By: Edward T. F. Wei PhD
It often causes facial nerve palsies gastritis histology purchase prevacid 30mg visa, unlike benign parotid tumours gastritis x ray discount prevacid 15mg on line, and is usually hard and fixed on examination gastritis liver purchase prevacid 15 mg free shipping. You will be expected to gastritis zimt purchase prevacid us be able to gastritis symptoms child discount prevacid 30 mg examine and describe them and arrive at a reasonable list of differential diagnoses. For many skin lumps, however, the final diagnosis may only be made after excision biopsy, usually under local anaesthetic. Typically, they consist of a soft swelling not fixed to Lumps in the Head, Neck and Skin 211 skin or deeper structures. The edge may be difficult to define in some cases and the swelling may be fluctuant since fat is liquid at body tem perature. Dercum’s disease is a condition which runs in families where patients have multiple subcutaneous lipomata. Lipomas need removing if they are causing a problem to the patient or are unsightly. Neurofibromas these are benign tumours of nerves which may be multiple and part of von Recklinghausen’s neurofibromatosis and associated with cafe au lait patches. They are common on the scalp but can occur anywhere except the soles and the palms (which do not have sebaceous glands). Typically they form a round, soft swelling attached to the skin but not deeper structures. Benign Naevi (Pigmented Moles) Surgically, the main importance of benign naevi is in the differential diagnosis of malignant skin lesions, principally malignant melanoma. These occur in elderly patients and are often multiple and may be pigmented flat discs. These are of no medical signifi cance but may need removing if they are catching on clothes or are a worry cosmetically. Campbell de Morgan Spots these red spots appear as patients grow older and are of no clinical signif icance. Exposure to ultra violet radiation is thought to be the major aetiological factor (especially sunburn as a child). Melanomas are highly malignant tumours derived from melanocytes and need to be diagnosed and removed early if a cure is to follow. The commonest sites are the torso in males and the legs in females (suggesting that sun exposure is a risk factor). Rare sites include the nail bed, the anorectal junction and the choroid in the eye. If you come across a patient in the exam with a glass eye and an enlarged liver, think melanoma! Any mole which either grows or appears rapidly, changes shape or colour, itches, ulcerates or bleeds should be regarded as suspicious and Lumps in the Head, Neck and Skin 213 removed. The types include • Superficial spreading melanomas (about 80%) — these grow slowly and metastasise late, and have a better prognosis. Total excisional biopsy is the method of choice for diagnosis, although in some circumstances (for example, in a huge lesion) a partial biopsy is necessary. The Breslow thickness is the depth of the tumour in millimetres and gives a good indication of the prognosis. Another system is Clark’s staging, which breaks down the depth into five anatomical levels. Stage I — confined to the epidermis; Stage V — penetrated into the subcutaneous fat). In practice, the two are combined together with the histological grade to give a more accurate stage. Prognosis the thickness of the primary tumour is the single most important prog nostic factor for patients with no evidence of distant spread. As a rough guide the following table lists the 5-year survival rates based on the depth: Thickness (mm) Five-Year Survival (%) 0. Women seem to survive longer than men, and this may be due in part to their having more tumours on the legs than men. Various histological types (such as those with increased 214 Surgical Talk: Revision in Surgery mitoses) and those with satellite lesions (implying that the dermal lym phatics are involved) have a worse prognosis. The surgical margins for resection are still controversial but, as a rough guide, impalpable lesions (thought to be 1 mm) should have a 1 cm mar gin, whereas thicker palpable lesions (1. Survival is independent of the width of excision, but local recurrence may not be. Dissection of the regional lymph nodes is again a controversial subject, but most surgeons would agree that this should only be performed if they are clinically palpable. Other modalities used include chemotherapy and isolated limb perfu sion, although with limited success, and prognosis is not greatly improved. They are low grade malig nancies, rarely metastasising, but they can erode into bone or other adja cent structures if they are left to grow large enough. Exposure to sunlight is a risk factor but they do not occur until middle age or later. Ninety per cent are found on the face, usually above a line from the lobe of the ear to the corner of the mouth. Early lesions consist of a raised pearly pink papule with fine telangectasia over it. Treatment is usually by surgical excision, although cryotherapy or radiotherapy is sometimes used. Treatment is by excision, with radiotherapy being used to treat recurrence or involved lymph nodes. Bowen’s Disease this is characterised by single or multiple brownish plaques, usually well defined and slightly raised and scaly. Their assessment is usually straightforward if a common sense approach to their examination and management has been developed and practised. We would sug gest the use of the following definition: A hernia is the protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position. When writing an answer on hernias, remember that they can also occur in sites away from the abdomen, such as when there is herniation of the brain through the foramen magnum with raised intracranial pressure or herniation of a muscle through a fascial defect in the leg. These other types of hernia should be mentioned for a complete written answer, although they should certainly not be more than a small part of any gen eral answer about hernias. In the clinical section of the exam, however, you are very unlikely to see anything other than abdominal hernias. The neck of a hernia is the margin of the defect through which the hernia has emerged. A hernia is reducible when its contents can return to the abdominal cavity either spontaneously or with manipulation. This term is usually used to describe an irreducible hernia where the irreducibility is due to adhesions within the sac in the absence of obstruction or strangulation. Some