Spine Healing Therapy

Dorn Spinal Therapy

Dorn Spinal Therapy has been in uses in the past 40 years. The credit of this method goes to Dieter Dorn, who has made a significant impact in the medical field. DORN- Method has been used on various patients where results could get witnessed instants. Due to the impact, this method has brought in the country. It has been declared the standard practice in treating Pelvical Disorders, Spinal, and Back pain. Dieter Dorn first used this method on his family, which was a sign of confidence in a method, which later gained much attention from different people in the country and also globally. Every day Dorn was able to offer treatment to 15- 20 patients in a day. His services were purely free which attracted attention both in the local and also global. The primary treatment that DORN-Method which could be treated using this method include spine healing therapy, misalignments of the spine, resolving pelvis and joints, and also solving out significant problems which could get attributed to vertebrae. Read more here...

Dorn Spinal Therapy Summary

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Vascular Supply Of The Spinal Cord

Spinal Cord White Ramus

There is only one anterior spinal artery, which arises from the vertebral arteries. It supplies the ventral two-thirds of the spinal cord. B. Posterior spinal arteries. There are two posterior spinal arteries that arise from the vertebral arteries or the posterior inferior cerebellar arteries. They supply the dorsal one-third of the spinal cord. 2. This artery is clinically important because it makes a major contribution to the anterior spinal artery. It also provides the main blood supply to the lower part of the spinal cord. 3. Ligation of the great radicular artery during resection of an abdominal aortic aneurysm may result in anterior spinal artery syndrome. Clinical findings include paraplegia, impotence, loss of voluntary control of the bladder and bowel (incontinence), and loss of pain and temperature sensation (although vibration and proprioception sensation are retained). III. THE SPINAL NERVE (Figures 2-1A and 2-2). There are 31 pairs of spinal...

Removal Of Spinal Cord In Infants

ANTERIOR APPROACH The basic principle is the same as in adults. The incomplete calcification of the spinal column permits the use of a scalpel blade instead of an oscillating saw blade. Fig. 6-8. Removal of cervical spine. Upper, scalpel blade is used to separate bone block at an intervertebral disk. Lower, bone block to be removed is reflected upward forcefully to break off at high cervical level. This method is faster, but not suitable when examination of the cervical spine (e.g., for fractures or disk protrusion) is necessary. Notice continuity of cervical roots with spinal cord. Fig. 6-8. Removal of cervical spine. Upper, scalpel blade is used to separate bone block at an intervertebral disk. Lower, bone block to be removed is reflected upward forcefully to break off at high cervical level. This method is faster, but not suitable when examination of the cervical spine (e.g., for fractures or disk protrusion) is necessary. Notice continuity of cervical roots with spinal cord....

Meninges Ventricles and Cerebrospinal Fluid

Meninges Ventricle

MENINGES are three connective tissue membranes that surround the spinal coal and brain. 1. The pia mater is a delicate, highly vascular layer of connective tissue. It closely covers t he surface of the brain and spinal cord. 1. The subarachnoid space (Figure 2-1) lies between the pia mater and the arachnoid. It terminates at the level of the second sacral vertebra. It contains the cerebrospinal fluid (CSF). b. In the spinal cord, it is a clinically insignificant potential space. b. The spinal epidural space contains fatty areolar tissue, lymphatics, and venous plexuses. The epidural space may be injected with a local anesthetic to produce a paravertebral (saddle) nerve block. E. Meningitis is inflammation of the pia-arachnoid area of the brain, the spinal cord, or both. Spinal cistern Figure 2-1. The subarachnoid spaces and cisterns of the brain and spinal cord. Cerebrospinal fluid is produced in the choroid plexuses of the ventricles. It exits the fourth ventricle, circulates in...

Management of spinal injury

Recognition of the presence or risk of spinal injury is essential at all levels of the health care system. The only resource needed for this is training. Included in this is the necessity to monitor neurological function at regular intervals, such as hourly, in the acute phase of injury, and this should be considered essential for all levels of care. It is increasingly recognized that patients with spinal cord injury, especially acute cervical spinal cord injury, may experience severe hypotension and severe problems in maintaining an airway and adequate ventilation. The risk of further neurological deterioration is increased when the ABC's of trauma management are neglected. Therefore, as with prevention of secondary brain injury, recognition of the importance of these factors in patients with spinal injury is deemed essential at all hospital levels. For several years, there has been an international movement towards a uniform methodology for the classification and scoring of acute...

Intradural spinal tumor

Intradural extramedullary spinal tumor The most frequent intradural extramedullary spinal solid tumor is the spinal meningioma. It is a slow-growing tumor that may also expand the spinal canal (Fig. 11.50a see also p. 241). Metas-tases often spread via the CSF also settle in the thecal sac (Fig. 11.50b). They are a feared complication, particularly in pediatric tumors of the posterior fossa. Intramedullary spinal tumor intramedullary spinal masses tend to be primary CNS-type tumors such as astrocytomas and ependymomas. Metastases are also seen (Fig. 11.50c).

Cerebrospinal Fluid Marker Concentrations

Endodermal Sinus Tumor Cns

The evaluation of cerebrospinal fluid (CSF) for P-hCG can be a valuable tool in the diagnosis of CNS metastases from GCTs. In patients in whom P-hCG is the predominant marker, measurement of CSF P-hCG may detect patients with CNS involvement with metastatic disease that is below the limits of detection by CT.6 The original work undertaken by Bagshawe and colleagues29,30 (in the era prior to CT and MRI) suggested that a high CSF P-hCG level was predictive of CNS disease. The cutoff for prediction of the presence of CNS metastases was where the CSF concentration exceeded 2 of the serum concentration. In confirmation of this finding, investigators at Memorial Sloan-Kettering Cancer Center reported that a CSF concentration greater than 2 of the serum concentration was of positive predictive value for CNS metastases at autopsy or on imaging studies (Table 17-4).4 Similarly, Kaye and colleagues found that a CSF P-

Lateral Radiograph of the Cervical Spine

By now the lateral radiograph of the cervical spine is ready for inspection. The trauma surgeons and the anesthesiologist want to know how careful they have to be during repositioning of the patient and whether the stiff collar can be taken off. The radiograph of the cervical spine is always difficult to evaluate and any mistakes can be fatal. f Twenty percent of all polytraumatized patients have an i injury of the cervical spine, a dislocation injury (particularly in deceleration trauma), or a compression injury due to extreme axial loading forces impacting vertebral bodies in the longitudinal direction. It is therefore crucial to check the cervical spine with great care. Definition, outline of all vertebral bodies, and posterior elements and their alignment must be smooth and harmonic

Movements of the lumbar spine

There are three main movements of the lumbar spine. As there is minimal rotation, which mainly occurs at the thoracic spine, rotation is not so important. The movements that should be tested, and their normal ranges are as follows Fig. 33.5 (a) Degrees of movement of the lumbar spine flexion and extension (b) degree of lateral flexion of the lumbar spine REPRODUCED FROM C. KENNA AND J. MURTAGH, BACK PAIN AND SPINAL MANIPULATION, BUTTERWORTHS, SYDNEY, 1989, WITH PERMISSION

Preexisting Spinal Problems That Increase Trauma Risk

Fig. 14.18a In ankylosing spondylitis, also called Bech-terew disease, slowly progressive ossification of the complete ligamentous apparatus of the spinal column occurs. You have already seen the prototypical appearance of the bamboo spine in Fig. 8.44b, p. 146. Note the fracture at the C6 7 level after a minor trauma in this patient. b In Forestier disease only the anterior longitudinal ligament of the spinal column ossifies, but the effect is the same the spine loses all its elasticity. Every motion that results in any significant axial loading force on the spine constitutes a considerable fracture risk for these patients. Minor trauma has led to a fracture of the C7 in this case.

Ventricles And Cerebrospinal Fluid

Lateral Aqueduct

Interconnected cavities called ventricles (ven'tri-klz) are located within the cerebral hemispheres and brain stem (fig. 11.3 and reference plates 53 and 54). These spaces are continuous with the central canal of the spinal cord and are filled with cerebrospinal fluid. To central canal of spinal cord To central canal of spinal cord The fourth ventricle is located in the brain stem just in front of the cerebellum. A narrow canal, the cerebral aqueduct (aqueduct of Sylvius), connects it to the third ventricle and passes lengthwise through the brain stem. This ventricle is continuous with the central canal of the spinal cord and has openings in its roof that lead into the subarachnoid space of the meninges. Tiny, reddish cauliflowerlike masses of specialized capillaries from the pia mater, called choroid plexuses, (ko'roid plek'sus-ez) secrete cerebrospinal fluid. These structures project into the cavities of the ventricles (fig. 11.4). A single layer of specialized ependymal cells (see...

Spinal Canal Stenosis

True Spondylolisthesis

Fig. 8.38a You are looking at an axial CT image through a lower lumbar vertebral body. The spinal canal is severely stenosed by the bone itself there is no sign of degeneration. This spinal canal stenosis is congenital in nature. Back problems are unavoidable and preprogrammed in these patients. b The vacuum phenomenon in this disk is well seen as well as the hypertrophic degenerative change in the intervertebral joints and the thickening of the posterior longitudinal ligament (the ligament that forms the posterior border of the spinal canal). This spinal canal stenosis is acquired and is due to chronic degenerative change. Fig. 8.40a The lumbar spine film of this patient shows no abnormality. A disk herniation is evident on MRI. The increases in transparency in projection over the upper and middle vertebral body are due to intestinal gas. b This axial CT image demonstrates the massive posterior prolapse of disk material into the spinal canal. The thecal sac is compressed and along...

