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By S. Deckard. Lock Haven University.

The cauda equina is loosely enveloped by arachnoid membrane order hydroxyzine 10mg amex, 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.

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The treatment of patients with hypercalcemia of malignancy includes volume and electrolyte repletion generic 10 mg hydroxyzine with visa, inhibition of bone resorption, and treatment of the underlying malignancy. Extracellular volume deficits exist in all patients with sympto- matic hyercalcemia of malignancy. The single most important and urgent treatment is the infusion of normal saline to correct the extracellular volume deficit, increase the glomeru- lar filtration rate, and, secondarily, increase renal calcium excretion. Loop diuretics should not be used until after the volume deficit has been fully corrected. Loop diuretics cause cal- ciuresis and therefore may be effective in acutely decreasing calcium levels after volume repletion. Thiazide diuretics decrease renal calcium excretion and should be specifically 30 BOARD REVIEW avoided. The bisphosphonates offer an improved and simplified treatment of hypercal- cemia of malignancy. The bisphosphonates have a high affinity for areas of high bone turnover, such as areas of bony involvement with malignancy, where they block osteoclast attachment to bone matrix and osteoclast recruitment and differentiation. A 72-year-old man with prostate cancer presents to the emergency department complaining of back pain. On further questioning, the patient reports having difficulty with ambulation for the past week, but he denies having bladder or bowel dysfunction. Physical examination reveals focal midthoracic ver- tebral body tenderness to percussion, 4/5 strength in the bilateral lower extremities, and normal patel- lar reflexes bilaterally. While plans for further evaluation are being made, the patient is treated with I. Which of the following imaging modalities of the spine is recommended to evaluate for this complication? CT with contrast Key Concept/Objective: To know that the current recommendation for the radiographic evalua- tion of patients with possible epidural spinal cord compression is gadolinium-enhanced MRI Epidural spinal cord compression should be suspected on the basis of the symptoms report- ed by the patient and the signs elicited by the physician on physical examination. Imaging of the spine provides the definitive diagnosis and the localization of the level of epidural spinal cord compression.

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Decision trees provide a graphic depiction of the decision-making process purchase hydroxyzine 10 mg online, showing the pathway based on findings at various steps in the process. A decision tree begins with a chief complaint or physical finding and then leads the diagnostician through a series of decision nodes. Each decision node or decision point provides a question or statement regarding the presence or absence of some clinical find- ing. The response to each of these decision points determines the next step. In this book, an example of a decision tree is Figure 12-5, which illustrates a decision-making process for amenorrhea. These devices are helpful in identifying a logical sequence for the decisions involved in narrowing the differential diagnosis and also provide cues to recommended questions/tests that should be answered through the diagnostic process. A decision tree should be accompanied by a description of the strength of the evidence on which it has been developed, as well as a description of the settings and/or patient population to which it relates. Clinical decision (or prediction) rules provide another support for clinical reasoning. Clinical decision rules are evidence-based resources, which provide probabilistic statements regarding the likelihood that a condition exists if certain variables are met and/or the prog- nosis of patients with specific findings. Decision rules use mathematical models and are Copyright © 2006 F. Assessment and Clinical Decision-Making: An Overview 7 Box 1-1 Online Sources of Medical Calculators Emergency Medicine on the Web: www. They are used to express the diagnostic statistics described earlier. The number of decision, or predictive, rules is growing, and select examples have been included in the text. For instance, the Ottawa ankle and foot rules are described in the discussion of musculoskeletal pain in Chapter 13. The Gail model, a well-established rule relevant to screening for breast cancer is discussed in Chapter 8. Many of the rules involve complex mathematical calculations, but others are simple.

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