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The posterior crico-arytenoid muscles are important because they are the only laryngeal muscles that abduct the vocal folds and maintain the opening between the vocal cords symptoms genital herpes buy generic chloromycetin 250mg online. The intrinsic muscles of the larynx attach to the cartilages of the larynx treatment vitiligo 250mg chloromycetin for sale, so these will be reviewed first medicine 44-527 cheap chloromycetin 500mg amex. The larynx lies at the C3 to C6 vertebral level symptoms quitting weed buy chloromycetin with a visa, just superior to the trachea, and consists of nine cartilages joined by ligaments and membranes. Posterior crico-arytenoid: the only pair of muscles that abduct the vocal folds 6. Arytenoid muscle: composed of transverse and oblique fibers, this muscle adducts the vocal folds and narrows the rima vestibuli 7. Arytenoid the intrinsic muscles of the larynx act largely to adjust the tension on the vocal cords (ligaments), opening or closing the rima glottidis (space between the vocal cords) and opening and closing the rima vestibuli, the opening above the vestibular Clinical Note: Hoarseness can be due to any condition that results in improper vibration or coaptation of the vocal folds. Inflammation and edema (swelling) are commonly the cause for hoarseness and can be induced by smoking, overuse of the voice, gastroesophageal reflux disease, cough, and infections. Plate 3-6 See Netter: Atlas of Human Anatomy, 6th Edition, Plates 79 and 80 Muscular System Intrinsic Muscles of the Larynx and Phonation 3 1 1 Hyoid bone Thyrohyoid membrane Corniculate cartilage Ary-epiglottic muscle 2 6 4 2 Vocal ligament 5 3 3 A. Posterior view Hyoid bone Ary-epiglottic muscle Lateral crico-arytenoid muscle 5 3 Thyro-epiglottic muscle 2 Thyro-arytenoid muscle 7 3 C. Right lateral view Lamina of cricoid cartilage Posterior crico-arytenoid muscle Arytenoid cartilage Arytenoid mm. Conus elasticus Cricothyroid muscle Vocal muscle Vocal ligament Lamina of thyroid cartilage E. Omohyoid Muscles of the neck divide the neck into several descriptive "triangles" that are used by surgeons to identify key structures within these regions. Posterior: between the trapezius and sternocleidomastoid muscles, this triangle is not subdivided further Anterior, which is further subdivided into the triangles listed below: n n n n 2. Carotid: contains the carotid artery In general, the muscles of the neck position the larynx during swallowing, stabilize the hyoid bone, move the head and upper limb, or are postural muscles attached to the head and/or vertebrae. The muscles below the hyoid bone are called "infrahyoid" or "strap" muscles, whereas those above the hyoid bone are called "suprahyoid" muscles. The muscles, vessels, and visceral structures (trachea and esophagus) are all tightly bound within three fascial layers that create compartments within the neck. Infections or masses (tumors) in one or another of these tight spaces can compress softer structures and cause significant pain. The fascial layers themselves also can limit the spread of infection between compartments. On the labeled diagram of the neck in transverse section, color the three fascial layers to highlight their extent. The three fascial layers include the: Investing layer of the deep cervical fascia: surrounds the neck and invests the trapezius and sternocleidomastoid muscles Pretracheal fascia: limited to the anterior neck, it invests the infrahyoid muscles, thyroid gland, trachea, and esophagus Prevertebral fascia: a tubular sheath, it invests the prevertebral muscles and vertebral column the carotid sheath blends with these fascial layers but is distinct and contains the common carotid artery, internal jugular vein, and the vagus nerve. Lateral view Styloid process Mylohyoid muscle Mastoid process Stylohyoid muscle Digastric muscle (posterior belly) Thyrohyoid muscle Hyoid bone 9 6 Digastric muscle (anterior belly) Geniohyoid muscle Sternohyoid muscle Omohyoid muscle (superior belly) Sternothyroid muscle Sternum 10 Thyroid cartilage 13 11 13 7 Omohyoid muscle (inferior belly) Scapula 10 12 Thyroid gland D. Infrahyoidal and suprahyoidal muscles and their actions Pretracheal fascia Carotid sheath Investing fascia Prevertebral fascia Retropharyngeal space Trachea C. This group of muscles includes the scalene muscles (anterior, middle, and posterior) that attach to the upper ribs and also are accessory muscles of respiration. Anterior scalene (note that the subclavian vein passes anterior to this muscle) 4. Middle scalene (note that the subclavian artery passes between this muscle and the anterior scalene muscle) 5. Infections and abscesses can gain access to this space and spread anywhere from the base of the skull to the upper portion of the thoracic cavity (superior mediastinum). Superficial muscles, which are superficially located, control movements of the upper limbs, largely by acting on the scapulae. Serratus posterior superior: intermediate group of muscles; have respiratory function 5. Intermediate muscles, just deep to the superficial layer, are accessory muscles of respiration and have attachments to ribs. The trapezius and latissimus dorsi are removed from the right side of the plate so that you can see this group of muscles. The superficial group migrates onto the back during development of the embryo, although they function as muscles of the upper limb. Obliquus capitis inferior (suboccipital region; muscles 5-7 in this list form the "suboccipital triangle") 7.
