OVERVIEW of the REGION the Trunk Is the Body Region That Includes the Thorax (The Before Extending Into the Arms
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The Anklyosed Spine: Fractures in DISH and Anklyosing Spondylitis
The Anklyosed Spine: Fractures in DISH and Anklyosing Spondylitis Lee F. Rogers, MD ACCR, Oct 26, 2012 Dallas, Texas Diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) are the most common diseases associated with spinal ankylosis. While they share the characteristic of ankylosis they are, in fact two separate diseases with distinct clinical, pathologic, and radiologic features. DISH: Diffuse idiopathic skeletal hyperostosis is a disease of older persons characterized by extensive ossification of the paraspinal ligaments anteriorly and laterally, bridging the intervening disc spaces. Bony bridging may be continuous or discontinuous. The anterior cortex of the vertebral body can be seen within the ossification. These findings are much more pronounced in the thoracic and lower cervical spine than in the lumbar area. Minor expressions of this disorder are commonly encountered in the mid-dorsal spine on lateral views of the chest. DISH characteristically spares the SI joints. The SI joints remain patent and clearly visible on radiographs or CT even in the presence of extensive disease in the thoracolumbar and cervical spine. DISH is also characterized by enthesopathy; ossification of ligaments or tendon insertions, forming so-called entheses. These appear as whiskering of the iliac crest, ischial tuberosites and greater trochanters. The radiographic appearance bears a superficial resemblance to that of AS. In DISH the spinal ossification is very irregular and unlike the thin, vertical syndesmophytes see in AS. The relative absence of changes in the lumbosacral spine, the patency of the SI joints, and absence of ankylosis of the facet and costovertebral joints should allow differentiation of DISH from AS. -
The Structure and Function of Breathing
CHAPTERCONTENTS The structure-function continuum 1 Multiple Influences: biomechanical, biochemical and psychological 1 The structure and Homeostasis and heterostasis 2 OBJECTIVE AND METHODS 4 function of breathing NORMAL BREATHING 5 Respiratory benefits 5 Leon Chaitow The upper airway 5 Dinah Bradley Thenose 5 The oropharynx 13 The larynx 13 Pathological states affecting the airways 13 Normal posture and other structural THE STRUCTURE-FUNCTION considerations 14 Further structural considerations 15 CONTINUUM Kapandji's model 16 Nowhere in the body is the axiom of structure Structural features of breathing 16 governing function more apparent than in its Lung volumes and capacities 19 relation to respiration. This is also a region in Fascla and resplrstory function 20 which prolonged modifications of function - Thoracic spine and ribs 21 Discs 22 such as the inappropriate breathing pattern dis- Structural features of the ribs 22 played during hyperventilation - inevitably intercostal musculature 23 induce structural changes, for example involving Structural features of the sternum 23 Posterior thorax 23 accessory breathing muscles as well as the tho- Palpation landmarks 23 racic articulations. Ultimately, the self-perpetuat- NEURAL REGULATION OF BREATHING 24 ing cycle of functional change creating structural Chemical control of breathing 25 modification leading to reinforced dysfunctional Voluntary control of breathing 25 tendencies can become complete, from The autonomic nervous system 26 whichever direction dysfunction arrives, for Sympathetic division 27 Parasympathetic division 27 example: structural adaptations can prevent NANC system 28 normal breathing function, and abnormal breath- THE MUSCLES OF RESPIRATION 30 ing function ensures continued structural adap- Additional soft tissue influences and tational stresses leading to decompensation. -
Paravertebral Block: Anatomy and Relevant Safety Issues Alberto E Ardon1, Justin Lee2, Carlo D
