Renal Division, Department of Medicine, Brigham and
Women's Hospital, Boston, MA
Acute Kidney Injury: Biomarkers from Bench to Bedside
Discussion: Increased health care costs arise from many factors muscle relaxant no drowsiness purchase 50 mg imuran free shipping, one of which is the increased 24 postoperative recovery period muscle relaxant for dogs best purchase imuran. They were assessed of consecutive patients undergoing the X-Stop procedure in relation to patient age quetiapine spasms buy imuran 50mg, sex muscle relaxant herbs purchase cheap imuran on-line, levels with implants muscle relaxant hyperkalemia discount 50mg imuran fast delivery, at one institution muscle relaxant bath buy discount imuran. We can conclude that X-Stop is an appropriate treatment consideration for neurogenic intermittent claudication with or without the presence of synovial facet cysts spasms under ribs cheap imuran 50mg with amex. Replacement Using Prodisc-L: Their Impact on Facet However spasms gums buy imuran 50mg without prescription, it seems that the changes of segmental motion Joint Degeneration and Clinical Outcomes did not signifcantly affect to facet joint degeneration. The results of perioperative parameters, radiographic images and Introduction: Minimally invasive approaches have been clinical outcomes were assessed. The pathology was then addressed Clinical Comparison of Two Implantation Systems in standard fashion. The results of this study demonstrate how drastically the surgery and Pedicle Screw Implantation of the Lumbar Spine related morbidity, and the the treatment cost, can be A Case Series Report 1 reduced. Arthroscopic Disectomy and Interbody Fusion of Hence, the need to develop the least invasive approach the Thoracic Spine a Report of Ipsilateral Two Portal which adequately addresses the pathology. Background data: the standard approach to the Study design: Prospective Study of case series treated Thoracic disc is through Thoracotomy. The transthoracic Methods: Surgical procedures included arthroscopic procedures involve defating the lung for access to the decompression of the foramina and the discs; interbody Questons Methods: 15 consecutive patients who underwent the culture was declared positive, if an agent could be arthroscopic decompression and interbody fusion dectect in at least 2 cultures, and negativ, if no growth of the thoracic spine were prospectively studied was visible after 14 days. Results: 15 patients with the average age of 54 years Also a variable with strong infuence on the were followed-up for 28 months post-operatively. The 70% had 5 cultures positive for the same bacteria, an operative room cost and the cost for hospital stay was additional 10% had 4 positive cultures out of 5 samples. Conclusion: the extra-pleural, bi-portal ipsilateral, In the controll group only 4 patients showed three or arthroscopic approach for the decompression and more positive cultures. Thus, the specifcity is 85% and interbody fusion of the thoracic spine is feasible, cost the risk of false positive cultures 15%. Keywords: Posterolateral, Endoscopic, retropleural, In the Control-Group only Propionibacterium acnes could disectomy, bone dowels, fusion. The clinical outcomes were investigated by clinical observations, radiologic studies Conservative Care versus Cross-over to and statistical analysis. Transpedicular internal fxation system has multiaxial screw of three Background: There is controversy about how to treat column fxation and plastic rods, which offer strong fxtion vertebral fractures. Methods: Elderly patients with painful osteoporotic 76 vertebral compression fractures were all treated with Cervical Percutaneous Nucleotomy and 6 weeks of conservative care (analgesics, bracing, Decompression and physiotherapy). At the 6 week follow-up after radiofrequency Study design: A prospective clinical study. Methods: In all cases a confrmative discography of Cervical Therapies and Outcomes the affected level was performed. The First Affliated Hospital of Suzhou University, Suzhou, Results: After two years 89,8% of the patients reported China excellent or good results. One with transpedicular internal fxation system (Sofamor patient had to be hospitalized because of bleeding from Danek Company). One operation time for the microscopically assisted group of patient had temporary hoarseness for 2 weeks. All patients recovered without residual related to posterior pedicle instrumentation was observed symptoms. Standard Laparotomy can be done more precisely with a better control of the L5-S1 Circumferential Fusion 1 Year Follow-up 1 1 1 1 margins of incision. Main limit to Biomechanics/Basic Science the approach is a higher rate of visceral and vascular complications. Technical 1A) [1] was modifed to simulate moderate degeneration difference between the two approaches lays mainly at levels C5-C6 and C6-C7 [2]. The microscopical view Bi-level Fusion Model: A fusion at C5-C6 and C6-C7 permitted a better and more detailed control of great was modeled by changing the material properties of the and small para and pre-vertebral vessel as well as of the intervertebral disc to that of bone [3]. However similar results concerning stabilization and reduction of the fracture are promoted. During fexion/extension rotation (Rot)) was measured with a spine tester; the the bi-level fusion exhibited a 98% decrease in motion height of the vertebral body was assessed radiologically. Similar trends rise in RoM was seen (Ex/Flex: 399/416 %, lateral were observed in lateral bending and axial rotation. Lechner1 Characterized by a Combination of Axis Guidance 1Armed Forces Hospital Ulm, Surgery, Ulm, Germany, 2Institute and Detachable Extender Systems for Degenerative of Orthopaedic Research and Biomechanics, University of Ulm, Spinal Disease Requiring Posterior Decompression H. The difference between pre-op and 1 year follow-up was statisticaly signifcant (-3. In one case an intra-op fracture of the Purpose of the study: Posterior lumber interbody body of L4 occurred. Previous studies with at 1 year follow-up were found satisfactory and super only short-term follow-up have not shown a difference imposable to other types of circumferential fusions. Its major limit is the L5-S1 R90/Hourglass interbody lordotic spacers, interbody level. Preoperative and 12-month data were collected 92 prospectively, and long-term follow-up was by mailed 10-year Experience in Autologous Disc Chondrocyte questionnaire. Biomechanically, using two parallel expandable corpectomy spacers on the cortical rim leads 96 to improved stability in fexion-extension and is clinically Lumbar Vertebral Reconstruction Using Dual conducive to a single-stage posterior approach. Typical reconstruction involves posterior instrumentation 2 levels above and below with a single central [Biomechanical testing constructs] expandable spacer. In the lumbar region, the nerve roots increase the technical diffculty and often prevent placement of a large corpectomy device. In both scenarios long posterior pedicle screw and rod Biomechanics/Basic Science fxation was included 2 levels above and below the spondylectomy. Additionally the effect of adding torsional cross-connectors to the rods of the treated level was 97 examined. Clinically, endoscopic constructs demonstrated rigidity less than 6% of intact foraminoplasty is not associated with instability of the motion. Specimens Consequently, an ideal implant will demonstrate an were divided into 2 surgical groups posterior and optimum stiffness which would minimize the above transforaminal. Multiple load stabilization and increase load sharing with the anterior cycles were applied and measurement was taken at the column. Following screws of a different design and could not be re-used on the transforaminal decompression, the posterior the same specimen without sacrifcing screw purchase. The addition of a increase in the foraminal area following posterior lateral interbody spacer provided much stability, similar decompression. With of the foraminal and anterior spinal canal is possible diffculty in predicting the contribution of the fusion through the transforaminal approach as opposed to mass, this study investigated the rigidity of posterior posterior approach. The material remained fexible, hydrophilic, and soft, without visible resorption or decomposition. The material was well tolerated by the animal, with minimal histological signs of infammation or rejection. Postsurgical maintance/restoration of segmental lordosis is usually adhesions can result in recurrent neurologic symptoms. The patients had was performed two levels above or below the implant reached an average of 22. Kyphosis angles were measured explant procedure at 30 and 90 days, and 2 sheep at preoperatively and at the latest follow-up. Twenty seven on all animals prior to implant and at multiple time points patients (87. Discussion and conclusions: Unexpectedly, from Results: 27 patients expressed satisfaction, and 4 the above results, it appears that the patients that patients did not. Estimated blood loss was none to minimal outcome compared to the other groups, even where in all patients. This study still does not clearly answer if weight bearing by 8-9 weeks (8 patients), 12 weeks the maintenance/restoration of segmental lordosis (21 patients), and 16 weeks (2 patients). Moon3 Background: Diagnosis and treatment of a dysfunctional 1Seoul National University College of Medicine, Neurological Surgery, Jongno-Gu, Seoul, Korea, Republic of, 2Dankook sacroiliac joint is challenging as well as controversial. We describe a new