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By: William S Anderson, M.A., M.D., Ph.D.
- Associate Professor of Neurosurgery
This form of spondylolisthesis is probably due to blood pressure apparatus buy coumadin overnight delivery degenerative disease of the inferior and superior facets blood pressure normal teenager discount coumadin 5mg with mastercard. It causes severe low back pain hypertension complications order 2mg coumadin overnight delivery, made worse by standing or walking and relieved by bed rest blood pressure medication by class cheap coumadin online. Symptoms of root compression are common, as indicated in the review by Alexander and colleagues. Patients with progressive vertebral displacement and neurologic deficits require surgery, usually posterolateral fusion and excision of the posterior elements. Reduction of displaced vertebral bodies before fusion and direct repair of pars defects are possible in special cases. Traumatic Disorders of the Low Back Traumatic disorders constitute the most frequent cause of low back pain. All movements must be kept to a minimum until an approximate diagnosis has been made and adequate measures have been instituted for the proper care of the patient. If the patient complains of pain in the back and cannot move the legs, the spine may have been fractured and the cord or cauda equina compressed or crushed. The neck should not be manipulated, and the patient should not be allowed to sit up. What was formerly referred to as "sacroiliac strain" or "sprain" is now known to be due, in many instances, to disc disease. The term acute low back strain is preferable for minor, self-limited injuries that are usually associated with lifting heavy loads when the back is in a mechanically disadvantaged position, or there may have been a fall, prolonged uncomfortable postures such as air travel or car rides, or sudden unexpected motion, as may occur in an auto accident. The discomfort of acute low back strain is often severe, and the patient may assume unusual postures related to spasm of the lower lumbar and sacrospinalis muscles. The pain is usually confined to the lower part of the back, in the midline or just to one side or other of the spine. The diagnosis of lumbosacral strain depends on the description of the injury or activity that precipitated the pain; the localization of the pain; the finding of localized tenderness; the augmentation of pain by postural changes-. In more than 80 percent of cases of acute low back strain of this type, the pain resolves in a matter of several days or a week even with no specific treatment. Sacroiliac joint and ligamentous strain is the most likely diagnosis when there is tenderness over the sacroiliac joint and pain radiating to the buttock and posterior thigh, but this always needs to be distinguished from the sciatica of a ruptured intervertebral disc (see further on). Strain is characteristically worsened by abduction of the thigh against resistance and is also felt in the symphysis pubis or groin. Treatment of Acute Low Back Strain the pain of muscular and ligamentous strains is usually self-limited, responding to simple measures in a relatively short period of time. The basic principle of therapy in both disorders is to avoid reinjury and reduce the discomfort of painful muscles. Rest, in a recumbent position, for one or several days has been the traditional treatment, but several clinical trials over the years have questioned this dictum (see Vroom and colleagues). Nonetheless, lying on the side with knees and hips flexed or supine with a pillow under the knees are the favored positions for relief of pain. With strains of the sacrospinalis muscles and sacroiliac ligaments, the optimal position is hyperextension, which is effected by having the patient lie with a small pillow under the lumbar portion of the spine or by lying face down. Physical measures- such as application of ice in the acute phase and, later, heat diathermy and massage- can be tried, but these are of limited value beyond several days. Muscle relaxants are of little use, serving mainly to make bed rest more tolerable. As a result of several studies that have failed to demonstrate a benefit of bed rest, recent practice has been to mobilize patients as soon as they are able and to prescribe corrective exercises designed to stretch and strengthen trunk (especially abdominal) muscles, overcome faulty posture, and increase the mobility of the spinal joints. Despite this modern approach, the authors can affirm from personal experience that some injuries produce such discomfort that arising from a bed or chair is simply not possible in the early days after injury. The use of spinal manipulation- practiced by chiropractors, osteopaths, and others- has always been a contentious matter in the United States, partly because of unrealistic therapeutic claims made in treating diseases other than low back derangements. By contrast, in certain parts of Europe, orthopedists often incorporate manipulative procedures into conventional practice. A type of slow muscle stretching and joint distraction (axial traction on a joint) administered by physiatrists and physical therapists is quite similar. It must be recognized that many patients seek chiropractic manipulation on their own, often before seeing a physician, and may not disclose this information to the physician. When the supporting elements of the spine (pedicles, facets, and ligaments) are not disrupted, chiropractic manipulation of the lumbar spine has provided acute relief to a considerable number of our patients with low back strain or facet pain; at issue is the durability of the effect, even with repeated so-called spinal adjustments. A randomized British trial has shown manipulation to be superior to analgesics and bed rest in returning patients to work after minor back injury (Meade et al). Some other trials have corroborated this finding (Hadler et al), while others have not, or, most often, the results have been ambiguous. In the study by Cherkin and colleagues comparing chiropractic, physical therapy (McKenzie method), and simple instruction to the patient from a booklet, manipulation yielded a slightly better outcome at the end of a month.