textbooks, however, define it as meaning a hernia which is irreducible because of faeces within the large bowel. Perhaps because of this confusion about the true definition of this term, it is best simply to refer to a hernia as being irreducible but not obstructed or strangulated. The patient may have the four cardinal signs of obstruction (pain, vomiting, distention and constipation). The blood supply to the contents of the hernia is occluded by pressure at the neck of the hernia. Usually, the veins are occluded first and then further swelling leads to arterial occlusion, which precedes gangrene developing. If the hernia contains only omentum, then this too can strangulate, but in this case bowel obstruction does not occur. A sliding hernia is one which contains a partially extraperitoneal structure, such as the caecum on the right or the sigmoid colon on the left. The importance of this is that particular care must be taken when excising the sac, to avoid damaging the bowel. This is where just part of the bowel wall is caught in the sac, and may become strangulated. Because only part of the bowel wall is in the sac, the patient is not usually obstructed. Then, one day, the lump becomes irreducible, implying that it had become incarcerated. The lump may then become painful and the overlying skin reddened, implying strangulation (he may or may not have symptoms of obstruction, depending on whether there is bowel within it). At this point this becomes a surgical emergency and the patient requires an urgent operation to relieve the ischaemia. This defect may be of two types: • Congenital • Acquired 220 Surgical Talk: Revision in Surgery Congenital the commonest types of congenital hernias are inguinal and umbilical hernias appearing in childhood. In males, when the testes develop and descend in utero they pass down and through the abdom inal wall into the scrotum, forming what will subsequently develop into the inguinal canal. As this happens a finger-like projection of peritoneum, called the processus vaginalis, is carried down with the testicle. This usually obliterates, but if it remains patent fluid or abdominal contents may enter down it, forming either a hydrocoele (fluid around the testicle) or a hernia (containing bowel or omentum). Umbilical hernias are com monly seen in infants and represent failure of complete obliteration of the umbilical opening. Surgical repair should therefore be reserved for those which persist after the age of five and those with a defect greater than 1 cm in size. Acquired To acquire a hernia, a weakness of the abdominal wall has to be produced. Inguinal hernias are proportionally more common in males than in females, and femoral hernias are proportionally more common in females than in males (possibly because of a wider pelvis and, hence, femoral canal). In both sexes, however, inguinal hernias are more common than femoral hernias in absolute numbers. As a lump (which may come and go; classically, the lump would appear on straining or lifting and disappear on lying down or when pressed on by the patient). To understand groin hernias properly, some basic anatomical knowledge is required. Femoral Hernias Femoral hernias emerge through the femoral canal, which normally con tains only fat and lymph nodes. The medial border of the femoral ring (the upper and widest part of the femoral canal) is the sharp-edged lacu nar ligament, which makes these hernias more prone to strangulation than inguinal hernias. Anteriorly is the inguinal ligament, posteriorly is the pectineal ligament and laterally is the femoral vein. Consideration of the position of the femoral canal will show why these hernias emerge below and lateral to the pubic tubercle. If identified, all femoral hernias should be repaired because of the risk of strangulation. Elective repair involves excision of the sac (herniotomy) and repair (herniorrhaphy), usually by suturing the inguinal ligament to the pectineal ligament with interrupted nonabsorbable sutures. Emergency repair is similar but usu ally utilises an incision through the inguinal canal or abdominal wall so that the bowel can be carefully assessed for strangulation and a bowel resection performed if necessary.
If a focal dystonia is persistent gastritis symptoms anxiety purchase prevacid 30 mg, then other diagnoses such as tics should be considered gastritis zinc buy 15 mg prevacid with mastercard. Focal dystonias that can occur in children include: • blepharospasm; • orofacial dystonia (combination with blepharospasm known as Miege syndrome); • writer’s cramp; • spasmodic torticollis gastritis diet and recipes buy cheap prevacid 15 mg. They may be spontaneous or re exive gastritis diet webmd cheap prevacid 30 mg amex, triggered by stimuli gastritis diet ìóëüòôèëüìû discount prevacid 30mg free shipping, such as noise and touch. This can either re ect a genetic (programming) error of brain development, or disruption by external injury or other noxious in uences in what was an otherwise normally developing brain. Evidence of bilateral, largely symmetrical changes indicate a likely genetic origin (with potential recurrence risk implications). Unilateral or strongly asymmetric patterns of involvement generally suggest acquired injury (with potentially lower recurrence risk implications); however, there are exceptions to this rule. These genes have relatively characteristic appearances in terms of the distribution of changes. A7 parasagittal hypoperfusion injury with cortical and subcortical damage in the parasagittal area (arrow); A8 acute severe term asphyxial insult of basal ganglia and thalamus lesions (left) with typical involvement of thalamus, globus pallidus and putamen (arrows), and lesions of the central region (arrows, right). B5 middle cerebral artery infarction with cortical, subcortical and thalamic involvement. The clinical patterns and molecular genetics of lissencephaly and subcortical band heterotopia. These can cause anxiety to inexperienced clinicians, radiologists, and of course, families. Minimize the risk of unearthing incidentalomas by resisting the temptation to perform non-indicated examinations! If the site of the incidentaloma is distant from the likely site of pathology, given the examination ndings, then it is easier to be reassuring about its non-signi cance. Small cysts, such as that shown, are commonly asymptomatic (the location at the anterior pole of the temporal lobe is typical). In situations of greater tonsillar