technique involving percutaneous University, Department of Mechanical Engineering, Yongin, Korea, Republic of, 321 Century Hospital, Neurosurgery, placement of porous plasma-coated triangular titanium Siheung, Korea, Republic of implants across the sacroiliac joint. Results from a non-randomized post-market study from a single center Consecutive Prospective Study will be presented. However, several reports have noted its levels were implanted: 2 at L2L3, 13 at L3L4, 21 at limitations and shortcomings. There were 3 double-levels, with Objective: the authors have newly developed an the remainder single-levels, and one level adjacent en bloc cervical laminoplasty procedure using a to a three-level fusion. There were no major intra trans-laminar screw to preserve the posterior midline operative complications. There was one reoperation structures so as to maintain spinal stability and prevent for compromised wound healing, one motor weakness postoperative axial pain and deformity. Signifcant improvement (p cervical spine with preserving the midline ligamentous 0. Next, using the same method a following screw was inserted to the adjacent segment from the opposite side; further screw fxations were made using this alternating fashion. Clinical outcomes were statistically improved during the mean follow-up period of 13 months. Clinical Score Summary] it was possible to preserve the midline ligamentous structures while obtaining good clinical and radiologic outcomes. Lumbar Therapies and Outcomes 136 Non-fusion Dynamic Stabilization in Addition to Decompressive Laminectomy for Spinal Stenosis [Figure 2. Objective: To analyze surgical outcomes after non Correlation with the duration of preoperative symptom fusion stabilization in addition to decompressive and the number of involved segments were compared laminectomy for spinal stenosis with a mild to moderate and analyzed between sedimentation sign positive degree of degenerative lumbar scoliosis. The segments for decompressive laminectomy were the improvement of these scores in Group I was better as follows: one segment in 6 patients (21. There were no traumatize spinal structure and leaves symptomatic newly developed neurological defcits or aggravation of epidural scarring in more than 10% of cases. The video-assisted surgery, described by Destandeau Conclusion: Non-fusion stabilization in addition to and K. Foley, is an alternative because of its benefts decompressive laminectomy resulted in a safe and during surgery: bleeding decreased, better view and after effective procedure for elderly patients with lumbar surgery: pain and decreased fbrosis compared with the stenosis with a mild to moderate degree of scoliosis conventional method. Ruetten has recently proposed an endoscopic clinical outcome was obtained at last follow-up with no technique with saline fow. Postoperatively, of infammation used to evaluate for postoperative we had an early recurrence of disc herniation causing wound infection. In addition, the the guidelines of our institution before beginning this complication rate decreases with experience, compared study. Patients undergoing posterior cervical, thoracic with the open technique, and there is an early recovery or lumbar spine instrumentation and fusion with the activities. One patient developed cervical discectomy and fusion with a Duocage a postoperative wound infection. In 9 cases progression incision, reduced muscle trauma with minimally invasive of spondylolisthesis could be found in the stabilized surgery, reduced operating risk by not having to insert segment. Moreover we found 4 cases of asymptomatic pedicle screws that can damage the nerve roots of the screw loosening. The Conclusion: Long-term results after monosegmental study is complemented by radiological evaluation of instrumentation of degenerative spondylolisthesis patients to determine the degree of arthrodesis at the L4/5 with the Dynesys-System are favourable. Although the remainig Lumbar Therapies and Outcomes motion in the stabilized segment is reduced, the rate of radiologically visible as well as clinically symptomatic adjacent segement degeneration appeares low. A high % of patients experience symptom and physical functional 157 improvement which is clinically important and evident shortly after surgery and at 12 month follow up. Patients usually present Minimal Invasive Muscle Preserving Approach for with leg pain and possibly back and/or buttock groin Spondylodesis in Patients with Degenerative Lumbar pain. The rehabliltation and lower adjacent segment problems are % of patients reaching the Minimal Clinical Important seen. Results were evident at 7 days and the lumbar spine after 6, 12, 24 months was done. Vertebroplasty involves the Outcome in 25 Cases direct injection of cement into the cancellous bone of a R. Kyphoplasty includes the percutaneous the most expanding felds in the treatment of single or placement of an infatable balloon tamp into the multilevel disc herniation and low grade degenerative fractured vertebra creating a cavity and attempting to changes. In our center we implanted 10-15 patients per restore vertebral height prior to cement insertion. Other type needed some more time for problems to become inclusion criteria are point tenderness at the fracture obvious. Other exclusion criteria include fractures symptoms due to an oversized Bryan prosthesis will also with greater than 50% collapse or with evidence of come to attention. The Crosstrees Pod may ultimately have a role in the Direct Lateral Interbody Fusion Combined with treatment of both pathologic and traumatic vertebral Percutaneous Pedicle Screws Fixation for Lumbar fractures. Their ages ranged from 49 to Objectives: To evaluate the correction effect of direct 72 years,with an average of 58. The front thigh and apical vertebral body rotation and the index of razor back groin area superfcial sensory loss occurred in 3 cases, after the surgeries and investigate the satisfaction at the which improved within a month all. For the advanced spinal metastatic tumor treated by long-segment fxed patients, the method is particularly percutaneous pedicle screws reconstruction of spinal suitable. Tan1 1 cases, in 6 cases, in 2 cases, all of them confrmed National University Health System, Orthopaedic Surgery, by pathology were advanced spinal metastatic tumor Singapore, Singapore before surgery. And no nerve root, spinal cord, vascular or chronic discogenic axial back pain in patients who failed adjacent organ were injured. No deep hematoma, wound conservative treatment infection or radioactive nerve and organ injury occurred. Materials and method: 18 patients with axial back All patients were followed up for 13. All patients Percutaneous Pedicle Screws Reconstruction were instrumented with this new minimal invasive of Spinal Stability Combined with 125I Seeds technique. The mean Cobb angle before surgery was 65,5 China, 2Zhejiang Provincial Corps Hospital, Jiaxing, China degrees (range from 45 to 80). In three cases the pedicle screw was 186 outside of the pedicle without clinical evidence. Ashkenazi1 the frst results have shown that the treatment of 1 Assuta Hospital, Tel Aviv, Israel deformities is possible with excellent results, less blood loss as in open procedures. Age radiological assessment of the Synergy Disc (Synergy ranged from 50-94 (mean 74). There were no radiographically diagnosed endplate fractures and assessed for the surgical level using quantitative motion there was no evidence of cement leakage (Figure 1). The surgeon directed measures between the 6 and 24 month follow-up periods control of the implant and cement injection prevented the in patients receiving cervical spinal implants. Additional complications, such as endplate fractures and cement study is needed to determine if outcome assessment leakage, frequently reported in the literature. It has previously been reported If and when an Interlaminar Elastic Assistance that when evaluating lumbar spine implants, there Device Can Stop or Reverse the Degenerative was no signifcant change in outcomes after 6 months Cascade of the Lumbar Spine Petrini2 study was to analyze prospective cervical spine surgery 1University and City Hospital Careggi, Neurosurgical, Firenze, studies reporting data at multiple specifc follow-up Italy, 2City Hospital, Orthopaedic and Traumatology, Citta di periods to determine if there were signifcant changes in Castello, Italy the clinical outcome throughout 24-month follow-up. Studies which were demonstrate if and when an interlaminar elastic motion preliminary results or single-center reports of a larger preservation device for disc assistance can stop or multicenter study were also excluded. The source of the pain in this fusion cage, and one compared a dynamic to a rigid group of patients (facet joint pain) was demonstrated cervical plating system. All studies were published since by a positive response to the facet joint block test. Accurate anticipation was best within the incidence of postoperative motor defcits compared pedicle wall, especially medially. Lenke fusion scores of (frequency and pitch) to differentiate cancellous bone 1-2 were present in 96. Since the use of the breach was confrmed by direct visualization and dexamethasone, no additional neural defcit developed, a an additional measurement was made. Another 5 drillings (7%) were interpreted as cortex, although the breach was still > 5 mm away (clinically a minor burden). Pullout strength and stiffness data were gathered posterior fxation, including compressive maneuvers. This will obviate the need for positioned variable-angle screws were compared using intraoperative patient re-positioning and minimize 0. Preoperative kyphotic group(N=65) for vertebral specimens averaged 39% and 55%, showed more evident lordotic change (4. There was no statistically signifcant relationship between degree of degeneration Figure 2: Pullout loads for screw angulation groups.
