Spinal and-spinal-cord284


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Spinal and-spinal-cord284

  1. 1. Spinal and spinal cord 外傷科主治醫師 Hsinglin
  2. 2. Low back pain and radiculopathy <ul><li>Imaging studies and further testing not helpful the first 4 weeks </li></ul><ul><li>Relief of discomfort with meds and spinal manipulation </li></ul><ul><li>Bed rest beyond 4 days may be more harmful </li></ul><ul><li>89-90% low back pain improve within 1 month </li></ul>
  3. 3. <ul><li>80% sciatica eventually recover </li></ul><ul><li>1% have nerve-root symptoms </li></ul><ul><li>1-3% have lumber disc herniation </li></ul><ul><li>85% no specific diagnosis made </li></ul>
  4. 4. definitions/classifications <ul><li>Radiculopathy : dysfunction of nerve root ( pain, sensory disturbances, weakness) </li></ul><ul><li>Mechanical low back pain : strain of paraspinal muscles, ligament, irritation of facet joints </li></ul>
  5. 5. Initial assessment of patient <ul><li>History : </li></ul><ul><ul><li>age, weight loss, cancer or infection, used of drug, during of S/S, trauma, cauda equina syndrome, work status </li></ul></ul><ul><li>PE : </li></ul><ul><ul><li>fever, vertebral tenderness, limited range of spinal cord </li></ul></ul><ul><ul><ul><li>Dorsiflexation of ankle and big toe – L5, 4 </li></ul></ul></ul><ul><ul><ul><li>Achilles reflex – S1 </li></ul></ul></ul><ul><ul><ul><li>Light touch </li></ul></ul></ul><ul><ul><ul><li>SLR text </li></ul></ul></ul>
  6. 6. Further evaluation of patients <ul><li>EMG : neuropathy, myopathy, myelopathy, unreliable < 3-4 weeks </li></ul><ul><li>SEPs (somatosensory evoked potential): spinal stenosis, or spinal myelopathy </li></ul><ul><li>NCVs (nerve conduction velocity): entrapment neuropathies that mimic radiculopathy </li></ul>
  7. 7. LS X-ray recommendation <ul><li>age >70yrs, or <20 yrs </li></ul><ul><li>systemically ill patients </li></ul><ul><li>temp. 38 °C </li></ul><ul><li>History of maligancy </li></ul><ul><li>Recent infection </li></ul><ul><li>Cauda equina syndrome </li></ul><ul><li>Heavy alcohol or drug abusers </li></ul><ul><li>DM </li></ul>
  8. 8. <ul><li>Immunosupressed patients (steroid) </li></ul><ul><li>Recent trauma </li></ul><ul><li>Recent urinary tract or spinal surgery </li></ul><ul><li>Unrelenting pain at rest </li></ul><ul><li>Persistent pain more than 4 weeks </li></ul><ul><li>Unexplained weight loss </li></ul>
  9. 9. Treatment <ul><li>Conservative treatment : </li></ul><ul><ul><li>1.activity modification: </li></ul></ul><ul><ul><ul><li>Bed rest : no more than 4 days </li></ul></ul></ul><ul><ul><ul><li>Activity modification : heavy lifting, total body vibration, asymmetric postures, sustained for long periods </li></ul></ul></ul><ul><ul><ul><li>Exercise : walking, bicycling, or swimming </li></ul></ul></ul>
  10. 10. <ul><li>2.analgesics : </li></ul><ul><ul><li>Panadol and NSAIDs </li></ul></ul><ul><ul><li>Opioids </li></ul></ul><ul><li>3.muscle relaxants : </li></ul><ul><ul><li>no effect </li></ul></ul><ul><li>4.education: </li></ul><ul><ul><li>condition will subside </li></ul></ul><ul><li>5.spinal manipulation therapy: </li></ul><ul><ul><li>acute low back pain without radiculopathy in 1 st month, not used in severe or progressive neurologic deficit </li></ul></ul>
  11. 11. <ul><ul><li>Epidural injection: no change in the need for surgery, short-term relief of radicular pain when control on oral medications is inadequate or not surgical candidates. </li></ul></ul>
  12. 12. Cauda equina syndrome <ul><li>Midline, most common at L4-5 </li></ul><ul><li>1.sphincter retension : </li></ul><ul><ul><li>A. urinary retension </li></ul></ul><ul><ul><li>B. Urinary and fecal incontinence </li></ul></ul><ul><ul><li>C. Anal sphincter tone </li></ul></ul><ul><li>2.saddle anesthesia </li></ul><ul><li>3.significant motor weakness </li></ul><ul><li>4.Low back pain and sciatica </li></ul><ul><li>5.Bilateral absence of achilles reflex </li></ul><ul><li>6.Sexual dysfunction </li></ul>
  13. 13. Surgical treatment <ul><li>Patients with <4-8 weeks </li></ul><ul><ul><li>A: urgent treatment (e.g. cauda equina syndrome, progressive neurologic deficit) </li></ul></ul><ul><ul><li>B: inability to control pain with medicine </li></ul></ul><ul><li>Patient with >4-8 weeks </li></ul><ul><ul><li>Severe and disabling and not improvement with time, correlated with findings on PH and PE. </li></ul></ul>
