Jeffrey Sellers, MD
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Incidentally, there are gliotic changes within the inferomedial frontal lobes, suggestive of unrelated prior traumatic injury. Perineural unfold is seen manifesting as cordlike thickening of V3 (thick arrows), positioned alongside the medial side of the lateral pterygoid muscle stomach (thin arrow; b). Without fats suppression, the involved muscle tissue are indistinguishable from fat and might be confused with fatty infiltration from extra continual denervation. There is superb differentiation of the intermediate to excessive sign tumor centrally (T) from the very excessive sign secretions in the left maxillary sinus and proper ethmoid air cells (arrowheads; a). Small areas with decrease sign on T2-weighted images in some uninvaded left ethmoid air cells have corresponding excessive sign on precontrast T1-weighted images, consistent with inspissated secretions somewhat than tumor (thick arrow; a,b). The distinction is much less clear on the postcontrast images due to tumoral and mucosal enhancement as nicely as the intrinsically excessive sign of those secretions on T1. Note artefactual sign abnormality within the inferomedial proper orbit on the fat-suppressed T2-weighted picture (thin arrow; b), related to inhomogeneous fat suppression ensuing from magnetic susceptibility artifact on the air�bone interface of the normal proper maxillary sinus. However, tumor spread and invasion of sentimental tissues is often greatest depicted overall on fat-suppressed postcontrast T1-weighted pictures and all sinus and neck protocols should embody a postcontrast acquisition with fats suppression. Once once more, one can leverage the intrinsic sign differences between tumor and fats to assist identification of marrow invasion. Bone marrow invasion will appear comparatively hyperintense on T2-weighted images and will enhance, resulting in a high signal, after administration of contrast. This is because reactive marrow edema will appear hyperintense on T2-weighted images and enhance. Tumor (T) fills a lot of the sinus, and has intermediate signal almost isointense to skeletal muscle. There is lobular, irregular extension of the mass into the premaxillary soft tissues, together with the expected location of the infraorbital nerve, deep to the levator labii superioris alaeque nasi muscle (thick black arrows). There is obliteration of the conventional excessive marrow signal in the right zygoma (black arrowhead) secondary to tumor invasion, in addition to encroachment of intermediate-signal tumor into the high-signal retromaxillary fats (white arrow). Tumor (T) extends outside the sinus with extensive involvement of the subcutaneous tissues and muscles of facial expression (white and black thin arrows) as properly as the maxillary alveolus marrow (white arrowheads). However, postcontrast T1-weighted photographs with out fats suppression additionally play an important complementary function, notably for the evaluation of perineural unfold of tumor. As such, some teams routinely carry out a minimal of one set of postcontrast but non�fat-suppressed T1-weighted images, sometimes in the coronal aircraft, in all studies evaluating the skull base and paranasal sinuses. It must be famous that thin linear dural enhancement alone is insufficient to diagnose dural invasion and could be reactive. The orbital periosteum, also referred to as the periorbita, is steady with the dura and the optic nerve sheath at the orbital apex. This sturdy layer is loosely adherent to the osseous orbit and supplies a displaceable barrier to tumor spread. Lymphatic spread is related to the extension of the primary tumor to the skin floor, alveolar buccal sulcus, or pterygoid musculature. Note loss of regular high-signal fat in the marrow of the sphenoid body (white arrows) in addition to early extension into the right pterygopalatine fossa (arrowhead). Most commonly, perineural spread of tumor along nerve bundles is in a central direction towards the skull base, although there may also be retrograde spread of tumor. Early signs of perineural spread of tumor are differential enhancement of major nerve bundles relative to the contralateral facet and early asymmetry secondary to infiltration of tumor density or signal tissue. In this regard, comparability with the contralateral facet is essential and may be very useful. When extra advanced, the nerve bundle can be grossly enlarged and if massive enough there can be reworking and expansion of the bony foramen. Note the graceful, low-signal orbital margins on both sequences, representing orbital cortex and adjacent orbital periostium (also referred to as periorbita, white arrows). T1-weighted pictures in particular reveal regular high-intensity extraconal fats (arrowheads; b) in contrast to sinonasal mucosa, cortex, periorbita, and extraocular muscle tissue. Limited bone erosion, aside from involvement of the posterior wall of the maxillary sinus and the adjacent pterygoid plates, denotes T2. T4a, reasonably advanced native illness, is distinguished by invasion of anterior orbital contents, pores and skin of the cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid, or frontal sinuses. T staging for nasal cavity and ethmoid sinus lesions is decided with a separate categorization system. Sinonasal neuroendocrine tumor (T) of the superior nasal cavity and ethmoid air cells on a fat-suppressed contrast-enhanced T1-weighted image in the coronal plane is shown. A focal area of nodular tumor tissue protrudes into the medial right orbit (white arrows), suggesting orbital invasion. Subsites of the nasal cavity embrace the septum, flooring, lateral wall, and vestibule. T2 tumors can invade two subsites in a single region or a single subsite with the involvement of an adjacent area in the nasoethmoidal advanced. Involvement of the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate denotes T3. T4a tumors invade anterior orbital contents, skin, pterygoid plates, sphenoid, or frontal sinuses. T4b lesions, much like maxillary sinus tumors, may invade the orbital apices, dura, mind, middle cranial fossa, cranial nerves other than V2, the nasopharynx, or the clivus. In regional lymph node staging, N1 denotes a single ipsilateral lymph node metastasis measuring 3 cm or less in biggest dimension. Multiple ipsilateral lymph nodes measuring not extra than 6 cm are considered to mirror stage N2b, whereas bilateral or contralateral lymph nodes measuring up to 6 cm are characterised as stage N2c. Metastasis to distant websites, together with lymph nodes beyond the cervical chain or to other organs, defines stage M1. Limited brain involvement can be managed with endoscopic or transcranial frontal lobe resection to obtain unfavorable margins. Various forms of maxillectomy are carried out relying on the extent of tumors involving the maxillary sinus, ground of the nostril, or hard palate, usually through a combined transoral, lateral rhinotomy procedure referred to as the Weber-Ferguson method. For tumors involving the frontal sinuses, the midpoint of the orbital roof is considered the purpose of maximum lateral access for an endoscopic endonasal strategy. Contraindications to a purely endoscopic strategy embrace dural involvement beyond the mid-orbit, invasion of skin, orbital invasion, maxilla involvement beyond the medial wall, or important mind involvement. Following resection, adjuvant radiotherapy is usually delivered to the operative bed and/or draining lymph nodes, relying on specific threat factors. Treatment of the operative bed is indicated for shut or optimistic margins, T3/T4 stage, and can be thought of for tumors with perineural invasion, lymphovascular invasion, or excessive histologic grade. A typical postoperative scientific target volume encompasses each halves of the nasal cavity and the ipsilateral maxillary sinus. The ethmoid sinuses and the ipsilateral medial orbital wall are additionally included if tumor includes the ethmoid air cells. Any tumor with documented perineural extension necessitates generous protection of the cranium base with extension of the scientific goal quantity to the appropriate neural foramina. Treatment to the regional lymph nodes is indicated for node-positive illness and can be thought of in the setting of a T3/T4 primary tumor. An extra margin is added to all clinical target volumes so as to account for day by day setup variation, and the ultimate volumes are referred to because the planning target volumes.
