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Orthopedics 5th year, 4th lecture (Dr. Hamid)


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The lecture has been given on May 15th, 2011 by Dr. Hamid.

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Orthopedics 5th year, 4th lecture (Dr. Hamid)

  1. 1. Kyphosis:
  2. 2. Kyphosis : <ul><li>Mobile Postural &compnsatory kyphosis . </li></ul><ul><li>fixed -Structural kyphosis : </li></ul><ul><li>A kyphos or gibbus . </li></ul>
  3. 6. Thorax kyphosis
  4. 7. Types of kyphosis : <ul><li>Child hood-Congenital,osteogenesis imperfecta TB,dysplsia. </li></ul><ul><li>Adolescent kyphosis (Sheuermann’s dis. ) </li></ul><ul><li>Adult-trauma,TB.AS </li></ul><ul><li>Kyphosis in the elderly-degenerative and osteoporosis. 1-2 </li></ul>
  5. 8. Congenital kyphosis : <ul><li>Failure of formation “type1”. </li></ul><ul><li>Failure of segmentation “type 2” . </li></ul><ul><li>Combination of both . </li></ul><ul><li>treatment </li></ul>
  6. 9. Failure of segmentation. Left: block vertebra. Right: unilateral unsegmented bar .
  7. 10. Adolescent kyphosis (Sheuermann’s disease) : <ul><li>In the thoracic spine. </li></ul><ul><li>In the lumbar spine . </li></ul>
  8. 11. Clinical features : <ul><li>age. </li></ul><ul><li>gender. </li></ul><ul><li>Cl/p </li></ul><ul><li>deformity : </li></ul><ul><li>backache and fatigue. </li></ul>
  9. 12. Examination : <ul><li>Smooth thoracic kyphosis- marked hump. </li></ul><ul><li>lumber lordosis. </li></ul><ul><li>Fixed deformity. </li></ul><ul><li>Movement-hamstring </li></ul><ul><li>Mild scoliosis is not uncommon. </li></ul>
  10. 13. complications : <ul><li>Spastic paresis . </li></ul><ul><li>Cardiopulmonary dysfunction . </li></ul><ul><li>lumbar backache.strain,facet, lumber sherman’s,hyperextension of lumber spine </li></ul>
  11. 14. X-rays : <ul><li>Lat.view-end platesT6-T10 irregular . </li></ul><ul><li>body may become wedge shaped. </li></ul><ul><li>Schmorl’s node .. </li></ul><ul><li>Overall kyphosis >40 is abnormal.5wedge </li></ul><ul><li>Mild scoliosis is common </li></ul>
  12. 15. Lateral X-ray
  13. 16. Preoperative lateral of a patient with an 85° thoracic deformity secondary to Scheuermann kyphosis .
