Spine Healing Therapy

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. Read more here...

Dorn Spinal Therapy Summary

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Spinal Immobilization

The preservation of integrity of the spinal column and the enclosed spinal cord is of paramount importance in the field. Cervical spine stabilization and airway assessment are performed simultaneously. Manual stabilization of the neck is not released until the patient has been transferred and securely strapped to a board. The length of boards used (whether short, long, or both) depends on the initial position in which the patient is found by the first responder or EMT. Carrying boarded patients takes a heavy toll on the backs of EMTs and paramedics. Evaluation of the boarded patient is expensive and time-consuming in the emergency department because of the need to clear the spine. Not all trauma victims require spinal immobilization for transport. The medical director should develop protocols or guidelines to avoid unnecessary field immobilization. 18 For example, a patient with no neck pain or tenderness (neck pain must be defined liberally and includes stiffness or feels funny), not...

Spinal Boards and Cervical Collars

Spine boards, either short or long, are made from plastic or wood to provide a rigid surface on which to bind the patient to ensure that no movement occurs in the cervical, thoracic, or lumbar spine during transportation. Straps with buckles or Velcro fasteners are used to secure the patient to the board. Some boards have attached firm head blocks for either side of the head and straps to go across these blocks to keep the head steady between them. Rolled up blankets (blanket rolls) secured to the board with tape are also effective head blocks. A popular and effective variation of the short board is the Kendrick extrication device (KED) (Ferno, Wilmington, OH), which consists of slats of rigid material bound together by heavy cloth. The KED immobilizes the cervical spine, wraps partly around the patient, and is then strapped the rest of the way around the thorax and around the thighs for secure immobilization. The patient can be lifted using the KED straps, allowing for easier and...

The Technique For Spinal Anaesthesia

Sterilise the skin over the lumbar spine with a spirit based antiseptic and raise a skin wheal with 1 lidocaine over the appropriate interspace. Inject 2-3 ml more lidocaine into the subcutaneous tissue. Anchor the skin over the interspace by pressing the non dominant index finger on the spine of the cephalad vertebra and insert the needle or introducer in the midline at 90 degrees to the skin. Feedback from the needle tip will monitor the progress of the needle through the supraspinous and interspinous ligaments, the ligamentum flavum and sometimes the dura mater. If bone is contacted, withdraw the needle to the subcutaneous tissue and redirect slightly cephalad in the first instance. Puncture of the dura is usually obvious and when the stylet is removed CSF should flow freely. DRUG DOSES IN SPINAL ANAESTHESIA Normally, the whole procedure is conducted with the patient conscious or lightly premedicated, so as to maintain verbal contact and co-operation. If turning the patient is...

Injury of the Cervical Spine

Combined wounding of the head and spine, a type of injury termed trauma in continuity, is very common. So-called craniospinal injury is seen in about 60 of cases with MBI (Davis et al. 1971). In cases involving significant brain trauma, therefore, it is imperative that a complete pathological examination is performed on the neck, vertebral vessels, and paraspinal muscles, partly even on the spine and the spinal cord, with special emphasis on the craniocer-vical junction. The utility of such detailed observations has been described by Saternus (Saternus 1979, 1993). This type of examination is important, especially in regard to the diagnosis of neck vessel injuries as demonstrated by Rommel et al. (1999). His team determined the frequency of injury of vessels of the neck by Doppler studies performed on 60 patients following either severe MBI (n 29), mechanical cervical spine injury (n 26), or combined head and cervical spine injury (n 5). Clinically, three patients sustained severe...

Cerebrospinal fluid culture

If the diagnosis of bacterial meningitis is a consideration, a lumbar puncture (LP) should be performed promptly. Routine morphologic and chemical analysis of the cerebrospinal fluid (CSF) in suspected bacterial meningitis should include a cell count, white blood cell differential count, glucose concentration, protein concentration, Gram stain, and bacterial culture.2 Table 5.3 Cerebrospinal fluid analysis In bacterial meningitis in adults

Some Basic Electrotonic Properties Of Dendritic Spines

The smaller the size and the narrower the stem, the higher the input resistance this gives a large-amplitude synaptic potential for a given synaptic conductance. Such a large depolarizing excitatory postsynaptic potential (EPSP) can have powerful effects on the local environment within the spine. Low spine membrane capacitance. The small size also means a small single spine membrane capacitance, implying that synaptic (and any active) potentials may be rapid this means that spines on dendrites can be involved in rapid information transmission. Increases in total dendritic membrane capacitance. Although the membrane capacitance of an individual spine is small, the combined spine population increases the total capacitance of its parent dendrite. This increases the filtering effect of the dendrite on transmission of signals through it. Decrement of potentials spreading from the spine. There is an impedance mismatch between the spine head and its parent dendrite...

Sequence of Spinal Immobilization

Prehospital personnel are taught to have a high index of suspicion for spine trauma. If the patient is sitting in a car after an accident and is stable from respiratory and circulatory standpoints, the short spine board and rigid cervical collar or KED are first used to safely get the patient onto a long spine board and out of the vehicle in a Radiographs can be obtained without difficulty through short and long boards. In general, patients should not be removed from these devices until the spine has been cleared clinically or radiographically. If removal off the spine board is necessary before clearing, the patient should be logrolled or lifted off carefully.

Malignant Spinal Cord Compression

Spinal cord compression is a debilitating complication of metastatic cancer identified in 5 -14 of cancer patients (Patchell et al. 2005). Among urologic malignancies, it is most commonly seen with prostate cancer (PCa), which accounts for 9 -24 of cases overall (van der Linden et al. 2005 Flynn and Shipley 1991). In fact, PCa is the second most common cause of malig nant spinal cord compression, with a cumulative incidence of 7 (Manglani et al. 2000 Rosenthal et al. 1992 Sorenson et al. 1990). Although RCC and TCC account for 6 and 2 of cases, respectively, PCa, by virtue of its higher incidence and preponderance for vertebral metastases, warrants the bulk of discussion. However, despite a few minor variances, the treatment Prostate cancer is the most commonly diagnosed noncutaneous malignancy in American men today and the second most common cause of cancer death (Jemal et al. 2005). Screening through the use of serum prostate-specific antigen (PSA) has led to both stage and risk...

Cerebrospinal Fluid Shunts

The shunting of cerebrospinal fluid (CSF) was first described in 1895, but it was not until the 1950s that shunting ventricular CSF became a routine procedure. 12 Hydrocephalus has an incidence of 3 cases per 1000 live births. Mechanical shunting is the primary treatment as there is usually no alternative corrective surgical or medical therapy for this disorder. Each year there are approximately 18,000 CSF shunts inserted, making it the most common pediatric neurosurgical procedure performed in the United States.1 The CSF shunt is also the neurosurgical procedure with the highest incidence of postoperative complications. 12

Neurophysiology Cerebrospinal fluid

Each day 500 ml of Cerebrospinal fluid (CSF) is secreted mostly by the choroids plexus within the lateral and with the 3rd and 4th ventricles. Very little appears to change the production rate of CSF other than quite markedly raised intracra-nial pressure which reduces it. The CSF flows from the lateral ventricles through the foramina of Munro into the 3rd ventricle and thence down the aqueduct of Sylvius situated in the midbrain and upper pons. Once in the 4th ventricle, a very small amount passes down the central canal of the spinal cord but the vast majority flows out through the lateral foramina of Luschka and the central foramen of Magendie. Thereafter the CSF can flow down the subarachnoid space in the spine or pass upwards eventually all CSF passes upward in the subarachnoid spaces around the midbrain and thence over the cerebral hemispheres and particularly to the para-sagittal areas. It is reabsorbed into the blood stream through the arachnoid villi which protrude into the...

Organization Of The Spinal Cord

To better understand somatotopic and modality-specific arrangements, it is helpful to review the general organization of the spinal cord (Figs. 1 and 2). Dorsal roots carrying sensory information and ventral roots transmitting motor signals occur in left and right pairs attached at 30 regular intervals along the spinal cord. Each point of attachment establishes a separate spinal segment. Rootlets from individual segments merge just distal to the dorsal root ganglia to form spinal nerves, which must pass through the vertebral column at notches between the vertebrae. Vertebrae and associated spinal brain stem spinal cord spinal nerves vertebrae

TABLE 2445 Spinal Column Differences in Children

Children with incomplete spinal cord deficits have a better prognosis for improvement in neurologic condition than those children with complete spinal cord injuries. Spinal cord trauma is associated with a higher mortality rate in children than in adults. CLINICAL FINDINGS Presentation is related to the presence or absence of a spinal cord injury. Children with fractures only will have pain, tenderness, or overlaying soft tissue injury. Children with spinal cord injuries with or without fracture will present based on the type of spinal cord injury. Over 50 percent of children with SCIWORA have a delayed onset of paralysis, sometimes up to 4 days. 20 Many of these children have transient paresthesias, numbness, or weakness at the time of or shortly after the injury. Because most spinal injuries fail to improve substantially, even in children, the most important factor in prognosis is the initial neurologic status. 20 Children with fractures and neurologic symptoms do worse than...

