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Know the indications for computed tomography of the head in a patient with blunt head trauma d. Plan treatment priorities in the management of children with head injuries due to blunt trauma 2. Know the role of pharmacology in the management of children with head injuries due to blunt trauma 3. Know the role of surgery in the management of children with head injuries due to blunt trauma 4. Know the principles of management using hyperventilation after severe blunt head injury 7. Understand the relationship between ballistics and penetrating injury to the brain c. Recognize the signs of increased intracranial pressure in a child with a penetrating injury to the central nervous system 2. Recognize the potential for infection following penetrating injury to the central nervous system d. Know the indications for radiographic studies in evaluating the condition of children with penetrating injuries to the head 2. Know mechanisms and patterns of injury associated with cervical spine injuries in children b. Differentiate between neurologically stable and unstable cervical spine injuries c. Recognize signs and symptoms of spinal cord injury syndromes (anterior, central, complete, posterior, Brown-Sequard) in children 2. Recognize the signs and symptoms of findings suggestive of cervical spine injury 3. Know indications for radiographic evaluation of cervical and spinal cord injuries 4. Recognize age-based radiologic variants of the spine and be able to differentiate from pathologic cervical spine injuries 5. Plan options for stabilization of cervical spine injuries in pediatric patients of different ages 4. Know the most common life-threatening causes of thoracolumbar spine injuries in children b. Know the significance of symptoms and physical examination findings after blunt thoracolumbar trauma 2. Know radiographic evaluation of thoracolumbar spine injuries, and recognize radiologic variants 3. Recognize injuries commonly found in conjunction with thoracolumbar spine injuries d. Plan options for evaluation, stabilization, and management of thoracolumbar spine injuries 5. Recognize urgent complications of facial, orbital, and nasal fractures (eg, retro-orbital hematoma, cribriform plate fractures, and septal hematoma) c. Differentiate the types of dental injuries and their treatment in pediatric patients of different ages. Recognize the physical examination findings and plan the management of mandibular fracture f. Recognize presentations of ocular foreign bodies and plan appropriate management 3. Recognize urgent complications of ear trauma, including perichondral hematoma, hearing loss, and traumatic otorrhea b. Know the most common life-threatening causes of blunt thoracic injuries in children b. Understand the pathophysiology of blunt trauma and differentiate it between adults and children c. Recognize the signs and symptoms of pulmonary contusion following blunt chest trauma 2.

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Introduce the instrument orally and wait till the patient feels the mercury tip has entered the stomach (30-4A). Inject 50ml water into the balloon (30-4B) and gently pull it up against the cardia 30. Then gradually inject a further 50-250ml water until the patient feels pain Sometimes, in a patient of 25-35yrs, there is dysphagia, (30-4D), keeping it inflated for 5mins. Squamous If there is persistent retrosternal pain and dysphagia, carcinoma of the lower oesophagus develops in c. The laceration occurs in the pharynx or cervical oesophagus just above the cricopharyngeus (30-1). Instrumentation to remove a sharp foreign body, and dilation of strictures are the other common causes of damage further down the oesophagus. A substantial oesophageal injury causes severe pain and quickly develops mediastinitis or peritonitis, which present as septic shock. If there is a mucosal tear (Mallory-Weiss syndrome), there is only bleeding; occasionally there is a small breach that allows a leak of organisms. South American Trypanosomiasis (Chagas Disease) in Textbook of Tropical Surgery, Westminster 2004, p. It can occur in serious sternomastoid and carotid sheath laterally with a finger, and the trauma in road accidents (usually head-on collisions), trachea and thyroid medially. C, dissect bluntly along the pre-vertebral fascia avoiding damage to the recurrent laryngeal and from penetrating injuries, including foreign bodies. Insert a soft tube into the oesophagus if the hole is large, or a these are likely to be fatal. If the perforation is higher up still a neck exploration or He is intensely thirsty, but sips of water make the pain thoracotomy, oesophageal repair and mediastinal drainage worse. Feel and listen with a stethoscope for surgical will be needed, which may well be impossible to organize. You might just save the patient by draining the upper Check for absent breath sounds or hyper-resonance in the oesophagus in the neck (30-5) and performing a left chest. The main differential diagnosis is a perforated peptic ulcer, but here the pain comes before the vomiting. Other differential diagnoses include myocardial infarction, spontaneous pneumothorax, and acute pancreatitis. Early on there are no clinical or radiographic signs in the