We have not found blood pressure practice order coumadin in united states online, as did by Chia and colleagues hypertension organization purchase 5mg coumadin visa, an unexpected vasculitis in the nerve biopsies of such patients blood pressure 7050 5 mg coumadin with amex. The vaso-occlusive and infiltrative condition of intravascular lymphoma often includes a syndrome of multiple painless mononeuropathies heart attack reasons buy coumadin pills in toronto. Neuropathy Due to Critical Limb Ischemia A number of patients with severe atherosclerotic ischemic disease of the legs will be found to have localized sensory changes or impairment of reflexes. Usually the other effects of ischemia- claudication and pain at rest, absence of distal pulses, and trophic skin changes- are so prominent that the neurologic changes are overlooked. In experimental studies, combined occlusion of the aorta and many limb vessels are required to produce nerve ischemia because of the profusely ramifying neural vasculature. Although paresthesias, numbness, and deep aching pain were characteristic, the patients were more limited by symptoms of their vascular claudication than the neuropathic ones. Restoration of circulation to the limb by surgical or other means resulted in some improvement of the regional neuropathy. Reviews of the literature on this subject are to be found in the writings of Chalk et al and Eames and Lange. A poorly understood but presumably localized ischemic neuropathy occurs in the region of arteriovenous shunts that have been placed for the purpose of dialysis. Complaints of transient diffuse tingling of the hand are not uncommon soon after creation of the shunt, but only a few patients develop persistent forearm weakness and numbness and burning in the fingers, reflecting variable degrees of ulnar, radial, and median nerve and possibly also muscle ischemia. The possible role of an underlying uremic polyneuropathy in facilitating this neuropathy has not been studied. A progressive, symmetrical polyneuropathy due to systemic cholesterol embolism has been described by Bendixen and colleagues. An inflammatory and necrotizing arteritis surrounds embolic cholesterol material within small vessels and appears to account for the progression of symptoms. This neuropathic process is probably more often discovered at autopsy than it is in the clinic, being eclipsed during life by the cerebral manifestations of cholesterol embolism. The entire illness simulates the generalized polyneuropathy of a small-vessel polyarteritis. Sarcoidosis Sarcoidosis infrequently produces subacute or chronic polyneuropathy, polyradiculopathy, or mononeuropathies. A painful, small-fiber sensory neuropathy has also been described by Hoitsma and colleagues. Involvement of a single nerve with sarcoid most often implicates the facial nerve (facial palsy), but sometimes multiple cranial nerves are affected in succession (see page 1183). Or, there may be weakness and reflex and sensory loss in the distribution of one or more spinal nerves or roots. The occurrence of large, irregular zones of sensory loss over the trunk is said to distinguish the neuropathy of sarcoidosis from other forms of mononeuropathy multiplex. This type of sensory loss, particularly when accompanied by pain, resembles diabetic radiculopathy (see earlier). Unlike the cases we have reported (Zuniga et al), in the series of 11 patients with sarcoid neuropathy studied by Said and colleagues, only 2 were known to have pulmonary sarcoidosis before the onset of neuropathic symptoms. Six had a focal or multifocal syndrome (including one with a clinical and electrophysiologic pattern that simulated multifocal conduction block). The remainder had a more nondescript symmetric polyneuropathy, one of acute onset. The pathologic changes in nerve and muscle biopsy specimens consisted mainly of epineurial granulomas and endoneurial inflammatory infiltrates, but there were indications of necrotizing vasculitis in 7 cases. Among the cases we studied, 6 of 10 had a subacute or chronic sensorimotor polyneuropathy. It is notable that in only 2 of their patients were levels of angiotensin-converting enzyme elevated in the serum. Lyme Disease (See also page 618) the neuropathy that develops in 10 to 15 percent of patients with this disease takes several forms. Cranial nerve involvement is well known, uni- or bilateral facial palsy being by far the most frequent manifestation (page 1182). Other cranial nerves are from time to time also affected and the disease may affect almost any of the somatic roots, most evident in the cervical or lumbar ones. There may be radicular pain not unlike that of cervical or lumbar disc or plexus disease. The triad of cranial nerve palsies, radiculitis, and aseptic meningitis is characteristic of Lyme disease during its disseminated phase, i. As to peripheral neuropathy with Lyme disease, the clinical situation is more complex.
