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Quantitative histomorphometric volume measures of new bone formation in response to the implantation of any of the four types of grafting materials corroborated histologic findings buy 1mg decadron with mastercard. That is buy cheap decadron 1 mg on line, the amount of new bone formation was significantly less in the positive and negative control groups by quantitative volume measures as expressed by the new bone volume index (see Table 2 1mg decadron visa; p 0 purchase decadron 0.5 mg free shipping. However cheap 1 mg decadron visa, there was no statistically significant difference in the new bone volume index between the two experimental groups suggesting that mixing the PPF-based bone graft extender with a small amount of autologous bone graft resulting in mixed formulations with an autologous bone graft content as low as 25% is just as effective as using higher amounts of cancellous autograft. DISCUSSION The reviewed in vivo study focused on the quantitative assessment of osteoinduction with the PPF-based bone graft extender at varying mixing ratios with cancellous autograft bone. This was achieved by analyzing the extender formulation at a high autograft/extender (75% autograft/ 25% extender) and at a low autograft/extender (25% autograft/75% extender) mixing ratio and by comparing these formulations to negative (extender alone) and positive (autograft alone) controls. To investigate these material properties the osetointegration and biocompatibility of the various formulations was evaluated in a rat tibial defect. Results of in vitro and in vivo studies demonstrated maintenance of the structural integrity of the bone graft extender material used alone or in combination with cancellous autograft. There was no evidence of implant failure or disintegration at 4 weeks postoperatively. In addition, it was clearly evident that these control grafts, which did not contain any autograft, were ex- tremely osteoconductive. The PPF bone graft extender formulations, which were mixed with cancellous autologous bone graft and presumably had enhanced osteoinductive properties in vivo did not disintegrate. New bone ingrowth was shown to reside within and around particles of the PPF-based bone graft extender material. In the mixed groups, the amount of new bone, which formed at the implantation sites was significantly higher. When compared to the mixed groups, the amount of new bone formation was significantly less in the positive and negative control groups The Table 2 New Bone Volume Index for Each Graft Type Based on Eight Rats per Group and 4 Weeks Postoperative Follow-up New bone volume index (%) Negative control (PPF alone) 24 3 Positive control (cancellous autograft alone) 15 6 75% autograft/25% PPF extender (high) 48 7 25% autograft/75% PPF extender (low) 46 5 A Polymer Bone Graft Extender 167 fact that there was no statistically significant difference in the new bone volume index between the two experimental groups containing PPF-based extender and cancellous autograft suggested that mixing the PPF-based bone graft extender with a small amount of autologous bone graft with an autologous bone graft content as low as 25% is just as effective as using higher amounts of cancellous autograft. These results clearly demonstrated that the porous PPF- based scaffold, in fact, can function as a true bone graft extender. These findings have immediate applicability to the development of bone graft extender formulations for clinical use. CONCLUSIONS Bioresorbable bone graft extenders could eliminate disadvantages associated with the use of autografts, allografts, and other synthetic materials currently used in clinical bone graft proce- dures. The major clinical application for this resorbable bone graft extender includes its use as an adjunct to filling of defects that arise from surgical removal of cysts and tumors, trauma, osteolytic defects, or surgical debridement of infections. Because autologous bone stocks are not sufficient to deal with extensive bony defects in clinical applications, a biodegradable bone graft extender requiring only minimal amount of autograft bone to produce an equivalent osteoin- ductive response as seen with autografts is increasing in demand. Initial studies, employing both ex situ and in situ cured bone graft extender materials, indicated that new bone formation at the implantation site appears to be closely coupled to the addition of autograft. Therefore, optimization of autograft/PPF ratios by controlled in vitro and in vivo studies seems critical for the understanding of healing of larger bony voids after implanta- tion in a clinical setting. Such optimization results from the consideration of the ratio of cancel- lous autologous bone to the polymeric extender, as well as the porosity of the extender. It is theorized that degradation of polymeric formulations that are structurally stable yet capable of initially developing in vivo porosities for bony ingrowth could be synchronized with the sequence of histologic events of the bone healing process. The investigations demonstrated that mixing a PPF-based bioresorbable graft extender with graft material increased the working volume of autograft or allograft bone material. Significant increases in new bone growth were observed in cases when as little as 25% autograft was mixed with the PPF-based extender material. These findings could have a significant impact on addressing the increasing problem of limited graft material supply. Moreover, the substitute material has the potential ability to reduce or eliminate the need for a secondary surgical site and the associated complications. Joseph Alroy, DVM, Associate Professor in Pathology, Tufts University Schools of Medicine and Veterinary Medicine for his assistance in the histologic analysis of this study. This work was supported in part by NIH/NIAMS Grant No. The Role of the Osteoconductive Scaffold in Synthetic Bone Graft. Donor site pain from the ilium: a complication of lumbar spine fusion. Bioresorbable bone graft substitutes of different osteoconductivities: a histological evaluation of osteointergration of poly(propylene glycol- co-fumaric acid)–based cement implants in rats. Calcium phosphate bone cement-the Norian skeletal repair system in orthopedic surgery. Histologic analysis of implant sites after grafting with demin- eralized bone matrix putty and sheets.

