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200 180 160 140 120 100 80 60 40 20 0 2000 April 1998 March 1997 June 1999 April 2001 April 1996 October 2002 January 2000 January 2002 April 1999 July 2000 July 1999 October 2000 October 2001 January 2001 October 2002 July 2001 July 1998 December 2002 October

Epidural fat deposition with spinal cord or cauda equina compression occurs in Cushing disease and after the long-term use of corticosteroids but also in the absence of these disorders The clinical picture may suggest discogenic disease (Lipson et al) Copious amounts of normal adipose tissue are found at laminectomy, and removal of this tissue is curative Lowering the dose of steroid and caloric restriction will help mobilize the fat and relieve the symptoms (An intraspinal lipoma is also a component of the developmentally tethered cord, but in this process the essential problem is a conus medullaris myelopathy from stretching of the cord, rather than compression; see Thomas and Miller) Arachnoid diverticula intra- or extradural outpouchings from the posterior nerve root are rare causes of a radicular-spinal cord syndrome rst described by Bechterew in 1893 They tend to occur in the thoracic or lumbosacral regions.

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The symptoms, in order of decreasing frequency, are pain, radicular weakness and sensory disorder, gait disorder, and sphincteric disturbances (Cilluffo et al) The frequent association of arachnoid diverticula with osteoporosis, ankylosing spondylitis, and arachnoiditis makes it dif cult to interpret the role of the diverticulae themselves Surgical obliteration of the pouches has yielded unpredictable results They have attained clinical importance more often in our experience as the source of spontaneous CSF leaks and a low-pressure syndrome (Chap 30) Spinal cord compression with paraplegia may be caused by extramedullary hematopoiesis in cases of myelosclerosis, thalassemia, cyanotic heart disease, myelogenous leukemia, sideropenic anemia, and polycythemia vera (Oustwani et al) A similar phenomenon occurs with ossi cation of the posterior longitudinal ligament, as described earlier Solitary osteochondromas of vertebral bodies and multiple exostoses of hereditary type are other reported causes of spinal cord compression.

In the case reported by Buur and Morch, the clinical syndrome was one of pure spastic paraparesis of several months progression..

This drug, originally synthesized as an MAO inhibitor, is now an important oral agent in the treatment of Hodgkin disease and other lymphomas and has found some use in bronchogenic carcinoma and malignant gliomas. It has also proved to be especially effective in the treatment of oligodendrogliomas. Neural complications are infrequent and usually take the form of somnolence, confusion, agitation, and depression. Diffuse aching pain in proximal muscles of the limbs and mild symptoms and signs of polyneuropathy occur in 10 to 15 percent of patients treated with relatively high doses. A reversible ataxia has also been described. Procarbazine, taken in conjunction with phenothiazines, barbiturates, narcotics, or alcohol, may produce serious degrees of oversedation. Other toxic reactions, such as orthostatic hypotension, are related to the MAO inhibitory action of procarbazine.

8:

intracranial pressure rises In fact, arti cially raising the intraspinal and intracranial pressure by the subarachnoid or intraventricular injection of sterile saline solution does not consistently result in headache This has been interpreted to mean that raised intracranial pressure does not cause headache a questionable conclusion when one considers the relief of headache in some patients that follows lumbar puncture and lowering of the cerebrospinal uid (CSF) pressure, particularly after subarachnoid hemorrhage Actually, most patients with high intracranial pressure complain of bioccipital and bifrontal headaches that uctuate in severity, probably because of traction on vessels or dura Dilatation of intracranial or extracranial arteries (and possibly sensitization of these vessels), of whatever cause, is likely to produce headache The headaches that follow seizures, infusion of histamine, and ingestion of alcohol are probably all due to cerebral vasodilatation.

Nitroglycerin, nitrites in cured meats ( hot-dog headache ), and monosodium glutamate in Chinese food may cause headache by the same mechanism It seems probable that the throbbing or steady headache that accompanies febrile illnesses has a vascular origin as well; it is likely that the increased pulsation of meningeal vessels activates pain-sensitive structures within their walls or around the base of the brain Certain systemic infectious agents, enumerated further on, seem to have a tendency to cause severe headache The febrile headache may be generalized or predominate in the frontal or occipital regions and is much like histamine headache in being relieved on one side by carotid or super cial temporal artery compression and on both sides by jugular vein compression It, like migraine, is increased by shaking the head.

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