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collagenous and elastic ligaments permit a limited degree of exion, extension, rotation, and lateral motion of the spine The stability of the spine depends on the integrity of the vertebral bodies and intervertebral discs and on two types of supporting structures, ligamentous (passive) and muscular (active) Although the ligamentous structures are quite strong, neither they nor the vertebral body disc complexes have suf cient integral strength to resist the enormous forces that may act on the spinal column; the stability of the lower back is therefore largely dependent on the voluntary and re ex activity of the sacrospinalis, abdominal, gluteus maximus, and hamstring muscles The vertebral and paravertebral structures derive their innervation from the meningeal branches of the spinal nerves (also known as recurrent meningeal or sinuvertebral nerves) These meningeal branches spring from the posterior divisions of the spinal nerves just distal to the dorsal root ganglia, re-enter the spinal canal through the intervertebral foramina, and supply pain bers to the intraspinal ligaments, periosteum of bone, outer layers of the annulus brosus (which enclose the disc), and capsule of the articular facets Coppes and associates have found A- and C pain bers extending into the inner layers of the annulus and even the nucleus pulposus Although the spinal cord itself is insensitive, many of the conditions that affect it produce pain by involving these adjacent structures For example, the sensory bers from the lumbosacral and sacroiliac joints enter the spinal cord via the fth lumbar and rst sacral roots Motor bers exit through the corresponding anterior roots and form the efferent limb of segmental re exes The sympathetic nerves contribute only to the innervation of blood vessels The spinal roots in the lumbar region, after exiting from the spinal cord, course downward in the spinal canal and are gradually displaced laterally until they angulate and exit at the intervertebral foramina Prior to entering the short foraminal canal, the spinal root lies in a shallow furrow along the inner surface of the pedicle called the lateral recess This is a common site of root entrapment by disc fragments and bony overgrowth The parts of the back that possess the greatest freedom of movement and hence are most frequently subject to injury are the lumbar, lumbosacral, and cervical In addition to bending, twisting, and other voluntary movements, many actions of the spine are re exive in nature and are the basis of posture Aging Changes in Spinal Structures Changes in the intervertebral discs and ligaments as a consequence of aging and perhaps a succession of minor traumas begin to occur as early as the rst part of the third decade Deposition of collagen and elastin and alterations of glycosaminoglycans combine to decrease the water content of the nucleus pulposus; concomitantly, the cartilagenous end plate becomes less vascular (Hassler) The dehydrated disc thins out and becomes more fragile Similar changes occur in the annulus of the disc, which frays to an increasing degree with the passage of time, permitting the nucleus pulposus to bulge and, sometimes with injury, to extrude This process can be observed by magnetic resonance imaging (MRI), which shows a gradual re-.

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Superior articular process Mamillary process Transverse process Inferior articular process Mamillary process Accessory process

The base case is straightforward (with d = 0), and the details of the inductive step can be lled in from the preceding discussion

Figure 11-1 The fth lumbar vertebra viewed from above (A) and from the side (B)

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duction in the high signal of the nucleus pulposus with the passage of time In women who had MRI for gynecologic reasons, Powell and coworkers found an increasing frequency of lumbar disc degeneration and bulging, approaching 70 percent by the ftieth year of life Similar abnormalities in asymptomatic men and women have been recorded by Jensen and colleagues The shrinkage of the disc alters the alignment of the articular facets and vertebral bodies, leading sometimes to facet arthropathy and bony spur formation The latter changes may contribute to stenosis of the spinal canal and also compromise the lateral recesses of the canal and the intervertebral foramina, where they impinge on nerve roots Osteoporosis, especially in older women, is an important cause of vertebral attening or collapse, additionally narrowing the spinal canal

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Adverse events with the cosmetic use of BTX-A are usually temporary in nature and not of serious consequence24 BTX-A puri ed protein has been used safely for medical treatment for two decades The therapeutic dose for cosmetic use of BTX-A is well below the therapeutic index LD50 of 2500 to 3000 units25 Complications of treatment include transient pain at the injection site, erythema, edema, and bruising Less common adverse effects are headache, nausea, and flu-like symptoms26 Weakness of nontargeted muscles can occur with improper injection technique Physicians should only use FDA-approved BTX-A product, as unlicensed BTX-A has resulted in severe, life-threatening botulism27 Because of its molecular structure, BTX-A is a protein capable of producing an immune response and neutralizing antibodies in patients who receive repeated treatments and large amounts of toxin Loss of ef cacy of BTX-A caused by formation of antibodies is an unusually rare event when used for cosmetic indications, with only a single case report in the literature28

Types of Low Back Pain Of the several symptoms of spinal disease (pain, stiffness, limitation of movement, and deformity), pain is of foremost importance Four types of pain may be distinguished: local, referred, radicular, and that arising from secondary (protective) muscular spasm These several types of pain can often be discerned from the patient s description; reliance is placed mainly on the character of the pain, its location, and conditions that modify it Local pain is caused by any pathologic process that impinges on structures containing sensory endings Involvement of the periosteum of the vertebral body, capsule of apophysial joints, muscles, annulus brosus, and ligaments is often exquisitely painful, whereas destruction of the nucleus pulposus alone produces little or no pain Local pain is most often described as steady and aching, but it may be intermittent and sharp and, though not well circumscribed, is always felt in or near the affected part of the spine Usually there is re exive protective splinting at the corresponding spinal segments by intense contraction of the paravertebral mus-

At the level of abstraction of Figure 48, Dijkstra s algorithm is structurally identical to breadth- rst search However, it is slower because the priority queue primitives are computationally more demanding than the constant-time eject s and inject s of BFS Since makequeue takes at most as long as |V | insert operations, we get a total of |V | deletemin and |V | + |E| insert/decreasekey operations The time needed for these varies by implementation; for instance, a binary heap gives an overall running time of O((|V | + |E|) log |V |)

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