  14. 14. Type of surgery <ul><li>Lumbar spinal fusion : fracture/dislocation or instability resulting from tumor or infection </li></ul><ul><li>Instrumentation as an adjunct to fusion : increasing the fusion rate </li></ul><ul><li>Pedicle screw-rod fixation : utilize following laminectomy, shorter length of fixation segment, rigid fixation of all 3 columns </li></ul>
  15. 15. <ul><li>Posterior lumber interbody fusion : bilateral laminectomy and aggressive discetomy followed by bone grafts </li></ul>
  16. 16. Intervertebral disc herniation <ul><li>Lumbar disc herniation </li></ul><ul><ul><li>Posteriorly, one side, compressing a nerve root, severe radicular pain </li></ul></ul><ul><li>Characteristics findings : </li></ul><ul><ul><li>Symptoms start with back pain, days after weeks yeilds radicular pain with reduction of back pain </li></ul></ul><ul><ul><li>Pain relief upon flexing the knee and thigh </li></ul></ul><ul><ul><li>Position change </li></ul></ul>
  17. 17. <ul><ul><li>Bladder symptoms : difficulty voiding, straining, or urine retention </li></ul></ul><ul><ul><li>Exacerbation with coughing, sneezing, straining at the stool </li></ul></ul><ul><ul><ul><li>Radiculopathy : </li></ul></ul></ul><ul><ul><ul><li>A.pain radiating down LE </li></ul></ul></ul><ul><ul><ul><li>B.motor weakness </li></ul></ul></ul><ul><ul><ul><li>C.dermatomal sensory changes </li></ul></ul></ul><ul><ul><ul><li>D.reflex changes </li></ul></ul></ul>
  18. 18. <ul><li>Straight leg raising test : <60, L5 and S1 </li></ul>
  19. 19. <ul><li>Spondylosis : no-specific degenerative process of the spine </li></ul><ul><li>Spondylolisthesis : anterior subluxation of one vertebral body on another </li></ul><ul><ul><li>Grade 1-4 </li></ul></ul><ul><li>Spondylolysis : alternative term for isthmic spondylolisthesis </li></ul>
  20. 20. Spinal stenosis <ul><li>Narrowing of the AP dimension of spinal canal </li></ul><ul><li>In the lumbar region : neurogenic claudication </li></ul><ul><li>In the cervical region : myelopathy and ataxia </li></ul><ul><li>In the spinal region : rare </li></ul>
  21. 21. Spinal trauma <ul><li>Uncommon in children </li></ul><ul><li>The fatality rate is higher with pediatric spinal injuries than with adults (opposite to the situation with head injury) </li></ul>
  22. 22. <ul><li>Complete lesion : </li></ul><ul><ul><li>no preservation of any motor or sensory function more than 3 segments below the level of the injury </li></ul></ul><ul><ul><li>Persistence of complete spinal cord injury beyond 24 hours : no distal function will recover </li></ul></ul>
  23. 23. <ul><li>Incomplete lesion: </li></ul><ul><ul><li>Any residual motor or sensory function more than 3 segments below the level of the injury. </li></ul></ul><ul><ul><li>Signs of incomplete lesion : </li></ul></ul><ul><ul><ul><li>Sensation or voluntary movement in the Legs </li></ul></ul></ul><ul><ul><ul><li>Sacral sparing </li></ul></ul></ul><ul><ul><li>Central cord syndrome </li></ul></ul><ul><ul><li>Bown-Sequard syndrome </li></ul></ul><ul><ul><li>Anterior and posterior cord syndrome </li></ul></ul>
  24. 24. Spinal shock <ul><li>A. interruption of sympathetics </li></ul><ul><ul><li>1. Loss of vascular tone </li></ul></ul><ul><ul><li>2. Leaves parasympathetics causing bradycardia </li></ul></ul><ul><li>B. Loss of muscle tone result venous pooling </li></ul><ul><li>C. True hypovolemia </li></ul>
  25. 25. Initial management of spinal cord injury <ul><li>Cause of death : aspiration and shock </li></ul><ul><li>SCI : </li></ul><ul><ul><li>Significant trauma </li></ul></ul><ul><ul><li>Loss of consciousness </li></ul></ul><ul><ul><li>Minor trauma with spinal pain </li></ul></ul><ul><ul><li>Associated findings suggestive of SCI : </li></ul></ul><ul><ul><ul><li>Abdominal breathing </li></ul></ul></ul><ul><ul><ul><li>priapism </li></ul></ul></ul>
  26. 26. Management in the hospital <ul><li>1. Immobilization </li></ul><ul><li>Hypotension: maintain SBP>90mmhg </li></ul><ul><ul><li>Dopamine, careful hydration, atropine for bradycardia associated with hypotension </li></ul></ul><ul><li>Oxygenation </li></ul><ul><li>NG tube decompression </li></ul><ul><li>Indwelling foley </li></ul><ul><li>Temperature regulation </li></ul>
  27. 27. <ul><li>Electrolytes </li></ul><ul><li>Medical management specific to spinal cord injury : </li></ul><ul><ul><li>methylprednisolone : given with 8 hours of injury </li></ul></ul>