We found a match
Your institution may have access to this item. Find your institution then sign in to continue.
- Title
OTHER HEADACHES AND PAIN.
- Abstract
Objective: To determine the prevalence and nature of sinovenous obstruction in idiopathic intracranial hypertension (IIH) using auto-triggered elliptic-centric-ordered three-dimensional gadolinium-enhanced MR venography (ATECO MRV). Methods: In a prospective controlled study, 29 patients with established IIH as well as 59 control patients underwent ATECO MRV. In a randomized blinded fashion, three readers evaluated the images. Using a novel scoring system, each reader graded the degree of stenosis seen in the transverse and sigmoid sinuses of each patient. Results: There was excellent agreement across the three readers for application of the grading system. Substantial bilateral sinovenous stenoses were seen in 27 of 29 patients with IIH and in only 4 of 59 control patients. Conclusion: Using ATECO MRV and a novel grading system for quantifying sinovenous stenoses, the authors can identify IIH patients with sensitivity and specificity of 93%. There was also an excellent accompanying editorial: Comment: Drs. Silberstein and McKinstry sum up the dilemma for clinicians in one question: “Can most cases of idiopathic intracranial hypertension actually be attributed to an undiagnosed structural lesion of the venous sinuses?” SJT In 1747, the German physician Oppermann described a peculiar clinical patient. A 35-year-old woman suffered from excruciating daily headache attacks, lasting 15 minutes, which occurred exactly every hour, day and night, with extraordinary precision. Oppermann defined this peculiar headache “hemicrania horologica” (clocklike hemicrania). It has been suggested that Oppermann's case was the first known of chronic paroxysmal hemicrania (CPH). We describe here a similar case. Objective: To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain. Design: Economic evaluation alongside a randomised controlled trial. Setting: Primary care. Participants: 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n = 60, spinal mobilisation), physiotherapy (n = 59, mainly exercise), or general practitioner care (n = 64, counselling, education, and drugs). Main Outcome Measures: Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques. Results: The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (447 euro; 273 pounds sterling; 402 dollars) were around one third of the costs of physiotherapy (1297 euro) and general practitioner care (1379 euro). These differences were significant: P < 0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P = 0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care. Conclusions: Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner. Comment: One major problem with this study is a lack of a specific neurologic diagnosis for the chief complaint of “neck pain.” The authors state, “Spinal mobilization was defined as low velocity passive movements within or at the limit of joint range of motion. Spinal manipulation (low amplitude, high velocity techniques) was not provided.” I am not sure I understand what this technique involves, but it may be worth pursuing, given equivalent outcomes and lower costs. SJT The syndrome of spontaneous intracranial hypotension is characterized by orthostatic headaches in conjunction with reduced cerebrospinal fluid (CSF) pressure or CSF volume, and characteristic magnetic resonance (MR) imaging findings. A 50-year-old man presented with a 1-year history of paroxysmal ataxia of gait and short attacks of blurred vision when he stood up from a recumbent position and began to walk. Orthostatic headache was not a feature of his clinical presentation. Magnetic resonance images of the brain revealed diffuse enhancement of the dura mater and hygromas over both cerebral convexities. Magnetic resonance images of the spine demonstrated dilated cervical epidural veins and dilation of the perimedullary veins. Radionuclide cisternography identified a CSF leakage that was localized to the T12-L1 level on subsequent myelograms and on computerized tomography scans obtained after the myelograms. An epidural blood patch was administered and visualized with tungsten powder. The patient's clinical symptoms and sites of disease on imaging completely resolved. The unusual clinical presentation in this case—paroxysmal ataxia of gait, lack of orthostatic headaches, and dilated epidural and perimedullary venousplexus—supports a recently noted broadening of both the clinical and imaging characteristics of spontaneous intracranial hypovolemia. Comment: Dr. Bahram Mokri of the Mayo Clinic defines 4 types of low cerebrospinal fluid (CSF) pressure headache: type I: classic headache, absent in recumbency, present upon arising plus classic magnetic resonance imaging (MRI) findings of pachymeningeal enhancement with contrast plus low CSF pressure with lumbar puncture (LP); type II: classic headache, classic MRI, normal CSF pressure at LP; type III: classic headache, normal MRI, low