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Laparoscopic techniques for anterior interbody fusion were developed in the 1990s to minimize surgical injury related to the anterior approach [38 hypertension quality improvement purchase lanoxin 0.25 mg, 170 pulse pressure with exercise discount lanoxin online mastercard, 252 blood pressure medication you can drink alcohol order lanoxin on line amex, 281] hypertension benign 4011 order 0.25mg lanoxin fast delivery. However, this technique did not prevail because of the tedious steep learning curve, longer operation time, expensive laparoscopic instruments and tools and need for a general surgeon familiar with laparoscopy without providing superior clinical results [50, 200, 281]. Many surgeons today prefer a mini-open anterior approach to the lumbar spine using a retraction frame (Case Introduction), which allows a one or two level anterior fusion to be performed through a short incision [2, 186]. Many initial reports have shown similar clinical results in terms of spinal fusion rates for both traditional open and minimally invasive posterior approaches [71, 84]. Diagnosis of nonunion by radiological assessment is not easy and solid fusion determined from radiographs ranged from 52 % to 92 % depending on the choice of surgical procedure [47]. Similarly to a primary intervention, the single most important factor in achieving a successful clinical outcome is patient selection [75]. There are conflicting results on the influence of the length of spinal fusion [46]. It remains to be seen whether disc arthroplasty will alter the rate of adjacent segment degeneration [128]. Motion Preserving Surgery Motion preservation surgery is still emerging With the advent of motion preserving surgical techniques, there is a great excitement among surgeons and patients that the drawbacks of spinal fusion can be overcome. The success of the paradigm shift toward motion preservation is still unproven but it makes intuitive and biomechanical sense [6]. A review of the biomechanical background of motion preserving surgery is included in Chapter 3. Total Disc Arthroplasty Attempts to artificially replace the intervertebral discs were already made in the 1950s by Fernstrom [79]. Total disc arthoplasty Female patient (48 years) with endplate (Modic) changes at L5/S1 treated by total disc replacement with Prodisc (Synthes). Dynamic Stabilization Abnormal loading patterns are a cause of pain the dynamic stabilization system may alter abnormal loading and thus be effective Best indications for dynamic stabilization are not well established the clinical effectiveness of interspinous stabilization remains to be proven Mulholland [201] has hypothesized that abnormal patterns of loading rather than abnormal movement are the reason that disc degeneration causes back pain in some patients. Both osteotomy and total joint replacement succeed because they alter the load transmission across the joint [201]. In this context, the spine is painful in positions and postures rather than on movement [201]. The rationale for dynamic or "soft" stabilization of a painful motion segment is to alter mechanical loading by unloading the disc but preserving lumbar motion in contrast to spinal fusion [205]. The Graf ligamentoplasty was the first dynamic stabilization system widely used in Europe [30, 96, 111]. This system increased the load over the posterior anulus, caused lateral recess and foraminal stenosis and was only modestly successful [201]. Only long-term follow-up data and controlled prospective randomized studies will reveal whether dynamic stabilization is superior to spinal fusion for selected patients [238]. The surgical patients had a significantly higher rate of subjective favorable outcome and return to work rate compared to the non-surgical group. For both the society and the healthcare sectors, the 2-year costs for lumbar fusion were significantly higher compared with non-surgical treatment, but all treatment effects were significantly in favor of surgery [88]. Longer term follow-up, however, revealed that the benefits of surgery diminished over time (P. Although this study was highly acclaimed for being the first of its kind, criticism arose with regard to the patient inclusion criteria. No significant differences were found in terms of subjective outcome or disability. The authors concluded that the main outcome measure showed equal improvement in patients with chronic low-back pain and disc degeneration randomized to cognitive intervention and exercises or lumbar fusion. Surgical fusion techniques do not differ in outcome Cognitive behavioral treatment and exercises are key elements of non-operative care Spinal fusion and intensive rehabilitation achieve similar results Scientific evidence for the effectiveness of spinal fusion is limited Complications the complication rate of surgical interventions for lumbar spondylosis is critically dependent on the extent of the intervention [253]. The reintervention rate ranges from 6 % (non-instrumented fusion) to 17 % (combined anterior/posterior fusion) [89]. However, the complication rate is also dependent on the surgi- 570 Section the surgeon skill factor remains widely unaddressed Degenerative Disorders cal skill of the individual surgeon, which is not well explored so far. The orientation of the facet joint appears to play a role in premature degeneration. Patients with discogenic back pain often complain of pain aggravation during sitting and forward bending. Standard radiographs are helpful in identifying lumbar-sacral transitional anomalies. Provocative discography remains the only diagnostic test for the diagnosis of discogenic back pain. Psychological, sociological and work-related factors have been shown to affect treatment outcome more than clinical and morphological findings. The mainstay of non-operative management consists of pain management (medication), functional restoration (physical exercises), and cognitive-behavioural therapy (psychological intervention). Particularly the combination of functional treatment and cognitive behavioral intervention has been shown to be effective for degenerative lumbar spondylosis.

