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These people can exhibit cognitive losses consistent with Key Questions confusion—apathy and drowsiness purchase cheap feldene on-line rheumatoid arthritis causes, impaired concen- l What specifc problems with mental abilities or tration discount feldene online arthritis neck & back pain center, and errors in thinking quality 20mg feldene arthritis and joint pain in dogs. Changes in Mental Abilities and Behaviors Patients with delirium have global cognitive losses Key Questions that involve memory feldene 20mg for sale arthritis in lower back what to do, thinking, perception, and judg- l Does the patient have any chronic health conditions? These patients can become disoriented, irritable, l Has the patient been hospitalized recently, and if so, and fearful. They show impaired concentra- Current and Past Health Status tion, experience sensory misperceptions, and make Obtain past medical records for a complete health his- errors in thinking. Most likely, you will have to use a relative or Early dementia presents with more selective cogni- close friend to determine current and past health sta- tive losses. Many systemic conditions and disorders can pro- remember recent events, are disoriented, irritable or duce alteration in mental status, particularly in older depressed, have poor hygiene, show poor judgment, patients (Box 9-2). Patients with multiple chronic health prob- medications, the existence of multiple medical con- lems are particularly at risk. Dementia occurs in approximately 5% to Could the confusion be caused by medication? Polypharmacy Older adults who are taking multiple medications are Medications at risk for medication interactions and resulting confu- Drugs that can produce altered mental status include sion (see also the preceding list of medications that can the following: produce altered mental status). People who stolic blood pressure greater than 120 mm Hg suggests are confused may be taking medications improperly, hypertensive encephalopathy, whereas a systolic blood which compounds the problem. Older adults may need pressure less than 90 mm Hg can indicate impaired lower doses or a gradual increase in dosages of medi- cerebral perfusion. In both dementia and depression, the individual is likely to be alert and aware although the mood can be Key Questions depressed. Age Perform a Mental Status Examination Older adults are at risk for the development of confu- A thorough mental status examination is essential. Factors Mental status assessment is used to determine cogni- that place them at risk include the use of multiple tive function. A number of assessment instruments are Chapter 9 • Confusion in Older Adults 101 l Loss of abstract reasoning Orientation to Time l “What is the date? The individual is aware of losses and can highlight disabilities, especially memory loss. Reading In older adults, also administer the Geriatric De- “Please read this and do what it says. Patients with dementia Normal neurological fndings are typical of early de- are cooperative and willing to try but make mistakes mentia and depression. Tremor and restlessness are Check vision, hearing, and sensory impairment as con- associated with alcohol intoxication or withdrawal. Dilated pupils suggest Tremor (especially resting), rigidity, and bradykinesia alcohol withdrawal; pinpoint pupils can indicate nar- indicate parkinsonism. Changes in pupil size as liver fap or liver tremor, is an involuntary tremor of can also indicate neurological changes, such as those the hands, tongue, and feet that is characteristic of he- that occur with stroke or neoplasm. Writhing move- ism can exhibit a typical facial presentation: masked ments (chorea) typify Huntington disease. Speech Gait abnormalities are found with multi-infarct is slowed, slurred, and monotonous. Specifc fndings can indicate A positive Babinski sign on testing the plantar refex a local or systemic cause for the confusion. If demen- tor weakness, especially of the legs, loss of coordina- tia seems likely, these same tests can rule in or rule out tion, and impaired handwriting are consistent with reversible or modifable causes of the dementia. Language Complete Blood Count Aphasia (language disturbance) is often present in de- Leukocytosis suggests infection. Focal depressed magnesium and calcium levels, hypoglyce- defcits also occur with cerebrovascular injury. Elevation in liver enzymes