On arrival order sildenafil australia erectile dysfunction daily medication, Scot was in shock with a high fever and a breathing rate of 36 (normal is 12 to 15/min) order sildenafil american express erectile dysfunction after prostatectomy. Because of the danger of respiratory failure buy sildenafil with mastercard young healthy erectile dysfunction, the attending physician immediately had Scot intubated and placed on assisted ventilation. Scot was lucky and was able to return to his classes after 12 weeks in the hospital and a bill of >$200,000. Other causes include cardiopulmonary bypass, smoke inhalation, high altitude, and exposure to irritant gases. Aggregation of neutrophils causes capillary endothelial damage by releasing a number of toxic products. These include oxygen free radicals, proteolytic enzymes, arachidonic acid metabolites (leukotrienes, thromboxane, prostaglandin), and platelet-activating factor. New approaches to therapy involve ways to reduce neutrophil chemoattraction and aggregation in the pulmonary capillaries and ways to reduce the amount of toxic substances released by neutrophils. The alveolar lining is coated with a special surface-active agent, pulmonary surfactant, which not only lowers surface tension at the gas–liquid interface but also changes surface tension with changes in alveolar diameter (see Fig. The functional importance of surfactant can be demonstrated by using a surface tension balance (Fig. Surface tension is measured by placing a platinum flag connected to a force transducer into a trough of liquid. Surface tension creates a meniscus on each side of the platinum flag, and the greater the contact angles of the meniscus, the greater the surface tension. The surface is repeatedly expanded and compressed by a movable barrier that skims the surface of the liquid (simulating lung inflation and deflation). Surface tension of pure water is 72 dyne/cm, a value that is independent of the surface area of water in the balance. Therefore, when the surface is expanded and compressed, surface tension does not change. When a detergent is added, surface tension is reduced but again is independent of surface area. However, when a lung lavage (a saline flush from the lungs) is added that contains pulmonary surfactant, surface tension not only is reduced but also changes in a nonlinear fashion with surface area. Therefore, pulmonary surfactant makes it possible for alveoli of different diameters that are connected in parallel to coexist and be stable at low lung volumes, by lowering surface tension proportionately more in the smaller alveoli (see Fig. A surface tension balance is used to measure surface tension at the air–liquid interface. When distilled water is placed in the balance, surface tension is independent of surface area (a constant 72 dynes/cm). The addition of a detergent reduces surface tension, but it is still independent of surface area. When lung surfactant (obtained from a lung lavage-a volume of saline flushed into the airways to rinse the alveoli) is placed in the balance, surface tension not only is decreased but also changes with surface area. At low lung volumes, when the molecules are tightly compressed, some surfactant is squeezed out of the surface and forms micelles. On expansion (reinflation), new surfactant is required to form a new film that is spread on the alveolar surface lining. When surface area remains fairly constant during quiet or shallow breathing, the spreading of surfactant is often impaired. A deep sigh or yawn causes the lungs to inflate to a larger volume and new surfactant molecules spread onto the gas–liquid interface. Patients recovering from anesthesia are often encouraged to breathe deeply to enhance the spreading of surfactant and prevent alveolar collapse, a phenomenon known as atelectasis. Patients who have undergone abdominal or thoracic surgery often find it too painful to breathe deeply; poor surfactant spreading results, causing part of their lungs to become atelectatic. Turnover of lung surfactant is high because of continual replacement of surfactant during lung expansion. The ratio of these cells in the epithelial lining is about 1:1, but type I cells occupy approximately two thirds of the surface area. Compared with type I cells, they are rich in mitochondria and are metabolically very active. These lamellar inclusion bodies, rich in surfactant, are thought to be the storage sites for surfactant. Stored surfactant from the lamellar inclusion bodies is discharged onto the alveolar surface. The turnover of surfactant is high because of the continual renewal of surfactant at the alveolar surface during each expansion of the lung. The high rate of replacement of surfactant probably accounts for the active lipid synthesis that occurs in the lung. Because the lungs are among the last organs to develop, the synthesis of surfactant appears rather late in gestation. In humans, surfactant appears at about week 34 (a full-term pregnancy is 40 weeks). Regardless of the total duration of gestation in any mammalian species, the process of lung maturation seems to be “triggered” about the time gestation is 85% to 90% complete. Clearly, the fetal lung is endowed with a special regulatory mechanism to control the timing and