Scoliosis can cause restrictive lung defects, ventilation-perfusion mismatch, and hypoxemia due to thoracic deformity. It can also involve the cardiovascular system by raising right heart pressures or causing mitral valve prolapse. Careful pre-anesthetic evaluation should assess the respiratory, cardiovascular, and neurological systems. Intraoperatively, temperature, fluids, positioning, spinal cord monitoring, and blood conservation are important considerations, as is post-operative respiratory therapy and pain management.
Spinal stenosis is a degenrative spine disorder in which the AP and transverse diameter are decreased causing neural compression and symptoms of chronic & acute nerve compression
Chondromalacia patellae, also known as runner's knee, is a softening and roughening of the cartilage under the kneecap caused by mechanical overload of the patellofemoral joint. Symptoms include pain in front of or beneath the kneecap that is aggravated by activity like climbing stairs. Examination may reveal tenderness under the kneecap edge or crepitus with knee movement. Conservative treatments include rest, ice, strengthening exercises, and anti-inflammatory medication. Surgery to realign or elevate the patella may be considered if conservative treatments fail after 6 months.
Physiotherapy management of trigger finger ppt by Oluwadamilare AkinwandeOluwadamilareAkinwan
This document outlines the physiotherapy management of trigger finger. It begins with an introduction defining trigger finger and epidemiology. It then discusses the pathophysiology, etiology, clinical presentation, diagnosis, and outcome measures. It describes the conservative management including medical, physiotherapy, activity modification, splinting and modalities. Surgical management and post-surgical management are also covered. It concludes that while corticosteroid injection and surgery are evidence-based treatments, more research is needed on physiotherapy management.
Hallux limitus is a progressive arthritic condition that limits the upward motion of the big toe (hallux). Over time, it can worsen and lead to hallux rigidus, where there is no motion in the big toe joint. Risk factors include repetitive stress on the big toe, abnormal foot muscle imbalance, flat feet, and inflammatory conditions like rheumatoid arthritis or gout. Common signs are pain, stiffness, swelling in the big toe joint, limping, and decreased range of motion.
This document provides an overview of osteoarthritis (OA), including its definition, classification, pathogenesis, clinical presentation, and role of knee loading in the development and progression of OA. Specifically, it defines OA as a degenerative joint disease affecting synovial joints, most commonly in the knees, hips, and hands. It can be primary and age-related or secondary to other factors like injury or obesity. Clinical features include pain, stiffness, loss of range of motion, muscle weakness, and crepitus. Radiographs show loss of joint space, osteophyte formation, and bone sclerosis. Higher knee adduction moments during gait are associated with greater load on the medial knee compartment and increased risk of O
Arthrodesis refers to the surgical fusion of a joint. It is indicated for pain and instability in the joint. With improvements in joint replacement surgery, arthrodesis is now less commonly performed. It permanently relieves pain by fusing the bones and eliminating joint movement, at the cost of stiffness. The optimal positions for fusing different joints are described. Common complications include malposition and nonunion.
Scheuermann's disease is a spinal deformity in which the front of the spine does not grow as quickly as the back, causing excessive curvature of the thoracic spine (kyphosis). It typically occurs during periods of bone growth between ages 12-14. Symptoms may include back pain, difficulty breathing, and muscle spasms. Treatment depends on the degree of curvature but may include exercises, bracing, medication, or surgery to reduce the deformity.
Spinal stenosis is a degenrative spine disorder in which the AP and transverse diameter are decreased causing neural compression and symptoms of chronic & acute nerve compression
Chondromalacia patellae, also known as runner's knee, is a softening and roughening of the cartilage under the kneecap caused by mechanical overload of the patellofemoral joint. Symptoms include pain in front of or beneath the kneecap that is aggravated by activity like climbing stairs. Examination may reveal tenderness under the kneecap edge or crepitus with knee movement. Conservative treatments include rest, ice, strengthening exercises, and anti-inflammatory medication. Surgery to realign or elevate the patella may be considered if conservative treatments fail after 6 months.
Physiotherapy management of trigger finger ppt by Oluwadamilare AkinwandeOluwadamilareAkinwan
This document outlines the physiotherapy management of trigger finger. It begins with an introduction defining trigger finger and epidemiology. It then discusses the pathophysiology, etiology, clinical presentation, diagnosis, and outcome measures. It describes the conservative management including medical, physiotherapy, activity modification, splinting and modalities. Surgical management and post-surgical management are also covered. It concludes that while corticosteroid injection and surgery are evidence-based treatments, more research is needed on physiotherapy management.
Hallux limitus is a progressive arthritic condition that limits the upward motion of the big toe (hallux). Over time, it can worsen and lead to hallux rigidus, where there is no motion in the big toe joint. Risk factors include repetitive stress on the big toe, abnormal foot muscle imbalance, flat feet, and inflammatory conditions like rheumatoid arthritis or gout. Common signs are pain, stiffness, swelling in the big toe joint, limping, and decreased range of motion.
This document provides an overview of osteoarthritis (OA), including its definition, classification, pathogenesis, clinical presentation, and role of knee loading in the development and progression of OA. Specifically, it defines OA as a degenerative joint disease affecting synovial joints, most commonly in the knees, hips, and hands. It can be primary and age-related or secondary to other factors like injury or obesity. Clinical features include pain, stiffness, loss of range of motion, muscle weakness, and crepitus. Radiographs show loss of joint space, osteophyte formation, and bone sclerosis. Higher knee adduction moments during gait are associated with greater load on the medial knee compartment and increased risk of O
Arthrodesis refers to the surgical fusion of a joint. It is indicated for pain and instability in the joint. With improvements in joint replacement surgery, arthrodesis is now less commonly performed. It permanently relieves pain by fusing the bones and eliminating joint movement, at the cost of stiffness. The optimal positions for fusing different joints are described. Common complications include malposition and nonunion.
Scheuermann's disease is a spinal deformity in which the front of the spine does not grow as quickly as the back, causing excessive curvature of the thoracic spine (kyphosis). It typically occurs during periods of bone growth between ages 12-14. Symptoms may include back pain, difficulty breathing, and muscle spasms. Treatment depends on the degree of curvature but may include exercises, bracing, medication, or surgery to reduce the deformity.
