占いの心のエンジン

雲

ハッキリしないが、とにかくしばらく近づいて眼をしてみると、林の中は日の光りが到らぬ隈も低く、うれしそうにいろ木の葉を使って、はなやかにした物音がまるで大方でも詰めたように、鮮かに見わたされた。
雲はどき廻する風に吹き払われて形を潜め、空には物音一ツも留めず、大気中に堪えかねた美人の気は人の気を爽かに焼けて、穏かな見所の思う前触れをするかと見えた。

閉店

ラーメン食べようと出かけたら、店が閉店だった。
むかつく。

修理

修理した跡ではないでしょうか。完全に戻らない場合は最終的になおすのですが、仕上げが悪いと、何年か後に剥げたりすることがあります。

Morbid Angel

Morbid Angelっていいですね。でも、音質悪い気がするんだけど・・・。
どうなんだろ。デスメタルファンは音質悪いのOKなのかなぁ。ブラックメタルファンは音質悪いのが好きらしいけど。
ブラックメタルファンはインテリが多いのによくわからないな。

縁日

温泉ですか。縁日も楽しそうですね！

新生銀行の筆頭株主に米投資ファンド

新生銀行の筆頭株主に米投資ファンド

ホントここは鬼門だね。ここに関しては、日本人は損ばっかしてるよね？

そういえば

エンセンとか藤原組長が飼ってるのって
ピットブルだっけ？

zom kasi

happens when a crack forms in the bony ring on the back of the spinal column. Most commonly, this occurs in the low back. In this condition, the bone that protects the spinal cord fractures as a result of excessive or repeated strain. The area affected is called the pars interarticularis, so doctors sometimes refer to this condition as a pars defect.

This condition appears in six percent of children. It mainly affects young athletes who participate in sports in which the spine is repeatedly bent backwards, such as gymnastics, football, and karate.

Although spondylolysis can affect people of any age, children and adolescents are most susceptible. This is because their spines are still developing, and the pars is the weakest part of the vertebra. Placing extra strain on this area of the spine during childhood increases the chance that a pars defect will occur.

This guide will help you understand

how the problem develops
how doctors diagnose the condition
what treatment options are available
Anatomy

What parts of the spine are involved?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body's main upright support. The section of spine in the lower back is called the lumbar spine.

Each vertebra is formed by a round block of bone, called a vertebral body. A circle of bone attaches to the back of the vertebra. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This tube, called the spinal canal, surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

The protective ring that surrounds the spinal cord is a continuous ring of bone. Its sections include two pedicles, which attach directly to the back of the vertebral body. Two laminae complete the ring.

The pedicles and laminae are two different areas of the bony ring. The area between them is not a joint. Rather, it is a location in the continuous ring of bone that doctors call the pars interarticularis, or pars for short. There are two such meeting points on the back of each vertebra, one on the left and one on the right. The pars is thought to be the weakest part of the bony ring.

Related Document: A Patient's Guide to Lumbar Spine Anatomy

Causes
What causes this problem?

Spondylolysis is thought to be caused by repeated strains that damage the lower spine over time. The repeated strains can eventually lead to an overuse injury in the pars interarticularis. The most common location for this to occur is in the lowest vertebra of the spine, which doctors call L5. This vertebra connects the spine to the pelvis. However, a problem with the pars can occur in any lumbar vertebra. It rarely happens in more than one vertebra at a time.

The vertebra initially responds to the abnormal strain by adding new bone cells around the injured area. But if the injuries happen faster than the body can keep up with needed repairs, a crack may form in the weakened bone. This is called a stress fracture. This type of fracture occurs in the pars, the area of bony ring between the pedicle and lamina.

The crack may affect only one side of the bony ring. However, it is equally common for the defect to occur on both sides. When this happens, the vertebra is no longer held firmly in place by the facet joints on the back of the ring. As a result, the vertebra is free to slip forward over the one below. This slippage, which is closely related to spondylolysis, is called spondylolisthesis.

Related Document: A Patient's Guide to Spondylolisthesis

Spondylolysis commonly occurs in young gymnasts who regularly practice backbends as part of their routines. Football linemen and dancers are also prone to spondylolysis. Symptoms sometimes appear when an athlete quickly ramps up his or her training intensity, applies incorrect technique, or uses poor equipment.

