DOCSLIB.ORG

Ankylosing Spondylitis New Insights Into an Old Disease

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Ankylosing Spondylitis New Insights Into an Old Disease PEER REVIEWED FEATURE 2 CPD POINTS Ankylosing spondylitis New insights into an old disease LAURA J. ROSS MB BS RUSSELL R.C. BUCHANAN MB BS(Hons), MD, FRACP Early recognition and treatment of patients with ankylosing spondylitis (AS) improves prognosis but is challenging. Suggestive symptoms include chronic back pain that worsens with rest and early morning axial pain and stiffness. NSAIDs and stretching exercises remain the mainstays of treatment. Tumour necrosis factor inhibitors improve quality of life for patients with refractory AS. nkylosing spondylitis (AS) is the positivity and familial aggregation.2 prototypic form of spondylo­ In the past decade, major progress has arthritis (SpA). Historically, the been made in the understanding, recog­ term SpA has referred to a group nition and treatment of SpA. As a result, Aof chronic systemic, inflammatory diseases the Assessment of SpondyloArthritis Inter­ that include AS, psoriatic arthritis, arthritis national Society (ASAS) has developed related to inflammatory bowel disease, new classification criteria for SpA.3 The reactive arthritis, undifferentiated SpA and ASAS system characterises SpA as either a subgroup of juvenile idiopathic arthritis.1 axial (affecting the spine and sacroiliac These diseases share overlapping features, joints) or peripheral (affecting mainly such as sacroiliitis, extra­articular mani­ peripheral joints), according to the pre­ festations (e.g. acute anterior uveitis, dominant articular features at presenta­ psoriasis and inflammatory bowel disease), tion, although these groups overlap and includes AS and n onradiographic axial human leucocyte antigen (HLA)­B27 one may progress to the other. Axial SpA SpA (Box 1).4 A characteristic feature of SpA is enthesitis, defined as inflammation at the site of attachment of tendons, ligaments, 2 MedicineToday 2016; 17(1-2): 16-24 joint capsule or fascia to bone. The enthe­ sis is thought to be the major target of the Dr Ross is a Registrar in the Department of Rheumatology, Austin Health, Melbourne. immune response in SpA and thus the Professor Buchanan is Director of the Department of Rheumatology, Austin Health, Melbourne; and primary site for its immunopathology.2 Associate Professor in the Department of Medicine, University of Melbourne, Melbourne, Vic. The different forms of SpA are associated 16 MedicineToday ❙ JANUARY/FEBRUARY 2016, VOLUME 17, NUMBER 1-2 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2016. KEY POINTS • Ankylosing spondylitis (AS) is a chronic systemic inflammatory disease characterised by sacroiliitis, extra-articular manifestations such as uveitis, human leucocyte antigen (HLA)-B27 positivity and familial aggregation. • Consider the diagnosis of AS in young patients with back pain and stiffness early in the morning and after prolonged sitting. • Appropriate initial investigations are a plain x-ray of the pelvis and blood tests for HLA-B27, erythrocyte sedimentation rate and C-reactive protein level. • MRI can identify early inflammatory bony changes not seen on x-ray and is prudent in patients with a clinical history consistent with AS but a normal x-ray appearance. • The mainstay of treatment for patients with AS remains NSAIDs and stretching exercises. • Tumour necrosis factor inhibitors are effective therapy for patients who fail to respond to first-line treatments. bridging and fusion of joints and ankylosis of the spine. Characteristic extra­articular manifestations in AS include acute anterior uveitis (prevalence of 26%), psoriasis (9%) and inflammatory bowel disease (7%).5 The prevalence of acute anterior uveitis increases with longer disease duration.5 AS is a slowly progressive disease, and x­ray changes often do not appear until a decade after onset of symptoms.6 In some people who have a clinical history con­ sistent with AS but lack the characteristic x ­ray changes, MRI can identify early inflammatory bony changes not seen on plain x­ray.7 Patients may be diagnosed with nonradiographic SpA when they have a history of inflammatory back pain and MRI changes of sacroiliitis with a normal appearance on plain x­rays. Clinical experience and limited data with characteristic extra­articular Definition of ankylosing