Brief Answer:
Some inflammatory markers elevated of questionable clinical significance

Detailed Answer:
Good morning XXXXX- For the sake of sending you at least a preliminary review and to let you know that I WANT TO STUDY these results more I send this note off to you this response is sent. I need to get to the office right now this morning and so I will have more time to review and formulate ideas to answer your questions later today or more likely this evening.

Obviously, the overall conclusions written by the pathologist suggest that analysis of the CSF doesn't show much in the way of active disease or problems that have gone on to cause "tissue destruction." I looked at the .pdf files and am interested in looking more closely at the assayed values of CMV, VZV, and the IEF quantities.

You're right that most of the report is very readable for me but there are several test names that I'm struggling to find an exact correlate to what we would call it in English. It appears to be a very comprehensive cytology and pathology report with cell counts. Boy, they must've sent A LOT OF CSF out to get all of this! You must've been on your back post procedure FOR DAYS! They literally checked you for everything but the kitchen sink.

But again, there may be more potential information that can be gleaned when put together with your clinical history that the pathologist could not have known so we will talk about this some more. The strategy for your return message here would be for you to send me back a response to this first intention message in roughly 12-18 hrs. from now because then, that will give me ample time to get back to you and still stay within the proscribed limits that Healthcaremagic recommends we adhere to when responding to patients queries. Few, on the other hand, will require nearly as much thought as this one!
And some after some research and contemplation--- I guess the only things that stuck out to me as being at all significant in this comprehensive CSF assay was I believe is an increased blood barrier permeability index which persists as well as the IgG immunoglobin fractions against cytomegalovirus (CMV) and varicella zoster (VZV). I suppose that following your protracted illness episode it is possible that at that time your body was up against a viral infection though I find it hard to believe you were manifesting CMV symptoms at that time that nobody could pick up. If it were EBV (ubiquitous) then, I'd understand and say you probably had mononucleosis....but CMV? That would be a stretch. The varicella antibody response is understandable since that comes from chickenpox which just about everybody over the age of 30-35 will show....less and less in the younger populations since now you KIDS (Ha!) are getting that vaccination as part of the childhood regimen and we are just not seeing it that much anymore....don't know how it is in Europe. I suspect you were vaccinated because you're in your 20's....but perhaps, not....so in that setting of possibilities could you have been exposed to a significant Herpes family virus....that wasn't detected again...because of course chicken pox is not that subtle when someone (even an adult) contracts it....you still get the blisters and pimples popping up...

As far as the increased blood barrier permeability. I looked up a number of entities of that as part of their syndromic presentation and the best I could come up were connective tissue disease entities such as Ehlers Danlos which I can't see you as having to be truthful. There are too many hormonal changes and autonomic function changes that you'd have to manifest which are just not there.....

Going back to the VZV for a second....a varicella encephalitis (which I've seen several in adults over the past 15 years or so) can carry with it symptoms of any type of encephalitis (high fever, lethargy, malaise, confusion) but in addition there are case reports as well which give us glimpses of movement disorders which accompany the disease as a long term sequelae....but they are more ataxic movements whereas your tremor is more described as "tremor" but your eye movements may be ataxic if you have "jumpiness" to your vision....which almost sounds like a line for Sydenham's Chorea....did you have a positive Strept culture at that time? But if we stick with the CMV/VZV antibodies then, cranial nerve defects which could bespeak of later autonomic dysfunction of some sort coupled with ocular ataxic movements which you sense as a jumpiness to your vision....

Could that be a smoking gun to a number of your complaints? Let's think some more about these ideas....give me some more data from your side.....of course, it would nice to have a nice NEURO-OPHTHALMOLOGICAL examination done on you by a specialist in that area to see whether or not there are any detectable eye movement abnormalities...which would admittedly be subtle. Anybody got some Frenzel goggles they can put on you or a nice eye movement lab with a balance plates and barany chairs (waste of money!).....

I pass the ball to you...SCRUM! HA

Total time to this point 35 minutes (well, that's not exactly true....but it's the total elapsed time ON THIS NETWORK doing the writing!) LOL......

Have a great weekend and be back to me please no sooner than 12-18 hrs. from now.

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Brief Answer:
Here we go

Detailed Answer:
I will try and recapitulate in highlighted form answers to your questions that I had virtually answered in their entirety before a fatal computer error befell this soul, or this soul's computer....and caused an irrecoverable crash. My apologies.

Ankylosing spondylitis is a fancy term for RHEUMATOID ARTHRITIS which affects the spinal column. Typically, this form of RA strikes younger individuals, some of whom can be shown to possess the haplotype marker known as HLA B27. The result of this rather aggressive and debilitating form of disease is an inflexible and eventually, fused spine which generally in the lumbar regions and can progress to other regions.