suggests liver Babinski sign; myoclonus; and bladder and bowel dysfunction. Psychomotor agitation or retardation is consistent Thyroid Function Tests with depression. An agitated confusional state without Abnormal levels of thyroid-stimulating hormone focal signs can occur with head trauma. Patients with dementia or depression, in the absence of concomitant lung disease, will have Serology for Syphilis normal fndings. The onset is rapid, and the condition can Chest Radiograph last from hours to weeks. Lumbar Puncture There is a tendency for the patient to mistake the Lumbar puncture is used to rule out bacterial, fungal, unfamiliar for familiar places and people. Physical exami- nation fndings depend on the underlying cause of Electrocardiography the delirium. The person can be apathetic and drowsy and Computed Tomography or Magnetic Resonance will show disorientation—especially for time, less for Imaging place, and almost never for self. The incidence of delirium increases progressively after The onset of symptoms is insidious, with the course the fourth decade of life. The condition can be with an increased risk of death, it should be considered present for months or years, with progressive deterio- frst in older patients who exhibit cognitive impairment ration. Hallucina- Box 9-3 Common Presentations tions are usually absent until late in the course of the of Dementia disease. On mental status examination, the patient tries • Depression • Hallucinations (late) hard and provides “near miss” answers. Box 9-3 lists common presentations of demen- • Insomnia • Falls, clumsiness tia, Box 9-4 lists phases of Alzheimer-type dementia, • Paranoia • Deteriorating interpersonal • Weight loss relationships and Box 9-5 describes a staging system for Alzheimer • Poor work performance • Personality changes disease. Damage typically begins • Apraxia: cannot perform motor skills although motor sys- with cells involved in learning and memory and gradually tem intact spreads to cells that control thinking, judgment, and behav- • Agnosia: failure to identify or recognize objects despite ior. The damage eventually affects cells that control and co- intact sensory function ordinate movement. The Alzheimer • Clear-cut defciencies in the following areas: Association uses seven stages to describe the progression of • Decreased knowledge of recent occasions or current Alzheimer disease. Some assistance with day-to-day activities be- Mild cognitive decline comes essential • Problems with memory or concentration; may be measur- • Individuals may: able in clinical testing or apparent during a detailed medi- • Be unable during a medical interview to recall such cal interview. Depression Box 9-6 Multi-Infarct versus Depression can produce confusion, especially in the Alzheimer-Type Dementia elderly. A past history Abrupt onset 2 of psychiatric problems, including undiagnosed de- Stepwise deterioration 1 pressive episodes, is common. During mental status Fluctuating course 2 Emotional lability 1 examination, the patient tends to highlight disabilities, Relative preservation of personality 1 especially memory loss. The cognitive losses, how- Somatic complaints 1 ever, are fuctuating rather than stable over time. The History of hypertension 1 patient manifests a depressed or anxious mood, includ- History of strokes 2 ing sleep and appetite disturbance.
Needle access to the synovial sacroiliac joint is sometimes problematic because of the irregular and meandering joint line and the fact that much of the synovial portion of the joint lies anterior to the sacro- iliac ligament generic 20mg feldene otc arthritis medication that causes cancer. Therefore buy on line feldene rheumatoid arthritis pleural effusion, disc T9 T9 protusion at L4-L5 compresses L5 spinal T10 nerve purchase feldene with a visa rheumatoid arthritis antibodies, not L4 spinal nerve generic feldene 20 mg with amex chinese arthritis relief hand movements. T11 Lumbar T12 enlargement T12 L1 Conus medullaris L4 (termination of L1 spinal cord) L4 L2 L2 L3 L5 L3 L5 Cauda equina Internal terminal L4 filum (pial part) L4 L5 S1 L5 Sacrum S2 S1 S3 External S2 terminal filum (dural part) S3 S4 Termination of S4 dural sac S5 S5 Coccygeal nerve Coccygeal nerve Coccyx Cervical nerves Central disc protrusion at L4-L5 uncommonly affects Thoracic nerves L4 spinal nerve, but may cause cauda equina Lumbar nerves syndrome with entrapment of L5 and S1-S4 spinal Sacral and