appearance of surfactant. Failure of proper lung maturation during the perinatal period is still a major cause of death in newborns. Anatomically, the lung may be structurally intact but functionally immature due to the inadequate amounts of surfactant available to reduce surface tension and stabilize surface forces during breathing. Surfactant is oriented perpendicularly to the gas–liquid interface at the alveolar surface; the polar end is immersed in the liquid phase, whereas the nonpolar portion is in the gas phase. Premature birth and certain hormonal disturbances (such as those seen in diabetic pregnancies) interfere with the normal control and timing of lung maturation. These infants have immature lungs at birth, which often leads to neonatal respiratory distress syndrome. Breathing is extremely labored because surface tension is high, making it difficult to inflate the lungs. Because of the high surface tension, these infants often develop regional atelectasis and pulmonary edema. These infants are at high risk until the lungs become mature enough to secrete surfactant. In addition to lowering alveolar surface tension and promoting alveolar stability, surfactant helps to prevent edema in the lung. The inwardly contracting force that tends to collapse alveoli also tends to lower interstitial pressure, which “pulls” fluid from the capillaries. Some pulmonary physiologists think that keeping the lungs dry may be the major role of surfactant, especially in adults.
Hartmann’s or Ringer’s lactate should be rapidly Fractured limbs should be stabilized by inflat- infused order sildenafil uk erectile dysfunction drugs bayer. Fluid infusion should be given if available cheap sildenafil 50 mg fast delivery erectile dysfunction treatment center, especially if the wounds are be slowed when the systolic blood pressure reaches extensive and heavily contaminated buy sildenafil on line amex erectile dysfunction frequency age. It Before transfer, wounds should be covered (espe- was originally thought that fluid administration cially chest wounds). Pressure dressings or digital should continue to maintain the blood pressure at a pressure may be appropriate. The rationale was that this would enable United Kingdom is the ambulance, which has the patient to better overcome a rapid decompensa- usually been summoned by an eye witness with a tion from further bleeding and reduce the risk of mobile phone. Satellite locating devices now allow developing some of the complications of prolonged a rapid response to a recognized position. The other intensive care consultants The hospital telephone exchange has the respon- sibility of contacting and requesting all the key The nurse in charge of theatres personnel to assemble at the A&E. The key contacts The blood transfusion consultants consultants in are shown in Table 6. A junior doctor The hospital manager on call should record the progress of the resuscitation and The communications department ensure that all the injuries and the clinical course of The specialist services the patient are carefully recorded. All members of plastic the team must be clearly identified by an appropri- ate tabard (a labelled overall or tunic). He/she should have the ability to contact the operating theatres, the blood bank, intensive The portering services care and the wards in order to arrange the transfer The mortuary of major casualties out of A&E as soon as they have been assessed and resuscitated. The doctor in over- all charge should undertake the initial triage of the made at the site of the accident (described above) patients into one of the following categories: and ensures that appropriate priority is given to the patients who require the most urgent treatment. It is also helpful if some surgeons go directly to the operating theatres to help staff prepare for the A sucking wound should be occluded. A chest amputations, laparotomies, fracture fixations and drain may need to be inserted. A pneumothorax should be treated by the inser- tion of a chest drain through the second anterior Initial resuscitation intercostal space or, alternatively, urgent insertion through the fifth intercostal space in the mid-axil- This follows the same system described above for lary line if it is a tension pneumothorax. A simple the scene of the accident, taking note of the valu- hollow needle or other hollow device may be used able information about the extent and cause of the as an alternative to deflate a life-threatening tension injuries provided by the transporting team. This should be repeated by the doctor in charge of Cardiac tamponade is one of the most difficult the triage to confirm initial reports and ensure that clinical diagnoses to make but should be suspected nothing has altered or been missed in the initial if there are congested neck veins, muffled heart survey. It should be treated by needle aspiration C is for catastrophic haemorrhage This must be con- of the pericardial sac using ultrasound guidance. C is for circulation The injured patients will often A is for airway Consideration is given to the cervical have had intravenous catheters inserted before they spine, which should be immobilized in a collar or by reach hospital but, if this has not occurred, two sand bags if there is