Prolapsed lumbar intervertebral disc occurs when the soft central portion of an intervertebral disc bulges out beyond the damaged outer rings of the disc. It commonly affects the lower back and can cause lower back pain and leg pain. Diagnosis involves physical examination, imaging studies like MRI, and ruling out other potential causes of back pain. Treatment options include conservative measures like physical therapy and epidural steroid injections or surgery like discectomy if conservative options fail. Surgery aims to relieve nerve compression and associated back pain.
SPONDYLOLISTHESIS: DIAGNOSIS, CLASSIFICATION, EVALUATION AND MANAGEMENTBenthungo Tungoe
Spondylolisthesis is the forward slippage of one vertebra on another. There are several classifications including developmental, isthmic, degenerative, traumatic, and postsurgical types. Developmental spondylolisthesis is usually asymptomatic and rarely progresses after adulthood. Isthmic spondylolisthesis has a risk of progression over 25% slippage or in symptomatic cases. Degenerative spondylolisthesis results from sagittal facet orientation or disc degeneration and increases in older females. The natural history depends on factors like age, gender, slip severity and progression.
The document discusses intervertebral discs, disc prolapse, and degenerative changes in the spine. It provides the following key points:
- Intervertebral discs act as shock absorbers between vertebrae and allow some spinal motion. Discs are made up of an inner gelatinous nucleus pulposus surrounded by the annulus fibrosus.
- Disc prolapse occurs when the nucleus pulposus extrudes through tears in the annulus fibrosus. Imaging like MRI and CT can detect disc prolapses and herniations.
- Degenerative changes in the spine include osteophytosis, ligament calcification and ossification, and a reduction in the size of the spinal
Recurrent Dislocation of patella -PAWANPawan Yadav
This document discusses recurrent patellar dislocation. It begins by defining recurrent patellar dislocation as the patella shifting laterally with minimal stress on knee flexion. It then discusses the anatomy and Q angle as well as predisposing causes such as increased Q angle, weak medial quads, and tight lateral structures. The document outlines clinical features, tests, x-ray findings, and treatment options including conservative immobilization and surgical procedures like realignment and patellectomy.
Dr. Mahak Jain presented on spondylolisthesis. Key points include:
1) Spondylolisthesis is the forward translation of one vertebra on another, commonly caused by defects in the pars interarticularis known as spondylolysis.
2) It is classified based on etiology, with dysplastic, isthmic, degenerative, traumatic, and pathological types.
3) Treatment depends on factors like grade, symptoms, and etiology, ranging from conservative care to surgical options like decompression, fusion, and instrumentation.
4) Studies show surgery with fusion has better outcomes for pain and function than nonsurgical treatment or decompression alone for degenerative
Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by pain and stiffness in the shoulder joint that limits range of motion. It involves thickening and scarring of the shoulder joint capsule. Treatment involves conservative measures like oral anti-inflammatory drugs, corticosteroid injections into the joint, physical therapy including heat therapy and gentle range of motion exercises, and manipulation under anesthesia for refractory cases. Physical therapy aims to reduce pain and inflammation in the early stage and increase mobility in the stiffening stage through heat, passive range of motion, and home exercises.
Recurrent shoulder dislocation and managementAnshul Sethi
This document provides an overview of recurrent shoulder dislocations. It discusses the anatomy of the shoulder joint and its stabilizers. The glenohumeral ligaments, labrum, rotator cuff muscles, and negative intra-articular pressure provide static stability, while dynamic stability comes from the rotator cuff and scapulo-thoracic motion. Younger age, returning to collision sports, and bone defects increase risk of recurrence. Evaluation involves assessing range of motion, translation, and special tests like the anterior drawer and sulcus sign. History and physical exam help determine treatment which may include rehabilitation or surgery to address labral tears or bone loss.
Spondylolisthesis is the forward slippage of one vertebra over another and most commonly occurs between L4-L5 or L5-S1. It can be caused by developmental abnormalities, stress fractures of the pars interarticularis, degeneration of the disc and facets, trauma or tumors. Symptoms include lower back pain and sciatica. Conservative treatment involves rest and bracing while surgery is indicated for progressive, high grade or neurologically compressive slips. Surgical options include fusion with or without instrumentation to reduce the slip and decompress the nerves.
Dr. Orakwele Arinze presented on cervical spondylosis. The presentation included an introduction to cervical spondylosis, relevant anatomy, epidemiology, etiology, pathophysiology, clinical features, diagnosis, differential diagnosis, management, physiotherapy management, and a case study. Cervical spondylosis is an age-related degeneration of the cervical spine that can lead to nerve root or spinal cord compression. Symptoms include neck and arm pain, weakness, and sensory changes. Physiotherapy is an effective treatment and includes modalities like TENS, traction, exercises and lifestyle advice. The case study demonstrated improvement in a patient's neck pain, range of motion and strength following physiotherapy
SPONDYLOLISTHESIS: DIAGNOSIS, CLASSIFICATION, EVALUATION AND MANAGEMENTBenthungo Tungoe
Spondylolisthesis is the forward slippage of one vertebra on another. There are several classifications including developmental, isthmic, degenerative, traumatic, and postsurgical types. Developmental spondylolisthesis is usually asymptomatic and rarely progresses after adulthood. Isthmic spondylolisthesis has a risk of progression over 25% slippage or in symptomatic cases. Degenerative spondylolisthesis results from sagittal facet orientation or disc degeneration and increases in older females. The natural history depends on factors like age, gender, slip severity and progression.
The document discusses intervertebral discs, disc prolapse, and degenerative changes in the spine. It provides the following key points:
- Intervertebral discs act as shock absorbers between vertebrae and allow some spinal motion. Discs are made up of an inner gelatinous nucleus pulposus surrounded by the annulus fibrosus.