suggest a sizeable proportion of patients manifestations, which can be useful to spondylitis with inflammation of sacroiliac joints on distinguish SpA from other types of AS is characterised by inflammatory back MRI will go on to develop x­ray changes.6 inflammatory arthritis and assist with pain that is typically subacute in onset and A review of the MRI changes associated prognostication.5 starts before the age of 45 years. Radio­ with axial SpA suggests that there is a win­ This article will address the contem­ graphic changes characteristically affect dow of six months to two years during porary definition of AS, early recognition the sacroiliac joints and may involve var­ which inflammatory changes seen on MRI in general practice of patients with AS iable levels of the spine. Inflammation at evolve into early structural changes associ­ and recent advances in diagnosis and these sites results in new bone formation ated with AS.8 Clinical symptoms among © JOHN KARAPELOU, W. CMI management. leading to the typical AS features of patients with nonradiographic SpA are MedicineToday ❙ JANUARY/FEBRUARY 2016, VOLUME 17, NUMBER 1-2 17 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2016. ANKYLOSING spondyliTIS continued 1. CLASSIFICATION OF THE 2. ASAS CLASSIFICATION CRITERIA FOR AXIAL SPONDYLOARTHRITIS* SPONDYLOARTHROPATHIES* Predominantly axial SpA Patient has back pain • Ankylosing spondylitis • for three months or longer AND • Nonradiographic axial SpA • age of onset younger than 45 years Predominantly peripheral SpA • Arthritis with inflammatory bowel disease • Sacroiliitis on imaging AND • HLA-B27 positive AND • Psoriatic arthritis • One or more spondylo arthritis • Two or more spondylo arthritis • Reactive arthritis features features • Undifferentiated SpA Abbreviation: SpA=spondyloarthritis. Sacroiliitis on imaging Spondyloarthritis features * Adapted from ASAS (Assessment of SpondyloArthritis • Active inflammation on MRI OR • Inflammatory back • Inflammatory International Society). Slide-educational kit. Available online at: http://www.asas-group.org • Definite radiographic pain bowel disease (accessed February 2016).4 sacroiliitis according to • Arthritis • Good response to modified New York criteria • Enthesitis (heel) NSAIDs comparable with those among patients with • Uveitis • Family history of spondyloarthritis x ­ray­proven AS.1 Abbreviations: ASAS = Assessment of • Dactylitis SpondyloArthritis International Society; • HLA-B27 positive ASAS has validated classification cri­ CRP = C-reactive protein. • Psoriasis • Elevated CRP level teria for axial SpA, including AS and non­ * Modified from Sieper et al. Ann Rheum Dis radiographic axial SpA (Box 2).3 Criteria 2009; 68: ii1-ii44.3 include the presence of inflammatory back pain, extra­articular manifestations of History contrast, mechanical back pain is often SpA and HLA­B27 positivity, with or with­ Patients with AS account for 5% of patients intermittent, exacerbated by activity and out x­ray changes of sacroiliitis. with chronic low back pain.10 Identifying better with rest (Table). patients with inflammatory back pain is Important additional clues to identify­ Diagnosis the key to diagnosing AS and requires a ing patients with inflammatory back pain Early diagnosis of AS remains a challenge targeted history.7 Useful questions to ask include a history of peripheral inflamma­ and is typically delayed up to eight to patients are listed in Box 3.11 Important tory arthritis, a family history of AS and 10 years after symptom onset.9 AS remains features of inflammatory back pain include a good response of the pain to NSAIDs. a clinical diagnosis based on symptoms significant morning stiffness, gel phenom­ The presence of alternating buttock pain, and signs. Treatment response is generally enon (stiffness following sitting or other commonly radiating into the posterior better in patients with short disease dura­ inactivity) and awakening in the second thighs, is highly suggestive of sacroiliac tion and good functional status. half of the night with spinal stiffness. In joint pain. Examination 3. QUESTIONS TO HELP IDENTIFY PATIENTS WITH INFLAMMATORY BACK PAIN* The characteristic examination finding in patients with AS is a reduced range of In patients with back pain of three months’ duration or longer: spinal movement. Lateral spinal flexion • Did your back pain start when you were