By A. Kerth. Santa Clara University.

The research is correlational in nature and does not rule out the possibility that patient anxiety reflects a realistic interpretation of the circumstances sur- rounding surgery purchase 120mg silvitra with mastercard. It is also possible buy silvitra 120 mg cheap, however discount silvitra 120mg mastercard, that anxiety serves to limit activity and thus reduces the probability of a positive outcome order 120mg silvitra overnight delivery. In line with this interpretation purchase silvitra 120mg amex, concurrent psychological intervention with surgery may serve to enhance surgical outcome. That is, psychological interventions specifically aimed at anxiety reduction and improving self-efficacy and con- trol may serve to facilitate recovery in some patients. In particular, usage of imagery and relaxation strategies following surgery was associated with significantly greater knee strength, and less pain anxiety about reinjury. Overall, there appears to be increasing support for psycho- logical interventions in improving outcomes following surgery, but clearly more research is needed in this area. PAIN IN CHILDREN Prior to concluding, it must be acknowledged that this chapter, due largely to space constraints, has focused on psychological interventions for adults with chronic pain. We recognize that psychological interventions are also used to manage pain among children and adolescents (McGrath & Hillier, 1996; see also chap. Cognitive interventions with children typically focus on modifying thoughts and coping abilities related to pain (e. McGrath (1987), in particular, strongly advocated a multistrategy approach (both pharmaco- logical and nonpharmacological) for optimal management of recurrent per- 10. PSYCHOLOGICAL INTERVENTIONS AND CHRONIC PAIN 295 sistent pain that is tailored to the child and follows from the needs identi- fied through a multidimensional pain assessment. The interested reader is encouraged to review Eccleston, Morley, Williams, Yorke, and Mastroyan- nopoulou (2002), who conducted a recent systematic review and meta- analysis that shows good efficacy, but only really for headache, and second- arily for abdominal pain and sickle cell where there has been some prelimi- nary research. There is no controlled research on several major childhood chronic problems such as juvenile rheumatoid arthritis. CONCLUSION Although psychological treatments for chronic pain have been shown to be valuable, there is far greater support for CB interventions than any other form of treatment. Even with this form of treatment, however, there is a need for further research evaluations. A number of valuable recommenda- tions in this regard have been made (e. Morley and Williams (2002) most recently highlighted some of the issues that deserve reflection for those considering conducting and evaluating psychological treatments for chronic pain. A significant chal- lenge, for instance, is to understand why patients vary in their response to treatment and to develop interventions that are sensitive to individual needs. They further noted that there are severe limits to the extensive test- ing of all the parameters of treatment such as length and intensity. In this regard, they suggested that the way to move forward is through articula- tion of theories of change, of both specific and process components, to guide research on efficacy and effectiveness of treatment. In the selection and development of outcome measures they suggested that we need to ex- amine the needs of various stakeholders and that both qualitative and quantitative approaches to this research are required. Schwartz and colleagues (Schwartz, Cheney, Irvine, & Keefe, 1997) cau- tioned that clinical research on psychosocial interventions has flourished in the past two decades, and that due to the wide availability of interven- tions, reliance on standard no-treatment control conditions is really no lon- ger possible. A new design for randomized clinical trials is described by Schwartz’s group (1997) that does not require a no-treatment control group, and that potentially identifies dose-response relationships between inter- ventions and treatment outcomes. They proposed use of a three-arm varia- tion of a standard crossover trial. In the first arm patients receive active treatment followed by standard care; in the second arm patients receive standard care followed by active treatment; and in the third arm, patients receive active treatment throughout, allowing also for the study of dose- response relationships. The design avoids ethical difficulties by ensuring all 296 HADJISTAVROPOULOS AND WILLIAMS patients receive treatment and also in the final arm allows for study of the process of change. Most studies are hopelessly underpowered for their aims, and the use of treatment rather than no-treatment controls (as recommended) will require even larger samples to show differences. Based on review of the research as it stands, it is apparent that many pa- tients have benefited from the development of psychological interventions outlined here and are substantially better served than they were 40 years ago. There is now widespread acceptance for the role of psychological in- terventions in the treatment of chronic pain, and, in particular, it has been recommended that pain treatment facilities, in addition to physical therapy and education, include CBT on a routine basis (Fishbain, 2000). At the present time a CBT approach would appear to have the greatest support in working with pa- tients. Within this approach, however, there is considerable variability in how this can be applied, and until further research is available, clinicians are likely to continue to tailor their approach to the needs of the patients.

