Barbara A. Pockaj, MD
- Department of Surgery
- Division of Surgical Oncology
- Mayo Clinic
- Phoenix, Arizona
Suicide: Multiple incised wounds of varying depths on the neck or wrists suggest a suicide cholesterol ranges hdl buy discount atorlip-20 20mg line. Fatal wounds are present over limited accessible areas of the body cholesterol reading order discount atorlip-20 line, such as front of neck cholesterol medication names australia buy 20 mg atorlip-20 mastercard, groin cholesterol levels on atkins diet buy 20mg atorlip-20 free shipping, Injuries Table 11 cholesterol test preparation coffee atorlip-20 20mg cheap. Situation Level Direction Number of wounds Edges Hesitation cuts Tailing Severity Wounds in other parts of body Defense wounds Hands Weapon at site Vessels Clothes Circumstantial evidence Suicidal cut-throat Left side of the neck and passing across the front of the throat High, above the thyroid cartilage Obliquely, above downwards and from left to right in right handed persons Homicidal cut-throat Usually on the sides Low, on or below the thyroid cartilage Transverse or from below upwards Multiple, may be 20-30, superficial, parallel Multiple, cross each other at a deep level and merged with main wound Usually ragged due to overlapping of multiple superficial incisions Present Present Less severe, one wound is severe, but sometimes, there may be 2-3 Often present across wrists, groin and thighs Absent, unintentional cuts may be found Weapons may be firmly grasped due to cadaveric spasm Usually present As head is thrown back, carotid artery escapes injury Not cut or damaged Quiet place, such as bed room; suicidal note Sharp and clean cut, beveling may be seen Absent Absent More severe, all tissues including vertebrae may be cut No wounds on wrists, but severe injuries on head and neck Present, unless taken unaware Fragments of clothing or hair may be grasped Usually absent Jugular vein and carotid artery are likely to be cut May be cut, corresponding to injuries in the body Disturbance at scene, footprints outside chest or back of legs. Hesitation cuts/marks or tentative cuts or trial wound: these cuts are multiple, small and superficial often involving only the skin and are seen at the beginning of the incised wound, presumably hesitating while gaining courage to make a final decisive cut. A person who commits suicide exposes his body by opening his clothes and then inflicts the wounds. When a safety razor blade is used, unintentional cuts are found on the fingers where the blade has been gripped. Most people have a vague knowledge of the anatomy and do not know where to cut a major 176 Fundamentalsof Forensic Medicine and Toxicology ii. Homicidal wounds: They are deep and deliberate in character and are seen on the head, throat and neck and sometimes on the trunk. Incised wounds on nose, ears and genitals are usually homicidal and may result from sexual jealousy, caused by a jilted lover, husband or wife. Defense wounds: Injuries are seen on the forearm and palm, when the victim may try to ward off on attack by raising hands and arms in defense or by grabbing the weapon. Self-mutilation: Sometimes, injuries may be caused by an individual with a mental disorder as a form of self-mutilation or by one who deliberately harms oneself for motives of gain. They are found anywhere on the body; superficial, multiple and avoiding vital areas such as lips, nose and ears. In the skull, the undermined edge of the fracture is the direction in which the force was exerted and slanted edge is the side from which the force was directed. Stab Wound Definition: Wound produced from penetration with long narrow instruments having pointed (sometimes blunt) ends into the depths of the body. Less often, injuries are caused by pieces of glass (broken-off bottle necks), scissors, dagger, screwdrivers, pens, ice picks or forks. They are caused by slender instruments, such as ice picks or knives with thin blades. Fatal penetrating injuries can be caused without leaving any easily visible external marks or bleeding. Penetrating wound: Weapon enters into the body cavity producing only one wound, i. For measuring the length of stab wound, the edges of the wound should be approximated. Depth corresponds to the length of the blade of the weapon entering the body, when the whole length of the weapon enters the body, but has not produced any wound of exit. If a single-edged weapon is used, the surface wound will be triangular or wedge-shaped and one angle of the wound will be sharp the other rounded, blunt or squared off. Virtually all stab wounds are made with 178 Fundamentalsof Forensic Medicine and Toxicology single-edged weapons. Sometimes, this is not always the case, as the blunt edge of the knife may split the skin and resemble a double-edged knife wound. If a double-edged weapon is used, the wound will be elliptical or slit-like and both angles will be sharp or pointed. A pointed square weapon may produce a crossshaped injury, each of the four edges tearing their way through the tissues (stellate shaped). Stabs produced with a broken bottle appear as clusters of wounds of different sizes, shapes and depths with irregular margins. A screwdriver will produce a slit-like stab wound with squared ends and abraded margins. If the blades were open, the injuries may look similar to those produced by a knife. A fork will produce clusters of 2-3 wounds depending on the number of prongs on the fork. Hemorrhage leading to hypovolumeic shock due to injuries of major vessels (most frequent cause). Aspiration of blood and air embolism-when the stab is located on the neck (injury to jugular vein). In homicide committed by female perpetrators, the victims had fewer stab wounds on an average than in homicides committed by male perpetrators. Personal conflict between the perpetrator and the victim, history of sex or drugs are associated factors. It is caused by falling against any projecting sharp objects, like glass or nails. When bleeding is profuse, physical activity is limited and with slow bleeding, the victim may be able to run a few meters from the assailant. A person can lose over a third of his blood volume before progressing to irreversible hemorrhagic shock. Death is due to hemopericardium if heart is involved, but cardiac tamponade can occur (accumulation > 150 ml of blood is fatal). The sudden evisceration