Physical Signs and Clinical Features of Cervical Myelopathy in Elderly Patients, Especially 80 Years or Older: Comparison of 100 Consecutive Operative Cases across Three Age Groups

STUDY DESIGN

Retrospective cohort study.

PURPOSE

The present study aimed to examine the characteristics of physical signs in elderly patients with cervical myelopathy (CM) and to compare the findings in three different age groups.

OVERVIEW OF LITERATURE

As the global population ages, the incidence of CM in elderly patients is increasing.

METHODS

We evaluated 100 consecutive surgical patients with CM and divided them into the following groups: 80s (34 patients; mean age, 83.9 years), 70s (33 patients; mean age, 73.9 years), and 69 or younger (33 patients; mean age, 60.9 years). The clinical symptoms and physical signs were evaluated and recorded.

RESULTS

Although the recovery rate decreased with increasing age, all groups demonstrated a significant improvement in clinical symptoms relative to preoperative values. The Hoffman sign and hyperreflexia of the triceps tendon were, respectively, present in 82% and 88% of patients in the 80s group, 74% and 64% of those in the 70s group, and 69% and 82% of those in the 69 or younger group, with no significant difference among the groups. In contrast, the rates of hyperreflexia of the patellar and Achilles tendons were, respectively, 59% and 32% in the 80s group, 85% and 48% in the 70s group, and 91% and 70% in the 69 or younger group, with significant differences.

CONCLUSIONS

The positivity rate of the lower extremity hyperreflexia decreased significantly with increasing age in patients with CM. The absence of hyperreflexia, particularly lower extremity, is not uncommon in elderly patients with suspected CM.

A physical sign of pathological myopia: myopic scleral pit

PURPOSE

Myopic scleral pit (MSP) is a rare physical sign of pathological myopia (PM). The aim of this study was to summarize the clinical characteristics of MSP and analyze its correlation with PM.

METHODS

Eight cases with PM and MSP were enrolled in this study. Comprehensive ophthalmic examinations, including subjective refraction, slit-lamp biomicroscope, intraocular pressure, fundus photographs, A- and B-scan ultrasonography and spectral-domain optical coherence tomography, were performed.

RESULTS

All the patients had a long history of PM with visual impairment, long axial length, and myopia-related fundus degeneration. Mean axial length was 31.48 ± 2.17 mm. Mean size of MSP was 0.69 ± 0.29 optic disc diameter (PD). Mean logMAR BCVA was 1.21 ± 0.88 logMAR. Spearman correlation analysis showed that the logMAR BCVA had no correlation with the size of pits (P = 0.34). Fundus examination revealed a focal pale concave located in the sclera exposed area of retinal choroid atrophy was found in all cases. OCT showed a deep scleral pit where the retinal choroid was thin or absent, without retinal sensory detachment or sensory defect.

CONCLUSIONS

This study identified a rare scleral lesion in all eight individuals with PM, which was termed "myopic scleral pit". This phenomenon is different from focal choroidal excavation and posterior staphyloma.

"Pointing forehead": a new physical sign in migraine

This study was designed to compare the presence of seven clinical signs in a group of patients with migraine with that of patients with non-migraine headache. Migraine is sometimes misdiagnosed. Therefore additional features are useful to improve the diagnostic accuracy of migraine. A cross sectional descriptive study was conducted in a group of 709 outpatients with headache. The physical signs were named as A–G. These were carefully observed certain gestures exhibited by patients themselves when they describe their headache. Sign A (pointing right side of the forehead) and sign B (pointing left side of the forehead) were significantly higher in patients with migraine (Sign A positive—123/339, Chi-square—15.784, p < 0.001; Sign B positive—146/339, Chi-square—20.813, p < 0.001). Sign F (keeping the head on a table) was significantly higher in patients with non-migraine headache (Sign F positive—132/370, Chi-square—12.954, p < 0.001). Sign A was more commonly associated with unilateral, severe headache which lasted for a longer period of time. However sign B was more commonly associated with unilateral, severe headache only. Sign C was significant in patients who had bilateral headache in both migraine and non-migraine groups than unilateral headache. It is concluded that pointing right or left side of forehead when the patient describes his or her headache is a characteristic sign of migraine. Keeping the head on the table during an attack of headache is not a characteristic sign of migraine.

Clinical significance of bilateral leg edema and added value of monitoring weight gain during follow-up of patients with established heart failure

Purpose

This study evaluated the clinical characteristics of bilateral leg edema during follow‐up of heart failure (HF) patients and determined the added value of monitoring fluid weight gain for deciding whether this non‐specific sign is a more clinically relevant sign.

Methods

Retrospective analysis was performed on 1826 visits from 83 ambulatory patients with established mild‐to‐moderate HF. Evaluated HF‐related signs included leg edema, pulmonary crackles, S3, weight gain, and ultrasound pleural effusion.

Results

During follow‐up, 75 patients with 161 visits had at least one of the following HF‐related events: weight gain (n = 107), leg edema (n = 90), ultrasound pleural effusion (n = 85), pulmonary crackles (n = 29), and S3 (n = 16). Compared with the events of sole leg edema (n = 23), leg edema events with additional HF‐related sign(s) (n = 67) accompanied more symptomatic worsening (7% vs. 55%, P < 0.0001), and a higher incidence (61% vs. 96%, P = 0.0002) and magnitude of increased serum B‐type natriuretic peptide. Sole leg edema events rarely progressed to worsening HF before the next regular clinic visit. Patients with the event of both leg edema and weight gain more often experienced worsening HF requiring extra clinic visits and/or hospitalization. Amongst a total of 67 leg edema events with additional HF‐related signs, 56 (84%) coexisted with weight gain. Therefore, additional monitoring of weight gain efficiently distinguished the clinically significant leg edema events from insignificant sole leg edema events.

Conclusions

During follow‐up of mild‐to‐moderate HF patients, sole leg edema appeared around 30% of the leg edema events, which is considered clinically insignificant. Additional checking for weight gain could be useful for determining whether this sign is a clinically relevant HF‐related sign. The appearance of these both signs during follow‐up of established HF patients should be intentionally watched or treated by extra diuretics and/or drug adjustment to prevent worsening of HF.