#Journal of Spine Surgery

[ourhaileydavies]

Expect the Unexpected with Erector Spinae Plane Block in Spine Surgery - Plan for the Worst and Hope for the Best: An Anesthesiologist Perspective-Juniper Publishers

Abstract

Spine surgery is associated with multiple postoperative complications, ranging from simple nausea and vomiting to devastating complications leading to postoperative morbidity or mortality. The postoperative neurological impairment, especially in the neurologically intact patient, is a dreadful event that makes it difficult for the surgeon to perform technically challenging or high-risk spine surgeries. Preoperative or intraoperative factors that can influence the postoperative neurological status include nature and the severity of the pathology, comorbid conditions of the patient, preexisting neurological symptoms, multiple levels involved, complex surgery or instrumentation, surgical blood loss, neurological monitoring, hemodynamic parameters, polypharmacy, and total duration of the surgery.

In addition to several known contributing factors (fixation failure, epidural hematoma, spinal cord edema, and ischemia-reperfusion injury), the role of the erector spinae plane block (ESPB) has recently been cited as a potential cause of postoperative transient paralysis after spine surgery. ESPB is considered a simple and safe regional anesthesia technique that may have an advantage in success rate and analgesic efficacy when used as an adjunct to general anesthesia in spine surgeries. Despite varied patterns of the drug spread, ESPB has been showing promising results due to consistent involvement of dorsal rami that supply all pain generators of the spine surgeries.

The potential role of ESPB in causing postoperative transient neurological complications is a diagnosis of exclusion that requires thorough clinical assessment and step-by-step evaluation using imaging modalities. Before administering ESPB in spine surgery, essential knowledge includes anatomical and technical considerations, drug distribution patterns, safe and effective volumes/types of local anesthetics, and possible associated complications. This review article describes the possible roles of all factors that lead to postoperative neurological impairment and suggests some tips and tricks for using ESPB in spine surgeries to prevent or manage such serious complications appropriately.

Keywords: Transient paraplegia; Erector spinae plane block; ESP block complications; ESP block in spine surgery; Paraplegia due to RA

Keywords: RA: Regional anesthesia; GA: General anesthesia; ESPB: Erector spinae plane block; ERAS: Enhanced recovery after surgery; LA: Local anesthetics; CT: Computed tomography; MRI: Magnetic resonance imaging; ESM: Erector spinae muscles; TP: Transverse process; SMPB: Sacral multifidus plane block; RLB: Retrolaminar block

Introduction

The occurrence of perioperative complications may be inevitable, but their prevention and management are always a shared responsibility of all team members involved. Thorough evaluation of such complications will help develop strategies to prevent and manage the same in the future. A systematic and stepwise approach is warranted before categorizing it as a surgical or anesthetic complication. Several interventions have been introduced in the surgical and anesthetic techniques to improve patient safety and satisfaction. Application of regional anesthesia (RA) alone or as an adjunct to general anesthesia (GA) is one such advance that helps reduce many polypharmacy-related side effects or complications. If a particular complication-reduction modality is inherently causing complications, it requires a comprehensive understanding of the situation and its contributing factors.

An erector spinae plane block (ESPB), a safe and simple RA technique, has shown promising results as an adjunct to multimodal analgesia in various orthopedic, general, thoracic, abdominal, obstetrics, and spine surgeries. In addition to its superior postoperative analgesic profile in spine surgeries at various levels, ESPB reduces hospitalization costs and the possible side effects of extensive anesthetic use. Since opioids have been linked to tumor recurrence [1,2], ESPB also reduces the risk of spine tumor recurrences by significantly reducing its consumption. ESPB meets all criteria suitable for enhanced recovery after surgery (ERAS) protocol [3] by facilitating early discharge and mobilization of patients. Being a novel RA technique, not many complications have been reported so far except for some anecdotal reports of bilateral quadriceps weakness, transient apathy or aphasia, minor neurological complications due to inadvertent intravascular injection of local anesthetics (LA) [4].

Recently, it has been described as a potential cause of transient paralysis after spine surgeries [5]. Therefore, it is essential to understand the differential diagnoses of postoperative neurological impairment, follow the step-by-step approach to rule them out one by one, determine the possible role of ESPB in their development, and learn the tricks for safely administering ESPB during spine surgery. This review article elaborates the essential background knowledge required before and after the administration of ESPB in spine surgeries.

Discussion

Postoperative neurological impairment after spine surgery in a neurologically intact patient is always daunting for the operating surgeon and the patient. Several common theories on neurological deterioration after decompressive spine surgeries include vascular compromise, hypotension, ischemia, direct trauma, or stretching of the neural elements. The major contributing factors of acute paralysis following spine surgery include fixation failure, epidural hematoma, spinal cord edema, and ischemia‑reperfusion injury [6].

Contributory factors

Neurons in the spinal cord are susceptible to ischemia and hypoxia. The mechanisms of spinal cord ischemia are multi-factorial and multi-channel. The pathogenesis of spinal cord lesions after spine surgeries is usually mechanical (pressure) damage via extensive hematoma or edema, resulting in pressure on the spinal cord leading to ischemic damage [7]. An altered cerebrospinal fluid flow dynamic may also cause cord compression [8]. In either case, the ultimate pathogenic cause is a secondary cellular injury due to the disruption of ionic homeostasis, development of free radicals, lipid oxidation, and degeneration of the cytoskeleton [7]. White cord syndrome, an imaging feature of spinal cord ischemia [9], is diagnosed as high intramedullary signal changes on sagittal T2 weighted MRI scans and is often seen in surgeries on the cervical spine.

The spinal infarct is one of the leading causes of paraplegia or quadriplegia in patients with preexisting vascular pathologies (thrombosis) or embolic events during surgery [10]. The anterior spinal cord has a higher risk of ischemia due to fewer anterior spinal artery feeding vessels [10] than the highly vascular posterior spinal cord due to anastomotic pial vessels. The sparing of the posterior column leads to unchanged intraoperative somatosensory evoked potentials [11]. The ischemia-reperfusion injury occurs upon restoring the blood flow to previously ischemic tissues and organs. Increased inflammatory cytokines such as TNF α and IL 1β may be considered vital indicators for evaluating decompression-associated spinal cord ischemia-reperfusion injury [12,13]. Its reported incidence is 2-5.7% following cervical and 14.5% following posterior thoracic decompression surgeries [14, 15].

Transient paralysis is one such complication that manifests itself as a temporary (up to 72 hours) loss of sensations, movements, anal reflexes, and sphincter function below the affected spinal segments [16]. It can occur after vertebroplasty, laminectomy, or thoracic decompressive procedures [17,18]. The longer duration of symptoms, multiple compression sites, and the high degree of preoperative stenosis are considered poor prognostic factors [18].

Who is the culprit?

The exact cause of the postsurgical neurological impairment is a diagnosis of exclusion requiring thorough clinical evaluation and imaging guidance to rule out each contributing factor (Table 1) in a step-by-step manner. Postoperative radiographic studies like computed tomography (CT) scan and magnetic resonance imaging (MRI) can help detect changes suggestive of misplaced implants, hematomas, edema, compressive lesions, white cord syndrome, or direct trauma to the spinal cord. Symptoms due to spinal cord edema typically occur at 48-72 hours post-surgery and may be relieved by anti-edema measures like fluid restriction [19].

The occurrence and severity of ischemia-reperfusion injury correlate with tissue ischemia time, the extent of ischemic tissue, and the oxygen requirement of the affected tissue [20]. The presence of deep tendon and superficial reflexes may rule out the possibility of hysterical paraplegia [18]. After excluding all contributing factors that may cause postoperative neurological impairment, the possible role of ESPB and LA can be considered and further evaluated. It requires an understanding of the anatomical and technical aspects, mechanism of drug spread, factors favoring neuraxial spread, and measures to avoid such incidents in the future [21].

Role of ESPB

ESPB involves depositing the local anesthetic solution between the erector spinae muscles (ESM) and the transverse process (TP) under ultrasound guidance. The ESM consists of three muscles: iliocostalis, longissimus, and spinalis. They arise from and insert into various bony components of the vertebral column [22] and form a paraspinal column that extends from the sacrum to the base of the skull. It gradually tapers upwards in the paravertebral groove on either side of the spinous processes. The retinaculum (thoracolumbar fascia in the lumbar region) that envelops this muscular column also facilitates the LA spread to several thoracic and lumbosacral levels [23]. The diverse multilayered fascial arrangement deep to the ESM may cause the inconsistent LA spread, resulting in multisegmented sensory block mainly involving dorsal rami with sometimes ventral rami.

This Para neuraxial block, when given bilaterally in spine surgery, can be advantageous in success rate and analgesic efficacy [24]. The absence of risks such as hypotension, vascular spread, or pneumothorax makes ESPB relatively safer than epidural anesthesia or paravertebral block. Bilateral ESPB offers effective perioperative analgesia without influencing the hemodynamic parameters. It significantly reduces the perioperative opioid requirements in spine surgeries at various levels (cervical, thoracic, and lumbar, and sacral) [25-32]. Its outcome depends on the volume and concentration of LA used, drug spread, and the anesthesiologist’s experience in selecting and locating the correct level of the TP.