  14. 17. Postoperative lateral
  15. 18. (Sheuermann’s disease) :
  16. 19. Kyphosis measure :
  17. 20. DDx. : <ul><li>Postural kyphosis : </li></ul><ul><li>Discitis , osteomyelitis, &TB spondylitis: </li></ul><ul><li>Spondyloepiphyseal dysplasia: </li></ul>
  18. 21. Rx. : <ul><li>Back straightening exercises r indicated if curves < 40 degrees . </li></ul><ul><li>Bracing is indicated if curves 40-60 degrees in a child who still has some years of growth ahead . </li></ul><ul><li>Operative Rx. Is indicated for curves >60 degrees.60-75,>75 </li></ul>
  19. 22. Kyphosis in elderly <ul><li>A-degenerative-OA of facet </li></ul><ul><li>B-osteoporosis </li></ul><ul><li>-post menopausal </li></ul><ul><li>-senile-exclude mm.2ndary-symptomatic </li></ul>
  20. 24. The infected spine
  21. 25. Pyogenic spinal infections <ul><li>present acute or chronic </li></ul><ul><li>depends on : the age , the immune response,organism </li></ul><ul><li>most common by is Staphylococcus aureus </li></ul><ul><li>Escherichia coli, Proteus, and streptococcal, pseudomonas </li></ul>
  22. 26. Pathology <ul><li>Source;Direct spr stab,gunshot ,disc surgery </li></ul><ul><li>indirect -2nd septic focus - haematogenus, </li></ul><ul><li>Age, site -is in the lumbar, ,post,ant -multipl-usual. </li></ul><ul><li>Infection may track along tissue planes, and without early control will cause 2dary abscess </li></ul><ul><li>vertebral canal may be invaded by pus and granulation tissue either directly from the disk space or through the exit foramenae causing meningitis or myelitis.--recovery is uncommon </li></ul><ul><li>Retropulsion of bone ordisk causes- neural comp </li></ul><ul><li>destruction of vertebral body and disks causes local instability and deformity.- control, </li></ul>
  23. 27. Pridisposing factors <ul><li>• the elderly </li></ul><ul><li>• intravenous drug users </li></ul><ul><li>• immune deficiency slates including AIDS </li></ul><ul><li>• rheumatoid arthritis </li></ul><ul><li>• malignancy </li></ul><ul><li>• spinal fractures and paraplegia </li></ul><ul><li>• infective endocarditis </li></ul><ul><li>• renal failure </li></ul><ul><li>• sickle cell disease </li></ul><ul><li>• chronic alcoholics. </li></ul>
  24. 28. Clinical features <ul><li>Hx-hx of spinal procedure,pain, unusual site and exacerbated by move and percussion, asso muscle spasm </li></ul><ul><li>--Fever… a third of cases •tachycardia </li></ul><ul><li>Signs </li></ul><ul><li>.localized tenderness </li></ul><ul><li>• muscle spasm and limitation of movement </li></ul><ul><li>• local or distant fluctuant mass </li></ul><ul><li>• sinus formation </li></ul><ul><li>• occasional angular defect </li></ul><ul><li>Neurologic signs 15%-quadri,para,m-root def </li></ul>
  25. 29. Investigations <ul><li>ESR above 50 mm/h miror.response to treatment </li></ul><ul><li>C-reactive protein and alkaline phosphatase may be raised </li></ul><ul><li>white cell count is raised in less than half of cases. </li></ul><ul><li>Blood cultures when the patient is febrile are more reliable </li></ul><ul><li>Urine culture may be valuable if urethral manipulation is considered to be causative </li></ul><ul><li>ASO,brucella and salmonella </li></ul>
  26. 30. Imaging <ul><li>plain radiography …little value in early cases. </li></ul><ul><li>Disk-space narrowing and irregularity reactive new bone and occasionally paraspinal shadow. </li></ul><ul><li>Radiographic changes are progressive with time but may remain limited to the disk complex. </li></ul><ul><li>Plain radiographs are not very useful in assessing response to treatment. </li></ul>
  27. 31. <ul><li>loss of disc height, irregularity of the disc space , end-plate erosion and reactive sclerosis </li></ul>
  28. 32. Nuclear studies <ul><li>T99m bone scans can be positive as early as 2 days… high sensitivity (95 per cent …specificity (75 per cent) </li></ul><ul><li>Indium and gallium scans. </li></ul><ul><li>Show incresed activity </li></ul>
  29. 33. CT scanning <ul><li>CT scanning is useful for assessing the degree of bone destruction and examining the surrounding soft tissues. </li></ul><ul><li>guide for needle biopsy. </li></ul><ul><li>usually combined with MRI to evaluate the degree of cord compression </li></ul>
