Lumbar spinal stenosis is a narrowing of the spinal canal in the lower back that puts pressure on the spinal cord and nerves. It commonly occurs in people over 50 due to age-related wear and tear causing bone spurs or thickened ligaments. The best test for diagnosis is an MRI of the lumbar spine, which will show if there is compression of the spinal cord or nerves. Conservative treatment includes medications like NSAIDs, muscle relaxants, and epidural steroid injections, as well as physical therapy. Surgery such as laminectomy or discectomy may be considered if conservative measures fail to provide relief from pain and symptoms.
As part of a class presentation, we attempted to make this to briefly explain what Torticollis meas, the Types of presentation of Torticollis, and Management strategies for a Physiotherapist for Congenital Torticollis especially.
I hope this helps. :)
The pictures and information had been taken from internet, complied to make a brief presentation for the purpose of class presentation.
I do not own any content.
Back pain
Etiology
Anatomical & pathophysiological concepts
Diagnostic approach
Clinical approach
Red flags & yellow flags
Investigations
Back pain in children & elderly
As part of a class presentation, we attempted to make this to briefly explain what Torticollis meas, the Types of presentation of Torticollis, and Management strategies for a Physiotherapist for Congenital Torticollis especially.
I hope this helps. :)
The pictures and information had been taken from internet, complied to make a brief presentation for the purpose of class presentation.
I do not own any content.
Back pain
Etiology
Anatomical & pathophysiological concepts
Diagnostic approach
Clinical approach
Red flags & yellow flags
Investigations
Back pain in children & elderly
LOW BACK PAIN. Dr Haki Selaj Residency in Kosovo QKUKHakiSelaj1
back pain is a very widespread pathology in the world. There are health and socioeconomic consequences. widespread both in the young and in the old. The causes are different. The overwhelming majority is mechanical pain without a specific cause, while the others are pain from disc, infections, tumors, fractures, metabolic.
What is structure of lumber disc? What is disc bulge/prolapse/herniation? What is difference between disc bulge, disc prolapse, disc herniation or disc extrusion? What is criteria to diagnose lumber disc prolapse? How lumber disc herniation is treated medically or surgically? How lumber disc herniation is treated by conservative method? How lumber disc herniation is treated through physical therapy? What is physiotherapy after various disc surgeries? What is radiological method to diagnose disc prolapse?
Lumbar spinal canal stenosis is one of the difficult topic of spine. All the information are taken from Campbell's operative orthopedics Thirteen edition and from internet. I also took help from the lectures of renowned orthopedics professors of Bangladesh.
Herniated disk in the lower back agrasen hospital dr sandeep agrawal gondia v...Dr.Sandeep Agrawal Gondia
Back Pain
Back pain is often a common symptom of many disease conditions and the back pain may range from simple or dull pain to sudden and sharp pain. If the pain persists for few days, it is acute pain whereas if continues for more than 3 months, it is considered as chronic pain. In most cases, back pain may resolve without any treatment however if persists for more than 3 days, medical intervention is necessary.
Neck Pain
The first 7 vertebral bones on the spinal column form the cervical spine and are located in the neck region. The neck bears the weight of the head, allows significant amount of movement, and also less protected than other parts of spine. All these factors make the neck more susceptible to injury or other painful disorders. Common neck pain may occur from muscle strain or tension in everyday activities including poor posture, prolonged use of a computer and sleeping in an uncomfortable position.
Spinal Deformity Surgery
The Spine or backbone provides stability to the upper part of our body. It helps to hold the body upright. It consists of several irregularly shaped bones, called vertebrae appearing in a straight line. The spine has two gentle curves, when looked from the side and appears to be straight when viewed from the front. When these curves are exaggerated, pronounced problems can occur such as back pain, breathing difficulties and fatigue and the condition will be considered as deformity. Spine deformity can be defined as abnormality in the shape, curvature and flexibility of spine.
Spine Injections
Spine injection is a nonsurgical treatment modality recommended for treatment of chronic back pain. Injection of certain medicinal agents relieves the pain by blocking the nerve signals between specific areas of the body and the brain. The treatment approach involves injections of local anaesthetics, steroids, or narcotics into the affected soft tissues, joints, or nerve roots. It may also involve complex nerve blocks and spinal cord stimulation.
Spine Trauma
Spine trauma is damage to the spine caused from a sudden traumatic injury caused by an accidental fall or any other physical injury. Spinal injuries may occur while playing, performing normal activities, operating heavy machines, lifting heavy objects, driving automobiles, or when you suffer a fall. Injury to spine may cause various conditions including fractures, dislocation, partial misalignment (subluxation), disc compression (herniated disc), hematoma (accumulation of blood) and partial or complete tears of ligaments.