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C and D shows the charac- teristic Beevor’s sign in another patient with abdominal wall in- volvement of Borreliosis Fig discount decadron 0.5 mg with mastercard. Herpes zoster: A classi- cal herpes with paraspinal-tho- racal vesicular lesions and radicular distribution (T8) generic decadron 1 mg with mastercard. C Sacral herpes zoster 127 There are twelve pairs of truncal nerves purchase 1 mg decadron otc, which innervate all the muscles and Anatomy skin of the trunk purchase decadron 0.5 mg line. The dorsal rami separate immediately after the spinal nerves exit from the nerve root foramina buy decadron 0.5mg fast delivery. They pass through the paraspinal muscles, then divide into medial and lateral branches. T1 ventral ramus consists of a large branch that joins the C8 ventral ramus to form the lower trunk of the brachial plexus, and a smaller branch that becomes the first intercostal nerve. T2–T6 are intercostal nerves that pass around the chest wall in the intercostal spaces. Half-way around they give off branches to supply the lateral chest. They end by piercing the intercostal muscles near the sternum to form the medial anterior cutaneous nerve of the thorax. The T2 ventral ramus is unique in size and distribution, and called the intercostobrachial nerve. It supplies the skin of the medial wall and the abdom- inal floor of the axilla, then crosses to the upper arm and runs together with the posterior and medial nerves of the arm (branches of the radial medial cord). The second and third intercostobrachial nerves arise from the lateral cutane- ous branches of the third and fourth intercostal nerves. T7–T11 rami form the thoracoabdominal nerves, and continue beyond the intercostal spaces into the muscles of abdominal wall. They give off lateral cutaneous branches and medial anterior cutaneous branches. The eleventh and twelfth thoracic nerves, below the 12th rib, are called the subcostal nerve. The roots have a downward slant that increases through the thoracic region, such that there is a two-segment discrepancy with vertebral body and segmen- tal innervation. Pain and sensory symptoms at various locations (dorsal, ventral nerve). Muscle weakness only seen if bulging of abdominal muscles can be palpated. Signs Skin lesions may be residual symptoms from Herpes zoster. Surgical intervention may be necessary for symptomatic spinal compression. Differential diagnosis: postoperative thoracic pain Drainage in the intercostal space Injection into the nerve Postmastectomy pain (spectrum from tingling to causalgia) Rib retraction Neoplastic: Malignant invasion from apical lung tumors Pleural invasion Vertebral metastasis: Pain either locally, or in uni- or bilateral radicular distribu- tion. Inflammatory: Herpes: preherpetic, herpetic and postherpetic neuralgia. Usually only one nerve, rarely two or more and rarely nerves on opposite sides. Polyradiculopathy is possible with HIV and acquired immunodeficiency syn- drome (CMV polyradiculopathy). Lyme radiculopathy: may affect thoracic roots and cause weakness. Diabetic truncal neuropathy: Thoracic spinal nerves; pain and paresthesia Trauma: Traumatic disc may cause cord compression. Herniation of intervertebral disc is uncommon and often caused by trauma. Intercostal neuralgia and notalgia paresthetica T5 paresthesia may mimick angina pectoris. Other causes: facet joint hypertrophy, arthritis, slipping rib syndrome. Notalgia paresthetica is a sensory neuropathy of second to sixth thoracic rami. Rectus abdominis syndrome: sharp pain in the anterior wall.