TABLE 2481 Spinal Cord Syndromes

A large number of descending and ascending tracts have been identified in the spinal cord. The three most important of these in terms of neuroanatomic localization of cord lesions are the corticospinal tracts, spinothalamic tracts, and dorsal (posterior) columns. The corticospinal tract is a descending motor pathway. Its fibers descend from the cerebral cortex through the internal capsule and the middle of the crus cerebri. The tract then breaks up into bundles in the pons and finally collects into a discrete bundle, forming the pyramid of the medulla. In the lower medulla, approximately 90 of the fibers cross (decussate) to the side opposite that of their origin and descend through the spinal cord as the lateral corticospinal tract. These fibers synapse on lower motor neurons in the spinal cord. The 10 percent of corticospinal fibers that do not decussate in the medulla descend in the anterior funiculus of the cervical and upper thoracic cord levels as the ventral corticospinal...

Nonoperative Spinal Stabilization

The goal of stabilization is to reduce deformities and then restrict motion and maintain alignment. In the cervical spine, it is important to determine the adequacy of cervical bony reduction. Subluxations are generally reduced using Gardner-Wells tongs, which are placed into the soft tissue of the temples under local anesthesia. The location and type of injury determine the amount of weight applied. The upper cervical spine generally requires less weight for traction than the lower cervical spine. Depending upon location, initial weight should be started at 5 to 10 lb. Weight should be increased in 2.5-to 5-lb increments. Ideally, this should be done under fluoroscopic guidance. If fluoroscopy is unavailable, radiographs and neurologic examinations should be performed after each increment of weight. The radiographs should be evaluated for alignment of the spinal column and to ensure that overdistraction has not occurred. Neurologic performance can improve if reduction is achieved....

Lumbar spinal anatomy

The lumbar spine consists of individual motion segments which comprise the vertebral body, intervertebral disc and facet joints. The spinal canal is made up of a bony-ligamentous ring which consists of the posterior aspect of the vertebral body and intervertebral disc anteriorly, pedicles and intervertebral foramina laterally together with the laminae and liga-mentum flavum posteriorly. The articular processes of the facet joints are posterolaterally. The facet joints are enclosed within the facet joint capsules. Along the posterior aspect of the vertebral bodies, extending down the posterior fibres of the annulus fibrosis, is the posterior longitudinal ligament. This bony-ligamentous ring of each motion segment completes the spinal canal posterior to the vertebral body. Contained within the canal are the thecal contents. The spinal cord ends at the lower border of the L1 vertebral body. Below this the cauda equina trails down from the conus medullaris, the individual nerve roots...

Cervical Spine Radiographs

LATERAL VIEW The lateral view radiograph detects 70 to 80 percent of traumatic cervical spine injuries. 14 The lateral view should include the cervothoracic junction, as 10 percent of cervical spine fractures will occur at this level. 15 Gentle traction on the upper extremities may move the shoulders out of the way and increase the yield of the interval view. Another radiographic technique for defining the bony anatomy of the cervicothoracic junction is the swimmer's view. This can be difficult to perform because of the positioning of the patient and film and difficult to interpret owing to overlying bone shadows and obliteration of the posterior spine. If plain radiographs do not define the cervicothoracic junction in a patient with suspected cervical spine injury, the patient should remain in cervical immobilization and alternate methods such as computed tomography (CT) should be employed.16 There should be no stepoffs or breaks in the lines. The anterior longitudinal ligament line...

TABLE 2643 Cervical Spine Injuries Mechanism of Injury

An understanding of the anatomy of the cervical spine is essential to the classification of injuries. For the purpose of understanding how mechanisms of injury affect the spine, consider the spine as consisting of two columns. The anterior column is composed of those structures anterior to the posterior longitudinal ligament. The ligamentous structures in the anterior column are the intervetebral disk, the annulus, and the anterior and posterior longitudinal ligaments. The posterior column is made up of the vertebral arch, the ligamentum flavum, the capsular ligaments and the interspinous and supraspinous ligaments. The posterior ligamentous elements resist flexion forces and the anterior ligamentous elements resist extension forces.

TABLE 2644 Classification of Thoracolumbar Spine Injury

A flexion-distraction mechanism places the anterior portions of the spine under compression while distracting the posterior elements. The lateral radiograph shows loss of height in the anterior portion of the vertebra with increased interspinous spaces posteriorly (fanning). This injury is unstable. Translational injuries are the result of large shear forces that cause complete disruption of spine stability. The lateral radiograph will show translation of one or more vertebral segments on subsequent segments. Associated neurologic injury is common. Specific injuries include slice fractures, rotational fracture dislocations, and pure dislocations.28 Minor fractures include spinous process fractures, transverse process fractures, and pars interarticularis fractures. Minor fractures have no associated neurologic compromise and are considered stable.

Ventricles And Cerebrospinal Fluid

The two largest ventricles are the lateral ventricles, one in each hemisphere, which underlie the frontal, parietal, occipital, and temporal lobes. These communicate with a single third ventricle, narrow and situated between the two thalami, via an opening in each lateral ventricle called the foramen of Monro. Finally, the tent-shaped fourth ventricle, just dorsal to the brain stem, is connected with the third ventricle by a small conduit in the midbrain called the cerebral aqueduct. The fourth ventricle, in turn, empties into a region of subarachnoid space called the cisterna magna through three apertures, the midline foramen of Magendie and the two lateral foramina of Luschka. More caudally, the CSF flowing from the ventricles travels down around the spinal cord to the lower end of the spinal canal and also circulates rostrally to the convexities of the brain, where it is eventually absorbed into the cerebral venous sinuses through structures known as arachnoid villi.

Fractures of the Tibial Spines and Tuberosity

Although isolated injuries of the tibial spine are uncommon, they usually result in cruciate ligament insufficiency. The injury is most often caused by a force directed against the flexed proximal tibia in an anterior or posterior direction, resulting in incomplete avulsion of the tibial spine, with or without displacement, or complete fracture of the spine. Vehicular and sporting accidents are the most common causes of these injuries.7 Fracture of the anterior tibial spine is about tenfold more common than fracture of the posterior spine. Examination shows a painful, swollen knee, secondary to hemarthrosis, inability to extend fully, and a positive Lachman's sign (see section on Ligamentous and Meniscal Injuries). If the fracture is incomplete or nondisplaced, it should be immobilized in full extension in a knee immobilizer. Protected weight bearing and outpatient orthopedic follow-up within a few days to a week is advised. Complete, displaced fractures require early orthopedic...

Cervical Spine Implants

The cervical spine is unique from the rest of the vertebral column due to the common use of halo fixation. A halo is simply a ring external fixator that is rigidly attached to the outer skull table with pins. Usually, four rods are used to connect this ring to a well-molded plastic or plaster body jacket. The halo limits the motion of the cervical spine, allowing fractures to heal or arthrodesis to unite. The most common cervical implant is a posterior cerclage wire (Fig . 2Z2z13), which limits motion between adjacent vertebrae while fusion occurs. A bone block taken from the iliac crest is often used as a biologic implant in the anterior cervical spine to gain fusion. Special plates and screws have been developed for the anterior cervical spine. Their use is likely to accelerate in the future. FIG. 272-13. This patient underwent posterior fusion of the entire cervical spine, with internal cerclage fixation supplemented by an external halo for 6 months.

Thoracic and Lumbar Spine

The thoracic spine is a rigid segment. The additional support provided by its articulation with the rib cage imparts a stiffness to the thoracic spine 2.5 times that of the ligamentous spine alone. Relative to other regions of the vertebral column, a large force is necessary to overcome the intrinsic stability of the thoracic spine. While injury to the thoracic spine is less common than in other regions, when it does occur it is usually significant. The spinal canal is narrower than that found in either the cervical or lumbar spine. The large spinal cord diameter relative to canal diameter increases the risk of cord injury. When cord injuries occur, most are neurologically complete. Of additional importance is the association between fractures of the thoracic spine and severe pulmonary injuries, including mediastinal hemorrhage. Patients with blunt chest trauma and mediastinal widening should be evaluated for both aortic and thoracic spine injuries. 4 The spine is divided into...

Acute Spinal Cord Compression

Spinal cord compression can result from bleeding, infection, or fracture. It may be the first sign of a neoplasm or can complicate pre-existing metastatic disease. The incidence is estimated at greater than 5 percent, and repeated occurrences in the same patient have been reported. Spinal cord compression occurs most commonly as a complication of breast or lung carcinoma and lymphoma. In at least 95 percent of patients, a long history of back pain, often several weeks to several months, elapses prior to diagnosis. The pain is progressive in severity and duration, typically continuous, and requires analgesics. It may be radicular, and when affecting the thoracic spine, radicular pain is characteristically bilateral. Symptoms and signs of myelopathy are late findings. Once neurologic deficits from spinal cord compression are present, the tempo of deterioration increases dramatically, with some patients progressing from weakness to complete paralysis in a matter of hours. Once ambulatory...

Evaluation of the forelimbs thoracolumbar spine hindlimbs and tail

Spinal reflex testing assesses the reflex arc and cord segments in which the reflexes are involved (Table 7.7). All reflexes are modified or co-ordinated by higher centres. The examination of spinal reflexes is best performed when the cat is in lateral recumbancy, gently restrained by an assistant. Flexor reflex abnormalities include areflexia, hyporeflexia, hyperreflexia, clonus and a crossed extensor response. Table 7.7 Spinal reflexes Spinal cord Table 7.7 Spinal reflexes Other spinal cord Spinal nerves (sensory) aSpinal cord segment in parentheses reflects a minor contribution to the reflex. aSpinal cord segment in parentheses reflects a minor contribution to the reflex. When a painful stimulus is applied to one limb of a cat in lateral recumbancy, the opposite (contralateral) limb extends. The crossed extensor reflex is not seen in a normal cat. Its presence is indicative of spinal cord pathology above the spinal cord segments controlling the reflex. Its presence has no...

