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Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
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Because there are various causes for back injuries, prevention must be comprehensive. Back injuries are predominant in manual labor so the majority low back pain prevention methods have been applied primarily toward biomechanics Prevention must come from multiple sources such as education, proper body mechanics, and physical fitness.
The diagnosis is largely a clinical one, generally done by physical examination of the groin. However, in obese patients, imaging in the form of ultrasonography, CT or MRI may aid in the diagnosis. An abdominal x-ray showing small bowel obstruction in a female patient with a painful groin lump needs no further investigation.
Several other conditions have a similar presentation and must be considered when forming the diagnosis: inguinal hernia, an enlarged inguinal lymph node, aneurysm of the femoral artery, saphena varix, and an abscess of the psoas.
MRI has become the most frequently used study to diagnose spinal stenosis. The MRI uses electromagnetic signals to produce images of the spine. MRIs are helpful because they show more structures, including nerves, muscles, and ligaments, than seen on x-rays or CT scans. MRIs are helpful at showing exactly what is causing spinal nerve compression.
A spinal tap is performed in the low back with dye injected into the spinal fluid. X-Rays are performed followed by a CT scan of the spine to help see narrowing of the spinal canal.
This is a very effective study in cases of lateral recess stenosis. It is also necessary for patients in which MRI is contraindicated, such as those with implanted pacemakers.
In 1977, Dyck and Doyle reported on the bicycle test, a simple procedure in which the patient is asked to pedal on a stationary bicycle. If the symptoms are caused by peripheral vascular disease, the patient will experience claudication, a sensation of not getting enough blood to the legs; if the symptoms are caused by lumbar stenosis, symptoms will be relieved when the patient is leaning forward while bicycling. Although diagnostic progress has been made with newer technical advances, the bicycle test remains an inexpensive and easy way to distinguish between claudication caused by vascular disease and spinal stenosis.
The straight leg raise may be positive, as this finding has low specificity; however, it has high sensitivity. Thus the finding of a negative SLR sign is important in helping to "rule out" the possibility of a lower lumbar disc herniation. A variation is to lift the leg while the patient is sitting. However, this reduces the sensitivity of the test.
The detection of spinal stenosis in the cervical, thoracic or lumbar spine confirms only the anatomic presence of a stenotic condition. This may or may not correlate with the diagnosis of spinal stenosis which is based on clinical findings of radiculopathy, neurogenic claudication, weakness, bowel and bladder dysfunction, spasticity, motor weakness, hyperreflexia and muscular atrophy. These findings, taken from the history and physical examination of the patient (along with the anatomic demonstration of stenosis with an MRI or CT scan), establish the diagnosis.
The benefits of the use of an external device to maintain reduction of the hernia without repairing the underlying defect (such as hernia trusses, trunks, belts, etc.) are unclear.
Femoral hernias, like most other hernias, usually need operative intervention. This should ideally be done as an elective (non-emergency) procedure. However, because of the high incidence of complications, femoral hernias often need emergency surgery.
Measurement and diagnosis of lumbar hyperlordosis can be difficult. Obliteration of vertebral end-plate landmarks by interbody fusion may make the traditional measurement of segmental lumbar lordosis more difficult. Because the L4-L5 and L5-S1 levels are most commonly involved in fusion procedures, or arthrodesis, and contribute to normal lumbar lordosis, it is helpful to identify a reproducible and accurate means of measuring segmental lordosis at these levels.
A visible sign of hyperlordosis is an abnormally large arch of the lower back and the person appears to be puffing out his or her stomach and buttocks. Precise diagnosis is done by looking at a complete medical history, physical examination and other tests of the patient. X-rays are used to measure the lumbar curvature, bone scans are conducted in order to rule out possible fractures and infections, magnetic resonance imaging (MRI) is used to eliminate the possibility of spinal cord or nerve abnormalities, and computed tomography scans (CT scans) are used to get a more detailed image of the bones, muscles and organs of the lumbar region.
Scoliosis is defined as a three-dimensional deviation in the axis of a person's spine In the diagnostic sense, it is defined as a spinal curvature of more than 10 degrees to the right or left as the examiner faces the person, i.e. in the coronal plane. Deformity may also exist to the front or back as the examiner looks at the person from the side, i.e. in the sagittal plane.
Scoliosis has been described as a biomechanical deformity, the progression of which depends on asymmetric forces otherwise known as the Heuter-Volkmann law.
