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Blue Boxes Back/Upper Limb – Jessica Magid 2011 1 Blue Boxes Back/Upper Limb – Jessica Magid 2011 Blue Boxes for Unit 1 Exam Lymph The spread of cancer (46) o Cancer invades the body by . contiguity (growing into adjacent tissue) or by . metastasis (the dissemination of tumor cells to sites distant from the original or primary tumor) by: Direct seeding of the serous membranes of body cavities Lymphogenous spread via lymphatic vessels o Lymphogenous spread is the most common route for the initial dissemination of carcinomas (epithelial tumors) . Cells loosen from the primary tumor and enter and travel via lymphatics . The lymph borne cells are filtered through and trapped by the lymph nodes, which then become secondary cancer sites . Pattern of lymph node involvement follows the natural routes of lymph drainage Hematogenous spread via blood vessels o The most common route for metastasis of the less common (but more malignant) sarcomas (connective tissue cancers) . Usually by venous routes . Therefore, liver and lungs are the most common sites of secondary carcinomas Lymphagitis, lymphadenitis, lymphedema (46-47) o Lymphangitis is the secondary inflammation of lymphatic vessels o Lymphadenitis is the secondary inflammation of lymph nodes . These conditions may occur when the lymphatic system is involved in chemical or bacterial transport after severe injury or infection . The lymphatic vessels may become apparent as red streaks in the skin and the nodes become painfully enlarged . Potentially dangerous bc the uncontained infection may lead to septicemia (blood poisoning) o Lymphedema is the localized accumulation of interstitial fluid, and it occurs when lymph does not drain from an area of the body . If cancerous lymph nodes are surgically removed from the axilla, lymphedema of the lymph may occur . Solid cell growths may permeate lymphatic vessels and form minute cellular emboli (plugs), which may break free and pass to regional lymph nodes CNS Damage to the CNS (47) o When the brain or spinal cord is damaged, the injured axons do not recover in most circumstances . Proximal stumps begin to regenerate, but this growth is blocked by astrocyte proliferation at the injury site, and the axonal sprouts are soon retracted . Permanent disability follows destruction of a tract in the CNS Rhizotomy (58) o Posterior and anterior roots are the only sites where motor and sensory fibers of a spinal nerve are segregated o Only at these locations the surgeon can selectively section either functional element for the relief of intractable pain or spastic paralysis Peripheral nerve degeneration and ischemia of nerves (58) o Neurons do not proliferate in the adult NS, except those related to the sense of smell in the olfactory epithelium o Neurons destroyed through disease or trauma are not replaced 1 Blue Boxes Back/Upper Limb – Jessica Magid 2011 o When peripheral nerves are stretched , crushed, or severed, their axons degenerate maily distal to the lesion bc they depend on their cell bodies for survival . If the axons are damaged but the cell bodies are intact, regeneration and return of function may occur in certain circumstances o Pressure on a nerve commonly causes paresthesia, the pins-and-needles sensation o Types of nerve injuries . Crushing nerve injury – damages or kills the axons distal to the injury site, but the neuronal cell bodies usually survive and the connective tissue coverings remain intact, no surgery required . Cutting nerve injury – requires surgical intervention bc regeneration of the axon requires apposition of the cut ends by sutures through the epineurium . Anterograde (wallerian) degeneration – the degeneration of axons detached from their cell bodies Involves the axon and its myelin sheath, even though the sheath is not part of the injured neuron . Compression of the vasa nervorum – causes compromising of a nerve’s blood supply and can cause nerve degeneration Prolonged ischemia may result in damage no less severe than that produced by crushing or even cutting the nerve Saturday night syndrome – named after an intoxicated individual who passes out with a limb dangling across the arm of a chair or the edge of a bed – is an ex of a more serious, often permanent, paresthesia If ischemia is not too prolonged, temporary numbness or paresthesia results Back Backache and back pain (478) o At least 10% of the population consults a physician, physiotherapist, or chiropractor each year about back pain o Backache is a nonspecific term used to describe back pain . More than 80% of people experience back complaints during their lifetime o Low back pain, the most common complaint, typically occurs between the ages of 30 and 70 o Back injuries occur frequently in competitive sports and in industrial and automobile accidents . In severe injuries, the examiner must be careful not to cause further damage by not flexing the neck or allowing the injured person to sit up . Improper handling of an injured person can convert an unstable lesion without a neurological deficit into one with a deficit that produces