of the internal organs causes immediate decrease of intra-abdominal pressure and cardiac return resulting in collapse and death. Defense Wounds Defense wounds are wounds of the extremities which result from the immediate and instinctive reaction of the victim to ward off an attack. Active defense injuries: They are seen when the victim tries to seize the weapon and the injuries are sustained on grasping the weapon. Injuries are usually located on the palms, the flexor sides of the fingers and the interdigital spaces, more common in the web between the base of the thumb and index finger. Passive defense injuries: these are seen when the victim raises the hands or arms for protection. They are located on the extensor or ulnar surfaces of forearms, wrists, knuckles and the back of the hands. In stabbing with single-edged weapon, if the weapon is grasped, a single cut is produced on the palm of the hand or on the bends of fingers. Cuts are usually irregular and ragged because skin tension is loosened by gripping of the knife. To avoid misinterpretation, therapeutic tubing should never be removed prior to sending the body for postmortem examination. Fabricated Wounds (Fictitious/Forged Wounds) Definition: Fabricated wounds are produced by a person on his own body or by another with his consent. Self-inflicted injury without conscious suicidal intent is a form of selfmutilation. For the purpose of insurance frauds Diagnosis: the diagnosis can be done by careful history taking and examination of injuries (Box 11. Classification of Firearms Firearms are broadly classified into two categories depending on the type of barrel: i. The rear end where the cartridge is inserted is known as the breech end and the front end where the bullet/shots comes out is the muzzle end. Butt/grip: Rear portion of stock in a shoulder arm or bottom of a handgun containing a magazine. Magazine: the receptacle for the cartridges in a repeating type of weapon from which the cartridges are fed automatically into the chamber by the action of mechanism. When the bullet passes through the bore, its surface comes in contact with the projecting spirals which gives 184 Fundamentalsof Forensic Medicine and Toxicology. Rifling gives the bullet a signature marking that is unique to the weapon that fired it. Autoloading pistols are semi-automatic wherein the empty cartridge is ejected after firing. It is intended to be fired from the shoulder, and is designated to fire multiple pellets from the barrel. Choke bore: A shotgun slightly constricted at the muzzle, usually distal 7-10 cm of the barrel is narrow. Balling or welding of shot: In shotguns, there may be conversion of shots (pellets) into compact mass which may cause a circular or oval large entry wound of 5-10 mm and several small circular punctures, suggesting use of two weapons-one rifle and the other a shotgun. Shotgun pellets fall into two categories depending on the size: birdshot and buckshot (larger shot). Plated shot: It is coated with a thin coat of copper or nickel to minimize distortion on firing-maintains good aerodynamic shape and increase the range. It specifically identifies a cartridge by giving the bullet diameter and the case length in millimeters, as well the type of cartridge case. The metal used is lead with varying amounts of antimony and/or tin added to provide hardness. Jacketed bullets: A tough metal envelope (made of copper and zinc, or copper and nickel with steel) covering the outside of the bullet-thickness ranges from 0. Partial metal-jacketed bullet: Covers the base and cylinder portion of the bullet, leaving the nose partly or fully exposed; designed to expand or mushroom. There is a pit present in front of the nose (compare to soft point bullet, which has exposed lead, but no hollow). When the bullet strikes a soft target, the pressure in the pit forces the ring of lead around it to expand into a mushroom-shape. This causes more soft tissue damage and higher incapacitation index on the target. Soft-point bullet: Jacketed bullet that is left open at the tip, exposing some of the lead inside. They are designed to expand upon impact, but slowly, as compared to the hollow-point bullets. Tandem bullet (Piggyback bullet): Bullets ejected one after the other, when the first bullet having been struck in the barrel, fails to leave the barrel and is ejected by a subsequently fired bullet. Duplex bullet: Contains two projectiles by design, used in military rifles and enter a target at different points. Frangible bullet: Designed to fragment upon impact, often to the point of disintegration, made mostly of copper, powdered tungsten, lead or iron. Souvenir bullet: Bullet present in the body for long time with no fresh bleeding around it and surrounded by a dense fibrous tissue capsule. It was not removed as it was not causing any harm or it was located in an area from where its retrieval could cause more damage to the body. Rubber bullets are usually non-lethal rubbercoated projectiles fired from guns, often used in riot control and to disperse protests. Wadcutter is a bullet specially designed for shooting paper targets, usually at close range and with significant velocities. Explosive bullets: these bullets, apart from causing extensive damage in the victim, pose considerable danger to the surgeon/doctor conducting autopsy because the bullet may explode during the procedures or might detonate during ultrasonography, if it had failed to detonate in the body. Percussion cap: It is made of either zinc or copper or a compound of both, so as to be malleable and deformable under the blow of the firing pin. Cartridge cases are classified into five types depending on the configuration of their bases: rimmed, rimless, semi-rimmed, rebated and belted. Small-arms cartridges are classified as centrefire or rimfire, depending on the location of primer. Blank cartridge: Cartridge with primer, gunpowder and wadding, but without any bullet. The cardboard disc behind the shot charge prevents the pellets from getting lodged in the felt wad. Black powder: It produces flame, smoke and heat, and consists of granular ingredients, like sulfur, charcoal and saltpeter (potassium nitrate). Smokeless powder: It is more effective than black powder as it burns more efficiently and produces much less smoke resulting in less blackening and tattooing around the entry wound.
