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. More here...

Dorn Spinal Therapy Summary

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Spinal Meninges Big Picture

The brain and spinal cord are surrounded and protected by three layers of connective tissue meninges called the dura mater, the arachnoid mater, and the pia mater (Figure 1-5A and B). The meninges are supplied by the general sensory branches of the cranial and spinal sensory nerves. The dura mater is the most superficial layer of the meninges and is composed of dense fibrous connective tissue. It forms a sheath around the spinal cord that extends from the internal surface of the skull to the S2 vertebral level where the dura mater forms the coccygeal ligament, which covers the pial filum terminale. The dura mater evaginates into each intervertebral foramen and becomes continuous with the connective tissue covering (epineurium) around each spinal nerve. The nerve roots in the subarachnoid space lack this connective tissue covering and, therefore, are more fragile than spinal nerves. The dura mater defines the epidural space and the subdural space. VThe epidural space is located between...

Indirect Corticospinal Projections

Corticorubrospinal, corticoreticulospinal, and corticovestibulospinal projections contribute to limb and trunk muscle contractions, especially for sustained contractions. Such contractions of muscle are important for stabilizing the trunk and proximal muscles during actions. The reticular and vestibular descending pathways project bilaterally in the ventral and ventrolateral funiculi of the spinal cord, reaching the ven-tromedial zone of the anterior horns to contribute to postural and orienting movements of the head and body and synergistic movements of the trunk and limbs. Kuypers suggested that the interneurons of the ventromedial intermediate zone of spinal gray matter represent a system of widespread connections among a variety of motor neurons, whereas the dorsal and lateral zones, which receive direct corticospinal inputs, are a focused system with a limited number of connections.106 Other corticomotoneurons project directly and by collaterals to the upper medullary medial...

Spinal Sensorimotor Activity

The pools of spinal interneurons and mo-toneurons translate the internal commands of the brain into simple (reflexes), rhythmic (walking, breathing, swallowing), and complex (speaking, reaching for a cup) movements. These motor pools integrate descending commands with immediate access to sensory feedback about limb position, muscle length and tension, tactile knowledge about objects, and other segmental inputs. The sensory and motor pools of the cord conduct simple and poly-synaptic movement patterns, recruit motor units for movements, and participate in rhythmic activity called pattern generation. Most importantly, the spinal motor pools are an integral part of motor learning. Indeed, the spinal cord reveals a considerable degree of experience-dependent plasticity that is induced, adjusted, and maintained by descending and segmental sensory influences.143,144 Another form of spinal plasticity results in pain after a pe

Plasticity in Spinal Locomotor Circuits

The cat's deafferented spinal cord below a low thoracic transection can generate alternating flexor and extensor muscle activity a few hours after surgery when DOPA or clonidine are administered intravenously or when the dorsal columns or dorsal roots are continuously stimulated. This is called fictive locomotion. Several weeks after a complete lower thoracic spinal cord transection without deafferenta-tion, adult cats and other mammals have been trained on a treadmill so that their paralyzed hindlimbs fully support their weight, rhythmically step, and adjust their walking speed to that of the treadmill belt in a manner that is similar to normal locomotion.375,376 Postural support alone is detrimental to subsequent locomotion, whereas rhythmic alternating movements of the limbs with joint loading seems critical to the recovery of locomotor output.377 Serotonergic and noradrenergic drugs enhance the stepping pattern378 and strychnine, through a glycinergic path, quickly induces it in...

An Introduction To Functional Diagnostics Of The Spine

Generally speaking, functional diagnostics are used to assess organ systems for the purpose of detecting dysfunction, identifying the underlying physiological defects, and indicating options for therapeutic intervention. For example, blood chemistry tests are used to assess liver function, while pulse rate monitoring and blood pressure testing are used to assess cardiovascular function. The spine is a series of multiarticulating joints whose primary functions are threefold (1) to allow multidirectional motions between individual vertebrae, (2) to carry multidirectional external and internal loads, and (3) to protect the delicate spinal nerves and spinal cord. Therefore, functional diagnostics of the spine focus on the assessment and measurement of intervertebral motion under various environmental and movement conditions. The results are then used to help guide the management of patients suffering from various conditions of the spine. In discussing spinal function as it relates to the...

Kinematics and coupled motion of the spine

Clinicians use palpatory assessment of individual intervertebral segments prior to the application of a thrust technique. The osteopathic profession has used Fryette's model of the physiological movements of the spine to assist in the diagnosis of somatic dysfunction and the application of treatment techniques. Fryette' outlined his research into the physiological movements of the vertebral column in 1918. He presented a model that indicated that coupled motion occurred in the spine and displayed different coupling characteristics dependent upon spinal segmental level and posture. The 'muscle energy' approach is one system of segmental spinal lesion diagnosis and treatment predicated upon Fryette's laws.2 Practitioners utilizing the muscle energy technique (MET) use these laws of coupled motion, as a predictive model, both to formulate a mechanical diagnosis and to select the precisely controlled position required in the application of both muscle energy and thrust techniques. Current...

Isolation and Culture of Spinal Ligament Cells and Reverse Transcription

Interspinous ligament tissues at the cervical spine were aseptically obtained during surgical operation using the expansive laminoplasty technique with the posterior approach from 10 OPLL and 10 non-OPLL (cervical spondylotic myelopathy) patients. The ligament tissues were washed with phosphate-buffered saline (PBS) several times and then minced into about 1 mm2 pieces. The explant cells were cultured in Dulbecco's modified Eagle's medium supplemented with 10 fetal bovine serum and 0.2 mM L-ascorbic acid 2-phosphate.

Growth of Dendritic Spines

Motor learning induces genes that modify cell structures and functions, such as increasing the number of synaptic spines.259 Indeed, dendritic spines increase with the induction of LTP.265 Growing evidence points to the relationship between morphologic remodeling of the postsynaptic membrane as a late response to LTP and functional changes in synaptic strength.266 In one proposal for this remodeling process, the induction of LTP increases the number of AMPA receptors in a postsynaptic dendritic spine. The postsynaptic membrane enlarges, then splits into several spines.267 The new spines send a retrograde message to the presynaptic membrane to trigger structural changes there. The number of synapses related to the initial activity-induced signal then increases. Long-term depression may involve the inverse of this process. A decrease in AMPA receptors and membrane material leads to a decrease in the size of the postsynaptic membrane, and finally to the loss of the dendritic spine.

Collecting Dynamic Images During the Bend through the Diagnostic Use of Fluoroscopy for Functional Testing of the Spine

With the current standard of care for conducting functional testing of the spine, only static images are collected while subjects hold static posture in their MVBAs no dynamic images are collected, and no images are collected during the bend. There have been several research groups who have addressed this potential shortcoming by collecting dynamic images at points throughout spine bending by using fluoroscopy.27-33 The principal advantage of using fluoroscopy instead of standard radiographs is that if a functional problem is only present dynamically, or if it is only visible at positions other than MVBA, it would never be detectable using the current standard of care. However, although arguably superior to the current standard of care, this method of functional imaging has never become widely used in the United States, because most major American payer organizations have refused to reimburse practitioners for such a use of diagnostic fluoroscopy.

Effect of posture on cervical spine

In slumped, relaxed sitting with lumbar flexion, the thoracic spine is also fully flexed this causes the lower cervical spine to be Hexed and the head protruded (McKenzie 1990). Conversely, in a more upright posture the head is more retracted (McKenzie 1990 Lee et al. 2005). If the individual is looking forward, then the upper cervical spine is in extension. Weak but positive correlations have been found between forward head posture and increased cervicothoracic kyphosis and upper cervical extension (Raine and Twomey 1994). It is important that the patient realises the link between the position of the lumbar and the cervical spine. As mentioned above, the starting position has an effect on the available range of movement (McKenzie 1990 Haughie et al. 1995 Walmsley et al. 1996). For instance, there is 10 degrees more extension in upright sitting (Haughie et al. 1995) and less rotation in extreme retraction and protraction compared to neutral (Walmsley et al. 1996). It is easy to...

Suggestions Regarding the Clinical Use of Recently Developed Methods for Conducting Functional Testing of the Spine

There have been innovations in functional testing technology that offer the promise of definitively detecting those functional presentations most relevant to the aging spine (immobility, hypomobility, and normal motion). These innovations involve a set of three potential changes to the current clinical standard of care The use of fluoroscopy to capture dynamic data regarding intervertebral motion during spine bending (as opposed to taking standard radiographs of patients holding static postures at the extremes of spine bending). of Care for Spinal Functional Testing Negative 5 (i.e., motion in the direction opposite the spine bend) Negative 5 (i.e. motion in the direction opposite the spine bend) Negative 5 (i.e., motion in the direction opposite the spine bend) Negative 5 (i.e., motion in the direction opposite the spine bend) TABLE 10-7 The Authors' Suggestions Regarding the Key Patient-Safety-Related Issues Related to the Adoption of Any of the Newer Methods for Conducting...

What is the natural history of lumbar spinal stenosis

Lumbar spinal stenosis is a potentially disabling condition, caused by compression of the thecal sac (central stenosis) and nerve roots (lateral stenosis). Patients may present with chronic low back pain, leg pain, and or neurogenic claudication. Pain is characteristically relieved by sitting or flexion of the trunk. In severe cases, patients may develop bladder dysfunction from compression of sacral roots. The natural history of lumbar spinal stenosis is favorable in only 50 of patients, regardless of initial or subsequent treatment. Significant deterioration in symptoms with nonsurgical treatment is uncommon. Surgery has been shown to be more effective than nonoperative management in patients with lumbar spinal stenosis, as well as degenerative spondylolisthesis associated with spinal stenosis in short- to medium-term follow-up (2-4 years). At long-term follow-up (8-10 years), low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar...