Pepsinogen blood pressure remedies buy lanoxin overnight delivery, a component of gastric juice arteriography discount lanoxin 0.25 mg with amex, is converted into active pepsin enzyme by hydrochloric acid (also in gastric juice) blood pressure medication and pregnancy trusted 0.25mg lanoxin. In the intestine hypertension level 2 order lanoxin without prescription, other enzymes (trypsin in the pancreatic juice and peptidases in the intestinal juice) finish the job of protein digestion. When enzymes have split up the large protein molecule into its separate amino acids, protein digestion is completed. For obvious reasons, the amino acids are also referred to as protein building blocks. Fat Digestion Very little carbohydrate and fat digestion occurs before food reaches the small intestine. Most fats are undigested until after emulsification by bile in the duodenum (that is, fat droplets are broken into very small droplets). After this takes place, pancreatic lipase splits up the fat molecules into fatty acids and glycerol (glycerine). For example, the name amylase indicates that the enzyme digests carbohydrates (starches and sugars), protease indicates a protein- digesting enzyme, and lipase means a fat-digesting enzyme. When carbohydrate digestion has been completed, starches (polysaccharides) and double sugars (disaccharides) have been changed mainly to glucose, a simple sugar (monosaccharide). Absorption After food is digested, it is absorbed; that is, it moves through the mucous membrane lining of the small intestine into the blood and lymph. In other words, food absorption is the process by which molecules of amino acids, glucose, fatty acids, and glycerol goes from the inside of the intestines into the circulating fluids of the body. As long as food stays in the intestines, it cannot nourish the millions of cells that compose all other parts of the body. Their lives depend on the absorption of digested food and its transportation to them by the circulating blood. Other nutrients are also actively transported into the blood of capillaries in the intestinal villi. Table 11-1 Chemical Digestion Digestive juices and enzymes Saliva Amylase Gastric Juice Protease (Pepsin) Proteins (intact of plus hydrochloric acid Pancreatic Juice Protease (trypsin) and Lipase Amylase Intestinal Juice Peptidases Sucrase Lactase Maltase Peptides Sucrose (cane sugar) Lactase (Milk sugar) Maltase (malt sugar) Peptides Fatty Maltose Amino acids Glucose and fructose (simple sugars) Glucose and galactose (Simple sugars Glucose acids, amino acids and glycerol partially digested) Fats emulsified by bile Starch Proteins Partially proteins digested Substance Digested (or hydrolysed) Starch (Polysaccharide) Maltose (disaccharide) Resulting Products* *Substances underlined are end products of digestion (that is, completely digested foods ready for absorption) 333 Human Anatomy and Physiology Review Questions 1. If you inserted 9 inches of an enema tube through the anus, the tip of the tube would probably be in what structure Differentiate between deciduous and permanent teeth with respect to kinds and numbers. The urinary system consists of: Two kidneys: this organ extracts wastes from the blood, balance body fluids and form urine. The urinary bladder: this reservoir receives and stores the urine brought to it by the two ureters. The urethra: this tube conducts urine from the bladder to the out side of the body for elimination. Acid base balancing production (rennin-angiotensin and 337 Human Anatomy and Physiology Figure: 12. They 338 Human Anatomy and Physiology are protected at least partially by the last pair of ribs and capped by the adrenal gland. On the medial concave border is the hilus (small indented area) where blood vessels, nerves & ureters enter and leave the kidney. The renal pelvis is the large collecting space with in the kidney formed from the expanded upper portion of the ureters. The pelvis branch to two cavities, these are 2-3 major calyces and 8 to 18 minor calyces. It consists of 8 to 18 renal pyramids, which are longitudinally