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While the cages retain height and provide support and stability cholesterol test results normal range purchase atorlip-20 cheap, bony fusion occurs within and/or around the cage cholesterol definition in food 20mg atorlip-20 for sale. However cholesterol levels smoking effects cheap 20mg atorlip-20 with visa, the biomechanical requirements on these devices are very high: on one hand they should provide enough compressive strength to keep disc space height while stress concentration on the implant-bone interface must be minimized to reduce penetration or subsidence into the underlying cancellous vertebral body cholesterol medication lipitor purchase atorlip-20 now. On the other hand cholesterol hdl generic 20 mg atorlip-20 otc, the bone graft around and within the cage must be stressed and strained sufficiently to evoke the biological signals (release of cytokines) for bone formation [17, 84] (Table 2). In this context it is proposed that extensive stress-shielding may lead to delayed or non-union. This conflict is reflected in most current cage geometries and materials, but further work is required to fully understand the underlying mechanobiology . When implanting interbody devices, the partial removal of the endplate is a prerequisite for proper graft incorporation, but a bleeding cancellous bone bed may also compromise the support of the device, especially if limited contact areas are present. Resistance to implant subsidence critically depends on the quality of underlying trabecular bone . Cage designs a the first cages had a cylindrical design and were screwed into the endplates (Image Zimmer, Inc. Based on this information, an effective compromise between the biological and biomechanical requirements for fusion may be achieved by choosing larger implants with more peripheral contact areas, such as the Syncage . Similar to endplate strength the overall stiffness of the stabilized spinal segment increases by a factor of three as an interbody cage is moved within the disc space towards the mechanically more advantageous anterior position . The indications for anterior fusion of the spine are various and include discitis/spondylitis and vertebral burst fractures but they are still also often controversial, especially for lumbar back pain. If the surgeon decides to remove the disc, the resulting degree of instability must be estimated before choosing the type of implant and extent of surgery. It has to be emphasized that a complete discectomy combined with the dissection of the anterior longitudinal ligament renders the spine substantially unstable for all loading conditions. For flexion and lateral bending, interbody devices can restore stability profoundly. Cage kinematics Stand-alone intervertebral cages for spinal fusion exhibit poor stabilization in extension. This has led to the opinion that stand-alone cages and anterior bone grafts cause segmental distraction and thereby incongruence of the facet joints. This indicates that, with distraction of the disc space and consequent tensioned anulus fibers, a compressive force on the cage is created. However, due to the viscoelastic anulus material properties, the compressive effect most likely acts only for a short time . Therefore, from the above-mentioned studies it can be concluded that posterior instrumentation with pedicle screws or translaminar screws in addition to the interbody cage must be recommended to establish the appropriate stability. Motion analysis demonstrated a significant increase in segmental stiffness with the Synfix compared to cage/ translaminar screw instrumentation in flexion-extension and rotation . For a definite judgment the comparative biomechanical behavior under repetitive loading (fatigue) as well as clinical results and fusion rates need to be evaluated. In the cervical spine in contrast to the lumber spine, stand-alone interbody cages (or structural bone grafts) are used routinely after one level discectomy, exhibiting near 100 % fusion rates. After single-level discectomy physiological segmental stability was reestablished with both techniques, but with the cage tending to result in slightly higher stiffness . Indications are theoretically numerous and apply for myelopathy, neoplastic and metastatic tumor growth, chronic spondylitis or severe fracture cases. However, the resulting instability, and thus the demand on the instrumentation, strongly depends on the number of involved levels and the preserved and functioning stabilizers. It is quite obvious that the function of incompetent or compromised anatomical structures has to be compensated. Pure bisegmental spinal stability after single-level corpectomy in the lumbar spine can theoretically be restored by pedicle screw systems . However, in the absence of anterior column integrity, the posterior bridge-construct bears 100 % of the load and will most likely fail even in the presence of a posterior spondylodesis. This phenomenon is well known from unstable burst fractures lacking anterior support . Furthermore, biomechanical tests have shown that corpectomy cages alone or in combination with an anterior angle-stable plate fixation are not capable of restoring physiological bisegmental stability. To ensure solid bony fusion it is commonly accepted that normal physiological spinal stability must be exceeded (to what extent is so far unknown). As segmental flexibility with either a stand-alone cage or a cage/anterior plate combination is especially increased in rotation, extension and lateral bending, the addition of pedicle screw fixation must be recommended to ensure a significant increase in overall stiffness . Thus far, from the biomechanical perspective, fundamental anterior instability like that found after corpectomy cannot be treated with anterior or posterior measures alone. Similarly to the lumbar spine, corpectomy in the cervical region is indicated for a variety of spinal pathologies: cervical myelopathy, cervical spine trauma and tumor manifestations. Anterior plating adds significant stability, particularly in rotation, which is only exceeded by posterior systems. Comparing stability of different anterior and posterior systems demonstrated that pedicle screws are more stable than lateral mass screws and constrained posterior systems are superior to unconstrained systems. In a two or more level corpectomy, anterior plating may already be insufficient (see tension band technique). In this case posterior instrumentation involving lateral mass or pedicle screws adds significant stability . Anterior Tension Band Technique Anterior cervical plating bears the risk of stressshielding the bone graft and thus may cause non-union Anterior cervical plates act as typical tension bands during extension but function as buttress plates during flexion. Anterior cervical plates are either constrained or unconstrained devices and are available as dynamic plates in various lengths. Constrained cervical systems have a rigid, angle-stable connection between the plate and screws, whereas unconstrained systems rely on friction generated by compression of the plate on the anterior cortex. In biomechanical testing, constrained systems have shown a greater rigidity, whereas unconstrained plates can lose a significant amount of their stability over time . The surgeon has the Spinal Instrumentation Chapter 3 79 option of selecting systems with monocortical or bicortical screw fixation, often with the same plate. Pull-out tests have demonstrated that bicortical is more stable than monocortical screw placement . Further improvements in stabilization have been made using monocortical locking expansion screws, their strength being comparable to bicortical screws . It has also been shown that the capability of anterior cervical plates to stabilize the spine after