Spinal Column Trauma in Spinal Canal Stenosis

Narrow Spinal Column

Fig. 11.51 a The spinal canal of this patient is extremely narrow secondarily to severe degenerative changes of the cervical spine with associated malalign-ment. Additional minor trauma was sufficient to induce a severe spinal cord injury with transverse paralysis. b In another patient who sustained minor trauma, signal changes can be seen in the spinal cord extending inferior to the level of the preexisting spinal canal stenosis. In this case the anterior spinal artery, which provides crucial blood supply to the cervical and upper thoracic spinal cord, has been compressed. Ischemia of the spinal cord is a feared complication (anterior spinal artery syndrome). Particularly if radicular symptoms are present, imaging findings and clinical symptoms should be seen in conjunction with the imaging findings to come to a sound and correct diagnosis. Many people have one or several herniated disks without ever developing any associated symptoms. Therefore, only the presence of both radicular...

Spinal trauma and preexisting spinal canal stenosis In a

Lower Ray After Bowel Resection

Stenotic spinal canal even minor trauma may induce major cord damage. This can be due to sudden compression of the whole myelon (Fig. 11.51a) or the focal compression of the anterior spinal artery (Fig. 11.51b). I Extradural Spinal Tumor Fig. 11.49a The spinal cord on this sagittal T1-weighted contrast-enhanced MR image is compressed considerably by the soft tissue component of a plasmacytoma. Plasmacytoma frequently causes destruction of the cancellous and cortical bone. b The coronar-yT1-weighted MRI section after contrast administration reveals a Pancoast tumor, a mass originating in the pulmonary apex that may invade the spinal canal through the neuroforamina and subsequently may cause spinal cord compression. Cranially it involves the brachial plexus and can present with Horner syndrome. I Intradural Spinal Tumor a Spinal meningioma a Spinal meningioma Fig. 11.50a This spinal meningioma is even detectable on the lumbar radiograph (left) because its slow growth has forced the...

Structure Of The Spinal Cord

Gray matter of the spinal cord consists of neuronal cell bodies and is divided into the dorsal horn, ventral horn, and lateral horn. 2. White matter of the spinal cord consists of neuronal fibers and is divided into the dorsal funiculus, ventral funiculus, and lateral funiculus. 3. The ventral median fissure is a distinct surface indentation that is present at all levels of the spinal cord. It is related to the anterior spinal artery. 4. The dorsal median fissure is a surface indentation that is less distinct than the ventral median fissure. It is present at all levels of the spinal cord. 6. The conus medullaris is the end of the spinal cord. It is located at vertebral level LI in the adult and at vertebral level L3 in the newborn. 7. The cauda equina consists of the dorsal and ventral nerve roots of spinal nerves L2 through coccygeal 1. These nerve roots travel in the subarachnoid space below the conus medullaris. 5. The subarachnoid space is located between the arachnoid and the pia...

Each Of The Thirty-one Segments Of The Spinal

Each of the thirty-one segments of the spinal cord gives rise to a pair of_. 2. The bulge in the spinal cord that gives off nerves to the upper limbs is called the_ 3. The bulge in the spinal cord that gives off nerves to the lower limbs is called the_ 4. The_is a groove that extends the length of the spinal cord posteriorly. 5. In a spinal cord cross section, the posterior_of the gray matter appear as the upper 6. The cell bodies of motor neurons are found in the_horns of the spinal cord. 7. The_connects the gray matter on the left and right sides of the spinal cord. 8. The_in the gray commissure of the spinal cord contains cerebrospinal fluid and is 9. The white matter of the spinal cord is divided into anterior, lateral, and posterior_. 4. follows irregular contours of spinal cord surface 5. contains cerebrospinal fluid

Positional Changes Of The Spinal Cord Figure 123

Fetal Conus Medullaris

At week 8, the spinal cord extends the entire length of the vertebral canal as spinal nerves exit the intervertebral foramina near their level of origin. This condition does not persist owing to the disproportionate growth of the vertebral column during the fetal period. Figure 12-3. The end of the spinal cord (conns medullaris) is shown in relation to the vertebral column and meninges. (A) Week 8. (B) Week 24. (C) Newborn. (D) Adult. As the vertebral column grows, nerve roots (especially those of the lumbar and sacral segments) are elongated to form the cauda equina. The SI nerve root is shown as an example. (Modified from Moore KL and Persaud TVN The Developing Human, 6th ed. Philadelphia, WB Saunders, 1998, p 459.) B. At birth, the end of the spinal cord (conus medullaris) extends to the L3 vertebral level. C. In adults, the end of the spinal cord (conus medullaris) extends to the L1-L2 interspace. E. An extension of the pia mater forms the filum terminale, which anchors the...

Spinal Nerve Injuries

Birth injuries, dislocations, vertebral fractures, stabs, gunshot wounds, and pressure from tumors can all injure spinal nerves. Suddenly bending the neck, called whiplash, can compress the nerves of the cervical plexuses, causing persistent headache and pain in the neck and skin, which the cervical nerves supply. If a broken or dislocated vertebra severs or damages the phrenic nerves associated with the cervical plexuses, partial or complete paralysis of the diaphragm may result. thigh, calf, ankle, and foot. Sciatica is most common in middle-aged people, particularly distance runners. It usually compresses spinal nerve roots between L2 and S1, some of which contain fibers of the sciatic nerve. Rest, drugs, or surgery are used to treat sciatica.

The Ventricles Of The Brain And Cerebrospinal Fluid

Cerebrospinal fluid originates from a choroid plexus located in the roof of each ventricle. The choroid plexus is a highly vascularized network of capillaries and nonconducting nerve cells. Cerebrospinal fluid is formed by filtration and secretion from each choroid plexus. Cerebrospinal fluid formed in the lateral ventricles flows into the third ventricle by way of the foramen of Monro and joins the fluid from the third ventricle. The fluid then moves down the aqueduct of Sylvius into the fourth ventricle joining the fluid from the fourth ventricle. The fluid then circulates into the subarachnoid space. The cerebrospinal fluid flows down the posterior aspect of the spinal cord, up the anterior surface of the spinal cord, and around the anterior surface of the brain. Most of the cerebrospinal fluid is absorbed into the sagittal sinus (a blood vascular cavity just under the sagittal suture of the cranium) through finger like projections of the arachnoid mater called arachnoid...

Auxiliary Lines for the Evaluation of the Cervical Spine

Posterior Atlanto Dental

Fig. 14.12a The auxiliary lines for the evaluation of the configuration of the lateral cervical spine run (from anterior to posterior) along the anterior edges of the vertebral bodies, along the posterior edges of the vertebral bodies, and along the anterior contour of the posterior vertebral arches. Another auxiliary line the Chamberlain auxiliary line courses from the hard palate to the occiput. The apex of the dens should not traverse it. Another important point is the atlanto-dental distance (arrow) it may not exceed 4 mm. Finally, the prevertebral soft tissue rim above the level of the esophageal inlet (about C4 5) may not exceed 7 mm in adults. b In the anterior-posterior projection, imagine lines along the spinous processes (do not get thrown off by bifid processes ) and the intervertebral joints. The well-centered position of the dens axis (arrow) relative to the atlanto-occipital joints and to the C1-C2 intervertebral joints is checked with care. (But beware Is the patient...

Ligamentary Injury of the Cervical Spine

Photo Cervical Mri After Whiplash

Spinal column injuries caudal to C3 Giufeng realizes that the so-called normal spine begins at C3. Starting at that level the spinal injuries are categorized as The involvement of the posterior edge of the vertebral body is, of course, essential because it indicates a potential hazard to the spinal canal. Fractures of the lower cervical spine mostly evolve in flexion-distraction movement patterns (type B). Any restriction of the spinal column flexibility, such as seen in ankylosing spondylitis (Fig. 14.18a) or Forrestier disease (Fig. 14.18b), increases the risk of unstable fractures even after minor trauma. While Giufeng is still busy studying the radiograph, Greg has already ordered a repeat study C6 and C7 are not depicted at all. The new radiograph is performed as an oblique view because, even with two strong trauma surgeons pulling the patient's shoulders footward, the cervi-cothoracic transition zone could not be adequately imaged on the lateral projection. The new finding...

Removal Of Spinal Cord In Adults

Spinal Cord Removal

Removal of the spinal cord has been traditionally neglected by general pathologists but can be accomplished very easily within 10-15 min by the use of an oscillating saw, as described below. This should be part of every autopsy. This methods allows easy exposure of the uppermost cervical spine and allows direct visualization of the craniocervical junction it is therefore recommended in cases in which neck injuries are suspected (flexion and extension neck injuries), in cases of craniocervical instability and in special situations, for example, when an occipital encephalocele needs to be excised or in situ exposure of an Arnold-Chiari malformation is required. A myelomeningocele also can be removed more easily by the posterior approach (see below). Many morticians object to the routine use of this method, because embalming fluids tend to leak from the incision on the back. Therefore, if embalming is planned, this approach should be chosen only when strictly indicated. Posterior...

The Human Spinal Cord

Referring to figure 4-4, you can see that the typical vertebra has a large opening called the vertebral (or spinal) foramen. Together, these foramina form the vertebral (spinal) canal for the entire vertebral column. The spinal cord, located within the spinal canal, is continuous with the brainstem. The spinal cord travels the length from the foramen magnum at the base of the skull to the junction of the first and second lumbar vertebrae. (1) Enlargements. The spinal cord has two enlargements. One is the cervical enlargement, associated with nerves for the upper members. The other is the lumbosacral enlargement, associated with nerves for the lower members. (2) Spinal nerves. A nerve is a bundle of neuron processes which carry impulses to and from the CNS. Those nerves arising from the spinal cord are spinal nerves. There are 31 pairs of spinal nerves. b. A Cross Section of the Spinal Cord (figure 11-6). The spinal cord is a continuous structure which runs...

