Malignant spinal cord compression: prospective study of delays in referral and treatment

OBJECTIVES: To examine the delay in presentation, diagnosis, and treatment of malignant spinal cord compression and to define the effect of this delay on motor and bladder function at the time of treatment. DESIGN: Prospective study of all new patients presenting to a regional cancer centre with this condition. SETTING: Regional cancer centre. SUBJECTS: 301 consecutive patients. MAIN OUTCOME MEASURES: Interval from onset of symptoms to presentation and treatment, delay at each stage of referral, and functional deterioration. RESULTS: The median (range) delay from onset of symptoms of spinal cord compression to treatment was 14 (0-840) days. Of the total delay, 3 (0-300) days were accounted for by patients, 3 (0-330) days by general practitioners, 4 (0-794) days by the district general hospital, and 0 (0-114) days by the treatment unit. Initial presentation to the regional cancer centre with symptoms of malignant spinal cord compression led to a significant reduction in delay to treatment and improved functional status at the time of treatment. Deterioration of motor or bladder function >=1 grade occurred at the general practice stage in 28% (57) and 18% (36) of patients, the general hospital stage in 36% (83) and 29% (66), and the treatment unit stage in 6% (19) and 5% (15), respectively. CONCLUSIONS: Unacceptable delay in diagnosis, investigation, and referral occurs in most patients with malignant spinal cord compression and results in preventable loss of function before treatment. Improvement in the outcome of such patients requires earlier diagnosis and treatment.     

Spinal cord compression in metastatic cervical cancer

Spinal cord compression secondary to metastatic cervical cancer may not be considered as a possible cause of neurologic symptoms by primary care physicians who do not often treat these patients. Delays in diagnosis and treatment may result in irreversible but potentially preventable neurologic changes. This report describes 5 cases of spinal cord compression in patients with metastatic cervical carcinoma, 2 of whom were previously undiagnosed with cervical cancer. These 2 patients represent 1.6% (2 of 121) of all new cervical cancer cases diagnosed during this time period. Two of 5 patients (40%) with spinal cord compression showed improvement following therapy by regaining the ability to walk, while none of the remaining patients had further acute deterioration of neurologic function. The mean survival of patients presenting with spinal cord compression from cervical cancer in this series was 4 months (maximum 6 months). This series illustrates the relative frequency with which spinal cord compression is seen in patients with a new diagnosis of invasive cancer. This diagnosis should be considered when evaluating neurologic complaints in known cervical cancer patients or any woman with apparent pelvic pathology. Rapid diagnosis and treatment of these lesions, while not likely to improve overall survival significantly, can improve function and alleviate symptoms.     

Neuropathologic findings and neurologic symptoms in twenty-three children with hemophagocytic lymphohistiocytosis

BACKGROUND: Primary hemophagocytic lymphohistiocytosis (HLH) is an autosomal recessive disorder with very high mortality rates, mainly affecting infants and young children, which is characterized by fever, hepatosplenomegaly, and cytopenias. Of great clinical importance are the neurologic symptoms, which are common and may even dominate the clinical picture and precede the systemic presentation. These symptoms are extremely variable, ranging from irritability, bulging fontanelle, and neck stiffness, to convulsions, cranial nerve palsies, ataxia, hemiplegia/tetraplegia, and unconsciousness. METHODS: To elucidate this neurologic involvement further, we reviewed the neuropathologic postmortem findings from 23 children and their neurologic symptoms. RESULTS: Macroscopically, edema was present in many cases, and in some with advanced disease, softening and destruction of the tissue were conspicuous. The microscopic picture was exceedingly variable, ranging from almost normal to very advanced changes. In the mildest form of HLH, only the meninges were involved with infiltration of lymphocytes and macrophages (stage I), whereas more advanced cases in addition also showed perivascular infiltrates (stage II). In even more advanced disease there was also a diffuse infiltration in the tissue (stage III), as well as a multifocal necrosis. A prominent astrogliosis was present in such cases. Hemophagocytosis was seen in most patients, most commonly in the leptomeninges. CONCLUSIONS: HLH affecting the central nervous system imitates several neurologic disorders and may be misdiagnosed. A staging system for the neuropathologic findings is presented. In children with obscure central nervous systems symptoms and a progressive encephalopathy, the diagnosis of HLH may be considered, in particular because treatments are available.     

