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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 Cord Stimulation

Spinal cord stimulation (SCS) has been proposed as a novel treatment strategy that may be effective in end-stage ischemic heart disease patients with intractable angina. The efficacy of spinal cord stimulation on the relief of otherwise intractable angina pectoris was studied in a 2-mo randomized study with 1-yr follow-up by quality-of-life parameters, cardiac parameters, and complications. Twenty-four patients were randomized to either an actively treated group A (12 patients received the device within a 2-wk period) or a control group B (10 patients had implantation after the study period). Spinal cord stimulation improved both quality-of-life and cardiac parameters. The latter included a trend towards reduction in ischemia after implantation of the device in both exercise testing with a treadmill (ETT) and 24-h ambulatory Holter recordings, with a concomitant improvement in exercise capacity (55). Indices of ischemia were studied with and without SCS in 10 patients with otherwise...

The Central Canal And Cerebrospinal Fluid

Running down through the center of the spinal cord is the central canal. Like the third ventricle mentioned earlier (with the thalamus), the central canal is part of the ventricular (ven-TRIK-yew-lar) system. This system is a collection of ''little bellies'' (ventricles) that contain and circulate the cerebrospinal (ser-e-broh-SPY-nal) fluid or CSF. The cerebrospinal fluid (CSF) is a clear, watery filtrate (FIL-trayt) - filtration product - of the blood plasma (PLAZ-mah). Somewhat like the blood plasma (liquid portion of the blood) circulates through the blood vessels, the CSF circulates through the cavities and passageways of the ventricular system. A major function of the cerebrospinal fluid is to serve as a shock absorber, protecting the delicate, butter-soft brain and spinal cord from knocking against the hard wall of surrounding bone tissue.

Spinal Taps Sample the

In summary, CSF circulates through the brain and spinal cord within the ventricular system, and around the outside of the brain and cord within the subarachnoid space. Because of its close, intimate contact with the actual neurons and nerve tissue, cerebrospinal fluid is often withdrawn and examined for possible abnormalities. A spinal tap is usually called a lumbar puncture. The reason is that a long needle is inserted into the subarachnoid space between lumbar vertebrae 3 and 4, or 4 and 5. A small sample of CSF is withdrawn and examined for the presence of pus, blood, bacteria, cancer cells, or other problems. A quick diagnosis of an important Biological Disorder of the nervous tissue may therefore be obtained. Study suggestion Ask yourself ''Why isn't a spinal tap performed above the thoracic region of the vertebral column ''

How should hypotension associated with spinal anesthesia be treated in a cesarean section or laboring patient

Historically ephedrine had been the preferred agent for treating hypotension associated with regional anesthesia during pregnancy because it was thought that other agents decreased uteroplacental blood flow, whereas ephedrine did not. Recent studies show that doses of ephedrine large enough to maintain homeostasis after induction of spinal anesthesia may be detrimental to the fetus. Problems observed with ephedrine are related to the p-agonist activity that causes increased fetal metabolism and include dose-dependent fetal metabolic acidosis, tachycardia, and abnormal FHR variability. Phenylephrine, a pure a-agonist, is as effective as ephedrine in restoring and maintaining maternal blood pressure. Phenylephrine does not appear to cause fetal acidosis even in large doses. However, it is important to note that all of these studies were done in healthy parturients at term undergoing cesarean section. It is reasonable to infer that ephedrine would cause similar metabolic derangements in...

How is combined spinalepidural anesthesia performed What are its advantages

The practitioner first finds the epidural space by loss-of-resistance technique with a Touhy needle. Subsequently a long (120 mm), small-gauge (24 to 27 G), noncutting spinal needle is advanced through the epidural needle until the dura is punctured and clear CSF is noted. A spinal dose of local anesthetic (plus narcotic, if desired) is injected into the subarachnoid space, and the spinal needle is removed. The epidural catheter is subsequently threaded into the epidural space. Small doses of spinal local anesthetics and opioids provide rapid and reliable analgesia for much of stage 1 labor. Epidural infusion of dilute local anesthetic and opioid will maintain analgesia. This technique does not increase the risk of PDPH over epidural analgesia alone.

How are the pharmacokinetics and quality of spinal anesthesia affected by age

Elderly patients have decreased blood flow to the subarachnoid space, resulting in slower absorption of anesthetic solutions. They also have a smaller volume of cerebrospinal fluid, the specific gravity of which tends to be higher than that of younger patients. This leads to a higher final concentration for a given dose and may alter the spread of the anesthetic. Elderly patients may have accentuated degrees of lumbar lordosis and thoracic kyphosis, increasing cephalad spread and pooling in the thoracic segments. Thus one might see higher levels of spinal anesthesia accompanied by faster onset of action and prolonged duration. Older patients also have a lower incidence of postdural puncture headaches when compared with younger patients.

Can continuous spinal anesthesia be performed

Continuous spinal anesthesia is a technique regaining popularity. In the early 1990s many cases of cauda equina syndrome were noted after inappropriate dosing of spinal microcatheters. It appeared that the lack of turbulence associated with injecting through microcatheters led to a pooling of local anesthetic caudad to the lumbar lordotic curve, leading to repeated and inappropriate dosing of local anesthetics. Continuous spinal anesthesia is safe and effective using 18- to 22-G epidural needles and catheters (and improved, specially designed kits). The incidence of hypotension is less, as is the need to rescue with vasopressors. This technique allows for titration of local anesthetics to effect and has been successfully used in elderly patients, patients with aortic stenosis, and trauma patients. This is an attractive technique for the elderly because they tend not to develop PDPH despite dural punctures with large-gauge epidural needles.

Key Points Somatosensoryevoked Potentials And Spinal Surgery

SSEPs are used when spinal cord or brain parenchyma is at risk for ischemia during surgery. 4. During distraction of the spinal column in scoliosis surgery (or other critical parts of surgery), minimize interventions that will lower mean arterial blood pressure or deepen anesthetic levels acutely to allow differentiation of changes in SSEP waveforms from anesthetic effect.

Meninges of the Spinal Cord

Denticulate Ligament

The spinal cord and brain are enclosed in three fibrous membranes called meninges (meh-NIN-jeez) singular, meninx2 (MEN-inks). These membranes separate the soft tissue of the central nervous system from the bones of the vertebrae and skull. From superficial to deep, they are the dura mater, arachnoid mater, and pia mater. 13. The Spinal Cord, Spinal Nerves, and Somatic Reflexes Chapter 13 The Spinal Cord, Spinal Nerves, and Somatic Reflexes 483 spinal spinal spinal Sacral spinal nerves Figure 1S.1 The Spinal Cord, Dorsal Aspect. The dura mater3 (DOO-ruh MAH-tur) forms a loose-fitting sleeve called the dural sheath around the spinal cord. It is a tough collagenous membrane with a thickness and texture similar to a rubber kitchen glove. The space between the sheath and vertebral bone, called the epidural space, is occupied by blood vessels, adipose tissue, and loose connective tissue (fig. 13.2a). Anesthetics are sometimes introduced to this space to block pain signals during childbirth...

How does an uncleared cervical spine modify the approach to the airway

Patients requiring emergent surgical procedures do not have time to have their cervical spines evaluated fully. There is no airway management technique that results in no cervical motion. However, there is no documentation of iatrogenic neurologic injury in patients with cervical fractures when cervical spine precautions are used. These precautions include an appropriately sized Philadelphia collar, sand bags placed on each side of the head and neck, and the patient resting on a hard board with the forehead taped and secured to it. When a cervical fracture or cervical spinal cord injury (SCI) is documented, most anesthesiologists choose fiber-optic intubation facilitated by some form of topical anesthesia to the airway and sedation, titrated to effect, keeping in mind the patient's other injuries and hemodynamic status. This allows postintubation assessment of neurologic status before induction of unconsciousness. It would not be advisable to ablate all protective airway reflexes in a...

Why are patients who have received spinal anesthetics especially sensitive to sedative medications What is

Caplan and associates (1988) published a landmark review of healthy patients who, while undergoing elective surgery using spinal anesthesia, experienced a sleeplike state without spontaneous verbalization followed by respiratory and cardiac arrest. Despite the fact that these were witnessed arrests, the patients were difficult to resuscitate and either died or had severe neurologic deficits. Subsequently it has been determined that patients receiving spinal anesthetics are especially sensitive to sedative medications. The cause of this may be loss of peripheral input into the reticular activating system (RAS), that part of the brainstem responsible for maintaining arousal. It appears that motor spinal fibers and afferent sensory input into the RAS contribute to wakefulness and this input is diminished by spinal anesthesia, rendering the patient prone to oversedation. Spinal (and epidural) anesthesia increases the hypnotic potential of midazolam, isoflurane, sevoflurane, and thiopental.