Both nerves are derived from anterior divisions in the lumbosacral plexus, indicating a primitive flexor origin for both components of the muscle. Table 18: Muscles of medial thigh: adductors of thigh Proximal attachment Distal attachment Innervationb Main action Musclea Adductor longus Body of pubis inferior Middle third of linea aspera Obturator nerve, department of, Adducts thigh to pubic crest of femur anterior division (L2, L3, L4) Adductor brevis Body and inferior Pectineal lines and proximal Adducts thigh; to some ramus of pubis part of linea aspera of femur extent flexes it Adductor half: obturator Adducts thigh Adductor magnus Adductor half: inferior Adductor part: gluteal ramus of pubis, ramus tuberosity, linea aspera, nerve (L2, L3, L4), branches of Adductor half: flexes thigh of ischium medial supracondylar lines posterior division Hamstring part: tibial a part of Hamstrings half: extends Hamstrings part: ischial Hamstring half: aductor tuberosity tubercle of femur sciatic nerve (L4) thigh Gracilis Body and inferior Superior part of medial Obturator nerve (L2, L3) Adducts thigh; flexes leg; ramus of pubis floor of tibia. Profunda femoris artery is the main blood supply � Adductor magnus is the largest muscle and is a hybrid muscle having two components. They cross each hip and knee joints, and integrate extension at the hip with flexion at the knee. As the muscular tissues span the back of the knee, they form the proximal lateral and medial margins of the popliteal fossa. Actions of posterior thigh muscle tissue performing from above, the posterior thigh muscle tissue flex the knee. Acting from beneath, they prolong the hip joint, pulling the trunk upright from a stooping posture towards the influence of gravity, biceps femoris being the principle agent. When the knee is semi-flexed, biceps femoris can act as a lateral rotator and semimembranosus and semitendinosus as medial rotators of the lower leg on the thigh on the knee. When the hip is prolonged, biceps femoris is a lateral rotator and semimembranosus and semitendinosus are medial rotators of the thigh. Some authors equate sacrotuberous ligament with the degenerated developmental remnant of the tendon of the lengthy head of the biceps femoris. Biceps femoris Long head: ischial tuberosity Short head: linea aspera and lateral supracondylar line of femur Collectively these three muscles are generally known as hamstrings the spinal twine segmental innervation is indicated. Semimembranosus � Hamstrings are: semitendinosus, semimembranosus, long head of biceps femoris and posterior a half of adductor magnus. Proximal flashy distal skinny � Semitendinosus is fleshy within the upper part and forms a cord-like tendon in the lower part, which lies posterior to semimembranosus muscle. Hip extension and knee flexion � Biceps femoris is doubtless one of the hamstring muscle tissue together with semitendinosus, semimembranosus, and ischial head of the adductor magnus, which lengthen the thigh on the hip and flex the leg on the knee. S2"s means that the nerves supplying the piriformis are derived from the first two sacral segments of the spinal cord). Damage to one or more of the listed spinalcord segments or to the motor nerve roots arising from them. Iliotibial tract � For gluteus maximus insertion, most fibers end in iliotibial tract, which inserts into lateral condyle of tibia; some fibers insert on gluteal tuberosity. Gluteus medius � Gluteus medius attaches to the lateral surface of higher trochanter. Superior gluteal nerve provides three muscles: gluteus medius, gluteus minimus and tensor fascia lata. Anterior and Lateral Leg Muscles of the leg consist of an anterior group of extensor muscles, which produce dorsiflexion (extension) of the ankle; a posterior group of flexor muscle tissue, which produce plantar flexion (flexion); and a lateral group of muscular tissues, which evert the ankle and that are derived, embryologically, from the anterior muscle group. In the anterior compartment two of the muscle tissue, extensor digitorum longus and extensor hallucis longus, also lengthen the toes, and two muscular tissues, tibialis anterior and fibularis tertius, have the additional actions of inversion and eversion, respectively. The lateral compartment contains fibularis (peroneus) longus and fibularis (peroneus) brevis. Table 21: Muscles of anterior and lateral compartments of leg Muscle Proximal attachment Anterior compartment Lateral condyle and superior Tibialis anterior (1) half of lateral surface of tibia and interosseous membrane Extensor digitorum longus (2) Extensor hallucis longus (3) Fibularis tertius (4) Lateral compartment Fibularis longus (5) Fibularis brevis (6) Lateral condyle of tibia and superior three quarters of medial floor of fibula and interosseous membrane Middle a part of anterior floor of fibula and interosseous membrane Inferior third of anterior floor of fibula and interosseous membrane Head and superior two thirds of lateral floor of fibula Inferior two thirds of lateral floor of fibula Distal attachment Medial and inferior surfaces of medial cuneiform and base of 1st metatarsal Middle and distal phalanges of lateral four digits Innervationa Main action Deep fibular nerve Dorsiflexes ankle and (L4, L5) inverts foot Extends lateral 4 digits and dorsiflexes ankle Dorsal side of base of distal Extends nice toe and phalanx of nice toe (hallux) dorsiflexes ankle