Journal of neurosurgery
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Journal of neurosurgery · Aug 1979
The anatomy of the so-called "articular nerves" and their relationship to facet denervation in the treatment of low-back pain.
Disections of the dorsal rami of L1--5 were performed in human cadavers, and the course of the dorsal rami, their branches, and the innervation of the zygapophyseal joints in the lumbar region were specifically studied. At the L-1 through L-4 levels, the dorsal rami divide into medial and lateral branches within the intertransverse ligaments. Each medial branch runs across the root of the adjacent superior articular process. ⋯ Beneath the mammillo-accessory ligament, medial branches occur that innervate the adjacent zygapophyseal joint, and distal zygapophyseal branches arise at the laminar level to innervate the next lower joint. The L-5 dorsal ramus runs along a groove between the ala of the sacrum and its superior articular process. A the caudal edge of the articular process, the ramus divides into medial and lateral branches, and the medial branch supplies the L5--S1 articulation.
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Every surgical procedure taxes the hemostatic defenses of the patient. If his hemostatic mechanism is sound, he is unlikely to have a bleeding problem during or after an operation, unless, of course, a suture or clip slips off. Two classes of patients do present bleeding problems to the surgeon. ⋯ The major hemostatic defect that may develop during an operation, or shortly thereafter, is disseminated intravascular coagulation. This syndrome, always secondary, may accompany shock, mismatched blood transfusion, septicemia, or extensive malignancy. Its prevention or early recongnition is much easier than treatment after circulating platelets and some coagulation factors have been consumed and fibrinolysis is destroying fibrin and fibrinogen.