A hemangiopericytoma is a low-grade malignant tumor discount 120 mg silvitra amex, and complete recovery can generally be achieved with a resection extending into healthy tissue silvitra 120 mg amex. Very rare tumor that is completely unrelated to ameloblastoma of the jaw generic silvitra 120 mg without prescription, which – in former times – also used to be known as an adamantinoma order silvitra 120mg line. Occurrence silvitra 120 mg low cost, site Very rare tumor occurring primarily between the ages of 10 and 40. Over 90% of all cases are located in the tibia, mainly in the di- aphysis, and possibly also in the metaphysis. Clinical features Since the tumor grows very slowly it causes few symptoms, although diffuse pain can occasionally occur. AP and lateral x-rays of an adamantinoma of the tibia in a may notice a nodular, bumpy surface on the anterior as- 17-year old female patient 621 4 4. Occasionally, Diagnostic value of the molecular genetic detection of the t(11,22) translocation in Ewing’s tumors. Virchows Arch 425: however, spindle cell epithelial formations occur that 107–12 are almost impossible to differentiate from the stroma 12. Fagioli F, Aglietta M, Tienghi A, Ferrari S, Brach del Prever A, Vas- Cytokeratin-positive individual cells in an osteofibrous sallo E, Palmero A, Biasin E, Bacci G, Picci P, Madon E (2002) High- dose chemotherapy in the treatment of relapsed osteosarcoma: dysplasia-like stroma constitute a special variant (osteo- an Italian sarcoma group study. J Clin Oncol 20: 2150–6 fibrous dysplasia-like adamantinoma) that is rarely able 14. Fellinger EJ, Garin-Chesa P, Glasser DB, Huvos AG, Retting WJ to metastazise. Am J Surg Pathol 16: 746–55 The tumor must be resected widely, otherwise it will re- 15. If left untreated, or usually after several recurrences, Mangham D, Davies A (2002) Risk factors for survival and local it can also metastasize. J Bone Joint Surg Br 84: is very important, therefore, to differentiate it unequivo- 93–9 cally from osteofibrous dysplasia, which is generally not 16. Gedikoglu G, Aksoy M, Ruacan S (2001) Fibrocartilaginous mes- enchymoma of the distal femur: case report and literature review. An intralesional resection Pathol Int 51: 638–42 of the adamantinoma is not sufficient. Grimer R, Taminiau A, Cannon S (2002) Surgical outcomes in os- bridging procedures are required after wide resections teosarcoma. Grimer RJ, Bielack S, Flege S, Cannon SR, Foleras G, Andreeff I, rarely involved, functionally effective bridging is usually Sokolov T, Taminiau A, Dominkus M, San-Julian M, Kollender Y, Gosheger G (2005) Periosteal osteosarcoma–a European review of possible. Guo W, Wang X, Feng C (1996) P53 gene abnormalities in osteosar- References coma. Hefti FL, Gächter A, Remagen W, Nidecker A (1992) Recur- Bertoni F, Versari M, Pignotti E (2002) Osteosarcoma of the limb. Bacci G, Ferrari S, Longhi A, Donati D, Manfrini M, Giacomini S, Bric- 21. Hefti F, Jundt G (1995) Is the age of osteosarcoma patients increas- coli A, Forni C, Galletti S (2003) Nonmetastatic osteosarcoma of ing? J Bone Joint Surg (Br) 77: (Suppl II) 207–8 the extremity with pathologic fracture at presentation: local and 22. Hoogendorn PWC, Hashimoto H (2002) Adamantinoma in: Tu- systemic control by amputation or limb salvage after preoperative mours of the soft tissues and bone. Itala A, Leerapun T, Inwards C, Collins M, Scully SP (2005) An Ayala AG (1990) Extraskeletal osteosarcoma. Jürgens HF (1994) Ewing’s sarcoma and peripheral primitive neu- K, Kotz R, Salzer-Kuntschik M, Werner M, Winkelmann W, Zoubek roectodermal tumor. Curr Opin Oncol 6: 391–6 A, Jürgens H, Winkler K (2002) Prognostic factors in high-grade 25. Jundt G, Remberger K, Roessner A, Schulz A, Bohndorf K (1995) osteosarcoma of the extremities or trunk: an analysis of 1,702 Adamantinoma of long bones-A histopathological and immuno- patients treated on neoadjuvant cooperative osteosarcoma study histochemical study of 23 cases. Burchill S (2003) Ewing’s sarcoma: diagnostic, prognostic, and B, Branscheid D, Kotz R, Salzer-Kuntschik M, Winkelmann W, Jundt therapeutic implications of molecular abnormalities. J Clin Pathol G, Kabisch H, Reichardt P, Jurgens H, Gadner H, Bielack S (2003) 56: 96–102 Primary metastatic osteosarcoma: presentation and outcome 6. Cecchetto G, Carli M, Alaggio R, Dall’Igna P, Bisogno G, Scarzello of patients treated on neoadjuvant Cooperative Osteosarcoma G, Zanetti I, Durante G, Inserra A, Siracusa F, Guglielmi M (2001) Study Group protocols. J Clin Oncol 21: 2011–8 Fibrosarcoma in pediatric patients: results of the Italian Coopera- 27.