descent, radiological evidence of foramen magnum crowding, and symptoms of headache, the ndings may be signi cant. In unclear situations a follow-up study after an interval of 12 mths may clarify its non-progressive nature. Recall that testing spinothalamic sensation in relevant dermatomes is the most sensitive clinical indicator of a syrinx (see b p. If appearances are striking, and head circumference is large, consider benign external hydrocephalus (see Figure 3. Approach the rst step is to distinguish hypomyelination or delayed myelination from dysmyelination. After this time, white matter should be normally be dark (re ecting completed myelination) on T2 (Figure 3. Further characterization is based on a combination of radiological features (particularly the anatomical location of abnormal white matter) and associated clinical features. Cortex White matter Basal ganglia T1 T2 Normal (after ~ 18m) or or T1 T2 T1 T2 T1 T2 T1 T2 Hypomyelination Leukoencephalopathy or Leukodystrophy Fig. Speci c scenarios • Unilateral hemi-syndrome: consider migraine or epilepsy (the duration of disturbed sensation will help differentiate). Proximal arm/shoulder pain or dysaesthesia often precedes the weakness of neuralgic amyotrophy. Much more commonly a child with developmental disability will show indifference to pain: he feels (and withdraws automatically from) painful stimuli but shows little emotional distress. Paroxysmal extreme pain disorder • the preferred name for what was previously known as familial rectal pain syndrome. Dif culties opening screw cap or door knob, turning key, buttoning clothes, writing, falling on uneven ground, tripping, hitting curb, dif culty in heel walking, toe walking, foot drop. Distal weakness is usually due to neuropathy (any), but also some muscle diseases (Emery–Dreifuss, myotonic dystrophy, dysferlinopathy, Miyoshi myopathy). Dif culties bending forward, lifting head off the bed, respiratory involvement, nocturnal hypoventilation, and diaphragmatic weakness; seen in congenital myopathies and glycogen storage disorders. Associated features/system enquiry • Toe walking: Duchenne, Becker, Emery–Dreifuss, Charcot–Marie Tooth. Examination • Examine parents and siblings: especially when considering neuropathies, myotonic dystrophy. Psychomotor regression and epilepsy Regression is often a feature of severe epilepsies (‘epileptic encephalop athy’). This latter is particularly a consideration in the presence of myoclonic seizures (see b p. Approach to diagnosis of neurodegenerative conditions There is no such thing as a ‘general neurometabolic screen’—narrow the differential diagnosis, and then focus investigations appropriately. It is important to have this perspective, but equally to be aware of local ethnicity considerations creating local ‘gene pools’. The six commonest diagnostic groups were leukoencephalopathies (7% combined), neuronal ceroid lipofuscinoses (5% combined), mitochondrial diseases (5%), mucopolysaccharidoses (4%), gangliosidoses (4%), and peroxisomal disorders (3%). Clues from imaging, electrophysiology and ophthalmology examination For approach to white matter abnormalities see b p. It can be hard to tell whether the problem is, in fact, longstanding, but has recently come to light due to increasing academic expectations. Non-rapid eye movement sleep Stage 1 (5–10% of sleep) • Occurs at sleep onset or following arousal from another stage of sleep (see Figure 3. Examination Pay particular attention to physical factors that may disturb sleep. Measures the time taken to get to sleep during 5 opportuni ties at least 2 h apart during the day. Dysarthria Weakness/paralysis of the musculature of speech (larynx, lips, tongue, palate, and jaw). Liquids usually fall by gravity; peristaltic waves push solids along (innervated by X). Problems with this phase can occur when there are motility disorders, mechanical obstruction or impaired opening of the lower oesophageal sphincter. Assessment of disordered swallowing A multidisciplinary team approach is bene cial in the assessment and man agement of children with swallowing problems. History • Feeding history: onset of problem (acute or chronic), severity (drooling, choking, coughing with feeds), voice change, nasal regurgitation, retention of food in the mouth, symptoms of gastro-oesophageal re ux. May suggest susceptibility to migrainous processes though such ndings are common and may be misleading! Slowly progressive ataxias (over months to years) with initial symptom-free period • Nearly all genetically determined progressive ataxias of older childhood are both extremely rare and dominantly inherited with high penetrance so that a family history will be informative (see b p. Congenital, non or slowly progressive ataxias with no initial symptom-free period • If imaging suggests unilateral or very asymmetric cerebellar involvement, the cause is probably acquired. Suggested approach to initial investigation of chronic non-progressive or slowly progressive cerebellar disorders (see b p. What children and families usually mean by this is ‘to one side of what I can see’. Central retinal artery occlusion (causing sudden painless and unilateral blindness) Visual loss is prominent in papillitis and is the usual presenting complaint (only in the mildest cases is it con ned to loss of colour vision). In addition, the causes of progressive loss overlap with the causes of congenital blindness. Toxic, nutritional • Usually present with decreased acuity and colour vision, especially if there are central scotomata. Recognition of ‘low level’ states Consciousness can simplistically be envisaged as having two components: • Arousal. This can occur in so-called ‘locked-in’ syndrome, although some preservation of eye movement is usual. Demonstrating low levels of awareness requires careful and skilled multidisciplinary assessment—identifying movements (typically eye blinks, eye pointing or limb movements) that are under some voluntary control, but may follow many seconds after requests. Unexplained distress on movement in children recovering from traumatic injury should prompt a careful evaluation for bony injury. Whilst a static concept of ‘full recovery’ of a previously fully established function after injury is meaningful in an adult (Figure 4. Returning to pre-injury levels of function (point A) is not ‘full recovery’: reaching point B as an adult is. In crude terms, motor development completes before language development, which completes