Cervical Spine Extension And Flexion

Cervical spine extension by tilting the head in a posterior direction. Note the approximation of the markers on the radiograph. Cervical spine extension in a typical forward-head posture. Note the similarity in the curve and the positions of the markers to those in the example above. Often, this slumped posture is mistakenly referred to as flexion of the lower cervical spine and extension of the upper cervical spine. However, the extension is more pronounced in the lower than in the upper cervical region. Good alignment of the cervical spine. Flexion (flattening) of the cervical spine by tilting the head in an anterior direction. Flexion of both the cervical spine and the upper thoracic spine occurs when the chin is brought toward the chest.

What are the pain generators of the spine

Symptoms of axial and radicular pain may be attributed to pathology involving bone, spinal soft tissues (muscles, ligaments, tendons), intervertebral discs, facet joints, sacroiliac joints, and neurologic structures (spinal cord and nerve roots). The interventional pain physician uses injection techniques in an attempt to identify a specific pain generator responsible for a patient's symptoms and guide subsequent treatment. It may be challenging or impossible to identify a specific pain generator in the setting of diffuse age-related degenerative spinal pathology. Consensus regarding the scientific basis for a single pain generator to explain the morbidity of chronic axial pain does not exist. Facet joints (zygapophyseal joints or z-jointS) are paired synovial joints in the posterior column of the spine, which are innervated by medial branches of primary dorsal rami. Lumbar facet pathology may result in referred pain involving the buttock, groin, hip, or thigh. Cervical facet joint...

Anatomy of Cervical Spine

Compared with the relatively rigid thoracic spine and moderately flexible lumbar spine, the cervical spine is the most flexible of the three allowing significant range of motion (ROM) in all planes at the cost of relative stability, especially when the structures of the neck are stressed. The region relies heavily on ligaments and other soft tissue structures to maintain physiological ROM. The cervical spine is composed of seven vertebrae. The occipital-atlantal and C1-C2 joints together account for 34 of the available cervical flexion and extension, whereas 54 of the total cervical rotation takes place at C1-C2. Motion at this these joints, however, accounts for only 10 of lateral bending. The greatest cervical flexion and extension takes place at C5-C6 and C6-C7, whereas the greatest side bending occurs at C2-C3 and C3-C4 with relatively less motion in all planes occurring at the lowest cervical levels. Excessive pathological neck mobility is kept in check by both static and dynamic...

Spinal Neurons As Targets

Some fundamental questions about the pools of neurons within the ventral and dorsal horns have yet to be answered. Which spinal neurons should neural repairists target with the new axons they coax down white matter columns of the cord One of the remarkable chasms in knowledge about spinal cord anatomy and physiology is that very little is known about how and where descending inputs to the dorsal and ventral horns make their connections. Over what expanse, rostrocaudal and mediolateral, do incoming axons normally join interneurons and sensory and motoneurons How many targets can one axon effectively reach and activate What are the neurotransmitters that drive and inhibit these pools Which descending inputs and which target cells would give new axons the greatest behavioral effects for restoration of movement, sensation, and bowel and bladder control Which inputs would prevent or eliminate at-level spinal pain The mechanisms that regulate target recognition within the cord have been...

Retraining the Spinal Motor Pools

The spinal neuronal pools become a new playing field when descending inputs and segmental afferents are withdrawn by injury. If neural repair strategies are to produce functional benefits to patients, biologic interventions will require motor learning and rehabilitation interventions to help train the new networks. A growing number of studies point to the augmented effectiveness of residual supraspinal, corticospinal, and afferent activity after SCI on the spinal and cortical regulation of facilitation and recruitment.312,313 These alterations may expand the cortical and subcortical representations for the sensorimotor activities of the limbs and trunk after a SCI. Cortical representations for the hand and trunk have shown considerable plasticity in people with complete SCI.314,315 The PET scans performed in people with complete SCI reveal an expansion of the hand's topographic map toward the leg area during hand movements and greater bilateral activation of the thalamus and...

Is severe back pain an indication for spinal surgery

Only in limited specific circumstances. Back pain is a symptom, not a diagnosis. The lifetime prevalence of back pain exceeds 70 . Surgery is not indicated for nonspecific low back pain. However, back pain may be a prominent symptom in patients with neural impingement, spinal instability, or certain spinal deformities. In such situations, appropriate spinal decompression, stabilization, and realignment may improve back pain symptoms related to serious underlying spinal pathology. In select degenerative disorders, spinal fusion is a reasonable option following adequate nonsurgical treatment if a definite nociceptive focus is identified in a patient without negative psychosocial factors. Caution is crucial when the indication for surgery is pain because this complaint is often subjective and personal and surgical results are uniformly poor when issues of secondary gain exist.

Unstable Cervical Spine Injuries

Cervical instability can result from bony and or ligamentous damage. White and Johnson et al. defined cervical instability as the inability of the neck to support the head while protecting the spinal cord or its nerve roots from disruption by the cervical column. In contact sports, instability is most often induced by axial compression with neck flexion. White determined that the adult cervical spine is unstable when at least one of the following criteria are met all anterior or posterior elements are destroyed or otherwise rendered unable to function 3.5 mm of horizontal vertebral subluxation is present on lateral radiographs (resting or flexion extension) or 11 degrees or more of angular displacement exists between adjacent vertebrae as measured on either resting or flexion extension radiographs. When assessing cervical stability, radiographs must be taken from the occiput to the C7-T1 junction. Several additional radiological abnormalities may indicate cervical instability,...

The Difference Between Spinal and Epidural

Despite their many similarities, the spinal and the epidural have significant differences. First, the anatomical location of the epidural space and the spinal fluid are different. The epidural space is approximately one or two millimeters shy of the membrane that contains the spinal fluid bathing the spinal cord (the dura mater). The proper placement of the epidural needle is just outside the dura. This is where medication is deposited in epidural anesthesia. For the spinal, we intentionally penetrate the tough dura mater membrane with the spinal needle and enter the space where the spinal fluid is contained. This is where medication is deposited in spinal anesthesia. The second difference is the equipment used. To place the spinal anesthetic, we use a specialized fine needle with a diameter only slightly larger than a horsehair. This hollow needle is advanced between the bony spines of the vertebral column in the lumbar region of the back and advanced until it penetrates the tough...

Analyses of Spinal Ligament Cells from OPLL and OYL Patients

Various cells derived from spinal ligaments and the surrounding tissues have been cultured and characterized, and the effects of BMPs and TGFPs on those cells have been examined in vitro 16,17 . The ligament cell lines obtained from nonossified sites in patients with OPLL were found to have several phenotypic characteristics for osteoblasts high alkaline phosphatase (ALP) activity, parathyroid hormone (PTH)- and prostaglan- din E2 (PGE2)-stimulated increases in cyclic AMP, and responses to both calcitonin (CT) and 1,25-dihydroxyvi-tamin D3 1,25-(OH)2D3 , suggesting that many cells with osteoblast-like characteristics are present 17 . ALP activity was high in the cultured cells of OPLL patients. Exogenous TGF inhibited proliferation in the OPLL cells but promoted proliferation in control cells, suggesting that the spinal ligaments of OPLL patients have an osteogenic predisposition and that TFG may play a role in the ossification 18 . Kon et al. isolated spinal ligament cells from OPLL...

Pathological Characteristics of Spinal Cord Damage Caused by OPLL

The spinal cord was markedly flattened by compression caused by the ossified mass, and the compression was most severe at the level of the intervertebral disk. The diameter of the spinal cord in transverse section was about 2 mm (Fig. 1). The posterior protrusion of the intervertebral cartilage played an important role in damage to the spinal cord damage by OPLL was correlated to spinal canal stenosis. At the upper cervical level, the spinal canal is wider, so marked cord compression did not develop despite a large ossified mass (Fig. 2). On the other hand, in the lower cervical level, severe spinal cord damage was brought about by ossification because the spinal canal is narrow (Fig. 3). The anterior horns were moderately flattened (Fig. 4) and showed loss of nerve cells (Fig. 5) and proliferation of glial cells. Fibrous gliosis of the anterior horns was found even at the level where no marked deformity of the spinal cord was found. The spinal cord damage was pathologically...

Imaging Of Degenerative Spine Disease

Correlation between imaging morphology of degenerative disease and clinical symptoms can be poor, particularly for the most common complaint of pain. The reasons of the discrepancy are not clear, but several factors may come into play. Subjective complaints such as pain may be due to inflammatory response in the surrounding soft tissues, rather than mass effect that can be visualized directly on imaging. In addition, degenerative changes may indirectly compress the nerve roots by distorting their normal surrounding soft tissue structures, such as epidural fat, rather than compress the nerves directly. Imaging usually provides only a static snapshot of the anatomical structures. For example, most imaging studies are acquired with the patient supine, which is most likely different from the posture of the patients when they experience their symptoms. Although specialized units such as upright MRI scanners are now available to address these issues, their use is not yet widely adopted....

Spondylolisthesis and Segmental Instability of the Spine

Spondylolisthesis, scoliosis, and segmental instability can result from degeneration of the stabilizing structures in the spine, including intervertebral discs, vertebral bodies, facet joints, joint capsules, and ligaments (see Figure 16-2). It is important to exclude other underlying pathologies, such as defect of the pars interarticularis or fracture. This consideration is particularly important when the anterolisthesis is greater than grade 1 (25 of the vertebral body diameter), or the degenerative changes are disproportionately mild to account for the high grade spondylolisthesis. Pars interarticularis defect can be detected using oblique radiography or CT. For occult pars defect or occult fracture, a nuclear bone scan may aid in their detection. Segmental instability of the spine can be seen as spine deformity or spondylolisthesis that increases with spine motion and progresses over time. Standing radiography that includes anteroposterior and lateral projections with flexion and...