Total time expended by physician directed services to this point 148 minutes.
Spondylitis on the other hand simply refers to an inflammatory condition of a vertebral body or its facets/joint regions, and so forth and does not necessarily specify any particular etiology or pathology other than the fact that there is inflammation.

So now the usual final step we who consider ourselves to be scholarly in any way like to take which is admittedly cliche and almost ridiculously predictable is:

While all people with ANKYLOSING SPONDYLITIS can be said to be SPONDYLTIC.....not everyone who is suffering from simple SPONDYLITIS has ANKYLOSING SPONDYLITIS.

King Devick Test- I'm afraid I'm entirely unaware of this test. When I have patients with ocular motility issues my habit is to examine them as carefully as my knowledge and examination techniques allow to try and determine what type of movement disorder we are dealing with and whether the problem originates from the brain control centers of eye movements (the 3rd, 4th, 6th complexes, etc.) or whether it's a peripheral type of issue as would occur in Myasthenia Gravis, muscular dystrophy types of diseases, dystrophin anomalies, metabolic disorders, hepatic or renal chronic diseases which metabolically cause derangements in eye muscle control....autoimmune processes (Sydenham's chorea, etc.).

Once we've identified the source of the problem and have a clear cut diagnosis then, we are in a better position to offer a solution....or as happens UNFORTUNATELY in many instances NO SOLUTION or less than satisfactory solutions (prisms to block the "bad" eye) so the person doesn't have diplopic vision and fall down the stairs, etc. etc.

If I can't figure it out I've got very capable and able bodied neuro-ophth colleagues who are excellent and either figure it out or publish it as something never before seen! LOL.....really, we have some top notch people here in that field so I never have had to resort to computer based software, self instruction types of programs or tests. I can't much form an opinion then, for you except to say in my way of old fashioned thinking (from the early 2000's when I started into the practice of neurology as a pup!) getting a good neuro-ophth exam would be the best way to go in order to characterize any eye movement disorder that exists followed by a plan for rehabilitation or intervention.

I think I mentioned XXXXXXX XXXXXXX in another email I sent to you and believe she may be an option to think of if we can characterize your ocular issues of jumpiness when reading making it difficult for you to read or comprehend things.

On the back pain and coccidynia issues.....WOW--- Not sure why your back pain is there...why there is urine leakage....why should you have coccidynia in the first place....the most common cause of that problem is trauma and I'm not aware that you've had any....is this to be a mystery viral that came out of the nether-land and set up shop to pound away at the coccyx with his chisel and hammer, "All the live long day?" (don't know if that last bit of humor was too abstract for you or not....there's a song that was popular back in the mid 1900's that workers would sing, "I've been working' on the Railroad".....you can look up the lyrics....it's cute and had a melodious hit to it that went with the day....I don't even think most kids of this day and age in this country would understand what I was referring to! LOL!....but maybe you would!

So, I can tell you that XXXXXXX XXXXXXX has great faith in an osteopath who she says does wonders with people's back pain and who she uses quite frequently for her musician students that need retraining of back muscles....frankly, I had a bit of an argument with her on this point yesterday about another patient that I sent to her and I told her that although I greatly respect her talents and expertise in the use of sEMG when dealing with other issues....that I'm not convinced at all that automatically sending my patients to other doctors, physicians or not, is what I was expecting from the consult request and that she should please check with me on the reason, modality that the physician plans to operate, and what the goal is before embarking upon such things.....bottom line was, I was pissed...as you can tell. I will embrace and support an alternative form of treating someone if and only if we've gone down the paths of standard medical treatments and diagnoses. Western Medicine still has much to offer and so I'm not of the opinion that it should be discarded at first intention just because it's a problem which is "hard" to solve in most people and likely will not yield positive results.

Ok....END RANT....my point is this....if you feel that your PT'ist is not benefitting you for whatever the reason....then, perhaps, Dr. Riley's "Shaman" could possibly help. To be clear, I'm not suggesting that you hop a bird and fly to XXXXXXX forthwith on any of these conjectures any more than I am ready to endorse ayuverdic therapy (because I'm really not into that either.....but I know you've been looking....so it's good you've got likely much more information than I do.....I just don't know that much about it) but IF, at some point down the road we get a better fix on what exactly happened that resulted in all of these seemingly unrelated problems and IF it turns out that the fix (or at least betterment) to some of these issues could come in the form of biofeedback therapy which you could be taught and then, implement and apply yourself.....and IF it seemed appropriate to have you evaluated and worked on by someone such as who Dr. XXXXXXX works.....THEN, it may make sense to hop a bird, come to XXXXXXX for a period of say 5-7 days, relax and enjoy the city for a spell which is undergoing a renaissance, and working out some type of plan of attack for how you can be put through a concentrated series of sessions, learn enough of the technique that you could then, be followed long distance using internet technology (SKYPE, HCM, or perhaps Dr. XXXXXXX may develop some way of getting a portal up and running for her international patients because she has a few), maybe even become the subject of a Grands Rounds session for White Ivory Tower types at one of the 2 giant monstrosity Health Care facilities who are constantly trying to cut off each others heads by espionage, ruthless demeaning publicity between their workforce physicians and other personnel, or by constantly building more and more out patient facilities across the WORLD to be able to keep saying that see more patients than the other. Of course, I'm referring to University Hospital of XXXXXXX which is the teaching hospital of the famed Case Western Reserve Medical School vs. the XXXXXXX Clinic which has "its own" medical school....hey, the place has its own zip code in the city it's that massive!