striped, one cone shaped area. It is divided in to two region the outer cortical and the inner juxtamedullary region. Filters (by hydrostatic presure) water, dissolved substances (minus most plasma proteins, blood cells) from blood plasma. Actively secretes substances such as penicillin, histamine, organic acids, organic bases. Glomerular capsule Proximal convoluted tubule Descending loop of the nephron Ascending loop of the nephron Distal Convoluted tubule Collecting duct the major functions of the kidneys are: 343 Human Anatomy and Physiology All the functions are directly or indirectly related to the formation of urine. The series of events leads to: To the elimination of wastes Regulation of total body water balance. Control of the chemical composition of the blood and other body fluid Control of acid base balance the processes in urine formation are: 1. Tubular secretion Average Comparison of filtration, re-absorption and excretion, here variation in urine composition will occur during variation in the daily diet, fluid intake, weather and exercise. The ureters pass between the parietal peritoneum and the body wall to the pelvic cavity, where they enter the pelvic cavity. The lumen of the ureters is composed of three layers: Innermost, Tunica Mucosa the middle, Tunica Muscularis (made of smooth muscle) the outer, Tunica Adventitia 12. It is located on the floor of the pelvic cavity and 346 Human Anatomy and Physiology like the kidneys and ureters. In females, it is located somewhat lower, anterior to the uterus and upper vagina. The opening of ureters and urethra in the cavity of the bladder outline triangular area called the trigone. At the site where the urethra leaves the bladder, the smooth muscle in the wall of the bladder forms spiral, longitudinal and circular bundles which contract to prevent the bladder from emptying prematurely. These bundles function as a sphincter called Internal Urethral Sphincter (Involuntary). Far there along the urethra in the middle membranous portion a circular sphincter of voluntary skeletal muscle form the external urethral sphincter.

Note also the presence of the vesical seminal blood pressure medication ptsd proven 0.25mg lanoxin, immediately below the terminal portion of the vas deferens heart attack 34 years old purchase lanoxin toronto, on the posterior aspect of the prostate (see next) blood pressure pregnancy buy generic lanoxin 0.25 mg on-line. Note also the presence of the seminal vesicles blood pressure 160 over 100 purchase 0.25mg lanoxin fast delivery, immediately below the terminal portion of the vas deferens, on the posterior aspect of the bladder. During ejaculation, the walls of the seminal vesicles contract to add their secretions into the ejaculatory ducts. Review the location of the openings of both the prostate and the ejaculatory ducts in the prostatic urethra. D Department of Regenerative Medicine and Cell Biology Center for Anatomical Studies and Education College of Medicine Medical University of South Carolina Slide 1. In this lecture, we describe the essentials features of the organs found in the female pelvis as well as their blood supply, venous and lymphatic drainages. We will also focus on the relationships of these organs with one another and some important clinical points related to these organs. In addition to the pelvic organs already described in the previous lecture of the male pelvis (sigmoid colon, rectum, etc), one can find the following organs in the normal female pelvis: a set of 2 ovaries and 2 uterine tubes (also called Fallopian tubes or oviducts), a uterus and a vagina. Note that all of these structures (with the exception of the lower vagina) are located in the pelvic cavity. On this posterior view, one can observe the relative arrangement of the 2 ovaries, 2 uterine tubes, uterus and vagina. Note also on this view how the peritoneum covers nearly the entire set of structures and by doing so create the broad ligament (see details later in the lecture). This organ is where the ovum (plural ova) develops through the regular