nyuuzyou/wikis huggingface dataset:
Lidocaine

Lidocaine was the first clinically used amide local anesthetic in 1948. It is widely used because of its potency; rapid onset; tissue penetration; and effectiveness in infiltration, peripheral nerve block, and both epidural and spinal blocks. In peripheral nerve blockage 1-1.5% is sufficient to produce a motor blockade, while for epidural and spinal blocks higher strengths are used.
==Pharmacology==
===Chemical Structure===
==Buffered Lidocaine==
==Formulations==
===Lidocaine Cream===
Lidocaine cream is not readily available in New Zealand and is not subsidised. It has to be ordered over the internet.
*Haim International for 10.56% lidocaine cream, apply twice daily
*4% Lidocaine patches can be purchased from ebay, brand name is Salonpas. They last for 8 hours.
=== Lidocaine Patches ===
Formulations are Verisatis (5%, not available in NZ), salonpas (4%, available on ebay),
For verisatis up to three plasters can be used at once 12 hours on, 12 hours off. It is a once daily application that provides 24 hour pain relief. No dosage titration is required. It doesn't seem to be easily available.
==Toxicity==
The central nervous system is where the premonitory signs of toxicity occur, and it is a graded response. Early symptoms include circumoral numbness, tongue paraesthesia, and dizziness. Patients may complain of sensory disturbance such as tinnitus and blurred vision. There may be excitatory signs, such as restlessness, agitation, nervousness, or paranoia. These may progress to muscle twitching and seizures. With severe toxicity, CNS depression can occur with coma. 
Cardiovascular effects with hypotension and bradycardia can occur as a result of a relative overdose with neuraxial blockage or nerve blocks nerve the CNS. Unintentional intravascular injection produces severe cardiotoxic reactions which include hypotension, atrioventicular heart block, idioventricular rhythms, ventricular tachycardia, and ventricular fibrillation. Even premonitory signs can progress to cardiotoxicity and so any reaction should be treated promptly.
==Maximum Dose==
The maximum safe dose for subcutaneous infiltration typically quoted as:
*Lidocaine WITHOUT adrenaline (also called plain lidocaine) – 4 mg/kg (0.4 mL/kg of lidocaine 1 percent, maximum total dose: 300 mg [30 mL of lidocaine 1 percent])
*Lidocaine WITH adrenaline – 7 mg/kg (0.7 mL/kg of lidocaine 1 percent, maximum total dose: 500 mg [50 mL of lidocaine 1 percent with epinephrine]).
Special considerations:
*In children under 8 years old, 80 percent of the maximum allowable dose should not be exceeded. 
*In elderly with severe liver or kidney disease, the total dose should be reduced by around 50% 
*The evidence for maximum dosing is actually quite poor, and highly variable dependent on the type of procedure. For example in intercostal nerve blocks the safe dose is 10 times less.
==See Also==
Buffered Local Anaesthetic
==References==
Category:Pharmacology
Category:Stubs
Ligaments of the Lumbar Spine