Dorsum of base of fifth metatarsal Dorsiflexes ankle and aids in eversion of foot Base of 1 st metatarsal and Superficial fibular Everts foot and weakly medial cuneiform nerve (L5, S1, S2) plantarflexes ankle Dorsal surface of tuberosity on lateral side of base of 5th metatarsal 954 a the spinal twine segmental innervation is indicated. L5" signifies that the nerves supplying the tibialis anterior are derived from the fourth and filth lumbar on the spinal cord). Damage to a quantity of at the listed spinal cord segments or to the motor nerve roots arising from them leads to paralysis of the muscular tissues involved. Inversion of foot � Tibialis anterior is a muscle of anterior (extensor) leg compartment for extension (dorsiflexion) at the ankle joint. Peroneus brevis � Peroneus longus and brevis cause eversion of foot at subtalar joint. Maintains arches of foot � Peroneus longus causes foot eversion and maintains lateral longitudinal and transverse arches of foot. Self Assessment and Review of Anatomy When the foot is off the ground, each flexor hallucis longus and flexor digitorum longus muscles flex the phalanges, appearing When the foot is on the ground and beneath load, they act synergistically with the small muscles of the foot and, especially within the case of flexor digitorum longus, with the lumbricals and interossei to maintain the pads of the toes in agency contact with the bottom, enlarging the weight-bearing area. It rotates the tibia medially on the femur or, when the tibia is mounted, rotates the femur laterally on the tibia. It retracts the posterior horn throughout lateral rotation and persevering with flexion, via its attachment to the lateral meniscus, and so prevents traumatic compression. It supplies dynamic stability to the posterolateral a part of the knee by stopping extreme lateral rotation of the tibia, partly by its direct motion, however more considerably by tensing the popliteofibular ligament. Table 22: Superficial muscles of posterior compartment of leg Muscle Gastrocnemius (1) Proximal attachment Lateral head: lateral aspect of lateral condyle of lemur Medial head: popliteal floor of femur; superior to medial condyle Soleus (2) Posterior facet of head and superior quarter of posterior surface of fibula; soleal line and middle third of medial border of tibia; and tendinous arch extending between the bony attachments Inferior finish of lateral supracondylar line of femur; indirect popliteal ligament Distal attachment Posterior surface of calcaneus via calcaneal tendon Innervationa Tibial nerve (S1, S2) Main motion Plantarflexes ankle when knee is extended; raises heel during walking; flexes leg at knee joint Plantarflexes ankle unbiased of position of knee steadies leg on foot Weakly assists gastrocnemius in plantarflexing ankle totally on the distal phalanges. It is a vestigial muscle (absent in 5�10% population), tendon is used for grafting. Soleus is called peripheral coronary heart, because it helps pumping the blood in the circulatory system. S3) of tibia inferior to soleal line; by a of lateral 4 digits broad tendon to fibula Tibialis posterior lnterosseous membrane: posteri- Tuberosity of navicular. Tibial nerve Plantarflexes ankle: inverts foot (6) or surf ace of tibia inferior to sole cuneiform. Plantaris � Plantaris is a muscle of calf area, which get stretched in dorsiflexion, and might get ruptured. Plantaris � the only muscle tissue which cross the knee joint in addition to ankle joint are gastrocnemius & plantaris. Inserted on medial meniscus � Popliteus muscle is inserted to lateral meniscus of knee joint. Talus bone in the foot and Incus bone within the middle ear cavity has no has no muscle attachments. Iliotibial Tract Iliotibial tract is the thickening of fascia lata on the lateral floor of thigh. It originates on the anterolateral iliac tubercle portion of the exterior lip of the iliac crest and inserts on the on the anterolateral the higher finish of the tract splits into two layers, where it encloses and anchors tensor fasciae latae and receives, posteriorly, Some deeper fibres are attached to the capsule of the hip joint. Iliotibial tract stabilizes the knee both in extension and in partial flexion; works continuously throughout strolling and operating. On leaning ahead with slightly flexed knees the iliotibial tract is the primary support of the knee towards gravity and prevents the individuals from falling forward. Trendelenburg Test Three muscular tissues (gluteus medius, gluteus minimus and tensor fascia lata) perform three actions and are provided by a the three activities (hip abduction, medial rotation and pelvic rotation) are proven beneath. This is generated by the other aspect muscle tissue (gluteus medius and minimus) by causing pelvic rotation. The muscles pull the left hip bone down, in order that the right hip bone goes up (pelvic rotation) and balance the gravity on proper facet pelvis Trendelenburg test is used to assess hip stability. In regular perform, the hip is held secure by gluteus medius appearing as an abductor in the supporting leg. If the pelvis drops on the unsupported facet - positive Trendelenburg signal - the hip on which the affected person is standing is painful or has a weak or mechanically-disadvantaged gluteus medius. In strolling, gravity tends to tilt pelvis and trunk to the unsupported facet, major factor in stopping this unwanted motion is: a.
