Nelson Hendler

A preoperative screening test for chronic back pain patients.

Abstract The authors describe a quickly administered screening test designed to aid in the diagnosis of patients with chronic pain complaints and to help predict the outcome of contemplated surgery. The test was applied retrospectively to 315 patients and was 83% accurate in selecting out those who had an organic basis for their pain. Two thirds of the patients who had negative physical findings scored in a range suggesting the absence of an organic cause for the pain. Preliminary results from a prospective trial of the test have confirmed its usefulness.

Thermographic validation of physical complaints in ‘psychogenic pain’ patients

To determine whether some patients complaining of chronic unexplained pain had received inappropriate psychiatric diagnoses, we used thermography to evaluate 224 consecutive patients. Abnormal results were found in 43 patients (19%), leading to diagnoses of reflex sympathetic dystrophy, nerve root irritation, and thoracic outlet syndrome. Three case histories illustrated by thermograms demonstrate the value of thermography in detecting otherwise overlooked organic disorders, particularly sympathetic dysfunction, that may easily be misdiagnosed as psychogenic pain.

A 24-hr monitoring of the integrated plasma concentration of aldosterone and cortisol in manic patients

Abstract (1) A 24-hr continuous monitoring of the fluctuations of plasma levels of cortisol and aldosterone was carried out in three manic-depressive patients during the manic phase. This study was done using a newly developed, portable, non-thrombogenic, constant blood-withdrawal system, that made possible the collection of blood samples for a 24-hr period, without interfering with the activity of the patient. The integrated concentration of aldosterone and cortisol in the plasma of the patient was determined every 20 min using radioimmunoassay, and competitive protein binding method respectively. The results of these studies were compared with those obtained in six normal subjects during a day of normal activity. (2) The 24-hr integrated concentration of aldosterone in patients was found to be 11.2, 13.6 and 14.2 ng/100 ml. These results were above the range found in healthy subjects (3.8–10.7 ng/100 ml). These findings are in agreement with the higher than normal levels of plasma aldosterone obtained from single blood samples in seven manic patients. (3) The 24-hr integrated concentration of cortisol of the three manic patients were 8.6, 8.2 and 11.4 μg/100 ml (normal range: 3.7–8.4 μg/100 ml). The previously described peaks of cortisol levels in normal subjects, which have been shown to be often related to emotional stress (De Lacerda, Kowarski & Migeon, 1973) were also present in manic patients. However, the underlying diurnal variation detected in all control individuals was not present in the manic patients. This could be related to the lack of regular sleeping pattern in patients during their manic phase.

Infectious Mononucleosis and Psychiatric Disorders

Infectious mononucleosis (IMN), considered to be a disease of adolescence, usually presents as a febrile illness associated with lymphadenopathy, hepatosplenomegaly, pharyngitis, malaise, and myriad other complaints. The yearly incidence for this normally benign disease is 38 per 100,000, and one per 3000 of these patients dies, often as a result of neurological complications (Penman, 1970). Nonfatal central nervous system involvement was first reported in 1931 (Epstein and Dameshek, 1971), and reviews since then have reported a wide spectrum of neurological dysfunction including meningoencephalitis (Bernstein and Wolff, 1950; Friedland and Yahr, 1977), encephalitis (Librach, 1972; Sworn and Urich, 1970; Walsh et al., 1954), Guillain-Barre syndrome (Rafferty et al., 1954; Smith, 1956), and mononeuritis (Saksena, 1943). Schnell and associates (1966) found one case in which neurological findings were the only presenting symptom of IMN, and Bonforte (1967) has reported convulsions as a presenting sign.

Group Therapy With Chronic Pain Patients

Abstract This article describes the role of the psychotherapist in group-therapy sessions for chronic pain patients, and points out the differences in that role for inpatient and outpatient groups. The authors discuss the topics most frequently raised by patients in therapy groups at Johns Hopkins Hospital. They con clude that long-term (outpatient) group therapy offers a very effi aent and productive use of the physicians time when treating chronic pain patients.

Fusion for Occult Posttraumatic Cervical Facet Injury

Persisting neck pain and headache is a common complication of acceleration/deceleration injury. Seventy patients with normal imaging studies and persisting pain after injury (median 1.7 y), who had failed all usual conservative forms of care were offered a diagnostic block protocol to determine the origins of the persisting pain. Blocks included C-2-3 roots bilaterally; C-2-3-4 zygapophyseal joints, and provocative discography at C-3-4, 4-5, 5-6, 6-7. Seventy patients entered the study; 67 completed the block protocol. On the basis of response to blocks, 44 patient were chosen for posterior cervical fusion of C-l, 2, 3, 4 in several combinations. Seventy-nine percent of patients achieved complete pain relief; 14% received satisfactory pain relief; fusion was achieved in 95%. These data support the hypothesis of Bogduk and associates that upper cervical facet injury is a common consequence of acceleration/deceleration accidents. The symptoms can be relieved by upper cervical fusion in some patients selected by concordant blocks.