Backache

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  • Add axial cuts
  • Convert to 2 slides.Add pictures swayback,, roundback
  • Touregintertransverse fusion diagram operative diagrams for spondylolisthesis
  • Grades of praplegia add from tuli
  • Reduction, fuzzy margins
  • Backache

    1. 1. BACKACHE DR MANOJ KUMAR DIRECTOR PROFESSOR DEPT OF ORTHOPAEDICS MAMC,NEW DELHI
    2. 2. Mechanics of the Back • Vertebral column is pillar like structure supported in all directions by musculature, • Anteriorly – the recti and abdominal muscles • Posteriorly- erector spine and quadratus • If any of these supports give way, vertebral column will move to the other side, and most of the times its anterior musculature that gives way,
    3. 3. Homo Sapiens- we have erect spine, bearing weight of trunk against gravity. Rest of the vertebrates do not suffer backache
    4. 4. Causes Mechanical (affecting spine only) • Muscle strain • Osteoarthritis • Spinal stenosis • Discogenic • Spondylolisthesis • Vertebral fracture • congenital Non mechanical (systemic diseases) • Ankylosing spondylitis • Neoplasms • Infections( TB, Herpes, osteomyelitis) • Atherosclerosis • Visceral pain Biomechanical causes • Poor posture • Sedentary lifestyle • Poor furnitre Pyschological causes • Depression • stress ENDLESS PRACTICALLY
    5. 5. Causes of Low Back Ache • Prolapsed intervertebral disc • Spondylolisthesis • Lumbar canal stenosis • Tuberculosis • Tumors
    6. 6. Risk Factors • Occupational • Age • Alcohol and Drug Abuse • Family History • Gender • Level of Activity (Physical Fitness) • Obesity • Poor Posture and Alignment • Previous Back Injury • Psychological, Social and Spiritual Factors • Smoking - Studies have shown that smokers have a 1.5 to 2.5 times greater risk of developing low back pain than nonsmokers. It is thought this may be due to reduced oxygen supply to disks and decreased blood oxygen from the effects of nicotine on constriction of the arteries. • Sports • Other factors
    7. 7. Prolapsed Intervertebral Disc • It’s a hydrostatic load bearing structure from C2- C3 to L5-S1 • Nucleus pulposus + annulus fibrosus • Relatively avascular • L4-L5 disc, largest avascular structure in body • Cervical disc much less common.
    8. 8. PIVD-clinical featues • History of trivial trauma or lifting weight • Shooting pain with spasm • Pain radiating down the leg below the knee • Aggravated by coughing/sneezing • Usually sudden onset • May be associated with concurrent neurological deficit; sensory or motor, paresthesias. • H/O remissions and excerbations.
    9. 9. Cauda equina syndrome • Low back pain • Numbness in the groin or area of contact if sitting on a saddle (perineal or saddle paresthesia) • Bowel and bladder disturbances • Lower extremity muscle weakness and loss of sensations • Reduced or absent lower extremity reflexes
    10. 10. PIVD- Examination Posture, movements, tenderness
    11. 11. PIVD- Examination • Straight leg raising (Lasegue’s test)
    12. 12. PIVD- Examination • Kernig’s Test
    13. 13. PIVD- Investigations • Plain x-ray • Myelography • Ct- scan • MRI (preferred) • EMG
    14. 14. PIVD- Treatment • Conservative management rest, drugs, physiotherapy • Operative intervention – failure of conservative measures, cauda equina syndrome 1. Fenestration 2. laminectomy 3. hemi-laminectomy 4. laminotmy fenestration
    15. 15. Spondylolisthesis Bilateral defect in the pars interarticularis which causes forward displacement of vertebra
    16. 16. Spondylolisthesis
    17. 17. Spondylolisthesis- clinical features Symptoms • Vary from mild to severe. May even have no symptoms. • Classically a “STEP” may be palpable. • Can produce increased lordosis (also called swayback), but in later stages may result in kyphosis (roundback) as the upper spine falls off the lower spine. • Lower back pain, tenderness • Muscle tightness (tight hamstring muscle) • Pain, numbness, or tingling in the thighs and buttocks • Weakness in the legs