Airway and Cervical Spine

It should be assumed that every patient sustaining significant blunt trauma (particularly above the clavicles) has a cervical spine injury, until proven otherwise. Properly trained paramedics will have applied cervical spine immobilisation at the accident scene (Figure TT.3). The most effective method comprises a combination of an appropriately sized semi rigid cervical collar (e.g. Nec-Loc or Stiffneck), and bilateral sandbags or blocks joined with tape or straps across the forehead. Use of a long spine board will minimise movement at the thoraco cervical junction. This combination will virtually eliminate neck flexion, although 30 of normal extension is still possible. If the patient has an unstable cervical spine injury, further movement may result in permanent injury to the cord. Thus, all airway manoeuvres must be performed carefully, and without moving the neck. Mask ventilation can produce at least as much displacement of the cervical spine as that produced by oral intubation....

Intubation In Cervical Spine Injury

Airway management of patients with the potential to have an unstable injury of the cervical spine challenges clinical judgment. There is no single best algorithm. Cervical spine radiography without a thorough and reliable neurologic examination does not clear the neck. From 20 to 30 percent of cervical spine injuries are not appreciated on a single cross-table lateral view. In addition, patients with blunt major trauma requiring tracheal intubation have associated unstable cervical spine injuries that range from 1 to 12 percent. Spinal cord injury without radiographic abnormality (SCIWORA), is an important consideration, especially in adolescents and children. There is a large selection of airway options to consider while attempting to maintain cervical spine immobilization. The selection is far less critical than the timing. Nasotracheal intubation, transillumination, fiberoptic laryngoscopy, and RTI are commonly selected options. Oral intubation appears safe when achieved without...

Spinal cord compression

The spinal cord lies within the vertebral canal from the foramen magnum to approximately the first lumbar vertebra, and thereafter continues as the nerve roots of the cauda equina. It is surrounded by the three meningeal layers of dura, arachnoid and pia. There is very little spare room within the vertebral canal and space-occupying pathological processes soon lead to spinal cord compression. To some extent the symptomatology depends on the vertebral level, the layer of meninges containing the pathological process and the speed of onset of compression - the faster the onset, the poorer the prognosis for recovery even with expeditious treatment, and the converse applies for slowly compressing lesions. In the thoracic region if the bone is involved, there is often pain in the spine and girdle pain around the chest wall in the distribution of the appropriate intercostal nerve, unilaterally or bilaterally. The arms are unaffected but the legs develop weakness and increased tone, and there...

Anterior and Posterior Thoracolumbar Spine Implants

Although the number of spinal instrumentation systems is overwhelming, the basic concepts are simple. A rigid plate or rod is connected to the spine to limit motion between vertebral segments and allow healing or fusion to occur. There are three ways of connecting the rod or plate to the vertebrae with a hook, a wire, or a screw. When reduced to these terms, the instrumentation is much simpler. Most advances in spinal instrumentation arose from the treatment of childhood scoliosis. The first was the Harrington rod-hook system ( Fig 272-14), introduced in developed with special hook designs that allow the basic Harrington rod concept to be used for a multitude of spinal problems. FIG. 272-14. This patient's posterior spine fusion was stabilized by a Harrington rod on the left and a Luque rod on the right. In the 1970s, Eduardo Luque developed a system in which smooth metal rods were laid along the spine and wired to each segment. This created an extremely rigid The drawback of rod-hook...

Spinal injury

Injury to the spine is of importance primarily because of the potentially catastrophic effects of damage to the spinal cord. It is by no means always accompanied by neurological damage, but because of the severe and usually permanent effects of neurological injury, it is essential to assume that the possibility of spinal instability exists in almost all injured patients until this can be satisfactorily excluded. Occasionally, neurological injury can occur, particularly in children, without there being an associated spinal fracture. Most spinal injuries are caused by road traffic accidents, falls or during sport. Many patients sustain a whiplash injury to the soft tissues and ligaments following road accidents, but bony and neurological injuries are more likely when the occupant has been ejected from the vehicle or suffered head injury. Falls from a height, either onto the head or feet, can cause spinal injury, whilst swimming (particularly diving) and horse riding, in addition to...

Spinal Nerves

There are 31 pairs of spinal nerves (eight cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal) formed in the vertebral canal by the union of ventral and dorsal nerve roots. The ventral roots transmit efferent motor impulses from the cord and the dorsal roots transmit sensory information to the cord. The cell bodies of the sensory fibres are grouped in a ganglion on the dorsal root. When each nerve leaves the vertebral canal it divides into ventral and dorsal rami. There is a wide variation in the dermatomes corresponding to the spinal nerves, relatively consistent landmarks are nipple at T4 5 and umbilicus at T10. The anatomy of the cervical, brachial, lumbar and sacral plexi is outlined in the following diagrams (CA. 19-CA.23). The autonomic nervous system consists of two complimentary components, the sympathetic and parasympathetic nervous systems whose fibres arise from the neurones of the visceral columns of the brain and spinal cord. Fibres synapse with peripheral ganglia...

Spinal Cord Injury

The most cataclysmic interference with autonomic feedback occurs when people suffer injury to the spinal cord and lose feeling in part of the body. Without sensations from the body, people cannot feel the effects of autonomic arousal, such as a pounding heart or butterflies in the stomach. Thus, individuals with spinal cord injuries would be expected to feel less intense emotions. The first study of this sort was conducted by Hohmann (1966). Hohmann interviewed people who had suffered spinal cord injuries about the changes in their emotional experiences and found that they reported less intense feelings of the high-arousal emotions of fear, anger, and sexual excitement. They reported no loss of intensity of low-arousal emotions such as sentimentality. The amount of sensation lost following a spinal cord injury is proportional to the height of the injury in the spinal cord. At the extreme, people whose injury occurs in the cervical area lose almost all sensation from their bodies,...

Cervical Spine

The cervical spine must be immobilized in any patient with a suspected spinal injury until cervical spine injury can be excluded. Immobilization is performed at the same time that airway management is started. Cervical spine immobilization can be provided by the same individual that maintains the jaw thrust. Whenever possible, a hard cervical collar should be used. However, due to the limited number of sizes available, a properly fitting collar may not be possible. Omitting the application of a cervical collar is acceptable in children for whom no properly fitting rigid collar is available. The child should be placed on a spinal board or in a pediatric immobilizer designed for trauma immobilization. The head should be secured to the board by using towel rolls or commercially available head blocks and tape applied across the forehead and under the chin of the collar. If a collar is not used, tape should not be applied under the chin, because this may prevent the mouth from opening. The...

Spinal Trauma

Spinal trauma is relatively uncommon in young children but is more commonly seen in adolescents.19 Cervical spine injuries predominate, although thoracic and lumbar injuries also occur (see lap-belt syndrome, below). Fractures or dislocations not related to birth trauma are very rare in children less than 16 months of age, having yet to be reported in the literature. Motor vehicle crashes are the most common reason for spinal injury, followed by falls and sports events. In young children, falls predominate and, in older children, motor vehicle crashes predominate. Due to increased flexibility of the spine and spinal column in younger children, fractures and dislocations rarely occur with minor trauma, and spinal cord injury without radiographic abnormality (SCIWORA) can occur. Adolescents more commonly have fracture patterns similar to those of adults. Also, 50 percent of spinal injuries and 67 percent of cervical spinal injuries in children under the age of 12 occur between the...

Spinal Cord Injuries

Vertebrae Spinal Stability Thoracicand,, Lumbar, Spine Sacrumand, Coccyx SpinalCord Spinal CordLesions Nonoperative, Spinal, Stabilization Spinal injuries are probably the most devastating of all trauma-related injuries. Treatment of multiple associated injuries often supersedes definitive management of spinal injuries. Emergency physicians must prioritize management yet not lose sight of the potential ramifications of spinal trauma. Stabilization of primary injury and prevention of secondary injury are the goals in order to optimize final outcome.

Spinal Stability

The determination of spinal stability is an important factor in the evaluation of the injured spine. White and Panjabi define stability as the ability of the spine to limit patterns of displacement under physiologic loads so as not to damage or irritate the spinal cord or nerve roots and to prevent incapacitating deformity or pain due to structural changes.2 CT evaluation applied to Denis's three-column system for classification of thoracolumbar injuries can be used to assess spinal stability. According to Denis, the spine consists of three columns.3 The anterior column is formed by the anterior part of the vertebral body, the anterior annulus fibrosus, and the anterior longitudinal ligament. The middle column is formed by the posterior wall of the vertebral body, the posterior annulus fibrosus, and the posterior longitudinal ligament. The posterior column includes the bony complex of the posterior vertebral arch and the posterior ligamentous complex. In order for an injury to be...