What opioids are used to provide spinal and epidural analgesia during labor Name their most common side effects Do they

The most commonly used neuraxial (spinal and epidural) opioids are fentanyl and sufentanil (Table 60-2). Pruritus, nausea, and vomiting are the most common side effects delayed respiratory depression is the most serious complication, although very uncommon in this OPIOIDS USED TO PROVIDE INTRATHECAL (SPINAL) ANALGESIA

What is the risk of neurologic injury after spinal anesthesia

Direct trauma to nerve fibers may occur from the spinal needle and may be heralded by a paresthesia, for which the spinal needle should be redirected. Hematoma formation from epidural venous bleeding (from direct trauma or coagulopathy) or abscess formation is suggested by persistent neurologic deficits or severe back pain. Early recognition and management are imperative to avoid permanent neurologic sequelae. In patients who have received any medication with anticoagulant potential, it is important not to attribute persistent neurologic deficits to residual effects of local anesthesia. Adhesive arachnoiditis has been reported and is presumably caused by injection of an irritant into the subarachnoid space.

What is a combined spinalepidural anesthetic Why use both

For a combined spinal-epidural anesthetic, a long spinal needle is passed through an epidural needle that has been placed in the epidural space, and the dura is punctured. When CSF is obtained from the spinal needle, a dose of local anesthetic is placed in the subarachnoid space, and the spinal needle is removed. The epidural catheter is then threaded into the epidural space, and the epidural needle is removed. This technique combines the advantages of both spinal and epidural anesthesia fast onset of an intense spinal block so that the surgery can proceed quickly and an epidural catheter to extend the duration of the block if necessary for a long surgical procedure or for postoperative pain management.

What factors may predispose a patient having spine surgery to postoperative visual loss

The causative factors associated with POVL after spine surgery are not fully understood. The incidence appears to be about 0.2 . The ASA has developed a visual loss registry in an effort to identify predisposing factors and make recommendations to reduce the incidence of this tragic complication. It is thought that there is a subset of patients at high risk for this complication, although it is not always possible to identify before surgery which patients are at high risk. These patients may have a history of hypertension, diabetes mellitus, smoking, other vasculopathies, and morbid obesity. Longer spine surgeries (longer than 6 hours) with significant blood loss (1 to 2 L or more) are common features in patients who have sustained POVL. It does not appear to be a pressure effect on the globe since many of these patients were placed in Mayfield pins. Deliberate hypotensive anesthetic techniques do not appear to be a factor, although it may be argued that sustained hypotension in the...

What challenges do spinal cordinjured patients pose

Some degree of neurogenic shock should be expected with injuries above the T6 level. However, hypotension in cord-injured patients is most likely caused by other injures. Catecholamine surges may produce pulmonary vascular damage, resulting in neurogenic pulmonary edema. There may be some element of myocardial dysfunction. If moderate fluid resuscitation does not result in hemodynamic improvement, central venous catheterization for monitoring may be required. Spinal cord injuries cephalad to midthoracic levels interrupt sympathetic cardioaccelerator fibers, resulting in bradycardia. If accompanied by hypotension, administration of atropine is indicated. Occasionally infusion of vasopressors such as phenylephrine is needed to support blood pressure. Anesthetic agents should be titrated carefully since drug-associated cardiovascular depression cannot be compensated for by increases in sympathetic tone. Doses of 30 to 50 of normal are likely to be sufficient. SCh may be administered in...

What are the most common complications of spinal anesthesia

Common complications include hypotension, bradycardia, increased sensitivity to sedative medications, nausea and vomiting (possibly secondary to hypotension), postdural puncture headache (PDPH), and residual back pain and paresthesias (usually associated with the use of lidocaine. Less frequent but more ominous complications include nerve injury, cauda equina syndrome, meningitis, total spinal, and hematoma abscess formation. Particular issues associated with these complications are discussed subsequently.

What are the advantages and disadvantages of cesarean section with epidural anesthesia vs spinal anesthesia What are

If epidural analgesia is used for pain relief during labor and delivery, higher concentrations of local anesthetics can provide surgical anesthesia. The local anesthetic should be given in increments, titrating to the desired sensory level. Titration of local anesthetic results in more controlled sympathetic blockade thus the risk of hypotension and reduced uteroplacental flow may be decreased. Typically epidural anesthesia produces less intense motor and sensory blockade than spinal anesthesia. Disadvantages of epidural anesthesia include slower onset, larger local anesthetic dose requirement, occasional patchy block unsuitable for surgery, and the risk of total spinal

Review the clinical features of total spinal anesthesia

Total spinal anesthesia results from local anesthetic depression of the cervical spinal cord and brainstem. Signs and symptoms include dysphonia, dyspnea, upper extremity weakness, loss of consciousness, pupillary dilation, hypotension, bradycardia, and cardiopulmonary arrest. Early recognition is the key to management. Treatment includes securing the airway, mechanical ventilation, volume infusion, and pressor support. The patient should receive sedation once ventilation is instituted and the hemodynamics stabilize. The effects of total spinal anesthesia usually resolve by the conclusion of the surgical procedure, and, unless otherwise contraindicated, the patient can be extubated.

Relate the advantages and disadvantages of spinal anesthesia for cesarean section Which drugs are frequently used in

Spinal anesthesia produces a dense neural blockade it is relatively easy to perform, has a rapid onset, and carries no risk of local anesthetic toxicity. The development of small-gauge, noncutting needles has significantly reduced the incidence of postdural-puncture headache (PDPH) to 1 or less. Hypotension can be treated by rapid hydration (1 L colloid or 1 to 2 L crystalloid), positioning to avoid aortocaval compression, and use of phenylephrine (50 to 100 mcg) or ephedrine (5 to 10 mg IV) if blood pressure does not improve with these measures. Commonly used drugs for spinal anesthesia are summarized in Table 60-3. TABLE 60-3. DRUGS USED FOR SPINAL ANESTHESIA FOR CESAREAN SECTION

What is kyphoplasty Would it help my spinal fractures

Spinal (or vertebral) fractures are a major concern for men and women with osteoporosis because they can lead to severe pain and disability (see Question 84). These fractures can also lead to kyphosis (see Figure 13 in Question 83). The spine deteriorates and curves due to fractures in individual vertebrae. Most osteoporotic vertebral fractures are traditionally treated with pain medications and a gradual return to normal activities. Although back braces to prevent twisting and support the spine were used in the past, they are infrequently For kyphoplasty, an incision is made in the spine under local anesthesia. The patient can be awake so that pain and neurological problems arising from the surgery can be immediately identified. An uninflated balloonlike instrument is inserted into the vertebra. The balloon is inflated, increasing the space within the vertebra. Sometimes this maneuver straightens the vertebra. Sometimes it doesn't. The balloon is removed and a special cement compound...

Spinal cord

The spinal cord ends inferiorly level with L3 at birth, rising to the adult level of L1-2 (sometimes T12 or L3) by 20 years. Below this level (the conus medullaris) the lumbar and sacral nerve roots (comprising the cauda equina) and filum terminale occupy the vertebral canal. The main ascending and descending tracts are shown in Fig. 10.4. Fig. 10.4 Ascending and descending tracts, spinal cord. Reproduced with permission from Yentis, Hirsch & Smith Anaesthesia and intensive care A-Z, 2nd edn, Butterworth Heinemann, 2000. The blood supply of the spinal cord is of relevance to obstetric anaesthetists, since Anterior spinal artery this descends in the anterior median fissure and supplies the anterior two-thirds of the cord. The anterior spinal artery syndrome (e.g. arising from profound hypotension) thus results in lower motor neurone paralysis at the level of the lesion, and spastic paraplegia, reduced pain and temperature sensation below the level and normal joint position sense and...

What is spinal MS

Spinal MS was a term used for primary progressive MS but has not generally been used for the last 30 years or so. It was a good descriptor for this illness because the predominant symptoms were those of slowly progressive weakness and sensory problems, predominantly affecting the legs. In the past, it was especially difficult to distinguish from cervical spondylosis. Modern imaging has made this distinction much easier. For the sake of clarity, the term primary progressive MS is preferable.

Spinal anaesthesia

High blocks associated with spinal anaesthesia are related to greater spread rather than deposition of local anaesthetic into the wrong space. This may result from use of hypobaric solutions, or compression of the dural sac from the outside as a result either of recent epidural top-up or of aortocaval compression, or it may represent an extreme of normal variation as anaesthetists have sought higher and higher blocks in order to avoid pain during surgery. The continuous presence of the anaesthetist and the immediate availability in the operating theatre of the necessary equipment and assistance ensure that further supportive measures are readily available if needed. Prevention of excessive block is achieved by using the minimum necessary dose of local anaesthetic, which should be hyperbaric to allow control of spread. Excessive barbotage should also be avoided. Maintenance of the natural kyphosis of the thoracic spine if in lateral tilt, or the use of pillows under the shoulders and...

Cerebrospinal Fluid

Cerebrospinal fluid (CSF) envelops the brain and spinal cord and has several functions. By cushioning and providing buoyancy for the bulk of the brain, the effective weight of the brain is reduced by a factor of 30. Of importance, CSF carries essential metabolites into the neural tissue and cleanses the tissues of wastes as it circulates around the entire brain, ventricles, and spinal cord. Every 3 to 4 hours, the entire volume of CSF is CSF is found in the subarachnoid space (see Table 55-1) and within cavities and canals of the brain and spinal cord. There are four large, fluid-filled spaces within the brain referred to as ventricles. Specialized secretory cells called the choroid plexus produce CSF. The choroid plexus is located centrally within the brain in the third and fourth ventricles about 23 mL of CSF are contained within the ventricles. The fluid travels around the outside areas of the brain within the subarachnoid space, driven primarily by the pressure produced initially...

