Be fearless when it comes to life, and careless when it comes to what people say and think about you...

If you don't make mistakes, you don't make anything

Emotional demons

Imagine you’re on a boat out at sea.
You’re alone, except for a pack of scary demons hiding below the deck. As long as you keep floating around on the open sea, they stay below deck and you feel okay—for the most part.  Except for that nagging feeling that there are frightening creatures just out of sight.
When you decide you’ve had enough of floating around and turn the tiller to head toward shore, the demons come rushing up from below, gnashing their teeth and waving their razor-sharp claws at you.
“You have to stay out on the open sea!” they roar at you. “We’re going to slice you up with our razor-sharp claws if you don’t turn away from the shore!”
Frightened and intimidated, you turn your boat around and head back out to open sea. Slowly, the demons shuffle back under the deck.
For a while, floating aimlessly again on the open sea is okay. At least you have some peace and don’t need to worry much about the demons lurking close by.
But then you begin to notice other boats heading toward shore. You remember that you have plans to go ashore to see things you want to see and do things you want to do. As your hand moves toward the tiller to change course, you hear the muffled sounds of roaring and growling below.
Your hand trembles above the tiller. How can you reach shore with those threatening demons ready to pounce at the least movement of the rudder?

Letting the demons decide our course

This scenario is a metaphor for the struggle many of us have with the painful emotions that get in the way of the life we want to lead. When we try to take control of the helm in our lives, we can be intimidated by our emotional demons and continue instead to float aimlessly through life.
Suppose you value being in a loving relationship, but every time you begin pursuing ways to meet a potential partner, you become overwhelmed by the demons of Anxiety and Doubt. You might try arguing with your demons, telling them that they’re irrational or wrong or stupid.
But this only feeds the demons and causes them to grow.
You might decide the demons are just too powerful and give up on your path of finding a partner. Your anxiety and doubt may diminish, only to be replaced by loneliness and restlessness as you float away from your cherished value.
Or, perhaps you value creating community and helping society. You feel a strong sense of purpose and meaning when you take action to steer in that direction. Yet thoughts of volunteering or taking a leadership position in your community are met with monstrous demons of Grief and Anger over the death of your adult child several years ago.
“I can’t help anyone when I’m so mixed up myself,” you might think, turning your ship around to head back out to open sea and leaving your important values behind you on the shore. The Anger and Grief demons trundle to the stern of the ship, not even bothering to go below deck.

The truth about demons

There is something important you need to know about these demons.
They can’t hurt you.
They appear nasty and can be loud and aggressive, gesturing with their sharp claws and growling with their deep voices. But the truth is, they can’t touch you. They can get right next to you and scream threats in your ear, but they can’t harm you.
As long as you believe their threats, they are in charge of the boat and you are left floating in an open, dreary sea. But when you see them for what they are, you can take back control of the tiller and sail anywhere you like.
The demons are real. It’s important to acknowledge that fact. But once you recognize that you can steer your boat despite their unwelcome presence, you will start to see the demons for what they are.
With your hands firmly on the helm, you’ll start to notice that the demons aren’t as big and ugly as you thought. And, even though they gather around to intimidate you into changing your course, it will become apparent that all they can do is hiss and roar and growl. They can’t hurt you with their claws that once seemed huge and razor-sharp but now appear to be merely overgrown fingernails.
So with the now-normal-sized demons around you, you set sail for developing a loving relationship or creating community or being kind to others or making a difference in the world or being tolerant or practicing any of the other values you hold close. After a while, your demons realize you’re not paying much attention to them, so they grumble their way to the back of the boat as you sail on in the direction you want to go.

Making room for your emotional demons

Realizing that your painful emotions can’t tear you to shreds and keep you from going where you want to go is an important first step. Learning how to allow them to just be, rather than fighting them or letting them push you in a non-valued direction, is a productive second step. Here are some ideas about how to do that.
1. Soften, expand, allow.
Sitting in a quiet place, close your eyes or gaze softly at an area on the floor in front of you. Take a few gentle, deep breaths and allow your mind to settle. Become aware of the painful emotion(s) that you’re struggling with. Try to locate this feeling in your body. Is it in your neck? Your stomach? Your back?
When you get a sense of where the feeling is located, take a breath in, and as you breathe out, imagine softening around the feeling. You may be accustomed to resisting the feeling, so softening may be new to you. Just imagine the outer edges of the feeling relaxing and growing soft.
Now as you inhale, see the area around the feeling expanding, giving room and space to the feeling. Allow the feeling to just be.
Your mind will want to take over during this exercise. That’s natural. Just let the thoughts go by like leaves floating down a stream and return to allowing your feeling to just be within you.
Remember that this exercise isn’t about feeling better or getting the feeling to go away. It’s about learning to allow the emotion so that you can continue on your path toward a richer and more meaningful life.
2. Be compassionate.
In your quiet place, visualize your feeling. Realize that, in a way, it is trying to help, perhaps to protect you or keep you safe. Create some compassion for your feeling. Imagine holding it close and soothing it, letting it know that it is okay and all will be well.
3. Remember that your feeling is normal.
Feelings—even feelings we don’t like—remind us that we are human and that we really care about something. Our painful feelings result from what author Russ Harris calls “the reality gap:” the space between what we want and what we have.
4. Healing hand.
Place your hand over the area in your body where you feel this emotion strongly. Imagine that your hand is sending warm, healing energy to the feeling. You’re not trying to get rid of the feeling. You’re just holding it gently and sending it healing warmth.

Remember that this is a practice and that the demons on your boat have been threatening and intimidating you for a long time. It may take awhile for you to accept them and create more space for them rather than trying to make them be quiet or go away. Be patient and compassionate with yourself as you set your course for the shore.

Craniotomy Steps & Basic info

Overview

Craniotomy is a cut that opens the cranium. During this surgical procedure, a section of the skull, called a bone flap, is removed to access the brain underneath. The bone flap is usually replaced after the procedure with tiny plates and screws.

A craniotomy may be small or large depending on the problem. It may be performed during surgery for various neurological diseases, injuries, or conditions such as brain tumors, hematomas (blood clots), aneurysms or AVMs, and skull fractures. Other reasons for a craniotomy may include foreign objects (bullets), swelling of the brain, or infection. Depending on the reason for the craniotomy, this surgery requires a hospital stay that ranges from a few days to a few weeks.

 

What is a craniotomy?

Craniotomy is any bony opening that is cut into the skull. A section of skull, called a bone flap, is removed to access the brain underneath. There are many types of craniotomies, which are named according to the area of skull to be removed (Fig. 1). Typically the bone flap is replaced. If the bone flap is not replaced, the procedure is called a craniectomy.

Figure 1. Craniotomies are often named for the bone being removed. Some common craniotomies include frontotemporal, parietal, temporal, and suboccipital.