three-level corpectomy is significantly limited after fatigue loading , whereas no difference in stability was noted for single-level corpectomy. Another concern regarding the cervical spine, with its inherent mobility and relatively low compressive forces, is delayed or non-union (pseudarthrosis) due to possible stress shielding of the graft. This is particularly true for the latest generation of constrained (locking) plates, with which it is more difficult to set the graft under compression. The load is transferred through a combination of compressive or tensile loading along the length of the implant and bending or torsion. Due to its profile and their position directly on the anterior column, bending forces are much lower than for posterior pedicle screw systems. However, their stabilizing potential is also lower, due to a shorter effective lever arm. The relative effectiveness of anterior, posterior and combined anteroposterior fixation in a corpectomy model has been addressed in a study by Wilke et al. Compared to pedicle screws, the anterior rod devices were slightly more unstable in flexion and lateral bending. In lateral bending, the implants provided better stabilization when the spine was bending away from the implant side, as the devices act as a tension band. Double-rod anterior systems with or without transverse elements are superior to single rod systems, and locking screws increase the stiffness. Finally, however, in all loading directions, only combined anteroposterior fixation can provide complete segmental stabilization. A three-level cervical corpectomy requires anterior and posterior instrumented fusion the stiffness of anterior tension band instrumentation differs from pedicle screws in all loading directions Biomechanics of the "Adjacent Segment" Spondylodesis normally results in an unphysiologically long and stiff spinal segment. It has often been suggested that adjacent segment degeneration is the result of increased biomechanical stress. In these experiments, a fixed displacement was applied to the entire spine specimen. To produce the total displacement, the motion at the adjacent segment must increase as the motion of the fused segment decreases due to its stiffness. Increased segmental motion is paired with an elevated intradiscal pressure, which correlates with the number of fused levels [19, 42]. Nevertheless, in another in-vitro study, application of controlled loads resulted in small but significant increases in adjacent segment mobility . It can be questioned whether "adjacent segment degeneration" is a result of altered biomechanical stresses or a natural progression of the disease. This issue depends on whether adjacent segment motion is indeed increased in vivo following fusion. Taken together, to date and despite numerous clinical and biomechanical studies, it still remains unclear whether the changed biomechanics or the progression of the natural history is responsible for adjacent segment degeneration. However, the overall incidence of adjacent segment degeneration would likely be much higher if its cause were purely mechanical. It is well accepted that disc degeneration is a multifactorial disease with genetic and environmental factors . To what extent mechanical factors contribute to the disease likely also determines whether or not disc degeneration is initiated or aggravated adjacent to a fused segment. Non-Fusion Principles Non-fusion devices may not be superior to instrumented spinal fusion in low back pain the aims of non-fusion devices are the stabilization and reestablishment of normal segmental anatomy including the preservation of segmental motion and thus without performing a spondylodesis. Several approaches have been described to replacing certain parts of the motion segment or to adding supporting stabilization. Depending on the primary pathology of the mostly multifactorial problem, disc arthroplasty, nucleoplasty or posterior dynamic stabilization is performed. Several different devices for various indications are nowadays on the market, or are currently under way. Arthroplasty in the spine has several potential advantages: preservation of segmental motion, lower rate of adjacent level degeneration and no need for harvesting autologous bone graft. The demands on the material properties and function of such devices are substantial. They must not only possess sufficient strength to withstand compressive and shear loads transmitted through the spinal column, but must also respect the complex kinematics of intervertebral motion. The design philosophy of many current disc prostheses reflects the evolution of other total joint prostheses. Due to its conformity throughout the full range of motion, stresses transmitted through the polyethylene and into the bone should be lower and thus reduce polymer wear and prosthesis loosening. Current designs for intervertebral prostheses or dynamic stabilization systems aim to respect this unique characteristic of spinal motion. As in the knee, motion of the natural intervertebral joint cannot be compared to a simple ball-and-socket joint. Segmental motion in flexion and extension is a combination of sagittal rotation plus translation. Thus, the instantaneous axis of rotation constantly changes throughout the full range of motion. This principle is reflected in the Bryan Cervical Disc System (Medtronic), which comprises a low friction elastic nucleus located between titanium endplates and a sealing flexible membrane, allowing free rotation and some translation in all directions. In contrast, the ProDisc (Synthes) and Maverick Artificial Disc (Medtronic) are constrained devices with a single articulation, allowing free rotation in all directions around a fixed center of rotation. Unconstrained devices allow a greater range of motion and theoretically prevent excessive facet loads in extreme motion. In contrast constrained disc arthroplasties may reduce shear force on the posterior elements . Only comparative prospective clinical trials can conclusively show if any of these concepts is advantageous for the patient . As with other total joint prostheses, the stability of the prosthesis and the motion segment likely depends on well balanced ligaments and surrounding soft tissues. Therefore, precise operation technique with retention of stabilizing tissue is essential for a good outcome. Histocompatibility was tested for titanium and polyethylene particles in animal models, and neither material induced a strong inflammatory host response [6, 18]. Finally, the kinematics of each new device must be verified against representative motion patterns of the normal spine . Designs of total disc arthroplasty Current intervertebral disc prostheses differ in the bearing material used (polyethylene or metal alloys) and have either a fixed (constrained) center of rotation. Unlike interbody fusion, also in the lumbar spine the disc prosthesis exhibited a near physiological segmental motion pattern in all axes except rotation, which was increased . Only few data exist so far about the lifetime of disc prostheses, preservation of motion and long-term patient satisfaction. Therefore, total disc replacement still has to establish its position against spondylodesis [24, 71, 101]. There is, however, little data on the long-term biomechanical behavior of such implants in the intervertebral disc space, and the overall effectiveness of replacing only the nucleus pulposus in a degenerated disc. Posterior Dynamic Stabilization Technique Indications for dynamic posterior stabilizing devices are difficult to define Non-rigid posterior stabilization of the spine is another concept for the treatment of various spinal pathologies. Graf introduced the ligamentoplasty, a posterior dynamic stabilization system consisting of pedicle screws which were connected via elastic polyester elements .
