1/10. Cultural competence in the multidisciplinary rehabilitation setting: are we falling short of meeting needs?We present issues relevant to rehabilitation providers who wish to develop or improve their cultural competence in their medical setting and interdisciplinary team. Two case scenarios are presented that illustrate the complexities introduced into the medical rehabilitation setting by the increased numbers of minority patients in the united states in the last 20 years. Professional codes of conduct and practice are discussed for 3 rehabilitation disciplines: physiatry, rehabilitation psychology and neuropsychology, and nursing. The current status of and improvements in professional and continuing medical education are then outlined. Challenges faced by rehabilitation providers seeking to become more culturally competent in their practices are related in the following topic areas: (1) continuing education in language and cultural issues, (2) assessment instruments appropriate for diverse patient populations, (3) majority versus minority population values and beliefs, (4) impact of the immigration and acculturation experiences, (5) health care and insurance coverage issues, (6) attitudes and beliefs about disability, and (7) past experiences with medical professionals and systems. Suggestions for developing and applying enhanced cultural awareness in clinical rehabilitation practice are provided.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
2/10. Intrapelvic intrusion of the lumbosacral spine.A 34-year-old female fell 7 meters onto her lower back and side, and sustained a nondislocated fracture of the 7th thoracic vertebra, a complex pelvic fracture with symphysiolysis and a left acetabular fracture in combination with a bilateral comminuted sacral fracture and downward intrusion of the lumbosacral spine. There was also a cauda equina-syndrome. laparotomy with exploration of the lumbosacral area was terminated early because of hemorrhage. Later internal fixation of the fractures was performed by an anterior approach with complete reduction of the bilateral sacral fracture and the lumbosacral spine intrusion. We conclude that an anterior approach to this area gives good visualization, but is hazardous owing to the close proximity of the fractures to the central vessels and retroperitoneal muscles. A posterior approach gives less good visualization but may cause less hemorrhage.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
3/10. Pathological studies and pathological principles on the management of extension injuries of the cervical spine.Extension injury to the arthritic spine of elderly individuals involves rupture of the anterior longitudinal ligaments and disks at several levels, but no bony injury can be observed on X-ray. There are many small focal haemorrhages in the central portion of the spinal cord and the injury is often accompanied by incomplete paresis. As the injury is a stable injury with the posterior ligament complex being intact, it is only necessary to immobilise the cervical spine conservatively. laminectomy is not indicated. In hyperextension injury of the rigid cervical spine and in momentary posterior dislocation observed in middle aged individuals, rupture of the anterior longitudinal ligament and disk is observed at a single site, but being spontaneously reduced, traumatic findings cannot be observed on X-ray. The spinal cord is crushed at the site of injury to bring about severe neural damage. When this type of injury is diagnosed or suspected, further damage may be inflicted on the spinal cord if skull traction is made with calipers in the extended position and the condition at the time of injury is reproduced. Therefore, the patient should be nursed in a shell or between sandbags in a neutral position or even in a position of slight flexion. In extension fracture dislocation with compression which resembles on X-ray a flexion injury, all of the three columns of the spine are destroyed to bring about an extremely unstable condition. As the spinal cord is extensively injured to involve several segments, decompression surgery for relief of neuroparalysis should not be performed when complete paralysis develops simultaneously with fracture dislocation. Therefore, it should be first treated conservatively with skull traction, and in cases where stability cannot be restored, surgical fixation of the spine should be performed.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
4/10. Atlanto-axial fusion for instability.The problem of how best to treat a patient with instability of the atlanto-axial complex is still somewhat controversial. In this follow-up study of fifty-nine patients, nineteen were treated by a plaster jacket and brace; eleven, by single midline wiring and onlay bone grafts; and thirty, by four circumferential wires around the posterior elements of the axis and atlas with two bone grafts wedged between these elements on each side according to the method described by Brooks and Jenkins. (One patient had both types of fusion.) Although direct comparison of the results of treatment in three groups was not possible because of the many variables that may have influenced the results, the incidence of solid fusion was distinctly higher after the Brooks fusions despite less postoperative immobilization.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
5/10. rehabilitation in a rural setting of a young quadriplegic accident victim. Integrative clinicopathological conference: medical, psychosocial, economic, preventive, and ethical dimensions of a case study.Problems encountered by a young, unmarried woman who, as a result of a spinal injury in an automobile accident, loses use of all four limbs and requires complex home health care services delivered by a network of health and social service agencies in a rural area of kentucky. Economic, psychosocial, ethical, preventive, and medical aspects of health care are discussed.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