Work time estimates for ophthalmic diagnoses and procedures. Results from the Eye Care Workforce Study

OBJECTIVE: To compare the clinical presentation, time elapsed to diagnosis, and survival of elderly patients (> or = 65 years) with that in younger patients with malignant primary brain tumors. DESIGN: Retrospective cohort study. SETTING: Four hospitals in Minneapolis, Minn. PATIENTS: Seven hundred fourteen patients diagnosed as having and treated for primary malignant brain tumors between 1980 and 1995; 230 (32%) were 65 years or older. MAIN OUTCOME MEASURES: The type and duration of the chief presenting symptom, the time elapsed to diagnosis, the treatment modalities used, and patient survival were analyzed. RESULTS: Time elapsed from onset of symptom to diagnosis was not longer for elderly patients than younger ones, with the exception of patients aged 18 to 24 years, who had a significantly longer delay in diagnosis (P = .004). Elderly patients were significantly less likely to present with headache or seizure (P<.001), and more likely to present with confusion, aphasia, or memory loss (for each, P<.001). With the single exception of confusion, the duration of all other presenting symptoms was not significantly longer for patients 65 years and older compared with younger patients. Survival is significantly reduced in older patients, and appears to worsen significantly in patients 45 years and older (P<.001). A significantly higher proportion of patients 65 years and older with glioblastoma multiforme received no treatment (P = .004) if diagnosed after 1990. CONCLUSIONS: Elderly patients (> or = 65 years) with malignant brain tumors are diagnosed as promptly as younger patients, although they have a markedly different constellation of symptoms. Since diagnosis of brain tumors continues to improve in the elderly, it may be more difficult to ascribe the steady increase in incidence to artifactual factors.     

"Chronic Lyme disease" as the incorrect diagnosis in patients with fibromyalgia

OBJECTIVE: To evaluate a large number of patients referred with persistent symptoms thought to represent chronic Lyme disease. METHODS: We retrospectively reviewed the charts of nearly 800 patients referred with persisting nonspecific musculoskeletal and/or neurologic symptoms thought to represent chronic Lyme disease. RESULTS: Seventy-seven patients were found to have fibromyalgia, not ongoing Lyme disease, as the explanation of their chronic symptoms. Many had received multiple courses of antibiotic therapy for symptoms of fibromyalgia mistakenly attributed to chronic Lyme disease. No patient reported permanent and/or total resolution of fibromyalgia symptoms following antibiotic therapy. Appropriate therapy for fibromyalgia in those who remained compliant, however, was often effective in improving some if not all of the chronic symptoms. CONCLUSION: Fibromyalgia is a treatable and potentially curable disorder, and should be considered in the evaluation of patients with "refractory Lyme disease."     

Intradural parenchymal involvement in the spinal subarachnoid space associated with primary lung cancer