On the contrary cholesterol ratio calculator mmol/l buy cheapest atorlip-20 and atorlip-20, the parasagittal section (b) of a 77-year-old individual demonstrates that the disc space has completely collapsed cholesterol levels blood pressure order atorlip-20 canada. Anterior or posterior displacement of the vertebral bodies is visible at all levels cholesterol test breastfeeding 20mg atorlip-20 with visa. The cartilaginous endplates are partially resorbed and exhibit severe sclerotic alterations zetia cholesterol medication side effects order 20mg atorlip-20 mastercard. Despite these dramatic changes there is no close link between these alterations and pain cholesterol qualitative test purchase atorlip-20 online pills. General Age-Related Changes Various mechanisms on a cellular and systemic level have been identified to contribute to age-related changes in the musculoskeletal system . These local alterations can then directly affect the function of the respective tissue. Although any part of the musculoskeletal system can be affected by agerelated alterations, lower extremities and especially the lumbar spine are the most frequently reported locations of musculoskeletal impairment (Case Introduction). Between 70 % and 85 % of the population in Western industrialized countries will experience back pain at least once during their lives, underlining the impact of age-related alterations to the spine [33, 35, 86, 151, 152]. These episodes of back pain often lead to sickness leave and sometimes to chronic disabilities (approx. In this context, it is important to notice that normal age-related degenerative changes and pathological degeneration leading to back pain have to be distinguished. Several studies have shown that between 7 % and 72 % of individuals that exhibit signs of disc degeneration never experienced relevant low back pain [15, 115, 155]. Among age-related alterations of the spine, the so-called "degenerating spondylosis" or spinal osteoarthritis is the most common and is probably inevitable with increasing age. This alteration is radiologically characterized by osteophytes (bone spurs) arising from the margin of the vertebral body and is usually accompanied by disc space narrowing. The term "spondylosis" was historically an effort to distinguish between degenerative changes in the spine and those in synovial joints (osteoarthritis) such as facet joints . However, it has been shown that pathological changes in the spine and osteoarthritis of the synovial joints coexist and in most cases are interrelated . Autopsy studies by Schmorl and Junghanns  reported evidence of spondylosis in 60 % of women and 80 % of men by the age of 49 years, and in 95 % of both sexes by the age of 70 years. The spine is most frequently affected by age-related alterations Degenerative spondylosis is inevitable with aging Functional Spine Unit the spine is a multi-segmented column, which provides stability and mobility to the body at each segmental level and gives protection to the nerve roots and the spinal cord. The smallest anatomical unit of the spine which exhibits the basic functional characteristics of the entire spine is called the "motion segment" or "functional spine unit". Each motion segment consists of two adjacent vertebrae, separated dorsally by the zygapophyseal joints or facet joints and anteriorly by the interposed intervertebral disc. The vertebrae are further connected by spinal ligaments, joint capsules and segmental muscles. The spinal ligament complex consists of the interspinous, supraspinous intertransverse, yellow, anterior and posterior longitudinal ligaments. In contrast to the extrinsic muscles, the intrinsic muscles span over two vertebrae and consist of splenius, erector spinae, transversospinal and segmental muscles. Spine motion, stability and equilibrium are achieved by the antagonist action of the powerful flexor and extensor muscle groups. The normal spinal function largely depends on the integrity of these components and their coordinated interplay. Kirkaldy-Willis  introduced the term "the three joint complex" to highlight the importance of a normal interaction of the three joints in a segment, i. Any alterations in one of these components will result in a disturbance of their interplay with subsequent dysfunction, finally leading to back pain, deformity and neurological compromise. Functional spinal unit Schematic representation of a functional spinal unit (motion segment) in a the cervical and b lumbar spine. Age-Related Changes of the Spine Chapter 4 95 the Intervertebral Disc and Cartilage Endplate the intervertebral discs are located between the vertebral bodies. They transmit load arising from body weight and muscle activity through the spinal column and also provide flexibility to the spine by allowing bending, flexion and torsion. Generally, the discs consist of three highly specialized structures: the anulus fibrosus, the nucleus pulposus and the cartilage endplate that forms the interface with the adjacent vertebral bodies. The disc consists of three highly specialized structures Intervertebral Disc Among all the tissue components of the spine, the intervertebral discs exhibit the most striking alterations with age. Because of these dramatic changes, many spine specialists believe that the disc is a major source of back and neck pain. The intervertebral disc has attracted much research to unravel the underlying molecular mechanism of disc degeneration. Although the intervertebral disc is much better explored than other components of the spine, our understanding of its molecular biology is still in its infancy. Elastin fibers intersperse the lamellae and may play an important role in restoration of shape after bending of the spine . The cellular part of the anulus fibrosus consists of thin and elongated fibroblast-like cells aligned to the collagen fibers. Surrounded by the anulus fibrosus is the nucleus pulposus, the gelatinous core of the intervertebral disc. The matrix of the nucleus pulposus consists of randomly organized collagen fibers and radially arranged elastin fibers that are embedded in a highly hydrated aggrecan-containing proteoglycan gel. Interspersed at a low density are rounded chondrocyte-like cells usually located inside a capsule in the surrounding matrix (so-called lacunae) . Macroscopically, the boundary between the anulus fibrosus and the gelatinous nucleus pulposus can only be distinguished in young individuals. The different mechanical properties of anulus fibrosus and nucleus pulposus are determined by composition and organization of the respective extracellular matrix. Although the mechanical properties of nucleus pulposus and anulus fibrosus are very different, the main components are very similar and consist of:) water) proteoglycans) collagen Water makes up 80 % of the wet weight of the nucleus and 70 % of the wet weight of the anulus [105, 162]. Normal anatomy and composition a Mid-sagittal section through a healthy young intervertebral disc. The white cartilage endplates, the gel-like nucleus pulposus and the surrounding anulus fibrosus can easily be distinguished. Small arrows indicate dissipation of the compressive forces to the anulus fibrosus. On the other hand, the nucleus pulposus that is responsible for dissipating the compressive forces on the disc by exerting a hydrostatic pressure on the anulus fibrosus consists of up to 50 % of proteoglycans (percent wet weight), whereas the anulus fibrosus only contains 20 % proteoglycans. These differences in proteoglycan content are also reflected by the water content of the two tissues (80 % in the nucleus pulposus and 70 % in the anulus fibrosus). The exact role of these additional matrix proteins and glycoproteins is not completely clear [55, 87]. It is important to keep in mind that the disc matrix is not a static but a dynamic structure. The components