Thoracic Spine Product

Dorn Spinal Therapy

Dorn Spinal Therapy has been in uses in the past 40 years. The credit of this method goes to Dieter Dorn, who has made a significant impact in the medical field. DORN- Method has been used on various patients where results could get witnessed instants. Due to the impact, this method has brought in the country. It has been declared the standard practice in treating Pelvical Disorders, Spinal, and Back pain. Dieter Dorn first used this method on his family, which was a sign of confidence in a method, which later gained much attention from different people in the country and also globally. Every day Dorn was able to offer treatment to 15- 20 patients in a day. His services were purely free which attracted attention both in the local and also global. The primary treatment that DORN-Method which could be treated using this method include spine healing therapy, misalignments of the spine, resolving pelvis and joints, and also solving out significant problems which could get attributed to vertebrae.

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Spinal Canal Stenosis

Central spinal canal stenosis may be developmental, acquired, or a combination of the two. Developmental stenosis is relatively uncommon and is estimated to account for approx 15 of all cases of spinal stenosis. It may be idiopathic or related to a more generalized disorder affecting the skeletal system, as in the case of the mucopolysaccharidoses or Down's syndrome. The idiopathic variant may selectively involve the lumbar region or may be generalized. It results from the formation of short pedicles with a resulting decrease in the cross-sectional diameter of the central canal. In isolation, this abnormality is generally not symptomatic but renders the patient more susceptible to relatively mild derangements of the disc or posterior elements. Acquired central spinal stenosis may be caused by various abnormalities related to degeneration of the intervertebral disc (vertebral osteophyte, circumferential disc bulge, focal disc protrusion or extrusion), facet joints (osteophyte, synovial...

Neoplastic Disease Of The Spine

MRI is the primary imaging modality used in the evaluation of spinal neoplasms (66). MRI has the advantage of multiplanar imaging capability and contrast sensitivity. Spinal canal lesions are classified into three categories by the anatomic compartment of origin (67-70) Intramedullary spinal cord masses Intradural extramedullary lesions in the dura, outside of the spinal cord

Extradural Spinal Masses

Spinal Hemangioma Mri Images

These lesions are found outside the dural sac involving the epidural space, paravertebral soft tissues, and spinal skeleton. The most common extradural masses are metastases from primary breast, lung, prostate, myeloma, and lymphoma. MRI is the preferred imaging modality to detect these lesions. Primary bone tumors rarely involve the lumbar spine. Nerve sheath tumors may present as extradural lesions but this is less common than their presentation in the intradural compartment. Chordomas classically occur in the sacrum and coccyx. Metastatic disease frequently affects the spine primarily involving the vertebral body, usually followed by neoplastic infiltration of the posterior elements and epi-dural compartment (Fig. 16). The vast majority of these lesions arise from hematogenous spread to vertebral bodies. The usual MRI appearance is neoplastic replacement of the normal fatty marrow with hypointense T1 signal and hyperintense T2 signal relative to bone marrow. Well defined oval or...

The Spinal Nerve In The Intervertebral Foramen

Sinuvertebral Nerve Anatomy

The spinal nerve and the proximal parts of its primary rami reside in the intervertebral foramen. Two early branches of the primary rami warrant mention here (Fig. 11). First, the sinuvertebral, or recurrent meningeal nerves, branch from the anterior primary ramus and reen- Fig. 17. Sagittal T1 MR of the lumbar spine. The epidural space is shown by the high signal fat within the epidural space. Fig. 16. Sagittal T1 MR through the cervical spine. Notice how the spinal cord becomes slightly larger at C6 and C7. Fig. 16. Sagittal T1 MR through the cervical spine. Notice how the spinal cord becomes slightly larger at C6 and C7.

Anatomy Cervical spine

The neural canal is almost filled by the cervical enlargement of the spinal cord and the emerging cervical roots pass through exit foraminae bounded by the facet joints posteriorly and the intervertebral discs and neurocentral joints anteriorly. The nerve roots, particularly in the lower cervical spine, may be compressed or irritated by lateral disc prolapse or osteophytes arising from the facet or neurocentral joints, A central disc prolapse may produce pressure on the cord itself.

Cervical spine implants posterior devices

Occipitocervical plates extend stabilization of the upper cervical spine to the occiput, and are secured to the skull with short screws. Lateral mass plates are applied to the posterior aspect of the lateral masses, and require very precise (CT-guided) screw hook placement (lateral angulation of 30 ) to avoid the vertebral artery.

Vertebroplasty For Spinal Neoplasms

Vertebroplasty was first performed for painful spinal hemangiomas (1,61-69). European practitioners have continued to treat large numbers of patients with spinal neoplasms (2,9,61,70-72). In North America, however, treatment of neoplastic disease of the spine has failed to gain widespread acceptance (73). extent and degree of bony involvement. Destruction of the posterior vertebral cortex renders vertebroplasty of higher risk, because of potential for cement extravasation into the spinal canal (Fig. 10) (9). However, osteolysis of the posterior wall is not an absolute contraindication. Only when frank epidural tumor is present should vertebro-plasty be avoided (9,24,70-72). Second, patients with multifocal spinal metastases may have great difficulty in lying in the prone position and general anesthesia should be strongly considered. Third, the routine transpedicular approach may be difficult or impossible in cases of pedicu-late involvement with tumor, and may require CT for needle...

Posterior Muscles Of The Spine

Transversospinal Group

The posterior muscles of the spine are well developed because most of the weight of the body lies anterior to the spine and more power is required to produce the primary function of the posterior group, which is extension. The muscles of the posterior group are divided into those that are extrinsic to the back and those that are intrinsic. The extrinsic muscles of the back developed embryo-logically on the anterior surface of the body and later migrated to their posterior position. These muscles have carried their motor innervation with them, and thus are innervated by anterior primary rami of spinal nerves, or in one case, by a cranial nerve. In terms of function, the extrinsic muscles are related either to movement of the upper limb (the appendicular group) or to respiration. There are five muscles in the appendicular group latissi-mus dorsi, rhomboid major, rhomboid minor, levator scapulae, and trapezius. The first four receive innervation from the anterior primary rami of cervical...

Thoracolumbar spine implants posterior devices

Constructs are best suited to the thoracic spine, whereas pedicle screw-and-rod systems are favoured in the lower thoracic and lumbar spine. Rod systems may be classified as distraction, segmental or pedicle screw systems. 3. Pedicle screws. Inserted through the pedicles into the vertebral body, pedicle screws give very secure fixation. The screws (modified Schanz screw) are linked via clamps to plates or rods. Rod systems (AO, Colarado, Olerud, Vermont) are versatile and may extend over a few or many vertebral levels, allowing segmental compression or distraction. These systems are commonly used in the trauma setting to stabilize unstable fractures at the thoracolumbar junction and in the lumbar spine.

Mri Appearance Of The Normal Spine

T1- and T2-weighted images are routinely performed in the evaluation of the spine. With Tl-weighting, the intervertebral disc demonstrates fairly homogeneous signal intensity that is slightly less than that of the vertebral body red marrow. Epidural fat can be distinguished by its relatively bright appearance or high signal intensity (1). Nerve tissue, on the other hand, is of low intensity (dark appearance) but may still be differentiated from cerebrospinal fluid (CSF), which appears black with an even lower signal. The thin lines of low signal intensity along the superior and inferior borders of vertebral bodies represent the cortical endplates and have been confirmed by correlation with cadaveric specimens (2). From Interventional Radiology of the Spine

Spinal Mechanisms And Pathways

The spinal cord is a major site for the regulation of pro- and anti-erectile outflows as well as the coordination of autonomic and somatic pathways. In patients with spinal cord injuries above the sacral segments, erections are triggered via the spinal reflex arc. The patients have poor-quality erections with premature detumescence because of the lack of supraspinal control (8). However, lesions involving the sacral spinal cord, the sacral roots, or the pelvic or pudendal nerves abolish reflexic erections. Psychogenic erections occur in men with complete lesions of the cord as high as T12, suggesting that the sympathetic pathways in these men mediate them. Penile erections remaining after sacral spinal cord lesions or lesions of the pelvic nerve are attributed to sympathetic outflow, suggesting that erections may be elicited by peripheral information integrated at suprasacral levels that activates sympathetic pathways (222, 223). A report of erectile dysfunction caused by lesions of...

Primary And Metastatic Spinal Tumors

Approximately 10 of spinal tumors are intramedullary. Ependymoma is the most common type of intramedullary tumor in adults (21). The remainder are other types of gliomas. Intramedullary lesions disrupt cord function by invasion and infiltration. Extramedullary tumors may be extradural or intradural in location. Among the primary extramedullary tumors, neurofibromas and meningiomas are relatively common, often benign, and either intradural or extradural. Carcinomatous metastases, lymphomatous or leukemic deposits, and myeloma are most often extradural lesions. Tumor involvement may lead to pathological fracture or direct cord compression. Spinal cord dysfunction may be the result of ischemia secondary to tumor causing arterial or venous obstruction. Vertebrae are a common location for primary and metastatic neoplasm. Primary neoplasms of the spine may present as benign lesions, such as the osteoid osteoma, osteoblastoma, or spinal osteochondroma, and are often found in patients between...