Craniotomies are also named according to their size and complexity. Small dime-sized craniotomies are called burr holes or keyhole craniotomies. Sometimes stereotactic frames, image-guided computer systems, or endoscopes are used to precisely direct instruments through these small holes. Burr holes or keyhole craniotomies are used for minimally invasive procedures to:

• insert a shunt into the ventricles to drain cerebrospinal fluid (hydrocephalus)
• insert a deep brain stimulator to treat Parkinson Disease
• insert an intracranial pressure (ICP) monitor
• remove a small sample of abnormal tissue (needle biopsy)
• drain a blood clot (stereotactic hematoma aspiration)
• insert an endoscope to remove small tumors and clip aneurysms

Large or complex craniotomies are often called skull base surgery. These craniotomies involve the removal of a portion of the skull that supports the bottom of the brain where delicate cranial nerves, arteries, and veins exit the skull. Reconstruction of the skull base is often necessary and may require the additional expertise of head-and-neck, otologic, or plastic surgeons. Surgeons often use sophisticated computers to plan these craniotomies and locate the lesion. Skull base craniotomies can be used to:

• remove or treat large brain tumors, aneurysms, or AVMs
• treat the brain following a skull fracture or injury (e.g., gunshot wound)
• remove tumors that invade the bony skull

There are many kinds of craniotomies. Ask your neurosurgeon to describe where the skin incision will be made and the amount of bone removal.

Steps Of Craniotomy

There are 6 main steps during a craniotomy. Depending on the underlying problem being treated and complexity, the procedure can take 3 to 5 hours or longer.
 
Step 1: prepare the patient
No food or drink is permitted past midnight the night before surgery. Patients are admitted to the hospital the morning of the craniotomy. With an intravenous (IV) line placed in your arm, general anesthesia is administered while you lie on the operating table. Once asleep, your head is placed in a 3-pin skull fixation device, which attaches to the table and holds your head in position during the procedure (Fig. 2). Insertion of a lumbar drain in your lower back helps remove cerebrospinal fluid (CSF), thus allowing the brain to relax during surgery. A brain-relaxing drug called mannitol may be given.

Figure 2. The patient’s head is placed in a three-pin Mayfield skull clamp. The clamp attaches to the operative table and holds the head absolutely still during delicate brain surgery. The skin incision is usually made behind the hairline (dashed line).

 
Step 2: make a skin incision
After the scalp is prepped with an antiseptic, a skin incision is made, usually behind the hairline. The surgeon attempts to ensure a good cosmetic result after surgery. Sometimes a hair sparing technique can be used that requires shaving only a 1/4-inch wide area along the proposed incision. Sometimes the entire incision area may be shaved.  
 
Step 3: perform a craniotomy, open the skull
The skin and muscles are lifted off the bone and folded back. Next, one or more small burr holes are made in the skull with a drill. Inserting a special saw through the burr holes, the surgeon uses this craniotome to cut the outline of a bone flap (Fig. 3). The cut bone flap is lifted and removed to expose the protective covering of the brain called the dura. The bone flap is safely stored until it is replaced at the end of the procedure.

Figure 3. A craniotomy is cut with a special saw called a craniotome. The bone flap is removed to reveal the protective covering of the brain called the dura.


Step 4: expose the brain
After opening the dura with surgical scissors, the surgeon folds it back to expose the brain (Fig. 4). Retractors placed on the brain gently open a corridor to the area needing repair or removal. Neurosurgeons use special magnification glasses, called loupes, or an operating microscope to see the delicate nerves and vessels.

Figure 4. The dura is opened and folded back to expose the brain.

 
Step 5: correct the problem
Because the brain is tightly enclosed inside the bony skull, tissues cannot be easily moved aside to access and repair problems. Neurosurgeons use a variety of very small tools and instruments to work deep inside the brain. These include long-handled scissors, dissectors and drills, lasers, ultrasonic aspirators (uses a fine jet of water to break up tumors and suction up the pieces), and computer image-guidance systems. In some cases, evoked potential monitoring is used to stimulate specific cranial nerves while the response is monitored in the brain. This is done to preserve function of the nerve and make sure it is not further damaged during surgery.  
 
Step 6: close the craniotomy
With the problem removed or repaired, the retractors holding the brain are removed and the dura is closed with sutures. The bone flap is replaced back in its original position and secured to the skull with titanium plates and screws (Fig. 5). The plates and screws remain permanently to support the area; these can sometimes be felt under your skin. In some cases, a drain may be placed under the skin for a couple of days to remove blood or fluid from the surgical area. The muscles and skin are sutured back together. A turban-like or soft adhesive dressing is placed over the incision.

Figure 5. The bone flap is replaced and secured to the skull with tiny plates and screws.

Recovery

The recovery time varies from 1 to 4 weeks depending on the underlying disease being treated and your general health. Full recovery may take up to 8 weeks. Walking is a good way to begin increasing your activity level. Start with short, frequent walks within the house and gradually try walks outside. It’s important not to overdo it, especially if you are continuing treatment with radiation or chemotherapy. Ask your surgeon when you can expect to return to work.

 

What are the risks?

No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Specific complications related to a craniotomy may include:

• stroke
• seizures
• swelling of the brain, which may require a second craniotomy
• nerve damage, which may cause muscle paralysis or weakness
• CSF leak, which may require repair
• loss of mental functions
• permanent brain damage with associated disabilities

Steps Of Modified Radical Mastectomy..MRM

Modified Radical Mastectomy

1. Arm on the affected side is extended on a side table. The patient is draped and the affected breast and axilla are exposed.
2. Drawing incision line (an optimal wound closure without any redundant skin must be taken into account)
3. Skin incision and formation of upper flap
4. Proceed cranially towards the pectoralis fascia just below the clavicula and laterally until the lateral margin of the pectoralis major muscle
5. Formation of lower flap from medial to lateral
6. Continue laterally until the latissimus dorsi muscle has been reached
7. Dissection of the breast from medial to lateral including pectoralis major 's fascia
8. Follow the lateral margin of the pectoralis major muscle and opening clavipectoral fascia
9. Identification of upper axillary margin (=axillary vein)
10. Dissection of axillary top (along axillary vein)
11. Identify and preserve thoracodorsal nerve/vessels
12. Identify and preserve long thoracic nerve
13. Finalize axillary dissection and remove all level I and II lymph nodes (for a complete oncologic resection it is sometimes necessary to cut the intercostobrachial nerve)
14. Remove axillary content en bloc with the breast
15. positioning of two drains (axilla-lower flap and upper flap)
16. Woundclosure, avoid any redundant skin

Some people are old at 18 and some are young at 90. Time is a concept that humans created.