Paravertebral block: anatomy and relevant safety issues Alberto E Ardon1, Justin Lee2, Carlo D. Franco3, Kevin T. Riutort1, Roy A. Greengrass1 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, 2Department of Anesthesiology, Olympia Anesthesia Associates, Providence St. Peter Hospital, Olympia, WA, 3Department of Anesthesiology and Pain Management, John H. Review Article Stroger Jr. Hospital of Cook County, Chicago, IL, USA Korean J Anesthesiol 2020;73(5):394-400 Paravertebral block, especially thoracic paravertebral block, is an effective regional anes- https://doi.org/10.4097/kja.20065 thetic technique that can provide significant analgesia for numerous surgical procedures, pISSN 2005–6419 • eISSN 2005–7563 including breast surgery, pulmonary surgery, and herniorrhaphy. The technique, although straightforward, is not devoid of potential adverse effects. Proper anatomic knowledge and adequate technique may help decrease the risk of these effects. In this brief discourse, we discuss the anatomy and technical aspects of paravertebral blocks and emphasize the im- Received: February 10, 2020 portance of appropriate needle manipulation in order to minimize the risk of complica- Revised: March 5, 2020 tions. We propose that, when using a landmark-based approach, limiting medial and later- Accepted: March 15, 2020 al needle orientation and implementing caudal (rather than cephalad) needle redirection may provide an extra margin of safety when performing this technique. Likewise, recog- Corresponding author: nizing a target that is not in close proximity to the neurovascular bundle when using ultra- Alberto E Ardon, M.D., M.P.H. sound guidance may be beneficial. Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 4500 Keywords: Anatomy; Paravertebral; Postoperative pain; Regional anesthesia; Safety; Trun- San Pablo Rd, Jacksonville, FL 32224, USA cal nerve block. -
Ligaments of the Costovertebral Joints Including Biomechanics, Innervations, and Clinical Applications: a Comprehensive Review W
Open Access Review Article DOI: 10.7759/cureus.874 Ligaments of the Costovertebral Joints including Biomechanics, Innervations, and Clinical Applications: A Comprehensive Review with Application to Approaches to the Thoracic Spine Erfanul Saker 1 , Rachel A. Graham 2 , Renee Nicholas 3 , Anthony V. D’Antoni 2 , Marios Loukas 1 , Rod J. Oskouian 4 , R. Shane Tubbs 5 1. Department of Anatomical Sciences, St. George's University School of Medicine, Grenada, West Indies 2. Department of Anatomy, The Sophie Davis School of Biomedical Education 3. Department of Physical Therapy, Samford University 4. Neurosurgery, Complex Spine, Swedish Neuroscience Institute 5. Neurosurgery, Seattle Science Foundation Corresponding author: Erfanul Saker, [email protected] Abstract Few studies have examined the costovertebral joint and its ligaments in detail. Therefore, the following review was performed to better elucidate their anatomy, function and involvement in pathology. Standard search engines were used to find studies concerning the costovertebral joints and ligaments. These often- overlooked ligaments of the body serve important functions in maintaining appropriate alignment between the ribs and spine. With an increasing interest in minimally invasive approaches to the thoracic spine and an improved understanding of the function and innervation of these ligaments, surgeons and clinicians should have a good working knowledge of these structures. Categories: Neurosurgery, Orthopedics, Rheumatology Keywords: costovertebral joint, spine, anatomy, thoracic Introduction And Background The costovertebral joint ligaments are relatively unknown and frequently overlooked anatomical structures [1]. Although small and short in size, they are abundant, comprising 108 costovertebral ligaments in the normal human thoracic spine, and they are essential to its stability and function [2-3]. -
Thoracic and Lumbar Spine Anatomy
ThoracicThoracic andand LumbarLumbar SpineSpine AnatomyAnatomy www.fisiokinesiterapia.biz ThoracicThoracic VertebraeVertebrae Bodies Pedicles Laminae Spinous Processes Transverse Processes Inferior & Superior Facets Distinguishing Feature – Costal Fovea T1 T2-T8 T9-12 ThoracicThoracic VertebraeVertebrae andand RibRib JunctionJunction FunctionsFunctions ofof ThoracicThoracic SpineSpine – Costovertebral Joint – Costotransverse Joint MotionsMotions – All available – Flexion and extension limited – T7-T12 LumbarLumbar SpineSpine BodiesBodies PediclesPedicles LaminaeLaminae TransverseTransverse ProcessProcess SpinousSpinous ProcessProcess ArticularArticular FacetsFacets LumbarLumbar SpineSpine ThoracolumbarThoracolumbar FasciaFascia LumbarLumbar SpineSpine IliolumbarIliolumbar LigamentsLigaments FunctionsFunctions ofof LumbarLumbar SpineSpine – Resistance of anterior translation – Resisting Rotation – Weight Support – Motion IntervertebralIntervertebral DisksDisks RatioRatio betweenbetween diskdisk thicknessthickness andand vertebralvertebral bodybody heightheight DiskDisk CompositionComposition – Nucleus pulposis – Annulus Fibrosis SpinalSpinal LigamentsLigaments AnteriorAnterior LongitudinalLongitudinal PosteriorPosterior LongitudinalLongitudinal LigamentumLigamentum FlavumFlavum InterspinousInterspinous LigamentsLigaments SupraspinousSupraspinous LigamentsLigaments IntertransverseIntertransverse LigamentsLigaments SpinalSpinal CurvesCurves PosteriorPosterior ViewView SagittalSagittal ViewView – Primary – Secondary -