Klippel-Feil syndrome is a congenital condition where two or more cervical vertebrae are fused. It is caused by mutations in genes GDF6 and GDF3 which regulate bone growth. People with Klippel-Feil syndrome have a short neck, limited neck movement, and sometimes scoliosis. Diagnosis involves x-rays and MRIs showing fused vertebrae. Treatment focuses on pain management through medications, physical therapy, and sometimes surgery to correct spinal abnormalities.
This document discusses 3D printing applications for chest wall pathologies like pectus excavatum. Pectus excavatum is a congenital chest wall deformity where the sternum is sunken in. It can cause cosmetic concerns and sometimes respiratory issues. The standard Ravitch repair technique involves resection of deformed cartilage and fixation of the sternum. 3D printing is now being used to plan complex pectus excavatum repairs in adults. One case presented involved a 43-year-old with severe pectus excavatum who underwent a 3D planned and guided repair that improved his chest wall shape and cardiac function. The future applications of 3D printing for complex chest wall surgeries are promising and allow for more
Reflex Sympathetic Dystrophy (CRPS I) is a chronic pain condition characterized by severe pain, swelling, and skin changes, often affecting a limb. It has no nerve damage. Early multimodal treatment including medications, nerve blocks, and physical therapy can help improve symptoms. Physical therapy focuses on reducing pain and edema, improving range of motion, and addressing vasomotor instability. As the condition progresses, symptoms may become more severe and irreversible changes can occur.
Bicipital tendonitis is inflammation of long head of the biceps tendon under the bicipital groove.
In early stage, tendon becomes red and swollen, as tendonitis develops the tendon sheath can thicken.
In late stage, often become dark red in color due to inflammation.
Physiotherapy management of chronic obstructive pulmonary disease ppt by Oluw...OluwadamilareAkinwan
This document presents an overview of physiotherapy management for chronic obstructive pulmonary disease (COPD). It discusses the epidemiology, pathophysiology, clinical features, diagnosis, stages, and medical management of COPD. It then describes the role of physiotherapy during acute exacerbations, including techniques to reduce work of breathing and secretion removal. Physiotherapy is also involved in pulmonary rehabilitation to improve patient function and management through exercise training and education. Physiotherapy aims to prevent exacerbations and optimize lung function in stable COPD patients.
Iliotibial Band Syndrome (ITBS) is an overuse injury of the iliotibial band, a thick fascia that runs down the outside of the thigh. ITBS is caused by training errors like increasing mileage too quickly, running on uneven surfaces, or having poor form. Anatomical factors like tight muscles or leg length differences can also contribute. Diagnosis involves pain tests like the Renne Test or Noble Compression Test. Treatment starts with rest, ice, stretching, and anti-inflammatories. Later stages may include corticosteroid injections, surgery for refractory cases. Prevention focuses on gradual mileage increases, proper footwear, stretching, and avoiding uneven terrain.
Pusher syndrome is a disorder following brain damage where patients actively push away from their non-paretic side, losing postural balance. It is caused by damage to the posterolateral thalamus, altering perception of the body's orientation to gravity. Treatment focuses on helping patients visually explore their surroundings to recognize their tilted posture. Prognosis is generally good, with function often recovering within 6 months.
Encephalitis: PT assessment and management Surbala devi
Encephalitis is an inflammation of the brain that can be caused by viruses, bacteria, or other microorganisms. Common symptoms include fever, headache, confusion, seizures, and personality changes. It is diagnosed through neurological exams, CSF analysis, imaging tests, and detection of antibodies or genetic material of the infecting pathogen. Treatment involves managing symptoms, treating any underlying infection, and rehabilitation. The prognosis depends on the cause - viral causes often have better outcomes than bacterial causes. Physical therapy can aid recovery through respiratory exercises, positioning, strengthening, and facilitating return of neurological function.
Spinal cord injuries can be either traumatic, from events like car accidents or falls, or non-traumatic, from conditions that damage the spinal cord. They are classified as either tetraplegia or paraplegia depending on whether the arms or legs are affected. Physiotherapy focuses on managing symptoms, preventing complications, and improving function through exercises for mobility, transfers, wheelchair skills, and more. The goal is to maximize independence and allow patients to safely perform daily living activities. Prognosis depends on the completeness of the injury and potential for recovery decreases over time as improvement plateaus.
Perthes disease, also known as Legg-Calve-Perthes disease, is caused by impaired blood flow in the femoral head that leads to bone death in children aged 3-12 years old, causing deformity of the femoral head; it is more common in boys and whites and symptoms include limping and hip pain that varies depending on the stage of bone regeneration. Genetic factors and growth abnormalities play a role in its development.
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
Deformities observed with Pes cavus includes :
*clawing of the toes
*posterior hind foot deformity (described as an increased calcaneal angle)
*contracture of the plantar fascia
*cock-up deformity of the great toe
Following References were used to prepare this powerpoint presentation which makes the slides accurate and relaible for studying purpose; Therapeutic Exrercise – Carolyn Kisner
Orthopaedic Physical Assessment – Magee
Orthopaedic Medicine – L. Ombregt
Campbell’s Operative Orthopaedics
Slides includes following headings;
DEFINITION
TYPES
ORTHOPAEDIC ASSESSMENT
MEDICAL MANAGGEMENT
PHYSIOTHERAPY MANAGEMENT
SURGICAL MANAGEMENT
Tennis elbow and golfer's elbow are forms of elbow tendinitis caused by overuse and repetitive strain on the tendons in the forearm. Tennis elbow involves the tendons on the outside of the elbow and is more common, while golfer's elbow affects the inner tendons. Both result from repetitive motions like swinging, gripping, or flexing and can be treated with rest, anti-inflammatories, bracing, and physical therapy.
Physiotherapy management for Bronchiectasis Sunil kumar
The document discusses physiotherapy treatment for bronchiectasis. The goals of treatment include maximizing quality of life and function by educating patients about self-management of their condition and optimizing secretion clearance, ventilation, lung volumes, and exercise capacity. Treatment involves monitoring patients and administering medication before physiotherapy sessions. The primary interventions include aerobic and strengthening exercises, breathing techniques, coughing maneuvers, airway clearance, and education to support long-term self-management.
This document discusses shoulder impingement syndrome, including its anatomy, causes, symptoms, diagnosis, stages, and treatment approaches. It provides details on the rotator cuff muscles, signs and symptoms of impingement, external and internal factors that can lead to impingement, stages of the syndrome, common tests used for diagnosis, goals of treatment, and manual therapy, therapeutic exercise, and preventative measures used in treatment.