Metastatic Lesions Affecting the Spine

Vertebral Hemangioma

Neoplastic and metastatic lesions can involve the vertebral bodies as well as intra- and extramedullary structures. The goal of endovascular treatment remains devascularization prior to a planned surgery or biopsy (Figure 16.7). Embolization significantly reduces the blood loss and improves the surgical resection.34-37 Because the embolization is performed with Gelfoam, PVA, or on some occasions with dehydrated ethanol, attention has to be paid to the potential supply of radiculomedullary radiculopial arteries to the anterior or posterior spinal arteries. An embolization can on rare occasion lead to tumor necrosis, with subsequent swelling and spinal cord compression. Preprocedural high-dose corticosteroid medication has been suggested.38 On rare occasions and in nonsurgical patients, embolization can be helpful for pain reduction and treatment of radicular compression.38 Although a reduction of tumor growth may be seen, embolization for spinal metastasis and malignant spinal tumors...

History Cervical spine

The patient may also report paraesthesiae in I he arm due to nerve root irritation or, less commonly when the spinal cord is involved, symptoms of lower limb weakness, difficulty walking, loss of sensation and sphincter control. Disease of the upper cervical spine affecting the atlantoaxial joints produces pain radiating into the occiput in the distribution of the C2 nerve root. Disease of the middle and lower cervical spine tends to cause pain radiating into the upper border of the trapezius, interscapular region or into the arms, often associated with local tenderness. Irritation of the C6 and 7 nerve roots can give rise to widely referred pain in the interscapular region or into the radial lingers and thumb. Irritation of CK can produce pain on the ulnar side of the forearm and into the ring and little lingers. Cervical spine pathology

Typical Spinal Nerve Figure 127

Typical Spinal Nerve

In the human body, every spinal nerve has essentially the same construction and components. By learning the anatomy of one spinal nerve, you can understand the anatomy of all spinal nerves. Like a tree, a typical spinal nerve has roots, a trunk, and branches (rami). Figure 12-7. A typical spinal nerve, with a cross section of the spinal cord. Figure 12-7. A typical spinal nerve, with a cross section of the spinal cord. a. Coming off of the posterior and anterior sides of the spinal cord are the posterior (dorsal) and anterior (ventral) roots of the spinal nerve. An enlargement on the posterior root is the posterior root ganglion. A ganglion is a collection of neuron cell bodies, together, outside the CNS. b. Laterally, the posterior and anterior roots of the spinal nerve join to form the spinal nerve trunk. The spinal nerve trunk of each spinal nerve is located in the appropriate intervertebral foramen of the vertebral column. (An intervertebral foramen is a passage formed on either...

Disorders of the Spine

Sealy Mattress For Cervical Spondylitis

Ankylosing spondylitis is a disease of the spine that appears mainly in males. Joint cartilage is destroyed eventually the disks between the vertebrae calcify and there is fusion of the bones (ankylosis) (Fig. 19-12). Changes begin low in the spine and progress upward, limiting mobility. In cases of a herniated disk (Fig. 19-13), the central mass (nucleus pulposus) of an intervertebral disk protrudes through the weakened outer ring (anulus fibrosus) of the disk into the spinal canal. This commonly occurs in the lumbosacral or cervical regions of the spine as a result of injury or heavy lifting. The herniated or slipped disk puts pressure on the spinal cord or spinal nerves, often causing pain along the sciatic nerve (sciatica). There may be spasms of the back muscles, leading to disability. A herniated disk is diagnosed by myelography, CT scan, MRI, and neuromuscular tests. Treatment is bed rest drugs to reduce pain, muscle spasms, and inflammation followed by an exercise program to...

Blood Supply Blood Brain Barrier Phenomena and Cerebrospinal Fluid

As mentioned earlier, the brain lies within the skull, and the spinal cord within the vertebral column. Between the soft neural tissues and the bones that house them are three types of membranous coverings called meninges the dura mater next to the bone, the arachnoid in the middle, and the pia mater next to the nervous tissue. A space, the subarachnoid space, between the arachnoid and pia is filled with cerebrospinal fluid (CSF). The meninges and their specialized parts protect and support the central nervous system, and they produce, circulate, and absorb the cerebrospinal fluid. (As described later, a portion of the cerebrospinal fluid is also formed in the cerebral ventricles.) The cerebrospinal fluid circulates through the interconnected ventricular system to the brainstem, where it passes through small openings out to a space between the meninges on the surface of the brain and spinal cord (Figure 8-47). Aided by circulatory, respiratory, and postural pressure changes, the fluid...

Table 51 Indications for spine biopsy

Suspected secondary spine tumor (i.e., metastasis) with either a known or an unknown primary tumor 2. Suspected secondary spine tumor, with a history of two or more preexisting primary tumors 3. Suspected primary spine or paraspinal tumor 6. Suspected inflammatory condition that involves the spine with noninvasive imaging modalities, such as computed tomography (CT) or magnetic resonance imaging (MRI), are also often referred for spine biopsy. In every instance, the decision to proceed with a biopsy procedure is based upon a thorough analysis of risks and benefits. The overall benefit of the information gained by the procedure should always favor its performance. The results of the biopsy will affect the subsequent clinical management of the patient and influence treatment decisions in such areas as surgery, chemotherapy, radiation therapy, and antibiotic therapy. Informed consent must be obtained prior to the procedure after the patient has received an explanation of the benefits and...

Cranial and Spinal Nerves

The central nervous system communicates with the body by means of nerves that exit the CNS from the brain (cranial nerves) and spinal cord (spinal nerves). These nerves, together with aggregations of cell bodies located outside the CNS, constitute the peripheral nervous system.

The neck and cervical spine

Cervical spine, especially side rotation and flexion for obvious reasons. Degenerative arthrosis of the ccrvical spine is common, especially in the middle-aged and elderly. Such patients may develop neck pain, long tract features or radicular symptoms. Flexion of the neck sometimes evokes electric shock-like sensations which shoot into the limbs, when the cervical spinal cord sensory tracts are diseased (Lhermitte's .sign). This phenomenon is particularly common in multiple sclcrosis but is also seen in syringomyelia, cervical cord tumours and spondylotic myelopathy.

Pain Following Spinal Surgery

Patients undergoing laminectomy and laminectomy with fusion have a 10-30 rate of continued or renewed low back pain (38). Causes of low back pain following surgery include degenerative facet or disc disease, recurrence of disc extrusion, infection, spinal stenosis, sacroiliitis, and pseudarthrosis (failure of fusion). Pseudarthrosis is a common complication of spinal fusion procedures. Unfortunately, flexion-extension radiographs and CT are often inaccurate in the diagnosis of pseudarthrosis (39). SPECT bone scintigraphy appears to be promising in the diagnosis of pseudarthrosis in the early years following spinal surgery (40,41). Slizofski et al. studied painful pseudarthrosis following lumbar fusion using SPECT and planar bone scintigraphy (40). SPECT was superior to planar bone scintigraphy. SPECT bone scintigraphy had a sensitivity of 78 and a specificity of 83 in diagnosing pseudarthrosis in symptomatic patients. However, it also showed increased activity in the fusion mass of 6...

Thoracolumbar spine injuries

This can fracture and displace into the spinal canal, with associated disc protrusion. This usually occurs in the lower lumbar spine and is often misdiagnosed as a prolapsed intervertebral disc. Laminotomy and removal of fragments from the spinal canal are required.

Spinal immobilization

Immobilization of the 'unstable' spinal column is required to prevent secondary injury. This may be achieved by non-operative or operative means. Nonoperative immobilization may be safely continued, with bed-rest, supervised nursing care, neck collar, tape and sandbags, etc. Skeletal traction via tongs or a halo is more secure and makes nursing easier in cervical spine injuries. Halo traction can be converted to halo-vest immobilization for early rehabilitation. 2. Operative immobilization of spinal fractures in the patient with a cord injury is controversial.

Table 52 Complications associated with spine biopsy

Example Oblique Body

Neural injury (spinal cord or nerve) resulting in transient or permanent paralysis Percutaneous spine biopsy can be performed with local anesthesia, with local anesthesia and conscious sedation, or under general anesthesia. The procedure is often performed with a combination of local anesthesia and intravenous conscious sedation using a short-acting benzodiazepine (Versed) and an analgesic such as fentanyl or morphine. While general endotracheal anesthesia is often not utilized owing to the requirement for prone positioning of the patient, general intravenous anesthesia can be performed with propofol. To minimize the possibility of infection, the study should be performed with strict aseptic technique. Patient positioning depends upon the spine level (cervical, thoracic, or lumbosacral) of the lesion and its location (vertebral body vs posterior elements). The prone position is optimal for accessing lesions in the thoracic or lumbosacral spine or, rarely, within the posterior aspect...