Both walking and sitting ability had been caused by disc degeneration disease at C3-C7 levels spasms after eating buy discount imuran on line. An anterior approach was used to implant the NuNec Surgical time was only 74 minutes muscle relaxant bodybuilding cheap 50 mg imuran free shipping, blood loss 334 device muscle relaxant 771 cheap imuran american express. In the follow-ups ranged from reliable infantile spasms 4 year old cheap imuran 50mg visa, had few complications and had less morbidity 3 to 6 months spasms vhs buy generic imuran 50 mg online, patients experienced signifcant pain than convensional fusion spasms meaning in telugu best imuran 50mg, with only 2% adjacent level reduction and functional improvement as measured by break down requiring surgery spasms of the bladder discount imuran 50mg with amex. Radiograph images showed no dislocation of the implant and maintaining of the normal range of motion spasms all over body order imuran 50 mg visa. In conclusion, this early clinical experience on NuNec suggested that the device is safe and effective. Most other cervical artifcial discs either are attention has been given to chitosan-based materials made of all metals or contain two metal plates which are in the feld of orthopedic tissue engineering. It is to our knowledge that NuNec is the frst radiolucent Methods: One titanium cage with collagen and one articulating artifcial cervical disc. Hence,for a segmental structure suffered with disability due to remaining back pain like the spinal canal, excluding conditions such as even after these procedures. Laminoforaminotomy for Degenerative Materials and methods: this is a retrospective, Radiculopathy A Comparison with Published single institution, matched-pair study with minimum Results Following Anterior Cervical Decompression 1-year follow-up. Mean age was 52 years, until 6 week and became similar to each other at 6 month compared with 44 years for the 1213 patients reported in and 1 year postoperatively. Pelton1 apparent that operative time and profciency does rapidly 1Rush University Medical Center, Orthopaedic Surgery, improve in adapting to a minimally invasive technique. Every patient had a diagnosis of either degenerative disc disease or spondylolisthesis and stenosis. Estimated blood loss was also myelopathy were performed open door laminoplasty signifcantly greater in the frst group. T1-T12 and T1-S1 length increased Results: the anterior margin of dura rarely changed by 11% and 12. According to this 502 mechanism, decompression range for laminoplasty Direct Neurologic Decompression Improves can be selected according to compression segments; Functional Neurologic Outcomes in Spinal Stenosis although the cervical curvature is straight or slight and Low-grade Spondylolisthesis: A Comparison of kyphosis, the cord may still shift signifcantly. Mean decompression and cofex interlaminar stabilization or curve preoperatively was 87. We evaluated course laminectomy and posterolateral spinal fusion with spinal of surgery, number of additional interventions, obtained instrumentation in a 2:1 ratio. There were no signifcant differences between the Methods: Actual cost of care data was available for cofex and fusion cohorts (p=0. Our data suggest the potential Biomechanics/ Basic Science for substantial cost-savings, without compromising clinical outcomes, with cofex interlaminar stabilization 511 compared with fusion in the treatment of spinal stenosis Does Applying Normal Saline Signifcantly Change and spondylolisthesis. In the surgical setting, moisture Background and purpose: Several topical adhesives on the skin surface starts the polymerization. Many of these have been application of water or saline has been used anecdotally used in spine surgery as a topical dressings. The Hypothesis: Null-Hypothesis the addition of Normal application of water or saline has been used anecdotally Saline to cyanoacrylates during curing does not to speed the curing time, however no studies to date change the wound bursting or cohesive strength. Specimens were randomized into two groups: Control Materials and methods: Dermabond was applied to 1. Specimens Dermabond applied as intstructed by industry in two were randomized into two groups: Control or Saline. The saline group had 5 Both groups had Dermabond applied as instructed by cc of normal saline applied in drip fashion from syringe industry in two layers at 30 second intervals. Strips sheet yielding a strip of Dermabond which was then cut of gauze were then applied to the Dermabond at 30 and tested on a materials testing machine (Instron) until second intervals. Phase 2 In Vitro Model: Wound bursting strength After fnal cure of 120 minutes, we attempted to peel off Full thickness incisions were made to porcine skin. For the control group, mean time for gauze to no Control group had no saline applied. Of multi-level cases, 2 levels group is needed to activate curing of Dermabond, adding were most common (83. No paper evaluations will be tions and possible contraindications on dangers in use, re distributed. In other individuals who are in a position to control the content order to process your certifcate, please make sure you com of an activity. Bertagnoli, Rudolf -(c,e)Synthes; (d) Paradigm Beutler, William (a,c,d,e) Globus Medical; (c,e) Aesculap E Bevevino, Adam (g) nothing to disclose Bisschop, Arno (g) nothing to disclose Eder, Claudia (g) nothing to disclose Blondel, Benjamin (g) nothing to disclose Errico, Thomas (c)K2M, Fastenetix; (f)DePuy Blumenthal, Scott (d) Spinal Motion, Fziomed, Anulex, Eubanks, Jason (g) nothing to disclose Centinel; (e) Orthofx, Anulex, Vertifex, Fziomed, Centinel, Exactech; (f)Orthofx, Centinel, Exactech F Boissiere, Louis available onsite Bono, Christopher (g) Nothing to disclose Fabrizi, Anthony (g) nothing to disclose Bonte, Francis (g) Nothing to disclose Feifei, Zhou (g) nothing to disclose Bornemann, Rahel (g) Nothing to disclose Feng, Ganjun available onsite Bradley, W. Specic causes related to narrowing and compression are degenerative bulging of an intervertebral disk; thickening of a vertebral arch, an apophyseal joint or the yellow ligament; and spondylolisthesis. All these factors, which are due to various dis eases, cause narrowing of the spinal canal, resulting in compression of the spinal nerves inside the canal and inducing neurological symptoms. The main symptoms are sciatica and intermittent claudication that are treated with therapies based on the severity of the stenosis. Especially in recent years, lumbar spinal canal stenosis has been treated increasingly in the elderly. Key words: Lumbar spine; Low back pain; Spinal canal stenosis; Intermittent claudication; Sciatica; Nerve root block vertebral arch, an apophyseal joint or the yel What is Lumbar Spinal Canal Stenosis Lumbar spinal canal stenosis is a syndrome these factors, due to various diseases, cause of symptoms that appear due to compression of stenosis of the spinal canal, resulting in com the cauda equina nerve bundle and nerve roots, pression of the spinal nerves inside the canal, as a result of narrowing of the lumbar spinal thus inducing neurological symptoms. Espe canal, and accompanies the degeneration that cially in recent years, lumbar spinal canal occurs with aging (Figs. Specic causes stenosis has been treated increasingly in the related to narrowing and compression are bulg elderly. The Japanese text is a transcript of a lecture originally aired on September 9, 2002, by the Nihon Shortwave Broadcasting Co. Right: At the L4/5 level, the dural canal is compressed signi cantly on the right side, due to protrusion of an intervertebral disk and thickening of the yellow ligament. Deformity in the lumbar spine is noted on a simple X-ray image (spur formation, intervertebral space reduction, etc. These symptoms gradu Neurogenic intermittent claudication must ally progress over time alternatively deteriorat be differentiated from vascular intermittent ing and improving. Points of differen nerve irritation or deciency phenomenon, as tiation are improvement of the symptoms by with disk herniation; or by severe pain at rest, assuming a lordotic posture, ndings on palpa as with metastatic cancer in a vertebra or tion of the plantar arteries, and measurement pyogenic spondylitis. Neurogenic intermittent claudication be classied into the following three groups Neurogenic intermittent claudication is pain, based on the clinical symptoms and the state of numbness, and weakness in the legs that occur stenosis: and intensify on walking (caused by the load of 1) Nerve root-type intermittent claudication the body weight on the spine), nally resulting is a single-root disorder, and it is characterized in an inability to step forward. Furthermore, by pain and numbness of the same lower limb these symptoms improve by bending forward as the responsible nerve root (Figs. Right: At the L4/5 level, the dural canal is compressed, due to deformity of an apophyseal joint and thickening of the yellow ligament. What Should Be Observed by 2) In cauda equina-type intermittent claudi Which Test Image test numbness of both legs as the chief complaint (1) Simple X-ray examination (Figs. In the images the condition of the