Each opens into the vestibule by a 2 cm duct, located within the groove between the hymen and the labium minora. The epithelium of the Bartholin duct is cuboidal close to the gland, however turns into transitional and finally stratified squamous near the opening of the duct. Perineal physique � the female exterior genitalia (or vulva/pudendum) consists of a vestibule of vagina and its surrounding buildings similar to mons pubis, labia majora, labia minora, clitoris, vestibular bulb and pair of larger vestibular glands. Located at the junction of anterior 1/3 and center 1/3 of labia majora � Bartholin gland is situated on the junction of middle 1/3 and posterior 1/3 of labia majora. Perineum Perineum is the diamond-shaped area between the thighs, which corresponds to the outlet of the pelvis and presents It contains perineal pouches (superficial and deep); ischiorectal fossa; pudendal canal and anal canal. Boundaries: Anterior: Pubic symphysis, arch and the arcuate ligament Anterolateral: Ischiopubic rami Lateral: Ischial tuberosities Postero-lateral: Sacrotuberous ligaments Posterior: Tip of the coccyx Floor: Skin and fascia Roof: Pelvic diaphragm and associated fascia It is divided into an anterior urogenital triangle and a posterior anal triangle by a line drawn throughout the floor connecting the ischial tuberosities. Pelvis Perineal Pouches Urogenital triangle incorporates the superficial and deep perineal pouches (spaces): Superficial Perineal Pouch It lies between the perineal membrane (inferior fascia of the urogenital diaphragm) and the Colles fascia (membranous layer of superficial perineal fascia). It is an open compartment, because of the truth that anteriorly, the house communicates freely with the potential house lying between the superficial fascia of the anterior abdominal wall and the anterior stomach muscle tissue. The superficial perineal muscles are removed within the left of the diagram to present crus and bulb of the penis. The superficial perneal muscles have been eliminated within the left half of the diagram to show bulb of the vestibule and larger vestibular gland. Deep perineal pouch is enclosed in part by the perineum, and located superior to the perineal membrane (inferior fascia It lies between the superior and inferior fasciae of the urogenital diaphragm. Recently the deep pouch is being described as the area between the perineal membrane and pelvic diaphragm. It incorporates muscle tissue like external urethral sphincter and deep transverse perinei, attaching to the perineal physique. The ducts move by way of the perineal membrane to attain superficial perineal pouch and open into the bulbous portion of the spongy (penile) urethra. Clinical Correlations � Episiotomy is a surgical incision of the perineum (and the posterior vaginal wall) to enlarge the vaginal opening throughout childbirth. Perineal Fascia Perineal fascia has two parts (superficial and deep) and each of these could be subdivided into superficial and deep elements. Posteriorly, it curves around the superficial transverse perineal muscle to be a part of the decrease margin of the perineal membrane. It emerges from the inferior side of the perineal membrane and continues along the ventral (inferior) penis with out covering the scrotum. It separates the skin and subcutaneous fats from the superficial perineal pouch and covers the muscular tissues in the pouch. It turns into continuous with the dartos tunic of the scrotum, with the superficial fascia of the penis, and with the Scarpa fascia of the anterior abdominal wall. Straddle injuries may rupture of the bulbous spongy urethra under the perineal membrane, leading to extravasation of urine into the superficial perineal pouch, which may unfold inferiorly into the scrotum, anteriorly across the penis, and superiorly into the lower part of the abdominal wall. Location: It is the roof (superior boundary) of the superficial perineal pouch, and the ground (inferior boundary) of the deep perineal pouch. It is thickened anteriorly to kind the transverse ligament of the perineum, which spans the subpubic angle simply behind the deep dorsal vein of the penis (or clitoris). Apex is directed forward, and is separated from the arcuate pubic ligament by an oval opening for the transmission of the deep dorsal vein of the penis (or clitoris). Lateral margins are connected on either aspect to the inferior rami of the pubis and ischium, above the crus penis. Base is directed towards the rectum, and related to the perineal body, posteriorly. Relations: It is steady with the deep layer of the superficial fascia behind the superficial transverse perineal muscle, and with the inferior layer of the diaphragmatic part of the pelvic fascia. Perforations: It lies between the urogenital diaphragm and the exterior genitalia and is perforated by the urethra (and vagina). Arteries to the bulb, and the ducts of the bulbourethral glands pierce pass through it. It is also pierced by the deep arteries of the penis (or clitoris), one on either facet near the pubic arch and by the dorsal arteries and nerves of the penis (or clitoris) close to the apex of the fascia. Its base is perforated by the perineal vessels and nerves, while between its apex and the arcuate pubic ligament the deep dorsal vein of the penis (or clitoris) passes upward into the pelvis. Membranous urethra � Membranous urethra is a content material of deep perineal pouch, which continues as spongy urethra in superficial perineal pouch. Ischiocavernosus � Muscles in the superficial perineal pouch are ischiocavernosus, bulbospongiosus and superficial transverse perinei. It is contributed by mainly two muscles: sphincter urethrae and deep transverse perinei. Perineal body is a fibromuscular body attached on the posterior border of perineal membrane within the midline. Perineal physique is an effective assist of pelvic viscera and is connected by quite a few muscle tissue of the perineum together with the muscle tissue of urogenital diaphragm � deep transverse perinei and sphincter urethrae. Bulb/Root of penis � Bulb/Root of penis lies in the superficial perineal pouch and never the deep perineal pouch. Sphincter urethrae � Sphincter urethrae (external urethral sphincter) is current in the wall of membranous urethra, in the deep perineal pouch, it additionally extends vertically, around the anterior aspect of the prostatic urethra. Other contents are: Crura of penis (males) / Crura of clitoris (females), bulb of penis (males) / Vestibular bulbs (females), Greater vestibular glands (female). It is a blended (sensory and motor) nerve to provide skin and skeletal muscles of perineum. Anal Triangle and Ischiorectal Fossa Anal Triangle has two elements: Muscles and Ischiorectal fossa Muscles of the Anal Triangle: External anal sphincter, Obturator internus, levator ani and coccygeus muscles. Boundaries: Anterior: Urogenital diaphragm (with perineal membrane) Posterior: Gluteus maximus (and sacrotuberous ligament) Superomedial: Sphincter ani externus and levator ani Lateral: Obturator internus muscle (with obturator fascia) on ischial tuberosity Floor: Skin Roof: Meeting level of obturator fascia (covering obturator internus) and inferior fascia of the pelvic diaphragm (covering levator ani muscle). Contents: Inferior rectal neurovascular bundle (nerve, artery and vein); fat; perineal branches of the posterior femoral cutaneous nerve, and the pudendal canal (with pudendal nerve, internal pudendal artery and vein). Note: Pudendal canal is fashioned either by the splitting of the obturator fascia (or by separation between the fascia lunata and the obturator fascia). Lateral: Obturator internus � Lateral boundaries of ischiorectal fossa is the ischial bone with obturator internus muscle lined by obturator fascia. Posterior labial nerve � Dissection of ischiorectal fossa, could contain harm to inferior rectal, pudendal, posterior scrotal (or labial) nerve and vessels along with perforating branches of S2-S3 and perineal branches of S4 nerve. Obturator fascia � Pudendal canal is formed in the obturator fascia within the lateral wall of the ischiorectal fossa. Lateral: Obturator externus � Obturator internus is present on the lateral wall of ischiorectal fossa. Urinary Bladder and Urethra Urinary Bladder Urinary Bladder is the hollow viscus with distinguished easy muscle (detrusor) partitions which is a brief reservoir for It is located beneath the peritoneum and extends upward above the pelvic brim as it fills; may attain as excessive because the umbilicus the empty bladder is tetrahedral-shaped and consists of a posterior floor, anterior surface, superior surface, apex, and neck. Relations: Posterior surface (Fundus or Base) Upper part is separated from rectum by the rectovesical pouch containing coils of the small intestine. Lower part is separated from rectum by the terminal elements of vas deferens and seminal vesicles. In females the bottom of bladder is separated from the cervix of uterus and by the vesicouterine pouch.
