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Repeat the maneuver with the head in the neutral position and then to the opposite side purchase mentat ds syrup 100 ml otc medicine hat mall. Nausea and Vomiting In cases of acute nausea and vomiting order 100 ml mentat ds syrup free shipping symptoms zoloft dosage too high, especially with diarrhea and fever buy mentat ds syrup 100 ml visa medicine zetia, the patient most likely has viral or bacterial gastroenteritis. This section does not concern these cases, nor does it concern cases of nausea and vomiting with abdominal pain. Physical examination of patients with chronic nausea and/or vomiting without abdominal pain begins with looking for hepatomegaly, an abdominal mass, or focal abdominal tenderness. Obviously, a vaginal examination needs to be done in females to rule out pregnancy, a uterine fibroid, an ovarian cyst, or other gynecologic pathology. Next, one should do a funduscopy to rule out papilledema and intracranial pathology. Check for nystagmus and do the Hallpike maneuvers to rule out benign positional vertigo. It may be necessary to consider giving the patient sublingual nitroglycerin to see if that precipitates an attack, which would point to abdominal migraine as the cause. When all these examinations are unrewarding, the physician relies on the history and diagnostic tests to get a diagnosis. Numbness and Tingling of the Extremities If the complaint is in the upper extremities, it is necessary for the physician to begin the examination by performing examinations for Tinel sign, at the wrist, and Phalen test. This is positive in ulnar neuropathy, which is usually associated with loss of sensation in 57 the fifth finger and lateral one-half of the fourth finger. Check for cervical radiculopathy by performing cervical compression and Spurling tests. Check the reflexes, power, and sensation to all modalities in the upper and lower extremities. If the reflexes are symmetrically depressed, consider the possibility of a polyneuropathy. If they are depressed in one or both upper extremities and increased in the lower, consider the possibility of a lesion of the cervical spinal cord. If there are cranial nerve signs, there may be a lesion in the brain stem or cerebral cortex. Numbness and tingling and/or weakness of one side of the body usually means there is a lesion of the opposite cerebral hemisphere such as a stroke or space-occupying lesion. If the onset of the hemihypesthesia and hemihypalgesia is acute, the reflexes on the side of the numbness and tingling will be depressed. If the numbness or tingling is in the lower extremities, one should begin by performing a straight leg raising test and/or a femoral stretch test to rule out a herniated lumbar disc. If there is loss of sensation in a dermatomal distribution, that would also be consistent with a herniated disc or other lesion of the lumbosacral nerve roots. Always do a rectal examination to determine tone and control of the rectal sphincter and a pelvic examination to look for a uterine or ovarian mass that may be compressing the sacral plexus. Stocking hypesthesia and hypalgesia suggests a polyneuropathy but may also be seen in the subacute combined degeneration of the spinal cord associated with pernicious anemia. If the reflexes are hyperactive and there are pathologic reflexes, suspect a cord tumor or multiple sclerosis. This is consistent with polyneuropathy, whereas a spastic gait would be consistent with multiple sclerosis or a thoracic cord lesion. It is necessary to check the pulses in the lower extremities, not just the dorsalis pedis and posterior tibial pulses, but the popliteal and femoral pulses as well. If these are diminished, they may represent peripheral arteriosclerosis or Leriche syndrome. If the numbness and tingling are present in only the feet, consider the possibility of tarsal tunnel syndrome or Morton neuroma, provided that the peripheral pulses are good. Palpitations 58 Outside of examining the heart for an arrhythmia or murmur, there are a few additional things a physician should do. First, it is necessary to check for an enlarged thyroid, exophthalmos, tremor, and diaphoresis—all findings that would point to hyperthyroidism. Remember, ingesting large amounts of caffeinated beverages can also produce tachycardia, diaphoresis, and tremor. Next, the clinician should take the blood pressure in the recumbent and upright position to rule out postural hypotension before initiating an expensive diagnostic workup with Holter monitoring or psychometric testing. The author recommends that the patient obtain an inexpensive electronic sphygmomanometer and check the blood pressure and pulses twice daily at home for a week; this might pick up a pheochromocytoma or cardiac arrhythmia. Seizures Suppose a clinician is called to the emergency department to examine a patient who has just had a grand mal seizure. All readers know that a good history is most important in establishing the diagnosis of a seizure disorder, but