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Clinical Director, Meharry Medical College School of Medicine

The dorsal root enters the dorsal portion of the spinal cord and carries afferent or sensory impulses from the periphery to the spinal cord depression symptoms and medication generic 25mg amitriptyline free shipping. The ventral root emerges from the ventral portion of the spinal cord and carries efferent or motor impulses from the spinal cord to muscle fibers or glands (Figure 13­15) depression hotline purchase amitriptyline 25 mg on-line. Spinal nerves supply sensory and motor fibers to the body region associated with their emergence from the spinal cord bipolar depression checklist amitriptyline 25mg online. After spinal nerves exit the spinal cord depression out of the shadows buy amitriptyline 25 mg otc, they branch to form the peripheral nerves of the trunk and limbs. Each forelimb is supplied from nerves that arise from the brachial (br-k-ahl) plexus (C6­T2), and each hindlimb is supplied from nerves that arise from the lumbosacral plexus (L4­S3). C represents cervical, T represents thoracic, L represents lumbar, S represents sacral, and Co and Cy represent coccygeal (or Cd represents caudal). These letter abbreviations are followed by numbers to represent the vertebral area from which the nerve exits the spinal cord. C4 represents cervical spinal nerve 4, T11 represents thoracic spinal nerve 11, and so on. Cauda equina 1S 2 3 L7 S Cd1 Cd2 Cd3 Cd4 Cd5 Cd6 Figure 13­14 Naming scheme for spinal nerves. Nerves of Steel Spinal cord Gray matter Sensory neuron Spinal ganglion 275 Skin Sensory nerve ending Interneuron Muscle Motor neuron White matter (Arrows indicate path of impulse) Motor nerve ending Figure 13­15 Spinal nerve. The two divisions of the autonomic nervous system are the sympathetic nervous system (sihm-pah-theh-tihck nr-vuhs sihstehm) and the parasympathetic nervous system (pahr-ahsihm-pah-theh-tihck nr-vuhs sihs-tehm). The two divisions of the autonomic nervous system work together to maintain homeostasis within the body. Homeostasis (h-m-st-sihs) is the process of maintaining a stable internal body environment. The cisterna magna is the subarachnoid space located between the caudal surface of the cerebellum and the dorsal surface of the medulla oblongata. A myelogram (m-eh-l-grahm) is the record of the spinal cord after injection of contrast material (Figure 13­18). Light is shone in one eye, and that eye (direct) and the opposite eye (consensual) should constrict. Pathology: Nervous System Pathologic conditions of the nervous system include the following: amnesia (ahm-n-z-ah) = memory loss. In the nervous system, a hematoma usually is Copyright 2009 Cengage Learning, Inc. An epidural hematoma (ehp-ih-doo-rahl h-mah-t-mah) is a collection of blood above or superficial to the dura mater. A subdural hematoma (suhb-doo-rahl h-mah-to-mah) is a collection of blood below (deep to) the dura mater and above (superficial to) the arachnoid membrane. As is the case with -plegia, the suffix -paresis is modified to describe the area of weakness. Hemiparesis (hehm-ih-pahr-sihs) is weakness on one side of the body; paraparesis (pahr-ah-pahr-sihs) is weakness of the lower body in bipeds or of hindlimbs in quadrupeds. The combining form narc/o means stupor, and the suffix -lepsy means seizure (episode). Nerves of Steel 279 paralysis (pahr-ahl-ih-sihs) = loss of voluntary movement or immobility. Abnormal sensations may include tingling, numbness, or burning and may be difficult to assess in animals. The suffix -ptosis means prolapse, drooping, or falling downward; refers specifically to the upper eyelid. Pathologic conditions of the nervous system may involve lesions that cause abnormal clinical signs on the same side or opposite side that the lesion occurs. In describing lesions of the nervous system, the terms ipsilateral and contralateral are used. Ipsilateral (ihp-s-laht-r-ahl) means on the same side, and contralateral (kohn-trah-laht-rFigure 13­24 Polioencephalomalacia in a sheep. These stages are as follows: preictal (pr-ihck-tahl) = period before a seizure; also called the aura (aw-rah).