Cervical spine

In early disease, many patients have cervical pain, which may be due to muscle spasm. During the course of their disease up to 90 of RA patients have some cervical spine involvement, and it is particularly common in long-standing disease and multiple joint involvement. Significant subluxations occur in about one-third of cases. Common radiological presentations include atlanto-axial subluxation (the most common sign) and atlanto-axial impaction (also called basilar invagination). Such patients should have an MRI of the cervical spine to highlight other features, such as pannus of the odontoid peg and cord compression

Spinal Trauma

The balance between the use of plain film radiography and CT in the evaluation of acutely injured patient continues to evolve. The debate over the appropriate triage algorithm considers such factors as time, cost, and diagnostic accuracy. In reality, other factors such as clinical judgment, regional practice variations, and the possibility of litigation also affect the utilization of resources. The issue boils down to two considerations. First, who should be imaged Second, how should they be imaged A complete discussion of all of these issues is beyond the scope of this chapter, but a few background points are worth noting. The National Emergency X-Radiography Utilization Study (NEXUS) was a large, multicenter prospective study that evaluated 34,069 patients with neck trauma in an attempt to determine criteria for classifying patients with an extremely low likelihood of clinically significant injury. The goal was to define a subset of patients for whom imaging would not be necessary....

Spinal Nerves

Spinal Cord Gray Matter Neuron

There are thirty-one pairs of spinal nerves. These nerves are grouped into eight cervical, twelve thoracic, five lumbar, five sacral, and one coccygeal according to the region of the vertebral column from which they arise (fig. 8.23). Each spinal nerve is a mixed nerve composed of sensory and motor fibers. These fibers are packaged together in the nerve, but they separate near the attachment of the nerve to the spinal cord. This produces two roots to each nerve. The dorsal root is composed of sensory fibers, and the ventral root is composed of motor fibers (fig. 8.24). An enlargement of the dorsal root, the dorsal root ganglion, contains the cell bodies of the sensory neurons. The motor neuron shown in figure 8.24 is a somatic motor neuron that innervates skeletal muscles its cell body is not located in a ganglion, but instead is contained within the gray matter of the spinal cord. The cell bodies of some auto-nomic motor neurons (which innervate involuntary effectors), however, are...

Spinal anaesthesia

Spinal (intrathecal) anaesthesia results from the injection of a local anaesthetic drug directly into the cerebrospinal fluid (CSF), within the subarachnoid space (Fig. 2.24b). The spinal needle can only be inserted below the second lumbar and above the first sacral vertebrae the upper limit is determined by the termination of the spinal cord, and the lower limit by the fact that the sacral vertebrae are fused and access becomes virtually impossible. A single injection of local anaesthetic is usually used, thereby limiting the duration of the technique. A fine, 22-29 gauge needle with a 'pencil point' or tapered point (for example Whitacre or Sprotte needle) is used (Fig. 2.25). The small diameter and shape are an attempt to reduce the incidence of postdural puncture headache (see below). To aid passage of this needle through the skin and inter-spinous ligament, a short, wide-bore needle is introduced initially and the spinal needle passed through its lumen. Positioning of the patient...

Spinal Tumors

Spinal tumors of children may be found anywhere along the vertebral column. They cause symptoms by compression of the contents of the spinal canal. Localized back pain in a child or adolescent should raise suspicion of a spinal cord tumor, especially if the back pain is worse in the recumbent position and relieved when sitting up. The major signs and symptoms of spinal cord tumors are listed in Table 17-3. Most spinal cord tumors have associated muscle weakness, and the muscle group affected corresponds to the spinal level of the lesions. Spinal tumors can be divided into three distinct groups 3. Extramedullary, extradural These tumors are most often of mesenchymal origin and may be due to direct extension of a neuroblastoma through the intervertebral foramina or due to a lymphoma. Tumors of the vertebra may also encroach on the spinal cord, leading to epidural compression of the cord and paraplegia (e.g., PNET or Langerhans cell histiocytosis occurring in a thoracic or cervical...

Thoracic Spine

Thoracic spine discography can be performed in the prone semioblique 45 position (using a wedge) with the less painful side up. Alternatively, the patient may be placed prone and anteroposterior images obtained with the endplates in alignment. The C-arm is rotated to the side of injection until a lucent zone directly in line with the beam is seen projecting over the thoracic disc (Fig. 13). This usually requires approx 20 of rotation. The needle should enter the disc lateral to the interpedicular line and medial to the costovertebral joints to avoid potential complications, such as accidental puncture of the lung or thecal sac. Generally a single-needle technique is used in the thoracic spine. Usually 25-gauge needles will suffice for small individuals however, 3.5-in., 23-gauge needles are often preferred because they are stiffer and can negotiate better around nerve roots and or the osseous structures if necessary. The thoracic disc normally accepts a small volume of injectant (

The Spinal Cord

The spinal cord extends from the medulla oblongata to between the first and second lumbar vertebrae. It has a central area of gray matter surrounded by white matter. The gray matter projects toward the back and the front as the dorsal and ventral horns. The white matter contains the ascending and descending tracts (fiber bundles) that carry impulses to and from the brain. Thirty-one pairs of spinal nerves connect with the spinal cord (Fig. 17-4). These nerves are grouped in the segments of the cord as follows A simple response that requires few neurons is a reflex (see Fig. 17-5). In a spinal reflex, impulses travel through the spinal cord only and do not reach the brain. An example of this type of response is the knee-jerk reflex used in physical examinations. Most neurologic responses, however, involve complex interactions among multiple neurons (interneurons) in the CNS.

Lumbar spine

There are three important components to the examination of the lumbar spine. The first is to inspect for the presence of deformity (see Disorders box), the second is to assess the movements of the spine, and the third is to assess the effects of lumbar spinal pathology on the spinal cord or nerve roots. With the patient standing, observe the posture from behind, checking that the spine is straight, and from the side checking that there is a normal lordosis. Whilst keeping the iegs straight, ask the patient first to bend backwards, then forwards and then to each side. Note the range of movement in each direction and the contour formed by the spine. I Carry out Schober's test where appropriate to quantify the range of lumbar spinal flexion (Fig. 8.10).

Spinal Stenosis

Lateral Recess Stenosis

Spinal stenosis refers to impingement upon neural tissue in the central spinal canal, intervertebral foramina, or lateral recesses. These conditions may result from developmental anomalies, one or any combination of the degenerative changes detailed in the preceding, or a number of other conditions (19). The term stenosis, however, should be reserved for patients with clinical findings consistent with such a diagnosis. Findings on imaging without clinical correlation should be referred to as narrowed (30,31). Developmental stenosis accounts for a minority of cases in roughly a 1 10 ratio with respect to degenerative causes, and can be grouped into those due to hereditary-idiopathic spinal stenosis and those related to disorders of skeletal growth, such as the mucopolysaccharidoses, Down's syndrome, and achondroplasia, among others (30). These stenoses result from a hypoplastic vertebral arch with short, thick pedicles. In addition, the distance between pedicles at a given level may...

List of Abbreviations

Britain & Ireland ADH antidiuretic hormone AED automated external defibrillator ALS advanced life support ALT alanine aminotransferase APC activated protein C APPT activated partial thromboplastin time ARDS acute respiratory distress syndrome ASA American Society of Anesthesiologists AST aspartate aminotransferase ATN acute tubular necrosis BLS basic life support BNF British National Formulary CAVH continuous arteriovenous haemofiltration CBF cerebral blood flow CCU coronary care unit CLCR creatinine clearance CNS central nervous system COPD chronic obstructive pulmonary disease COX cyclo-oxygenase enzymes (COX-1, 2) CPAP continuous positive airway pressure CPR cardiopulmonary resuscitation CSF cerebrospinal fluid CT computerized tomography CVP central venous pressure CVS cardiovascular system CVVH venovenous haemofiltration DIC disseminated intravascular coagulation DNAR do not attempt resuscitation ECF extracellular fluid EMLA eutectic mixture of local anaesthetics ENT ear, nose and...

Previous anaesthetics and operations

Patients may have been issued with a 'Medic Alert' type bracelet or similar device giving details or a contact number. Although halothane is now less popular for maintenance of anaesthesia, the approximate date of previous anaesthetics should be identified if possible to avoid the risk of repeat exposure (see page 33). Details of previous surgery may reveal potential anaesthetic problems, for example cardiac, pulmonary or cervical spine surgery.

Inborn Errors of Folate Transport and Metabolism

Hereditary folate malabsorption (congenital malabsorption of folate) is due to a rare autosomal recessive trait and is characterized by megaloblastic anemia, chronic or recurrent diarrhea, mouth ulcers, failure to thrive, and usually loss of developmental milestones, seizures, and progressive neurologic deterioration. The most important diagnostic feature is megaloblastic anemia in the first few months of life, associated with low serum, red cell, and cerebrospinal fluid folate levels.