Physiologic Factors Of Spinal Stabilization

Stability of the lumbar spine requires both passive stiffness, through the osseous and ligamentous structures, and active stiffness, through musculature. Any injury to the passive supporting network of the spine will result in instability.14 That is why optimal muscle strength can protect the damaged spine from repetitive shear forces or nonphysiologic weight bearing. The thoracolumbar fascia acts as a physiologic corset, in essence providing a link between the lower limb and the upper limb, supporting the spinal segments and providing proprioceptive feedback to the individual. Therefore a comprehensive stabilization or facilitation of the abdominal, pelvic, and trunk muscles, which attach to the thoracolumbar fascia and provide for flexion, extension, and rotation of the spine, is a key component to improving trunk strength and preventing future exacerbation of pain. Stabilization of the spine progresses through a sequence of events that begins with strengthening of the smaller...

What soft tissue sarcoma is most likely to involve the spine in the pediatric population

Technetium bone scan and MRI are indicated for evaluation of pediatric patients with a suspected organic spine disorder. 5. Epstein NE. Lumbar surgery for 56 limbus fractures emphasizing noncalcified type 3 lesions. Spine 1992 17 1489-96. 6. Garg S, Dormans JP. Tumors and tumor-like conditions of the spine in children. J Am Acad Ortho Surg 2005 13 372-81. 8. Jeffries LJ, Milanese SF, Grimmer-Somers KA. Epidemiology of adolescent spinal pain a systematic overview of the research literature. Spine 2007 32 2630-7. 9. Neuschwander TB, Cutrone J, Macias BA, et al. The effect of backpacks on the lumbar spine in children a standing magnetic resonance imaging study. Spine 2009 35 83-8.

Extradural Spinal Cord Compression

Extradural spinal cord compression is a clinical emergency. MRI is the study of choice because it yields information regarding the entire spine and will identify multiple levels of compression, even those between two levels of complete block. It also delineates the extent of extraosseous component, thus limiting the chance of geographic miss of partial radiation therapy. All patients should be initially treated with high-dose intravenous glucocorticoids even as neuroimaging work-up is progressing. The probability of restoring neurologic function once it is impaired is inversely proportional to the lapse time from the onset of deficit to the initiation of treatment and inversely proportional to the degree of deficit. As a result, we recommend treating patients within 24 hours of the onset of acute neurologic symptoms. It is rare for a patient who has lost the ability to walk with assistance or to control bowels or bladder to regain these functions. However, patients who still have...

Parenchymal Spinal Cord Metastases

Parenchymal spinal cord solid tumor metastases are the rarest form of extension of breast carcinoma to the CNS and indeed are extremely rare for any histologic primary.127 They must be distinguished from nodular surface accentuation of carcinoma-tous meningitis, which is far more common. They usually cause myelopathy and spinal cord syndromes associated with the predominant location of the lesion within the spinal cord. They are best diagnosed with contrast-enhanced MRI. Lesions arising above the level of the innervation of the diaphragm (C3, 4, and 5) are best treated conservatively with high-dose steroids and fractionated radiation therapy to avoid the disastrous QOL outcome of respirator-dependent quadriplegia. Lower lesions can be surgically explored and occasionally resected with good outcome depending on the lesion's proximity to the dorsal surface of the cord (Figure 55-8). All lesions should be treated initially with high-dose intravenous glucocorticoid therapy and...

Catastrophic Cervical Spine Injury

Injury to the spinal cord resulting in temporary or permanent neurologic injury is a rare but potentially catastrophic event during sports competition. Cervical spine trauma is most common in contact and collision sports such as American football, rugby, ice hockey, gymnastics, skiing, wrestling, and diving (Cantu and Mueller, 1999 Carvell et al., 1983 Tator and Edmonds, 1984 Wu and Lewis, 1985). Cervical spinal cord injuries are the most common catastrophic injury in American football and the second leading cause of death attributable to football. The National Center for Catastrophic Sports Injury Research reported that the incidence of cervical spinal cord injury in American football between 1977 and 2001 was 0.52, 1.55, and 14 per 100,000 participants in high school, college, and professional football, respectively (Cantu and Mueller, 2003). Axial loading is the most common mechanism for catastrophic injury to the cervical spine during sports competition (Torg et al., 1979, 1990)....

For osteoporotic spine fracture prevention and treatment

Twin Cities Spine Center, Minneapolis, Minnesota, USA Spine Unit, Bordeaux University Hospital, Abstract There is a relatively high prevalence of osteoporotic vertebral compression fractures (VCFs) in the elderly population, especially in women aged 50 or older. The result of these VCFs is increased morbidity and mortality in the short and long term. Medical treatment of these fractures includes bed rest, orthotics, analgesic medication and time. Percutaneous vertebroplasty (PVP) consists of percutaneous injection of biomaterial, such as methylmethacry-late, into the VCF to produce stability and pain relief. Biomechanical testing has shown that PVP can restore strength and stiffness of the vertebral body to the pre-fracture levels. Clinical results show immediate and maintained pain relief in 70-95 of the patients. Possible major complications include cement leakage into the spinal canal or into the venous system. Additionally, percutaneous ver-tebroplasty may alter the normal

Cervical spine C27

Keep your left index or middle finger firmly pressed upon the contact point while you spread the other fingers and thumb of the left hand to securely support the head, mandible and neck, thereby locking the applicator in position. You must now keep the applicator on the contact point until the technique is complete. The weight of the head and neck is now balanced between your right and left hands, with the cervical spine positioning controlled by the converging pressures of your two hands.

Spinal Epidural Metastasis

Spinal epidural metastasis from gynecologic neoplasms is extremely uncommon, accounting for only 3.3 of cases of spinal cord compression or cauda equina syndrome (CES).36 Epidural metastasis occurs hematogenously through spinal epidural veins (also known as Batson's plexus) or by direct per-inervous spread from the pelvis.3 Pain, particularly at night or persisting in recumbency, is characteristic of spinal epidural metastasis. Other symptoms include weakness, sensory disturbance, and urinary retention or urgency. Rapidly progressive lower extremity weakness or bowel and bladder involvement signifies spinal cord compression or CES and requires emergent evaluation by MRI or CT myelogram and rapid treatment. Because treatment does not prolong survival, pain control and minimization of neurologic deficit is the ultimate goal. This includes institution of high-dose steroids, surgical decompression, or radiation therapy. One complicating factor is that previous pelvic irradiation may...

New developments for treatment of osteoporotic spine

Vertebroplasty carries its share of risks and complications, but it does lead to significant pain reduction and improved function. It does not, however, improve the sagittal balance or the kyphosis caused by the fracture. Kyphoplasty is a new technique, which tries to address this issue. Kyphoplasty is similar to vertebroplasty except that it calls for introduction of an inflatable bone tamp into the vertebral body which, when inflated, tries to restore the vertebral body height back to its original height while creating a cavity that can be filled with cement (Fig. 4). This technique is performed via a bipedicular approach for a uniform restoration of the compression. Why might reduction of the kyphosis be important in these patients It has been shown that patients with spinal osteoporotic fractures have significantly diminished pulmonary function compared to those without fractures. More importantly, the reduction in the pulmonary functions has been shown to correlate significantly...

Spinal Axis Tumors Incidence Classification And Diagnostic Imaging

The consideration of spinal tumor is important in the complete differential diagnosis for any patient with myelopathy, radiculopathy, or neck or back pain. An expeditious and thorough work-up can quickly rule out a spinal tumor, and timely diagnosis can substantially improve the outcome for some patients with these lesions. Primary tumors that involve the spinal cord or nerve roots are similar to intracranial tumors in cellular type. They may arise from glial cells located within the parenchyma of the cord, Schwann cells of the nerve roots, or meningeal cells covering the cord. Primary tumors that are unique to the spine can arise from the intraspinal vascular network, the sympathetic chain, or bony elements of the vertebral column. Metastatic spinal tumors can result from dissemination of a primary systemic cancer or, more rarely, from drop metastasis of primary intracranial lesions.

Other Diagnostic Considerations Cerebrospinal Fluid

When there is a complete subarachnoid block, the CSF is usually xanthochromic as a result of the high protein content. It may be only slightly yellow or colorless if the subarachnoid block is incomplete. The cell count is usually normal, but a slight pleocytosis is found in approximately 30 of patients. Cell counts between 25 and 100 per mm3 are found in approximately 15 of patients' subarachnoid block secondary to spinal tumor. The CSF protein content is increased in more than 95 of patients. Values of more than 100 mg dl are present in 60 of the patients, and values of more than 1000 mg dl are present in 5 these values may, in rare cases, lead to communicating hydrocephalus. The glucose content is normal unless tumor of the meninges is present. Cytologic evaluation of the CSF is useful when malignant tumors are suspected.33

Nerve Sheath Tumors Of The Spine

Nerve sheath tumors of the spine are relatively common entities. Except in instances of rare malignant tumors, these lesions have a favorable prognosis. They arise from the supportive tissue of the peripheral nerves that begin just beyond the Obersteiner-Redlich zone that demarcates the transition from the central nervous system (CNS) to the peripheral nervous system (PNS).8 These tumors may be intradural and extra-medullary in location, may extend with the nerve root through the neural foramen to form a transdural dumbbell tumor, or may be purely extradural.

Pain Of Spinal Origin

The number of pain-sensitive structures now recognized as potential causes of persistent pain of spinal origin is increasing. The anulus of the intervertebral disc, the facet joint and capsule, the spinal nerve, the dorsal root ganglion (DRG), the dura, the posterior longitudinal ligament, and the paravertebral musculature, as well as the articulations at either end of the vertebral column, with the pelvis (sacroiliac joint, STJ) and the skull (OA joint), are common sites of chronic pain generation. Tn the cervical region, the sinuvertebral nerve receives contributions from the ramus communicans, the sympathetic trunk, and the stellate ganglion and provides innervation to the dura, the posterior longitudinal ligament, and dorsal anulus fibrosus. The sinuvertebral nerve in the lumbar area supplies sensation to the lateral and dorsal intervertebral disc, the posterior longitudinal ligament, and the dura. Additional fibers to the posterolateral disc from the...