==Interspinous ligament==
There are three parts to the interspinous ligaments. Ventrally there are fibres that run posterocranially from the dorsal aspect of the ligamentum flavum to the anterior half of the lower border of the upper spinous process. Dorsally there are fibres that run from the posterior half of the upper border of the lower spinous process and pass behind the posterior border of the upper spinous process. Viewed anteriorly but not posteriorly, there are two interspinous ligaments that are separated by fat. The interspinous ligaments provide little resistance to spinous process separation with forward flexion.
==Supraspinous ligament==
The supraspinous ligament is not a true ligament, but rather largely consists of tendinous fibres from the back muscles, and is only well developed at the upper lumbar levels. It terminates at L3 in 22%, L4 in 73%, bridges L4-5 in 5%, and is routinely absent at L5-S1.
The superficial layer is collagenous and thought to represent superficial fascial condensation, and anchors the skin to the thoracolumbar fascia. It provides little resistance to spinous process separation. The middle layer consists of intertwining fibres of the thoracolumbar fascia and the aponeurosis of longissimus thoracis. The deep layer consists of strong tendinous fibres from the aponeurosis of longissimus thoracis. The tendons aggregate in a parallel manner towards the spinous processes, creating the impression of a ligament.
At the caudal levels of L4 and L5 there are only oblique fibres of the thoracolumbar fascia that intersect over the spinous processes and fuse with the aponeurosis of the longissimus thoracic that attach to the spinous processes.[2]
==Mamillo-Accessory Ligament==
There is a notch between the mamillary process and accessory process on each side of every lumbar vertebra. This notch is converted into a foramen by the mamillo-accessory ligament, through which the medial branch of the dorsal ramus passes through to supply the facet joint and multifidus. The ligament at any segment is related to the nerve of the next caudal segment (e.g. the L5 ligament is related to the L4 medial branch).
It is not a true ligament because it connects two points on the same bone. Its structure resembles a tendon more than a ligament and it has been interpreted as being a tendon of the semispinalis musculature in the lumbar spine. It is about 1-2mm thick.
The ligament can be ossified which converts the notch into a bony foramen, which is a normal phenomenon in a minority of people.
The structure has no biomechanical significance.
File:Lumbar mamillo-accessory ligament.png|The lumbar mamillo-accessory ligaments. Transverse process (tp), superior articular process (sap), mamillary process (mp), accessory process (sp), mamillo-accessory ligament (mal). 
File:Lumbar mamillo-accessory ligament posterior view.png|Dorsal aspect of the third lumbar vertebra showing a probed MAF on the left. mamillary process (MP), accessory process (AP), mamillo-accessory foramen (MAF), mamillo-accessory ligament (MAL).
==Further Reading==
==References==
Category:Lumbar Spine Anatomy
Category:Ligaments of the Spine
Local Anaesthetic Pain Reduction Techniques

==Solution Preparation==
*Buffer the lidocaine with sodium bicarbonate.
*Warm the local anaesthetic
==Equipment Factors==
*Use fresh needles with repeated injections
*Use a small diameter needle
==Patient Preparation==
*Distraction
*Patient looks away
==Reducing Needle Puncture Pain==
*Topical anaesthetic creams
*Cooling with ice
*Tactile distraction
*Inject into subcutaneous fat if there is an open wound
*Insert needle perpendicularly to the skin
==Reducing Injection Pain==
*Stabilise the syringe holding hand to reduce needle movement
*Inject subdermally instead of intradermally
*Inject a small bleb and then pause
*Inject very slowly
*Keep the local anaesthetic wheal 10mm ahead of the needle tip
*Reinsert the needle only within 1cm of the blanched skin border
*Learn by asking all patient to score their injeciton pain
==Resources==
==References==
Category:General Procedure Concepts
Loeys-Dietz Syndrome

Loeys-Dietz Syndrome (LDS) is a Marfan-like disease that was only discovered in 2005.
== Clinical Features ==
LDS can affect the following areas:
* Vascular findings: cerebral, thoracic, and abdominal arterial aneurysms and/or dissections. Aortic root dilatation is the most common (95% of probands)
* Neuromusculoskeletal findings: pectus excavatum or pectus carinatum, scoliosis, joint laxity, arachnodactyly, talipes equinovarus, cervical spine malformation and/or instability, dural ectasia
* Craniofacial findings: widely spaced eyes (hypertelorism), strabismus, bifid uvula / cleft palate, and craniosynostosis that can involve any sutures)
* Cutaneous findings: velvety and translucent skin, easy bruising, and dystrophic scars
* Other: strong predisposition to allergic and inflammatory disease including atopy, IBD, and eosinophilic gastrointestinal disorders.
It has locus heterogeneity. Multiple different genes can cause the condition. There are five types depending on the gene. There is variation in phenotype even amongst family members with the same pathogenic variant.
== Diagnosis ==
Diagnosis is made by finding a pathogenic variant on molecular genetics PLUS either aortic root enlargement or other compatible systemic features with special emphasis on arterial tortuosity.
== Resources ==
GeneReviews - Loeys-Dietz Syndrome
Category:Heritable Connective Tissue Disorders
Low Back Pain Differential Diagnoses