before cognitive development: hence the particular concern about late cognitive outcomes, and children injured at a young age. In contrast, rehabilitation is characterized by a cross-disciplinary, forward-looking setting of speci c, relevant and measurable goals, ideally involving child and family. Unfortunately, this has led to a misplaced optimism that ‘plasticity’ allows the young head-injured child greater scope for recovery in general. This period ends with the restoration of orientation (awareness of time, place and person) and the ability to form new memories (‘who came to visit you this morning Vascular • the anterior spinal artery supplies the ventral two-thirds of the cord. Sparing of the dorsal cord (different blood supply) leads to classic preservation of dorsal column (vibration, joint position) sensation (see Figure 2. Extreme care must be taken in administering enemas and other potentially noxious stimuli below the level of the lesion. Long-term management Many long-term management issues are shared with children with spina bi da, and these clinics (if available) may be best suited to meet the needs of a child with an acquired paraplegia. Sensory Skin breakdown due to lack of pain sensation from pressure (not being turned, ill tting shoes, etc. For diseases with prominent renal involvement (Henoch Schonlein purpura, haemolytic–uraemic syndrome), see b p. This possibility should be particularly considered in the context of: • New onset aggressive epilepsy of unidenti ed cause, particularly in school age children. Sydenham chorea (St Vitus dance) Regarded as a major neurological manifestation of rheumatic fever. Cardiological aspects • All children should be evaluated for rheumatic cardiac valve disease and if found should commence anti-streptococcal penicillin prophylaxis. Encephalitis lethargica/post-encephalitic Parkinsonism • A striking picture of extrapyramidal movement disorder (particularly akinesia) and oculogyric crisis with disturbed arousal (prolonged coma and/or disrupted sleep wake cycle) presenting weeks to years after a febrile illness with sore throat. It is possible that a large proportion of encephalitic illnesses that would previ ously have been ‘presumed viral’ are in fact autoimmune in origin. Symptoms re ect dysfunction of the hippocampus (short-term memory loss), the remainder of the limbic system (confusion, seizures, psychosis) and/or brainstem (central hypoventilation), producing a ‘limbic encephalitis’ syndrome. History and examination the following features may present with an acute or subacute onset and not all need be present: • Behavioural change, agitation or neuropsychiatric symptoms: often a uctuating, encephalopathic course.
Considerations to gastritis spanish order prevacid in india keep in mind when interpreting experimental findings Historically gastritis symptoms on dogs cheap 30 mg prevacid, basic research scientists have extensively utilized the rat and the mouse as mammalian model systems for the study of pain gastritis diet ëàìîäà buy cheap prevacid 30mg online. Most recently gastritis diet çàãàäêè generic 30 mg prevacid with mastercard, the mouse has become popular for the study of pain gastritis in spanish 15mg prevacid sale, largely because the mouse is advantageous over the rat when it comes to genetic studies. However, it should be kept in mind that animal models, such as the rat and the mouse, might not always be good models for pain in humans. For example, exogenous substance P, when applied to rat dorsal horn neurons has a prolonged excitatory action that resembles the pattern of excitation observed after noxious stimulation. One must therefore be very cautious in extrapolating experimental findings in lower animals to humans. Functionally the spinal roots are classically divided into dorsal roots for sensory transmission and ventral roots for motor transmission. However, in humans and other mammals on the order of one third of all axons in the ventral roots are unmyelinated, have their cell bodies in the dorsal root ganglion, and are predominantly nociceptive. Nociceptors differ in many ways: the growth factors they are dependent upon, their response to different noxious stimuli, the receptors and ion channels they express, the conduction velocity of their axons, their capacity for sensitization by inflammation or injury, the neurotransmitters they release from their synaptic terminals, etc. One of the problems in trying to understand the processing of nociceptor signals by the spinal cord is deciding which characteristics of the nociceptor input are relevant. First consider the noxious stimuli: nociceptors respond to noxious cold, noxious heat and high threshold mechanical stimuli as well as a variety of chemical mediators. The question of whether a given nociceptor responds to a particular noxious stimulus can be problematic because the apparent lack of a response may result because the stimulus intensity is insufficient. Moreover the application of a high intensity stimulus of one modality may alter the response properties of the nociceptor to other modalities. Consequently it is not possible to generate a comprehensive list of all the different types of nociceptors and the noxious stimuli and chemicals each one responds to. Therefore when studying the second order nociceptive cells of the spinal cord one does not know the specific properties of all the 7-1 nociceptors that synapse onto it. Moreover, second order nociceptive cells are usually classified in terms of the noxious stimuli applied to their nociceptive inputs and not to the chemicals that activate their nociceptive inputs. Spinal cord processing of nociceptive signals One can think of the spinal cord as a black box with inputs and outputs: where input information from nociceptors is processed in the spinal cord and output nociceptive information is sent to higher centers of the brain involved in the sense of pain. In order to understand how the spinal cord processes signals emanating from nociceptors it is important to identify all the spinal cord inputs and outputs involved in nociceptive signaling. Pain and temperature afferents entering through the dorsal roots enter the spinal column and travel one or two segments up or down the cord before penetrating the gray matter of the dorsal horn where they synapse on second order neurons. The trigeminal ganglion (not shown) is analogous to the dorsal root ganglia of the spinal cord and is responsible for painful sensation