Plasma cellsB lymphocytes and antibodies

Antibody production is a property of plasma cells, the terminally-differentiated stage of the B cell lineage. During the acute phase of an infectious process, activated B cells plasmablasts circulate in the blood and localize to various distal sites. In the viral encephalitides, for instance, B cells plasmablasts can be seen to transit 32 from the blood to the central nervous system (CNS), where they become plasma cells and continue local antibody production in the long term 52, 98 . Persistent infection with a defective variant of measles virus in subacute sclerosing panencephalitis is characterized by massive, long-term local antibody production 114 . Subclinical infection of the CNS with an encephalitic virus can also lead to the sustained presence of neutralizing Ig in cerebrospinal fluid (CSF) at titers that are clearly discordant with levels in serum, providing a clear indication of local Ig synthesis in the brain 98 .

Bradley M Thomas John M Olsewski and Jerry G Kaplan History and Clinical Presentation

Examination revealed a patient in no acute distress, with a full range of motion of the cervical spine. Reproduction of his right arm pain was elicited with extension of the neck and rotation of his head to the right (Spurling's maneuver). He appeared to have mild deltoid wasting on his right with prominence of his acromion. Motor testing was symmetric with 5 5 strength in bilateral deltoids, biceps, triceps, wrist flexors, wrist extensors, finger flexors, finger extensors, and hand intrinsics. His deep tendon reflexes were 2+ and symmetric, with the exception of the biceps reflex, which was depressed on the right side compared with the left. He had a negative Hoffman's sign and his gait was within normal limits. Tinel's and Phalen's testing of the median nerve at the wrist were not provocative.

Neurological features

There are several neurological features of RA. The most common is nerve entrapment, the best example of which is carpal tunnel syndrome. Cervical myelopathy is a further example, which develops due to synovitis involving the cervical spine. These types of nerve entrapment occur due to local factors and are not limited to those with sero-positive disease. Other neurological features, occur as 'classical' extra-articular features in seropositive

Related topic of interest

Intra-articular fractures constitute 75 of fractures and follow RTAs and falls from a height (classically a ladder) - both result in axial load. Five to ten per cent are bilateral. Other fractures are commonly associated - 20 have an ipsilateral limb injury, such as tibial plateau or hip fracture, and 10 have a cervical or lumbar spine fracture.

Clinical Manifestation

Multifocal neurologic signs and symptoms are the hallmark of LM. Symptoms can be divided into CNS, cranial neuropathies or spinal radicular (Table 2). The mechanisms in which LM cause neurological signs and symptoms include obstruction of CSF flow or drainage with resultant increased intracranial pressure (ICP), meningeal irritation, or focal signs from local invasion or irritation of the brain, cranial nerves, spinal cord or spinal nerves. LM can cause cerebral infarction from a cerebral vasculopathy changes in brain metabolism and reduction in cerebral blood flow may cause a diffuse encephalopathy.62, 106 Isolated neurologic symptoms occur in 30-53 of patients with LM,9,61,85,131,135,137 with CNS85 and spinal radicular61 the most common. Multifocal involvement is seen in 40-80 of cases.9,61,85, 131, 135 137 In one study, a combination of two sites was seen in 47 of cases (CNS 29 , CNS and spinal radicular 10 , and spinal radicular 8 ) and involvement of all levels was seen in 13 of...

John M Mathis Ali Shaibani and Ajay K Wakhloo

Pedicle Lamina

The spine and its anatomical components are complex. Authors have approached it from a variety of perspectives including surgical, anatomical, and diagnostic (imaging). Our interest in spinal anatomy concerns the treatment of pathological processes affecting the spine. This chapter describes spine anatomy that is of interest to the image-guided interventionist. The spine is composed of 33 bones there are 7 cervical vertebra, 12 thoracic vertebra, 5 lumbar vertebra, 5 sacral segments (fused), and 4 coccygeal segments (variably fused).1 Natural curvature is found throughout the spine (Figure 1.1). Viewed from the side, the cervical spine is convex forward, the thoracic spine is convex backward (centered at T7), the lumbar spine is convex forward, and the sacral bone is convex backward. The vertebrae progressively enlarge from the cervical through the lumbar regions. There is also variability in vertebra size at any particular level based on the individual's body size (Figure 1.2). The...

Bone Scintigraphy General Principles

Bone scintigraphy is a frequently requested and widely available method of diagnosing a variety of bony lesions of the spine. Bony lesions have predictable patterns of increased tracer uptake that are characteristic of the underlying disease process. Single photon emission computed tomography (SPECT) of the spine shows greater lesion contrast than planar studies (1). SPECT images are also easier to correlate with other tomographic-based studies, such as magnetic resonance imaging (MRI) or computed tomography (CT). Comparison of SPECT bone images with planar images is useful in identifying the correct vertebral level. When available, radiographic correlation is useful in identifying normal variants, such as six lumbar vertebrae or sacralization of the lumbar spine (2).

Sports Injuries

Cervical spine. Injuries to the cervical spine range from mild to severe. Certain athletic activities (football, diving, gymnastics) are associated with an increased incidence of cervical spinal injury in comparison with other sports. Prompt recognition and treatment of persons who suffer cervical spinal injuries may prevent the progression or severity of the associated neurologic injury. B. Classification of cervical spinal injuries. Neck injuries can be classified according to neurologic sequelae or the type of force acting on the cervical spine at the time of injury.

Other connective tissue diseases and overlap syndromes

Despite the lack of systemic features, osteoarthritis in some people can be diffuse in distribution, mildly inflammatory, and associated with significant, if slowly progressive, deformity and disability. The joint distribution typically involves the first carpometacarpal joint of the thumb first metatarsophalangeal joint distal and proximal interphalangeal joints of the hands, hips, and knees and the cervical and lumbar spine (see CMpiei ).

Degenerative Spondylolisthesis

Images Degenerative Spondylolisthesis

In degenerative spondylolisthesis, damage to each element of the three-joint complex causes instability between adjacent vertebra. Central to this condition is injury to the facet joint (Fig. 7). A symmetric anterolisthesis may result in stenosis of both the central canal and lateral recesses. The neural arch of the upper vertebra and the posterosu-perior aspect of the lower vertebral body combine to narrow the spinal canal, while the inferior articular processes of the superior vertebra encroach upon the lateral recesses (20). In the case of a retrolisthesis, central canal stenosis would be found between the post-eroinferior portion of the upper vertebral body and the lamina of the lower vertebrae. Central stenosis is not as common with retrolisthesis as anterolisthesis owing to a decreased degree of instability in this condition (24). A degenerative retrolisthesis may also result in intervertebral foramen stenosis at the affected level, as the space between the posterior aspect of...

Vertebral Canal And Its Contents

Coccyx And Nerve Nodes

The spinal cord is the continuation of the medulla oblongata and begins at the vertebral foramen of the atlas. The spinal cord is thin and slender, and almost circular in cross section, being flattened slightly from anterior to posterior. There are 31 pairs of spinal nerves emerging from the spinal cord 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each spinal nerve is composed of an anterior and a posterior root (Fig. 15). Each anterior root contains multiple rootlets that are the peripheral pro Fig. 15. Meninges and vasculature of the spinal cord. The spinal nerve is short and branches immediately after its formation into anterior and posterior primary rami. The spinal arteries and veins pierce the pia to vascularize the cord. The spinal branches shown are representative of many spinal branches supplied by segmental arteries in the cervical, thoracic, and lumbosacral regions. The internal venous plexus (anterior labeled) lies in the epidural space. (Courtesy of...

Spaces Within The Vertebral Canal

Lumbar Epidurogram

And can be opened to fill with fluid during disease processes or therapeutic intervention. Superficial to the dura, between the dura and the inner aspect of the vertebral canal, is the epidural space, filled with fat and the epidural venous plexus (Figs. 16 and 17). Loss of resistance to air or saline is commonly used to indicate successful placement of a needle into the epidural space. The ligamenta flava plays an important role in this loss of resistance, and the anatomic variability of this ligament may contribute to false-positive assessments of needle placement. It has been suggested that epidurography can improve the accuracy of needle placement and medication delivery to targeted areas of spinal pathology (15) (Fig. 18). Deep to the dura, between it and the arachnoid is a potential space, the subdural space. During administration of spinal anesthesia, the needle may push the arachnoid membrane away from the dura, instead of piercing the arachnoid. In this case, the injectate...

Leptomeningeal Metastasis Of Primary Central Nervous System Cns Neoplasms

In certain tumors including medulloblastoma, ependymoma, germ cell tumors, and primary CNS lymphoma, seeding of the cerebrospinal fluid space is a critical factor in determining stage, prognosis and appropriate therapy. Other tumor types, such as glioma, may have radiographic evidence of leptomeningeal metastases without clear impact on prognosis or therapy.

