Lumbar spinal stenosis in an elderly patient

BACKGROUND

The general population is aging, and lumbar stenosis is one of the more frequent conditions observed in an orthopedic or neurosurgical practice.

METHODS

This case presentation is of an 86-year-old male who developed lumbar spinal stenosis with a progressive neurologic deficit that caused severe leg pain, affected bladder function, and affected gait. Relevant medical literature is reviewed.

RESULTS

Bladder function and gait returned after spinal surgery, and this patient's pain was greatly reduced. A multidisciplinary team applied therapy after surgery. The medical literature does not concentrate solely upon patients older than 80, but a few are included in studies of younger patients.

CONCLUSIONS

This case report illustrates that a patient over 80 can have a successful outcome with multidisciplinary medical coverage of medical, surgical, rehabilitative, social, and psychological areas. More studies need to be done of these patients.

Peripheral neuropathy associated with IgM monoclonal gammopathy: correlations between M-protein antibody activity and clinical/electrophysiological features in 40 cases

Forty cases of polyneuropathy associated with IgM monoclonal gammopathy were retrospectively studied to investigate the relevance of clinical and electrophysiological features to M-protein antibody activity. There were 26 men and 14 women; mean age was 65 +/- 11.7 years at the time of the study. Thirty-nine patients had a symmetrical polyneuropathy, of whom 13 had a predominantly sensory and 17 a purely sensory neuropathy (i.e., 30 sensory neuropathies). The remaining patient had a multifocal mononeuropathy. Electrophysiological studies allowed the polyneuropathies to be classified as demyelinating in 33 cases (82.5%) and axonal in 6 cases. Antibody studies disclosed anti-MAG antibodies in 65% and anti-SGPG antibodies in 82.5% of patients. Anti-MAG antibodies were associated with only demyelinating polyneuropathies. Anti-SGPG antibodies were found in 91% of demyelinating polyneuropathies and 50% of axonopathies. In addition, anti-MAG/SGPG antibody activity was significantly correlated with the subgroup of sensory neuropathies (P < 0.01). Last, antisulfatide antibodies were found at significant titers in 18 cases, and their presence was significantly correlated with anti-MAG/SGPG antibody activity, but not with some clinical/electrophysiological features.

Painless acute aortic dissection presenting as left lower extremity numbness

Acute aortic dissection may have variable presentations, making the diagnosis clinically challenging. Acute neurologic syndromes secondary to dissection of the aorta are uncommon. However, including aortic dissection in the differential diagnosis is imperative. This report describes the first reported case of an acute thoracic aortic dissection presenting with the chief complaint of unilateral lower extremity numbness. Peripheral ischemic neuropathy as the result of vascular occlusion is uncommon. The pathophysiology and clinical manifestations of ischemic neuropathies in the setting of acute aortic dissection are discussed.

Sensory axonopathy in mild to moderate peripheral arterial disease

The effect of mild to moderate arterial occlusive disease on peripheral nervous system conduction was prospectively investigated in 18 subjects and 18 control subjects, aged 40 to 85 years. Experimental and control subjects underwent a thorough history and physical followed by vascular and electrophysiologic studies. The primary outcome measure was the sensory nerve action potential. Although 33% of the subjects with peripheral arterial disease had experienced paresthesias, the clinical evaluation of sensation was relatively unaffected. Sensory conduction studies revealed 30% absent sural responses and 56% absent superficial peroneal nerve responses in subjects with peripheral arterial disease compared with 3 and 14% absent responses in control subjects, respectively (P = 0.044; 0.025). There were no differences in distal latency or sensory amplitude, although the superficial peroneal amplitude did approach significance (P = 0.06). No significant differences were found in motor distal latency, amplitude, or conduction velocity. Age, leg length, temperature, disease severity, presence of paresthesias, cholesterol levels, and past alcohol or tobacco ingestion did not account for the difference in sensory responses. These results support the presence of a mild sensory axonopathy in subjects with peripheral arterial disease. Electromyographers should be cognizant of absent distal responses from peripheral arterial disease so as not to ascribe the findings to an alternative pathology and should not attribute abnormal motor conduction results to the presence of this degree of peripheral arterial disease.

Sensory alterations after breast cancer surgery

Many patients experience a variety of sensory alterations at and around the site of their breast cancer surgery, which they often report as severe and distressing. Prevalence, characteristics, and treatment options associated with these sensory alterations remain understudied, as does the effect they have on patients. This article will review important studies that address these issues and discuss treatment options and nursing implications. With this knowledge, nurses can play an important role in helping patients to understand and manage these sensations.

