1. Surgical management of spasticity involves selecting appropriate cases and classifying procedures based on their anatomical location and physiological effect.
2. Non-ablative procedures like intrathecal baclofen and spinal cord stimulation are reversible options, while ablative procedures permanently interrupt spinal circuits through neurotomy, rhizotomy or Drezotomy.
3. The goal of these surgeries is to reduce harmful, resistant spasticity and improve motor function and quality of life, with risks including weakness, pain and recurrence of spasticity. Careful patient selection is important for success.
Full-endoscopic lumbar discectomy is an innovative, minimally invasive alternative to microdiscectomy for patients with symptomatic lumbar disc herniations. IELD and TELD offer two complementary surgical corridors to spinal pathology and allow for treatment of the vast majority of lumbar disc herniations. There is level one evidence suggesting that full-endoscopic spine surgery results in similar functional outcomes compared with microsurgical technique, and has a favorable rate of perioperative complications.
http://www.drsandeepagrawal.com/spine.php
There are many different types of conditions that cause back pain. Like most medical conditions, back pain is treatable through several methodologies. Determining what condition you have is the key to determining the right treatment option for you. Back pain comes in many forms, lower back pain, middle back pain, and upper back pain are just a few of the symptoms associated with spinalconditions. You may also have pain or tingling in your extremities that may be indications of spinal conditions. Feel free to browse through our articles about conditions. Contact your doctor to set up an appointment to start your road to recovery.
Every person is different, so symptoms of conditions may present
differently for different people. Symptoms also vary depending on the
condition, its severity, location, and other factors.
covers common causes of low back pain, indications and techniques of epidural steroid injections- interlaminar, caudal, transforaminal approaches, both surface landmark and guided methods.
Carotid artery disease is commonly seen in association with atherosclerosis and complicate the situation. clearcut guidelines with necessary surgical details are provided in presentations.
Regional Blocks of the Upper Limb and Thorax RRTRanjith Thampi
Blocks of the UL and Thorax made easy. Most methods mentioned here are modifications and not classical methods used that maybe be required for examination writing purpose.
Full-endoscopic lumbar discectomy is an innovative, minimally invasive alternative to microdiscectomy for patients with symptomatic lumbar disc herniations. IELD and TELD offer two complementary surgical corridors to spinal pathology and allow for treatment of the vast majority of lumbar disc herniations. There is level one evidence suggesting that full-endoscopic spine surgery results in similar functional outcomes compared with microsurgical technique, and has a favorable rate of perioperative complications.
http://www.drsandeepagrawal.com/spine.php
There are many different types of conditions that cause back pain. Like most medical conditions, back pain is treatable through several methodologies. Determining what condition you have is the key to determining the right treatment option for you. Back pain comes in many forms, lower back pain, middle back pain, and upper back pain are just a few of the symptoms associated with spinalconditions. You may also have pain or tingling in your extremities that may be indications of spinal conditions. Feel free to browse through our articles about conditions. Contact your doctor to set up an appointment to start your road to recovery.
Every person is different, so symptoms of conditions may present
differently for different people. Symptoms also vary depending on the
condition, its severity, location, and other factors.
covers common causes of low back pain, indications and techniques of epidural steroid injections- interlaminar, caudal, transforaminal approaches, both surface landmark and guided methods.
Carotid artery disease is commonly seen in association with atherosclerosis and complicate the situation. clearcut guidelines with necessary surgical details are provided in presentations.
Regional Blocks of the Upper Limb and Thorax RRTRanjith Thampi
Blocks of the UL and Thorax made easy. Most methods mentioned here are modifications and not classical methods used that maybe be required for examination writing purpose.