Ch22: Actions of the Respiratory Muscles
CHAPTER 22 ACTIONS OF THE RESPIRATORY MUSCLES André de Troyer he so-called respiratory muscles are those muscles that caudally and ventrally from their costotransverse articula- Tprovide the motive power for the act of breathing. Thus, tions, such that their ventral ends and the costal cartilages although many of these muscles are involved in a variety of are more caudal than their dorsal parts (Figure 22-2B, C). activities, such as speech production, cough, vomiting, and When the ribs are displaced in the cranial direction, their trunk motion, their primary task is to displace the chest wall ventral ends move laterally and ventrally as well as cra- rhythmically to pump gas in and out of the lungs. The pres- nially, the cartilages rotate cranially around the chon- ent chapter, therefore, starts with a discussion of the basic drosternal junctions, and the sternum is displaced ventrally. mechanical structure of the chest wall in humans. Then, the Consequently, there is usually an increase in both the lateral action of each group of muscles is analyzed. For the sake of and the dorsoventral diameters of the rib cage (see Figure clarity, the functions of the diaphragm, the intercostal mus- 22-2B, C). Conversely, a displacement of the ribs in the cau- cles, the muscles of the neck, and the muscles of the abdom- dal direction is usually associated with a decrease in rib cage inal wall are analyzed sequentially. However, since all these diameters. As a corollary, the muscles that elevate the ribs as muscles normally work together in a coordinated manner, their primary action have an inspiratory effect on the rib the most critical aspects of their mechanical interactions are cage, whereas the muscles that lower the ribs have an expi- also emphasized. -
The Erector Spinae Plane Block a Novel Analgesic Technique in Thoracic Neuropathic Pain
CHRONIC AND INTERVENTIONAL PAIN BRIEF TECHNICAL REPORT The Erector Spinae Plane Block A Novel Analgesic Technique in Thoracic Neuropathic Pain Mauricio Forero, MD, FIPP,*Sanjib D. Adhikary, MD,† Hector Lopez, MD,‡ Calvin Tsui, BMSc,§ and Ki Jinn Chin, MBBS (Hons), MMed, FRCPC|| Case 1 Abstract: Thoracic neuropathic pain is a debilitating condition that is often poorly responsive to oral and topical pharmacotherapy. The benefit A 67-year-old man, weight 116 kg and height 188 cm [body of interventional nerve block procedures is unclear due to a paucity of ev- mass index (BMI), 32.8 kg/m2] with a history of heavy smoking idence and the invasiveness of the described techniques. In this report, we and paroxysmal supraventricular tachycardia controlled on ateno- describe a novel interfascial plane block, the erector spinae plane (ESP) lol, was referred to the chronic pain clinic with a 4-month history block, and its successful application in 2 cases of severe neuropathic pain of severe left-sided chest pain. A magnetic resonance imaging (the first resulting from metastatic disease of the ribs, and the second from scan of his thorax at initial presentation had been reported as nor- malunion of multiple rib fractures). In both cases, the ESP block also pro- mal, and the working diagnosis at the time of referral was post- duced an extensive multidermatomal sensory block. Anatomical and radio- herpetic neuralgia. He reported constant burning and stabbing logical investigation in fresh cadavers indicates that its likely site of action neuropathic pain of 10/10 severity on the numerical rating score is at the dorsal and ventral rami of the thoracic spinal nerves. -
Chapter 21 Fractures of the Upper Thoracic Spine: Approaches and Surgical Management