Spinal Tracts

Knowledge of the locations and functions of the spinal tracts is essential in diagnosing and managing spinal cord injuries. Ascending tracts carry sensory information up the cord and descending tracts conduct motor impulses down. All nerve fibers in a given tract have a similar origin, destination, and function. Several of these tracts undergo decussation10 (DEE-cuh-SAY-shun) as they pass up or down the brainstem and spinal cord meaning that they cross over from the left side of the body to the right, or vice versa. As a result, the left side of the brain receives sensory information from the right side of the body and sends its motor commands to that side, while the right side of the brain senses and controls the left side of the body. A stroke that damages motor centers of the right side of the brain can thus cause paralysis of the left limbs and vice versa. When the origin and destination of a tract are on opposite sides of the body, we say they are contralateral11 to each other....

Recognition Of Sciatica And Its Associated Symptomatology

Domenico Cotugno (Fig. 5), an eighteenth century Italian physician (7), introduced the term sciatica into the medical vocabulary. Without having knowledge of the common etiology of this disabling spinal disorder, he described some of the signs and symptoms commonly seen in association with sciatic pain. Subsequently, Cotugno's disease as an entity gained acceptance in European medicine. Associated clinical findings of sciatica Fig. 4. Cauterization points for spine and other disorders. (Reprinted with permission from ref. 5.) Fig. 4. Cauterization points for spine and other disorders. (Reprinted with permission from ref. 5.)

Identification Of Anatomical And Pathological Conditions Of The Intervertebral Disc

In the late nineteenth and early twentieth centuries, many investigators contributed to the understanding of intervertebral disc anatomy. In 1857, Virchow (12) published autopsy findings on the intervertebral disc in a patient who was injured and later expired. In 1868, von Luschka (13) described posterior disc protrusion in cadavers found in the course of routine autopsy procedures. Kocher (14) referred to his findings on intervertebral discs at L1-L2 in a patient who had a traumatic injury. Schmorl's (15) contribution to anatomical structures of the intervertebral disc also deserves recognition. In 1926, he reported on autopsy findings on 5000 intervertebral discs, 15 of which showed evidence of disc protrusion into the spinal canal. However, despite this significant anatomical finding, he had not yet established the causal connection between disc herniation and sciatic pain.

Identification Of A Safe Zone Adjacent To Nerve Roots For Anchoring Of Instruments

Illustration demonstrating complications that may become associated with localization of needle in the center of the disc at the onset of percutaneous spine surgery. Note that the needle may pass through the ligamentum flavum dora and enter the intervertebral disc with a final satisfactory radiographic appearance in the anteropasterior and lateral projection. Fig. 15. Illustration demonstrating complications that may become associated with localization of needle in the center of the disc at the onset of percutaneous spine surgery. Note that the needle may pass through the ligamentum flavum dora and enter the intervertebral disc with a final satisfactory radiographic appearance in the anteropasterior and lateral projection. The triangular working zone is bordered anteriorly by the exiting root, inferiorly by the proximal plate of the lower lumbar segment, and medially by the traversing root and the dural sac. The floor of the triangular working zone is occupied by the...

Triangular working zone

The triangular working zone is a safe zone on the posterolateral surface of the annulus adjacent to the spinal canal. It is suitable for safe lodging of instruments during posterolateral access to the intervertebral disc and the spinal canal (Fig. 3) (see Chapters 3 and 4). The annular surface in the triangular working zone is bordered anteriorly by the exiting root, inferiorly by the proximal plate of the inferior lumbar segment, medially by the dural sac and the traversing root, and posteriorly by the articular processes of the adjacent segment (1,2). The annular surface in the triangular working zone is covered with loosely woven globules of adipose tissue (Fig. 4A,B). It should be noted that the fatty tissue is relatively stationary and does not From Arthroscopic and Endoscopic Spinal Surgery Text and Atlas Second Edition Edited by P. Kambin Humana Press Inc., Totowa, NJ Fig. 2. The paravertebral muscles of the lumbar spine are seen as a moderately vascular muscle bundle. Fig. 2....

Nerve roots and root ganglia

Both exiting and traversing roots that form the lateral and medial boundaries of the triangular working zone are in the path of dorsolaterally inserted instruments and may be subject to insult during intradiscal or extraannular approaches to the lumbar spine. At the onset of arthroscopic disc surgery, the final and proper positioning of the instruments is best determined by accurate placement and documentation of the tip of the inserted instruments (18-gage needle or guide wire) on the annular surface in the triangular working zone. The fibers of the posterior longitudinal ligament extend laterally into the triangular working zone and extraforaminal region (4-8) (Fig. 8). These fibers are innervated by branches of sinu-vertebral nerve and are highly sensitive to palpation by the inserted instruments. The superficial layer of the annulus and the expansion of the posterior longitudinal ligament must be adequately anesthetized during the operative procedure and annular fenestration. The...

Intracanalicular ligaments

In a virgin spine, fine and mobile vascular and ligamentous structures on the floor of the spinal canal may be seen under endoscopic magnification (Fig. 12A,B). Hoffman's ligament, which extends from the ventral and lateral dura to the posterior longitudinal ligament, and the dural ligament, which extends from the dura and traversing root to the posterior longitudinal ligament and periosteum, may be identified following adequate hemostasis.

Capsular ligamentous flavum complex

During foraminal or transforaminal intracanalicular surgery (3,4,9), the capsule of the facet joints combined with a thickened inflamed ligamentous flavum may interfere with free passage of instruments for surgical removal, or vaporization of the content of the spinal canal.

DiAgnoSiS of luMbAr DiSC hErni AtionS inClu Sion AnD ExClu Sion Crit EriA

A careful assessment of the patient's complaints followed by a thorough physical examination is the essential and most reliable initial step in arriving at an accurate diagnosis. A simple questionnaire that includes a pain analog scale will provide a wealth of information to the operating surgeon. When the distribution of pain extends to a level below the knee or involves the calf or lateral aspect of the leg, the surgeon's attention is directed toward L5 or S1 root involvement. By contrast, disc herniation in the middle or upper lumbar spine is associated with anterior thigh or groin pain. Similarly, expression of numbness or pins and needles sensations involving the fifth toe or calf area suggests S1 root compression most likely at the L5-S1 level. However, when similar complaints are expressed on the dorsum of the great toe and lateral aspect of the leg, attention should be drawn to L5 nerve root involvement. From Arthroscopic and Endoscopic Spinal Surgery Text and Atlas Second...

AbCs of oPErAtiVE tEChniquES

Arthroscopic or endoscopic spinal surgery via a posterolateral approach is performed through the triangular working zone located on the posterolateral annulus (5,23,24). Considering that the intervertebral disc is an amphiarthrosis when the surgery is being performed via an intradiscal approach, the term arthroscopic surgery is applicable. Some investigators have used the term endoscopic spinal surgery to describe the pos-terolateral approach to the contents of the spinal canal. However, note that the spinal canal is not a cavity, so the term extra-articular or periannular arthroscopic discectomy may be more appropriate. The operating room table for arthroscopic spinal surgery must be radiolucent and relatively narrow so that the C-arm can be rotated from the anteroposterior (AP) to the lateral projection with minimal risk of contaminating the surgical field. A pacemaker extension may be attached to the available operating room table and used for minimally invasive spinal surgery. A...

History Of Surgical Management Of Sciatica

In the early twentieth century, laminectomy was being performed for the treatment of a variety of spinal disorders. In 1911, Goldthwait (16) described the management of a 39-yr-old male who underwent spinal manipulation, and then he developed paralysis in the lower extremities. His conservative management included plaster immobilization and rest. The patient failed to show improvement, and 6 wk later he underwent extensive decompressive laminectomy, extending from L1 to S2. The patient responded to the operative procedure and showed improvement. Goldthwait (16) attributed the patient's neurological deficit to detachment and protrusion of the fibrotic annulus into the spinal canal, slippage of the articular processes, and abnormality of the transverse process of the lumbar segment. In 1913, Dr. Elsberg of the New York Neurological Institute and Mt. Sinai Hospital, reported on his findings on 60 consecutive laminectomies. However, he did not believe disc pathology was responsible for...

Management Of Back And Leg Pain In Ancient Medicine

Low back and sciatic pain has been one of the most common and disabling spinal disorders recorded in medical history. The role of the spinal canal's contents in extremity function is well demonstrated in the Dying Lioness (Fig. 1), a ca. 650 bc. Assyrian artwork. In the writings of Hippocrates (460-370 bc) one can find references to the anatomy of the brain, brachial plexus, and sciatic nerve. In animal dissections it appears that he had difficulty in differentiating tendons from peripheral nerves. However, he attributed the development of paresthesia, weakness of the limbs, and fecal and urinary retention to spinal cord compression (1). Avicenna (980-1037 ad), a Persian physician and philosopher who was born in Bokhara, also wrote extensively on human anatomy and the peripheral nerves. However, his writings make no clear reference to sciatic pain. His text Canon of Medicine formed the cornerstone of medical practice for ensuing centuries. Avicenna condemned the reliance on mysticism...