Intraspinal Opioid Therapy

This way of relieving pain has gained tremendous popularity recently because of its high rate of success, predictability, and relative safety. Because it demands more attention than treatment with simple oral medications, it is only used when oral medications don't provide enough relief or cause unpleasant side effects. Many terms are used to describe what amounts to similar treatment, including epidural morphine, intrathecal or subarachnoid morphine, and spinal implants or spinal pumps. As described earlier, morphine is a basic painkiller that traditionally is taken orally, rectally, or by an injection into a vein, muscle, or under the skin. In each case, relatively large doses must be given so that enough can eventually get to the specific locations in the body where morphine produces its effects. The key factors responsible for morphine's capacity to relieve pain are receptors, highly specialized microscopic protein structures that are wedged into cell walls. Receptors are...

Intraspinal Drug Therapy

The decision to start intraspinal drug therapy is based on pain location, pain mechanism, and life expectancy. In contrast to neurolysis, intraspinal drug therapy may be effective in controlling more generalized pain. This is because the drug diffuses throughout the intrathecal space to reach receptors located at multiple levels of the spinal cord. As discussed earlier, neurolysis is less effective for neuropathic pain. Therefore, intraspinal drug therapy may be more effective in these cases. The location of the pain influences the technique of delivery. Pain that is localized and unilateral is often better managed with the epidural delivery of opioid and local anesthetic combinations. However, if the life expectancy is longer than 3 months, epidural delivery may be more costly and less effective over time because of development of epidural fibrosis. Pain that is more diffuse is better managed with intrathecal drug delivery. Because neuropathic pain is often less responsive to the...

Spinal Cord Hemangioblastomas

Hemangioblastomas can be found throughout the entire central nervous system but are most commonly located in the cerebellum and spinal cord. They occur sporadically (in approximately two thirds of cases), or in association with von Hippel-Lindau (VHL) disease (in approximately one third of cases).3 Whether they occur sporadically or in relationship to VHL disease, spinal cord hemangioblastomas are histologically identical, benign, highly vascular tumors that can be cured by complete surgical resection. Despite their benign histologic features, spinal cord hemangioblastomas may be associated with significant neurologic deficits related to their size, location, or the presence of associated edema or syrinx.11,17 Recent insights into their natural history, as well as improvements in imaging and refinement in microsurgical removal, have enhanced the diagnosis and treatment of these tumors.

Therapeutic Options For Treating Metastatic Spine Tumors

Therapeutic options for the treatment of metastatic spine tumors are principally external-beam radiation therapy (EBRT) and surgery. Chemotherapy, hormones, and immunotherapy play more limited roles. Regardless of the treatment modality chosen, metastatic spine tumors are treated with the intention to provide palliation. The goals of treatment are to maintain or improve the patient's neurologic and functional status, achieve mechanical stability, reduce pain, optimize local tumor control, and improve overall quality of life.8 The indications for EBRT and surgery have evolved over the past 40 years however, decisions are typically based on anecdotal experiences of referring physicians and institutional preferences. As a result of suboptimal surgical outcomes and high morbidity rates, radiation therapy became the mainstay of therapy for metastatic spine disease. Neurologic and functional outcomes were as good, if not better, than with noninstrumented laminectomy. In early radiation...

Subaxial Cervical Spine

Compression and burst fractures in the subaxial cervical spine often result in severe movement-related pain. As opposed to the AA spine, radiation in an external orthosis does not typically relieve the mechanical pain. These patients often require operation. Tumor resection must often take into account the location of the vertebral artery, which is often pushed laterally and anteriorly by the tumor. Anterior reconstruction with a fibula allograft and cervical plate has been reliable. Most often anterior reconstruction is supplemented with posterior lateral mass screw-rod systems.

Intrinsic Metastatic Spinal John H Chi and Andrew T Parsa Cord Tumors

Intramedullary spinal cord metastasis (ISCM) is a rare sequelae of systemic metastatic malignancy. Although historically considered to be untreatable lesions, current management paradigms have demonstrated good functional outcome and prolonged survival after aggressive treatment. Because of its overall rarity, most of the current knowledge on ISCM derives from autopsy series and small case series. Improvement in diagnostic capabilities, survival from metastatic cancer, and treatment efficacy will likely result in more patients with ISCM becoming diagnosed earlier, living longer, and requiring therapy.

When is it appropriate to refer a patient with nonspecific LBP to a spine specialist

When patients with nonspecific LBP fail to improve with noninvasive treatment after a minimum period of 3 months, it is reasonable to refer the patient to a spine specialist for further evaluation. A spine specialist can assist by providing recommendations regarding exercise therapy, interdisciplinary care, and spinal injections. Surgical intervention is generally deferred until symptoms have persisted for at least 1 year. 4. Dagenais S, Haldeman S, editors. Special issue on evidence-informed management of chronic low back pain without surgery. Spine J 2008 8 1-277.

Stenosis in the Cervical Spine

Radiographs, seen in Figure 50-1A and B, demonstrate loss of normal cervical lordosis, severe spondylosis, and a spondylolisthesis of C4 on C5. Sagittal and coronal MRI cuts, seen in Figure 50-2A and B, demonstrate significant spinal stenosis, loss of normal disc height, and severe spinal cord compression with myelomalacia. lateral postoperative radiographs. Note the restoration of natural cervical lordosis accomplished through multiple anterior discectomies. Posterior decompression and fusion creates additional space for the spinal cord and provides increased stability for fusion.

Epidemiology Traumatic Spinal Cord Injury

Estimates of the prevalence of traumatic SCI in the United States range from 525-1124 cases per 1 million population,2 up to approximately 230,000 survivors.3 The yearly incidence of hospitalized patients is approximately 40 per 1 million persons or 11,000 additional victims each year. Serious nontraumatic SCI cases are about double this incidence. Valuable epidemiologic information regarding SCI in the United States comes from at least 3 prospectively collected sources. The National Spinal Cord Injury Statistical Center (NSCISC) (www.spinal-cord.uab.edu) provides data collected by 24 rehabilitation sites of the Model Spinal Cord Injury Systems Program, funded since around 1974 by the National Institute on Disability and The Uniform Data System for Medical Rehabilitation (UDSmr) in Buffalo, N.Y. reports each year on first rehabilitation admissions for approximately 5000 patients with traumatic and 10,000 with nontraumatic myelopathies.6 These patients represent nearly half of all...

Spine cervical thoracic and lumbar

This section addresses modifications in technique for the cervical spine for those patients aged four years and under. Readers are referred to Section 6 for guidance in the technique for the adult spine. Referral criteria for the spine as a whole are slightly different and include scoliosis (the whole spine should be performed as described for whole spine) congenital anomaly of spine or lower limbs trauma (however, this is not routine, since spine fractures are uncommon in children but indicated when significant injury).

Acute injuries of the spine

Traffic accidents are the single most common cause of spinal cord injury, followed by sports activities. The i-year prevalence of spinal cord injury in sports in Fig. 6.5.6 Schematic showing the polysegmental attachments of the multifidus fascicles originating from Li vertebrae. Their function is that of fine adjustment of loads of polysegmental spinal structures. Original drawing by Ane Reppe. Reprinted with permission from Aage Indahl. Low back pain a functional disturbance. Thesis. University of Oslo, Norway, 1999. Fig. 6.5.6 Schematic showing the polysegmental attachments of the multifidus fascicles originating from Li vertebrae. Their function is that of fine adjustment of loads of polysegmental spinal structures. Original drawing by Ane Reppe. Reprinted with permission from Aage Indahl. Low back pain a functional disturbance. Thesis. University of Oslo, Norway, 1999. North America is about 30 per million. About 50 of all sports-related spinal cord injuries result in complete...

Neurophysiological investigation of the cervical spine

Patients with spinal disorders, with or without sensorimo-tor symptoms and signs, often show discrepancies in clinical and neuroradiological (MRI, CT, myelogram) findings, which make it difficult to pinpoint the cause (i.e., particular nerve root or spinal cord segment) of the patient's complaints. Therefore, questions are raised as to which level or nerve root should be surgically approached. For spinal cord evaluation, SEPs are relevant. These are potentials recorded from the lumbar and cervical spine as well as the first components of scalp recordings. SEPs are generally recorded after electrical stimulation of peripheral nerves or skin. The nerves used are the posterior tibial, sural, or common peroneal nerves of the lower limbs, and the median radial and the ulnar nerve for the upper limbs. In radicular and spinal disease, several nerves, supplied by different segments, must be stimulated for a level diagnosis. SEPs from tibialis nerve are recommended for the diagnosis of...

Surgical Options Cerebrospinal Fluid Diversion

Treatment of colloid cysts is surgical. The indications for external ventricular drainage have been discussed previously, and although drainage may be life-saving, it should not be instituted indiscriminately, because some surgical procedures become more difficult when the ventricles have collapsed. Options for treatment include permanent cerebrospinal fluid diversion with a shunt or direct procedures to aspirate or remove the cyst. Direct procedures include stereotactic aspiration, endoscopic procedures, or craniotomy and resection by a transcortical, transventricular, or interhemispheric, transcallosal approach.

Resection of OLF of the Thoracic Spine Using an Image Guidance System

When thoracic myelopathy due to OLF occurs, conservative treatment is not effective, and surgery is often indicated. Because OLF is situated in the posterior part of the thoracic spinal canal, a posterior procedure with laminectomy has been employed 16-18 . Although controversial, it has been reported that laminectomy sometimes causes complications owing to scar formation in the epidural space and increased kyphotic deformity of the spine, especially in the thoracolumbar junction 17 . To prevent these complications, some surgeons have adopted laminotomy with medial face-tectomy to resect OLF while preserving the spinous processes with the supraspinous and interspinous ligaments, the cranial part of each lamina, and the lateral facets 19 . This procedure is theoretically superior to conventional wide laminectomy because posterior structures of the spine are preserved. However, OLF causing myelopathy is usually extensive, and its shape is irregular. Moreover, the spinal cord becomes...