Chapter 21 Fractures of the Upper Thoracic Spine: Approaches and Surgical Management Sean D Christie, M.D., John Song, M.D., and Richard G Fessler, M.D., Ph.D. INTRODUCTION Fractures occurring in the thoracic region account for approximately 17 to 23% of all traumatic spinal fractures (1), with 22% of traumatic spinal fractures occurring between T1 and T4 (16). More than half of these fractures result in neurological injury, and almost three-quarters of those impaired suffer from complete paralysis. Obtaining surgical access to the anterior vertebral elements of the upper thoracic vertebrae (T1–T6) presents a unique anatomic challenge. The thoracic cage, which narrows significantly as it approaches the thoracic inlet, has an intimate association between the vertebral column and the superior mediastinal structures. The supraclavicular, transmanubrial, transthoracic, and lateral parascapular extrapleural approaches each provide access to the anterior vertebral elements of the upper thoracic vertebrae. However, each of these approaches has distinct advantages and disadvantages and their use should be tailored to each individual patient’s situation. This chapter reviews these surgical approaches. Traditional posterior approaches are illustrated in Figure 21.1, but will not be discussed in depth here. ANATOMIC CONSIDERATIONS AND STABILITY The upper thoracic spine possesses unique anatomic and biomechanical properties. The anterior aspects of the vertebral bodies are smaller than the posterior aspects, which contribute to the physiological kyphosis present in this region of the spine. Furthermore, this orientation results in a ventrally positioned axis of rotation, predisposing this region to compression injuries. The combination and interaction of the vertebral bodies, ribs, and sternum increase the inherent biomechanical stability of this segment of the spine to 2 to 3 times that of the thoracolumbar junction. -
Muscles of the Thorax, Back & Abdomen
MUSCLES OF THE THORAX, BACK & ABDOMEN Muscles of the Thorax Thoracic Muscles Origin Insertion Action Innervation M. pectoralis clavicula pars clavicularis major (medial ½ ) manubrium sterni et adduction, internal M. pectoralis pars crista tuberculi cartilagines costae rotation, arm flexion; major sternocostalis majoris (2nd-7th) auxiliary inspiratory m. M. pectoralis vagina musculi recti pars abdominalis major abdominis Plexus brachialis processus pulls the clavicle; M. pectoralis minor 3rd - 5th rib coracoideus auxiliary inspiration m scapulae pulls clavicule → clavicula indirectly the shoulder M. subclavius first rib (inferior surface) distoventrally; auxiliary inspiration m. pulls the clavicle from scapula the backbone; pulls M. serratus anterior cranial 9 ribs (margo medialis et inferior angle laterally → angulus inferior) rotates scapula; auxiliary respirat. m. Thoracic Muscles Origin Insertion Action Innervation inferior margin of ribs - superior margin of elevation of lower ribs, from the costal tubercle Mm. intercostales externi ribs immediately thorax expansion → to the beginning of rib below inspiratory m. cartilage inferior margin of adduction of cranial superior margin of ribs - Nn. Mm. intercostales interni ribs immediately ribs to caudal ribs → intercostales costal angle to sternum above expiratory m. internal surface of cartilagines costae M. transversus thoracis xiphoid process and expiratory muscle verae body of sternum inner surface of xiphoid Diaphragma sternal part process inner surface of Diaphragma costal part cartilage of ribs 7-12 main inspiratory Plexus central tendon muscle; abdominal ligamentum cervicalis lumbar part, press Diaphragma longitudinale anterius medial crus (vertebrae lumbales) ligaments jump over the lumbar part, Diaphragma psoas and quadratus lateral crus muscles Muscles of the Back Superficial muscles . functionally belong to the upper limb Intermediate muscles . -
Pain Pattern Explanation Forms
Pain Pattern Explanation Forms 1. Cervical Facet Pain Pattern 2. Cervical Radicular/Dynatome Pain Pattern 3. Costotransverse Joint Pain Pattern 4. Fibromyalgia Points 5. Hip Joint Pain Pattern 6. Lumbar Dermatomes: Chemical Radiculitis 7. Lumbar Dermatomes: Disc Pathology 8. Lumbar Disc Pathology Healed 9. Lumbar Epidural Fibrosis 10. Lumbar Facet Pain Pattern 11. Lumbar Stenosis 12. Sacroiliac Joint Pain Pattern 13. Thoracic Facet Pain Pattern 14. Upper Cervical Joint Pain Pattern The OEA pain pattern handouts are PDF files that can be used for patient education and marketing. They help you explain your diagnosis with original illustrations that the patients can take home with them. There is limited text so you can tell your explanation of the treatment plan. The pain patterns can be printed in color or black and white. Once purchased, our business card will be replaced with yours to personalize each