ADVAntAgES of ArthroSCoPiC AnD EnDoSCoPiC DiSC Surg Ery

Although the microscope permits visualization of the dorsolateral aspect of the contents of the spinal canal, spinal endoscopy via a posterolateral approach makes it possible to visualize the medial, lateral, and ventral surfaces of the nerve root and the dural sac without undue manipulation and retraction of neural tissue. Recurrent herniation following open laminotomy and discectomy is not uncommon. Atken and Bradford (7) reported an incidence of reherniation up to 24 . Balderston et al. (8) reported recurrent herniation of 12 in two groups of patients who underwent open discectomy with simple fragment extraction or fragment removal and curettage of the disc space. They reported similar outcomes in both groups. Recurrent disc hernia-tions at the site of previous surgery may be diagnosed with enhanced magnetic resonance imaging (MRI) studies. However, many of these herniations are asymptomatic and do not require surgical management. During open translaminar discectomy, annular...

Vascular structures

Vascular structures of epidural and neural tissue play an important role in the patho-physiology of pain that is commonly observed in individuals with symptomatic disc herniation, spinal stenosis, and failed back surgery syndrome. It has been shown that interference with the normal blood flow of delicate neural and epidural venous systems (Fig. 10) may cause venous stasis edema of the nerve root, neural fibrosis, and chronic pain (4,8). This phenomenon is usually observed in patients presenting with symptomatic disc herniation and spinal stenosis. Segmental arteries, branches from the aorta and the internal iliac artery, provide blood supply to the neural, osseous, and muscular structures of the spinal column. Branches from the lumbar arteries depart from the segmental arteries and enter the intervertebral foramen (radicular artery) with the exiting root to supply the medullary arteries of the spinal cord and the nerve roots. ject to insult and injury. However, when the instruments...

Annulus fibrosus

Anatomical and imaging presentations. A partial tear of the annular fibers may cause an intraannular herniation with imaging evidence of a small and gradually developed bulge or protrusion of the annulus (Fig. 17A) (11). By contrast, a subligamentous migration of the collagenized nuclear tissue is associated with a sudden change in the external geometry of the annulus, with an imaging appearance of a distinct herniation having smooth borders (Fig. 17B). When the integrity of the posterior longitudinal liga-mentum has been altered, the collagenized nuclear fragments are dislodged into the spinal canal. Imaging studies will reveal a large extradural sequestered fragment with irregular and uneven borders (Fig. 17C).


Cannulas A number of cannulas are available and have been used by various surgeons for arthroscopic spinal surgery. The round universal cannula has a 6.4-mm od that provides an inner diameter (id) working area of 5 mm. Recently, a round, bevel-ended cannula has been introduced and utilized by some surgeons (T. Yeung, personal communication). From Arthroscopic and Endoscopic Spinal Surgery Text and Atlas Second Edition Edited by P. Kambin Humana Press Inc., Totowa, NJ Fig. 1. Instruments for spinal surgery. Shown are from left to right a 5 x 10 mm id oval cannula, a 5 x 8 mm id oval cannula, a 5 x 5 mm id cannula, a cannulated obturator, an 18-gage needle, and guide wire. Fig. 1. Instruments for spinal surgery. Shown are from left to right a 5 x 10 mm id oval cannula, a 5 x 8 mm id oval cannula, a 5 x 5 mm id cannula, a cannulated obturator, an 18-gage needle, and guide wire.

Surgical approaches

Additional instruments used for arthroscopic and endoscopic spinal surgery. From top to bottom, upbiting forceps, straight punch forceps, deflecting tube and flexible-tip forceps, punch forceps, deflecting suction forceps, and a variety of trimmer blades (disco shavers). Fig. 7. Additional instruments used for arthroscopic and endoscopic spinal surgery. From top to bottom, upbiting forceps, straight punch forceps, deflecting tube and flexible-tip forceps, punch forceps, deflecting suction forceps, and a variety of trimmer blades (disco shavers). The uniportal approach is commonly utilized for retrieval of paramedial, small central, foraminal, and extraforaminal herniations (see Chapter 4). Uniportal use of a 5 mm id cannula also provides adequate access for a transforaminal approach to the spinal canal (see Chapter 4). In the bilateral biportal technique, two cannulas are inserted contralaterally from the right and left sides of the intervertebral disc (Fig. 10A,B). A small...

Other Ion Channel Mechanisms

N-Tvpe Calcium Channel Modulators - Voltage-gated calcium channels (VGCCs) modulate excitability of nociceptive sensory neurons in the dorsal horn of the spinal cord, and appear to be involved in the development and maintenance of neuropathic pain (34,35). VGCCs are classified into three major categories based upon their electrophysiologic and pharmacologic properties high voltage-activated (L-, N-, P-, and Q-types), intermediate voltage-activated (R-type) and low voltage-activated (T-type) (36). N-type VGCCs are expressed mainly on dendrites and pre-synaptic terminals, suggesting a role for these channels in neuropathic pain. Consistent with this idea, knockout of the N-type Cav2.2 gene in mice decreased the magnitude of inflammatory and neuropathic pain behaviors (37). Ziconotide (SNX-111), an amino acid co-conotoxin peptide, is a selective N-type VGCC blocker with preclinical and clinical effects (38). Related peptide toxins isolated from Conus venoms have recently been reported....

What is multiple sclerosis

In the classic sense, multiple sclerosis (MS) is a disease of the central nervous system (the brain and spinal cord) that most commonly affects young adults. Sclerosis means hardening MS means that there are multiple areas of hardened tissue in the brain and spinal cord. The word disease means a loss of a feeling of ease (i.e., dis-ease), or otherwise stated, a loss of a sense of well-being. This is a meaningful definition for MS patients faced with a bewildering variety of other specific symptoms. Often, patients afflicted with MS have difficulty describing just how they feel. Although the MS patient appreciates and understands this concept, many healthy persons, including physicians, unfortunately, often do not.

Management options

Many authorities advocate spinal anaesthesia as the technique of choice since only a small amount of a single drug is administered, although epidural anaesthesia is also acceptable. If spinal or epidural anaesthesia is chosen, standard techniques are used. The procedure itself requires a less extensive block than Caesarean section

Brief Note on MRA Data Acquisition and Prefiltering

A brief understanding of MRA data acquisition is necessary to appreciate the vascular segmentation. Before we discuss the data acquisition, we first discuss the five kinds of surface receive coils used for collecting the MRA data sets. Figure 1.9 shows five types of radio-frequency (RF) surface receive coils used for collecting time-of-flight (TOF) MRA data sets. The Head Coil (top row middle), Anterior Neck Coil (top row right) and Posterior Neck Coil (bottom row left), and Integrated Spine Array (ISA) (bottom row right) Coils shown are manufactured by Marconi Medical Systems, Inc., Cleveland, OH. The Head Coil is a single channel receive-only design, used for imaging the head and its associated vasculature. The Anterior and Posterior Neck Coils

Etiology Of Vasospasm Potential Pathogens

The principal cause of vasospasm is the periarterial subarachnoid blood clot. Several substances that have been implicated in vasospasm are gradually released from the blood clot (Table 2). Of these, the most extensively studied is oxyhemoglobin, which is widely believed to be the principal pathogen of vasospasm (17). However, it is likely that the cascade of events that eventually lead to irreversible vasoconstriction is modulated by many other factors. Studies designed to examine the importance of the different fractions of the breakdown products of whole blood have predominantly focused on the ability of these substances to cause cerebral arteries to contract, as well as the timeframe within which these substances can be measured in the cerebrospinal fluid (CSF). As we begin to unravel the intracellular events that follow SAH, we might be able to better appreciate the importance of these substances.

Incidence And Bacterial Etiology

Brook et al. (15) reported the concomitant recovery of B. fragilis group from lung aspirates of two patients with pneumonitis Harrod and Sevens (21) recovered B. fragilis from the inflamed placenta Dysant and associates (14), Brook et al. (15), Kasik et al. (13), and Webber and Tuohy (22) recovered B. fragilis from the cerebrospinal fluid of a total of four patients with meningitis. Kosloske et al. (20) isolated Clostridium spp., B. fragilis, and Eubacterium spp. from the peritoneal cavity of four patients with necrotizing enterocolitis (NEC). Brook et al. (34) isolated Clostridium difficile from the peritoneal cavity of a newborn with NEC. Spark and Wike (36) summarized four cases of isolation of Clostridium spp. from omphalitis, and Heidemann et al. (38) isolated a gas-forming C. perfringens in the cerebrospinal fluid of a newborn with meningitis.

Normal pregnancy and delivery

10 ANATOMY OF THE SPINE AND PERIPHERAL NERVES Although not exclusive to obstetric anaesthesia, a sound knowledge of the anatomy pertinent to epidural and spinal anaesthesia is fundamental to obstetric anaesthetists because of the importance of these techniques in this field. In addition, knowledge of the relevant peripheral nerves is important in order to differentiate central from peripheral causes of neurological impairment. The structures involved in obstetric neuraxial anaesthesia comprise the vertebrae and sacral canal, vertebral ligaments, epidural space, meninges and spinal cord. The important peripheral aspects are the lumbar and sacral plexi and the muscular and cutaneous supply of the lower part of the body.

