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F. Thorald, M.A., M.D., M.P.H.

Medical Instructor, New York Institute of Technology College of Osteopathic Medicine

The advantage of an anterior correction is the shorter fusion length and better derotation pregnancy 24 order 20mg tamoxifen overnight delivery. The anterior approach has a cosmetic advantage if the operation is performed by means of a mini-thoracotomy or thoracoscopy leaving only small scars womens health ucsf tamoxifen 20 mg low price. Although spontaneous lumbar curve correction occurs after both selective posterior and anterior thoracic fusion menopause numbers cheap tamoxifen 20 mg overnight delivery, the correction was found to be better in the latter approach [111] women's health boutique in escondido quality 20 mg tamoxifen. When planning surgery for double-thoracic curves, preoperative shoulder balance (T1-tilt) and size (Cobb angle) and rigidity of the proximal thoracic curve must be considered to achieve a good outcome [108]. Thoracolumbar and Lumbar Curves Pedicle screws allow for a better scoliosis correction In double thoracic curves attention must be paid to shoulder balance, curve size and rigidity An isolated fusion of these curve types without addressing the thoracic curve (if present) is possible if the thoracic curve reduces to less than 25° in the bending radiograph [142]. These curves benefit most from a short anterior scoliosis correction (Case Introduction), preserving more mobile motion segments com- Thoracolumbar curves are best treated from anteriorly 650 Section Spinal Deformities and Malformations pared to posterior fusion [60, 142]. If the thoracic curve remains larger than 25° in the bending radiograph, it should probably be addressed surgically in order to avoid decompensation of spine and shoulder balance. Double Major Curves Motion segment preservation is an important goal these curve patterns with a thoracic and a thoracolumbar or lumbar structural curve are usually operated on from posteriorly indicating that a big part of the spine has to be fused. Attempts to fuse the lumbar curve anteriorly and only the thoracic curve posteriorly have recently been suggested. It was reported that an anterior release with instrumented fusion of the lumbar curve was superior to an anterior release followed by posterior instrumented fusion [236]. Only preliminary data is available on the short selective anterior fusion of both the thoracic and the lumbar curve with the potential advantage of preserving motion segments in double major curves [141]. Adult Idiopathic Scoliosis Surgical treatment is strongly influenced by the pain sources the goal is to achieve a balanced spine without pain and normal neurology the general state of health, age and bone quality play important roles in the surgical decision-making. Morbidity for surgery is lower in younger patients (< 40 years) and the chance of a better outcome will also be higher than in older patients (> 40 years) [17, 46, 210]. Surgical decision-making in adult idiopathic scoliosis strongly depends on the underlying causes of pain, which have to be explored thoroughly. With predominant irradiating pain or claudication without relevant back pain, selective spinal decompression may be performed as a standalone procedure [1]. In younger patients a partial correction of the deformity may already lead to a sufficient decompression without a formal decompression being performed (Case Study 2). If additional segmental instability, extensive degenerative changes and progressive deformity lead to back pain, posterior and/or anterior fusion and stabilization with/without decompression and correction may be required [194]. To achieve a balanced spine and prevent a postoperative collapse of the adjacent segment, the fusion usually has to extend beyond the major curve. Stopping the fusion of a lumbar curve below the thoracolumbar junction usually bears a high risk of sagittal decompensation of the spine cranially [83]. It is still controversial whether or not the lumbosacral junction should be included in the fusion [17, 19, 45, 90]. If unfused, the L5/S1 segment has to take all the movements and loads of the fused lumbar spine [107, 194]. Furthermore, a fusion to the sacrum leads to higher stress for the sacroiliac and hip joints. Nonunion rates of up to 30 % are reported if the fusion is not done circumferentially [19, 59]. It has to be borne in mind that the spine may be in a fragile balance before surgery and that a decompression and/or a partial fusion may lead to a deterioration of this balance leading to progressive deformity and disability. If spinal balance is preserved, fusion in situ will often be the method of choice as an adjunct to decompression [1]. An imbalanced spine with secondary degenerative changes requires extensive release of the posterior structures and in some cases multiple spinal osteotomies (see Chapter 26). Idiopathic Scoliosis Chapter 23 651 c d a b Case Study 2 A 25-year-old female with a known but untreated scoliosis for many years presented because of incapacitating lumbar back and leg pain with inability to continue with full time work. Standard radiographs demonstrated a major thoracolumbar curve of 56 degrees and a minor thoracic curve of 42 degrees (a, b).