- Disc prolapse occurs when the nucleus pulposus extrudes through tears in the annulus fibrosus. Imaging like MRI and CT can detect disc prolapses and herniations.
- Degenerative changes in the spine include osteophytosis, ligament calcification and ossification, and a reduction in the size of the spinal
Recurrent Dislocation of patella -PAWANPawan Yadav
This document discusses recurrent patellar dislocation. It begins by defining recurrent patellar dislocation as the patella shifting laterally with minimal stress on knee flexion. It then discusses the anatomy and Q angle as well as predisposing causes such as increased Q angle, weak medial quads, and tight lateral structures. The document outlines clinical features, tests, x-ray findings, and treatment options including conservative immobilization and surgical procedures like realignment and patellectomy.
Dr. Mahak Jain presented on spondylolisthesis. Key points include:
1) Spondylolisthesis is the forward translation of one vertebra on another, commonly caused by defects in the pars interarticularis known as spondylolysis.
2) It is classified based on etiology, with dysplastic, isthmic, degenerative, traumatic, and pathological types.
3) Treatment depends on factors like grade, symptoms, and etiology, ranging from conservative care to surgical options like decompression, fusion, and instrumentation.
4) Studies show surgery with fusion has better outcomes for pain and function than nonsurgical treatment or decompression alone for degenerative
Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by pain and stiffness in the shoulder joint that limits range of motion. It involves thickening and scarring of the shoulder joint capsule. Treatment involves conservative measures like oral anti-inflammatory drugs, corticosteroid injections into the joint, physical therapy including heat therapy and gentle range of motion exercises, and manipulation under anesthesia for refractory cases. Physical therapy aims to reduce pain and inflammation in the early stage and increase mobility in the stiffening stage through heat, passive range of motion, and home exercises.
Recurrent shoulder dislocation and managementAnshul Sethi
This document provides an overview of recurrent shoulder dislocations. It discusses the anatomy of the shoulder joint and its stabilizers. The glenohumeral ligaments, labrum, rotator cuff muscles, and negative intra-articular pressure provide static stability, while dynamic stability comes from the rotator cuff and scapulo-thoracic motion. Younger age, returning to collision sports, and bone defects increase risk of recurrence. Evaluation involves assessing range of motion, translation, and special tests like the anterior drawer and sulcus sign. History and physical exam help determine treatment which may include rehabilitation or surgery to address labral tears or bone loss.
Spondylolisthesis is the forward slippage of one vertebra over another and most commonly occurs between L4-L5 or L5-S1. It can be caused by developmental abnormalities, stress fractures of the pars interarticularis, degeneration of the disc and facets, trauma or tumors. Symptoms include lower back pain and sciatica. Conservative treatment involves rest and bracing while surgery is indicated for progressive, high grade or neurologically compressive slips. Surgical options include fusion with or without instrumentation to reduce the slip and decompress the nerves.
Dr. Orakwele Arinze presented on cervical spondylosis. The presentation included an introduction to cervical spondylosis, relevant anatomy, epidemiology, etiology, pathophysiology, clinical features, diagnosis, differential diagnosis, management, physiotherapy management, and a case study. Cervical spondylosis is an age-related degeneration of the cervical spine that can lead to nerve root or spinal cord compression. Symptoms include neck and arm pain, weakness, and sensory changes. Physiotherapy is an effective treatment and includes modalities like TENS, traction, exercises and lifestyle advice. The case study demonstrated improvement in a patient's neck pain, range of motion and strength following physiotherapy
Bennett's fracture is a common intra-articular fracture of the base of the thumb metacarpal bone that extends into the carpometacarpal joint. It is usually caused by an axial force on a partially flexed thumb. Left untreated, it can lead to long-term pain, weakness, arthritis, and diminished hand function. While sometimes minimally displaced fractures can be treated non-surgically, surgical intervention like closed reduction or open reduction is often needed to ensure proper healing and restore thumb function. Long-term outcomes often include weakness and arthritis, with severity depending on how well the fracture was reduced.
This document provides information on spinal stenosis including its definition, history, clinical anatomy, pathophysiology, types, investigations, and treatment options. Spinal stenosis is defined as a narrowing of the spinal canal or intervertebral foramina causing compression of neural structures. It was first described in the late 19th/early 20th century and can be developmental, degenerative, post-traumatic, or iatrogenic in nature. Clinical features include neurogenic claudication relieved by flexion. Investigations include imaging like MRI, CT, and myelography. Treatment involves conservative options like activity modification initially, with surgery considered if conservative measures fail.
Pp for lumbarization and sacralization by Dr Dhruv Taneja Assistant ProfessorDhruv Taneja
Lumbarization is a condition where the first sacral vertebra appears like a lumbar vertebra rather than being fused with the sacrum. This occurs when the first and second sacral segments fail to fuse during development. A lumbarized S1 vertebra may have its own disc or an underdeveloped disc space, making it difficult to accommodate and more prone to injury with age. Sacralization is a related condition where the fifth lumbar vertebra fuses with the sacrum, reducing mobility and increasing stress on the L4 vertebra. Both conditions can potentially lead to back pain and disc problems.
TB of the spine commonly affects the thoracic and lumbar regions. It spreads hematogenously and causes destruction of vertebral bodies. Common presentations include chronic back pain and deformities. Advanced cases may involve neurological deficits due to spinal cord compression. Diagnosis involves imaging tests like x-rays and MRI. Treatment is with anti-TB medications along with rest. Surgery is indicated for complications like paraplegia. Prognosis depends on factors like age, duration of symptoms and severity of neurological involvement.
This document discusses intervertebral disc prolapse. It begins by describing disc anatomy, development, and location in the spine. It then explains the pathology of prolapse, which involves nuclear degeneration, displacement, and fibrosis. Risk factors for prolapse include heavy lifting, smoking, obesity, and improper posture. Clinical features include low back pain radiating to the buttocks, aggravated by certain movements. Investigations include CT, MRI, and myelography. Treatment options range from conservative measures like rest and physical therapy to operative procedures like fenestration, hemi-laminectomy, and endoscopic discectomy.
