PART 2 in Microsoft Office

Making QR Code ISO/IEC18004 in Microsoft Office PART 2

PART 2
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CARDINAL MANIFESTATIONS OF NEUROLOGIC DISEASE
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On completion of the examination of the back and legs, one turns to a search for motor, re ex, and sensory changes in the lower extremities (see Protrusion of Lumbar Intervertebral Discs, further on in this chapter)
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Ancillary Diagnostic Procedures
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5 3 4 7 8 9 10 6 Depending on the circumstances, these may include a blood count and erythrocyte sedimentation rate (especially helpful in screening for infection or myeloma); calcium, phosphorus, uric acid, alkaline phosphatase, acid phosphatase, and prostate-speci c antigen (if one suspects metastatic carcinoma of the prostate); a serum protein electrophoresis (myeloma proteins); in special cases, a tuberculin test or serologic test for Brucella; a test for rheumatoid factor; and HLA typing (for ankylosing spondylitis) Radiographs of the lumbar spine (preferably with the patient standing) in the anteroposterior, lateral, and oblique planes are still useful in the routine evaluation of low back pain and sciatica Readily demonstrable in plain lms are narrowing of the intervertebral disc spaces, bony facetal or vertebral overgrowth, displacement of vertebral bodies (spondylolisthesis), and an unsuspected in ltration of bone by cancer In cases of suspected disc herniation or tumor in ltration of the spinal canal, one generally proceeds directly to MRI Although these imaging procedures have largely replaced conventional myelography, the latter examination, when combined with computed tomography (CT), provides detailed information about the dural sleeves that surround the spinal roots, at times disclosing subtle truncations caused by laterally situated disc herniations and at times revealing surface abnormalities of the spinal cord, such as arteriovenous malformations Administration of gadolinium at the time of MRI enhances regions of in ammation and tumor Injection of contrast medium directly into the intervertebral disc (discogram) is practiced in very few institutions and is more dif cult to interpret than CT myelography and MRI; it carries the risk of damage to nerve roots or the introduction of infection Discography is indicated only in special circumstances and should be undertaken only by those who are specialized in its performance Isotope bone scans may disclose tumors and in ammatory processes such as osteomyeltitis, but these are also evident on CT and MRI Nerve conduction studies and electromyography (EMG) are particularly helpful in suspected root and nerve diseases, as indicated further on, in the discussion of protruded lumbar discs However, as for all the aforementioned tests, they must be interpreted in the context of the history and clinical examination; otherwise they are subject to overuse and overinterpretation
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Figure 11-3 (1) Costovertebral angle (2) Spinous process and interspinous ligament (3) Region of articular facet ( fth lumbar to rst sacral) (4) Dorsum of sacrum (5) Region of iliac crest (6) Iliolumbar angle (7) Spinous processes of fth lumbar and rst sacral vertebrae (tenderness faulty posture or occasionally spina bi da occulta) (8) Region between posterior superior and posteroinferior spines Sacroiliac ligaments (tenderness sacroiliac sprain, often tender, with fth lumbar or rst sacral disc) (9) Sacrococcygeal junction (tenderness sacrococcygeal injury; ie, sprain or fracture) (10) Region of sacrosciatic notch (tenderness fourth or fth lumbar disc rupture and sacroiliac sprain) (11) Sciatic nerve trunk (tenderness ruptured lumbar disc or sciatic nerve lesion)
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tebrae is consistent with lumbosacral disc disease [Fig 11-3, (2) and (3)] Tenderness in this region and in the sacroiliac joints is also a frequent manifestation of ankylosing spondylitis Arthritic changes at a facet may cause the same tenderness Tenderness over the costovertebral angle often indicates genitourinary disease, adrenal disease, or an injury to the transverse process of the rst or second lumbar vertebra [Fig 11-3, (1)] Tenderness on palpation of the paraspinal muscles may signify a strain of muscle attachments or injury to the underlying transverse processes of the lumbar vertebrae Focal pain in the same parasagittal line along the thoracic spine points to in ammation of the costotransverse articulation between spine and rib (costotransversitis) In palpating the spinous processes, it is important to note any deviation in the lateral plane (this may be indicative of fracture or arthritis) or in the anteroposterior plane A step-off forward displacement of the spinous process and exaggerated lordosis are important clues to the presence of spondylolisthesis (see further on) Abdominal, rectal, and pelvic examinations are essential elements in the study of the patient with low back symptoms that fail to be clari ed by the aforementioned spinal maneuvers Neoplastic, in ammatory, or degenerative disorders may produce symptoms referred to the lower part of the spine
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