Vertebral Fractures
Vertebral compression fractures occur when the normal vertebral body of the spine is squeezed or compressed. The bone collapses when too much pressure is placed on the vertebrae, resulting in pain, limited mobility, loss of height, and spinal deformities. In severe compression fractures the vertebral body is pushed into the spinal canal which will apply pressure on the spinal cord and nerves.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
9. SPINAL STENOSIS
• Spinal stenosis Refers to narrowing of the spinal canal, nerve
root canals, or intervertebral foramina due to compression
• Can put pressure on spinal cord and nerves
• Commonly occurs in the neck and low back
• Lumbar canal stenosis is common cause of back pain
• Most Common indication for Spinal Surgery
10. Causes of medical view
• Age related wear and tear
• Mostly effect people over 50
• Most spinal stenosis occurs when something happen to reduce
the amount of space available within the spine such as:
1. Overgrowth of bone: Osteoarthritis and bone spurs
2. Herniated disk
3. Thickened ligament
4. Spinal injuries
11.
12. CLASSIFICATION OF SPINAL STENOSIS
1. GENERALISED/LOCALISED
2. SEGMENTAL
A. Central: Narrowing of the AP dimension
B. Lateral recess stenosis
C. Foraminal
3. ANATOMICAL
A. Cervical Stenosis: C5-C6 > C6-C7 (Seen)
B. Thoracic Stenosis – Seldom occurs (rare)
C. Lumbar Stenosis– L4-L5 (Most Common)
14. Case Presenation
• A 65-year-old male presents to his primary care physician with
complaints of lower back pain. He states this pain has been gradually
worsening over approximately the last year. He describes the pain as
improving when he leans forward, and radiates to his buttocks and
thighs; this pain interferes with his walking. On physical exam, pedal
pulses are normal. Which of the following is the best next step in the
management of this patient?
1. Prescribe NSAIDs and see the patient back in 2 weeks
2. Perform a lumbar steroid injection
3. Send the patient for an MRI of the lumbar spine
4. Send the patient for a radiograph of the lumbar spine
5. Refer the patient to physiatrist and see the patient back in 1 month
15. 3. Send the patient for an MRI of the lumbar spine
The patient in this vignette most likely has lumbar spinal stenosis. The
best test for this condition is an MRI scan of the lumbar spine.
Lumbar spinal stenosis classically presents with weakness, back pain
and referred buttock pain, pain worsens with extension (walking
downhill, standing upright) and is relieved with flexion at hips and
bending forward (sitting, leaning over shopping cart).
Answer 1: NSAIDs are a valid treatment for lumbar spinal stenosis but only after
a diagnosis has been confirmed.
Answer 2: Steroid injections are a valid treatment for lumbar spinal stenosis but
only after a diagnosis has been confirmed.
Answer 4: X-rays are not the preferred imaging modality for this condition.
Answer 5: Physical therapy is a valid treatment for lumbar spinal stenosis but
only after a diagnosis has been confirmed.
16. Lumbar Spinal Stenosis
• Narrowing of central or lateral lumbar spinal canal
caused by degenerative joint diseaseleads to
compression of nerve roots.
• Commonly found in middle-aged or elderly people
• Mostly occurs at the L3-L4 and L4-L5 levels(MC)
18. Clinical Features
• Numbness and tingling sensation in your arms, hands, leg, and foot
• Pain in the low back and buttock region
• Neurogenic claudication is common symptom
1. Pain radiates to buttocks and lower extremities.
2. Pain or feeling of cramps in the legs after standing for a long period of time or
while walking.
3. Pain relieved by sitting or lying down and increase by standing or walking.
4. The pain usually goes away when the person either bends forward or sits
down (Pain relieved by forward flexion)
5. Pain exacerbated by standing and walking.
• leg pain (often unilateral)
• Weakness and imbalance while walking
• bladder disturbances
• cauda equina syndrome (rare)
19. Neurogenic claudication VS Vascular claudication
Features Neurogenic claudication Vascular claudication
Pain distribution Dermatomal Sclerotomal
Sensory loss Dermatomal Stocking type
Aggravating factors • Variable amount of physical
activity
• Pain on standing (65%)
• Coughing (38%)
• Fixed amount of activity
• Rest pain rare
• Pain on standing (27%)
Relief with rest • Slow (> 30 min)
• Special posture
• Immediate
• No special posture
Claudication distance Variable day to day (62%) Constant (88%)
Lifting or bending Pain common (67%) Uncommon (15%)
Limb elevation No pallor Profound
Pulses Normal Absent or decreased
Skin temperature Normal Decreased
20. Physical examination
• Kemp sign: unilateral radicular pain from foraminal stenosis made
worse by extension of back
• Straight leg raise (nerve root tension sign) is usually negative
• Valsalva test does not worsen pain (pain is worse in the case of
herniated disc)
• Reduced spinal mobility.