chest; these come later when treatment may be too late. Pull down the occur if there is a blood clotting disorder, or the patient is stomach to expose the lower oesophagus. The oesophageal tear is usually longitudinal just above the the cause is a small laceration of the mucosa of the lower oesophago-gastric junction, slightly on the left. You can then not usually see it at Put a continuous suture along the left edge of the subsequent endoscopy. A more substantial tear may cause problems rupture and the left edge of the gastric patch. Now wrap some of the posterior wall of the stomach round the oesophagus as in a fundoplication (30-6B), and suture the posterior gastric wall around the front of the oesophagus to the anterior gastric wall, allowing enough room for the oesophagus within. The difficulty inserting the sign before the tooth Various dental problems may lead to serious illness; number has made this system unpopular. Do not forget that a hospital As so often, much of what you can do will be limited by can play a key role in dental health and education; your anaesthetic skills, or those of your assistant. When mixed together on a glass slab with the spatula listed above, these make an effective analgesic and a mildly antiseptic dressing for. Besides causing sore, bleeding gums, periodontal disease (22) decay spreads to dentine, which becomes sensitive to heat & causes more lost teeth in many communities even than cold, and infection spreads to pulp cavity.

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The slippage is usually minor with only about 11% of adolescents and 5% of adults progressing to more than 10mm of slippage. A fracture through both cortices of the pars interarticularis, usually due to repetitive overuse beginning as a fatigue stress fracture. About half of the patients report an initiating event; symptoms in the rest come on gradually. Patients often report difficulty falling to sleep due to pain (75%) and pain which is worse with sitting and with standing (75%). Unfortunately, these complaints are nonspecific and present in other competing diagnoses as well. It may be completely normal, although pain is frequently aggravated by hyperextension, especially if it mimics the sporting movement that generally elicits pain. In some patients, the pain may also be aggravated by extending from a flexed postured and rotation or lateral flexion to the side of lysis. In some cases, flexion may offer pain relief; in other cases, it may be limited by hamstring spasm. It may have limited to use to increase suspicion of a bilateral break (when the test is positive bilaterally). Otherwise, there may be no tenderness to palpation except for some discomfort with deep percussion. Advanced imaging is reported to detect between 32-44% pars defects in patients suspected of having spondylolysis based on history and physical exam assessment. If these radiographs are equivocal or appear normal but there remains a high index of suspicion, advanced imaging may be necessary to clarify the best treatment approach. The initial two view strategy exposes the patient to 7-9 times less radiation dose than bone scanning. One important disadvantage, especially in the pediatric population, is the high radiation exposure. Consider for fracture fracture further investigation to rule out alternative pathology. Conservative care outcomes are usually good-excellent and reported to be as high as 95%. Dynamed (2017) reports level 3 evidence that most patients can return to sports activity in about 5. Behavioral modification advice should be given to help patients avoid hyperextension postures and activities. Physiological rest the first phase of treatment is for the patient to stop the activity or sport that evokes the back pain for an average of 2-4 weeks. But in cases of true fracture or if symptoms do not resolve refraining from these sports activities may be required for 3-6 months. Dynamed (2017) reports that there is midlevel evidence that stopping sports activity for 3 months is associated with better pain improvement than stopping sports for < 3 months. Orthosis (bracing) Bracing is a commonly recommended intervention (Dynamed 2017, Kurd 2007), but high-level evidence is lacking. A 2009 meta-analysis of children and young adults treated conservatively for spondylolysis and spondylolisthesis found that 83. In these pooled results from observational trials, bracing did not seem to affect patient outcomes. Bracing can be considered in patients who continue to have symptoms despite an initial period of rest. Additional indications for the consideration of using an external brace are presence of a true fracture, the presence of spondylolisthesis, or lack of patient compliance to activity restrictions (Malanga 2016). If a brace is used, some authorities suggest it is more effective if applied as soon as possible. In a 2015 study of children (ages 5-14), treatment included wearing a brace all day except at bedtime. The patient is slowly weaned off it as symptoms resolve even if the fracture has healed in nonunion. Patients were allowed to sleep without the brace if symptoms were not exacerbated. This was compared to conservative management, which included the use of a conventional soft lumbar corset for 3-6 months.

