Transient unresponsiveness in the elderly. Report of five cases.

Five hospitalized elderly patients had one or more self-limited episodes of unresponsiveness that could not be explained by metabolic, structural, convulsive, or psychiatric disorders. They accounted for approximately 2% of cases referred to us for evaluation of coma. Despite some heterogeneity, shared clinical features in these patients suggest an age-related disorder of arousal that may be more common than is generally appreciated.

Dexamethasone is not superior to placebo for treating lumbosacral radicular pain.

In a prospective double-blind study, we compared dexamethasone and placebo in 33 subjects with lumbosacral radicular pain. Of subjects with resting pain, 7/21 improved on dexamethasone, and 4/12 improved on placebo. Of subjects with pain on straight-leg raising, 8/19 improved on dexamethasone and 1/6 on placebo. Of 27 subjects evaluated 1 to 4 years after treatment, 8/16 who had received dexamethasone were asymptomatic or had only occasional mild low-back pain, compared with 7/11 who had received placebo. Thus, dexamethasone is not superior to placebo for either early or long-term relief of lumbosacral radicular pain, but may reduce pain evoked by stretch of acutely inflamed spinal nerve roots.

Metastasis of intracranial germinoma through a ventriculoperitoneal shunt.

A young man developed a tumor in the pineal region that grew along ventricular surfaces and caused obstructive hydrocephalus. Cytologic examination of cerebrospinal fluid demonstrated malignant cells consistent with germinoma. Following a ventriculoperitoneal shunt and radiotherapy, the tumor and the hydrocephalus regressed. Three years later, an intraperitoneal tumor appeared that was diagnosed by transcutaneous biopsy specimen as a germinoma. The abdominal germinoma also regressed after radiotherapy. While extracranial metastases of intracranial germinomas via shunts are probably rare, their occurrence, as exemplified by this case, argues for including protective filters in the shunts.

Colonic ileus complicating laminectomy.

Colonic ileus is an unusual form of adynamic ileus that often mimics true intestinal obstruction and that, if not recognized and adequately treated, may be fatal. We have encountered three patients in whom this syndrome followed apparently uncomplicated laminectomy for herniated disc or spinal stenosis. Two of our three patients required abdominal exploration for diagnosis and treatment of the complication. At operation, a large distended colon without volvulus or tumor was found. Cecostomy was performed in both patients. The third patient was treated conservatively. All three patients recovered without sequelae. The pathogenesis of the illness is unknown, but the most widely held view is that ileus results from increased sympathetic activity that inhibits the bowel. Conservative management consisting of correction of any fluid or electrolyte abnormalities, continuous gastric suction via nasogastric tube, and placement of a rectal tube may relieve the symptoms. Patients should, however, be followed carefully and, if distention of the cecum exceeds 12 cm, a decompressive operation is indicated.