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This refers to an intrinsic degenerative disease of the spinal cord, probably somewhat more common than SCD and affecting the posterior and lateral columns (in this sense, also a combined system disease) There is no association with vitamin B12 or folate de ciency, but low serum copper and ceruloplasmin levels are found in some cases and replacement of copper results in stabilization of the illness (Kumar et al) Posterior column signs and gait ataxia are said to predominate The problem seems to be one of absorption of copper, for example, after bowel surgery, and there may be an anemia In a recent case on our service, without explanation for the discovered copper de ciency, MRI of the cervical cord revealed distinctive signal changes in both the posterior and lateral columns It is doubtful that copper depletion accounts for all cases of combined system disease that are not linked to B12 de ciency, but the resemblance of the clinical syndromes is remarkable Other cases unrelated to B12 or to copper de ciency display predominantly corticospinal signs and are of unknown cause Little is known of its pathologic basis and perhaps it is a manifestation of several processes Progressive spastic or spastic-ataxic paraparesis of a chronic, irreversible type may also develop in conjunction with chronic, decompensated liver disease (page 967); with AIDS; in certain cases of adrenoleukodystrophy, particularly in the symptomatic heterozygote, ie, the female carrier (page 837); in tropical spastic paraplegia (HTLV-I); in radiation myelopathy; and in adhesive spinal arachnoiditis, which is discussed later

Here, as in MS, the degree of ataxia and spastic weakness is variable A few patients have an almost pure state of spastic weakness of the legs, requiring differentiation from motor system disease and familial spastic paraplegia Such a syndrome, formerly called Erb s spastic paraplegia and attributed to meningovascular syphilis, is now recognized as being nonspeci c and more often due to demyelinative disease In a minority of chronic syphilitic patients, sensory ataxia and other posterior column signs predominate Ventral roots are involved in the chronic meningeal in ammation, giving rise to signs of segmental amyotrophy Hence the term syphilitic amyotrophy of the upper extremities with spastic paraplegia Con rmation of this now infrequent diagnosis depends on nding a lymphocytic pleocytosis, an elevated protein and gamma globulin, and a positive serologic reaction in the CSF Other aspects of this disease and treatment are discussed on page 618

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Figure 11 A C (Continued) depends on factors such as the patient s sense of con dence in the physician and the of ce staff, the appearance of the of ce, and the degree to which the patient feels a bond with the physician This last factor cannot be underestimated and there are several strategies that can help to increase this bond The physician should greet the patient by name There are several methods of beginning a consultation and the physician should try to nd the style that ts his or her personality There is no right or wrong style and patients can usually spot a physician who is trying to act rather than to interact on a personal level One style that helps to establish a relationship is to use statements such as Tell me a little about what you would like to change, neutral questions such as Have you ever had any cosmetic procedures before or reviewing the intake form and relating your questions to the areas of interest expressed on the form Providing the patient with a handheld mirror can also evoke a number of previously unmentioned concerns A brief review of the patient history form (Figure 12) will reveal several salient features about the person s life Common interests are one potential area for discussion Many patients presenting for cosmetic procedures will share their educational, social, and economic background to begin a friendly discussion People typically enjoy discussing how they spend their days, so, if they are employed, it is helpful to discuss what they do for a living Retired people are happy discussing their activities and other daily events Most people coming in for cosmetic consultations will have traveled within the past few months and discussing where they went and what they did is a neutral way to begin a dialogue Many cosmetic physicians nd it helpful to discuss prior cosmetic procedures during the patient consultation In order to do this, one must integrate this question.

Spinal Arachnoiditis (Chronic Adhesive Arachnoiditis)

3 7 11 15 19

This is now a relatively uncommon spinal cord disorder that was introduced in relation to the subject of low back pain (page 180) It is characterized clinically by a combination of painful root and spinal cord symptoms that may mimic intraspinal tumor Pathologically there is opaci cation and thickening of the arachnoidal membranes and adhesions between the arachnoid and dura the result of proliferation of connective tissue The subarachnoid space is unevenly obliterated In this sense, the term arachnoiditis is not entirely appropriate, although it seems likely that the connective tissue overgrowth is a reaction to an antecedent arachnoidal in ammation Some forms of arachnoiditis can be traced to syphilis or to a subacute, therapeutically resistant meningitis of another type Most others have followed the introduction of a variety of substances, most no longer used, into the subarachnoid space for diagnostic or therapeutic purposes These included penicillin and other antibiotics, methylene blue, iophendylate (Pantopaque), and other contrast media and corticosteroids At one time, many examples of adhesive arachnoiditis were observed following spinal anesthesia, occurring soon afterward or after an interval of weeks, months, or even years Our colleagues observed more than 40 such cases This complication was eventually traced to a detergent that had contaminated vials of procaine If enough of the contaminant

Subacute Combined Degeneration of the Spinal Cord (SCD; see also Chap 41, page 992)

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