Spinal Cord

The spinal cord is a cylindrical structure that begins at the foramen magnum, where it is continuous with the medulla oblongata of the brain. Inferiorly, it terminates in the tapered conus medullaris at the lower border of the first lumbar vertebra. The conus is continued at its apex by a prolongation of the pia mater, the filum terminale, which extends to the base of the coccyx. The spinal cord gives rise to 31 pairs of spinal nerves 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each spinal nerve emerges through the intervertebral foramen corresponding to the appropriate spinal cord level. There is disproportionate growth in the length of the spinal cord and the vertebral column. As a result of this inequality, the length of the nerve roots increase and at lower levels, both progressively. The lower nerve roots, inferior to the conus medullaris, form an array of nerves around the filum terminale this is called the cauda equina.

The Spinal Cord

The caudal part of the CNS is the spinal cord (Fig. 1). Sensory impulses enter through its 31 paired spinal nerves, and sensory data processing begins. Messages flow up over modality-specific tracts, fast and direct or slow and indirect, to higher cord regions and the brain to the medulla, pons, cerebellum, midbrain, and thalamus. The thalamus integrates this information with other input and in reciprocal association with the cerebral cortex. In due course, or on its own, commands from the cerebral cortex and certain brain stem regions flash down to spinal motor neurons and nearby local-circuit neurons. These small cells regulate the motor neurons and integrate their activity from one level to another and across the midline. Although its intrinsic spinal activity is monitored by higher centers, the spinal cord draws up swift and complex reflexes on its own, playing out movement programs (like walking or running) as if from a computer-numeric-control tape.

Cervical spine pain

Pain emanating from the cervical spine may be localized to the back of the neck radiating into the intercapsular region or be diffusely referred to the shoulder girdle. Radiculopathy implies damage to the nerve root exiting from the spinal cord. It may be secondary to compression or inflammation. Myelopathy implies damage to the spinal cord itself and one can use symptoms and signs to localize the level of myelo-pathy. Radicular pain follows a typical nerve root distribution and is easy to discern by careful history taking. Very commonly, rather diffuse pain is difficult to isolate to any one particular structure in the cervical spine, be it a disc, facet joint or ligament. To assess these patients accurately, a good working knowledge of the anatomy of the cervical spine is needed as well as of the myotomal and dermatomal distribution of the cervical nerve roots to the upper limbs. There may be confusion as to whether the pain emanates from structures within the cervical spine or...

Thoracic Spine

Although spine pain complaints are more common at cervical and lumbar levels, thoracic complaints can be as disabling. This region of the spine is comparatively stable and protected both by the rib cage and the orientation of the facet joints. In this region, the spinal cord and paired segmental nerves traverse the narrowest of bony canals and any compromise of the available space can result in rapid and profound neurologic deficits. Thoracic spine fractures occur most commonly at the T10-L2 levels and can occur from direct trauma as well as forced hyperflexion of the trunk, as in lap-belt injuries. Vertebral fractures resulting from spinal osteoporosis occur in 8 percent of women over 80 years of age. Such compression fractures are usually wedge-shaped and stable. The presenting symptom is usually severe pain, and accompanying myelopathy is rare. However, when long tract signs, such as hyperreflexia, Babinski's sign, and urinary incontinence are present, a malignancy metastatic to...

Dendritic Spines

Certain dendrites possess fingerlike extensions, 1-2 mm in length, called dendritic spines. In low magnification images, a high density of dendritic spines gives dendrites a fuzzy appearance (Figs. 1 and 2). Spiny protrusions are also found on the cell soma and on the axon initial segment, but the dendritic spines are more numerous and have received the most study. Neurons that have large numbers of spines on their dendrites are referred to as spiny neurons, whereas those with smooth dendrites or few dendritic spines are termed aspiny. Dendritic spines are one of the most intensively studied structures in the central nervous system because they receive the bulk of excitatory synaptic input and are thought to be key sites of synaptic plasticity, the process by which neurons are able to modify their properties in response to activity. Dendritic spines vary widely in their size and morphology between classes of neurons and even within the same neuron (Fig. 7). The prototypical spine,...

Type Natriuretic Peptide

Like BNP, C-type natriuretic peptide (CNP) was first isolated from porcine brain. It is the most highly expressed natriuretic peptide in this tissue. Similarly in cerebrospinal fluid, CNP is 2 pM, which is about tenfold higher than ANP or BNP. BNP is also found at high concentrations in cytokine-treated endothelial cells and bone tissue. Because it is barely detectable in plasma, CNP is expected to signal primarily in a paracrine manner.

Blood supply to the brain and the role of the bloodbrain barrier

Equilibrium with the cerebrospinal fluid which fills the four ventricles of the brain, and covers the surface of the brain and the spinal cord. Cerebrospinal fluid is formed from the blood and may be considered as an ultra filtrate of plasma. Thus cerebrospinal fluid contains most of the electrolytes and low molecular weight nutrients but is low in protein. It is formed from a network of capillaries in the ventricles termed the choroid plexus but the cerebral capillaries also contribute to the production of cerebrospinal fluid. The extracellular fluid and the cerebrospinal fluid compartment is separated from the blood by the blood-brain barrier. This is a barrier formed by tight junctions that exist between the endothelial cells lining the capillaries and the epithelial cells at the choroid plexus. Such a barrier prevents the influx of large molecular weight molecules but enables small molecular weight substances such as glucose, amino acids, fatty acids, electrolytes, etc., which are...

Fiberoptic Assistance

The flexible fiberoptic laryngoscope or bronchoscope can be a valuable adjunct when there are anatomic or traumatic limitations that prevent visualization of the vocal cords. Clinical examples include conditions that prevent opening or movement of the mandible, congenital anatomic abnormalities, and cervical spine immobility.

Alternative Laryngoscope Blades Figure

The Bullard laryngoscope is a rigid bladed indirect fibre-optic laryngoscope with a shape designed to match the airway. The fibre-optic bundle passes along the posterior aspect of the blade and ends 26 mm from the distal tip of the blade allowing excellent visualisation of the larynx. Intubation can be achieved using an attached intubating stylet with pre loaded endotracheal tube. Although this device requires a considerable amount of practice it is particularly useful in those patients with upper airway pathology, limited mouth opening or an immobile or unstable cervical spine

Clinical Features

The initial cardiovascular response after spinal cord injury may include hypertension, widened pulse pressure, and tachycardia. 1 This acute response has been shown experimentally to last from 2 to 3 min.9 In animal experiments, the hypotension that is characteristic of neurogenic shock generally begins within 5 min of the acute spinal cord injury.9 The anatomic level of the spinal cord injury influences the likelihood and severity of neurogenic shock. Any injury above T1 should be capable of disrupting the spinal tracts that control the entire sympathetic system. Any injury from T1 to L3 has the potential to partially disrupt the sympathetic outflow intuitively, the higher the injury in this zone, the more likely or more severe the resulting neurogenic shock.1 In one of the few studies to quantify this relationship, Zipnick and colleagues described this relationship in five patients with true neurogenic shock resulting from penetrating injuries two in the cervical region, one in the...

Chapter References

Zipnick RI, Scalea TM, Trooskin SZ, et al Hemodynamic responses to penetrating spinal cord injuries. J Trauma 35 578, 1993. 2. Atkinson PP, Atkinson JLD Spinal shock. Mayo Clin Proc 71 384, 1996. 3. Bracken MB, Shepard MJ, Hellenbrand KG, et al A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. N Engl J Med 322 1405, 1990. 4. Savitsky E, Votey S Emergency department approach to acute thoracolumbar spine injury. J Emerg Med 15 49, 1997. 6. Meyer PR, Cybulski GR, Rusin JJ, Haak MH Spinal cord injury. Neurol Clin 9 625, 1991. 7. Tator CH Acute spinal cord injury A review of recent studies of treatment and pathophysiology. Can Med Assoc J 107 143, 1972. 8. Tator CH, Rowed DW Current concepts in the immediate management of acute spinal cord injuries. Can Med Assoc J 121 1453, 1979. 9. Guha AB, Tator CH Acute cardiovascular effects of experimental spinal cord injury. J Trauma 28 481, 1988. 10. Gilson GJ, Miller AC, Clevenger FW,...

Arachniodes cavalerii

Description The rhizome is erect or very short-creeping. The dark plum-colored stipes are sparsely scaly at the base and one-half of the frond length. Thin-textured but luminous bi-pinnate to tripinnate blades are broadly triangular with tapered tips and five or more pairs of spine-tipped pinnae. The sori with kidney-shaped indusia are scattered along veins.

The Blood Brain Barrier

Each portion of the nervous system is separated from the blood (and thus the rest of the body) by a metabolic 'barrier,' which modulates the access of nutrients to and the removal of metabolites from the neurons and glia within it. For the brain and spinal cord, this barrier is termed the 'blood-brain barrier' (BBB there is also a blood-cerebrospinal fluid (CSF) barrier CSF is made from blood) for the retina, it is called the 'blood-retinal barrier,' and for peripheral neurons, the 'blood-nerve barrier.' The functions of

Synaptic Transmission In The Central Nervous System

The tap of a neurologist's hammer to a ligament elicits a reflex extension of the leg, illustrated in Fig. 20. The brief stretch of the ligament is transmitted to the extensor muscle and is detected by specific receptors in the muscle and ligament. Action potentials initiated in the stretch receptors are propagated to the spinal cord by afferent fibers. The receptors are specialized regions of sensory neurons with somata located in the dorsal root ganglia just outside the spinal column. The axons of the afferents enter the spinal cord and make at least two types of excitatory synaptic connections. First, a synaptic connection is made to the extensor motor neuron. As the result of its synaptic activation, the motor neuron fires action potentials that propagate out of the spinal cord and ultimately invade the terminal regions of the motor axon at neuromus-cular junctions. There, ACh is released, an EPP is produced, an action potential is initiated in the muscle cell,...