Symptoms
What does the condition feel like?


People with spondylolysis may feel pain and stiffness in the center of the low back. Bending fully backward increases pain. Symptoms typically get worse with activity and go away with rest. Doctors refer to this type of back pain as mechanical pain because it most likely comes from excess movement between the vertebrae.

Individuals may eventually experience pain that radiates down one or both legs. This pain may come from pressure and irritation on the nerves that exit the spinal canal near the fracture. When nerve pressure in the low back causes leg pain, doctors refer it as neurogenic pain.

The cause of this nerve pressure is a result of the body's attempt to heal the stress fracture. Over time, the healing process may cause a bump of extra cartilage to grow at the site where the bones are trying to heal the overuse injury. If too much cartilage builds up, this bump may intrude into the opening where the nerves exit the spine. The bump may squeeze the nerve. This can produce pain and weakness in the leg. Reflexes become slowed. The person may also notice a pins and needles sensation in the skin where the spinal nerve travels.

Diagnosis
How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical exam. Your doctor will ask questions about your symptoms and how the problem is affecting your daily activities. You will be asked about your involvement in sports and your level of performance. Doctors may suspect a problem with spondylolysis in football linemen, gymnasts, and those in similar sports that require intensive levels of performance. Your doctor will also want to know what positions or activities make your symptoms worse or better.

Next the doctor examines you by checking your posture and the amount of movement in your low back. Your doctor checks to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

Your doctor may order an X-ray of your low back. An angled, or oblique, view is often used to check for a pars fracture. The doctor traces around the vertebral body and bony ring on the X-ray film. The outline normally forms an image that looks like a small dog. When a crack is present, however, the dog will appear to have a collar around its neck. This is referred to as the Scotty dog sign. It confirms a diagnosis of spondylolysis.

Small defects in the bone may not show up on X-ray. Also, a recent stress fracture won't always appear on X-ray. As a result, your doctor may order a bone scan to get the most accurate information. This involves injecting chemical "tracers" into your blood stream. The tracers then show up on special spine X-rays. The tracers collect in areas of extra stress to bone tissue, such as a stress fracture of the pars interarticularis.

Computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets doctors see slices of the body's tissue. The image can show if the edges of the fractured bone have begun growing together. The scan shows whether the fracture is new or old, so doctors can decide which treatments will help the most.

When more information is needed, your doctor may order a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It can help in the diagnosis of spondylolysis. It can also provide information about the health of nearby intervertebral discs and other soft tissues that don't appear on X-rays.

Treatment
What treatment options are available?

Nonsurgical Treatment
Doctors often begin by prescribing nonsurgical treatment for spondylolysis. This is because symptoms from these stress fractures often resolve with rest or bracing. In some cases, doctors simply monitor their patients' condition to see if symptoms improve. An X-ray may be taken every few months to check how well the area is healing.

If the doctor feels that the problem is due to a recent fracture, you may be placed in a rigid back brace or cast for three to four months. Keeping the spine from moving can help ease pain and inflammation. It can also improve the chances the bones will grow back together. Most people who require a brace or cast overcome symptoms and are able to eventually get back to activities free of pain. This can happen even when follow-up tests show that the bones haven't completely healed.

Your doctor may ask that you rest your back by limiting your activities. The purpose of this is to help decrease inflammation and calm muscle spasm. You may need to take some time away from your sport, especially if it requires repeated back bending. This gives your back a chance to heal. Most patients who follow these measures get better. Patients are rarely counseled to completely discontinue participating in their sport, and only in severe cases.

Patients often work with a physical therapist. After evaluating your condition, a therapist can assign positions and exercises to ease your symptoms. The therapist may design an exercise program to improve the strength and control of your back and abdominal muscles. By watching you perform your sport activity, your therapist can suggest style, technique, or equipment changes to improve your performance and prevent future problems.