The current surgical treatment of primary malignant melanoma of the skin

In our Department, between 1991 and 1996, 132 patients, there of 87 male-45 female, average age of 48.2 years underwent surgery because of stage 1 (T2) to stage 3 melanoma that was located on the skin. None of patients suffered from early or in situ melanoma. Our retrospective study was based on those 94 patients who had been followed up by Department or dermatology-oncology in our medical centre. Surgery is still the primary treatment for cutaneous malignant melanoma. Thin melanomas (up to 2 mm in thickness) can be excised with 2 cm margins. Whether this is also true for thicker melanomas is not known and the only way to obtain more knowledge is to participate in prospective randomised studies. Elective lymph node dissection is associated with significant morbidity which includes lymphedema, wound complications and paresthesias of the extremity. For this reason we use an alternative operative approach uses selective lymphadenectomy with identification of the sentinel node.

Unusual sensory disturbance in the thoracic region after stroke: relationship to cheiro-oral and cheiro-oral-pedal syndrome

Three patients with unusual unilateral sensory disturbances in the thorax, in addition to hand and mouth, hand and foot, and hand, mouth and foot regions, respectively, after stroke, are described. Magnetic resonance imaging (MRI) showed a causative lesion in the ventral posteromedial and ventral posterolateral nucleus of the contralateral thalamus in two patients and the contralateral thalamocortical projections in one patient. Symptoms in three patients were due to infarction. Objective sensory loss was not found, but subjective paresthesia was observed in the thorax, in addition to the hand and mouth, hand and foot, and hand, mouth and foot regions, respectively. Paresthesia recovery time was evaluated in these three patients in addition to seven patients with cheiro-oral syndrome and eight patients with cheiro-oral-pedal syndrome. All thirteen patients who demonstrated recovery showed regional improvement of paresthesia in the following sequences: thorax, foot, mouth and then hand, which suggests that the detection threshold, from highest to lowest, occurs in the following sequences: thorax>foot>mouth>hand. These three cases with thoracic sensory disturbance form the explanatory links between the cheiro-oral syndrome and the cheiro-oral-pedal syndrome; cases with sensory disturbance in the hand, mouth, foot or thorax could be regarded as cases of sensory hemisyndrome in which the subjective experience of symptoms was restricted to the hand, mouth, foot or thorax. These symptoms may possibly be attributable to differential detection thresholds.

Paresthesias: a practical diagnostic approach

Paresthesias may be caused by central or peripheral nervous system abnormalities. Central nervous system-induced paresthesias are most commonly caused by ischemia, structural or compressive phenomena, infection, inflammation or degenerative conditions. Peripherally induced paresthesias can be caused by entrapment syndromes, metabolic disturbances, trauma, inflammation, connective tissue diseases, toxins, hereditary conditions, malignancies, nutritional deficiencies and miscellaneous conditions. Confirming the diagnosis and establishing an etiology may require appropriate laboratory and radiologic studies, or other studies. In most cases, the specific clinical syndromes associated with the paresthesias, coupled with the presenting neurologic findings, provide the physician with a framework for the diagnosis.

Cervical cord neurapraxia: classification, pathomechanics, morbidity, and management guidelines

One hundred ten cases of the transient neurological phenomenon, cervical cord neurapraxia (CCN), are presented. The authors established a classification system for CCN, developed a new computerized measurement technique for magnetic resonance (MR) imaging, investigated the relationship of the cervical cord to the canal, and analyzed clinical, x-ray, and MR data. One hundred nine males and one female were included in the study; the average age of the participants was 21 years (range 13-33 years). All episodes occurred during sports participation; 87% occurred while the patient was playing football. Follow-up review lasting an average of 3.3 years was available for 105 patients (95%). Narrowing of the sagittal diameter of the cervical canal in the adult spine was confirmed to be a causative factor. Cervical cord neurapraxia was not associated with permanent neurological injury and no permanent morbidity occurred in patients who returned to contact activities. Of the patients returning to contact activities, 35 (56%) experienced a recurrent episode. The risk of recurrence was increased with smaller spinal canal/vertebral body ratio (p < 0.05), smaller disc-level canal diameter (p < 0.05), and less space available for the cord (p < 0.05). There was no correlation between either the classification of the CCN episode or the disease noted on MR imaging and x-ray films and the risk of recurrence. The authors conclude that: 1) CCN is a transient neurological phenomenon and individuals with uncomplicated CCN may be permitted to return to their previous activity without an increased risk of permanent neurological injury; 2) congenital or degenerative narrowing of the sagittal diameter of the cervical canal is a causative factor; 3) the overall recurrence rate after return to play is 56%; and 4) the risk of recurrence is strongly and inversely correlated with sagittal canal diameter and it is useful in the prediction of future episodes of CCN (p < 0.001). These data will enable the physician to counsel individuals regarding a predicted risk of recurrence based on canal measurements.