Amplified reverse transcriptase AmpRT

Amyotrophic lateral sclerosis (ALS) A devastating motor neuron disease first discovered in 1869, involving degeneration of upper motor neurons in the motor cortex and lower motor neurons in the brain stem and spinal cord. Can be familial, but 90 of cases appear to be sporadic. Little is known of the etiology, but it was reported that enterovirus RNA sequences related to echovirus 7 are present in spinal cord neurons of patients with the disease.

General Concepts For Specimen Collection And Handling

This is a particular problem, for example, in specimens collected from mucous membranes that are already colonized with microorganisms that are part of an individual's endogenous or normal flora these organisms are usually contaminants but may also be opportunistic pathogens. For example, the throats of hospitalized patients on ventilators may frequently be colonized with Klebsiella pneumoniae although K. pneumoniae is not usually involved in cases of community-acquired pneumonia, it can cause a hospital-acquired respiratory infection in this subset of patients. Use of spedal techniques that bypass areas containing normal flora when this is feasible (e.g., covered brush bronchoscopy in critically ill patients with pneumonia) prevents many problems assoaated with false-positive results. likewise, careful skin preparation before procedures such as blood cultures and spinal- taps decreases the chance that organisms normally present on the skin will contaminate the spedmen.

The Nervous System Jolts Us Into Action

Some of these motor neurons are present within the brain, while others are located in the spinal cord. And after the spinal cord, various nerves supply the skeletal muscles. Besides stimulating muscles to contract, there are other nerves that supply sensory (SEN-sor-ee) information about the body - such as pain, touch, and temperature - back towards the brain and spinal cord. Such information comes from sensory receptors (ree-SEP-tors) or ''receivers.'' This is a vital communication function that helps regulate the internal environment.

Molecular composition of ionotropic receptors

While GABAA receptors are found throughout the central nervous system, GABAc receptors have a more restricted distribution, having been found in the retina, hippocampus, spinal cord, pituitary and gut 24-28 . Their role may include visual processing, regulation of sleep-waking rhythms, pain perception, memory, learning, regulation of hormones and neuroendocrine gastrointestinal secretion 18 .

New Approaches To Antipsychotic Drug Development

In rat spinal cord, receptor binding and autoradiographic techniques have shown that phencyclidine (PCP) and sigma sites are two distinct populations which are differentially localized (80). PCP and sigma sites have also been characterized in a cloned cell line (81). In irradiation studies (82), a multiple-site model for the sigma receptor has been proposed. However, the potential for multiple sigma receptor types remains a possibility. Additional autoradiographic studies have localized haloperidol-displaceable 3H-DTG binding sites in the substantia nigra pars compacta and this specificity was associated with an increase in D2, but not D,, related ligand binding (83). This suggests an interaction between dopaminergic and sigma systems. This interaction is supported by recent experiments which demonstrated that the sigma site is linked to a guanine nucleotide regulatory (G) protein and that subchronic treatment with rimcazole produced an up-regulation and decrease in affinity for the...

Cortical Spreading Depression

Also be aware that needling of the cortex is effective, and it seems inescapable that more complex surgical manipulations of similar, susceptible tissue are likely to be effective if, as seems clear from the recent findings in patients 4 , CSD does indeed occur in the human brain. There is also experimental evidence that spreading depression occurs in the spinal cord 9 . What determines susceptibility, by which is meant the frequency of occurrence of CSD (rather than vulnerability to damage from depolarisa-tions), is an important theme of this review. The factors which are currently believed to affect this are species differences, location in the brain, haemodynamic and metabolic conditions in the cortex, anaesthesia, and systemic metabolic variables (essentially - in the present state of knowledge - plasma glucose). All of these factors are best considered after we have first reviewed the basic electrophysiological, haemodynamic and metabolic properties of CSD. Spreading depression...

What causes the inflammation in the plaque

(mostly CD4+ cells) monocytes (macrophages) from the blood stream usually cause inflammation in the nervous system. Cells and fluids in the blood are normally restricted from entering the nervous system by the blood-brain barrier. This is formed by endothelial cells lining the venules with tight junctions uniquely occurring in the brain and spinal cord. A second layer of foot processes from astrocytes (star-like cells) buttresses this barrier. In the process of inflammation, these WBCs eat holes through the lining of the smallest blood vessels (venules) and enter the nervous system. Lymphocytes and macrophages are not normally present in the nervous system. However, in some patients, a different type of immune reaction occurs

Diagnosis Of Subarachnoid Hemorrhage And Aneurysms

In suspected aSAH cases, if the head CT is not diagnostic, a lumbar puncture is mandatory. The lumbar puncture remains the most sensitive test for aSAH. Once a hemorrhage occurs in the subarachnoid space and blood becomes mixed in the cerebrospinal fluid (CSF), sufficient lysis of the red blood cells and formation of bilirubin and oxyhemoglobin form within 6 to 12 hr

Ab aggregation and neurotoxic oligomers

A number of reports have described the biochemical characterization of the soluble Ab extracted from human AD brain. The presence of sodium dodecyl sulfate (SDS)-stable dimers and trimers in the soluble fraction of human brain and in extracts of amyloid plaques suggests that SDS-stable, low n oligomers of Ab are the fundamental building blocks of insoluble amyloid deposits and could be the earliest mediators of neuronal dysfunction 20 . Recent studies have described the physiological characterization of Ab dimers isolated from AD brains that inhibit long-term potentiation (LTP), a physiological correlate of memory, and reduce dendritic spine density in normal rodent hippocampus 21 . In addition, the dimers disrupt memory of a learned behavior when directly injected into the brains of normal rats.

Laboratory Diagnosis

Antibody examinations are mostly performed with serum. Anticoagulants added to whole blood may interfere with complement activity and enzyme functions, and should be avoided. In certain situations (SSPE, herpes simplex encephalitis) antibody titration is performed on cerebrospinal fluid. Acute infection is diagnosed by demonstrating a rise in titre, seroconversion or specific IgM (or IgA). A rise in titre may be seen both in primary infections and in reinfection or after reactivation. A positive IgM test usually indicates a primary infection, but lower concentrations of specific IgM are found in reactivations (CMV infections and zoster) and reinfections (rubella). A variety of methods (complement fixation (CF), haemagglutination inhibition (HI), enzyme-linked immunosorbent assay (ELISA), immunofluorescence (IF)) are

Describe the patterns of hyperkalemia observed after the administration ol succinylcholine

Mild hyperkalemia (an increase of approximately 0.5 mEq L) occurs after routine administration of succinylcholine, but susceptible patients may experience life-threatening hyperkalemia. Examples of such patients include those with chronic spinal cord or denervation injuries, head injuries, and unhealed significant burns, and patients who have been immobile (e.g., patients in intensive care). I am aware of an otherwise healthy patient who experienced hyperkalemic cardiac arrest after administration of succinylcholine. His only risk factor was that he was a hospitalized prisoner chained to the bed day after day.

Interpretation Of Results

Isolation of a virus does not prove that the virus is the cause of the clinical condition concerned. Enteroviruses, for example, may be shed into the pharynx and the intestines for long periods after an acute episode. A concomitant antibody titre rise supports the evidence of a causal connection. By contrast, isolation of a virus from the blood or from the cerebrospinal fluid will usually be diagnostic whatever the antibody findings.

Endoscopic sclerotherapy est Indications and Technique

EST is performed with a short 25-gage needle that is directed into the veins (intravariceal injection) or into the esophageal wall next to the variceal vein (paravariceal injection). Both techniques are effective but the intravariceal injection is utilized most commonly. Several sclerosants are available for EST, including 1 sodium tetradecyl sulfate, 5 ethanolamine oleate, 5 sodium morrhuate, and 0.5 -1 polidocanol (not available in United States). 1 to 2 mL of sclerosant is injected under direct vision into each varix, starting just above the gastroesophageal junction (GEJ) (Fig. 1). The procedure is repeated at higher levels up to 5 cm from the GEJ. The injections should not be made at higher levels to avoid spinal cord injury. A maximal dose of 20 mL per session is recommended to avoid complications. Occasionally, two or more injections are needed to control bleeding from a very large varix. Preferentially, the injection is made just below the point of bleeding, though a precise...

Fraunhofer solar spectrum

The hospital's X-ray department is next to the ENNR unit (Fig. 2) which is necessary because of frequently required plain films and special radiological diagnostics. Computerized cranial tomography (CCT) has become the gold standard as an imaging diagnostic procedure. Thin-section tomography, vascular imaging, and spinal CT with bone fenestration reveal potential pathological symptoms in the brain, vascular system, ventricular system, and bone structures, also in the region of the base of the cranium. Magnetic resonance tomography (MRT) follow-up studies of the damaged brain allow prognostic prediction 27, 29 .

Antibiotics for Animals and Crops Lead to Resistance for People

The membrane surrounding the brain and spinal cord) in newborns, especially the premature infants. It also is a common cause of diarrhea, especially that disease of travelers we call la tourista. More rarely, certain strains cause a very severe diarrhea sometimes associated with kidney failure - the famous E. coli OH157 of undercooked burger fame. It tends to remain rather susceptible to antibiotics globally. But, about 60 of isolates causing infections in patients in the US are resistant to tetracycline. Of course, tetracycline is still used in humans as well as animals and for crops. But surprisingly, around 20 of strains were also resistant to streptomycin even though this drug is hardly ever used for treatment of people anymore. There is good reason to believe that part of this is due to streptomycin use for crops.