Typical Spinal Nerve

In the human body, every spinal nerve has essentially the same construction and components. By learning the anatomy of one spinal nerve, you can understand the anatomy of all spinal nerves. a. Parts of a Typical Spinal Nerve (figure 11-8). Like a tree, a typical spinal nerve has roots, a trunk, and branches (rami). Figure 11-8. A typical spinal nerve with a cross section of the spinal cord. Figure 11-8. A typical spinal nerve with a cross section of the spinal cord. (1) Coming off of the posterior and anterior sides of the spinal cord are the posterior (dorsal) and anterior (ventral) roots of the spinal nerve. An enlargement on the posterior root is the posterior root ganglion. A ganglion is a collection of neuron cell bodies, together, outside the CNS. (2) Laterally, the posterior and anterior roots of the spinal nerve join to form the spinal nerve trunk. The spinal nerve trunk of each spinal nerve is located in the appropriate intervertebral foramen of the vertebral column. (An...

Cerebrospinal Fluid

A clear fluid called cerebrospinal fluid (CSF) is found in the cavities of the CNS. CSF is found in the ventricles of the brain (para 11 -9d), the subarachnoid space (para 11-11b(2)), and the central canal of the spinal cord (para 11 -10b(1)). CSF and its associated structures make up the circulatory system for the CNS.

Spinal Nerves

Thirty-one pairs of spinal nerves originate from the spinal cord. They are mixed nerves, and they provide two-way communication between the spinal cord and parts of the upper and lower limbs, neck, and trunk. Spinal nerves are not named individually but are grouped by the level from which they arise, with each nerve numbered in sequence (fig. 11.30). Thus, there are eight pairs of cervical nerves (numbered C1 to C8), twelve pairs of thoracic nerves (numbered T1 to T12), five pairs of lumbar nerves (numbered L1 to L5), five pairs of sacral nerves (numbered S1 to S5), and one pair of coccygeal nerves (Co). The nerves arising from the superior part of the spinal cord pass outward almost horizontally, whereas those from the inferior portions of the spinal cord descend at sharp angles. This arrangement is a consequence of growth. In early life, the spinal cord extends the entire length of the vertebral column, but with age, the column grows more rapidly than the cord. Thus, the adult...

Spinal anaesthesia

This is the deliberate injection of local anaesthetic into the cerebrospinal fluid (CSF) by means of a lumbar puncture. It is normally given as a single injection, but can be used in conjunction with epidural anaesthesia (combined spinal-epidural anaesthesia) for longer procedures. The incidence of headache following dural puncture is dependent on the size and type of spinal needle. Not Pencil-tip, spinal needles, such as Whiteacre and Sprotte, split, rather than cut, the dura and also reduce the risk of headache. Local anaesthetic solutions for spinal anaesthesia are isobaric or hyperbaric with respect to the CSF. Isobaric solutions are claimed to have a more predictable spread in the CSF, independent of the position of the patient. Hyperbaric solutions are produced by the addition of glucose and their spread is partially influenced by gravity. Many factors determine the distribution of local anaesthetic solutions in the CSF this makes prediction of the level of blockade difficult...

Spinal Trauma

Cervical spine (C-spine) injuries are present in around 1-2 of all blunt trauma patients and 5-10 of patients with head trauma. It is important to maintain C-spine precautions, document a complete neurologic exam, and assess the respiratory status frequently since high spinal injuries can impair breathing. The patient may be cleared clinically if there is no C-spine pain, a full range of motion, no tenderness to palpation, no intoxication or altered mental status, no distracting injury, and no neurologic deficits. In all other cases, C-spine x-rays must be obtained and the full cervical spine seen, including C7-T1. In patients with a fracture on plain films or those with a neurologic deficit, neurosurgery should be called immediately. Extensive diagnostic investigations, including CT or MRI, may be required. Spinal Cord Injury (SCI) Syndromes Compression of the cord or spinal artery occlusion results in loss of all motor and sensory function below the lesion other than position sense...

Plate 27 Spinal Cord

The spinal cord is organized into two discrete parts. The outer part, called the white matter of the cord because of its appearance in unfixed specimens, contains ascending and descending nerve fibers. Some of the fibers go to and from the brain, whereas others connect different levels of the spinal cord. The inner part of the spinal cord, called the gray matter because of its appearance in unfixed specimens, contains the cell bodies of neurons as well as nerve fibers. The gray matter forms an H-or butterfly-shaped pattern surrounding the central canal. The gray matter is described as having dorsal (posterior) horns and ventral (anterior) horns. The ventral horns contain the large cell bodies of motor neurons, whereas the dorsal horns contain neurons that receive, process, and retransmit information from the sensory neurons whose cell bodies are located in the dorsal root ganglia. The size of the gray matter (and, therefore, the size of the spinal cord) is different at different...

Topoisomerase Inhibitors

Etoposide is a natural product that derives from podophyllotoxin (see Fig. 2.11). Its mechanism of action is to cause single-strand and double-strand breaks in DNA through interaction with DNA topoisomerase II, inducing arrest in the G2-phase of the cell cycle 8,21,154 . This activity is mediated through the formation of a stable complex with DNA and topoisomerase II. In addition, etopo-side binds to tubulin and inhibits microtubular assembly. Although etoposide is highly lipophilic, it does not readily pass the blood-brain barrier due to its large size concentration in the cerebrospinal fluid after an intravenous bolus is less than 10 per cent of plasma. Etoposide can be administered orally, by bolus intravenous infusion, or by continuous intravenous infusion over several days. Some authors report improved efficacy when etoposide is given by

Manual Versus Automated Segmentation

Semiautomated or fully automated segmentation in anatomical imaging such as CT and MR is very successful, especially in the brain, as there are many well-developed schemes proposed in the literature (see surveys in 14 ). This may be because these imaging modalities provide very high resolution images in which tiny structures are visible even in the presence of noise, and that four general tissue classes, gray matter, white matter, cerebrospinal fluid (CSF), and extracranial tissues such as fat, skin, and muscles, can be easily classified with different contrast measures. For instance, the T1- and T2-weighted MR images provide good contrast between gray matter and CSF, while T1 and proton density (PD) weighted MR images provide good contrast between gray matter and white matter. In contrast to CT and MRI, PET and SPECT images lack the ability to yield accurate anatomical information. The segmentation task is further complicated by poor spatial resolution and counting statistics, and...

Comparison of 30 T and 15 T MR Imaging

In principle, the linear dependence of SNR on magnetic field strength should result in its doubling from 1.5 T to 3.0 T. In practice, this is true only of some tissues such as cerebrospinal fluid (CSF). In white and grey matter and in the grey nuclei the increase is much

Clinical Presentation

Brain tumors can cause either generalized or focal neurological dysfunction. Included within the generalized grouping are those signs and symptoms related to increased intracranial pressure (ICP) and seizures. Increases in ICP may result from cerebral edema (damage to brain tissue from tumor infiltration), vasogenic edema (produced by leakage of the blood-brain barrier), obstruction of cerebrospinal fluid (CSF) flow, or obstruction of venous flow. Under these conditions, the patient may develop headache, nausea, vomiting, lassitude, and visual abnormalities like papilledema or diplopia. An acute rise in ICP (as caused by blockage of CSF pathways or hemorrhage into the tumor) may cause a sudden onset of these symptoms accompanied by a significant change in level of alertness. If elevations in ICP go untreated, patients may develop herniation. There are three general types of herniation tentorial, tonsillar, and subfalcine. Tonsillar herniation entails downward displacement of the...

Bone Cartilage and Ligaments

Lateral Meniscus Popliteus

Those found in wrists and ankles are boxlike in appearance. Flat bones form the roof of the skull, sternum, the ribs, and the scapula. They protect the underlying soft tissues from the forces of impact. They also offer an extensive surface area for the attachment of skeletal muscles. Irregular bones such as the vertebrae of the spinal column have complex shapes with short, flat, and irregular surfaces. Sutural bones are small, flat, and oddly shaped bones of the skull in the suture line. Finally, sesamoid bones such as the patellae are usually small, round, and flat. They develop inside tendons. Cartilage is a gelatinous matrix that covers bone surfaces at a large number of articulations. It is glassy smooth, glistening, and bluish-white in appearance. It is found in the connections between the ribs and the sternum, and on the surface of articulating bones of the shoulder and hip joints, elbow, knee, and the wrist. Cartilage pads are positioned between spinal vertebrae. One important...

Standard 30 T MR Imaging4

Magnetic resonance imaging (MRI) studies of the brain can be classified into two general categories based on the type of information that is being collected morphological or functional. Standard morphological studies are performed to depict tissue, cerebrospinal fluid (CSF) spaces, vessels and fibre bundles functional studies include mapping of brain function (fMRI), perfusion and diffusion imaging, and metabolic studies by means of spectroscopy.