Effects of intravenous lipoprostaglandin E1 on neurogenic intermittent claudication

Circulation disturbances in the cauda equina and nerve roots have been implicated in the genesis of neurogenic intermittent claudication (NIC) in patients with lumbar spinal stenosis (LSS). We report the clinical results of lipoprostaglandin E1 (lipo-PGE1) treatments in patients with NIC. Lipo-PGE1 was administered intravenously for 10 consecutive days to 40 patients, 31 of whom showed a response to the treatment. Of the clinical symptoms examined, walking ability and leg numbness were significantly improved with an average effective period of 2.5 months. However, patients with radicular pain and severely affected patients did not respond well. Nerve root circulation in eight patients who subsequently underwent surgery was measured with a laser Doppler flowmeter. We observed increased blood flow in seven of these eight patients, after the intraoperative administration of lipo-PGE1. Lipo-PGE1 produced symptomatic improvement for a limited period in the treatment of NIC associated with LSS. The drug appeared to exert its effects through an increase in the circulation of blood in the nerve roots and the cauda equina.

Cerebrospinal fluid protein concentrations in patients with sciatica caused by lumbar disc herniation: an investigation of biochemical, neurologic, and radiologic predictors of long-term outcome

We studied 180 adult patients admitted to the Neurological Department, Haukeland Hospital in Bergen, Norway, for a period of 5 years from 1984 to 1988. One hundred fifty-seven patients were followed up 3.9-9.0 years after admittance to the Neurological Department. The purpose of this study was to find out if the total cerebrospinal fluid (CSF) protein concentration could predict the outcome of lumbar disc surgery or conservative treatment in patients with sciatica. Neurologic and radiologic parameters were also included in the investigation. The increase of the CSF total protein concentration in sciatica without spinal block is assumed to be due to leak of plasma proteins into the CSF from the nerve root. A relationship between CSF protein concentrations and certain clinical parameters has been found. At myelography, 10 ml of CSF was collected for analysis. The patients were evaluated for involvement of the nerve root and/or the dural sac, respectively. The neurologic parameters investigated were: straight leg raising tests, paresis, disturbances of sensibility, and altered reflexes. At follow-up, the patients were asked to fill in questionnaires concerning job function, sick leave or disability pension, subjective physical disability and pain perception, and a clinical examination with the same neurologic parameters was performed. Elevated CSF total protein concentration was related to chronic leg pain, leg pain, and subjective physical disability at follow-up. Nonoperated women reported higher subjective physical disability scores and were more often on sick-leave or disability pension than were men at follow-up. Lateral prolapses were associated with good job function outcome and less risk for sick-leave or disability pension. Reduced lower extremity reflexes, laterally located disc herniation and elevated CSF total protein concentration were associated with a favorable long-term outcome in patients with sciatica. CSF proteins as objective measures on nerve root injury are discussed. CSF total protein concentration can be regarded as an indicator of the functional status of the nerve root and a prognostic factor in patients with sciatica.

Intraoral morbidity following free buccal mucosal graft harvesting for urethroplasty

Buccal mucosa is the preferred donor tissue for urethroplasty in many cases. This study documents donor site morbidity associated with this technique in 12 patients. Nine patients had a transiently decreased parotid salivary flow for 1 week, and one patient reported transient nerve involvement (long buccal nerve). Intraincisal opening returned to presurgical values within 6 weeks and in some cases exceeded presurgical values. This appears to be a low morbidity technique with high patient acceptance.

Aneurysmal bone cysts of the maxilla: a clinicopathologic review

PURPOSE

This study evaluated the significant differences in clinicopathologic features of aneurysmal bone cyst in the maxilla and mandible.

MATERIALS AND METHODS

A search of the literature showed 30 recorded maxillary cases, and these together with one previously unrecorded case formed the basis of the study.