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More adolescents reported using substances alone than using with friends in either virtual or face-to-face contexts. Prac cal ps oered: create ac vity schedule, sleep/physical ac vity, reading/listening to music, medita on, family me + alone me, self-monitoring screen me esp for children, digital well-being apps, use analog tools, reach out to friends/family, seek help. Because our training is in the elds of pediatrics, child psychiatry, and infec ous disease, and not in the eld of educa on, we do not have the exper se to comprehensively or cri cally evaluate the educa on literature about the educa onal outcomes of remote learning. We therefore include resources provided by educator colleagues that may be of value for physicians advising school districts. Narra ve Reviews, Including Both Medical Literature and Lay Press (mul ple topics) these reviews provide good summaries of many of the data included in this Resource Library, and may be useful for sharing on social media, etc. If we all agree on that principle, then it is inexcusable to open nonessen al services for adults this summer if it forces students to remain at home even part me this fall. When Science looked at strategies from South Africa to Finland to Israel, some encouraging pa erns emerged. Together, they suggest a combina on of keeping student groups small and requiring masks and some physical distancing helps keep schools and communi es safe, and that younger children rarely spread the virus to one another or bring it home. Discusses how online may be safer and much more prac cal, although there are social and emo onal aspects to consider. They are now at home, having to confront domes c violence, parental substance use, and possibly child abuse. These kids are o en the ones who get into trouble at school, and that is usually the rst step in helping them get treatment. Webinars these webinars provide balanced reviews of available data and policy considera ons. Department of Medicine Grand Rounds, Covid-19: Epidemiology Update, and the Tenuous Balance between Speed and Safety in the Pandemic 0 6/1/20. There are no data about the combined eec veness of masks plus face shields plus physical distancing. It is valuable to keep in mind that some data on mask ecacy from healthcare se ngs have focused on risk of acquiring infec on for the wearer (may be most applicable to teachers), whereas in many community se ngs the data have focused on risk of transmi ng infec on from the wearer, especially people with asymptoma c infec ons (may be most applicable to students). Dierent types of cloth face coverings lead to very dierent eec veness in impending respiratory droplets. There are no medical contraindica ons to mask-wearing, and many resources exist to help children and adults tolerate masking. Well-conducted Lancet systema c review and meta-analysis of the eect of distancing, masks, and face shields on transmission. These are the best data to date demonstra ng the eec veness of masks and social distancing. Some considera ons (quoted from paper): 0 Face shields can be reused indenitely and are easily cleaned with soap and water, or common household disinfectants. They are comfortable to wear, protect the portals of viral entry, and reduce the poten al for autoinocula on by preven ng the wearer from touching their face. People wearing medical masks o en have to remove them to communicate with others around them; this is not necessary with face shields. The use of a face shield is also a reminder to maintain social distancing, but allows visibility of facial expressions and lip movements for speech percep on. In a simula on study, face shields were shown to reduce immediate viral exposure by 96% when worn by a simulated health care worker within 18 inches of a cough. Of note, no studies have evaluated the eects or poten al benets of face shields on source control, ie, containing a sneeze or cough, when worn by asymptoma c or symptoma c infected persons. However, with ecacy ranges of 68% to 96% for a single face shield, it is likely that adding source control would only improve ecacy, and studies should be completed quickly to evaluate this. Most of these randomised controlled trials used dierent interven ons and outcome measures. In the community, masks appeared to be eec ve with and without hand hygiene, and both together are more protec ve.