Aorta passes via an intercrural gap posterior to the diaphragm (T-12 vertebra level). Muscular part of diaphragm Oesophagus passes through muscular part of the diaphragm, surrounded by fibres of proper crus and few fibres from left crus often. Azygos vein and thoracic duct the aortic hiatus transmits the aorta, thoracic duct, lymphatic trunks from the decrease posterior thoracic wall and, typically, the azygos and hemiazygos veins. Azygos vein Aorta and thoracic duct cross via the aortic hiatus, which lies posterior to the diaphragm. Azygous vein might move via this opening generally, normally it pierces through the crus of diaphragm to enter the thorax. Greater splanchnic nerve often pierce via the crus of diaphragm to enter the thorax. The respiratory portion consists of the respiratory bronchioles, alveolar ducts, atria, and alveolar sacs. Oxygen and carbon dioxide exchange takes place throughout the wall (blood�air barrier) of lung alveoli and pulmonary capillaries. Trachea (Refer) Right principal bronchus is short (length), wide (lumen) and more vertical (in line with trachea), as in contrast with the left principal bronchus. It branches into 3 lobar bronchi (upper, middle, and lower) and at last into 10 segmental bronchi. The first branch, the superior lobar bronchus, then enters the proper lung reverse the fifth thoracic vertebra. The azygos vein arches over it, and the right pulmonary artery lies at first inferior, then anterior to it (the eparterial bronchus). After giving off the superior lobar bronchus, which arises posterosuperior to the proper pulmonary artery, the best principal bronchus crosses the posterior aspect of the artery, enters the pulmonary hilum posteroinferiorly, and divides into middle and inferior lobar bronchi. It runs inferolaterally inferior to the arch of the aorta, crosses anterior to the esophagus and thoracic aorta and posterior to the left pulmonary artery. It divides into 2 lobar or secondary bronchi, the upper and decrease, and eventually into 8 to 10 segmental bronchi. The branching of segmental bronchi corresponds to the bronchopulmonary segments of the lung. The long axis of right principal bronchus deviates about 25� from the long axis of the trachea, whereas long axis of the left principal deviates about 45� from the long axis of the trachea. Pleura Pleura is a skinny serous membrane around the lungs that consists of a parietal and a visceral layers. Parietal Pleura strains the internal floor of the thoracic wall and the mediastinum and has costal, diaphragmatic, mediastinal, and cervical elements. Parietal pleura is separated from the thoracic wall by the endothoracic fascia, which is an extrapleural fascial sheet lining the thoracic wall. It types the pulmonary ligament, a two-layered vertical fold of mediastinal pleura, which extends along the mediastinal floor of each lung from the hilus to the bottom (diaphragmatic surface) and ends in a free falciform border. It supports the lungs in the pleural sac by retaining the decrease parts of the lungs in position. Visceral Pleura (Pulmonary Pleura) adheres intimately to the lung surfaces and dips into all of the fissures. It accommodates a film of fluid that lubricates the floor of the pleurae and facilitates the motion of the lungs. Costomediastinal recess is slit-like spaces between the costal and mediastinal parietal pleura. During inspiration, the anterior borders of each lungs expand and enter the best and left costomediastinal recesses. In addition, the lingula of the left lung expands and enters a portion of the left costomediastinal recess, causing that portion of the recess to seem radiolucent (dark) on radiographs. According to the floor it strains parietal pleura is split into the next 4 parts: Costal, diaphragmatic, mediastinal and cervical. The cervical pleura (cupula) is the dome of the pleura, projecting into the neck above the neck of the primary rib. It is bolstered by Sibson fascia (suprapleural membrane), which is a thickened portion of the endothoracic fascia, and is attached to the first rib and the transverse strategy of the seventh cervical vertebra. Table 18: Details of pleura of pleura Type Location Development Nerve supply Visceral Lines the surface of the lung Lateral plate mesoderm (Splanchnopleuric layer) Parietal Lines the thoracic wall and mediastinum Lateral plate mesoderm (Somatopleuric layer) � Autonomic (pain insensitive)*: � Sympathetic (T1-5) � Parasympathetic (vagus) � � � � � Somatic (pain sensitive): � Intercostal nerves (T2-5) provide peripheral costal pleura and peripheral portion of diaphragmatic pleura central portion of the diaphragmatic pleura � Phrenic nerve supplies mediastinal central pleura and � Bronchial arteries Arterial supply Internal thoracic Superior phrenic Posterior intercostal Superior intercostal arteries Venous drainage Systemic veins Pulmonary veins *Visceral pleura is delicate to stretch (may be concerned in respiratory reflexes). Clinical Correlations � � Pleuritis (inflammation) involving visceral pleura present with no ache, whereas parietal pleuritis is associated with sharp native pain and referred pain, felt in the thoracic wall (intercostal nerves) and root of the neck (phrenic nerve (C3,4,5). Surgical posterior method to the kidney could harm the pleura in case rib 12 is very brief and rib 11 is mistaken for rib 12. Lungs Lungs are attached to the guts and trachea by their roots and the pulmonary ligaments. The lung bases relaxation on the convex floor of the diaphragm, descend during inspiration, and ascend during expiration. Right Lung as an apex that initiatives into the neck and a concave base that sits on the diaphragm. It is divided into higher, center, and lower lobes by the indirect and horizontal fissures. Left Lung is split into higher and lower lobes by an indirect fissure, is usually extra vertical within the left lung than in the proper lung. Lingula is a tongue-shaped portion current within the higher lobe that corresponds to embryologic counterpart to the best middle lobe. It reveals a cardiac impression, a cardiac notch (a deep indentation of the anterior border of the superior lobe), and grooves for varied structures. It is identical sequence in right lung as well but with the addition of a bronchus above the artery (epi-arterial bronchus). In all these constructions bronchus is the most posterior construction on the lung hilum. There are 2 veins which are named anterior and inferior in accordance with their location at the hilum. Table 19: Arrangement of constructions at the lung hilum Right facet Left side Pulmonary artery Left principal bronchus Inferior pulmonary vein � Eparterial � Pulmonary artery � Hyparterial bronchus � Inferior pulmonary vein In situs solitus, the best principal bronchus is short and eparterial (its branch for the proper upper lobe lies over the second department of the best pulmonary artery) and the left principal bronchus is longer and hyparterial (it courses beneath the left pulmonary artery). In situs ambiguus, the bronchi and lungs can display both a bilateral proper morphology with bilateral trilobed lungs and bilateral eparterial bronchi (heterotaxy syndrome: incomplete or inappropriate lateralization of the thoracic and stomach viscera, and asplenia) or a bilateral left morphology with bilateral bilobed lungs and bilateral hyparterial bronchi (heterotaxy syndrome and polysplenia). Bronchopulmonary Segments 596 the bronchopulmonary section is the anatomical, useful, and surgical unit of the lungs. Thorax It is the wedge formed largest subdivision of a lobe, named according to the segmental bronchus supplying it, and is surgically resectable. It accommodates a segmental (tertiary or lobular) bronchus, a branch of the pulmonary artery, and a branch of the bronchial artery, which run together by way of the central a half of the section, surrounded by a fragile connective tissue (intersegmental) septum. The tributaries of pulmonary veins are intersegmental and lie on the margins of bronchopulmonary segments. They create surgical planes, which a surgeon can observe for segmental resection, with minimal tissue damage. Apical and posterior of left higher lobe sometimes combine into apicoposterior phase. Anterior and medial basal of left lower lobe often combine into anteromedial basal segment.
