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These core biopsy needles can be used as part of either a tandem needle sys- tem or a coaxial system generic kamagra polo 100mg without a prescription. In the tandem tachnique order kamagra polo 100 mg visa, the needle that is used in the initial application of local anesthesia both localizes the le- sion and serves as a visual guide buy cheap kamagra polo 100 mg line. In a simultaneous tandem system buy generic kamagra polo 100mg on line, the biopsy needle is placed alongside a thin needle that was previously placed to anesthetize the biopsy tract buy kamagra polo 100mg otc. In a sequential tandem system, 74 Chapter 5 Image-Guided Percutaneous Spine Biopsy TABLE 5. Some commercially available biopsy systems System Manufacturer or city Aspiration 3. The localizing needle has a removable hub and serves as a me- chanical guide for the biopsy needle. A guiding cannula, through which multiple biopsy needle passes can be made, is left in place. Coaxial biopsy needle systems are particularly helpful for cervical spine biop- FIGURE 5. An 18-gauge soft tissue–cutting needle (arrow) is used to obtain a core of soft tissue from this large paraspinal mass that erodes the lateral mar- gin of the vertebral body. The major advantages of the coaxial system, therefore, are a de- creased procedure time, resulting from better accuracy, and decreased procedure complications. Only a single biopsy tract is used with the coaxial system, thus avoiding the risk of additional soft tissue struc- ture injury associated with a second pass. Additionally, the guiding cannula can serve as a guide for fine-needle aspiration prior to core biopsy, or for obtaining multiple core biopsy samples with a soft tis- sue–cutting needle. Accessory guidance systems have been de- veloped to facilitate needle localization. Biopsy Techniques An important decision that is made before and during spine biopsy is the choice of approach. The location of "criti- cal" normal anatomical structures will also modify the approach. Un- less the lesion is clearly localized to the left side of the spine, for example, a right-sided approach is preferable to a left-sided approach for accessing thoracic spine tumors without damaging the aorta. In the cervical spine, the critical structures include the great vessels of the neck, the pharynx and hypopharynx, the trachea, the esophagus, the thyroid gland, the lung apices, and the spinal cord. In the lumbar spine, the critical structures are the aorta, inferior vena cava, kidneys, large and small bowel, conus, and exiting spinal nerves. The objective is to choose a trajectory that enables access to the lesion without com- promising normal, critical structures (Figure 5. The specific location of the lesion within the spine will also influence the approach that is selected. The type of pos- terior approach (posterolateral, transpedicular, or transcostovertebral) TABLE 5. Biopsy approaches Location Approach Spine level Bone Paraspinal oblique Transpedicular Thoracic or lumbar Transcostovertebral Thoracic Posterolateral Lumbar thoracic cervical Anterolateral Cervical Disc Paraspinal oblique Posterolateral Thoracic or lumbar Anterolateral Cervical Paraspinal Paraspinal oblique Soft tissues Posterolateral Thoracic or lumbar Anterolateral Cervical 76 Chapter 5 Image-Guided Percutaneous Spine Biopsy FIGURE 5. Axial CT image shows a localizing needle adjacent to the right pedicle (long arrow) of a lumbar vertebra. A transpedicular approach was cho- sen to access the most proximal (small arrow) of three sclerotic lesions in a pa- tient with a history of breast cancer. Axial CT image shows an expansile lytic lesion within the right transverse process and posterior vertebral body of this thoracic vertebra. Fine- needle aspiration of the right transverse process (arrow) was therefore per- formed with a 22-gauge Chiba needle. Diagram of vertebra indicating the biopsy routes for the postero- lateral transpedicular, and transcostovertebral approaches. The pos- terolateral approach can be used to access lesions located within the ver- tebral body, disc, or paraspinal soft tissues of the lumbar spine (Figures 5. The transpedicular approach can be used to safely access le- sions within the thoracic or lumbar vertebrae. A transcostovertebral ap- proach can be used for thoracic disc space lesions, thoracic paraspinal soft tissue masses, or vertebral body lesions (Figure 5. Axial CT image obtained during a disc and vertebral endplate biopsy (arrow) shows a bone biopsy needle inserted via a left posterolateral approach. Axial CT image shows a left parapedicular approach (arrow) used to sample this destructive vertebral body lesion. Axial CT image shows a right transcostovertebral approach (ar- row) used to sample this destructive vertebral body lesion (fungal os- teomyelitis).