==Epidemiology==
File:Chronic low back pain sources.PNG
Sources of pain in chronic low back pain as a function of age.
Copyright © 2020 American Academy of Pain Medicine
==Clinical Features==
File:Low back pain somatic and radicular features.PNG
From Manchikanti et alManchikanti L, Kaye AD, Soin A, et al. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines Facet Joint Interventions 2020 Guidelines. Pain Physician. 2020;23(3S):S1-S127.
==References==
Category:Differential Diagnosis Checklists
Category:Lumbar Spine
Low Dose Naltrexone

Start with 1.5mg mane, and can increase up to 4.5mg maximum. Efficacy maximum at 4-6 weeks.
In Auckland can get it from Compound Labs or Optimus. Cost is around $90 for three month supply. Some people are sensitive to the filler. Use sucrose or ginger filler instead of cellulose in that instance.
If the patient is able to manage then the cheaper and more adjustable option is you can prescribe the 50mg tablets, get them to dissolve in 100mL of water, making a concentration of 0.5mg/mL, and store in the fridge covered in aluminium foil. Use a syringe to measure doses (0.5mg, titrating up to max of 4.5mg). Warn them that it tastes foul. This can be a useful option when initiating in order to work out the dose needed.
==External Links==
https://www1.racgp.org.au/ajgp/2023/april/low-dose-naltrexone-in-the-treatment-of-fibromyalg
https://www.medicinesinformation.co.nz/2023/07/05/naltrexone-oral-liquid-formula/?pos=naltrexone
==References==
*
Category:Pharmacology
Lumbar Fat Herniation

Episacral lipomata, also known as back mice, and subfascial fat herniation among other terms, are an uncommon cause of chronic low back pain with only infrequent mention in the literature. They occur over the posterior iliac crest as an ovoid, mobile, and subcutaneous small mass.
==Pathophysiology==
There are two hypotheses regarding the pathophysiology. Some authors state that the condition is where deep fat herniates through the thoracolumbar fascia in a more superficial extramuscular, subcutaneous location. Other authors report that they are discrete lipomata or fibro-fatty nodules. It may be that these are two separate conditions with similar clinical presentations.
The thoracolumbar fascia has fenestrations where cutaneous branches of the dorsal rami pass through, but it isn't clear how fat herniation can actually cause pain however. The hypermobility of the mass may be a factor in the pain.
They are a discrete entity from inferior lumbar hernias. Lumbar hernias are where there is herniation of intra- or retro-peritoneal structures through the inferior lumbar triangle into the soft tissues of the low back.
==Epidemiology==
There is a wide range of reported prevalence from 10–58%, and may be bilateral. They are usually asymptomatic. They have a predilection for females.
==Clinical Features==
The patient may report a painful subcutaneous mass in about the posterior superior iliac spine. The pain may radiate to to the buttock or thigh. Pain may radiate to the buttock or thigh. Pressure over the mass may reproduce the patients pain.
==Imaging==
Ultrasonography may demonstrate hypermobile deep fat between the superficial and deep fascial layers in the low back near the PSIS. There may or may not be a capsule. Where there is a lack of a capsule, it is not a true lipoma, and the correct term should be subfascial herniation. There may be a lack of a distinct lateral margin.
==Diagnosis==
The diagnosis is supported by abolition of pain with infiltration of local anaesthetic.Bogduk, Nikolai. Clinical and radiological anatomy of the lumbar spine. Chapter 15. Edinburgh: Elsevier/Churchill Livingstone, 2012.
==Treatment==
The prognosis is unknown, but symptoms may resolve on its own. Treatment options include local anaesthetic and/or steroid injections, and excision. 
==External Resources==
*Open access review by Bicket et al.
== References ==
Category:Lumbar Spine Conditions
Lumbar Intervertebral Discs

== Structure Overview ==
Structures 	Features	Microstructure
Anulus fibrosus 	 	
Nucleus pulposis 	 	
Vertebral end plate	 	
 	 	