Recommendations for the surgical treatment of congenital scolioses Anomaly Treatment Wedge vertebra order 120 mg silvitra free shipping, block vertebra buy cheap silvitra 120 mg online, butterfly vertebra Generally no treatment Single lateral hemivertebra of the mid and lower Generally no treatment thoracic or lumbar spine Single dorsal hemivertebra of the mid and lower Hemivertebrectomy from a posterior approach thoracic or lumbar spine Single hemivertebra of the cervical purchase silvitra 120mg with mastercard, upper thoracic Hemivertebrectomy from an anterior and posterior approach or lumbosacral spine Double hemivertebra silvitra 120 mg discount, whole spine Hemivertebrectomy from an anterior and posterior approach Unilateral bar Instrumentation with VEPTR Unilateral bar and contralateral hemivertebra Instrumentation with VEPTR order 120mg silvitra with amex, possibly hemivertebrectomy in addition Intraspinal deformity Neurosurgical resection References 15. Bächli H, Wasner M, Hefti F (2002) Intraspinale Missbildungen– gotic twins. Bradford DS, Heihoff KB, Cohe M (1991) Intraspinal abnormalities spine deformities for intraspinal anomalies with magnetic reso- and congenital spine deformities: A radiographic and MRI study. Brouwer I, van Dusseldorp M, Thomas C, van der Put N, Gaytant M, in congenital scoliosis: a preliminary report. J Pediatr Orthop 11: Eskes T, Hautvast J, Steegers-Theunissen R (2000) Homocysteine 527–32 metabolism and effects of folic acid supplementation in patients affected with spina bifida. Campbell R, Smith M, Mayes T, Mangos J, Willey-Courand D, Kose N, Pinero R, Alder M, Duong H, Surber J (2003) The characteristics 3. Campbell R, Hell-Vocke AK (2003) Growth of the thoracic spine in Congenital, unilateral contraction of the sternocleido- congenital scoliosis after expansion thoracoplasty. J Bone Jt Surg (Am) 85: 409–20 mastoid muscle with inclination of the head towards the 6. Campbell R, Smith M, Mayes TV, Mangos JA, Willey-Courand DB, side of the shortened muscle, rotation towards the oppo- Kose N, Pinero RF, Alder ME, Duong HL, Surber JL (2004) The ef- site side and facial asymmetry. Connor JM, Conner AN, Connor RA, Tolmie JL, Yeung B, Goudie For a long time it was assumed that congenital muscular D (1987) Genetic aspects of early childhood scoliosis. Am J Med torticollis was caused by birth trauma during delivery Genet 27: 419–24 from a breech presentation. Dickson RA, Stamper P, Sharp AM, Harker P (1980) School screen- explain why a pulled muscle should result in a permanent ing for scoliosis: cohort study of clinical course. Jarcho S, Levin PM (1938) Hereditary malformations of the verte- lesion heals up more or less completely without any bral bodies. Lawhon SM, Mac Ewen GD, Bunnell WP (1986) Orthopaedic from a breech presentation nowadays, since a cesarean aspects of the VATER association. J Bone Joint Surg (Am) 68: section is generally performed for this intrauterine posi- 424–9 tion. McMaster M, Ohtsuka K (1982) The natural history of congenital scoliosis. McMaster MJ (1984) Occult intraspinal anomalities and congenital examination of biopsy preparations taken during surgical scoliosis. J Bone Joint Surg (Am) 66: 588–601 treatment revealed any form of hemosiderin deposits 13. Poussa M, Merikanto J, Ryoppy S, Marttinen E, Kaitila I (1991) The such as would be expected after a pulled muscle. Spine 16: 881–7 congenital muscular torticollis is indeed often associated 14. Purkiss S, Driscoll B, Cole W, Alman B (2002) Idiopathic scoliosis in families of children with congenital scoliosis. Clin Orthop with a breech presentation, it has probably nothing to do 401:27–31 with the birth process. Microscopic examination reveals a fibrosis of the children, the sternocleidomastoid muscle is palpable as a muscles that is sometimes seen after necrosis. An ab- tough cord, and it usually easy to detect whether the cla- normal intrauterine posture may be a contributory factor vicular part, the sternal part or both parts are shortened. The A clicking sound is also occasionally elicited by a stretch- occurrence of torticollis in families has been observed. Imaging is not usually necessary 3 Ocular causes are not infrequently involved. X-rays of the cervical spine Congenital muscular torticollis is relatively common, al- are often difficult to interpret in patients with muscular though corresponding epidemiological figures are not torticollis since the bony structures are distorted and the available. In a study in Japan involving 7,000 infants, the vertebral bodies are not shown in the standard projection. The facial asymmetry is not just present as a primary sign, but can also develop secondarily or become Clinical features, diagnosis exacerbated if the torticollis persists for a prolonged Congenital muscular torticollis can be diagnosed on the period.