BACKGROUND: Intradural parenchymal involvement (IPI) in the spinal subarachnoid space associated with primary lung cancer is rare. A retrospective study was undertaken to investigate the clinical and pathologic features of IPI. METHOD: A total of 1215 cases of primary lung cancer were studied at autopsy; the results were reviewed retrospectively. RESULTS: Twenty (1.65%) of the cases revealed IPI in the spinal subarachnoid space. The histologic diagnoses were small cell carcinoma in ten cases, adenocarcinoma in eight cases, and squamous cell carcinoma in two cases. In 14 (70%) cases, the IPI was located between the lumbar and cauda equina of the spinal cord. However, no metastases were observed in the cervical spinal cord. Brain metastasis, vertebral metastasis, and meningeal carcinomatosis were seen in 70%, 60%, and 40% of the 20 cases, respectively, suggesting that these metastases may be related to the metastatic pathway to the spinal cord. Most patients had neurologic symptoms or signs referable to IPI; IPI could be diagnosed before death in only one patient by magnetic resonance imaging. The median interval between diagnosis of lung cancer and development of IPI and median survival after the onset of neurologic symptoms referable to IPI were 415 days and 110 days, respectively. CONCLUSION: The authors retrospectively received 1215 autopsies of patients with primary lung cancer and found 20 (1.65%) with IPI.     

Malignancy and sensory neuropathy of unexplained cause: a prospective study of 51 patients

OBJECTIVE: To investigate the frequency of cancer developing in patients with peripheral sensory neuropathy of unexplained cause. DESIGN: Prospective study. SETTING: A neurologic unit in a general hospital. METHODS: Following the diagnosis of neuropathy, we searched for occult malignancy. This search was repeated together with neurologic evaluations every 6 months thereafter. Patient recruitment began January 1, 1988, and ended December 31, 1995. The end point of the study was December 31, 1996. RESULTS: In the study period, we observed 363 patients with peripheral sensory neuropathy. Of these, 53 patients without any identified cause of neuropathy were invited to participate in the study. Of the 53, 2 patients refused. Thus, we examined and followed up 51 patients, 42 men and 9 women, with a mean age of 64.5 years (range, 19-80 years). The range between the onset of neurologic symptoms and the diagnosis of neuropathy was 2 to 72 months (mean, 13.9 months). The follow-up period ranged from 14 to 94 months (mean, 51.4 months). In 18 patients (35.3%) (16 men and 2 women) whose mean age at diagnosis of neuropathy was 66.5 years. malignant growths were found 3 to 72 months (mean, 27.4 months) after the onset of the neuropathy. The cancer was in the liver in 4 patients (all had a primary hepatoma), the bladder in 3, the lymph nodes in 3 (all with non-Hodgkin lymphoma), the prostate gland in 2, the lungs in 2 (small cell lung cancer in both), the breast in 1, the pancreas in 1, the sublingual gland in 1, and the bone in 1 (a metastatic sarcoma). CONCLUSIONS: More than one third of the patients with peripheral sensory neuropathy of unexplained cause developed cancer without any predominating type of malignancy.     

Impact of deltamethrin impregnated mosquito nets on the transmission of malaria in the coastal lagoon area, Benin]

Neopterin has been determined in blood as a marker of cellular immune system activation. We studied cerebrospinal fluid (CSF) neopterin levels in children with neurologic diseases, and the following results were obtained: (1) CSF neopterin levels markedly increased at the acute phase of bacterial meningitis, aseptic meningitis, and encephalitis as compared with those in patients without neurologic diseased. (2) In the CSF of patients with bacterial meningitis and aseptic meningitis, neopterin levels decreased more rapidly than the total cell count and 2'5' oligoadenylate synthetase (2-5 AS) did. (3) CSF neopterin in patients with non-infectious neurologic diseases was almost equal to that in patients without neurologic diseases. (4) There was no correlation between CSF neopterin and other CSF values, such as total cell count, mononuclear cell count, protein, and 2-5 AS. These results suggest that CSF neopterin is a useful marker of inflammatory central nervous diseases.     

