Differential Diagnosis 1 – Weeks 3 & 4. Seizures.
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Although approximately 6% of adults will experience at least one afebrile seizure in their lifetime, only 0.5% will have recurring seizures (epilepsy) (So and Hauser ref). This must be considered prior to initiating medical management decisions.
So NK. Recurrence, remission, and relapse of seizures. Cleve Clin J Med 1993;60:439-443.
Hauser WAS, Rich SS, Annegers JF, Anderson VE. Seizure recurrence after a 1st unprovoked seizure: an extended follow-up. Neurology 1990;40:1163-1167.
Twenty-four percent of epileptic patients are elderly with 38% of new cases occurring in the elderly (with stroke accounting for one-third of cases). (Stephen ref)
Stephen LJ. Epilepsy in elderly people. Lancet 2000;355:4-8.
Infancy- childhood: developmental, infection, trauma, cerebrovascular disease (CVD)
Adult – brain tumor, trauma, developmental disorder, infection, CVD
Late adulthood-elderly: CVD, brain tumor, degenerative disease, trauma
Cortical malformations – may be involved with partial or generalized epilepsy.
Glial cell – glial cells, although primarily supportive, also serve functions of buffering that help maintain uptake of potassium and glutamate (among other metabolic balances). The result may be increased levels of extracellular potassium decreasing the threshold for neuronal firing (hyeprexcitability).
The Normal Thalamocortical Circuit and EEG Patterns during Wakefulness, Non-Rapid-Eye-Movement (Non-REM) Sleep, and Absence Seizures
Chang B and Lowenstein D. N Engl J Med 2003;349:1257-1266
Valproic acid (Depacon) – tremor and weight gain
Phenytoin (Dilantin)– in young patients gingival hyperplasia and hirsutism
Carbamazapine (Carbatrol, Tegretol, Tegretol-XR) and oxcarbazepine (Trileptal) - hyponatremia in patients who drink large amounts of fluids or on diuretics
Various surgical options – usually for those with a well-defined structural lesion
Vagal nerve simulation
Deep brain stimulation
For refractive epilepsy there are several options dependent on the type, age, location and type of lesion. Following is a list of current surgical options with related types that may be treated (Nguyen ref):
Resective surgery – the epiloptogenic area must be delineated using several approaches to a convergent localization that allows accuracy in resection. Temporal lobe epilepsy is one example of epilepsy that may be responsive to resection.
Multiple Subpial transactions – based on the knowledge that functional cortical organization is primarly vertical. Intracortical fibers that are generally responsible for seizures are horizontally oriented. Small parallel cortical slices are made perpendicular to the long axis of the gyrus in an effort to spare function. This procedure is used alone or in combination with resective surgery for seizures arising in or around motor, sensory, or language cortical areas.
Gamma-Knife surgery – This is a stereotactic delivery of radiation to a very specific point in the brain which has been identified using MRI. There is a delay effect in results that may occur as much as one to three years post-procedure. Currently, three types of epilepsy are being evaluated for success using this treatment including hypothalamic hamartomas, vascular malformations, and mesial temporal lobe sclerosis. In selected cases, success rates for cessation of seizures is around 75%.
Nguyen DK, Spencer SS. Recent advances in the treatment of epilepsy. Arch Neurol 2003;60:929-935.
For long-term memory the postsynaptic cell needs to stimulate the manufacture of synapse-strengthening proteins (CREB proteins) that might then add more receptors or change the post-synaptic response in some way
Information that is declarative (people, places, events) must pass through the hippocampus before being recorded in the cerebral cortex.
cholinesterase inhibitors (tacrine [Cognex] donepaxil [Aricept]) yet this tx does not alter the course of the disease
memantine, is an uncompetitive NMDA-receptor antagonist (anti-glutamatergic)
Aspirin may be preventive
Estrogen, Ginko-biloba, and memory games have been shown to have no effect
The only apparent effective therapy is aerobic exercise
Aerobic exercise training increases brain volume in aging humans.
Colcombe SJ, Erickson KI, Scalf PE, Kim JS, Prakash R, McAuley E, Elavsky S, Marquez DX, Hu L, Kramer AF.
J Gerontol A BiolSci Med Sci. 2006 Nov;61(11):1166-70.
Fitness effects on the cognitive function of older adults: a meta-analytic study.
Colcombe S, Kramer AF.
Psychol Sci. 2003 Mar;14(2):125-30.
The mostcommon cause of cervical radiculopathyis
Only about 20% are due to a disc herniation
Protection from the PLL (posterior longitudinal ligament)
The location of the nerve roots/spinal nerve in the IVF
The loss of a nucleus pulposis by age 45
Posterior IVF Compression
Fibrous tissue in IVF
Buckling of ligamentum flavum
Osteophytes from superior and inferior articular processes
Patients trace a dermatome when they have
nerve root involvement
Pain Patterns and Descriptions in Patients with Radicular Pain: Does the Pain Necessarily Follow a Specific Dermatome?Murphy DR, Hurwitz E, Gerrard JK, Clary RChiropractic & Osteopathy 2009; 17:9
Pain was non-dermatomal in 69.7% cases of cervicalradiculopathy
Pain was non-dermatomal in 64.1% of cases of lumbarradiculopathy
Patients claim weakness when they have
nerve root involvement
64%-75% will have weakness on examination
Only 15%-34% will complainof weakness
Lauder TM. Physical Examination Signs, Clinical Symptoms, and Their Relationship to Electrodiagnostic Findings and the Presence of Radiculopathy. Phys Med Rehabil Clin N Am. 2002:451-467
31% will have no weakness on examination
33%-45% will have no sensory abnormalities
Although forearm flexion/wrist extension are used for C6 and elbow extension for C7, pronation is an option
For C6 – 72% had pronation weakness (wrist extension weak in 36%)
For C7 – 23% had pronation weakness with elbow extension weakness; pronation was only weakness in 10%
Rainville J, Noto DJ, Jouve C, Jenis L. Assessment of forearm pronation strength in C6 and C7 radiculopathies. Spine. Jan 1 2007;32(1):72-75.
The area of numbnessextends throughout the area of pain radiation
There is only one muscle that is found weak with each nerve root
Trauma is usually reported when cervical radiculopathy symptoms begin
Traumais reported in only 15% of cases of cervical radiculopathy
Radhakris K, Litchy WJ, O’Fallon Wm et al. Epidemiology of cervical radiculopathy: A population-based study from Rochestor, Minnessota, 1976 through 1990. Brain 1994;117:325-335.
Lumbar disc herniations compress the nerve root that is
exiting at that level
The straight leg raise is positive for nerve root involvement only from 30 to 70 degrees
Jonsson B, Stromqvist B. Spine, 20(1), 27-30, 1995
Prior cadavericstudies indicated little dural tension until 30 degrees therefore positives below 30 degrees were not indicative of disc herniation as a cause of LBP
SLR positive in 26% of patients from 30-60 degrees
There is always radiation into the extremity with disc “rupture”
Most tests for cervical and lumbar nerve root involvement
are equal in ruling-in or ruling-out radiculopathy
Kortelainen P, Puranen J, Koivisto e, et al. Spine 1985;10(1)88-92
Pain projection into the S1 area is found with
all lumbar disc lesions including high levels
With concomitant S1 findings accuracy of pain projection into L5 and EH weakness were still accurate
Extensor hallicus weakness and sensory defect in L5 area were 100% reliable for L4-L5 herniation
You can know when someone has a radiculopathy BUT
you can’t always know when they don’t