of the matrix are continuously degraded and replaced by newly synthesized molecules. Degradation of matrix components is the anulus resists high tensile forces the collagen and proteoglycan interplay influences disc functions In the normal disc, matrix degradation and synthesis are in balance Table 1. The balance between synthesis, degradation and accumulation of matrix molecules determines the quality and integrity of the disc matrix and is also prerequisite for adaptation/ alteration of the matrix properties to changing environmental conditions. The blood vessels closest to the disc matrix are therefore the capillary beds of the adjacent vertebral bodies and small capillaries in the outermost part of the anulus fibrosus [24, 46]. The blood vessels present in the longitudinal ligaments running adjacent to the disc and in young cartilage endplates (less than 12 months old) are branches of the spinal artery [49, 50, 142]. As a consequence of the avascularity, the nutrient supply to the disc cells and removal of metabolic waste products is entirely dependent on diffusion mainly from or to the capillary beds of the adjacent vertebrae . Animal experiments indicated that the role of the peripheral small capillaries for the nutrient supply is only of minor importance . The dependency of nutrient supply to the inner parts of the disc on diffusion together with the poor diffusion capacity of the disc matrix severely limits nutrient and waste exchange. As a result, a gradient between the inner parts and the peripheral regions of the disc builds up with very low levels of glucose and oxygen and high levels of the waste product lactic acid on the inside . These gradients are even further aggravated by the disc cells using oxygen and glucose and producing lactic acid [49, 56]. The restricted nutrient supply and the increasing acidic milieu, due to the accumulation of lactic acid, are considered the main factors limiting cell viability and therefore the integrity of the disc matrix. Macroscopic Disc Alterations Onset and progression of age-related alterations of the disc can be determined with various techniques. Disc nutrition Glucose and oxygen concentration were found to drop steeply from the endplate towards the inner part of the nucleus pulposus (glc glucose, O2 oxygen). Lactate concentration displayed the opposite course, with highest levels in the inner region (lac lactate). This profile reflects the nutrient limitations in the inner disc and the lower pH values on the inside due to the acidic waste product lactate. The sagittal section through an intervertebral disc shows the region of the determined concentrations (adapted from ). However, more detailed information has been gained from macroscopic postmortem analysis of intervertebral disc tissue from individuals of various ages . These studies have led to grading systems that on one hand allow the evaluation of stages of disc degeneration, but also illustrate the process of age-related degeneration. The original grading system was established by Friberg and Hirsch (and propagated by Nachemson) and has been further refined by Thompson et al. Intervertebral Disc) chondrocyte proliferation (increasing cell clusters due to reactive proliferation)) mucous degeneration (accumulation of mucous substances)) cell death) tear and cleft formation) granular changes: increasing accumulation of granular tissue Cartilage Endplate) cell proliferation) cartilage disorganization) presence of cracks in the cartilage) presence of microfractures) formation of new bone) bony sclerosis First signs of tissue degradation are seen between 10 and 16 years of age when tears in the nucleus pulposus occur along with focal disc cell proliferation and granular matrix transformation . In parallel, the amount and extent of acidic mucopolysaccharides in the matrix increase. The general structure of the nucleus pulposus and the anulus fibrosus, however, is preserved in this age group. The nucleus is accordingly transformed by multiple large clefts and tears and the matrix shows significant granular changes. In this age group particularly the anulus fibrosus Chondrocyte proliferation is the first sign of disc degeneration 102 Section Advanced disc degeneration is indicated by a loss of nuclear/annular distinction Basic Science Disc degeneration exhibits a spatial heterogeneity is more and more affected, resulting in a loss of the clear distinction between nucleus and anulus. Huge clusters of proliferating cells are observed near clefts and tears that are filled with granular material. In individuals older than 70 years, the structural abnormalities change more to scar-like tissue and large tissue defects. Therefore, histological features can hardly be determined and characterize a "burned-out" intervertebral disc. The histological approach, although it largely parallels the macroscopic classification proposed by Thompson et al. Whereas macroscopic and histological approaches concur in the progressive loss of structure in all anatomical regions of the intervertebral disc, the microscopic approach revealed an earlier occurrence of nuclear clefts already in the second decade of life. In addition, the histologic approach revealed the heterogeneity of the alteration within the disc, indicating relevant spatial differences with more alterations usually present in the posterolateral aspects of the disc. In addition, the microscopic approach underlined the importance of nutritional supply to the disc cells for the maintenance of a healthy disc and the lack thereof for the onset and progression of disc degeneration. Since vascularization was seen to disappear from the disc during the first decade, nutritional supply to the disc cells becomes severely impaired during the subsequent phase of growth . Age-Related Changes in Vascularization and Innervation the disc is the largest avascular structure of the human body Vascular changes in the endplate play a key role in the nutritional supply Calcification of the endplates and occlusion of the vascular channels are detrimental to the disc Although there is still some debate over the presence of blood vessels and nerve endings in the inner portions of pathologic discs, there is consensus that the healthy adult disc is the largest avascular and aneural tissue in the human body [61, 88]. This absence of significant vascular supply to the intervertebral disc matrix has important consequences for the maintenance of discal structures as discussed above [17, 88]. In fetal and early infantile intervertebral discs blood vessels penetrate both the endplate and the peripheral region of the anulus fibrosus. However, by late childhood the blood vessels disappear, leaving only small capillaries accompanied by lymph vessels that penetrate up to 2 mm into the outer anulus fibrosus [46, 124]. Since the importance of this peripheral vascularization for the nutrient supply of the disc is not known in detail, the consequences of its disappearance are also unknown. More important for the blood supply to the inner regions of the disc and therefore better described is the vascularization of the interface between adjacent vertebral bodies, cartilage endplate and the disc. The vertebral bodies are supplied by different arteries that are either responsible for the outer regions, the mid-anulus region, or the central core [23, 116]. These arteries of the vertebral body feed capillaries that, after penetrating channels in the subchondral plate, terminate in loops at the bone-cartilage interface . The channels penetrating the subchondral plate are present in the fetus and infants, but disappear during childhood, compromising the blood supply to the inner disc . Later during aging, sclerosis of the subchondral plate is observed and the cartilage endplates undergo calcification followed by resorption and finally replacement by bone [14, 28].