At operation all the articular surfaces are replaced ­ with metal on the femoral side depression lack of motivation cheap amitriptyline generic, polyethylene on a metal tray on the tibial side and polyethylene alone on the patella depression icd 10 discount amitriptyline online. It is important to ensure correct placement of the implants so as to reproduce the normal mechanics of the knee as closely as possible depression symptoms fatigue order amitriptyline online pills. The tibial and patellar components are fixed with cement depression test kostenlos purchase amitriptyline canada, whereas the femoral component may be press-fitted. Bone defects may be filled either with bone graft, metal augmentation wedges or cement. The development of suitable prostheses and instrumentation in recent years has led to vast improvements in technique, so the results are now similar to those of hip replacement. Constrained joints Artificial joints with fixed hinges are used when there is marked bone loss and severe instability. Their main value nowadays is to provide a mobile joint following resection of tumours at the bone ends. The lack of rotation in these implants places severe stresses on the bone/implant interfaces and they are liable to loosen, to break or to erode the tibial or femoral shafts unless physical activity is severely restricted. Moreover, a considerable amount of bone has to be removed, and this makes a subsequent arthrodesis difficult. Minimally invasive total knee replacement this is in its early stage of development and is not yet widely used. Early results suggest that it provides some benefits over conventional total joint replacement: less pain, faster recovery, better quadriceps strength and a better range of movement. Prophylaxis, either pharmacological (anticoagulants) or mechanical (foot pumps, compression stockings), is recommended. For established and intractable infection, treatment by debridement and antibiotics, or by exchange replacement in one or two stages, are obvious possibilities, though probably the safest salvage operation is arthrodesis; this is especially applicable in immunosuppressed patients and in those with resistant bacteria. Aseptic loosening results from faulty prosthetic design, inaccurate bone shaping, incorrect placement of the implants or a combination of these factors. Revision surgery for loose prostheses must deal with the cause, be it malposition of the prosthesis, accumulation of wear debris or infection. A loose prosthesis can be re-cemented, but unless the cause is dealt with, loosening will recur. They include: (1) recurrent patellar subluxation or dislocation, which may need realignment; and (2) complications associated with patellar resurfacing, such as loosening of the prosthetic component, fracture of the remaining bony patella, and catching of soft tissues between the patella and the femur. Patellar tracking as assessed on the operating table after implantation of the prosthesis is important. Any tendency to sublux must be corrected: common causes are unequal soft-tissue tension (for which a lateral release will be needed), a tibial component placed in internal rotation and/or a femoral component placed in internal rotation. The risk of patellar fracture postoperatively can also be lessened if care is taken not to divide the geniculate vessels when performing a lateral release. The bones of the tibiofemoral joint have little or no inherent stability; this depends largely upon strong static and dynamic stabilizers such as ligaments and muscles. The patellofemoral joint is so shaped that the patella moves in a shallow path (or track) between the femoral condyles; if this track is too shallow the patella readily dislocates, and if its line is faulty the patellar articular cartilage is subject to excessive wear. It is in line with the shaft of the femur, whereas the patellar ligament is in line with the shaft of the tibia. Because of the angle between them (the Qangle) quadriceps contraction would pull the patella laterally were it not for the fibres of vastus medialis, which are transverse. This muscle is therefore important and it is essential to try to prevent the otherwise rapid wasting that is liable to follow any effusion. The shaft of the femur is inclined medially, while the tibia is vertical; thus the normal knee is slightly valgus (average 7 degrees). The line of body weight falls medial to the knee and must be counterbalanced by muscle action lateral to the joint (chiefly the tensor fascia femoris). To calculate the force transmitted across the knee, that due to muscle action must be added to that imposed by gravity; moreover, since with each step the knee is braced by the quadriceps, the force that this imposes also must be added. Clearly the stresses on the articular cartilage are (as they also are at the hip) much greater than consideration only of body weight would lead one to suppose. It is also obvious that a varus deformity can easily overload the medial compartment, leading to cartilage breakdown; similarly, a valgus deformity may overload the lateral compartment. For several decades, the prevailing opinion was that the movements of the knee are guided by the cruciate ligaments functioning as a crossed four-bar link.

