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

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

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

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

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