Anaplastic Astrocytoma

The AA can be quite variable in location but nearly all are supratentorial and most are centered in the deep white matter and may secondarily involve the deep gray-matter structures. These masses generally have poorly defined margins and are somewhat heterogeneous in signal intensity characteristics on all MR pulse sequences, most evident on the FLAIR and T2-weighted images (Fig. 1). The amount of surrounding vasogenic edema is quite variable but more commonly relatively mild and frequently indistinguishable from the margins of the nonenhancing component of the mass. Consequently, it is difficult to determine the true extent of neoplastic cell invasion when planning complete resection by MRI. FLAIR and T2-weighted images certainly demonstrate the extent of parenchymal involvement better than the T1-weighted images but tumor cells can extend into parenchyma that is normal in signal intensity on all pulse sequences. Of the two, the FLAIR images generally make it easier to appreciate the...

Elastic Connective Tissue

Elastic connective tissue mainly consists of yellow, elastic fibers in parallel strands or in branching networks. Between these fibers are collagenous fibers and fibro-blasts. This tissue is found in the attachments between vertebrae of the spinal column (ligamenta flava). It is also in the layers within the walls of certain hollow internal organs, including the larger arteries, some portions of the heart, and the larger airways, where it imparts an elastic quality (fig. 5.22).

Adaptive Bayesian Segmentation

FIGURE 2 Results of the adaptive fuzzy c-means algorithm on double-echo MR data. (a) PD-weighted MR image after preprocessing, (b) T2-weighted MR image after preprocessing, (c) maximum membership segmentation computed using AFCM, (d) gray matter fuzzy membership function, (e) white matter fuzzy membership function, (f) cerebrospinal fluid fuzzy membership function.

Mass Spectrometrybased Diagnostics

Mass spectrometry has been used in two different settings in the area of cancer diagnostics, first for the discovery of novel cancer biomarkers and second as a cancer diagnostic and imaging tool. The discovery of biomar-kers and their use as early detectors of cancer is based on the hypothesis that a complex interplay exists between a tumor and its host microenvironment (Liotta and Kohn, 2001). As blood perfuses through a diseased organ, the serum protein profile is altered as a result of ongoing physiological and pathological events. This may include proteins being overexpressed and or abnormally shed, clipped, modified, or removed due to abnormal activation of the proteolytic degradation pathway, generating a unique signature in blood (Fig. 2). As a consequence, the expressed serum protein profile is different between normal and diseased states. This creates a unique opportunity to exploit accessible body fluids, such as serum, urine, saliva, seminal plasma, malignant ascites, or...

Predictive Modeling Of Therapeutic Vulnerability Of Brain Tumors

It is important to keep in mind that differential gene expression does not necessarily translate into differentially expressed protein products. Post-translational modifications as well as protein-protein and protein-DNA interactions are important determinants for biological functions. Expression microarrays are powerful high-throughput tools capable of creating and testing hypotheses that need to be validated at the protein level as well as functionally. In recent years, proteomic techniques have become increasingly available and are employed to identify surrogate markers for early diagnosis of cancer to monitor response to therapy as well as to discover new therapeutic targets. To characterize the proteome of malignant gliomas, Iwadate and coworkers exploited a combination of two-dimensional (2D) gel electrophoresis and MALDI-TOF (Matrix Assisted Laser Desorption - Time Of Flight) identifying a set of 37 proteins differentially expressed between normal brain tissue and gliomas 60 ....

Treatment Prion Diseases

One goal of medical management is to prevent the infectious spread of prion diseases. Prions can be transmitted from one organism to another if nervous system tissue containing PrPSc from an infected patient is transferred to another patient. Thus, the equipment used in neurosurgery, corneal transplants, and depth electrodes must be decontaminated by methods that inactivate prions if they have come in contact with a patient with a prion disease. Procedures for decontaminating operating and autopsy rooms have been developed and are unique for prions (Committee on Health Care Issues, American Neurological Association, 1986 Steelman, 1999) Universal precautions should be used when handling cerebrospinal fluid, optic tissue, blood, and urine. Cerebrospinal fluid and optic tissue have the highest titers of infectious prions, but small amounts of infectious prions have been found in other tissues, blood, and urine (Committee on Health Care Issues, American Neurological Association, 1986)....

Osteopenia Osteoporosis

The following tests should be performed on all patients with AIDS a lumbar spine X-ray in the standard anteroposterior and lateral views, bone density measurement (DEXA scan) of the lumbar spine and hip and laboratory blood tests, including calcium, phosphate and alkaline phosphatase. Osteopenia should be treated with 1000 I.E. vitamin D daily and a calcium-rich diet or calcium tablets with a dose of 1200 mg day. Patients should be advised to exercise and give up alcohol and nicotine. In cases with osteoporosis, aminobiphosphonates should be added. Because testosterone suppresses osteoclasts, hypogonadism should be treated (Cheonis 2002, Cheonis 2000, Mondy 2003, Tebas 2000).

Clinical Features Of Patients With Megaloblastic Anemia

Megaloblastic anemia is usually a disease of middle-aged to older age with a high predilection for women. Severe anemia, in which the hemoglobin drops to 7 to 8 g dL, is accompanied by symptoms of anemias such as shortness of breath, light-headedness, extreme weakness, and pallor. Patients may experience glossitis (sore or enlarged tongue), dyspepsia, or diarrhea. Evidence of neurological involvement may be seen with patients experiencing numbness, vibratory loss (paresthesias), difficulties in balance and walking, and personality changes. Vitamin B12 deficiency causes a demyeliniza-tion of the peripheral nerves, the spinal column, and the brain, which can cause many of the more severe neurological symptoms such as spasticity or paranoia. Jaundice may be seen, because the average red cell life span in megaloblastic anemia is 75 days, a little more than one half of the average red cell life span of 120 days. The bilirubin level is elevated, and the lactate dehydrogenase (LDH) level is...

MR of postnatal brain development

Tl-weighted images look like cut brain. Cerebrospinal fluid spaces, such as the ventricles and sulci, are dark on Tl-weighted images. Fatty tissues are bright. Myelin, containing phospholipids, is also bright relative to other intracranial structures. Thus, by the process of myelination, brain areas that are myelinated appear bright or hyperintense relative to other areas on the image. Moreover, areas of the brain with very tightly packed fiber bundles, such as the corpus callosum, extrude any free water from their myelin fibers and thus appear even brighter on the image.

Brain Imaging And Related Methods

When the application of the RF energy is terminated, the system reapproaches equilibrium, a process known as relaxation. Different types of tissue have different rates of relaxation, which is why we can obtain MR images that can distinguish between gray and white matter, bone, cerebrospinal fluid, and vasculature. For most functional MRI studies, the critical source of contrast derives from changes in the oxygen content of cerebral vasculature, typically referred to as Blood Oxygen Level Dependent (BOLD) signal (Bandettini, Wong, Hinks, Tikofsky, & Hyde, 1992 Kwong et al., 1992 Ogawa, Lee, Kay, & Tank, 1990 Ogawa etal., 1992).

Systemic Manifestations

More than 30 of skeletal TB cases involve the spine (tuberculous spondylitis or Pott's disease). The most commonly affected area is the lower thoracic spine, followed by the lumbar, cervical, and sacral areas. The mode of spread to the spine is usually hematogenous, but it also can result from contiguous disease or lymphatic spread from TB pleuritis. In contrast to common bacterial causes of spinal osteomyelitis that initially present as discitis with adjacent vertebral body involvement, TB spondylitis typically begins within the anterior vertebral body. With time, spread to the adjacent disc and vertebra occurs, and vertebral body wedging develops. Pott's disease is a disease of older age in developed countries and presents with local symptoms of pain and stiffness without systemic manifestations such as fever or weight loss. Initial roentgenograms can be negative. Thus, the diagnosis can be difficult to make, and late complications often appear. These can include...

Peripheral Nervous system

The peripheral nervous system (PNS) consists of the nerves that branch from the central nervous system (CNS), connecting it to other body parts. The PNS includes the cranial nerves that arise from the brain and the spinal nerves that arise from the spinal cord. The peripheral nervous system can also be subdivided into somatic and autonomic nervous systems. Generally, the somatic nervous system consists of the cranial and spinal nerve fibers that connect the CNS to the skin and skeletal muscles, so it oversees conscious activities. The autonomic nervous system (awto nom'ik ner'vus sis'tem) includes fibers that connect the CNS to viscera such as the heart, stomach, intestines, and various glands. Thus, the autonomic nervous system controls unconscious actions. Table 11.8 outlines the subdivisions of the nervous system.

Nerve Fiber Classification

Like nerve fibers, nerves that conduct impulses into the brain or spinal cord are called sensory nerves, and those that carry impulses to muscles or glands are termed motor nerves. Most nerves, however, include both sensory and motor fibers, and they are called mixed nerves. Nerves originating from the brain that communicate with other body parts are called cranial nerves, whereas those originating from the spinal cord that communicate with other body parts are called spinal nerves. The nerve fibers within these structures can be subdivided further into four groups as follows 1. General somatic efferent fibers carry motor impulses outward from the brain or spinal cord to skeletal muscles and stimulate them to contract. 2. General visceral efferent fibers carry motor impulses outward from the brain or spinal cord to various smooth muscles and glands associated with 3. General somatic afferent fibers carry sensory impulses inward to the brain or spinal cord from receptors in the skin...

Amorphous Silicon Detectors

The Cyberknife localization method can, in principle, be used wherever radio-opaque features are associated with an anatomical target, a concept that would allow the extension of radiosurgical technique to extracranial sites. The Cyberknife has already been used to treat sites within the spine 9-11 , lung, and pancreas. To overcome the above limitations, the previous cameras in the Cyberknife have been replaced with flat-panel amorphous silicon X-ray cameras (dpiX, Palo Alto, CA) 12,13 . These devices have a pixel pitch of 0.125 mm and acquire flat images that avoid distortions inherent to lensed or X-ray image intensifier techniques. When images from these sensors are processed by the new 6D registration software, a tenfold improvement in spatial resolution is achieved. The new imaging software and hardware have been specifically designed to provide variable fields of view and magnification ranges that can be adapted to multiple anatomical locations. For example, amorphous-silicon...

