Review/perspective on hysterical paralysis: A diagnosis of exclusion for spinal surgeons

BACKGROUND: Hysterical paralysis (HP) and/or conversion disorders (CD) are diagnoses of exclusion for spine surgeons. Before assigning this diagnosis to a patient, they must first undergo a full neurodiagnostic evaluation (i.e., X-rays, MR, CT/Myelo-CT) to rule out organic spinal pathology. Here, we reviewed select articles highlighting how to differentiate HP/CD patients from those with spinal disease. METHODS: Several case studies and small series of patients with HP/CD were included in our analysis. Notably, prior to being assigned the diagnoses of HP/CD, patients had to first undergo X-ray, MR, CT, and/or Myelo-CT evaluations to rule out spinal disorders; typically, their neurodiagnostic studies were normal. RESULTS: Patients with HP/CD often presented with varying clinical complaints of motor paralysis despite intact reflexes, normal sensory examinations, and lack of sphincter disturbance (i.e. intact rectal tone). Further, go and nogo functional MRI (fMRI) examinations demonstrated inconsistencies in areas of brain activation for patients with HP/CD complaints. CONCLUSIONS: HP/CD are diagnoses of exclusion, and patients should first undergo a full panel of neurodiagnostic studies to rule out organic spinal disease. While those with HP/CD should not have unnecessary operations, those with real “surgical pathology” should have appropriate spine surgery performed in a timely fashion.