Mechanical nerve root compromise is not closely related to symptoms Cervical Spondylotic Myelopathy In contrast to the lumbar spine medications ending in ine proven 500 mg chloromycetin, obliteration of the spinal canal by a disc herniation or osseous spurs can lead to severe neurological deficits because of a direct compromise of the spinal cord resulting in the clinical syndrome of myelopathy symptoms uterine fibroids chloromycetin 500 mg low price. The degree and combination of each symptom can vary extensively and there is no close relationship between the extent of compression and clinical symptoms symptoms quadriceps tendonitis chloromycetin 500 mg visa. A narrowing of the spinal canal size can result from disc degeneration symptoms zinc poisoning buy chloromycetin 250 mg otc, vertebral osseous spurs, osteophyte formation at the level of the facet joints, and yellow ligament hypertrophy, calcification or ossification [205]. Patients with a congenitally narrow spinal canal (< 13 mm) have a higher risk for the development of symptomatic cervical myelopathy [9, 74]. The percentage of cord area reduction never exceeded 16 % and averaged approximately 7 %. Flexion of the cervical spine causes a lengthening of the spinal cord which can be stretched over posterior vertebral spondylosis. In an already narrow canal this motion may damage anterior spinal cord structures [80]. Extension of the cervical spine provokes a buckling of the ligamentum flavum with dorsal compression of the spinal cord combined with anterior compression due to posterior disc bulging and/or vertebral body osteophytes [80]. This results in a pincer effect that places the neurons of the spinal cord at great risk [40, 201, 205]. Advanced disc degeneration and height loss may allow for a translative movement with spondylolisthesis in an anterior or posterior direction decreasing the spinal canal by 2 3 mm. Loss of disc height and hypermobility of facet joints can lead to loss of lordosis and finally to kyphosis. Dynamic changes and increasing kyphosis place increased strain and shear forces on the spinal cord [16]. Biologic and Molecular Factors Corticospinal tracts are very vulnerable to ischemia Vascular factors can play a significant role in the development of myelopathy. A compressed spinal cord will not tolerate a diminished perfusion and a marginally vascularized cord will not tolerate compression [98, 252]. Blood supply of the different tracts in the spinal cord impacts on the pattern of ischemia and subsequent axonal degeneration. Transverse perforating vessels arising from the anterior sulcal arterial system are very susceptible to tension and likely to cause early ischemia and degeneration of the gray matter and medial white matter (anterior spinal cord syndrome) [87]. Spinal cord ischemia especially affects oligodendrocytes, which results in demyelination exhibiting features of chronic degenerative disorders. Particularly the corticospinal tracts are very vulnerable and undergo early demyelination initiating the pathologic changes of cervical myelopathy [40, 80, 95, 255]. Static mechanical factors causing compression, shear and distraction and dynamic repetitive compromise are seen as primary injury whereas ischemia and the subsequent cascade at the cellular and molecular level are considered as secondary injury. These secondary mechanisms include [80, 151, 204]:) glutamatergic toxicity) free radical-mediated cell injury Degenerative Disorders of the Cervical Spine Chapter 17 435) cationic-mediated cell injury) apoptosis Traumatic and ischemic injuries lead to an increase in extracellular levels of glutamate, which is assumed to be excitotoxic leading to neuronal death. The generation of free radicals and lipid peroxidation reactions may render neurons sensitive to the excitotoxic effects of glutamate [80]. The failure of the Na+-K+-adenosine triphosphatase pump results in an accumulation of axonal Na+ through noninactivated Na+ channels. Apoptosis represents a fundamental biological process that contributes to the progressive neurological deficits observed in spondylotic cervical myelopathy [151]. A common finding of many investigations of spinal cord disorders is the observation that oligodendrocytes appear to be particularly sensitive to a wide range of oxidative, chemical, and mechanical injuries, all of which lead to oligodendrocyte apoptosis [67, 167, 255]. Furthermore, the involvement of many growth factors and cytokines, including bone morphogenetic proteins and transforming growth factor- q, were identified in various histochemical and cytochemical analyses. The primary goal of the clinical assessment is to differentiate (see Chapter 8):) specific cervical disorders, i. Accordingly, in non-specific cervical disorders no such correlate can be detected. Patients can only be classified in the latter group after they have undergone a thorough clinical and diagnostic work-up. Patients frequently present with pain syndrome located in the neck-shoulder-arm region, which sometimes makes it difficult to differentiate neck and shoulder problems. Before the diagnosis of non-specific neck pain 436 Section Degenerative Disorders can be made, it is mandatory to exclude differential diagnoses. General aspects of history-taking and physical examination are presented in Chapter 8. History Differentiate neck and arm pain the predominant symptom for patients with degenerative cervical disorders is pain.
