This presentation is very beneficial for those who are in the field of prosthetics & orthotics. I have covered the basics of prosthetic foot, its mechanisms & its types. I have mentioned advanced prosthetic foot also. Hope this will help you all.
Case Review #47: 20 year old female with Adult Idiopathic ScoliosisRobert Pashman
A 20 year old female from Mexico presented with 58 degree lumbar scoliosis. She was diagnosed at age 14, and was not prescribed a TLSO brace. Dr. Pashman performed a posterior spinal fusion on the patient.
Case Review #12: Adult Scoliosis Revision Surgery due to FlatbackRobert Pashman
A 59 year old male presented status post scoliosis surgery using Cotrel-Duboussett instrumentation. The patient had Flatback Syndrome, low back pain, leg pain, and required revision surgery.
This presentation is very beneficial for those who are in the field of prosthetics & orthotics. I have covered the basics of prosthetic foot, its mechanisms & its types. I have mentioned advanced prosthetic foot also. Hope this will help you all.
Case Review #47: 20 year old female with Adult Idiopathic ScoliosisRobert Pashman
A 20 year old female from Mexico presented with 58 degree lumbar scoliosis. She was diagnosed at age 14, and was not prescribed a TLSO brace. Dr. Pashman performed a posterior spinal fusion on the patient.
Case Review #12: Adult Scoliosis Revision Surgery due to FlatbackRobert Pashman
A 59 year old male presented status post scoliosis surgery using Cotrel-Duboussett instrumentation. The patient had Flatback Syndrome, low back pain, leg pain, and required revision surgery.
Case Review #27: 59 Year Old Female with Progressive Adult ScoliosisRobert Pashman
59 year old female presented with Progressive Adult Idiopathic Scoliosis, Spondylolisthesis, Flatback Deformity, and Stenosis. The patient was treated with a spinal fusion,
Case Review #2: 41 year old female presented with Adult Scoliosis and Spodylo...Robert Pashman
A 41 year old female with a 50° thoracolumbar curve and Spondylolisthesis. Dr. Pashman treated the patient with an Posterior Spinal Fusion from T10-Pelvis. Her curve was a KIM/SRP Classification 2.
Case Review 15: Adult Scoliosis treated with Spinal Fusion and OteotomiesRobert Pashman
A 50 year old female presented with progressive Adult Idiopathic Scoliosis. The patient had severe low back pain and leg pain. She was treated with a posterior spinal fusion with spinal osteotomies.
Research for Medical Students: Luxury or Necessity?Sohail Bajammal
An invited keynote speech, delivered on April 22, 2014 at the 4th Medical Students Research Symposium, Faculty of Medicine ay King Fahd Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
It argues the necessity of research methodology teaching in medical schools.
Case Review #5: 43 year old woman with Adult Idiopathic ScoliosisRobert Pashman
A 43 year old woman, presented with Adult Idiopathic Scoliosis, 50° lumbar curve. Dr. Pashman treated her with Posterior Spinal Fusion from T9 - L5. Curve was a KIM/SRP Classification 2.
Case Review #9: Adult Idiopathic Scoliosis with a Double CurvatureRobert Pashman
A 54 year old female presented with Adult Idiopathic Scoliosis. In addition to lower back pain, she noticed that her height was decreasing. Her spine was significantly rotated and she required a spinal fusion.
Case Review #6: 53 year old woman with Adult ScoliosisRobert Pashman
A 53 year old woman, with an 85° thoracic curve, and a 75° lumbar curve. Dr. Pashman treated her with an Anterior fusion followed by a Posterior Spinal Fusion from T1 to the Pelvis. Curve was a KIM/SRP Classification 3.
Case Review #25: 39 year old female with Progressive Adult ScoliosisRobert Pashman
39 year old female presented with Progressive Adult Idiopathic Scoliosis. Dr. Pashman treated the patient with a posterior spinal fusion from T3-L4. KIM/SRP Classification 1
Case Review #53: 58 year old female with Adult Scoliosis and low back painRobert Pashman
A 58 year old female presented with severe, progressive, Lumbar Scoliosis. The patient failed conservative therapy and had unrelenting leg pain. She was treated with a posterior spinal fusion from T11-pelvis.