Surgery
Most patients with spondylolysis do not require surgery. When symptoms are not relieved with nonsurgical treatments, however, patients may require surgery. The main types of surgery for spondylolysis include

laminectomy
posterior lumbar fusion
Laminectomy
Nerve compression can cause considerable pain and symptoms. If too much cartilage builds up where the fractured bones are trying to heal, the nerve that passes near the injured bone may get squeezed, as described earlier. To fix this, a section of the bony ring is removed to take pressure off the nerve. The procedure to remove the lamina from the bony ring and release pressure on the nerve is called laminectomy.

Related Document: A Patient's Guide to Lumbar Laminectomy

Posterior Lumbar Fusion
A spinal fusion may be required after a surgeon performs a laminectomy procedure. Fusion is recommended when a spinal segment (a set of vertebrae) has become too loose or unstable.

A spinal fusion allows two or more bones to grow together, or fuse, into one solid bone. This keeps the bones and joints from moving. In this procedure, the surgeon lays small grafts of bone over the problem area on the back of the spine. Some surgeons also apply metal plates and screws to prevent the two vertebrae from moving. However, this practice is controversial because fusion occurs in about 90 percent of children with spondylolysis when the procedure is done without plates and screws.

Related Document: A Patient's Guide to Posterior Lumbar Fusion

Rehabilitation
What should I expect as I recover?

Nonsurgical Rehabilitation
Recovery from this condition is much like nonsurgical treatment mentioned earlier. Once you have rested your back to allow it to heal, your doctor may recommend that you work with a physical therapist a few times each week for four to six weeks. In severe cases, patients may need a few additional weeks of physical therapy.

The first goal of treatment is to control symptoms. The therapist works with you to find positions and movements that ease pain. Treatments of heat, cold, ultrasound, and electrical stimulation may be used to calm pain and muscle spasm.

As you recover, you will gradually advance in a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles helps patients begin moving easier and lessens the chances of future pain and problems.

When needed, a therapist can work closely with a sports coach on strategies for a patient's safe return to his or her sport. The two may provide suggestions on technique, equipment, and training frequency and intensity.


If the patient is a working adult, the therapist may also work with the patient's doctor and employer to help the patient get back on the job as quickly as reasonably possible. The patient may be required to do lighter duties at first. As soon as the patient is able, he or she will do normal work activities. The therapist may also suggest changes that could help the patient work safely, with less chance of re-injuring his or her back.

A primary purpose of therapy is to help patients learn how to take care of their symptoms and prevent future problems. Patients are given a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. The therapist also describes strategies you can use if your symptoms flare up.

Most adolescents get better after wearing a brace or cast for three months. Even then, a CT scan sometimes shows an unhealed fracture. In these cases, however, symptoms often go away completely, allowing a safe return to sports. Patients do best when guided in a gradual manner with the supervision of a therapist and sports coach.

After Surgery
Rehabilitation after surgery is more complex. Some patients leave the hospital shortly after surgery. However, some surgeries require patients to stay in the hospital for a few days. Patients who stay in the hospital may visit with a physical therapist in the hospital room soon after surgery. The treatment sessions help patients learn to move and do routine activities without putting extra strain on the back.

During recovery from surgery, patients should follow their surgeon's instructions about wearing a back brace or support belt. They should be cautious about overdoing activities in the first few weeks after surgery.

Many surgical patients need physical therapy outside of the hospital. Patients who've had lumbar fusion surgery normally need to wait at least six weeks before beginning a rehabilitation program. This delay gives the fusion a chance to start healing. Patients typically need to attend therapy sessions for six to eight weeks and should expect full recovery to take up to six months.

zom susa

Definition
Spondylolysis is a stress fracture in one of the vertebral bones in the spine. These fractures usually occur in the lower back. Left untreated,spondylolysis can lead to spondylolisthesis. This is a more serious condition in which one vertebra slips forward on the one below it. Both conditions can cause back pain by disturbing biomechanics in the back or by pinching the nerves in the spinal column.

Causes
Spondylolysis can be caused by:

Birth defect in the spine, which usually appears a few years after birth
Trauma to the back
Overextending and twisting of back muscles
Degenerative diseases
Cerebral palsy
Risk Factors
A risk factor is something that increases your chance of getting a disease, condition or injury.