Gallbladder the gallbladder stores and concentrates bile medicine qd cheap chloromycetin 500mg fast delivery, which is secreted by the hepatocytes in the liver medications prescribed for pain are termed buy 250 mg chloromycetin mastercard. Consequently medicine 93 3109 purchase chloromycetin 250 mg fast delivery, bile that reaches the duodenum is a mixture of the more dilute bile directly flowing from the liver and the concentrated bile from the gallbladder medications for gout cheap chloromycetin 500mg without prescription. The mucosa of the gallbladder is specialized for electrolyte and water absorption, which allows the gallbladder to concentrate the bile. Main pancreatic duct Exocrine Pancreas the pancreas is both an exocrine and endocrine organ (see Plate 11-6). The pancreas lies posterior to the stomach in the floor of the lesser sac (omental bursa) and is a retroperitoneal organ except for the distal tail, which is in contact with the spleen. The pancreatic head is nestled within the C-shaped curve of the duodenum, with its uncinate process lying posterior to the superior mesenteric vessels. Clinical Note: Gallstones occur in 10% to 20% of the population in developed countries and usually are precipitates of cholesterol (crystalline cholesterol monohydrate, 80%) or pigment stones (bilirubin calcium salts, 20%). Risk factors include increasing age, obesity, female gender, rapid weight loss, estrogenic factors, and gallbladder stasis. The stone may pass through the duct system, collect in the gallbladder, or block the cystic or common bile ducts, causing inflammation and obstruction to the flow of bile. Pancreatic cancer is the fifth leading cause of cancer deaths in the United States. Most of these cancers arise from the exocrine pancreas, and about 60% are found in the head of the pancreas (can cause obstructive jaundice). Plate 8-10 See Netter: Atlas of Human Anatomy, 6th Edition, Plates 280 and 281 Gastrointestinal System Gallbladder and Exocrine Pancreas 2 3 Liver Duodenum 1 4 Proper hepatic artery 4 Right gastric artery Gastroduodenal artery Cut edge of anterior layer of lesser omentum Stomach Colon 5 6 7 4 8 2 3 1 A. Gallbladder: anterior view Mucosal fold Epithelium Crypts Lamina propria Muscle Adventitia Inferior vena cava B. Gallbladder: microscopic section Suprarenal gland Spleen Right kidney (retroperitoneal) Tail Pancreas Neck Body Transverse colon (cut) Duodenum Attachment of transverse mesocolon Head Transverse colon (cut) Left kidney (retroperitoneal) Jejunum Uncinate process of pancreas Attachment of transverse mesocolon D. Histologically, the portal triad refers to the presence of a branch of the portal vein and hepatic artery, and which of the following structures? The cul-de-sac posterior to the stomach and anterior to the pancreas is known by this term. Bile leaving the gallbladder passes down the common bile duct and enters which portion of the gastrointestinal tract? As food enters the oral cavity and is mixed with saliva, what enzyme is secreted by the serous glands of the tongue that aids in digestion? Pancreas Stomach Pancreas Duodenum Mesentery of the small intestine (jejunum and ileum) 5. Lingual lipase 9 Chapter 9 Urinary System 9 Overview of the Urinary System kidney. Grossly, each kidney measures about 12 cm long Ч 6 cm wide Ч 3 cm thick and weighs about 150 g, although variability is common. Approximately 20% of the blood pumped by the heart passes to the kidney each minute for plasma filtration, although most of the fluid and important plasma constituents are returned to the blood as the filtrate courses down the tubules of the nephron. Each ureter is about 24 to 34 cm long, lies in a retroperitoneal position and contains a thick smooth muscle wall. The urinary bladder serves as a reservoir for the urine and is a muscular "bag" that expels the urine, when appropriate. The urethra in the female is short (3-5 cm) and in the male is long (about 20 cm). The male urethra runs through the prostate gland, the external urethral sphincter, and the corpus spongiosum of the penis (see Plate 10-8). The urinary system includes the following components: Kidneys: paired retroperitoneal organs that filter the plasma and produce urine; they are located high in the posterior abdominal wall just anterior to the muscles of the posterior wall Ureters: course retroperitoneally from the kidney to the pelvis and convey urine from the kidneys to the urinary bladder Urinary bladder: lies subperitoneally in the anterior pelvis, stores urine, and, when appropriate, discharges the urine via the urethra Urethra: courses from the urinary bladder to the exterior the kidneys function to: Filter plasma and begin the process of urine formation Reabsorb important electrolytes, organic molecules, vitamins, and water from the filtrate Excrete metabolic wastes, metabolites, and foreign chemicals, such as drugs Regulate fluid volume, composition, and pH Secrete hormones that regulate blood pressure, erythropoiesis, and calcium metabolism Convey urine to the ureters, which then conduct the urine to the bladder the kidneys filter about 180 L of fluid each day through a tuft of capillaries known as the glomerulus, which then delivers the filtrate to a tubule and collecting duct system that, together with the glomerulus, is called the nephron. Urethra Plate 9-1 See Netter: Atlas of Human Anatomy, 6th Edition, Plates 308 and 315 Urinary System Overview of the Urinary System Diaphragm 9 Adrenal gland Renal artery Inferior vena cava Renal vein 1 2 Aorta Psoas major muscle Testicular artery and vein (right) Testicular artery and vein (left) Rectum 3 4 Prostate gland A.