There is currently no medical recommendation about how to manage an inguinal hernia condition in adults, due to the fact that, until recently, elective surgery used to be recommended. The hernia truss is intended to contain a reducible inguinal hernia within the abdomen. It is not considered to provide a cure, and if the pads are hard and intrude into the hernia aperture they may cause scarring and enlargement of the aperture. In addition, most trusses with older designs are not able effectively to contain the hernia at all times, because their pads do not remain permanently in contact with the hernia. The more modern variety of truss is made with non-intrusive flat pads and comes with a guarantee to hold the hernia securely during all activities. Although there is as yet no proof that such devices can prevent an inguinal hernia from progressing, they have been described by users as providing greater confidence and comfort when carrying out physically demanding tasks. A truss also increases the probability of complications, which include strangulation of the hernia, atrophy of the spermatic cord, and atrophy of the fascial margins. This allows the defect to enlarge and makes subsequent repair more difficult. Their popularity is likely to increase, as many individuals with small, painless hernias are now delaying hernia surgery due to the risk of post-herniorrhaphy pain syndrome. The elasticised pants used by athletes also provide useful support for the smaller hernia.
Many people are managed through day surgery centers, and are able to return to work within a week or two, while intense activities are prohibited for a longer period. People who have their hernias repaired with mesh often recover within a month, though pain can last longer. Surgical complications include pain that lasts more than three months, surgical site infections, nerve and blood vessel injuries, injury to nearby organs, and hernia recurrence. Pain that lasts more than three months occurs in about 10% of people following hernia repair.
People who initially present with scoliosis are examined to determine whether the deformity has an underlying cause. During a physical examination, the following are assessed to exclude the possibility of underlying condition more serious than simple scoliosis.
The person's gait is assessed, and there is an exam for signs of other abnormalities (e.g., spina bifida as evidenced by a dimple, hairy patch, lipoma, or hemangioma). A thorough neurological examination is also performed, the skin for "café au lait" spots, indicative of neurofibromatosis, the feet for cavovarus deformity, abdominal reflexes and muscle tone for spasticity.
When a person can cooperate, he or she is asked to bend forward as far as possible. This is known as the Adams Forward Bend Test and is often performed on school students. If a prominence is noted, then scoliosis is a possibility and an X-ray may be done to confirm the diagnosis.
As an alternative, a scoliometer may be used to diagnose the condition.
When scoliosis is suspected, weight-bearing full-spine AP/coronal (front-back view) and lateral/sagittal (side view) X-rays are usually taken to assess the scoliosis curves and the kyphosis and lordosis, as these can also be affected in individuals with scoliosis. Full-length standing spine X-rays are the standard method for evaluating the severity and progression of the scoliosis, and whether it is congenital or idiopathic in nature. In growing individuals, serial radiographs are obtained at three- to 12-month intervals to follow curve progression, and, in some instances, MRI investigation is warranted to look at the spinal cord.
The standard method for assessing the curvature quantitatively is measuring the Cobb angle, which is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebra involved and the lower endplate of the lowest vertebra involved. For people with two curves, Cobb angles are followed for both curves. In some people, lateral-bending X-rays are obtained to assess the flexibility of the curves or the primary and compensatory curves.
Congenital and idiopathic scoliosis that develops before the age of 10 is referred to as early onset scoliosis (EOS). Scoliosis that develops after 10 is referred to as adolescent idiopathic scoliosis.
Genetic testing for AIS, which became available in 2009 and is still under investigation, attempts to gauge the likelihood of curve progression.
Differential diagnosis of the symptoms of inguinal hernia mainly includes the following potential conditions:
- Femoral hernia
- Epididymitis
- Testicular torsion
- Lipomas
- Inguinal adenopathy (Lymph node Swelling)
- Groin abscess
- Saphenous vein dilation, called Saphena varix
- Vascular aneurysm or pseudoaneurysm
- Hydrocele
- Varicocele
- Cryptorchidism (Undescended testes)
Potential surgical treatments include:
- Anterior cervical discectomy and fusion - A surgical treatment of nerve root or spinal cord compression by decompressing the spinal cord and nerve roots of the cervical spine with a discectomy in order to stabilize the corresponding vertebrae.
- Laminoplasty - A surgical procedure relieve pressure on the spinal cord by cutting the lamina on both sides of the affected vertebrae (cutting through on one side and merely cutting a groove on the other) and then "swinging" the freed flap of bone open.
- Laminectomy - A surgical procedure in which the lamina of the vertebra is removed or trimmed to widen the spinal canal and create more space for the spinal nerves and thecal sac.
Potential non-surgical treatments include:
- Education about the course of the condition and how to relieve symptoms
- Medicines to relieve pain and inflammation, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs)
- Exercise, to maintain or achieve overall good health, aerobic exercise, such as riding a stationary bicycle, which allows for a forward lean, walking, or swimming can relieve symptoms
- Weight loss, to relieve symptoms and slow progression of the stenosis
- Physical therapy, to provide education, instruction, and support for self-care; physical therapy instructs on stretching and strength exercises that may lead to a decrease in pain and other symptoms
Computed tomography scans of the suspected areas with intravenous contrast can assist in diagnosis.