Neurological disability

Finally, the patient should be exposed such that full and complete examination can be undertaken, but at each stage the patient should be protected from hypothermia. Once this first rapid assessment of the patient's condition has been made, his condition should have begun to stabilise, although continued close observation is needed to ensure that further deterioration from a missed injury does not occur. It is only at this stage that initial radiographs (usually chest, cervical spine, pelvis) and basic monitoring (pulse oximetry, electrocardiogram (ECG), urine output) are instituted. Thereafter, a full top-to-toe reassessment of the entire patient is undertaken and specific investigations arranged as clinically indicated.

Cellto Cell Signalling During Sea Urchin Development

Professor Minganti's group focused attention on the role of cholinergic neurotransmitter system molecules in cell-to-cell communication mediated by ion fluxes, and confirmed the exportability of the results to other animal models as well, including chordates and high vertebrates (Minganti et al. 1981). We have followed Minganti's line of research with studies on the development of the Mediterranean sea urchin, Paracentrotus lividus, from fertilisation up to metamorphosis. Cholinergic signalling system molecules have been found at each developmental stage, playing different roles according to the temporal windows and the degree of differentiation, including the neuromuscular function in the rudiment and in the juvenile (Vidal et al. 1993 Falugi et al. 1999 2002), localised in radial muscles, in the tube feet and at the basis of the spines (Fig. 2). Fig. 2A-E. Paracentrotus lividus larva 18 days old, competent for metamorphosis. A Section of the larva containing a sagittal section of...

Body Fluid Compartments And Their Contacts With The Outside World

Transcellular Space Fluid Compartments

The total body water (TBW) in higher animals is distributed among three major compartments the blood plasma, the interstitial fluid (ISF), and the intracellular fluid (ICF). The plasma is separated from the ISF compartment by highly permeable capillaries together, plasma and ISF constitute the extracellular fluid (ECF) compartment. This compartment is separated from the ICF compartment by cell membranes, which in most instances, as discussed in Chapter 3, are highly permeable to water but very selective with respect to the passage of solutes. A fourth, small compartment, called the transcellular fluid compartment, consists primarily of fluid in transit in the lumina of epithelial organs (e.g., the gall bladder, stomach, intestines, and urinary bladder), as well as the cerebrospinal fluid and the intraocular fluid.

Subtypes of Connections 1 Morphological Evidence

Long-distance projecting axons typically exhibit a spectrum of conduction velocities and caliber (Fig. 11). Projections from cortical motor areas to the spinal cord (corticospinal tract) are subdivided into slow and fast components. Slow fibers, comprising the majority, have an antidromic latency of about 2.6 msec from the brainstem pyramid, whereas for fast fibers the equivalent latency is 0.9 msec. These latencies respectively correspond to conduction velocities greater than or less than 30 msec 1, and axon calibers < 4 mm or > 6 mm (in man). Curiously, in this system there does not seem to be any correlation of fiber size with either phylogenetic status or digital dexterity. From comparative studies, the largest fibers (25 mm) have been reported in the seal. Figure 9 Photomicrographs of two morphologically distinct types of corticopulvinar axons. (A) A field of thin axons with slender, spine-like terminations. Portions of two thicker axons pass in the vicinity (asterisk). (B) A...

Fully Method of Stature Estimation

Thomas Dwight published a paper in 1894 (23) on what he termed the anatomical method of stature estimation. Dwight's method involved articulating the entire skeleton on a measuring board and correcting for the curvature of the spine and thus estimating stature. During the mid-1950s, Georges Fully (20) developed his own anatomical method a much simpler version of Dwight's method. Because Fully's anatomical method involves the lower extremity, it is included here. Fully's anatomical method requires the observer to take the following measurements from the skeleton Tibia length without tibial spine

Assessment of the Painful

Hip Adductor Tendonitis Mri

The examination begins as the patient walks into the office, with assessment of gait pattern. Intra-articular hip disorders will be manifested by a Trendelenburg gait, but unfortunately some extra-articular causes can present with a similar gait pattern. The patient must be adequately undressed for proper examination. Inspection normally reveals a level pelvis. Pelvic obliquity suggests leg length discrepancy or scoliosis, which may or may not be associated with hip disease. Range of motion of the spine will help demonstrate any true spinal abnormality. This examination should include lumbar range of motion as well as motor, sensory, and reflex testing of the lower extremities. A straight leg raise, prone and supine, should also be performed to exclude nerve root irritation. An upper level lumbar herniated disc (L2-L3 or L3-L4) can produce pain radiating to the groin, thus mimicking hip pain. Contracture of the hip may cause a compensatory obliquity of the pelvis. If inspection of the...

Induced Cortical Plasticity as Therapy

One possible therapeutic avenue for ameliorating the effects of an adverse fetal environment on subsequent motor development may be by inducing beneficial plastic changes in the motor areas of the brain and or spine. While it may be difficult to prevent some types of fetal growth restriction, it may be possible to exploit the immature brains extraordinary capacity for reorganisation postnatally, to effectively reprogram the maladaptive motor programming induced in utero. Plasticity, in its broadest sense, can be defined as the process by which synapses, cells or tissues alter their structure and or function in response to altered central or peripheral input. Adaptive plasticity refers to the processes by which neural circuits in the brain and spinal cord reorganise the strength and nature of their functional synaptic connectivity to improve function in response to an alteration in sensory input or injury. Repetitive performance of voluntary movements, such as practising a musical...

Noninfectious Complications Of Cardiac Transplantation

Aseptic necrosis of the femoral heads and thoracic and lumbar spine compression fractures are not uncommon manifestations of long-term steroid therapy. The development of hip pain referred to the medial thigh or knee is often indicative of early aseptic necrosis. Magnetic resonance imaging (MRI) is the most sensitive

Electron Beam Computed Tomography

Radiation exposure is a consideration with all CT scanning methods. With conventional or helical CT, radiation levels are 2 to 4 cGy (2 to 4 rad) per CT slice. If multiple slices are taken at the same level of the heart, then the radiation increases directly in proportion to the number of slices. Electron-beam CT has less exposure to radiation for the patient each slice has an exposure of 0.54 cGy (540 mrad). However, more imaging slices are acquired with electron-beam CT in obtaining a cine sequence of the heart, so that 10 cine frames would result in an exposure of 5.4 rad. For comparison purposes, a single x-ray of the lumbar spine is approximately equivalent to 1 cGy (1 rad), whereas radiation exposure from a chest x-ray is 0.06 cGy (60 mrad).

Central Neural Blockade

There are three neuraxial techniques in common use and their terminology can confuse because terms are used interchangeably. Spinal (synonym intrathecal or subarachnoid), Epidural (synonym extradural or peridural) and Caudal (synonym sacral epidural) are the preferred terms for anaesthesia and analgesia within the boundaries of the spinal column. Spinal Anaesthesia Spinal anaesthesia is used for a wide variety of both elective and emergency surgical procedures below the level of the umbilicus. For surgery above the umbilicus, high spinals are now rarely used because of associated difficulties of maintaining spontaneous ventilation and abolishing the painful stimuli from traction on the peritoneum and pressure on the diaphragm. Spinal anaesthesia requires the injection of a small volume of local anaesthetic agent directly into the cerebrospinal fluid (CSF) in the lumbar region, below the level of L1 2, where the spinal cord ends. Figure RA.3 shows the typical anatomy of the lumbar...

Look for our other Daviss Notes titles

The heart, located in the mediastinum, is the central structure of the cardiovascular system. It is protected by the bony structures of the sternum anteriorly, the spinal column posteriorly, and the rib cage. Directly between Vs and spinal column at posterior 5th intercostal space

The Technique For Epidural Insertion

The Tuohy needle, the loss of resistance syringe, the catheter and filter must be examined and prepared for use. Connect the filter and catheter and fill with saline to ensure free passage of solution. Position the patient in either the lateral or sitting position as for a spinal injection and identify the appropriate vertebral interspace. Sterilise and drape the area, raise a skin wheal with 1 lidocaine and anchor the skin over the cephalad spine of the interspace with the non dominant index finger. Insert a 21G hypodermic needle at right angles to the skin exactly in the midline of the interspace to inject more local anaesthetic into the interspinous ligaments and identify the route of the Tuohy needle. Insert the Tuohy needle in the direction indicated by the hypodermic needle. The needle will pass easily through the superficial layers but as it passes through the supraspinous and interspinous ligaments, resistance will become more obvious. If the needle strikes bone withdraw it...

The Spread and Localization of Intraperitoneal Abscesses

Right Paracolic Gutter

(b) T1-weighted and (c) T2-weighted MR images show that the lesser sac collection exhibits high signal intensity on both, compatible with a resolving hematoma in the extracellular methemoglobin phase. A thin hypointense rim around the collection is attributed to hemosiderin within macrophages. The gastrohepatic collection is nonhemorrhagic ascites, with signal similar to cerebrospinal fluid. (b) T1-weighted and (c) T2-weighted MR images show that the lesser sac collection exhibits high signal intensity on both, compatible with a resolving hematoma in the extracellular methemoglobin phase. A thin hypointense rim around the collection is attributed to hemosiderin within macrophages. The gastrohepatic collection is nonhemorrhagic ascites, with signal similar to cerebrospinal fluid.