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Switching to high blood pressure medication and sperm quality order generic coumadin from india warfarin from anti-platelet agents is sensible in some circumstances but should be done with caution hypertension nclex questions order generic coumadin on-line. Other Forms of Medical Treatment Treatment by hemodilution was popularized by the studies of Wood and Fleischer heart attack and vine cover order 2mg coumadin free shipping, who showed a high incidence of short-term improvement when the hematocrit was reduced to arteria yugular externa buy coumadin 1 mg cheap approximately 33 percent. Earlier observations had shown a reduction in the overall neurologic deficit, but almost all larger randomized trials- which included patients in many settings who were treated at various times up to 48 h after stroke- failed to confirm any such benefit, and the use of this treatment has been virtually abandoned. Nevertheless, we continue to see a few patients whose hemiparesis and aphasia have improved during and just after removal of a unit or more of blood and replacement with albumin and saline. While this treatment cannot be recommended as a routine approach, it may have some merit in selected situations, such as fluctuating stroke. Therapies aimed at improving blood flow by enhancing cardiac output (aminophylline, pressor agents), by improving the microcirculation (mannitol, glycerol, dextran), or by use of a large number of vasodilating drugs (see below) have failed to show consistent benefits, but several are still under study. Induced hypothermia limits the size of ischemic stroke, but it is technically difficult to administer and often has serious side effects. However, several multicenter clinical trials that compared calcium channel blockers with placebo did not establish a difference in outcome in the two groups. Vasodilators may actually be harmful, at least on theoretical grounds, since by lowering the systemic blood pressure or dilating vessels in normal brain tissue (the autoregulatory mechanisms are lost in vessels within the infarct), they may reduce the intracranial anastomotic flow. Moreover, the vessels in the margin of the infarct (border zone) are already maximally dilated. New discoveries regarding the role of nitric oxide in vascular control will probably give rise to new pharmacologic agents, which will have to be evaluated. Surgery and Angioplasty for Symptomatic Carotid Stenosis Comments have already been made concerning the opening of an occluded carotid artery soon after a stroke. The region that most often lends itself to such therapy is the carotid sinus (the bulbous expansion of the internal carotid artery just above its origin from the common carotid). Other sites suitable for surgical management include the common carotid, innominate, and subclavian arteries. Operation on the vertebral artery at its origin has proved successful only in exceptional circumstances. In recent years balloon angioplasty and stenting of the carotid artery have become increasingly popular as an alternative to surgery (see below). Surgery and angioplasty, in our opinion, are as yet applicable mainly to the group of patients with symptomatic carotid artery stenosis (the asymptomatic ones are discussed below) who have substantial extracranial stenosis but not complete occlusion, and, in special instances, in those with nonstenotic ulcerated plaques. The conclusion, reached in each of these studies, was that carotid endarterectomy for symptomatic lesions causing severe degrees of stenosis (70 to 80 percent reduction in diameter) is effective in