yellow ligament nerve root-type disorder, nerve root irritation and peridural fat tissues are observed, and with symptoms and nerve deciency symptoms, T2-enhanced images, the range and degree such as perception disturbances, weakened of compression of the dural canal can be muscle strength, and decreased lower limb observed, because the cerebral spinal uid deep tendon reexes, are noted, as with shows a high intensity. For this, it is necessary to conrm the responsible Nerve root type nerve roots by nerve root block before surgery. Decompression Cauda equina type of the entire dural canal is conducted by extensive laminectomy and spinal canal extended operation. Decompression of the dural canal (cauda equina) and nerve roots is Mixed type conducted. It is suitable for observing the Block treatment includes epidural block, hourglass patterned compression image of the caudal block, and nerve root block, and it is dural canal, complete block, the cystic image of used for severe low back pain and leg pain. Selective nerve root block ward curving of the lumbar spine and increase Selective nerve root block is useful for speci the abdominal pressure. A simple corset and a fying which vertebra is really responsible, even Williams orthosis (canvas corset) can be used when many vertebrae seem to be narrowed, to for several months. Exercise treatment includes various exer cises that increase the dorsolumbar muscle strength. Surgical treatment Treatment varies depending on the type of When symptoms do not improve on various stenosis. As a general treatment policy, conser conservative therapies, surgical treatment is vative treatment is usually effective and is considered. The purpose of surgery is to con therefore the rst choice for the nerve root duct full decompression of the cauda equina type. On the other hand, for the cauda equina and the nerve roots, while minimizing architec type, there is not a tendency of spontaneous tural destruction of the spine. Therefore, for the cauda equina and decompression is sometimes insufcient, and mixed types, the patients are rst given conser restenosis can occur. On the other hand, exten vative treatment for a while, and if it is shown sive decompression can cause instability after to be ineffective, surgical treatment may be surgery, through architectural weakening of selected, after the patient understands fully. In such a case, the cauda equina nerve is relaxed or tortuous (root redundancy), and mild adhesive arachnoiditis occurs. As such, even with surgery, the symp toms may not necessarily be alleviated, and symptoms may relapse several years later. This disease is therefore sometimes each case, decompression of the pressed dural not easily understood by the people around canal and nerve roots is conducted (Table 2), the patient. In many cases, patients and their through posterior wide fenestration surgery families stop treatment, considering the symp (Fig. When vertebral instability (slipping) is Therefore, the pathology of this disease should also present, spinal fusion is also considered. It is previously numb soles immediately after sur not true that the patients will be paralyzed, or gery, the efcacy of the operation is judged to that they will be forced to use a wheelchair, if be very good. However, symptoms that point that symptoms do not improve with used to be present at rest, especially numbness adequate conservative therapy, operative treat of the soles, and bladder and rectal distur ment should be considered. Today, as more old bances, due to cauda equina-type disorder, people want to maintain an active life, lumbar take time to recover. The existence of neuro spinal canal stenosis is one of the diseases for logical symptoms even at rest before surgery, which treatment opportunities will increase. Its aim is to promote quality improvement in patient outcomes, and in particular, to increase the impact that clinical audit, outcome review programmes and registries have on healthcare quality in England and Wales. At that time the method was also changed so that anyone could suggest an idea for a topic for review and the topics and reviews became more focused. Each report explores a specific topic in detail and over the years, a number of common themes have emerged that are relevant to the care of all patients admitted to hospital. It is important to note that there may be additional common themes in the reports that have not formed recommendations. Or maybe we had simply stopped repeating a recommendation, such as the call for more hospital post mortem examinations. The patient was diagnosed with gallstone pancreatitis and was given antibiotics and supportive treatment. The inpatient notes for the admission were poor and there was no evidence of consultant input. After two weeks the patient was transferred to a tertiary unit with a necrotic pancreas for percutaneous drainage of a peripancreatic collection. The Reviewers were of the opinion that there had been inadequate consultant review, there was no clear management plan and that initial fluid resuscitation had been inadequate. The first is for acute admissions where the time between arrival and first consultant review is important. The second is for patients already admitted who require specialist review to meet the needs of their condition. Early clinical review in an emergency admission is essential as it impacts on the management plan for that patient. The recommendation was later supported in documents from the Royal College of Physicians, 2 3 London, the Royal College of Surgeons of England and the Royal College of Paediatrics and 4 Child Health. This area of consultant review overlaps with the common theme of documentation (Chapter 7). It is harder to define a time point for review in patients who are already in hospital and for whom specialty consultant review is needed. Other examples include high risk surgical patients not being seen by a consultant postoperatively 3 or the decision to operate not made by a consultant. This area of consultant review overlaps with the common theme of supervision of trainee doctors (Chapter 6). Patients admitted as an emergency should receive a specialty relevant consultant review as soon as possible and at the latest within 14 hours after admission to hospital. Inpatients should be reviewed by specialty relevant consultants as frequently as required to plan and manage their clinical need. Consultants must ensure that lines of communication are open between them and their junior staff, particularly when the junior staff are seeing patients without them. Royal College of Physicians Consultant physicians working with patients. Royal College of Paediatrics and Child Health Facing the Future: standards for paediatric 5. They had an acute kidney injury on admission and blood sugar was poorly controlled. The first review by a physician was by the medical registrar seven days after admission following a medical emergency call when the patient developed signs of severe sepsis. Earlier review by a medical team could have optimised management of diabetes, sepsis and renal function and both prevented deterioration and allowed earlier surgery. As the demographics of the patient population have shown a natural tendency towards older age, reflecting the general population, the prevalence of co-morbid conditions has also increased. This has impacted on the skills of the team who treat the patient, as the need for multidisciplinary input is ever increasing. Prior to planned admissions for surgical and other invasive procedures, there will have been involvement by pre-operative assessment teams. Patients should receive relevant care from multidisciplinary and multispecialty healthcare teams to treat their condition as well as any underlying co-morbidities. Initial physiological observations were blood pressure 95/55mmHg, pulse 135 bpm, temperature 37. Over the next 48 hours observations were repeated eight times and revealed persistent hypotension, tachycardia and, on the four occasions where it was measured, tachypnoea. Biochemistry performed 48 hours after admission showed urea 33mmol/l, creatinine 455micromol/l and a severe metabolic acidosis. Despite eventual escalation of care to include critical care admission and renal replacement therapy the patient did not recover. The Reviewers believed that there were long delays in recognition of signs of acute illness that prevented the provision of timely and appropriate care. A middle-aged patient was admitted to the intensive care unit with an acute kidney injury on the background of known alcohol-related liver disease. The critical care outreach team reviewed them daily and for three days requested monitoring of fluid balance. The Reviewers felt that monitoring of fluid balance was unsatisfactory and that better monitoring had the potential to prevent the deterioration that occurred. Deficiencies in the recognition of ill patients have been identified for many years and the care of the acutely ill hospitalised patient presents ongoing problems for healthcare services. This consists of a monitoring tool which can track changes in patient condition to ensure rapid identification of high risk patients and a structure to ensure an appropriate response. This area of monitoring overlaps with the common theme of critical care reviews (Chapter 4). There should be agreed arrangements in place to respond to each trigger level, including: a) the speed of response required in each situation b) a clear escalation policy covering 24/7 care c) the seniority and clinical competencies of the responder d) the appropriate settings for ongoing acute care e) timely access to high dependency care, if required f) frequency of subsequent clinical monitoring. Hospitals should have systems in place to undertake accurate monitoring of fluid balance in all inpatients, and act on any abnormalities. By the time the patient arrived in the emergency department they were awake and mildly confused but otherwise physiologically stable. As the patient was unconscious, intubated and making no respiratory effort a referral was made to the critical care unit. The patient was seen by an SpR in critical care who stated the patient was not suitable to be admitted to intensive care. In the opinion of the Advisors the patient should have received treatment for the myocardial infarction and supportive care in a critical care unit. The Advisors also questioned the apparent lack of consultant input into the decision making in the peri-arrest period.