The exact mechanism of action of the ESP block and pattern of the drug spread is still unclear. It has been suggested to anesthetize the spinal nerves by passing through the costotransverse foramen of Cruveilhier, accompanying the dorsal ramus and artery to the paravertebral space [33]. The deposited drug can spread in any direction, such as craniocaudal, anterior-posterior, and lateral-medial planes to reach the paravertebral space, neural foramina, epidural space, or sympathetic chain [34-38]. Fluoroscopic, CT, and MR imaging in living subjects have similarly confirmed the injectate tracking to the paravertebral area, intervertebral foramina, and epidural space following lumbar ESPB [39-42]. There is also a possibility of LA diffusion through the microscopic gaps in the mostly acellular architecture of interlinked collagen fibers of the fascia covering the erector spinae muscle [43].

ESPB at various spine levels

The anatomical differences at the various spine levels can cause varied drug spread and ultimately affect the outcomes of ESPB. Cervical ESPB is technically challenging due to the difficulty in identifying the tips of the cervical transverse processes due to their shorter length. It is mainly given at the C6 or C7 vertebral level. The probe needs to be kept anterolaterally rather than posteriorly to see the cervical TPs [44]. It may not be safe due to its proximity to the neuraxis (shorter transverse processes) and the possibility of bilateral phrenic nerve involvement [45-48].

Thoracic ESPB at the upper vertebral levels (T2 orT3) can be preferred in cervical spine surgery by inserting the needle from caudal-to-cranial direction to achieve the desired LA spread and avoid technical difficulties and complications associated with cervical ESPB. Thoracic ESPB can provide multilevel analgesia even with the small volumes of LA due to rigid boundaries of the thoracic paravertebral spaces that facilitate drug spread at several levels involving ventral and dorsal rami. Lower thoracic level ESPB is mainly performed for lumbar spine surgeries by inserting the needle from cranial-to-caudal direction to achieve the desired LA spread and avoid technical difficulties associated with lumbar ESPB [49,50].

The lumbar ESPB can also be technically challenging due to the increased thickness of the ESMs with their tendinous attachment to the TPs [51, 52] and increased corresponding depth of the intermuscular plane in the lumbar region. The psoas muscle is also closely adherent to the vertebral bodies and the anterior surface of the TPs. The anterior drug spread to include ventral rami may be compromised due to the lack of clear boundaries of lumbar paravertebral spaces [53]. There is a communication through the fat-filled plane between the ESM and TP with the fat-filled psoas compartment containing lumbar nerve roots and plexuses. The spread of LA to the epidural space is possible through this communication [54]. The compressed lamina and the ligaments of the lumbar spine favor LA spread more into the epidural space [55, 56]. Thus, the lumbar ESPB may result in either lumbar plexus block or epidural anesthesia. The resultant weakness in the quadriceps or lower extremity muscles depends on the LA concentration and volume used in ESPB.

Sacral ESPB is mainly described for gender reassignment surgery or perineal surgery [57-61]. Its application for lower lumbar or sacral spine surgery is yet to be determined. The sacral multifidus plane block (SMPB), one of the variants of the paraspinal block, involves the deposition of LA in the plane under the multifidus muscle and bony area between the median and intermediate crests of the sacrum. The possible mechanism of action of SMPB includes blocking the dorsal rami and medial cluneal nerves directly by LA deposition and ventral rami by anterior LA spread through dorsal and ventral sacral foramina. The SMPB may also block the pudendal nerve (S2–S4), lumbosacral plexus, and sciatic nerve via the anterior and cranial LA spread [61, 62].

The role of LA

The possible role of the LA used in ESPB in causing postoperative neurological compromise depends on its inadvertent spread into either the epidural or subarachnoid space. It can be determined based on the occurrence and recovery pattern of the neurological symptoms. Distal-to-proximal and motor-before-sensory recovery patterns are the hallmarks of the differential blockade of the LA [23]. Inadvertent spread of LA into the subarachnoid space can lead to severe hypotension and bradycardia, resulting in unstable intraoperative hemodynamics. The consequences of the epidural spread depend on the density of LA around the spinal nerves, which could be compromised in a subsequent surgical dissection affecting the potentiality of the epidural space.

The concentration of LA, which determines the mass of the drug, also affects the efficacy of any block. The deliberate use of LA in low concentrations can result in a preferred motor-sparing analgesic effect of such high-volume blocks [63, 64]. Bupivacaine and ropivacaine are the most commonly used LAs for bilateral ESPB. Both LA agents consistently display preferential blockade of C-fibres (slow pain) > A-delta fibers (fast pain) > A-beta fibers (touch/pressure) in both preclinical and clinical studies [64-66]. With the increasing concentration, these agents may result in loss of proprioception and loss of motor function. Lipid solubility and higher pKa of LA facilitate intraneural diffusion and ion channel blockade. Ropivacaine exhibits a relative motor-sparing effect due to its lower lipid solubility than bupivacaine [67]. Twenty milliliters of 0.375% ropivacaine is recommended for each side of the bilateral ESPB in adults [68, 69].

Technical aspects of ESPB

Unexpected outcomes like a neurological compromise can be correlated with possible technical errors while administrating ESPB. The first technical aspect is identifying the correct landmark under ultrasound depending on the surgical extent and the desired level of the block. It may further depend on the sonoanatomy quality and the experience of the anesthetist. Sometimes misidentifying the lamina as the tip of the TP can lead to the retrolaminar block (RLB), another variant of the paraspinal block. In RLB, the needle insertion is slightly medial, targeting the lamina of the vertebra instead of the tip of the TP. It works via diffusion of LA into the paravertebral space through the soft tissue gaps between adjacent vertebrae [70]. Both RLB and ESPB were consistently associated with the posterior spread of injectate to the back muscles and fascial layers [37].

Fluoroscopic-guided ESPB can lead to RLB due to the inability to see the tip of TP clearly like under ultrasound, resulting in deposition of the LA solution over the lamina. The proximity of the RLB to the neuraxis can lead to a high probability of epidural spread, which carries the risk of motor weakness. The second important aspect is the ergonomics associated with bilateral ESPB. Administering the bilateral ESPB by standing on only one side of the patient may result in deviation from the ideal needle trajectory on one side compared to the other. Therefore, technical considerations should focus on stabilizing the needle by one person, injecting LA by another person, and performing such bilateral blocks while standing on either side.

The third important aspect includes technical modifications such as keeping an ultrasound probe in a transverse view to help differentiate intramuscular drug spread from the effective linear drug spread between ESM and TP [71]. The fourth aspect is finding alternatives that involve dorsal rami consistently without causing drug spread to other unwanted areas. The thoracolumbar interfacial plane block is one such alternative that targets only the dorsal rami of the spinal nerve. Thus, it can provide more focused dermatomal coverage of the back required for thoracic and lumbar spine surgeries [72, 73]. However, its efficacy in spine surgeries is yet to be determined. We have suggested some tips and tricks for using ESPB in spine surgeries (Table 2), keeping all technical aspects in mind.

Conclusion

Postoperative neurological impairment following spine surgery is a serious concern for the operating surgeon and the patient. The role of ESPB in causing such complications is the diagnosis of exclusion made after a thorough evaluation of clinical symptoms and radiological studies. For that, understanding of various mechanisms involved in ESPB leading to neurological impairment is essential. It should encourage the anesthetists to take extreme precautions while administering this novel block, considering the anatomical differences at various spine levels. Surgeons should anticipate and explain the possibility of neurological deterioration while explaining the risks and benefits of the proposed surgical intervention. Intraoperatively, real-time neurophysiological monitoring is recommended as a useful tool to avoid further neurological deterioration, especially in extensive and multilevel surgeries or in high-risk and neurologically compromised patients.

After identifying or diagnosing such complications, intensive care and regular checking of spinal function are of great importance, along with simultaneous radiological workups to rule out various causative factors. Once paralysis occurs, early diagnosis and early intervention are essential in restoring spinal function. Despite the rare possibility of such complications, ESPB is still a promising option for ensuring effective perioperative analgesia in spine surgeries. It helps reduce postoperative morbidity by keeping the hemodynamic parameters stable and significantly reducing intraoperative blood loss. It can also avoid postoperative complications that lead to delay in mobility and discharge by significantly reducing the need for opioids and polypharmacy. However, further studies are needed to determine the safe concentration and volume of the LA solution used in ESPB, the exact surgery-specific vertebral level to cover desired surgical innervations, and the accurate LA deposition site to prevent spread to undesired areas.

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#spine surgery #spinal cord injury #spine #Juniper Publishers #open access journals

[oxfordpublishers]

Journal of Cervical Spine Trauma and Spinal Cord Surgery published Case Reports in Cervical Spine, Case Reports in Spinal Cord Surgery, Journal of Spinal Surgery and Trauma, Cervical Spine Trauma Journal, Clinical Images in Spine Injury, Images of Spinal Cord Surgery etc. Cervical Spine: The cervical spine is made up of two anatomically and functionally different segments. 

Authors can submit their manuscripts through the journal's online submission portal and For more information on Oxford City Publishers - Cervical Spine Trauma Journal visit our site:-https://www.orthopaedicsurgeryjournal.org/event/Journal-of-Cervical-Spine-Trauma-and-Spinal-Cord-Surgery.html

#Spinal Cord Surgery Journal #Cervical Spine Trauma Journal #case reports in Spinal Cord Surgery #Spinal Cord Surgery case reports journal

[juniperpublisherscasestudies]

Holistic Approach for Intervention in Geriatric Male Patient with Parkinson’s Disease: A Case Study

Abstract

Parkinson’s disease (PD) occurs most often in the people in their 50’s and 60’s. Hypokinetic dysarthria has been reported to occur in 73% of the patients suffering from PD [1]. The disease is closely related to cognitive difficulties such as impaired attention, disorganized thinking, inefficient processing of abstract new/old information. Speech Language Pathologist’s (SLP) role in the intervention of individuals with PD is not limited to working upon speech impairment but also improving various cognitive functions. This case study reflects the importance of inter-professional collaboration between neurologist, SLP along with other professionals and training of caretaker which plays a crucial role in intervention of individual with Parkinson’s disease. Also, SLP’s focus upon cognitive linguistic deficits, augmentative communication method and communication enhancement strategies could result in achieving communication goals.

