By C. Deckard. University of Mississippi. 2017.

These views will in most cases optimally demonstrate both nuclear morphology and annular pathology that might exist purchase 60caps ayurslim fast delivery. Immediately after filming, the patient is questioned about the expe- rience during injection. Patients are asked to describe in detail their perceptions, whether pain, pressure, or no sensation at all. On occa- sion, patients are asked to draw with a felt-tipped marker on the front and back on a human figure where they perceived the sensation(s). They are asked whether the sensation(s) perceived was/were familiar or unfamiliar (concordant vs nonconcordant) relative to their clinical complaints. Patients are thereafter requested to rate the maximum in- tensity of the experience on a scale of 0 (no sensation whatsoever) to 10 (extreme pain/pressure). Painless (1/10 nonconcordant pressure) injection into an L1-2 disc ex- hibiting minimal fissuring; images obtained during distention of the disc with contrast agent. Patient reported 9/10 concordant ipsilateral back, buttock, hip and dorsolateral leg pain. Note full- thickness lateral tear (ar- row in B) opposite side of needle placement. It is common for patients to initially describe an extremely painful experience as "nonconcor- dant" when in fact the pain they experienced was otherwise in a typ- ical location. One must be aware that discography may, and in fact of- ten does, provoke pain that is more intense than the clinical pain under investigation. The discographer must carefully question each patient to determine why an experience is concordant or nonconcordant, since otherwise a true positive (concordant intensity rating of 7/10, with annular tear) disc may be incorrectly recorded as "nonconcordant. We have found that injecting a lo- cal anesthetic into painful discs decreases the likelihood of producing false positive results later in studies of adjacent discs. The transmis- sion of pain to an already sensitive, adjacent, torn disc can and does 102 Chapter 6 Discography FIGURE 6.

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Color Doppler imaging (22) improves the sensitivity from that of conventional gray-scale imaging cheap ayurslim 60caps with amex, as does Doppler flow imaging using intravascular ultrasound contrast agent (23). Still, these techniques have not made the quantum leap that would be necessary to propel TRUS into a widely used screening role. Also, TRUS costs considerably more than DRE or PSA, which diminishes its cost- effectiveness further (17,18,24), as does the lower patient compliance with TRUS than with DRE and PSA (17). Ultrasound does play a limited role in screening for prostate cancer by refining the use of serum PSA, which is another test with less-than-ideal sensitivity and specificity (23). The ratio of PSA to prostate volume, usually determined by TRUS and termed PSA density, has been found in some series to be a more accurate test than a single PSA determination (24–30). Transrectal ultrasound facilitates volume assessment of the peripheral zone, where most prostate cancer arises; using this volume to calculate PSA density may increase accuracy (31). The PSA density may help predict whether extracapsular disease will be found at surgery and longer-term prognosis (32,33). Summary of Evidence: Transrectal ultrasound appears to be useful to guide systematic biopsies into the peripheral zone, and increase diagnostic yield if focal abnormalities (especially those demonstrated by flow-sensitive techniques) are biopsied, hence justifying its continued use as a biopsy guide (limited evidence). Chapter 7 Imaging in the Evaluation of Patients with Prostate Cancer 123 Supporting Evidence: Intraprostatic carcinoma can be diagnosed only his- tologically, and, as screening becomes more widespread and as fewer prostate resections are performed for voiding symptoms, an ever-higher percentage of prostate cancers are diagnosed by prostate biopsy. Originally, prostate biopsy was performed using digital guidance, but with the advent of TRUS an increasing number of biopsies have been performed using this method as guidance. Early after the invention of TRUS, it became appar- ent that certain prostates contained local abnormalities in echogenicity, which, at least sometimes, indicated foci of carcinoma. The commonest appearance was that of a local region of diminished echogenicity; with time, it became apparent that some prostate carcinomas presented as hyperechoic regions, some as discrete areas with echogenicity roughly equal to the surrounding tissue, and many were not visible at all (34).

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Posterior view diagram of the lum- bar spine depicting the typical course of the "facet nerve" or medial branch dorsal ramus buy 60 caps ayurslim otc. 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. Bone scanning may demonstrate increased bony turnover locally, and examination by magnetic resonance imaging (MRI) may reveal enhancement locally about the joint. Often, however, there is a poor correlation between pain and imaging abnormalities, and the diagnosis is typically made on clinical grounds and confirmed by diagnostic facet joint block with elimination of pain. Joint injections may be requested for either diagnostic or therapeu- tic indications. The joint selected for injection may be specifically requested or determined from imag- ing studies or physical examination. Intra-articular injection of steroid may be used for longer acting anti-inflammatory activity, and there are reports of long-term effectiveness in pain management ( 6 months pain relief) depending, of course, on the exact pathological process in the joint.