Tarsal tunnel syndrome involves compression of the tibial nerve as it passes beneath the flexor retinaculum in the ankle. It causes pain, numbness and tingling in the foot. Non-surgical treatments include orthotics, stretching, weight loss and activity modification. Surgery to release the flexor retinaculum may be considered if non-surgical options fail. Anterior tarsal tunnel syndrome is a similar condition affecting the deep peroneal nerve. Risk factors include ankle injuries and activities that put repetitive stress on the ankle.
The document discusses prolapsed lumbar intervertebral disc (PLID), which occurs when the soft central portion of an intervertebral disc bulges out beyond the damaged outer rings. It causes severe back and leg pain. Key points include: PLID most commonly occurs at the L4/L5 level. Common symptoms are radiating pain, numbness, and weakness. MRI is the preferred imaging method to detect herniations. Treatment options include conservative measures like NSAIDs, physical therapy, and epidural injections or surgery for severe/progressive cases.
Trigger finger is a condition where the finger or thumb gets stuck when bent, caused by inflammation of the tendons. Symptoms include a tender lump, catching, and pain when bending the finger. It is often caused by repetitive motions and can be treated with rest, splinting, corticosteroid injections, or surgery to release the tendon sheath if other treatments don't help. Recovery from surgery usually takes a few weeks but may be up to 6 months to fully resolve swelling and stiffness.
This document discusses radial nerve injury, including its anatomy, causes, clinical presentation, diagnostic workup, and management. It describes the radial nerve's course from the brachial plexus into the arm and forearm. Radial nerve injuries can be caused by fractures, compression, or traction injuries. Clinical examination involves assessing motor function of wrist and finger extensors and sensory function on the back of the hand. Management includes nonsurgical treatment, nerve repair or grafting, and tendon transfers in chronic cases. The goal of treatment is to restore wrist and finger extension through nerve regeneration or reconstruction of function.
This document discusses thoracolumbar fractures of the spine. It begins by describing the anatomy of the spine and functional spinal units. It then discusses the physiological anatomy of the thoracic and lumbar spine. It describes the etiology, classifications including the Denis three-column theory and AO/MAGREL classification, clinical presentations, investigations including x-rays, CT and MRI, and classifications of spinal instability for thoracolumbar fractures.
The document describes several classification systems for femoral fractures:
1. The Singh Index grades femoral head osteoporosis on a scale of 1-6 based on the visibility and integrity of trabecular groups in the proximal femur on radiographs. Grades 3 and below indicate definite osteoporosis.
2. Boyd and Griffin classify intertrochanteric femoral fractures into 5 types based on the trabecular structure of the proximal femur which provides strength.
3. The primary blood supply to the femoral head comes from the medial femoral circumflex artery, with minor contributions from cervical arteries and the foveal artery.
Tuberculosis of the hip joint is the second most common site of bone and joint TB after the spine. It typically affects people in their first three decades of life. The infection spreads from a primary focus such as the lungs to the hip joint via the bloodstream. It can initially involve different areas of the hip and pelvis before spreading to the joint. Patients present with hip pain, limping, and constitutional symptoms. Treatment involves anti-TB drugs along with rest, traction, and surgery if needed to address complications like joint destruction and deformity. Surgical options depend on the stage of disease and can include synovectomy, arthrodesis, osteotomy, or arthroplasty.
The document discusses spinal canal stenosis, including:
1. It describes spinal canal stenosis as the narrowing of the spinal canal and compression of the spinal cord and nerve roots, most commonly occurring in the lumbar vertebrae.
2. Symptoms include back pain radiating into the legs, numbness, and weakness that is relieved by bending forward and made worse by standing upright or walking.
3. Treatment options range from non-surgical approaches like medication, physical therapy, and epidural injections for mild-to-moderate cases to surgical decompression like laminectomy or the X-STOP implant for more severe cases.
This document defines scoliosis and provides classifications and descriptions of different types. It begins with defining scoliosis as a lateral curvature of the spine greater than 10 degrees, along with vertebral rotation. It then discusses:
1. Structural vs non-structural classifications based on flexibility.
2. Etiologies including idiopathic, congenital, neuromuscular.
3. Age-based classifications of idiopathic scoliosis.
It also covers clinical features, assessments including radiography, and general management approaches.
Tarsal tunnel syndrome is caused by entrapment of the tibial nerve in the tarsal tunnel behind the medial malleolus. It causes burning, tingling sensations on the sole of the foot, worse at night. Electrodiagnostic studies can diagnose it, while treatment options include non-surgical approaches like injections and orthotics, as well as surgery if non-surgical methods fail.
De Quervain's tenosynovitis is an inflammation of the tendon sheaths of the abductor pollicis longus and extensor pollicis brevis muscles in the wrist. It commonly affects women ages 30-50 and is caused by repetitive motions like knitting or computer use that strain the thumb and wrist. Symptoms include pain on the radial side of the wrist worsened by thumb movement. Conservative treatment involves splinting, anti-inflammatories, corticosteroid injections, and physical therapy exercises. Surgery may be considered if symptoms persist after several weeks of conservative care.
This document provides an overview of adhesive capsulitis or "frozen shoulder" presented by Dr. Shazia Khalfe. It defines adhesive capsulitis as a condition characterized by pain and loss of shoulder range of motion. There are two types: primary which is idiopathic, and secondary which occurs after shoulder injuries or immobilization. Clinical presentation includes pain and limited range of motion. Treatment involves exercises to improve range of motion and strengthen muscles, modalities like heat for pain relief, and patient education on home exercises and prognosis. The goal is to regain full range of motion and normal shoulder function.