The presentation includes new insight to rotator cuff anatomy, rotator cable, concept of force couple, different classifications of rotator cuff tear, signs and symptoms, special tests, non operative and operative management of rotator cuff tear, comparison of recent surgical modalities, management of irreparable cuff tears, post operative rehabilitation protocols, SLAP lesion, Parsonage Turner Syndrome
This a power point presentation (Iecture slides) on regional anaesthesia techniques. It explains in detail the regional anaesthesia techniques involved, the indications as well as the contraindications.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. • One of the most important factors in the success of spasticity
relieving surgery is correct selection of cases
• People with spasticity can have many other neurological deficit and
/or musculoskeletal complications.
3. Factors to be noted
1. Non progression of neurological deficits.
2. Harm-full Spasticity
1. Disabling spasticity
2. Complications of spasticity and disfigurement
3. Discomfort , pain and high energy consumption
3. Resistant spasticity
4. Safety and usefulness of the procedure
5. Goals
4. Ideal case
• A well motivated person having non progressive , harmful resistant
spasticity with good control who has no musculoskeletal
complications is considered.
5. Anatomical classification
CONTROL PATHWAYS
SUPRASEGMENTAL ON CNS
SEGEMENTAL THE PROCEDURE THAT INTERRUPTS THE SPINAL CIRCUIT
RESPONCIBLE FOR MAINTENANCE OF TONE
ON PERIPHERAL NS
LOCATION
CENTRAL WHEN SURGERY IS PERFORMED ON THE BRAIN OR
SPINAL CORD
PERIPHERAL WHEN SURGERY IS PERFORMED ON CRANIAL NERVES,
SPINAL ROOTS PERIPHERAL NERVES
6. Physiological classification
CLASSIFIED ACCORDING TO THEIR EFFECTR ON NS
NON ABLATIVE A REVERSIBLE NEURAL RESPONSE IS OBTAINED WITHOUT
CREATING A LESION WITH HELP OF NEUROSTIMULATION
OR CHEMICAL SUBSTANCES ( EG . SCS)
ABLATIVE AN IRREVERSIBLE LESION IS CREATED IN THE NEURAL
TISSUE
(EG. RHIZOTOMY , FASCICULOTOMY)
7. SITE NON ABLATIVE ABLATIVE
1. SEGMENTAL (SPINAL
CIRCUIT)
A. PNS
1. EXTRACRANIOSPINAL MYONEURAL JUNCTION
PERIPHERAL NERVES
-
TEMP. NEURAL BLOCK
PERIPHERAL NERVE
STIMULATION
BOTULINUM TOXIN
PERM. NEURAL BLOCK
FASCICULOTOMY
(NEUROTOMY)
2. INTRASPINAL SPINAL ROOT - RHIZOTOMY
B. CNS
INTRA SPINAL SPINAL CORD INTRATHECAL BACLOFEN DREZOTOMY
MYELOTOMY
9. Non ablative segmental ( spinal circuit)
procedures
• Peripheral – Temporary nerve blocks
• Chemical substances ( Eg. Bupivacaine) are used on peripheral nerve
structures to relieve spasticity,
• Acts by reducing excessive gamma fusimotor drive.
• Closed
• Open
10. • Closed : easily accessible nerves like the obturator, tibial , peroneal,
musculocutaneous , ulnar and median N
• Open: inaccessible nerves are exposed surgically and a catheter that is
connected to reservoir for repeated injections is introduced.
• Eg. In Axilla to relieve spasticity in upper limb.
• Both these procedures can be used prior to – definitive neuro-interventional
method – to determine the amount of relief that can be expected.
11. Central procedures ( non ablative )
• Intrathecal baclofen (ITB).
• Birkmayer (1967 ) – introduced oral Baclofen
• Penn and Kroin – intrathecal use
• Baclofen – GABA – B agonist drug – gets bound to the receptors on the
superficial layers of the posterior horn .
• Inhibits presynaptic transmitter release, by depolarising AP induced
calcium conductance.
12. • Under GA / LA ,
intrathecal tube is
placed through the
lumber
intervertebral
space and left in
subarachnoid
space.