Economics of Spine Care

Health care has changed much in recent years, and will likely continue to do so. While some amazing advancements have been made in fields ranging from diagnostic imaging to new pharmaceuticals, as well as new surgical interventions, numerous challenges have arisen with respect to cost and access. Regardless of the economic and political discussions of health care, there is certainty that amid the changing current climate, the population is aging. The first of the baby boomers are entering their 60s and will soon become part of the Medicare population. This will greatly increase the number of older patients who will expect high-quality care. In this chapter, the authors will provide an overview of the economics affecting health care, current challenges, and how these topics fit into providing spine care to an aging population. OVERVIEW OF SPINE CARE Spine care is far from immune from the challenges health care is facing. Guyer described this paradox in spine care with the excitement of...

Unifocal Langerhans Cell Histiocytosis of the Spine

Confirming the diagnosis of a spinal lesion as LCH requires a biopsy specimen. This can usually be accomplished through a percutaneous CT-guided needle biopsy.41 In the absence of mul-tifocal involvement, treatment of spinal LCH is determined by various factors. First, in the rare case of neurologic deficit from spinal cord compression, decompressive surgery may be war-ranted.25 Second, in the presence of a potentially unstable lesion, some form of spinal immobilization is required (e.g., cervical collar, halo vest, or thoraco-lumbar bracing). There have been reports of simply observing spinal LCH lesions after immobilization with good results.26 Also, it has been reported that in long-term follow-up review many of these lesions tend to heal very well. In fact, even in the presence of vertebral collapse, restoration in vertebral body height has been reported, sometimes to near normal levels.26,38 Further treatment options for spinal LCH include local radiation therapy or chemotherapy....

Micro and Nanotechnology and the Aging Spine

The aging process presents a cascade of events that affect the health of the musculoskeletal system, in particular, the human spine. The maximum bone mineral density of an individual is reached between the ages of 18 to 20 years of age. As aging progresses, muscle size and strength begin to decrease, by as early as age 25. Accompanying these changes are reductions in hormone levels for both men and women, contributing to a decline in bone density and muscular strength. As we age, the musculoskeletal system experiences degenerative changes resulting in fibrosis, stiffening, and shrinkage of the soft tissue bone loss joint changes and tissue desiccation due to a reduction in proteoglycans and a change in collagen type (i.e., intervertebral disc).10 With respect to the aging spine, this fibrosis and stiffening reduces the osmotic properties of the disc and the ability of the disc to obtain and or maintain vital nutrients while eliminating noxious wastes. Disc desiccation initiates a...

Significance of Intraoperative Spinal Cord Monitoring

In Japan, spinal cord evoked potentials (SCEPs), as described by Tamaki et al., have generally been used to monitor spinal cord function. Although this method is reliable for obtaining stable evoked potentials, the disadvantages of this procedure are that it requires intricate manipulation of recording electrodes placed in the epidural or subarachnoidal space, that it does not allow adjusting the electrode position in areas outside the surgical field, and it does not allow direct monitoring of the integrity of the spinal motor tract 13,14 . Recent advances in spinal cord monitoring techniques have led to the wide use of electromyographic monitoring using high-frequency transcranial electrical stimulation 15 . This technique allows the surgeon to monitor motor tract function easily and directly. stimulation to monitor spinal motor tract function. Only four channels were used initially, but 16-channel monitoring has been utilized since August 2002. This method allows intraoperative...

Spinal Deformity Scoliosis Kyphosis

Scoliosis, kyphosis, and sagittal imbalance are spinal deformities that are degenerative in nature in the older spine. Scoliosis is a three-dimensional deformity that affects the coronal, sagittal, and axial planes. Kyphosis causes sagittal imbalance and is identified as a degenerative curvature that affects the sagittal plane. Lumbar deformities can be classified as idiopathic with superimposed degenerative changes and de novo degenerative scoliosis, in which the deformity starts at age 40 or greater, resulting from osteoporosis and or age-related degenerative disc changes. These deformities are characterized by the location of their curvatures (i.e., thoracic, lumbar, or tho-racolumbar) and can be biplanar in nature. Treatment for such pathology often results in a fusion with rigid instrumentation for curvature correction. Currently, trapezoidal mesh cages with bone morphogenic protein (BMP) are used to provide the anterior column support and improved curve correction with BMP to...

Cerebrospinal Fluid

The brain and spinal cord are surrounded by three meningeal layers the pia, the arachnoid and the dura mater. The first of these layers is closely applied to the brain and between it and the arachnoid is the subarachnoid space containing the circulating CSF. This space is enlarged in parts of the brain to form ventricles, which contain both CSF and areas for secretion of this fluid, the choroid plexuses. CSF circulates in the subarachnoid space surrounding both the brain and the spinal cord and is reabsorbed by the arachnoid villi which lie mainly in the superior sagittal sinus over the surface of the brain. It is essential that circulation of CSF is unimpeded, because obstruction of the foraminae leading to and from the ventricles or to the aqueduct of Sylvius causes local accumulation of CSF and hydrocephalus. In the normal adult, there are 120 ml of CSF, of which about 50 ml are in the spinal subarachnoid space. Its composition is similar to protein-free plasma and it is formed at...

Spinal Column Tumors In Pediatric Patients

I Primary tumors of the spinal column in children are relatively uncommon, constituting less than 1 of all childhood tumors. They demonstrate a wide spectrum of pathologic types and can occur anywhere in the spinal axis. There are three general categories of primary pediatric spinal column tumors (1) benign primary bone tumors, (2) benign tumors of nonosseous elements, and (3) malignant tumors involving the spine. The initial symptoms of spinal tumors in children depend on a variety of factors, including the patient's age and the tumor type. Patients may be evaluated by either plain radiographs or by several different, but complementary, radiographic modalities. Defining the appropriate treatment for a specific spinal column tumor in the pediatric population can be difficult and may present unique challenges to the clinician. In general, the goals of treatment are threefold complete excision of the lesion (when possible), preservation of neurologic function, and consideration of...

Spinal cord injury Commentary

This question occurs more commonly in the examination than in most anaesthetists' clinical practice. Approximately two individuals are paralysed each day in the UK after traumatic spinal cord injuries. Anaesthetists may be involved in their immediate care, but the more difficult, and from the examiners' point of view, more interesting aspects of spinal cord injury, only occur once they have been transferred to specialist centres. Your own knowledge, as well as that of your examiner, is likely to be largely theoretical, and the emphasis of the viva will be on the applied anatomy and pathophysiology of the condition.

Malignant Tumors Involving the Spine Ewings Sarcoma

Ewing's sarcoma is the most common nonprimary malignant tumor involving the spine in children, accounting for approximately 10 of all such lesions. Although originally thought to derive from the reticuloendothelial system, it is now known to derive from neuroectodermal tissue.15 The cells in question are thought to be from postganglionic parasympathetic tissue, because they can synthesize choline acetyl transferase and have no sympathetic precursors. Grossly, Ewing's sarcomas appear gray, firm, and friable. On histologic inspection, they typically demonstrate primitive cells with hyperchromatic nuclei, little Ewing's sarcoma commonly affects the sacral region, with thoracolumbar lesions seen less often.5 Cervical lesions are rare but can occur (Figure 104-2). The tumors grow rapidly, producing unremitting nighttime pain and neurologic deficit as the initial symptoms. Because of tumor bulk and the soft tissue involvement, systemic symptoms such as weight loss and fever may also occur....

Pediatric Intradural And Extramedullary Spinal Cord Tumors

In 1888 Sir William Macewen, a Scottish neurosurgeon and well-known pioneer in the field of craniospinal surgery, reported the removal of five extradural spinal tumors via laminectomy in a lecture to the Glasgow Medical Society. The first patient, a 9-year-old boy, underwent surgical resection in 1882. All but one patient (who died) made a significant degree of functional recovery.25 In 1887 Sir Victor Horsley, another pioneer in the field, successfully removed the first intradural, extramedullary spinal cord tumor, which had been initially diagnosed by Sir William Gowers.8 Today's neurosurgeon, aided in diagnosis by magnetic resonance imaging (MRI) and in resection by modern microneurosurgical techniques, continues to redefine and improve the body of knowledge regarding pediatric spinal cord tumors. The pre-MRI literature reports the incidence of spinal cord tumors at up to 2.5 per 100,000 people and from 3 to 12 times less common than brain tumors in the general population.1 With...

Future Directions in Spinal Cord Monitoring

Intraoperative spinal cord monitoring has been recognized as a specialized technique that is performed only in some leading medical institutions. This is likely because excessive emphasis has been placed on the scientific aspects of the technique, which makes understanding spinal cord monitoring difficult for general spine surgeons who had not specialized in electrophysi-ology. The CMAP method, which uses stimulation of the motor cortex to move muscles, is relatively easy to understand and would be accepted by many spinal surgeons. In addition, considering the recent challenges facing spinal surgeons (i.e., the increasing number of medicolegal problems), CMAP spinal cord monitoring is likely to become a standard essential technique during general spinal surgery.

Intramedullary Spinal Tumors

Intramedullary spinal neoplasia represents a particularly cruel clinical problem, especially in childhood, because it causes pain, deformity, and progressive disability without blunting the patient's awareness of self and circumstances until, in malignant instances, the very last stages of the illness. In the past the obscurity of the symptoms often delayed the diagnosis, and the initial surgical management often contributed to the morbidity of the disease. Fortunately, universal access to magnetic resonance imaging (MRI) has simplified and has probably shortened the diagnostic process. Improvements in surgical instrumentation and electrophysiologic monitoring methods have bolstered the surgeon's confidence in approaching intramedullary tumors and have probably enhanced outcomes as well. These recent advances in patient care may season this chapter with satisfaction and hope.

Epidural and Spinal Anesthesia

Epidural anesthesia is administered by injecting local anesthetic into the epidural space and can be performed in the sacral hiatus or in the lumbar, thoracic, or cervical regions of the spine. Spinal anesthesia follows the injection of local anesthetic into the CSF in the lumbar space. Significant differences between epidural and spinal anesthesia are that the dose of local anesthetic used in epidural anesthesia can produce high concentrations in blood following absorption from the epidural space, and that there is no zone of differential sympathetic blockade with epidural anesthesia thus the level of sympathetic block is close to the level of sensory block.y Probable causes of neurological complications following epidural and spinal anesthesia include trauma, the nature of the injected material, infection, vascular lesions, or pre-existing pathology. The incidence of transient paralysis following epidural anesthesia is 0.1 percent, and the incidence of permanent paralysis is 0.02...