Depressive symptoms in patients with systemic lupus erythematosus: association with central nervous system lupus and Sj?gren's syndrome

OBJECTIVE: To determine if patients with systemic lupus erythematosus (SLE) with depressive symptoms differ in regard to organ involvement and serological activity from other patients with SLE. METHODS: Disease manifestations were compared between 71 patients with SLE with a history of depressive symptoms and 278 patients without a history of depressive symptoms by univariate analysis and multiple logistic regression. RESULTS: Both univariate and logistic regression analysis revealed an association of depressive symptoms with neuropsychiatric lupus and secondary Sj?gren's syndrome (SS). Patients with neuropsychiatric lupus had an adjusted odds ratio of 3.43 (95% CI 2.55, 4.63; p = 0.00005), and patients with secondary SS had an adjusted odds ratio of 2.97 (95% CI 2.08, 4.25; p = 0.0006) for depressive symptoms. No other organ involvement or serological abnormality was associated with depressed mood. CONCLUSION: These discrete associations of depressive symptoms with neuropsychiatric lupus and secondary SS suggest that depression does not occur purely as a response to social stresses, and may be a manifestation of autoimmune disease in some patients.     

Outcome of peroneal neuropathies in patients with systemic malignant disease

BACKGROUND: Peroneal neuropathies in patients with systemic cancer previously have been attributed to weight loss, but to the authors' knowledge other associated conditions have not been assessed, and the outcome of peroneal neuropathies in cancer patients has not been studied. METHODS: A retrospective chart review of patients evaluated at the Mayo Clinic between 1984 and 1993 with systemic malignant disease and a clinical diagnosis of peroneal neuropathy was performed to define factors associated with peroneal neuropathies and to assess outcome. All patients underwent neurologic examination and electromyography. RESULTS: Fifty-eight patients with systemic malignant disease were found to have a peroneal neuropathy. Peroneal neuropathies occurred more often in men (45 patients) than in women (13 patients). The median age of the patients was 70 years. The most common cancers were hematologic (12 patients) and pulmonary (11 patients), followed by tumors of the prostate (8 patients), gastrointestinal tract (7 patients), transitional cell (5 patients), breast (5 patients), and colon (5 patients), as well as sarcomas and melanoma (5 patients). The median time to the diagnosis of peroneal neuropathy after the diagnosis of cancer was 5 months. At the time of diagnosis, 34 patients had severe deficits, 19 had moderate deficits, and 5 had mild deficits. Associated factors included weight loss (occurring in 60% of patients), leg crossing (35% of patients), recent chemotherapy (16% of patients), cutaneous vasculitis (5% of patients), and local metastatic lesions (3% of patients). In nearly 50% of patients, peroneal neuropathy improved (25.9%) or resolved (22.4%). In 39.7% of patients, follow-up was inadequate because death occurred soon after diagnosis. Of the patients with adequate follow-up before death, 80% had either improvement (42.9%) or resolution (37.1%). CONCLUSIONS: For those patients with systemic malignant disease in whom peroneal neuropathy develops, the outcome of the neuropathy is good, with the majority of patients achieving partial or complete resolution.     

Long-term sequelae of pneumococcal meningitis in children

The purpose of this study was to assess the long-term effects of pneumococcal meningitis in children. From 1967 to 1988, a total of 90 children were admitted to the Hospital for Infectious Diseases, Thessaloniki, Greece, with the diagnosis of pneumococcal meningitis. Sixteen patients died in the hospital as a direct result of meningitis. Eleven others were excluded from the study (neurologic deficits prior to onset of meningitis, two; death subsequent to hospitalization, two; recurrent meningitis, seven). Of the remaining 63 survivors, we were able to evaluate 47 patients (75%). Evaluation was performed 4 to 23 years (mean 12.3 +/- 5.8 years) after discharge. Forty patients returned to hospital for evaluation, and seven were evaluated by their primary physicians, who sent information by a standardized questionnaire. The following examinations were carried out: history, physical and neurologic examination, ophthalmologic and hearing evaluation, and psychometric testing. Fourteen patients (30%) had at least one neurologic handicap; nine (19%) had mental retardation, eight (17%) hearing loss, seven (15%) seizure disorder, five (11%) motor defects, and one each (2%) behavioral problems and visual impairment. The presence of coma was the strongest predictor of increased morbidity. The high frequency of long-term sequelae observed in our study supports the need of an effective vaccine.     

