders, and low back pain in this group were compared with the same complaints in a sex-matched and age-matched control group of uninjured individuals selected randomly from the population register of the same geographic area.

FINDINGS

Neck pain was reported by 71 (35% [95% CI 29-42]) accident victims and 67 (33% [27-40]) controls. Headache was reported by 107 (53% [46-60]) accident victims and 100 (50% [42-57]) controls. Chronic neck pain and chronic headache (more than 7 days per month) were also reported in similar proportions (17 [8.4%; 5-13] vs 14 [6.9%; 4-12] and 19 [9.4%; 6-15] vs 12 [5.9%; 3-10]) by the two groups. Of those who reported chronic neck pain or daily headache after the accident, substantial proportions had had similar symptoms before the accident (7/17 for chronic neck pain; 10/12 for daily headache). There was no significant difference found. No one in the study group had disabling or persistent symptoms as a result of the car accident. There was no relation between the impact severity and degree of pain. A family history of neck pain was the most important risk factor for current neck symptoms in logistic regression analyses.

INTERPRETATION

Our results suggest that chronic symptoms were not usually caused by the car accident. Expectation of disability, a family history, and attribution of pre-existing symptoms to the trauma may be more important determinants for the evolution of the late whiplash syndrome.

[Sleep disorders]

There has been a great development in sleep medicine during the past 20-25 years and the International Classification of Sleep Disorders now lists about 90 relatively well-defined conditions related to sleep. Several of them are severely underdiagnosed. This review considers frequent and/or disabling sleep disorders, in particular disorders for which treatment is available.

Neck pain in the general population

STUDY DESIGN

A randomized cross-sectional questionnaire was used to determine the prevalence of neck pain in Norwegian adults.

OBJECTIVES

The frequency and duration of neck pain were assessed.

SUMMARY OF BACKGROUND DATA

Reliable epidemiologic studies on the prevalence of neck pain in the general population have been sparse.

METHODS

A questionnaire that inquired about neck pain within the last year was sent to a random sample of 10,000 adult Norwegians.

RESULTS

Overall, 34.4% of the responders had experienced neck pain within the last year. A total of 13.8% reported neck pain that lasted for more than 6 months.

CONCLUSIONS

Chronic neck pain is a frequent symptom in the general population, particularly in women. Although reservations have to be taken as to the interpretation, the reported prevalence of persisting pain after whiplash injuries is of the same magnitude as the prevalence of chronic neck pain in the general population.

Do decreased trace metal concentrations in surficial skagerrak sediments over the last 15-30 years indicate decreased pollution?

Varying concentrations of Zn, Pb and Cu over the last 15-30 years (1963-1991) have been found in two undisturbed cores with preserved sediment-water interfaces from the Skagerrak (Station A: 645 m, Station B: 405 m water depth). Mass Accumulation Rates (MAR) in g/m2/year were used to resolve the question of increased or decreased supply. Station A-MAR increased exponentially: Zn from 0.05 to 0.28, Cu from 0.009 to 0.044, and Pb from 0.003 to 0.114 g/m2/year, while concentrations did not show this increase over the last 15-30 years. Station B-MAR increased exponentially: Zn from 0.07 to 0.29, Cu from 0.013 to 0.049, and Pb from 0.014 to 0.114 g/m2/year, while concentrations decreased over the same period. MAR indicated that both stations received similar trace metal flux. Release of trace metals from the sediment to the water column and/or dilution by water and organic matter within the upper few centimeters of the sediment accounted for the concentration decrease at both stations. MAR revealed an increase in trace metal supply, and thus an increase in pollution, over the last 15-30 years, although concentrations indicated the opposite.

[Mononucleosis and neurological manifestations]

Infectious mononucleosis is a relatively common disease. In this paper, three patients with neurological symptoms related to infectious mononucleosis are described. Patient no. 1 had myelitis, one of the most frequent neurological complications. Patient no. 2 had cerebellar symptoms, with ataxia and disturbance of gait. In this case magnetic resonance revealed vermis atrophy, a finding which, to the best of our knowledge, has not been reported before. Patient no. 3 had bilateral optic neuritis. Repeated serologic tests may be necessary to confirm the diagnosis. Infectious mononucleosis should be considered in younger patients with neurological symptoms of uncertain origin.