any hint of a neck injury. A long mouth if this hasn’t already been done by the para- saphenous vein cut-down or bone marrow infusion medics. Endotracheal intubation of the airway is car- can be life-saving if these approaches fail. Blood should be sent for blood grouping and if B is for breathing This is assessed once a clear airway a transfusion is likely to be needed, cross-matching. If the patient is breathing sponta- All known wounds should be inspected for overt neously, has a good colour and is talking no further bleeding. All other major laboured or ineffective or if the oxygen saturation bleeding is likely to be covert rather than overt and is low poor while the patient is being given oxygen. Overloading with crystalloid is not help- systems briefly assessed, a secondary survey is care- ful. Blood and blood products should be given as fully carried out to ensure that important injuries soon as possible, especially if there is evidence of have not been missed during the early drama and continuing haemorrhage. Urine respiration, oxygen saturation, Glasgow score and output is a reliable indication of rehydration and urine output should be monitored continuously. Its value has now from the patient, if conscious, focusing on their been firmly established. Pericardiocentesis be ‘log-rolled’ by several staff to inspect their back can be life-saving. D is for disability Primarily disability can be caused The rest of the secondary survey can be per- by any associated brain injury. A alert V responding to verbal stimuli Head and neck P responding to painful stimuli The scalp should be inspected and palpated for U unresponsive. A deeply This can be used to provide a rapid assessment depressed area, especially if there is an overlying of cerebral function until, as soon as possible, a scalp wound, suggests there may be a depressed or full Glasgow Coma Scale has been calculated (see compound fracture of the skull. Battle’s sign and racoon eyes suggest the pres- ence of a fracture of the base of the skull (see E is for exposure All clothing should be removed or Symptoms and Signs). The presence of diplopia on upward gaze suggests there may be a blow-out fracture of the orbital floor. Anaesthesia over the cheek with bruising and enophthalmos suggests the presence of a fractured zygoma. The cornea and conjuctiva of both eyes should be inspected and the visual acuity checked with a Snellen’s chart. The mouth should be opened and the stability of the upper jaw checked by putting a finger and thumb inside the mouth and pulling it backwards and (A) forwards. All wounds in the neck should be carefully assessed to indicate the possibility of damage to major vessels, the airway or, rarely, the gullet. Chest (upper torso) The presence of respiratory distress should have been detected in the primary survey, but it is worthwhile rechecking that the chest movement is equal and full and that there is no evidence of any stridor. The chest wall should be carefully inspected for bruising, asymmetry and possible penetrating lacerations. Look for the presence of a flail segment, a condi- tion in which an area of chest wall is sucked inwards (B) as the chest expands during inspiration (Fig 6. The lungs should be percussed to together with the presence of pulsus paradoxus and check for dullness (a haemothorax or ruptured muffled or inaudible heart sounds is one of the diaphragm) or excessive resonance (a pneumo- main signs of cardiac tamponade. Air entry at the bases and vocal resonance The chest wall should be carefully palpated completes the examination. Plain radiographs and duplex scanning of the Abdomen and pelvis (lower torso) vessels should be carried out if a vascular injury is suspected (see below). Any wounds are documented, espe- Disposal cially if they could have breached the abdominal After completing the secondary survey the patient cavity. There may be signs of visible bruising (seat may require further imaging or may need to be belt) or distension. Local tenderness in a conscious transferred to the intensive care or high dependency patient can be helpful, especially if there is tenderness unit, the ward or the operating theatre. The bladder area should be percussed A further rapid assessment of the patient should (if a catheter has not been passed), to detect any blad- be carried out before they are transferred.
Angulation at the site of endoscopic balloon dilatation buy generic sildenafil canada erectile dysfunction louisville ky, stenting and surgical the tumour may purchase sildenafil paypal erectile dysfunction drugs after prostate surgery, however order sildenafil with amex erectile dysfunction young adults, prevent this approach. A percutaneous transhepatic approach is required Dilatation, although of value, often fails to pro- in these cases and for proximal lesions. Type of stent Stenting is frequently complicated by sludging Following negotiation of the malignant stricture and cholangitis, which require multiple admissions with a guide wire, a biliary stent is passed over the for antibiotic control and stent replacement. A plastic stent is preferable if there is In cases where a metal Wall stent has been used, any possibility that future surgery may be possible. When it is not possible to insert