Central nervous system infections in patients with malignant diseases

Infections of the nervous system remain a significant source of morbidity and mortality in patients with cancer. This paper reviews the main pathogens and emphasizes some of the principles of diagnosis and management of nervous system infections in cancer patients. Due to immunosuppression, diagnosis is more difficult in this group, secondary to the multitude of potential pathogens, and often by their atypical presentations. Fever or headache are often the only symptoms. Clinical history and general examination should guide appropriate studies such as neuroimaging. CSF analysis, cultures, and brain biopsy. Diagnostic evaluation should be pursued rapidly and aggressively since specific treatments can often reduce morbidity and mortality. Bacterial infections are generally due to break-down of the natural barriers and neutropenia. In neutropenia, Pseudomonas aeruginosa, and Enterobacteriae are the most frequent etiology. If all causes of immunodepression are included, Listeria monocytogenes meningitis is the main bacterial infection encountered. Fungal infections have emerged as a major cause of death among cancer patients. The prognosis of cryptococcosis and histoplasmosis meningitis are markedly improved with new antifungal therapy. Aspergillosis and Mucormycosis, which may cause cerebral abcesses and secondary vascular complications, are almost always fatal. The incidence of meningo-cerebral Candidiasis is often underestimated. Similar to Histoplasmosis, it is frequently disseminated. Viral infections are mainly seen in patients with T-lymphocyte defects. Herpes-simplex virus and Varicella-Zoster virus encephalitis should quicky lead to intravenous treatment with Acyclovir. As in AIDS patients, cerebral toxoplasmosis is the most frequent parasitic infection and appropriate therapy greatly reduces morbidity. It should be emphasized that multitude pathogens are often seen in cancer patients. Despite development of new therapeutic agents, central nervous system infections should still be considered life-threatening. Therefore, antibacterial, antifungal, and antiviral prophylaxis should be the rule for all cancer patients.     

Meningitis after combined spinal-extradural anaesthesia in obstetrics

We report two cases of meningitis which developed after combined spinal-extradural procedures for obstetric analgesia. The first case was thought to be caused by aseptic or chemical meningitis and the second was a case of bacterial meningitis in a patient who also received an extradural blood patch. It is important that meningitis is considered as a differential diagnosis in patients who present with headache after spinal anaesthesia and that antibiotic therapy is selected to cover unusual organisms.     

Neuropsychiatric manifestations of Lyme disease

Lyme disease is a multisystem illness that may affect the central nervous system and subsequently produce mild to severe psychiatric disorders. Physicians who treat patient with Lyme disease need to be aware of its neuropsychiatric symptoms, which may emerge months to years after the initial infection. Prompt diagnosis and effective treatment are needed to avoid the debilitating and possibly irreversible mental illness associated with the neurologic involvement of this spirochetal infection. The author reviews the neuropsychiatric manifestations of Lyme disease and provides diagnostic and therapeutic approaches for the management of the central nervous system disease that may cause them.     

Meningococcal meningitis presenting as stroke in an afebrile adult

We describe a healthy, afebrile 26-year-old man who presented to the emergency department with left hemiparesis and cranial nerve deficits caused by meningococcal meningitis. The results of the computed tomographic scan of the head were negative. Magnetic resonance imaging showed lesions in the basal ganglia and caudate consistent with ischemic infarcts. The neurologic deficits initially progressed but improved to near-resolution after 1 month. This case was unusual in that the patient was afebrile despite a high bacterial load and significant neurologic deficits. His presentation thus mimicked a straightforward stroke. Close attention to the physical examination findings led to a comprehensive evaluation that yielded the correct diagnosis.     

