Spine

4,183 views

Published on

Common Orthopaedic Spinal Problems

Published in: Health & Medicine
1 Comment
10 Likes
Statistics
Notes
No Downloads
Views
Total views
4,183
On SlideShare
0
From Embeds
0
Number of Embeds
200
Actions
Shares
0
Downloads
0
Comments
1
Likes
10
Embeds 0
No embeds

No notes for slide

Spine

  1. 1. SPINE
  2. 2. Examination of Spine <ul><li>SYMPTOMS </li></ul><ul><li>Pain </li></ul><ul><li>Sciatica </li></ul><ul><li>Stiffness </li></ul><ul><li>Deformity </li></ul><ul><li>Numbness or paraesthesia </li></ul><ul><li>Urinary symptoms </li></ul><ul><li>Other </li></ul>
  3. 3. Examination of Spine <ul><li>Signs with the patient standing </li></ul><ul><li>Look </li></ul><ul><ul><li>Skin </li></ul></ul><ul><ul><li>Shape and posture </li></ul></ul><ul><li>Feel </li></ul><ul><ul><li>Tenderness </li></ul></ul><ul><li>Move </li></ul><ul><ul><li>Flexion / Extension </li></ul></ul><ul><ul><li>Rotation / Lateral flexion </li></ul></ul>
  4. 4. Examination of Spine <ul><li>Signs with patient lying face downwards </li></ul><ul><ul><li>Bony outlines </li></ul></ul><ul><ul><li>Tenderness </li></ul></ul><ul><ul><li>Sensations and Power </li></ul></ul><ul><ul><li>Femoral stretch test </li></ul></ul><ul><li>Signs with patient lying on his back </li></ul><ul><ul><li>Straight leg raising test (sciatic stretch) </li></ul></ul><ul><ul><li>Neurological examination of lower limbs </li></ul></ul><ul><ul><li>Circulation in the limbs </li></ul></ul><ul><ul><li>Rectal examination </li></ul></ul>
  5. 5. Cutaneous distribution of nerve roots
  6. 6. Muscle Power Testing (MRC Scale <ul><li>0 Total paralysis </li></ul><ul><li>1 Barely detectable contracture </li></ul><ul><li>2 Not enough to act against gravity </li></ul><ul><li>3 Strong enough to act against gravity </li></ul><ul><li>4 Still stronger but less than normal </li></ul><ul><li>5 Full power </li></ul>
  7. 7. Imaging <ul><li>Plain x-rays </li></ul><ul><ul><li>AP and lateral views </li></ul></ul><ul><ul><li>Oblique views </li></ul></ul><ul><ul><li>PA view of S.I. Joint </li></ul></ul><ul><li>Computed tomography (with mylography) </li></ul><ul><li>MR imaging </li></ul><ul><li>Radioisotope scanning </li></ul><ul><li>Discography and facet joint arthrography </li></ul>
  8. 8. Low back pain <ul><li>Lifetime incidence ranges from 60 -80% </li></ul><ul><li>Most cases resolve spontaneously </li></ul><ul><li>D/Dx: </li></ul><ul><ul><li>Simple back pain (non specific low back pain) </li></ul></ul><ul><ul><li>Nerve root pain </li></ul></ul><ul><ul><li>Possible serious spinal pathology </li></ul></ul>
  9. 9. Simple back pain <ul><li>Presentation 20 - 50 years </li></ul><ul><li>Lumbosacral, buttocks and thigh </li></ul><ul><li>“Mechanical” pain </li></ul><ul><li>Patient well </li></ul><ul><li>Specialist referral not required </li></ul>
  10. 10. Treatment for acute low back pain <ul><li>Vast majority improve within 2 months </li></ul><ul><li>Symptomatic Rx with Aspirin/NSAIDs </li></ul><ul><li>Bed rest should be limited to 1-2 days </li></ul><ul><li>? Corsets, TENS, Traction </li></ul><ul><li>Exercise - Stretching & range of motion active </li></ul>
  11. 11. Chronic low back pain <ul><li>Pain that persists after 3 months </li></ul><ul><li>< 5% of patients with L.B.P develop Ch.L.B.P </li></ul><ul><li>Multiple factors </li></ul><ul><ul><li>Disc, facet joints, annulus fibrosis, ligaments </li></ul></ul><ul><li>Psychosocial factors </li></ul><ul><li>Surgery is rarely helpful </li></ul><ul><li>Functional restoration programme </li></ul>
  12. 12. Acute disc prolapse <ul><li>Uncommon in very young and the very old </li></ul><ul><li>Nerve root pain follows the dermatome of the involved nerve </li></ul><ul><li>Pain is generally worse in the leg than in the back </li></ul><ul><li>Exacerbation of leg pain by straining, sneezing or coughing </li></ul><ul><li>Localised neurological signs </li></ul>
  13. 13. Cauda Equina Syndrome <ul><li>Large midline disc prolapse </li></ul><ul><li>Compresses several nerve roots </li></ul><ul><li>Sphincter disturbance </li></ul><ul><li>Saddle anaesthesia </li></ul><ul><li>Prompt surgical intervention </li></ul>
  14. 14. Treatment acute disc prolapse <ul><li>Conservative </li></ul><ul><ul><li>Bed rest for 48-72 hours </li></ul></ul><ul><ul><li>NSAIDs </li></ul></ul><ul><ul><li>Epidural steroids </li></ul></ul><ul><ul><li>85% relief rate </li></ul></ul><ul><li>Surgical treatment </li></ul><ul><ul><li>10-15% of patients ultimately require surgery </li></ul></ul><ul><ul><li>More rapid relief but the ultimate end point is the same regardless of treatment </li></ul></ul>