Case Presentation#56: Adult Idiopathic ScoliosisRobert Pashman
A 28 year old female with progressive Adult Idiopathic Scoliosis postponed surgery from age 17 to 28. The patient failed conservative therapy and decided to have surgery due to pain and curve progression.
Case Review #29: 57 year old female with Adult Thorcolumber ScoliosisRobert Pashman
57 year old female with Adult Idiopathic Scoliosis. She presented with a 62 degree thoracolumbar curve. Dr. Pashman treated the patient with a posterior spinal fusion from T10-Pelvis. Dr. Pashman took great care with incision closure to preserve the patient's tattoo. KIM/SRP Classification 2.
Diffuse idiopathic skeletal hyperostosis (DISH) is a common skeletal process of uncertain etiology found in 12 to 18% of Indian populations above 50 years. The primary manifestations of DISH are calcification and ossification of the spinal ligaments, as well as entheseal ossification within extraspinal sites
In this presentation, we review the current evidence of scaphoid fracture non union based on a book review of the current evidence. Options such as vascularized vs traditional bone grafting are discussed
Avascular necrosis of Hip - treatment modalities and current concepts.pptxVivek Jadawala
Slide 1 - Treatment modalities of Avascular Necrosis of Hip
JOURNAL CLUB PRESENTATION
Dr. Vivek Jadawala
PGY-3, Dept. of Orthopaedics,
JNMC, DMIHER
Slide 2 - image
slide 3 - image
slide 4 - Osteonecrosis of Hip - Osteonecrosis is death of living elements of involved bone (cells including marrow) with progressive destruction and alteration of bone architecture as a result of compromised vascularity.
Usually aseptic but may be incited by loss of vascularity from infection.
Slide 5 - Epidemiology - Male > Female
Average age group – 35 to 50 years
Bilateral Hip joints – 80 % of the cases
Most common site – Antero-lateral aspect of femoral head
Slide 6 - Blood supply of femoral head
Slide 7 - Classification of AVN: Ficat and Arlet -STAGE 0 :
X-ray : normal
MRI: normal
clinical symptoms: nil
STAGE I :
X-ray : normal or minor osteopenia
MRI: edema
bone scan: increased uptake
clinical symptoms: pain typically in the groin
Slide 8 - Stage I
Slide 9 - Stage II -
X-ray: mixed osteopenia and/or sclerosis and/or subchondral cysts, without any subchondral lucency (crescent sign)
MRI: geographic defect
Bone scan: increased uptake
clinical symptoms: pain and stiffness
Slide 10 - Stage III - X-ray: Crescent sign and eventual cortical collapse
MRI: same as plain radiograph
clinical symptoms: pain and stiffness +/- radiation to knee and limp
Slide 11 - Stage IV - X-ray: end-stage with evidence of secondary degenerative change
MRI: same as plain radiograph
clinical symptoms: pain and limp
Slide 12 - Stage IV
Slide 13 - image
Slide 14 - Steinberg staging of AVN
Slide 15 - Steinberg staging - STAGE 0:
- normal or non-diagnostic radiographs, MRI and bone scan of at risk hip (often contralateral hip involved, or patient has risk factors and hip pain)
STAGE I:
normal radiograph, abnormal bone scan and/or MRI
STAGE II:
- cystic and sclerotic radiographic changes
STAGE I AND II
A, mild: <15% head involvement as seen on radiograph or MRI
B, moderate: 15% to 30%
C, severe: >30%
Slide 16 - STAGE III:
- subchondral lucency or crescent sign
A, mild: subchondral collapse (crescent) beneath <15% of articular surface
B, moderate: crescent beneath 15% to 30%
C, severe: crescent beneath >30%
STAGE IV:
flattening of femoral head, with depression graded into
A, mild: <15% of surface has collapsed and depression is <2 mm
B, moderate: 15% to 30% collapsed or 2-4 mm depression
C, severe: >30% collapsed or >4 mm depression
Slide 17 - STAGE V:
- joint space narrowing with or without acetabular involvement
STAGE VI:
- advanced degenerative changes
Slide 18 - Association Research Circulation Osseous classification
Slide 19 - image
Slide 20 - Kerboul angle - Original classification was proposed on radiographs where he divided the necrotic region into small, medium and large regions:
Small - less than or equal to 160°
Medium - 161 to 199°
Large - 200 or more degrees.