The Technique Of Inguinal Field Block

Lie the patient in the supine position and identify the anterior superior iliac spine (ASIS) and the pubic tubercle the bony landmarks which define the two injection points. The top injection point will be 1 cm medial and 2 cm caudal to the ASIS. Make a skin wheal of lidocaine at this point and insert a 22 G short bevel regional block needle, at right angles to the skin, directly downwards through the skin and subcutaneous tissue. At a depth of 1-2 cm (more in obese patients), the needle will encounter the external oblique aponeurosis which will offer marked resistance to penetration. Move the needle from side to side in a horizontal plane and a distinct scratching over the surface of the aponeurosis will be felt. The iliohypogastric nerve (T12 L1) lies just deep to the aponeurosis, so once the needle penetrates it, immobilise the needle and inject 5 ml of local anaesthetic. Carefully advance the needle another 0.5-1 cm to penetrate the internal oblique muscle (there is often a slight...

Perioperative Management

Position Arm Dependent Position

A basic requirement of anesthesia for hip arthroscopy is satisfactory muscle relaxation at the hip. This allows distraction of the joint and permits adequate arthroscopic visualization. Regional techniques such as spinal or epidural anesthesia will provide the required muscle relaxation, but often require intravenous adjuncts for patient comfort. Although hip arthroscopy may be accomplished with patients in the supine position on a fracture table,2 the preferred method at our institution is to place the patient in the lateral decubitus posi-tion.3 (See Chapter 9.) After surgical prep and draping, the patient is seldom able to watch the procedure on a video monitor due to obstructed vision. Thus, the advantages of regional anesthetics are lost on two counts The patient's position may be quite uncomfortable during extended cases, and can require substantial amounts of supplemental intravenous medications. Furthermore, patient expectations to remain awake Additional precautions should...

The Unprotected Airway

Although not yet officially advocated, the LMA is said to offer the best current alternative to endotracheal intubation by inexperienced personnel (ERC 1996). The basic principle that rise and fall of the chest during ventilation equates with a clear airway must be emphasised if relatively inexperienced staff are to be taught the techniques of LMA insertion. The practicalities of insertion may be relatively simple the assessment of correct positioning is not so easy. Although endotracheal intubation is preferable to the LMA, the device may be useful in a difficult intubation in that it can be used to establish a clear airway and then a bougie or a small endotracheal tube inserted through it. The LMA may also be considered if there is an unstable cervical spine fracture and where intubation is not deemed to be essential.

Central Nervous System

Mannitol is an osmotic diuretic which is utilized clinically to decrease intracranial pressure. This agent is administered as a hypertonic solution such that an osmotic gradient is created favoring the movement of water from the brain parenchyma into the intravascular compartment across the blood-brain barrier. As long as the blood-brain barrier is intact, mannitol is effective in decreasing the water content of the brain, thereby reducing intracranial pressure (see Table 1). When the integrity of the blood-brain barrier is disrupted, however, the effectiveness of mannitol declines. In this setting, mannitol diffuses into the brain parenchyma, thereby preventing the establishment of an osmotic gradient favoring water movement into the vascular compartment. The ability of mannitol to decrease intracranial pressure is independent of its diuretic effect as a fall in cerebrospinal fluid pressure can be demonstrated even in the absence of urine flow. Acetazolamide has been shown to affect...

Physical Examination

Like the history, the findings upon physical examination of a patient with acute appendicitis depend on the duration of the illness prior to the examination. Early in the course of acute appendicitis, the patient may not have localized tenderness. As the illness progresses, the patient typically develops tenderness, especially to deep palpation, over McBurney's point. This is a point just below the middle of a line connecting the umbilicus and the anterosuperior iliac spine. Pain in the right lower quadrant with palpation of the left lower quadrant (Rosving sign) may also be elicited. As with the subjective pain, the localization of tenderness varies with the anatomic position of the appendix. If the patient has a pelvic appendix, the patient's tenderness may be most pronounced on rectal examination. With a retrocecal appendix, tenderness to palpation may be attenuated by the overlying cecum or may be most pronounced in the right flank. Additional components of the physical...

Assessment and Management of the Trauma Patient

In the United Kingdom, pre hospital management of severely injured patients is performed mainly by paramedics. These personnel are trained in advanced airway management (including intubation), intravenous cannulation, fluid resuscitation, the provision of analgesia and spinal immobilisation. Paramedics are trained to consider the Golden Hour' and minimise on scene time a prolonged time to definitive care will increase mortality. The receiving hospital must be given advanced warning of the impending admission of a severely injured patient. Ideally, the ambulance officer at the scene should be able to communicate directly with accident department staff via a talk through link. Concise and essential information on the patient's condition and estimated time of arrival must be given. Accident department staff can then decide whether to alert individual specialists or, depending on hospital policy, the trauma team. Cervical spine, chest, and abdominal X-rays, other X-rays as requested by...

Differences Between Aquatic And Terrestrial Systems

Although the examples previously discussed are based on an aquatic system, the model also applies to terrestrial systems. This is not to say that there are no differences between aquatic and terrestrial systems in the way induced defenses act on consumers. In aquatic systems gape limitation is very important, as many consumer species have no means to tear their prey to pieces (Hairston and Hairston, 1993 Bronmark et al., 1999). Algae, zooplankters, and fish are mostly ingested as whole individuals. Consequently, many inducible defenses in aquatic systems involve morphological changes such as colony- and spine-formation and deepened body shapes, that hinder handling and ingestion by gape-limited consumers.

Heterogeneous Food Web Nodes And Flexible Links

FIGURE 2 Trophic interactions in a simplified food web, when prey are (A) undefended, (B) have induced defenses, or (C) are completely defended. Defenses and intraspecific heterogeneity in prey vulnerability determine which links are present and how strong they are. Thickness of arrows represents the strength of per capita feeding interactions. Inducible defenses are predator-density dependent. This causes variability in the fraction of defended individuals in prey food web nodes, when predator abundance changes. Species in this food web example are Perca (zooplanktivorous fish), Chaoborus (invertebrate predator), Daphnia (herbivorous zooplankton), and Scenedesmus (green alga). In this example, both Chaoborous and Daphnia can make use of a refuge from fish predation. Induced morphological defenses include spine formation in daphnids and colony formation in algae. FIGURE 2 Trophic interactions in a simplified food web, when prey are (A) undefended, (B) have induced defenses, or (C) are...

Possible mechanisms of complement and disease associations

In the case of viral antigens, small ICs may escape from CRl-mediated clearance by erythrocytes if the individual is C4-deficient. Circulating ICs may even, after years, be deposited in the brain, having passed the blood-cerebrospinal fluid barrier, contributing to cytotoxic effects in the central nervous system, as seen in diseases such as SSPE and AIDS.

Cannulation of the Subclavian Vein

The ATLS committee do not recommend the central veins for rapid fluid resuscitation because, in their opinion, in the hypovolaemic patient, the complication rate is high and the time taken to achieve access is slower than that for peripheral cut down. In reality, many anaesthetists would be more competent and successful with central venous cannulation than peripheral cut down and the choice must lie with the individual. The major complications are pneumothorax and accidental arterial puncture. Significant air emboli are very rare. In the blunt trauma patient, internal jugular venous cannulation is not recommended because most approaches to this vein require turning of the patient's head this cannot be done unless the cervical spine has been cleared. Subclavian cannulation can be performed while the patient's cervical collar is on and with the head and neck in neutral alignment. If a pulmonary artery introducer sheath is used it will allow rapid flow and the ability to monitor central...

Biomechanics Of Ligaments

Ligaments are tough connective tissues that connect bones to guide and limit joint motion, as well as provide important proprio-ceptive and kinesthetic afferent signals (Solomonow, 2004). Most joints are not perfect hinges with a constant axis of rotation, so they tend to have small accessory motions and moving axes of rotation that stress ligaments in several directions. The collagen fibers within ligaments are not arranged in parallel like tendons, but in a variety of directions. Normal physiological loading of most ligaments is 2-5 of tensile strain, which corresponds to a load of 500 N (112 lbs) in the human anterior cruciate ligament (Carlstedt & Nordin, 1989), except for spring ligaments that have a large percentage of elastin fibers (ligamentum flavum in the spine), which can stretch more than 50 of their resting length. The maximum strain of most ligaments and tendons is about 8-10 (Rigby, Hirai, Spikes, & Eyring, 1959).

Homocysteine Excitotoxic Amino Acids And Vascular Disease

Although the underlying mechanisms are not completely defined, there is a very strong association between increased plasma homocysteine and cerebrovascular, coronary artery, and peripheral vascular disease. Recently, in our ongoing studies of the neurotoxicity of antifolates such as methotrexate, we documented marked increases in the cerebrospinal fluid (CSF) content of adenosine and homocysteine and its metabolic products, the so-called excitotoxic amino acids (4). Excitotoxic amino acids activate the NMDA receptor, which may result in a cascade of events that are associated with neuronal glial cell death (5). These recent findings add to the large body of literature showing that a folate deficiency leads to homocystinemia (6,7). Most recently, decreases in CSF S-adenosylmethione (SAM) and increases in S-adenosylhomocysteine (SAH), resulting in a very abnormal SAM SAH ratio, has been found in two children who had developed methotrexate leu-koencephalopathy (8).