Anorectal fistula.... Mucosal advancement Flap, Step by Step

Mucosal advancement Flap, Step by step

1. Position patient in lithotomy position
2. Place the intra-anal retractor
3. Identify fistula site
4. Canulate and brush the fistula tract (or flush with hydrogen peroxide,or both)
5. Excise the intra-anal fistula site (elliptical shape)
6. Create a wide flap by extending the proximal anorectal wall upwards
7. Close the internal fistula opening with absorbable suture
8. Further dissect the flap above the fistula including a thin layer of internal sphincter
9. Prepare the advancement flap and optimize the size before suturing
10. Complete the repair with single sutures

Mucosal advancement flap for treatment of anorectal fistula

General information

• For classification and diagnosis of perianal fistulas MRI is the most appropriate diagnostic tool
• The majority of patients with perianal fistula show epithelialization of the fistula tract, that might prevent closure of the tract. Curettage of perianal fistulae must therefore be considered an essential step in the surgical treatment of perianal fistula.
• Closure of the primary fistula opening using a biological anal fistula plug and anal flap advancement result in similar fistula healing rates in patients with high transsphincteric fistulae. These 2 strategies are superior to seton placement and fibrin glue.
• Given the low morbidity and relative simplicity of the procedure, the anal fistula plug is a viable alternative treatment for patients with high transsphincteric anal fistulas.

Treatment options

• A drainage seton. A safe option to provide adequate drainage. Surrounding tissue will get the opportunity to heal for future treatment. This option does not cure the fistula.
• Lay-open. The fistula is cut open. With this technique there is a risk of cutting to much sphincter tissue (depending on the position of the fistula) which can impair the sphincter's function leading to incontinence. Therefore this option is not suitable for high fistulas (e.g. crossing the entire anal sphincter). At least 2/3 of the sphincter should remain after the procedure.
• Cutting seton. A tied seton is tightened over time, resulting in gradually cutting through the sphincter. This technique can be used until the fistula is completely cured, or can be left in place until the fistula tract is lowered to a level allowing a safe lay-open technique. This technique can sometimes cause incontinence.
• Fistula plug. With this technique the fistula is plugged with a small stretched cone (plug) made of porcine small intestine submucosa. The plug is biodegradable allowing the fistula to heal almost physiologically. Success rates are reported up to 80%.
• Fibrin glue. In this technique the fistula tract is injected with biodegradable glue. However the anal fistula plug treatment shows better results when compared to fibrin glue injection.
• Mucosal advancement flap. In this technique the internal fistula opening is excised and covered with a flap of mucosal tissue. This technique can be combined with a fistula plug. 

Inguinal Hernia...Tension free mesh repair, step by step

Tension free mesh repair, step by step

1. Skin incision about 1.5 cm above and parallel to Inguinal ligament.
2. Ligation of the superficial epigastrivc vein (do not coagulate)
3. Opening Scarpa's fascia
4. Opening external aponeurosis following fibre direction. Avoid damage to the ilioinguinal nerve.
5. Isolate spermatic cord
6. Identify genitofemoral nerve (genital branche), this runs dorsal and parallel to the spermatic cord, underneath the cremaster muscle fibers
7. Isolate hernia sac and/or preperitoneal lipoma
8. Repositioning hernia (do not ligate!)
9. Lipoma can be ligated
10. In case of a large lateral hernia (scrotal) the hernia sac can be transected and proximally ligated. The distal part can remain in situ however needs to be left open widely.
11. Suture mesh with Prolene. First suture through the lateral rectus border just cranially to the pubic tubercle. Proceed along inguinal ligament with large steps and small bites.
12. Tie a knot when the internal ring has been reached (preferably an Aberbeen knot)
13. Create a new internal ring by attaching the lower edge of the upper part of the mesh to inguinal ligament.
14. Secure upper part with single sutures. Beware of the iliohypogastric nerve.
15. Close the external aponeurosis and create new external ring
16. Close Scarpa's fascia
17. Skin closure (intracutaneous resorbable)
18. Infiltrate wound with local anaesthesia

Inguinal Hernia

Risk factors
Positive family history, prolonged increased abdominal pressure (COPD, constipation, prostatism, peritoneal dialysis), aortic abdominal aneurysm, smoking.

Examination
Basically only physical examination; groin mass cranially from Poupart's ligament. Differentiate between a lateral or medial hernia with physical examination is unreliable. Describe testicles, contralateral side and reducibility. Further test are rarely necessary but in doubt a herniography, US or MRI can be considered.

Differential diagnosis
Femoral hernia, varicosis, lymph node, aneurysm, abscess, soft tissue tumor.

Treatment
Asymptomatic hernia; consider conservative treatment
Symptomatic hernia; planned surgery
Incarcerated hernia; acute surgery

Surgical technique
Unilateral; Mesh-repair.Extensive research has been done for the Lichtenstein's and the endoscopic technique. Lichtenstein's technique is recommended.
Bilateral; Mesh-repair. Lichtenstein or endoscopy if enough expertise is available. When endoscopically treated, the TEP is superior to the TAPP.
Recurrent hernia; Technique depends on earlier treatment. In case of an earlier anterior approach, a pre-peritoneal mesh or TEP should be performed. In case of an earlier posterior approach, an anterior mesh or TAPP should be performed.

 
Antibiotics
Antibiotic prophylaxis does not prevent the occurrence of wound infection after groin hernia surgery and should therefore not routinely be given. Prophylactic antibiotics is only recommended in high risk patients.

Appendectomy by laparotomy, step by step

Appendectomy by laparotomy, step by step

1. Skin incision at McBurney's point
2. Opening Scarpa's fascia
3. Opening aponeurosis
4. Atraumatic spreading of muscle fibers
5. Identify and opening of peritoneum
6. Identify cecum and appendix
7. Deliver cecum and appendix
8. Identify and ligate appendiceal artery
9. Crush appendix at base
10. Ligate and remove appendix at base
11. If desired place a purse string suture around base of appendix
12. Closing peritoneum
13. Closing aponeurosis
14. Skin closure

Thats all...CHILL ;-)

Acute Appendicitis, General remarks

Classification Acute appendicitis has 6 types: 1. catarrhalis appendicitis; slightly red 2. phlegmonous: moderate inflammation and ischaemia 3. gangrenous: (partial) necrosis 4. perforated 5. appendicular mass 6. appendicular abscess

Treatment

In case of an acute appendicitis, an appendectomy should be performed, either by laparotomy or by laparoscopy. Fertile females should get a laparoscopy, to exclude any gynaecologic pathology. An appendicular mass should be treatment with medicine and other conservative measures (e.g. rest, no enteral nutrition)
Abscesses should be drained.

Antibiotics

All patients with an acute appendicitis should receive antibiotics. Normally the patient receives a single dose of antibiotics against gram-positive, gram-negative an anaerobes organisms. This treatment should be continued for 5 days in case of gangrenous and perforated appendicitis. In children a total of three days is sufficient.

Wondclosure

The skin can be closed entirely, and does not cause more wound-site infections compared to an approximating stitch. This also accounts for a perforated appendicitis.