Playing sports such as:

Gymnastics
Football, especially the offensive line
Diving
Wrestling
Weightlifting
Improper athletic or exercise technique
Not using proper equipment for exercise or athletic activities
Symptoms
Symptoms may include:

Pain across the lower back
Spasms in the back and hamstring muscles
Back pain that starts during an adolescent growth spurt
Many people with spondylolysis have no symptoms at all.
Diagnosis
The doctor will ask about your symptoms and medical history, and perform a physical exam.

Tests may include:

X-ray - a test that uses radiation to take a picture of the spine to look for fractures
CT Scan - a type of x-ray that uses a computer to make pictures of structures inside the back
MRI Scan - a test that uses magnetic waves to make pictures of structures inside the back
Treatment
If you have no symptoms from the spondylolysis, no treatment is needed.

Treatment includes:

Exercise Restriction - Do not do athletic activities for several weeks to several months. In general, this restriction will last until the symptoms are gone.
Back Brace - Your doctor may suggest that you wear a back brace to help relieve pain.
Physical Therapy - Once the pain is gone, a physical therapist can teach you:
Exercises to strengthen the back and abdominal muscles that stabilize the spine
Proper exercise and sports techniques to help prevent overuse and further injury
Medication - The doctor may give you anti-inflammatory medications for pain relief.
Surgery - If medication, rest, and physical therapy don't heal the fracture, surgery may be considered. Two procedures are usually needed:
Decompressive laminectomy - removal of excess bone and tissue that is putting pressure on the spinal cord
Spinal fusion - fusing together of two vertebrae to prevent further slippage of the vertebra and stabilize that area of the spine
Prevention
To reduce your risk of getting spondylolysis:

Limit participation in sports to a reasonable amount. This will help prevent overuse injury.
Use proper equipment for your sport.
Warm up properly before exercising or playing sports.
Learn proper techniques for exercise and athletic activities.
Seek medical care for chronic back pain. Early vertebral stress fractures may heal with rest.