Genomic organization and mutational analysis of KVLQT1, a gene responsible for familial long QT syndrome

BACKGROUND: Turcot's Syndrome is the association of multiple adenomatous polyps of the colon with a primary tumor of the central nervous system. We present the first reported case of Turcot's Syndrome in a patient with malignant ependymomas. Recent advances in the elucidation of the genetic basis for the hereditary forms of colon cancer have provided a clearer understanding of the etiology of Turcot's Syndrome. This new information is relevant to the neurosurgical community and provides updated guidelines in the diagnosis and management of patients with this complex disease process. RESULTS: Turcot's Syndrome is related to two distinct genetic errors. The first involves a germ-line mutation in the adenomatous polyposis coli (APC) gene, which is postulated to act as a tumor suppressor gene. The second is a germ-line defect in one of a group of genes responsible for DNA nucleotide mismatch repair. CONCLUSION: The elucidation of the gene defects responsible for the hereditary forms of colon cancer has provided a clearer understanding of the molecular basis of Turcot's Syndrome. Patients with hereditary forms of colon cancer and neurologic symptoms require immediate and thorough investigation because of their significantly increased risk of developing CNS tumors. Previously healthy patients diagnosed with a CNS tumor with a family history of adenomatous polyposis coli should undergo screening and surveillance colonoscopy as the CNS lesion may precede colonic symptoms. CNS screening guidelines for asymptomatic patients with adenomatous polyposis coli requires further risk analysis studies. All patients diagnosed with Turcot's Syndrome should be tested for the gene defect, including the CNS tumor tissue to provide further data on the genetic relationship between Turcot's Syndrome and the hereditary forms of colon cancer.     

Longitudinal assessment of symptoms of depression, agitation, and psychosis in 181 patients with Alzheimer's disease

OBJECTIVE: The goal of this study was to define the recurrence or continuation of neuropsychiatric symptoms in patients with Alzheimer's disease who were observed serially for a 1-year period. METHOD: One hundred eighty-one patients with probable Alzheimer's disease were assessed five times at 3-month intervals with a standardized neuropsychiatric rating instrument. RESULTS: Recurrence rates of neuropsychiatric symptoms during the 1-year period were 85% for depression, 93% for agitation, and 95% for psychosis. Symptom frequency at any point in time underestimated the cumulative 1-year frequency. Recurrence rates were significantly greater among patients who had multiple symptoms. Women exhibited more symptoms than men. Patients in the oldest age group (76-87 years) had more psychosis, less depression and agitation, and slower cognitive decline. Psychosis was associated with more rapid cognitive decline, and agitation was associated with more rapid functional deterioration. CONCLUSIONS: These results indicate that once psychiatric symptoms are present in patients with Alzheimer's disease, they frequently recur. These symptoms vary with age, sex, and rate of illness progression.     

Bacterial meningitis in Swaziland: an 18 month prospective study of its impact

STUDY OBJECTIVE: To describe the epidemiology, clinical features, and outcome of bacterial meningitis in Swaziland. DESIGN: Prospective study of patients diagnosed as having meningitis of nonviral aetiology during an 18 month period from February 1991 to July 1992. SETTING: Four regional hospitals covering the population of the four districts in Swaziland. SUBJECTS: All patients with non-viral meningitis admitted to hospital within the study period. MAIN RESULTS: Altogether 85 patients were reported to have bacterial meningitis: 48.3% were aged under 1 year. Causative organisms were identified in 60% of cases, and Streptococcus pneumoniae was found to be the commonest (49% of cases). Overall, case fatality was 38.8% for all age groups, and 62.5% (15 of 25) for adults. Neurological sequelae occurred in 22.4%. Three of the adult cases were HIV seropositive. Seizures, but not duration of symptoms before admission, were associated with a poor prognosis. There was a significant rise in incidence related to a period of drought. Fifteen patients were reported with tuberculous meningitis, of whom five were known to be HIV seropositive; the case fatality was 73.3%. CONCLUSIONS: The aetiology and age distribution of cases of meningitis differs greatly from that in developed countries. Rising HIV infection may have an important impact on the future incidence of meningitis. The high case mortality found should encourage efforts towards earlier diagnosis and treatment, and strengthens the need to develop appropriate vaccines.     