 

Differences in Composition of Capillary and Venous Blood Specimen

Blood obtained through skin puncture (capillary blood) differs from blood that is obtained through venipuncture. When analyzing the major characteristics of capillary blood, such as pH, PCO₂, PO₂ and oxygen saturation, freely flowing capillary blood is actually more similar to arterial than to venous blood. On the other hand, due to the method of collection, capillary blood is contaminated with interstitial and intracellular fluids, which will influence the analytic values obtained from these samples. It is for this reason that capillary blood is not recommended for coagulation testing. Differences also exist between venous and capillary blood analyte concentrations (see table below). This is by no means an exhaustive list, and since the data were taken from two different studies, does not include identical analytes for both specimen types, i.e. plasma and serum.

Differences in Composition of Capillary and Venous Blood Specimen

Lumbar Stenosis

Lumbar Stenosis

Stenosis, the narrowing of the bony canal that protects the spinal cord and its branching nerves, in the lower back is often characterized by radiating pain in the buttocks and legs.

Signs & Symptoms

Frequently people afflicted with lumbar stenosis have varying degrees of low back discomfort. The pain typically occurs most often during activities and is relieved by resting, sitting or bending forward. In some cases, the pain is centralized in the lower legs and feet. In severe cases, it also can impact continence and sexual function.

Diagnosis

Doctors use two kinds of tests to diagnose spinal stenosis. Some of the tests are aimed at making sure there isn’t another cause producing the symptoms. Others can indicate that the vertebral narrowing has occurred. After asking you questions about your symptoms, your doctor probably will check your reflexes, gait and other indicators of spinal problems.

Tests include:

• X-ray– High-energy radiation is used to take pictures of the spine.
• Magnetic Resonance Imaging (MRI)– An MRI provides detailed pictures of the spine that are produced with a powerful magnet linked to a computer.
• Computed Tomography (CT) Scan– A CT scan uses a thin X-ray beam that rotates around the spine area. A computer processes data to construct a three-dimensional, cross-sectional image.
• Myelogram– This is an X-ray of your spine taken after a special dye has been injected into the spinal column. It can show pressure on the spinal cord or problems with discs or vertebrae.
• Bone Scan– This test detects areas of increased or decreased bone metabolism, which can indicate a problem in the bone such as a fracture or infection.

Treatment

The initial treatment for stenosis is to treat the symptoms rather than the condition itself. These treatments include:

• Medication such as aspirin or ibuprofen to relieve inflammation and pain
• Rest
• Physical therapy
• Posture changes such as lying with the knees drawn up to the chest or leaning forward while walking may relieve the pressure on the nerves
• Losing weight
• Epidural corticosteroid injections to reduce inflammation and relieve pain

If several months of treatment haven’t improved the symptoms, and if the stenosis is severe, surgery to widen the spinal canal may be necessary. Because bone continues to deteriorate, additional treatment may be needed several years after even successful surgery. Operations used to treat stenosis include:

• Decompressive Laminectomy– The roof of the vertebrae, called the lamina, is surgically removed. The procedure also may include removing part of the disc or fusing the vertebrae (spinal fusion).
• Foramenotomy– The area where nerve roots leave the spinal canal, called the foramen, is removed.
• Laminoplasty– The covering over the upper spine is elevated but not removed to allow decompression of the spinal cord and minimize the development of instability and deformity.
• Laminotomy– Only a small portion of the lamina is removed.
• Medial Facetectomy– Part of the spinal joints, called the facet, is partially removed to relieve pressure on the nerve roots passing underneath it.

Cervical Stenosis

Cervical Stenosis

Stenosis in the neck, also called the cervical spine, affects the upper part of the body including the arms and hands. Stenosis is the narrowing of the bony canal that protects the spinal cord and its branching nerves to the point where it injures the spinal cord or nerves. This may be caused by a number of conditions including bone spurs or rupture of the spinal discs, the spongy pads of tissue that keep the vertebrae from grinding against each other when you bend your back.

Signs & Symptoms

Cervical stenosis may even cause pain, numbness, or weakness in the legs. The pain may move from one part of the body to another but is often most noticeable in the neck.

Diagnosis

Doctors use two kinds of tests to diagnose spinal stenosis. Some of the tests are aimed at making sure there isn’t another cause producing the symptoms. Others can indicate that the vertebral narrowing has occurred. After asking you questions about your symptoms, your doctor probably will check your reflexes, gait and other indicators of spinal problems.

Tests include:

• X-ray — High-energy radiation is used to take pictures of the spine.
• Magnetic Resonance Imaging (MRI) — An MRI provides detailed pictures of the spine that are produced with a powerful magnet linked to a computer.
• Computed Tomography (CT) Scan — A CT scan uses a thin X-ray beam that rotates around the spine area. A computer processes data to construct a three-dimensional, cross-sectional image.
• Myelogram — This is an X-ray of your spine taken after a special dye has been injected into the spinal column. It can show pressure on the spinal cord or problems with discs or vertebrae.

Treatment

• The initial treatment for stenosis is to treat the symptoms rather than the condition itself. These treatments include:
• Medication such as aspirin or ibuprofen to relieve inflammation and pain
• Rest
• Physical therapy
• Posture changes, such as lying with the knees drawn up to the chest or leaning forward while walking, may relieve the pressure on the nerves
• Losing weight
• Corticosteroid injections to reduce inflammation and relieve pain
• A cervical collar

If several months of treatment have not improved the symptoms, and if the stenosis is severe, surgery to widen the spinal canal may be necessary. Because bone continues to deteriorate, additional treatment may be needed several years after even successful surgery. Operations used to treat stenosis include:

• Anterior Cervical Discectomy and Fusion– A small incision in the front of the neck is used to access the upper spine. The ruptured or herniated disc is removed and replaced with a small bone plug, which eventually grows to connect the two adjacent vertebrae.
• Cervical Corpectomy– Part of the vertebra and discs are removed and replaced with a bone graft or a metal plate and screws to support the spine.
• Decompressive Laminectory– The roof of the vertebrae, called the lamina, is surgically removed. The procedure also may include removing part of the disc or fusing the vertebrae (spinal fusion).
• Foramenotomy– The area where nerve roots leave the spinal canal, called the foramen, is removed. This procedure can be performed using a minimally invasive approach with an endoscope, an instrument that allows the surgeon to see inside the body through a tiny incision. The surgeon can then use other tiny incisions to perform the surgery, avoiding the discomfort and muscle atrophy associated with the traditional open technique that uses a large incision.
• Laminoplasty– The compressive bone in the back of the neck is gently lifted off of the spinal cord creating a new “roof” over the spinal cord and nerve roots. This procedure effectively decompresses the spinal cord over multiple segments without the need for fusion or hardware. It also minimizes the chance of spinal instability or deformity that may result from the traditional laminectomy procedure.
• Laminotomy– Only a small portion of the lamina is removed.
• Medial Facetectomy– Part of the bone structure in the spinal canal, called the facet, is removed.
• Cervical Disc Replacement– A new technology that will be undergoing clinical trials at UCSF Medical Center. Instead of fusing the affected area, the natural disc material is replaced with a metal and plastic prosthesis that maintains or restores the motion segment. This will hopefully prevent degeneration of the next disc level

Thoracic Disc Herniation

Thoracic Disc Herniation

The thoracic spine consists of the 12 vertebrae between your neck and lower back. The ends of your ribs, although not attached to the spine, rest in indentations in the thoracic vertebrae that help support the ribs. This arrangement also makes the thoracic vertebrae more stable than other vertebrae. Disc herniation in the thoracic spine is relatively rare compared to the lumbar vertebrae in the lower back and the cervical vertebrae in the neck. Thoracic disc herniations account for less than 1 percent of all protruded discs.