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#juniper publishers publons #Juniper Publishers in USA #Journal of Case Studies #rheumatology #transplant surgery #spine #vascular surgery #pharmacology

[astarab1aze]

➥ Runaway Mage

⸻Technical Information. // Face, Voice, etc.

01. Faceclaim. Yoru   [ Shishi no Odoriko ] & Personal or Comm'd art 04. Voice Claim. Miyavi, if he had noticeable vocal cord damage

⸻Profile Information. // Name, Age, etc.

01. Name. Kaede Shikabane   02. Alias. Shizuka, Kae   03. Sex. Male 04. Gender. Male   05. Age. 46   [ Dependent ] 06. Birth Date. October 31st   [ Balemagus ] 07. Blood Type. AB+ 08. Race. Half-Elfhen & Half-Feline, Zurine by nationality ; Yuureian by ethnicity. 09. Marital Status. Single   [ Multiship ] 10. Orientation. Bisexual   [ Biromantic / heavy male preference ] 11. Residence. He has no home, ever on the move, trying a little too hard to escape his own life in more ways than one. 

⸻Physical Information. // Body, Equipment, Family, etc.

17. Physical Description. Kaede’s hair is rather long and layered, so it tends to sit in a boyish, fly-away sort of way. It’s a dark violet shade - or, pretentiously, midnight - and incredibly soft to the touch. The lighter, floral blue of his eyes contrasts nicely with his hair. More often than not, he prefers to wear it down, as he feels the style compliments his overall appearance. His body is slim with some light toning and he stands at a rough 5'5", a little on the short side even for an elf. His skin is somewhat unusually pale, denoting a lack of sleep and improper nutrition. He wears a crimson jade hip ornament said to have healing properties, handed down in his family by patriarchal members. He has an abundance of barely-there freckles all over his body and both self-harm & combat scars, a large gash across his throat and quite a few on each of his thighs - and many more on his arms, front, and back; Also has a birthmark under his right buttcheek that looks something like a smeary bruise. There is a surgical scar on his right hip caused by a near-ruinous injury and the surgery that followed. On each pointed long-ear, his lobes are pierced, as well as two cuffs on his right ear. He has a natural pair of darkly spotted snow leopard ears and a long, fluffy tail as well as slit pupils, long canines, patches of dark fur along his spine and shoulders, and claw-like nails. Also x3, he has a phenomenal ass.

13. Equipment. He is effectively always ready for a fight, keeping a Yuureian silsaph katana and at least four knives of varying styles and lengths on his person at all times. He will also have various items kept in a limitless bag including Zurine medical tools, a journal, palmseal, singing stones, minor husbandry tools, some specific alchemical reagents, witchlights, a collection of both expired and current border passes, various international currencies, witchlights, and some other magical items and tools. 14. Occupation. Untethered sorcier with allegiance to no governing body on the continent ; He has chosen to never kill for a ruler or agency, as well as never to be a court mage, devoting himself to a life of drifting in order to escape his obligations. 15. Job Performance. Not Applicable 16. Parents. Juno Miris of Lakensov, Vago (deceased) and Kurai Shikabane of Chiisana, Yuurei (deceased) ; He doesn't much remember his mother and though he doesn't know it, she remains attached to him in spirit as a demonic presence - his father, however, he is glad to be rid of. 17. Siblings. Terin Shikabane (deceased) and Morrigan ( @elysiumtouched ) through seemingly tenuous relations, but they are in fact all half-brothers.

⸻Personality Information. // Likes, Strengths, etc.

18. Likes. Kirati dragon's breath, Myrrdinian chocolate oranges, specifically Yuureian tea, most animals, long moonlit walks, most international foods, taking naps, drawing, listening to local street music, dancing, men with light hair, singing, spending time with his lixni Muushi, Vagoan whisky, knives, flowers, black coffee, sharing snacks and drinks, ignoring Crimson-Talon letters, reading and researching, exploring old ruins, etc. 19. Dislikes. Inefficiency, most mushrooms, most sweet things, being forced to improvise, being flustered or confused, blood on his skin or staining his clothes, the sight of corpses, failure, imperfection, being responsible for other people’s lives, lack of control, being noticed, most nightfolk, most humans, all Wildlings, the undead, cottonmouth cakes, scarbuncle cheese, most other sorciers, most other elves, etc.

20. Positive Traits. Honest. Diligent. Loyal. Protective. Committed. Persistent. Strong willed. Hard-working. Thoughtful. Kind. Generous. Earnest. Firm. Loving. Prepared. Giving. Mostly merciful. Self-sacrificing. Open-minded. Accepting. Proud. 21. Negative Traits. Distrustful. Obstinate. Conflicted. Reckless. Guarded. Hard-headed. Hot-tempered. Bratty. Snobby. Self-loathing. Self-conscious. Reactive. Melancholic. Isolative. Impatient. A smidge obsessive. May get jealous. Envious. Naive. Prone to panic. 22. Goals. To try to find a way to beat the madness before it takes him. 23. Desires. Freedom from his grief, and forgiveness for the lives he couldn’t save or had to take, whether against his will or not; To love and be loved as though he were truly worthy of it. He’s tired of floating through life with nothing to show for it, and being hunted as a consequence. 24. Alignment. Neutral Good

25. Personality. Kaede has some difficulty forming relationships with other people and is generally very slow to start. Incidentally, this frees up a lot of his time, so he pours nearly all his focus into his work. He’s incredibly flawed in some aspects of his reasoning and decision-making, despite his intelligence, having assigned an arbitrary amount of blame to himself for past failures and horrific incidences, perceived or not. He’s the small and silent type, with a spoonful of emotional baggage and social ineptitude. Though he comes off as cold and formal at times, he has a mischievous streak and can be rather playful under the right conditions. He can also be sweet and somewhat boyish, though he’s mostly a bit bratty and hardheaded. He’s a sensitive soul at the end of the day, riddled with trauma responses and other behaviors resulting from years upon years of emotional, mental, and physical abuses - where the bulk of his trust and mental health issues stem from. He has vivid flashbacks about the massacres, nightmares too, and such will drag him back into an incosollable state of fear and misery. Although, he tends to hide, like a feline trying to lick their wounds in private.

⸻Sorcery Information. // Affinity, Talent, etc.

26. Affinity. Necrotic and Fire - high-level control, practiced and mastered well at the Zurine Mages' University. 27. Shapeshifting. Not applicable - he never cared much for transformation as a school of magic and wasn't born naturally capable of it in the first place. 28. Utility. Wards, curses, summoning, husbandry, and illusions - moderate.  29. Specialization. Lightning Magic, summoning, illusions, and some Bestial magic - highly skilled thanks to years of careful study, practice, and fine-tuned familial & cultural techniques handed down for generations. 30. Graduate School. Zurine Mages’ University - the only active school for mages on the pangea ; Extremely dedicated to quality, well-rounded education and therefore expensive, though they do offer scholarships based on potential ; Open to all magical folk, or those who can afford it ; Generally treated as a sort of haven for them. 31. Classification. Anthromorph, Runaway Mage ; Anthromorphs are a sub-type of shapeshifter or were whose human and primary animal forms are permanently apparent in some combination - they are equally as animal as they are ‘human’ in appearance and physiology. Kaede is somewhat different as he gets his animal parts from his elfhen side ; Runaway mages, or untethered sorciers (typically), are effectively deserters and thereby marked for capture and hollowing, which drains a mage of their magic and leaves them a weak, nearly-mindless husk of their former selves - there is a steeper cost to receiving an education at the University. 

⸻Background Information. // Past to Present. // Warnings for...death, arranged marriages, underage marriage, murder, cheating, very dysfunctional families, abuse, and other things that were kinda common in medieval times. There's a lot more to Kaede's story et all, but I've kinda beaten all the details to death.

    Kaede has really only ever known death and misery over the course of his life.

Born to miserable people - Juno of Clan Miris in Lakensov, a free spirit of a fledgling warrior, and Kurai of the Shikabane Clan out of Yuurei, an insecure, powerless man - in a miserable, atypical arranged marriage brought on by desperate need for saphluvium and pig-iron. Juno was young when she was promised to Zenchuu Shikabane, and at the time, Kurai was only a handful years older than her. The two were inseparable when they met, and Zenchuu, next in line as head of the Shikabane, thought nothing of it. Allowing Juno and Kurai to befriend one another - seemed only fair when considering how much older Zenchou was in reality (14 versus 349). But such was the way of things, to secure much needed resources.

Some Vagoans dedicate their lives entirely to monster hunting and extermination, curse breaking, escorting, smuggling, artisanship, among other related fields of work - they forge their weapons and tools with saphluvium, silver, and both proper and pig-iron. With local mines fast-depleting, the Miris Clan was losing grip on their trade, gradually becoming poorer and poorer. It came to a point they couldn't take care of the children anymore, so they arranged marriages, hoping to restore their clan through agreements, alliances, and, well, marriages. Insodoing with Juno, they were able to secure enough iron, silver, and saphluvium to get back on track and breathe some new life back into their clan and community - the hope, then, was that her new family would treat her well and care for her in the ways they couldn't at the time, though it took much longer than it seems, and she wasn't treated well.