Slide 21 - Modified Kerboul angle - based on MRI has much higher values as the MRI overestimates the necrotic region
Diagrammatic Summary of Research Methodology, Ethics & StatisticsSohail Bajammal
A diagrammatic summary of three presentations given for the UQU Medical Research Club "Your Journey Towards Research: Writing Research Proposal" held at King Abdullah Medical City, Makkah. May 17, 2012.
Presentations summarized include:
1. Research Methodology
2. Research Ethics
3. Statistics
A presentation on important research methodology concepts for research proposals. Given for the UQU Medical Research Club "Your Journey Towards Research" held at King Abdullah Medical City, Makkah. May 17, 2012
A brief presentation on important research ethical concepts for research proposals. Given for the UQU Medical Research Club "Your Journey Towards Research" held at King Abdullah Medical City, Makka
UQUMRC KAMC Biostatistics for your Research Proposal 2012Sohail Bajammal
A brief presentation on important statistics concepts for research proposals. Given for the UQU Medical Research Club "Your Journey Towards Research" held at King Abdullah Medical City, Makkah. May 17, 2012
http://uqu2020.com
A virtual brainstorming on Twitter using the hashtag #uqu2020 with UQU staff and students on how to make UQU a better university in 2020.
The Consultant Experience in Saudi Arabia. A presentation given at:
“Research by Medical Trainees: Current Status and Future Planning Workshop”
King Faisal Specialist Hospital & Research Center – Riyadh in collaboration withSaudi Commission for Health Specialties
June 14-15, 2011
Evidence-based Back Pain Management (EBM in general)Sohail Bajammal
A generic introductory presentation on using evidence-based medicine (EBM) principles to answer clinical questions. Back pain was used as an example to introduce the concept. The presentation does not address the treatment of back pain. The presentation was given in May 2010.
A comprehensive presentation on the epidemiology, pathophysiology, clinical presentation, decision making and treatment options of spinal metastases. Supported with the best available evidence as of October 6, 2008
2. Adult Scoliosis
• Terminology
• Incidence & Prevalence
• Pathophysiology
P th h i l
• Clinical presentation
• Evaluation
• Treatment strategy and controversies
• Complications
3. Terminology
• Scoliosis (>10º) in an adult patient:
(>10 )
– Pre-existing from adolescence:
• Idiopathic: most common
• Less common: congenital or paralytic
– De novo:
• Degenerative: most common
• Less common: osteoporosis, iatrogenic
4. SRS Classification
Lowe et al. The SRS Classification for Adult Spinal Deformity. Spine 2006;
31:S119–S125
5. Incidence
• Kobayashi et al 2006:
– Community volunteers
– 60 subjects aged 50 84 years
50-84
– Followed 12 years
– Scoliosis developed in 22 subjects (37%)
– Predictors of de novo scoliosis:
• > 20% d
decrease i unilateral di h i ht
in il t l disc height
• > 5 mm longer osteophyte on one side
6. Prevalence
• Schwab et al 2005:
– Volunteers, Inclusion criteria: >60, no known
history of scoliosis
– Health survey questionnaire, AP spine and
nutritional parameters
– Mean age: 70.5
– 68% met the definition of scoliosis (Cobb
angle >10°)
7. Pathophysiology of
Degenerative S li i
D i Scoliosis
• Degenerative disc disease
• Facet joint arthropathy
j p y
• Spinal stenosis
• Osteoporosis
• Lumbar hypolordosis
• Segmental instability: including rotatory
9. Back Pain
• The most common complaint, 85%
• Back pain in the area of curvature is related to:
– the degree of disc degeneration
– facet arthropathy
p y
– rotatory subluxation and lateral listhesis
• Generalized back pain: related to muscle fatigue
from either coronal or sagittal imbalance
10. Claudicatory Leg Pain
• Can be due to central, lateral recess
and/or foraminal stenosis
– Often corresponds to the concavity of the
p y
curve, especially at L3 or L4
• Or due to rotatory subluxation
• Both dynamic pathologies:
– Might not show up on MRI
– Consider CT/myelogram
11. Radiculopathy
• 22 consecutive patients of scoliosis
• MRI, CT/myelography, discography
• L3 or L4 roots: by foraminal or extra-
y
foraminal stenosis at the concave side
• L5 or S1 nerve roots: by lateral recess
stenosis at the convex side
Liu et al. Characteristics of nerve root compression caused by degenerative
lumbar spinal stenosis with scoliosis. Spine J. 2003;3(6):524-9.