Vertebral body 	 	
 	 	
Spine 	1.Vertebral body: (have horizontal and vertical oriented trabeculae to distribute load)
2. Posterior elements: 
- Pedicle
- transverse process
- Facet joint: IAP, SAP (articular process above and below connect via facet joints. Synovial joint)
- Lamina: 
- Spinous process 
- Canal (vertebral foramen): 
- neuroforamen: each nerve root exits
- Mamillary process
- Accessory process 
3.The disc sits between the vertebral bodies
-annulus fibrosis
- nucleus pulposis. 
- end plate.	Function of LS individual components
Vertebral bodies: resist axial compressive forces via inner trabeculae. 
Facet joint: can be flat, C shaped, or J shaped, resist forward translation and rotation of L vertebra. 
Disc: NP evenly distributes compressive force, AF resist twisting plus translation in each direction. 
Vertebral endplate allow nutrient to transmit through the endplate.
== Innervation ==
Posterior Disc: sinuvertebral nerve from ventral ramus 
Anterolateral disc: Grey ramus communicans of the lumbar sympathetic trunk 
Anterior disc: sympathetic branches from the sympathetic trunk or ganglion. 
Sinuvertebral nerve: also known as recurrent meningeal nerves or recurrent nerves of Luschka. Innervate the meninges, ligaments, and periosteum of the spinal canal and the anulus fibrosus of the intervertebral disk and carry sensory information, including pain, from those structures. 
Category:Lumbar Spine Anatomy
Category:Joints of the Spine
Lumbar Pain Maps

==Lumbar Facet Joints==
File:Lumbar Facet pain.PNG
From Manchikanti
== Lumbar Interspinous Ligaments ==
600px|Referred pain patterns from noxious stimulation of the lumbar interspinous ligaments. Kellgren 1939.
==Lumbar Radicular Pain==
===Sensory Deficit Maps with Nerve Block===
In 1993 Nitta et al looked at dermatome patterns by doing fluoroscopically guided spinal nerve anaesthetic blocks in patients with radicular pain. They found the following sensory deficits.
File:L4 nerve block sensory deficit Nitta.png|L4 block pattern: Extending from the midline of the trunk posteriorly, across the buttock, through the lateral and anterior side of the thigh and the medial side of the leg to the first digit of the foot.
File:L5 nerve block sensory deficit Nitta.png|L5 block pattern: Extending from the midline of the trunk posteriorly, across the buttock, through the posterior, lateral aspect of the thigh and leg, to the 5th digit of the foot.
File:S1 nerve block sensory deficit Nitta.png|S1 block pattern: Extending from the midline of the trunk posteriorly, across the buttock, through the lateral side of the thigh, the lateral side of the leg, and the medial side of the dorsum of the foot to the first digit.
File:L4-S1 nerve block distinctive sensory deficit Nitta.png|Distinctive regions. L4 is medial side of the lower leg in 88%. L5 is first dorsal digit in 82%. S1 is lateral side of 5th digit in 83%.
File:L4-S1 nerve block band like Nitta.png|Proportion having band like deficits.
===Inadvertent Pain Maps during TFI===
Furman et al in 2019 mapped lower limb radicular symptoms based on inadvertent pain patterns during supraneural transforaminal injections, the data is modified in table format below. They confirmed that history and pain charts cannot predict the nerve root level. The buttock is a very common pain referral location across all nerve roots, while pain in the thigh and leg frequently follows dermatomal distributions. A significant limitation of the study is that injectate in transforaminal injections frequently traverses segment levels.
Nerve Root 	L3 	L4 	L5 	S1
Buttock 	45%	43%	62%	64%
Groin 	0% 	3% 	0% 	0%
Anterior Thigh 	27%	29%	12%	0%
Posterior Thigh	36%	25%	59%	36%
Medial Thigh 	18%	11%	3% 	0%
Lateral Thigh 	0% 	14%	9% 	0%
Knee 	9% 	7% 	6% 	9%
Anterior Leg 	0% 	14%	3% 	0%
Posterior Leg 	18%	18%	50%	45%
Medial Leg 	0% 	7% 	6% 	0%
Lateral Leg 	9% 	14%	24%	0%
Foot 	0% 	3% 	0% 	0%
==See Also==
*Sacroiliac Pain Maps
*Somatic Referred Pain
*Thoracic Pain Maps
*Cervical Pain Maps
==References==
Category:Lumbar Spine
Category:Pain Maps
Category:Stubs
Lumbar Spine Examination