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Abbott A spasms after stroke purchase imuran 50 mg with visa, Tyni-Lenne R muscle relaxant id order genuine imuran on-line, Hedlund R: Early rehabilitation targeting cognition muscle relaxant neck pain buy cheapest imuran and imuran, behavior muscle relaxant drug list purchase imuran 50 mg fast delivery, and motor function after lumbar fusion: a extensively impaired that more comprehensive training randomized controlled trial muscle relaxant whiplash purchase imuran 50 mg mastercard. Aalto A: Rand 36-item health survey 1 spasms near tailbone buy 50mg imuran,0: suomenkielinen versio terveyteen exercises muscle relaxant otc meds buy imuran overnight. Biering-Sorensen F: Physical measurements as risk indicators for low-back stabilizing muscles muscle relaxant drug names purchase imuran 50 mg without prescription. Norris C, Matthews M: the role of an integrated back stability program in patients with chronic low back pain. Nemoto K, Gen-no H, Masuki S, Okazaki K, Nose H: Effects of high-intensity and take full advantage of: interval walking training on physical fitness and blood pressure in middle-aged and older people. Backache has affected human depending on the specific region in which one resides in beings throughout recorded history. Despite the different health care systems, knowledge, expertise, and health care resources for spinal treatment availability, and costs, there seems to be little pathologies, chronic disability resulting from nonspecific difference in clinical outcomes or the social impact of low low back pain is rising exponentially in modern society. Naturally, the education, training, skills, and experience of Low back pain is not a specific disease, rather it is a this diverse group vary considerably when it comes to symptom that may occur from a variety of different treating low back pain. In up to 85% of people with low back pain, variance in expertise and opinion within each health despite a thorough medical examination, no specific cause profession and subspeciality that treat low back pain. It is the second most common organs within the abdomen, pelvis, or chest may also be neurologic complaint in the United States, second only to felt in the back. Low back pain accounts for approximately 15% within the abdomen, such as appendicitis, aneurysms, of the sick leave, and is the most common cause of kidney diseases, kidney infection, bladder infections, pelvic disability in persons less than 45 years of age. The infections, ovarian disorders, uterine fibroids, and prognosis for most cases of low backache is good. Normal pregnancy can cause back pain in many symptoms will improve within two months no matter ways, including stretching ligaments within the pelvis, what treatment is used, and even if no treatment is given. Additionally, An historic review shows that there is no change in the the effects of the female hormone estrogen and the pathology or prevalence of low back pain: What has ligament-loosening hormone relaxin may contribute to changed is our understanding and management. A person with o Leg length difference spinal stenosis may have pain radiating down both lower o Restricted hip motion extremities while standing for a long time or walking even o Misaligned pelvis-pelvic obliquity, anteversion or short distances. A person would experience pain, possible loss of spondylitis) sensation, and bowel or bladder dysfunction. Fibromyalgia results in z Psychosomatic widespread pain and tenderness throughout the body. The jelly-like central portion of the disc upper back pain or in the lumbar area to cause low back bulges out of the central cavity and pushes against a nerve pain. Psychological and emotional factors, Spondylosis occurs as intervertebral discs lose moisture particular depression, can play a role14. Recent significant trauma such as a fall from a height, Pain in the lumbosacral area (lower part of the back) is motor vehicle accident, or similar incident. One may have numbness or weakness in the part of the leg that receives its nerve supply from a compressed 4. Any person older than 70 years of age: There is an sacral nerve is compressed or injured. Another example increased incidence of cancer, infections, and would be the inability to raise the big toe upward. Also included would be the inability to raise perform a thorough neurologic examination to assess the big toe upward or walk on the heels or stand on the deep tendon reflexes, sensation, and muscle strength toes. The physician should assess joint and including difficulty starting or stopping a stream of urine, muscle flexibility in the lower extremities, examine the or incontinence, can be a sign of an acute emergency and entire spine and assess stance, posture, gait, and straight requires urgent evaluation in an emergency department. In this equivalent to being exposed to daily chest radiograph for situation, further psychological testing and/or behavioural more than one year17. Chronic changes include decreased inter-vertebral height, vacuum Why we need imaging It is an X-ray study in which a radio-opaque dye is injected the other study found that oblique views of the spine directly into the spinal canal. Exposure to study disc herniation and/or arachnoiditis in post unnecessary ionising radiation should be avoided. Complications are headache, of symptoms to rule out more serious underlying nausea, vomiting, back pain, and seizures. They are also useful in localising a lesion, images of tissues with no known biohazard effects. In addition, the timing of the pain are frequently of questionable clinical significance. Hence, electrodiagnostic studies than 60 years of age, and in 33 per cent of those more have only a limited role in the evaluation of acute low than 60 years of age11. Therefore it is very important to correlate Electrodiagnostic studies may not add much if the clinical Journal, Indian Academy of Clinical Medicine z Vol. This is done to test the nerves, are more likely to develop depression, blood clots in the muscle strength, and assess the presence of tension on leg, and decreased muscle tone. Depending on these findings, it may be necessary to Medical history perform an abdominal examination, a pelvic examination, or a rectal examination. These examinations look for Because many different conditions may cause back pain, diseases that can cause pain referred to the back. One randomised clinical trial found 36 Journal, Indian Academy of Clinical Medicine z Vol. The biomechanical rationale for bed per cent fewer days of work and presumably avoided the rest is that intradiscal pressures are lower in the supine effects of deconditioning and the fostering of a position. Sitting, even in a reclined position23, actually raises intradiscal pressures and can Laboratory and radiographic findings in selected theoretically worsen disc herniation and pain. With activity condition restriction, the patient avoids painful arcs of motion and Back strain No abnormalities Usually negative tasks that exacerbate the back pain. These modalities provide analgesia and muscle in the presence of root Myelography localises site of disc entrapment herniation and the presence of root relaxation. Use of leukocyte antigen-B27 Bone scans are useful for a corset for a short period (a few weeks) may be indicated assay in 90 per cent of demonstrating increased activity in in patients with osteoporotic compression fractures. The mechanism of action is unclear, and the Blood culture or intervertebral disc height, changes tuberculin test may be indicative of bony erosion and relationship between cardiovascular conditioning and rate positive reactive bone formation. Excess weight, Gallium citrate scanning or Indium however, has a direct effect on the likelihood of developing labelled leukocyte imaging may be low back pain, as well as an adverse effect on recovery26. Prostate-specific antigen Bone scans are useful for early musculotendinous structures appear to be most helpful or alkaline phosphatase demonstration of blastic lesions. Cold packs Analgesia Impaired sensation, circulation, Apply to affected area for 20 to 30 minutes; inspect Limitation of oedema formation cognition skin frequently during therapy; repeat application in acute musculoskeletal injury History of cold intolerance every 2 hours for 48 hours after injury as needed. Psychologic evaluation Medications Psychosocial obstacles to recovery may exist and must Medication treatment options depend on the precise be explored. The use of manipulation for people with chronic back pain has been studied as well, also with conflicting results. The Muscle relaxants: Paraspinous muscle