a stent because Surgical bypass (hepatodochojejunostomy) in of oedema or other technical reasons, it is vital to the hands of an experienced hepatobiliary surgeon leave an external proximal percutaneous catheter is therefore the preferred definitive treatment. Otherwise the patient will be left with an this reason it is wise not to insert a metal stent if obstructed system, a perforation in the biliary sys- reconstruction at a later date is to be considered as tem upstream to the obstruction, and be at risk of these stents cannot be removed. There are, however, a number of other conditions Complications of stenting of the gall bladder which will be briefly discussed. The immediate complications of stenting are: Acalculus choleycystitis sepsis haemorrhage This is common in patients admitted to the intensive acute pancreatitis care unit with major trauma, sepsis and splanchnic perforation and bile leak (peritonitis). Gangrene and perforation of the bladder may develop and this is fatal if left untreated. The late complications are: The diagnosis is difficult as the patients are often recurrent jaundice caused by: unconscious on a ventilator. It requires a high index stent displacement of suspicion and may only be diagnosed by a specula- sludge in the stent tive ultrasound in an otherwise extremely sick patient. It can be seen as a filling defect on ultrasound and is only diagnosed by investiga- tion of the gall bladder, e. Carcinoma of the gall bladder Empyema of the gall bladder This rare condition is invariably related to gall stones. Patients often present with symptoms or This is the same as a mucocoele but the gall blad- signs of acute or chronic choleycystitis. Fever, pain jaundice is common and a result of bile duct and a mass situated beneath the liver that is tender invasion. It is rarely diagnosed with certainty preopera- Confirmation is by ultrasound and treatment is by tively, but ultrasound will demonstrate gall stones cholecystectomy. It may be treated conservatively by cholecystec- This occurs in diabetics when anaerobic bacteria tomy and stenting or aggressively by central liver proliferate in the gall bladder, which then contains resection followed by chemotherapy. Plain X-rays show the gas, which can also be The prognosis is poor whatever the treatment. Antibiotics and stone removal may be followed Free bile can be imaged in the peritoneal cavity. This condition has an appreciable mortality – Radical hepatic resection is indicated for localized greater than 10 per cent. It is associated with ulcerative colitis (75 per cent) and other autoimmune conditions. The liver function tests show an obstruc- tive picture with a raised bilirubin and alkaline phosphatase. Eventually, liver transplantation may be required for patients developing liver failure. Occasionally duodenal obstruction (vomiting) and splenic vein thrombosis (portal hypertension and haematemesis) and obstructive jaundice can be presenting symptoms. Random blood sugars and a pancreatic gland, often containing cystic collections glucose tolerance test may confirm the presence of and calcification. Faecal fat Endoscopic ultrasound should not show a local- Levels above 5 g per day on a normal diet are indica- ized mass in the head as this is suggestive of a neo- tive of steatorrhoea. Pancreatic juice can be sent for cytology to can also be measured by an isotope test. Imaging Management Plain abdominal X-rays may show calcification, Pain relief and abstinence from alcohol will improve which can be confirmed to be in the pancreas by the patient’s condition, even if they are jaundiced. Pancreatic extracts (creon) can help diarrhoea, and 450 Abdominal symptoms, masses, the spleen and obesity surgery There are a few benign neoplasms of the pancreas, usually cyst adenomas, which are only detected by chance when abdominal scans are obtained for other reasons. They can be sympto- matic when they become very large and have to be differentiated from pseudocysts and cyst adenocar- cinomas. Malignant pancreatic neoplasms are usually ductal adenocarcinoma (see below), but cyst ade- nocarcinomata and acinar cell carcinomata are also reported. Jaundice can be weight loss and epigastric pain radiating through treated by inserting a stent (see above). Pain and weight loss are the main symptoms when the Surgical options tumour arises in the body or tail of the gland, and diabetes and steatorrhoea may develop in any pan- Pancreaticojejunostomy (Fig 18. Liver metastases option but can preserve the tail of the pancreas, and may cause an enlarged, knobbly mass in the right as a consequence preserve endocrine function. Thrombophlebitis migrans (Trousseau’s severe diabetes and loss of exocrine function with sign) is a rare late complication. Prognosis This is often poor, with many patients being con- stantly readmitted to hospital over many years, and Blood tests only 60–70 per cent remaining free of severe pain Anaemia is common when jaundice is present. A random or fasting become drug addicts and Munchausen’s syndrome blood sugar may be raised. Chronic pancreatitis Cystadenocarcinoma of pancreas Laparotomy Lymphoma of the pancreas It may still not be possible to differentiate chronic pancreatitis from carcinoma at laparotomy. It is