The thoracic cage is incomplete superiorly and inferiorly at apertures which permit passage of structures to and from the neck and the abdomen women's health clinic doncaster cheap tamoxifen 20mg otc. The superior aperture at the root of the neck is bordered by the T1 vertebral body pregnancy kit cost cheap tamoxifen 20 mg on line, the 1st ribs and the superior edge of the manubrium pregnancy glucose screening discount 20mg tamoxifen with mastercard. The inferior aperture is bordered by the body of the T12 vertebra womens health yuma az discount tamoxifen 20mg without prescription, the entire costal margin, and the xiphisternal joint. The superior thoracic aperture is bordered anteriorly and laterally by the atypical 1st rib, which has grooves on its superior side for subclavian vein and artery and a scalene tubercle for attachment of the anterior scalene muscle. It allows the passage of the esophagus, aorta, inferior vena cava, and nerves to the abdomen. In the lower drawing, the pericardium on the diaphragm and parietal pleura are cut away to show the domes of the diaphragm. Due to its curved shape, at mid-inspiration the opening of the inferior vena cava is at the T8 vertebral level, the esophageal hiatus at T10, and the aortic hiatus at T12. The intercostal veins, arteries, and nerves travel a course between the internal and innermost layers. It originates along lower borders of the ribs and inserts on superior borders of the next ribs below. Fiber directions are downward and anteriorly directed (like putting your hands into your front pants pockets). The muscle extends from the rib tubercles around anteriorly as far as costochondral junctions. From there, the superficial layer continues as an aponeurosis called the external intercostal membrane. The internal intercostal muscle originates in the subcostal grooves and inserts on the superior border of the next rib. Fibers are directed downward and posteriorly (like when you give a military salute). The muscle extends from just adjacent to the sternum around posteriorly as far as the angle of the ribs. From the angle, this second layer continues as the aponeurotic internal intercostal membrane (see next slide). The innermost intercostal muscles are the deepest muscles across intercostal spaces. Note how the intercostal nerves and vessels pass between internal and innermost intercostal muscle layers. In the same plane are 2 other more minor muscle sets of muscles associated with the innermost intercostals: the transversus thoracis on the anterior wall and subcostals (not shown on this slide, see next) on the posterior wall, near the angles of the ribs. Visualize on this drawing from Drake the transversus thoracis on the posterior aspect of the anterior wall and subcostals on the anterior aspect of the posterior wall, near the angles of the ribs. In this image of the deep side of the posterior thoracic wall, the intercostal veins, arteries and nerves are beginning their course between the innermost and internal intercostal muscle layers. At the top rib in this group, the vessels and nerves are just entering the subcostal groove. The arrangement of the linear structures in the subcostal groove from superior to inferior is consistently Vein, Artery, Nerve. Air or fluid may be removed through an intercostal space by needle thoracocentesis or thoracostomy drainage tube. The layers penetrated include: skin, superficial fascia, serratus anterior muscle, external, internal and innermost intercostal muscles, endothoracic fascia, and parietal pleura. Insertion should be at the superior edge of a rib to avoid damage to vessels and nerves. Both of these procedures differ from a thoracotomy, an opening through an intercostal space. Intercostal nerves are continuation of the anterior primary rami of thoracic spinal nerves, providing cutaneous supply to lateral and anterior thoracic wall (and abdominal wall), motor supply to intercostal muscles, motor supply to abdominal wall muscles (T7-12), and sensory supply to the parietal pleura and peritoneum (T7-12). The 12th nerve is given the special name, subcostal nerve, as it runs below the 12th rib (in the abdominal wall). The superior intercostal artery (a branch of the costocervical trunk, itself a branch of the subclavian artery) supplies the first 2 intercostal spaces on both sides. Starting at the 3rd intercostal space, the other posterior intercostal arteries are branches of the descending thoracic aorta. All the intercostal arteries travel around the thoracic wall in the subcostal grooves between the internal and innermost intercostal muscle layers.