12. Curve Progression
• Weinstein and Ponseti 1983:
– 40-year follow-up data on idiopathic curves
– Thoracic curves > 50 degrees at skeletal maturity
g y
progressed an average of 29.4 degrees
– Thoracolumbar curves between 50 and 75 degrees
increased an average of 22 3 degrees
22.3 degrees.
– Lumbar curves had the most progression, especially
when the L5 vertebra was not well seated and when
the apical rotation was greater than 33%.
14. Clinical Evaluation
• General:
– General health, comorbidities, nutritional,
psychological,
psychological disabilities
• Specific:
– Spine & lower extremities
–VVascular status
l t t
15. Radiographic Evaluation
• Radiographs:
– 36-in standing AP & lateral Spine X-ray
– Supine side-bending X ray
side bending X-ray
• MRI
• Myelogram & post ye og a C
ye og a post-myelogram CT
• DEXA scan: to assess BMD
17. Non-
Non-operative Treatment
• Goals:
– Core (abdominal & lumbar) strengthening
– Gluteal strengthening
– Hamstring and iliopsoas flexibility
– Improvement in cardiovascular endurance
p
• Modalities:
– Physiotherapy, aqua & chiropractic therapy
– NSAIDs
– Nerve root injections
18. Systematic Review of
Non-
Non
N -operative T
i Treatment
• There is indeterminate, Level III/IV evidence on
the effectiveness of any conservative option
• Level IV evidence on the role of physical
therapy,
therapy chiropractic care and bracing
care,
• Level III evidence for injections in the
conservative treatment of adult deformity
Everett & Patel. A systematic literature review of nonsurgical treatment in
adult scoliosis. Spine. 2007;32:S130-4.
19. Indications for Surgery
1.
1 Back pain failing conservative care
2. Progressive leg pain or neurologic deficit
3. Muscle f ti
3 M l fatigue secondary t spinal
d to i l
imbalance
4. Curve progression
5. Progressive p
g pulmonary compromise
y p
secondary to deformity
6.
6 Severe deformity
20. Goals of Surgery
• To decrease pain
• T halt progression or i
To h lt i improve neurologic
l i
symptoms
• To stabilize the curve
21. Surgical Planning
• Overall health of the patient
• Patient's expectations
Patient s
• Different from adolescent scoliosis:
– Presence of disc degeneration, facet
arthropathy, and osteopenia
– Problem of adjacent segment problems:
degeneration, junctional kyphosis
22. Preparing for Surgery
Hu & Berven. Preparing the Adult Deformity Patient for Spinal Surgery.
Spine 2006; 31: S126–S131
23. Preparing for Surgery
Hu & Berven. Preparing the Adult Deformity Patient for Spinal Surgery.
Spine 2006; 31: S126–S131
24. Surgical Options
• Decompression alone
• Decompression and posterior
instrumented fusion
• Decompression, combined anterior and
posterior i t
t i instrumented fusion
t df i
25. Controversy in Decision Making
• Role of decompression alone or limited
arthrodesis
• Role of combined anterior and posterior
• Choice of fusion level (how high and how
low)
l )
26.
27.