handout. Each illustration is based on the pain patterns that have been established in books or research articles when available. Normal anatomy and pathoanatomy illustrations are shown for the clinician to explain the diagnosis to the patient and how their treatment can influence the pain generator. These can also be utilized as marketing tools. The following pages are some guidelines that can be utilized to explain the handouts to patients. Cervical Facet Pain Pattern The cervical facet joints are the joints of the neck. Neurophysiologic studies have shown that cervical facet‐joint capsules are sources of neck pain.1 Dwyer et al.2 established pain patterns of the cervical facet joints. o Parasagittal cervical and cervicothoracic pain. -
Active Release Techniques Spine Level 2
Active Release Techniques Spine Level 2 Dates of program- Montvale, NJ February 18-21, 2021 Colorado Springs, CO March 4-7, 2021 Orlando, FL June 10-13, 2021 Chicago, IL September 30 – October 3, 2021 Total Hours: 24 Summary: Active Release Techniques® Spine Level 2 offers intense training in 75 manual treatment protocols of the cervical, thoracic, and lumbar spine. ART® treatment utilizes manual techniques to move tissues and joints while under tension. The system allows for relative motion between the tissues and articulations. This seminar emphasizes the manipulation of the neuromusculoskeletal system to diagnose and correct alterations in tissue texture, tension, movement, and function between tissues. Evaluation and treatment occur simultaneously. Learning Outcomes: 1. By the end of the seminar, learners will be able to correctly identify (palpate) 75 facial seams of soft-tissue structures within the spine. 2. By the end of the seminars, learners will be able to correctly state the muscle actions of two adjacent spinal muscles. 3. By the end of the seminar, learners will be able to effectively recognize common symptom patterns of spinal neuromuscular injuries and disorders. 4. By the end of the seminar, learners will correctly identify the structure treated and associated concentric and eccentric muscle actions via video presentations. 5. By the end of the seminar, the learner will correctly move the muscle from its shortened position to elongated position using two-hand placement techniques. 6. By the end of the seminar, the learner can successfully differentiate between healthy and unhealthy tissue utilizing hands-on palpation techniques. 7. By the end of the seminar, the learner will proficiently palpate 75 anatomical soft-tissue structures within the spine, using an appropriate tension, depth, and motion to properly perform the treatment protocol. -
Spinal Cord Organization
Lecture 4 Spinal Cord Organization The spinal cord . Afferent tract • connects with spinal nerves, through afferent BRAIN neuron & efferent axons in spinal roots; reflex receptor interneuron • communicates with the brain, by means of cell ascending and descending pathways that body form tracts in spinal white matter; and white matter muscle • gives rise to spinal reflexes, pre-determined gray matter Efferent neuron by interneuronal circuits. Spinal Cord Section Gross anatomy of the spinal cord: The spinal cord is a cylinder of CNS. The spinal cord exhibits subtle cervical and lumbar (lumbosacral) enlargements produced by extra neurons in segments that innervate limbs. The region of spinal cord caudal to the lumbar enlargement is conus medullaris. Caudal to this, a terminal filament of (nonfunctional) glial tissue extends into the tail. terminal filament lumbar enlargement conus medullaris cervical enlargement A spinal cord segment = a portion of spinal cord that spinal ganglion gives rise to a pair (right & left) of spinal nerves. Each spinal dorsal nerve is attached to the spinal cord by means of dorsal and spinal ventral roots composed of rootlets. Spinal segments, spinal root (rootlets) nerve roots, and spinal nerves are all identified numerically by th region, e.g., 6 cervical (C6) spinal segment. ventral Sacral and caudal spinal roots (surrounding the conus root medullaris and terminal filament and streaming caudally to (rootlets) reach corresponding intervertebral foramina) collectively constitute the cauda equina. Both the spinal cord (CNS) and spinal roots (PNS) are enveloped by meninges within the vertebral canal. Spinal nerves (which are formed in intervertebral foramina) are covered by connective tissue (epineurium, perineurium, & endoneurium) rather than meninges.