Cervical disc prolapse occurs when a cervical disc herniates and compresses the nerve root. The cervical spine has 7 vertebrae and 6 intervertebral discs that act as shock absorbers and allow motion. A disc is composed of an inner nucleus pulposus surrounded by the outer annulus fibrosus. Common sites of prolapse are C5-C6 and C6-C7. Clinical features include neck pain radiating to the arm. Imaging like MRI or CT is used to confirm prolapse. Treatment involves rest, medications, traction and surgery like anterior cervical discectomy if non-operative measures fail.
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?
The document discusses Ayurvedic management of disc prolapse. It begins by describing the causes as repetitive mechanical activities, obesity, poor posture, injury, and genetics. Symptoms include severe back pain radiating to the lower limbs. Diagnosis involves physical exam and imaging tests. Conventional treatments include bed rest, anti-inflammatories, physical therapy, and injections. Ayurvedic management focuses on detoxification, strengthening tissues, proper nutrition and herbs, yoga, and therapies like oil massages. The goal is to reduce pain and inflammation, strengthen tissues, and prevent further deterioration.
Bennett's fracture is a common intra-articular fracture of the base of the thumb metacarpal bone that extends into the carpometacarpal joint. It is usually caused by an axial force on a partially flexed thumb. Left untreated, it can lead to long-term pain, weakness, arthritis, and diminished hand function. While sometimes minimally displaced fractures can be treated non-surgically, surgical intervention like closed reduction or open reduction is often needed to ensure proper healing and restore thumb function. Long-term outcomes often include weakness and arthritis, with severity depending on how well the fracture was reduced.
This document provides information on spinal stenosis including its definition, history, clinical anatomy, pathophysiology, types, investigations, and treatment options. Spinal stenosis is defined as a narrowing of the spinal canal or intervertebral foramina causing compression of neural structures. It was first described in the late 19th/early 20th century and can be developmental, degenerative, post-traumatic, or iatrogenic in nature. Clinical features include neurogenic claudication relieved by flexion. Investigations include imaging like MRI, CT, and myelography. Treatment involves conservative options like activity modification initially, with surgery considered if conservative measures fail.
Pp for lumbarization and sacralization by Dr Dhruv Taneja Assistant ProfessorDhruv Taneja
Lumbarization is a condition where the first sacral vertebra appears like a lumbar vertebra rather than being fused with the sacrum. This occurs when the first and second sacral segments fail to fuse during development. A lumbarized S1 vertebra may have its own disc or an underdeveloped disc space, making it difficult to accommodate and more prone to injury with age. Sacralization is a related condition where the fifth lumbar vertebra fuses with the sacrum, reducing mobility and increasing stress on the L4 vertebra. Both conditions can potentially lead to back pain and disc problems.
TB of the spine commonly affects the thoracic and lumbar regions. It spreads hematogenously and causes destruction of vertebral bodies. Common presentations include chronic back pain and deformities. Advanced cases may involve neurological deficits due to spinal cord compression. Diagnosis involves imaging tests like x-rays and MRI. Treatment is with anti-TB medications along with rest. Surgery is indicated for complications like paraplegia. Prognosis depends on factors like age, duration of symptoms and severity of neurological involvement.
This document discusses intervertebral disc prolapse. It begins by describing disc anatomy, development, and location in the spine. It then explains the pathology of prolapse, which involves nuclear degeneration, displacement, and fibrosis. Risk factors for prolapse include heavy lifting, smoking, obesity, and improper posture. Clinical features include low back pain radiating to the buttocks, aggravated by certain movements. Investigations include CT, MRI, and myelography. Treatment options range from conservative measures like rest and physical therapy to operative procedures like fenestration, hemi-laminectomy, and endoscopic discectomy.
Tarsal tunnel syndrome involves compression of the tibial nerve as it passes beneath the flexor retinaculum in the ankle. It causes pain, numbness and tingling in the foot. Non-surgical treatments include orthotics, stretching, weight loss and activity modification. Surgery to release the flexor retinaculum may be considered if non-surgical options fail. Anterior tarsal tunnel syndrome is a similar condition affecting the deep peroneal nerve. Risk factors include ankle injuries and activities that put repetitive stress on the ankle.
The document discusses prolapsed lumbar intervertebral disc (PLID), which occurs when the soft central portion of an intervertebral disc bulges out beyond the damaged outer rings. It causes severe back and leg pain. Key points include: PLID most commonly occurs at the L4/L5 level. Common symptoms are radiating pain, numbness, and weakness. MRI is the preferred imaging method to detect herniations. Treatment options include conservative measures like NSAIDs, physical therapy, and epidural injections or surgery for severe/progressive cases.
Trigger finger is a condition where the finger or thumb gets stuck when bent, caused by inflammation of the tendons. Symptoms include a tender lump, catching, and pain when bending the finger. It is often caused by repetitive motions and can be treated with rest, splinting, corticosteroid injections, or surgery to release the tendon sheath if other treatments don't help. Recovery from surgery usually takes a few weeks but may be up to 6 months to fully resolve swelling and stiffness.
This document discusses radial nerve injury, including its anatomy, causes, clinical presentation, diagnostic workup, and management. It describes the radial nerve's course from the brachial plexus into the arm and forearm. Radial nerve injuries can be caused by fractures, compression, or traction injuries. Clinical examination involves assessing motor function of wrist and finger extensors and sensory function on the back of the hand. Management includes nonsurgical treatment, nerve repair or grafting, and tendon transfers in chronic cases. The goal of treatment is to restore wrist and finger extension through nerve regeneration or reconstruction of function.
This document discusses thoracolumbar fractures of the spine. It begins by describing the anatomy of the spine and functional spinal units. It then discusses the physiological anatomy of the thoracic and lumbar spine. It describes the etiology, classifications including the Denis three-column theory and AO/MAGREL classification, clinical presentations, investigations including x-rays, CT and MRI, and classifications of spinal instability for thoracolumbar fractures.