coccygeal nerves nerves. The spinal cord gives rise to 31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal  (Fig. Spinal nerves exit the spinal cord and course outward to the peripheral body through intervertebral foramina which begin at C2/C3. The frst intervertebral neural foramen is formed at C2/C3 and transmits the C3 nerve root . There are no neural foramina above C2/C3, and the spinal nerve roots of C1 and C2 lie posterior to the atlanto-occipital and atlantoaxial joints, respectively. Spinal nerve roots from C3 to L5 exit anterior to the zygapophysial joints through the neural foramina (Figs. Each spinal nerve consists of a dorsal and a ventral root which come together to create a short, unifed segment within the intervertebral neural foramen. This short, intraforaminal segment is the spinal nerve proper although it is sometimes imprecisely referred to as the spinal nerve root. The dorsal roots contain primarily afferent axons which originate from pseudounipolar neurons with cell bodies contained within the dorsal root ganglion. The Spinal Cord and Its Coverings These pseudounipolar neurons include A-delta and C fber pain afferents whose peripheral processes advance outward The relatively substantial dura mater surrounds the brain with the peripheral mixed nerves and whose central pro- and the spinal cord and contains the central nervous sys- cesses synapse with ascending pain afferents within the spi- tem within a single compartment flled with cerebrospinal nal cord dorsal horn as depicted schematically in Fig. Cephalad the spinal dura mater is bound to the edges Each dorsal root typically fans out into six or eight rootlets of the foramen magnum and to the posterior aspects of the which enter the cord in a vertical row. The spinal dura is then con- The frst cervical nerve is called the suboccipital nerve tiguous with the intracranial dura which continues intra- and is primarily motor with the dorsal primary ramus supply- cranially to surround the brain. The second cervical into the sacrum and ends with the flum terminale at nerve is a larger mixed sensory-motor nerve with a promi- approximately S1/S2 (Fig. The spinal fuid is cre- nent dorsal root ganglion which lies directly dorsal to the ated in the third, fourth, and lateral ventricles of the brain atlantoaxial joint. The medial branch of the dorsal primary by the actions of the highly vascular choroid plexuses. Other causes for chronic occipital pain may within the cranium associated with the cardiac cycle. There include injury or arthritis involving the atlanto-occipital, is a secondary slow circulation of spinal fuid throughout the atlantoaxial, and/or upper cervical zygapophysial joints. Cervical disc herniation may also cause pain referred into the Radioactive tracers injected into the lumbar intrathecal space occipital region. The Since there are seven cervical spinal levels and eight cer- spinal fuid is reabsorbed into the venous circulation through vical spinal nerves, the spinal nerve numbering convention is the arachnoid granulations which are located primarily different in the cervical region from that in the thoracic and within the superior sagittal sinus. The frst cervical foramen occurs at C2/ fuid is approximately 150 mL with 125 mL surrounding the C3 and transmits the C3 spinal nerve. C4 exits the C3/C4 foramen, and C7 exits the C6/C7 fora- The epidural space extends from the level of C1 down to men). Numbering changes at the C7/T1 foramen where the the sacral hiatus and encircles the spinal dura in a circumfer- C8 nerve exits since from T1/T2 and below, the numbering ential manner (Fig. The space is flled potential space between the closely apposed dura and arach- with fat, connective tissue, and a venous plexus. This space can bands may course through the epidural space, binding the sometimes be inadvertently entered with needles or catheters dura to the interior walls of the spinal canal. Nerve root flling not clearly identifed as in Anterior posterior view of lumbar myelogram demonstrating normal myelogram (c). Lateral demonstrating ventral deformities of the thecal sac at the L3/L4 and L4/ view of lumbar myelogram demonstrating ventral deformities (white L5 levels (d) (Adapted from Botwin  and Manchikanti and Singh arrows) of the thecal sac at the L3/L4 and L4/L5 levels (b). A contrast dye local anesthetic injected epidurally or intrathecally, and spread pattern that stops at the upper aspect of