[Physician's statement concerning whiplash injuries. Significance of supplementary information]

The frequency of insurance cases following traffic accidents involving the whiplash mechanism is increasing in Norway. The economic consequences are obviously great, both for the individual patient and for society. Declarations by medical specialists may be of vital importance when assessing the degree of medical invalidity. We have investigated some of the information provided by 27 patients who were submitted for assessment of medical invalidity after traffic accidents. In eight of these cases, the information in reports from their usual doctor or physiotherapist varied from the case history described by the patient. In all these cases, a previous history of neck pain was found in the health reports, but was not mentioned, and was partly denied, by the patients. Our results underline the importance of supplementary information.

The prevalence of delayed and advanced sleep phase syndromes

To determine the prevalence of the delayed sleep phase syndrome (DSPS) and the contrasting advanced sleep phase syndrome (ASPS), a cross-sectional nationwide epidemiological study was performed in Norway. Screening questionnaires were sent to a random sample of 10,000 adult individuals (18-67 y), of both sexes, taken from the National register of Norway. The response rate was 77%. Diagnoses of DSPS and ASPS were based on International Classification of Sleep Disorders (ICSD) criteria. All individuals suspected of having DSPS or ASPS were requested to fill out a second questionnaire, and a sleep log for four weeks. Subjects for whom the suspicion of DSPS or ASPS could be upheld were contacted by telephone for a final confirmation. Of the 129 possible DSPS cases identified from the screening questionnaires, 17 (9 f; 8 m) remained with the confirmed diagnosis of DSPS. The prevalence was calculated to be 0.17% (95% Confidence Intervals: 0.10-0.28). Thirteen individuals had a mild to moderate DSPS and four had a severe DSPS. The mean age of onset was 15.4 y, and mean duration was 19.2 y. There was no significant correlation between prevalence and age. A sleep phase delay (MSPD) induced by social/environmental or psychological factors was found in 55 subjects (prevalence = 0.72%). Using strict ICSD criteria, no case of ASPS was detected, confirming earlier assumptions of the extreme rarity of this condition.

Palatopharyngoglossoplasty in the treatment of patients with obstructive sleep apnea syndrome

A new technique (palatopharyngoglossoplasty (PPGP)) has been developed for surgical treatment of patients with the obstructive sleep apnea syndrome (OSAS). In 20 operated patients 18 reported immediate marked improvement of daytime sleepiness, alertness and vigilance during the day, and of working capacity. However, polysomnography carried out pre- and postoperatively showed that only 10 patients were "cured", defined as 50% or more reduction in apnea/hypopnea index (AHI). Cephalometric analysis pre- and postoperatively indicated that nonresponders had a long and narrow posterior airway space, and we suggest that during sleep this part of the upper airway collapses before as well as after the operation. The discrepancy between the subjective improvement observed after PPGP and the postoperative reduction in AHI may be due to reduced/eliminated snoring and/or improvement in sleep quality after the operation.

"Hemicrania continua": a clinical review

Hemicrania continua (HC) is a headache entity completely responsive to indomethacin. Since 1984, 18 cases have been described, 15 females and 3 males, i.e. a F:M ratio of 5.0. The finding of a female preponderance, like that in chronic paroxysmal hemicrania, is a new observation. HC is, in general, a unilateral headache in the sense that it sets in on one side and subsequently sticks to this side. In two cases, both sides might possibly be involved, when the pain was at its maximum. In another (somewhat dubious) case the headache was bilateral. The pain was continuous from the beginning in 8 of 18 cases (early stage ratio continuous: non-continuous = 0.8). Over time, the headache developed a continuous character in 16 of the 18 cases, producing a "continuous: non-continuous ratio" of 8:1. The intensity of pain generally was moderate and was not reported as excruciatingly severe by any patient. The autonomic involvement from a clinical point of view, was clearly less pronounced than that of other unilateral headaches, such as cluster headache and chronic paroxysmal hemicrania.