• Extension is more usually limited than flexion.
• Lumbar, paraspinal and gluteal tenderness.
• Neurologic examination typically normal or reveals only such a
mild weakness, sensory changes and difficulty in walking.
21. Special test
1. Stoop test:
Ask patient to walk pain develop continue to walk
patient assumes a stooped posture symptom
disappear the pain decreases by forward bending
because the canal length increase by 2.2 mm.
2. Lumbar extension test – (Katz et al)
Ask the standing patient to hyperextend the lumbar
spine for 30 to 60 second.
A positive test is reproduction of the buttock or leg pain.
22.
23. Diagnostic Approach
• Physical history & medical History
• Blood tests: CBC, ESR, C-Reactive protein
• Imaging: X-ray, CT Mylogram, MRI (IxCx)
1. CT Myelogram: A CT scan combined with myelogram provides an
excellent picture of the nerve details
can diagnose early defects and slip
shows how the bone is affecting the nerve roots.
CT myelogram is a sensitive test to detect nerve impingement and can identify
even minute scratches or injuries.
2. MRI show if there is any pressure exerted on the spinal cord or its nerves
(diagnose cord compression), MRI) is the best imaging test that can be
helpful in diagnosing different types of stenosis.
3. X-rays can help in identifying any change in the bones such as bone
spurs. These spurs may narrow the space within the spinal column.
32. Non-Surgical Management
1. Steroids: Epidural Steroid injections can help reduce inflammation and
relieve the pressure. As a long-term use of steroid injections has a
tendency to cause weakening of nearby bones and connective tissues,
these are prescribed cautiously, and only a limited number of injections
are advised in a year.
2. NSAIDs: These are effective in relieving pain and inflammation.
3. Muscle relaxants: Medicines reduce muscle contractions that occur
occasionally with spinal stenosis.
4. Anti-seizure drugs: Anti-seizure drugs effective in reducing the pain
caused due to nerve damage.
5. Antidepressants: Antidepressants relieving chronic pain/ Fibromyalgia
6. Other drugs such as Opioids / narcotics may be advised to get relief
from pain.
33.
34.
35.
36. Non-Surgical Treatment
Physiotherapy Tx
1. Improve strength, endurance and tone of abdominal muscle.
2. Back ergonomics avoiding extension attitude are taught.
3. Lumbar corset should be used provide back support.
4. Emphasis on flexion exercise and generalized flexion attitude avoiding
extension.
5. Gentle passive manipulation technique.
6. Lumbar traction to relive spasm.
7. Walking on inclined treadmill. Harness supported treadmill ambulation.
8. Strong isometric exercise for abdomen.
9. Single Knee to chest exercise.
10. Spinal flexion exercise.
11. Hamstring stretching performed by extending the knee with hip flexed 90*.
12. Hip flexor stretching is performed by maintains posterior pelvic tilt while in a
half kneeling posture.
13. Mini squats for general lower extremity strengthing exercises.
40. Indications for spine surgery
• Altered bladder and bowel function
• progressive neurological deficits
• Pain worsen with conservative treatment
• Radiculopathy/Neurogenic Claudication
• Cauda Equina Syndrome
41. Complications
No improvement
– Recurrence of pain
– Recurrent disc prolapse
Epidural fibrosis
Failed back surgery syndrome
Infection
– Disc
– Wound
Neural injury
Vascular injury
CSF fistula
42. Surgical treatment
• Surgical treatment is indicated in patient with
moderate or marked compression of the nerve root
or severe cauda equina syndrome.
• The aim of surgery is to decompress the cord.
For central canal stenosis
1. LAMINECTOMY - Decompression laminectomy is
useful. It is mostly done in central canal stenosis.
2. DISCECTOMY - Discectomy and osteotomy of
inferior articular process helps to remove the
hypertrophic element.
43. For lateral canal stenosis
1. LAMINECTOMY
2. DISC EXCISION
3. PARTIAL MEDIAL FACETECTOMY
4. FORAMINOTOMY
Spinal fusion to stabilize the lumbar spine is usually not
required as instability is less commonly seen in lumbar
canal stenosis.