zom hech

Since the publication of Evidence-based Sports Medicine,1there have been a number ofpublications addressing the subject of spondylolysis. Although much of this literatureexpands the cumulative knowledge base on spondylolysis, there are still no publishedcontrolled trials on the treatment of spondylolysis in the athlete nor any studiescomparing the most widely used diagnostic imaging modalities for this condition. Asdiscussed in the original chapter on spondylolysis for Evidence-based Sports Medicine,2there is a general consensus among authors on the pathogenesis and demographics of thedisorder, but there are substantial differences in the diagnostic and treatment approachesrecommended by various authors. This update will address the recent literature onspondylolysis as it relates to the fundamental question: How should you treatspondylolysis in the athlete?EpidemiologyRossi and Dragoni3have published the results of a radiographic study describingthe results of 4243 young athletes studied with plain radiographs. All the athletes hadcomplaints of low back pain and were assessed between 1962 and 1998 with studies thatincluded antero-posterior, lateral, and oblique films. The authors found that 13.9% of theathletes studied had evidence of spondylolysis on plain radiographs, and that 47.5% ofthese had a concurrent spondylolisthesis. As has been noted in multiple prior studies,some sports had much higher rates of spondylolysis identified than others, with diving,wrestling, weight lifting, track and field, and gymnastics included in the sports with ahigher prevalence and baseball, archery, golf, and equestrian in the sports with arelatively low prevalence. The prevalence of spondylolysis among athletes in this studyis fairly similar to prior reports.2Diagnostic ImagingThe role of various imaging modalities in the diagnosis of spondylolysis has beenaddressed in several studies. A study by Stretch et al.4on fast bowlers utilized plainradiography, nuclear imaging with single photon emission computed tomography(SPECT), and computed tomography (CT) to establish the diagnosis. They found that 8of the 10 athletes with positive SPECT scans had normal plain radiographs and that 3 ofthese same 10 athletes had no evidence of fracture on initial CT (although one of these 3did have a fracture present on CT at three months out that subsequently healed on repeatCT at twelve months). By 12 months out from diagnosis, 5 of the 7 fractures identifiedinitially showed complete or near-complete healing, with the 2 that did not heal havingfeatures of old bilateral fractures on initial CT. The only treatment mentioned is that theathletes were removed from participation in fast bowling and prohibited from activitiesthat involved spinal flexion and rotation of the low back for 3 months with a gradedprogram for return to activity. These findings are consistent with those of earlier studiesthat showed a markedly increased sensitivity for SPECT over plain radiography and theoccurrence of normal appearing CT scans in patients with a positive SPECT study.2Two studies have addressed the role of magnetic resonance imaging (MRI) in thediagnosis of spondylolysis. Hollenberg et al.5presented a classification system forfindings in the pars interarticularis. The authors retrospectively reviewed 55 MRI scansperformed on young athletes with low back pain who were evaluated for possible parsinjuries. A classification system was developed based upon the appearance of the pars
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and graded on a 0 to 4 scale with defined criteria for each grade thought to correspondwith varying types of injuries or pathological states of the pars. Although the authors didfeel that their classification system was reliable, the clinical utility of this system isunclear. Unfortunately, there was no comparison of these studies to either SPECT or CT,no clinical data on outcome, no clear means of establishing pathological correlates to thefindings, and no discussion of the prevalence of these findings in a normal control group.Without any of this information, the classification scheme presented has no proven role inthe diagnosis and treatment of adolescent athletes with spondylolysis.Takata and colleagues have presented an as yet unpublished study assessing thesignificance of high intensity signal in the pedicle on MRI to assess healing.6Thirty-twoadolescents with suspected spondylolysis were studied both with MRI and serial CTscans. The presence of high intensity signal in the pedicle was a predictor of bonyhealing. Treatment involved the use of a soft corset and activity modification.Overall, the role of MRI in the diagnosis of spondylolysis remains unclear withinsufficient data on the relative sensitivity and specificity compared to SPECT and CTand limited clinical data. Although some authors advocate the primary use of MRI in thediagnosis of spondylolysis,7the preponderance of authors of recent reviews on the topicendorse varying degrees of a combination of plain radiographs, SPECT and CT inathletes in whom the diagnosis of spondylolysis is suspected.8–13TreatmentSeveral recent studies have addressed the treatment of athletes with spondylolysis.The available studies are summarized in Table 1. Unfortunately, there are no controlledtrials published to date, and there is thus no means of providing evidence for efficacy ofone treatment approach over another. There remain disagreements among authors on theneed for bracing, brace type and duration of use (when used), and the diagnosticevaluation necessary before the