RESULTS

There were no differences in the age and sex incidence. Only two patients complained of pain, and no patient complained of tenderness. No patient gave a history of trauma. Swelling was present in virtually every patient. In seven cases, there was tooth mobility or migration of teeth. Two patients complained of paresthesia. Four patients presented with proptosis, two of whom complained of diplopia. The radiographic appearance of the aneurysmal bone cyst is suggestive but not diagnostic.

CONCLUSION

Although these differences do not enable the clinician to make a definitive diagnosis before biopsy, they have important implications for management.

Meralgia paresthetica after aortic valve surgery

We report a case of meralgia paresthetica, a rare neurological complication, following aortic valvuloplasty. Although this complication was previously described after coronary artery bypass surgery, we believe this is the first case described after a valve procedure and hypothesize on its etiology.

Lower lip paraesthesia following restoration of a second premolar tooth. Case report

A forty year old female patient developed paraesthesia of the right side of her lower lip following the placement of an extensive pin-retained amalgam restoration in her lower right second premolar tooth. Radiographs indicated that the mental foramen was close to the apex of this tooth and it was assumed that postoperative pulpitis and periapical inflammation had caused the paraesthesia through the effects of pressure on the mental nerve. The paraesthesia resolved following endodontic treatment of the lower second premolar tooth and the patient has had no further signs or symptoms.

Management of solid ameloblastoma of the jaws with liquid nitrogen spray cryosurgery

OBJECTIVE

This study evaluated the results of the use of curettage followed by liquid nitrogen spray cryosurgery in a number of solid or multicystic ameloblastomas of the jaws and the postoperative complications related to this treatment modality.

STUDY DESIGN

Thirty-six patients with solid ameloblastoma of the jaws were treated with curettage followed by cryosurgery. The cryotherapy consisted of hand instrumented curettage of the bone lesion followed by three freezing cycles, of 1 minute each, of the remaining bone cavity with liquid nitrogen spray. Postoperative complications were evaluated clinically and radiographically.

RESULTS

Local recurrence occurred in 11 (30.6%) patients. Excepting local recurrence, postoperative complications were frequent but not severe: wound dehiscence (5.5%), paraesthesia (5.5%), infection (5.5%), and pathologic fracture (11.1%).

CONCLUSION

Management of solid or multicystic ameloblastomas of the jaws with curettage followed by cryosurgery may decrease the local recurrence rate and also to reduce the initial indication of resection with continuity defect.

Surgical treatment of carpal tunnel syndrome in patients with peripheral neuropathy

Outcome after carpal tunnel surgery was studied retrospectively in 32 patients with peripheral neuropathy and carpal tunnel syndrome. Nocturnal paresthesias were almost universally relieved, followed in order of responsiveness by pain, numbness, and weakness. Twenty-five of 28 patients said they would have the surgery again if the outcome were the same. Patients with carpal tunnel syndrome and peripheral neuropathy benefit from surgical treatment of carpal tunnel syndrome.

Tarsal tunnel syndrome. Outcome of surgery in longstanding cases

Cases of longstanding (median, 60 months) tarsal tunnel syndrome were decompressed surgically in 14 female and four male patients. Patients reported intermittent dysesthesia, paresthesia, or anesthesia at the medial plantar aspect of the foot. Symptoms were aggravated by physical activities. Previous trauma was noted in four patients. Tinel's sign was positive in 16 patients. Magnetic resonance imaging was performed in 10 patients but was conclusive in only two. At surgery, the posterior tibial nerve or one of its branches was found to be entrapped in 15 patients. Entrapments were observed isolated or in combination within the fascial septa (n = 5), varicose veins (n = 6), scar tissues (n = 4), tenosynovitis and edema (n = 1), or within the abductor hallucis muscle (n = 1). Two neuromas were excised. In three patients no obvious entrapments were found. Clinical followup was performed a median 18 months after surgery. Relief of symptoms was reported as long as 1 year after surgery. All symptoms were relieved in 11 (61%) patients. Three (17%) patients with previous trauma had relatively severe pain after surgery and were considered to have failed results. Surgical decompression was beneficial in most patients with longstanding tarsal tunnel syndrome.

Endodontic-related inferior alveolar nerve and mental foramen paresthesia

Paresthesia is a condition that involves perverted sensations of pain, touch, or temperature. It has a variety of possible causes. This article presents a literature review and case reports of endodontically related inferior alveolar nerve and mental foramen paresthesia. Nondrug prevention methods and the dental uses of dexamethasone are also discussed.