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that affects motor neurons, leading to their degeneration and death. This causes muscles to weaken and atrophy, resulting in paralysis. Eventually, respiratory muscles are affected and the disease becomes fatal. ALS has causes linked to glutamate toxicity, mutations in the SOD1 gene, and oxidative stress damaging motor neurons. There is no cure for ALS and available treatments can only moderately slow progression of the disease.
Piriformis syndrome is a condition where sciatica symptoms occur due to involvement of the piriformis muscle, often caused by muscle tightness or trauma. It results in entrapment of the sciatic or pudendal nerves, leading to pain, tingling, and numbness in the buttocks, thigh, and leg. Diagnosis involves physical tests like the Freiberg test and treatment focuses on stretching, strengthening, and modalities like massage to relieve tightness while surgery is rarely needed.
This document discusses different types of ankle fractures and dislocations, including isolated malleolar fractures, bimalleolar fractures, trimalleolar fractures, syndesmotic injuries, and dislocations. It provides details on incidence, classification systems like the Weber classification for lateral malleolar fractures, treatment approaches such as casting, open reduction and internal fixation (ORIF), and postoperative weight bearing status. Specific fractures like posterior malleolar fractures, Bosworth fracture dislocations, pilon/plafond fractures, and fractures in diabetics are also covered.
Introduction:
Patellofemoral pain (PFP) is one of the most common disorders of the knee. The knee is involved in around 10% of all sporting injuries.
Tria and Alica, described Wiberg classification of patella facet shapes, and there is another classification based on Morphology ratio.
The purpose of this case control study is comparison between the different morphologic types of the patella (Wiberg classification and morphology Ratio) in patients with chondromalacia and normal persons.
Patients & Methods:
In this study we evaluated 30 limbs in 30 patients with chondromalacia (20 females, 10 males ). Medial and lateral facets were calculated on patellar knee view. Also patellar articular length and overall patellar length were calculated in knee joint in 30 flexion. The results were compared to values obtained from 30 limbs in 30 healthy volunteers.
Results:
In Wiberg classification, 57% of normal persons had patella type I while 17% of patients with chondromolacia had this type (p=0.01). Also 43% of normal persons had patella type II while 83% of patients had this type (p= 0.01).
In Morphology ratio classification, 40% of normal persons had patella type II while 13% of patients had this type (p=0.02). Also none of normal persons had patella type III while 13% of patients had this type (p=0.03).
Discussion:
A variety of sports commonly lead to chondromoalacia patella due to unusual compressive forces. Therefore young population specially athletes should pay attention to their patella shapes for selecting the sports types.
This document provides an overview of scoliosis, including:
- Definitions and classifications of scoliosis types like idiopathic, congenital, neuromuscular, etc.
- Descriptions of curve patterns, measurements, and radiographic assessments.
- Clinical features and evaluations like trunk examination, scoliometer use, and Adams forward bend test.
- Etiology, progression risks, and long-term effects of different scoliosis types.
- Common curve classifications including King's type and Cobb angle measurement method.
It serves as a reference for the clinical presentation, evaluation, and management considerations for different scoliosis conditions.
Scoliosis is an abnormal curvature of the spine. It is classified as structural or non-structural. Treatment options include conservative approaches like bracing for mild curves or operative approaches like spinal fusion for more severe curves. Factors like curve degree, progression risk, skeletal maturity and patient symptoms are considered for treatment decisions. Surgery aims to halt progression, straighten the curve and fuse the spine. Complications can include neurological issues, decompensation or pseudarthrosis.
Klippel-Feil syndrome is a congenital condition where two or more cervical vertebrae are fused. It is caused by mutations in genes GDF6 and GDF3 which regulate bone growth. People with Klippel-Feil syndrome have a short neck, limited neck movement, and sometimes scoliosis. Diagnosis involves x-rays and MRIs showing fused vertebrae. Treatment focuses on pain management through medications, physical therapy, and sometimes surgery to correct spinal abnormalities.
This document discusses 3D printing applications for chest wall pathologies like pectus excavatum. Pectus excavatum is a congenital chest wall deformity where the sternum is sunken in. It can cause cosmetic concerns and sometimes respiratory issues. The standard Ravitch repair technique involves resection of deformed cartilage and fixation of the sternum. 3D printing is now being used to plan complex pectus excavatum repairs in adults. One case presented involved a 43-year-old with severe pectus excavatum who underwent a 3D planned and guided repair that improved his chest wall shape and cardiac function. The future applications of 3D printing for complex chest wall surgeries are promising and allow for more
Reflex Sympathetic Dystrophy (CRPS I) is a chronic pain condition characterized by severe pain, swelling, and skin changes, often affecting a limb. It has no nerve damage. Early multimodal treatment including medications, nerve blocks, and physical therapy can help improve symptoms. Physical therapy focuses on reducing pain and edema, improving range of motion, and addressing vasomotor instability. As the condition progresses, symptoms may become more severe and irreversible changes can occur.
Bicipital tendonitis is inflammation of long head of the biceps tendon under the bicipital groove.
In early stage, tendon becomes red and swollen, as tendonitis develops the tendon sheath can thicken.
In late stage, often become dark red in color due to inflammation.
Physiotherapy management of chronic obstructive pulmonary disease ppt by Oluw...OluwadamilareAkinwan
This document presents an overview of physiotherapy management for chronic obstructive pulmonary disease (COPD). It discusses the epidemiology, pathophysiology, clinical features, diagnosis, stages, and medical management of COPD. It then describes the role of physiotherapy during acute exacerbations, including techniques to reduce work of breathing and secretion removal. Physiotherapy is also involved in pulmonary rehabilitation to improve patient function and management through exercise training and education. Physiotherapy aims to prevent exacerbations and optimize lung function in stable COPD patients.
Iliotibial Band Syndrome (ITBS) is an overuse injury of the iliotibial band, a thick fascia that runs down the outside of the thigh. ITBS is caused by training errors like increasing mileage too quickly, running on uneven surfaces, or having poor form. Anatomical factors like tight muscles or leg length differences can also contribute. Diagnosis involves pain tests like the Renne Test or Noble Compression Test. Treatment starts with rest, ice, stretching, and anti-inflammatories. Later stages may include corticosteroid injections, surgery for refractory cases. Prevention focuses on gradual mileage increases, proper footwear, stretching, and avoiding uneven terrain.