hormonal cycle to be released close to the opening of the uterine tube. The ovary is attached to the pelvic wall by the suspensory ligament (which contains the ovarian artery and vein, and lymphatic vessels) and to the uterus by the ovarian ligament (proper ligament of the ovary). It is also suspended from the main broad ligament by the mesovarium (a part of the broad ligament). On this posterior view, observe the 3 attachments of the ovary, the suspensory ligament, the mesovarium and the proper ligament of the ovary. On this anterior view of the organs of the female pelvis, observe the same set of structures. Note however that one can see much better the mesovarium forming a shelf-like structure from the main broad ligament. Note also on this view the round ligament of the uterus passing on each side anteriorly toward (through) the inguinal canal (see later in lecture). This view shows in more details the suspensory ligament attaching the ovary to the posterior pelvic wall (intact on the right side and dissected on the left side). Note that this structure is also called the infundibulopelvic ligament by surgeons. The uterine tubes have several important functions and features: It conveys the ovum from the ovary to uterus (has mobile cilia lining the mucosa) It also conveys the sperm from uterus to the ovum It provides a environment for the fertilization of the ovum It is enclosed in the most superior part of broad ligament on each side Note that the part of the broad conveying the blood supply to the uterine tube is called mesosalpinx (salpinx in Greek means trumpet). The uterine tube is composed of several distinct parts, namely the: Fimbria: a set of fingerlike processes Infundibulum: a funnel shaped structures with the fimbria at the end Ampulla: the widest part of the tube where fertilization usually takes place Isthmus: the narrowest part of the tube immediately adjacent to the uterus Intramural part of the tube: within the wall of the uterus (see next slide) Slide 10. Observe on this frontal section of the uterus the different parts of the uterine tube. Normally in pregnancy, the fertilized ovum, also called zygote, implants on the posterior wall of the body of the uterus (see next slide). An ectopic pregnancy is defined as a pregnancy in which the zygote implants in an abnormal location. A common site for an ectopic pregnancy is in the ampulla of the uterine tube as shown on this image. This is an extremely dangerous situation as the wall of the tube is not suited for this purpose and can rupture with the growth of the embryo. Rupture of the tube can lead to serious hemorrhage and in life-threatening emergency. The uterus also has named portions: the fundus: the portion above the entrance of the uterine tube the body: extends between the entry point of the two uterine tubes superiorly and the isthmus inferiorly the isthmus: is the narrow portion between the body and the cervix the cervix: the neck-like portion of the lower uterus. Note also that the cervix has an internal os and an external os with the cervical canal between the two. The presence of the fornix in the upper vagina creates spaces that are called the anterior, posterior, and lateral fornices. To fertilize the ovum, the sperm has to pass from the vagina to the ampulla of the uterine tube. Observe in these pictures (mid-sagittal section) that the uterus does not align with the vagina. Note that the cervical canal is normally at a 90 degree angle with the vagina (anteversion). In some cases, the anteflexion can be excessive or the body of the uterus can also be found in the opposite position called retroflexion. The uterus also presents 2 surfaces: the intestinal surface: found posterosuperiorly and related to the ileum and sigmoid colon the vesical surface: found anteroanteriorly and related to the urinary bladder. The uterine artery brings blood supply to the organ laterally through the broad ligament at about the level of the isthmus. It provides ascending and descending branches passing upward and downward in the thickness of the broad ligament.