reducing the incidence of ipsilateral hemispheral strokes. These two trials differed in the method of estimating the degree of stenosis, but when adjustments are made, the results are comparable (Donnan et al). Patients in the European study with mild or moderate stenosis (up to 70 percent) did not benefit from endar- terectomy. In the North American study, however, they did so, but to a lesser extent than the group with severe stenosis. Further analysis of the North American trial by Gasecki and colleagues has indicated that the risk of cerebral infarction on the side of the symptomatic stenosis is increased if there is a contralateral carotid stenosis but that operated patients (on the side of symptomatic stenosis) still had fewer strokes than those treated with medication alone. In those with bilateral carotid disease, the risk of stroke after 2 years was 69 percent, and if operated, 22 percent. In the final analysis, the relative benefits of surgery or medical treatment (anticoagulation or aspirin) depend mainly on the true surgical risk- i. If the surgeon, by an independent audit of his procedures, has an established operative complication rate of no more than 4 to 5 percent and preferably lower, then surgery can be recommended in symptomatic patients with carotid stenosis greater than 70 percent. Before operation or angioplasty, the existence of the lesion and its extent must be determined. Arteriography, the procedure that yields the best images and most accurate measurements of the residual lumen, carries a very small risk of worsening the stroke or producing new focal signs (this notion has never been documented systematically). Severe stenosis is reflected in conventional angiography by the filling of the distal branches of the external carotid artery before the branches of the middle cerebral artery are opacified- a reversal of the usual filling pattern, indicating low flow in the distal carotid circulation. Increasingly the diagnosis of carotid stenosis is being made by noninvasive methods, but with both ultrasound and magnetic resonance arteriography, there is difficulty in quantifying severe stenosis and separating it from complete carotid artery occlusion. If the patient is in good medical condition, has normal vessels on the contralateral side, and has normal cardiac function (no heart failure, uncontrolled angina, or recent infarction), these lesions can usually be dealt with safely by endarterectomy. It may be followed by a new hemiplegia or aphasia that becomes evident immediately or soon after endarterectomy, usually by the time the patient arrives in the recovery room. In general, surgeons prefer to return the patient to the operating room and open the artery, as discussed earlier on. An intimal flap at the distal end of the endarterectomy and varying amounts of fresh clot proximal to it are usually encountered; but after removal and repair of the vessel, the effects of the stroke, if one has occurred, are not usually improved. An uncommon but rather striking hyperperfusion syndrome develops several days to a week after carotid endarterectomy. The features are headache, focal deficits, seizures, brain edema, or cerebral hemorrhage; these are thought to reflect an abrupt loss of autoregulatory ability of the cerebral vasculature in the face of hypertension and increased perfusion on the side of the recently opened artery. Unilateral severe headache is the commonest symptom and may be the only manifestation. Treatment is by control of hypertension; it is unclear whether anticonvulsant medications are required if there has been a single seizure, but they seem valuable to us.