    18. 18. Palpable Step
    19. 19. Spondylolisthesis- investigations Scottish dog sign
    20. 20. Spondylolisthesis- Treatment • Conservative methods for grade 2 to 3 spondylolisthesis, including brace and analgesics • Spine flexion exercises • Failure of conservative and severe listhesis may require operative intervention- intertrasverse fusion or internal fixaton.
    21. 21. Intertransverse fusion Pedicle screw fixation
    22. 22. Lumbar Canal Stenosis • Due to the common occurrence of spinal degeneration that occurs with aging. • sometimes caused by spinal disc herniation, osteoporosis or a tumor. • In the cervical and lumbar region, can be a congenital condition to varying degrees.
    23. 23. Lumbar Canal Stenosis- features • Low back ache – dull aching nature • Weakness and tingling sensation in b/l lower limbs. • frequently unable to walk for long distances • symptoms improved when bending forward while walking with the support of a walker or shopping cart • Psuedo-claudication (neurogenic claudication) Bicycle test of van Gelderen
    24. 24. Claudication
    25. 25. Lumbar Canal Stenosis
    26. 26. Lumbar Canal Stenosis Axial cuts
    27. 27. Lumbar Canal Stenosis
    28. 28. Lumbar Canal Stenosis • Management mostly conservative on • Analgesics • Rest • Specific drugs like pregabalin and gabapentin • Epidural injections of steroid- cortisone • Surgery indicated- no response to conservative Laminectomy and stablisation
    29. 29. Midline decompresion
    30. 30. TB Spine- Pott’s Disease • Spine most common extrapulmonary site • Dorsolumbar region common • Paradiscal type most common
    31. 31. Types of TB spine Paradiscal central anterior posterior
    32. 32. TB Spine- Clinical features • Constitutional symptoms- night cries, low apetite • Commonest- backache • Vary from LBA to complete paraplegia. • Muscle spasm • Cold abscess • Deformity of spine- kyphosis • Upper motor neuron type Para paresis, brisk reflexes, clonus and increased tone.
    33. 33. Neurological complication • Early onset paraplegia-paraplegia in active phase of disease (generally within 2 yrs) • Pathology- • inflamatory edema • granulation tissue • abscess • caseous material • Late onset paraplegia-paraplegia many year after the disease (more than 2 years) • Pathology-debris,sequestra,internal gibbus,stenosis,deformity
    34. 34. Stages of paraplegia  Stage 1 (negligible)- Patient unaware Ankle clonus Plantar extensor  Stage 2 (mild)- Patient aware of deficit but manage to walk with support  Stage 3(moderate)- Nonambulatory Paralysis in extension Sensory loss less than 50 %  Stage 4(severe)- 3 + flexor spasms/paralysis in flexion/flaccid/sensory loss more than 50 % Bladder involvement
    35. 35. • Reduction of disc space • Fuzziness of margins
    36. 36. MRI Pictures
    37. 37. MRI Picture
    38. 38. TB Spine - Treatment • Conservative if no neurological deficit or improving deficit- ATT and bed rest, followed by ash brace • Indication for surgery- • Neurologic deficit – • Spinal deformity with instability or pain • No response to medical therapy • Continuing progression of kyphosis or instability • Large paraspinal abscess
    39. 39. Operative interventions • Costotransversectomy, anterolateral decompression
    40. 40. Anterolateral Decompression
    41. 41. Tumors • Most common tumors in spine- seconadaries • Primary spine tumors less common • Most common primary- multiple myeloma
    42. 42. Multiple myleoma
    43. 43. Secondaries
    44. 44. Metastasis MRI Imaging
    45. 45. Lesions in spine

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