in the face. The anterolateral system, which is composed of a bundle of fibers located in the ventrolateral aspect of the spinal cord, is typically described as transmitting nociceptive and thermal information to higher brain centers (see Figure 7-1). The nerve fibers of the anterolateral system originate from cell bodies of projection neurons in the contralateral dorsal horn, which give off axons that decussate via the anterior white commissure. The anterolateral system consists of the spinothalamic tract, spinoreticular tract, spinomesencephalic tract and spinohypothalamic tract. Anterolateral cordotomy, surgical division of the pain-conducting tracts in the anterolateral quadrant of the spinal cord, provides the selective loss of pain and temperature perception several segments below and contralateral to the segment at which the lesion is placed. This procedure is performed on patients experiencing severe pain due to cancer or other diseases for which there are no cure. Although cordotomy is effective in the relief of pain, the effect is usually temporary and pain tends to recur after cordotomies in the form of central pain, that is, pain resulting from a lesion or dysfunction of the central nervous system. The use of cordotomy may be appropriate for the treatment of dying patients with intractable pain. Historically, the dorsal column pathway was not thought to be involved in pain perception. However, data from clinical studies have shown that the dorsal column pathway is involved in relaying visceral nociceptive information. These studies have shown that small lesions, that disrupt fibers of the dorsal columns (see Figure 7-1) that ascend close to the midline of the spinal cord, significantly relieve pain originating in visceral organs. The nerve fibers of these dorsal column neurons originate from the cell bodies of projection neurons many of which are located in the vicinity of the central canal. These descending pathways may either block or facilitate transmission of pain information at the level of the dorsal horn. The nerve fibers of the descending pathway travel in the dorsolateral funiculus (see Figure 7-1) and originate in the rostroventral medulla, the nucleus tractus solitarius, the parabrachial nucleus, the dorsal reticular nucleus, the hypothalamus and the cortex. In addition to these ascending and descending pathways there are also interneurons in the dorsal horn whose axons do not leave the spinal cord. Both excitatory and inhibitory interneurons (see Figure 7-1) are involved in the processing of nociceptive signals before they leave the spinal cord. No description of spinal cord processing of nociceptive signals would be complete without a consideration of these interneurons. Neurotrophic factors and the development of nociceptive circuitry Sensory neurons are dependent for their survival on the production of neurotrophic factors by targets of innervation such as skin and muscle. This disorder affects more neurons than just nociceptors and is characterized by anhidrosis (inability to sweat), the absence of reaction to noxious stimuli, and mental retardation. The lack of the ability to experience pain can cause very serious health problems such as self-mutilation, auto-amputation, and corneal scarring. The termination of two types of nociceptive C-fibers and one type of nociceptive A fiber within the dorsal horn of the spinal cord. In order to ablate neurons expressing the Mrgprd receptor the human diphtheria toxin receptor was inserted into cells expressing the Mrgprd receptor. Adult mice in which diphtheria toxin was used to kill neurons expressing Mrgprd exhibit a reduced behavioral sensitivity to noxious mechanical stimuli determined with von Frey hairs but not to heat or cold stimuli. Interestingly, no deficits in mechanical pain sensitivity were found in mice in which diphtheria toxin was used at birth to kill neurons expressing Mrgprd. Apparently the young mice can compensate for the loss of Mrgprd expressing nociceptors (Cavanaugh, Lee et al. However, this interpretation does not explain why they also respond to thermal stimuli. This treatment blocks inflammatory hyperalgesia and neurogenic inflammation as well. As mentioned above, intrathecal administration of resiniferatoxin or capsaicin blocks inflammatory hyperalgesia and neurogenic inflammation. Both compounds blocked acute pain resulting from intraplantar capsaicin injection with the same potency. Both mechanical and thermal hyperalgesia following injection of Freund’s complete adjuvant were greatly reduced. One could imagine how sensitization of the input, to spinal nociceptive neurons, from unmyelinated low threshold mechanoreceptors could give rise to mechanical allodynia (see Peripheral sensitization versus central spinal sensitization). However, it is not clear how their absence would lead to a decreased response to intense noxious mechanical stimuli. Recall that intense noxious stimuli resulting in tissue damage often lead to hypersensitivity, that comprises both primary hypersensitivity an increased sensitivity within the injured area predominantly due to peripheral nociceptor sensitization, and secondary hypersensitivity, an increased sensitivity in the 7-13 surrounding uninjured area thought to be mediated centrally. In chapters 4 & 5 a number of intracellular biochemical pathways that could be involved allodynia and hyperalgesia in peripheral nociceptors were considered. What about hypersensitivity that is mediated centrally, possibly in the spinal cord Nevertheless a conjugate of substance P and saporin (where saporin is a protein that inactivates ribosomes, shutting down protein synthesis and resulting in cell death) can be used to selectively kill cells containing the substance P receptor. Following intrathecal injection of such a conjugate responses, to highly noxious stimuli, were markedly attenuated as were mechanical and thermal hyperalgesia (Mantyh, Rogers et al. In subsequent experiments loss of substance P receptor neurons was shown to lead to an apparently permanent reduction of thermal hyperalgesia and mechanical allodynia associated with both neuropathic and inflammatory pain (Nichols, Allen et al. Consequently, neurons expressing the substance P receptor play an essential role in the maintenance of allodynia and hyperalgesia and the communication of highly painful stimuli. However, binding of substance P to its receptor does not appear to be essential for these phenomena. Calcitonin