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Two groups one with reviewed; eligible patients were identifed within a deep and one with superfcial infection with bacterial database that was compiled as part of a previous study. All deep infections have Demographic, operative and perioperative measures been treated with wide debridement, jetlavage, were statistically evaluated to compare patients that drainage, parenteral antibiotics over 7 to 10 days with did and did not receive drains. Patients with drains were classifed by the duration of the drain (fewer or antibiogramm. The superfcial infections have been greater than 3 days) as well as by the length of their treated after revision 3 days with parenteral then with postoperative antibiotic treatment (24 hours or the oral antibiotics by antibiogramm. Risk factors for infection were also Results: 01/2006 06/2011 156 open mono and 128 bi evaluated. With 24 hours of antibiotics, patients whose drains were 2, 06% deep, 1, 03% superfcial, 2008 1, 12% deep and in place for fewer than 3 days (n=156) had a signifcantly 1, 12% superfcial infections. This was not true of patients who received and long-term antibiotics was necessary. Bacterial deep infections in two cases showed (n=127) while those with a drain for more than 3 days Staph. Superfcial infections showed in 3 cases signifcant differences in infection rates between patients Staph. Wiltse approach and the postoperative scar of the Risk factors amongst patients that received drains with muscle is much lower. For patients receiving antibiotics for complication in case of screw displacement, neurological the duration of the drain, risk factors for infection were complications, pseudoarthrosis, and failure of the smoking (p=0. The shorter time of operation, identifed risk factor in patients without drains was the the less invasive trauma for the muscle and the less surgical approach (p=0. Our and also the rate of screw loosening is reduced results suggest that, regardless of antibiotic treatment, signifcant. Our results suggest that more aggressive prophylactic measures may be appropriate for spinal patients who have postoperative drains for more than 3 days. Plate and screw system fxation may be necessary for patients 392 having disease with more than two levels. Chen4 1Taichung Veterans General Hospital, Department of Neurosurgery, Taichung, Taiwan, Republic of China, 2National Defense Medical Center, School of Public Health, Taipei, 111 Taiwan, Republic of China, 3Taichung Veterans General Anterior Cervical Discectomy and Fusion versus Hospital, Department of Radiology, Taichung, Taiwan, Republic of China, 4China Medical University Hospital, Department of Cervical Disc Arthroplasty: Cost Analysis of Peri Orthopaedic Surgery, Taichung, Taiwan, Republic of China operative and Operating Room Related Costs D. Anterior interbody fusion is the treatment of choice to restore the physiological Purpose: Patients with cervical disc herniation and disc height and provide segmental stability and solid radiculopathy from single-level disease have traditionally arthrodesis after adequate decompression. However, subsidence may occur in the rates and reduced adjacent segment degeneration is interbody fusion process with a stand-alone cage. We aim to structure Purpose: To determine the possible risk factors causing to future research in relative cost effectiveness of interbody cage subsidence and how to prevent it. Study design: A retrospective analysis of image fndings Methods: the medical and fnancial records of 28 and clinical results. All patients were treated for single-level cervical trauma or cervical spondylosis who received cervical disc disease. The traditional surgical approach for this disorder has been to remove the posterior arch of L5 and decompress the L5 nerve roots if the patient presents with radicular complaints. Tan 1National University Health System, Orthopaedic Surgery, Methods: Twenty-six consecutive patients with Singapore, Singapore symptomatic L5-S1 level isthmic spondylolisthesis (grade 1 or grade 2) successfully underwent this combined Purpose: To determine whether additional implantation procedure. A reduction in one while those opting for decompression alone formed or more grade of the spondylolisthesis was achieved in the Control group (24 patients). No complications resulted from the disability and pain scores were measured using the procedures.