28. Operative Management of Degenerative
Scoliosis: An Evidence-Based Approach to
Evidence-
Surgical Strategies Based on Clinical and
Radiographic Outcomes
• Retrospective study (Level III)
• 60 consecutive patients
• Data available for 38 patients
– 30 posterior only fusion
– 4 anterior only surgery
– 4 combined anterior and posterior
• Improvement in pain is more reliable than
improvement in function
29. L5-
L5-S1: To fuse or not to fuse
Swamy et al. The Selection of L5 Versus S1 in Long Fusions for Adult
Idiopathic Scoliosis. Neurosurg Clin N Am 18(2007): 281–288
30. L5-
L5-S1: To fuse or not to fuse
Swamy et al. The Selection of L5 Versus S1 in Long Fusions for Adult
Idiopathic Scoliosis. Neurosurg Clin N Am 18(2007): 281–288
31. L5-
L5-S1: To fuse or not to fuse
Swamy et al. The Selection of L5 Versus S1 in Long Fusions for Adult
Idiopathic Scoliosis. Neurosurg Clin N Am 18(2007): 281–288
32. How High?
Upper I
U Instrumented V
d Vertebra (UIV)
b
• Ai for a stable, neutral vertebra
Aim f t bl t l t b
• Should not end instrumentation at a segment with:
– Posterior column deficiency
– Listhesis in any direction
y
– A rotated spinal segment
– A region of junctional kyphosis, or
– At the apex of deformity in coronal and sagittal plane.
Shufflebarger et al. Debate: Determining the Upper Instrumented Vertebra in
the Management of Adult Degenerative Scoliosis. Spine 2006: S185–S194
33. When to go from the front?
• A long fusion to the L-S junction
LS
• A large coronal deformity: > 60° structural
60
curve or >5cm decompensation
• The need to improve sagittal alignment
significantly with anterior structural support
Mok & Hu. Surgical Strategies and Choosing Levels for Spinal Deformity: How
High, How Low, Front and Back. Neurosurg Clin N Am 18 (2007) 329–337.
35. • Retrospective chart reviews
• Si l surgeon
Single
• MIS LIF without decompression (XLIF or
DLIF) ± Axial Lumbar Interbody Fusion
(AxialLIF)
• MIS pedicle screw fixation (Longitude)
36. XLIF
Ozgur et al. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique
for anterior lumbar interbody fusion. The Spine Journal. 6(4): 435-43, 2006.
37.
38.
39. XLIF
Ozgur et al. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique
for anterior lumbar interbody fusion. The Spine Journal. 6(4): 435-43, 2006.
40. AxiaLIF
Marotta et al. A novel minimally invasive presacral approach and instrumentation
technique for anterior L5–S1 intervertebral discectomy and fusion. Neurosurg
Focus 20 (1): E9, 2006
43. Primary Measure(s)
• Blood loss
• Length of surgery
• Post
P t operative hospital stay
ti h it l t
• Preoperative and post-operative visual
analog score (VAS) and the Treatment
Intensity Score (TIS)
44. Results
• 12 patients
• Age: 50-85 (mean 73)
• Number f levels: 2 8 (mean 3.5)
N b of l l 2-8 ( 3 5)
• Mean hospital stay: 8.6 days
• Mean Cobb angle: 18.93° preop 6.19°
p
postop
p
47. Complications
• 3 thigh dysathesias postoperatively
resolved in 6 weeks
• Hip flexor weakness and pain: resolves
within 2 weeks
• Transient quadriceps weakness: 1 p
q p patient
who had L4-5 interbody fusion: resolved
completely in 6 weeks
p y
49. Mortality after Deformity Surgery
• 361 adults with spinal deformity
p y
• Underwent 407 corrective procedures
– 146 primary, 261 revision
– 211 scoliosis, 65 kyphosis,
, yp ,
– 89 scoliosis with pseudoarthrosis, 42 kyphosis
with pseudoarthrosis
• Age: 20 to 86 (mean 48)
Pateder et al. Short-term Mortality and Its Association With Independent Risk
Factors in Adult Spinal Deformity Surgery. Spine 2008.
50. Mortality after Deformity Surgery
• 30-day mortality
y y
• Examined for possible predictors:
– Demographic ( g , g
g p (age, gender))
– ASA classification
– Operative time
– Surgical approach
– Number of fusion levels
– Primary versus revision surgery
– Intraoperative blood loss
Pateder et al. Short-term Mortality and Its Association With Independent Risk
Factors in Adult Spinal Deformity Surgery. Spine 2008.