Symptomatic epigastric hernias are repaired with surgery. Even if they are asymptomatic, they can be surgically corrected for cosmetic reasons. In general, cosmetic surgery on infants is delayed until the infant is older and better able to tolerate anaesthesia.
Examination for pain sensation, by pinprick, shows leg (lumbar nerves) analgesia with perineal (sacral nerves) escape. The maintenance of perineal sensation with absence of pain sensation over the lumbar nerve roots is typical for an extra-medullary and intra-thecal (outside the cord and within the dural sheath) process. Inability to walk, with this unusual sensory examination completes a triad of signs and usually represents spinal tuberculosis. The triad is paraplegia with lumbar loss of pain sensation and presence of perineal altered sensation.
Diagnosis is usually confirmed by an MRI scan or CT scan, depending on availability. Early surgery in acute onset of severe cases has been reported to be important.
Patients typically present with either an intermittent mass, localized pain, or signs of bowel obstruction. Ultrasonography or a CT scan can establish the diagnosis, although CT scan provides the greatest sensitivity and specificity.
These hernias should be repaired because of the high risk of strangulation; fortunately, surgery is straightforward, with only larger defects requiring a mesh prosthesis. Varied Spigelian hernia mesh repair techniques have been described, although evidence suggests laparoscopy results in less morbidity and shorter hospitalization compared with open procedures. Mesh-free laparoscopic suture repair is feasible and safe. This novel uncomplicated approach to small Spigelian hernias combines the benefits of laparoscopic localization, reduction, and closure without the morbidity and cost associated with foreign material.
Initial treatment in lumbar disc disease is one or two days of bedrest (although growing number of studies shows that it makes little difference) and pain relieving medications. In cases with ongoing pain despite conservative treatments, a surgical operation that will remove the compressing disc material, a microdiscectomy or discectomy may be recommended to treat a lumbar disc herniation.
In some communities mothers routinely push the small bulge back in and tape a coin over the palpable hernia hole until closure occurs. This practice is not medically recommended as there is a small risk of trapping a loop of bowel under part of the coin resulting in a small area of ischemic bowel. This "fix" does not help and germs may accumulate under the tape, causing infection. The use of bandages or other articles to continuously reduce the hernia is not evidence-based.
An umbilical hernia can be fixed in two different ways. The surgeon can opt to stitch the walls of the abdominal or he/she can place mesh over the opening and stitch it to the abdominal walls. The latter is of a stronger hold and is commonly used for larger defects in the abdominal wall. Most surgeons will not repair the hernia until 5–6 years after the baby is born. Most umbilical hernias in infants and children close spontaneously and rarely have complications of gastrointestinal-content incarcerations.
How far the projection of the swelling extends from the surface of the abdomen (the belly) varies from child to child. In some, it may be just a small protrusion; in others it may be a large rounded swelling that bulges out when the baby cries. It may hardly be visible when the child is quiet and or sleeping.
Normally, the abdominal muscles converge and fuse at the umbilicus during the formation stage, however, in some cases, there remains a gap where the muscles do not close and through this gap the inner intestines come up and bulge under the skin, giving rise to an umbilical hernia. The bulge and its contents can easily be pushed back and reduced into the abdominal cavity.
In contrast to an inguinal hernia, the complication incidence is very low, and in addition, the gap in the muscles usually closes with time and the hernia disappears on its own. The treatment of this condition is essentially conservative: observation allowing the child to grow up and see if it disappears. Operation and closure of the defect is required only if the hernia persists after the age of 3 years or if the child has an episode of complication during the period of observation like irreducibility, intestinal obstruction, abdominal distension with vomiting, or red shiny painful skin over the swelling. Surgery is always done under anesthesia. The defect in the muscles is defined and the edges of the muscles are brought together with sutures to close the defect. In general, the child needs to stay in the hospital for 2 days and the healing is complete within 8 days.
At times, there may be a fleshy red swelling seen in the hollow of the umbilicus that persists after the cord has fallen off. It may bleed on touch, or may stain the clothes that come in contact with it. This needs to be shown to a pediatric surgeon. This is most likely to be an umbilical polyp and the therapy is to tie it at the base with a stitch so that it falls off and there is no bleeding. Alternatively, it may be an umbilical granuloma that responds well to local application of dry salt or silver nitrate but may take a few weeks to heal and dry.
The diagnosis of a hiatus hernia is typically made through an upper GI series, endoscopy or high resolution manometry.