Failed Back Syndrome

The syndrome involves recurrent or residual low back pain after lumbar disk surgery the incidence ranges from 5 to 40 . Deafferentation pain, which is usually constant and burning Permanent nerve root injury from the original disk herniation - Immediate Permanent injury to the nerve roots from surgery (deafferentation pain, which is usually constant and burning, and is responsible for 6-16 of persistent symptoms in postoperative patients) - Late Pseudomeningocele, from a dural tear at the time...

Differential Diagnosis of Parkinsonism

Parkinson's disease is a progressive neurological disease with the following clinical characteristics. Asymmetric findings Levodopa response dyskinesia Lewy bodies Dysarthria dysphagia Myoclonus Sleep impairment Family history The clinical heterogeneity of Parkinson's disease makes it difficult to differentiate it from other parkinsonian disorders based on the clinical criteria alone. The pathological examination may prove the diagnosis of Parkinson's disease wrong in 10 -15 of patients....

Stages and Estimation of Age of Hemorrhage on MRI

Recognizing cerebral hemorrhage is critically important, and a knowledge of the complex parameters that influence the MRI appearance of an evolving hematoma is therefore essential. The MRI of a hematoma depends on whether Tl-shortening proton electron dipole - dipole (PEDD) interactions or T2-shortening preferential T2 proton relaxation enhancement (PT2-PRE) occur. The interaction that predominates thereafter depends on the particular heme moiety present (e.g., oxyhemoglo-bin, deoxyhemoglobin,...

Postoperative Brain Scar Versus Residual Brain Tumor

There is nothing more frustrating for the neurosurgeon than a postoperative CT scan or MRI showing residual tumor after a supposedly complete resection. Granulation tissue, which enhances on CT and MRI due to its fi-brovascular nature, develops 72 hours after surgery. After that time, it is consequently difficult to distinguish between enhancing surgical bed tissue and marginal residual tumor, assuming that there was preopera-tive tumor enhancement. The scan enhancement may persist for several...

Herniated intervertebral disk

- Original disk not re- This may occur if a disk fragment is left in the inter-moved vertebral disk space, or if the wrong disk level was removed. Patients will continue to have the preoperative leg pain, due to continued mechanical compression and inflammation of the same nerve root. Patients will wake up from surgery complaining of the same preoperative pain, and will continue without ever being pain free. Patients will benefit from repeat surgery - Recurrent disk at the Patients will develop...

Postherpetic Neuralgia

This is a common and severe form of neuropathic pain in the elderly, caused by reactivation of the varicella zoster virus, usually a childhood infection. The incidence of postherpetic neuralgia (PHN) after herpes zoster varies between 9 and 15 , with 35-55 of patients continuing to have pain three months later, and 30 having intractable pain for one year. The dermatomal distribution and frequencies of PHN are as follows.

Multifocal White Matter Lesions

Hypertension and ischemic white matter lesions (leukokraurosis) Increases with age, and has also been seen with chronic hypertension. There are two types of ischemic white matter lesions - Lesions involving the watershed distribution of the major brain arteries - Lesions caused by intrinsic disease of the small penetrating medullary arteries (arteriolar sclerosis) Enlargement of these perivascular spaces with age and hypertension, associated with thinning, pallor and atrophy of the adjacent...

Bacterial Infections

Streptococcus pneumoniae Haemophilus influenzae Neisseria meningitidis Staphylococcus aureus Staphylococcus epidermidis Streptococcus, group A Streptococcus, group B Listeria monocytogenes Escherichia coli Proteus mirabilis Pseudomonas aeruginosa Mycobacterium tuberculosis Acinetobacter species The incidence of bacterial meningitis in the USA is 4-10 cases per 100000 persons per year. The causative agents vary with the age of the patients. The mortality rates for all types of meningitis are...

Malformations of the occipital bone

Manifestations of occip- These are ridges and outgrowths around the bony ital vertebrae margins of the foramen magnum. Although the bony anomaly occurs extracranially at the anterior margin, it is often associated with an abnormal angulation of the craniovertebral junction, resulting in a ventral compression of the cervicomedullary junction. This particular anomaly is frequently associated with primary syringomyelia and Chiari malformation Basilar invagination - The term basilar invagination...