Burst And Compression Fractures

Lumbar Comminuted With Retropulsion

The burst fracture is a comminuted fracture of the vertebral body caused by axial loading or vertical compression. With vertical compression forces, there is increase in intradiscal pressure with subsequent herniation through the endplate of the adjacent vertebral body, causing the body to explode from within outward and resulting in disbursement of the bony fragments in all directions. Retropulsed fragments are characteristically seen narrowing B spinal canal frequently associated with spinal cord, conus medullaris, or cauda equina injury (Fig. 20).

Is The Leptomeningeal Space As The Anterior Subarachnoid Space

Extracellular Matrix Brain Image

Abbreviations A1 A2 lst 2nd segment of Anterior Cerebral Artery ACA Anterior Cerebral Artery AChorA Anterior Choroidal Artery ACommA Anterior Communicating Artery ACommV Anterior Communicating Vein AICA Anterior Inferior Cerebellar Artery ICA Internal Carotid Artery MCA Middle Cerebral Artery MCV Middle Cerebral Vein MedPostChorA Medial Posterior Choroidal Vein Pl-P3 1st through 3rd segments of Posterior Cerebral Artery PCA Posterior Cerebral Artery PCommA Posterior Communicating Artery PICA Posterior Inferior Cerebellar Artery PSA Posterior Spinal Artery SCA Superior Cerebral Artery. The arrangement of the layers of the spinal leptomeninges differs significantly from that of the cerebral leptomeninges because of the presence of an actual epidural space in the spine. The epidural space is found caudal to the attachment of the dura to the foramen magnum13 and contains the epidural veins, lymphatics, and adipose tissue.5 Attachment of the pia to the arachnoid in the spine is not...

Facet Joint Degeneration

Osteophytosis of the articular processes may encroach on different areas of the spinal canal. Because of the anterolateral location of the superior articular process of the inferior vertebra, osteophytes may grow anteromedially to narrow the lateral recess of the spinal canal. The postero-medially located inferior articular processes may form osteophytes that directly impinge upon the central canal (20). With facet joint degeneration, synovial cysts may develop. Oftentimes, they are found at the medial aspect of the facet joint and protrude into the spinal canal. They may also encroach on intervertebral foramina and affect the exiting spinal nerves (20) (Fig. 5). These cysts are believed to originate from degenerative changes that cause chronic joint effusions with proliferation and expansion of the joint capsule. They are most common in the lumbar spine and are rarely bilateral (26). Because they are fluid filled, they are seen as high signal masses on T2-weighted images. This is in...

Magnetic resonance imaging

MRI is of limited benefit in acute trauma care. However, MRI generates excellent images of the axial skeleton and spinal cord, which is relevant in spinal trauma, especially the cervical spine, and some brachial plexus injuries. MRI is valuable in some acute soft tissue injuries to the knee or shoulder. In the acute setting, there may be evidence of bone bruising or oedema following peri-articular injuries. Diagnostic information may be obtained with stress fractures and occult fractures. MRI is more frequently applied to the diagnosis of chronic shoulder, spinal and knee conditions.

Significant Interactions Occur Among the Chemoresponses

The sequence of events in the response to hypoxia (e.g., ascent to high altitude) exemplifies interactions among chemoresponses. For example, if 100 oxygen is given to an individual newly arrived at high altitude, ventilation is quickly restored to its sea level value. During the next few days, ventilation in the absence of supplemental oxygen progressively rises further, but it is no longer restored to sea level value by breathing oxygen. Rising ventilation while acclimatizing to altitude could be explained by a reduction of blood and CSF bicarbonate concentrations. This would reduce the initial increase in pH created by the increased ventilation, and allow the hypoxic stimulation to be less strongly opposed. However, this mechanism is not the full explanation of altitude acclimatization. Cerebrospinal fluid pH is not fully restored to normal, and the increasing ventilation raises Pao2 while further lowering Paco2, changes that should inhibit the stimulus to breathe. In spite of much...

Evaluation Of Patients

Since the autonomic areas of the brain are not accessible to direct measurement, one must measure the responses of various organ systems to various physiologic or pharmacologic challenges. In addition, recent advances have allowed for the determination of serum urine and cerebrospinal fluid levels of some autonomic neuromodulators and neurotransmitters. Foremost, however, is the determination of the blood pressure and heart rate response to positional change, with measurements taken while supine, sitting, and standing. The exact change in pressure considered to be significant is still under discussion, but is usually believed to be 20-30 mm Hg systolic and 10-15 mm Hg diastolic. Remember that standing blood pressure should be measured with the arm extended horizontally (to avoid the possible hydrostatic effects of the fluid column of the arm). Since the body's responses to active standing differ from those of passive tilting, we also frequently perform tilt-table testing on these...

Experiment 213 Identification of Pneumococci

Pneumococci are among the most important agents of bacterial pneumonia. Other microorganisms such as staphylococci (Exercise 20), Haemophilus influenzae (Experiment 22.1), and Klebsiella pneumoniae (Exercise 24) may also be associated with serious pulmonary disease. Bacterial agents of pneumonia cause an acute inflammation of the bronchial and or alveolar membranes. When the alveoli are involved, their thin membranes may be disrupted by hemorrhage of alveolar capillaries and collections of inflammatory exudate (pus) containing many white blood cells. Laboratory diagnosis is often made by isolating the causative agent from sputum sent for culture. However, because sputum specimens pass through the oropharynx as they are expectorated, contaminating members of the normal throat flora may interfere with culture results by overgrowing the pathogen. The causative organism is often found in the bloodstream during early stages of infection, and therefore, patient blood should also be...

Organization Of The Nervous System

The central nervous system is composed of two major subdivisions the brain and the spinal cord. These two parts are joined at the base of the brain so that there is constant passage of signals to and from the brain and body. The CNS is encased in protective bone, with the skull surrounding the brain and the backbone (or spinal column) surrounding the spinal cord. Both parts receive sensory messages from the afferent In general, the spinal cord serves two major functions (1) carrying impulses back and forth from body to brain or brain to body and (2) controlling many reflexes. The brain controls many more sophisticated functions, including perception, memory, and voluntary movements as well as basic functions such as breathing and swallowing. (Brain signals even may modify actions that occur at the spinal cord level.) Structure and Function of the Brain. The brain has three major anatomic regions or layers. The first layer forms the hindbrain, a...

Clinical presentation

The classic presentation occurs in a young man between 15 and 40 years old who experiences the insidious onset of intermittent or persistent low back pain and stiffness that is often worse in the morning hours and after prolonged rest. The pain is typically relieved by physical activity. It is usually centered in the lumbosacral spine but may also be present in the buttocks and hips and occasionally radiate into the thighs. B. Chest pain. The patient may complain of thoracic spine, neck, or shoulder pain and stiffness. Thoracic involvement can lead to anterior chest pain that may mimic angina pectoris.

Physical examination

Loss of spinal motion (lateral motion, flexion, and extension) occurs early in most cases, and several maneuvers can be employed to detect and then follow such changes. With progression of disease, there is typically loss of the normal lordosis, progressive kyphosis of the thoracic spine, fixed flexion of the neck, and ultimately a stooped posture with fixed flexion contractures of the hips and knees. In the Schober test (spinal forward flexion), the patient stands erect. The examiner makes marks at two points along the spine (the lumbosacral junction and a point 10 cm above). The distance between the marks is measured in maximum forward flexion. Less than 5 cm of distraction is abnormal.

Treatment knowledge

Performed to verify the stenosis and to provide a description of the existing collateral circulation. Three-dimensional rotational angiography can be a very helpful method for the imaging and evaluation of the stenosis. The diameter of the stenosis, referring to the next normal sized vessel part and the stenosis length have to be measured based on the standardized criteria 68 . The choice of the appropriate micro-guidewire to be used for probing the stenosis is also of considerable importance. Intracranial vessels are located in the subarachnoid space surrounded by the cerebrospinal fluid and follow quite a convoluted course. Additional, small penetrating vessels extend from the major intracranial arteries supplying the brain tissue with blood. These small penetrating vessel are invisible in neuroimaging. Particular care must be taken with the lateral lenti-culostriate arteries arising from the Ml-segment of the middle cerebral artery. The use of stiff micro-guidewires, involves the...

Generalized Tonic ClonicSeizures

A single study examined PRL and beta endorphin in cerebrospinal fluid (CSF) after GTCS. CSF levels of beta endorphin were elevated, but PRL was normal. CSF samples were obtained up to 2 hour postictally, which may have missed changes in greater proximity to the seizure (26).

