Severe pain confounds neuropsychological test performance.

There is little information on the effect of pain on neuropsychological test performance. We have undertaken this study to explore which tests are affected by pain, the magnitude of these changes, and other confounders of neuropsychological performance in a population of patients having spine surgery. Twenty-four elderly English speaking Caucasian patients (age > 60 years) were enrolled pre-operatively in this Institutional Review Board approved study. Pain scores using an 11-point Numeric Pain Intensity scale and performance on a neuropsychological battery (Controlled Oral Word Association, Rey Complex Figure, Trails A and B) were assessed at two times, before and one day after surgery. Scores were calculated using the standard algorithms and change scores were calculated by subtracting the baseline from follow-up scores. After surgery, performance on the Rey Complex Figure ( r = -0.577, p = 0.004) and Trails Part A (r = 0.527, p = 0.01) declined with increasing post-operative pain scores. Women reported higher pain scores post-operatively than men (p = 0.046), and performed worse than men for change in performance on Trails Part A (p = 0.027). These data suggest that pain can influence performance on certain cognitive tests, and that some gender differences in these effects may occur. Interpretation of performance measures should take into account possible effects of pain, although our understanding of pain effects and ability to predict them in individual people, currently are quite limited.

Acoustic schwannoma and epidermoid cyst occurring as a single cerebellopontine angle mass.

The case of a 66-year-old man with a 3-year progressive hearing loss and a homogeneous left cerebellopontine angle mass on magnetic resonance imaging scan is described. At surgery, the major portion of the mass was a typical encapsulated, solid, acoustic schwannoma, but the most rostral portion was a distinct, flaky, cystic mass without a well-defined capsule, typical of an epidermoid cyst. The radiographic and operative findings of this unique coexistence of two different benign cerebellopontine angle masses are presented.

Radiculopathies of structural origin.

In dealing with foot pain of a radicular nature, it is important to interpret the clinical signs and symptoms of the pathology carefully and arrive at an adequate diagnosis. All appropriate ancillary aids should be used to help confirm the diagnosis. Appropriate treatment plans will follow; most often they will include referrals to qualified orthopedic specialists. In this sense, the treatment of lower-extremity radiculopathy is seen as a multidisciplinary problem. The podiatrist has the opportunity to make the diagnosis, explain the problem to the patient, and perhaps deal with the resolution of the pathology. This article attempted to present a differential diagnosis of a structural radiculopathy presenting in the lower extremity. It is hoped that the discussion of symptomatology, diagnostic aids, and numerous illustrations help to add to the knowledge of this disease process.

Spinal dysraphisms.

The practitioner is faced with the challenge of identifying occult presentations of spinal dysraphism and providing follow-up treatment of foot and leg deformities. The initial symptoms of a spinal dysraphic condition may be subtle and involve the lower extremity. An increased understanding of spinal dysraphism will encourage early diagnosis and prompt effective treatment.

Depression of circulating blood volume in patients after subarachnoid hemorrhage: implications for the management of symptomatic vasospasm.

The result of 42 blood volume determinations made with autologous red blood cells labeled with chromium-51 are reported. The subjects consisted of 11 control patients and 25 patients with recent subarachnoid hemorrhage (SAH). The mean red blood cell volume (RBCV) and the total blood volume (TBV) for female patients after SAH were significantly lower than corresponding control values (P less than 0.01). No depression of blood volume was found in males as a group. Seventy-two per cent of females had below-normal RBCV and 50% had below-normal TBV. Fifteen patients demonstrated angiographic vasospasm or signs of cerebral ischemia. Only 1 patient with asymptomatic vasospasm had a below-normal RBCV or TBV, whereas 6 of 7 patients with symptomatic vasospasm had a subnormal RBCV or TBV. The mean RBCV and mean TBV for female patients with symptomatic vasospasm were significantly lower than corresponding control values (P less than 0.02) and lower than values for female patients with asymptomatic vasospasm (P less than 0.05). The data suggest that volume status may be the important differential between asymptomatic and symptomatic vasospasm. Delayed ischemic deficits can be expected to develop in patients who have both spasm of the intracranial vessels and decreased TBV. Patients with normal blood volume are far less likely to experience cerebral ischemia, even if vasospasm develops.

Transient neurological deficits secondary to saccular vertebrobasilar aneurysms. Report of two cases.

Aneurysms have rarely been implicated as a possible cause of transient neurological deficits, and most reports of this phenomenon describe aneurysms in the anterior circulation. There is only one previous report of a saccular posterior circulation aneurysm associated with transient ischemic attacks. The authors document two cases of giant saccular vertebrobasilar artery aneurysms associated with transient neurological deficits.

Computed tomographic demonstration of giant aneurysms of the vertebrobasilar system: report of eight cases.

Giant aneurysms of the vertebrobasilar system can easily mimic other mass lesions in the posterior fossa and 3rd ventricle. Recently, we treated eight cases of giant aneurysm in the vertebrobasilar circulation that were demonstrated by computed tomography with angiographic correlation. We describe the salient radiological features that help to distinguish giant aneurysms from neoplasms and discuss their clinical manifestations and surgical management.

Combined otoneurosurgical approach to patients with chronic ear disease and cerebrospinal otorrhea.

We report a combined otoneurosurgical approach in the treatment of a patient with meningitis due to an arachnoid cyst, extending through the dura and petrous bone into the middle ear. The combination of mastoid surgery and temporal craniotomy including opening the dura was necessary to determine the nature of the problem, excise the disease and repair the defects. Two recent cases at our Institution of cerebrospinal otorhinorrhea and chronic ear disease illustrate the difficulty in carrying out definitive repair of dural defects from within the mastoid cavity. Case 2 had three bouts of meningitis and two brain abscesses separated by 25 years. Case 3 had eight bouts of meningitis in 19 years. The authors recommend at otoneurosurgical team approach in patients with cerebrospinal otorhinorrhea permitting treatment of the temporal bone, dura and brain.