  15. 15. Spinal Stenosis <ul><li>Commonest cause of neurologic leg pain in older patients </li></ul><ul><li>Symptoms </li></ul><ul><li>Neurogenic claudication - Vascular claudication </li></ul><ul><li>Treatment </li></ul>
  16. 16. Red flags for possible serious spinal pathology <ul><li>Presentation under age 20 or onset over 55 </li></ul><ul><li>Thoracic pain </li></ul><ul><li>Past hx of carcinoma, steroids </li></ul><ul><li>Unwell, weight loss </li></ul><ul><li>Widespread neurology </li></ul><ul><li>Structural deformity </li></ul><ul><li>Abnormal blood parameters </li></ul>
  17. 17. Spondylolisthesis <ul><li>Forward slippage of one vertebral body on another </li></ul><ul><li>Causes </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Isthmic </li></ul></ul><ul><ul><li>Traumatic </li></ul></ul><ul><ul><li>Pathologic </li></ul></ul><ul><ul><li>Degenerative </li></ul></ul><ul><li>Treatment </li></ul>
  18. 18. Spondylolisthesis <ul><li>Forward slippage of one vertebral body on another </li></ul>
  19. 19. Spondylolysis Spondylolisthesis
  20. 20. Discitis
  21. 21. Spinal Deformity <ul><li>Deformity may occur in either coronal or sagittal plane </li></ul><ul><li>Scoliosis - Lateral curvature of the spine </li></ul><ul><ul><li>Structural </li></ul></ul><ul><ul><li>Nonstructural </li></ul></ul><ul><li>Kyphosis - Sagittal plane deformity in the thoracic or thoracolumbar spine </li></ul>
  22. 22. Scoliosis <ul><li>Idiopathic Scoliosis </li></ul><ul><li>80% of all scoliosis </li></ul><ul><li>Adolescent - age 10 or over </li></ul><ul><li>Juvenile - age 4 to 9 </li></ul><ul><li>Infantile - age 3 or under </li></ul>
  23. 23. Scoliosis - Cobb angle
  24. 24. Adolescent idiopathic scoliosis <ul><li>Structural scoliosis presenting at or about the onset of puberty and before maturity </li></ul><ul><li>80 % of cases of idiopathic scoliosis </li></ul><ul><li>Mostly (90%) in girls </li></ul><ul><li>Predictors of progression </li></ul><ul><li>very young age </li></ul><ul><li>marked curvature </li></ul><ul><li>Risser sign </li></ul>
  25. 25. Adolescent idiopathic scoliosis <ul><li>Treatment </li></ul><ul><li>Prevent a mild deformity from becoming severe </li></ul><ul><li>Correct an existing deformity </li></ul><ul><li>Nonsurgical treatment </li></ul><ul><li>Curves between 20-40 when spinal growth is incomplete </li></ul><ul><li>Curves > 30 (Risser 2 or less) even if no progression </li></ul><ul><li>Surgical treatment </li></ul><ul><li>Curves >40 in skeletally immature </li></ul><ul><li>Unbalanced curves between 20 - 40 in skeletally immature </li></ul><ul><li>Curves >50 </li></ul>
  26. 27. Congenital scoliosis <ul><li>Due to congenital anomalous vertebral development </li></ul><ul><li>Hemivertebrae </li></ul><ul><li>Wedged vertebrae </li></ul><ul><li>Fused vertebrae </li></ul><ul><li>Absent or fused ribs </li></ul><ul><li>Treatment </li></ul><ul><li>Early fusion in progressive curves </li></ul>
  27. 28. Congenital Hemivertebra
  28. 29. Neuromuscular scoliosis <ul><li>Causes </li></ul><ul><li>Poliomyelitis </li></ul><ul><li>Cerebral palsy </li></ul><ul><li>Syringomyelia </li></ul><ul><li>Friedrich’s ataxia </li></ul><ul><li>Muscular dystrophies </li></ul><ul><li>Typical paralytic curve is long, convex towards </li></ul><ul><li>the side with weaker muscles </li></ul>
  29. 30. Neuromuscular scoliosis <ul><li>Treatment </li></ul><ul><li>Mild curves No treatment </li></ul><ul><li>Moderate curves with spinal stability </li></ul><ul><li>As for idiopathic scoliosis </li></ul><ul><li>Severe curves Fitting a suitable sitting support </li></ul><ul><li>Surgical stabilization of the entire spinal segment </li></ul>
  30. 31. Kyphosis <ul><li>Postural (Round back) </li></ul><ul><li>Compensatory </li></ul><ul><li>Structural </li></ul>
  31. 32. Kyphosis <ul><li>Causes </li></ul><ul><li>Postural kyphosis Postradiation kyphosis </li></ul><ul><li>Scheuermann’s disease Metabolic disorders </li></ul><ul><li>Myelomeningocele Skeletal dysplasias </li></ul><ul><li>Traumatic kyphosis Tumourous conditions </li></ul><ul><li>Postsurgical Infections </li></ul>
  32. 33. Scheuermann’s disease <ul><li>Excessive thoracic kyphosis (Cobb angle >45° with wedging of 5° or more) of at least 3 adjacent apical vertebrae and vertebral end plate irregularities </li></ul><ul><li>Aetiology unknown </li></ul><ul><li>Incidence 1% of general population with slight female dominance </li></ul>
  33. 34. Scheuermann’s disease
  34. 35. Scheuermann’s disease <ul><li>Treatment </li></ul><ul><li>Orthotic treatment </li></ul><ul><li>Skeletally immature - Milwaukee brace (poor compliance) </li></ul><ul><li>Surgical (rare) </li></ul><ul><li>Severe deformity in skeletally mature </li></ul><ul><li>Severe deformity and neurologic signs </li></ul>

×