The document describes several classification systems for femoral fractures:
1. The Singh Index grades femoral head osteoporosis on a scale of 1-6 based on the visibility and integrity of trabecular groups in the proximal femur on radiographs. Grades 3 and below indicate definite osteoporosis.
2. Boyd and Griffin classify intertrochanteric femoral fractures into 5 types based on the trabecular structure of the proximal femur which provides strength.
3. The primary blood supply to the femoral head comes from the medial femoral circumflex artery, with minor contributions from cervical arteries and the foveal artery.
Tuberculosis of the hip joint is the second most common site of bone and joint TB after the spine. It typically affects people in their first three decades of life. The infection spreads from a primary focus such as the lungs to the hip joint via the bloodstream. It can initially involve different areas of the hip and pelvis before spreading to the joint. Patients present with hip pain, limping, and constitutional symptoms. Treatment involves anti-TB drugs along with rest, traction, and surgery if needed to address complications like joint destruction and deformity. Surgical options depend on the stage of disease and can include synovectomy, arthrodesis, osteotomy, or arthroplasty.
The document discusses spinal canal stenosis, including:
1. It describes spinal canal stenosis as the narrowing of the spinal canal and compression of the spinal cord and nerve roots, most commonly occurring in the lumbar vertebrae.
2. Symptoms include back pain radiating into the legs, numbness, and weakness that is relieved by bending forward and made worse by standing upright or walking.
3. Treatment options range from non-surgical approaches like medication, physical therapy, and epidural injections for mild-to-moderate cases to surgical decompression like laminectomy or the X-STOP implant for more severe cases.
This document defines scoliosis and provides classifications and descriptions of different types. It begins with defining scoliosis as a lateral curvature of the spine greater than 10 degrees, along with vertebral rotation. It then discusses:
1. Structural vs non-structural classifications based on flexibility.
2. Etiologies including idiopathic, congenital, neuromuscular.
3. Age-based classifications of idiopathic scoliosis.
It also covers clinical features, assessments including radiography, and general management approaches.
Tarsal tunnel syndrome is caused by entrapment of the tibial nerve in the tarsal tunnel behind the medial malleolus. It causes burning, tingling sensations on the sole of the foot, worse at night. Electrodiagnostic studies can diagnose it, while treatment options include non-surgical approaches like injections and orthotics, as well as surgery if non-surgical methods fail.
De Quervain's tenosynovitis is an inflammation of the tendon sheaths of the abductor pollicis longus and extensor pollicis brevis muscles in the wrist. It commonly affects women ages 30-50 and is caused by repetitive motions like knitting or computer use that strain the thumb and wrist. Symptoms include pain on the radial side of the wrist worsened by thumb movement. Conservative treatment involves splinting, anti-inflammatories, corticosteroid injections, and physical therapy exercises. Surgery may be considered if symptoms persist after several weeks of conservative care.
This document provides an overview of adhesive capsulitis or "frozen shoulder" presented by Dr. Shazia Khalfe. It defines adhesive capsulitis as a condition characterized by pain and loss of shoulder range of motion. There are two types: primary which is idiopathic, and secondary which occurs after shoulder injuries or immobilization. Clinical presentation includes pain and limited range of motion. Treatment involves exercises to improve range of motion and strengthen muscles, modalities like heat for pain relief, and patient education on home exercises and prognosis. The goal is to regain full range of motion and normal shoulder function.
Cervical disc prolapse occurs when a cervical disc herniates and compresses the nerve root. The cervical spine has 7 vertebrae and 6 intervertebral discs that act as shock absorbers and allow motion. A disc is composed of an inner nucleus pulposus surrounded by the outer annulus fibrosus. Common sites of prolapse are C5-C6 and C6-C7. Clinical features include neck pain radiating to the arm. Imaging like MRI or CT is used to confirm prolapse. Treatment involves rest, medications, traction and surgery like anterior cervical discectomy if non-operative measures fail.
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?
The document discusses Ayurvedic management of disc prolapse. It begins by describing the causes as repetitive mechanical activities, obesity, poor posture, injury, and genetics. Symptoms include severe back pain radiating to the lower limbs. Diagnosis involves physical exam and imaging tests. Conventional treatments include bed rest, anti-inflammatories, physical therapy, and injections. Ayurvedic management focuses on detoxification, strengthening tissues, proper nutrition and herbs, yoga, and therapies like oil massages. The goal is to reduce pain and inflammation, strengthen tissues, and prevent further deterioration.
The document discusses Ayurvedic management of disc prolapse. It begins by describing the causes as repetitive mechanical activities, obesity, poor posture, injury, and genetics. Symptoms include severe back pain radiating to the lower limbs. Diagnosis involves physical exam and imaging tests. Conventional treatments include bed rest, anti-inflammatories, physical therapy, and injections. Ayurvedic management focuses on detoxification, strengthening tissues, proper nutrition and herbs, yoga, and therapies like oil massages. The goal is to reduce pain and inflammation, strengthen tissues, and prevent further deterioration.
This document discusses intervertebral disc herniation. It begins by describing the anatomy of the lumbar spine motion segment and intervertebral disc. It then discusses the causes, risk factors, symptoms, diagnosis and management of intervertebral disc herniation. Common locations for herniation are the L4-L5 and L5-S1 discs. Symptoms can include back pain and radicular leg pain. Diagnosis involves physical exam, imaging like MRI, and ruling out other conditions. Management includes conservative options like physical therapy and injections initially. Surgery is considered if conservative options fail or if neurological deficits are present. Microdiscectomy is a common surgical procedure for disc herniation.