permanent disability Laminectomy (482) o Surgical excision of one or more spinous processes and the adjacent supporting vertebral laminae in a particular region of the vertebral column o Term is also used to denote removal of most of the vertebral arch by transecting the pedicles o They are preformed surgically to gain access to the vertebral canal, providing posterior exposure of the spinal cord, if above the L2 level . Often performed to relieve pressure on the spinal cord or nerve roots caused by a tumor, herniated IV disc, or bony hypertrophy (excess growth) Dislocation of the cervical vertebrae (485) o Less tightly interlocked that other vertebrae bc of their more horizontally oriented articular facets . They are stacked like books and can be dislocated in neck injuries with less force than is required to fracture them o Bc of the large vertebral canal in the cervical region, slight dislocation can occur without damaging the spinal cord o Severe dislocations, or dislocations with fractures, injure the spinal cord . If the dislocation does not result in “facet jumping” with locking of the displaced articular processes, the cervical vertebrae may self-reduce (slip back into place) so that a radiograph may not indicate that the cord has been injured, this requires an MRI to see the soft tissue damage 2 Blue Boxes Back/Upper Limb – Jessica Magid 2011 Fracture and dislocation of the atlas (485-486) o Vertebra C1 is a bony ring with 2 wedge-shaped lateral masses connected by relatively thin anteriorly and posterior arches and a transverse ligament o Bc the thick side of the lateral mass wedges is directed laterally . Vertical forces (as would result from a blow to the top of the head from a falling object, or striking the bottom of a pool in a diving accident) compressing the lateral masses between the occipital condyles and the axis drive them apart, fracturing one or both of the bony arches . If the force is sufficient, rupture of the transverse ligament that links them will occur = Jefferson or burst fracture Does not necessarily result in SC injury bc the dimensions of the bony ring increase Spinal cord injury is more likely if the transverse ligament has also been ruptured, indicated radiographically by widely spread lateral masses Fracture and dislocation of the axis (486-487) o Fractures of the vertebral arch of the axis are one of the most common injuries of the cervical vertebrae – up to 40% . Usually occurs in the bony column formed by the superior and inferior articular processes of the axis, the pars interarticularis . Fracture in this location, called a traumatic spondylolysis of C2 Usually occurs as a result of hyperextension of the head on the neck o This was used to execute criminals by hanging, therefore it is called hangman’s fracture Whiplash injury results from the combined hyperextension of the head and neck In more severe injuries, the body of the C2 vertebra is displaced anteriorly with respect to the body of C3 with or without such subluxation (incomplete dislocation) of the axis, injury of the SC and/or brainstem is likely, sometimes resulting in quadriplegia – paralysis or all four limbs – or death . Fracture of the dens are also common axis injuries – 40-50% May result from a horizontal blow to the head or as a complication of osteopenia = pathological loss of bone mass Lumbar spinal stenosis (489) o A stenotic (narrow) vertebral foramen in one or more lumbar vertebrae o May be a hereditary anomaly that can make a person more vulnerable to age-related degenerative changes such as IV disc bulging o Narrowing is usually maximal at the level of the IV discs . Stenosis of a lumbar vertebral foramen alone may cause compression of one or more of the spinal nerve roots occupying the inferior vertebral canal . Electromyography can confirm that the denervation is restricted to muscles innervated by the lumbosacral nerve roots o Surgical treatment of lumbar stenosis may consist of decompressive laminectomy o When IV disc protrusion occurs in a patient with spinal stenosis, it further compromises a vertebral canal that is already limited, as does arthritic proliferation and ligamentous degeneration Caudal epidural anesthesia (493) o The sacral hiatus is closed by a membranous sacrococcygeal ligament, which is pierced by the terminal filum – a connective tissue strand extending from the tip of the spinal cord to the coccyx . Deep (superior) to the ligament, the epidural space of the sacral canal is filled with fatty connective tissue o In caudal epidural anesthesia, a local anesthetic agent is injected into the fat of the sacral canal that surrounds the proximal portions of the sacral nerves . This can be accomplished by several routes: Sacral hiatus – bc it is located between the sacral cornua and inferior to the S4 spinous process or median sacral crest, these palpable bony landmarks are important for locating the hiatus 3 Blue Boxes Back/Upper Limb – Jessica Magid 2011 o The anesthetic spreads superiorly and extradurally, where it acts on the S2-Co spinal nerves of the cauda equine .
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