51. Mortality after Deformity Surgery
• 30-day mortality: 10/407 (2.4%)
y y ( )
Pateder et al. Short-term Mortality and Its Association With Independent Risk
Factors in Adult Spinal Deformity Surgery. Spine 2008.
52. Mortality after Deformity Surgery
• Only ASA class was strongly associated
y gy
with 30-day mortality
• The rest of factors were not statistically
different between the two groups
Pateder et al. Short-term Mortality and Its Association With Independent Risk
Factors in Adult Spinal Deformity Surgery. Spine 2008.
53. Medical Complications
Baron & Albert. Medical Complications of Surgical Treatment of Adult Spinal
Deformity and How to Avoid Them. Spine 2006. 31: S106–S118
54. Baron & Albert. Medical Complications of Surgical Treatment of Adult Spinal
Deformity and How to Avoid Them. Spine 2006. 31: S106–S118
55. Medical Complications
Baron & Albert. Medical Complications of Surgical Treatment of Adult Spinal
Deformity and How to Avoid Them. Spine 2006. 31: S106–S118
56. Surgical Complications
• Pseudoarthrosis
• Proximal junctional kyphosis
• Loss of sagittal b l
L f itt l balance
• Deep wound infection
• Neurovascular injury
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392
57. Pseudoarthrosis
• The most common complication
• Associated with lower functional outcomes
• Most common at L-S & T-L junctions
• Risk factors:
– Age > 55yr
– Thoracolumbar kyphosis > 20
– Fusion > 12 segments
g
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392
59. Proximal Junctional Kyphosis
• Most commonly at thoracolumbar junction
• Rates: 26% to 42%
• DeWald 2006, Glattes 2005, Yang 2003
D W ld 2006 Gl tt 2005 Y
• Risk factors:
– 5°-10° kyphosis at adjacent level cephalad to
the upper instrumented vertebra
– osteoporosis
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392
60. Loss of Sagittal Balance
(Sagittal D
(S i l Decompensation) i )
• C7 plumb line ≥5 cm anterior to the
posterior aspect of S1 superior end plate
• Glassman et al 2005:
– 752 patients, multicentre, retrospective
– All measures of health status showed
significantly poorer scores as C7 plumb line
deviation increased.
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392
61. Causes of
Sagittal Decompensation
S i lD i
• O t
Osteoporotic compression fractures within or
ti i f t ithi
adjacent to a deformity construct
• Ankylosing spondylitis
• Posttraumatic kyphosis
• Di t ti instrumentation
Distraction i t t ti
• Adjacent segment disease
• Poor correction based on pre-existing sagittal
balance
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392
62. Treatment of Sagittal
Decompensation
D i
• R i i surgery with a S ith P t
Revision ith Smith-Peterson
osteotomy or pedicle subtraction
osteotomy
t t
63. Deep Wound Infection
• Lonstein et al 1973: 80 patients
patients,
Harrington instrumentation, 20% in adults,
7.5%
7 5% in adolescent
• K et al 2004: 3230 cases, i t
Kuo t l 2004 instrumented
t d
spine, 2.2%
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392
64. Neurovascular Injury
• Bridwell et al 1998: 1090 cases, 4 major
j
complications
– All 4 combined anterior & posterior, with
p ,
harvesting of convex segmental vessels
– All 4 had hyperkyphosis
y y
• Guigui et al 2005: 3311 patients, 1.8%,
increased risk with initial angle and double
thoracic and lumbar curves
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392
65. Neurovascular Injury
• Pedicle screws: irritation of nerve roots
(0.15% to 1%)
• L5-S1 ALIF: sexual dysfunction 0.42% to
5%
• Vascular complications: 1.4% to 20%,
anterior approach, most common @ L4
i h L4-5
– Left common iliac vein, iliolumbar vein
Burch. Surgical Complications of Spinal Deformity Surgery. Neurosurg Clin N
Am 2007: 385–392