The iliopsoas muscle originates on the anterior aspect of the lumbar spine and passes over the hip joint to the inside of the femur womens health 2012 quality 20mg tamoxifen. Vertebral muscle is composed of 50 ­ 60 % type I muscle fibers menstrual ovulation discount tamoxifen 20 mg with mastercard, the so-called "slow twitch" women's health clinic rock springs wy trusted 20 mg tamoxifen, fatigue-resistant muscle fibers found in most postural muscles [9] breast cancer encouragement discount 20mg tamoxifen amex. Anterior spinal muscles a Abdominal muscles with a superficial layer, b intermediate layer, c deep layer. Deep muscles of the back a the deep muscles of the back can be separated into the sacrospinalis (erector spinae) group (left side), the transversospinal group (right side), and the short back muscles group. The sacrospinalis group consists of the iliocostalis muscles, longissimus muscles and spinalis muscles. The transversospinal group consists of semispinalis muscles, multifidus muscles and the rotator muscles. The short back muscle group consists of the intertransverse and interspinal muscles. Superficial muscles of the back the geometric relationship between the muscle line of action and the intervertebral center of rotation determines the functional potential Spinal muscle activity can be determined by direct electromyographic measurement or by using mathematical models of the spine, which include a detailed description of the origin and insertion points of muscles, muscle cross sections, muscle fiber length and muscle type. Of particular importance is the geometric relationship of the muscle line of action to the rotation center of the joint in consideration (the moment arm: larger moment arm greater potential to produce torque). Detailed descriptions of the anatomy of spinal muscles have been published, which include the variation in moment arm length resulting from changing posture [14, 48, 65, 92]. Owing to the large number of muscles, the inherent redundancy, and the possibility for muscular co-contraction, the calculation of muscle activity with mathematical models often requires the use of additional formulae which consider optimal muscle stress levels or maximum contraction forces to obtain a unique solution. Spinal Stability Through Muscular Activity Spine stability is enhanced by the activity of the transverse abdominis, multifidus and psoas muscles the muscular system can also be divided into three functional groups [10]:) local stabilizers) global stabilizers) global mobilizers Biomechanics of the Spine Chapter 2 53 Figure 6. Interplay of anterior and posterior spinal muscles the transverse abdominis, the deep lumbar multifidus and the psoas are among the local stabilizing muscles best suited to control the neutral zone in the lumbar spine. The transverse abdominis attaches directly to the lumbar spine and stiffens the spine by creating an extensor moment on the lumbar spine and by creating pressure on the anterior aspect of the spine (intra-abdominal pressure), resisting collapse of the natural curvature of the spine. Examples of local stabilizers are the transverse abdominis, the deep lumbar multifidus and the psoas. Local stabilizers operate at low loads and do not induce motion, but rather serve to stiffen the spinal segment and control motion. A dysfunction of the local stabilizer can result in poor segmental control and pain due to abnormal motion. The global muscle system comprises the larger torque-producing muscles which contract concentrically or eccentrically to produce and control movement. Examples of global muscles are the oblique abdominis, rectus abdominus and erector spinae (spinalis, longissimus and iliocostalis). Although global muscles are traditionally targeted for treating patients with low back pain, there is compelling evidence that retraining of the local stability system may be most beneficial. Clinical instability has been defined as a significant decrease in the ability to maintain the intervertebral neutral zone within physiological limits [67], and the muscles best suited to control the neutral zone in the lumbar spine are the transverse abdominis, the deep lumbar multifidus and the psoas [41]. The transverse abdominis attaches directly to the lumbar spine via the lumbodorsal fascia and Training of local stabilizers improves spinal stability 54 Section Basic Science the psoas is an important spine stabilizer stiffens the spine by inducing an extensor moment on the lumbar spine and by creating pressure on the anterior aspect of the spine (intra-abdominal pressure), resisting collapse of the natural curvature of the spine. The multifidus attaches directly to each segment of the lumbar spine and intrinsically stiffens the intervertebral joint by direct contraction. However, the presence of multiple fascicles of the psoas attaching to the individual lumbar vertebrae, and the predominant fiber orientation on the anterior aspect of the vertebrae, facilitate its function as a spine stabilizer [74]. Muscle Activity During Flexion and Extension Flexion is achieved through the forward weight shift of the upper body and controlled by compensatory activity of the extensor muscles Due to the nearly oblique configuration of thoracic facets and the intrinsic stiffness of the ribcage, the majority of spine flexion and extension occurs in the lumbar spine, augmented by pelvic tilt [19, 29]. Flexion is initiated by the abdominal muscles and the vertebral portion of the psoas. Additional flexion is achieved through the weight shift of the upper body, which induces an increasing forward bending moment, and is controlled by compensatory activity of the extensor muscles. In full flexion, it has been proposed that the forward bending moment is counteracted passively by the elasticity of the muscles and posterior ligaments of the spine, which are initially slack but progressively tightened as the spine flexes [29]. However, more recent studies with measurements of muscle activity have shown that deep lateral lumbar erector spinae muscles are still active in full flexion [7], perhaps for stabilization.