important steps in the physical examination are often overlooked. Is there a unilateral dilated pupil or papilledema suggesting a space-occupying lesion, aneurysm, or herniation? Are there focal neurologic signs such as hemiparesis, cranial nerve palsies, or mental changes suggesting a stroke or space-occupying lesion? To further evaluate for a stroke, one must check the carotid artery for bruits and listen to the heart for murmurs of arrhythmias. If so, consider meningitis or a subarachnoid hemorrhage in the differential diagnosis. Finally, it is necessary to look for skin lesions such as petechiae (suggesting subacute bacterial endocarditis), adenoma sebaceum (indicating tuberous sclerosis), fibromas (suggesting neurofibromatosis), or a port wine stain of the face (suggesting Sturge–Weber syndrome). Tremor 59 The examination of a patient presenting with tremor begins by looking for a thyroid mass, diaphoresis, exophthalmos, and tachycardia. If a tremor is absent at rest and occurs primarily in motion or during a finger-to-nose test, it is most likely familial. Tremor on one side of the body associated with hemianalgesia and hemihypesthesia is due to a thalamic syndrome (occlusion of the thalamogeniculate artery). Look for hepatomegaly and a Kayser–Fleischer ring in the cornea in younger people with tremor to rule out Wilson disease. A unilateral intention tremor associated with ataxia may indicate a cerebellar tumor. Weakness or Fatigue It is necessary to begin with a good general physical examination. Particularly, the physician should look for signs of weight loss, a thyroid or abdominal mass, hepatosplenomegaly, and lymphadenopathy. Do not forget to perform a neurologic examination to exclude peripheral neuropathy, dementia, and other degenerative neurologic diseases. Recent weight gain, acne, hirsutism, and purple striae may indicate Cushing syndrome. Although many of these cases wind up in the psychiatrist’s or psychologist’s office, one should not give up on them too easily. Weight Loss The examination of a patient with weight loss demands a thorough routine physical examination (see page 444).
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Ingress refers to where the irrigation fluid enters the joint order 100 ml mentat ds syrup free shipping treatment 4 ringworm, and egress refers to where the irrigation leaves the joint order mentat ds syrup 100 ml amex symptoms 14 days after iui. Common Portals Anteromedial Portal The anteromedial portal is made medial to the anterior tibialis tendon and lateral to saphenous vein and saphenous nerve buy generic mentat ds syrup on line symptoms 2 days before period. Anterolateral Portal The anterolateral portal is made just lateral to the peroneus tertius tendon. Care should be taken to avoid the superficial peroneal nerve branches (medial and intermediate dorsal cutaneous nerves). Transillumination is a technique 737 where the arthroscope is inserted through the medial portal and directed laterally to transilluminate the soft tissues. This technique is useful for proper portal placement and avoiding critical structures. The sural nerve, lesser saphenous vein, and peroneal tendons should all be lateral to the portal. Posterior-Central Portal Also called the trans-Achilles, portal is created directly through the posterior aspect of the Achilles tendon at the level of the ankle. While this portal involves splitting the Achilles tendon, it is farther from any local nerves as compared with the other portals. Lateral Gutter The lateral gutter is the space between the lateral articular surface of the talus and the fibula. These injuries are considered contaminated, but if they are left without treatment for 6 to 8 hours, they are considered infected. Classification (Gustilo and Anderson) Type I Fracture with an open wound less than 1 cm in length Clean, with minimal soft tissue damage/necrosis Fracture is usually simple (transverse or short oblique) with minimal or no comminution. Most infecting bacteria are skin flora, and so a first- generation cephalosporin is a good choice (e. Vancomycin and/or aminoglycoside antibiotic–impregnated polymethylmethacrylate beads may also be beneficial. Wound closure should be performed as soon as possible under minimal skin tension to prevent nosocomial infections. These forces are seen in people with overuse and repetitive activities, such as runners and athletes. Ninety-five percent of stress fractures occur in the lower extremity, most notably the neck of the 2nd metatarsal. They may take 14 to 21 days to present radiographically after a bony callus has developed. If x-rays are inconclusive, a three-phase technetium bone scan may be positive as early as 2 to 8 days after onset of symptoms. Turf toe is more common in sports played on synthetic surfaces, hence the name “turf toe. The easiest way to make the distinction is to compare current radiographs with previous films, if available. When earlier films are not available, comparing the contralateral foot can be useful. Fractured