Syndromes
It is common even in peer-review journals to see long cassette radiographs published that are so shrunken in size that important radiographic details and spinal balance cannot be appreciated by the reader symptoms xanax treats chloromycetin 250 mg low price. I can only hope that major publishers will look at this manual and adopt these standards for clarity and size of reproduction for long cassette films medications you cannot crush generic chloromycetin 500mg fast delivery. This Radiographic Measurement Manual will finally provide researchers and clinicians a common language to discuss spinal deformity medicine 93 5298 chloromycetin 500 mg sale. It is a tremendous resource treatment keloid scars discount chloromycetin online mastercard, not only for clinical research, but also for day-to-day practice. I am hopeful that when medical students and orthopaedic and neurosurgery residents see this manual that they will be inspired to devote their careers to the study of spinal deformity and related clinical research. I would be remiss if I did not mention the names of several mentors who have inspired all of us. These spinal surgeons have been responsible for the rapid growth and advancement of spinal deformity research and treatment over the last 40 years. I wish to recognize and thank David Poley and Michael Ferguson at Medtronic for their continuous support of the Spinal Deformity Study Group and for making this landmark project possible. Significant time and effort has been put forth over three years to finalize this manual. Recognition is also given to the section editors and members of the Spinal Deformity Study Group who have participated in this project. And finally special thanks and appreciation must be given to JoAnn Jones with Medtronic for her tireless support and assistance in bringing this book to publication. The written explanations accompanying the figures throughout the text are clear and concise. The section on clinical photography provides a standardized methodology to produce clinical photographs of patients acceptable for any need. The same may be said for the instructions on obtaining and capturing radiographic images. The section on adolescent idiopathic scoliosis provides one-stop shopping for all clinically relevant measurements. The adult deformity section repeats many of the measurements described in the adolescent chapter, with additional measurements specific for adult onset degenerative scoliosis. The spondylolisthesis section will familiarize the reader with all measurements pertinent to this condition, and to accurately utilize them clinically. There should be little question in the future as to how a particular measurement is correctly made. Mike, Tim, Kathy, and Larry Table of Contents Radiographic Measurement Manual Chapter 1: Spinal Anatomy and Alignment. Without a clear understanding of normal anatomy, one cannot understand the importance or implications of the sometimes subtle anatomic variations identified in spinal deformity. Only with a clear understanding of both normal and altered anatomy will the surgeon be able to effectively interpret the radiographic images and formulate a plan to correct spinal deformities. In addition to visualizing and understanding the anatomic variations present in spinal deformity, it is essential that the deformity can be reliably described in a quantitative fashion. Quantifying the deformity facilitates developing a clear understanding of the important structural features of the altered spinal anatomy necessary to develop an effective treatment plan. Equally important, it facilitates accurate communication between healthcare providers regarding the important features of the deformity so that comparative analysis of alternative treatment regimens can be undertaken for similar deformities. Although a detailed description of spinal anatomy is beyond the scope of this current work, it is germane to briefly touch on normal spinal anatomy. There are four distinct regions of the spine: cervical, thoracic, lumbar, and sacropelvic. Each region is separated by transition zones: craniocervical, cervicothoracic, thoracolumbar, and lumbosacropelvic. These transition zones represent areas of anatomic metamorphoses between spinal regions. It is important to understand the unique anatomy, biomechanics, and alignment of each of these regions of the normal spine. Only then can an appreciation be developed for the consequences of spinal deformity so that an effective surgical plan can be created. Abnormalities in embryologic, osseous, and neurologic development may precipitate the development of spinal deformities. Segmentation defects caused by abnormalities in embryologic development may result in osseous pathology, such as hemivertebra, block vertebra, and bars.
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