Conclusion s and Future Directions

A common language for the estimation and description of physiologic quantities that determines the dynamic behavior of diffusible and non-diffusible contrast agents. Future applications of DCE-MRI may introduce additional physiological parameters. Furthermore, techniques like texture analysis may allow discrimination between tumors by applying common first-order and second-order statistics. Until now, such methods have been restricted to fine discrimination between white matter, cortical gray matter, and cerebrospinal fluid (Kj r et al. 1995). Nevertheless, the use of DCE-MRI to estimate perfusion in pathological conditions, such as different types of brain tumors, should not be used without careful consideration of the underlying vascular nature of the tissue of interest.

Disruption of the Craniocervical Junction

As already mentioned, disruption of the spinal cord at the craniocervical junction is a type of open SCI that almost invariably results in instant death. It is often associated with intentional killing of a victim who is powerless to resist due to physical restraints or threat. It is caused by the types of execution carried out in the Holocaust (Kucharski 1998) and, more recently, during the Kosovo conflict (Pozgain et al. 1998 Sprogoe-Jakobsen et al. 2001). The injury can involve complete transection of the lower brain stem and or upper cervical cord with unilateral or bilateral disruption of the vertebral arteries. This type of injury has been reported after extreme hyperextension (retroflexion) of the cervical spine usually followed by sudden death (Hinz and Tamaska 1968). Transection of the cervical cord with dural tears has been found as a complication of birth Fig. 10.3a-e. Gunshot injury of the spinal cord (three cases). cervical spine and cord (c) associated with penetrating...

Anterior Horn Tissues from FALS and SALS Cases

The XRF spectra in Fig. 7.6 show the accumulation of Ca in the samples obtained from the FALS and SALS cases. The Ca peaks of these spectra are higher than that of the control case. It is generally considered that the mechanism of cytotoxic injury of neurons involves excessive entry of extracellular Ca through the receptors. The increased glutamate levels in cerebrospinal fluid that increases free Ca through the direct activation of Ca-permeable receptors or voltage-gated Ca channels are found in patients with SALS 18 . The finding of Ca accumulation is supportive for this mechanism and the evidences that Ca had accumulated in motor neurons through cerebrospinal fluid.

Contusional Injury of the Cord

Commonly the term contusio spinalis designates all primary mechanical alterations of the cord and its coverings caused by blunt violence to the cord. Spinal cord contusion injuries also include all non-disruptive injuries without evidence of continuing compression but those more severe than reversible functional disturbances are referred to as concussion injuries (Jellinger 1976). Fig. 10.5a-d. Fracture of the dens axis (arrows in a, b) and in- cipito-cervical junction and fracture of the dens axis c epidural traspinal hemorrhage as a result of a combined retroflexion and hemorrhage and intraspinal hemorrhage d intraspinal hemor-rotation around the z-axis a Spine and spinal cord in situ b oc- rhage Fig. 10.5a-d. Fracture of the dens axis (arrows in a, b) and in- cipito-cervical junction and fracture of the dens axis c epidural traspinal hemorrhage as a result of a combined retroflexion and hemorrhage and intraspinal hemorrhage d intraspinal hemor-rotation around the z-axis a Spine and...

Iatrogenic Cord Injury

Complications may be due to diagnostic spinal tap, injection of contrast agents or drugs into the spinal subarachnoid space, or spinal anesthesia. Cases such as these are sometimes encountered in medicolegal practice. The clinical sequelae may result from mechanical irritation or chemical intoxication. Spinal taps are usually performed at the level of the segments L5 S1, where only the cauda equina is located spinal anesthesia is commonly administered at the level of the segments L2 L3, the tip of the conus medullaris usually lying at L1 L2 although it may extend further (Saifuddin et al. 1998). Access is achieved in most cases with an atraumatic needle and is checked by free flow of cerebrospinal fluid. Access at the level of L5 S1 causes a merely transient mechanical irritation of a single nerve root. Bleeding is often observed, but remains clinically inconsequential. Access at the level of L2 L3 using spinal anesthesia sometimes induces persistent unilateral sensory loss (and...

TABLE 1127 Signs and Symptoms of Neonatal Sepsis

When a neonate is thought to be septic, microscopic analysis of cerebrospinal fluid, blood, and urine, and cerebrospinal cultures should be obtained. The infant should be admitted and intravenous antibiotics started. Initial treatment of a neonate with suspected bacterial septicemia or meningitis entails a combination of ampicillin and an aminoglycoside. An alternative regimen of ampicillin and a cephalosporin (e.g., cefotaxime or ceftazidime) is active against most etiologic gram-negative bacilli and can be used in cases when gram-negative meningitis is strongly suspected. Cerebrospinal fluid total white blood cell count less than 10 pL, complete blood count total white blood cell count less than 15,000 pL, urinalysis white blood cell count less than 10 cells hpf, and negative results for bacteriuria, leukocytes, esterase, and nitrite

Anatomical Changes With

Both cross-sectional and longitudinal aging studies of changes in brain structure have been performed on healthy subjects using either X-ray CT or MRI. Our focus is mainly on the results of the MRI studies because of the better spatial resolution and contrast obtainable with this method. One can manipulate the scanning parameters of a MRI device in several ways, each of which emphasizes signals corresponding to somewhat different features of brain tissue. In this overview, we discuss senescent changes in volumetric measures of gray matter, white matter, cerebrospinal fluid (CSF) space, and a few fairly well-defined brain regions, such as the hippocampus and the basal ganglia. The absence of clearly and easily identifiable landmarks makes it difficult to measure the volumes of specific regions of the neocortex in a rigorous way. We also review some of the findings about age-related alterations in white matter hyperintensities.

The cranial nerves provide the sensory and motor interfaces

Between the brain and the structures of the head. They supply the sensory inputs from our more than five senses and the motor (effector) innervation of muscles and glands. Like spinal nerves, the cranial nerves have sensory, or afferent, components that innervate structures in the head as well as the viscera of the thorax and abdomen and motor, or efferent, components that innervate muscles and glands in the head and the viscera. Three additional special components of cranial nerves are commonly recognized that spinal nerves lack however, insights into the embryological derivation of sensory structures and muscles in the head allow us to discard this special category. Considering the sensory cranial nerves, humans arguably have at least 13 different senses, but even so we lack some additional senses that are present in other vertebrates. Some tetrapods, including most mammals, have an accessory olfactory (vomeronasal) system, for example, that is present in humans only transiently...

Traditional Functional Components

The first two pairs of classification terms for cranial nerves correspond to the four components of spinal nerves. Sensory nerve components are thus either somatic afferent or visceral afferent, and motor components are likewise either somatic efferent or visceral efferent. Spinal nerve components and some cranial nerve components are additionally classified as general, so they are designated general somatic afferent (GSA), general visceral afferent (GVA), general somatic efferent (GSE), and general visceral efferent (GVE). The sensory GSA components innervate the skin of the face and position sense (proprioception) receptors in head musculature, whereas GVA components innervate the viscera of the thorax and abdomen and a few structures in the head and neck, such as the mucous membranes of the oral cavity. The motor GSE components innervate extraocular eye muscles and the muscles of the tongue, whereas GVE components supply parasympathetic innervation to the thoracic and abdominal...

Motor Vehicle Crash Trauma

Lap belt or lap belt-shoulder harness combination (instead of a booster seat), the belt tends to rest across the mid-abdomen instead of the bony pelvis. The violent deceleration of a head-on collision may result in the lap belt crushing against the spine, causing bowel injuries, chance fractures of the lumbar spine, and even transection of the lumbar spinal cord and thus lower extremity paralysis (4).

First Applications Of

Another early application on radiopharmaceuticals and biological vaccines mentioned earlier involved the detection of endotoxin in intrathecal injections into the cerebrospinal fluid of drugs. Cooper and Pearson (4) reported that ten such samples implicated in adverse patient responses were obtained and tested by LAL, and all ten reacted strongly. The rabbit pyrogen test was negative for all samples when tested on a dose-per-weight basis. They concluded that the rabbit pyrogen test was not sensitive enough for such an application given that endotoxin was determined to be at least 1000 times more toxic when given intrathecally.

Homocysteine And The Fetus

Dawson et al. (105) found a 60 decrease of amniotic fluid vitamin B12 and folate levels between 15 and 20 wk gestation associated with an increase in amniotic fluid volume. The vitamin B12 and folate levels of amniotic fluid of NTD fetuses were below the range of unaffected pregnancies. Wenstrom et al. (106) demonstrated that high amniotic fluid homocysteine levels, heterozygosity or homozygosity of 5,10-MTHFR mutations were associated with defects of the cervical lumbar spine and occipital encepha-locele. Anencephaly, exencephaly, and sacral defects did not seem to be related to altered homocysteine metabolism.

History Of The Electrophysiology Of The Brain

Sources, however, remained undefined until the 1970s, when it was demonstrated in dog that the alpha rhythm is generated by a dipole layer centered on layers IV and V of the visual cortex. It is not surprising that the mechanisms of generation and the functional significance of the EEG remained controversial for a relatively long time, considering the complexity of the underlying systems of neuronal generators and the involved transfer of signals from the cortical surface to the scalp due to the geometric and electrical properties of the volume conductor (brain, cerebrospinal fluid, skull, and scalp).