sesamoids may show irregular jagged edges of separation with interrupted peripheral cortices, longitudinal or oblique division lines, or a bone callus formation. There are three main types of ankle sprains: inversion sprains, eversion sprains, and high ankle sprains. Eversion sprains are rare for two reasons: The fibula prevents the foot from everting and the deltoid ligament on the medial ankle is very strong. Most ankle sprains are inversion sprains, in which the foot inverts and the lateral ligaments are damaged. The position of the foot at the time of an inversion sprain determines which ligaments are damaged. When the foot is dorsiflexed at the time of injury, the calcaneofibular ligament is most likely damaged. Due to its proximity, rupture of the calcaneofibular ligament may also result in tearing of the peroneal tendon sheath. Diagnosis Arthrograms Arthrograms are useful only in acute ruptures while the ligaments are still damaged; after 5 to 7 days, fibrosis may seal off injury and arthrograms will be of no use. Dye is injected into the ankle joint and should remain in the ankle joint on x-ray. Some individuals have a normal connection between the ankle joint and the peroneal tendon sheath, which should not be misdiagnosed as a rupture. The integrity of the articular cartilage should also be inspected with an arthrogram. The dark bands of the articular cartilage should be apparent with the radiopaque dye between them forming the “Oreo cookie sign. A positive test is a 6-mm or greater gap between the posterior lip of the tibia and the nearest part of the talar dome. A talar tilt of greater than 5° as compared with the contralateral side indicates a rupture. Treatment Nonsurgical treatment is aimed at decreasing inflammation and splinting/supporting the damaged tissues to prevent reinjury. Surgical treatment involves procedures that reinforce and stabilize the damaged and elongated ligaments. Surgical Treatment for Eversion Sprains Schoolfied Procedure The deltoid ligament is detached from the tibia, the foot is maximally inverted, and the ligament is reattached superiorly to the detachment site. DuVries Procedure A large cruciate form incision is made in the deltoid ligament and then sutured back together. The theory behind the procedure is that the resultant scar tissue will effectively reinforce and stabilize the medial ankle. Half the tendon is detached proximally and passed inferiorly to superiorly through a drill hole in the distal tibia and sutured back on itself with the foot forcibly inverted. The mechanism of injury is eversion, dorsiflexion, and pronation, which forces the talus against the fibula widening the mortise. The distal tibiofibular syndesmosis is a fibrous joint connecting the bones just above the ankle joint. Extreme dorsiflexion can cause separation of the distal tibiofibular articulation and injure the ligamentous structures. Diagnosis Diagnosis, Clinical Dorsiflexion may elicit pain as the wider anterior portion of the talus is rotated into the mortise and separates the bones. Pain is elicited with dorsiflexion and external rotation of the foot when the knee is flexed at 90° and the leg is stabilized. Distal Compression Test Medial lateral compression at the level of the malleoli elicits pain due to compression of the ligaments. Medial lateral compression at the midcalf level elicits pain due to a slight distraction that 751 results distally at the syndesmosis. There is also the “crossed-leg test,” which mimics the mechanism of the squeeze test.
Contraindications Suspected perforation order mentat ds syrup once a day symptoms 5 days post embryo transfer, recent rectal biopsy buy mentat ds syrup 100 ml lowest price medications drugs prescription drugs, toxic megacolon cheap mentat ds syrup online treatment questionnaire, or pseudo- membranous colitis. Common fndings • Solitary flling defect: polyps are classifed according to histology. Also found are adenocarcinoma (i risk in ulcerative colitis, polyposis syndromes, villous adenoma) and less commonly metastases and lymphoma. Colonoscopy Remains a complementary technique and has the advantage of being both therapeutic and diagnostic (e. In elderly patients, Ct with prior bowel preparation and air insufation is less invasive and less arduous. Virtual colonoscopy Helical Ct images of distended colon taken during a breath-hold are used to obtain 2D or 3D images of the colon. Images are acquired in the supine and prone positions to assess lesional mobility (and thus distinguish stool from polyps). Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. Intravenous urogram this provides a good overview of the urinary tract and, in particular, the pelvicalyceal anatomy. An increasingly dense delayed nephrogram is seen in acute obstruction, acute hypotension, AtN, and renal vein thrombosis. May be due to obstruction (functional as in ° megaureter) or mechanical stenosis as in ureteric or urethral stricture and in refux disease. Diferentials include tumour (transitional cell carcinoma, metastatic), infammatory (tB, schistosomiasis), congenital, trauma (radiation or iatrogenic). Computed tomography in genitourinary pathology Ct is the preferred method for assessment of many pathologies within the genitourinary (GnU) tract, including trauma, complex infections, renal and adrenal masses, neoplastic disease, retroperitoneal processes, renovascular hypertension, and in renal colic. Depending on institutional protocol, the examination is performed as a 2- or 3-part study. It has a high sensitivity (95%) in detect- ing upper urinary tract uroepithelial malignancies. Dedicated pelvic coils and endoluminal coils show excellent results in stag- ing pelvic and gynaecological malignancies. Micturating cystourethrogram following catheterization of the bladder, contrast is introduced till bladder capacity is reached. It is also used if there are recurrent UtIs or suspected lower urinary tract obstruction. Ascending urethrography Contrast is injected directly into the urethra in ♂ in the assessment of urethral trauma, strictures, and congenital anomalies such as hypospadias. Mammography is the frst-line tool for detection of breast cancer; however, sensitivity of screening mammogram is variable and is infuenced by vari- ables such as density of breast tissue. Sensitivity is between 68 and 90% and is higher if the patient is symptomatic (93%). Since 1990, mortality from breast cancer has steadily declined, and this has been attributed to advances in adjuvant therapy as well as to mammographic screening. Mammography Technical factors Breast tissue has a narrow spectrum of inherent densities, and in order to display these optimally, a low-kilovoltage (kV) beam is used. Dedicated mammographic units provide low-energy X-ray beams with short expo- sure times. High resolution is paramount in order to detect microcalcifca- tion (as small as 0. Adequacy of the lateral oblique view may be gauged by the pectoralis major muscle, which should be visible to the level of the nipple, inclusion of the axillary tail, Fig. Mammographic signs the breast parenchyma is made up of glandular tissue in a fbrofatty stroma. Systematic evaluation of a mammogram • Adequacy of study; are additional views required? Comparison with prior imaging is imperative, as changes can be subtle and progressive. Primary signs of a malignancy • A mass with ill-defned or spiculate borders (see fig. Breast ultrasound this largely forms a modality for assessment, not diagnosis or detection, and is a valuable adjunct and problem-solving tool. It can be used to evalu- ate non-palpable masses and palpable masses not seen on mammography, to determine the internal architecture (solid vs cystic), to assess asymmetric density, to assess breast implants, and as a ° imaging modality in young women (<35 years), as well as pregnant and lactating women. It is especially useful to detect recurrent breast carcinoma and where conventional techniques are unable to help in the distinction from more benign lesions. In problematic mammographic patients, it can be useful in distinguishing dense breast tissue or fbrosis from malignancy. In the post-operative setting, it can be used in patients with +ve surgical margins or to assess post-operative scar vs disease recurrence. It is an important cross-sectional modality and has widespread applications in the abdomen, neck, pelvis, and extremities. At diagnostic levels, there are no known damaging sequelae to tissues, and therefore it is safe for use in obstetrics, providing invaluable imaging of the developing fetus. Highe-frequency probes provide greater resolution but have limited depth of penetration and may therefore be suitable for assessment of superfcial structures (e. Again, advances in technology have resulted in vast improvements in the resolution of this modality, such that subtle pathology is more readily identifable. Applications • Head and neck: may be used for evaluation of the salivary glands, thyroid, lymph nodes, and palpable or clinically suspected masses. Doppler is used to assess the carotid vessels and quantify the degree of stenosis/ occlusion. Retroperitoneal masses and lymph nodes may be visible, depending on patient habitus. It can also be used for infertility monitoring, egg retrieval, and the exclusion of suspected ectopic pregnancy. Indications include advanced maternal age, abnormal biochemical markers (triple screen or AfP), and a history of genetic/chromosomal disorders. Hysterosalpingogram • Indications: for assessment of infertility, to defne uterine anatomy, and to evaluate tubal patency as a precursor for in vitro fertilization or for evaluation of congenital anomalies. Pelvic magnetic resonance imaging Indications Include locating and confrming the presence of leiomyomas (often pre- and post-uterine fbroid embolization (Ufe); E Interventional radiology, pp. Current scanners can acquire data in a continuous helical or spiral fashion, shortening the acquisition time and reducing artefacts caused by patient movement. Prior to scanning the abdomen or pelvis, dilute oral contrast is given to opacify the bowel. Multislice Ct scanners are third-generation scanners with helical capabili- ties and low-voltage slip rings, which acquire anywhere between 64 and 320 slices (and counting! Dose management has become more of a concern with the i utility of Ct across a spectrum of pathologies.