==Standing==
*Gait
*Stature
*Build
*Romberg
*Transitioning movements
*Posture and alignment
**Thoracolumbar alignment coronal and sagittal plane
**Lumbar alignment coronal and sagittal plane
**Pelvic alignment
**Foot alignment
*Movement
**Forward flexion
**Extension
**Side flexion
**Compound extension and rotation
*Trendelenburg
==Sitting==
*Breathing
*Pelvic alignment
*Slump test
==Lying==
*Skin drag and rolling
*Allodynia to cold and pin prick
*Palpation
**Vertebral springing tenderness
**Rotation testing
**Bony landmarks: Iliac crest, PSIS, LPSL, sacroiliac joint
**Soft tissue: sacrotuberous and sacrospinous ligaments, gluteus medius and gluteus minimus, piriformis, iliopsoas, quaratus lumborum, hamstring origin
*SIJ provocation testing: distraction, thigh thrust, sacral thrust, compression
*Hip joint range of motion
*Special tests
**Straight leg raise
**Femoral stretch test
**Iliopsoas length test and tenderness
**Direction preference
**Centralisation phenomenon
*Neurological examination
**Tone
**Power: hip flexion (L2), hip adduction (L3), ankle dorsiflexion (L4), great toe extension (L5), knee flexion (S1)
**Reflexes: knee (L3, L4), medial hamstring (L5), achilles (S1) 
**Sensation: L2, L3, L4 (medial lower leg 88%), L5 (first dorsal digit 82%), S1 (lateral 5th digit 88%), S2, S3. Don't forget sacral sensation if bladder/bowel symptoms, bilateral leg weakness/sensory change.
**Plantar reflexes
**Co-ordination: Rombergs, tandem Romberg, etc.
==Paediatric Examination of the Whole Spine==
A consensus approach to the MSK examination in children was developed by Foster et al in 2011. They did not differentiate between cervical, thoracic, and lumbar spine. The underlined components are those that are additional to the adult examination. The italicised components are those that the doctor should be aware of but not necessarily competent in.
With the patient standing:
* Look at the spine from the side and from behind
* Look at the skin and natal cleft 
* Look at limb and trunk proportions 
* Look at the face and jaw profile 
* Feel the spinal processes and paraspinal muscles and Temporomandibular joints (TMJs)
* Assess movement: lumbar flexion and extension and lateral flexion; cervical flexion, extension, rotation and lateral flexion, thoracic rotation 
* Assess TMJ opening  
* Options – Schober’s test, “stork test”
With the patient sitting on couch (standing in younger child):
* Assess thoracic rotation
With the patient lying on couch:
* Perform straight leg raising and dorsi-flexion of the big toe
* Assess limb reflexes
* Option – leg length, hypermobility, sacroiliac joint palpation (Faber’s / Patrick’s test)
==References==
Category:Examination
Category:Lumbar Spine
Category:Stubs
Lumbar Transitional Pseudoarthrosis Injection

==Procedure==
=== Ultrasound ===
*Patient prone with pillow under pelvis
*Obtain transverse view of target injection site
*Identify lateral to the spinous process the multifidus muscle, facet joint, transverse process, iliac crest, and the pseudoarthrosis of the L5 transverse process with the iliac crest.
*Insert needle using an in-plane approach with an approximate angle of 45-60 degrees lateral to the facet joint, medial to lateral, into the pseudoarthrosis.
See images by Chen and colleagues.
== See Also ==
Transitional Vertebral Anatomy
== References ==
Category:Lumbar Spine Procedures
Lumbosacral Plexus