Sites Of Drug Action For Inhibition Of Micturition Reflexes

Once the action potential from the primary afferent fiber reaches its spinal synaptic terminal or en passanf boutons, an influx of calcium is necessary to cause fusion of the synaptic vesicles with the plasma membrane and subsequent release of the primary afferent neurotransmitters. Thus, compounds that can reduce the flow of calcium through blockade of N-type calcium channels or through activation of GPCR receptors (e.g. opioid) will reduce release of transmitters and subsequent excitation of 2nd order neurons in the reflex pathway. Another strategy for blocking 2nd order neuron activation is to block the postsynaptic receptors on the 2nd order neurons that respond to the transmitters of the primary afferent neurons (e.g. NK1 receptor antagonists to block substance P-induced excitation). However, because there is a redundancy of transmitters in primary afferent neurons (e.g. glutamate, substance P, vasoactive intestinal polypeptide), it remains to be shown that blocking a single...

Describe the examination of the neck

It is also important to have the patient demonstrate the range of motion of the head and neck. Preparation for laryngoscopy requires extension of the neck to facilitate visualization. Elderly patients and patients with cervical fusions may have limited motion. Furthermore, patients with cervical spine disease (disk disease or cervical instability, as in rheumatoid arthritis) may develop neurologic symptoms with motion of the neck. Radiologic views of the neck in flexion and extension may reveal cervical instability in such patients. It is my experience that the preoperarative assessment of range of motion in patients with prior cervical spine surgery does not equate well with their mobility after anesthetized and paralyzed, suggesting that in this patient group wariness is the best policy and advanced airway techniques, as will be described, should be considered.

Functional properties of the ACh innervation in the mature and the developing cortex

Fig. 4. (A-F) Electron micrographs of asynaptic (A, C, E) and synaptic (B, D, F) ACh axon varicosities from rat parietal cortex, at postnatal ages P8 (A-B), P16 (C-D) and P32 (E-F). These ChAT-immunostained profiles are identified as axon varicosities by their content in aggregated synaptic vesicles, often associated with a mitochondrion. The two ACh varicosities at P8 (A, B) are from layers VI and V, respectively. The one in B makes a symmetrical synaptic junction (between thin arrows) on a dendritic branch (upper d). Both the ACh varicosities at P16 are from layer VI. In C, the nonsynaptic ACh profile is juxtaposed to the base of a dendritic trunk (dt). The synapse made by the ACh varicosity in D (between thin arrows) is again symmetrical and made with a dendritic branch (d). The two ACh varicosities at P32 are from layer V. The one in E is juxtaposed to a dendritic branch (d), below, and a neuronal cell body (N), above. The synapse made by the varicosity in F is of the perforated...

Herpes simplex virus latency

Fig. 3.5 Visualization of rabies virus-infected neurons in experimentally infected animals. (a) A schematic representation of the pathogenesis of rabies in an experimentally infected laboratory animal. (b) Immunofluorescent detection of rabies virus proteins in neurons of infected animals. As described in Chapters 7 and 12, the ability of an antibody molecule to specifically combine with an antigenic protein can be visualized in the cell using the technique of immunofluorescence. The cell and the antibody bound to it are then visualized in the microscope under ultraviolet light, which causes the dye to fluoresce (a yellow-green color). The top left panel shows replication of rabies virus in a sensory nerve body in a dorsal root ganglion along the spine of an animal infected in the footpad. The bottom left panel shows the virus replicating in a neuron of the cerebellum, while the top right panel shows infected neurons in the cerebral medulla. Infection of the brain leads to the...

Neuroimaging Studies in Benign MS

In a study of benign MS, secondary progressive MS, and healthy controls, spinal cord area and transverse decimeter at C5 on MRI were inversely correlated with the degree of disability this likely reflects preservation of neural tissue in benign MS 16 . Other studies have failed to show a good correlation between amount of white matter lesions on T2-weighted MR and disability 15, 31, 53, 62 . The rate of development of new gadolinium-enhancing lesions is, however, less than in the relapsing-remitting patients 63 . Similar numbers of brain lesions have been reported for both benign and secondary progressive MS despite significant in

Potential Therapeutic Applications

Pain - It has been reported that NPY modulates nociception at different levels in the central nervous system. At the spinal level, it was shown that intrathecal injection of NPY can be anti-nociceptive and pronociceptive in uninjured animals models depending on the dose due to biphasic dose-effect curves (39,40). Experiments with Y1 knockout mice suggest that Y1 receptors contribute to the antinociceptive effects of intrathecal NPY in rodent models of acute nociception (41). After experimentally-induced nerve injury, NPY gene expression is upregulated within the population of medium- and large-diameter DRG neurons of the A beta-fiber class and follows a time course which is consistent with the development of tactile hypersensitivity-induced allodynia (42). NPY microinjection into the n. gracilis of uninjured rats induced reversible tactile allodynia, but not thermal hypersensitivity, in the ipsilateral hindpaw. In addition, NPY anti-serum and the NPY Y1 receptor antagonist BIBO 3304...

Fetal heart rate and CTG

The monitor uses either an external transducer or a 'clip' applied to the fetal head. It is generally recommended that women with epidural analgesia have continuous fetal monitoring, although there is some evidence to suggest that women who have a mobile (low-dose) epidural may not need this. The need for continuous fetal monitoring during epidural analgesia is related to the cardiovascular instability that may follow administration of large doses of local anaesthetic solutions into the epidural space. There is also evidence that epidural or spinal opioids may cause transient fetal bradycardia.

Birth Trauma

Birth trauma refers to those injuries sustained during labor and delivery. Despite skilled and competent obstetric care, some may be unavoidable. Factors predisposing infants to injury include macrosomia, prematurity, cephalopelvic disproportion, dystocia, prolonged labor, and abnormal presentation. In 1988, birth injuries ranked eight as major causes of neonatal mortality and caused 4.6 deaths per 100,000 live births. The clinician who cares for newborn infants must be familiar with the conditions caused by birth injury. Injuries are known to occur to the soft tissues, head, eyes, ears, vocal cords, neck and shoulder, spine and spinal cord, intra-abdominal organs, extremities, and genitalia. Although many are mild and self limited, others are serious and potentially lethal.

Diagnostic Evaluation

Lumbar puncture should only be performed in cases of high clinical suspicion of SAH in the context of negative CT. It may be difficult to distinguish a traumatic lumbar puncture from a true SAH. The presence of xanthochromia, best determined by spectrophotometry (4), reflects high levels of either cerebrospinal fluid (CSF) protein ( 200dL mg dL) or bilirubin, the end product of hemoglobin conversion (a complex process that takes up to 12 hr). Determining if cell count declines from the first to last collected tube of CSF does not reliably distinguish between traumatic tap and SAH.

Which bones are affected by osteoporosis

Although the hipbones and the vertebrae (bones of the spine) provide the best measurements of bone loss, osteoporosis occurs in all bones. The osteoblasts and osteoclasts are most active in the bones of the body's central region, that is, bones of the hip and vertebrae, and the long bones of the arms and legs. The skull bone is very rarely affected by osteoporosis. Individual bones of the spine. Fractures of these bones are the most common fractures in people with osteoporosis.

Gabi Nindl Waite PhD Chap 10 From Cells to Organisms and Editor

Waite received his B.S. in Mechanical Engineering in 1980 and his M.S. and Ph.D. in Biomedical Engineering in 1985 and 1987 from Iowa State University. He has taught numerous courses such as biofluid mechanics, biomechanics, biomedical instrumentation, graphical communications, and mechanics of material. He is a registered professional engineer and an engineering consultant for a number of companies and institutions, including Axiomed Spine Corporation, and the Heart Surgery Laboratory at the University of Heidelberg in Germany. Waite has also served as visiting professor at Kanazawa Institute of Technology in Japan.

Who gets osteoporosis

When I went for my annual gynecology check-up at around the age of 52, my gynecologist asked me, as usual, if my family history of medical conditions had changed. His ears perked up when I told him that my mother had been diagnosed with spinal stenosis. When I looked back, I remembered My doctor said that I should have a bone density test to determine if I had osteoporosis in my hip or spine. My test did show some bone loss in my hip. I was angry because I had no symptoms whatsoever and believed that I was taking good care of my health.

Discuss the effect of lipid solubility on neuraxial opioid action

Lipophilic opioids diffuse across spinal membranes more rapidly than hydrophilic opioids. As a result, they have a more rapid onset of analgesia. However, they also diffuse across vascular membranes more readily, typically resulting in increased serum concentrations and a shorter duration of action. Hydrophilic opioids achieve greater cephalo-caudal spread when administered into the epidural or subarachnoid space. They attain broader analgesic coverage than lipophilic opioids but may result in delayed respiratory depression following cephalad spread to the brainstem.