Disorders of the Spinal Nerve Roots

Radicular pain in nerve root distribution - Inflammatory radiculitis - Intervertebral disk protrusion E.g., brachialgia, girdle pain, sciatica. Pain is aggravated by cough (increased intraspinal pressure) movement of that part of the spine and stretching (e.g., straight leg raising L4, L5, SI femoral stretch test L2, L3, L4) Lower motor neuron type (e.g., weakness, tendon reflexes decreased or absent, flaccidity, fasciculations, and atrophy if existing for long enough) E.g., all modalities...

Cervical Spondylotic Myelopathy

In its complete form, this condition is characterized by neck pain and brachialgia, with radicular motor sensory reflex signs in the upper extremities, in association with myelopathy. Similar clinical findings can be produced by other causes of spinal cord compression, such as those listed below. Differential Diagnosis of Extramedullar and Intramedullary 213 - Benign tumors and tumor-like conditions Intradural and extra-medullary tumors Epidermoid and dermoid cysts and tera-tomas Chronic...

Malformations of the axis

Dens dysplasias - Ossiculum terminale Occurs in 0.25 of the population it only causes neurological symptoms and signs in one-quarter or one-third of this number Very rare, except when associated with Klippel-Feil syndrome Results from the persistence of the summit ossification center seldom appears before the age of five years Results from nonfusion of the epiphyseal plate and separation of the deformed odontoid process from the axial centrum. There is an increased incidence in patients with...

Secondorder neuron

(Hypothalamus to upper thoracic cord) E.g., hemispherectomy massive infarction may cause The sympathetic and spinothalamic pathways in the brain stem lie throughout their course next to each other. Horner's syndrome here is therefore frequently associated with contralateral pain and temperature loss E.g., dorsolateral pontine lateral medullary or Wallenberg's syndrome E.g., multiple sclerosis These usually cause loss of pain and deep tendon reflexes in the arms, and frequently a bilateral...

Syndrome of Inappropriate Secretion of Antidiuretic Hormone and Diabetes Insipidus

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) involves the release of antidiuretic hormone (ADH) at levels inappropriate for a low serum osmolality. Due to continued water ingestion, the elevated ADH results in water retention, hyponatremia, and hypo-osmolality. SIADH results from partial damage to the supraoptic and paraventricular nuclei or neighboring areas, or from production of ADH by tumor or inflammatory tissue outside the hypothalamus. The laboratory criteria...

Headache associated with substances or their withdrawal

Headache induced by acute substance use or exposure Headache induced by chronic substance use or exposure Headache due to substance withdrawal (acute use) Headache due to substance withdrawal (chronic use) Headache associated with substances but with uncertain mechanism Nitrate nitrite-induced headache Monosodium glutamate-induced headache Carbon monoxide-induced headache Alcohol-induced headache Other substances Ergotamine-induced headache Analgesic abuse headache Other substances Alcohol...

Subarachnoid Space Metastases

Between 6 and 18 of central nervous system (CNS) metastases involve the arachnoid and subarachnoid space, or the pia, or both. The subarachnoid space can be diffusely or focally involved by spread from a primary CNS tumor, or by an extraneural malignancy. The typical locations for metastatic seeding are at the basal cisterns, the cerebellopontine angle cistern, the suprasellar cisterns, along the course of the cranial nerves, and over the convexities. Subtle leptomeningeal and sub-arachnoid...

Rocky Mountain Spotted Fever

Rickettsia rickettsii This is transmitted via contact with the wood tick, the dog tick, or the Lone Star tick, with an overall incidence of 0.2-0.5 cases per 100000 population. The usual neurological features consist of headache, neck stiffness, altered sensorium, and convulsions. Other neurological abnormalities include ataxia, aphasia, neural hearing loss, and papilledema. The neuro-pathological findings consist of cerebral edema, perivascular and meningeal lymphocytic infiltration, and...

Neurological manifestations

Secondary to anticoagulation therapy Loss of all sensory modalities below the level of the lesion, e.g. pain, temperature, light touch, position sense, and vibration. Localized vertebral pain accentuated by vertebral palpation or percussion may occur with destructive lesions (e.g. infections and tumors), and may have some value for locating the lesion. Pain that is worse when recumbent and better when sitting or standing is common with spinal malignancies - Paraplegia or Initially flaccid and...