younger than 40 years? is often the first movement to be affected. • Did your back pain develop gradually? Important objective measures of spinal • Does your back pain improve with movement? mobility are described in Box 4 and • Do you find your back pain worsens when you rest? Figure 1. • Do you have back pain that worsens overnight and then improves when you get up? • Do you ever have back pain that radiates into your buttocks? Extra-articular manifestations A ‘yes’ answer to four or more of these questions usually indicates inflammatory back Extra ­articular manifestations that sup­ pain requiring further investigation. port the diagnosis of AS or other forms of * Adapted from Sieper et al. Ann Rheum Dis 2009; 68: 784-788.11 SpA include anterior uveitis, psoriasis and inflammatory bowel disease. Around 18 MedicineToday ❙ JANUARY/FEBRUARY
Load more

Recommended publications
  • Evicore Spine Imaging Guidelines
    CLINICAL GUIDELINES Spine Imaging Policy Version 1.0 Effective February 14, 2020 eviCore healthcare Clinical Decision Support Tool Diagnostic Strategies: This tool addresses common symptoms and symptom complexes. Imaging requests for individuals with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or individual’s Primary Care Physician (PCP) may provide additional insight. CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT® book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein. © 2019 eviCore healthcare. All rights reserved. Spine Imaging Guidelines V1.0 Spine Imaging Guidelines Procedure Codes Associated with Spine Imaging 3 SP-1: General Guidelines 5 SP-2: Imaging Techniques 14 SP-3: Neck (Cervical Spine) Pain Without/With Neurological Features (Including Stenosis) and Trauma 22 SP-4: Upper Back (Thoracic Spine) Pain Without/With Neurological Features (Including Stenosis) and Trauma 26 SP-5: Low Back (Lumbar Spine) Pain/Coccydynia without Neurological Features 28 SP-6: Lower Extremity Pain with Neurological Features (Radiculopathy, Radiculitis, or Plexopathy and Neuropathy) With or Without Low Back (Lumbar Spine) Pain 32 SP-7: Myelopathy 36 SP-8: Lumbar Spine Spondylolysis/Spondylolisthesis 39 SP-9: Lumbar Spinal Stenosis 42 SP-10: Sacro-Iliac (SI) Joint Pain, Inflammatory Spondylitis/Sacroiliitis and Fibromyalgia 44 SP-11: Pathological Spinal Compression Fractures 47 SP-12: Spinal Pain in Cancer Patients 49 SP-13: Spinal Canal/Cord Disorders (e.g.
    [Show full text]
  • Juvenile Spondyloarthropathies: Inflammation in Disguise
    PP.qxd:06/15-2 Ped Perspectives 7/25/08 10:49 AM Page 2 APEDIATRIC Volume 17, Number 2 2008 Juvenile Spondyloarthropathieserspective Inflammation in DisguiseP by Evren Akin, M.D. The spondyloarthropathies are a group of inflammatory conditions that involve the spine (sacroiliitis and spondylitis), joints (asymmetric peripheral Case Study arthropathy) and tendons (enthesopathy). The clinical subsets of spondyloarthropathies constitute a wide spectrum, including: • Ankylosing spondylitis What does spondyloarthropathy • Psoriatic arthritis look like in a child? • Reactive arthritis • Inflammatory bowel disease associated with arthritis A 12-year-old boy is actively involved in sports. • Undifferentiated sacroiliitis When his right toe starts to hurt, overuse injury is Depending on the subtype, extra-articular manifestations might involve the eyes, thought to be the cause. The right toe eventually skin, lungs, gastrointestinal tract and heart. The most commonly accepted swells up, and he is referred to a rheumatologist to classification criteria for spondyloarthropathies are from the European evaluate for possible gout. Over the next few Spondyloarthropathy Study Group (ESSG). See Table 1. weeks, his right knee begins hurting as well. At the rheumatologist’s office, arthritis of the right second The juvenile spondyloarthropathies — which are the focus of this article — toe and the right knee is noted. Family history is might be defined as any spondyloarthropathy subtype that is diagnosed before remarkable for back stiffness in the father, which is age 17. It should be noted, however, that adult and juvenile spondyloar- reported as “due to sports participation.” thropathies exist on a continuum. In other words, many children diagnosed with a type of juvenile spondyloarthropathy will eventually fulfill criteria for Antinuclear antibody (ANA) and rheumatoid factor adult spondyloarthropathy.