A: Bony anatomy relevant to thoracic facet medial branch block or radiofrequency treat- ment purchase genuine mentat ds syrup line treatment without admission is known as. Three-dimensional reconstruction computed tomography of the high thoracic spine as viewed in the posterior approach used for needle insertion trusted mentat ds syrup 100 ml medicine ball. The base of the transverse process joins the superior articular process just superolateral to the pedicle order mentat ds syrup 100 ml with visa treatment action group. The arrows indicate the targets for medial branch nerve blocks or radiofrequency treatment at the C7 to T3 levels on the left. A: Bony anatomy relevant to thoracic facet medial branch block or radiofrequency treat- ment. Three-dimensional reconstruction computed tomography of the low thoracic spine as viewed in the posterior approach used for needle insertion. The transverse processes are less prominent at low thoracic levels and often difﬁcult to see at all at T12. The base of the transverse process joins the superior articular process just superolateral to the pedicle, and the pedicle is used as a landmark to locate the target for injection. The arrows indicate the targets for medial branch nerve blocks or radiofrequency treatment at T10 to L1 levels on the left. Cannula placement his or her degree of pain relief in the hours immediately for thoracic pulsed radiofrequency treatment is carried out following the diagnostic blocks. Block Technique: Radiofrequency Treatment Lumbar Medial Branch Block and Radiofrequency cannulae are placed using a technique Radiofrequency Treatment identical to that described for medial branch blocks. Once the nee- the base of the transverse process, where they join with dle is seated against the superior margin of the transverse the superior articular processes (Figs. The process, the cannula is walked superolaterally off the trans- medial branch nerve lies in the groove between the trans- verse process and advanced 2 to 3 mm to position the active verse process and the superior articular process, which tip along the course of the medial branch nerve (Figs. A pillow is placed under the needle tip is in position at the base of the superior artic- the lower abdomen in an effort to tilt the pelvis backward ular process and has not been advanced anteriorly into the and swing the iliac crests posteriorly away from the lum- intervertebral foramen (Fig. The C-arm is positioned over the lum- sory-motor dissociation is conducted (the patient should bar spine with 25 to 35 degrees of oblique angulation so report pain or tingling during stimulation at 50 Hz at <0. Thereafter, great care must be be advanced in the axial plane without caudal angulation taken to prevent any movement of the cannulae. The arrows indicate the range, from medial to lateral extremes, where the medial branch nerves may pass over the superior margin of the trans- verse process (based on anatomic dissection studies). Unlike the very predictable location of the nerve near the junction of the transverse process and superior articular process at lumbar spinal levels, the position of the nerve is less predictable at thoracic levels. A: Bony anatomy relevant to thoracic facet medial branch block or radiofrequency treat- ment. Three-dimensional reconstruction computed tomography of the low thoracic spine as viewed in the lateral projection used to verify ﬁnal needle position; the bony elements of the right lateral hemithorax have been removed to allow better visualization of the spine. Interpretation of the lateral radiograph is complicated by the dramati- cally differing contrast within the abdomen and pelvis as well as the multiple conﬂuences of shadows due to the overlying ribs. Nonetheless, discerning the location of the superior articu- lar surface is simple: identify the superior end plate of the vertebral body at the level of interest, and follow the margin posteriorly until the posterior margin of the vertebral body joins the pedicle (the structures have been labeled on T12). The superior margin of the pedicle forms the inferior border of the intervertebral foramen. Follow the superior border of the pedicle posteriorly and it will slope upward where it joins the superior articular process of the facet joint. The superior extent of the superior articular process is easily identiﬁed as notch along the posterior margin of the intervertebral foramen. The articular surface is then easily identiﬁed as a line sloping in a posterior and inferior direction. The junction of the superior articular process and the transverse process is behind the overlying rib; the tips of each needle are located at