Pusher syndrome is a disorder following brain damage where patients actively push away from their non-paretic side, losing postural balance. It is caused by damage to the posterolateral thalamus, altering perception of the body's orientation to gravity. Treatment focuses on helping patients visually explore their surroundings to recognize their tilted posture. Prognosis is generally good, with function often recovering within 6 months.
Encephalitis: PT assessment and management Surbala devi
Encephalitis is an inflammation of the brain that can be caused by viruses, bacteria, or other microorganisms. Common symptoms include fever, headache, confusion, seizures, and personality changes. It is diagnosed through neurological exams, CSF analysis, imaging tests, and detection of antibodies or genetic material of the infecting pathogen. Treatment involves managing symptoms, treating any underlying infection, and rehabilitation. The prognosis depends on the cause - viral causes often have better outcomes than bacterial causes. Physical therapy can aid recovery through respiratory exercises, positioning, strengthening, and facilitating return of neurological function.
Spinal cord injuries can be either traumatic, from events like car accidents or falls, or non-traumatic, from conditions that damage the spinal cord. They are classified as either tetraplegia or paraplegia depending on whether the arms or legs are affected. Physiotherapy focuses on managing symptoms, preventing complications, and improving function through exercises for mobility, transfers, wheelchair skills, and more. The goal is to maximize independence and allow patients to safely perform daily living activities. Prognosis depends on the completeness of the injury and potential for recovery decreases over time as improvement plateaus.
Perthes disease, also known as Legg-Calve-Perthes disease, is caused by impaired blood flow in the femoral head that leads to bone death in children aged 3-12 years old, causing deformity of the femoral head; it is more common in boys and whites and symptoms include limping and hip pain that varies depending on the stage of bone regeneration. Genetic factors and growth abnormalities play a role in its development.
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
Deformities observed with Pes cavus includes :
*clawing of the toes
*posterior hind foot deformity (described as an increased calcaneal angle)
*contracture of the plantar fascia
*cock-up deformity of the great toe
Following References were used to prepare this powerpoint presentation which makes the slides accurate and relaible for studying purpose; Therapeutic Exrercise – Carolyn Kisner
Orthopaedic Physical Assessment – Magee
Orthopaedic Medicine – L. Ombregt
Campbell’s Operative Orthopaedics
Slides includes following headings;
DEFINITION
TYPES
ORTHOPAEDIC ASSESSMENT
MEDICAL MANAGGEMENT
PHYSIOTHERAPY MANAGEMENT
SURGICAL MANAGEMENT
Tennis elbow and golfer's elbow are forms of elbow tendinitis caused by overuse and repetitive strain on the tendons in the forearm. Tennis elbow involves the tendons on the outside of the elbow and is more common, while golfer's elbow affects the inner tendons. Both result from repetitive motions like swinging, gripping, or flexing and can be treated with rest, anti-inflammatories, bracing, and physical therapy.
Physiotherapy management for Bronchiectasis Sunil kumar
The document discusses physiotherapy treatment for bronchiectasis. The goals of treatment include maximizing quality of life and function by educating patients about self-management of their condition and optimizing secretion clearance, ventilation, lung volumes, and exercise capacity. Treatment involves monitoring patients and administering medication before physiotherapy sessions. The primary interventions include aerobic and strengthening exercises, breathing techniques, coughing maneuvers, airway clearance, and education to support long-term self-management.
This document discusses shoulder impingement syndrome, including its anatomy, causes, symptoms, diagnosis, stages, and treatment approaches. It provides details on the rotator cuff muscles, signs and symptoms of impingement, external and internal factors that can lead to impingement, stages of the syndrome, common tests used for diagnosis, goals of treatment, and manual therapy, therapeutic exercise, and preventative measures used in treatment.
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that affects motor neurons, leading to their degeneration and death. This causes muscles to weaken and atrophy, resulting in paralysis. Eventually, respiratory muscles are affected and the disease becomes fatal. ALS has causes linked to glutamate toxicity, mutations in the SOD1 gene, and oxidative stress damaging motor neurons. There is no cure for ALS and available treatments can only moderately slow progression of the disease.
Piriformis syndrome is a condition where sciatica symptoms occur due to involvement of the piriformis muscle, often caused by muscle tightness or trauma. It results in entrapment of the sciatic or pudendal nerves, leading to pain, tingling, and numbness in the buttocks, thigh, and leg. Diagnosis involves physical tests like the Freiberg test and treatment focuses on stretching, strengthening, and modalities like massage to relieve tightness while surgery is rarely needed.
This document discusses different types of ankle fractures and dislocations, including isolated malleolar fractures, bimalleolar fractures, trimalleolar fractures, syndesmotic injuries, and dislocations. It provides details on incidence, classification systems like the Weber classification for lateral malleolar fractures, treatment approaches such as casting, open reduction and internal fixation (ORIF), and postoperative weight bearing status. Specific fractures like posterior malleolar fractures, Bosworth fracture dislocations, pilon/plafond fractures, and fractures in diabetics are also covered.
Introduction:
Patellofemoral pain (PFP) is one of the most common disorders of the knee. The knee is involved in around 10% of all sporting injuries.
Tria and Alica, described Wiberg classification of patella facet shapes, and there is another classification based on Morphology ratio.
The purpose of this case control study is comparison between the different morphologic types of the patella (Wiberg classification and morphology Ratio) in patients with chondromalacia and normal persons.
Patients & Methods:
In this study we evaluated 30 limbs in 30 patients with chondromalacia (20 females, 10 males ). Medial and lateral facets were calculated on patellar knee view. Also patellar articular length and overall patellar length were calculated in knee joint in 30 flexion. The results were compared to values obtained from 30 limbs in 30 healthy volunteers.
Results:
In Wiberg classification, 57% of normal persons had patella type I while 17% of patients with chondromolacia had this type (p=0.01). Also 43% of normal persons had patella type II while 83% of patients had this type (p= 0.01).
In Morphology ratio classification, 40% of normal persons had patella type II while 13% of patients had this type (p=0.02). Also none of normal persons had patella type III while 13% of patients had this type (p=0.03).
Discussion:
A variety of sports commonly lead to chondromoalacia patella due to unusual compressive forces. Therefore young population specially athletes should pay attention to their patella shapes for selecting the sports types.