spasm associated effectiveness of this treatment remains unknown. In chronic pain, studies have shown a benefit from Steroid injections into the epidural space have not been the strengthening exercises. Physical therapy can be found to decrease duration of symptoms or improve guided optimally be specialised therapists. Injections into the posterior joint spaces, the facets, may be beneficial After their initial visit for back pain, patients are for people with pain associated with sciatica. This includes taking the medications Trigger point injections with a steroid and a local and performing activities as directed. One should keep the object close by, and not the prevention of back pain is, itself, somewhat stoop over to lift. In fact, several studies have Low back pain prognosis found that the wrong type of exercise such as high-impact activities may increase the chance of suffering back pain. The prognosis for people with acute back pain associated Nonetheless, exercise is important for overall health and with red flags (described earlier) depends on the should not be avoided. Up to 90% of people swimming, walking, and bicycling can increase overall experience an episode of back pain without other health fitness without straining the low back. Specific exercises About 80% of people with sciatica will eventually recover, Patients should learn from their doctor about how to with or without surgery. Although not useful to treat back pain, stretching exercises are helpful in alleviating tight back muscles. Speed walking, swimming, or stationary bike riding 30 minutes a day can Workers who frequently perform heavy lifting are often increase muscle strength and flexibility. Chairs of appropriate height for the task at hand with good Your back supports weight most easily when lumbar support are preferable. A thick mattress pad will time, rest your feet on a low stool or a stack of books. J Spinal Disord1992; your knees, pull in your stomach muscles, and keep 5(4): 398-402. Objective clinical tract bleeding/perforation: an overview of epidemiologic studies evaluation of physical impairment in chronic low back pain. Frequency, clinical evaluation, and treatment patterns from Primer on the Rheumatic Diseases, 13th ed. Further, five secondary hypotheses were tested using pooled outcome data for the purpose of informing future research directions. These related to intervention, changes to low back movement, self-report outcomes, pathology and age group. This was done to control variables by minimising atypical movement due to other structures. Cluster analysis was performed on pooled outcome data to test the five secondary hypotheses. A sub-group of cases receiving neurosurgery clustered separately to pain management and other cases receiving neurosurgery when compared with their self-report outcomes. While no dominant pathology was shown in the middle age group, the youngest contained predominantly radiculopathies, and the oldest included the majority of the bilateral facet joint cases. Many thanks are extended to all the volunteers who participated in various studies comprising this project. Without the participation of the volunteers, this project would not have been possible. Each of the supervisors provided valuable input from their specific area of expertise. Their high standards and expectations provided me with the drive to be productive, maintain momentum and produce work to the best of my ability. Thank you to my co-ordinating supervisor, Winthrop Professor Kevin Singer, who knew all of the research milestones, hazards and solutions well before they presented. His frequent questioning (often rhetorical) encouraged me to think outside the box, problem solve and develop solutions for the many administrative and scientific challenges presented throughout the candidature. Thank you to Dr Roger Price who was a true asset in the planning of the project, data interpretation, recruitment logistics and proof reading of manuscripts. His attention to detail and need to think-out a problem from multiple perspectives has taught me lessons for life. Professor Lind guided me through multiple avenues in a large tertiary hospital to improve participant invitation. Their hospitality, assistance and readiness to volunteer as asymptomatic participants was much appreciated. Thank you to Ray Smith (Scientific Programmer, School of Surgery, the University of Western Australia) for his time and effort to teach me how to use the laboratory equipment and how to process data. To Dr Peter Fazey, for his contributions as co-author in a professional issue publication, for proof reading and advice as a specialist manual therapist and for support throughout the studies. Thank you to my wife Kalindi for her support through the lengthy candidature and tolerance of my spikes in stress levels and frustration. Without your nod of approval and continual support, this thesis examination would not have been possible. Last, but not least, thank you to my (now) nine year old daughter Sahlia and seven year old son Tyson. I hope that my passion and dedication to previous studies, this thesis project, and my work as a physiotherapist, has a positive influence on your education and work ethic. The recruitment of volunteers and management of this project were the sole responsibility of the author. The author conducted all aspects of recruitment and examination required for this research project. The author independently analysed the data in consultation with his supervisors and the occasional consultation with Mrs Laura Firth or Mr Marty Firth, statistical consultants for the Centre for Applied Statistics, the University of Western Australia. The material compromising this thesis is the original work of the author towards the PhD degree, unless otherwise stated. This thesis has not been submitted, either in part or whole, for the award of any other degree at this or any other university. Consent from the convenience sample of volunteers was given face-to-face, during personal communication with the author, before examination. Funding Funding for incidental expenses related to the studies in this thesis was provided by the Centre for Musculoskeletal Studies, School of Surgery, the University of Western Australia. Computer aided combined movement examination of the lumbar spine and manual therapy implications: Case report. Evidence of structure specific movement patterns in patients with chronic low back dysfunction using lumbar combined movement examination. Evidence of structure specific movement patterns in patients receiving neurosurgery for low back dysfunction: using lumbar combined movement examination. Non-invasive lumbar spine movement: Validation of the MotionStar 3-D electromagnetic tracking system and preliminary evidence. Supervisors provided advice and suggestions for the manuscript prior to submission to journals. Computer-aided combined movement examination of the lumbar spine and manual therapy implications: Case report. Non-invasive lumbar spine movement: Validation of the MotionStar 3-D electromagnetic tracking th system and preliminary evidence. The standard th format uses horizontal lines which from the top represent the maximum, 25 percentile, th median, 75 percentile and minimum values. Combined movement: Combined movement of a vertebral segment refers to movement in more than one cardinal plane, simultaneously. A spinal segment (or region) can be flexed or extended, and side-flexed to the left or right, simultaneously. For example, in the case of a painful left lumbar spine during lumbar extension, the left facet joint may be the source of the pain. Statistical significance: Statistical significance was defined throughout this thesis with p<0. For clarification, the results and conclusions in Studies 1-3 are reported using data obtained by a computer-aided 3-D motion tracking system, accurate to 0. It is one of the five most common reasons for physician consultation, with a lifetime prevalence as high as 85% (Joud et al. More than 90% of all episodes of back pain are probably attributable to mechanical causes, but the precise pathoanatomic lesion is rarely identifiable (White and Gordon, 1982). Furthermore, social factors involving relationships, family, work and navigating the medico-legal system may amplify or prolong pain (Deyo, 2015). Together, the history and physical examination should result in a provisional diagnosis (Maitland, 1997, Sahrmann and Van Dillen, 2015). A biopsychosocial model with a multidisciplinary approach is therefore widely accepted and recommended for use (Waddell, 1992, Deyo, 2015).