  30. 34. <ul><li>CT scan in a child with sickle cell disease reveals the infected site which had been missed at surgical exploration. </li></ul>
  31. 35. <ul><li>CT scan in a patient demonstrates extensive destruction of the vertebral endplate </li></ul>
  32. 36. <ul><li>needle in a biopsy of the infected disk space guided by CT scan </li></ul>
  33. 37. Myelography <ul><li>carries risks of spreading an infection and is rarely indicated nowadays </li></ul>
  34. 38. MRI scanning <ul><li>most important investigation </li></ul><ul><li>sensitivity of 96% </li></ul><ul><li>specificity …up to 95% </li></ul><ul><li>MRI shows the soft tissue well, including the neural components </li></ul><ul><li>defines abscess cavities precisely </li></ul>
  35. 39. <ul><li>extensive destruction of the endplates of the adjacent vertebral bodies </li></ul>
  36. 40. <ul><li>thoracic diskitis with an associated epidural abscess and spinal cord compression </li></ul>
  37. 41. <ul><li>typical vertebral destruction from Staph. aureus. There is clearly cord compression </li></ul>
  38. 42. Microbiology <ul><li>Pus from needle biopsy of the primary focus or from more distant abscess cavities is cultured. </li></ul><ul><li>Reports of 80 to 90% successful culture have been published </li></ul><ul><li>Blood and midstream urine cultures may prove to be useful </li></ul>
  39. 43. Differential diagnosis <ul><li>Infection Vs tumor. </li></ul><ul><li>Hematomas may mimic epidural infection. </li></ul>
  40. 44. Nonoperative treatment <ul><li>.indication; </li></ul><ul><li>When the diagnosis is certain, the organism is known,and there are no progressive neurologic features, </li></ul><ul><li>Bed rest and intravenous antibiotics may be required initially with the acute presentation, and this should be continued until pain reduces and a response can be confirmed. </li></ul><ul><li>The patient may then be mobilized in a brace and continue on oral antibiotics. </li></ul>
  41. 45. <ul><li>As a guide, intravenous antibiotics should be used for a period of 6 to 8 weeks followed by a similar period of treatment with oral antibiotics. </li></ul><ul><li>Serial ESR examination is usually of value and antibiotics should continue for a month after both symptoms and ESR have returned to normal. </li></ul><ul><li>Radiographic and MRI evaluation is useful, but there is a distinct lag-time before healing can be confirmed. </li></ul><ul><li>The risk of conservative management is failure to control disease. </li></ul>
  42. 46. Surgical management <ul><li>Indication; </li></ul><ul><li>failure of conservative treatment </li></ul><ul><li>the diagnosis and organism cannot be confirmed </li></ul><ul><li>neurologic deficit, particularly when there is epidural spread. </li></ul><ul><li>Mechanical instability. </li></ul>
  43. 47. <ul><li>The aims are: </li></ul><ul><li>to drain the abscess </li></ul><ul><li>make a definitive diagnosis </li></ul><ul><li>decompress the neural tissue, either root or cord. </li></ul><ul><li>to achieve stability and rapid healing of the lesion by bone grafting. </li></ul><ul><li>If the organism has been identified and the patient is on antibiotic cover, it is acceptable to graft primarily and to use metallic implants for stability. </li></ul><ul><li>Surgery…to the area of pathology. </li></ul><ul><li>In the debilitated patient it is possible to drain an abscess by the posterolateral approach. I </li></ul>
  44. 48. Granulomatous infections of the spine <ul><li>Granulomatous lesions </li></ul><ul><li>The most common TB and brucellosis, </li></ul><ul><li>but fungi can also be a cause. </li></ul>
  45. 49. Pathology <ul><li>Blood-borne infection usually settles in a vertebral body adjacent to the intervertebral disc. </li></ul><ul><li>Bone destruction and caseation follow… with spreading. </li></ul><ul><li>As the vertebral bodies collapse into each other, a sharp angulation (or kyphos) develops. </li></ul><ul><li>Caseation and cold abscess formation may extend to neighbouring vertebrae or escape into the paravertebral soft tissues. </li></ul><ul><li>There is a major risk of cord damage due to pressure by the abscess or displaced bone, or ischaemia from spinal artery thrombosis. </li></ul><ul><li>With healing, the vertebrae recalcify and bony fusion may occur between them. </li></ul>
