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Orthopedics 5th year, 6th lecture (Dr. Hamid)
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Orthopedics 5th year, 6th lecture (Dr. Hamid)

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The lecture has been given on May 22nd, 2011 by Dr. Hamid.

The lecture has been given on May 22nd, 2011 by Dr. Hamid.


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  • 1. Prolapsed Intervertebral Discs
  • 2.  
  • 3. Pathology
    • 1-Chronic-Normal aging-disc degeneration-displacement of facet joint--2ndary effect-aquired SS
    • 2-Acute disc herneation-pain---Effects of pressure on the nerve root
    • -Compressive
    • -Deformation-str,& fun, changes
  • 4.  
  • 5.  
  • 6.  
  • 7.  
  • 8.
    • Clinical picture
  • 9. Clinical picture
  • 10. Imaging
    • X-ray
    • MRI
    • CT scans with or without myelography
    • -intolerant to MRI
    • -Unsuitable for MRI
    • gadolinium-enhanced MRI
    • This will help to delineate which part of the previous operation site is disc and which is epidural fibrosis (the latter enhancing).
  • 11.  
  • 12. DDX
    • Good general condition,mild N/D,-ve
    • Investigation,normalCSF,+veMRI,on.off,1-2 level, neither young nor old
    • DDX
    • -----Acute muscular&ST strain
    • ------inflammatory
    • ----Infection
    • -----Vertebral and nerve Tumor
  • 13. treatment
    • REST-
    • Reduce-traction
    • Remove
    • Rehablitate
  • 14. rest
    • First attack
    • • Any attack, early period
    • • 75 to 80% respond
    • • Principle – rest – 3wks
  • 15.
    • GENTLE MASSAGE
    • 􀂙 Helps to loosen tight muscles in spasm.
    • 􀂙 Psychological well being effect
  • 16.
    • BRACES & CORSETS
    • 􀂾 Helps to restrict movements
    • 􀂾 Sense of well being
    • 􀂾 Prevails tortional movements
    • Not to be used for more than 3 wks.
  • 17.
    • Anti inflammatory
    • Analgesics
    • Muscle relaxant
    • Small doses of diazepam to relieve apprehension
    • Medicines for constipation
  • 18.
    • PRECAUTIONS
    • 􀂉 Straining
    • 􀂉 Wt lifting
    • 􀂉 Jerky movements
    • 􀂉 Torsion of back
    • 􀂉 Forward flexion
  • 19.
    • EPIDURAL BLOCK
    • Very valuable
    • Immediate relief from pain
    • Should not have neurological deficit
    • SLR should be more than 45o
    • Should not have bilateral signs
  • 20. Indications for diskectomy
    • -Progressive Neurological deficit
    • Failure of conservative treatment-refractory
    • Significant motor deficit
    • Severe incapacitating pain - does not respond to any form of treatment
    • Cauda equina syndrome
  • 21. surgical treatment
    • -lamenectomy
    • --partial lamenectomy-fenstraion-tailor
    • -percutanous-
    • -endoscopic-spinoscope
    • --Microdisectomy
    • -LASER
    • ---disc replacement
  • 22.
    • PRINCIPLES OF SURGERY
    • Decompress the root
    • Prevent further extrusion
    • Avoid too much scarring
    • Minimum handling of muscles
    • Least excision of bone
    • Early mobilization
    • Early discharge
  • 23.
    • THE LAMINECTOMY
    • 􀂙 Today there is no indication to laminectomy
    • in PID
    • 􀂙 May create instability
    • 􀂙 Involves lot of scarring & morbidity
    • 􀂙 Cannot return to work early
    • 􀂙 Introduces restrictions on life
  • 24.
    • THE FENESTRATION
    • The approach is good and adequate
    • Unilateral exposure
    • Minimum damage
    • Ligamentum flavum removed
    • Contiguous margins of laminae
    • removed.
    • 2/3 upper lamina and 1/3 lower lamina
    • removed.
  • 25.
    • MICROLUMBAR DISCECTOMY
    • Best ,Short paramedian incision – less than one inch
    • Bone is not touched
    • The approach is through lateral half of lig.flavum.
    • Good illumination, magnificationVisualisation
    • Meticulous haemostasis
    • Same day mobilisation
    • Discharge within 24 hours
  • 26.  
  • 27. Complications
    • -mechanical intraop;
    • dural tear
    • nerve root injury
    • vascular injury
    • epidural haematomas.
  • 28.
    • -early postop
    • Superficial wound infections
    • Discitis
    • Haematoma
    • -late postop
    • Non-union
    • Instability
    • deformity
  • 29.  
  • 30.  
  • 31.  
  • 32. Persistent post operative back pain and sciatica
  • 33. Back Pain
  • 34.
    • 70-80% of population at least once
    • 13% of sickness absences
    • most common cause of work-related disability
    • most expensive cause of work-related disability
    • 7% chronic pain
    • Men= women
    • Most common between 30-50 yrs
    Epidemiology
  • 35. Risk Factors
    • Heavy lifting
    • Bodily vibration
    • Obesity
    • High risk occupations :miscellaneous labor, warehouse work, and nursing
  • 36. Aetiology Conginetal --Kyphoscoliosis --Spina bifida --Spondylolisthesis
  • 37. Acquired Traumatic Vertebral fractures Ligamentous injury Joint strains Muscle tears
  • 38. Infective Osteomyelitis-acute and chronic TB,Discitis
  • 39. Inflammatory Ankylosing spondyolitis Rheumatology disorders
  • 40. Neoplastic Primary tumors Secondary tumors
  • 41. Degenerative Osteoarthritis Spondylosis
  • 42. Metabolic Osteoporosis Osteomalacia
  • 43. Endocrine Cushing's -osteoporosis
  • 44. Idiopathic Paget's disease Scheuermann's disease
  • 45. Psychogenic Psychosomatic backache
  • 46. Visceral Penetrating peptic ulcer Carcinoma of the pancreas Carcinoma of the rectum
  • 47. Vascular Aortic aneurysm Acute aortic dissection
  • 48. Renal Carcinoma of the kidney Renal calculus Inflammatory kidney disease
  • 49. Gynaecological Uterine tumors Pelvic inflammatory disease Endometriosis
  • 50. Approach to diagnosis
    • -Transiet back ache following musc,activity
    • -sudden acute pain &scitica
    • -intermittent low back pain
    • --pain+claudication
    • -sever constant, localized pain
  • 51. THANK YOU THANK YOU