Computed tomography is remarkable for coarse calcifications of the pancreas and a dilated pancreatic duct with a diameter of 5 mm. Alcohol also causes zymogens to be activated prematurely, leading to autodigestion of the pancreas. Finally, alcohol use causes increased secretion of proteins and ionized calcium from acinar cells with a relative lower in bicarbonate secretion; this results in precipitation of proteins and obstruction of ductules. Contributing elements embrace genetic abnormalities (see later), modest alcohol consumption in prone sufferers, surreptitious alcohol use, trauma, and smoking. This permits elevated activation of assorted zymogens to their lively proteolytic varieties, main in flip to autodigestion of the pancreas. Autoimmune pancreatitis � Autoimmune pancreatitis is a persistent inflammatory and fibrosing disease of the pancreas. The pain is typically epigastric and should radiate to the back and generally around to the flanks in a bandlike method. Malabsorption � Exocrine pancreatic insufficiency sometimes happens after acinar cell reserve is decreased by 90%. Deficiencies in different fatsoluble vitamins � A, E, and K � and vitamin B12 can also happen. Impaired glucose tolerance and diabetes mellitus � Impaired glucose tolerance resulting in diabetes mellitus results from destruction of the islet cells and is similar to sort I diabetes mellitus; nevertheless, alpha cells are additionally destroyed, so patients lose the ability to secrete glucagon, thereby making hypoglycemia more widespread and more severe. Physical examination � the one consistent discovering on physical examination is epigastric tenderness. Diagnosis Imaging � Imaging research are incessantly diagnostic in superior illness. Pancreatography reveals ductal abnormalities including stenoses, dilatation (normal diameter of the main pancreatic duct is as much as 3 mm), and irregularities of the main pancreatic duct and its facet branches. Tests of pancreatic operate � Exocrine pancreatic insufficiency can be recognized instantly by sampling duodenal contents for pancreatic secretions after administration of secretin or cholecystokinin. Patients should bear imaging evaluation for the presence of complicating or concurrent elements, together with pseudocysts, biliary stricture, or pancreatic cancer. General remedy recommendations include abstaining from alcohol and smoking and eating small, frequent lowfat meals to restrict pancreatic enzyme secretion and to cut back symptoms of malabsorption. Uncoated pancreatic enzymes, which suppress the release of cholecystokinin, the hormone that stimulates pancreatic secretion. Tricyclic antidepressant medicine, selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, gabapentin, or pregabalin. Extracorporeal shock wave lithotripsy can also be useful in circumstances of pancreatic duct stones. Maldigestion and steatorrhea: � Pancreatic enzyme replacement with entericallycoated formulations that comprise at least forty 000 U of lipase with every meal is really helpful. Vitamin B12 usually is cleaved from Rproteins by proteases from the pancreas, thereby permitting the B12 to bind to intrinsic factor for absorption within the terminal ileum. Pancreatic insufficiency could cause vitamin B12 deficiency by resulting in lowered cleavage of B12 from Rproteins. A pseudoaneurysm could rupture, inflicting bleeding into the pseudocyst, adjacent viscera, or the peritoneal cavity. They may also bleed into the pancreatic duct, inflicting hemosuccus pancreaticus, which may current as gastrointestinal bleeding. Transgastric or transduodenal endoscopic drainage with placement of conventional stents or lumenapposing stents is often the preferred method. Pancreatic ascites and pleural effusion � Disruption of the pancreatic duct or rupture of a pseudocyst can result in accumulation of pancreatic fluid within the pleural or peritoneal house. Diuretics, serial paracentesis or thoracentesis, and octreotide Chronic Pancreatitis 309 are additionally used. Many sufferers profit from endoscopic placement of a stent throughout a disrupted pancreatic duct. Biliary or duodenal obstruction � Obstruction of the bile duct or the duodenum occurs at rates of 10% and 5%, respectively. Obstruction could additionally be brought on by a pseudocyst or by fibrosis and inflammation in the pancreatic head. Splenic vein thrombosis � Pancreatic inflammation can cause thrombosis of the splenic vein, which programs alongside the posterior facet of the pancreas. Most sufferers die from an associated situation, similar to issues from continued alcohol use or smoking, or from pancreatic most cancers or postoperative issues. Pearls the analysis of chronic pancreatitis requires a excessive index of medical suspicion in a affected person presenting with continual belly pain. Tobacco use and ongoing alcohol use predict a worse prognosis, and sufferers must be encouraged to stop smoking and alcohol consumption. A 55yearold man with alcoholic chronic pancreatitis presents to the emergency department with hematemesis for the previous hour. His blood stress is 92/63 mmHg, pulse fee one hundred fifteen per minute, and respiratory fee 18 per minute. A 58yearold woman is referred for evaluation of a current 30lb weight loss and irregular liver biochemical test results. She has a known historical past of chronic pancreatitis related to chronic tobacco use, and she takes pancreatic enzyme alternative for malabsorption and steatorrhea. The bile duct is 7 mm in diameter in contrast with 5 mm on a earlier imaging research 2 years earlier. Abdominal imaging shows pancreatic calcifications and a dilated pancreatic duct consistent with chronic pancreatitis. A 59yearold man with alcoholic continual pancreatitis presents with a grievance of oily stools seven or eight occasions per day. B Patients with pseudocysts are at risk for having bleeding from both vessels within the pseudocyst or from pseudoaneurysm formation associated to erosion of the pseudocyst into an adjacent vessel. Appropriate treatment would involve embolization of a pseudoaneurysm by interventional radiology. Splenectomy is the therapy of choice for bleeding gastric varices ensuing from splenic vein thrombosis. The affected person presents with weight reduction and rising dilatation of the bile duct, elevating concern for potential malignancy in the head of the pancreas. C the commonest type of persistent pancreatitis in southern India and other tropical areas including Africa, southeast Asia and Brazil, is tropical pancreatitis. Hereditary pancreatitis and autoimmune pancreatitis are potential diagnoses on this case, however as a result of the affected person is from southern India, tropical pancreatitis is extra doubtless. D Patients with continual pancreatitis may have exocrine pancreatic insufficiency, resulting in malabsorption and steatorrhea. The most acceptable remedy is pancreatic enzyme alternative with coated pancreatic enzymes. He describes his stools as watery and small in volume, but denies blood within the stool.
