By Z. Lester. Ashland University.
The muscles of the axial skeleton position the head and the spinal column order 300 mg ranitidine overnight delivery, and move the rib cage so as to make breathing possible discount ranitidine 300mg overnight delivery. They are also re- sponsible for the minute and complex movements of facial features buy ranitidine 150 mg on line. The vertebral column begins at the support of the skull with a verte- bra called the atlas and ends with an insert into the hip bone (Fig. From a mechanical view- point, it is a flexible rod charged with maintaining the upright position of the body (Fig. The vertebral column fulfills this role with the help of a large number of ligaments and muscles attached to it. A typical vertebra is made of the vertebral body (found anteriorly) and the vertebral arch (positioned posteriorly). Be- tween the vertebral bodies are 23 intervertebral disks that are made of relatively deformable fibrous cartilage. These disks make up approxi- mately one-quarter of the total length of the vertebral column. The shock absorbance characteristics of the vertebral disks are essential for physical activity. The compressive force acting on the spine of a weight lifter or a male figure skater during landing of triple jumps peak at many times the body weight. The numbers in parentheses indicate the number of bones of a certain type (or in a certain subgroup). The vertebral disks are also instrumental in determining the curvature of the spinal column. Most of the body weight lies in front of the vertebral col- umn during standing, walking, and running. The curvatures in the cervical (neck) and lumbar (pelvic) regions are primarily caused by the greater anterior thickness of the disks in that region. The reverse S shape of the vertebral column in the standing position brings the weight in line with the body axis. The bodies of the vertebrae are held together by longitudinal ligaments that extend the entire length of the vertebral column. Human Body Structure (a) 1 (b) cervical 7 1 thoracic 12 1 lumbar 5 sacral FIGURE 1.
In the cervical spine ranitidine 150mg free shipping, the me- dial branch courses from the foramen to the joint across a ridge in the middle aspect of the lateral mass of the vertebra (Figure 11 generic ranitidine 300 mg mastercard. The course of the medial branch in the thoracic spine is less well estab- lished cheap 150mg ranitidine, though it is thought to be homologous to the course of the lumbar branches, extending over the medial aspect of the transverse processes. Facet Joints in Spinal Pain As a synovial joint, the z-joint may be affected by any of the inflam- matory processes that involve joints, including rheumatoid arthritis 206 Chapter 11 Facet Joint Injections A B FIGURE 11. Axial computed tomography images depicting the anatomical variation in the articular surface of the facet joints. Joints may have straight or curved articular surfaces, and osteophytic ridging may make joint access dif- ficult for intra-articular injections. In this patient, the articular processes have relatively convex and concave articular surfaces. Osteophytic ridging may make intra- articular access difficult without CT guidance. Posterior view diagram of the lum- bar spine depicting the typical course of the "facet nerve" or medial branch dorsal ramus. In the lumbar spine, the nerve takes a very typical course along a groove at the junction of the su- perior articular process and transverse process of a vertebra. Note that each facet joint is sup- plied by smaller branches arising from the two adjacent medial branches. The fibrous, bony, and cartilaginous components of the joint may also be injured traumatically. Pain fibers (unmyelinated nerve endings) as well as substance P have been demonstrated in the synovial membrane within the joint and synovial membrane, and within the joint capsule as well. Pain innervation is also present in other local soft tissue structures adjacent to the joint including the multifidus, FIGURE 11. In the cervical spine, the medial branch stereotypically courses along a small groove in the midportion of the lateral mass of a vertebra, before coursing along the bone to innervate the joint. As in the lumbar spine, each joint is supplied by medial branches from levels above and below the joint. Joint inflam- mation may cause localized hyperemia and venous stasis, thus affect- ing other local tissues. The exact neurological mechanisms of facet- mediated pain is incompletely understood, although demonstration of pain fibers in the joint and locally provide some possible explanation for what is now a relatively well-accepted pain syndrome (facet syn- drome). The facet syndrome is characterized by one or more of the follow- ing typical complaints: Local paraspinal tenderness over a facet joint Posterior pain aggravated by extension and rotation toward the in- volved side Hip and buttock pain in a nonradicular distribution Morning pain and stiffness Occasional improvement with heat or anti-inflammatory drugs Positive response (pain relief) with joint injection Images may demonstrate abnormalities in the joints including osteo- phytic spurring, accumulation of fluid in the joint capsule, or a local- ized synovial cyst.
Indications that emotional reactivity is complicating adjustment to ill- ness include reactions that appear especially intrusive and out of proportion to the situation purchase 150mg ranitidine mastercard, problems that do not respond to the couples’ usual coping strategies cheap 300 mg ranitidine amex, or conflicts or concerns that have a sticky quality—that repeat endlessly and with a level of anxiety or intensity that is not easily calmed or soothed cheap ranitidine 300 mg fast delivery, even temporarily. When these signs are present, it is helpful to ex- plore what else might be going on internally that is driving the response, in addition to the real challenges presented by the illness. STEP 3: REDIRECT ATTENTION FROM THE OUTER REALITY OF THE ILLNESS TO THE INNER RESPONSE AND MEANING OF THE ILLNESS Having determined which areas of concern are most likely to be colored by emotional reactivity, it can then be useful to explore the underlying mean- ings associated with those areas of concern. The goal is to begin to clarify 264 SPECIAL ISSUES FACED BY COUPLES the sources of the emotional reactivity. The first step in the process is to highlight the emotions or reactions that are elicited by the particular cir- cumstance or conflict. As a first approach, each member of the couple can be asked why he or she imagines he or she is having such a reaction: To the healthy spouse: "Of course this illness is devastating, but do you have any idea about the reasons for the depth of your frustration about your hus- band’s illness? Having begun this process in the previous step, each individual is now asked to further describe his or her reactions. In the process of description, the speakers elaborate on their internal processes. The therapist responds empathically, underlining the emotions or attitudes hinted at in the speaker’s statement and asking ques- tions to help the speaker continue to elaborate, subtly directing attention to his or her inner experience. As this process continues, the focus shifts from the external difficulty to the speaker’s reaction to it. For example: • The patient begins with an external focus: PATIENT: "This endless treadmill of doctor’s appointments is running us into the ground. STEP 5: CONNECT THESE EMOTIONS TO EACH PERSON’S PARTICULAR VULNERABILITIES AND PREVIOUS INJURIES With the speaker now more clearly in contact with the internal feeling state elicited by the external conflict or challenge, the therapist can ask when, under what circumstances, or with whom he or she may have felt such feel- ings before. Was there ever a time when you were younger that anyone interacted with you in a way that left you feeling like your feelings don’t matter and you just have to do what’s demanded of you? My mother was so control- ling, I wasn’t even allowed to have an opinion about what flavor ice cream I wanted. The spouse often jumps in at this point with a revealing comment about the speaker’s childhood experiences. The husband in one couple I (WHW) saw would feel enraged when his wife asked him questions about the man- agement of the house when she was laid up with her illness. His wife convincingly explained that he had this reaction to the most innocent and gentle of questions she might ask. I asked him if he had ever had a similar feeling or reaction before with anyone else.