Cataracts (a clouding of the lens of the eye) also may decrease vision in people with MS order 100 mg kamagra polo with amex. Because cortisone promotes the develop- ment of cataracts effective kamagra polo 100mg, they often develop at an earlier age than normal in the MS population purchase kamagra polo 100 mg fast delivery. Surgical removal of the abnormal lens some- times brings about a substantial improvement in vision discount kamagra polo 100mg without a prescription. As with all symptoms of MS order kamagra polo 100 mg otc, significant fluctuations in visual symptoms may occur. Visual acuity often falls and double vision may increase with fatigue, increases in temperature (Uthoff phe- nomenon), stress, and infection. Pain appears to result from what might be termed short-circuits in the tracts that carry sensory impulses between the brain and the spinal cord. This severe, stabbing facial pain usually is treated with carba- mazepine (Tegretol®), which appears to "calm" some of the short- circuiting in the sensory areas. To avoid its primary side effect of sleepiness, the medication initially is given at low doses and slowly increased to a point at which it adequately controls the pain. Other medications that may be used to control trigeminal neuralgia include phenytoin (Dilantin®), whose action is similar to but milder than that of carbamazepine; baclofen, which most commonly is used for spasticity; and Cytotec®, a medication that is taken for gas- tric distress. Newer anticonvulsants (used for epilepsy) that also can decrease neuralgic pain include Neurontin®, Trileptal®, Keppra®, and Gabitril®. If medications fail to control pain, a surgical procedure may be performed to eliminate the pain, leaving a much less disturbing numbness in its place. This procedure, called percutaneous rhizoto- 96 CHAPTER 15 • Pain my, is performed under local anesthesia with laser technology. Occasionally, an unusual "electrical" sensation is felt down the spine and into the legs when the neck is moved. This is a momentary sensation, called L’ hermitte’s sign, which usually is surprising and dis- turbing. The predominant type of pain seen in MS is a burning, toothache- type pain that occurs most commonly in the extremities, although it also may occur on the trunk. The same medications that are used for trigeminal neuralgia are used for these burning "dysesthesias," but they appear to be less effective than they are for this burning pain. An antiepileptic drug, gabapentin (Neurontin®), has become a useful treatment for this type of discomfort. In doses of 1800–2400 mg per day, gabapentin significantly lessens the pain with relatively minimal side effects. Neurontin® has a very short half life of four hours which means that half of it is gone every four hours. From a practical point of view this means that the medication usually must be taken at least four times a day. Some people with MS have found that antipain cream (Zostrix®, or capsaic acid) may be helpful. Electrical stimulation (transcutaneous nerve stimulation, or TNS) applied over the area of pain occasionally provides relief. However, it frequently has the opposite effect and therefore is not often recommended. Acupuncture may be helpful for the pain associated with MS but, unfortunately, even in the best of hands it usually fails over the long term. Mood-altering drugs such as tranquilizers and antidepressants may be effective in some cases because they alter the interpretation of the message of pain. Several such drugs are available, and some relief may be provided with careful manipulation of the type and dose. Additionally, biofeedback, meditation, and similar techniques may be of help in specific circumstances. Because pain is a symp- tom that clearly increases in severity when it is dwelt on, a con- 97 PART II • Managing MS Symptoms certed effort to treat the reaction to pain is an important part of the overall treatment plan. What is clear is that standard pain medications, including aspirin, codeine, and narcotic analgesics, are not effective because the source of pain is not the same as the pain that occurs with injury.

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Typical of these reports is one published in the Scandinavian Journal of Rheumatology in 1986 (Vol generic kamagra polo 100 mg on line. What this means for the etiology (cause) of TMS buy kamagra polo 100 mg without prescription, as I have long maintained order kamagra polo 100mg visa, is that fibromyalgia buy kamagra polo 100 mg low price, also known as fibrositis and myofibrositis (and to some as myofasciitis and myofascial pain) discount 100 mg kamagra polo visa, is synonymous with TMS. I have treated a large number of patients who came with the diagnosis of fibromyalgia; their medical histories and physical examinations were consistent with severe TMS. Therefore, it is reasonable to maintain that the finding of mild oxygen deprivation in the muscles of patients with fibromyalgia supports the hypothesis that the cause of pain in TMS is the same—oxygen debt. As mentioned earlier, TMS manifests itself in many ways, both qualitatively and quantitatively, and it is clear that what is called fibromyalgia is one of the ways in which TMS occurs. These patients are among those who suffer the most severe conditions, for they tend to have pain in many different muscles and to suffer from insomnia, anxiety and depression as well as generalized fatigue. All these manifestations are interpreted as evidence of a higher level of repressed emotionality, primarily anger and, therefore, more severe symptoms. Most contemporary medical investigators cannot accept such an explanation since it violates their basic presumption that the etiologic explanation for physical abnormalities must be in the body itself. They cannot conceive of the idea that something like back pain might originate in the brain. And therein lies a great tragedy for the patient, for as long as this conceptual recalcitrance persists the patient will continue to be misdiagnosed. It is responsible