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Segmental spinal joint mobility is addressed in the section on subluxation syndrome. Standard joint goniometers are common, but now there are more sophisticated tools, many with electronic data recording capabilities. Mobility can be assessed with the patient actively involved, or as the passive object being mobilized. The reliability of a number of common methods of measuring trunk mobility of the lumbar spine was reviewed by Liebenson (1989). He concluded that the modified Schober technique, inclinometers, flexible rulers, and spondylometers had received the most scientific support. The fingertip-to-floor method was not considered valid because of errors introduced by hip motion, hamstring flexibility and arm length. Nansel (1989) concluded that taking the mean of five repeated measures of cervical lateral flexion with an inclinometer was also a reliable method. The responsiveness of kinematic measurements of the range of regional spine motion (neck or trunk mobility) has been repeatedly demonstrated in clinical trials (Anderson, in press; Ottenbacher, 1985), and under laboratory conditions. In additional study, rotational asymmetries in the transverse plane were reduced by upper cervical 257 adjustments (Nansel, 1991). Evans (1978) reported outcomes of spinal flexion, while Sims-Williams (1978, 1979) used spinal mobility and straight leg raising. Zylbergold (1981) made use of assessments of spinal mobility, and Nwuga (1982) used measures of spinal mobility and straight leg raising. Farrell (1982) used a functional rating questionnaire and lumbar motions as outcomes. Arkuszewski (1986) used six signs and symptoms on a three point scale: posture, gait, pain, active spinal mobility, manual examination of spine, and a neurological evaluation. Waagen (1986) used a global index of spinal mobility created by summing the results of all planes of motion. Hoehler (1981) used measures of spinal mobility, straight leg raising, activities of daily living, and patient report of effectiveness. Howe (1983) assessed measures of cervical mobility and improvement in pain and stiffness. Lopex (1991) also assessed range of motion and pain immediately after manipulation. Also, such issues as patient positioning, patient motivation and proper interpretation of the instrument must be addressed. Muscle Function: the evaluation of muscle function encompasses a number of parameters: strength, work and power, and endurance (Sapega, 1990). The distinctions center upon the nature of the applied load or by the velocity and direction of change in the length of the muscle. Concentric contractions indicate a shortening of the muscle whereas eccentric contractions occur as the muscle is lengthening. Various sophisticated machines can now measure various combinations of these muscle function parameters in the extremities and the spine. Quite a number of factors can affect the validity and reliability of muscle function testing. These include but are not limited to: stabilization and positioning of the body, velocity of test movements, gravitational influences, familiarity with testing procedures, inertial forces, calibration, time of day, and patient motivation (Sapega, 1990). Most manual muscle testing procedures which are commonly used in the chiropractic profession combine elements of isometric testing with eccentric dynamic variable resistance. This lessens the validity of manual tests as true tests of muscular strength (Nicholas, 1978). In one study, patients with as much as a 50% decrease in strength were rated as normal by manual methods (Watkins, 1984). Trained examiners found it difficult to detect differences of less than 25% between paired limbs (Beasley, 1956).


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Prevention of late bacterial infections with vaccinations Immunizations (Table 6) are recommended for preventing infection with S. However, if a uoroquinolone is considered, suggested dosing is as follows: levooxacin 10 mg/kg/dose daily or ciprooxacin 10-15 mg/kg/dose twice daily. Notes: Patients who do not tolerate standard doses of ganciclovir should be treated with foscarnet. Ganciclovir and foscarnet doses should be reduced in patients with renal impairment. Note: For patients requiring prophylaxis for cytomegalovirus and herpes simplex virus after engraftment, ganciclovir alone provides effective prophylaxis for both pathogens. Pathogen: Adenovirus Indication First Choice Alternatives Preemptive therapy among high-risk Cidofovir, i. Notes: Rimantadine dose should be reduced for patients with impaired renal function or for severely impaired hepatic function. Neither rimantadine nor amantadine are Federal Drug Administration-approved for children <1 year old. Patients at high risk for infections from molds or uconazole-resistant Candida species Indication First Choice Alternatives Prophylaxis in the setting of Micafungin, 50 mg i. Notes: Patients who are receiving sulfadiazine-pyrimethamine for toxoplasmosis therapy are protected against Pneumocystis jiroveci and do not need ad ditional prophylaxis. Trimethoprim-sulfamethoxazole is not recommended for patients <2 months old, because of risk for kernicterus. Notes: Among immunocompromised patients, multiple courses at 2-week intervals might be required; however, cure might not be achievable. The twice-weekly isoniazid dose is 15 mg/kg orally or intramus cularly (maximum dose, 900 mg). Part of this commitment includes daily Yes, No, wellness screening of parents/guardians, other family 2. Have any of the visitors been sick with fever, diar members, and visitors here to see hospitalized pa rhea or vomiting in the past 3 days or had any tients. This screening process helps us to prevent cold symptoms including fever, cough, sore throat, the spread of infection. If On days 1 through 5, the stock suspension is di desensitization cannot be performed before transplan luted: One (1) mL of stock 1 tation, the desensitization process should be started 9 mL saline in a 10 mL syringe 5 0. If the pa If no rash appears, continue dosing at 1 single tient tolerates this test dose, then restart dosing at 1 strength tablet twice daily for 30 days. If the patient tolerates therapy, if no reaction has occurred, full therapy can this test dose, then restart dosing at 1 single-strength be given. The project partners and their contact address: Alsomocsolad local government erasmusplusam@gmail. In case of any modification the owner requires information about the changes in the material. How do I make my Family (older and younger members) and my Environment Accept the Problem. The honour and respect, the taken for granted attitudes of earlier historical periods towards the elderly, was replaced by a radically different new social phenomenon appearing in the modern era of the globalized world and its welfare societies.