Cervical spine and vertebrobasilar insufficiency VBI Background

Traditionally a series of movements or positions thought to test the integrity of the vertebrobasilar arteries have been advocated prior to manipulation or mobilisation of the cervical spine (Maitland 1986 Grant 1994a McKenzie 1990). Such cervical procedures have sometimes been associated with complications, very rarely of a serious nature, such as death or cerebrovascular accident. The aim of the test movements and certain direct questions is to try to identify patients for whom this type of treatment may be contraindicated. The topic is a controversial one. Some authorities are of the opinion that the risks of manipulation outweigh the benefits (Di Fabio 1999 Refshauge et al. 2002), and many consider the screening procedures unreliable and invalid (Dunne 2001 Rivett 2001 Gross and Kay 2001). Di Fabio (1999) reviewed 177 reports of injuries associated with cervical manipulation published between 1925 and 1997. The most common were arterial dissection, injury to the brain stem,...

Intradural Intramedullary and Intradural Extramedullary Lipomas Unassociated with Spinal Dysraphism

Spinal cord intradural, intramedullary lipomas are rare entities, usually found along the dorsal aspect of the thoracic spine and in the midline.12,23 In one early report, they were found in decreasing frequency over the cervical-thoracic spine and over the cervical spine. In addition, there are eight reports of intramedullary spinal cord lipomas affecting nearly all levels of the spinal cord, known as holocord lipomas.12 Patients with spinal cord lipomas most often have slowly progressive signs of spinal cord compression. The most commonly reported presenting symptoms are those of an ascending spastic motor weakness in one or both legs.10,12,23 The clinical presentation and examination findings reflect the location and size of the spinal cord lipoma. Spinal cord lipomas are uncommon, with approximately 200 reported cases, predominantly of the intradural or extra-medullary type, having been identified in the cervical and upper thoracic spine since the first report by Gowers in 1876.12...

Cervical Spine Injuries In Athletesi

Sports-related cervical injuries can involve the muscles, ligaments, intervertebral discs, osseous structures, and the neural structures they protect. Injuries to consider include muscular strains, intervertebral disc injuries, major minor cervical spine fractures, stinger burner injuries, and transient quadriplegia. In addition, preexisting cervical conditions predispose an athlete to neurologic injury and may be discovered during subsequent evaluation. These include congenital cervical stenosis, Klippel-Feil syndrome, and os odontoideum. It is important to engage in spinal precautions and leave the headgear in place until the cervical spine can be completely evaluated. The team personnel should have a means available for removal of the facemask so that the airway is readily accessible. Immediate removal of the helmet should not be performed until the proper medical personnel are prepared for an emergency situation. If circumstances require helmet removal, the shoulder pads should be...

What are the options for reconstruction of the anterior and middle spinal columns after resection of a metastatic

Vertebral Body Height Loss

Options for reconstruction of the anterior and middle spinal columns include bone graft (autograft or allograft), methylmethacrylate, titanium mesh cages, and carbon fiber or polyether ether ketone (PEEK) cages. Expandable cages have been popularized for use in this setting. All of these intracolumnar implants are used in combination with anterior spinal instrumentation (plate systems, rod systems) and or posterior segmental spinal fixation. 29. What is the role of kyphoplasty and vertebroplasty in the treatment of spinal metastatic disease Kyphoplasty and vertebroplasty provide a minimally invasive approach for reduction of pain associated with pathologic spine fractures resulting from metastatic disease. Ihe injected cement does not interfere with radiation therapy. Ihe most common complication associated with these techniques is local cement extrusion. Contraindications to these procedures include vertebral body height loss exceeding 75 , posterior vertebral body cortex...

Pagets disease of the spine

Mitch Fracture

The second part of this paper looks at Paget's disease, another osteometabolic disorder that can affect the aging spine. It describes the spinal involvement of Paget's disease in bone and outlines best treatment options. Prevalence of back pain and spinal stenosis The spine is the second most commonly affected site in PD 2, 30, 95 , predisposing patients to low back pain and Fig. 12 Bone modeling of vertebra depicted diagrammatically to demonstrate tendency of bone expansion in all directions, leading to hypertrophic facet osteoarthropathy and spinal stenosis. Reprinted, with permission, from Hadjipavlou A, Lander P (1995) Paget's disease. In White AH, Schofferman JA (eds) Spinal care. Mosby, St Louis, pp 1720-1737 Fig. 12 Bone modeling of vertebra depicted diagrammatically to demonstrate tendency of bone expansion in all directions, leading to hypertrophic facet osteoarthropathy and spinal stenosis. Reprinted, with permission, from Hadjipavlou A, Lander P (1995) Paget's disease. In...

Lipomas of the Spinal Cord Associated with Spinal Dysraphism

The term lipomyelomeningocele refers to a congenital lesion of the meninges or spinal cord plus meninges and the presence of benign fat, both of which exist with a dysraphic spinal column. Depending on the classification system used, these lesions may be divided into as many as five subtypes as they appear on neuroimaging.2 In general, a lipomyelomeningocele is recognized on MRI as a caudally descended conus medullaris invested in fat. Arai et al, using conventional myelogram and MRI, define lipomyelomeningocele as a low lying tethered spinal cord that enters a subcutaneous cystic meningeal sac and terminates in the lipomatous mass on the wall of the meningeal sac. 2 The lipoma and meningocele may appear together or on opposite sides of the spinal canal. The asymmetric variety is less common and is generally associated with more severe deformities of the sacrum and lower extremities.23 Lipomyelomeningoceles may also be associated with a syringomyelia, tethered spinal cord, dermal...

Cervical Spine Assessment

Examining the cervical spine requires a thorough neurological and a rthrological scan of the spine and entire upper quadrant. The temporomandibular joint, upper thoracic spine, costovertebral joints, costotransverse joints, first rib, rib cage, and shoulder complex also have a large influence on the cervical spine and should be ruled out when assessing cervical pathologic conditions. Because of the frequent occurrence of motor vehicle accidents, the athlete must always be questioned regarding a previous accident or whiplash injury. If there has been a previous whiplash to the cervical spine, there is usually scar tissue and dysfunction that will affect the testing. It is also important to determine the emotional status of the athlete in the general history because stress or increased muscle tension can make testing more difficult and may alter the results. The joints of the cervical spine include the atlanto-occipital joint (O-Cl or A-O joint), atlantoaxial joint (C1-C2 or A-A joint),...

Identification of serious spinal pathology

It is recommended that the same 'red flags' used to provide clues as to the existence of serious spinal pathology in patients with back problems be applied to patients with neck pain (Nachemson and Vingard 2000 Honet and Ellenberg, 2003). The recommendation exists because there is a lack of evidence with regard to 'red flags' for the cervical spine (Nachemson and Vingard 2000 Honet and Ellenberg, 2003). Minimal work has been done to evaluate the diagnostic accuracy, incidence or comprehensiveness of these 'red flags' in large groups of neck (or thoracic) pain patients. Indeed, most reports on 'red flags' have been based on case studies or series that are present in the literature, but are not helpful in addressing these issues. Rather than seeking to identify specific pathology through individual items of history or physical examination, an alternative approach has been to predict serious spinal pathology in general from these items (Waddell 2004). When diagnostic triaging is...

Cranial and Spinal Subdural Empyema

Subdural empyema is a pyogenic infection in the space between the dura mater and the arachnoid and represents 13 to 20 percent of localized intracranial infections. The arachnoid is not a very strong barrier, and subdural empyema may breach the arachnoid and cause subpial infection. y The most common predisposing condition that leads to the development of a subdural empyema is paranasal sinusitis, especially frontal sinusitis. Paranasal sinusitis is the primary cause of a subdural empyema in 50 to 80 percent of patients, and otitis media is the primary cause in 10 to 20 percent. y , y Superficial infections of the scalp and skull, craniotomy, or septic thrombophlebitis from sinusitis, otitis, or mastoiditis may extend to the subdural space causing empyema. y Subdural empyema in infants usually represents an infected subdural effusion complicating a bacterial meningitis. y , y An empyema may rarely develop in the subdural area of the spinal cord. with...

Other Disorders of the Skull and Spine Dwarfism

Clinically, there are short limbs, a narrow thorax with short ribs, a short spine with flat vertebral bodies, and a large-appearing cranium with a flat nasal bridge. There are two subtypes the more common variety (type I) with bowed bones but rarely a cloverleaf skull, and a second form (type 2) with straight bones but with a complex craniosynostosis giving rise to the cloverleaf skull. Hydrocephalus is common with the second type of craniosynostosis. Both forms are associated with mutations in FGFR3. Achondroplasia can be associated with a number of neurological complications. y Stenosis at the level of the foramen magnum can cause a high cervical or lower medullary myelopathy. In case of lower medullary myelopathy, apneic spells or respiratory insufficiency can result high cervical myelopathy can give rise to long tract symptoms, including frank quadriparesis. Stenosis of the spinal canal with myelopathy or radiculopathy can occur at any level. Careful assessment for...

Lipomas of the Filum Terminale without Spinal Dysraphism

Lipomas of the filum terminale occur at the caudal tip of the spinal canal. These malformations are more common than lipomyelomeningoceles and greater than 90 are recognizable Surgical resection and untethering of the spinal cord are the mainstays of treatment for symptomatic lipomas of the filum terminale. Outcome data for these patients are similar to patients with spinal cord lipomas, with the majority showing improved motor, bowel, and bladder function and decreased pain.3 Recurrence of these lipomas has not been reported. However, recurrent tethering of the spinal cord may occur and should be suspected when recurrent or progressive symptoms are noted.