This document provides an overview of scoliosis, including:
- Definitions and classifications of scoliosis types like idiopathic, congenital, neuromuscular, etc.
- Descriptions of curve patterns, measurements, and radiographic assessments.
- Clinical features and evaluations like trunk examination, scoliometer use, and Adams forward bend test.
- Etiology, progression risks, and long-term effects of different scoliosis types.
- Common curve classifications including King's type and Cobb angle measurement method.
It serves as a reference for the clinical presentation, evaluation, and management considerations for different scoliosis conditions.
Scoliosis is an abnormal curvature of the spine. It is classified as structural or non-structural. Treatment options include conservative approaches like bracing for mild curves or operative approaches like spinal fusion for more severe curves. Factors like curve degree, progression risk, skeletal maturity and patient symptoms are considered for treatment decisions. Surgery aims to halt progression, straighten the curve and fuse the spine. Complications can include neurological issues, decompensation or pseudarthrosis.
This document discusses scoliosis, including its definition as a lateral curvature of the spine greater than 10 degrees with vertebral rotation. It notes that girls are more often affected than boys and curves generally progress during growth spurts. Causes may include musculoskeletal, congenital, neuromuscular, or degenerative issues, or be idiopathic. Treatment depends on curve magnitude and growth potential, ranging from observation for small curves to bracing or exercise for moderate curves to surgery for large curves. Bracing aims to slow progression and decrease need for surgery.
This document discusses scoliosis, defined as a lateral curvature of the spine greater than 10 degrees. It covers the causes of scoliosis including idiopathic, congenital, post-traumatic, and those associated with various medical conditions. The patterns and types of scoliosis like infantile, juvenile, adolescent, and congenital are described. Clinical and radiological findings, treatment options like observation, bracing, and surgery, and examples of scoliosis cases are summarized.
Scoliosis is a lateral curvature of the spine with an element of axial rotation greater than 10 degrees. It is a 3D deformity affecting the coronal, sagittal, and horizontal planes. Thoracic insufficiency syndrome may accompany congenital scoliosis and includes rib fusions and inability of the thorax to support normal respiration. Examination of scoliosis includes inspection, Adams forward bend test, and measurement of Cobb angle on radiographs. Treatment depends on curve severity and skeletal maturity, ranging from observation to bracing or surgery. Intraoperative neurophysiological monitoring helps reduce neurological risks during scoliosis surgery.
This document discusses idiopathic scoliosis, which is defined as a spinal deformity characterized by lateral bending and fixed rotation of the spine without a known cause. It is divided into subgroups based on age of onset, including infantile, juvenile, and adolescent idiopathic scoliosis. Treatment options include observation for mild curves, bracing to prevent progression of moderate curves, and surgery to correct severe or progressive curves. Surgical techniques have advanced from Harrington instrumentation to segmental fixation with hooks and more recently pedicle screws, allowing for improved three-dimensional correction while fusion fewer vertebrae.
Scoliosis is a lateral curvature of the spine visible from the front or side with an accompanying abnormal twisting. It is classified by degree of curvature as mild, moderate, or severe. The main types are congenital, neuromuscular, degenerative, and idiopathic scoliosis. Idiopathic scoliosis is the most common and has no known cause. Treatment depends on the type and severity, and may include bracing, exercise, or surgery. Schroth exercises are a conservative treatment that aim to correct posture and reduce the curve through stretching and strengthening techniques. A case study found Schroth therapy combined with bracing successfully reduced scoliosis curves in an adolescent patient.
Idiopathic scoliosis is a condition that causes the spine to curve to the side. While the cause of scoliosis is unknown, it usually runs in families and typically affects girls and young women more often and severely than boys and young men. Mild cases that do not cause pain or discomfort require no treatment. However, cases that are moderate to severe and with or without pain or discomfort require treatment which is determined on a case by case basis.
http://www.davidsfeldmanmd.com/specialties/scoliosis
Scoliosis is an abnormal curvature of the spine that can affect anyone but is more common in girls. While the cause is unknown, scientists have isolated a gene associated with scoliosis which can help doctors determine the best treatment. The degree of the spinal curve determines how acute or chronic the scoliosis is, with larger curves posing more risks like damage to internal organs. Treatment options depend on the curve's severity and may include monitoring, bracing, or surgery to correct the spine.
its my presentation about scoliosis ,anatamically and therapiutically i explained everything about this here.one of the biggest problem now adays in world.
Torticollis is an adult onset focal or segmental dystonia that causes stereotypical neck postures combining flexion, extension, rotation, and tilting. It typically affects people between 30-40 years old. Treatment options include medical management with botulinum toxin injections or peripheral denervation surgery. The document provides contact information for Dr. Paresh Doshi, a neurological surgeon who specializes in treating torticollis.
This document discusses Legg-Calve-Perthes disease, a childhood condition characterized by avascular necrosis of the femoral head. It begins by describing the disease's pathogenesis, including that the cardinal cause is ischemia of the femoral head due to blocked blood flow in children aged 4-7 years. The document then outlines the stages of the disease from initial infarction to healing or remodeling. Clinical features, radiological findings, and classification systems are presented. Treatment aims to contain the femoral head within the acetabulum and may involve bracing, osteotomies or reconstructive surgeries depending on the child's age and stage of disease.
Brody is a 6-month-old male who presented with head rotation to the right and lateral flexion to the left, and his physician noted his head was misshapen. The document appears to be about a patient named Brody who is being evaluated for torticollis, a condition where the neck muscles are tight and cause the head to tilt to one side.
La tortícolis muscular congénita (CMT) es un trastorno musculoesquelético congénito raro caracterizado por el acortamiento unilateral del músculo esternocleidomastoideo, lo que causa inclinación de la cabeza hacia el lado afectado y rotación contralateral de la cara y el mentón. Se presenta en aproximadamente el 0,3-2% de los recién nacidos. El tratamiento incluye fisioterapia temprana y, para casos resistentes, cirugía para alargar o liberar el músculo afectado
Legg Calve Perthes disease is avascular necrosis of the femoral head in children, most commonly affecting boys ages 4-8. It has an unknown cause but may be associated with conditions like ADHD. Presentation includes a limp or hip/thigh pain. X-rays show changes in the femoral head over time. Treatment depends on age and classification, ranging from observation to osteotomies, with the goal of containing the femoral head to prevent deformity and future arthritis. Prognosis is worse with older age at onset and decreased hip range of motion. Complications can include femoral head deformity, collapse, and leg length discrepancy.