Low back pain is a common cause of disability that affects people of all cultures. It can be acute, lasting less than three months, or chronic, lasting over three months. Common causes include muscle strains, arthritis, herniated discs, and osteoporosis. Physical examination involves assessing range of motion, neurological function, and diagnostic tests like x-rays and MRIs. Physiotherapy management aims to reduce pain and inflammation, improve muscle strength and flexibility, and prevent recurrence through exercises and physical agents like ultrasound, TENS, and spinal traction.
The document discusses the anatomy, physiology, causes, symptoms, diagnosis and management of intervertebral disc herniation. Key points include:
1) Intervertebral discs act as shock absorbers between vertebrae and allow limited spinal movement. Herniation occurs when a tear in the disc allows the nucleus pulposus to bulge beyond the annulus fibrosus.
2) Common causes are repetitive strain, trauma, obesity and poor posture. Symptoms vary depending on location but often include back pain radiating into the legs.
3) Diagnosis involves physical examination including the straight leg raise test and sometimes imaging tests. Management focuses on reducing pressure on neural elements through treatments like
An intervertebral disc prolapse occurs when a tear in the annulus fibrosus allows the nucleus pulposus to bulge out. This most commonly affects the lumbar region, specifically the L4-L5 and L5-S1 discs. Symptoms include back pain radiating into the buttocks and legs. A physical exam reveals limited back movement, muscle spasms, and tenderness over the affected disc. Straight leg raises can reproduce the pain. Diagnosis is confirmed with imaging studies.
This document discusses low back pain, sciatica, and lumbar disc prolapse. It provides details on the anatomy of the lumbar discs and describes how disc prolapses typically occur at the L4/L5 and L5/S1 levels. Clinical features of disc prolapses are outlined for different levels. Conservative and surgical treatment options are discussed. Cervical disc prolapse is also covered, including typical levels of involvement, clinical presentations, and management approaches.
1. Prolapsed intervertebral disc occurs when the gelatinous nucleus pulposus squeezes through the annulus fibrosus and bulges posteriorly or laterally, commonly compressing spinal nerves.
2. Spinal stenosis is a narrowing of the spinal canal that results in cord or root compression. It is often caused by degenerative changes like osteophyte formation.
3. Spondylosis, or spinal osteoarthritis, involves degenerative changes in discs, facets, and joints that cause loss of normal spinal structure and function, commonly affecting the cervical, thoracic, or lumbar regions.
A spinal disc herniation occurs when the soft central portion of an intervertebral disc bulges out beyond the damaged outer rings of the disc. It is commonly caused by trauma, lifting injuries, or unknown causes. Most herniations occur in the lower back and cause low back pain and leg pain. Treatment begins with rest, medications, and physical therapy, with surgery as a last resort if symptoms do not improve. Rehabilitation focuses on reducing pain and inflammation while strengthening muscles through modalities like electrostimulation, heat/cold therapy, and weightlifting.
Places one hand on the ASIS and
the other on the PSIS of the
uppermost hip
Action:
Examiner applies a gentle
posterior shear force while
assistant stabilizes the pelvis
Positive finding:
Unilateral pain at SI joint
Sacroiliac Joint Distraction Test:
Test position:
Subject prone; examiner stands at
subject’s feet
Action:
Examiner places one hand on the
sacrum and the other on the iliac
crest and applies a gentle
posterior-to-anterior shear force
Positive finding:
Unilateral pain at SI joint
Sacroiliac Joint Compression Test:
Cervical Laminoplasty by Pablo Pazmino MDPablo Pazmino
This video explains Cervical Stenosis and Cervical Spondylosis/Arthritis. When stenosis begins to affect the spinal cord this is called Cervical Spondylotic Myelopathy. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Cervical Stenosis/Arthritis for a Laminoplasty feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
A spinal disc herniation occurs when a tear in the outer ring of an intervertebral disc allows the soft central portion to bulge out. Most herniations occur in the lumbar region and cause pain that may radiate into the legs. Diagnosis is made based on symptoms and physical exam, and may include imaging tests. While minor herniations may heal on their own, severe or persistent cases sometimes require surgery.
Low back pain is a common musculoskeletal disorder affecting 40% of people at some point in their lives. It can be acute (lasting less than 7 weeks) or chronic (more than 7 weeks). Common causes include muscle strains, poor posture, obesity, and injuries. Diagnosis involves physical examination and imaging tests like x-rays, CT scans, or MRIs. Treatment depends on whether the back pain is acute or chronic. For acute pain, conservative treatments like NSAIDs, muscle relaxants, and physical therapy are usually effective. Chronic back pain may require more intensive exercises, antidepressants if depression is present, or surgeries like laminectomy or spinal fusion if conservative treatments fail.
This document summarizes the case of a 14-year-old male castrated Border Collie mix named Shaka that presented with a 3-month history of progressive loss of pelvic limb function and shifting non-weight bearing hind limb lameness. Physical examination revealed signs consistent with lumbosacral stenosis. Radiographs and the dog's history and clinical signs led to a working diagnosis of degenerative lumbosacral stenosis. The dog was initially treated with medications, acupuncture, and epidural steroid injections, which provided significant improvement in pain and mobility.
Spine.pptx and its functions with complete assesmentalishbasohail3
This document discusses various pathologies related to the management of spine and musculoskeletal disorders. It covers topics such as intervertebral disc herniation, protrusion, and extrusion. It also discusses prolonged flexion posture and its relationship to disc issues. Signs and symptoms of disc lesions are outlined. Additional pathologies covered include spondylosis, rheumatoid arthritis, ankylosing spondylitis, and Scheuermann's disease.
The document discusses various chronic pain syndromes including low back pain, sciatica, complex regional pain syndrome, trigeminal neuralgia, and cancer pain. It provides details on the definition, causes, symptoms, diagnostic tools and treatment options for low back pain and sciatica, which are the most commonly discussed chronic pain conditions. The treatment sections cover medications, physical therapy, injections including epidural steroid injections, radiofrequency ablation, and other minimally invasive procedures.