gene related peptide and migrane headaches It was originally proposed that neurogenic inflammation (see chapter 4) in the dura mater mediated by substance P released from trigeminal nerve endings was responsible for migraine headaches. However, some patients taking telcagepant developed high levels of liver enzymes (transaminases) and the clinical trials were ended. Numerous studies have identified several categories of cells having partial or complete nociceptive properties in these laminae. In many studies it was not determined whether these nociceptive cells were spinal interneurons or projection neurons that contribute to anterolateral system or the dorsal columns. The axons of lamina I projection neurons ascend in the anterolateral system (see Figure 7-1), therefore presumptive recordings from lamina I projection neurons can be confirmed by antidromic activation of their axons by stimulating electrodes placed in anterolateral system projection areas. In addition to the lamina I neurons with nociceptive properties, that we are interested in, there are also a group of lamina I neurons sensitive to warm and cool innocuous thermal stimuli and a group of lamina I neurons sub serving the sense of itch. Primary hypersensitivity and secondary hypersensitivity Remember that intense noxious stimuli resulting in tissue damage often lead to an increase in the response to subsequent painful stimuli, called hypersensitivity. Two areas of hypersensitivity are recognized according to their location relative to the site of injury, primary hypersensitivity, an increased sensitivity within the injured area partially due to peripheral nociceptor sensitization, and secondary hypersensitivity, an increased sensitivity in the surrounding uninjured area (see diagram below). A number of studies have shown that primary hypersensitivity involves sensitization to both mechanical and heat stimuli. On the other hand, the area of secondary hypersensitivity is characterized by sensitization to mechanical stimuli only. This has led to the widely held view that the sensitization of nociceptors to heat stimuli may be sufficient to account for the heat hypersensitivity component of primary hypersensitivity. One might think that within the region of primary hypersensitivity, the mechanisms for mechanical hypersensitivity and heat hypersensitivity are identical. However, this is not the case, for example, intradermal bradykinin injection in humans evokes hypersensitivity to heat stimuli with no measurable hypersensitivity to mechanical stimuli measured with von Frey hairs (Manning, Raja et al. Although sensitization of nociceptors to mechanical stimuli has been documented it is currently thought that it cannot quantitatively account for mechanical hypersensitivity in the zone of primary hypersensitivity, and that central sensitization may contribute to the mechanical hypersensitivity. Peripheral sensitization of nociceptors contributes to pain hypersensitivity at inflamed sites (primary hyperalgesia); it appears to play a major role in altered heat but not mechanical sensitivity, which is a major feature of central spinal sensitization. In contrast to peripheral sensitization, central spinal sensitization, allows low-threshold mechanoreceptor afferents to mediate pain although these afferents do not normally cause pain. In this respect, central spinal sensitization represents a dramatic functional shift in the way we perceive somatosensory inputs: low threshold stimuli, which may have been pleasant previously, are now painful. In this situation we are experiencing the pain as coming from outside stimuli, although the actual stimuli are not themselves noxious. It is important to keep this in mind because the target for treatment in this circumstance is not the periphery but is actually the central nervous system. That the sensitization to mechanical stimuli of secondary hypersensitivity is mediated centrally rather than peripherally is not at all obvious.
In the authors view gastritis loss of appetite buy generic prevacid 15mg line, muscle section is an adjunctive procedure for cervical dystonia and should be considered in cases with long standing dystonia which exhibit evidence of soft tissue stiffness or muscle shortening gastritis pain purchase prevacid with paypal. Furthermore gastritis diet for diabetics order prevacid 30 mg online, it may be performed on muscles which are difficult to gastritis diet 0 carbs 15 mg prevacid otc denervate (Ondo & Krauss gastritis diet ýðîòè÷åñêèå discount 30 mg prevacid free shipping, 2004), such as the scalene muscles. However, among our patients with uncomplicated or simple cervical dystonia, we did not encounter substantial difference of outcome between the patients who underwent pallidal deep brain stimulation and those who underwent peripheral denervation. Therefore, we always chose peripheral nerve resection as the primary surgical therapy in the uncomplicated cases. On the other hand, we consider the deep brain stimulation as the prerequisite treatment of complex cervical dystonia, such as mobile cervical dystonia, segmental dystonia, head tremor, anterocollis, severe retrocollis, in the patients who have significant extracervical symptoms, or who have never been improved by botulinum toxin injection (primary botulinum toxin non-responder). Such complicated cases are always difficult to deal with through selective peripheral denervation (Albanese et al. However, currently, it appears to be a good surgical option in various pain disorders, particularly in neuropathic pain and pain of ischemic origin (Forouzanfar et al. This chapter focuses on peripheral nerve surgery in the cervical region for cervical dystonia which refers to selective peripheral denervation in terms of patient selection, preoperative evaluation, operative procedures with relevant surgical anatomy, and surgical outcome. Patient selection Selective peripheral denervation is chiefly indicated in patients with failed botulinum toxin injection, including those who have never responded to the injection (primary botulinum toxin non-responder) or who have a change from significant previous response to poor recent response (secondary botulinum toxin non-responder) (Albanese et al. Good surgical candidates for the operation include those who meet the following parameters (Braun et al. Preoperative electromyography and imaging of the cervical muscles are concordant with clinical manifestation Furthermore, selective peripheral