Subaxial Cervical and Upper Thoracic Spine Fractures in the Elderly

Discoligamentous Injury Mri

Elderly patients are at increased risk of neurological injuries, including central cord syndrome, due to degenerative stenosis, spondylotic stiffness, and changes in spinal cord morphology and vasculature. Spinal ankylosis increases the risk of unstable fractures, which may not be diagnosed on initial imaging studies such as plain radiographs. Elderly patients with subaxial cervical and upper thoracic spine fractures have increased treatment risks as compared to young patients, related to medical comorbidities, ankylosed segments, osteoporotic bone, and preexisting stenosis. Spinal reconstruction in the setting of osteoporotic fractures may require specific operative techniques to prevent hardware failure. The geriatric cervical spine is prone to injury. The susceptibility to bony, ligamentous, and neurological injury may be associated with age-related changes including osteoporotic bone, stiffened spinal articulations, preexisting stenosis, and altered spinal cord vasculature and...

Describe the course of the vertebral artery in the cervical spine

Vertebral Artery

Vertebral artery. (From Winter R, Lonstein J, Denis F, et al. Posterior upper cervical procedures Atlas of Spinal Surgery. Philadelphia Saunders 1995. p. 23.) 7. Where is the vertebral artery injured most frequently in upper cervical spine exposures 9. Describe the posterior exposure of the lower cervical spine. The midline posterior exposure is the most common approach used in the cervical spine. Care is taken to carry dissection through the ligamentum nuchae to minimize blood loss. Once the tips of the spinous processes are identified at the appropriate levels through radiographic confirmation, subperiosteal dissection of the posterior elements is then carried out. The posterior approach is extensile and is easily extended proximally to the occiput and distally to the thoracic spinal region. A process termed creeping fusion extension may occur when unwanted spinal levels are exposed during the fusion procedure. This is especially common in children and may lead to...

From spinal cord to cerebral cortex

Disproportionate Body Parts

The spinal cord has a relatively simple structural organization a central region of 'grey matter' containing synapses and the cell bodies of neurons and a surrounding 'white matter' consisting of the axons transmitting information up and down the cord. The spinal cord is segmental and at each segment there are two pairs of 'roots', one dorsal and one ventral, which connect the spinal cord to the body. The ventral roots contain the outgoing axons of motor neurons and the dorsal roots contain the incoming axons of sensory neurons. The cell bodies of the sensory neurons reside in swellings called dorsal root ganglia close to the spinal cord. Cell bodies of the motor neurons are found in the ventral grey matter, clustered together in functionally related groups. Thus motor neurons that innervate a given muscle are grouped together and motor neurons of the extremities are found laterally in the cord, whereas those innervating trunk muscles are more centrally located. This grouping by...

Spinal Roots Spinal Nerves And Rami The Big Picture

Spinal Nerves

At each spinal cord segment, ventral and dorsal spinal roots join to form spinal nerves that bifurcate into ventral and dorsal rami. Spinal roots carry sensory (dorsal root) or motor (ventral root) neurons, whereas the spinal nerves and rami contain a mixture of sensory and motor neurons. The dorsal rami seg-mentally innervate deep back muscles (motor) and the skin of the back (sensory). This section of the chapter helps to differentiate among vertebral levels, spinal cord levels, and spinal nerve levels. SPINAL ROOTS At each spinal cord segment, paired dorsal and ventral roots exit the lateral sides of the cord to form left and right spinal nerves. As a result of unequal growth between the vertebral canal and the spinal cord (the vertebral canal is longer than the spinal cord in adults), the nerve roots follow an oblique course from superior to inferior (Figure 1-7A). Only in the cervical region are the segments of the spinal cord at the same level with the corresponding cervical...

How does RA affect the cervical spine

Rheumatoid Arthritis Anaesthesia Spine

The cervical spine is composed of 32 synovial joints. The occiput-C1 and C1-C2 articulations rely on soft tissue integrity for stability. In the subaxial cervical spine, the facet joints are true synovial joints. Rheumatoid pannus produces enzymes that destroy cartilage, ligaments, tendons, and bone. This synovitis leads to spinal instability, subluxation, and spinal deformity. Secondarily, the discs in the subaxial spine degenerate, which may result in additional facet joint subluxation and or ankylosis. Spinal cord and brainstem compression may develop secondary to static or dynamic spinal deformities or from direct pressure by synovial pannus. Figure 68-1. A, Dynamic radiographic series of a 68-year-old patient with rheumatoid arthritis. The black arrows indicate the spinolaminar line. Anterior subluxation occurs in flexion, and slight posterior atlantoaxial subluxation is revealed in extension. Note the increased atlantodens interval (ADI), reduced space available for the cord...

Cranial and Spinal Epidural Abscess

Cranial epidural abscesses develop in the space between the dura and inner table of the skull and are usually caused by the spread of infection from the frontal sinuses, middle ear, mastoid, or orbit. y Epidural abscesses may also develop as a complication of a craniotomy or compound skull fracture. At present, the most common cause of a cranial epidural abscess is craniotomy that has been complicated by an infection of the wound, bone flap, or epidural space.y Epidural abscesses may result from or be associated with an area of osteomyelitis. A spinal epidural abscess develops in the space outside the dura mater but within the spinal canal. The spinal epidural space is only a true space posterior to the spinal cord and the spinal nerve roots. The anteroposterior width of the epidural space is greatest in the area where the spinal cord is smallest, that is from approximately T4 to T8, and from L3 to S2. d , y The most common location for an epidural...

Major spinal deformity and widespread neurologic disorders

Major spinal deformity and widespread neurologic disorders are rare but should be obvious - again, provided you are aware. You should not miss a major deformity such as a kyphosis or structural scoliosis providing you get the patient to undress. This may seem obvious, but one recent survey found that more than 50 of patients with back pain said their doctor had never examined them. In backache the common deformity is a list (Fig. 2.2). Muscle spasm pulls the spine to one side when the patient is standing and may also cause loss of the lumbar lordosis. In true scoliosis there is a fixed deformity with compensatory curves above and below (Fig. 2.2). A spinal list usually, but not always, improves when the patient lies prone and the muscles relax, but true scoliosis never changes. You can see early scoliosis as a rib hump when the patient reaches down to his or her toes.

Natural history of the aging spine

Abstract The unrelenting changes associated with aging progressively affects all structures of the spinal units. The degenerative process starts early during the first decade of life at the disc level. Discal degeneration is associated with biochemical changes followed by macroscopic alterations including tears and fissures, which may lead to discal herniation, the main cause of radiculopathy in the young adult. Moreover, nociceptive nerve fibers have been demonstrated in degenerated discs. They may be a source of nociception and of pure low-back pain. Facet joint changes are usually secondary to discal degeneration. They include subluxation, cartilage alteration and osteo-phytosis. Facet hypertrophy and laxity, associated with discal degeneration, and enlargement of the ligamen- tum flavum progressively create narrowing of the spinal canal as well as degenerative instabilities such as spondylolisthesis and scoliosis, which are the main causes of neurogenic claudication and...

What is the anatomic basis for EDX as it relates to the assessment of spinal disorders

Metatarsophalangeal Joint

The purpose of the EDX is to assess the motor and sensory function related to the spinal nerves. Each spinal nerve contains both motor and sensory fibers and contributes to the formation of the peripheral nerve. The cell bodies for the motor axons are situated within the anterior horn of the spinal cord. The cell bodies for the sensory axons are located within the dorsal root ganglion near its junction with the ventral root. There it forms the mixed spinal nerve in the region of the intervertebral foramina. After exiting the neural foramen, the spinal nerve root divides into anterior and posterior rami. The anterior rami supply the anterior trunk muscles and, after entering the brachial or lumbosacral plexus, the muscles of the extremities. The posterior rami supply the paraspinal muscles and skin over the neck and trunk (Fig. 17-1). Figure 17-1. General organization of the somatic peripheral system to show the formation of rootlets, spinal nerve rami and plexuses, and individual...

Joint Movements Of The Cervical Spine

Movimenti Cervicale

The normal anterior curve of the spine in the cervical region forms a slightly extended position. Cervical spine extension is movement in the direction of increasing the normal forward curve. It may occur by tilting the head back, bringing the occiput toward the seventh cervical vertebra. It also may occur in sitting or standing by slumping into a round-upper-back, forward-head position, bringing the seventh cervical vertebra toward the occiput. Cervical spine flexion is movement of the spine in a posterior direction, decreasing the normal anterior curve. Movement may continue to the point of straightening the cervical spine (i.e., the end range of normal flexion), and in some instances, movement may progress to the point that the spine curves convexly backward (i.e., a position of mild kyphosis). Gore et al., using cervical radiographs, reported cervical kyphosis as a normal variant in asymptomatic individuals. (1) Harrison et al. used radiographs Movement of the spine in the frontal...

Stenosis in the Lumbar Spine

Vertebrae Abnormalities Xray

An active 90-year-old man was referred to the spine surgery clinic with a long history of worsening bilateral buttock pain and decreased walking tolerance. He was otherwise in excellent health, but noted a burning pain in his buttocks with radiation down the posterior and lateral thighs after ambulating more than about 50 yards. The pain quickly improved with rest, and would not occur if he had a shopping cart to lean on while ambulating. Descending stairs or inclines would aggravate symptoms but ascending stairs would not. He had been evaluated by the vascular surgery service and was not found to have vascular insufficiency. Despite an intensive program of physical therapy focusing on core strengthening, flexibility, and cardiovascular fitness his symptoms persisted. Interventions by the pain management service, including epidural steroid injections, had been unsuccessful. FIGURE 50-7 A, AP x-ray of lumbar spine showing multilevel spondylosis with a degenerative scoliosis and mild...