6/10. Displacement of the spinolaminar line--a sign of value in fractures of the upper cervical spine.The spinolaminar line is an important anatomical landmark easily visualized on the lateral radiograph of the cervical spine. Any displacement in this line may be an indication of subtle traumatic vertebral damage. This is particularly relevant to the upper cervical spine in which the complex anatomy and frequent absence of associated neurological deficit make diagnosis difficult. Two case histories are presented which emphasize the importance of evaluation of the spinolaminar line on the lateral radiograph after trauma to the head and neck.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
7/10. CT in the evaluation of spine trauma.Fifteen patients admitted for spine trauma in an 8 month period were studied with computed tomography (CT). All the patients had initial routine plain film screening, and 10 of 15 were also examined with conventional tomography. Five patients sustained vertical fall, axial-load injuries in the thoracolumbar junction region; two others suffered missile injury to the spine. CT provided more information than plain films in all these patients due to its superior imaging of bony detail and its ability to assess soft-tissue damage. In four of these patients, conventional tomography was done but contributed no additional information. Eight other patients sustained complex fractures of the cervical spine. In all but one, the combination of plain films and CT allowed complete evaluation of the injury. In one patient, conventional tomography showed an additional linear fracture one vertebral level below the main region of injury. Plain films and CT allow complete, safe, rapid, easily interpretable evaluation of spine trauma patients in the acute setting. Conventional tomography yields no additional clinically vital information in the acute evaluation of spine trauma, when plain films are abnormal. Its current ability to show finer bony detail than CT can be reserved for evaluating equivocal plain film and CT findings or more complete evaluation (if indicated) after the patient is clinically stable.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
8/10. Cervicodorsal injury presenting as sternal fracture.Clinically silent cervicodorsal fracture may occur following upper-thoracic injury in the presence of a characteristic buckling injury to the sternum. Failure to recognise the association may result in gross kyphotic deformity. Three examples are provided, illustrating the role of radiology in the management of this complex traumatic lesion.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
9/10. Spondylectomy, microsurgical decompression and osteosynthesis in the treatment of complex disorders of the cervical spine.In 44 patients with complex degenerative, traumatic, neoplastic and infectious disorders of the cervical spine an aggressive surgical approach was used, consisting of spondylectomy, radical microsurgical decompression and osteosynthesis. The patient group consisted of 23 patients with multisegmental cervical spondylosis, 9 patients with primary or metastatic malignant tumour disease spread along the cervical spine, 6 patients with complex cervical trauma and 6 patients with infection affecting one or more cervical segments. Considering the heterogeneity of the group of patients treated, a multitude of neurological symptoms and signs were present. Excruciating pain was the predominant symptom in 84% of the patients, followed by sensory and motor signs of varying degrees in 77% and 65% respectively. Involvement of the long tracts was present in 51%, gait disturbance in 49% and bladder disfunction in 28%. Considering the nature of the underlying disease, in the group with multisegmental cervical spondylosis (MSCS), advanced cervical myelopathy was the predominant clinical symptom, whereas in those patients with trauma, tumour or infection, pain was the leading symptom, followed by disturbed motor and/or sensory function. Altogether 59 vertebrae have been removed in the 44 patients. In 28 patients spondylectomy was performed at one level, in 15 patients at two levels and in one female tumour patient at three levels. In 34 patients an iliac crest bone graft was used and in 10 patients bone cement. Within the observation period, solid fusion was achieved in all patients. In one tumour patient screw loosening was demonstrable at follow-up, but the fusion remained stable. 2 patients with infectious disease required re-operation due to significant loosening of screws and plates. However, after re-stabilization solid fusion was achieved. Considering amelioration of specific pre-operative symptoms and signs, excruciating pain responded best to the stabilizing procedure, with improvement in over 90% of the patients, followed by improvement of sensory and motor deficits in 85% and 82% respectively. Improvement in pre-operative gait disturbance could be achieved in 81% of the patients, while disturbance of bladder function is less likely to improve after surgery with a positive response in only 58%. None of the patients became neurologically worse after surgery. With regard to the underlying disease, patients with MSCS and tumour had the best results with overall improvement in 62% and 75% respectively. While in patients with infection improvement could be achieved in 58%, improvement in trauma patients was demonstrable in only 34% while in 66% the pre-operative clinical status remained unchanged.(ABSTRACT TRUNCATED AT 400 WORDS)- - - - - - - - - - ranking = 6keywords = complex (Clic here for more details about this article) |
10/10. Traumatic vertebral arteriovenous fistula associated with cervical spine fracture.A case of a traumatic vertebral arteriovenous fistula associated with a high cervical fracture-dislocation is reported. The fistula was not suspected clinically but was fortuitously diagnosed by brachial arteriography carried out for a deteriorating level of consciousness. The patient's complex injuries were managed by conservative treatment of the fracture-dislocation and later by ligation of the proximal and distal vertebral artery for trapping of the fistula. The indications and the various surgical procedures for the treatment of vertebral arteriovenous fistula are discussed. The report emphasizes the value of cerebral angiography in head and neck injuries.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
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