The Shikabane are, in some ways, obsessed with death due to generational curses, malice, and genuine evil that'd taken root hundreds of years ago. For some time, they were isolatory, refusing to interact with anyone outside the clan. Naturally, predictable problems cropped up, problems that some were desperate to be rid of and others were only too happy to wallow in. Much of their history is buried, though accurate and detailed descriptions of what sins were committed by their number exist, if only in theory. Such that happened to Juno, whose betrayal of Zenchuu by having an affair with Kurai resulted in her murder a handful years later, when Kaede was small enough to perhaps not remember her later on in life...and the Madness that gripped Taisho, the head of the family before Zenchou, that caused him to slaughter so many.

The madness persisted, and it was soon found a host of demons had possessed certain members of the Shikabane hundreds of years before, biding their time, lying in wait, on top of the threat of ever encroaching insanity - the curse of the Mad Empress all elfhen are subject to. Worse still, it was found Taisho aimed to use Kaede in a blood ritual as a vessel to house the devils inhabiting his body at the time. Taisho violently killed as many people as he could, from the oldest members of the clan to some of the youngest, and far too many had died before he could be stopped by the likes of Kurai and the few who remained that weren't children.

From that day on, though the blame wasn't Kaede's to bear, he was treated as responsible for it all because he was mentioned by name in Taisho's journals, multiple times. Endless obsessive rants about stealing his body, smothering his soul, working his way up to clan head again, murder murder murder- Kaede was special after all. The only member of the family in hundreds of years capable of wielding not one, not two, but multiple forms of magic with a very unique proclivity toward lightning magic and illusions. Taisho killed so many just for a chance to take him and use him, so the remaining family associated Kaede with their loss, as the cause of it, the reason. More than that, however, was the fear Taisho's ritual had worked, and the simple fact Kaede was there where Taisho was dead.

So Kaede got the brunt of everyone's wrath, but especially Kurai's. All failure, every misstep, every stumble out of line was punished severely for years. Kurai would beat him, lock him up in a cell beneath the main house, isolate him through manipulation, shunning, setting too many expectations for him to follow, preventing him from ever leaving the estate. He was kept a prisoner in his own home, taumatized and without any support, forced to learn how to master certain family techniques until such a time came they decided to ship him off to Zuri with Aoi and Terin.

Terin died along the way, slaughtered by Wildlings on the border between Chimeria and western Vago. It wasn't Kaede's fault, but Aoi would see his failed plan as the cause regardless, but the truth was that the Wildlings were faster and armed with silsaph blades. They didn't stand a chance, not really, not ever. In the end, Terin knew this well and had already accepted his fate, thinking of his death before it came a sacrifice to see Kaede and Aoi get away. It would've been easier if Kaede'd been the one who died, however, for upon arrival in Zuri, Aoi informed the sorciers in Azura of Kaede's ineptitude - bitter and angry at Terin's passing. For the following ten years, he wasn't allowed to leave the University tower, at all, put on an effective house arrest until one day, they ended this punishment and gave him an ultimatum: Serve us willingly, or serve us in death.

Naturally, he took their offer - anything to be free, even if only for a little while. They were unwilling to allow his talents go to waste, no matter how he felt on the issue, and resolved themselves to use him exclusively to suit whatever ends they saw fit. Treating him in his beastly-elfhen form as expendable, only still breathing because he's useful to them, ostracized by all irrespective of him in his totality. And, for a time, he played along, intending fully to escape the minute he breathed his first breath of fresh air outside the tower.

When such opportunity arose, tasked with hunting down a runaway mage, he killed his companions in cold blood, burned the order, and ran. He's been running ever since.

#➥ Kaede. #♞ // Verse: Of Endless Suffering. #/ bleh #/ not happy about how i wrote the backstory so might rewrite it at a later date #/ servicable for now tho

[nelapanela94]

Your eyes are the first thing he sees when he wakes up every morning. And a smile that doesn't disguise everything you want to do to him. But before the first beams of daylight greet him, he lets your fingers read in braille each one of his scars, as if they were a story or a language on their own, telling an episode of his life that will always be part of him.

Over the years, the red had blenched, and the texture had smoothed out. But they will never go away completely.

Pain, anger, and shame. He eventually dropped them somewhere along the road, easing the journey; he learned to accept them and to accept himself.

“I don’t know how to help you Levi” Your voice was shaky, tears of helplessness drenched your cheeks. “All I can do is to give you a hug, if you let me.”

And there he learned that hugs are lifesavers.

In your arms he found refuge. In your chest he soaked in serenity. Until then you were nothing, and you became everything.

You stood by his side in every surgery, recovery and therapy. You celebrated every progress together. Baby steps. Like when he was able to roll out of bed and stump to the bathroom on his own.

Or his first walk after years of being in a wheelchair. You made it to the end of your street without the aid of the cane, but had to spend almost two hours in the café, drinking tea and sharing an almond croissant while the pain ebbed.

The next day, you went to the park for vanilla and lemon ice cream. You sat on a bench, saying everything to each other without words, barely exchanging timid glances. You'd been fighting together for years, watching each other's backs, him putting up with your outrageous laughter, and you pretending his shitty jokes were funny. Both thinking that love had forgotten about you. Rather, without realizing it, you had put it aside, for fear of ending up with a broken heart.

But that afternoon, your hands slowly found each other, groping their way across the bench until your little fingers crashed together, tangling to never let go.

Three months later, you were besieging his closet, planting your scent on his pillows.

And one Sunday at the farmer's market, you picked up a pair of silver rings that were 60% off. Amidst the nudging and bustle you made an altar, without priest, vows, but dozens of witnesses you exchanged the rings and continued your way to the cheese and jam stall.

Love doesn't need titles.

He stopped loathing your camera lens.

He became the protagonist of your shots; the first ones just smudges, black against his pallor without sharp edges when you were just learning how to freeze seconds.

Now you had albums and journals crammed on your shelves full of memories, of trips, maps and subway tickets, of adventurous kisses whose passports were stamped to the last page.

But your favorites were the ones of Levi sleeping.

Life has finally granted him the peace he deserved.

Flimsy snores sweep past his parted lips, hands tucked beneath the pillow. His chest rises and fall; disheveled strands point in every direction over his forehead. He’s lovely, and you need to capture it.

Stealthily, you slide off the bed, and tiptoe to the closet, dodging the spots where the wood creaks. Your fumbling hands open it, a chilled bead of sweat sears down your spine. Your eyes, from time to time, snap to the sleeping figure, and you plead is not too late for the perfect shot. You take the cap off and ventured back to the bed.

Today, Levi wakes up to a startling click. Instead of your eyes, the first thing he sees is the lens zooming out to him.

Twitching his eyes off, he slings an arm over his face, warding off from your attack.  

“No! You’re ruining my shots!” You grab his hand and take his arm out of the way.

“At least take the flash off!” He growls.

Surrounded by a cloud of giggles and squeals, you wrangle for the camera, but for a decisive second, you let your guard down, and he snatches it, stealing the control.

“C’mere.” He mutters. Winding an arm around, he draws you to his chest, and presses his lips on your head, and stays there until his finger finally finds the shutter-release.

Click. And click. And click.

He pushes again and nothing.

“What’s wrong?” His voice fans over your temple.

“We ran out of film.” You reach out for the camera and set it on the nightstand.

“I’ll buy more this afternoon.” He flings the covers over the two, trapping you in a cocoon. “Just let me sleep for now.”

“But–“

His arms tighten around you.

Now you have to hold your pee.

For Levi, that's what living is all about, not forgetting that one day it hurt, but also remembering that the sun continues to peek through every morning, in the form of a smile and beaming eyes.

#levi ackerman x reader #levi ackerman #attack on titan #aot #shingeki no kyojin #snk #levi attack on titan #snk levi #levi aot #levi x reader #levi x you #nela writes

[eccentricsubmissive]

Dear Followers

I have been thinking about starting a side blog to do most of my actual journaling on. Today I decided I would rather keep it all here. Why start a side blog or keep it all split? It is all part of me and who I am. As an OG tumblr users I want to stay the way I have always been. Transparent and open here. I am not just a kink blogger or adult blogger. I am a human with very real thoughts and feelings outside of the kink catagory. Why not just be me here and now and in the moment?

I have currently been struggling mentally and emotionally with my health and all that comes with it. It still angers me to feel like a year and half ago I really felt like I had found that place in life where everything is calm and you just sit back and marvel at how far you have come and then suddenly without warning you walk out your front door and your entire would changes. Yes, angry is a familiar feeling as of late.

June 30th 2022 I had emergency surgery to have my cervical spine fused and bone grafts placed. This is due to me having a very narrow spinal canal and my spinal fluid and blood flow to my brain was cut off. At this time I also learned that I have Rheumatoid arthritis, Osteoarthritis along with Degenerative disc disease, SLE Lupus, Sjogrens Syndrom. there are a list of other things that go along with all this but I will spare you the long version. I went from being the rock of the family who never stops to being told not to even lift things. All of this will progress and blah blah...Because of it all I am feeling alone and lonely. There are days I feel like I am watching everyone I love live life and I am counting down the days or wondering how many decent days I will have left in me. I no longer know where I fit in the kink world. I still feel submissive but also most days I am so angry I don't feel like I belong anywhere anymore.. Nothing at all seems fair.. Eccentric Submissive

#dear diary #word vomit #random thoughts #this is me #welcome to my world #SLE Lupus #rheumatoid arthritis #osteoarthritis #sjogrens syndrome #degenerative disc disease #spinal stenosis #Chronic Illness #auto immune disease #spinal fusion

[isonoe-kallichore-kirby]

The Smile Sad face killer

This is my first ever creepypasta OC. I made him when I was 8, so if the story is a little weird, that is way. Anyway,  I hope you like it <3

TW: identity crisis, demon, demon poisson, murder, blood, axe

Word count: 10,792

One fateful day, while sifting through dusty jars in an old lab, Lee unearthed a weathered leather journal. The book's spine cracked and its pages yellowed, but Lee couldn't resist its alluring aura. As he turned the fragile pages, he realized that this wasn't just any old journal; it belonged to the infamous Smile, Sad Face Killer. The handwriting within the pages was eerie and twisted, as if written by a different person entirely. As he began to read, Lee found himself drawn into the tortured mind of the killer, feeling an unsettling mix of revulsion and empathy.

