[Severe reversible dysphagia caused by herniation of the cerebellar ectopia]. / Ernstige, reversibele slikstoornis door herniatie van cerebellaire tonsillen.

A 58-year-old woman developed headaches and increasingly severe dysphagia over two years, which made her dependent on a nasogastric tube. Other symptoms were an unsteady gait and paraesthesias in the face, hands and feet. MR scanning of the craniospinal junction showed cerebellar ectopia with protrusion into the foramen magnum (Chiari I malformation). The patient recovered completely following surgical decompression. Previous reports show that this reversible cause of dysphagia is often not recognised until at a late stage.

[Chronic, unexplained pain: from complaint to action]. / Chronische, onverklaarde pijn: van klacht naar doel.

Every physician encounters patients with physical symptoms that remain unexplained, despite appropriate investigations. Medical curricula and textbooks fail to provide guidance about the management of such problems. Particularly specialists tend to feel helpless; this often leads to more referrals and unnecessary operations. Three patients, referred to a neurologist for a second opinion, had chronic, unexplained, crippling pains: a woman aged 53 with low back pain radiating to the right leg for 27 years, a man aged 31 with neck pain for 3 years and a woman aged 31 with pain in the left arm for 1.5 years. They had no recognisable features of depression. Their illness behaviour reversed after the neurologist reassured the patients and advised them to embark upon a strict programme of gradually increasing activities. In two of the patients, the scheme was supervised by the general practitioner. A follow-up interview (after a median interval of 3 years) of 27 similar patients referred for a second opinion showed some success with this approach in about half of them. In retrospect no predictive factors at baseline could be identified other than age and duration of symptoms. An indispensable first step in patients with unexplained, chronic pain is unqualified recognition of the symptoms, reassurance, and an explanation that avoids the mind-body division.