The neurogenic claudication respond poorly to the
conservative treatment but respond well to surgical
decompression.
44. In my opinion, surgery for
spinal stenosis should only be
considered if your quality of life
has been severely affected
45. SURGICAL PROCEDURE
• There are seven steps of the procedure.
• The operation generally lasts 1 to 2 hours.
• Approach to the spine:
1. Anterior (Transthoracic) Approach to the Thoracic Spine
2. Anterolateral (Retroperitoneal) Approach to the Lumbar Spine
3. Anterior (Transperitoneal) Approach to the Lumbar and Lumbosaccral Spine
4. Posterior Approach to the Lumbar Spine
• Surgical technique for spine
1. Minimally invasive spinal surgery
2. Keyhole Spinal Surgery
46. Posterior Approach to the Lumbar Spine
• the most common approach to the lumbar spine
• providing access to the cauda equina and the intervertebral discs
• expose the posterior elements of the spine
• Uses
– Excision of herniated discs
– Exploration of nerve roots
– Spinal fusion
– Removal of tumors
47. Posterior Approach to Lumbar Spine
Step 1: Prepare the patient
1. Positioning: Prone “Mecca” position
2. Anesthesia: General anesthesia (Protect airway in prone position)
3. Localization:
1. Between two paraspinal muscles (erector spinae)
2. Templating, which is performed preoperatively, consists of identifying
the anteroposterior axis of the spinous process and measuring its
shortest depth to understand the spine anatomy for each patient and
avoid overpenetration of the osteotomy into the spinal canal.
3. The maximum anteroposterior depth of the spinous process above the
spinous process junction with the dorsal lamina is chosen as the depth
of the osteotomy.
4. Using fluoroscopy, the spinous process to be osteotomized is identified
and the skin is marked (Needle localization and marking of the spinous
process).
4. Skin Preparation: Scrub skin with pyodine solution
48. • Position of the
Patient
• prone position
• On side
– Flex the patient's hips and
knees to flex the lumbar
spine and open up the
interspinous spaces
49. • Landmarks
• Spinous processes
• Line drawn between the
highest points on the iliac
crest is in the L4-5 interspace
• To determine the exact level
is use a radiograph
50. Step 2: Incision
Landmarks
can palpate spinous process (midline)
highest point on iliac crest marks L4-5 interspace
make midline incision
2 to 5 inch incision in the at the over
the appropriate vertebrae
NOTE: A midline skin incision is made,
and the subcutaneous tissue is dissected
until the thoracolumbar fascia is reached.
51. • Incision
• midline longitudinal incision
• length of the incision
depends on the number of
levels to be explored
52. Step 3: Superficial dissection
Incise fat and lumbodorsal fascia to spinous process
Preserve interspinous ligament
Detach paraspinal muscles (erector spinae) subperiostally
(Erector spinae (iliocostalis, Longissimus, and spinalis), are
dissected/split down the middle and moved to either side exposing the
lamina of each vertebra)
Dissect down spinous process and lamina to facet joint
Move medial to lateral taking down or sparing the facet capsule
Continue anterior to transverse process if necessary
53.
54. Step 4: Deep dissection
Ligamentum flavum:
Remove ligamentum flavum by cutting attachment to edge of lamina,
Ligamentum flavum attaches to the lamina halfway up the
undersurface
identify epidural fat and dura
using blunt dissection stay lateral to dura and continue to floor of
spinal canal
Note: Decompress the spinal cord: Once the lamina and ligamentum flavum are
removed the protective covering of the spinal cord (dura mater) is visible. The
surgeon can gently retract the protective sac of the spinal cord and nerve root to
remove bone spurs and thickened ligament.
55.
56. The facet joints, which are directly over the nerve roots, may then be
undercut, or trimmed, to give the nerve roots more room. (Fig 5). Called
a foraminotomy, this maneuver enlarges the neural foramen (where the
spinal nerves exit the spinal canal). If a herniated disc is causing
compression the surgeon will perform a discectomy.
After the surgeon has confirmed that all pressure has been removed
from the nerve, the paraspinal muscles are sewn back together to cover
the laminectomy site.
Step 5: Decompress the spinal nerve
57.
58. Step 6: Spinal Fusion (if necessary)
– Spinal fusion where two or more vertebrae are joined together with a section
of bone to stabilize and strengthen the spine
– For those who has spinal instability or have laminectomies to multiple
vertebrae, a fusion may be performed.
