Lumbar indications

Studies have demonstrated that treatment with soy or phytoestrogen enriched diets is effective in conserving bone in rodent models of osteoporosis (Anderson and Gamer, 1998 Ishimi et al, 2000 Draper et al, 1997). The mechanism of action of phytoestrogens on bone health is unclear but several mechanisms including inhibition of bone resorption and stimulation of bone formation maybe involved (Fanti etal, 1998 Ishimi e/a/., 1999 Picherit eta/., 2000). Limited data from studies in postmenopausal women have indicated that phytoestrogen supplements have a small, beneficial effect on bone loss in the lumbar spine (Alekel et al, 2000 Potter et al, 1998 Somekawa et al, 2001). 

Physical, neurologic, and laboratory examination (SMA-20, complete blood cell count, urinalysis, and special blood chemistries) may identify an etiology. A lumbar puncture may be indicated if there is fever. 

The exclusion of organic disease as the cause of a neuropsychiatric syndrome can be difficult. In this context, among other tests, lumbar puncture is indicated because many diseases of the brain are associated with a barrier disorder or an increased cell count. Both findings, sensitive yet nonspecific, are suggestive of central nervous system disease. Apart from these two nonspecific alterations, targeted CSF analysis is an important additional tool, depending on the clinical setting (F4, R6, T2). 

It is indicated in spasticity due to neurological disorders e.g., multiple sclerosis, chronic myelopathy, degenerative diseases of the spinal cord, cerebrovascular accidents and cerebral palsy painful muscle spasm associated with static and functional disorders of the spine (cervical and lumbar syndromes) painful muscle spasm following surgery e.g., for herniated intervertebral disc or for osteoarthritis of the hip. 

The indications, rationale, techniques, alternatives, contraindications, complications, and efficacy of lumbar and caudal epidural glucocorticoid injections have been reviewed (SEDA-21, 420 452). 

Pregnant rats and mice exposed to 1250 ppm of CH2CI2 (gestation days 6 to 15, 7 hr. daily) showed a lower incidence of lumbar ribs than controls, and increased incidence of delayed ossification. A significant number of mouse pups had an extra center of sternal ossification (ref. 36). Exposure of rats to 4500 ppm of the dichloride for the 21 days prior to, and seven days during gestation altered environmental habituation rates. Preliminary observations indicate a possible behavioral effect on progeny of dams exposed to dichloromethane (ref. 37). 

Cerebrospinal fluid is often abnormal in cerebral venous thrombosis the pressure is usually raised and there may be elevated protein and pleocytosis, especially in patients with focal signs. Lumbar puncture may be indicated in patients with isolated intracranial hypertension in order to lower cerebrospinal fluid pressure when vision is threatened and to exclude meningeal infection. 

Cerebrospinal fluid examination and electroencephalography are not required routinely in the investigation of dementia. Lumbar puncture is indicated in suspected Creutzfeldt-Jakob disease or other forms of rapidly progressive dementia. Electroencephalography should be considered if delirium, frontotemporal dementia or Creutzfeldt-Jakob disease are possibilities. Electroencephalography may also be required in the assessment of associated seizure disorder in those with dementia. 

FIGURE 20.10 20.10 Bone mineral density change with placebo and three doses of raloxifene. Symbols indicate observed responses to placebo (A) and daily doses of 30 mg ( ), 60 mg (T), and 150 mg ( ). Curves show predictions assuming disease progress is due to increased loss, and raloxifene reduces loss. The model is the same as that shown in Figures 20.8 and 20.9. (Curves fit to lumbar spine data from Delmas PD, BjarnasonNH, Mitlak BH, Ravoux A-C, Shah AS, Huster WJ et al. N Engl J Med 1997 337 1641-7.)... 

Tropacocaine is employed as a local anesthetic and closely resembles cocaine in its action. It is said to possess only one-half the toxicity of cocaine and to produce less dilation of the pupil of the eye. Anesthesia sets in more rapidly and is more prolonged than in the case of cocaine. In lumbar anesthesia tropacocaine is indicated as the most reliable and least dangerous of the drugs in use. 

Hip OA is common in the elderly, with a characteristic presentation as shown in Table 90-3. However, pain located on the lateral hip typically represents trochanteric bursitis, while pain in the buttock region may indicate lumbar spine OA or iliopsoas bursitis. 

Fig. 2. Schematic representation of vertebral defects in Cdx and RARy-Cdxl mutant offspring. Wild type, Cdxl-. Cdx2 11, Cdxl 1 C,dx2+, RARay-/, and RARy-/-Cdxl-/ skeletal patterns are shown. Designation of vertebrae is indicated to the left of the each mutant (BO, basioccipital C, cervical T, thoracic L, lumbar S, sacral CA, caudal) Vertebral numbering, with Cl denoted as the first element, is indicated to the right. Arrows indicate vertebral transformations, with the length of the arrow denoting transformation extending over one (short arrow) or two (long arrow) vertebrae.

Indications Chronic bi patterns, liver/kidney dual deficiency, qi and blood insufficiency. Chronic rheumatoid arthritis, osteoarthritis, rheumatic sciatica, lumbar strain, lumbar intervertebral disc herniation, pain in the midline and back during pregnancy, hemiplegia due to stroke, and the sequelae of poliomyelitis... 

Chloroprocaine (1 to 2% injection with methylparaben as a preservative) is indicated in the production of local anesthesia by infiltration and peripheral nerve block. Chloroprocaine without methylparaben is indicated in peripheral and central nerve block, including lumbar and caudal epidural blocks. Chloroprocaine has an onset of action of 6 to 12 minutes. 

Lidocaine hydrochloride is a local anesthetic/vasopressor preparation. Lidocaine stabilizes neuronal membranes by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action. Epinephrine stimulates both alpha and beta receptors within sympathetic nervous system relaxes smooth muscle of bronchi and iris and is an antagonist of histamine. They are indicated for production of local or regional anesthesia by infiltration techniques such as percutaneous injection, by peripheral nerve block techniques such as brachial plexus and intercostals, and by central neural techniques such as lumbar and caudal epidural blocks. 

Lidocaine is indicated for production of local or regional anesthesia by the infiltration technique, and by central neural techniques such as lumbar and caudal epidural blocks. 

FIGURE 61-10 Relative efficacy of different therapeutic interventions on bone mineral density of the lumbar spine. Teriparatide (40 pg), PTH (25 /xg) + estradiol, alendronate (10 mg), estradiol (0.625 mg/day), raloxifene (120 mg), calcitonin (200 lU). Typical results with placebo treatment underscore the inexorable bone loss without intervention. Some of the indicated treatment interventions involved combination therapy, and absolute comparisons should not be made. 

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