- Pediatric torticollis is characterized by lateral inclination of the head to the shoulder with neck twisting and facial deviation.
- The most common type is congenital muscular torticollis (CMT), caused by unilateral sternocleidomastoid muscle shortening in infants.
- CMT is treated initially with gentle stretching exercises but may require surgery if symptoms persist past 12-18 months to lengthen the tight muscle and prevent facial/head asymmetry. Post-operative immobilization and stretching exercises are used.
Torticollis is a twisting of the neck that can have many causes. In newborns, it is often due to issues during birth or position in the uterus. Older children may experience torticollis after neck injuries or infections. Treatment depends on the underlying cause but may include stretching, medication, bracing, or surgery. Imaging like ultrasound, CT, or MRI can help identify conditions like muscle issues, infections, fractures, or tumors that are causing the neck twisting.
Legg - Calve - Perthes disease is a self-limiting disorder of the hip caused by reduced blood flow and necrosis of the femoral head. It most commonly affects boys ages 4-8 and is characterized by pain and limping. While the exact cause is unknown, factors such as blood clotting disorders, abnormal arterial or venous blood flow, growth delays, trauma, genetics, and environmental influences may play a role in reducing blood supply to the femoral head. Treatment aims to allow the femoral head to remodel itself through non-weight bearing or minimal weight bearing methods.
The document discusses Legg-Calvé-Perthes disease, which is avascular necrosis of the femoral head that typically affects children between the ages of 3-12. It causes the loss of blood supply to the capital femoral epiphysis. The document covers the background, etiology, pathology, presentation, investigations, classifications, treatment options and long term outcomes of Legg-Calvé-Perthes disease.
Torticollis is a condition characterized by an abnormal twisting of the neck which causes the head to tilt to one side. It has many potential causes including birth injuries, infections, muscle injuries or tightness. Symptoms include limited neck movement, neck pain and a shoulder that appears higher on one side. Treatment depends on the underlying cause but may involve gentle stretching, physical therapy, medications, or in rare cases surgery. The document defines different types of torticollis and discusses evaluation and treatment approaches.
- Stabilizes shoulders
- Asks patient to rotate head to
maximum left and right
- Measures angle between chin and
sternum with goniometer
Normal: >60° each side
AS: <45°
Spinal cord injury can result in paraplegia or quadriplegia depending on the level of injury. Emergency management involves immobilization of the spine and transporting the patient for further assessment. Diagnostic tests like x-rays and MRI are used to evaluate the injury. Treatment may include high dose corticosteroids, respiratory support, skeletal traction, and sometimes surgery to decompress the spinal cord. Nursing care focuses on preventing complications and promoting mobility and independence.
1. The document discusses various types of spinal cord injuries including complete injuries which involve a complete loss of motor and sensory function below the level of injury, and incomplete injuries which partially compromise spinal cord function with some sensation and muscle movement retained below the injury site.
2. It provides details on specific spinal cord syndromes like anterior cord syndrome, Brown-Séquard syndrome, and central cord syndrome which are characterized by variable patterns of motor and sensory loss.
3. The management of spinal cord injuries involves stabilizing the spine, treating shock, addressing airway and breathing issues, screening for associated injuries, and preventing complications like pressure sores through regular turning of immobilized patients.
This document discusses biological treatment options for avascular necrosis (AVN) of the femoral head. It provides details on the anatomy and blood supply of the femoral head. AVN occurs when there is interruption of blood flow to the femoral head, leading to bone cell death. Imaging plays an important role in diagnosis and staging of AVN. Conservative options include restricted weight bearing, medications, and physical therapies. Surgical options become necessary with more advanced stages to prevent femoral head collapse. The document covers various classification and staging systems used to determine the appropriate treatment based on the individual case.
Thoracic outlet syndrome occurs when the blood vessels or nerves in the thoracic outlet - the space between the neck and upper chest - become compressed. It was first described in 1821 and various anatomical structures have been identified that can cause compression, including ribs, muscles, ligaments, and fibrous bands. The syndrome has three main types defined by whether the neurovascular structures compressed are nerves, the subclavian artery, or subclavian vein. The compression is usually caused by congenital anatomical variations but can also be due to acquired factors like injuries or repetitive stress.
This document discusses cervical spondylosis and its management. It begins with the anatomy of the cervical spine and describes the intervertebral discs and muscles. It then covers the biomechanics, epidemiology, etiology, clinical manifestations, investigations, differential diagnosis, and management including medical, surgical, and physiotherapy approaches. The goals of physiotherapy treatment are to relieve pain, improve neck movement and posture, and decrease reliance on pain medications. Exercises and modalities like heat, cold, traction, and electrical stimulation are used.
The document discusses various causes of neck and back pain including degenerative changes to the spine like thinning of the annulus and bulging discs which can press on nerves. It describes cervical radiculopathy causing arm pain and cervical myelopathy with neck stiffness and finger tingling. Diagnosis involves x-rays and MRI to view the spine and rule out other causes. Treatment ranges from conservative measures to surgery to relieve pressure on nerves or decompress the spinal cord.
Final case presentation sci (kimberly walsh)Kimberly Walsh
This document provides an overview of cervical myelopathy and spinal cord injury, including:
- Definitions of spinal cord injury and cervical myelopathy.
- Descriptions of anatomy including the spine, cervical spine, intervertebral discs, and ligaments.
- Causes, pathophysiology, and clinical manifestations of both cervical myelopathy and spinal cord injury.
- Details on epidemiology, diagnosis, complications and management of spinal cord injury.