Peripheral vasoconstriction is not a feature of these conditions in the absence of hypovolaemia depression after test e amitriptyline 50 mg free shipping, unlike cardiogenic shock mood disorder in young children purchase amitriptyline 25 mg on line, and the veins remain full depression and pregnancy cheap amitriptyline american express. Cardiogenic shock Cardiogenic shock results from a decrease in myocardial contractility nber depression definition cost of amitriptyline, and hence a reduction in stroke volume and cardiac output. This classically follows myocardial infarction or severe ischaemia, but can follow trauma damage to the myocardium from blunt or penetrating injury. The disproportionate vasoconstriction is due not to hypovolaemia, but an outpouring of catecholamines and the profound autonomic stimulus, which can put further strain on the heart by causing vasoconstriction and increasing afterload. Trauma patients may present with cardiogenic shock if the cardiac event precedes, and indeed causes, the traumatic event. Septic shock this results from the entry of toxins into the circulation, which poison the vasoconstrictive mechanisms within the blood vessels. These toxins usually come from infection, or are released from Neurogenic shock is produced by high spinal cord injury, which disrupts the sympathetic nerves controlling vasoconstriction. The peripheral vasculature relaxes and becomes profoundly dilated, reducing pre-load and afterload. Even with a raised cardiac output, the patient cannot maintain an adequate blood pressure, and shock ensues. Since neurogenic shock is always related to traumatic spinal cord damage, it is likely to co-exist with a degree of hypovolaemia from associated trauma. Exposure to an antigen to which an individual has previously been sensitized triggers off a cascade reaction. The mast cells degranulate and release large quantities of histamine into the bloodstream. Massive capillary leakage results in sudden oedema, which with loss of fluid into the bowel causes hypovolaemia [1 mm depth of oedema across the body surface equates to a 1. Anaphylaxis can be triggered by many common antigens such as shellfish or peanuts. Of particular significance to the hospital practitioner are allergies to drugs and latex. Hypovolaemic shock passes through a number of clinical stages as blood loss increases, and these have been grouped into four classes of shock, with increasingly apparent signs [adult blood volume is approximately 7 per cent of ideal body weight, or 5 L for a non-obese man weighing 70 kg]. It should be remembered, however, that the development and progression of shock is a continuum. The pulse rate is a good indicator of shock level, as is the respiratory rate; tables showing normal parameters for children at different ages are available. However, practitioners tend to overestimate the blood pressure if pulses are palpable, although there is wide variation (Deakin and Low, 2000). Recognition of shock therefore depends on a rapid clinical assessment of the patient, with measurement of the appropriate vital signs. The look, listen, feel sequence should be applied to identify the signs of hypovolaemic shock; blood pressure and pulse alone are not adequate. Look and listen 22 the management of major injuries peripheral/central cyanosis and pallor sweating tachypnoea and respiratory distress change in mental status ­ anxiety, fear, aggression, agitation · depressed level of consciousness or unconsciousness Feel · · · · · Peripheral perfusion poor ­ cool, clammy, shut down · Capillary refill time > 2 seconds (this is unreliable in cold and frightened patients) · Pulse rate and character ­ tachycardia and thready pulse · Loss of pulses ­ radials, then femorals, then carotids as severity of shock increases · Blood pressure ­ initially a raised diastolic with narrowed pulse pressure, then drop in systolic and diastolic, and finally an unrecordable blood pressure. Observation of these factors will usually enable an assessment to be made of the presence and level of shock, and the likely degree of blood loss. This will act as a guide to whether volume replacement is indicated, and if so how much. Hypovolaemic shock that remains unresponsive to treatment is likely to be due to bleeding into the body cavities or potential spaces, and evidence of this should be sought. A useful reminder of where to look is the catchy slogan: bleeding onto the floor and four more. Bear in mind, though, that there are other forms of shock that need to be excluded. Septic, neurogenic and anaphylactic shock are characterized by vasodilatation as opposed to vasoconstriction. The veins tend to be full, and the peripheral pulses easily palpable and bounding.