Centric occlusion position represents to describe an accurate spasms lower right abdomen buy generic imuran 50 mg on line, positive reproduction of a maxil the first contact of the teeth that occurs when the lary or mandibular dental arch infantile spasms 8 months generic 50 mg imuran with visa. Therefore spasms after stroke buy 50mg imuran fast delivery, cen monly used to provide more specific meanings for the tric occlusion position is a maxillomandibular relationship term (eg spasms with cerebral palsy order imuran without a prescription, diagnostic cast muscle relaxant reversals 50 mg imuran, master cast muscle relaxant pictures discount imuran 50mg line, refractory cast) spasms while sleeping purchase 50 mg imuran free shipping. For purposes of this discus should be a reasonable facsimile of an object muscle relaxant and pregnancy 50mg imuran fast delivery, but need sion, retention may be defined as resistance to displace not be an accurate reproduction such as that required for ment away from the teeth and soft tissues of the dental construction of a successful prosthesis. Undoubtedly the most defined term in and stability may be defined as resistance to displacement prosthodontics is centric relation, closely followed by maxi in a mediolateral or anteroposterior direction (Fig 1-9). The Those terms that deal directly with the components basic definition of centric relation is the physiologic relation of a removable partial denture will not be presented ship of the mandible to the maxilla when both condyles are here, but will be covered in subsequent chapters. This would occur with the teeth in position 1 and the temporomandibular joints in position 2. Contraindications for When all factors are favorable, the treatment of choice dental implant therapy include unfavorable regional for a partially edentulous patient is placement of a fixed anatomy, uncontrolled systemic disease, high-dose head 5 1 Introduction and Classification and neck radiation, and extreme surgical risk. Moreover, preservation of that which remains, and not the meticu there are contraindications associated with any type of lous replacement of that which has been lost. Age of patient If, on the other hand, it is determined that the health of all or part of the remaining oral structures will be com Most patients younger than 18 years are poor candidates promised, alternative forms of treatment must be consid for fixed partial dentures because of large dental pulps and ered. Tooth reduction sufficient to were considered stepping stones on the road to com reestablish normal coronal anatomy in the cast restoration plete dentures. With the materials, equipment, and tech often compromises the health of the pulpal tissues. Conse niques currently available, this type of thinking must be quently, an interim partial denture should be considered relegated to the past. Length of endentulous span Indications for removable partial One of the rules of dentistry that has most successfully denture therapy passed the test of time is that of Dr Irvin Ante. Without this distribution of forces, the Loss of supporting tissues leverage and torque on the abutment teeth would be When a large amount of the edentulous ridge has been excessive. Replacement of missing tissues with a fixed partial denture generally makes it difficult for the patient to main Where there is no tooth posterior to the edentulous tain a healthy oral environment. In contrast, restoration with space to act as an abutment, the choice of replacements a removable partial denture allows the patient to remove is limited. This facilitates cleaning of the only one end (ie, cantilevered fixed partial dentures) pro prosthesis and permits increased access to the remaining duce harmful torquing forces (Fig 1-10). Rationale for removable partial In some instances, one or more dental implants may be placed in the edentulous area, and the arch may be re denture therapy stored with a fixed partial denture. Reduced periodontal support for successful regenerative therapies (eg, bone grafting, guided tissue regeneration), it may be possible to restore optimum remaining teeth dimensions to severely resorbed residual ridges. But for pa In mouths where bony support for the remaining teeth tients in whom regenerative therapy is not a viable option, has been severely compromised, prospective abutments denture bases can be used to restore missing portions of may be unable to support fixed prostheses. Therefore, properly contoured denture tions, removable partial dentures can derive appreciable bases may be used to support the lips and cheeks, and to support from the remaining teeth and residual ridges. Hence, the total support that must be provided by the abutment teeth is diminished. Physical or emotional problems exhibited by patients Need for cross-arch stabilization the lengthy preparation and construction procedures for When stabilization of the remaining teeth is needed to fixed partial dentures can be trying, especially for patients offset mediolateral and anteroposterior forces (eg, after with physical or emotional problems. In many instances, re treatment of advanced periodontal disease), cross-arch movable partial denture therapy is indicated to minimize stabilization frequently is required. Treatment should be designed can provide excellent anteroposterior stabilization, but lim to prevent further oral deterioration and continued until ited mediolateral stabilization. Because removable partial the underlying physical or emotional problems are re dentures are bilateral prostheses, cross-arch stabilization is solved or appropriately managed. Excessive bone loss within the residual ridge Esthetics of primary concern When a missing tooth is replaced by a fixed partial den In some instances, a practitioner is faced with the option ture, the artificial tooth (pontic) is positioned so its neck of fixed versus removable partial denture therapy. This is have caused excessive bone loss, a clinician also must deal particularly true when the practitioner must simulate the with replacement of ridge contours. With the advent of appearance of diastemata, dental crowding, dental rotation, 7 1 Introduction and Classification or extreme changes in the soft tissue architecture (eg, Classification of Partially recreation of papillae to avoid the appearance of dark in terdental spaces). During the early 1900s, dental practitioners began devising methods for the classification of partially edentulous Immediate need to replace extracted teeth arches. While numerous classification systems were pro the replacement of teeth immediately following extrac posed, few met the needs of the profession. Some classifi tion is most readily accomplished using a removable pros cation systems were overly simplified, while others were thesis. It was decided that for a classification able partial dentures may be altered rather easily. Acrylic system to be acceptable, it should: resin denture bases may be relined as ridge resorption oc curs. Allow visualization of the type of partially edentulous treatment can be undertaken with fixed or removable arch being considered partial dentures. Be universally accepted Patients sometimes insist on removable prostheses in place of fixed prostheses (1) to avoid operative proce Kennedy Classification System dures on sound, healthy teeth; (2) to avoid the placement of one or more implants; and (3) for economic reasons. The most widely used method for classification of partially Patients who have had unpleasant experiences with previ edentulous dental arches was proposed by Dr Edward ous dental procedures often object strenuously to the Kennedy of New York in 1925. Differences in the numeric sequence of the classification system was these forms of treatment should be explained to patients. Successful removable partial denture therapy should be expected if fundamental principles are observed. Because of the difficulties associated with tulous area located anterior to the remaining natural complete denture therapy in such a patient, every attempt teeth. It is important to note that the edentulous space should be made to retain the teeth that may support re must cross the dental midline (Figs 1-17 and 1-18). Failure to retain such teeth may result in extremely difficult restorative situations. If the third molar is missing and not to be replaced, it is not considered in the classification (Fig 1-23). In reality, additional areas of eden ment, it is considered in the classification (Fig 1-24). The extent of the modification is not considered, only cation of partially edentulous arches, there was some un the number of additional edentulous areas (Fig 1-28). Classification should follow rather than precede Properly classified maxillary and mandibular arches are extractions that might alter the original classification presented in Figs 1-30 to 1-35. Fig 1-23 If a third molar is missing and is not to be Fig 1-24 If a third molar is present and is to be used replaced, it is not considered in the classification. Modification Classification Fig 1-25 If a second molar is missing and is not to be Fig 1-26 the most posterior edentulous area(s) al replaced, it is not considered in the classification. Fig 1-28 the extent of the modification is not considered; only the number of additional edentulous areas is impor tant. Any edentulous area lying posterior to the single bilateral area determines the classification. Fundamental Design Concentration of forces upon the remaining teeth may Considerations produce rapid destruction of the periodontal tissues and potential abutment loss. Concentration of forces upon Any discussion of removable partial denture design should the residual ridges may produce rapid destruction of the be preceded by a basic understanding of oral biomechan associated tissues and an accompanying decrease in ridge ics. Consequently, practitioners must carefully consider rived from the remaining teeth, the hard and soft tissues of the effects of removable partial denture design upon the the residual ridge, or both. The following features must be a significant difference in the support that can be derived included in the design of Class I removable partial den from these structures. As a result, there may be a significant difference denture bases in the support provided by the teeth and the tissues of the residual ridge. It is important to understand this differ All portions of a residual ridge that are capable of provid ence when designing removable partial prostheses. Broad coverage permits a favorable distribu prevent displacement of removable