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Spine 23: 1785–1792 Johnsson K order 1mg decadron otc, Uden A order decadron 0.5 mg on-line, Rosen I (1991) The effect of decompression on the natural course of spinal stenosis buy decadron 0.5mg fast delivery. A comparison of surgically treated and untreated patients order 0.5mg decadron visa. Spine 16: 615–619 137 Cauda equina Genetic testing NCV/EMG Laboratory Imaging Biopsy + The conus medullaris terminates at vertebrum L1 order decadron 1 mg without prescription. The lower segmental ventral Anatomy and dorsal lumbar and sacral nerve roots form the cauda equina. The lumbar nerve roots run obliquely downwards and laterally. The sacral spinal nerves divide into rami within the spinal canal. Each ramus passes through a pelvic sacral foramen to join the sacral plexus; each dorsal ramus emerges through a dorsal sacral foramen to supply paraspinal muscles and the skin over the sacral and medial gluteal areas. The cauda equina is loosely enveloped by arachnoid membrane, from which a sleeve extends to cover each nerve root. As a nerve passes into the nerve foramen it is invested in a short sleeve of dura. Symptoms Acute central (disc) herniation: Pain bilaterally in the buttock, sacral, perineal, and posterior leg regions, and sphincter dysfunction. Acute: Signs Weakness of S1 and S2 muscles, sensory loss from soles to perineal region with saddle anesthesia. Roots positioned most laterally (lower lumbar and upper sacral) are most often affected, while the central roots can be spared (S3–S5). Muscle wasting in chronic conditions may resemble chronic polyneuropathy. Toxic: Pathogenesis Anesthesia (spinal and epidural anesthesia) Contrast media Cytotoxic drugs (intrathecal methotrexate) Radiation: TRI (transient radicular irritation) Spinal arachnoiditis 138 Vascular: AV fistulas (spinal/dural) may mimic spinal stenosis Cauda equina claudication Spinal subarachnoid hemorrhage Infectious: AIDS: CMV infections Herpes simplex infection Others: cryptococcal, syphillis, tuberculosis Inflammatory/Immune: Bechterew’s disease Neoplastic: Ependymoma Neurofibroma Rare: dermoid, hemangioblastoma, lipoma, meningioma, paragangliomas, schwannoma Malignant disease: astrocytoma, bone tumors, leptomeningeal carcinomatosis, metastases, multiple myeloma Acute central disc protrusion: A large acute central disc may cause acute and dramatic bilateral sciatic pain. Also pain in the buttock and perineal regions, numbness and weakness of the legs, and sphincter dysfunction. Chronic central disc: Mimics tumors of the conus medullaris and is associated with perineal pain, paresthesias and urinary dysfunction. Trauma: Fractures of the sacrum Spinal surgery Vertebral injury Genetic: Tethered cord Diagnosis Imaging of bony structures and MRI. CSF in inflammatory conditions Electrophysiology: EMG of S1–S3 muscles Sensory conductions Reflex techniques (F waves, H reflex) Spincter EMG including bulbocavernosus reflex Magnetic stimulation Differential diagnosis Spinal cord (epiconus- medullary lesions) Rapidly ascending polyneuropathy Sensorimotor neuropathies with autonomic involvement Therapy Depends on the cause 139 Guigui P, Benoist M, Benoist C, et al (1998) Motor deficit in lumbar spinal stenosis: a References retrospective study of a series of 50 patients. J Spinal Disord 11: 283–288 Hoffman HJ, Hendrick EB, Humphreys RB, et al (1976) The tethered spinal cord; its protean manifestation, diagnosis and surgical correction. Childs Brain 2: 145–155 Tyrell PNM, Davies AM, Evans N (1994) Neurological disturbances in ankylosing spondyli- tis. Ann Rheum Dis 53: 714–717 Yates DAH (1981) Spinal stenosis. J R Soc Med 74: 334–342 141 Mononeuropathies 143 Mononeuropathies are an essential part of clinical neurology. The clinical Introduction diagnosis depends on the knowledge of anatomy, the presentation of clinical syndromes and numerous etiologies. The individual mononeuropathies of the upper extremity, the trunk and the lower extremities are discussed by the anatomic course of the nerve , anomalies and their symptoms and signs. The most likely causes of damage are discussed and differential diagnosis is considered. Therapeutic aspects and if available prognosis are mentioned. Most of our artist‘s illustrations are devoted to this section. The clinical photography should help the reader to identify the patient’s abnormalities. The concept is an accurate and brief description of the most important clinical features. The trunk nerves which are often neglected are summarized in a separate subsection. The nerve continues through the axilla (quadrilateral space), with a motor branch to the teres minor and two further divisions. The posterior division innervates the posterior head of the deltoid muscle and gives off the superior lateral cutaneous nerve. The anterior division innervates the lateral and anterior heads of the deltoid muscle (see Figs.

