Standard EEG and the difficult-to-assess mental status.

BACKGROUND: Delirium commonly appears on the differential diagnostic list of psychiatric patients in acute care settings. When a patient is unable or unwilling to answer questions about orientation, determination of possible delirium or other probable etiologies becomes difficult. The role of the standard electroencephalogram (SEEG) in evaluating such patients is not known. METHODS: Exhaustive MEDLINE and PsycInfo searches were performed for the period 1950-2007 for all articles cross-referenced for "delirium" and "EEG." The focus was on method, comorbid conditions, demographics, and prevalence and nature of reported abnormalities. RESULTS: We reviewed a total of 45 articles, of which 12 met criteria for more stringent review. All findings are presented in chronological order. Our analysis focuses on SEEG, although we also allude to quantitative EEG when described. CONCLUSIONS: Diffuse slowing of the EEG is considered one of the hallmarks of an encephalopathic process and is commonly reported in psychiatric patients. The EEG may be helpful in the diagnostic evaluation of patients with a difficult-to-assess mental status.

Airway changes after anterior cervical discectomy and fusion.

INTRODUCTION: Anterior cervical discectomy and fusion (ACDF) is a common procedure for radicular and spondylotic disease of the cervical spine. Radiographs are routinely used to evaluate complications in the postoperative ACDF patient, especially airway compromise. Our purpose was to establish baseline data on the amount of change that can be expected in the prevertebral soft tissues after this procedure in the uncomplicated asymptomatic (no airway compromise) 1 or 2-level ACDF patient. Our hypothesis was that the upper cervical spinal levels (C2-C4) would experience greater degrees of swelling than the lower cervical spine (C5-C7). To date no published data exist in the English literature upon which to judge symptomatic patients (experiencing postoperative airway distress) radiographically. METHODS: We prospectively evaluated preoperative and postoperative x-rays of 32 patients undergoing ACDF for radicular or spondylotic cervical pathology. Measurements were taken from the anterior body of the cervical spine to the posterior aspect of the airway. The postoperative differences for each level from C2 to T1 were calculated. RESULTS: We found that the greatest level of swelling or change in the prevertebral soft tissues occurred at the mid-body of C4 in uncomplicated cases with an average change of 10.7 mm. No patients measured greater than 25 mm at C4. CONCLUSIONS: As we predicted, the greatest edema was noted in the upper cervical spine. Studies need to be performed to compare the radiographic data of symptomatic patients with the baseline data we have collected.

Somatosensory evoked potential monitoring during anterior cervical discectomy and fusion.

STUDY DESIGN: A retrospective, multicenter clinical review was conducted. OBJECTIVE: To examine our experience using somatosensory evoked potential (SSEP) monitoring during anterior cervical discectomy and fusion (ACDF) to determine if monitoring of the spinal cord with SSEPs was helpful in identifying reversible causes of neurologic impairment while performing the procedure. SUMMARY OF BACKGROUND DATA: Recent studies have strongly supported the use of SSEP monitoring during complicated and upper-cervical spine surgery. METHODS: The complete medical records of 163 patients who underwent ACDF, and who were monitored with SSEPs during the procedure between 1995 and 2002 were retrospectively reviewed. A single observer who was uninvolved with patient care abstracted these medical records. Demographic data, length of symptoms, workers' compensation status, primary diagnosis, preoperative neurologic status, number of levels fused, bone graft type, implants used, SSEP findings, postoperative neurologic status, complications, and recovery from complications were recorded. Final neurologic status was determined through phone contact with patients or outpatient charts of patients who could not be contacted personally. RESULTS: There were 3 false positive (1.8%) intraoperative SSEP findings in which SSEP changes intraoperatively did not reflect a neurologic deterioration after surgery. There was 1 false negative (0.6%) in which a new neurologic deficit occurred after surgery, despite no change in SSEP amplitudes during the operation. There were 2 true negatives (1.2%) in which SSEP monitoring showed a preexisting neurologic deficit, which did not change during the operation. CONCLUSION: In no instance were positive SSEP findings clinically useful in alerting the surgeon to potential intraoperative complications. Intraoperative SSEP monitoring is not helpful to the surgeon when performing routine ACDF. Additionally, ACDF is a safe procedure with a low rate of neurologic complications.

Cervical-peritoneal shunt placement for postoperative cervical pseudomeningocele.

Postoperative pseudomeningocele after an anterior approach to the cervical spine is an uncommon complication and may present a difficult challenge to treat. Patients with ossification of the posterior longitudinal ligament (OPLL) are especially prone to dural leaks and resultant pseudomeningocele formation. We present a case of recalcitrant pseudomeningocele in a patient with OPLL after anterior decompression and stabilization of the cervical spine treated with cervical-peritoneal shunt.

Hysterical paralysis: a report of three cases and a review of the literature.

STUDY DESIGN: Three cases of hysterical paralysis are reported and the literature is reviewed. OBJECTIVE: To report and discuss three cases of psychogenic paraplegia in order to increase the awareness and assist in the diagnosis and treatment of this uncommon disorder. SUMMARY OF BACKGROUND DATA: Hysterical paralysis, a form of conversion disorder, is an uncommon psychogenic, nonorganic loss of motor function precipitated by a traumatic event. The prevalence of conversion disorder in the general population reportedly is between 5 and 22 per 100,000 persons. The pursuit of a diagnosis for the hysterical paraplegic patient necessarily consumes valuable resources and time. If early recognition can be facilitated, these resources may be conserved. METHODS: The medical records for three healthy young women who presented to the authors' service reporting complete loss of lower extremity function were reviewed retrospectively along with the related laboratory, electrodiagnostic, and imaging studies. Two of the women were involved in motor vehicle accidents. One had a history of a previous hysterical seizure. Inconsistencies in physical examination and studies were noted. RESULTS: All three patients had normal laboratory, electrodiagnostic, and imaging studies. Discrepancies included complete loss of motor control and sensation in the lower extremities in the face of normal deep tendon reflexes as well as incontinence of bowel and bladder despite intact rectal tone. The patients spontaneously recovered and ambulated out of the hospital without assistance after their normal test results and physical examination inconsistencies were presented to them. CONCLUSIONS: Hysterical paraplegia is a type of conversion disorder. It is a diagnosis of exclusion that typically presents as mono-, hemi-, para-, or quadriplegia. The pursuit of a diagnosis for the hysterical paraplegic patient necessarily consumes valuable resources and time. The typical patient is a female from a low socioeconomic background with limited education. The DSM-IV-TR criteria must be met to fulfill the diagnosis of conversion disorder. Electrodiagnostic and imaging studies can aid in the diagnosis. Treatment revolves around explaining the normal diagnostic results to the patients and guiding them to appropriate psychiatric and physiotherapy. Rapid recovery should be expected, but can take up to 6 months.