The lunate and scaphoid are tilted somewhat volarwards and the capitate and metacarpals lie anterior (volar) to the radius depression test child cheap 25 mg amitriptyline mastercard. Even with apparently trivial injuries depression while pregnant generic amitriptyline 50mg visa, ligaments are sometimes torn and the patient may later develop carpal instability depression test color discount 25mg amitriptyline amex. If the x-rays are normal but the clinical signs strongly suggest a carpal injury depression physical pain cheap 25 mg amitriptyline fast delivery, a splint or plaster should be applied for 2 weeks, after which time the xrays are repeated. A fracture or dislocation may become more obvious after a few weeks, but a second negative x-ray still does not exclude a serious injury. If these tests are not readily available, then the patient should be re-examined repeatedly until the symptoms settle or a firm diagnosis is made. With unstable fractures there may also be disruption of the scapho-lunate ligaments and dorsal rotation of the lunate. A radioisotope scan will confirm a wrist injury although it may not precisely localize it. Mechanism of injury and pathological anatomy the scaphoid lies obliquely across the two rows of carpal bones, and is also in the line of loading between the thumb and forearm. The combination of forced carpal movement and compression, as in a fall on the dorsiflexed hand, exerts severe stress on the bone and it is liable to fracture. Most scaphoid fractures are stable; with unstable fractures the fragments may become displaced. This accounts for the fact that 1 per cent of distal third fractures, 20 per cent of middle third fractures and 40 per cent of proximal fractures result in non-union or avascular necrosis of the proximal fragment. Usually the fracture line is transverse, and through the narrowest part of the bone (waist), but it may be more proximally situated (proximal pole fracture). A few weeks after the injury the fracture may be more obvious; if union is delayed, cavitation appears on either side of the break. Relative sclerosis of the proximal fragment is pathognomonic of avascular necrosis. Clinical features the appearance may be deceptively normal, but the astute observer can usually detect fullness in the anatomical snuffbox; precisely localized tenderness in (a) (b) (c) (d) (e) (f) (g) 25. If the clinical features are suggestive of a fracture, then immobilize the wrist and repeat the x-ray 2 weeks later when the fracture is more likely to be apparent. The fracture may be (d) through the proximal pole, (e) the waist, or (f) the scaphoid tubercle. Treatment Fracture of the scaphoid tubercle needs no splintage and should be treated as a wrist sprain; a crepe bandage is applied and movement is encouraged. Undisplaced fractures need no reduction and are treated in plaster; 90 per cent of waist fractures should heal. The cast is applied from the upper forearm to just short of the metacarpo-phalangeal joints of the fingers, but incorporating the proximal phalanx of the thumb. The plaster must be carefully moulded into the hollow of the hand, and is not split. After 8 weeks the plaster is removed and the wrist examined clinically and radiologically. If the scaphoid is tender, or the fracture still visible on x-ray, the cast is reapplied for a further 4 weeks. At that stage, one of two pictures may emerge: (a) the wrist is painless and the fracture has healed ­ the cast can be discarded; (b)the x-ray shows signs of delayed healing (bone resorption and cavitation around the fracture) ­ union can be hastened by bone grafting and internal fixation. Displaced fractures can also be treated in plaster, but the outcome is less predictable. It is better to reduce the fracture openly and to fix it with a compression screw. This should increase the likelihood of union and reduce the time of immobilization. Early percutaneous fixation with a compression screw, though technically demanding, can dramatically reduce the time away from work and the difficulties associated with personal care. Complications Avascular necrosis the proximal fragment may die, especially with proximal pole fractures, and then at 2­ 3 months it appears dense on x-ray. Although revascularization and union are theoretically possible, 782 they take years and meanwhile the wrist collapses and arthritis develops. Bone grafting, as for delayed union, may be successful, in which case the bone, though abnormal, is structurally intact.