General Characteristics

Reflexes in which sensory signals originate from receptors within the viscera and the skin regulate autonomic activities. Afferent nerve fibers transmit these signals to nerve centers within the brain or spinal cord. In response, motor impulses travel out from these centers on efferent nerve fibers within cranial and spinal nerves.

Parasympathetic Division

The preganglionic fibers of the parasympathetic division (craniosacral division) arise from neurons in the mid-brain, pons, and medulla oblongata of the brain stem and from the sacral region of the spinal cord (fig. 11.40). From there, they lead outward on cranial or sacral nerves to ganglia located near or within various organs (terminal ganglia). The short postganglionic fibers continue from the ganglia to specific muscles or glands within these organs (fig. 11.41). Parasympathetic preganglionic axons are usually myelinated, and the parasympathetic post-ganglionic fibers are unmyelinated. 75 of all parasympathetic fibers.) Preganglionic fibers arising from the sacral region of the spinal cord lie within the branches of the second through the fourth sacral spinal nerves, and they carry impulses to viscera within the pelvic cavity (see fig. 11.40).

Behavior And Reproduction

Many cusk-eels and their relatives produce sound with their swim bladder, forward vertebrae (ver-teh-BREE), and the ligaments and muscles attached to those vertebrae. The swim bladder is an internal sac that fishes use to control their position in the water. Vertebrae are the bones that make up the spinal column. In some cusk-eels and their relatives, the swim bladder is hard and serves as an echo chamber. Some species make the sound just before mating.

Peripheral Nervous System page 426

The peripheral nervous system consists of cranial and spinal nerves that branch out from the brain and spinal cord to all body parts. It can be subdivided into somatic and autonomic portions. 4. Spinal nerves a. Thirty-one pairs of spinal nerves originate from the spinal cord. b. These mixed nerves provide a two-way communication system between the spinal cord and the upper limbs, lower limbs, neck, and trunk. c. Spinal nerves are grouped according to the levels from which they arise, and they are numbered sequentially. e. Just beyond its foramen, each spinal nerve divides into several branches. f. Most spinal nerves combine to form plexuses that direct nerve fibers to a particular body part.

HHV6 reactivation in DRESS innocent bystander or causal agent of systemic symptoms

But the best argument of the causal role of HHV-6 in systemic symptoms is the demonstration of the presence of HHV-6 in visceral lesions. We already precised that HHV-6 genome had been detected in skin lesions (Suzuki et al., 1998, Descamps et al., 2001). Recently, we and two other groups reported cases of HHV-6 meningoencephalitis that complicated DRESS (Fujino et al., 2002 Masaki et al., 2003 Descamps et al., 2003a). Diagnosis of HHV-6 meningoencephalitis was made on the detection of HHV-6 genome in the cerebrospinal fluid. As commented by Hashimoto et al. (2003) the case reported by its group (Masaki et al., 2003) is very demonstrative of the link of HHV-6 infection and visceral involvement. An allopurinol-induced DRESS developed in a 51-year-old man, 23 days after initiation of the treatment. Corticosteroid treatment (40mg day of prednisolone) induced a rapid control of the symptoms. But reduction of the systemic corticosteroid was followed by the development of encephalitis and...

Management of head injury

Intracranial pressure (ICP) monitoring for appropriate indications (e.g. Glasgow coma scale less than 9 and abnormal CT scan of the head) and the ability to treat raised ICP through such means as sedation, osmotic diuresis (with mannitol), paralysis, cerebrospinal fluid (CSF) drainage and hyperventilation are deemed desirable at the tertiary care level. They are also desirable at the specialist-level hospital if a neurosurgeon is present. They are also desirable at the specialist-level hospital if a general surgeon with considerable neurosurgical expertise is available, in a setting in which facilities for referral to a tertiary centre are limited.

Thoracic pain of lower cervical origin

The pain from the lower cervical spine can also refer pain to the anterior chest, and mimic coronary ischaemic pain. The associated autonomic nervous system disturbance can cause considerable confusion in making the diagnosis. The medical profession tends to have a blind spot about various pain syndromes in the chest, especially the anterior chest and upper abdomen, caused by the common problem of dysfunction of the thoracic spine. Doctors who gain this insight are amazed at how often they diagnose the cause that previously did not enter their 'programmed' medical minds. Physical therapy to the spine can be dramatically effective when used appropriately. Unfortunately, many of us associate it with quackery. It is devastating for patients to create doubts in their minds about having a 'heart problem' or an 'anxiety neurosis' when the problem is spinal and it can be remedied simply ( Chapter 34 ). Lumbar spinal dysfunction Typical examples of referral and radicular pain patterns from...

Physical Characteristics

Hornbills have patches of bare skin around the eyes and throat and long eyelashes on their upper lids. To support their head and large bill, they have strong neck muscles and two neck vertebrae, bones in the spinal column, connected together. Hornbill plumage, feathers, is not very colorful, usually with areas of black, white, gray, or brown. The color and size of plumage and the shape of the casque identifies the age and sex. Hornbills vary in size and shape, from 11.8 to 47.3 inches (30 to 120 centimeters) long, and weigh between 3.5 ounces and 13.25 pounds (100 grams and 6 kilograms). Males are larger and heavier than females and have bills that are up to 30 percent longer.

Energy Metabolism The Critical Role of Mitochondrial Function Decay

Other areas of the old human brain appear to be differently affected by a decrease in CBF, but the most commonly observed age-related impairment has been found in the frontal lobes bilaterally. Moreover it has been found that in aging there is a decrease of CBF in gray, but not in white, matter (Leenders et al., 1990). The quantitative estimations of CBF may easily be affected by physiological, psychological, and environmental factors. However, the regional values estimated in each individual are normalized to the whole brain blood flow with the aim of eliminating variations in the measurements of absolute flow. Multiple factors may be responsible for the age-related changes in CBF, and these include a decline in the mechanisms that regulate CBF, alterations of the cerebral blood vessels due to age (e.g., mild amyloid angiopathy), and a decrease of neuron function leading to brain atrophy. The 18F-deoxyglucose is the most commonly used radiopharmaceutical for PET...

Physiologic And Pathological Barriers To Antineoplastics In The

The unique physiological and pathological barriers encountered in the central nervous system impede drug delivery for the treatment of brain lesions. Oral and intravenous injections of chemotherapeutics have difficulty reaching therapeutic concentrations at brain tumor sites because of these barriers, including the blood-brain barrier (BBB), blood-cerebrospinal fluid barrier (BCB), and blood-tumor barrier (BTB) 5 . The BCB is an additional obstacle that impedes drug delivery to the CNS 5 . Choroid epithelial cells, which line the ventricles and produce cerebro-spinal fluid, form a tightly bound barrier that regulates the transfer of molecules into the interstitial fluid that surrounds the brain parenchyma. In this manner, the BCB prevents the penetration of chemotherapeutics. Also, analogous to the BBB, there exists an organic-acid transport system that actively removes molecules such as chemotherapeutics from the cerebrospinal fluid.

Inborn Errors of Metabolism

The successful application of NMR in this field has been thoroughly documented 6, 17, 30-32 . A recent study by Wevers and colleagues 31 highlighted > 20 metabolites present in over half the biofluid samples measured over a 10 year period that are not detected by routine metabolic screening techniques. These include ketoacids, glycerol, trimethylamine N-oxide, allantoin, and hippuric acid, amongst others. Over 55 inborn errors of metabolism have been catalogued using NMR, and a few key examples to illustrate the approach include phenylketonuria, 5-oxoprolinuria, alcapto-nuria, maple syrup disease, and fish odour syndrome. Urinary biomarkers have already been catalogued for the most common IEMs 17, 31 . Although an invasive and potentially dangerous technique, several biomarkers from cerebrospinal fluid have also been reported 17, 31 .

Primary survey or ABCD

Look at you Is the cervical spine immobilized Is the airway preserved If not, correct with positioning (chin lift and jaw thrust), oral airway, suction and if necessary intubation (with in-line immobilization to protect the cervical spine). Immobilize the head and neck, and maintain the cervical spine in a neutral position. Assume a cervical spine injury is present until proven otherwise.

Orotracheal intubation

Head position place the head in the sniffing position if there is no cervical spine injury. The sniffing position is characterized by flexion of the cervical spine and extension of the head at the atlanto-occipital joint (achieved by placing pads under the occiput to raise the head 8-10 cm). This position serves to align the oral, pharyngeal, and laryngeal axes such that the passage from the lips to the glottic opening is most nearly a straight line. The height of the OR table should be adjusted to bring the patient's head to the level of the anesthesiologist's xiphoid cartilage.