Cholangiocarcinoma of bile ducts important to try to obtain a correct preoperative Vipoma diagnosis if possible to avoid radical and danger- Gluconoma ous surgery being offered to patients with chronic Insulinoma pancreatitis. Sclerosing cholangitis Management Gastric carcinoma The management of jaundice is discussed above. Duodenal carcinoma with secondary deposits in the Curative treatment for pancreatic neoplasms portahepatis requires pancreatic resection, but only 10 per cent of all patients with malignant tumours are suitable for surgery. Urine tests Bilirubin is present and urobilinogen is absent Curative treatment when there is total obstruction of the common bile Whipple’s procedure of radical pancreaticoduo- duct. The continuity of cannot differentiate tumours from chronic pan- the pancreatic bile duct and intestine is restored by creatitis with certainty. The mortality of this procedure is stone obstruction and cholangiocarcinoma of the now less than 5 per cent but the survival is only bile duct, although ampullary tumours may be dif- 10–20 per cent at 5 years in these highly selected ficult to diagnose without endoscopic biopsy. Pylorus preserving operations and radical Endoscopy total pancreatectomies (the only procedure for Duodenoscopy and biopsy can confirm the diag- extensive tumours of the body of the pancreas) nosis of an ampullary cancer and can be combined have similar survival rates with few discernable with ultrasound and biopsy to positively diagnose benefits. Distal pancreatectomy may be possible for Endoscopic retrograde cholangiopancreotog- tumours in the tail of the gland. Adjuvant radio- raphy is mainly used to pass stents for treatment therapy and chemotherapy may marginally improve rather than as a diagnostic test, as it can cause severe survival at the cost of increased side-effects. The pancreatic juice can be collected for cytology at Endoscopic stents are now used more commonly the same time as a stent is passed to relieve biliary than triple bypass. Ten per cent of cated for palliation and pain relief by analgesics, insulinomata are malignant and should be radically coeliac plexus block and splanicectomy may all be resected if possible.
Half of all spinal infections occur in the lumbar The mycobacteria family include M purchase 50 mg sildenafil erectile dysfunction due to diabetic neuropathy. The primary infection is usually caused to develop an infection within the disc space itself by inhalation of aerosolized organisms order sildenafil 50mg visa erectile dysfunction washington dc, which (a discitis) via haematogenous spread discount 25 mg sildenafil overnight delivery erectile dysfunction statistics. The patient usu- less vascular disc is less amenable to the spread ally quickly recovers from what is often a relatively of infection via the blood stream and therefore minor respiratory infection but years later a reac- infection typically starts as a vertebral endplate tivation may occur with presentation of secondary 212 The spine extrapulmonary metastases, which are most com- T1 as it is mainly made up of fat) becomes replaced monly seen in the vertebral bodies. The granulomatous identifying the presence of epidural abscess (results response involves the accumulation of monocytes, in ring enhancement of the abscess). With gadolinium there may result in a kyphotic deformity and neurologi- is an absence of rim enhancement as the infecting cal sequelae. It con- Investigation firms the diagnosis in both pyogenic infections and Clinical diagnostic indicators tuberculosis. Children usually present with either non-specific back pain or difficulty or refusal to walk. Management of pyogenic infections Adults typically present with non-specific back The mainstay of treatment is the intravenous pain and may also have constitutional symptoms administration of an appropriate antibiotic. Adults require longer treatment with antibiotics as The presence of neurological abnormalities is their discs are avascular. Progressive the failure of medical management, progressive kyphosis can result in neurological sequelae (Pott’s spinal deformity, neurological compromise or sig- paraplegia). Management of non-pyogenic Imaging infections Plain radiographs are often unhelpful as visible The pharmacotherapeutic treatment of tuber- change can take up to 12 weeks to develop. There is an increased signal include isoniazid, rifampicin, pyrazinamide and intensity on T2 weighted images caused by the pres- streptomycin. Early-onset scoliosis differs from late-onset scoliosis in that it is more common in boys, and Spinal deformity can occur in the coronal plane (sco- left thoracic curves predominate. Some of these liosis – a lateral curvature of the spine) and the sagit- children have associated abnormalities, such as tal plane (kyphosis, lordosis and spondylolisthesis). Rarer causes include The prevalence of adolescent idiopathic scoliosis infection, tumour, degeneration and trauma. It is four times more common in girls (and for those Congenital scoliosis requiring intervention the ratio is 9:1). Congenital scoliosis is a lateral curvature of the spine caused by developmental vertebral anomalies Management that result in an imbalance in the lateral longitudi- The management of early and late onset