Tenosynovitis produces features similar to those of cuff lesions depression definition and effects buy amitriptyline toronto, including tears of supraspinatus or biceps bipolar depression quizzes 25mg amitriptyline overnight delivery. Joint and tendon lesions usually occur together and conspire to cause the marked weakness and limitation of movement that are features of the disease papa roach anxiety order amitriptyline 25 mg. Treatment the general treatment of rheumatoid arthritis is discussed in Chapter 3 depression symptoms on the body purchase amitriptyline with paypal. In the early stages, local treatment in the form of intra-articular injections of methylprednisolone may be needed. If synovitis persists, operative synovectomy is carried out; at the same time, cuff tears may be repaired. Provided the rotator cuff is not completely destroyed and there is still adequate bone stock, total joint replacement with an unconstrained prosthesis may be carried out. This operation provides good pain relief, moderate shoulder function and reasonable durability (Stewart and Kelly, 1997). Surface replacement arthroplasty has comparable outcomes to total Clinical features the patient may be known to have generalized rheumatoid arthritis; occasionally, however, acromioclavicular erosion discovered on an x-ray of the chest is the first clue to the diagnosis. If the rotator cuff is destroyed, or bone erosion very advanced, arthrodesis may be preferable; despite its apparent limitations, it gives improved function because scapulo-thoracic movement is usually undisturbed. In advanced cases, if pain becomes intolerable, shoulder arthroplasty is justified. It is usually secondary to local trauma, recurrent subluxation or longstanding rotator cuff lesions. Often chondrocalcinosis is present as well but it is not known whether this predisposes to osteoarthritis or appears as a sequel to joint degradation. The changes are now attributed to hydroxyapatite crystal shedding from the torn rotator cuff and a synovial reaction involving the release of lysosomal enzymes (including collagenases) which lead to cartilage breakdown (McCarty et al. The shoulder disorder, however, has come to be known as Milwaukee shoulder, after the city from whence McCarty hailed. Clinical features the patient is usually aged 50­60 and may give a history of injury, shoulder dislocation or a previous painful arc syndrome. There is usually little to see but shoulder movements are restricted in all directions. Clinical features the patient is usually aged over 60 and may have suffered with shoulder pain for many years. Over a period of a few months the shoulder becomes swollen and increasingly unstable. On examination there is marked crepitus in the joint and loss of active movements. Treatment Analgesics and anti-inflammatory drugs relieve pain, and exercises may improve mobility. Most patients manage to live with the restrictions imposed by stiffness, provided pain is not severe. Movements are so restricted that she has difficulty dressing herself and combing her hair. X-rays show severe erosion of the articular surfaces, subluxation of the joint and calcification in the soft tissues. Treatment Resurfacing arthroplasty relieves pain and allows good rotations at waist level but will not improve abduction, because the rotator cuff is disrupted and the joint is unstable. It is quick and minimally invasive, retaining bone stock and keeping options open for future revision or arthrodesis. Reverse shoulder arthroplasty in cuff tear arthropathy allows good elevation in the presence of a wellfunctioning deltoid as it depends less on the status of the cuff. It is thus advisable to avoid reverse shoulder arthroplasty in the younger patient. X-ray of the shoulder shows the classic features of osteonecrosis, including a long subarticular fracture of the humeral head. Associated abnormalities of the cervical spine are common and sometimes there is a family history of scapular deformity.

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