BTW, if you did come to XXXXXXX I would want you to retake the neuropsychology battery because I'm not sure what to make of what your neuropsychologist told you....i.e. nothing wrong but at the same time didn't want to share the report of the test results.....that doesn't tell me good things about that person and how they work. Dr. XXXXXXX XXXXXXX is a person who studied at McGill University under some of the leading neuropsych gurus of the 1960's and 1970's. I have gone to him for legal cases, for complex TBI cases, even for cases involving my family members and have always been impressed by his thoroughness and academic resolve to always uncover something organic in REAL patients and not simply pass them off to the psychiatric institutes without being justly deserving of that diagnosis. Once he stops practicing....I honestly, may have to stop myself...because who to go to anymore in this age of either YOU SEE it on paper or it's in one's imagination and not worth looking at anymore?

As far as the last part of the question on substances that are considered psychedelic there seems to be a renewal not just here but in Europe and other places in the world to discuss this class of medicinal elements for different ailments. I have not had enough time to really digest or review that entire spectrum of discussion let alone the website you're referring. I'm just becoming comfortable with being an outspoken fan of the Linus Pauling Institute that researches and promotes the use of Vitamin C. Within the next year I expect that I will also be embracing even more strongly and tenaciously the role of Vitamin D when it comes to fighting infections of a viral nature which is something I really never thought I'd do....so, my point is that my learning curves are long and steep when it comes to giving my nod to things such as you're mentioning. Almost daily there are articles coming out on marijuana and its uses now that so many states are making it legal. Are we doing something potentially unhitching and staring down the barrels of loaded shotguns without even realizing? Perhaps...and so again, my interest in what you bring to light is much farther ahead of where my scientific knowledge base is and the 2 are in constant lag with one another....which also is a reason why I almost never use new FDA approved drugs without giving at least a 2-3 grace period to see how many people the drug either mames or kills before it's pulled from the market. I have at least 10 colleagues who are now swimming in lawsuits for using all sorts of drugs that the FDA said were safe but because they wanted to give free samples out to their patients and be "the good guys"...now, they've got lawyers eating them out of house and home......not my persuasion.

Bottom line....I would personally run very lightly and tread very gingerly when it came to alternative ANY TYPE of medicinal from ANY CULTURE or persuasion of thinking until and unless it's been well accepted by the grand masses (Eastern and Western Medicine....for instance ayuverdic therapy can include in some of its treatment protocols, heavy metals-- clearly believed to be highly toxic for human consumption). Of course, the argument that ayuverdic oriented practitioners will make is that the toxicity factor is greatly reduced or eliminated by strategic combinations with other elements and organic substances...or that when ingested into the body....the milieu of that environment changes toxicity levels and patterns....a "smart" toxic drug???? Why don't they utilize them doggies to go fight cancer cells??? Well, because a huge number of practitioners, doctors of medicine, researchers, and so forth don't believe the claims nor have those claims been studied to any significant extent in the peer reviewed literature. And so, I invoke the first Hippocratic precept of treating any living creature which is above all else, "Do No Harm".....even if that means at the expense of curing someone....St. XXXXXXX will forgive me at the Pearly Whites if that happens....I hope.

Total time spent 157 minutes to this point on physician directed activities.

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Brief Answer:
You are referring to the Eagle's Syndrome that someone thought possible

Detailed Answer:
Hmmmm....I was of the opinion that the diagnosis of Eagle's was rather tenuous based upon your actual numbers not being that too terribly off from normal. And of course, the treatment for ES is surgical. Can't comment on how physical therapy stretched the muscles in the hyoid region but if that helped with any swallowing difficulties, is it possible for you to simply relearn those exercises and keep up with them? I definitely remember not recommending you go for any surgery given how UNimpressive the numbers of your styloids actually were.

Remind me if you've had a swallowing study done yet or not? And do you recall what it showed? And was it a barium swallow or cookie swallow if it was a study to begin with....

My impression of the dynamic x-rays is that they will not likely yield much useful information and so they won't help with management very much. I say you stick with the PT plan

Let's see how things progress. Perhaps, you'll have an opportunity to check out XXXXXXX Riley's webpage on biofeedback using surface EMG equipment.

Cheers!

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