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Disinfectants: 1:10 dilution of common household bleach or a freshly prepared sodium hypochlorite solution is recommended cholesterol treatment chart purchase cheap atorlip-20. The most common method of exposure includes being pricked with a used needle or other contaminated material zinc cholesterol levels purchase atorlip-20 20 mg free shipping. After that cholesterol ratio percentage buy atorlip-20 amex, the body should be wrapped in double layer plastic sheet bag and secured properly cholesterol busting foods cheap atorlip-20 20 mg overnight delivery, so that there is no leakage foods lower cholesterol blood sugar atorlip-20 20mg with visa. In case of accidental injuries or cuts with instruments, contaminated or not with blood or body fluids, while working on a body, the wound should be immediately washed thoroughly under running water, bleeding encouraged and the wound disinfected. Fluid of the pleural and peritoneal cavity should be flushed copiously with running water and drained off directly into the sewer. Contaminated clothing should be thoroughly cleaned with soap and water, for suitable decay of the radioactive material before being sent to laundry. Organs may be removed and detailed dissection is done away from the body, or placed in a glass jar and preserved in a fixative or kept in cold storage for later examination when radioactivity has fallen to a safer level. The presence of a cardiac pacemaker must be recorded, especially if it is one which might contain a radioactive substance. The individual should be advised that he/ she could possibly have been infected by the needleprick and counseled appropriately. Definition: Thanatology (Greek thanatos: death) is the scientific study of death in all its aspects including its cause and phenomena. Somatic death: the question of death is important in resuscitation and organ transplantation. Skin and bone remains metabolically active for many hours and these cells can be successfully cultured days after somatic death. During early 20th century, irreversible cessation of circulatory and respiratory functions was sufficient basis for diagnosing death. Initial changes occur due to metabolic dysfunction and later from structural disintegration. Brain/Brainstem Death As ventilator technology advanced, circulation and respiration could be maintained by means of a mechanical respirator, despite loss of all brain functions and thus have brought the concept of brain death, i. Increase in the intracranial pressure compresses the entire brain including the brainstem and total brain infarction follows. If this area is dead, the person is unable to breath spontaneously or regain consciousness. The crucial point in determining brain death is the demonstration of absence of all brainstem functions. Many countries, including India, now legally consider brainstem death as brain death. Mechanism of Brain Death Brain injury has a number of causes, such as traumatic or cerebrovascular injury and generalized hypoxia, all of which produce brain edema. Edema is accompanied by an increase in intracranial pressure leading to gradual decrease in cerebral circulation to the level of almost cessation, causing aseptic necrosis of the brain. Brain death is the absence of clinical brain function when the proximate cause is known and demonstrably irreversible. Exclusion of complicating medical conditions that may confound clinical assessment. The three cardinal findings in brain death are coma, absence of brainstem reflexes and apnea. Absent oculovestibular reflex (Caloric test): No deviation of eyes to irrigation in each ear with 50 ml of cold water. No grimacing to deep pressure on nail bed, supraorbital ridge, or temporomandibular joint. No gag reflex: No response after stimulation of the posterior pharynx with tongue blade. Apnea test: It is based on the fact that loss of brainstem function definitively results in loss of centrally controlled breathing, with resultant apnea. Thanatology Exclusion of Reversible Conditions the most important reversible conditions/confounding factors that must be excluded are: i. Other conditions: Brainstem encephalitis, severe hypophosphatemia, encephalopathies associated with hepatic failure, uremia and hyperosmolar coma of diabetes mellitus. Observation period: the length of the observation period is still a matter of great controversy. Neurological examination must not be done within 30 min of cardiopulmonary resuscitation. The doctors involved should be experts in the technique of brain death assessment. Under no circumstances are brainstem death tests performed by transplant surgeons or any doctor in the transplant team. Beating-heart donor or living cadavers: After brainstem death has been established, the retention of the patient on the ventilator facilitates a fully oxygenated cadaver transplant, the so-called beating-heart donor or living cadavers. Cause, Mechanism and Manner of Death Two of the most important functions of the forensic doctor are the determination of the cause and manner of death. A particular mechanism of death can be produced by multiple causes of death and vice versa. Thus, if an individual dies of hemorrhage, it can be produced by a gunshot wound or a stab wound or a malignant tumor of the lung eroding into a blood vessel. Manner of death can generally be categorized as natural (death due to disease), homicide, suicide, accident or undetermined (Flow chart 8. An individual can die of massive hemorrhage (mechanism of death) due to stab wound of heart (cause of death), with the manner being homicide (someone stabbed him), suicide (stabbed himself), accident (fell over the weapon) or undetermined (not sure what happened). Modes of Death (Proximate Causes of Death) According to Xavier Bichat, a French physician, there are three modes of death depending upon the system most obviously affected, irrespective of what the remote cause of death may be: i. These are for disease processes that have led directly to death and that are causally related to one another, Table 8. Systemic disorders, such as diabetic ketoacidosis, uremia, heat stroke, eclampsia iii. Intoxication with alcohol, opium, cocaine, chloral hydrate, anesthetics, atropine, cyanide, phenol iv. Postmortem examination: It may reveal the cause, such as inflammation of the meninges, compression from hemorrhage, tumor or vascular lesion. In case of poisoning and metabolic disorders, a