"1/12/99. Everyone here is so nice to me; they didn't make fun of me. There's this guy; I don't know his name because he keeps looking me up and down. I think he likes me. Maybe I could... no, that's stupid. I'll just wait. Maybe he'll talk to me first." Lee's heart sank as he continued to read. The pages were filled with the twisted musings of a tortured soul, detailing the daily struggles and small victories of the Smile Sad Face Killer. He felt a strange sense of connection to this person, as if he were peering into the deepest, darkest corners of their minds. The more he read, the more he realized that the killer was just as much of a victim as their countless victims.

"2/3/99. They said I would get surgery to fix my face. But I don't have any problems with it, or at least I don't think I do. They say it's for my own good that I'll be more beautiful. But I don't want to be beautiful. I just want to be left alone." Lee's brow furrowed as he read these lines. The killer seemed to be struggling with their own identity, grappling with the idea of being "fixed" against their will. He felt a pang of empathy for this lost soul, trapped in a world where they didn't belong. The handwriting on the page grew more erratic, as if the emotions were becoming too much for the killer to contain.

"2/3/99. The guy who keeps looking me up and down said I would look better if I wore more 'revealing clothing' or something. I don't know what that means, but I think it's rude. I don't want to look better; I just want to be me. Why can't they understand that? It's like they all want to change me into something I'm not. Maybe that's why I'm like this. Maybe it's because they never accepted me for who I am. I wish I could just disappear, just fade away into nothingness." The pages continued to chronicle the killer's inner turmoil and their struggles with identity and self-acceptance amidst a world that seemed intent on changing them into someone they didn't want to be. Lee felt a deep sense of sadness well up within him as he read on, his heart aching for the lonely soul trapped within the twisted mind of the Smile Sad Face Killer. He could feel the weight of their suffering pressing down upon him, as if he were the only one who truly understood their pain.

"2/4/99. They fucking ripped off half of my face; they lied to me! I wish I was dead. I wish I never woke up from that dream. Why did they have to do this? I can't even look at myself in the mirror anymore. It hurts so much, and it's not like it's going to help. It's not like anyone's going to love me now. They all just want me to be pretty and perfect. Well, fuck them. I wish they could see what they've done. I wish they could feel this pain." Lee's stomach churned as he read these words. The despair and anger were palpable, almost tangible. He could feel the weight of the killer's suffering pressing down on him. It was as if he were living through this nightmare himself. The journal continued to detail the killer's descent into madness, chronicling their first kill and the twisted justifications they made for it. Lee couldn't help but feel a sense of horror and disbelief as he turned the pages, each new entry more chilling than the last.

"3/1/99. They gave me a mask to hide my face; it has half a smile and half a sad face. They said I would 'look better' and 'I look good in this' mask that hides me. I hate them, I hate this place, and I hate myself. But I don't want to die; I don't want to be alone. So I'll keep going, I'll keep smiling, and I'll keep killing. Maybe then they'll leave me alone; maybe then I'll finally be free." The pages of the journal grew increasingly stained with blood, the ink running like tears. The killer's handwriting became more and more erratic, reflecting the turmoil within their minds. They spoke of the pleasure they found in watching their victims suffer and the relief they felt when they finally took their last breath. The world around them became a blur of pain and confusion as they struggled to maintain their tenuous grip on sanity.

"6/23/99. They won't stop calling me Test 609; my name is Cabal! I can't take it anymore. The voices, the pain, the faces. They all blur together into one endless nightmare. I wish I could just sleep and never wake up. But no, they won't let me die. They keep me alive; they keep me suffering. Why? What have I done to deserve this?" The killer's thoughts spiraled out of control, their handwriting becoming more and more illegible. They spoke of their hatred for the doctors, the nurses, and the orderlies. They dreamt of escaping, of finding a way out of the labyrinthine hospital. But each time they tried, their weakened state made it impossible. They felt like caged animals, trapped in a world that didn't want them to exist.

"8/2/99. There is this demon, and he keeps telling me that if I let him in, he would end all my pain. I don't trust him, though; he makes me feel like if I let him use my body, he will kill people, and I won't be able to control my body." Lee flipped the page, his heart racing as he read the killer's inner turmoil. I can't sleep, and I can't eat. All I can do is think about them and how they look at me. I want them to suffer, just like I do. I want them to feel the pain that they put me through. I want them to know what it's like to be trapped in this body, in this prison."

"8/9/99. The demon keeps talking to me; I can hear it; it's in my dreams now; it won't let me sleep unless I let it in; it says if I let it in, it will end everything; it will end my pain; it will make them suffer for what they did; it will make everything better. I'm so tired; I just want to sleep, but the demon won't let me. It keeps whispering in my ear, and I can't ignore it anymore. I feel like I'm losing control, like I'm not in charge of my own body. It's so hard to think straight and to remember who I am and what they did to me. The demon is winning, and I don't know how much longer I can fight it." The journal entries became increasingly erratic after that date, with incoherent ramblings about the demon and its promises of revenge. Lee could feel the killer's sanity slipping away, their grip on reality growing more tenuous with each passing day. The entries became more violent, with the killer expressing a desire to hurt and kill everyone around them, not just their original victims.

"8/11/99. Who am I? What is my name any more? Is it Cabal or Coco? I don't know any more. The demon has a name; it's name is Darcy, and it tells me that it will help me and that it will make everything better. It says that we can work together and that we can make them suffer. It tells me that it will give me the strength to escape and find my way out of this nightmare. Sometimes, when I close my eyes, I can feel it inside me, whispering to me and guiding me. It feels so good to finally have someone on my side, someone who understands what I've been through. But at the same time, I'm scared. I'm scared of what it might make me do. I'm scared that I might lose myself completely. I wish there was someone who could help me—someone who could make it all stop. But there isn't. There's just me and Darcy, and the endless cycle of pain and suffering." Lee feels bad for the killer and for the desperate situation they're in. He wonders if there's anything he could do to help or make things better. But he knows that it's unlikely. The hospital is a fortress, and the killer is a prisoner, trapped in their own mind. There's no easy way out of this nightmare. 

"8/12/99. The demon is getting stronger; I can feel it. It's taking control more and more, pushing me towards things I know are wrong. It tells me that it will make everything better and that it will help me escape, but I can't shake the feeling that there's something else going on. Sometimes, when it's in control, I feel a cold, dark presence inside me. It's like there's another person living inside my skin, and they're not the person I want to be. I try to fight it, but it's hard. The demon is so powerful and seductive. It tells me that it loves me, that it will always be there for me, and that I don't have to be afraid anymore. But I am afraid. I'm afraid of what it will make me do and what will become of me if I let it win." The killer's desperation is palpable in their words. Lee can feel the weight of their suffering pressing down on him. He wishes there was something he could do to help, but he knows that the hospital is not a place for heroes. He continues to read, hoping to find some clue as to what might be going on inside the killer's head. 

"8/13/99. The demon is in control now. It's been hours, maybe even days. Time doesn't mean anything anymore. All that matters is the voice in my head and the whispers that tell me what to do. It's so strong and persuasive. It's like it knows every weakness I have, every fear, and every doubt. It uses them against me, twisting my thoughts and my feelings until I don't even recognize myself anymore. I can feel it changing me, turning me into something dark, cold, and unfeeling. I want to fight it, but I'm so tired. I just want the pain to stop, even if it means becoming something monstrous in the process." The killer's struggle becomes increasingly apparent as Lee reads on. The weight of the demon's influence grows heavier with each passing day, and the killer's grip on reality slips further away. Lee can feel the hopelessness and despair emanating from the pages, and it's a heavy burden to bear.

"8/14/99. Oh god, the blood is everywhere. What happened? I blacked out, and now there's blood on the walls and on my hands. I can't remember. What did I do? I can feel something inside me; it's like this thing—this thing that's not me—it's like it's alive, it's inside my head, and it's making me do things. I can hear it whispering, telling me that it'll make everything better and that it'll protect me from them. But I can't trust it; I can't trust myself. I just want this to stop. I want to go back to before, when I was just a normal person with a normal life. Who am I?"

#my writing #writers on tumblr #beginner writer #creepypasta #creepypasta oc #creepypasta story #tw demons #TW demon poisson #tw blo0d #TW blood #tw axe

[heyitssashag]

About This Blog:

Hey! I’m Sasha!

I originally started this “brain dump” to record my treatment through stage 4/metastatic breast cancer and my fractured neck rehab (due to bone mets). If you want to know more about my story, you can read all about it here. I also discuss chronic pain, fitness, running, mental health, books + the adventures of parenting an autistic teen.

📍From Canada’s West Coast.

Please know that I really appreciate you coming to check my blog out. I’m hoping some of it educates and brings awareness around living with metastatic breast cancer.