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The prolapsed or extruded part was removed under endosopic vision with special Questons Mean angle of the screw the inferior endplate was perforated, abraded and all to the center of the spine in the axial plane was 21. Seventy-nine percent of all reported an excellent or good result, 2, 8% a fair and screws had ideal facet capture. Results: the open technique resulted in a signifcantly According to MacNab criteria: 44, 8% of the patients greater distance from the screw to spinal cord than the felt fully regenerated, 48, 8 % felt their capacity slightly percutaneous technique. The surgical techniques did restricted, 5, 6% felt they were noticeably restricted and not statistically differ in distance from the screw to the 0, 8 % felt unchanged. Reducing screw size from 16 to 14 mm patients where treated endoscopically again, 3 had a will reduce the risk to neurovascular structures. Lidar1 1Tel Aviv Sourasky Medical Center, Spine Unit, Departments of Neurosurgery and Orthopaedic Surgery, Tel-Aviv, Israel 449 Cervical Transfacet Fixation: Safety and Accuracy of Background context: Surgical decompression of Open versus Percutaneous Approaches thoracic disc herniation is technically challenging since A. Thoracic instability and avoidance of neurovascular structures and accuracy of bony fusion were assessed clinically and radiographically screw placement. Operative time, blood Methods: Eighty cervical facet joints from 8 cadaveric loss, complications and hospital length of stay were spines were used. Operated levels were T5-6 (2/12), T6-7 (2/12), mm length) were placed over guide wires across each T7-8, T8-9 (3/12), T10-11 (3/12), and T11-12 (2/12). Mean distance from the screw to the developed asymptomatic fbrous nonunion with no vertebral artery was 5. This might be encountered especially in cases Keywords: Vertebral compression fractures; where the foramen is relatively small, such as in the Osteoporosis; Balloon kyphoplasty; Vertebroplasty; upper thoracic level in smaller patients, or when the disc Meta-analysis. Patients showed A randomized Trial of Balloon Kyphoplasty and Non no clinical or radiological signs of spinal instability. Meeting expectations is highly related to a high satisfaction rate; however, failure to meet expectations did Aims: Clinical outcomes of spine surgery may be related not preclude being satisfed as more than half of patients to many factors including patient expectations prior to the whose expectations were not met were satisfed. The purpose of this study was to investigate the relationships between patient expectations, changes in pain levels, and satisfaction with treatment outcome. Methods: Data were collected prospectively for 160 505 patients as part of a presurgical psychosocial screening Low-grade Spondylolisthesis Can Be Effectively study. Bae4 current pain level, how well their outcome met their 1Department of Orthopaedic Surgery, Hospital for Joint expectations, and their level of satisfaction with surgery. Post-operatively, the median Introduction: the gold standard treatment for low current pain level was signifcantly greater than the grade degenerative spondylolisthesis with spinal expected levels (p< 0. Results: Follow-up for the entire cohort at 24 months Introduction: Laminectomy and posterior spinal fusion was 96. There were no group differences at spondylolisthesis and spinal stenosis with signifcant low back pain. Cofex patients experienced signifcantly to the search for motion-preserving, less-invasive alternatives. The overall complication rate was similar between [Figure: Angulation (Top) and Translation (Bottom)] the groups. At 2 years fusion controls exhibited signifcantly increased sagittal plane translation (p=0. The reduced perioperative morbidity, shorter interlaminar stabilization compared to fusion in the treatment hospital length of stay, equivalent or superior clinical of spinal stenosis and degenerative spondylolisthesis. Cofex interlaminar stabilization is a safe and effcacious alternative, and provides several distinct advantages over lumbar spinal fusion with 499 pedicle screw instrumentation. Especially at L1 and L2, decompressing the executing a stable canal decompression. Purpose: Instrumented fusion after decompression Methods: the interpars distance was defned as the is a well-established treatment for symptomatic low narrowest distance between the lateral edges of the grade spondylolisthesis. Direct measurements were recorded slip has theoretical advantages of indirect foraminal using a digital caliper accurate to 0.