CSF pressure; and type IV: no headache, classic MRI, low pressure. The patient in this case appears to be a variant of type IV of the low CSF pressure syndromes. SJT Object: The aim of this study was to evaluate the pathophysiology underlying headache associated with cough in patients with Chiari I tonsillar abnormality. The authors hypothesized that peak intrathecal pressure during coughing is higher in patients with headache aggravated by cough than in patients without or in healthy volunteers. In addition, the authors evaluated the use of intrathecal pressure during cough as a means of assessing obstruction to the free flow of cerebrospinal fluid (CSF) at the craniocervical junction. Methods: Twenty-six adult patients with Chiari I malformation and syringomyelia, four adult patients with Chiari I malformation without syringomyelia, and 15 healthy volunteers were prospectively studied. Testing before surgery included the following: clinical evaluation for the presence of headache associated with cough; and 2) evaluation of lumbar subarachnoid pressure at rest, during three to five coughs, while performing the Valsalva maneuver, during jugular compression, and after removal of CSF. Patients underwent suboccipital craniectomy, C-1 laminectomy, and duraplasty. Testing was repeated 6 months after surgery. Conclusions: Peak intrathecal pressures during cough and at baseline were elevated in patients with headache associated with cough compared with either patients without headache or healthy volunteers. After surgery, intrathecal pressures during cough were significantly lower than preoperative values and headache aggravated by cough was resolved partially or completely. Headache linked to coughing in patients with Chiari I malformation is associated with sudden increased intrathecal pressure caused by obstruction to the free flow of CSF in the subarachnoid space. Comment: The question is whether, despite the confirmation of the increased pressure and obstruction to flow, these patients needed surgery. Most patients with cough headache and only a Chiari I will respond to indomethacin. Neil Raskin also published his cases on the use of high volume CSF removal as a treatment: Raskin NH. The cough headache syndrome: treatment. Neurology. 1995;45:1784. Significant Arnold-Chiari malformation must always be ruled out in cough headache and corrected when present, but there is a question whether Chiari I without syringomyelia, manifesting as a headache disorder known to be treatable with indomethacin or lumbar puncture, constitutes a significant enough form of Chiari to merit suboccipital craniectomy, C1 laminectomy, and duraplasty. No randomized study exists to answer this question, but being a neurologist, I always seek a noninvasive remedy first. SJT Purpose: To examine the role of unilateral temporal artery biopsy (TAB) in suspected giant cell arteritis (GCA). Design: Retrospective interventional case series. Participants: We identified 181 subjects from pathology and diagnostic code databases at the University of Pennsylvania Medical Center who underwent TAB between January 1990 and January 2001. Methods: The medical records for all subjects who underwent TAB were reviewed. Follow-up information was obtained by telephone or record review for those patients who had negative unilateral TAB. Main Outcome Measures: Follow-up information for patients with unilateral negative TAB was reviewed for potential adverse outcomes caused by missed or delayed diagnoses of GCA. Presenting signs and symptoms and laboratory values were recorded for all subjects. Comparisons of clinical profiles between subsets of subjects were performed using Fisher's exact test, significance level alpha = 0.01. Results: Follow-up information was available for 88 (86%) of 102 subjects who had unilateral negative biopsy samples. One (1%) subjects of 88 had a subsequent positive contralateral TAB; no adverse outcomes occurred for this subject or for any other subjects with unilateral negative TAB. Compared with subjects who had unilateral positive or who underwent bilateral TAB (n = 74), those who had unilateral negative TAB (n = 88) had a significantly lower prevalence of jaw claudication (P = 0.007). Compared with subjects diagnosed with GCA (n = 39), those with unilateral negative TAB (n = 88) had significantly lower frequencies of jaw claudication (P = 0.001), “chalky white” optic disc edema (P = 0.002), and fever (P < 0.0001). Compared with subjects with positive TAB (n = 33), subjects with negative TAB (n = 148) had significantly lower prevalence of jaw claudication (P < 0.0001), “chalky white” disc edema (P = 0.0002), pale disc edema (P = 0.006), or any systemic symptom other than headache (P = 0.0002). (“Chalky white” denotes notably extreme disc pallor). The most common indications for biopsy in subjects with unilateral negative TAB were elevated erythrocyte sedimentation rate (ESR) (74%), headache (69%), visual complaints (58%), and ophthalmic signs (52%). Although ESR was a significant predictor