How to Manage Your Lost Opportunities in Odoo 17 CRMCeline George
Odoo 17 CRM allows us to track why we lose sales opportunities with "Lost Reasons." This helps analyze our sales process and identify areas for improvement. Here's how to configure lost reasons in Odoo 17 CRM
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Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
Executive Directors Chat Leveraging AI for Diversity, Equity, and InclusionTechSoup
Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
His expertise extends across a diverse spectrum of reporting, database, and web development applications, underpinned by an exceptional grasp of data storage and virtualization technologies. His proficiency in application testing, database administration, and data cleansing ensures seamless execution of complex projects.
What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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How to Add Chatter in the odoo 17 ERP ModuleCeline George
In Odoo, the chatter is like a chat tool that helps you work together on records. You can leave notes and track things, making it easier to talk with your team and partners. Inside chatter, all communication history, activity, and changes will be displayed.
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
हिंदी वर्णमाला पीपीटी, hindi alphabet PPT presentation, hindi varnamala PPT, Hindi Varnamala pdf, हिंदी स्वर, हिंदी व्यंजन, sikhiye hindi varnmala, dr. mulla adam ali, hindi language and literature, hindi alphabet with drawing, hindi alphabet pdf, hindi varnamala for childrens, hindi language, hindi varnamala practice for kids, https://www.drmullaadamali.com
9. • Secondary curves
Secondary curves develops in response to
weight bearing. Purpose of these curves
are to keep the spine balanced in sagittal
plane. The lordotic cervical & lumbar
curves are the secondary curves.
15. Intervertebral Disc
Is a hydrostatic, load bearing structure between
the vertebral bodies from C2-3 to L5-S1.
1/6th of vertebral column
Nucleus pulposus + annulus fibrosus.
Is relatively avascular.
L4-5, largest avascular structure in the body.
16. Vital Functions of the IVD
Restricted intervertebral joint motion
Contribution to stability
Resistence to axial, rotational, and bending
load
Preservation of anatomic relationship.
18. Annulus Fibrosus
Outer boundary of the disc.
Helicoid pattern, more than 60 distinct
concentric layer of overlapping lamellae of
type I collagen.
Resist tensile, torsional and radial stress
Attached to the cartilaginous and bony end-
plate at the periphery of the vertebra.
19. Nucleus Pulposus
Type II collagen strand + hydrophilic
proteoglycan.
Water content 70 ~ 90% Confined fluid within
the annulus.
Convert load into tensile strain on the annular
fibers and vertebral end-plate.
22. Diurnal Change
During day time- disc shrinks by 20%
Body height reduced by 15 – 25 mm
In night- body height is increased.
23. Natural disc ageing: Degeneration starts
as early as at 16 years of age
Loss of the proteoglycan molecule from the
nucleus of the disc.
Progressive dehydration.
Progressive thickening.
Brown pigmentation formation.
Increased brittleness of the tissue of the disc.
24. Factors Contributing To
Disc Ageing
Idiopathic Blood Vessel/Nutrient LossAnd
Dehydration/Decreased Proteoglycans
Production
Vertebral end plate calcification
Arterial stenosis
Smoking
DM
Exposure to vibration
25. Disc pressure
Normal intra-discal pressure: 10-15 kg/cm2
(Sitting)
In lying: Pressure decreases by 50% than
sitting
In standing: < 30% Of sitting.
26. Prolapsed Lumbar Intervertebral Disc
(PLID)
Is a medical condition affecting lumbar spine,
in which a tear in the outer fibrous ring
(annulus fibrosus) of an intervertebral disc that
allows the soft, central portion (nucleus
pulposus) to bulge out beyond the damaged
outer rings
27. This tear may result in the release of
inflammatory chemical mediators which cause
severe pain, even in the absence of nerve root
compression.
Disc herniations are a condition in which the
outermost layers of the annulus fibrosus are
still intact, but can bulge when the disc is
under pressure.
33. Epidemiology
Disc herniation can occur in any disc
Two most common forms are lumbar and
cervical disc herniation.
The former is the most common, causing
lower back pain (lumbago) and often leg pain
as well (sciatica).
34. Epidemiology
Lumbar disc herniation occurs 15 times more
often than cervical disc herniation.
Most disc herniations occur in thirties or
forties when the nucleus pulposus is still a
gelatin-like substance.
With age the nucleus pulposus changes ("dries
out") and the risk of herniation is greatly
reduced
Mostly at L4/5 level.
35. Epidemiology
After age 50 or 60, osteoarthritic degeneration
(spondylosis) or spinal stenosis are more
likely causes of low back pain or leg pain.
Of all individuals, 60% to 80% experience
back pain during their lifetime.
Generally, males have a slightly higher
incidence than females.
36. Causes of PLID
Unaccustomed work
Bad posture
Over weight
Heavy weight lifting
Prolong standing /sitting
Pregnancy
Strenuous activity ( sneezing , coughing,
chronic Constipation)
38. EFFECT OF SMOKING
Blood vessel get
constricted
Transport of nutrients
& disposal of waste
products decreased
Disc cells get
deficient nutrition or
die
Disc degenerates
& results in DISC
INSTABILITY
39. History
Age : 20-45 yrs
Pain starts while lifting/forward bending.
Radiation :towards buttock ,lower limbs.
It is worsen by coughing or straining.
Later paraesthesia/numbness in legs/feet .
Cauda equina : urinary retention & perineal
numbness.
Muscle Weakness
41. Clinical Features
Vary depending on the location of the
herniation and the types of soft tissue that
become involved.
Often herniated discs are not diagnosed
immediately, as the patients come with
undefined pains in the thighs, knees, or feet.