Note: My stream of consciousness tends to grow legs and run away so you may witness some of my “think out loud” moments here, too. 😜

I have over 400 posts with a few direct links below:

Click here for my very first post on May 3 2021

My second post

Radiation planning

Second radiation

Eighth radiation

Cancer Resources & Supports (*BC or Canada-Wide)

Low Neutrophils and Ideas to Raise Them (before labs)

Mental Health Resources (*BC or Canada-Wide)

A Message To: Newly Diagnosed Breast Cancer Patients 💕

Two Year Anniversary C-Spine Surgery Post

20 Journaling Prompts

An Evening of MBC Storytelling (my part is around the 37:30 mark)

My comedy set with Stand up for Mental Health.

#pinned intro #pinned post #metastatic breast cancer #breast cancer #cancer #mental health #canadian

[blenderchildren]

February 1st. National Serpent's day.

Surgery tomorrow after the snake bit me that I wrote about in a previous journal entry(3 or 4 days ago) on one of my pages, inducing my current stay at the hospital.

If I find it, I'll repost it after I eat lunch.

I don't read into this sort of subject as a bad thing from the artist or the divine.

Dragonlord - Lamia

First it feels like you're wearing a rubber suit, or made of elastic netting, trying to pull you down, gradually getting worse, until you lay down.

(The whole lay down to make the tension subside makes me think of some pecking order of weakest link in the chain of natural order, or of life-force ideal. i.e.-a life is born, so a life is removed from the cycle or specific tree of life)

I myself curled up with my knees to my chest. The snake bite was sort of like attaining nirvana. White serpent wrapped around my spine same as a cadeuces medical staff and curled around my neck and slowly worked its way up over the jawline, then covered my scalp like a stocking cap, then lifted out and then bit my neck and penetrated the base of my neck like a corkscrew to get inside. It then spread through the inside of my head and could not feel anything, as it washed over the back of my eyes, bright and blinding me. Then I felt a snap of a fiber strand on my neck. I had to tell myself to move my head and assess my body to make sure everything was still connected. I could not feel anything from head to toe. Once I could sit up, I called for paramedics. I was afraid to stand up because I didn't want to tear my inside body tissues, arteries, and veins, organs and nerve fibers that are affected by marfans.

That was last weekend. Today is Feb 1st, Serpent's Day. I go into surgery tomorrow. My stepmother's birthday is tomorrow.

I was moved to a different hospital between the time of my 911 call and my surgery a week later, and I don't remember anything during my stay there, with the exception of a kind nursing staff member who played a song on his ukulele for me. I also don't remember a thing about my transfer to another hospital or going into surgery, during that week.

#Youtube

[babyseraphim]

i am in so much pain. i am in so much pain all the time, and it never stops. there is no end. painkillers rarely help, physical therapy has very little effect, pain reduction surgery has made no difference.

i’m not suicidal. i don’t want to die, i love my life and i want to live it. but death feels like the only escape from this pain sometimes. i’m not even diagnosed with anything, its just been chalked up to having a defective body. i have a fused spine, but that doesn’t explain this. next month is the 8 year anniversary of being in unending, inexplicable pain. i don't even have a name for this pain that's stealing my life from me

tomorrow, i’ll cope. i’ll take my pet to the vet, clean my room, and write in my journal. i’ll be in so much pain, and i’ll make it work. but tonight, this is all i can think about

#chronic pain #spinal fusion #scoliosis

[neuroensurgery]

Address :

8929 Wilshire Blvd Ste #215

Beverly Hills, CA 90211

Phone : [phone]

Website : https://www.neuroendospine.surgery/

Dr. Rappard has been performing NeuroEndospine surgery since 2009. He is regarded as one of the leading NeuroEndospine surgeons in the United States.

Dr. Rappard regularly teaches NeuroEndospine surgery to physicians both new to and experienced in NeuroEndospine surgery. His state-of-the-art NeuroEndospine surgery facility in Beverly Hills is regarded as the best equipped and most advanced NeuroEndospine teaching and operating facility in the West Coast.

Like most masters in the field, Dr. Rappard not only teaches but regularly performs research in the area of spine surgery care. He is the author of multiple scientific publications and continuously presents original scientific research in the field.

Dr. Rappard serves internationally recognized scientific and professional medical societies by lending his expertise and experience. The Doctor reviews scientific evidence and helps to set procedure standards for the Spine Intervention Society (SIS). He trains doctors in NeuroEndospine surgery for the American Society of Interventional Pain Physicians (ASIPP). Dr. Rappard serves in patient safety, patient education and scientific reviewer roles for the North American Spine Society (NASS). He is a senior member of the Society of NeuroInterventional Surgery (SNIS) and is a scientific reviewer for the Journal of Neurointerventional Surgery, the official journal of SNIS. Dr Rappard is also a scientific reviewer for the Pain Medicine Journal, the official journal of the American Academy of Pain Medicine. Lastly, the Doctor has joined the editorial board of the Pain Physician Journal, the official journal of the American Society of Interventional Pain Physicians.

Dr. Rappard is a recognized medico-legal expert in NeuroEndospine surgery. He has testified in the courtroom on many occasions and remains highly regarded for his experience and his ability to educate jurors. Dr. Rappard also has a track record as an expert physician in cases leading to large settlements and judgements in patients requiring NeuroEndospine surgery for their injuries.

Dr. Rappard’s multi-disciplinary background makes him a unique asset in the field of NeuroEndospine surgery. As an expert in Neuroradiology, Dr. Rappard interprets his MRI’s personally. Dr. Rappard’s neurological examination of the patient was honed over years in providing Neurocritical Care and Neuroendovascular surgery to the most ill neurological patients. To pinpoint the patient’s source of pain, he relies on his experience in having performed thousands of diagnostic and interventional spinal injection procedures. Before taking up NeuroEndospine surgery, Dr. Rappard was already a nationally recognized expert in minimally invasive endovascular brain operations. He brings the same level of care and precision to his performance of NeuroEndospine surgery procedures.

Dr. Rappard is confident in his results because, unlike most surgeons, he tracks his results long-term. Patients are followed for a year after their procedures. Their conditions and pain scores are reported and analyzed objectively. Consequently, Dr. Rappard’s results are validated by many patients over many years.

Keywords: Neuro Endospine Surgery at Beverly Hills, CA. Health at Beverly Hills, CA.

Hour : Mon-Fri: 9am-6pm

Year : 2009

[ourhaileydavies]

Skin Closure with Barbed Sutures: An Early Evaluation of Cosmesis and Complications

Author By:  Vinay Kumar Tiwari

Abstract

Introduction: Barbed sutures have the potential advantage of decreased operative time and better wound cosmesis due to bidirectional fixation of wound. Present study evaluates the complications and scar cosmesis after skin closure with barbed sutures.

Material and Methods: This was a prospective, observational study. Patients underwent subcuticular skin suturing in surgically created clean wounds. Half of the wound closure was done with barbed absorbable suture and other half with non-barbed absorbable sutures. Comparison of scar cosmesis and wound complications was done.

Results: Mean time taken for suturing per cm of wound was lower in barbed suture group. Suture extrusion rate was higher in barbed suture group. No statistically significant difference was found between cosmesis of scar and rates of infection between the two groups.

Conclusion: The current study did not find any added advantage of using barbed sutures over and above conventional sutures in terms of cosmesis of scar. The only advantage was that of decreased operative time.

Keywords: Barbed sutures; Wound cosmesis; Operative time; Scar; Suture extrusion

Introduction

Barbed sutures have been in use since many decades. They provide effective wound closure due to bidirectional fixation within the wound. The presence of barbs leads to distribution of tension across the wound and also eliminates the need for knots. A barbed suture prevents backward slippage of the sutures, and as a result it does not gape in areas of tension allowing for an aesthetic subcuticular closure. Some clinical studies have shown a better resultant scar.

These sutures allow for a running closure of the wound, with fewer preliminary buried sutures leading to saving of one third to half of the time taken in suturing which can be their greatest benefit [1,2]. This study was done in Indian population where previously no such study has been reported. This study was done by using barbed and non-barbed suture in the same wound by dividing it into two halves thus removing all the confounding factors.

Material and Methods

This prospective, observational study includes 50 patients and was conducted from February 2018 to August 2019. Patients of all age groups were included in the study. The study population consisted of all the patients coming to plastic surgery department at our institute. All patients undergoing primary wound closure in a wound length of greater or equal to 5cm were included in the study. The study included patients with surgically created wounds and included simple surgical incisions and excisional wounds.

Patients with uncontrolled diabetes mellitus, collagen vascular disease, irradiated skin, immunodeficient states, past history of keloid formation, active cutaneous or systemic infection at the time of surgery, chronic renal or hepatic failure were excluded from the study. Preoperatively, patient’s wounds were marked, and dimensions were noted by using Vernier Callipers. Wound was divided into two equal halves and marked. Subcuticular continuous skin closure of one half of the wound was done by conventional polydioxanone sutures while the other half was sutured by barbed polydioxanone sutures. The wound closure was done by the same surgeon. Time taken for surgical closure was noted.

Post operatively various parameters were monitored to evaluate outcome and complications of patients. All patients were followed up for 2 weeks, 1 month, and 3 months after surgery and scar assessment was done by an independent and blinded observer. Scar cosmesis was compared by using POSAS and Vancouver scar scale. Width of the scar, time taken for surgical closure, median scar width and wound infection rates were compared. Wound infection was defined as wound erythema, tenderness or pus discharge from the wound.