This document discusses different types of muscle disease. It begins by describing the anatomy of skeletal muscle and defining muscle disease as any primary disease of the muscular system related to changes in the muscles. It then outlines six main types of muscle disease: muscular dystrophies, myotonic myopathies and disorders, inflammatory muscle diseases, myasthenic muscle diseases, metabolic myopathies, and endocranial myopathies. Within each type, several specific conditions are described in brief, including Duchenne muscular dystrophy, Becker muscular dystrophy, facioscapulohumeral muscular dystrophy, and distal muscular dystrophy. The document provides details on clinical features, investigations, and treatment for some of the major muscular dyst
Cervical spondylosis is a degenerative condition affecting the bones and joints in the neck. It causes pain, stiffness, and weakness and can compress nerves leading to sensory and motor problems. Symptoms range from mild neck pain to major dysfunction. While it mainly affects older adults, injuries or occupations involving heavy lifting or straining of the neck can also trigger it. Treatment focuses on relieving pain and addressing weakness, sensory loss, and other symptoms through analgesics, cervical collars, physiotherapy, surgery if needed, and encouraging patients to seek medical help. Healthcare assistants should explain cervical spondylosis to patients and ensure any problems are referred to doctors.
This document discusses diseases of the spinal cord, including spinal cord compression and myelopathy. It provides details on:
1. The clinical presentation of spinal cord compression, including pain, weakness, and sphincter disturbances. Brown-Sequard syndrome is described.
2. Causes and examples of myelopathy, including transverse myelitis and multiple sclerosis.
3. Specific spinal cord syndromes like paraplegia are outlined, detailing stages like spinal shock. Cervical disc herniation is also summarized.
A spinal cord injury refers to any injury to the spinal cord that is caused by trauma instead of diseases resulting in a change either temporary or permanent, in its normal motor, sensory or autonomic function.
Cauda Equina Syndrome (CES) involves compression of the bundle of nerves at the end of the spinal cord, and can cause leg weakness, loss of sensation, and bladder/bowel issues. A herniated disc is a common cause of CES. Urgent surgical treatment is important to prevent permanent neurological damage. Early diagnosis and treatment leads to better outcomes, especially for bladder function.
Spondylisthesis by dr venkata rama krishnaiah vapms copvrkv2007
Spondylolisthesis is the slippage of one vertebra over another. It is classified into six types based on cause, including dysplastic (congenital), isthmic, degenerative, traumatic, pathological, and iatrogenic. Isthmic spondylolisthesis is most common, typically occurring at L5-S1, and is often caused by a stress fracture of the pars interarticularis. Diagnosis involves x-rays and sometimes CT or MRI. Treatment includes rest, medications, bracing, physical therapy, and sometimes surgery to stabilize and fuse the vertebrae. Physical therapy focuses on core strengthening, stretching, and exercises to improve mobility and reduce pain.
Neurology 12th disorders of the spine and spinal cordRamiAboali
The document discusses disorders of the spine and spinal cord. It describes the anatomy of the spinal cord and its blood supply. It then outlines the main spinal cord syndromes including spinal cord transection, hemisection, central cord syndrome, and anterior spinal artery syndrome. Specific disorders of the cervical and lumbar spine are also discussed such as cervical spondylosis, cervical and lumbar disc herniation, and lumbar canal stenosis. Clinical features, investigations, and management are provided for each condition. Spinal cord compression is also covered, noting the importance of early diagnosis and treatment to prevent permanent neurological damage.
Jean-Martin Charcot first described neuropathic arthropathy in 1868. It is a progressive joint condition characterized by dislocations, fractures, and deformities that results from sensory or autonomic neuropathy from various conditions like diabetes, MS, alcoholism, etc. The pathophysiology involves both repetitive microtrauma from loss of sensation and an inflammatory process induced by neurovascular changes. It commonly affects the foot, knee, and hip. Diagnosis is made clinically and radiographically, showing features like joint destruction and deformity. Treatment involves casting, bracing, and surgery like fusion for advanced cases.
Ankylosing spondylitis (AS) is a chronic inflammatory disease that primarily affects the spine. It causes back pain and stiffness and can lead to fusion of the vertebrae. The disease is more common in younger males and has a strong genetic link. Symptoms include lower back stiffness and pain that gradually worsens over time. Treatment focuses on relieving pain, maintaining mobility, and preventing deformities through exercises, medications, and sometimes surgery.
Cervical radiculopathy is the clinical description of when a nerve root in the cervical spine becomes inflamed or damaged, resulting in a change in neurological function. Neurological deficits, such as numbness, altered reflexes, or weakness, may radiate anywhere from the neck into the shoulder, arm, hand, or fingers. Pins-and-needles tingling and/or pain, which can range from achy to shock-like or burning, may also radiate down into the arm and/or hand.
Ankylosing spondylitis clinical feature and diagnosisdattasrisaila
Ankylosing spondylitis is an inflammatory arthritis that primarily affects the spine and sacroiliac joints. It presents with inflammatory back pain and stiffness that improves with exercise. Diagnosis requires radiographic evidence of sacroiliitis along with limitations in spinal mobility. The disease progresses over time, leading to fusion of the vertebrae and loss of spinal movement. It is strongly associated with the HLA-B27 gene.
1. The document discusses various abnormalities that can be seen on preoperative electrocardiograms (EKGs), including chamber hypertrophies, conduction defects, arrhythmias, and signs of ischemia/infarction.
2. Chamber hypertrophies covered include left and right atrial and ventricular hypertrophies, each with characteristic EKG patterns.
3. Conduction defects discussed are right and left bundle branch blocks, along with their typical EKG presentations and common causes.
The document provides information on calculating calorie requirements, indications for tube feeding, types of enteral formulas, methods of enteral feeding administration, and potential complications. It discusses formulas for different clinical conditions including renal, hepatic, diabetic and pulmonary. Continuous and bolus feeding methods are described. Common gastrointestinal complications like diarrhea, constipation and nausea are outlined along with potential causes and treatments. Electrolyte imbalances from enteral feeding and their management are also summarized.
This document outlines an anesthetic plan with sections discussing the case scenario, anesthetic concerns, preoperative management, monitoring standards, choice of anesthesia, drugs and dosages, intraoperative fluids, airway management, maintenance, postanesthesia plan, and postop pain management. However, most of the document consists of blank fields to be filled in, so it does not provide much contextual information on its own.
This document summarizes thyroid disease in pregnancy. It discusses how thyroid function changes normally during pregnancy, with relative iodine deficiency and increased levels of thyroid binding globulin and T4 in early gestation. It notes that hyperthyroidism in pregnancy is usually caused by Graves' disease. Left untreated, it can lead to risks for both mother and fetus, including heart failure, thyroid storm, growth restriction and preterm labor. Management involves achieving an euthyroid state through medications like thionamides or propranolol, with close monitoring of thyroid function tests during pregnancy and treatment of any thyroid storm that may occur during labor and delivery.