for the excruciating pain that people experience when they are having an acute attack, as described in the first chapter. In the thousands of patients I have examined through the years I have rarely found the involved muscles to be in spasm. Wolfe in a paper published in 1952 titled “Life Situations, Emotions and Backache,” published in Psychosomatic Medicine (Vol. It is of great interest that both muscle spasm and this chemical buildup can be observed in long-distance runners, whose muscles suffer from oxygen deprivation. The presence of muscle pain, either felt spontaneously or induced by the pressure of an examiner’s hand, means that the muscle is mildly oxygen deprived. The Physiology of TMS 65 Trigger Points The term trigger points, which has been around for many years, refers to the pain elicited when pressure is applied over various muscles in the neck, shoulders, back and buttocks. There is some controversy over what precisely is painful, but most would agree that it is something in the muscle. Rheumatologists, who have taken the lead in studying fibromyalgia (TMS), appear to avoid using the term, probably because of its association with other diagnoses through the years. I neither use it nor avoid it, for I have concluded that these points of tenderness are merely the central zones of oxygen deprivation. Further, there is evidence that some of these points of tenderness may persist for life in TMS-susceptible people, like me, though there may be no pain. In the first chapter the point was made that most patients with TMS will have tenderness at six key points: the outer aspect of both buttocks, both sides of the small of the back (lumbar area) and the top of both shoulders. These tender points, trigger points, call them what you will, are the hallmark findings in TMS and they are the ones that tend to persist after the pain is gone. It is an important part of the physiology of TMS to know that the brain has chosen to implicate these muscles in creating the syndrome we know as TMS. If the brain intends to create a state of oxygen deprivation it will do so regardless of how oxygen-rich the blood is. It is likely that oxygen debt causes nerve pain because the reduced level of 66 Healing Back Pain oxygen threatens the integrity of the nerve, as it does not in muscle. In other words, muscle can withstand a lot of oxygen debt before it will be damaged, far beyond that which occurs in TMS. More sensitive nerve tissue, however, is more easily damaged and in order to warn the brain that something is wrong, pain begins with very mild oxygen deprivation. The person may experience feelings of numbness, tingling, pins and needles, burning, pressure and others less common. These sensations and the pain are felt in that part of the body served by the nerve. They transmit messages from the brain designed to cause muscles to activate and move body parts. But they also transmit messages in the opposite direction, bringing information to the brain about what is going on in the body.

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We can put ourselves in the way of it order 100mg kamagra polo fast delivery, but we cannot wrest it from fate by following a system or using main force generic kamagra polo 100 mg overnight delivery. UTILITY AND THE PAST In explaining rational choice as it is usually defined 100 mg kamagra polo with amex, Robyn Dawes states that one criterion of such choice is that it is based on the possible future consequences of the choice buy 100 mg kamagra polo with mastercard. Even when the future costs of continued involvement clearly outweigh the future benefits generic 100mg kamagra polo otc, we tend to enter the sunk costs into the balance as future costs of abandonment 144 CHAPTER 5 or, conversely, benefits of continuance. Jung once said that he would not divulge Sigmund Freud’s dreams, told to him in confidence, even though Freud had been dead for decades. But is it not possible that Jung might have gotten far more gratification out of telling Freud’s dreams than keeping them a secret, and yet still have remained loyal to the deceased Freud? Is it not possible that we do some things because our acts nourish our characters (souls, to use another word) and because we want integrity itself, not just good feelings about apparent integrity? To decide that anything past should be honored only if doing so makes us feel good is a large leap from the simple observation that sometimes it is a good idea to quit a losing cause. The narratives of our lives are not properly carried out only by considering their endings in isolation from what has gone before. The outcome of a piece of music is not the same as the end: it is the integrated whole. The long sweep of living reaches back, confirms, affirms, respects, regrets, justifies, embraces and rejects aspects of the past. We cannot just "put a thing behind us" as though it was disconnected from our present selves, without diminishing those selves. This is why economic talk about "sunk costs" is not sufficient to dismiss much concern about the past. I will go so far as to assert that our present and future acts and experiences actually have a sort of consequence for the past. What whole sections of the past are in terms of value, can be altered and completed in the present and future. It can be argued that the past is not final because in the qualitative sense it is not wholly over. Jung’s action affected not only himself and his contemporary world, but even Freud, although Freud was not aware of it. Actions have all sorts of "effects" on their antecedents: on how we must interpret those antecedents, and on how we remember, value and evaluate them. This means that while we can and should write off some things as "sunk costs," and while we need to let go of old convictions, hopes, plans and goals in the appro- PREFERENCE, UTILITY AND VALUE IN MEANS AND ENDS 145 priate circumstances, we cannot write off the past as a whole. BROADER REASONING ABOUT ENDS The rational use of instruments (means) just cannot be separated