Anterior perforations in lumbar discectomies. A report of four cases of vascular complications and a CT study of the prevertebral lumbar anatomy

Four cases of vascular complications to anterior perforations during discectomy prompted a CT study to measure lumbar disc diameters and to evaluate the prevertebral anatomy. Fifty young adults who had been referred for low-back pain and/or sciatica but had not undergone operation were included. In five additional patients, prone versus supine CT examinations were compared. Six typical configurations of the vascular anatomy could be classified to explain the type of vascular complications occurring at the L3-4 and L4-L5 disc levels. The sagittal diameter of the three lowest lumbar discs varied from 33 to 56 mm, indicating the importance of this parameter as an intraoperative guideline for the spine surgeon. Air-filled intestines were observed anterior to the L5-S1 disc predominantly in the prone position. The possible relationship between this finding and postoperative discitis is discussed.

[Delayed sleep phase syndrome. The most frequent cause of primary chronic insomnia?]

During the past four years the author has seen six cases of chronic persistent insomnia with onset in childhood. Four of these cases had delayed sleep phase syndrome, a disturbance in sleep-wake schedule characterized by the inability to fall asleep, and by continuous sleep of normal length later in the night. The article describes the case histories of two adolescent patients and experience from using chronotherapy. It appeared that chronotherapy was effective, but the demands on the sleep-wake schedule discipline were difficult to accept. It is suggested that delayed sleep phase syndrome may be the most frequent cause of chronic insomnia with onset in childhood.

Subdural hematoma presenting as headache in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) affects the nervous system in 75% of cases (1). A female with several neurological manifestations in the case history presented with severe headache, psychiatric disturbances, and increasing paraparesis. She was found to have bilateral subdural hematomas, and after evacuation her neuropsychiatric symptoms, including headache, disappeared. It is speculated that the reported low incidence of subdural hematomas in SLE may be more apparent than real. On the basis of our case, we recommend repeated neuroradiological investigations to uncover this important, treatable and otherwise potentially fatal cause of headache.

The significance of age, sex, and cerebrospinal fluid pressure in post-lumbar-puncture headache

In this study of 300 neurological inpatients aged between 18 and 60 years the incidence of post-lumbar-puncture headache (PPH) was 37.3%. The more severe the headache, the more frequently it was associated with dizziness, nausea, vomiting, and tinnitus. If PPH occurred during the first day after lumbar puncture (LP), it was more severe, and lasted longer than PPH, which started later. The incidence of PPH and associated symptoms decreased with increasing age, and was much higher in females than males. The sex difference was nearly exclusively explained by a marked preponderance of PPH in females below 40 years of age, i.e. women in the fertile age. Furthermore, there was a decreased incidence of PPH and associated symptoms in patients with an initial higher than average cerebrospinal fluid (CSF) pressure (162 mm H2O). All these differences were statistically significant. Particularly high frequencies of PPH were found in young women with an initial CSF pressure lower than mean.

Post-lumbar-puncture headache: the significance of body posture. A controlled study of 300 patients

In this single-blind, randomized study of post-lumbar-puncture headache (PPH) in 300 neurologic inpatients the significance of body posture after lumbar puncture (LP) was evaluated. Immediate mobilization was compared with bed rest for 6 h (3 h prone followed by 3 h supine posture). Contrary to the widely held belief, this investigation did not show significant differences between recumbent and ambulant patients as to frequency of PPH in the total material (39% versus 35%) or when men (31% versus 29%) and women (48% versus 41%) were evaluated separately. Headache associated with nausea was significantly more frequent in the recumbent than in the ambulant patients both in the total material (23% versus 13%) and in women (35% versus 16%). Thus, immediate mobilization seems to be preferable after LP.