Bone and Joint Infections

Patients with infections of the spine require special mention, particularly those with underlying comorbidities like diabetes and end-stage renal disease who have infections caused by MRSA. It has been the experience of many clinicians, including the authors, that 6-8 weeks of parenteral antimicrobial therapy may not suffice to eradicate infection, and relapses of infections are seen. We have had success by employing an extended (3-6 months) of oral minocycline and rifampin combination therapy for susceptible organisms if significant radiographic disease persists by MRI or if the sedimentation rate remains markedly elevated at the end of parenteral therapy. Patients who do not respond to this approach would be re-evaluated for surgical therapy.

Management options Analgesia

The use of CSE for labour analgesia varies. Some maternity units employ the technique routinely, others never. The benefits include rapid onset of pain relief (usually within 5 minutes) and absence of significant motor block in most cases. The major disadvantage is the additional potential for complications introduced by deliberate dural puncture. The use of a spinal needle in addition to an epidural needle also adds to the cost of labour analgesia. The original regimen for the spinal component recommended in the UK was 25 mg of fentanyl and 2.5 mg of bupivacaine (1ml of 0.25 solution), 25 Combined spinal-epidural analgesia and anaesthesia 65 made up to a volume of 2 ml with saline further experience has suggested that smaller doses of fentanyl (5-10 mg) may be adequate and that 3-5 ml of the standard 'low-dose' epidural mixture (bupivacaine 0.1 with fentanyl 2 mg ml) may also be suitable and not require a separate ampoule of fentanyl to be obtained from the locked controlled drug...

Problemsspecial considerations

The main considerations for single-shot spinal analgesia are the risk of postdural puncture headache and the choice of solution, given the requirement for maximal analgesia and minimal motor block and other side effects (see Chapter 26, Combined spinal-epidural analgesia and anaesthesia, p. 63). Modern intrathecal catheters are very fine (e.g. 28-32 G) and thus may be difficult to handle and insert. They are usually supplied in a kit with a spinal needle originally these needles had cutting tips, but they are now available with pencil-point tips in an attempt to reduce the incidence of postdural puncture headache. However, even with fine catheters, 22-26 G spinal needles are required. Some catheters include a removable wire to make them stiffer for insertion. A catheter-over-needle kit also exists, in which a 27-29 G needle protrudes from the distal end of a 22-24 G catheter the catheter is slid over the needle into the subarachnoid space whilst advancement of the needle is prevented...

B cells and antibodymediated immune responses in chronic neuroinflammation

A genuine autoimmune humoral response, as in the (NZB x NZW) F1 murine model for systemic lupus erythematodes (SLE), presents with stable and persistent autoantibodies in the serum as a hallmark of its pathology. These serum autoantibodies presumably derive from long-lived plasma cells in the bone marrow and are characteristically present already before onset of the disease (Hoyer et al., 2004). This is not the case for classic MS (Antel and Bar-Or, 2006), but some of these traits can be found in another type of chronic neuroinflammation called neuromyelitis optica (NMO, also Devic's syndrome), a demyelinating CNS disease with distinct clinical, therapeutic, and histopathologic features compared to MS. CNS infiltrates in NMO are marked by extensive eosinophil infiltration, complement activation, and necrotizing demyelination with prominent vascular hyalinization (Lucchinetti et al., 2002). Recent serological studies have identified a serum autoantibody called NMO-IgG, which binds to...

Symptoms And Signs

Like poliovirus the coxsackieviruses and echoviruses multiply primarily in lymphoid tissue in the pharynx and the small intestine. In about 5 of cases virus may spread to other target organs, the main ones being the meninges, the brain and spinal cord, myocardium and pericardium, striated muscles and skin. Infection leads to lasting type-specific immunity. Fever of short duration and sometimes a rash or mild upper respiratory symptoms are the most frequent clinical diseases. A few cases progress to one of the following syndromes Aseptic meningitis. In typical cases a biphasic course is seen. After an interval of 1-2 days with few or no symptoms, the temperature rises again to 38-39 C, accompanied by headache, neck stiffness and vomiting. A non-specific maculopapular rash, sometimes with petechial elements, may be seen. The CSF is clear with slight or moderate elevation of cell count (up to 500 x 106 litre, mainly lymphocytes) and protein content, but with normal sugar content. The...

Transgenic Mice Expressing Wildtype Tau Transgenes

Observed in human tauopathies including AD (16,17). The 2N4R animals also showed motor disturbances in tasks involving balancing on a rod and clinging from an inverted grid. This observation was consistent with the presence of prominent axonopathy characterized by swollen axons with neurofilament, tubulin, mitochondria, and vesicles in the brains and spinal cords of these mice. Dys-trophic neurites that stained with antibodies recognizing hyperphosphorylated and conformational tau epitopes (e.g., Alz50) were also identified. Astrogliosis, demonstrated by glial fibrillary acidic protein (GFAP) immunoreactivity, was also observed in the cortex and spinal cord. Wild-type 4R tau transgenic mice did not, however, develop filamentous tau inclusions characteristic of neurofibrillary tangles (NFTs) and neuronal loss was not observed. The adult mouse brain predominantly expresses 4R tau isoforms. Therefore, Ishihara and coworkers generated transgenic mice that overexpress the shortest tau...

Emotion in the arts and in sport

To take another example of emotion regulation through the arts, music has much of its effect through emotion. Simply watch a crowd at a classical concert or a rock concert or even a head-banging crowd at a rave and the emotional effect of music is obvious. But, again, how does it work From time to time, many of us will play music to fit in with our mood or to change our mood, or whatever, but how does this work Do particular types of rhythm or speed or rising tones have particular emotional effects Sometimes, a piece of music will produce a chill down the spine, a physical shiver. This seems a very basic, primitive sort of reaction. What is this tapping into Is this bringing up some basic evolutionary process, such as a mixture of warmth and coldness or approach and withdrawal or rejection

Transgenic Mice Expressing Ftdp17associated P301l Mutant Tau Transgenes

The P301L tau mice developed NFTs composed of 15- to 20-nm diameter straight and wavy tau filaments that were concentrated in the spinal cord, brainstem, and basal telencephalon. Occasional NFTs (one to two per section) were observed in the cortex and hippocampus. Pretangles had a much wider brain distribution. The NFTs contained hyperphosphorylated tau, were congophilic, and were positive with silver stains. Additionally, NFTs were negative for neurofilament and some were positive for ubiquitin. In addition to NFT, argyrophilic oligodendroglial inclusions were also detected in the spinal cord, and the glial inclusions were composed of tau-immunoreactive fibrils with electron microscopy (25). Tau-immunoreactive astrocytes were also detected, but they did not have argyrophilia and ultrastructural studies showed dispersed tau fibrils (25). Consistent with the neuropathology, the mice accumulated hyperphosphorylated tau that was insoluble after sarkosyl extraction of brain tissue...

Specimen Processing

Several commerdal antigen detection kits are available for diagnosis of neonatal sepsis and meningitis caused by group B streptococci. Developed for use with serum, urine, or cerebrospinal fluid (CSF), the best results have been achieved with CSF false-positive results have been a problem using urine. Latex agglutination procedures appear to be the most sensitive and specific. Because neonates acquire S. agalactiae infection during passage through the colonized birth canal, direct detection of group B streptococcal antigen from vaginal swabs has also been attempted. However, direct extraction and latex particle agglutination have not been sensitive enough for use alone as a screening test.

Clinical implications

A more complete understanding of the development and function of sex differences in AVP and OXT innervation may also provide novel clues as to the origin of behavioural disorders such as depression, autism and schizophrenia (De Vries, 2004 Ring, 2005 Landgraf, 2006 Carter, 2007). Each of these disorders shows sex differences in occurrence (Altemus, 2006 Goldstein, 2006 Knickmeyer and Baron-Cohen, 2006), and, in case of AVP, can be linked to variability in AVP signalling, such as elevated AVP levels in the cerebrospinal fluid or polymorphisms in the V1a receptor gene (Linkowski et al., 1984 De Bellis et al., 1993 Bartz and Hollander, 2006 Yirmiya et al., 2006). If AVP and OXT play different roles in male and female brains in humans as they do in other vertebrates (Bluthe and Dantzer, 1990 Insel and Hulihan, 1995), disruptions in receptor gene expression will affect one sex more than the other.

Biological significance of leptin produced at the site of inflammation

Adipocytes represent the primary source of leptin (38). However, several studies have reported local leptin production by lymphocytes and other cells at inflamed areas. The first of these studies demonstrated local leptin production in inflammatory infiltrates around neurons in the brain and spinal cord of mice with experimental autoimmune encephalomyelitis (39). Another study showed leptin production of colon epithelial cells at the sites of inflammation (34). Our own group demonstrated leptin production by LPMC as well as T-cells from mesenteric lymph nodes in the CD4+CD45Rbhigh transfer model of colitis (37). However, it remained unclear whether or not leptin released by these activated lymphocytes is of significance for the inflammatory process itself. In order to address this question, the CD4+CD45Rbhigh transfer model of colitis was used. Cells isolated from either WT or leptin-deficient ob ob mice were transferred into scid mice and were compared for their ability to induce...