C1 is con- unintended subdural injection can sometimes account for sistent with an epidural location, whereas contrast that excessive sensory-motor block after epidural injection pro- extends above C1 is likely intrathecal (Fig. All rights reserved) 7 Anatomy of the Spine for the Interventionalist 85 Blood Supply to the Spinal Cord thoracic cord is most vulnerable to ischemia from hypoten- sion because it is most distant from the lower cervical and The spinal cord receives its blood supply from three longitu- upper lumbar anterior medullary feeding arteries. Since the number and position of segmental medullary The longitudinal arteries include a single anterior spinal spinal feeder arteries is variable and relatively unpredict- artery and two posterior spinal arteries. The anterior spinal able, great care must be taken with any injection into any artery is formed from paired branches which exit the bilat- intervertebral neuroforamen. The foramina most likely to eral vertebral arteries just prior to their anterior convergence contain these arteries are in the lower cervical, lower tho- to form the basilar artery (Fig. These paired branches racic, and upper lumbar regions of the spine, although any course caudally and unite in the anterior midline to form the intervertebral foramen may contain a feeding spinal artery single anterior spinal artery. These mid-thoracic region of the cord is considered to be the “vul- arteries typically anastomose with the anterior spinal arter- nerable zone” with respect to circulation and is most easily ies and provide direct routes for blood fow into the paren- damaged by severe hypotension. Any particulate matter (including rior spinal artery that penetrate the cord parenchyma are end particulate steroid) has the potential to occlude the distal arteries and do not anastomose further. There have which supply blood to the exiting spinal nerve roots at every been a number of cases of paralysis and death associated level. These segmental radicular arteries enter the spinal with inadvertent injection of particulate steroid into intrafo- canal through the neuroforamina to arborize around and pen- raminal segmental spinal feeding arteries during interven- etrate the parenchyma of the spinal nerve roots and supply tional pain procedures [9–13]. In the cervi- cal region, the segmental radicular arteries may originate from the vertebral arteries or less commonly from ascending Key Points or deep cervical arteries. In the thoracic region, the segmen- tal arteries originate from the posterior intercostal arteries 1. It is crucial for the spinal injectionist to have a detailed which branch directly from the aorta, and in the lumbar understanding of spinal anatomy. The spinal column is a complex structure consisting of In addition, the anterior spinal artery is reinforced at a multiple bones, ligaments, and intervertebral discs, number of levels by feeder arterial branches from various which are functionally integrated to facilitate upright arteries including lumbar arteries, intercostal arteries, and locomotion and to provide protection for the spinal cord. The image appearing on the fuoroscopic monitor is a mental anterior medullary arteries” and are important to the composite representation of the overlapping tissue den- spinal injectionist because they constitute a direct route for sities that lie between the x-ray tube and the image delivery of potentially damaging particulate medication into intensifer. The prototypical vertebra is composed of an anterior of eight anterior medullary feeder arteries (inclusive of all cylindrical block of bone called the vertebral body which spinal levels bilaterally), the largest of which is the great is connected to the posterior neural arch by the pedicles. Fluoroscopically, the pars interarticularis is represented total number of anterior medullary feeder arteries varies by the neck of the “Scotty dog,” and a pars defect appears from 2 to 17 in different individuals, with an average of three as a “collar” on the dog’s neck. The artery of Adamkiewicz typically in part to transmit weight from the upper body to the enters the cord on the left side (77% of specimens) anywhere lower extremities through the sacroiliac joints. The spinal cord begins within the skull, exits the fora- may be the main blood supply to the lower 2/3 of the spinal men magnum, and ends with the flum terminale at cord. In the cervical region, the largest