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By T. Hamil. Mid-America Nazarene University.

Weakness and wasting of the hypothenar and in- trinsic hand muscles result in the loss of power grip and impaired preci- sion movements cheap super viagra 160mg mastercard. Cervical radiculopathy May cause sensory symptoms in the fourth and fifth (C8–T1) fingers cheap super viagra 160mg otc, and also along the medial forearm buy super viagra 160mg cheap. Although the elbow is a common C8 referral site generic super viagra 160mg with mastercard, pain is more proximal cheap super viagra 160mg without a prescription, centering in the shoulder and neck – Electrodiagnosis! Ulnar sensory potentials in C8 are intact in radiculopathies, and there are no focal conduction abnormalities across the elbow segment! Needle EMG demonstrates denervation in C8–T1 median-innervated thenar muscles, as well as in ulnar-innervated muscles Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Radial Nerve Palsy 239 Thoracic outlet syn- – Sensory symptoms involve not only the fourth and drome, lower brachial fifth fingers, but also the medial forearm plexopathy – Weakness involves both the hypothenar and (more severely) the thenar muscles – Electrodiagnostic studies show normal conduction and a lesion in the lower trunk of the brachial plexus Syringomyelia – Dissociated sensory loss is characteristic, with spar- ing of large-fiber sensation – Median-innervated C8 motor function is impaired as well as ulnar motor function. There are often as- sociated long track findings in the legs – Electrodiagnosis shows normal ulnar sensory potentials, due to the preganglionic nature of the lesion – MRI is diagnostic Motor neuron disease – Sensory disturbances are not found – There is weakness and wasting of intrinsic hand muscles. Fasciculations may be present, indicating the widespread nature of the disease Ulnar nerve entrapment – Sensory loss in the medial fourth and fifth fingers. The most specific study is a prolonged distal motor latency to the first dorsal interosseus compared to the abductor digiti minimi! Needle EMG may demonstrate active or chronic denervation in either thenar or hypothenar muscles, with sparing or ulnar- innervated forearm muscles EMG: electromyography; MRI: magnetic resonance imaging. Radial Nerve Palsy The radial nerve is a continuation of the posterior cord of the brachial plexus, and consists of fibers from spinal levels C5 to C8. It descends be- yond the posterior wall of the axilla, entering into the triangular space. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Compression in the Axilla This can occur with incorrect use of crutches, improper arm positioning during inebriated sleep, or with a pacemaker catheter. The le- sions are usually due to displaced fractures of the humeral shaft after in- ebriated sleep, during which the arm is allowed to hang off the bed or bench ("Saturday night palsy"), during general anesthesia, or from callus formation due to an old humeral fracture. There may be a familial his- tory, or underlying diseases such as alcoholism, lead and arsenic poison- ing, diabetes mellitus, polyarteritis nodosa, serum sickness, or advanced Parkinsonism. The clinical findings are usually similar to those of an axillary lesion, except that: a) the triceps muscle and the triceps reflex are normal; b) sensibility on the extensor aspect of the arm is normal, whereas that of the forearm may or may not be spared, depending on the site of origin of this nerve from the radial nerve proper. Lesions distal to the spiral groove and above the elbow—just prior to the bifurcation of the radial nerve and distal to the origin of the bra- chioradialis and extensor carpi radialis longus—produce symptoms sim- ilar to those seen with a spiral groove lesion, with the following excep- tions: a) the triceps reflex is normal; b) the brachioradialis and extensor carpi radialis longus muscles are spared. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Radial Nerve Palsy 241 Compression at the Elbow Just above the elbow and before it enters the anterior compartment of the arm, the radial nerve gives off branches to the brachialis, coraco- brachialis, and extensor carpi radialis longus before dividing into the posterior interosseous nerve and the superficial radial nerve. The poste- rior interosseous nerve is the deep motor branch of the radial nerve, passing through a fibrous band (the arcade of Frohse) of the supinator muscle in the upper forearm. Entrapment is thought to be due to the following conditions: – A fibrotendinous arch where the nerve enters the supinator muscle (arcade of Frohse) – Within the substance of the supinator muscle (supinator tunnel syndrome) – The sharp edge of the extensor carpi radialis brevis – A constricting band at the radiohumeral joint capsule There are two recognizable clinical syndromes in this disorder—the radial tunnel syndrome and posterior interosseous neuropathy. The radial tunnel contains the radial nerve and its two main branches, the posterior interosseous and superficial radial nerves. Forced repeated pronation or supination, or inflammation of supinator muscle attachments (as in tennis elbow) may traumatize the nerve, sometimes due to the sharp tendinous margins of the exten- sor carpi radialis brevis muscle. The condition is characterized by a lateral dull ache deep in the extensor muscle mass of the upper forearm. There is tenderness over the extensor radialis longus muscle, just where the posterior interosseous nerve enters the supinator muscle mass. Pain increases with forced supination, or with resisted extension of the middle finger (the middle finger test) while the patient’s elbow and wrist are extended. Although the site of entrapment is similar to that in posterior interosseous neuropathy, in contrast to that condition there is usually no muscle weakness. Structural pathology, such as lipomas, ganglia, rheumatoid synovial overgrowths, fibromas, and dislocations of the elbow, may all account for compression of the radial and posterior interosseous nerves at this site, resulting in PIN. The condition can also be caused by entrapment, which is thought to have the following causes.