  46. 51. Clinical features <ul><li>1-Hx---usually long history . </li></ul><ul><li>In some cases deformity is the dominant feature. </li></ul><ul><li>Occasionally with a cold abscess pointing in the groin </li></ul><ul><li>paraesthesia and weakness of the legs </li></ul><ul><li>2-Exam. </li></ul>
  47. 52. <ul><li>POTT'S PARAPLEGIA </li></ul><ul><li>Paraplegia is the most feared complication of spinal tuberculosis. </li></ul><ul><li>Early-onset paresis is due to pressure by an abscess, caseous material or a bony sequestrum. </li></ul><ul><li>The patient presents with lower limb weakness, upper motor neurone signs and sensory dysfunction, together with vertebral disease. </li></ul><ul><li>CT and MRI may reveal cord compression. </li></ul><ul><li>Late-onset paresis is due to increasing deformity, or reactivation of disease or vascular insufficiency of the cord. </li></ul>
  48. 56. X-ray <ul><li>The entire spine should be x-rayed, because vertebrae distant from the obvious site may also be affected. </li></ul><ul><li>The earliest signs of infection are local osteoporosis of two adjacent vertebrae and narrowing of the intervertebral disc space </li></ul><ul><li>Later an angular deformity of the spine. </li></ul><ul><li>Paraspinal soft-tissue shadows may be due either to oedema and swelling or to a paravertebral abscess…thoracic disease. </li></ul><ul><li>With healing paravertebral abscesses may calcify. </li></ul>
  49. 57. <ul><li>Early disease with loss of the disc space </li></ul>
  50. 60. Investigations <ul><li>The Mantoux test </li></ul><ul><li>ESR </li></ul><ul><li>Doubt... needle biopsy </li></ul>
  51. 61. Differential diagnosis <ul><li>pyogenic infection </li></ul><ul><li>malignant disease. </li></ul><ul><li>If the patient presents with paraplegia, other causes of cord compression have to be excluded. </li></ul>
  52. 62. Treatment <ul><li>The objectives are </li></ul><ul><li>(1) to eradicate or at least arrest the disease </li></ul><ul><li>(2) to prevent or correct deformity </li></ul><ul><li>(3) to prevent or treat the major complication - paraplegia. </li></ul>
  53. 63. <ul><li>Antituberculous chemotherapy is as effective as any other method (including surgical debridement) in stemming the disease. </li></ul><ul><li>conservative treatment alone carries the risk of progressive kyphosis if the infection is not quickly eradicated. </li></ul>
  54. 64. <ul><li>With modern anlituberculous drugs, a reasonable compromise would be as follows: </li></ul><ul><li>Ambulant chemotherapy alone is appropriate for early or limited disease with no abscess formation. Treatment is continued for 6-12 months, or until the x-ray shows resolution of the bone changes. Compliance is sometimes a problem. </li></ul>
  55. 65. <ul><li>Continuous bed rest and chemotherapy may be used for more advanced disease when the necessary skills and facilities for radical anterior spinal surgery are not available, or where the technical problems are too daunting (e.g. in lumbosacral tuberculosis) - provided there is no abscess that needs draining. </li></ul>
  56. 66. <ul><li>Operative treatment is indicated </li></ul><ul><li>(I) abscess that can readily be drained and </li></ul><ul><li>(2) for advanced disease with marked bone destruction </li></ul><ul><li>(3) threatened or actual severe kyphosis or paraparesis. </li></ul><ul><li>(4) instability </li></ul><ul><li>(5) sequestrae </li></ul><ul><li>Through an anterior approach, all infected and necrotic material is evacuated or excised and the gap is filled with rib grafts that act as a strut. </li></ul><ul><li>If several levels are involved, posterior fixation and fusion may be needed for additional stability. </li></ul><ul><li>Antituberculous chemotherapy is still necessary, of course </li></ul>
  57. 67. <ul><li>Thank you </li></ul>