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The prevalence of post-polio syndrome is probably even higher than these figures suggest. Symptoms and underlying mechanisms the additional problems are of a varying nature (2). Many are associated with an increase in muscular weakness, which is one of the most common post-polio symptoms. The added weakness may affect muscles previously affected by the disease, as well as those muscles in which no earlier weakness has been perceived. Increased muscular fatigue and diffi culty in regaining muscular strength following muscular exertion are not unusual. In the event of muscular over-exertion, the individual may experience muscle pain during or after the exertion. If the respiratory muscles have been affected by polio, causing breathing problems, the respiratory problems may be further accentuated by additional ventilatory problems. Another recurrent problem is the general fatigue that many individuals experience in addition to muscular fatigue. Another type of problem is associated with overloading and consequential instability in joints surrounded by weakened muscles. This problem is not necessarily directly linked to an additional or increased weakness of the muscles. Other problems that are perhaps a little harder to explain include reduced sensitivity and enhanced intolerance to cold. Psychological symptoms such as apprehension, anxiety, depression, irritability and concentration diffi culties are also frequently reported. However, a relatively high proportion of post-polio patients in an active age continue to work (3). The problems in managing work are, however, accentuated with the onset of additional symptoms at which point more than half of those in working life report difficul ties at work. Many with post-polio symptoms find it difficult to carry on with their normal leisure-time activities and the majority find alternative activities (3). In spite of this, many of these individuals are satisfied with their leisure time activities and have consequently adapted well to a reduced function. Additional or aggravated muscle weakness in muscles affected by polio, often with additional symptoms. Not all persons with residual polio symptoms are diagnosed with the post-polio syndrome since the diagnosis requires additional symptoms with increased muscular weakness. Muscular function In case of an anterior horn nerve cell loss as seen in poliomyelitis, compensatory mecha nisms in the form of collateral innervation (sprouting) are activated. A reinnervation of denervated muscle fibres occurs through the regrowth of sinuvertebral nerve endings from surviving motor axons. As a result, the remaining motor units will contain a significantly increased amount of muscle fibres. Collateral innervation is an important mechanism for the improvement of muscle function in the early stages of polio. However, denervation and subsequent reinnervation has been noted in some patients several decades after the onset of polio (5). This is interpreted as a loss of anterior horn cells or certain motor units losing a part of the collaterally innervated muscle fibres. There are many different theories as to the cause of the ante rior horn nerve cell loss such as aging or a shorter life span owing to over-utilisation or partial nerve damage as a consequence of polio. Some retrospective studies indicate that patients with an initially severe paralysis that is followed by a stable phase of considerable improve ment, reasonably good function and level of activity are at a greater risk of a late onset of aggravated or additional muscle weakness (7). Another essential compensation for loss of motor units is the growth (hypertrophy) of the remaining muscle fibres. However, the degree of muscle fibre hypertrophy varies significantly and is prob ably dependent on the relative load experienced by the muscle in question. Conversely, no significant compensatory increase in muscle fibres is noticeable in patients with near to normal muscle strength.