42. Clinical Features
Unlike a pulsating pain by muscle spasm, pain
from a herniated disc is usually continuous or
at least is continuous in a specific position of
the body.
If the disc protrudes to one side, it may irritate
the dural covering of the adjacent nerve root
causing pain in the buttock, posterior thigh
and calf (sciatica).
43. Clinical Features
Neurological changes such as numbness,
tingling, muscular weakness, paralysis,
paresthesia, and affection of reflexes.
A large central rupture maycause
compression of the cauda equina.
Sometimes a local inflammatory response with oedema
aggravates the symptoms
44. Clinical Features
A posterolateral rupture presses on the nerve
root proximal to its point of exit through the
intervertebral foramen; thus a herniation at
L4/5 will compress the fifth lumbar nerve
root, and a herniation at L5/S1, the first sacral
root.
45. DISC & NERVE ROOT
RELATION
L5 is
TRAVERSIN
G NERVE
ROOT
L5 is
EXITING
NERVE
ROOT
46. Features Of Cauda Equina
Syndrome
Bladder and bowel incontinence.
Perineal numbness.
Bilateral sciatica .
Lower limb weakness.
Crossed straight-leg raising sign.
47. Physical Examinations
The straight leg raise test is
positive if pain in the sciatic
distribution is reproduced
between 30° and 70° passive
flexion of the straight leg.
Straight Leg Raise Test
Dorsiflexion of the foot
exacerbates the pain
49. Physical Examinations
Fever – possible infection.
Vertebral tenderness - not specific and not
reproducible between examiners.
Limited spinal mobility – not specific.
If sciatica or pseudoclaudication present – do
straight leg raise.
50. Physical Examinations
Positive test reproduces the symptoms of
sciatica.
Ipsilateral test sensitive – not specific: crossed
leg is insensitive but highly specific.
51. Diagnosis
Examination in a patient with suspected
lumbar (intervertebral) disk disease may
feature the following:
Abnormal gait
Abnormal postures
Decreased lumbar range of motion
Positive straight leg raising test: Indicative of
nerve root involvement
52. Diagnosis
Usually negative nerve root stretch test results
Perform the usual motor, sensory, and reflex
examinations (including perianal sensation
and anal sphincter tone when appropriate). It
is also mandatory to perform a careful
abdominal and vascular examination.
54. Investigations
Laboratory tests are generally not helpful in
the diagnosis of lumbar disk disease.
Indications for screening laboratory tests such
as the following include pain of a non
mechanical nature, atypical pain pattern,
persistent symptoms, and age older than 50
years.
55. Investigations
Complete blood count with differential
Erythrocyte sedimentation rate
Alkaline and acid phosphatase levels
Serum calcium level
Serum protein electrophoresis
56. Imaging studies
Plain radiograph
MRI: Imaging modality of choice
CT scanning
Myelography:
Dynamic L/S spine X-ray . : to rule out the
instability .
Bone scanning: To rule out tumors, trauma, or
infection
57. Imaging studies
X-Ray : lumbo-sacral spine
Loss of lumber lordosis
Narrowed disc spaces
CT scan : lumber spine
Shape and size of the spinal canal
Its contents and the structures around it
58. Imaging studies
Myelogram
pressure on the spinal cord or nerves,
such as herniated discs, tumors, or bone spurs
MRI : lumbar spine
Intervertebral disc protrusion
Bulging out disc
Compression of nerve root
63. Conservative
Anti-depressants
Lumbosacral back support
Tobacco cessation
Weight control
Intravenous sedation, analgesia-assisted
traction therapy (IVSAAT)
Epidural cortisone injection.
64. Epidural Steroid Injection (ESI)
The ESI is usually reserved for more severe
pain due to a herniated disc.
It is not usually suggested if surgery is
indicated
The ESI is probably only successful in
reducing the pain in about half the cases that it
is used.
65. Indications Of Surgery
Cauda equina syndrome
Progressive neurologic deficit
Profound neurologic deficit and
Severe and disabling pain refractory to four to
six weeks of conservative treatment.
66. The objectives of surgery
Relief of nerve compression.
Allowing the nerve to recover.
Relief of associated back pain.
Restoration of normal function
68. Surgical Options
The Tessys method:
The Tessys method
(transforaminal endoscopic
surgical system) is a
minimally invasive surgical
procedure to remove
herniated discs .
71. Surgical Options
Chemonucleolysis:
Chemical destruction
of nucleus pulposus.
Intradiscal injection
ofchymopapain , causes
hydrolysis of protein of
the nucleus pulposus.
Indicated in disc
herniation not responding
to conservative therapy
72. Surgical Options
Lumbar fusion:
Surgeons use this procedure
when patients have
symptoms from disc
degeneration, disc
herniation, or spinal
instability.Lumbar fusion is
only indicated for recurrent
lumbar disc herniations, not
primary herniations
73. Surgical Options
Dynamic stabilization:
Dynamic stabilization is a
surgical technique designed
to allow
movement of
while maintaining
for some
the spine
enough
stability to prevent too
much movement.
74. Surgical Options
Nucleoplasty:
The most advanced form of
percutaneous discectomy
developed to date. Tissue
removal from the nucleus
acts to “decompress” the
disc and relieve the pressure
exerted by the disc on the
nearby nerve root . As
pressure is relieved the pain
is reduced
75. Future treatment
(stem cell therapy)
Substantial progress has been made in the
field of stem cell regeneration of the
intervertebral disc. Autogenic mesenchymal
stem cells in animal models
intervertebral disc degeneration
can arrest
or even
partially regenerate it and the effect is
suggested to be dependent on the severity of
the degeneration.
76. Persistent pain after disc surgery ?
Wrong disc surgery
Recurrent disc Prolapse
Double root in same space
Spare of root in a space
Segmental instabilty
Incomplete removal of disc
Injury to root ( Iatrogenic )