The tissue consists of fill the cavity with autologous and/or homologous can- thin purchase 120mg silvitra, slightly collagenized and vascularized connective cellous bone discount 120 mg silvitra with mastercard, sometimes using an allograft (⊡ Fig effective 120 mg silvitra. Differential diagnosis: It can sometimes be difficult to distinguish between the simple bone cyst and an aneu- rysmal bone cyst (ABC) buy silvitra 120 mg, and active cysts in particular 4 cheap 120mg silvitra. However, the ABC almost always non-ossifying bone fibroma, fibrous produces an eccentric swelling of the bone. The MRI dysplasia, histiocytosis, infarct) scan does not always clarify matters, since fluid levels Simple bone cyst can occur with both lesions. Fibrous dysplasia can also lead to similar swellings in the metaphyseal area. Moreover, during childhood and adolescence, filled with serous flu- fibrous tumors can show relatively high signal levels id and located centrally in the metaphyses of long bones. A Langerhans cell Cause unknown, probably atrophic-degenerative, not an histiocytosis, non-ossifying bone fibroma and enchon- actual tumor. The lesion almost always occurs sone administration [42, 48] seems to be more successful, between the ages of 5 and 15 and heals on completion although recurrences are still possible, particularly with of growth. The most susceptible site is the proximal polycystic lesions close to the epiphyseal plate. The cyst is humerus, where almost 50% of all simple bone cysts are aspirated using two large cannulas. For cysts in the proximal be vaguely discernible, or even completely extin- femur we reinforce the bone using Prévot nails in order to guished, on a conventional x-ray. In contrast with avoid any fractures, which would otherwise be difficult malignant tumors, the lesion is sharply defined in to stabilize at this site. The MRI scan shows typical fluid levels, which are signal-intensive Aneurysmal bone cyst (ABC) in the T2-weighted images. If these > Definition are observed, the possibility of a teleangiectatic os- A lesion that grows expansively and eccentrically, with teosarcoma should be considered in the differential unknown, and probably non-uniform, etiology. In addition to the usual pseudocystic endothelial covering cells and giant cells. In the solid variant, the cavi- sexes are affected with roughly equal frequency. They ties fade completely into the background, leaving the tend to occur between the ages of 10 and 20, and are hard- impression of a compact tumor. The cysts are most Differential diagnosis: In view of the location and often found in the metaphyses of long bones, particularly radiographic findings, an ABC can be confused with in the knee area and the spine, usually in the area of the a giant cell tumor, simple bone cyst, chondromyxoid vertebral arches or processes. At this site the aneurysmal fibroma, but also with a teleangiectatic osteosarcoma. In the long bones, the lesion is never Aneurysmal bone cysts are also frequently a second- located primarily in the epiphysis, although it spreads ary component of other tumors (e. The ABC shows a characteristic translocation t(16;17)(q22;p13) that has been detected in classic ABCs, Treatment, prognosis as well as in solid and extraosseous variants [11. The Aneurysmal bone cysts usually grow expansively and translocation t(16;17)(q22;p13) has been shown to lead can reach a considerable size, although individual cases to upregulation of the USP6 protease, which is probably of spontaneous healing have been described. Freedom of this translocation in secondary ABCs suggests that the from recurrence can be achieved reliably only by at least etiology of secondary (reactive) lesions differs from that a marginal, or preferably wide, resection. Since aneurysmal bone Aneurysmal bone cysts spread rapidly and can therefore cysts rarely extend into the epiphysis, en-bloc resection is be painful. This leads If, in the event of a recurrence, resection of the com- to palpable swellings and protuberances. A biopsy should located, metaphyseal osteolytic lesion with minimal always be taken before the resection since aneurysmal marginal sclerosing or septum formation. It is perfectly is blown up like a balloon and is often paper-thin, re- possible for a malignant tumor to be concealed beneath sembling a soap bubble (⊡ Fig. The cortex is frequently replaced by an any rate, the therapeutic consequences would be minimal indented neocortex. Usually, however, it shows a if a wide resection is performed, whereas a curettage distinct border, though this may occasionally just would be the wrong treatment in such cases.

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