partial dentures away tion of stresses, often described as a snowshoe effect (Fig from the underlying oral tissues. Inadequate soft tissue coverage can lead to stress ture design, the components responsible for retention of concentration, breakdown of underlying bone, and a de the prosthesis are termed direct retainers and indirect re crease in ridge volume. These components will be discussed more fully in tension base is often so critical that a second impression subsequent chapters. Class I removable partial dentures Flexible direct retention Kennedy Class I removable partial dentures present signif icant challenges for patients and dentists alike. Because the soft tissues are displaceable and allow vertical move Class I removable partial dentures exhibit bilateral exten ment of the denture bases upon loading (Fig 1-38). Vertical sion bases, they must derive support from the remaining displacement of the denture bases may result in the appli teeth and residual ridges (Fig 1-36). Im maining teeth and residual ridges, removable partial den properly designed direct retainers may magnify these 14 Fundamental Design Considerations Fig 1-37 Full extension of the denture base permits a more favorable distribution of applied forces. Fig 1-38 Because the soft tissues are displaceable, loading often produces vertical movement of denture bases. Flexi ble direct retention must be utilized to prevent the application of harmful torquing forces to the abutments. Clasp design is a edentulous space, denture bases generally do not rotate key factor in successful removable partial denture service. First, In some instances, sticky foods may lift denture bases away support should be provided entirely by the abutment from the supporting tissues. Residual ridges should be used for sup controlled to prevent damage to the remaining teeth and port only when edentulous spans are long or abutments oral tissues. To accomplish this objective, auxiliary rests display decreased periodontal support. It is also important to remember that appropriate di Because the auxiliary rests minimize rotation and aid in re rect retention must be incorporated into the design. The characteristics of commonly used clasping assemblies are presented in chapter 3. As previously noted, the dentures do not tend to move or rotate in function, there prosthesis must include a well-adapted denture base, is no need for indirect retention. However, if direct reten properly designed direct retention, and appropriately po tion cannot be obtained on one or more abutment teeth, sitioned indirect retention. The fundamental principles, design and construction of crown and bridge prosthesis. Current Clinical Dental Terminology: A Glossary of tures constructed for patients in North America. For example, a major connector serves as the principal method for connecting the opposing sides of a removable partial denture. A rest contacts the surface of the abutment tooth to prevent movement of the removable partial denture toward the underlying tissues. Components of a clasp assembly are further classified as retentive and reciprocal elements based upon their primary functions. Retentive clasps are designed to keep a removable partial denture in position, Fig 2-1 A major connector (arrows) is a relatively large, rigid band of while reciprocal clasps are intended to brace abutment metal that joins components on the right and left sides of a remov able partial denture. Minor connectors include ment to prevent movement of the prosthesis toward proximal plates (a) and resin-retaining elements (b). Properly positioned rests maintain the correct placement of the removable par tial denture and prevent damage to the hard and soft tissues. Fig 2-6 A denture base (arrows) spans an edentulous Fig 2-7 A representative maxillary removable partial area and provides a platform for prosthetic teeth. Consequently, the major connector an incisal rest (b) traverses the incisal edge of an must follow a curved path in crossing the anterior anterior tooth. Fig 2-10 Struts (arrows) that connect occlusal and Fig 2-11 Infrabulge clasps (arrow) are frequently incisal rests to the remainder of the prosthesis are used to provide retention. Fig 2-12 In some instances, a denture base (arrows) Fig 2-13 A representative mandibular removable must derive at least part of its support from the partial denture. Where the major connector crosses a gingival margin, A major connector joins the components on one side of relief (ie, space) must be provided between the metal and the arch with those on the opposite side. If relief is not provided, inflammation of the components are attached to the associated major connec soft tissues will result. In addition to the aforementioned requirements, a To function effectively and minimize potentially major connector also must provide a means for obtaining damaging effects, all major connectors must: indirect retention where indicated. Protect the associated soft tissues common method for controlling this movement is through 3. Provide a means for obtaining indirect retention the use of one or more indirect retainers. For practical where indicated purposes, indirect retainers will always take the form of 4. When properly positioned, these rests can minimize ture bases the rotational movements of a prosthesis. Promote patient comfort It is important to note that a major connector should never be considered an indirect retainer. Although a major the first requirement for all major connectors connector may play an auxiliary role in resisting rotation of is rigidity. Structural rigidity permits broad distribution the prosthesis, it is the action of the rests and rest seats of applied forces. Hence, occlusal loads may be transmit that is responsible for indirect retention. A major connec ted to abutment teeth, other teeth included in the partial tor that is not properly rested will undergo rotation and denture design, the associated soft tissues, and underlying may cause orthodontic movement of the associated teeth. Other components of a removable partial denture A fourth requirement for major connectors involves such as retentive clasps, occlusal rests, and indirect retain the proper placement of denture bases. Flexibility tors are indicated for anterior tooth replacement, while allows forces to be concentrated on individual teeth and others are not. This may lead to tooth for tooth-supported removable partial dentures, but not mobility or tooth loss. In each instance, a small segments of the residual ridges may cause resorption major connector must allow appropriate placement of the of the hard and soft tissues. Consequently, the edges of a major connector the second fundamental requirement of a major should be contoured to blend with the oral tissues. This is connector is that it must not permit impingement upon particularly true for major connectors that cross the ante the free gingival margins of the remaining teeth. The anterior border of a maxillary major ginal gingivae are highly vascular and susceptible to injury connector should not end on the anterior slope of a from sustained pressure. The additional thickness pro exercised during the design and fabrication of removable duced by metal coverage will create a noticeable promi partial dentures. Instead, the anterior should be located at least 6 mm from the free gingival border of the major connector should be terminated on margins (Fig 2-14). In the mandibular arch, the borders the posterior slope of a prominent ruga (Fig 2-18b). In this of a major connector should be positioned at least 3 mm manner, the edge of the prosthesis may be blended with from the free gingival margins (Fig 2-15). Posterior borders must should run parallel to the gingival margins of the remaining also be placed with regard for patient comfort teeth (Fig 2-16). Otherwise the major connector should be carried onto the lingual surfaces connector should be carried onto the lingual surfaces of the teeth in the form of plating. Fig 2-16 the borders of the major connector Fig 2-17 Gingival margins should be crossed at right should run parallel to the gingival margins of the angles (arrow) to minimize coverage of the delicate remaining teeth. In this manner, the edge of the prosthesis may be blended with the existing soft tissue contours. Fig 2-21 All major connectors should exhibit smooth, Fig 2-22 When partial denture components must be rounded contours (arrows). Sharp angles may produce extended onto the teeth, embrasures (arrow) may be patient discomfort and also concentrate stress. It is good design policy to make the major connector A removable partial denture also must be designed to as symmetrical as possible. Therefore, a major connec maxillary major connector should cross the palatal midline tor must not create food entrapment areas. Tissues covering the maxillary instances, it is best to avoid covering the lingual surfaces of midline are often thin and susceptible to irritation. However, crossing the maxillary midline at right angles, the length of when freeing the gingival margin will result in a design that the crossing may be minimized and the potential for may cause the entrapment of food or other debris, the irritation reduced. In the tant to note that food entrapment is most frequently en maxillary arch, a major connector may cover a small torus countered when an attempt is made to free the gingival if its surgical removal is impossible and if it cannot be margin around a single tooth. If a maxillary torus must be covered, relief should be pro When it is necessary to extend components of a vided.