– Fusion is the joining of two vertebrae with a bone graft held together with
hardware such as plates, rods, hooks, pedicle screws, or cages.
– The goal of the bone graft is to join the vertebrae above and below to form
one solid piece of bone.
– The most common type of fusion is called the posterolateral fusion.
– The top most layer of bone on the transverse processes is removed with a
drill to create a bed for the bone graft to grow. Bone graft, taken from the top
of your hip, is placed along the posterolateral bed.
– The surgeon may reinforce the fusion with metal rods and screws inserted
into the vertebrae. The back muscles are laid over the bone graft to hold it in
place.
59. The split spinous processes are approximated using transosseous
restorable sutures (Figure 7).
The supraspinous and interspinous ligaments are repaired with
interrupted sutures restorable
closed wound suction drain placed deep to the lumbodorsal fascia if
drain is required
The erector spinae muscle and fascia is closed with watertight closure
and skin incisions are sewn together with sutures
Step 7: closure
60.
61.
62.
63.
64. Discharge instructions:
1. Conservative Management for 3-4 weeks
2. Keep wound clean and dry.
3. No lifting greater than 10 pounds, strenuous activity,
crawling, stooping, bending or twisting for 1 months after
surgery.
4. Watch for the development of fever or redness and
drainage from the wound.
5. Pain may require many days to resolve.
6. Please alert your doctor of sudden onset of new pain.
7. Call your doctor if you have any concerns.
8. Evaluation and treatment for osteoporosis.
65. High-yield Points
• Spinal -- epidural abscess - Staph. aurous [50 – 60%]
• Cervical Spondylosis: Most common occurs at C5-6 > C6-7 levels
• Sciatica is the most common symptom of a lumbar herniated disc
• Sciatica most commonly caused by lumbar disc prolapse
• Piriformis muscle compression lead to Sciatica/ Sciatica-type-pain
• Whiplash Injury- Hyperextension of lower cervical spin
• Jefferson fracture is burst fracture of ring of atlas (C1) vertebrae
• Burst fracture is a vertical compression fracture
• Flexion rotation injury is the most common spinal injury followed by
compression extension injury (2nd most common).
• Tear drop fracture is caused by combined axial compression and flexion
injury
• Hangman’s Fracture- It occurs when a fracture line passes through the
neural arch of the axis (C2) vertebrae
66. Best diagnostic test for calcification of
ligaments MRI or CT
• Calcification of any tissue in body CT Scan is the
investigation of choice.
• Remember
– C for CT scan C for Cortex and C for Calcification.
– M for MRI, M for Marrow. MRI is also the best
radiological investigation for soft tissues and cartilage.
67. High yield points
1. X-rays is done for screening (Cartilage not seen)
2. CT Scan is done for bone Cortex and Calcification
3. Calcification of Ligament–CT Scan
4. MRI is done for Soft tissues/Cartilage/ Bone Marrow/Unilateral stress fractures
(Investigation of choice)
5. MRI is done for occult fracture neck femur
6. Bone scan is done for bilateral stress fractures. (Investigation of choice) and
metastasis.
7. Metastasis–PET CT scan > Bone Scan
8. Culture is best for infection, T.B. Spine CT guided biopsy gold standard
9. Best radiological investigation for bone infection is MRI >Bone Scan
10.Bone and joint infections Gold standard is always culture and sensitivity
11.Inflammatory Joint swellings order of investigations is X-MAS
X-RAY MRI Aspiration Swelling of a joint
Spinous process:
Surgeon removes the bony spinous process. Next, the bony lamina is removed with a drill or bone-biting tools.
The spinous process to be split is always superior to the interspace to be decompressed (e.g., for an L3–4 decompression, the L3 spinous process would be split).
Lamina:
After the spine is approached, the lamina is removed, allowing visualization of the nerve roots.
After the lamina and any other sources of pressure on the nerve roots are removed, the nerve roots have room to heal.
Segmental vessels
between facet and transverse process
supply paraspinal muscles
vigorously cauterize as they are encountered
Nerve roots
each nerve root must be identified and protected
Venous plexus
surrounds nerve roots
may bleed during blunt dissection
stop with Gelfoam or bipolar cautery
Iliac vessels
can be damaged during discectomy if you pass instruments too far anterior through the annulus
Dura
dura exposed after entering ligamentum flavum
thin spatula tool can be used to gently retract dura away from area of focus
epidural veins may bleed and make visualization difficult so hemostasis is of utmost importance