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L5 Somatosensory evoked responses will show delayed or absence latency which can occur as a result of compression of the spinal cord or cauda equina cheap vardenafil 20mg online. S1 BIBLIOGRAPHY PER Spivak JM discount vardenafil 10mg with amex, Vaccaro AR purchase 20mg vardenafil otc, Cotler JM 20 mg vardenafil amex. J Am Acad Orthopaed Surg 1995;3:345 BCR Spivak JM, Vaccaro AR, Cotler JM. J Am Acad Orthopaed Surg 1995;3:353 40µV 20ms Zamani MH, MacEwen GD. Herniation of the lumbar disc in children and adolescents. J Pediatr Orthop 1982;2:528 Electrodiagnostic studies from a patient with unilateral cauda equina injury secondary to a lumbar disc protrusion. The corti- cal somatosensory evoked potentials on stimulation of the S1 dermatome and the pudendal nerve are unobtainable on the symptomatic side, whereas the responses on stimulation of the L4 and L5 dermatomes are normal. There is also an abnormal bulbocavernosus reflex on the left or symptomatic side ©2002 CRC Press LLC 5 Chronic pathological changes The effects of acute and cumulative trauma result in ciated with degenerative changes and disc herniation progressive degenerative changes that affect both the can have profound effects on the sensitive structures intervertebral disc and the posterior facets and can within the spinal canal and the spinal musculature. Multilevel degenerative changes can result in decreased mobil- SPINAL STENOSIS ity of the spine and even fusion between the inter- vertebral bodies. Disc herniation, especially when The expansion of the facet joints as a result of degen- painful, also results in reduced mobility and dimin- erative changes can encroach on the central canal ished levels of activity. These chronic changes asso- and the lateral foramina. Courtesy Churchill-Livingstone (Saunders) Press ©2002 CRC Press LLC Figure 5. There is stenosis or narrowing of the central canal at both a levels due to osteophytes protruding into the canal at the level of the disc. Courtesy Churchill-Livingstone (Saunders) Press Figure 5. The spinal fluid has a bright signal intensity and the compression of the intrathecal rootlets is apparent. On the axial T2 MR This CT transverse section through the lumbar spine shows image (b), the central canal stenosis is caused by thickening of marked central canal stenosis. The posterior muscle has been the posterior neural arch and ligamentum flavum, and over- partially replaced by fibrofatty tissue. Courtesy Churchill- growth of the posterior facet joints. This causes significant flat- Livingstone (Saunders) Press tening of the normally ovoid-appearing thecal sac ©2002 CRC Press LLC Figure 5. Anteroposterior (a) and lateral (b) views of the lumbar spine following a myelogram, demon- strating a complete block of the contrast at the L2–L3 level Continued become quite marked, especially in the presence of MUSCLE TRAUMA, IMMOBILIZATION AND large osteophytes from the vertebral bodies, and can ATROPHY result in significant stenosis of the central canal and lateral foramina. These changes can be visualized on As degenerative changes progress in the spine or MRI and CT scanning, and, when severe, can disrupt following disc herniation, the mobility of the spine is function within the spinal cord and nerve roots. This immobilization has profound with pain or numbness in the legs on activity and effects on paraspinal muscles. Within 3–4 weeks, which is relieved with rest, known as neurogenic atrophy of the muscle fibers can be seen on claudication, or it can become permanent, leading to microscopy. The cells become smaller, the number neurologic deficits as a result of encroachment on of nuclei decreases and the spaces between muscle the spinal cord or cauda equina. Within 7 weeks, the spaces The degree of spinal stenosis can be measured on between muscle fibers become large and filled with CT and MRI imaging. Hypertrophy of the posterior fibrous collagen and the degeneration of muscle facets encroaching on the neuroforamen is also fibers becomes prominent. The effect of compres- remobilization of the spine, regeneration can be seen sion on the spinal cord, cauda equina and/or nerve in the muscle fibers. Prominent myoblast chains are roots is determined by electrodiagnostic studies.

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Time course May occur at any age from childhood to 70 years buy generic vardenafil 20mg online, mainly 30–50 years generic vardenafil 20 mg line. Onset/age May occur at any age but is more common in subjects between 30 and 60 years of age order vardenafil 10 mg with amex. Clinical syndrome There is an equal distribution in men and women generic 10 mg vardenafil free shipping. Patients may have a solitary, asym- 371 metric muscle mass, enlarging over several months. Most cases spontaneously resolve, and recurrence is unusual. A focal inflammation develops in isolated muscles and may repre- Pathogenesis sent a localized cell mediated response. Laboratory: Diagnosis Serum CK and ESR may be mildly elevated, but are usually normal. Electrophysiology: Nerve conduction studies are usually normal. EMG shows increased insertional activity only in affected muscles. Short duration polyphasic motor unit action potentials, mixed with normal and long duration units are seen in the affected muscle/s. Imaging: Focal enlargement and edema, especially observed on T2 weighted images and T1 with gadolinium. Muscle biopsy: Muscle fiber hypertrophy and fibrosis are more common than in PM and DERM. There is formation of clusters of tightly packed fibers surrounded by fibrosis (Fig. Inflammation is mild, with predominant T-lymphocytes. Therapy – Corticosteroids in a short course may help some patients. Usually excellent and the swelling resolves spontaneously. Recurrence may Prognosis occur in a minority of patients. Caldwell CJ, Swash M, Van Der Walt JD, et al (1995) Focal myositis: a clinicopathological References study. Neuromuscular Disorders 5: 317–321 Heffner R, Barron S (1981) Polymyositis beginning as a focal process. Arch Neurol 38: 439–442 Hohlfeld R, Engel AG, Goebels N, Behrens L (1997) Cellular immune mechanisms in inflammatory myopathies. Curr Opin Rheumatol 9: 520–526 Smith AG, Urbanits S, Blaivas M, et al (2000) The clinical and pathological features of focal myositis. Muscle & Nerve 23: 1569–1575 372 Connective tissue diseases Genetic testing NCV/EMG Laboratory Imaging Biopsy – +++ +++ + +++ Fig. A prominent inflamma- tory response is seen (arrow), with a degenerating fiber (arrow head) Distribution/anatomy Any muscle may be affected, although proximal muscles are more likely to be involved. Time course Variable, although involvement of muscle is unusual and tends to be seen more in chronic connective tissue disorders. Onset/age Can affect any age depending on the specific connective tissue disorder. Clinical syndrome The following types of connective tissue diseases are associated with myopa- thy: 1) Mixed connective-tissue disease (MCTD); 2) Progressive systemic sclero- sis (PSS); 3) Systemic lupus erythematosus (SLE); 4) Rheumatoid arthritis (RA); 5) Sjögren’s syndrome (SS); 6) Polyarteritis nodosa (PAN); and 7) Behçet’s syndrome (BS). Most patients develop a progressive weakness associated with fatigue. The weakness may be associated with an inflammatory myop- athy that resembles polymyositis, or may be associated with poor nutrition and disuse atrophy.