Spinal Cord Stimulators

Placed over the dorsal spinal cord in the epidural space, electrical stimulation, initially preformed to reduce some types of central pain, may also lessen hypertonicity after SCI.29 Stimulation of the upper lumbar cord has also produced rhythmic leg movements in subjects with complete SCI.30 Stimulation with four dorsally placed lumbar electrodes reportedly improved the gait pattern of a patient with spastic quadriparesis. Walking speed and endurance increased beyond what had been accomplished with body weight-supported treadmill training alone.31 The common thread among these spinal stimulation interventions for pain, spasticity, and automatic flexor and extensor leg movements appears to include rhythmic drive of dorsal horn afferents, including Ia fibers (see Chapter 1 under Central Pattern Generation). Thus, epidural stimulation may be an adjunct to locomotor training in highly disabled patients, along with FNS, should reliable and safe techniques evolve. As discussed in Chapter...

What is the role of chemotherapy in the treatment of a metastatic spinal lesion

Chemotherapy is used in patients with documented spinal metastases, patients at risk of developing spinal metastases, and patients with spinal lesions not amenable to surgical excision. The response to chemotherapy is determined by the tumor type. Tumors that are highly sensitive to chemotherapy include small-cell carcinoma of the lung, Ewing's sarcoma, thyroid carcinoma, breast carcinoma, lymphoma, germ cell tumors, and neuroblastoma. Tumors that are relatively resistant to chemotherapy include adenocarcinoma of the lung and GI tract, squamous cell carcinoma of the lung, metastatic melanoma, and renal cell carcinoma.

When are antidepressants useful for patients with spine problems

Antidepressants have several potential uses in patients with chronic spinal problems, including the treatment of back pain, neuropathic pain, sleep disturbance, and depression. Only the antidepressants with primarily nonadrenergic activity are useful for pain. The data regarding efficacy of antidepressants for axial pain are equivocal. At best, isolated studies show about 30 reduction in pain in one third of patients. In addition, recent data suggest these drugs are not very effective for radicular pain caused by ongoing neural compression. However, they may be quite effective for neuropathic extremity pain. The sedating antidepressants can be effective for sleep but have not been compared with standard hypnotics. They may have more side effects and greater risk. Most antidepressants can be effective for depression in the patient with chronic spinal pain, but it may take two or three trials before finding the best drug.

Low Cerebrospinal Fluid Pressure Headache

Headache present when the patient is upright but resolving in the supine position is often related to low cerebrospinal fluid (CSF) pressure. This may occur spontaneously, but most often is the result of prior lumbar puncture resulting in persistent leak of CSF. The headache pain and other clinical manifestations can be quite debilitating.

The Cervical Thoracic Spine Mechanical Diagnosis Therapy

Spinal Publications New Zealand Ltd Raumati Beach, New Zealand The Cervical & Thoracic Spine Mechanical Diagnosis & Therapy First Edition first published in 1990 by Spinal Publications New Zealand Ltd Second Edition first published in April 2006 Reprinted February 2007, March 2008 by Spinal Publications New Zealand Ltd PO Box 2026, Raumati Beach, New Zealand Email enquiries spmalpublications.co.nz

Serious thoracic spinal pathology

Thoracic spine pain is often found in lists of 'red flags' indicating serious spinal pathology (CSAG 1994 Waddell 2004). Not all pain originating in the thoracic spine is serious, and much of it is normal mechanical pain. However, as there is a much lower prevalence rate of thoracic pain compared to lumbar and cervical, proportionately there is a higher incidence of serious pathology in this region. A range of serious pathologies can occur in the thoracic spine, some more commonly in this region than at the cervical or lumbar regions. In a survey that included thirty-three patients deemed to have thoracic pain and who underwent a mechanical evaluation, two (6 ) were thought to have serious spinal pathology compared to less than 2 and 0 in the lumbar and cervical regions (May 2004b). It is essential that Chapter 8 is read in full to help in the identification of serious pathologies, and Table 8.1 is consulted as a checklist of possible 'red However, the folloWing points should be noted...

The First Spinal Anesthetic

James Corning ( Fig. 2-1 ), a New York City neurologist, heard in 1885 of the local anesthetic properties of cocaine, which had been discovered by the Viennese ophthalmologist, Carl Koller, in 1884. 3 Corning began a series of experiments to determine whether local medication of the spinal cord was within the range of practical achievement. He reasoned that cocaine might be the ideal agent to treat neurologic disease if applied in the vicinity of the venae spinales of the cord. If it were delivered to the spinal region, it could be absorbed and carried to the affected area, having a much greater effect, like that of strychnine when it was injected in the same way. His first subject was a dog. Corning injected cocaine below the spinous processes of two of the inferior dorsal vertebrae. After a few minutes, the dog's hindquarters became paralyzed. A short while later, he tried the same technique on a young man with seminal incontinence. The young man received 2 mL of a 3 solution of the...

Table 441 Incidence Of Severe Complications Related To Spinal And Epidural Anesthesia

Direct trauma from needle or catheter placement rarely results in significant neurologic injury. However, paresthesias during needle placement are a risk factor for lasting neurologic complications. In two large studies examining spinal anesthetics, one retrospective and one prospective, 67 and 63 , respectively, of persistent paresthesias were preceded by paresthesias during needle placement.13 Persistent paresthesia after epidural block may occur in association with paresthesias during needle placement up to 100 of the times There are no data to guide the clinician in deciding whether to continue the block or to move to a different interspace should a paresthesia occur during needle placement.1 Indwelling neuraxial catheters may increase the incidence of paresthesias. In one study, the rate of paresthesias with single-dose and continuous spinal anesthetics was 13 and 30 , respectively.1121 The presence of a catheter may increase the risk of postoperative neurologic deficit, either...

Table 256 Epidural Versus Spinal Anesthesia For Cesarean Delivery

Spinal Risk of total spinal Some discussions have called into question whether prehydration prevents regional anesthesia-induced hypotension, and how much of what intravenous solution should be administered. Administration of crystalloid, 20 mL kg, immediately before initiation of spinal anesthesia decreased the incidence of hypotension from 71 to 55 . Although colloid (500 mL) administration was associated with less hypotension than crystalloid administration, the incidence was still 40 to 58 . 1249 I2 I2 In conclusion, if time permits, parturients should receive intravenous crystalloid prehydration, 10 to 20 mL kg, immediately before the initiation of spinal anesthesia. This dosage will decrease but not eliminate the incidence of hypotension. Non-glucose-containing solutions should be administered, because glucose may contribute to neonatal hypoglycemia. Some anesthesiologists advocate the use of prophylactic ephedrine in an attempt to decrease the incidence of hypotension. Although...

Spinal Cord Stimulation For Abdominal Pain

The putative mechanism for the efficacy of spinal cord stimulation for abdominal pain is similar to those for other conditions stimulation of the dorsal horn or dorsal column of the spinal cord or direct stimulation of nerve roots in the lateral aspect of the spinal canal. The latter mechanism is probably more effective because it will cover both somatic and visceral fibers. Ilioinguinal and genitofemoral neuralgia has been treated with spinal epidural electrodes placed at the T11-L2 level, about 5 to 7 mm from the midline.11 The use of the spinal epidural retrograde technique directed at the T12 nerve root has also been described.11 Reports on the use of spinal stimulation for abdominal pain are very limited. Both the paramedian and lateral canal (direct nerve root) electrode placement techniques seem to be reasonably effective for pain control in these conditions. These reports are too limited and follow-up periods too short for more detailed comment about outcome expectations....

Spinal Anesthesia

Spinal anesthesia is indicated for most elective cesarean deliveries and for urgent cesarean deliveries in patients without preexisting epidural analgesia. The advantages of spinal over epidural anesthesia include the following ( Table 25-6 ) (1) it is a technically easier block with a higher success rate (2) onset of anesthesia is faster (3) the sensory block is more dense (4) there is no risk of systemic local anesthetic toxicity and (5) there is minimal transfer of drug to the fetus.1213 1213 Disadvantages include the following (1) it is not a continuous technique and (2) acute onset of sympathectomy may not be tolerated in select patients. With the advent of pencil-point spinal needles, the incidence of PDPH is equal for spinal and epidural anesthesia.12

Spinal Anesthesia And Hypotension

Hypotension is the commonest problem following spinal anesthesia for cesarean section. It results from a decrease in arteriolar and venous tone secondary to sympathetic block, with a resulting reduction in systemic vascular resistance and venous return. The prevention of aortocaval compression by left uterine displacement and the prophylactic administration of IV crystalloid solutions have been widely advocated for years and are considered mandatory. These measures may not be adequate and ephedrine is often required to treat hypotension. Table 7-3 is a summary of several studies that have addressed this problem in different ways. Mathru and coworkers used 5 albumin in Ringer's lactate with 5 dextrose solution at 15 mL kg as a preload and compared it with the same volume of solution without albumin in 87 patients undergoing

Spinal And Epidural Opioids

Pert and colleagues reported on the presence of opioid receptors in high density in the dorsal horn of the spinal cord in 1973 and thus provided the impetus for the use of spinal opioids reported by Sabbe and Yaksh. The intrathecal administration of opioids markedly prolongs the analgesic effect compared with systemic administration. In patients undergoing cardiac surgery, analgesia of about 36 hours' duration was reported by lumbar intrathecal injection of 2 to 4 mg of morphine. In patients having total hip replacement, lower doses gave 24 to 48 hours of analgesia. In contrast, other investigators have noted that intrathecal opioids provide prolonged analgesia but of a lesser duration. Jacobson and colleagues compared the analgesic effects of intrathecal methadone and intrathecal morphine in patients scheduled for orthopedic surgery. The time to the onset of discomfort severe enough to require supplemental morphine was longer after intrathecal morphine than after methadone however,...

Spaceoccupying Lesions Of The Spinal Canal

Epidural abscesses, spinal abscesses, and hematomas are rare complications of neuraxial anesthesia. If they occur, timely diagnosis and treatment are essential to prevent permanent neurologic deficits.1 Signs and symptoms include backache, lower extremity sensory and motor deficits, bowel and bladder dysfunction, fever, and malaise. Separately and combined, these signs and symptoms are not unusual in the postpartum period therefore, a high index of suspicion must be maintained.

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