    [Show full text]
  • Etiopathogenesis of Sacroiliitis
    Korean J Pain 2020;33(4):294-304 https://doi.org/10.3344/kjp.2020.33.4.294 pISSN 2005-9159 eISSN 2093-0569 Review Article Etiopathogenesis of sacroiliitis: implications for assessment and management Manuela Baronio1, Hajra Sadia2, Stefano Paolacci3, Domenico Prestamburgo4, Danilo Miotti5, Vittorio A. Guardamagna6, Giuseppe Natalini1, and Matteo Bertelli3,7,8 1Dipartimento di Anestesia, Rianimazione, Terapia Intensiva e del Dolore, Fondazione Poliambulanza, Brescia, Italy 2Atta-ur-Rahman School of Applied Biosciences, National University of Science and Technology, Islamabad, Pakistan 3MAGI’s Lab, Rovereto, Italy 4Ortopedia e Traumatologia, Ospedali Civili di Legnano e Cuggiono, Cuggiono, Italy 5Cure Palliative e Terapia del Dolore, ICS Maugeri, Pavia, Italy 6Cure Palliative e Terapia del Dolore, IRCCS IEO, Milano, Italy 7MAGI Euregio, Bolzano, Italy 8EBTNA-LAB, Rovereto, Italy Received January 16, 2020 Revised March 17, 2020 The sacroiliac joints connect the base of the sacrum to the ilium. When inflamed, Accepted April 16, 2020 they are suspected to cause low back pain. Inflammation of the sacroiliac joints is called sacroiliitis. The severity of the pain varies and depends on the degree of Handling Editor: Kyung Hoon Kim inflammation. Sacroiliitis is a hallmark of seronegative spondyloarthropathies. The presence or absence of chronic sacroiliitis is an important clue in the diagnosis of Correspondence low back pain. This article aims to provide a concise overview of the anatomy, physi- Stefano Paolacci ology, and molecular biology of sacroiliitis to aid clinicians in the assessment and MAGI’s Lab, Via delle Maioliche, 57/D, management of sacroiliitis. For this narrative review, we evaluated articles in Eng- Rovereto, Trentino 38068, Italy lish published before August 2019 in PubMed.
    [Show full text]
  • Case Report Spinal Gout with Lumbar Spondylolisthesis: Case Report and Review of the Literature
    Int J Clin Exp Med 2017;10(3):5493-5496 www.ijcem.com /ISSN:1940-5901/IJCEM0043949 Case Report Spinal gout with lumbar spondylolisthesis: case report and review of the literature Hui Zhang, Wenhao Zheng, Naifeng Tian, Xiangyang Wang, Yan Lin, Yaosen Wu Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China Received November 9, 2016; Accepted December 30, 2016; Epub March 15, 2017; Published March 30, 2017 Abstract: Gout, a metabolic disorder, is commonly accepted as a peripheral joint disease of the appendicular skel- eton by the deposition of monosodium urate crystals. Gouty involvement of the spinal column is rare. In this paper, we report a case of spinal gout with spondylolisthesis, meanwhile, we review the clinical, radiological features, diagnosis and treatment of spinal gout in literature. The patient was 60-year-old with low back pain. Radiological examinations of the lumbar spine showed L4 spondylolisthesis with bone erosion in facet joints and lamina. The patient was treated by L4/5 transforaminal lumbar interbody fusion. The postoperative histological examination confirmed the diagnosis of spinal gout. Spinal gout is rare and can easily be underestimated. Clinician should keep in mind spinal gout as a differential diagnosis especially in patients with long history of gout and axial symptoms. Keywords: Spine, gout, low back pain, spondylolisthesis, cord compression, computed tomography Introduction treatment with enalapril and indapamide are used to control hypertension. However, there is Gout is a common metabolic disorder which is no effective treatment of gout. characterized by precipitation of urate crystals in joints and soft tissue.