Biological Basis For Tamoxifen As A Breast Cancer Preventive

Sporadic reports19,104 and placebo-controlled randomized trials20,105 demonstrated that ta-moxifen can increase bone density in the lumbar spine, forearm, and neck of the femur by 1 -2 . Although the increases are modest compared to the results obtained with estrogen or biphosphonates (5 increase in bone density), tamoxifen produced a marginal decrease in hip and wrist fractures as a secondary end point in the breast cancer prevention trial.106

Neuroprotective Effects Of Monoamine Oxidase Inhibitors

Models that have demonstrated neuroprotection by either rasagiline or selegi-line include glutamate toxicity in hippocampal neurons (48), focal brain ischemia in rats (39,40), memory and learning tasks following anoxic brain injury (49) and motor and spatial memory in a rodent closed head injury model (50), optic nerve crush injury (51), rescue of dorsal root ganglia sensory neurons (52) and of axotomized motoneu-rons (53), and protection against cell death in rat pheochromocytoma PC-12 cells deprived of oxygen and glucose (54). Selegiline given after intrathecal injection of rat pups with cerebrospinal fluid from human amyotrophic lateral sclerosis (ALS) subjects protects against anterior horn cell loss (55). Pretreatment with rasagiline is neu-roprotective in primate MPTP (56) and rodent 6-OHDA models of PD (38). Primates treated with selegiline and MPTP simultaneously do not develop parkinsonism (57).

Retrogasserian Glycerol Rhizolysis

As the needle tip punctures the foramen, a slight contraction of the masseter muscle is often felt as a gentle bite on the surgeon's gloved finger. Intravenous sedation is given for this step. As the trocar is removed from the needle, cerebrospinal fluid may drip from its lumen, but this finding is not essential for correct placement and may occur even if the needle is lateral to the intended target. Indeed if glycerol has been previously injected, cerebrospinal fluid may not flow from the trigeminal cistern at all.

General Functions of the Nervous System

Nissl Bodies

The organs of the nervous system can be divided into two groups. One group, consisting of the brain and spinal cord, forms the central nervous system (sen'tral ner'vus sis'tem) or CNS, and the other, composed of the nerves (cranial and spinal nerves) that connect the central nervous system to other body parts, is called the peripheral nervous system (pe-rif'er-al ner'vus sis'tem) or The nervous system includes the central nervous system (brain and spinal cord) and the peripheral nervous system (cranial nerves and spinal nerves). The nervous system includes the central nervous system (brain and spinal cord) and the peripheral nervous system (cranial nerves and spinal nerves). Dendrites are usually highly branched, providing receptive surfaces to which processes from other neurons communicate. (In some kinds of neurons, the cell body itself provides such a receptive surface.) Often the den-drites have tiny, thornlike spines (dendritic spines) on their surfaces, which are contact points...

Osteoporosis Prevention

In a recent trial by Atkinson et al, loss of lumbar spine bone mineral content and bone mineral density was significantly reduced in women taking red clover-derived isoflavones (43.5 mg day) compared to placebo in a double-blind, placebo-controlled, randomised trial in 205 women over 12 months (Atkinson et al 2004c). Bone formation markers were also significantly increased however, no improvement in hipbone mineral content or bone mineral density was noted. A double-blind study of 46 postmenopausal women investigated the effects of a red clover isoflavone preparation (Rimostil) containing genistein, daidzein, formononetin and biochanin A after a single-blind placebo phase and followed by a single-blind washout phase. Patients were randomly assigned to receive 28.5 mg, 57 mg or 85.5 mg phyto-oestrogens daily for a 6-month period. After the test period, the bone mineral density of the proximal radius and ulna rose significantly, by 4.1 with a dose of 57 mg day and by 3.0 with a dose of...

What Are Carrot Shaped Brain Tumors

High Grade Large Cell Malignancy

Composed of oval to carrot-shaped cells, with a dense speckled nucleus and tapering eosinophilic cytoplasm (see Fig. 1.11) 46 . Some tumors have cells with a more glial appearance and more background fibrillar-ity or more epithelioid cells and architecture. Perivas-cular pseudorosettes, which are commonly observed, are circular arrangements of tumor cells that send processes towards vessel walls, creating a perivascu-lar ''nuclear-free zone'' that can be noted at low-power. Less commonly, true ependymal rosettes, surrounding a true lumen, can be observed. Ependymomas are usually GFAP positive. Anaplastic ependymomas (WHO grade III) have additional features such as increased cellularity, mitotic activity, pleomorphic nuclei, vascular hyperplasia, nuclear atypia, and necrosis. Myxopapillary ependymomas are WHO grade I tumors that arise in the lower spine within the cauda equina. They display an admixture of fibrillated and epithelioid cells with an exuberant connective tissue stroma....

S general structure of the kidney

The kidneys are large, reddish, bean-shaped organs located on either side of the spinal column in the retroperitoneal space of the posterior abdominal cavity. They extend from the 12th thoracic to the 3rd lumbar vertebrae, with the right kidney positioned slightly higher. Each kidney measures approximately 10 cm long X 6.5 cm wide (from concave to convex border) X 3 cm thick. On the upper pole of each kidney, embedded within the renal fascia and a thick protective layer of perirenal adipose tissue, lies an adrenal gland. The medial border of the kidney is concave and contains a deep vertical fissure, called the hilum, through which the renal vessels and nerves pass and through which the expanded, funnel-shaped origin of the ureter, called the renal pelvis, exits. A section through the kidney shows the relationship of these structures as they lie just within the hilum of the kidney in a space called the renal sinus (Fig. 19.1). Although not shown in the illustration, the space between...

Selection ofthe Administration Route

When tumor cells penetrate into the intrathecal and subarachnoid space and metastasize along the leptomeninges, the subsequent neoplastic meningitis carries a dramatically poor outcome despite chemotherapy and radiotherapy of the entire neuroaxis. MAbs administered into the intrathecal or intraventricular compartments circulate via the cerebrospinal fluid (CSF) stream along the brain and spine to the disseminated leptomeningeal tumor cells (7). However, one must bear in mind that compounds injected in the lumbar area may not effectively reach the lateral ventricles because of a unidirectional flow pattern (45).

History And Physical Examination

The physical examination should be thorough. The position of the hip at rest should be noted, as it may indicate the underlying pathology. For example, a hip that is abducted, flexed, and externally rotated achieves the greatest capsular volume, suggesting an effusion or synovitis. The patient's gait should be noted. Examination of the lumbar spine including motor function, sensation, range of motion, reflexes, and straight-leg raises must be performed to rule out lumbar spine pathology as the cause of symptoms. Leg-length discrepancies should be assessed 12,13 .

Seven masquerades checklist

Depression, diabetes, drugs, spinal dysfunction and urinary tract infection can all cause abdominal pain although the pain may be more subacute or chronic. Abdominal pain and even tenderness can accompany diabetic ketoacidosis. Drugs that can cause abdominal pain are listed in Table 30.4 . Spinal dysfunction of the lower thoracic spine and thoracolumbar junction can cause referred pain to the abdomen (Fig 30.1). The pain is invariably unilateral, radicular in distribution, and related to activity. It can be confused with intra-abdominal problems such as biliary disease (right-sided), appendicitis and Crohn's disease (right side), diverticular disease (left-sided) and pyelonephritis.

The Case of Agostino Martinez

P. 9) or tissue may be left behind or misdirected on its path of migration. Congenital midline lesions of the face can extend deep into the cranium and ultimately even extend to the subarachnoid space or the brain. Ill-informed surgical procedures may result in serious complications such as cerebrospinal fluid (CSF) leak or meningitis.

Krabbe Globoid Cell Leukodystrophy

Krabbe globoid cell leukodystrophy is largely a disease of early infancy characterized by marked irritability, progressive neurodeterioration with signs of peripheral neuropathy, elevated cerebrospinal fluid protein levels, and with a clinical onset of 4 to 6 mo (1). Older patients (juvenile and adult onset variants) constitute about 10 of all proven cases and display the same neurological features of the infantile form, but with a more protracted course. In all variants the nervous system, particularly the central and the peripheral system myelin (see Fig. 1), is the exclusive site of clinical and pathological

Ventricular System

Internal Capsule Hemorrhage

CEREBROSPINAL FLUID is a colorless acellular fluid. It flows through the ventricles and into the subarachnoid space. Cerebrospinal Fluid Profiles in Subarachnoid Hemorrhage, Bacterial Meningitis, and Viral Encephalitis Cerebrospinal Fluid Profiles in Subarachnoid Hemorrhage, Bacterial Meningitis, and Viral Encephalitis

Neuroimaging And Initial Treatment

The most sensitive technique to diagnose medulloblastoma is neuro-imaging with contrast-enhanced MRI 1,3-5,13,17 . MRI is more sensitive than CT for tumors within the posterior fossa and has the added benefit of midsagittal images. Hydrocephalus (75 to 85 per cent of cases) is clearly demonstrated with either modality. On T2 images, the tumor is a heterogeneous high signal lesion within the cerebellum (midline or hemispheric). Regions of calcification, cyst, necrosis, or hemorrhage are not common. On T1 images, the mass appears hypointense or isointense compared to surrounding brain. After administration of gadolinium, there is heterogeneous tumor enhancement in at least 90 per cent of the cases 13,17 . Peritumoral edema is often present, contributing to compression or displacement of the fourth ventricle. It is important to carefully review the brain MRI for leptomeningeal enhancement and infiltration into the brainstem, since this information is important for tumor staging and risk...

Intradiscal Electrothermal Annuloplasty And Nucleoplasty

Radiofrequenz Nucleoplasty

Heary reviewed presentations on experience with IDET at the 2000 North American Spine Society meeting (65). One such presentation noted that, of 170 of 259 patients treated with IDET by 28 physicians, 76 responded in a 6-month follow-up survey that their pain was reduced (66). Despite this and other positive reports, Heary urged caution in adopting the procedure because there was no information from well-controlled studies, and he considered the underlying scientific rationale questionable at best and perhaps incorrect. The contraindications of IDET have not yet been firmly established, but the criteria used to exclude subjects from trials include herniations larger than 4 mm, sequestered disc herniations (when pulposus material separates from the disc nucleus and floats in the spinal column), previous lower back surgery, vertebral canal stenosis, spondylolisthesis at the site, scoliosis, compression radiculopathy, pregnancy, and certain allergies. Complication rates have been low,...