A pea-to bean-sized depression on the lower internal surface of the body of the mandible near the symphysis heart arrhythmia 4 year old cheap lanoxin 0.25 mg fast delivery, for attachment of the digastric muscle blood pressure ranges female generic lanoxin 0.25mg. Oblique ridge extending from the posterosuperior to anteroinferior aspect of the body of the mandible pulse pressure ratio purchase lanoxin 0.25 mg with mastercard. Its posterior end is the origin of the mylopharyngeal part of the superior constrictor muscle of the pharynx pomegranate juice blood pressure medication buy lanoxin 0.25 mg mastercard. Depression for the sublingual gland on the anterior part of the mandible above the mylohyoid line. Depression for the submandibular gland on the posterior half of the body of the mandible below the mylohyoid line. Protrusions on the external surface of the mandible caused by the fan-like roots of the teeth. Posteriorly directed process which combines with the zygomatic process of the temporal bone to form the zygomatic arch. A B 20 4 5 21 22 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 15 13 11 12 9 8 6 a Orbital eminence. Median connective tissue bridge between the right and left halves of the mandible. A cephalometric landmark indicating the lowest point on the midline of the mandible. C Bones 27 7 6 6a 4 8 8 6a 4 6 7 1 2 3 5 2 5 3 9 10 4 5 6 7 8 9 A Zygomatic bone, lateral view B Zygomatic bone, medial view 23 10 11 12 16 26 12 13 15 17 24 18 31 19 17 20 21 24 22 25 13 14 D Mandible, medial view C Mandible 15 16 17 29 28 30 18 19 31 20 27 E Mandible, superior view 21 22 23 24 25 a a A 28 Bones 1 2 3 4 5 1 2 3 4 6 7 8 9 10 7 6 5 Ramus of mandible. It is most erect in adults and very 18 wide in newborns and toothless elderly in19 dividuals (ca. Anthropometric landmark indicating 20 the most inferior, posterior, and lateral point of 20 a the angle of the mandible. Roughened area occasionally present on the external surface of the angle of the mandible. Layer of spongy bone (spongiosa) between the external and internal tables, especially in the cranial bones. Roughened area occasionally present on the internal surface near the angle of the mandible. Opening on the inner aspect of the mandibular ramus leading into the mandibular canal. Bony canal within the mandible for passage of the inferior alveolar artery and nerve. It begins at the mandibular foramen and passes beneath the roots of the teeth to the vicinity of the median plane. Groove extending forward and downward from the mandibular foramen and housing the mylohyoid nerve and the mylohyoid branch of the inferior alveolar artery. Muscular process separated from the posteriorly situated condylar process by the mandibular notch. D E 28 29 30 31 32 33 34 15 16 17 18 19 20 21 22 23 24 15 12 13 14 10 10 a Temporal crest. Sharp bony ridge at the anterior margin of the coronoid process for attachment of the temporalis muscle. Anteromedial pit below the head of the mandible for attachment of the lateral pterygoid muscle. Cranial cavity extending from the wall of the frontal bone to the lesser wing of the sphenoid. Cranial cavity extending from the lesser wing of the sphenoid to the petrous ridge of the temporal bone. Cranial cavity extending from the petrous ridge to the posterior (occipital) wall of 19 the skull. Canal formed by the palatine bone and maxilla for the descending palatine artery and the greater palatine nerve. Point of passage of the lesser petrosal nerve and point of exit of the chorda tympani from the skull. Cleft between the petrous temporal and occipital bones extending medially from the jugular foramen. Irregular, fibrocartilage-covered opening in the middle cranial fossa between the apex of the petrous part of the temporal bone and the sphenoid bone. Opening of the greater palatine canal located near the posterior margin of the bony palate between the palatine bone and maxilla. Tiny (matchheadsized), epithelium-covered depression which receives the incisive canal and the incisive foramina. Posteriorly descending segment of bone between the sella turcica and foramen magnum. Grooves for meningeal veins occasionally present on the inner wall of the parietal bone. Grooves on the inner wall of the skull produced primarily by the middle meningeal artery and its branches. Important cephalometric landmark indicating the point where the frontal, parietal, temporal, and sphenoid bones meet. Bony arch formed by the union of the zygomatic process of the temporal bone with the temporal process of the zygomatic bone. Inferior continuation of the temporal fossa located between the ramus of the mandible and the greater wing of the sphenoid. It contains the pterygoid muscles, the pterygoid plexus, and the ramus of the mandibular nerve. Longitudinal elevation occasionally present in the midline of the hard palate projecting toward the oral cavity.