    [Show full text]
  • New ASAS Criteria for the Diagnosis of Spondyloarthritis: Diagnosing Sacroiliitis by Magnetic Resonance Imaging 9
    Document downloaded from http://www.elsevier.es, day 10/02/2016. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Radiología. 2014;56(1):7---15 www.elsevier.es/rx UPDATE IN RADIOLOGY New ASAS criteria for the diagnosis of spondyloarthritis: ଝ Diagnosing sacroiliitis by magnetic resonance imaging ∗ M.E. Banegas Illescas , C. López Menéndez, M.L. Rozas Rodríguez, R.M. Fernández Quintero Servicio de Radiodiagnóstico, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain Received 17 January 2013; accepted 10 May 2013 Available online 11 March 2014 KEYWORDS Abstract Radiographic sacroiliitis has been included in the diagnostic criteria for spondy- Sacroiliitis; loarthropathies since the Rome criteria were defined in 1961. However, in the last ten years, Diagnosis; magnetic resonance imaging (MRI) has proven more sensitive in the evaluation of the sacroiliac Magnetic resonance joints in patients with suspected spondyloarthritis and symptoms of sacroiliitis; MRI has proven imaging; its usefulness not only for diagnosis of this disease, but also for the follow-up of the disease and Axial spondy- response to treatment in these patients. In 2009, The Assessment of SpondyloArthritis inter- loarthropathies national Society (ASAS) developed a new set of criteria for classifying and diagnosing patients with spondyloarthritis; one important development with respect to previous classifications is the inclusion of MRI positive for sacroiliitis as a major diagnostic criterion. This article focuses on the radiologic part of the new classification. We describe and illustrate the different alterations that can be seen on MRI in patients with sacroiliitis, pointing out the limitations of the technique and diagnostic pitfalls.
    [Show full text]
  • Brown Tumors, Presenting with a Degenerative Lumber Disc Like Pain
    Open Access Archives of Pathology and Clinical Research Case Report A great mimicker of Bone Secondaries: Brown Tumors, presenting with a ISSN 2640-2874 Degenerative Lumber Disc like pain Zuhal Bayramoglu1*, Ravza Yılmaz1 and Aysel Bayram2 1Department of Radiology, Istanbul Medical Faculty, Istanbul University, Capa, Fatih, 34093, Istanbul, Turkey 2Department of Pathology, Istanbul Medical Faculty, Istanbul University, Capa, Fatih, 34093, Istanbul, Turkey *Address for Correspondence: Dr. Zuhal ABSTRACT Bayramoglu, Department of Radiology, Istanbul Medical Faculty, Istanbul University, Capa, Fatih, 34093, Istanbul, Turkey, Tel: +90-212- 414-20-00, This report presents an adult patient suffering from sacroiliitis like low back pain, lumbosacral radiculopathy Fax: +90-212-631-07-28; Email: and elbow swelling. Multimodality imaging revealed multiple lytic bone lesions located in supra acetabular [email protected] iliac bone, sacrum, and distal end of radius. Painful numerous lesions due to the extension to the articular Submitted: 06 June 2017 surfaces are not expected for Brown tumors. Less than ten cases with multiple Brown tumor due to primary Approved: 14 July 2017 hyperparathyroidism has been reported. Although Brown tumors are mostly diagnosed incidentally, this case Published: 17 July 2017 would awake the physicians about rheumatological symptoms in the presentation of Brown tumors. Since Brown tumors are non-touch bone lesions that are expected to regress after parathyroid adenoma removal, it is Copyright: 2017 Bayramoglu Z. This is an important to distinguish Brown tumors from the giant cell tumors. open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in CASE PRESENTATION any medium, provided the original work is properly cited.