this junction in the image. T12 T12 L1 L1 L2 L2 Medial branch L3 block L3 Medial branch L4 o block L4 25–35 Radio- from frequency o sagittal 0 L5 plane L5 o 25–30 Figure 7-36. Position and angle of needle entry for lumbar medial branch blocks and radiofrequency treatment. Cannulae placement for conventional radiofrequency treatment should be carried out with 25 to 30 degrees of caudal angulation of the C-arm to bring the axis of the active tip parallel to the course of the medial branch nerve in the groove between the transverse process and the superior articular process. Cannulae placement for conventional radiofrequency treatment should be carried out with 25 to 30 degrees of caudal angulation of the C-arm to bring the axis of the active tip parallel to the course of the medial branch nerve in the groove between the transverse process and the superior articular process. For conventional radiofrequency treatment, the cannulae must be walked off the superior margin of the transverse process and advanced 2 to 3mm to place the active tip along the course of the medial branch nerve (inset). The lumbar level can be identiﬁed be parallel to the medial branch nerve within the groove by counting upward from the sacrum. The needle is adjusted to remain coax- ial and advanced toward the base of the transverse process, Block Technique: Diagnostic Medial Branch Blocks where it joins the superior articular process (see Figs. Once the needle where the block is to be carried out are anesthetized with is in position, a small volume of local anesthetic is placed Chapter 7 Facet Injection: Intra-articular Injection, Medial Branch Block, and Radiofrequency Treatment 113 Medial Medial Radio- branch branch frequency block block Radio- frequency Figure 7-38. The C-arm is positioned over the lumbar spine with 25 to 35 degrees of oblique angulation so the facet joints themselves and the junction between the transverse process and the superior articular process are clearly seen. For medial branch blocks, the needle can be advanced in the axial plane without caudal angulation. However, for radiofrequency treatment, the C-arm should be angled 25 to 30 degrees caudal to the axial plane so the active tip of the radiofrequency cannulae will be parallel to the medial branch nerve in the groove between the transverse process and the superior articular process. A: Bony anatomy relevant to lumbar medial branch blocks and radiofrequency treatment. Three-dimensional reconstruction computed tomography of the lumbar spine as viewed in the left oblique projection used for needle insertion. Three radiofrequency cannulae are in place at the base of the transverse processes and superior articular processes at the L3, L4, and L5 levels on the right. Note the presence of a transitional vertebra at L5, with sacralization of the L5 vertebra (thin laminar arch and absence of a discernable inferior articular process at L5, yet clear segmentation of the L5 vertebral body on the lateral image shown in Fig. The contours of the posterior bony elements of the spine on the oblique projection take a shape similar to the silhouette of a Scottish terrier or “Scotty dog”. Following this contour around its perimeter, the front leg of the dog is the inferior articular process of the vertebra, the snout is the transverse process, the ear is the superior articular process, the back is the superior margin of the lamina, the buttocks and hind leg is the spinous process, and the belly of the dog is the inferior margin of the lamina. Compare the outlined areas of the radiograph with the contour of an actual Scottish terrier shown in the inset in the lower right corner of this image. The patient is instructed to Proper testing for sensory-motor dissociation is conducted assess his or her degree of pain relief in the hours immedi- (the patient should report pain or tingling during stimula- ately following the diagnostic blocks. There- Block Technique: Radiofrequency Treatment after, great care must be taken to prevent any movement Radiofrequency cannulae are placed using a technique iden- of the cannulae. Cannula placement for lumbar pulsed radiofre- plane so the active tip of the radiofrequency cannulae will quency treatment is carried out in the same manner. Once the needle is seated against the superior Radiofrequency Treatment margin of the transverse process, where it joins the supe- rior articular process of the facet, the cannula is walked off Complications associated with diagnostic medial branch the superior margin of the transverse process and advanced nerve blocks are uncommon and similar to those follow- 2 to 3 mm to position the active tip along the course of the ing intra-articular facet injection. Unlike intra-articular Chapter 7 Facet Injection: Intra-articular Injection, Medial Branch Block, and Radiofrequency Treatment 115 A Superior articular process Transverse Spinous process processes L3 Laminae Needle tips Pedicles L4 Iliac crest B C Figure 7-40.
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