What causes walking difficulty in MS

Difficulty with walking in MS can result from plaques in different places in the brain stem and spinal cord. The location of the plaques determines, in large part, whether that difficulty is due to the particular problems of weakness, loss of sensation, or incoordination of the legs. In certain places in the brain and spinal cord, plaques can produce weakness those in the back part of the spinal cord cause certain kinds of sensation loss (position sense) others in the cerebellum and its connections lead to incoordination in the legs. Any or all of these disturbances can contribute to gait difficulty. The most common problem that causes difficulty in walking is weakness. When a patient complains of weakness, he or she is often describing one of several different problems. Muscle weakness in nervous system disease is often the result of messages not getting to the muscles from the brain and spinal cord. A signal or message may begin in the brain (the precentral or motor area of the...

Management options Suitability of the technique

Unlike spinal anaesthesia, the operation cannot be started as fast as if general anaesthesia is used. In the true emergency, therefore, such as massive placental abruption or prolapsed cord, spinal or general anaesthesia remains the technique of choice. Having said this, the use of a bolus dose of 15-20 ml concentrated solution (e.g. bupivacaine 0.5 or lidocaine 2 ) over 2-3 minutes can convert a moderate T10 block to a block suitable for surgery within about 10-15 minutes in most cases. Use of carbonated solutions and mixtures of lidocaine and bupi-vacaine have been shown to speed onset for elective Caesarean section, but clinical trials in emergency Caesarean section are few. It is clear that there is considerable variation in onset times between patients. Slow injection of a bolus necessitates cutting corners, with the precautions mentioned above about fractionating doses. The risks and benefits to the mother and fetus of epidural versus general anaesthesia in these circumstances...

Preoperative preparation

This is also discussed in Chapter 35, Spinal anaesthesia for Caesarean section (p. 90). It is particularly important in these patients to mention the risk of intraoperative pain and to have a plan to deal with this should it occur. Because of the occasional need for general anaesthetic supplementation, full antacid precautions must be employed these should include oral sodium citrate and an intravenous H2 antagonist in the emergency situation. Assessment of the airway for possible intubation difficulty is also mandatory. Prophylactic vasopressors are rarely needed but should be available, and a large-bore intravenous cannula must be inserted to allow rapid fluid infusion.

How is a diagnosis of MS made

George Schumacher was the head of a National Institutes of Health committee that was charged with the responsibility of coming up with simple standardized minimal criteria that were to be used in making a diagnosis of MS in patients entering clinical trials in MS. The criteria reiterated the need to establish that the lesions (plaques) were disseminated in both time and space. In other words, to make a diagnosis of MS, there must be evidence of at least two separate affected areas in the brain and spinal cord, and the lesions must have occurred at least at two different times separated by at least 1 month. Bearing in mind that this preceded diagnostic imaging, this was a challenge. diagnosis of MS from diagnostic imaging and improvements in spinal fluid examination was a major advance. The terms clinically definite, clinically probable, and laboratory-supported diagnoses come into use in academic circles but were rarely used elsewhere. Nevertheless, the committee recommendations...

Bone Resorption Inhibitors

The study and use of Selective Estrogen Receptor Modulators for the prevention and treatment of post-menopausal osteoporosis continues 7 . These compounds bind to the estrogen receptor and show agonist effects on bone, with antagonist effects on the endometrium and breast 8 . The only currently approved SERM is raloxifene 1, which increased bone mass in the spine and hip while having no significant effect on endometrial thickness, breast pain, or hot flashes 9 . Raloxifene reduced the incidence of fracture in the spine, however, no effect on non-vertebral fractures was demonstrated 10 . Newer SERMs are currently under study in the clinic. Bazedoxifene 2 (TSE-424), lasofoxifene 3 (CP336156) and ospemifene 4 have entered late-stage clinical trials and show a beneficial effect on BMD and or markers of bone turnover 11-14 .

ADAR Substrates in the Central Nervous System 41 Glutamate Gated Ion Channels 411 AMPA Receptors

The editing of GluR-2 mRNA has been implicated recently in the etiology of sporadic amyotrophic lateral sclerosis (ALS), a progressive neurodegenerative disorder involving primarily motor neurons of the cerebral cortex, brain stem and spinal cord, eventually leading to death from respiratory failure (Naganska and Matyja 2011). The editing of GluR-2 transcripts (Q R site) in spinal motor neurons of ALS patients appears to be inefficient compared to control patients or unaffected neurons (Hideyama et al. 2010), suggesting that the inclusion of the GluR-2(Q) subunit into heteromeric AMPA channels results in a Ca2+-mediated excitotoxicity that contributes to cell death (Kawahara et al. 2003, 2004, 2006 Kwak and Kawahara 2005 Takuma et al. 1999). Support for this hypothesis was recently demonstrated in a mutant mouse line where ADAR2 expression was specifically ablated in *50 of motor neurons using a conditional ADAR2-null allele in combination with Cre recombinase under the control of the...

Summary And Concluding Remarks

Together with the fact that many of the compounds exert their effects at concentrations at which only a small part of the FKBP12 present in a typical neuron would be inhibited, indicates that FKBP12 inhibition is not the source of neurotrophic activity. It is possible that other FKBPs, present in lower concentrations in nerve cells, may be involved. Injection of FK506 subcutaneously into monkeys caused increased expression of hsp70, a heat shock protein, in neurons in animals.291 Regions of the nervous system so affected included the spinal cord, dorsal root ganglion, and several regions of the brain. Noting these results, Gold has suggested FKBP52 as a potential target of the compounds.259 Administration of FK506 has also been found to increase messenger RNA levels for GAP-43 in neurons. Other proteins containing FKBP or FKBP-like domains may possibly be responsible for mediating some or all of the neuroprotective and neuroregenerative actions described here.

Role of PARP1 and PAR Polymer in Excitotoxicity

(D'Amours et al. 1999 Virag and Szabo 2002). PARP-1 is considered a genome guardian, because it takes part in DNA repair under physiological conditions (Jeggo 1998 Poirier et al. 1982). Under mild genomic stress, PARP-1 is activated to induce DNA repair, whereas severe cell stress induces massive PARP-1 activation that ultimately leads to cell death (Virag and Szabo 2002). Both gene deletion and pharmacological inhibition studies have shown that PARP-1 activation plays a key role in cytotoxicity following ischemia reperfusion, neurodegeneration, spinal cord injury, ischemic injury in heart, liver, and lungs, and in retinal degeneration, arthritis and diabetes (Virag and Szabo 2002). In the nervous system, massive PARP-1 activation is triggered by excitotoxic stimuli. It was originally presumed that cell death in PARP-1 toxicity was induced by the intracellular energy depletion from PARP-1's use of NAD+ (Virag and Szabo 2002). NAD+ is an important cellular molecule for many...

Role Of Inflammation And Glutamate

Although expression of cytokines and their contribution to neural injury and inflammatory responses are well characterized in instances of cerebral ischemia and head injury, ICH was not associated with expression of TNF-a, IL-1P, or IL-6, either in the perihematoma region or in other regions of the brain, when blood and cerebrospinal fluid (CSF) were tested 1 hr after the onset of hemorrhage (74). The increase of inflammatory markers only becomes measurable in situations in which the BBB is permeable (75 ).

Clinical Implications Of Resistance

And short-term all-cause mortality for pneumococcal pneumonia suggested that penicillin resistance is associated with a higher mortality rate than is penicillin susceptibility in hospitalized patients with pneumococcal pneumonia (62). These data are conflicting even for patients with bacteremic pneumococcal pneumonia (63,64). Further, there seems to be a paradox in which the interpretation of in vitro resistance profiles may not appear to predict the in vivo outcome of pneumococcal pneumonia (61). Several possible reasons for such a paradox exist, including the fact that accepted susceptibility breakpoints may not be appropriate for pneumo-coccal pneumonia. The stepwise accumulation of PBP mutations means that susceptibility to beta-lactams is not an all-or-none phenomenon but, rather, concentration-dependent. Up until recently, the National Committee for Clinical Laboratory Standards (NCCLS), now the Clinical Laboratory Standards Institute (CLSI), recommended that isolates with...

After the operation

Positional changes may cause sudden cranial spread of the block even at this late stage. A fully-staffed recovery area is mandatory, and the sitting position may be carefully adopted if the blood pressure is stable. The mother should not be moved to the ward until cardiovascular stability is certain and the block is receding. Blood pressure recordings should be continued on the ward at 30-minute intervals until leg movements have returned. Respiratory rate and conscious level should be checked hourly for 12-24 hours if spinal opioids have been used, and no other opioids should be used during this period without consultation with an anaesthetist. Anaesthetic follow-up for symptoms of PDPH or persistent block should continue for 48 hours.

How is osteoporosis diagnosed

The gold standard (best test) for diagnosing osteoporosis or identifying osteopenia is dual-energy x-ray absorptiometry (DXA). Because your hip, spine, or whole body may be evaluated using DXA, you will need to lie down on an x-ray type of table while a machine takes measurements of your bone density. The measurements and images of your bones are sent to a computer nearby, usually in the same room. Figure 7 shows a woman undergoing bone mineral density testing with a DXA machine. The presence of fractures, osteoarthritis, and calcifications (calcium deposits) can interfere with the accuracy of BMD testing, particularly of the spine (see Questions 32-33).