denervation is sometimes considered as a major alternative to botulinum toxin injection in the treatment of cervical dystonia. For example, for patients who do not require multiple repeated injections or who cannot afford the cost of the toxin, the operation is meaningful for them (Taira, 2009). Nevertheless, some kinds of cervical dystonia are not suitable for the procedure, including head tremors, anterocollis, complex cervical dystonia or cervical dystonia with marked phasic movement. In such kinds of dystonia, pallidal deep brain stimulation should be considered first (Albanese et al, 2006; Nunta-aree et al. Preoperative evaluation In the surgical point of view, consideration before decision of the denervating procedure should cover the following. Visualization of abnormal posture of the neck, palpable deviant muscle tone and tension usually give valuable preliminary information about the group of involved muscles. Electromyography or video-electromyography is an important tool to define the specific group of dystonic muscles (Brin & Benabou, 1999; Dressler, 2000; Feely, 2003; Krauss et al. The information about injected muscles which accomplish good outcomes is very critical for operative planning. It can be simply revealed by noting passive range of motion of the neck and plain radiographic studies of the cervical spine. Limitation of passive neck motion implies probable fixed deformity which often impairs surgical outcome, particularly in terms of postoperative neck posture. By both the methods, a higher level of score indicates increased severity of cervical dystonia (Comella et al. The score can be used for comparison between before and after a treatment or between among various alternatives of treatment. Maximal excursion 0 N one(0)o 1 Slight (< 1/4 range, 1o 22o) Rotation o o 2 Mild (1/4 1/2 range, 23 45) (turn: right or left) 3 Moderate [1/2 3/4 range, 46o 67o) 4 Severe (>3/4 range, 68o 90o) 0 N one(0)o Laterocollis o o 1 Mild (1 15) (tilt: right or left, exclude o o 2 Moderate (16 35) shoulder elevation) 3 Severe (> 35o) 0 N one 1 Mild downward deviation of chin a. Anterocollis 2 Moderate downward deviation (approximates 1/2 possible range) Anterocollis 3 Severe (chin approximates chest) or retrocollis 0 N one (a or b) 1 Mild backward deviation of vertex with upward deviation of chin b. Retrocollis 2 Moderate backward deviation (approximates 1/2 possible range) 3 Severe (approximates full range) Lateral shift 0 Absent (right or left) 1 Present Sagittal shift 0 Absent (forward or backward) 1 Present B. Duration factor (weighted x 2) 0 N one 1 Occasional deviation (< 25% of the time, most often submaximal) Occasional deviation (< 25% of the time, often maximal) or 2 Intermittent deviation (25 50% of the time, most often submaximal) Duration factor Intermittent deviation (25 50% of the time, often maximal) or (weighted x 2) 3 Frequent deviation (50 75% of the time, most often submaximal) Frequent deviation (50 75% of the time, often maximal) or 4 Constant deviation (>75% of the time, most often submaximal) 5 Constant deviation (>75% of the time, often maximal) Dystonia and Peripheral Nerve Surgery in the Cervical Area 157 C. Effect of sensory tricks 0 Complete relief by one or more tricks Effect of sensory tricks 1 Partial or only limited relief by tricks 2 Little or no benefit from tricks D. Shoulder elevation/Anterior displacement 0 Absent 1 Mild (< 1/3 possible range, intermittent or constant) Shoulder elevation/Anterior Moderate (1/3 2/3 possible range and constant, > 75% of the time) displacement 2 or Severe (> 2/3 possible range and intermittent) 3 Severe and constant E. Range of motion (without aid of sensory tricks) 0 Able to move to extreme opposite position Able to move head well past midline but not to extreme opposite 1 Range of motion position (without aid of sensory tricks) 2 Able to move head barely past midline 3 Able to move head toward but not past midline 4 Barely able to move head beyond abnormal posture F. Time (up to 60 seconds) for which patient is able to maintain head within 10o of neutral position without using sensory tricks (mean of two attempts) 0 > 60 seconds 1 46 60 seconds Time 2 31 45 seconds 3 16 30 seconds 4 < 15 seconds 2. Disability scale (maximum = 20) 0 No difficulty Normal work expectations with satisfactory performance at usual 1 level of occupation but some interference by torticollis Most activities unlimited, selected activities very difficult and 2 A. Work hampered but still possible with satisfactory performance (occupation or housework/home Working at lower than usual occupation level; most activities management) 3 hampered, but all possible with less than satisfactory performance in some activities Unable to engage in voluntary or gainful employment; still able to 4 perform some domestic responsibilities satisfactorily 5 Marginal or no ability to perform domestic responsibilities 0 No difficulty with any activity 1 Activities unlimited but some interference by torticollis B. Activities of daily living Most activities unlimited, selected activities very difficult and 2. Driving Can drive only short distances 3 Usually cannot drive because of torticollis 4 Unable to drive and cannot ride in a car for long stretches as a 5 passenger because of torticollis Unlimited ability to read in normal seated position but bothered by 1 torticollis Unlimited ability to read in normal seated position but requires use 2 of tricks to control torticollis D. Reading Unlimited ability to read but requires extensive measures to control 3 torticollis or is able to read only in nonseated position. Television Unlimited ability to watch television but requires extensive measures 3 to control torticollis or is able to view only in nonseated position. Activities outside the 2 Unlimited activities but requires simple tricks to accomplish home Accomplishes activities only when accompanied by others because. Pain scale (maximum = 20) Rate the severity of neck pain due to spasmodic torticollis during the last week on a scale of 0 10 where a score of 0 represents no pain and 10 A. Score calculated as: [worst + best + (2 x usual)]/4 Best Worst Usual Score 0 N one 1 Present < 10% of the time 2 Present 10 25% of the time B. Duration of Pain 3 Present 26 50% of the time 4 Present 51 75% of the time 5 Present > 75% of the time Dystonia and Peripheral Nerve Surgery in the Cervical Area 159 0 No limitation or interference from pain 1 Pain is quite bothersome but not a