for most purposes from the reflective consideration of ends. The many shortcomings of "utility" already enumerated render it unfit as a standard for judging the worth of ends. Several authors have suggested ways that ends cannot only be described but also justified. Perhaps there is some reasonable "logic of values" even if such logic does not absolutely compel assent as demonstrative proof would. Michael Stocker Michael Stocker, in Plural and Conflicting Values, argues that rational deliberation about ends is indeed possible even in the presence of true value multivalence. The existence of plural values47 means that internal and interpersonal conflict cannot be merely averaged over. However quantitative weighing is not necessarily the only means of adjudication among them. Stocker suggests that disparate vectors of value, representative of the qualitative differences among our goals, could be conceptualized as directions on a pan. Quantities could be represented by weights and intensities or intricacies perhaps by distances. If we imagine a pan suspended on a cord through its center, we can also imagine many different arrays of weights at various positions on the pan, some affording balance and others not. Stocker posits that contrasting values need to be in equilibrium, represented as a balanced array on the pan. Many possible arrangements of that equilibrium could correspond, conceptually, to different ways of balancing the pan. With this model, however, qualitative differences, contrasts and other relations are retained, an infinite number of equilibria are feasible, and arguments can be constructed to show that many constellations of value are not in equilibrium and thus mutually upsetting. Such a metaphorical arrangement of coherent values, or desirable states, of course does not lend itself easily if at all to mathematical treatment. The simplicity of expected utility allows for the success of a rational actor calculus in the realm of games and their strict analogues.

Muscle cells convert chemical energy found in fatty acids and blood sugar glucose into movement and heat generic 100mg kamagra polo amex. Actin and myosin are protein molecules that are associated with motility in liv- ing systems buy discount kamagra polo 100mg online. Relative translation between thick and thin filaments is re- sponsible for much of the change in length of a muscle during contrac- tion (Fig cheap kamagra polo 100 mg with amex. According to the sliding filament theory of muscle contraction order kamagra polo 100 mg without prescription, myosin heads on the thick filaments (crossbridges) interact with actin-binding sites on the thin filaments purchase kamagra polo 100mg on line. The crossbridges are pre- sumed to generate force only when they are attached to actin. Skeletal muscle must be stimulated by the central nervous system be- fore it contracts. Messages to activate a muscle travel from the brain to the nervous system and to individual muscle fibers. The amount of tension produced by a skeletal muscle depends on both the frequency of stimulation and the number of motor units involved in the activation. In the muscles of the eye, a motor neuron might control only two or three fibers because precise control is extremely important. On the other hand, in leg muscles more than 2000 fibers are controlled by a single neuron. Even when a muscle ap- pears to be at rest, some motor units in the muscle may be active. The contraction of the activated muscle fibers does not produce enough pull to cause movement but they do tense the muscle. Resting muscle tone stabilizes the positions of bones and joints and maintains body position. A simplified schematic diagram of thick and thin filaments during two stages of contraction. According to the sliding filament model of muscle contrac- tion, muscle force is generated by the interaction of myosin heads on the thick fil- ament with the actin sites on the thin filament. This interaction becomes bio- chemically favorable immediately after the stimulation of the muscle by the central nervous system. In a parallel mus- cle, muscle fibers are parallel to the long axis of the muscle (Fig. While some parallel muscles (abdominal muscles) form flat bands, others are spindle shaped with cordlike tendons at both ends. When it contracts it gets shorter and the belly increases in diame- ter to keep the muscle volume constant. When muscle fibers are parallel to the long axis of the muscle, all the fibers contract the same amount. In a pennate muscle, one or more tendons run through the body of the muscle, with fibers attached to them at an oblique angle (Fig. Pen- nate muscles do not move their tendons as far as parallel muscles do be- cause the fibers pull on the tendon at an angle less than 90°. On the other hand, pennate muscle contains more muscle fibers than a parallel mus- cle of the same size. Depending on the pennate angle, a pennate muscle has the potential of generating larger levels of tension than a parallel mus- cle of the same size. If all the muscle cells in a pennate muscle are found on the same side of the tendon, the muscle is called unipennate. If the tendon branches within the pennate muscle, then the muscle is said to be multipennate. In a convergent muscle, muscle fibers are based over a broad area, but all the fibers come together at the common insertion site (Fig. In this muscle the direction of the pull can be changed by activating one group of muscle cells at any one time. When all the cells in this muscle group are activated at once, they generate less force than a parallel mus- cle of the same size. Human Body Structure (a) (b) parallel unipennate bipennate (c) (d) circular convergent FIGURE 1. In pen- nate muscles, the tendon and the muscle fibers are oriented at an oblique angle (b). In convergent muscle, muscle fiber direction varies within the muscle but all the fibers converge at a point (c). Circular muscles contract to control the size of an orifice of the human body (d).

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