Clinical Correlations

Variations of spina bifida and encephalocele. SP spinal cord CSF cerebrospinal fluid V ventricle. (Modified from Haines DE edj Fundamental Neuroscience. New York, Churchill Livingstone, 1997, p 69.) 2. Spina bifida with meningocele occurs when the meninges project through a vertebral defect and form a sac filled with CSF. The spinal cord remains in its normal position. 3. Spina bifida with meningomyelocele (Figure 12-6 B). This form occurs when the meninges and spinal cord project through a vertebral defect to form a sac. Figure 12-6. (A) Spina bifida occulta. Note the presence of the bony vertebral bodies (VB) along the entire length of the vertebral column. However, the bony spinous processes terminate much higher (*) because the vertebral arches fail to form properly. This creates a vertebral defect. The spinal cord is intact. B) Spina bifida with meningomyelocele as seen on an ultrasonogram of a 14-week-old fetus. Note the cyst-like protrusion (m meningomyelocele) and...

Unique Aspects Of Pediatric Injury And Illness

Cervical Spine Injury Cervical spinal injuries are less common in children than in adults, and the specific types of C-spine injuries differ particularly in those less than 8 years of age because of anatomic differences. C-spine fractures are rare in pediatric patients. If they do occur, they are usually higher in the spine C1, C2 than in the adult, because in children the fulcrum of movement is at C2-3 compared to C5-7 in older children and adults. Children are at greater risk for subluxation because their disproportionately large head size increases the force to the neck, and with flexion and extension vertebral bodies are more anteriorly wedged, the facet joints are flatter, the joint capsules and intraspinous ligaments are more flexible, and the paraspinal muscles are less well developed. Anterior pseudosubluxation up to 4 mm, usually of C2 or C3 and less commonly of C3 on C4, is a normal variant that is seen in 40 of children aged less than 7 years and 20 less than age 14 years....

Pagets disease of bone

Paget's disease of bone (PDB) is one of the most common chronic skeletal diseases affecting up to 3 of many White populations over the age of 60 years. Its ethnic and geographic distribution is variable, with a high prevalence in Whites from the United Kingdom, Australia, North America and Western Europe. PDB is characterized by focal areas of increased bone resorption and formation, leading to deformity and or enlargement. The axial skeleton (pelvis, lumbar and thoracic spine, and sacrum) is most frequently involved, followed by the femur, skull, and tibia. The newly formed bone in pagetic lesions is disorganized, frequently resulting in bowing and increased fracture. Bony overgrowth in the skull may lead to nerve entrapment, headache, and deafness.

Metabolic Disorders Are Associated With Each Reaction Of The Urea Cycle

A deficiency of or-nithine transcarbamoylase (reaction 2, Figure 29-9) produces this X chromosome-linked deficiency. The mothers also exhibit hyperammonemia and an aversion to high-protein foods. Levels of glutamine are elevated in blood, cerebrospinal fluid, and urine, probably due to enhanced glutamine synthesis in response to elevated levels of tissue ammonia. Citrullinemia. In this rare disorder, plasma and cerebrospinal fluid citrulline levels are elevated and 1-2 g of citrulline are excreted daily. One patient lacked detectable argininosuccinate synthase activity (reaction 3, Figure 29-9). In another, the Km for citrulline was 25 times higher than normal. Citrulline and argini-nosuccinate, which contain nitrogen destined for urea synthesis, serve as alternative carriers of excess nitrogen. Feeding arginine enhanced excretion of citrulline in these patients. Similarly, feeding benzoate diverts ammonia nitrogen to hippurate via glycine (see Figure 31-1)....

Removal Of Brain In Adults

Coronal Mastoid Incision

Ideally, sawing should be stopped just short of cutting through the inner table of the cranium, which will easily give way with the use of a chisel and a light blow with a mallet. Leaving the dura and underlying leptomeninges intact allows to view the brain with the overlying cerebrospinal fluid (CSF) still in the subarachnoid space. To obtain this view, after removal of the skull cap, the dura must be cut with a pair of scissors along the line of sawing and reflected. Cranial nerves VII, VIII, IX, X, XI, and XII are then cut identifying each one in sequence. The vertebral arteries are severed with scissors as they emerge into the cranial cavity. Then, the cervical part of the spinal cord is cut across as caudally as possible, but too oblique a plane of sectioning should be avoided. Curved scissors will be best for this purpose. If a critical lesion exists in the region, a cross-section perpendicular to the neuroaxis at the pontomedullary junction or higher may be elected in order to...

Rationale in Imaging Neurodegenerative Diseases

Generally, neuropsychological impairment of neu-rodegenerative diseases is due to biochemical alterations, structural abnormalities and circuit impairment, which are interrelated. Biochemical changes occur earlier than histological and macroscopic alterations, preceding clinical symptoms. In AD, neuronal loss is more prominent in temporal and parietal lobes, particularly in entorhinal cortex, hippocampus and amygdala, withvolume reduction ofbrain and enlargement of cerebrospinal fluid spaces (CSF) 4 . Areas of neuronal loss vary according to the underlying disease AD patients have significantly smaller left temporal lobes and parahippocampal gyri than those with dementia with Lewy bodies 5-7 . In addition, volume loss and cognitive impairment have been shown to be associted with genotype, particularly with APOE epsi-lon4 allele 8 -12 . Volume loss of hippocampal formation, which correlates with functional impairment, has been observed in preclinical AD patients, and volume loss rate...

Glutamatergic Dysregulation In Ethanoldependent Patients

Clinical research studies have begun to document the enhancement in glutamatergic function during withdrawal. Postmortem studies of ethanol-dependent individuals suggest that the Bmax or KD of NMDA receptors are increased in cortical structures alcoholics (43,44). In vivo, ethanol withdrawal increases cerebrospinal fluid glutamate levels (45), consistent with preclinical evidence of enhanced glutamate release (46,47). Repeated episodes of withdrawal may promote the initiation of forms of neural sensitization that may contribute to increased startle magnitude (48) and enhanced seizure risk (49,50). It is possible that withdrawal-related neuroplasticity contributes to associative learning, as might be reflected in drug-craving (51).

Patient Selection And Test Dosing

Baclofen, which is gamma-amino-butyric acid (GABA), acts as an agonist at the intraspinal inhibitory sites along the stretch reflex pathway, thereby effecting a decrease in the patients spasticity. Baclofen may be administered orally however, it is water soluble and, therefore, only small amounts cross the blood-brain barrier effectively 6 . Too often maximum oral doses may not sufficiently control the patients spasticity, and patients may even experience unpleasant side effects, such as nausea, drowsiness, mental confusion, ataxia, and headache. The rationale, therefore, for administering baclofen intrathecally is that it concentrates the drug at the dorsal gray matter of the spinal cord where it is required for therapeutic effect. Furthermore, when introduced directly into the intrathecal space, effective cerebrospinal fluid (CSF) concentrations of baclofen are achieved with plasma concentrations 100 times less than those occurring with oral administration, thereby avoiding any...

Probability diagnosis

The commonest cause of low back pain is vertebral dysfunction, which then has to be further analysed. Muscle or ligamentous tears or similar soft tissue injuries are uncommon causes of back pain alone they are generally associated with severe spinal disruption and severe trauma such as that following a motor vehicle accident. In the lumbar spine most problems originate from either the apophyseal joints or the intervertebral Degenerative changes in the lumbar spine (lumbar spondylosis) are commonly found in the older age group. This problem, and one of its complications, spinal canal stenosis, is steadily increasing along with the ageing population.

Neurological examination

The importance of the neurological examination is to ensure that there is no compression of the spinal nerves from a prolapsed disc or from a tumour. This is normally tested by examining those functions that the respective spinal nerves serve, namely skin sensation, muscle power and reflex activity. The examination is not daunting but can be performed quickly and efficiently in two to three minutes by a methodical technique that improves with continued use. The neurological examination consists of

General considerations

A rapid assessment of the patient must take place before resuscitation and treatment. Physical examination must include a careful assessment of the cervical spine as there is a high correlation between skull fractures and neck fractures. The neck should be immobilised by in-line cervical traction, or a stiff neck collar, until radiographic exclusion of a fracture has been undertaken. Life-threatening chest and abdominal injuries should be looked for carefully, and control and treatment of these should take priority over transfer, or neurosurgical intervention. Neurosurgical units are often isolated hospitals and have to transfer patients to nearby hospitals for major thoracic and abdominal surgery before neurosurgical intervention.

Thoracic back pain

Since learning about the various causes of chest wall pain I am continually amazed about the number of pain syndromes that I am diagnosing as originating from the thoracic spine. I wonder what I was thinking beforehand. Thoracic (dorsal) back pain is common in people of all ages including children and adolescents. Dysfunction of the joints of the thoracic spine, with its unique costovertebral joints (which are an important source of back pain), is very commonly encountered in medical practice, especially in people whose lifestyle creates stresses and strains through poor posture and heavy lifting. Muscular and ligamentous strains may be common, but they rarely come to light in practice because they are self-limiting and not severe. This dysfunction can cause referred pain to various parts of the chest wall and can mimic the symptoms of various visceral diseases such as angina, biliary colic and oesophageal spasm. In similar fashion, heart and gall bladder pain can mimic spinal pain.

