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isolation The most familiar form of spinal arachnoiditis was, in the past, that which followed the use of chemically contaminated spinal anesthetics Our colleagues saw more than 40 cases of this type, now rare, dating from the time when vials of anesthetic were stored in detergent sterilizing solutions Instillation of the anesthetic agent was followed immediately by back pain and a rapidly progressive lumbosacral root syndrome (are exic paralysis, anesthesia of the legs, and paralysis of sphincters) Several cases have, in our more recent experience, followed prolonged spinal anesthesia with the patient in a decubitus position, usually for orthopedic procedures, but the resulting myelopathy or cauda equina radiculopathy is then dif cult to separate from a direct toxic effect of the anesthetic The CSF protein rises rapidly in cases that were precipitated by injection of substances in the subarachnoid space, but pleocytosis is minimal In other instances, protracted back pain lasting days to weeks is the only effect but is followed, after a period of months or years, by a progressive myelopathy This takes the form of some combination of spinal arachnoiditis with ataxic paraparesis and sensory disturbance, hydrocephalus, or opticochiasmatic arachnoiditis The point to be made is that there is always some risk attached to the subarachnoid instillation of any foreign agent Opticochiasmatic Arachnoiditis This condition was well known to neurologists during the period when neurosyphilis was a common disease It occurs after years of chronic syphilitic meningitis, sometimes in conjunction with tabes dorsalis or meningomyelitis However, there were always nonsyphilitic cases, the cause of which was never ascertained A constriction of visual elds, usually bilateral and asymmetrical (rarely scotomas), developed insidiously and progressed Pathologically, the optic nerves were found to be enmeshed in thickened, opaque pia-arachnoid The optic nerves are atrophic in apperance Idiopathic cases are likely to be confused with multiple sclerosis Pachymeningitis The term pachymeningitis refers to a chronic, circumscribed, in ammatory thickening of the dura The term is somewhat confusing insofar as the pia and arachnoid are usually equally involved in the in ammatory thickening and all three membranes are bound together by dense brous adhesions This type of meningeal reaction, which is now exceedingly uncommon, was rst described by Charcot and Joffroy It occurred mainly in the cervical region (hence the name pachymeningitis cervicalis hypertrophica) and was attributed to syphilis Indeed, in some instances there was a gummatous thickening of the dura Involvement of cervical roots and compression of the spinal cord gave rise to variable degrees of paraparesis in association with root pain, paresthesias, sensory loss, and amyotrophy of the upper limbs In the modern era, rheumatoid arthritis, sarcoidosis, and chronic local infection (fungal, tuberculous) have been the main causes, but some of the cases remain unexplained Idiopathic instances continue to be reported; a summary of published cases and two personally studied ones is given by Dumont and colleagues The subdural space and dura can be involved by extension of a pathologic process from the arachnoid, especially in infants and children, in whom subdural hygromas regularly follow meningitis The brous connective tissue of which the dura is composed may also undergo pronounced thickening in the course of a mucopolysaccharidosis, especially in cases where broblasts are implicated The basal pia-arachnoid may be involved, leading to obstructive hydrocephalus Older medical writings often made reference to syphilitic cranial pachymeningitis, which later proved to be the.

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These functions are tested in detail if the patient s history or behavior during the general examination has provided a reason to suspect some defect Questions should then be directed toward determining the patient s orientation in time and place and insight into his current medical problem Attention, speed of response, ability to give relevant answers to simple questions, and the capacity for sustained and coherent mental effort all lend themselves to straightforward observation Useful bedside tests of attention, concentration, memory, and clarity of thinking include the repetition of a series of digits in forward and reverse order, serial subtraction of 3s or 7s from 100, recall of three items of information or a short story after an interval of 3 min, and naming the last six presidents or prime ministers The patient s account of his recent illness, medical consultations, dates of hospitalization, and his dayto-day recollection of medical procedures, meals, and other incidents are excellent tests of memory; the narration of the illness and the patient s choice of words (vocabulary) provide information about his intelligence and coherence of thinking Many other tests can be devised for the same purpose Often the examiner can obtain a better idea of the clarity of the patient s sensorium and soundness of intellect by using these few tests and noting the manner in which he deals with them than by relying on the score of a formal intelligence test If there is any suggestion of a speech or language disorder, the nature of the patient s spontaneous speech should be noted In addition, his ability to read, write, and spell, execute spoken commands, repeat words and phrases spoken by the examiner, name objects and parts of objects, and solve simple arithmetical problems should be assessed The ability to carry out commanded tasks (praxis) has great salience in the evaluation of several aspects of cortical function Bisecting a line, drawing a clock or the oor plan of one s home or a map of one s country, and copying gures are useful tests of visuospatial perception and are indicated in cases of suspected cerebral disease The testing of language, cognition, and other aspects of higher cerebral function are considered in Chaps 21, 22, and 23.

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