A physician diagnoses a congenital malformation in a tissue that is a derivative of the embryonic endoderm menstrual history purchase tamoxifen 20 mg amex. Which of the following approaches is the best one for imaging bony structures because it subjects the patient to the lowest dosage of x-rays but is still highly accurate? The coronal plane is named for the coronal suture on the skull and is a plane that is parallel to that suture and synonymous with frontal plane menopause icd 9 cheap tamoxifen 20mg amex. Axial pregnancy pact purchase tamoxifen 20 mg on-line, transverse menopause estrogen levels tamoxifen 20mg amex, and cross section also are synonymous terms and divide the body into superior and inferior portions. Two sesamoid bones also usually exist at the base of each thumb and base of each large toe. Bone growth in length occurs at the epiphysial plate, where hyaline cartilage undergoes proliferation and ossification. The hip is a perfect example of a ball-and-socket joint and is one of the more stable synovial joints in the body. The shoulder joint also is a ball-and-socket joint but is more mobile and less stable than the hip joint. The antagonist is the muscle that opposes the action of the agonist, the muscle that is contracting and in this case the muscle being tested by the orthopedist. Venous blood from the body passes through the right side of the heart (right atrium and ventricle) and then passes into the pulmonary trunk, which divides into a right pulmonary artery and a left pulmonary artery carrying blood away from the heart and to the lungs for gas exchange. The thoracic duct drains lymph from about three quarters of the body and returns it to the venous system at the junction of the left internal jugular and left subclavian veins. The dura mater is heavily innervated by sensory nerve fibers, whereas the arachnoid and pia mater are not innervated. It is a two-neuron efferent system, and different transmitters are co-localized and released. The only exception is the neuroendocrine cells of the adrenal medulla, which are modified postganglionic sympathetic neurons innervated by preganglionic sympathetic fibers. The ureter is the duct connecting the kidney (renal pelvis) to the urinary bladder. The gallbladder stores and concentrates bile, which is necessary for the emulsification of fats in our diet. The pericardium and the heart reside in the mediastinum (middle space), the region between the two pleural cavities, all of which are in the thoracic cavity. This is when the trilaminar disc (ectoderm, mesoderm, endoderm) develops and when the ectoderm begins to migrate medially and fold along the midline axis to form the future neural tube and spinal cord. Later in its development, the neural crest (neural folds of ectoderm) also plays an important role. Ultrasound uses very-high-frequency longitudinal sound waves, is relatively safe, and is cost effective compared with the other imaging modalities. Unfortunately, it is not suitable for all imaging; its resolution is limited and it cannot penetrate bone. The densest structure in the body is bone, with the greatest attenuation of photons, followed by soft tissues, water (the reference medium), fat, lung (mostly air), and then air itself. On a plain radiograph, a very dense tissue like bone appears white, while air appears black. This movement is the same as extension and is the opposite of flexion (plantarflexion). Most patients will not be familiar with the term dorsiflexion (or extension), so the physician must phrase the instruction in words that are easily understood. A second-degree burn penetrates both the epidermis and the dermis, but does not go further. All the other bones listed are part of the appendicular skeleton (bones associated with the limbs). The dorsalis pedis pulse is also important because it is the pulse farthest from the heart; it is detected on the dorsal surface of the foot. A considerable amount of fluid is lost to the extracellular compartment at the level of the capillaries. The fluid can be recaptured by the lymphatic vessels and returned to the venous system.