hyperemic condition of the brain and its covering membranes may be found. Syncope this is death from failure of the function of the heart resulting in hypoxia and hypoperfusion of the brain. Poisoning: Digitalis, tobacco, aconite and oleander Postmortem examination: Non-specific findings. The cavities of the heart contain comparatively little blood, the organs are pale, and capillaries are congested. Cyanosi s: Bluish discoloration of skin, face (particularly lips and ears), nailbeds, mucous membranes or internal organs. Petechial hemorrhages on the face, conjunctiva, subpleura or subepicardium (Tardieu spots). Congestion and edema of the face and visceral congestion due to raised venous pressure. Other features: Pronounced lividity, cardiac dilatation, or pathological changes which are dependent upon the type of death, like local injuries to the neck in hanging, strangulation and throttling, and color of blood in carbon monoxide poisoning. It is usually not possible to certify that a person died of coma, syncope or asphyxia without mentioning the cause which has produced them. Anoxia According to Gordon, cessation of vital functions is brought about by tissue anoxia. Histotoxic anoxia: It means inhibition of oxidative processes in the tissue which cannot make use of oxygen in the blood. Stagnant/ischemic anoxia: In this type, impaired circulation results in reduced oxygen delivery to the tissues. Sudden death is important from a medico-legal point of view, as it raises a suspicion of foul play. Therefore, in all such cases, an autopsy is necessary to obviate the possibility of death due to foul play. Cardiovascular (44-50% of cases): Cardiovascular disease, particularly coronary artery atherosclerosis is the most common cause of sudden death. Thanatology 113 Coronary Atherosclerosis the most common cause of death from cardiovascular disease is coronary atherosclerosis. However, significant stenotic lesions that may produce chronic myocardial ischemia show more than 75% (threefourth) reduction in the cross-sectional area of a coronary artery or its branch. Zones of occlusion are usually less than 5 mm in length and the area of the severest involvement is about 3-4 cm from the coronary ostia, more often at or near the bifurcation of the arteries, suggesting the role of hemodynamic forces in atherogenesis. Acute occlusion of coronary artery may result from thrombosis or hemorrhage within the wall of the artery. Old thrombi appear as homogeneous yellowish or gray, firm plugs blocking the vessels. Hypoxic myocardium is electrically unstable and liable to arrhythmias and ventricular fibrillation, especially at moments of sudden stress, such as exercise or with/ during an adrenaline response, such as anger or emotion. Early infarcted fibres show a shift of their secondary emission towards yellow, away from the usual olivegreen of healthy fibres. It is generally accepted that at least 12-24 h of survival postinfarction must occur for the earliest recognizable change to evolve in the heart. The essential sequence of events consists of coagulation necrosis and inflammation, followed by the formation of granulation tissue, resorption of the necrotic myocardium, and finally organization of the granulation tissue to form a collagen-rich scar. These events occur in a fairly predictable pattern, allowing one to estimate the age of a given infarct from its gross and microscopic appearance (Table 8. Coronary artery spasm can cause death in patients suffering from angina without narrowing of the coronary arteries and without significant atherosclerosis or congenital anomalies. The lesions of the conducting system of the heart may sometimes cause arrhythmias and death. Any person with a heart in excess of 420 g is at risk of sudden death, even though the coronary arteries are normal. Dehydrogenases-succinic, lactic, malic, hydroxybutyric and cytochrome oxidase are among those used. With malate dehydrogenase, normal Anaphylactic Deaths Most anaphylactic deaths seen by forensic pathologist are caused by insect bites, drugs or foods. Signs and symptoms: Faintness, itching of the skin, urticaria, tightness in the chest, wheezing, respiratory difficulty and collapse. A typical anaphylactic reaction results in acute respiratory distress or circulatory collapse. Obstruction of the upper airway can be caused by pharyngeal or laryngeal edema; of the lower airway, by bronchospasm with contraction of the smooth muscle of the lungs, vasodilatation and increased capillary permeability. In anaphylactic deaths, the onset of symptoms is usually immediate or within the first 15-20 min. Beyond that time, one would need a well-documented medical history of gradually developing symptoms to implicate an anaphylactic reaction. Mechanism: It acts through a reflex arc in which the afferent (sensory) nerve impulses arise in the carotid complex of nerve endings, but not in the vagal nerve trunk itself. These impulses pass through glossopharyngeal nerves to the tenth nucleus in the brainstem, then return through the vagus (efferent) supply to the heart and other organs. This reflex arc acts through the parasympathetic autonomic nervous system and is 115 independent of the main motor and sensory nerve pathways. Affarent fibres are present over the skin, pharynx, glottis, pleura, peritoneum and cervix, which pass into the lateral tracts of spinal cord and finally to the brain. Impaction of food in the larynx or sudden inhalation of fluid into the upper respiratory tract. The cause of death can be inferred only by exclusion of other pathological conditions and from the observation of reliable witnesses, history and clinical findings concerning the circumstances of death. Vitals functions are at low pitch that cannot be detected by clinical examination 4. A woman with infertility receives an ovary transplant from her sister who is an identical twin. Agonal period is the duration between: Fundamentalsof Forensic Medicine and Toxicology 11. An old lady with mitral stenosis underwent hysterectomy for uterine fibroid and died after developing pulmonary edema. D Signs of Death 9 the changes which occur after death are helpful in estimation of the approximate time of death and to differentiate death from suspended animation. Irreversible cessation of the function of brain including brainstem: this is earliest sign of death with stoppage of functions of the nervous system.
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