Archetype Regulatory Sequence

The regulatory region of the JCV DNA cloned by Yogo et al. (1990) lacked any repetition of a sequence of significant length (Fig. 7.1). It contained 23 and 66 bp sequences, which were inserted into the 98 bp sequence present in a tandem repeat in Mad-1. As a result, the 98 bp sequence was split into three portions of 25, 55, and 18 bp (Fig. 7.1). The 23 bp sequence had been identified in a majority of PML-derived variants, although it was absent in a few, including Mad-1 (Frisque et al., 1984 Martin et al., 1985). As described below, it was later found that a significant number of isolates from the brain and cerebrospinal fluid (CSF) of PML patients retained a region encompassing the 66 bp sequence (Ault and Stoner, 1993 Agostini et al., 1997a Sugimoto et al., 1998). The regulatory sequence depicted in Figure 7.1 was designated as

Fluid Attenuated Inversion Recovery Flair Mri

More recently, FLAIR MRI has been introduced to complement conventional T2-weighted sequences. FLAIR MRI provides a very heavily T2-weighted image of brain parenchyma and nullifies the signal from cerebrospinal fluid (CSF) 65 . FLAIR MRI is particularly useful in identifying periventricular and cortical infarcts which may be less obvious on conventional T2-weighted sequences because of partial volume effects and high CSF signal adjacent to the

Which Diffusion MR Measure is Best for Stroke Imaging

There exist a large number of variations of images that can be derived from the DWI or DTI examination. These are loosely described as ''isotropic'' (the combined or averaged diffusion-weighted images acquired along the x-, y-, and z-gradient axes the ADC maps acquired from the low and high b-value images the ''trace'' images or ADC maps similar to the averaged x-, y-, and z-axis diffusion-weighted images exponential ADC ( eADC'' or ADC ''Expo'') maps in which the large ADC values (primarily seen in cerebrospinal fluid) are suppressed and the DTI-derived anisotropic maps of relative anisotropy ''RA'', fractional anisotropy ''FA''. Recent studies, seeking to sort the relative merits of these measures to visualize the presence and extent of acute clinical stroke, found that the average absolute percentage changes for the isotropic strategies were all above 38 (Harris et al., 2004).

What is the Value of Adding Inversion Recovery Pulses to DWI

The ADC derived from diffusion-weighted images has been used to differentiate reversible from irreversible ischemic injury. However, the ADC can be falsely elevated by partial volume averaging of cerebrospinal fluid (CSF) with parenchyma, which may limit the accuracy of this approach. IR sequences have been shown to help delineate low-ADC lesions by suppressing the hyperintense CSF signal from the ADC maps (Lansberg et al., 2001). Recent investigations were conducted to test whether the accuracy of differentiating reversible from irreversible ischemic injury could be improved by CSF suppression at image acquisition (Bykowski et al.,

Falsenegative results of immunofluorescence assay or enzymelinked immunosorbent assay may be caused by the following

Lyme disease patients with negative IFA or ELISA serologies may occasionally be positive for cerebrospinal fluid antibodies or, as mentioned above, demonstrate a T-cell proliferation response to Bb. H. False-positive results of immunofluorescence assay or enzyme-linked immunosorbent assay are common. They may be caused by the following

Haematological and biochemical findings

Anaemia is normocytic and may be severe (haemoglobin 4 g dl). Thrombocytopenia ( 100 000 platelets pl) is usually present, and peripheral leukocytosis is found in patients with the most severe disease. Elevation of serum creatinine, bilirubin and enzymes, e.g. aminotransferases and 5'-nucleotidase, may be found. Levels of liver enzymes are much lower than in acute viral hepatitis. Severely ill patients are commonly acidotic, with low capillary plasma pH and bicarbonate concentrations. Fluid and electrolyte disturbances (sodium, potassium, chloride, calcium and phosphate) are variable. Concentrations of lactic acid in the blood and cerebrospinal fluid are often high in both adults and children, in proportion to the severity of the disease.

The Pattern of the Vertebrate Nervous System

Although the various vertebrates show differences in the organization of their respective nervous systems, they all follow a similar anatomical pattern. The nervous system can be partitioned conveniently into two major divisions the peripheral nervous system (PNS) and the central nervous system (CNS). These divisions are determined by their location and function. The CNS consists of the spinal cord and the brain. The PNS, that part of the nervous system outside the CNS, connects the CNS with the various sense organs, glands, and muscles of the body. The PNS joins the CNS in the form of nerves, which are cordlike bundles of hundreds to thousands of individual, parallel nerve-cell (neuron) axons (long tubular extensions of the neurons) extending from the brain and spinal cord. The nerves extending from the spine are called spinal nerves, while those from the brain are called cranial nerves. The elements of the PNS include sensory neurons (for example, those in the eyes and in the...

Isolation of CNSInfiltrating Lymphoid Populations

Spinal cords are removed by intrathecal hydrostatic pressure after making incisions through the spinal column at the neck and lumbosacral area, cold PBS is injected with a 20-mL syringe and 19-gauge needle into the caudal vertebral column. Brains are removed by dissection. Single cords brains are placed into a bijou containing 1 mL wash buffer (see Note 9).

Techniques used in BLS Patient evaluation

The head is held stable during the assessment to guard against the possibility of aggravating an injury to the cervical spine. Jaw thrust(Fig. 4.3) This is used if the above technique fails to create an airway, or there is a suspicion that the cervical spine may have been injured. The patient's jaw is 'thrust' upwards (forwards) by the rescuer applying pressure behind the angles of the mandible.

Patient Preparation

Fig. 7. (A) Sagittal T2-weighted MRI of the lumbar spine showing a large disc herniation at L5-S1. This would not be amenable to percutaneous techniques. Also notice the disc bulge at L4-5 (arrowhead). This could be treated with IDET or nucleoplasty if indicated. (B) Axial T2-weighted MRI at L5-S1. The arrowhead demonstrates the large disc herniation. Fig. 7. (A) Sagittal T2-weighted MRI of the lumbar spine showing a large disc herniation at L5-S1. This would not be amenable to percutaneous techniques. Also notice the disc bulge at L4-5 (arrowhead). This could be treated with IDET or nucleoplasty if indicated. (B) Axial T2-weighted MRI at L5-S1. The arrowhead demonstrates the large disc herniation.

Rheumatoid Arthritis Distal Interphalangeal Joint Arthrodesis

A 38-year-old right hand dominant woman previously diagnosed with rheumatoid arthritis approximately 10 years prior to the current evaluation complains of pain and deformity in the index finger of her right hand. The pain has been progressive in nature, and functionally she has been having increasing difficulty performing activities of daily living that require any type of pinch strength. She has been conservatively managed with a course of occupational therapy, splints, and medical management, without significant relief. Patient denies any associated constitutional symptoms, numbness, paresthesias, or symptoms with cervical spine range of motion.

Specific clinical problems

Some rheumatoid patients with sufficiently severe joint destruction to necessitate hip or knee replacement surgery may also have significant involvement of the cervical spine. Atlanto-axial or subaxial subluxation should be ruled out on flexion-extension films in patients with neck pain or crepitus on range of motion, radicular symptoms, or arm or leg weakness. These patients are at increased risk for cord compression during intubation or during uncontrolled neck movement while being positioned for surgery. All such lesions should be well-defined preoperatively and discussed with the anesthesiologist and surgeon. These patients should wear a soft cervical collar in the operating room for immobilization and to warn all involved in their care not to manipulate the neck excessively. If possible, epidural or spinal anesthesia should be used. B. The spondylitic patient. Patients with ankylosing spondylitis may have spinal or peripheral joint involvement and may...

FDA and CDC collaboration on epidemiologic investigations

The epidemiological interpretation of the available data was complicated by several predisposing factors for meningitis in the cochlear implant population. First, certain congenital inner ear malformations, such as the Mondini malformation, are associated with cerebrospinal fluid (CSF) fistulae and recurrent episodes of meningitis, even without cochlear implantation or other otologic surgery 2 . Second, meningitis is the primary etiology of deafness for a significant number of adult and pediatric implant recipients, and it is well established that the risk for contracting meningitis is greater for an individual who has a prior history of this serious infection 3 . Third, there has been a strong trend toward implanting children at an earlier age, based on data showing improved long-term functional outcomes 4 . By the year 2000, one manufacturer had received FDA approval for use in children as young as 12 months. The incidence of meningitis is very high in this very young age group 5...

Examination and investigation

Chest, cervical spine and shoulder X-rays are mandatory. Further assessment with EMG studies may be necessary to localize the site of the injury. Supraclavicular injuries may need investigation with a CT myelogram or MRI, if surgery is contemplated. In cases of root avulsion pseudomeningoceles may be seen, which alter the prognosis and management. Investigation should be delayed a few weeks to allow CSF leaks to seal.

Eyach and Kemerovo Viruses

Eyach virus is a coltivirus present in ticks in Europe antibodies have been reported in some patients with meningoencephalitis and polyneuritis, but no causal relationship has been established Kemerovo virus, a member of the genus Orbivirus, is an arbovirus carried by ticks in Siberia antibodies to it have been recorded in patients suffering from febrile illnesses, and the virus has been isolated from Ihe blood and cerebrospinal fluid of patients with meningoencephalitis from the Kemerovo region of Siberia.

