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Spinal and-spinal-cord284

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

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