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It is probably caused by a combination of things heart attack 5 hour energy lanoxin 0.25 mg discount, including closure of the atrioventricular valves pulse pressure product effective 0.25mg lanoxin. It occurs at the beginning of ventricular relaxation and is due in large part to sudden closure of the semilunar valves blood pressure medication news discount 0.25 mg lanoxin fast delivery. Some abnormal sounds called murmurs are usually due to faulty action of the valves blood pressure smoothie order lanoxin overnight delivery. For example, if the valves fail to close tightly and blood leaks back, a murmur is heard. Another condition giving rise to an abnormal sound is the narrowing (stenosis) of a valve opening. The many conditions that can cause abnormal heart sounds include congenital defects, disease, and physiological variations. A murmur due to rapid filling of the ventricles is called a functional (flow) murmur; such a murmur is not abnormal. An abnormal sound caused by any structural change in the heart or the vessels connected with the heart is called an organic murmur. Blood Vessels Functional classification the blood vessels, together with the four chambers of the heart, from a closed system for the flow of blood; only if there 269 Human Anatomy and Physiology is an injury to some part of the wall of this system does any blood escape. Arteries carry blood from the ventricles (pumping chambers) of the heart out to the capillaries in organs and tissue. Veins drain capillaries in the tissues and organs and return the blood to the heart. Capillaries allow for exchanges between the blood and body cells, or between the blood and air in the lung tissues. Note smooth muscle is found in the middle layer or tunica media of arteries and veins. Because the thicker muscle layer in the artery wall is able to resist great pressures generated by ventricular systole. In arteries, the tunica medial plays a critical role in maintaining blood pressure and controlling blood distribution in the body. This is 270 Human Anatomy and Physiology a smooth muscle, so it is controlled by the autonomic nervous system. A thin layer of elastic and white fibrous tissue covers an inner layer of endothelial cells called the tunica interna in arteries and veins. The tunica interna is actually a single layer of squamous epithelial cells called endothelium that lines the inner surface of the entire circulatory system. As you can see in Figure 9-7, veins have a unique structural feature not present in arteries. When a surgeon cuts into the body, only arteries, arterioles, veins, and venules can be seen. The most important structural feature of capillaries is their extreme thinness-only one layer of flat, endothelial cells composes the capillary membrane. Instead of three layers or coats, the capillary wall is composed of only one-the tunica interna. Substances such as glucose, oxygen, and wastes can quickly pass through it on their way to or from the cells. Smooth muscle cells that are called precapillary sphincters guard the entrance to the capillary and determine into which capillary blood will flow. It continues down behind the heart just in front of the vertebral column, through the diaphragm, and into the abdomen (Figure 9-8 and 9-9). The thoracic aorta lies just in front of the vertebral column behind the heart and in the space behind the pleura. The abdominal aorta is the longest section of the aorta, spanning the abdominal cavity. The thoracic and abdominal aorta together makes up the descending aorta 272 Human Anatomy and Physiology Figure 9-7. Sections of small blood vessels showing the thick arterial walls and the thin walls of veins and capillaries. These from a crown around the base of the heart and give off branches to all parts of the myocardium. Branches of the Aortic Arch the arch of aorta, located immediately beyond the ascending aorta, gives off three large branches. After extending upward somewhat less than 5 cm (2 inches), it divides into the right subclavian artery, which supplies the right side of the head and the neck. The left common carotid artery extends upward from the highest part of the aortic arch. The left subclavian artery extends under the left collar bone (clavicle) and supplies the left upper extremity. Branches of the Thoracic Aorta the third part of the aorta supplies branches to the chest wall, to the esophagus, and to the bronchi and their treelike subdivisions in the lungs. There are usually nine to ten pairs of intercostal 274 Human Anatomy and Physiology arteries that extend between the ribs, sending branches to the muscles and other structures of the chest wall. Branches of the Abdominal Aorta As in the case of the thoracic aorta, there are unpaired branches extending forward and paired arteries extending toward the side. The superior mesenteric artery, the largest of these branches, carries blood to most of the small intestine as well as to the first half of the large intestine. The much smaller inferior mesenteric artery, located below the superior mesenteric and near the end of the abdominal aorta, supplies the second one half of the large intestine.