In addition, Balseiro and Nottheimer36 reported two instances of postoperative pain that showed proof of osteolysis seemingly originating from their preexisting subchondral endplate cysts, citing their preoperative existence as a attainable danger factor for subsequent osteolysis. These early reports seemed to suggest affiliation of osteolysis with early unfavorable outcomes with variable longer term implications. They reported minimal associated cage migration or subsidence, though not quantified, and advised the posterior instrumentation stabilized and negated any potential resultant instability. They calculated imply subsidence as 24% (13�40%) versus 12% (11�14%) in the two teams, respectively. The resultant lack of intrinsic power of the graft and endplates was followed by subsidence of the graft and loss of intervertebral height. Eight of the 9 (88%) patients with cage migration required revision secondary to neurological symptoms. Later revisions found the cages fused of their posteriorly migrated place with both cage and heterotopic bone impingement on neural buildings. Placement of cages/spacers at peripheral areas of interbody house is probably much less vulnerable to subsidence if osteolysis occurs. Preexistence of subchondral endplate cysts may be a danger factor for creating adjoining osteolysis. Osteolysis with associated cage migration can be evident at or earlier than 6 weeks postoperative on plain radiographs. Maintaining an increased awareness of those potential issues when osteolysis is current is critical. Cage migration with ensuing radicular ache often, but not all the time, requires revision surgery with worse medical outcomes. Complications of Posterior and Transforaminal Lumbar Interbody Fusion One difficulty in evaluating results of osteolysis is the differing postoperative imaging protocols. No sufferers required revisions for osteolysis, subsidence, or migration, although no medical outcomes were described. Subsequently, reappearance of the pain and incomplete enchancment of the numbness happen. He felt strongly the cause was a traumatic results of overzealous retraction of the nerve roots because of inadequate surgical exposure and advocated a wider exposure with partial facetectomy throughout nerve root decompression. Pheasant and Dyck54 of their 1982 article on failed lumbar disc surgical procedure, attribute the "battered root" and the ensuing arachnoiditis as one reason for failure. Soon thereafter in 1985, a German group reported profitable therapy of the "battered root syndrome" with indwelling spinal twine stimulators. Battered root syndrome warrants additional investigation into the incidence, mechanism, prevention, and treatment. On the opposite, one potential collection similarly reported very high rates of osteolysis, but differed in that cage migration with resultant radiculopathy was additionally discovered at a high rate. Both revisions discovered a discrete inflammatory mass at time of decompression that exhibited histopathology of "diffuse osteoid and woven bone amidst a fibrovascular stroma densely populated by lymphocytes and eosinophils. They noted a ensuing lower within the price of radiculitis from 20 to 5% with use of the sealant. Because of its hydrophilic properties, Duraseal is known to have expansile properties, but has been relatively secure when used in this "off-label" fashion in the backbone with only isolated case reviews of such dramatic complications. Neidre and Macnab64 developed a classification system for lumbosacral nerve root anomalies. Recognition of the anomaly is an important think about coping with these anatomic variants and infrequently necessitates abandonment or modification of the unique surgical plan, as these are sometimes not recognized on preoperative imaging findings. Although not reaching statistical significance, this implies the broader publicity with whole facetectomy allows for higher nerve root decompression as well as decreased necessity for nerve root retraction. A cadaveric examine of a novel spine shaver gadget used to put together the interbody area noted the variety of insertions wanted to prepare the disc space was six occasions larger using conventional manual instruments, and the gadget could probably lower the risk of inadvertent neurologic damage from Kim et al. Avoidance of Neurologic Complications Recognize elevated danger with revision surgery and extra invasive surgical procedures. Recognition and awareness of anatomic nerve root variants earlier than and during surgery. Minimize duration, drive, and frequency of retraction of nerve roots and thecal sac. The timing of onset of signs is usually a key component to prognosis of neurologic problems if no intraoperative complications are famous. Assessment of compressive pathologies including pedicle screws, cages, bone graft, or hematoma/ seromas is important to acknowledge and manage, and ruling out these distinct causes of compression is important previous to arriving at different diagnoses of exclusion. Failure of surgical success due to neurological compression typically requires direct management with revision decompression, no matter timing of onset of signs. Medications mentioned by multiple authors include oral corticosteroids or neuropathic agents such as gabapentin or pregabalin. Often a final resort includes postoperative nerve root blocks or corticosteroid injections if confident that the postoperative symptoms are truly transient as failure of those injections is usually one of many authentic indications for the surgical procedure. Modifiable patient components can embody affected person choice, preoperative decolonization of nares, medical and dietary optimization, and management of immune-modulating, blood glucose, and anticoagulation medicines, as well as risk factors for thrombophilia. Prophylactic intraoperative powdered vancomycin applied to the wound previous to closure has been proposed as one technique of preventing or reducing postoperative spine an infection. Furthermore, no price evaluation was mentioned in relation to the overall worth of such a protocol. Despite the revision with autograft interbody support, complete collapse of the disc space occurred with a mean loss of both height (12. Better prevention protocols, earlier diagnostic capabilities, and fewer morbid treatment methods are needed. Intraoperative local vancomycin powder within the wound and/or bone graft may lower infection rates. Successful treatment is feasible with each explantation and retention of the interbody gadget at time of surgical debridement. Complications of Posterior and Transforaminal Lumbar Interbody Fusion of infectious L3�L4 spondylodiscitis occurred with resultant migration to the left pulmonary artery. Bone union rate with autologous iliac bone versus native bone graft in posterior lumbar interbody fusion. Guideline replace for the efficiency of fusion procedures for degenerative disease of the lumbar spine. These techniques permit circumferential lumbar fusion without accessing anterior approaches to the backbone and have developed over time, reducing lots of the complications which initially restricted their acceptance. Despite being a useful and usually secure process, numerous possible issues exist and symbolize real challenges to each surgeon and patient. Clinical course and significance of the clear zone around the pedicle screws within the lumbar degenerative illness.