    [Show full text]
  • Sacroiliitis Mimics: a Case Report and Review of the Literature Maria J
    Antonelli and Magrey BMC Musculoskeletal Disorders (2017) 18:170 DOI 10.1186/s12891-017-1525-1 CASE REPORT Open Access Sacroiliitis mimics: a case report and review of the literature Maria J. Antonelli* and Marina Magrey Abstract Background: Radiographic sacroiliitis is the hallmark of ankylosing spondylitis (AS), and detection of acute sacroiliitis is pivotal for early diagnosis of AS. Although radiographic sacroiliitis is a distinguishing feature of AS, sacroiliitis can be seen in a variety of other disease entities. Case presentation: We present an interesting case of sacroiliitis in a patient with Paget disease; the patient presented with inflammatory back pain which was treated with bisphosphonate. This case demonstrates comorbidity with Paget disease and possible ankylosing spondylitis. We also present a review of the literature for other cases of Paget involvement of the sacroiliac joint. Conclusions: In addition, we review radiographic changes to the sacroiliac joint in classical ankylosing spondylitis as well as other common diseases. We compare and contrast features of other diseases that mimic sacroiliitis on a pelvic radiograph including Paget disease, osteitis condensans ilii, diffuse idiopathic skeletal hyperostosis, infections and sarcoid sacroiliitis. There are some features in the pelvic radiographic findings which help distinguish among mimics, however, one must also rely heavily on extra-pelvic radiographic lesions. In addition to the clinical presentation, various nuances may incline a clinician to the correct diagnosis; rheumatologists should be familiar with the imaging differences among these diseases and classic spondylitis findings. Keywords: Case report, Ankylosing spondylitis, Clinical diagnostics & imaging, Rheumatic disease Background We conducted a search in PubMed including combi- The presence of sacroiliitis on an anterior-posterior (AP) nations of the following search terms: sacroiliitis, sacro- pelvis or dedicated sacroiliac film is a defining feature of iliac, and Paget disease.
    [Show full text]
  • Efficacy and Surgical Complications in the Treatment of Scoliotic Patients with Ehlers-Danlos Syndrome: a Literature Review
    Research Article ISSN: 2574 -1241 DOI: 10.26717/BJSTR.2020.32.005202 Efficacy and Surgical Complications in the Treatment of Scoliotic Patients with Ehlers-Danlos Syndrome: A Literature Review Thibault Cloché1, Stéphane Bourret*1, Cédric Maillot2, Wendy Thompson M1, Agostino Cirullo1, Jean Charles Le Huec1 1Institut Vertebra, Polyclinique Bordeaux Nord Aquitaine, France 2Département de Chirurgie et de Traumatologie, Hôpital Beaujon, France *Corresponding author: Stéphane Bourret, Recherche Clinique, Polyclinique Bordeaux Nord Aquitaine, France ARTICLE INFO ABSTRACT November 12, 2020 Received: Objective: To compile the current knowledge of the surgical approach performed in Published: November 24, 2020 the treatment of scoliosis in Ehlers-Danlos patients. Summary of Background Data: Ehlers-Danlos syndrome (EDS) has a low incidence Citation: Thibault Cloché, Stéphane in the population and is often associated with the development of scoliosis during the Bourret, Cédric Maillot, Wendy Thompson growth. Few articles are reported in the literature describing the effectiveness and the M, Agostino Cirullo, Jean Charles Le Huec. risks associated with the surgical treatment of scoliosis in EDS patients. Such approach has been shown to increase life expectancy but is largely controversial because of the the Treatment of Scoliotic Patients with high rate of complications and morbidity. Due to the lack of knowledge about this disease, Ehlers-DanlosEfficacy and SurgicalSyndrome: Complications A Literature in Review. Biomed J Sci & Tech Res 32(1)- of surgery. 2020. BJSTR. MS.ID.005202. appropriate recommendations are needed to propose an efficient approach for this kind Methods: A literature search was conducted using PubMed (MEDLINE) database. The Medical Subject Headings keywords used in this research were “Ehlers-Danlos Keywords: Ehlers-Danlos Syndrome; Sco- syndrome” associated with a combination of the following terms “spine”, “scoliosis” or liosis; Surgical Procedure; Spine “ktphoscoliosis”, “spinal fusion”, ‘spinal surgery”, “surgery”.