Signs & Symptoms

• Pain in the upper back
• Numbness, pain or tingling from the upper back and around the chest
• Leg weakness
• Chest pain

Diagnosis

Your doctor will examine your movements, strength and reflexes. He or she also may recommend the following tests:

• Magnetic Resonance Imaging (MRI) — An MRI provides detailed pictures of the spine that are produced with a powerful magnet linked to a computer.
• Computed Tomography (CT) Scan — A CT scan uses a thin X-ray beam that rotates around the spine area. A computer processes data to construct a three-dimensional, cross-sectional image.
• Myelogram — This is an X-ray of your spine taken after a special dye has been injected into the spinal column. It can show pressure on the spinal cord or problems with discs or vertebrae.

Treatment

Most often, thoracic disc herniation is treated with bed rest and pain medication. However, surgery may be recommended if the condition doesn’t respond to conservative treatment or if the disc is impinging on the spinal cord and causing symptoms or signs of spinal cord dysfunction.

Surgical treatment consists of removing the damaged disc or discs, a procedure called a discectomy. It also may include removing the lamina, the upper part of the vertebrae, to give the spinal cord more room. In the past, discectomy was usually a major surgery done through a large incision. Today, it is more likely to be performed using small incisions, miniature instruments and a viewing instrument called an endoscope.

Lumbar Disc Herniation

Lumbar Disc Herniation

The lumbar spine consists of the five vertebrae in the lower part of the spine, each separated by a disc, also called a lumbar disc. The discs in this part of the spine can be injured by certain movements, bad posture, being overweight and disc dehydration that occurs with age. Although the lumbar vertebrae are the biggest and strongest of the spinal bones, risk of lumbar injury increases with each vertebrae down the spinal column because this part of the back has to support more weight and stress than the upper spinal bones. The lumbar disc is the most frequent site of injury in several sports including gymnastics, weightlifting, swimming and golf, although athletes in general have a reduced risk of disc herniation and back problems.

Signs & Symptoms

Symptoms of disc herniation in the lower back are slightly different from symptoms in the cervical or thoracic parts of the spine. The spinal cord ends near the top lumbar vertebrae but the lumbar and sacral nerve roots continue through these spinal bones. A lumbar disc herniation may cause:

• Lower back pain
• Pain, weakness or tingling in the legs, buttocks and feet
• Difficulty moving your lower back
• Problems with bowel, bladder or erectile function, in severe cases

Diagnosis

Initial diagnosis of lumbar herniation generally is based on the symptoms of lower back pain. Your doctor will examine your sensation, reflexes, gait and strength. Your doctor also may suggest the following tests:

• X-ray — High-energy radiation is used to take pictures of the spine.
• Magnetic Resonance Imaging (MRI) — An MRI provides detailed pictures of the spine that are produced with a powerful magnet linked to a computer.
• Computed Tomography (CT) Scan — A CT scan uses a thin X-ray beam that rotates around the spine area. A computer processes data to construct a three-dimensional, cross-sectional image.
• Electromyography — This test measures muscle response to nervous stimulation.

Treatment

Conservative treatment of lower disc pain usually is successful over time. It includes:

• Pain medication or pain therapies such as ultrasound, massage or transcutaneous electrical nerve stimulation
• Anti-inflammatory medication such as aspirin, ibuprofen and acetaminophen
• Physical therapy
• Steroid injections
• Education in proper stretching and posture
• Rest

However, if your pain doesn’t respond to conservative treatment in two to four weeks, your condition affects your bowel or bladder function, or if it threatens permanent nerve damage, your doctor may suggest surgery. Modern methods of surgery allow some spine operations to be performed through tiny incisions using miniature instruments while a microimaging instrument called an endoscope is used to view the surgery site.

The surgery usually includes removing the part of the disc that has squeezed outside its proper place, called a discectomy. The surgeon also may want to remove the back part of the vertebrae, called the lamina, in a laminectomy; or to surgically open the foramen, the holes on the side of the vertebrae through which the nerves exit, in a foramenotomy. Only about 10 percent of adult lumbar disc patients require surgery and even fewer children and adolescents.

UCSF Spine Center orthopedic surgeons also are investigating the effectiveness of an implant that may replace damaged lower back discs.

Cervical Disc Herniation

Cervical Disc Herniation

The cervical spine consists of the top seven bones, called vertebrae, in your spine located between the skull and chest. The first symptom of cervical disc herniation is usually neck pain. Others symptoms may include:

• Pain in one arm or in both arms
• Limited head and neck motion, especially turning to the side of the herniated disc
• Hyperactive reflexes
• Spasticity
• Loss of bladder or bowel control, erectile dysfunction

Signs & Symptoms

The cervical spine consists of the top seven bones, called vertebrae, in your spine located between the skull and chest. The first symptom of cervical disc herniation is usually neck pain. Others symptoms may include:

• Pain in one arm or in both arms
• Limited head and neck motion, especially turning to the side of the herniated disc
• Hyperactive reflexes
• Spasticity
• Loss of bladder or bowel control, erectile dysfunction

Diagnosis

Your doctor will check your range of motion in your arms, shoulders and neck. Other tests may include:

• X-ray — High-energy radiation is used to take pictures of the spine.
• Magnetic Resonance Imaging (MRI) — An MRI provides detailed pictures of the spine that are produced with a powerful magnet linked to a computer.
• Computed Tomography (CT) Scan — A CT scan uses a thin X-ray beam that rotates around the spine area. A computer processes data to construct a three-dimensional, cross-sectional image.
• Myelogram — This is an X-ray of your spine taken after a special dye has been injected into the spinal column. It can show pressure on the spinal cord or problems with discs or vertebrae.
• Discography — This test is sometimes used to evaluate back pain in preparation for surgery.