The most well-described variations are the posterior ponticulus, V3 phase anomaly, and high-riding vertebral artery (discussed in part "Relevant Anatomy"). While the commonly described place for screw placement is the inferior lateral mass, in the case of an artery that programs inferior to the C1 arch, the vessel can be in danger. Given the proven success utilizing alterations of the screw start line, surgeons ought to preoperatively assess vertebral artery position and tailor the approach to the lateral mass instrumentation approriately. The authors described that during the case, brisk bleeding was noted surrounding the screw entry website. During cervical backbone surgery performed in the susceptible position, incidence of air embolus is exceedingly low with only a few reported circumstances. Yet, this patient illustrates the importance of the venous plexus surrounding the atlas and the vertebral artery. Control of bleeding from the higher cervical venous system is usually achieved by direct strain. A cylinder of bone wax wrapped in Surgicel is used to isolate the vertebral operative area from the vascular construction. In a considerably restricted examine, the authors demonstrated good success using this novel method. Regardless of particular technique, great care should be taken to keep away from injury to the upper cervical venous buildings. This house is bordered superiorly by the posterior arch of the atlas and inferiorly by the lamina of the axis. While the superficial plexus is found extending from the subcutaneous layer, the deep plexus surrounds the vertebral artery and its tributaries. Nevertheless, bleeding from this space is a major contributor to general blood loss during atlantoaxial fusion with a screw�rod construct. This morbid complication is believed to be in giant part because of bleeding from the venous 26 Kim et al. Complications of C1 Lateral Mass Screw Fixation shooting, or lightning-like pains within the occipital area of the scalp. Rarely, a misplaced screw may be recognized as the trigger of the neuropathic symptoms. As mentioned beforehand, the C2 foramen is sort of unforgiving to the C2 nerve root, so encroachment of that house my result in nerve root compression. In such circumstances, reoperation to remove the offending screw has proven successful in relieving signs in a restricted variety of case reviews. Many current studies have targeted on the prevention of C2 neuropathy following C1 instrumentation. A research by Elliott et al51 compared posterior arch screw placement with normal central lateral mass placement with regard to C2 nerve standing. While the posterior arch starting point decreases the incidence of C2 neuralgia in comparison with the usual method, C2 nerve section presents a good lower incidence of postoperative neuralgia. In a nonrandomized research of 23 sufferers, with 18 present process C2 sacrifice, the authors showed a lower in blood loss and operative time in patients whose C2 nerve roots are sacrificed. In this study of 20 patients, 20% complained of occipital numbness with 10% experiencing paresthesias. On exam, half of the sufferers were discovered to have some degree of occipital anesthesia. This examine demonstrated a big increase in malpositioned screws and neuropathic pain in sufferers with preserved C2 nerves. Also, as expected there was a marked increase in the fee of postoperative C2 numbness in sufferers whose C2 roots had been sacrificed. Avoidance of C2 nerve-related issues must be a big concern of the surgeon performing this procedure. There is a average threat of postoperative neuralgia ought to harm to or impingement of this nerve occur. As demonstrated in the introduced studies, sacrifice of the C2 nerve is a viable choice and should a minimum of be thought-about in patients whose C2 ganglion is offering important obstruction to the instrumentation entry point. It usually lays approximately 2 to 3 mm lateral to the middle of the anterior lateral mass. Therefore, these could serve as landmarks to keep away from potential damage to the hypoglossal nerve. The authors reemphasized that slightly medial angulation of screw placement is recommended to avoid injury to each the vertebral artery and the hypoglossal nerve. Indeed, the authors have been unable to explain the precise explanation for this affected person with transient hypoglossal nerve palsy. At the level of the atlantoaxial junction, a quantity of suboccipital muscles connect to the cervical vertebrae. In one evaluation of 1,002 sufferers undergoing screw�rod atlantoaxial fixation, solely 2 (0. Furthermore, most intraoperative durotomies are observed before closing the patient and are thus managed with a major repair of the dura. This is evidenced within the previously mentioned case research of the patient suffering a subarachnoid hemorrhage following C1 lateral mass instrumentation. Again, it seems that a dural tear together with brisk venous bleeding contributed to this disastrous end result. Therefore, establishment of imaging protocols which may be each sensitive and specific for the extra frequent anatomic anomalies has the potential to stop many of the problems described on this chapter. Standard C-arm fluoroscopy, Oarm imaging in youngsters, and isocentric C-arm three-dimensional imaging have all been demonstrated to enhance screw placement accuracy in C1 lateral mass instrumentation. One of essentially the most vital limitations of the current fixation strategies is the restriction of movement at the atlantoaxial joint. In latest years, synthetic atlanto-odontoid joint systems have been developed and studied as an alternative alternative to the posterior atlantoaxial fusion. While these techniques are nonetheless in cadaveric testing levels, they offer promise of improved range of motion following an injury to the axial backbone. As such, efficiency of stabilization procedures such because the posterior screw�rod instrumentation described in the chapter are important in cases of harm to this region. Instrumentation of the C1 lateral mass is general a very secure and effective procedure for providing stabilization to the atlantoaxial joint. Nevertheless, the complicated and susceptible arrangement of neurovascular buildings right here provides ample alternative for surgical problems. Certainly, given the relatively low volume of these procedures carried out, knowledge assortment and analysis ought to and is at present being carried out to further perceive the sources of danger concerned on this operation. Given these limitations, the currently available information do point to some specific areas for additional investigation in the close to future in addition to basic knowledge assortment on the procedure. Complications of C1 Lateral Mass Screw Fixation References [1] Jeanneret B, Magerl F. The unstable spine-an "in vitro" and "in vivo research" on higher understanding of clinical instability [in German]. Outcome comparability of atlanto-axial fusion with transarticular screws and screw-rod constructs: meta-analysis and evaluation of literature.
References
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