Data was entered in Microsoft Excel spreadsheet. Statistical analysis was performed using SPSS (version 18.0). Categorical variables were summarized as frequencies and percentage. Continuous variables were presented as mean and standard deviation or median and inter quartile range based on the normality of data. Normality was assessed using Kolmogorov mirnov test. In case of non-normal or asymmetric distribution, non-parametric test was performed to assess statistical significance.

The following statistical tests were applied

(1) Quantitative variables were compared using Unpaired t-test/Mann-Whitney Test (when the data sets were not normally distributed) between the two groups.

(2) Qualitative variables were compared using Chi-Square test /Fisher’s exact test. A p value of <0.05 was considered to be statistically significant.

Results

A total of 50 patients were studied for a period of 18 months. There were 16 (32 %) women and 34 (68%) men. Maximum (54%) of patients were in the age group of 20-39 years (Table 1). The wounds involved head and neck in 7 patients, trunk in 23 patients, upper extremity in 5 patients, and lower extremity in 25 patients. The width of the scar was evaluated at 2 weeks, one month and 3 months post-operative period. Median scar width (in mm) was compared. Mann-whitney test was performed (Figure 1, 2 and 3).

There was no statistically significant difference in the width of the resultant scars between barbed and non-barbed sutures (Table 2). Time taken in suturing per cm of wound between barbed and nonbarbed suture groups was compared. In our study the time taken for barbed suture was less (23.38 seconds per cm of wound) than conventional absorbable sutures (25.16 seconds per cm of wound) and the difference was statistically significant with a p value of 0.001.

Comparison of Vancouver scar scorewas done at 2 weeks, one month and 2 months’ time period. The median scar score was higher for barbed sutures at one-month postoperative period. Mann-whitney test was performed and the difference was not statistically significant (Table 3). POSAS score (patient) was compared at 2 weeks, one month and 2 months’ time period (Figure 4, 5 and 6). Mann-whitney test was performed and the difference was not statistically significant. The median score was same for both the groups at 2 weeks follow up period. The score was higher for barbed suture group as compared with non-barbed suture group at 1 month and 3 months follow up period. But this difference was not statistically significant (Table 4).

POSAS score (observer) was compared at 2 weeks, one month and 2 months’ time period. The score was higher for barbed suture group as compared with non-barbed suture group at 2 weeks and 1 month follow up period. Mann-Whitney test was performed. The difference was not statistically significant (Table 5). Overall, no significant difference was found in wound cosmesis between barbed and nonbarbed suture group as evaluated by Vancouver scar scale and POSAS observer and patient scar scale. The wounds were evaluated for surgical site complications. Comparison of suture extrusion between groups was done.

In barbed suture group suture extrusion was seen in 9 cases over a period of 3 months. 7 cases were with wounds involving lower extremity and 2 patients with wounds in upper extremity. Only one case of suture extrusion was present in nonbarbed suture group which occurred in upper extremity. Chi square test was performed, p value was <0.01 and the difference was considered as statistically significant. Comparison of surgical site infection at two weeks, one month and 3 months’ time period was done. Chi square test was performed. Higher rate of infection was seen with barbed sutures but the difference was not statistically significant (Table 6).

Discussion

Scarring is an inevitable result of any surgery. Since time immemorial surgeons have been searching for techniques to reduce postoperative starring. Barbed sutures were introduced as tool to reduce scarring. The presence of barbs leads to better tissue fixation and lesser scarring. Theoretically barbed sutures lead to bidirectional fixation of wound which leads to lesser wound gaping and decreased width of resultant scar [1,2]. This was not seen in our study and there was no statistically significant difference in width of the resultant scars between the barbed and non- barbed suture groups.

Decreased width of scar leads to a better aesthetic outcome. A study by Koide et al displayed a significantly better aesthetic outcome in the barbed suture group than nonbarbed suture group [3]. But in our study, there was no statistically significant difference in scar cosmesis as compared by Vancouver scar scale and POSAS (observer and patient scar scale) between the barbed and the non-barbed suture groups. Our findings were similar to studies by Kristen Aliano et al, Amy P Murtha et al, Rubin et al and Grigoryants et al [4-7]. As our study evaluated the scar for only three months, a prolonged follow up is further required to evaluate the scar after remodelling. The time taken per cm of wound was evaluated for both barbed and non-barbed side.

In our study the time taken for barbed suture was less than conventional absorbable sutures and the difference was statistically significant. Similar results were seen in studies done by Koide et al, Kristen Aliano et al,Grigoryants et al, Jeremy P. Warner et al and Blacam et al [3,4,7-9]. Jandali et al, found that using barbed sutures reduced the operative time of unilateral breast reconstruction significantly, but no significant difference was seen in the operative time of bilateral breast reconstruction [10]. The only study showing increased operative time was that by Murtha et al, but the results were not statistically significant [5]. The decreased time taken in barbed suture group in our study is likely because there is no need to put a knot in barbed suture at the ends of the suture line. Also, the handling of suture is improved as the tissue gets fixed with each stitch with a barbed suture.

Our study evaluated the wound for surgical site infection. It was seen that barbed sutures were associated with a higher rate of surgical site infection, but the difference was not statistically significant. Overall, it was seen that the patients having lower extremity wounds had more surgical site infection. This may be due to a greater number of patients having wounds in lower extremity. Also, lower extremity skin is less lax hence wounds are usually closed under more tension leading to wound ischemia and more wound infection. Similar results were seen in studies done by Murtha et al, Jandali et al, where more infections were seen in barbed suture group, but it was not statistically significant [5,10].

Roberto Cortez et al, studied the complications associated with barbed sutures. Their retrospective study found that barbed sutures were associated with significantly higher rates of minor wound complications [11]. The increased incidence of infections in the barbed suture group may be due to the fact that the presence of barbs in the suture leads to colonization of bacteria and resultant higher rates of infection. In our study suture extrusion was seen in 9 out of 50 patients in the barbed suture site as compared to only one patient in the conventional sutures group. The difference was statistically significant. Suture extrusions or stitch abscesses were noted in a total of 10 patients, a probable consequence of the superficial placement of the sutures during subcuticular closure of dermal and subdermal layers.

Similar results were seen in a study done by Rubin et al, which showed increased suture extrusion on the barbed suture side than on the smooth suture side [6]. These findings were consistent with the findings of our study. In a study by Murtha et al, suture extrusion was seen in 10.2 percent of barbed suture subjects as compared with 19.7 percent control suture subjects [5]. The placement of sutures in our study was superficial dermal which might have led to the higher extrusion rate. Further study is warranted to evaluate the extrusion rate of sutures placed in deeper dermis. We used delayed absorbable sutures in our study which could also have contributed the higher rate of extrusion of sutures.

As Grigoryants et al, compared extrusion rate of slow absorbing and rapidly absorbing barbed sutures and found that rapidly absorbing barbed suture had lesser extrusion rate than delayed absorbing barbed sutures [7]. Overall, the complication rate was higher for the barbed suture group. These findings were in contradiction to a study done by Blacam et al, comparing abdominal closure with barbed and non-barbed sutures which found that the complications associated with barbed sutures were lesser. But the follow up period in this study was one month as compared to three months in our study which could have led to the difference in the findings [9].

Conclusion

Barbed sutures lead to decreased operative time but there was no advantage in terms of better scar cosmesis. Though there was an increased rate of surgical site infection barbed sutures, the difference was not statistically significant. The suture extrusion rate with barbed sutures was higher and the difference was statistically significant. Probably study over a larger sample size will give us a better picture. Barbed sutures are costlier than conventional sutures, but their use is less time consuming. So further studies in terms of cost analysis in relation to decreased operative time are warranted to fully evaluate the cost of using these sutures.

#spine surgery #Head and neck surgery #spine #Juniper Publishers #open access journals

[oxfordpublishers]

Journal of Cervical Spine Trauma and Spinal Cord Surgery published Case Reports in Cervical Spine, Case Reports in Spinal Cord Surgery, Journal of Spinal Surgery and Trauma, Cervical Spine Trauma Journal, Clinical Images in Spine Injury, Images of Spinal Cord Surgery etc. Cervical Spine: The cervical spine is made up of two anatomically and functionally different segments.

#Spinal Cord Surgery Journal #Cervical Spine Trauma Journal #case reports in Spinal Cord Surgery #Spinal Cord Surgery case reports journal

[unifiedcitationjournals]

Beyond Borders: Innovations in Gastroenterology

Introduction: Gastroenterology, the branch of medicine focused on the digestive system, has seen remarkable advancements in recent years. From diagnostic tools to treatment modalities, innovations in gastroenterology are transcending borders, both geographical and technological. In this blog post, we delve into the exciting developments that are shaping the field of gastroenterology and transforming patient care worldwide. Cancer. The mere mention of the word can send shivers down one's spine. It's a diagnosis that no one wants to hear, a disease that has touched the lives of millions around the world. But what exactly is cancer, and why does it hold such power over us? At its core, cancer is a group of diseases characterized by the uncontrolled growth and spread of abnormal cells in the body. These cells, which can originate from almost any tissue in the body, divide and proliferate rapidly, forming tumors that can invade nearby tissues and organs. Left unchecked, cancer can metastasize, spreading to distant parts of the body and compromising vital functions. The causes of cancer are complex and multifaceted, often involving a combination of genetic, environmental, and lifestyle factors. While some cancers have well-defined risk factors – such as smoking for lung cancer or excessive sun exposure for skin cancer – others arise seemingly without rhyme or reason. And while advances in our understanding of cancer biology have shed light on many of the underlying mechanisms driving the disease, there is still much to learn. But amid the complexity and uncertainty, there is hope. Thanks to decades of relentless research and innovation, our arsenal against cancer has never been stronger. From surgery and radiation therapy to chemotherapy and immunotherapy, there are now more treatment options available than ever before. And with the advent of precision medicine and targeted therapies, we are increasingly able to tailor treatments to the specific characteristics of an individual's cancer, maximizing efficacy while minimizing side effects. UCJournals provide a platform for , We cordially extend an invitation to researchers from all around the globe to submit their research work for publishing in our Global Journal Of Gastroenterology & Hepatology Research.