• Brought out at a
convenient site in
abdomen through
Subcutaneous
tunnel and
connected to a
reserviour.
13. • Good and sustained relief – in spinal origin spasticity
• Less effect in cerebral spasticity
• Higher doses can reduce spasticity further – but can cause weakness and other
side effects
• Positive : Non ablative, reversible, titrable.
• Improves motor functions.
• Side effects : Unconsciousness, respiratory failure, infection, disconnection of
tube, geographical dependency, high expense, worsening of seizures.
14. Non ablative suprasegmental procedures –
Central procedures
• Spinal cord stimulation
• Thalamic stimulation
• Chronic cerebellar stimulation
15. Spinal cord stimulation ( Dorsal )
• First introduced in 1962 – neural
stimulation
• Cook and Weinstein – relief in
spasticity ( MS )
16. • Electrodes are implanted in the
midline posteriorly at the cervical
,thoracic and lumber epidural space
• Open / closed
• Connected to receiver ( subclavicular
/ subcostal)
• Frequency adjusted through external
spinal cord stimulation system –
transmitter.
17. Spinal cord stimulation ( Dorsal )
• Stimulation of descending
inhibitory pathways
• Bloackade of nociceptive
afferent influences on long
loop reflexes
• Influences on the ascending
and descending reticular
systems
19. Chronic cerebellar stimlation
• A. Stimulation of the cerebellar cortex:
• Electrodes are placed on the posterior lobe of cerebellum under GA though
bilateral small craniotomies.
• Connected to receiver
• Neurotoxic effects observed
• B. Dentate nuclei stimulation:
• Scwarts et al.
• Direct stimulation of dentate nuclei
20. • Spinal cord stimulation and ablative procedures are producing
encouraging results
• Therefore , the central neuro – stimulation procedures have not
received wide acceptance.
• Expensive
22. Peripheral nerve blocks
• Chemical used – ablative
• Irreversible
• Phenol in glycerin and Alcohol.
• Results – suboptimal , High rate of recurrence of spasticity.
23. Peripheral nerve blocks
• Myoneural Junction block - Botulinum toxin.
• No use in contracture
• Repeatative
• Antibodies – ineffective
• Functional goal – less .
24. • Waltz – 1991 – reported improvement – 75 % cases
• Highly selected case
• Side effects :
• Leakage of current ,
• displacement of electrodes,
• CSF leak,
• infection ,
• pain at stimulation site,
• high expenses.
25. Neurotomy ( Neurectomy , Fasciculotomy )
• 1887 – Lorenz – first obturator neurotomy
• Gros et al – 1977 – intraoperative electrical stimulation of nerves.
Classification
CLOSED PROCEDURES RADIOFREQUENCY LESION (RF)
OPEN PROCEDURES
NON FUNCTIONAL TOTAL NEUROTOMY
PARTIAL NEUROTOMY
FUNCTIONAL FUNCTIONAL ( SELECTIVE NEUROTOMY, SELECTIVE
MOTOR NEUROTOMY - SMF)
26. • Indicated for optimization of focal spastic tone
• Also can be used in multiple muscles – when rhizotomy is contraindicated
• Chosen nerve is exposed to its entry into the spastic muscle
• Component fascicles are dissected – stimulated with bipolar current.
• Intensity of the response to the threshold current and the train stimulus
is recorded.
• Fascicles that show hyperactive response are considered for ablation.
27. • The fascicles are ablated by cutting them and cauterizing the proximal
stump by bipolar current.
28. NERVES FOR SMF SPASTIC POSTURE AND
MOVEMENT
SPASTIC MUSCLES
MUSCULOCUTANEOUS ELBOW FLEXION BICEPS BRACHI
BRACHILAIS
MEDIAN FOREARM PRONATION PROANTER TERES
PROANTER QUADRANTS
ULNAR WRIST FLEXION
ULNAR WRIST FLEXION
FLEXOR CARPI RADIALIS
FLEXOR CARPI ULNARIS
OBTURATOR HIP ADDUCTION ADDUCTER LONGUS
ADDUCTER BRAVIS
ADDUCTER MAGNUS
SCIATIC KNEE FLEXION HAMSTRINGS
TIBIAL ANKLE PLANTER FLEXION
TOE FLEXION
INVERSION
GASTROCNEMEUS, SOLEOUS
TOE FLEXORS
29. • Following SMF , the spastic tone gets optimized right on the table.