Once it is established that the patient has an untreatable dementing brain disease and the diagnosis is sufficiently certain arrhythmia unborn baby discount 1 mg coumadin mastercard, a responsible member of the family should be informed of the medical facts and prognosis and assisted in the initiation of social and support services blood pressure 35 year old female order cheap coumadin line. Patients themselves need be told only that they have a nervous condition for which they are to blood pressure z score calculator quality coumadin 5 mg be given rest and treatment blood pressure chart what your reading means buy coumadin with visa. Some physicians (and patients) find this too patronizing; certainly, in the current social environment, many patients ask directly if they have Alzheimer disease. To this query we respond that they may, but that more time is required to be certain. Some intelligent patients have insisted on knowing the details and implications of this statement, and we have felt obliged to give as much useful information as required by them; but little is accomplished by telling them more. Reassurance that the physician will be available to help the patient and family manage the situation is of utmost value. They should be spared responsibility and guarded against injury that might result from imprudent action, such as leaving a stove turned on or driving and getting lost- or worse. If they are still at work, plans for occupational retirement should be carried out. In more advanced stages of the disease, when mental and physical enfeeblement become pronounced, nursing home or institutional care should be arranged. So-called nerve tonics, vitamins, vasodilators, and hormones are of no value in checking the course of the illness or in regenerating atrophic tissue. The value of newer, centrally acting cholinergic agents and glutamate antagonists in the treatment of Alzheimer disease is clear but modest and should be weighed against the need for blood testing and side effects. They may, however, offer psychologic benefit to the patient and family; the use of these medications is discussed in Chap. Undesirable restlessness, nocturnal wandering, and belligerency may be reduced by administration of one of the antipsychotic or benzodiazepine drugs (see Chaps. Emotional lability and paranoid tendencies may be managed by the judicious use of quetiapine, olanzapine, risperidone, or haloperidol. Some patients are helped by short-acting sedatives such as lorazepam without any worsening of the mental condition, but all these drugs must be given with caution and some may be particularly problematic in patients with combined parkinsonism and dementia syndromes. Visiting nurses, social agencies, live-in health-care aides, day care settings, and respite care to relieve families from the constant burden of caring for the patient should all be used to advantage. Some of the inevitable practical problems accompanying the dissolution of personal life caused by dementia can be ameliorated by judicious use of powers of attorney or guardianship and similar legal vehicles. Clinicians and physiologists have demonstrated beyond doubt that particular functions are assignable to certain cortical regions. For example, the pre- and postrolandic zones control motor and sensory activities, the striate-parastriate occipital zones control visual, the superior temporal and transverse gyri of Heschl are auditory, and so on. Beyond these broad correlations, however, there is a notable lack of precision in the cortical localization of many of the behavioral and mental operations described in Chaps. In particular, of the higher-order physiologic and psychologic functions- such as attention, vigilance, apperception, thinking, etc. One may suitably pause and inquire into what precisely is meant by cerebral localization. Does it refer to the physiologic function of a circumscribed aggregate of neurons in the cerebral cortex, indicated clinically by a loss of that function (negative symptom) when the neurons in question are paralyzed or destroyed? From what we know of the rich connectivity of all parts of the so-called cortical centers, one must assume that this is only partly the case, in that a lesion in a particular cerebral region, or in the fiber systems with which it is connected, is most closely associated with certain impairments of function. While it is appropriate for the clinician to operate on the principle of correlation between certain neurologic signs or syndromes and damage (lesion) in particular regions of the brain, it is readily apparent that certain positive symptoms resulting from the lesion-. And how is one to interpret the seeming inconsistencies from one case report to another, in which several different functions have been assigned to the same region of the brain and any one region appears to be the anatomic substratum of multiple functions or in which a particular sign arises from damage in one of several areas? Most modern theorists who ponder this subject believe that the organization of cerebral function is based on discrete networks of closely interconnected afferent and efferent neurons in several regions of the brain. These networks must be linked by both regional and more widespread systems of fibers. This is especially apparent in the discussion of the anatomy of complex cognitive properties such as intelligence, as described in Chap. They viewed function not as the direct property of a particular, highly specialized group of cells in one region of the cerebrum but as the product of complex, diffusely distributed activity by which sensory stimuli are analyzed and integrated at various levels of the nervous system and are united, through a system of temporarily acquired (experientially derived) connections, into a working mosaic adapted to accomplish a particular task. To some extent, this model has been corroborated by functional imaging studies, which show increased metabolic activity in several cortical regions during every form of human behavior, including willed motor acts, language tasks, and perceptive and apperceptive sensory experiences. Within such a functional system, the initial and final links (the task and the effect) remain unchanged, but the intermediate links (the means of performance of a given task) may be modified within wide limits and will never be exactly the same on two consecutive occasions. Thus, when a certain act is called for by a spoken command, the dominant temporal lobe must receive the message and transmit it to the premotor areas. Or it may be initiated by the intention of the individual, in which case the first measurable cerebral activity (a negative "readiness potential") occurs anterior to the premotor cortex. The motor cortex is also always under the dynamic control of the proprioceptive, visual, and vestibular systems.
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