The lumbosacral plexus can be divided into two anatomical parts: the upper lumbar plexus and the lower lumbosacral plexus. 
==Lumbar Plexus==
The lumbar plexus is located within the psoas muscle. It contains the canterior rami of the T12 to L4 nerve roots. Only the femoral nerve can be reliably tested by EMG. The lateral femoral cutaneous nerve can be tested but it is unreliable.
==Sacral Plexus==
The sacral plexus is derived from the anterior rami of spinal nerves L4-S4.
==Other Branches==
Nerve 	Segment	Motor Supply 	Action 	Sensory Supply
Tibial 	L4-S3 	Hamstrings (except short head of biceps femoris, posterior part of adductor magnus), triceps surae, tibialis posterior, popliteus, flexor digitorum longus, flexor hallucis longus, intrinsic muscles of foot	Knee flexion(primary), foot plantar flexion, toe flexion 	skin of posterior leg and sole of foot
Common fibular	L4-S2 	short head of biceps femoris, fibularis longus and brevis, tibialis anterior, extensor hallucis 	knee flexion (short head of biceps femoris), foot dorsiflexion and eversion, toe extension	skin of anterior and lateral leg and dorsum of foot
==Videos==
<youtube>dPpEDxFnEOo</youtube>
<youtube>-OqTl7DihPc</youtube>
==Additional Images==
Lumbar Plexus.png|Lumbar Plexus
==References==
Category:Lumbar Spine Anatomy
Category:Nerves of the Lower Limb and Lower Torso
Category:Nerves
Category:Nerves of the Spine
Maximum doses of anaesthetic agents

===Maximum Doses of Anesthetic Agents===
Agent 	Without Adrenaline 	With Adrenaline 	Duration 	Notes
Lidocaine 	5 mg/kg (max 300mg) 	7 mg/kg (max 500mg)	30-90 min 	
*1% soln contains 10 mg/ml 
*2% soln contains 20 mg/ml
Mepivicaine	7 mg/kg 	8 mg/kg 	 	
Bupivacaine	2.5 mg/kg (max 175mg)	3 mg/kg (max 225mg)	6-8 hr 	
*0.5% soln contains 5 mg/ml
*May cause cardiac arrest if injected intravascularly
*Do not buffer with bicarbonate
Ropivacaine	3 mg/kg 	 	 	
Prilocaine 	6 mg/kg 	 	 	
Tetracaine 	1 mg/kg 	1.5 mg/kg 	3hrs (10hrs with epi) 	
Procaine 	7 mg/kg 	10 mg/kg 	30min (90min with epi)	
Category:Pharmacology
Category:Stubs
Median Nerve

== Motor Supply ==
All but five intrinsic hand muscles are innervated by the ulnar nerve. The remaining are innervated by the C8-T1 roots via the Median Nerve. The mnemonic AbOF can be used to remember which muscles are above the law in that they aren't innervated by the ulnar nerve: the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law).
== References ==
Meta-analyses and Systematic Reviews

Systematic reviews are research summaries that address a focused clinical question in a structured, reproducible manner, often accompanied by a meta-analysis, which is a statistical pooling of results from different studies providing a single estimate of effect. When searching for evidence to answer a clinical question, it is preferable to seek a systematic review, especially one that includes a meta-analysis. Single studies are liable to be unrepresentative of the total evidence and be misleading. Systematic reviews include a greater range of patients than any single study, potentially enhancing confidence in applying the results to the patient at hand.
When clinicians apply the results of a systematic review or meta-analysis to patient care, they should start by evaluating the credibility of the methods of the systematic review. Credibility depends on whether the review addressed a sensible clinical question; included an exhaustive literature search; demonstrated reproducibility of the selection and assessment of studies; and presented results in a useful manner.
For reviews that are sufficiently credible, clinicians must decide on the degree of confidence in the estimates that the evidence warrants (quality of evidence). Confidence depends on the risk of bias in the body of evidence; the precision and consistency of the results; whether the results directly apply to the patient of interest; and the likelihood of reporting bias. Shared decision making requires understanding of the estimates of magnitude of beneficial and harmful effects, and confidence in those estimates.
==Resources==
Category:Statistics