• Better appreciated once operative pain subsides
• Improves ROM across joint.
• Improves posture of joint and body.
• Maximum improvement – 6 months
• Spasticity – does not reccur.
• Cost effective
30. • Side effects ( Rare)
• Paresthesia
• Limb edema
• DVT
• Hypotonia
• Injury to vascular structures
31. Rhizotomy
• Ablation of spinal roots.
• Depending on – posterior ( dorsal , sensory )
• - anterior ( Motor)
• Selective Rhizotomy – root is split into component rootlets and each
one is stimulated with bipolar current.
• Hyperactive rootlet is selected for ablation.
32. • Usually under correction is
performed
• Not requiring cauterization of
root
• 25-40 % of rootlets are ablated
• For diffuse spasticity
33. • Open surgical method
• Lumbosacral
• T12 –L1 ( Fasano’s technique )
• L2 – L5 ( Peacock’s technique)
• L2-S2 SPR
• Cervicothoracic
• For disuse spasticity involving both upper limbs
• C5-T1 laminectomy
• Bilateral C5 – T1 SPR
• Sacral
• For spastic bladder
• All sacral roots stimulated
• Detrussor contractions are observed through cystometry
34. • Closed surgical method
• Percutaneous RF posterior rhizotomy
• Thermocoagulation of the posteriot
roots blocks the conduction of ‘A’
delta and ‘C’ fibers
• Under GA in lateral position
• Skin incision 6 cm lateral to midline
• High recurrence rate
• Chemical Rhizotomy
• Phenol / Alcohol
• Short life expectancy
35. Results of SPR
• Spasticity and spasm
• Optimum reduction in hypertonicity
• Considerable expertise required
• Well appreciated after 3-4 days of surgery
• Long term follow up – no recurrence
• Weakens monosynaptic reflex arc – reduction in hypertonia
• No significant reduction in spasm , spastic patterns and mass reflex - multisynaptic
36. • Motor functions
• Pre surgical motor functions improve withing 3-9 months
• Improvement in posture , balance, duration and ease of doing activity
• Contraindicated in : Ataxias, dystonia, Athetosis
• Also in Multiple severe contractures, MR , helpful spasticity.
37. • Side effects
Useful ( positive)
IMPROVEMENT IN UPPER LIMB FUNCTIONS TO EXTENT OF PICKING OF HAIR AND
THREADING THE NEEDLE, BOWEL HABBITS, SWALLOWING AND SQUINT
CLARITY OF SPEECH
SMOOTH FLOW AND EASY INITIATION OF URINATION
DECREASE IN SEIZURES
IMPROVEMENT IN REPSIRATORY FUNCTIONS
HARMFUL ( NEGATIVE)
POST OP NUMBNESS
HYPOTONIA
TOUCH IMPAIRMENT
38. Drezotomy
• Dorsal Root Entry Zone
• At DREZ , the fine myelinated and unmyelinated
nociceptice fibers and large ‘A’ fibers are
rearranged more centrally and laterally .
• This fibers are sectioned
• A lesion at 45 degree – spares lemniscal fibers,
responsible for carrying touch and kinesthetic
sensations.
39. • Under GA – Hemi / complete laminectomy
• Dura opened
• Selected segment – confirmed by electrostimulation of roots / rootlets
• Under magnification , selected posterior rootlets are retracted dorsomedially
from dorsolateral sulcus , to reach venterolateral region of DREZ.
• 2 mm incision is made at a 45 degree angle.