Facet joint syndrome

Pain from facet joints tend to be localized to the back with radiation to the buttock and posterior thigh (and rarely below the knee joint). Pain also occurs with extension and rotation of the spine. Accounts for about 15 of low back pain. 3. Medial branch rhizotomy can provide long-term analgesia for facet joint disease in the lumbar and cervical spine.

Anatomical and clinical features

The functional unit of the thoracic spine is illustrated in Figure 34.1 . It appears that pain from the thoracic spine originates mainly from the apophyseal joints and rib articulations. Any one thoracic vertebra has ten separate articulations, so the potential for dysfunction and the difficulty in clinically pinpointing the precise joint at a particular level are apparent. The costovertebral joints are synovial joints unique to the thoracic spine and have two articulations costotransverse and costocentral. Together with the apophyseal joints, they are capable of presenting with well-localised pain close to the midline or as referred pain, often quite distal to the spine, with the major symptoms not appearing to have any relationship to the thoracic spine. Fig. 34.3 Dermatomes for the thoracic nerve roots, indicating possible referral areas REPRODUCED FROM C. KENNA AND J. MURTAGH, BACK PAIN AND SPINAL MANIPULATION

Upper thoracic pain

Dysfunction of the joints of the upper thoracic spine usually gives rise to localised pain and stiffness posteriorly but also can cause distal symptoms, probably via the autonomic nervous system. A specific syndrome called the T4 syndrome 2 has been shown to cause vague pain in the upper limbs and diffuse, vague head and posterior neck pain.

Thoracic back pain in children

The most common cause of thoracic back pain in children is 'postural backache', also known as 'TV backache', which is usually found in adolescent schoolgirls and is a diagnosis of exclusion. Important, although rare, problems in children include infections (tuberculosis, discitis and osteomyelitis) and tumours such as osteoid osteoma and malignant osteogenic sarcoma. Dysfunction of the joints of the thoracic spine in children and particularly in adolescents is very common and often related to trauma such as a heavy fall in sporting activities or falling from a height, e. g. off a horse. Fractures, of course, have to be excluded. Inflammatory disorders to consider are juvenile ankylosing spondylitis and spinal osteochondritis (Scheuermann's disorder), which may affect adolescent males in the lower thoracic spine (around T9) and thoracolumbar spine. The latter condition may be asymptomatic, but can be associated with back pain, especially as the patient grows older. It is the commonest...

Thoracic disc protrusion

Fortunately, a disc protrusion in the thoracic spine is uncommon. This reduced incidence is related to the firm splintage action of the rib cage. Most disc protrusions occur below T9, with the commonest site, as expected, being T11-T12. The common presentation is back pain and radicular pain that follows the appropriate dermatome. However, disc lesions in the thoracic spine are prone to produce spinal cord compression, manifesting as sensory loss, bladder incontinence and signs of upper motor neurone lesion. The disc is relatively inaccessible to surgical intervention, but over the past decade there has been a significant improvement in the surgical treatment of thoracic disc protrusions, due to the transthoracic lateral approach.

Modulating Specific Downstream Targets

May have promise in alleviating disease symptoms. An mGluR5 antagonist, 2-methyl-6-(phenylethynyl)pyridine (MPEP), decreased audiogenic seizures and macroorchidism seen in Fmrl knockout mice (Yan et al. 2005) and corrected the neuroanatomical and behavioral defects resulting from an FMRP deficit in the fly (McBride et al. 2005). MPEP also increased survival of HD mice (Schiefer et al. 2004). However, while MPEP has high potency, it is relatively nonselective and is not very soluble in cerebrospinal fluid. Better outcomes may result from the use of more selective mGluR5 receptor antagonists such as (MTEP) (Busse et al. 2004).

Cross Sectional Anatomy of the Brain

Mid Sagittal Brain Fornix

Midsagittal magnetic resonance imaging section through the brain stem and diencephalon. Note the cerebrospinal fluid tract lateral ventricle, interventricular foramen of Monro, third ventricle, cerebral aqueduct, fourth ventricle, foramen of Magendie, cerebellomedullary cistern, and spinal subarachnoid space. Note also the relation between the optic chiasm, infundibulum, and hypophysis (pituitary gland). Spinal cord Subarachnoid space Figure 1-3. Midsagittal magnetic resonance imaging section through the brain stem and diencephalon. Note the cerebrospinal fluid tract lateral ventricle, interventricular foramen of Monro, third ventricle, cerebral aqueduct, fourth ventricle, foramen of Magendie, cerebellomedullary cistern, and spinal subarachnoid space. Note also the relation between the optic chiasm, infundibulum, and hypophysis (pituitary gland). Spinal cord Subarachnoid space

Axial Image Through The Midbrain Mamillary Bodies And Optic Tract Figures 110 111 112 and 113 The location of the

Cerebral Aqueduct Axial

Axial magnetic resonance imaging (MR1) section at the level of the midbrain and mamillary bodies. Because of the high iron content, the red nuclei, mamillary bodies, and substantia nigra show a reduced MR1 signal in T2-weighted images. Flowing blood in the cerebral vessels stands out as a signal void. Cerebrospinal fluid produces a strong signal in the ventricles and cisterns. Figure 1-11. Axial magnetic resonance imaging (MR1) section at the level of the midbrain and mamillary bodies. Because of the high iron content, the red nuclei, mamillary bodies, and substantia nigra show a reduced MR1 signal in T2-weighted images. Flowing blood in the cerebral vessels stands out as a signal void. Cerebrospinal fluid produces a strong signal in the ventricles and cisterns.

Clinical Procedures

Spinal Anaesthetic Subarachnoid Space

Lumbar puncture (Figure 2-4) can be performed to withdraw cerebrospinal fluid or to inject an anesthetic (e.g., spinal anesthesia). 2. The needle passes through the following structures skin superficial fascia supraspinous ligament interspinous ligament ligamentum flavum epidural space containing the internal vertebral venous plexus dura mater arachnoid subarachnoid space containing cerebrospinal fluid. B. Spinal anesthesia (spinal block, or saddle block) 1. Spinal anesthesia is produced by injecting anesthetic into the subarachnoid space it may be used during childbirth. 2. Sensory nerve fibers for pain from the uterus travel with the pelvic splanchnic nerves (parasympathetic) to spinal levels S2 4 from the cervix, and may be responsible for referred pain to the gluteal region and legs. Sensory nerve fibers for pain also travel with the hypogastric plexus and lumbar splanchnic nerves (sympathetic) to spinal levels LI-3 from the fundus and body of the uterus and oviducts, and may...

Combined Motor And Sensory Lesions

Spinal cord hemisection (Brown-Sequard syndrome) see Figure 8-2E is caused by damage to the following structures B. Ventral spinal artery occlusion (see Figure 8-2F) causes infarction of the anterior two-thirds of the spinal cord, but spares the dorsal columns and horns. It results in damage to the following structures E. Friedreich's ataxia has the same spinal cord pathology and symptoms as subacute combined degeneration. F. Multiple sclerosis (see Figure 8-2B). Plaques primarily involve the white matter of the cervical segments of the spinal cord. The lesions are random and asymmetric. F. The protein level in the cerebrospinal fluid is elevated, but without pleocytosis (albu-minocytologic dissociation). B. The nucleus pulposus impinges on the spinal roots, resulting in spinal root symptoms (i.e., paresthesias, pain, sensory loss, hyporeflexia, and muscle weakness). VI. CAUDA EQUINA SYNDROME (SPINAL ROOTS L3 TO CO) results usually from a nerve root tumor, an ependymoma, a dermoid...

Clinical Considerations

Rectal Nerve Block

Figure 16-2. (A) Administration of a pudendal nerve block transvaginal and lateral to the labia majora. The ischial spine (not shown) is a good anatomic landmark. (B) The path of the pudendal nerve (curved arrow) as it passes out of the pelvic cavity through the greater sciatic foramen (posterior to the ischial spine) and returns to the pelvic cavity through the lesser sciatic foramen as it proceeds to the perineum. SS sacrospinous ligament ST sacrotuberous ligament. (C) The perineum in the lithotomy position. The posterior labial (PL) and inferior rectal (IR) nerves are terminal branches of the pudendal nerve. In addition, the ilioinguinal nerve ( L), genitofemoral nerve (GF), and perineal branch of the posterior femoral cutaneous nerve (PFC), which also must be anesthetized by cutaneous injection of 1 lidocaine to obtain complete anesthesia of the perineal region, are shown. Labels L1, L2, L3, S2, S3, S4, and S5 indicate the dermatomes of the perineal region. (A reprinted with...

What is Your Diagnosis

Spinal Dysraphism

Arnold-Chiari malformations The Arnold-Chiari I malformation is a complex group of malformations characterized by the downward displacement of the cerebellar tonsils and the medulla oblongata into the cervical spinal canal (Fig. 11.46c). Arnold-Chiari II malformations are more complex and include spinal dysraphism and menin-goceles or myelomeningoceles. Fig. 11.46a This meningocele presents itself as a dorsal outpouching of the dura through an osseous defect. The dural pouch is filled with CSF. b On this axial CT image the vermis is missing, the fourth ventricle is enlarged, and the temporal horns are dilated considerably, indicative of hydrocephalus. This is a patient with Dandy-Walker complex. c Descent of cerebellum and brainstem into the spinal canal is characteristic of the Arnold-Chiari malformation. There is also an associated malformation of the osseous craniocervical junction zone. d The corpus callosum is missing completely (arrow, left image) on this coronal MR image...

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