of positive TAB overall (unilateral and bilateral TAB) in logistic regression models accounting simultaneously for subject age (P = 0.04), ESR did not significantly predict unilateral negative status in our patients (P = 0.13). Conclusions: In this cohort of patients, unilateral TAB was associated with an extremely low frequency (1%) of subsequent positive contralateral TAB and was not associated with adverse visual or neurologic outcomes for any subject. We conclude that in the hands of experienced physicians, a unilateral TAB is sufficient to exclude a diagnosis of GCA in populations for which clinical suspicion is low. Jaw claudication, pale optic disc edema, particularly “chalky white” disc edema, fever, or any systemic symptom other than headache should raise suspicion for a diagnosis of GCA. Comment: This is a study that may change my practice. I will probably stop with the one negative biopsy, unless I am really suspicious of the diagnosis. SJT Objective: Concern about cerebrovascular accidents after cervical manipulation is common. We report a case of cerebrovascular infarction without sequelae. Clinical Features: A 39-year-old man with nonspecific neck pain was treated by his general practitioner with cervical manipulation. Intervention and Outcome: This immediately elicited severe headache and neurologic symptoms that disappeared completely within 3 months despite permanent signs of a complete left-sided cerebellar infarction on computed tomography and magnetic resonance imaging. At 7-year follow-up the patient was fully employed, and repeated magnetic resonance imaging still showed infarction of the left cerebellar hemisphere. However, the patient remained completely free of neurologic symptoms, and color duplex ultrasonography showed normal cervical vessels, including patent vertebral arteries. Conclusion: It appears that the risk of cerebrovascular accidents after cervical manipulation is low, considering the enormous number of treatments given each year, and very much lower than the risk of serious complications associated with generally accepted surgery. Provided there is a solid indication for cervical manipulation, we believe that the risk involved is acceptably low and that the fear of serious complications is greatly exaggerated. Comment: I might take a slightly different view. The risk of manipulation, or chiropractic cervical adjustment, may be low but it is not zero. And although this patient had what proved to be a subjective recovery from cerebellar stroke, other posterior fossa strokes can, of course, be catastrophic. The first chiropractor-induced stroke I saw in practice occurred when one chiropractor adjusted the neck of another chiropractor, and she incurred a posterior cerebral occipital stroke which left her unable to drive. Please see the next abstract for more on the issue of the risks of manipulation of the neck, a therapy many patients with posterior headache seek out. Since stroke can occur with both “manipulation” and “adjustment,” caveat emptor. SJT Objective: To determine whether spinal manipulative therapy (SMT) is an independent risk factor for cervical artery dissection. Methods: Using a nested case-control design, the authors reviewed all patients under age 60 with cervical arterial dissection (n = 151) and ischemic stroke or TIA from between 1995 and 2000 at two academic stroke centers. Controls (n = 306) were selected to match cases by sex and within age strata. Cases and controls were solicited by mail, and respondents were interviewed using a structured questionnaire. The medical records of interviewed patients were reviewed by two blinded neurologists to confirm that the patient had stroke or TIA and to determine whether there was evidence of arterial dissection. Results: After interview and blinded chart review, 51 patients with dissection (mean age 41 ± 10 years; 59% female) and 100 control patients (44 ± 9 years; 58% female) were studied. In univariate analysis, patients with dissection were more likely to have had SMT within 30 days (14% vs 3%, P = 0.032), to have had neck or head pain preceding stroke or TIA (76% vs 40%, P < 0.001), and to be current consumers of alcohol (76% vs 57%, P = 0.021). In multivariate analysis, vertebral artery dissections were independently associated with SMT within 30 days (OR 6.62, 95% CI 1.4 to 30) and pain before stroke/TIA (OR 3.76, 95% CI 1.3 to 11). Conclusions: This case-controlled study of the influence of SMT and cervical arterial dissection shows that SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain. Patients undergoing SMT should be consented for risk of stroke or vascular injury from the procedure. A significant increase in neck pain following spinal manipulative therapy warrants immediate medical evaluation.
- Subjects
HEADACHE; NEURALGIA; INTRACRANIAL hypertension; VENOGRAPHY; PHYSICAL therapy
- Publication
Headache: The Journal of Head & Face Pain, 2003, Vol 43, Issue 9, p1021
- ISSN
0017-8748
- Publication type
Article
- DOI
10.1046/j.1526-4610.2003.03200_6.x