Treatment

Conservative treatment for cervical disc herniation includes:

• Rest
• A cervical collar or neck brace
• Anti-inflammatory medication
• Steroid medication
• Physical therapy that may include cervical traction

Only about 10 percent of cervical herniation patients require surgery. Various surgical procedures are available depending on the severity of herniation. They include:

• Microdiscectomy or removal of the herniated part of the disc
• Anterior cervical decompression and fusion in which the disc is removed and the vertebrae are fused together by means of a dowel bone graft, which comes from cadaver bone, between the vertebrae
• Cervical endoscopic foramenotomy, with or without discectomy, is a minimally invasive procedure in which the herniated disc material is removed using tiny incisions

Scoliosis

Scoliosis

Everyone’s spine has natural curves. These curves round our shoulders and make the lower back curve slightly inward. But some people have spines that also curve from side to side, a common condition called scoliosis. On an X-ray, a spine with scoliosis looks more like an “S” or a “C” than a straight line. Some of the bones in a scoliotic spine also may have rotated slightly, making the person’s waist or shoulders appear uneven.

Scoliosis affects about 2 percent of the population, including children and adults, and tends to run in families. If someone in a family has scoliosis, the likelihood of another family member having it is much higher – about 20 percent.

As the population ages, adult degenerative scoliosis is becoming more common, with the condition typically developing at between age 50 to 70. The condition can have devastating effects on a person’s life in later years. Treatment in this older population presents particular changels due to other back conditions, such as osteoporosis. But significant advances – including minimally invasive surgery, new neuro-monitoring techniques and 3-dimensional imaging – allows older patients to receive limited doses of anesthesia and benefit from quicker recovery.

Scoliosis is defined as curvature of the spine greater than 10 degrees, as measured on an X-ray. Anything less is simply due to normal variation.

Signs & Symptoms

Scoliosis may be divided into five types:

• Congenital Scoliosis– Congenital means that a person is “born with” scoliosis. Congenital scoliosis is caused by an abnormality of one or more vertebrae where they fail to form properly. This can be seen on X-ray and directly in the operating room.
• Idiopathic Scoliosis– This is the most common form of scoliosis. The name idiopathic means “the cause is unknown.” Those with this type of scoliosis are otherwise healthy and normal. The spine shows no abnormality of the bones themselves on X-rays or by looking at it directly in the operating room. While the overall incidence is equal in females and males, progressive or severe idiopathic scoliosis is about six to seven times more frequent in females.
• Neuromuscular Scoliosis– This type of scoliosis occurs in people who have a disease of the nervous system, such as cerebral palsy.
• Postural Scoliosis– Also known as “hysterical scoliosis,” postural scoliosis may be a result of pain, as a patient tilts to relieve the pain. It can be reversed by relieving the pain or by having the patient lie flat. X-rays don’t show any abnormality of the vertebrae.
• Syndromic Scoliosis– This type of scoliosis occurs in people with a syndrome, such as Marfan syndrome or one of the skeletal dysplasias such as achondroplasia.

Progressive, severe scoliosis can produce three major problems:

• If the part of the spine in the chest, called the thoracic spine, curves more than 60 degrees, the volume of the chest can be reduced, potentially compromising the function of the heart and lungs. For example, the heart may have to work harder to pump the normal volume of blood or the affected individual may have shortness of breath.
• Severe curvature of the lower half of the spine that connects the chest with the pelvis, known as the lumbar spine, may push the contents of the abdomen against the chest and interfere indirectly with heart and lung function. Curvature of the lumbar spine also may alter sitting balance and posture.
• Severe curvature of either the thoracic (upper) or the lumbar (lower) spine, or both, eventually becomes visible to others. The resulting tilting and twisting of the back, shoulders and pelvis may produce an appearance that the individual finds unacceptable. If idiopathic scoliosis affects a girl around the time of puberty, when body image is developing hand-in-hand with self-esteem, the condition can pose significant psychological and emotional challenges.

Idiopathic scoliosis may also involve pain, which is more common in adults with scoliosis.

Diagnosis

Uneven ribs and shoulders may be the first noticeable signs of scoliosis. The diagnosis is based upon an X-ray of the spine.

Other tests may be necessary if an underlying disease is suspected as the cause of scoliosis. Symptoms of a possible underlying disease include:

• Deformities of the foot, such as an abnormally high arch that could cause imbalance.
• Discolored skin spots or pigmented birthmarks that could be a sign of neurofibromatosis, a genetically inherited disease in which nerve tissue grows tumors. Neurofibromas may be harmless or may cause skeletal or neurological problems, including pressure on spinal nerves.
• Significant pain, which typically is not a symptom of scoliosis. Patients who tilt to relieve pain can develop scoliosis.

Certain types of scoliosis are associated with other diseases, such as kidney disease. If an underlying disease is suspected, additional tests – such as an ultrasound to look for kidney disease and a magnetic resonance imaging (MRI) scan to look for a possible neurological disorder – may be performed.

Treatment

Scoliosis treatment is based on the degree of curvature of the spine, viewed from the front or back by X-ray. The following are general guidelines for treatment.

Less Than 10 Degrees

This is not scoliosis. Scoliosis is defined as spinal curvature greater than 10 degrees. Curvature under 10 degrees is considered a normal variation, just as there is a normal range for weight and for height.

10 Degrees to 30 Degrees

In this range, scoliosis is observed to see if it progresses.

30 Degrees to 50 Degrees

In this range, bracing is the standard of care in the United States. The scoliosis brace is known as a TLSO, which stands for thoraco-lumbar spinal orthotic. The idea behind bracing is to stop or slow progression of the curve so that it stays under 50 degrees. The two principal types of braces used are the Milwaukee brace, developed by Dr. Walter Blount of Milwaukee, and the Boston brace, developed by Dr. John Hall of Boston. Brace treatment successfully stops curve progression in about 80 percent of children.

More Than 50 Degrees

Beyond 50 degrees, the spine loses its ability to compensate and progression becomes inevitable even after the child is mature. The only way to stop progression at this stage is a surgery called spinal fusion. Think of the vertebrae as beads on a string. The spine bends between the vertebrae as a string bends between the beads, causing the beads to move. The way to stop the beads from moving is to stick them together. Spinal fusion surgery joins the vertebrae.

There is no clear evidence that untreated scoliosis or scoliosis treated with bracing or spinal fusion will increase the risk of back pain or arthritis in the long term. The younger a child is when diagnosed with scoliosis – or the more the child has to grow – the greater the risk of scoliosis progressing.

After puberty, curves under 50 degrees are not likely to get worse. For this reason, the goal of scoliosis mangement is to keep curves under 50 degrees until the child has matured. Children with curves under 50 degrees typically grow up into adults with no significant problems related to scoliosis.

Medication, Physical Therapy

In most cases, treatment for adults begins with a combination of non-surgical treatments administered from several weeks to months. These include:

• Anti-inflammatories, such as ibuprofen and mild narcotics to relieve pain
• Epidural steroid injections to relieve leg pain
• Physical therapy to stablize the spine

Minimally Invasive Surgery

UCSF Medical Center is one of the few medical centers in Northern California to offer advanced minimally invasive spinal fusion surgery. These include XLIF (eXtreme Lasteral Interbody Fusion) or DLIF (Direct Lateral Interbody Fusion) procedures that limit the dose of anesthesia and effectively restore quality of life.