    [Show full text]
  • Anatomical Skin Dimples
    Innovative Journal of Medical and Health Science 5:1 January - February (2015)15 – 18. Contents lists available at www.innovativejournal.in INNOVATIVE JOURNAL OF MEDICAL AND HEALTH SCIENCE Journal homepage:http://innovativejournal.in/ijmhs/index.php/ijmhs Revıew ANATOMICAL SKIN DIMPLES M.D. Rengin Kosif Department of Anatomy, Faculty of Medicine,Abant Izzet Baysal University, Bolu, Turkey ARTICLE INFO ABSTRACT Corresponding Author: Dimples are visiable identations of the skin and a dominant trait. M.D. Rengin Kosif Anatomically, dimples may be caused by variations in the structure of the Assistant Prof. some body tissue for example muscles, connective tissues, skin and Department of Anatomy, Faculty of subcutaneous tissue. Dimples types of the human body: Fovea buccalis Medicine,Abant Izzet Baysal (dimple of cheek), fovea mentalis (dimple of chin), zygomatic dimples, fossa University, BOLU, TURKEY supraspinosus (bi-acromial dimple=dimple of shoulder), elbow dimples, fossa lumbales laterales (dimple of back), gluteal dimples and sacral- coocygeal dimples (pilonidal dimple). Sometimes, dimples are permanently present, but sometimes not permanent. They vanish away when the excessive fat goes away. Dimples are not indicators good health. DOI:http://dx.doi.org/10.15520/ijm hs.2015.vol5.iss1.45.15-18 ©2015, IJMHS, All Right Reserved INTRODUCTION A dimple (also known as a gelasin) is a small disappears with theaging process, causes transient natural indentation in the flesh on a part of the human dimples, so also is the stretching or lengthening of muscles body. Dimples may appear and disappear over an extended during growth, leading togradual obliteration of the defect. period. They may be genetically inherited and have been This explains while some dimples are commoner and more called a simple dominant trait.Dimples is the word given to conspicuous in theyounger age groups (3).
    [Show full text]
  • Long-Term Outcome After Monosegmental L4/5 Stabilization
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Bern Open Repository and Information System (BORIS) PRIMARY RESEARCH Long-term Outcome After Monosegmental L4/5 Stabilization for Degenerative Spondylolisthesis With the Dynesys Device Sven Hoppe, MD,*w Othmar Schwarzenbach, MD,* Emin Aghayev, MD,z Harald Bonel, MD,y and Ulrich Berlemann, MD* results. The rate of secondary surgeries is comparable to other Study Design: Retrospective analysis of prospectively collected dorsal instrumentation devices. Residual range of motion in the clinical data. stabilized segment is reduced, and the rate of radiologic and Objective: To assess the long-term outcome of patients with symptomatic adjacent segment degeneration is low. Patient monosegmental L4/5 degenerative spondylolisthesis treated with satisfaction is high. Dynesys stabilization of symptomatic L4/5 the dynamic Dynesys device. degenerative spondylolisthesis is a possible alternative to other stabilization devices. Summary of Background Data: The Dynesys system has been used as a semirigid, lumbar dorsal pedicular stabilization device Key Words: monosegmental degenerative spondylolisthesis, since 1994. Good short-term results have been reported, but dynamic stabilization, long-term follow-up, Dynesys little is known about the long-term outcome after treatment for (Clin Spine Surg 2016;29:72–77) degenerative spondylolisthesis at the L4/5 level. Methods: A total of 39 consecutive patients with symptomatic degenerative lumbar spondylolisthesis at the L4/5 level were egenerative lumbar spondylolisthesis (DLS) is a treated with bilateral decompression and Dynesys in- Dcommon condition in elderly patients and a frequent strumentation. At a mean follow-up of 7.2 years (range, cause of spinal stenosis.