Indications And Contraindications

Percutaneous vertebroplasty can be utilized in both osteo-porotic compression fractures as well as neoplastic involvement of the spine. This chapter is focused primarily on osteoporotic compression fractures. The primary indication for vertebroplasty is for treatment of painful, osteoporotic compression fractures that have not responded to medical therapy (3-22). However, the definition of failed medical therapy is in flux at the present time. When the procedure was initially introduced, most patients were treated with vertebroplasty only after a relatively prolonged course of failed medical therapy, on the order of 6 wk to several months. With the increased use of vertebroplasty, the definition of failed medical therapy Retropulsion of bony fragments represents a relative contraindication to vertebroplasty (17,24). Concern in cases of retropulsed fragments arises not only from the fear that cement extravasation into the spinal canal might occur, but also that surgical decompression,...

Vibrio cincinnatiensis and Vibrio carchariae

The patient did not have a history of rashes, diarrhea, or liver disease. The pathogen was recovered from the cerebrospinal fluid and blood. In one instance it has been isolated from stools of an immunocompromised patient suffering from diarrhea (86). It is not clear as to whether the pathogen played a role in the diarrheal disease.

Assessment and investigation

A clear description of the accident is useful in determining whether there is an occult spinal injury, the extent and level of primary cord or root trauma, and any likely associated injuries. Polytrauma may result in delayed diagnosis of spinal injury, especially in the cervical spine. 2. Examination and special tests. A full examination of the spine and detailed peripheral neurological assessment is undertaken. The patient is log-rolled, by four experienced personnel, with the examiner observing for visual signs of head or spinal injury such as abrasions, tenderness, step off, interspinous widening, etc. 3. Neurology. Levels of motor and sensory function are summarized in Table 1. Reflex activity is indicative of the nature and level of cord injury (Table 2). Absent reflexes are indicative of spinal shock, or a lower motor neurone lesion. Brisk reflexes are indicative of an upper motor neurone lesion or intracranial event. The bulbocavernous reflex and anal wink test are...

Current proposed revision of criteria for juvenile rheumatoid arthriti6

General criteria for juvenile rheumatoid arthritis. Persistent arthritis of one or more joints for at least 6 weeks is sufficient for diagnosis if the conditions listed under exclusions have been eliminated. Arthritis is defined as swelling of a joint or limitation of motion with heat, pain, or tenderness. Pain or tenderness alone is not sufficient for the diagnosis of arthritis. Joints are counted individually with certain exceptions. The cervical spine is considered one joint. The carpal joints of each hand are counted as one joint, as are the tarsal joints on each foot. The metacarpophalangeal, metatarsophalangeal, and proximal and distal interphalangeal joints are counted individually.

Viral Diseases of the Central Nervous System

Certain viruses have a predilection for particular parts of the CNS, and the clinical signs of the resulting disease often reflect this. For example, most enteroviruses do not go beyond the meninges, but polioviruses invade the anterior horn of the spinal cord and the motor cortex of the cerebrum, whereas rabies singles out Ammon's horn, herpes simplex virus the temporal lobes, and so on. Some viruses lyse neurons directly, and there is abundant evidence of inflammation in the brain (Fig. 36-4A) others do their damage in more subtle ways, leading to demyelination of nerves (Fig. 36-4B), sometimes involving immunopathologic processes. One must distinguish between neurovirulence, that is, the ability to cause neurologic disease, and neuroinvasiveness, that is, the ability to enter the nervous system. Mumps virus, for example, displays high neuroinvasiveness, in that evidence of very mild meningitis accompanied by changes in the cerebrospinal fluid (CSF) are detectable in about half of...

Related topics of interest

Spinal fracture classification, p. 262 Spine - C3 to C7, p. 269 Spine - occiput to C2, p. 272 Spine - thoracic and lumbar fractures, p. 275 Sixty per cent of spinal cord injuries involve the cervical spine. The most commonly injured levels are CI, followed in order of frequency by C5, 6 and 7. Historically, 33 of patients with a significant cervical spinal injury were transported to hospital without immobilization. The factors predisposing to delayed diagnosis are altered consciousness, head injury and inadequate radiographic visualization of the cervical spine.

Positional Changes Of The Cord

In the third month of development the spinal cord extends the entire length of the embryo, and spinal nerves pass through the intervertebral foramina at their level of origin (Fig. 19.13A). With increasing age, however, the vertebral column and dura lengthen more rapidly than the neural tube, and the terminal end of the spinal cord gradually shifts to a higher level. At birth, this end is at the level of the third lumbar vertebra (Fig. 19.13C). As a result of this disproportionate growth, spinal nerves run obliquely from their segment of origin in the spinal cord to the corresponding level of the vertebral column. The dura remains attached to the vertebral column at the coccygeal level. In the adult, the spinal cord terminates at the level of L2 to L3, whereas the dural sac and subarachnoid space extend to S2. Below L2 to L3, a threadlike extension of the pia mater forms the filum terminale, which is attached to the periosteum of the first coccygeal vertebra and which marks the tract...

Principles of treatment

The cervical spine can be stabilized using Gardner-Wells tongs and 5 kg of traction. After application, a lateral film should be obtained and neurological observations undertaken. Closed reduction should be attempted in all patients with malalignment. Reduction is performed under close radiological and neurological observation, after each weight addition. The initial weight is 10 kg, with 2.5 kg increments. A maximum weight of 30 kg is applied for the lower cervical spine and 10 kg for CI and C2. Traction should be discontinued in the presence of

Assessment of the safety and effectiveness of intervertebral disc replacement

Most importantly, no randomized clinical controlled trials have evaluated the long-term results of intervertebral disc replacement 61 . Its success needs to be evaluated and compared with the clinical outcomes for spinal arthrodesis, especially perioperative complications, implant survivability, and measures of patient improvement in pain, disability, and activity level. In addition it is important to understand the acceptability and safety of subsequent salvage procedures by examining the rates of complications for patients who require further surgery and or device removal. Another study that followed a case series of 27 patients for a mean time period of 53 months found problems with polyethylene wear, subsidence of the prosthesis, and adjacent vertebral deterioration 63 . Metal sensitivity and immune reaction to materials of the artificial discs have been understudied 64,65 . The carcinogenic potential of orthopedic implants has been an area of concern, partly as a result of animal...

Studying Water Balance

The concentration of the test substance in a sample of the blood, or lymph, or cerebrospinal fluid gives an indication of the dilution caused by the volume of the fluid within the compartment. There is no perfect test substance each is associated with problems affecting the accuracy of the measurement. Inulin is used to determine the volume of interstitial fluid, but inulin diffuses slowly through dense connective tissue. Radioactive sodium enters most compartments, but it binds to the crystalline structure of bone. The dye Evans blue, which binds to plasma proteins, and radio-iodinated serum albumin are used to measure plasma volume, but these substances move out of capillaries.

Neurons Are Treated With A Drug That Permanently Stops The Na K Atpase Pumps. What Happens To The Resting Membrane

Spinal cord Dura-arachnoid -Pia- The ventricular system of the brain and the distribution of the cerebrospinal fluid, shown in blue. The blood-brain barrier, which comprises the cells that line the smallest blood vessels in the brain, has both anatomical structures, such as tight junctions, and physiological transport systems that handle different classes of substances in different ways. For example, substances that dissolve readily in the lipid components of the plasma membranes enter the brain quickly. Therefore, the extracellular fluid of the brain and spinal cord is a product of, but chemically different from, the blood. In addition to its blood supply, the central nervous system is perfused by the cerebrospinal fluid. The cere-brospinal fluid is secreted into the ventricles by epithelial cells that cover the choroid plexuses, which form part of the lining of the four ventricles. A barrier is present here, too, between the blood in the capillaries of the choroid plexuses and the...

Leptomeningeal Metastases From Leukemias And Lymphomas

That of solid tumors in a number of clinically important aspects. Specific histologic variants of lymphoma and leukemia have such a high incidence of cerebrospinal fluid (CSF) dissemination that assessing CSF cytology at diagnosis is crucial and prophylactic therapy of the CSF compartment is required. Furthermore, while the overall prognosis for patients with leptomeningeal metastases from leukemia and lymphoma is similar to solid tumors, selected patients have excellent response to therapy and attain durable remission. Therefore, aggressive treatment is warranted.

Peripheral Nervous System

Nerve fibers in the peripheral nervous system transmit signals between the central nervous system and receptors and effectors in all other parts of the body. As noted earlier, the nerve fibers are grouped into bundles called nerves. The peripheral nervous system consists of 43 pairs of nerves 12 pairs of cranial nerves and 31 pairs that connect with the spinal cord as the spinal nerves. The cranial nerves and a summary of the information they transmit were listed in Table 8-8. In general, of the spinal nerves, eight cervical nerves control the muscles and glands and receive sensory input from the neck, shoulder, arm, and hand. The 12 thoracic nerves are associated with the chest and abdominal walls. The five lumbar nerves are associated with the hip and leg, and the five sacral nerves are associated with the genitals and lower digestive tract. (A single pair of coccygeal nerves brings the total to 31 pair.) A. Contains all the fibers passing between the spinal cord, forebrain, and...