During these procedures, a surgeon creates a small portal in a patient’s side, between the ribs and hip, minimizing muscle stripping while allowing access to the spine. The procedures enable surgeons to correct the side-to-side curvature of the spine and restore spinal balance or alignment so the spine is not pitched forward.

Potential Complications

A potential complication of spine surgery is damage to the nerves running along the psoas muscle, one of the body’s major muscles responsible for stabilizing the base of the spine and allowing the spine to flex and rotate the hip joint. To limit potential nerve injuries, doctors at UCSF Medical Center use neuromonitoring during spine surgery, which allows surgeons to stimulate and test nerves during surgery.

Our doctors also use 3-dimensional imaging techniques during surgery to see the spine more clearly, increase accuracy when placing spinal instruments and improve patient safety.

Treatment for Children

Most spine curves in children with scoliosis will remain small and need only to be watched by an orthopedist for any sign of progression. If a curve does progress, an orthopedic brace can be used to prevent it from getting worse. Children undergoing treatment with orthopedic braces can continue to participate in a full range of physical and social activities.

If the curve of the spine is severe when first seen, or if treatment with a brace does not control the curve, surgery may be necessary.

Kyphosis

Kyphosis

Kyphosis describes the exaggerated curve of the spine that results in a rounded or hunched back. Kyphosis may develop for several reasons. Postural kyphosis in children and adolescents may be related to habit and posture rather than underlying spinal deformity. In contrast, structural kyphosis refers to a round-back posture that is not reversible by paying attention to your posture and making an effort to sit and stand up straight. In adolescents, structural kyphosis may be caused by initial spine development with a rounded shape that is made worse by further growth. In the elderly, compression fractures characteristically result in loss of height and kyphotic deformity.

Signs & Symptoms

• Back pain
• Difficulty standing with an upright posture
• Early fatigue to the back and legs

Diagnosis

The diagnosis of kyphosis is based on physical examination of the spine and X-rays. Your doctor may ask you to bend forward so that he or she can evaluate the spine in the position of maximal extension to assess the flexibility of the spine and the structural nature of the deformity.

Treatment

Treatment depends on the severity of the deformity. In patients with a flexible deformity, physical therapy and attention to posture may result in significant improvement. In patients with rigid deformity of the spine, surgery may be needed.

Surgery for kyphosis involves extending the rounded spine, fusing vertebrae together and using braces to maintain correction. In older patients with kyphosis that is related to compression fractures and osteoporosis, kyphosis may be corrected with a minimally invasive procedure called a balloon kyphoplasty. During this procedure a small balloon is inserted, through a small incision, into the collapsed bone to restore its shape. It is then filled with a substance that hardens and helps the bone expand.

Spondylolisthesis

Spondylolisthesis

Spondylolisthesis is a condition in which one vertebra slips forward on the one below it. In children, spondylolisthesis may occur as the result of a birth defect that affects the back of the spine or be caused by stress fractures within the back part of the spine. Spondylolisthesis is the most common cause of low back pain in adolescent athletes. In older people, the most common cause is degeneration of the discs between the vertebrae. With aging, the discs lose moisture, dry out and flatten, bringing the bones on either side closer together to the point where one slips forward on the other.

Signs & Symptoms

Typical symptoms of spondylolisthesis include pain across the lower back and legs, which occurs when the slipped vertebra irritates the nerves around it. However, a person can have the condition and not have pain.

Diagnosis

A number of test may be used to aid in the diagnosis of spondylolisthesis and to locate the affected bone, including:

• X-ray — High-energy radiation is used to take pictures of the spine.
• Magnetic Resonance Imaging (MRI) Scan– An MRI provides detailed pictures of the spine that are produced with a powerful magnet linked to a computer.
• Computed Tomography (CT) Scan — A CT scan uses a thin X-ray beam that rotates around the spine area. A computer processes data to construct a three-dimensional, cross-sectional image.

Treatment

Most often, treatment for spondylolisthesis includes:

• Physical therapy to strengthen the back muscles
• Pain medication
• Bed rest
• Wearing a back brace or corset

Children and adolescents whose spines have slippage greater than 30 percent to 50 percent may be candidates for spinal fusion surgery. Children and adults who have persistent pain despite non-operative care also may be considered for surgery.

Surgery for spondylolisthesis may involve decompression of the nerve roots by removing bone and/or intervertebral disc material, followed by fusion of the vertebrae with or without bracing.

Anklosing Spondylitis

Anklosing Spondylitis

Ankylosing spondylitis is an inflammatory condition that involves the spine and skeleton of the head and trunk. The disorder causes inflammation and pain in joints in the spine, pelvis and other parts of the skeleton. In addition, parts of the spine, the sacroiliac joints where the hips join the lower back, or the hips may fuse, or grow, together.

Signs & Symptoms

Pain Stiffness, especially in the morning, Functional limitation, When the disorder affects the spine, it also may result in progressive deformity including curvature of the back, called kyphosis, and the inability to stand up straight.

Diagnosis

The first clue in diagnosing ankylosing spondylitis is the presence of symptoms, especially back pain. In addition, X-rays are taken to look for signs of the disorder, such as fused joints. A blood test for the HLA-B27 gene, which is found in about 90 percent of the people with ankylosing spondylitis, also may be performed. However, only 10 percent to 15 percent of people who inherit the gene develop ankylosing spondylitis.

Treatment

Ankylosing spondylitis usually is treated with:

• Pain or anti-inflammatory medications
• Antirheumatic drugs
• Exercise
• Physical therapy

Doctors in the UCSF Spine Center are currently working with new medications that inhibit immune-system cells, called cytokines, which appear to cause some of the symptoms of ankylosing spondylitis.

Joint replacement surgery, most commonly of the hips and shoulders, may be an option for severely affected patients. In addition, spinal reconstruction and internal bracing may be necessary to treat severe spine deformities associated with ankylosing spondylitis.

Cervical Spine Injury Management Guidelines

Guidelines for the Treatment of Cervical Fractures with or without Spinal Cord Injury

1. Admission Guidelines:
All patients with the following clinical conditions MUST be admitted to the ICU for close respiratory and neurological monitoring. The pre-printed Spinal Cord Injury Orders will be used on all patients.

• Radiographic evidence of unstable cervical fracture or dislocation (i.e. atlantococciptal dislocation, bilateral subaxial facet dislocation,..) and/or

• Clinical or radiographic evidence of spinal cord injury

All field collars should be changed out to a permanent rigid collar (Aspen or Miami-J) within 6 hours of admission.
Admission location and monitoring criteria for patients with documented cervical fractures without radiographic evidence of dislocation (i.e. transverse foramen fractures, spinous process fractures,.. ) and without clinical or radiographic evidence of spinal cord injury is left to the discretion of the admitting Attending Physician.