To know more, visit here: https://www.ucjournals.com/journals/global-journal-of-gastroenterology-hepatology-research/

Yet, for all the progress we've made, cancer remains a formidable adversary. It can be relentless and unforgiving, testing the limits of our physical and emotional resilience. The journey through cancer is often fraught with challenges – from the initial shock of diagnosis to the rigors of treatment and the uncertainty of what lies ahead. It's a rollercoaster ride of hope and despair, of triumphs and setbacks, with no clear end in sight. But amidst the darkness, there is light. Cancer has a way of bringing out the best in us – of uniting communities, rallying support, and inspiring acts of kindness and compassion. It's a reminder of the strength and resilience of the human spirit, of our capacity to endure, adapt, and overcome even the greatest of challenges. And it's a testament to the power of hope – the belief that no matter how bleak the prognosis may seem, there is always reason to hold onto hope. As we look to the future, the fight against cancer continues. It's a fight that requires collaboration, innovation, and unwavering commitment. It's a fight that transcends borders and ideologies, bringing together people from all walks of life in a shared mission to conquer this disease once and for all. So let us stand together, united in our resolve to defeat cancer. Let us support those who are fighting their own battles, offering comfort, encouragement, and above all, hope. And let us never lose sight of the fact that, in the face of adversity, the human spirit has the power to shine brightest. UCJournals provide a platform for , We cordially extend an invitation to researchers from all around the globe to submit their research work for publishing in our Global Journal Of Gastroenterology & Hepatology Research.

To know more, visit here: https://www.ucjournals.com/journals/global-journal-of-gastroenterology-hepatology-research/

Endoscopic Innovations: Endoscopy, a procedure that allows physicians to visualize the digestive tract using a thin, flexible tube with a camera, has undergone significant innovations. Beyond traditional endoscopes, advanced technologies such as capsule endoscopy and confocal laser endomicroscopy are revolutionizing diagnostic capabilities. Capsule endoscopy enables non-invasive imaging of the small intestine, providing valuable insights into conditions such as Crohn's disease and obscure gastrointestinal bleeding. Meanwhile, confocal laser endomicroscopy allows real-time microscopic examination of tissue during endoscopy, facilitating early detection of precancerous lesions and guiding targeted biopsies. Artificial Intelligence in Diagnosis: Artificial intelligence (AI) is making waves in gastroenterology by enhancing diagnostic accuracy and efficiency. AI-powered algorithms analyze medical imaging and pathology slides with unparalleled speed and precision, aiding in the detection of gastrointestinal conditions such as colorectal cancer and inflammatory bowel disease. By analyzing vast amounts of data and identifying subtle patterns, AI algorithms assist clinicians in making more informed decisions, leading to earlier detection and improved patient outcomes. Therapeutic Advancements: In addition to diagnostic innovations, gastroenterology has witnessed significant advancements in therapeutic interventions. Minimally invasive procedures such as endoscopic mucosal resection and endoscopic submucosal dissection allow for the removal of precancerous and early-stage gastrointestinal tumors without the need for surgery. Furthermore, advanced endoscopic techniques such as endoscopic ultrasound-guided therapy and endoscopic retrograde cholangiopancreatography (ERCP) enable the treatment of complex conditions such as pancreatic cancer and bile duct strictures with precision and minimal risk. Telemedicine and Remote Monitoring: The advent of telemedicine has expanded access to gastroenterological care, particularly in underserved regions and rural areas. Teleconsultations enable patients to connect with gastroenterologists remotely, facilitating timely evaluation and management of gastrointestinal symptoms. Moreover, remote monitoring technologies such as ingestible sensors and wearable devices allow for continuous monitoring of gastrointestinal function and disease activity, empowering patients to actively participate in their care and enabling healthcare providers to intervene proactively when necessary. Personalized Medicine: The era of personalized medicine is transforming the practice of gastroenterology, allowing for tailored treatment approaches based on individual patient characteristics and genetic profiles. Precision medicine initiatives leverage genomic data to identify genetic markers associated with gastrointestinal diseases, guiding treatment selection and predicting treatment response. By understanding the unique molecular signatures of each patient's condition, gastroenterologists can optimize therapeutic outcomes and minimize adverse effects, ushering in a new era of personalized gastroenterological care. UCJournals provide a platform for , We cordially extend an invitation to researchers from all around the globe to submit their research work for publishing in our Global Journal Of Gastroenterology & Hepatology Research.

To know more, visit here: https://www.ucjournals.com/journals/global-journal-of-gastroenterology-hepatology-research/

Conclusion: The field of gastroenterology is undergoing a period of unprecedented innovation, driven by advancements in technology, research, and clinical practice. From endoscopic innovations to artificial intelligence, telemedicine, and personalized medicine, the landscape of gastroenterological care is evolving rapidly, transcending borders and improving patient outcomes worldwide. As we continue to push the boundaries of what is possible, the future of gastroenterology holds promise for further advancements that will shape the way we diagnose, treat, and manage gastrointestinal diseases beyond borders.

[premierspinenj]

Pros and Cons of Disc Replacement Surgery

#neurosurgery center #orthopedic spine center #spine and orthopedic center #spine surgery center #neurosurgeon #neurosurgeon doctor #spine neurosurgeon

[forcedhellos]

Unlocking the Power of Chiropractic Care: Can a Chiropractor Really Help with Back Pain?

In the realm of alternative medicine, chiropractic care stands as a beacon of hope for those seeking relief from back pain. While mainstream treatments often involve medication or surgery, chiropractic therapy offers a non-invasive and holistic approach to addressing back issues. But the question lingers: Can a chiropractor truly alleviate back pain? Let's delve into the intricacies of chiropractic care and explore its efficacy in tackling this pervasive problem.

Understanding Chiropractic Care

Chiropractic care revolves around the principle that proper alignment of the spine facilitates the body's natural ability to heal itself. Chiropractors, through manual adjustments and manipulations, aim to correct misalignments, known as subluxations, in the spine. These adjustments not only relieve pain but also enhance overall well-being by restoring balance to the musculoskeletal system.

The Science Behind Chiropractic Treatment

Chiropractic adjustments target specific areas of the spine, aiming to restore mobility and alleviate pressure on nerves. Research suggests that these adjustments can trigger the release of endorphins, the body's natural painkillers, providing immediate relief from discomfort. Moreover, studies have shown that chiropractic care can improve spinal function and promote long-term healing.

Evaluating the Evidence

Numerous studies have examined the effectiveness of chiropractic care for back pain, yielding promising results. A meta-analysis published in the Journal of Manipulative and Physiological Therapeutics found that chiropractic adjustments were more effective than medication in reducing pain intensity. Additionally, patients who received chiropractic treatment reported higher satisfaction levels compared to those undergoing conventional therapies.

Benefits of Chiropractic Care

Non-invasive: Unlike surgery, chiropractic adjustments are non-invasive and carry minimal risks, making them a safer alternative for individuals with back pain.

Holistic Approach: Chiropractors assess the root cause of back pain, addressing not only symptoms but also underlying issues that contribute to discomfort.

Personalized Treatment: Each chiropractic session is tailored to the individual's unique needs, ensuring targeted and effective care.

Complementary Therapy: Chiropractic care can complement other treatments, such as physical therapy or exercise, enhancing overall recovery and rehabilitation.

Dispelling Common Misconceptions

Myth: Chiropractic Care is Painful

While some individuals may experience mild discomfort during adjustments, chiropractic care is generally gentle and well-tolerated. Many patients report feeling immediate relief following a session.

Myth: Chiropractors Only Treat Back Pain

While back pain is a primary focus of chiropractic care, chiropractors can address a wide range of musculoskeletal issues, including neck pain, headaches, and joint disorders.

Myth: Chiropractic Care is Not Supported by Science

Contrary to popular belief, numerous studies have demonstrated the effectiveness of chiropractic care for various musculoskeletal conditions. Research continues to evolve, further validating the benefits of this holistic approach to wellness.

Chiropractic care offers a promising solution for individuals struggling with back pain. By addressing spinal misalignments and promoting natural healing processes, chiropractors empower patients to reclaim their health and vitality. With its non-invasive nature, personalized approach, and evidence-based efficacy, chiropractic care stands as a beacon of hope for those seeking relief from back pain.

FAQs (Frequently Asked Questions)

Is Chiropractic Care Safe?

Yes, chiropractic care is considered safe when performed by a licensed and trained practitioner. It is important to communicate any concerns or medical conditions with your chiropractor to ensure a tailored and safe treatment plan.

How Many Chiropractic Sessions are Needed to Relieve Back Pain?

The number of chiropractic sessions required varies depending on the severity and underlying cause of the back pain. Some individuals may experience relief after just a few sessions, while others may require ongoing care for chronic conditions.

Can Chiropractic Care Prevent Future Episodes of Back Pain?

While chiropractic care can provide immediate relief from back pain, its long-term benefits extend beyond symptom management. By promoting spinal health and proper alignment, chiropractic adjustments may help prevent future episodes of back pain and enhance overall quality of life.

#chiropractic care #chiropractor #chiropractic treatment #family chiropractic