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tebrae is consistent with lumbosacral disc disease [Fig 11-3, (2) and (3)] Tenderness in this region and in the sacroiliac joints is also a frequent manifestation of ankylosing spondylitis Arthritic changes at a facet may cause the same tenderness Tenderness over the costovertebral angle often indicates genitourinary disease, adrenal disease, or an injury to the transverse process of the rst or second lumbar vertebra [Fig 11-3, (1)] Tenderness on palpation of the paraspinal muscles may signify a strain of muscle attachments or injury to the underlying transverse processes of the lumbar vertebrae Focal pain in the same parasagittal line along the thoracic spine points to in ammation of the costotransverse articulation between spine and rib (costotransversitis) In palpating the spinous processes, it is important to note any deviation in the lateral plane (this may be indicative of fracture or arthritis) or in the anteroposterior plane A step-off forward displacement of the spinous process and exaggerated lordosis are important clues to the presence of spondylolisthesis (see further on) Abdominal, rectal, and pelvic examinations are essential elements in the study of the patient with low back symptoms that fail to be clari ed by the aforementioned spinal maneuvers Neoplastic, in ammatory, or degenerative disorders may produce symptoms referred to the lower part of the spine

Osmolarity Sodium Potassium Calcium Magnesium Chloride Bicarbonate Carbon dioxide tension pH Nonprotein nitrogen Ammonia Uric acid Urea Creatinine Phosphorus Total lipid Total cholesterol Cholesterol esters Glucose Lactate Total protein Prealbumin Albumin Alpha1 globulin Alpha2 globulin Beta globulin (beta1 plus tau) Gamma globulin

A d-ary heap is identical to a binary heap, except that nodes have d children instead of just two This reduces the height of a tree with n elements to (log d n) = ((log n)/(log d)) Inserts are therefore speeded up by a factor of (log d) Deletemin operations, however, take a little longer, namely O(d log d n) (do you see why ) The array representation of a binary heap is easily extended to the d-ary case This time, node number j has parent (j 1)/d and children {(j 1)d + 2, , min{n, (j 1)d + d + 1}} (Exercise 416)

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295 mosmol/L 1380 meq/L 28 meq/L 21 meq/L 23 meq/L 119 meq/L 230 meq/L 48 mmHg 733 190 mg/dL 300 g/dL 024 mg/dL 47 mmol/L 11 mg/dL 16 mg/dL 15 mg/dL 04 mg/dL 03 mg/dL 60 mg/dL 16 meq/L 15 50 mg/dL 1 7% 49 73% 3 7% 6 13% 9 19% 3 12%

295 mosmol/L 1380 meq/L 41 meq/L 48 meq/L 19 meq/L 1010 meq/L 230 meq/L 38 mmHg (arterial) 741 (arterial) 270 mg/dL 700 g/dL 55 mg/dL 54 mmol/L 18 mg/dL 40 mg/dL 7500 mg/dL 1800 mg/dL 1260 mg/dL 900 mg/dL 10 meq/L 65 84 g/100 dL Trace 56% 4% 10% 12% 14%

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Figure 411 (a) A binary heap with 10 elements Only the key values are shown (b) (d) The intermediate bubble-up steps in inserting an element with key 7 (e) (g) The sift-down steps in a delete-min operation (a)

cules such as brinogen, IgM, and lipoproteins are mostly excluded from the CSF There are other notable differences between the protein fractions of CSF and plasma The CSF always contains a prealbumin fraction and the plasma does not Although derived from plasma, this fraction, for an unknown reason, concentrates in the CSF, and the level is greater in ventricular than in lumbar CSF (perhaps because of its concentration by choroidal cells) Also, the CSF beta2 or tau fraction (transferrin) is proportionally larger than that in the plasma and again higher in the ventricular than in the spinal uid The gamma globulin fraction in CSF is about 70 percent of that in serum At present only a few of these proteins are known to be associated with speci c diseases of the nervous system The most important is IgG, which may exceed 12 percent of the total CSF protein in diseases such as multiple sclerosis, neurosyphilis, subacute sclerosing panencephalitis, and other chronic viral meningoencephalitides The serum IgG is not correspondingly increased, which means that this immune globulin originates in (or is preferentially transported into) the nervous system However, an elevation of serum gamma globulin as occurs in cirrhosis, sarcoidosis, myxedema, and multiple myeloma will be accompanied by a rise in the CSF globulin Therefore, in patients with an elevated CSF gamma globulin, it is necessary to determine the electrophoretic pattern of the serum proteins as well Certain qualitative changes in the CSF immunoglobulin pattern, particularly the demonstration of several discrete (oligoclonal) bands and the ratio of IgG to total protein, are of special diagnostic importance in multiple sclerosis, as discussed in Chap 36 The albumin fraction of the CSF increases in a wide variety of central nervous system (CNS) and craniospinal nerve root diseases that increase the permeability of the blood-CSF barrier, but no speci c clinical correlations can be drawn Certain enzymes that originate in the brain, especially the brain-derived fraction of creatine kinase (CK-BB) but also enolase and neopterin, are found in the CSF after stroke or trauma and have been used as markers of brain damage in experimental work.

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