scoliosis nal growth of the spine. These osteogenic anomalies differ as the early onset group are too young to can be classified as failures of formation (hemiver- undergo definitive fusion (as this would restrict tebrae, see Figure 10. This disorders of the homeobox genes during the first is achieved by the use of serial plaster jackets, spinal trimester of pregnancy and is associated with a high braces and in the cases that are progressive the use incidence (up to 60 per cent) of other abnormalities of growing rod constructs that can be lengthened as within or outside the spine, particularly in those the child grows. Plaster jackets are used for progressive cures in the genitourinary system and the heart. Older children can have thermo- per cent also have intraspinal anomalies, including plastic braces to try and control curve progression. The objectives of surgery in these children is The failure of formation most commonly seen to maintain growth and control the curve. Several is the hemivertebra (unilateral complete failure of techniques have been described but none is perfect. The hemivertebra may be Many advocate the use of a posterior growth rod described as fully segmented (with a disc above and technique, which allows for longitudinal growth below), semi-segmented (a single disc either above while maintaining distraction across the curvature or below) or unsegmented (fused above and below). Adolescent idiopathic scoliosis A failure of segmentation results in the forma- Adolescent idiopathic scoliosis is much more com- tion of a bony bar that tethers the growth of a mon in girls, and typically results in the formation vertebral segment, resulting in differential growth of a right thoracic curvature. There is occasionally a family history, and most severe risk of curve progression. These children are essentially normal, but during periods of sig- Idiopathic scoliosis is classified as early onset (less nificant spinal growth the vertebrae rotate resulting than 5 years old) or late onset (more than 5 years in the typical thoracic rib hump deformity. Factors associated with a high risk of curve progression are a young age at diagnosis, female sex, double major curves, left-sided curves and the curve magnitude at diagnosis. Imaging When viewing a plain radiograph, the curves are described as if one is looking at them from behind in the same way as one views the child clinically. On reaching skeletal maturity, a curve of less than 40 degrees is unlikely to progress further. Such curves are unlikely to be cosmetically troublesome and therefore can be managed conservatively. Curves that are greater than 50 degrees on attainment of skeletal maturity have the poten- tial to continue to progress at an expected rate of 1–2 degrees per year. These curves must be managed on an individual basis and the degree of cosmetic deformity also taken into account. If conservatively managed, it is imperative that these curves are monitored for evidence of late progression. There is certainly no role for braces in curves that are of (B) a significant magnitude and in children who are approaching skeletal maturity. This is a diaphragm splitting thoraco-abdominal approach) essentially a fusion procedure and meticulous or posterior. The majority of curves are managed decortication of the posterior elements must be via the posterior route using multisegmental performed prior to laying down of bone graft. Treatment should aim to reduce the deform- (Greek; Spondylos = vertebrae, lysis = defect). The surgical options are similar to those for The highest incidence, which is seen in Alaskan idiopathic curvatures. The majority are treated by Native Americans (up to 26 per cent), is postulated a posterior instrumented spinal fusion. However, to be caused by the amount of time spent stooping in contrast to idiopathic curves where one is trying down while harvesting whale blubber! The types of spondylolisthesis (Willtse and Newman) Investigation Type 1 – congenital/dysplastic (a, b, c) Clinical diagnostic indicators Type 2 – isthmic (a, lytic fatigue fracture of pars; b, elongated but intact pars; c, acute pars Eighty per cent of spondylolistheses are symptom- fracture) less. Of the 20 per cent of patients who develop symptoms, half have a slip that is mild and rarely Type 3 – degenerative progresses. Thus the vast majority of patients with Type 4 – traumatic spondylolisthesis have a benign clinical course with- Type 5 – pathological (generalized or local bone out a significantly increased risk of low back pain. Dysplastic spondylolisthesis is more common in The risk factors for progression are onset at a females (2:1). The young age, female sex, a high degree of slip at pres- posterior facet complexes either fail to fully develop entation, a slip angle of greater than 40 degrees, and or are abnormally aligned such that they fail to act instability on flexion/extension radiographs. Although the spine is mechanically vulnerable and Imaging displacement tends to occur early, the degree of dis- (Fig 10. Spondyloptosis is the most L5 vertebral body slips forward, the movement of severe form and describes the translation of the the posterior bony arch causes the early symptoms of entire vertebral body in front of the one below.