anterior medullary approximately L1/L2, giving rise to 31 pairs of spinal arteries typically enter at C4/C5 or C5/C6 . Schultz Posterior spinal arteries Anterior spinal artery Anterior segmental medullary artery Anterior radicular artery Posterior radicular artery Branch to vertebral body and dura mater Spinal branch Dorsal branch of posterior intercostal artery Posterior intercostal artery Paravertebral anastomoses Prevertebral anastomoses Thoracic (descending) aorta Section through thoracic level: anterosuperior view Right posterior spinal artery Sulcal (central) branches to right side of spinal cord Peripheral branches from pial plexus Posterior radicular artery Sulcal (central) branches to left side of spinal cord Anterior segmental Left posterior spinal artery medullary artery Pial arterial plexus Anterior and posterior radicular arteries Anterior spinal artery Posterior radicular artery Arterial distribution: schema Anterior segmental medullary artery Note: All spinal nerve roots have associated radicular or Pial arterial plexus segmental medullary arteries. Both types of arteries run along roots, but radicular arteries end before reaching anterior or posterior spinal arteries; larger segmental medullary arteries continue on to supply a segment of these arteries. All rights reserved) 7 Anatomy of the Spine for the Interventionalist 87 Crura of diaphragm Posterior longitudinal ligament Psoas Dura Pedicle Internal vertebral plexus of veins in extradural space Aorta Ligamenta flava Cauda equina Interspinous ligament Supraspinous ligament Quadratus lumborum Erector spinae Vein muscles Lumbar artery Intervertebral foramen Intervertebral disc Vertebra Skin Lamina Fig. Cervical transforaminal epidural injections are associ- vertebral bodies from C2 to the sacrum with a central ated with extremely high risk.
Clinical Manifestations Patients commonly are asymptomatic order feldene with amex treating arthritis of the knee, and the tumor is seen as an incidental finding on 2D echocardiography discount feldene 20 mg with visa arthritis pain diet mayo clinic. When symptoms are present discount 20mg feldene mastercard arthritis pain homeopathy, dyspnea discount feldene 20 mg with amex arthritis fingers crooked, especially dyspnea that is worse while lying on the left side, should alert the astute clinician to the possibility of a myxoma. Most clinical presentations related to myxoma result from mitral valve obstruction (syncope, dyspnea, and pulmonary edema) 17,19 followed by embolic manifestations. Less commonly they may have thrombocytopenia, clubbing, cyanosis, or Raynaud phenomenon. Physical examination findings can reveal a systolic or diastolic murmur suggestive of mitral stenosis. A tumor “plop” may also be heard (a low-pitched diastolic sound heard as the tumor prolapses 17,19 into the left ventricle). The most common auscultation findings are a systolic murmur (in 50% of cases) followed by a loud first heart sound (32%), 19 an opening snap (26%), and a diastolic murmur (15%). The reason for the systolic murmur may be damage to the valves, failure of the leaflets to coapt, or narrowing of the outflow tract by the tumor. A diastolic murmur is present due to obstruction of the mitral valve by the myxoma. Tumor plop may be 20 confused with a mitral opening snap or a third heart sound; it can be detected in up to 15% of cases. Involvement of cerebral vessels results in neurologic signs; involvement of coronary arteries may result in an acute coronary syndrome; intestinal arterial obstruction may result in an ischemic bowel; and peripheral arterial obstruction can result in limb-threatening ischemia. Chest x-ray findings are also nonspecific and include signs of congestive heart failure, cardiomegaly, and left atrial enlargement. A 2D echocardiogram usually should demonstrate a mass in the atrium, with the stalk attached to the interatrial septum (see Fig. Generally, after median sternotomy, the myxoma is surgically excised using cardiopulmonary bypass and cardioplegic arrest. The tumor is removed by either right or left atriotomy or combined atriotomy, depending on the site and extent of the tumor. Atrial myxomas can also be approached via sternal sparing or minimal access approaches. Using a right limited thoracotomy and peripheral cannulation, patients are placed on cardiopulmonary bypass; cold fibrillatory arrest or cardioplegic arrest may then be used, the atria may be explored, and