Immunodeficiency states

Gram-negative organisms (isolated in 5-20 of shunt infections, particularly in infants) Other pathogens Pseudomonas spp., Streptococcus spp., Propionibacterium acnes, Coryne-bacterium diphtheriae, Candida Streptococcus pneumoniae (65 ). Pneumococ-cus is the predominant organism, presumably due to its common presence in the upper airway Other streptococci (10 ) Haemophilus influenzae (9 ) Neisseria meningitidis (5 ) Staphylococcus aureus (5 ) Enteric Gram-negative bacilli (4 ) Staphylococcus...

Compression within the Spiral Groove of the Humerus

Lesions of the radial nerve occur most commonly in this region. The lesions are usually due to displaced fractures of the humeral shaft after inebriated sleep, during which the arm is allowed to hang off the bed or bench (Saturday night palsy), during general anesthesia, or from callus formation due to an old humeral fracture. There may be a familial history, or underlying diseases such as alcoholism, lead and arsenic poisoning, diabetes mellitus, polyarteritis nodosa, serum sickness, or...

Multiple System Atrophy

Multiple system atrophy (MSA) is characterized clinically by a combination of parkinsonian, pyramidal, cerebellar, and autonomic symptoms. In contrast to Parkinson's disease, rest tremor is usually absent, and the findings are relatively symmetric. The autonomic symptoms are disabling and help differentiate MSA from other parkinsonian disorders. The pathological features include cell loss and gliosis in the striatum, substantia nigra, locus ceruleus, inferior olives, pontine nuclei, dorsal...

Diffuse Lewy Body Disease

Diffuse Lewy body disease (DLBD) is considered to be a variant or overlapping condition lying between Alzheimer's disease and Parkinson's disease. Clinical differentiation may therefore be difficult. In most patients with DLBD, however, psychosis and dementia are often found to precede parkinsonism (gait disturbance, rigidity, and resting tremor). The differentiation between DLBD and other parkinsonian syndromes, especially progressive supranuclear palsy, is particularly difficult when a...

Multiple Lumbar Spine Surgery Failed Back Syndromes

A history of failed lumbar spine surgery represents a diagnostic and therapeutic challenge for the physician. The first step is to distinguish between patients whose back or leg pain originates from a systemic cause (e.g., pancreatitis, diabetes, abdominal aneurysm) and those with a mechanical problem a thorough medical evaluation should therefore be undertaken in this group at the same time as the neurosurgical evaluation is carried out. Patients with profound emotional disturbances and...

Radial Nerve Injury at the Wrist

Wrist injuries frequently involve the superficial radial sensory branch, as a consequence of its exposed position (crossing the extensor pollicis longus tendon it can often be palpated at this point with the thumb in extension). Tight casts, watch bands, athletic bands, and handcuffs can cause transient compression of the superficial radial sensory branch, resulting in anesthesia, hypesthesia, or hyperesthesia over the dorsum of the radial side of the hand. It is often not the loss of sensation...

Human Immunodeficiency Virus HIV

Among acquired immune deficiency syndrome (AIDS) patients, 40-60 develop significant neurological symptoms or signs, and approximately 10-20 present with symptoms of neurological illness. Two forms of meningitis have been described with HIV-1 infection. At the time of seroconversion to HIV-1, most patients develop cerebrospinal fluid (CSF) abnormalities, and a few develop symptoms of headache, meningitis, encephalitis, myelopathy, and plexitis. This acute meningitis is clinically...

Spinal Intradural Cysts

Intraspinal neurenteric cysts form a spectrum that merges with intraspinal teratomas and intraspinal der-moids and epidermoids. More than 60 of the cases are diagnosed in the first 20 years of life 44 are located totally or partially in the cervical spinal canal, 37 are located in the thoracic spinal canal, and 19 in the lumbosacral spinal canal. The neurological signs and symptoms of a slowly progressing mass are associated by congenital anomalies, such as thickened or pigmented skin, a...