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Muscle Nerve 16: 1261–1264 Mumenthaler M cheap vardenafil 20mg with amex, Schliack H purchase vardenafil 10 mg amex, Stöhr M (1998) Läsionen der Rumpfnerven vardenafil 20 mg sale. In: Mumenthaler M buy 20 mg vardenafil with mastercard, Schliack H, Stöhr M (eds) Läsionen peripherer Nerven und radikuläre Syndrome. Thieme, Stuttgart, pp 368–374 Staal A, van Gijn J, Spaans F (1999) The intercostal nerves. In: Staal A, van Gijn J, Spaans F (eds) Mononeuropathies. Saunders, Londons, pp 84–86 Stewart J (2000) Thoracic spinal nerves. Lippincott, Williams & Wilkins, Philadelphia, pp 499–508 Thomas JE (1972) Segmental zoster paresis: a disease profile. Neurology 22: 459–466 196 Intercostobrachial nerve Anatomy Originates from lateral cutaneous nerve of second and third intercostal nerves to innervate the posterior part of the axilla. This nerve often anastomizes with the medial cutaneous nerve of the upper arm (from the medial cord of the brachial plexus). Signs Sensation is impaired in the axilla, chest wall, and proximal upper arm. Differential diagnosis Operations in the axilla (removal of lymph nodes) Following surgery for thoracic outlet syndrome Lung tumors Reference Assa J (1974) The intercostobrachial nerve in radical mastectomy. J Surg Oncol 6: 123–126 197 Iliohypogastric nerve Fig. Then the nerve crosses the transverse abdominal muscle above iliac crest and passes between the transverse and oblique internal abdominal muscles. Finally two branches are given off: the lateral anterior and anterior cutaneous nerves. Burning and stabbing pain in the ilioinguinal region, which may radiate to- Symptoms wards the genital area or hip. Differential diagnosis Spontaneous entrapment in abdominal wall, surgery, hernioraphy, appendecto- my, abdominoplasty, nephrectomy, endometriosis. Ilioinguinal nerve le- sion after gynecologic surgery. The sensory loss (marked with a ball pen) reached almost the la- bia 200 Anatomy The ilioinguinal nerve originates with fibers from T12 and L1. The motor component innervates the internal and external oblique muscles, and the transverse abdominal muscle. The sensory component covers the skin overlying the pubic symphysis, the superomedial aspect of the femoral triangle, the anterior scrotal surface, and the root of the penis/labia majora and mons pubis (Fig. Clinical syndrome Hyperesthesia, sometimes with significant pain over the lower abdominal quadrant and the inguinal region and genitalia (Fig. Causes Abdominal operations with a laterally placed incision Biopsy Endometriosis, leiomyoma, lipoma Herniotomy Iliac bone harvesting Pregnancy, child birth Spontaneous entrapment – “inguinal neuralgia“ Diagnosis Studies: no standard electrophysiologic techniques are available Therapy Local anesthetic infiltration Surgical exploration and resection of the nerve Differential diagnosis Genitofemoral neuropathy Inguinal pain syndrome Iliohypogastric neuropathy L1 radiculopathy (very rare) References Dawson DM (1990) Miscellaneous uncommon syndromes. Little Brown, Boston, pp 307–323 Komar J (1971) Das Ilioinguinalis Syndrom. Nervenarzt 42: 637–640 Mumenthaler M (1998) Läsionen einzelner Nerven im Beckenbereich und an den unteren Extremitäten, 7. Thieme Verlag, Stuttgart, pp 393–464 Purves JK, Miller JD (1986) Inguinal neuralgia; a review of 50 patients. Can J Surg 29: 585–587 Stulz P, Pfeiffer KM (1982) Peripheral nerve injuries resulting from common surgical procedures in the lower portion of the abdomen. Arch Surg 117: 324–327 201 Genitofemoral nerve The nerve originates from the ventral primary rami of L1 and L2, then runs Anatomy along the psoas muscle to the inguinal ligament. In the inguinal canal the genital branch runs with the ilioinguinal nerve, to supply the skin of the mons pubis and labium majus. The genital branch also innervates the cremaster muscle, while the femoral branch innervates the proximal anterior thigh. May give rise to continuous pain, sometimes called “spermatic neuralgia”.

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