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Myocardial contusion is the most common blunt injury purchase 0.5 mg decadron visa. The right ventricle buy decadron 1 mg on-line, because of its location immediately beneath the sternum buy decadron 0.5mg line, is the chamber most often involved trusted decadron 1 mg. The pathologic changes in myocardial contusion consist of myocardial necrosis with hemorrhage decadron 0.5 mg sale, which may range in severity from scattered petechiae to intramural extravasations with associated transmural necrosis. In some instances, coronary arterial occlusion with secondary myocardial infarction is present. Seemingly innocuous blows to the chest by missiles such as baseballs or hockey pucks may cause sudden arrhythmic death, probably when they strike directly over the heart during the vulnerable portion of the T wave and induce ventricular fibrillation. The most impor- tant complication of myocardial contusion is cardiac arrhythmia. Hypotension, intracar- diac thrombus, congestive heart failure, and cardiac tamponade occur occasionally. Blunt trauma may injure any of the cardiac valves and lead to valvular regurgitation. Traumatic valvular regurgitation is more likely to be recognized after the patient has recovered from the acute injury; it is less likely to play a major role in the early postinjury course. A 23-year-old man reports a 3-day history of a constant left-sided chest pain, which worsens with inspi- ration and activity. His symptoms were preceded by several days of fatigue, rhinorrhea, and cough. He is worried that he has broken a rib from coughing. He reports no other symptoms and has no risk fac- tors for cardiovascular disease. Other findings on physical exami- nation are as follows: blood pressure, 120/70 mm Hg; pulse, 94 beats/min; respiratory rate, 12 breaths/min; temperature, 100. Cardiovascular examination shows tachycardia, but otherwise the results are normal. Which of the following should be the appropriate step to take next in this patient’s workup? None of the above Key Concept/Objective: To be able to recognize the presentation of acute benign viral pericarditis This patient’s presentation is classic for acute viral pericarditis: constant anterior chest pain that is worse with inspiration, tachycardia, and a low-grade fever. A pericardial fric- 38 BOARD REVIEW tion rub is often heard when patients are symptomatic but may be missed on examina- tion. The differential diagnosis includes pneumonia, spontaneous pneumothorax, and musculoskeletal pain; an electrocardiogram would be the appropriate first step in the evaluation. A finding of diffuse ST segment elevations without reciprocal changes or PR depressions would confirm the diagnosis of viral pericarditis. The patient in Question 65 is found to have PR depressions on electrocardiography. What should be the next step in this patient’s management? Treatment with codeine Key Concept/Objective: To understand the management of acute pericarditis This patient has acute benign pericarditis. Anti-inflammatory medications, including aspirin, are usually effective for reducing pericardial inflammation and decreasing pain. Codeine or another narcotic may be added for pain relief if needed. Although prednisone is effective as well, steroids are generally reserved for patients who are unresponsive to other treatments, because symptoms may recur after steroid withdrawal. Patients do not require hospitalization unless they have other complications such as arrhythmia or tamponade. A 44-year-old man on long-term dialysis for lupus nephritis presents with progressive dyspnea on exer- tion. He has no chest pain or lower extremity edema, nor does he have any other symptoms. Other results of his physical examination are as follows: blood pressure, 130/70 mm Hg; pulse, 84 beats/min; respiratory rate, 14 breaths/min.

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