    [Show full text]
  • Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy
    Y Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines 1 G Evidence-Based Clinical Guidelines for Multidisciplinary ETHODOLO Spine Care M NE I DEL I U /G ON Diagnosis and Treatment of I NTRODUCT Lumbar Disc I Herniation with Radiculopathy NASS Evidence-Based Clinical Guidelines Committee D. Scott Kreiner, MD Paul Dougherty, II, DC Committee Chair, Natural History Chair Robert Fernand, MD Gary Ghiselli, MD Steven Hwang, MD Amgad S. Hanna, MD Diagnosis/Imaging Chair Tim Lamer, MD Anthony J. Lisi, DC John Easa, MD Daniel J. Mazanec, MD Medical/Interventional Treatment Chair Richard J. Meagher, MD Robert C. Nucci, MD Daniel K .Resnick, MD Rakesh D. Patel, MD Surgical Treatment Chair Jonathan N. Sembrano, MD Anil K. Sharma, MD Jamie Baisden, MD Jeffrey T. Summers, MD Shay Bess, MD Christopher K. Taleghani, MD Charles H. Cho, MD, MBA William L. Tontz, Jr., MD Michael J. DePalma, MD John F. Toton, MD This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason- ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physi- cian and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution. I NTRODUCT 2 Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines I ON Financial Statement This clinical guideline was developed and funded in its entirety by the North American Spine Society (NASS). All participating /G authors have disclosed potential conflicts of interest consistent with NASS’ disclosure policy.
    [Show full text]
  • REVIEW ARTICLE Korean J Spine 8(1):1-8, 2011
    REVIEW ARTICLE Korean J Spine 8(1):1-8, 2011 History of Spinal Deformity Surgery Part I: The Pre-modern Era Samuel K. Cho1, Yongjung J. Kim2 1Spine Service, Leni and Peter May Department of Orthopaedics, Mount Sinai School of Medicine, New York, NY 2Spine Service, Department of Orthopaedic Surgery, Columbia University College of Physicians and Surgeons, New York, NY Spinal deformity is one of the oldest known diseases that date back thousands of years in human history. It appears in fairy tales and mythologies in association with evil as its dramatic appearance in patients suffering from the disease easily lent itself to be thought of as a form of divine retribution. The history of spinal deformity dates back to prehistoric times. The early attempts to treat patients suffering from this disease started from Hippocrates age. Side traction or axial traction and cast immobilization were the only possible option prior to the discovery of anesthesia. The first surgical attempts to correct scoliosis occurred in the mid 19th century with percutaneous myotomies of the vertebral musculature followed by postoperative bracing, which outcomes were very quite horrifying. Hibbs’ fusion operation had become a realistic treatment option to halt the progression of deformity in the early 20th century. Harrington’s introduction of the internal fixation device to treat paralytic scoliosis in 1960’s started revolution on deformity correction surgery. Luque developed a segmental spinal using sublaminar wiring technique in 1976 and Cotrel developed Cotrel-Dubousset (CD) instrumentation, which was a posterior segmental instrumentation system that used pedicle and laminar hooks on either thoracic or lumbar spine and pedicle screws on the lumbar spine.
    [Show full text]