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This allows subtle biases to creep in cheap 160mg super viagra mastercard, since the clinician m ight be m ore (or less) likely to enter a particular patient into the trial if he or she believed that the patient would get active treatm ent purchase super viagra 160mg visa. In particular super viagra 160mg fast delivery, patients with m ore severe disease m ay be subconsciously withheld from the placebo arm of the trial buy super viagra 160mg cheap. Exam ples of unacceptable m ethods include random isation by last digit of date of birth (even num bers to group A 160 mg super viagra sale, etc. The questions which best lend them selves to the RCT design are all about interventions, and are m ainly concerned with therapy or prevention. It should be rem em bered, however, that even when we are looking at therapeutic interventions, and especially when we are 47 H OW TO READ A PAPER not, there are a num ber of im portant disadvantages associated with random ised trials (see Box 3. There are, in addition, m any situations in which RCTs are either unnecessary, im practical or inappropriate. Som e people would argue that it is actually unethical to ask patients to be random ised to a clinical trial without first conducting a system atic literature review to see whether the trial needs to be done at all. RCTs are inappropriate • W here the study is looking at the prognosis of a disease. For this analysis, the appropriate route to best evidence is a longitudinal survey of a properly assem bled inception cohort (see section 3. For this analysis, the appropriate route to best evidence is a cross-sectional survey of patients clinically suspected of harbouring the relevant disorder (see section 3. For exam ple, an RCT com paring m edical versus surgical m ethods of abortion m ight assess "success" in term s of num ber of patients achieving com plete evacuation, am ount of bleeding, and pain level. The patients, however, m ight decide that other aspects of the procedure are im portant, such as knowing in advance how long the procedure will take, not seeing or feeling the abortus com e out, and so on. For this analysis, the appropriate route to best evidence is a qualitative research method47 (see Chapter 11). All these issues have been discussed in great depth by the clinical epidem iologists,3, 6 who rem ind us that to turn our noses up at the 49 H OW TO READ A PAPER non-random ised trial m ay indicate scientific naïveté and not, as m any people routinely assum e, intellectual rigour. N ote also that there is now a recom m ended form at for reporting RCTs in m edical journals, which you should try to follow if you are writing one up yourself. The follow up period in cohort studies is generally m easured in years (and som etim es in decades), since that is how long m any diseases, especially cancer, take to develop. N ote that RCTs are usually begun on patients (people who already have a disease), whereas m ost cohort studies are begun on subjects who m ay or m ay not develop disease. A group of patients who have all been diagnosed as having an early stage of the disease or a positive screening test (see Chapter 7) is assem bled (the inception cohort) and followed up on repeated occasions to see the incidence (new cases per year) and tim e course of different outcom es. They followed up 40 000 British doctors divided into four cohorts (non- sm okers, light, m oderate and heavy sm okers) using both all cause (any death) and cause specific (death from a particular disease) m ortality as outcom e m easures. Publication of their 10 year interim results in 1964,51 which showed a substantial excess in both lung cancer m ortality and all cause m ortality in sm okers, with a 50 G ETTIN G YOU R BEARIN G S "dose–response" relationship (i. The 20 year52 and 40 year53 results of this m om entous study (which achieved an im pressive 94% follow up of those recruited in 1951 and not known to have died) illustrate both the perils of sm oking and the strength of evidence that can be obtained from a properly conducted cohort study. Clinical questions which should be addressed by a cohort study include the following. As John Guillebaud has argued in his excellent book the Pill,54 if 1000 wom en went on the pill tom orrow, som e of them would get breast cancer. The question which epidem iologists try to answer through cohort studies is "W hat is the additional risk of developing breast cancer which this wom an would run by taking the pill, over and above her "baseline" risk attributable to her own horm onal balance, fam ily history, diet, alcohol intake, and so on? D ata are then collected (for exam ple, by searching back through these people’s m edical records or by asking them to recall their own history) on past exposure to a possible causal agent for the disease. Like cohort studies, case-control studies are generally concerned with the aetiology of a disease (i. An im portant source of difficulty (and potential bias) in a case-control study is the precise definition of who counts as a "case", since one m isallocated subject m ay substantially influence the results (see section 4. In addition, such a design cannot dem onstrate causality; in other words, the association of A with B in a case-control study does not prove that A has caused B. Clinical questions which should be addressed by a case-control study include the following.

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