The Generation Of Electric And Magnetic Extracellular Fields

Specific models of the sources and of the volume conductor. The simplest source model is a current dipole. However, it should not be considered that such a model means that somewhere in the brain there exists a discrete dipolar source. It simply means that the best representation of the EEG MEG scalp distribution is by way of an equivalent dipolar source. In the sense of a best statistical fit, the latter describes the centroid of the dipole layers that are active at a certain moment. The estimation of equivalent dipole models is only meaningful if the scalp field has a focal character and the number of possible active areas can be anticipated with reasonable accuracy. An increase in the number of dipoles can easily lead to complex and ambiguous interpretations. Nevertheless, methods have been developed to obtain estimates of multiple dipoles with only the a priori information that they must be located on the surface of the cortex. An algorithm that performs such an analysis is...

Neurologic Complications

TOXOPLASMOSIS Toxoplasmosis is the most common cause of focal encephalitis in patients with AIDS. Symptoms may include headache, fever, focal neurologic deficits, altered mental status, or seizures. Serologic tests are not useful in making or excluding the diagnosis because antibody to T. gondii is prevalent in the general population. The presence of antibody to T. gondii in the cerebrospinal fluid is helpful, although there is a high rate of false-negative results. On a noncontrast scan, toxoplasmosis typically appears as multiple subcortical lesions with a predilection for the basal ganglia. CRYPTOCOCCOSIS Cryptococcal CNS infection may be seen in up to 10 percent of AIDS patients and may cause either focal cerebral lesions or diffuse meningoencephalitis. The most common presenting signs are fever and headache, followed by nausea, altered mentation, and focal neurologic deficits. Presentation may be subtle. Diagnosis relies on identifying organisms in cerebrospinal fluid by...

Diagnosis And Treatment

The diagnosis of rabies is frequently made postmortem. This occurs because of the rarity of the disease, the increasing numbers of persons without an obvious exposure, and clinical confusion with other disorders. Important clues to diagnosis include a history of an animal bite and the development of the pathognomonic signs of hydrophobia and aerophobia. Tetanus should not be confused with rabies, because in tetanus the mental status is usually normal and the cerebrospinal fluid is normal. Other diseases that may be confused with rabies include poliomyelitis, Guillain-Barre syndrome, transverse myelitis, postvaccinial encephalomyelitis, intracranial mass lesions, cerebrovascular accidents, and poisoning with atropine-like compounds. During the incubation period of rabies, no diagnostic test is available for either animals or persons that will indicate infection. Routine laboratory tests are of limited value for the diagnosis of rabies. Specific tests are required to diagnose rabies....

Clinical Description Of Infection Spectrum

Count. 4 In particular, in ATL, this indicates that the proviral load corresponds to tumor burden of ATL cells including minimal residual disease (MRD) in remission state because ATL cells usually harbor one proviral genome monoclonally integrated within the same genomic integration site of clonal ATL cells. Thus, detection of the proviral load by real-time PCR is relevant and sufficient to clinically screen HTLV-1-associated disorders and to evaluate the HTLV-1 pathological status by monitoring the infected cell count in peripheral blood, body fluids such as cerebrospinal fluid, and lymph node suspension cells.

Streptococcal Toxic Shock Syndrome

Neurosyphilis is evident by the presence of CNS findings in the setting of a reactive serologic test for syphilis and a reactive VDRL in cerebrospinal fluid. Late syphilis with clinical manifestations other than neurosyphilis is manifested by inflammatory lesions of the cardiovascular system, bone, and skin. Rarely, lesions of the upper or lower respiratory tracts, mouth, eye, abdominal organs, reproductive organs, lymph nodes, or skeletal muscles occur. Evidence of late syphilis is seen after more than 15 years of untreated infection.

Case presentation 2 continued

PCR, polymerase chain reaction CSF, cerebrospinal fluid IgM, immunoglobulin M IgG, immunoglobulin G. includes common arboviruses in North America including St Louis encephalitis, La Crosse encephalitis, eastern equine encephalitis, and western equine encephalitis. PCR, polymerase chain reaction CSF, cerebrospinal fluid IgM, immunoglobulin M IgG, immunoglobulin G. includes common arboviruses in North America including St Louis encephalitis, La Crosse encephalitis, eastern equine encephalitis, and western equine encephalitis.

Medical Device Standards

Manufacturers may retest LAL test failures with the LAL test or a USP rabbit pyrogen test. If the endotoxin level in a device eluate has been quantitated by LAL at 0.5 EU mL endotoxin or greater, then retest in rabbits is not appropriate. Medical devices that contact cerebrospinal fluid should have less than 0.06 EU mL of endotoxin. These values correspond to those set by the CBER for intrathecal drugs. Manufacturers shall use an LAL reagent licensed by OBRR in all validation, in-process, and end product LAL tests.

Morphology and Subtypes

Structurally, ependymoglial cells are characterized by different types of processes that are determined by contact with various microenvironmental compartments. The type I process is a feature of every ependymoglia cell. The endfoot comes into contact with a fluid or space into which extend many microvilli. The apical pole contains abundant mitochondria, which indicates a high level of metabolic activity. Another characteristic of apical processes in some but not all ependymoglia is the presence of kinocilia, a simple cilia consisting of a ring of nine pairs of tubules. Type 1 processes are interconnected by various types of apicolateral junctions. In regions where no endo-thelial blood-barrier exists, ependymoglia cells form a cerebrospinal fluid (CSF) barrier by the expression of tight junctions. Ependymoglial type 2 processes are characterized by basal mesenchymal contact and a cytoskeleton with abundant intermediate filaments. These filaments consist primarily of vimentin when the...

Anatomical Distribution In The Central Nervous System

Metabolic Pathway For Dopamine

Pathways in the human brain, almost 90 of catabo-lism in the rat striatum takes place via the monoamine oxidase (MAO) pathway. In the rat, the level of 3,4-dihydroxylphenylacetic acid is thought to reflect catabolism of intraneuronal dopamine, which includes dopamine that is taken back up by the dopamine transporter, whereas 3-methoxytyramine levels are thought to reflect metabolism of extracellular dopa-mine. Cerebrospinal fluid (CSF) levels of homovanillic acid (HVA) are often used as an indicator of dopaminergic activity in humans.

Extraperitoneal Perforations of the Colon and Appendix

Pararenal Space

Figure 8-45 illustrates that extraperitoneal perforations of the colon can be identified as clearly localized to the anterior pararenal space, even on plain films. The extra-peritoneal collection of mottled gaseous lucencies is oriented with a general vertical axis, medially overlaps the psoas muscle and approaches the spine, and does not obscure the flank stripe laterally. In this patient, who The collection has a generally vertical axis. Laterally, the lucent flank stripe is intact (white arrows). Medially, spread approaches the spine over the psoas muscle. Superiorly, it follows the obliquity of the kidney, and there is extension to the bare area of the liver at the site of reflection of the coronary ligament (black arrows). (From Meyers et al.12) Mottled lucent areas on the right represent collections of gas extending medially over the psoas muscle and approaching the spine. The flank stripe is intact. These changes localize the extraperitoneal gas to the anterior pararenal space.

Disease in Cultured Sea Urchins

There are reports of catastrophic sea urchin die-offs attributable to pathogenic water-borne microorganisms (Lessios et al. 1984 Scheibling and Henni-gar 1997), and of heavy infestations by a parasitic nematode in Norwegian populations of S. droebachiensis (Sivertsen 1996). The appearance of contagious disease typically accompanies the intensification of culture effort. In Japan, where sea urchins have been in culture the longest, there are reports of bacterial diseases affecting juveniles maintained in tanks (Tajima and Lawrence 2001), the outbreaks related to high summer and low spring seawa-ter temperatures. The symptoms include green or black lesions on the body surfaces, spine loss, discoloration of the peristomal membrane and tube feet that are limp or unable to attach to surfaces. Several bacterial strains have been isolated as the causative agents and methods for their control reported. However, as yet, there is no substantial reporting of contagious sea urchin diseases in...

Mitral valve prolapse

Valve conservation has the same advantages as for any other patient. However, these patients have many problems in their lives. My preference is towards mechanical valve replacement, particularly if surgery is being performed or has already been performed on the root and aortic valve. An opposite point of view would be biological solutions to spare anticoagulation throughout, in case the patient later needs multiple eye or spine operations.

Polysynaptic Withdrawal Reflex

When a noxious stimulus is applied to a limb, the signal is first transmitted via sensory fibres to the interneurone(s) in the spinal cord and then onto the a motor neurones. This is an example of a polysynaptic withdrawal reflex (Figure NE.22). The neuronal circuitry involves not only activation of muscle(s) which carry out the withdrawal, but also the inhibition of the antagonist muscles. Other muscle groups may also be stimulated or inhibited so that the withdrawal of the limb and movement of the rest of the body are coordinated to move safely away from the noxious stimulus. Spinal Shock Transection of the spinal cord is accompanied by various changes that demonstrate important physiological principles. In man, cord transection is followed by a variable period during which all spinal reflexes are profoundly depressed or absent. All muscles innervated by spinal nerves below the level of the cord lesion become paralysed and their voluntary control is lost forever. Anaesthesia of the...

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