Meningitis caused by Streptococcus bovis

Streptococcus bovis was isolated from the CSF of a 66-year-old man with meningitis. His clinical appearance was unusual in that he lacked typical signs and symptoms of pyogenic meningitis. Streptococcus bovis was also recovered from his blood, which suggested that bacterial endocarditis was the source of his CNS infection. He was cured after four weeks of therapy with intravenous penicillin G potassium. This is the fourth reported case of meningitis caused by S bovis. The previous three patients also had endocarditis caused by S bovis. Because of the reported propensity of S bovis to infect heart valves and the frequent association of S bovis bacteremia with malignant gastrointestinal (GI) tract tumors, recovery of this organism form CSF should prompt a search for bacterial endocarditis and occult GI cancer.     

Clinical analysis of two-level compression of the cauda equina and the nerve roots in lumbar spinal canal stenosis

STUDY DESIGN: This study is a prospective, clinical study assessing the efficacy of selective decompression of the responsible level in two-level stenosis in accordance with neurologic findings defined by the gait load test, and functional diagnosis based on selective nerve root block. OBJECTIVE: To clarify the clinical features of two-level stenosis regarding the neurologic level responsible for the symptoms, neurogenic intermittent claudication, and the outcome of selective decompression. SUMMARY OF BACKGROUND DATA: Experimental studies have indicated that double-level compression of the cauda equina induces a more severe impairment of nerve function than does single-level compression. However, few studies have focused on the clinical importance of two-level stenosis. The clinical effects of two-level stenosis on the cauda equina and nerve roots are unknown. METHODS: A total of 81 patients with lumbar spinal canal stenosis due to spondylosis and degenerative spondylolisthesis were divided into two groups, two-level stenosis at L3-L4 and L4-L5, and one-level stenosis at L4-L5, based on myelography. The types of neurogenic intermittent claudication, the level responsible for neurologic findings, and the postsurgical outcome were compared between both groups. The level responsible for the symptoms in two-level stenosis was determined in accordance with neurologic findings on the gait load test and functional diagnosis based on a selective nerve root block. All patients underwent a prospective, selective decompression at the neurologically responsible level only. The average follow-up period was 4.6 years (range, 1-8 years). RESULTS: The patients with two-level stenosis more frequently had cauda equina symptoms than those with one-level stenosis, except patients with degenerative spondylolisthesis. It was therefore assumed that two-level stenosis was associated with cauda equina impairment, Changes in neurologic condition before and after the gait test were observed in four patients with two-level stenosis. Finally, for 28 patients with two-level stenosis, the levels responsible for the neurologic symptoms were the caudal level (L4-L5) in 22 patients, the cranial level (L3-L4) in 1 patient, and both cranial and caudal levels (L3-L4 and L4-L5) in 5 patients. All stenotic levels on the myelogram were not always symptomatic in two-level stenosis. However, in one-level stenosis, all of the responsible levels completely corresponded to the myelogram. Selective decompression only at the neurologically responsible level improved neurogenic intermittent claudication in all patients. The asymptomatic levels at which the stenotic condition was left unchanged at surgery did not become symptomatic at follow-up; in addition, there was no significant difference in the postoperative outcome between two-level stenosis and one-level stenosis. CONCLUSIONS: Two-level stenosis in patients with lumbar spondylosis is associated with production of cauda equina lesions. The gait load test provides information regarding changes in symptoms and neurologic condition during exercise. The responsible levels should be determined based on neurologic findings after the gait load test and a selective nerve root block. It is uncommon for both stenotic levels to be symptomatic in patients with two-level stenosis. Less invasive surgery such as selective decompression for the responsible level in patients with two-level stenosis is a useful technique with a good potential for long-term success.