Cephalic Pain

Migraine headache - Classical migraine (hemicrania) A pulsatile headache that starts in the temple on one side and spreads to involve the whole side of the head. Usually self-limiting, lasting from 30 minutes to several hours Nocturnal attacks of pain in and around the eye, which may become bloodshot and with the nose stuffed up, with lacrimation and nasal watering. Bouts last 6-12 weeks and may recur at the same time each year Unilateral, shooting, drilling headache, associated with...

Multiple Sclerosis Like Lesions

Multiple sclerosis (MS) is a clinical diagnosis that should never be made using neuroimaging alone. In 78-95 of clinically diagnosed MS patients, gadolinium-enhanced magnetic resonance imaging (MRI) features include ovoid periventricular, infratentorial, temporal lobe, and corpus callosum white matter lesions that are isointense to hypointense on Tl-weighted images, and show high intensity on proton density and T2-weighted images. Many conditions have to be taken into account in the...

Metastatic brain tumors

Although intraventricular neurocytomas have a more benign course, they are more often subject to hemorrhage than oligodendrogliomas, which may suggest the diagnosis Bronchial carcinomas spread to the CNS in 30 of cases oat-cell carcinoma is the most frequent, whereas squamous-cell carcinoma is the least frequent subtype to metastasize to the brain It is estimated that 18-30 of patients with breast cancer will develop brain metastases Third most common neoplasm, with a propensity for metastatic...

Sciatica

Intervertebral disk dis- In most cases, sciatica is disk related and is caused by ease degenerative changes of the two lower lumbar motion Spinal stenosis In many cases, caused indirectly by a disorder of the Spondylolisthesis Spondylitis Vertebral tumors Extravertebral retroperitoneal tumors Sciatic nerve damage due to injection Is usually bilateral, and is little influenced by position changes and or traction Nerve root irritation is bilateral, and not influenced by motion or traction. Night...

Scar Versus Residual Disk

Magnetic resonance imaging (MRI) without intravenous contrast is at least as good as contrast computed tomography (CT) in distinguishing scar tissue from disk material, yielding an accuracy of 83 . The addition of gadolinium diethylene-triamine-penta-acetic acid (Gd-DTPA) enhancement further increases the diagnostic accuracy from 89 to 96 . Overall sagittal and axial Tl-weighted pre-Gd-DTPA and post-Gd-DTPA MRI remains the single most effective method of evaluating the postoperative lumbar...

Herpesviruses

Herpes simplex virus The reactivation and replication of HSV leads to intype 1 (HSV-1) flammation and extensive necrosis and edema of the medial temporal lobe and orbital surface of the frontal lobe of immunocompetent patients, producing the characteristic clinical picture. Patients develop fever, headache, irritability, lethargy, confusion and focal neurological signs, such as aphasia, motor and sensory deficits, and seizures (major motor, complex partial, focal, and absence attacks). CSF...

Fig 1 Suprasellar lesions neoplastic

Coronal T1 WI with a pituitary macroadenoma in close relationship with the optic chiasm presenting a heterogeneous, post-contrast high intensity signal. 3. Pituitary macroadenoma. Sagittal T1 WI shows a pituitary tumor with a heterogeneous postcontrast high intensity signal with cystic and or necrotic features in its posterior section filling the suprasellar cisterns and exerting compression on the optic chiasm. 4, 5. Craniopharyngioma. A suprasellar...

Clinical Grading Scales in Subarachnoid Hemorrhage

Conscious, with or without signs of bleeding in the subarachnoid space I Drowsy, without significant neurological deficit II Drowsy, with significant neurological deficit III Major neurological deficit, deteriorating, or older with preexisting Moribund or near-moribund, failing vital centers, extensor rigidity V Asymptomatic or mild headache I Moderate to severe headache, nuchal rigidity, may have oculomotor Confusion, drowsiness, or mild focal signs III Coma, moribund appearance, and or...

Fungal Infections

Zygomycetes (especially Mucor, Rhi-zopus) Cryptococcus neofor- The point of entry for Cryptococcus is the lungs. Pul-mans monary infection is not evident in healthy individuals, but becomes invasive in immunocompromised patients. Cryptococcal meningitis is the most common CNS infection (50 )in chronically immuno-suppressed non-AIDS patients. Cryptococcal meningitis presents as a chronic febrile syndrome with headache. The ensuing meningoencephalitis reflects cognitive changes or dementia,...