2. Immobilization Guidelines:
Unstable Cervical Fracture or Dislocation, with/without Spinal Cord Injury:

• All patients will be maintained in a rigid cervical collar with strict cervical and log roll precautions until temporary stabilization using halo traction or halo vest is applied (Note: If the patient will be maintained in halo traction for >24 hours he/she should be placed on a rotorest bed to promote respiratory toileting, to be discontinued after surgical fixation)

• Definitive operative stabilization of such fracture dislocations should occur within the first 24-48 hours of hospitalization

Stable Cervical Fracture without Dislocation, without Spinal Cord Injury:

• All patients will be maintained in a rigid cervical collar, unless otherwise determined by the Attending Physician.

• Log roll precautions, operative intervention and length of collar use to be determined by the Attending Physician.

3. Neurological Examination:

• Every 1-2 hours until definitive stabilization is achieved and for at least 24 hours post-operatively, unless otherwise determined by the Attending Physician.

• After 24 hours, the frequency of neurological examination may be progressively weaned as determined by the Attending Physician.

• Evaluation should be based upon the ASIA scoring system, unless otherwise determined by the Attending Physcian.

4. Steroids Administration:

• Steroids can be administered in all patients with evidence of spinal cord injury (excluding penetrating injury and/or nerve root injury) unless contraindicated by co-morbidities or injuries as determined by the Attending Physician.

• Load: Methylprednisolone 30mg/kg IV over 15 minutes

• Infusion: (Begin 45 minutes after bolus)
  • Within 0-3 hours of injury: Methylprednisolone 5.4mg/kg/hr IV for 23 hours
  • Within 3-8 hours of injury: Methylprednisolone 5.4mg/kg/hr IV for 47 hours

• All patients receiving steroids must also have the following ordered
  • Pepcid 20mg IV/PO/FT Q12 or Prevacid 30mg PO/FT Daily
  • Routine finger stick blood sugar monitoring with institution of and insulin sliding scale or insulin gtt for BS >140

5. Blood Pressure Management:

• To promote spinal cord perfusion MAPs will be maintained >85 mm Hg for 7 days post injury
• Pressures should be maintained using the following:
  • Dopamine 2-10 mcg/kg/min IV
  • Phenylephrine 5-200mcg/min IV
  • When able to take PO’s institute one of the following oral agents and begin weaning gtt
  • Ephedrine 25mg PO Q6 (maximum dose 150mg/24 hours)
  • NaCl tablets 1-2gms PO TID (maximum dose 4gms TID
  • Florinef 0.2mg PO Daily (maximum 1mg/24 hours)
  • Midodrine 10mg 30 min before sitting up or TID (do not use in combination with ephedrine)

• Institute abdominal binding and elastic (ACE) bandages to lower extremities when placed in the sitting position or cleared for OOB activity

6. Respiratory Management:

• All patients must receive continuous oxygen saturation monitoring (Maintain a low threshold for intubation in high cervical injury C5 or above)
• Initiate quad cough and suctioning Q2 hours when appropriate
• Incentive spirometer Q2 hours when appropriate
• Albuterol 2.5mg in 3cc NS per nebulizer, every 6 hours in the intubated and high cervical (C5 or above) non-intubated patient

7. DVT Prophylaxis:

• Upon admit all patients will received SCS with antiembolic stockings unless contraindicated by lower extremity injuries
• Non-operative cases will receive enoxaparin 30mg SQ BID within 48 hours of admission, unless otherwise determined by the Attending Physician.
• Operative cases will have enoxaparin 30mg SQ BID started within 48 hours of surgery regardless of drain placement.
• DVT prophylaxis in patients with traumatic brain injury, in addition to their spinal injury, will be evaluated on a case by case basis by the Attending Neurosurgeon.

8. Additional Treatment Guidelines:

• All patients not on a rotorest bed will be turned every 2 hours
• All patients will initially receive an indwelling foley catheter with Q2 I&O Monitoring
  • The patient will intitally be allowed an attempt at self evacuation, this will be followed up with a bladder scan or straight catheterization if results provide proof of retention (> 100cc unless history significant for BPH then may liberalize to 150cc) a routine catheterization program will be instituted
  • I&0 catherterization will begin once urine output is <2 liters in 24 hours and will be ordered in the following manner
    • I&O cathererization Q6 hours if >400cc change frequency to Q4 hours
• All patients will have the following consults within 48 hours of admission unless contraindicated secondary to instability (emphasis on early mobilization
  
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy for Swallow evaluation
    • If unable to pass or participate in swallow evaluation; a feeding tube will be placed and nutritional support initiated within 48 hours of admission
  • Physical Medicine and Rehabilitation

• All patients with evidence of altered rectal tone, pernineal sensation, or with evidence of lack of bowel function will be started on the following bowel regimen within 24-48 hours of admission
  • Colace 100mg PO/FT BID
  • Bisacodyl Suppository 10mg PR with digital stimulation administered at the same time daily

Paediatrics MCQs with key

1.An eight year old boy presented to the casualty with high fever, pruritic erythematous rash, joint pain and lymph node enlargement. There is a history of upper respiratory tract infection for which he was on cefaclor – 8 days completed of a 10 day course. The most likely diagnosis is?
A. Serum sickness like illness
B. HSP
C. Type III hypersensitivity
D. Kawasaki disease

Correct answer : A. Serum sickness like illness
Serum sickness like reaction can occur following the use of certain drugs, especially cefaclor in children. It presents with an urticarial / purpuric rash, arthritis, lymphadenopathy and fever. But unlike true serum sickness (a type III hypersensitivity response), it is not caused by circulating immune complexes.

2.A one year old child presented to the OPD with the history of short stature, tiredness and constipation. Examination revealed a palpable goitre. Serum T4 was decreased and TSH levels were increased. Which is the most probable diagnosis?
A. Thyroid dysgenesis
B. Thyroid Dyshormonogenesis
C. TSH receptor blocking antibody
D. Central hypothyroidism

Correct answer : B. Thyroid Dyshormonogenesis
Among the options given, only Thyroid Dyshormonogenesis presents with a palpable goitre.

 

 

3.Most common tumour associated with Neurofibromatosis I in children is?

A. AML
B. CML
C. ALL
D. JMML (Juvenile myelomonocytic leukemia)

Correct answer :  D. JMML (Juvenile myelomonocytic leukemia)
Children with NF1 have a 200-500 times increased incidence of JMML.

 

4.The protective effects of breast milk are known to be associated with:

A. IgM antibodies
B. Lysozyme
C. Mast cells
D. IgA antibodies

Correct answer : D. IgA antibodies
Although breast milk contains both breast milk and antibodies; antibodies play the major role in providing immunity. Breast fed babies have lower incidence of diarrhoea, otitis media, pneumonia, bacteremia and meningitis.

5.All of the following therapies may be required in a 1 hour old infant with severe birth asphyxia except:
A. Glucose
B. Dexamethasone
C. Calcium gluconate
D. Normal saline

Correct answer : B. Dexamethasone
Steroids should not be used in management of infants with asphyxia

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