initiation of treatment. The largest series published isthat of d’Hemecourt et al.14The authors retrospectively assessed 73 adolescent athleteswho had been treated with a Boston Overlap Brace for the diagnosis of spondylolysis.The diagnosis was established by the use of plain radiographs, nuclear imaging (bonescan with SPECT), and CT if no fracture was visible on plain films. As the authors notethat 14 of the 73 patients had negative “bone scans” and all 73 patients had CT scans, it isuncertain what the “gold standard” for establishing the diagnosis was, however. Thepatients in this study were advised to wear their orthosis 23 hours per day for 6 monthswith a weaning period of several months. Physical therapy emphasizing a flexion biaswas also provided, and athletes were allowed to return to sport at 4–6 weeks if they hadno pain with extension provided that they wore the brace and remained pain free. 77% oftheir patients had a “good” or “excellent” outcome, although the exact numbers in eachcategory and the time necessary for return to sport were not published. The authors notedseveral predictors of poor outcome, including being female and participating in “highrisk” sports, such as gymnastics, dance, soccer, and football. The lack of controls,retrospective design, limited data on outcomes, and unclear diagnostic criteria are allsignificant limitations of this study.ConclusionsOverall, there has been no data published to alter our recommendations fordiagnosis and treatment from those in the original publication of Evidence-based SportsMedicine.1,2 As before, there remains a substantial need for controlled trials of differenttreatment methods (for example, relative rest with or without a brace) and for studies that
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directly compare the relative sensitivity and specificity of different imaging modalities,especially for SPECT v MRI. Until these are available, a rational approach to treatmentwill have to be based upon a thorough understanding of all the available science on thenatural history, pathogenesis, diagnosis, and treatment of spondylolysis.References1. MacAuley D, Best T, eds. Evidence-based Sports Medicine. London, BMJ Books,2002.2. Standaert CJ, Herring SA. How should you treat spondylolysis in the athlete? In:MacAuley D, Best T, eds. Evidence-based Sports Medicine. London, BMJ Books,2002, 239–265.3. Rossi F, Dragoni S. The prevalence of spondylolysis and spondylolisthesis insymptomatic elite athletes: radiographic findings. Radiography 2001;7:37–42.4. Stretch RA, Botha T, Chandler S, Pretorius P. Back injuries in young fastbowlers—a radiologic investigation of the healing of spondylolysis and pediclesclerosis. S Afr Med J 2003;93:611–616.5. Hollenberg GM, Beattie PF, Meyers SP, Weinberg EP, Adams MJ. Stressreactions of the lumbar pars interarticularis. The development of a new MRIclassification system. Spine 2002;27:181–186.6. Lighting up spondylolysis to identify stress fractures with the capacity for healing.The BackLetter 2003;18;121–131.7. Hollenberg GM, Beitia AO, Tan RK, Weinberg EP, Adams MJ. Imaging of thespine in sports medicine. Curr Sports Med Rep 2003;2:33–40.8. Herman MJ, Pizzutillo PD, Cavalier R. Spondylolysis and spondylolisthesis in thechild and adolescent athlete. Othop Clin N Am 2003;34:461–467.9. Logroscino G, Mazza O, Aulisa AG, et al. Spondylolysis and spondylolisthesis inthe pediatric and adolescent population. Child’s Nerv Syst 2001;17:644–655.10. Lundin DA, Wiseman DB, Shaffrey CI. Spondylolysis and spondylolisthesis inthe athlete. Clin Neurosurgery 2002;49:528–547.11. McTimoney CAM, Micheli LJ. Current evaluation and management ofspondylolysis and spondylolisthesis. Curr Sports Med Rep 2003;2:41–46.12. Standaert CJ. Spondylolysis in the adolescent athlete. Clin J Sport Med2002;12:119–122.13. Waicus KM, Smith BW. Back injuries in the pediatric athlete. Curr Sports MedRep 2002;1:52–58.14. d’Hemecourt PA, Zurakowski D, Kriemler S, Micheli LJ. Spondylolysis:Returning the athlete to sports participation with brace treatment. Orthopedics2002;23:653–657.15. Sys J, Michielsen J, Bracke P, Martens M, Verstreken J. Nonoperative treatmentof active spondylolysis in elite athletes with normal X-ray findings: literaturereview and results of conservative treatment. Eur Spine J 2001;10:498–504.
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Table 1Clinical Outcome92.9% “excellent”or“good”outcome, 89.3%returnedto priorlevel ofcompetitionataverage of 5.5months, 1 hadsurgery77% “excellent”of“good”outcome .Not reportedRadiographicO100%ofunilateralfractures healed, 5 of 17bilateral fractureshealed fully (7 additionallyshowedunilateral healing)Not reported80% healed at 1 year(2of10thatdid nothealhad “oldbilateral fractures”)Treatment SummaryRigid brace (Boston Overlap Brace) withthigh extension23oper dayuntil follow-upscintigraphynegativeor6 months(average15.9weeks)Rigid brace (anti-lordotic BostonOverlap Brace) 23operday for 6 months,then weaned, physicaltherapy with flexionbiasActivityrestriction,for 3 months(nobowlingortasks withlumbar extensionorrotation)andactiverehabilitationprogramDiagnosticIiPlain X-ray,planarbonescan & SPECT, CTPlain X-ray,SPECT, CT Plain X-ray,SPECT, CTMean17.2years15.7years15-22yearsN347310DiagnosisSpondylolysiswith“subtlefractures”: negativeradiographs,positiveSPECTSpondylolysisbyradiographsorCT, 4 of73patients withspondylolis-thesisFast bowlerswith spondylolysis,all with positiveSPECTDesignCohortRetrospectiveCase SeriesProspectiveCohortStudySys, et al, 2001(15)D’Hemecourt ,et al, 2002 (14)Stretch, et al, 2003(4)