Chemoreceptors in the Medulla

Pco2 And Total Minute Volume

An increase in arterial PCO2 causes a rise in the H+ concentration of the blood as a result of increased carbonic acid concentrations. The H+ in the blood, however, cannot cross the blood-brain barrier, and thus cannot influence the medullary chemoreceptors. Carbon dioxide in the arterial blood can cross the blood-brain barrier and, through the formation of carbonic acid, can lower the pH of cerebrospinal fluid (fig. 16.30). This -Cerebrospinal fluid (CSF) Figure 16.29 Chemoreceptor control of breathing. This figure depicts the negative feedback control of ventilation through changes in blood PCO2 and pH. The blood-brain barrier, represented by the orange box, allows CO2 to pass into the cerebrospinal fluid but prevents the passage of H+. Figure 16.30 How blood CO2 affects chemoreceptors in the medulla oblongata. An increase in blood CO2 stimulates breathing indirectly by lowering the pH of blood and cerebrospinal fluid (CSF). This figure illustrates how a rise in blood CO2 increases...

Parasympathetic Division

Collateral Ganglia Location

The parasympathetic division is also known as the craniosacral division of the autonomic system. This is because its preganglionic fibers originate in the brain (specifically, in the midbrain, medulla oblongata, and pons) and in the second through fourth sacral levels of the spinal column. These pre-ganglionic parasympathetic fibers synapse in ganglia that are located next to or actually within the organs innervated. These parasympathetic ganglia, called terminal ganglia, supply the postganglionic fibers that synapse with the effector cells. The comparative structures of the sympathetic and parasympathetic divisions are listed in tables 9.2 and 9.3. It should be noted that most parasympathetic fibers do not travel within spinal nerves, as do sympathetic fibers. As a result, cutaneous effectors (blood vessels, sweat glands, and arrector pili muscles) and blood vessels in skeletal muscles receive sympathetic but not parasympathetic innervation. Figure 9.3 The pathway of sympathetic...

Hall Drill And Saline Coolant

Skeleton Crossword

Four years ago, L.R., who is now 15, had a posterior spinal fusion (PSF) for correction of idiopathic adolescent scoliosis in a pediatric orthopedic hospital in another state. Her spinal curvature had been surgically corrected with the insertion of bilateral laminar and pedicle hooks and two 3 16-inch rods. A bone autograft was taken from her right posterior superior ilium and applied along the lateral processes of T4 to L2 to complete the fusion. During a follow-up visit, she presented with a significant prominence of the right scapula and back pain in the mid and lower back. She denied numbness or tingling of the lower extremities, bowel or bladder problems, chest pain, and shortness of breath. A CT scan of the upper thoracic spine showed a prominent rotatory scoliosis deformity of the right posterior thorax with acute angulation of the ribs. Her deformity is a common consequence of overcorrection of prior spinal fusion surgery, called crank shaft phenomenon. L.R. was referred to...

The Victim S Injured Extremities Were Immobilized Before Transport. Immobilized Means

Cephalocaudal Assessment

At the hospital, the emergency department physician ordered radiographs for B.R. Before the procedure, the radiology technologist positioned a lead gonadal shield centered on the midsagittal line above B.R.'s symphysis pubis to protect her ovaries from unnecessary irradiation by the primary beam. The technologist knew that gonadal shielding is important for female patients undergoing imaging of the lumbar spine, sacroiliac joints, acetabula, pelvis, and kidneys. Shields should not be used for any examination in which an acute abdominal condition is suspected.

Hypogonadotropic Hypogonadism

Langerhans cell histiocytosis, also called Hand-Schuller-Christian disease or Histiocytosis X, is characterized by infiltration of lipid-containing histiocytic cells in the skin, bone, and viscera. Cyst-like areas can be found by X-ray in the flat bones of the skull, pelvis, dorsolumbar spine, scapula, and long bones of the arms and legs. CNS involvement and, in particular, hypothalamic-pituitary involvement are well-described features of Langerhans cell histiocytosis. The precise incidence of CNS-Langerhans cell histiocytosis disease is unknown, and the natural history is poorly understood. Diabetes insipidus is reported to be the most common and well-described manifestation of hypothalamic-pituitary involvement (up to 50 ). Anterior pituitary dysfunction occurs in up to 20 of patients with Langerhans cell histiocytosis and almost exclusively together with diabetes insipidus. Although histiocytosis is not a tumor, it can be treated with chemotherapeutic...

Contusion of external genital organs

Fracture of lumbar spine and pelvis 532.0 Fracture of lumbar vertebra Fracture of lumbar spine 532.7 Multiple fractures of lumbar spine and pelvis 532.8 Fracture of other and unspecified parts of lumbar spine and pelvis lumbosacral spine NOS Dislocation, sprain and strain of joints and ligaments of lumbar spine and pelvis 533.1 Dislocation of lumbar vertebra Dislocation of lumbar spine NOS 533.3 Dislocation of other and unspecified parts of lumbar spine and pelvis 533.5 Sprain and strain of lumbar spine 533.7 Sprain and strain of other and unspecified parts of lumbar spine and pelvis Injury of nerves and lumbar spinal cord at abdomen, lower back and pelvis level 534.0 Concussion and oedema of lumbar spinal cord 534.1 Other injury of lumbar spinal cord 534.2 Injury of nerve root of lumbar and sacral spine

Indications and Technique

Posterior Annular Fissure

The procedure is generally performed in a fluoroscopy suite,21 using an intravenous conscious sedation protocol, typically with mi-dazolam and fentanyl. The sedation level should be such that the patient is comfortable and sleepy but can be roused easily for questioning about radicular symptoms during needle placement and catheter heating. As with all spinal procedures, the indications for the procedure, risks, and appropriate expectations should be discussed with the patient prior to beginning, and informed consent should be obtained. If performed carefully by a skilled operator, IDET is very safe, and complications are very rare (

Traumatic spondylolisthesis of the axis

This injury is caused by hyperextension and axial loading. Typically these injuries widen the spinal canal and therefore rarely produce neurological damage. The traditional 'Hangman's fracture' (extension in association with distraction) is seldom seen today. Spondylolisthesis of the axis was classified by Effendi and later modified by Levine

Needle Introduction and Placement

Transpedicular Versus Extrapedicular

The original choice of a device for percutaneous cement introduction was based on device availability. The size of these devices was empirically chosen to allow the viscous PMMA cement to be injected. Originally 10- to 11-gauge trocar-cannula systems were used. It is becoming progressively common to see smaller gauge (13-15) needles used routinely. All will work with the least resistance during injection found with the larger bore, while the smaller needles are useful in small pedicles or in the cervical spine. From the thoracic through lumbar spine, a 13-gauge cannula can be placed through the adult pedicle without fear of its being too large. In the cervical spine, a transpedicular route is very difficult, so an anterolateral approach may be used as an alternative. Needle introduction must avoid the carotid-jugular complex. To accomplish this goal, the operating physician (as in cervical discography) can manually push the carotid out of the path of the needle. Alternatively, CT can...

Table 192 Contributions of Neural Crest Cells and Placodes to Ganglia of the Cranial Nerves

Sympathetic Neuroblasts

Once the sympathetic chains have been established, nerve fibers originating in the visceroefferent column (intermediate horn) of the thoracolumbar segments (T1-L1,2) of the spinal cord penetrate the ganglia of the chain (Fig. 19.43). Some of these nerve fibers synapse at the same levels in the sympathetic chains or pass through the chains to preaortic or collateral ganglia (Fig. 19.43). They are known as preganglionic fibers, have a myelin sheath, and stimulate the sympathetic ganglion cells. Passing from spinal nerves to the sympathetic ganglia, they form the white communicating rami. Since the visceroefferent column extends only from the first thoracic to the second or third lumbar segment of the spinal cord, white rami are found only at these levels. Other fibers, the gray communicating rami, pass from the sympathetic chain to spinal nerves and from there to peripheral blood vessels, hair, and sweat glands. Gray communicating rami are found at all levels of the spinal cord.

Neural Control Mechanisms

Central Nervous System Spinal Cord Autonomic Nervous System Blood Supply, Blood-Brain Barrier Phenomena, and Cerebrospinal Fluid divided into two parts (1) the central nervous system (CNS), composed of the brain and spinal cord and (2) the peripheral nervous system, consisting of the nerves, which extend between the brain or spinal cord and the body's muscles, glands, and sense organs (Figure 8-1). For example, branches of the peripheral nervous system go between the base of the spine and the tips of the toes and, although they are not shown in Figure 8-1, between the base of the brain and the internal organs.