complete removal of the mass and reconstruction of any defects may be performed. This approach is limited in that only mitral and tricuspid valvulopathy can be corrected. The choice of technique also depends on associated conditions that need surgical intervention, such as valve repair or replacement, and coronary disease if present. Lifelong follow-up is needed because myxomas have some tendency to recur, at rates 19,20 from 5% to 14%. Rhabdomyomas Rhabdomyomas are usually found in the ventricle and are the most common benign cardiac tumor found in 14,15 14 children. The majority of these patients have signs of or a family history of tuberous sclerosis. In one study of patients with tuberous sclerosis complex, a cardiac tumor was found in 48% of the patients, with 21 an incidence of 66% in patients less than 2 years old. Frequently, these patients are asymptomatic, 14,21 although some patients with rhabdomyoma may present clinically with arrhythmias and heart failure. As a result of these uncertain outcomes, long-term clinical and echocardiographic follow-up is needed in patients with tuberous sclerosis. Most often, surgery can be avoided, although if arrhythmias become a symptomatic 14 problem, antiarrhythmics and ultimately surgery may have to be considered. Fibromas Fibromas are histologically composed primarily of fibroblasts or collagen. Typically they occur in 12,17,22 children, although they can also occur in adults. Most often a fibroma is located in the ventricle and interventricular septum, and patients may present with chest pain, pericardial effusion, heart failure, or arrhythmias; the first manifestation may also be sudden death. Cardiomegaly is frequently seen on chest x- 22 ray, which may also show the calcification within the tumor mass. Typically, these tumors are associated with arrhythmias and might require multimodality treatment with medications, electrophysiologic procedures, and/or surgery. A distinguishing 12 feature of fibromas, contrasted to rhabdomyomas, is that there is frequently calcification. Lipomas 23 A lipoma is a rare benign cardiac tumor; it makes up only 3% of all benign tumors. Lipomas tend to occur in the left ventricle or the right atrium but may be found anywhere in the heart, as well as the pericardium (Fig. Although frequently asymptomatic, they may grow large enough to cause obstructive symptoms. B, Hematoxylin-and-eosin staining depicts mature adipocytes in the tumor with an associated vascular supply (×200). Papillary Fibroelastomas Valvular structures may have a papillary fibroelastoma, which is often found incidentally. They are small in size, typically less than 2 cm, and most commonly occur on the aortic valve, followed by the mitral valve. Most fibroelastomas that have been 24 reported are solitary; multiple ones have been reported rarely. Fibroelastomas may result in embolic phenomena, and when situated on the aortic valve, can cause coronary ostial occlusion. Grossly, a papillary fibroelastoma has a characteristically frondlike appearance, resembling a sea anemone, and histologically it has an inner central core of collagen surrounded by a layer of acid mucopolysaccharides 24 and covered by endothelial cells. For the most part, complete surgical resection is recommended, mainly due to the high likelihood of a systemic embolism (i. A recent report with clinical outcomes of a large population of patients with papillary fibroelastomas indicated that rates of cerebrovascular accident or death were increased if 25 surgical removal was not performed. On imaging, especially echocardiographic imaging, there is a characteristic small, mobile, pedunculated, and very echocardiographically dense core that enables the tumor to be differentiated from a vegetation or thrombus. Once the tumor has been completely removed, the chance at recurrence appears low, and there are no compelling data for continuing anticoagulation 24 over the long term unless there are other indications to do so. Paragangliomas 28,29 Paragangliomas are highly vascular tumors and may present with hypertension and chest pain. The 29 tumor may be located in the pericardial space with no intracardiac extension. Paragangliomas are often located around the roof of the left atrium and aortic root and may involve the cardiac structures (eFig. The tumors originating from the roof of the left atrium are often large and require extensive 30 surgery, including cardiac autotransplantation.