source of disability Pain definitely interferes with some tasks but is not a major 2 contributor to disability 3 Pain accounts for some (less than half) but not all of disability C. Disability due to pain Pain is a major source of difficulty with activities; separate from this, 4 head pulling is also a source of some (less than half) disability Pain is the major source of disability; without it most impaired 5 activities could be performed quite satisfactorily despite the head pulling Table 1. Operative procedures and relevant surgical anatomy Selective peripheral denervation consists of several surgical procedures. One well-known operation is the Bertrand procedure which originally included section of peripheral branches of the cervical spinal nerve and selective denervation of the sternocleidomastoid nerve. Cutting of peripheral branches supplying the sternocleidomastoid or levator scapulae endeavors to reduce their dystonia resulting in improved neck posture and function. The authors simply divide the denervating procedures into three main themes, including denervation of the posterior cervical paraspinal, sternocleidomastoid, and levator scapulae muscles. In order to understand these operations, each of them will be preceded by exposition of its relevant surgical anatomy. In addition, identification of nerves by using intraoperative electrical nerve stimulator, conclusion of nerve supply to the neck muscles, options in selective denervation, and combined operations will be discussed consecutively. They are abnormal on the same side of rotating or tilting head in torticollis or laterocollis, respectively (Anderson et al. This group of muscles are found to be dystonic bilaterally in retrocollis (Taira, 2009). The commonly involved muscles include the splenius capitis, semispinalis capitis, semispinalis cervicis, multifidus, suboccipital muscles (rectus capitis posterior major and minor, obliquus capitis superior and inferior), and upper trapezius (Taira, 2009) (Fig. Aside from the trapezius, all of them are innervated by the posterior rami of the C1 to C8 spinal nerves while the upper twig of the accessory nerve directly supplies the trapezius. Consequently, a common procedure of posterior neck muscle denervation is C1-C6 posterior ramisectomy (Krauss et al. The C1 segmental nerve emerges from the atlanto-occipital space located superior to the atlas, then it abruptly branches into the anterior and posterior rami. Unlike the C2 to C6 posterior rami, the C1 posterior ramus does not ramify into medial and lateral branches (Fig. The posterior ramus of the C2 spinal nerve always bifurcates into medial and lateral branches. The medial branch mainly contains sensory fibers which it terminates as the greater occipital nerve supplying the posterior scalp up to the vertex (the C2 dermatome). The lateral branch is composed of motor fibers supplying the upper portion of the posterior cervical group (Fig. The C3-C6 posterior rami often divide into medial and lateral branches innervating the corresponding skin as well as paraspinal muscles of the neck (Clemente, 1985; Kayalioglu, 2009; Roman, 1981) (Fig. Major cervical paraspinal muscles involved in cervical dystonia and their nerve supply. The former, originating from the C2 level, terminates as the greater occipital nerve. This genuine extraspinal procedure provides good surgical outcome and is currently a widely used operation for cervical dystonia (Bronte-Stewart, 2003; Krauss, 2010; Sitthinamsuwan & Nunta-aree, 2010; Taira, 2009). Denervating procedure on peripheral nerves supplying the posterior cervical group is typically performed on those arising from the C1 to C6 spinal cord segment (Brin & Benabou, 1999; Dashtipour et al. Alternatively, C1-C2 posterior ramisectomy can be used instead of C1-C2 extradural rhizotomy (Brin & Benabou, 1999; Munchau et al. During dissection, muscular branches emerging from the C1-C6 posterior rami are identified by using an electrical stimulator and prepared for ramisectomy. The ablation is done just before the peripheral nerves penetrating the targeted muscles (Fig. A midline surgical incision on the back of the neck in posterior cervical ramisectomy Dystonia and Peripheral Nerve Surgery in the Cervical Area 163 Fig. The muscular branches of the C1-C6 nerves supplying dystonic muscles on the affected side are identified and subsequently sectioned. A common pitfall of posterior cervical ramisectomy is inadequate denervation of the semispinalis capitis resulting in residual or recurrent cervical dystonia. The pitfall may occur as a result of complex innervation of this muscle comprised of two entities. The first one is motor branches originating from the medial branches of the posterior cervical rami. They intervene in the plain between the semispinalis capitis and semispinalis cervicis and then enter into the deep surface of the semispinalis capitis (Fig. In the same manner, the other entity is muscular branches coming from the lateral branches of the posterior cervical rami which they are situated in the plain between the semispinalis capitis and splenius capitis, then supply the semispinalis capitis through its superficial aspect (Taira, 2009) (Fig. Hence, to accomplish complete denervation of the semispinalis capitis, exploration and resection of the motor nerves in both the plains are mandatory. In patients suffering from retrocollis, bilateral posterior cervical muscle denervation is required. With caution, bilateral section of the C6 posterior rami should be avoided, particularly in elderly females who have thin neck muscles. Following bilateral C6 posterior ramisectomy, such patients probably develop difficulty in their neck extension and swallowing (Bertrand, 1988; Taira 2009). In our experience of bilateral posterior cervical denervation for intractable retrocollis, we always performed C1-C6 posterior cervical ramisectomy on a more severe side and cut from the C1 posterior ramus caudally to the C4 or C5 posterior ramus with total preservation of the C6 one on the contralateral side. A major sequelae of Bertrand procedure is dysesthesia over the skin innervated by the C2 spinal nerve. The sensory disturbance of the C2 dermatome is inevitable in almost all cases who undergo this procedure. It always occurs in the early postoperative period as a result of resection of the proximal C2 dorsal ramus containing both motor and sensory nerve fibers (Albanese et al.
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