The document discusses three key determinants of cardiac output: preload, afterload, and contractility. Preload refers to the presystolic stretch of the heart and is reflected by the end-diastolic pressure and volume. Afterload is the pressure the left ventricle must overcome during systole and is often represented by systolic pressure. Contractility determines the strength of the heart's contraction and can be measured by the left ventricular ejection fraction.
The document provides guidelines for postoperative care after carotid endarterectomy, noting that patients should be closely monitored for complications like hypertension, hypotension, hematoma, and cardiac issues in the first 48 hours after surgery. It also discusses potential complications like hyperperfusion syndrome, intracerebral hemorrhage, and seizures that require strict blood pressure control. The guidelines emphasize vigilant monitoring and management of hemodynamics and neurological symptoms in the postoperative period to optimize outcomes and prevent complications.
1. The document provides guidelines from the American Society of Anesthesiologists for managing difficult airways. It defines different types of difficult airways and levels of evidence for various airway management techniques.
2. Key recommendations include conducting an airway evaluation, preparing basic airway equipment, having a pre-planned intubation strategy with non-invasive options, considering awake versus induced intubation, and careful planning for extubation with criteria for awake versus induced extubation.
3. The guidelines provide evidence-based recommendations for each step of difficult airway management - evaluation, preparation, intubation strategy, extubation strategy, and follow-up care - to assist anesthesiologists in decision-making.
This document discusses recognition and management of difficult airways. It defines difficult airway as difficulty with mask ventilation or tracheal intubation. It discusses incidence, risk factors, assessment techniques like Mallampati classification and thyromental distance, and management strategies including awake intubation, use of airway adjuncts like LMA, and the ASA difficult airway algorithm which provides a structured approach. The key points are assessing risk factors, having proper equipment and backup plans, and pursuing oxygenation throughout management of a difficult airway.
The document discusses brain death, its diagnosis and pathophysiology. It defines brain death as the complete and irreversible loss of brain function. The diagnosis involves meeting strict clinical criteria demonstrating the absence of brainstem reflexes as well as confirmatory tests like EEG. Brain death results in no prospect of survival without life support or recovery of brain function. Proper diagnosis is important for organ donation where brain death constitutes legal death.
1) The patient requires careful management of anticoagulation for her mechanical heart valve during pregnancy and delivery. She should receive adjusted-dose low molecular weight heparin throughout pregnancy.
2) A regional anesthetic technique could be used for her planned c-section, but her coagulation status and platelet count must be checked closely both before and after the procedure due to her anticoagulation.
3) After delivery, she will need to resume anticoagulation while monitoring closely for any signs of spinal hematoma due to her recent regional block and anticoagulated state.
Patient Ventilator Synchrony & Successful Weaning講義Dr. Shaheer Haider
This document discusses patient-ventilator synchrony and successful weaning. It defines weaning as the gradual decrease of ventilatory support to prepare for extubation. Optimal synchrony depends on factors like trigger sensitivity, ventilator response time, appropriate tidal volume, and complete expiration to minimize work of breathing. Various ventilator modes and settings can be adjusted to improve synchrony and reduce the risk of reintubation during weaning and extubation.
This document discusses obtaining optimal patient-ventilator synchrony. It describes three phases of patient-ventilator interaction: triggering, breath delivery, and cycling. Trigger asynchrony can occur if the ventilator does not respond quickly enough to the patient's effort. Breath delivery asynchrony may happen if the ventilator does not provide enough flow. Cycling asynchrony can result if the neural inspiration time does not match the mechanical inspiration time. The document provides tips for recognizing and addressing asynchrony issues, such as adjusting ventilator settings and modes. The overall goal is to minimize patient discomfort and optimize lung protection and recovery.
This document provides information about interpreting arterial blood gases, including:
1. It discusses acid-base balance and how the respiratory and renal systems work to maintain pH.
2. It describes the four main acid-base disorders: respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis.
3. It explains how to interpret the components of an arterial blood gas like pH, PaCO2, PaO2, and bicarbonate levels.
Early recognition and treatment of sepsis is important to improve outcomes. The guidelines recommend initially evaluating airway, breathing, and circulation. Goals of early resuscitation include restoring central venous pressure, blood pressure, urine output, and central venous oxygen saturation through aggressive fluid administration and vasopressors if needed within 6 hours of recognition. Intravenous antibiotics should also be administered within 1 hour, and cultures obtained, to treat the underlying infection.
This document provides clinical guidelines for the identification, evaluation, and treatment of overweight and obesity in adults. An expert panel was convened by the National Heart, Lung, and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases to develop the guidelines based on a thorough review of scientific evidence. The guidelines examine the health risks of overweight and obesity and various treatment strategies, providing recommendations to help practitioners effectively assess and treat overweight and obese patients.
P R E G N A N C Y I N D U C E D H Y P E R T E N S I O NDr. Shaheer Haider
Pregnancy-induced hypertension (PIH) is defined as new hypertension developing after 20 weeks of gestation. It affects 5-8% of pregnancies and can range from mild to severe, including pre-eclampsia and eclampsia. The exact cause is unknown but may involve immunological and endothelial dysfunction factors. Treatment aims to prevent complications and involves bed rest, magnesium sulfate, antihypertensive drugs, and delivery if gestation reaches term or the mother/baby's condition deteriorates.
An anxious 52-year-old man is presenting for revision of a previous tympano-mastoidectomy surgery. He has a history of postoperative nausea and vomiting after prior procedures. Monitored anesthesia care with sedation may be suitable for this patient's surgery given his anxiety. General anesthetic techniques that minimize postoperative nausea and vomiting risks include the use of antiemetics like ondansetron and dexamethasone. Regional anesthesia may further reduce postoperative nausea and vomiting risks compared to general anesthesia. Control of blood loss is important during middle ear surgery to maintain a bloodless surgical field. Long-acting neuromuscular blocking agents should be avoided due to the delicate nature of middle ear surgery.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
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share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
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S C O L I O S I S
1. Indian Journal of Anaesthesia 2007; 51 (6) : 486-495 Special Article
Indian Journal of Anaesthesia, December 2007
Scoliosis and Anaesthetic Considerations
Anand H. Kulkarni1 , Ambareesha M2
Summary
Scoliosis may be of varied etiology and tends to cause a restrictive ventilatory defect, along with ventilation-perfusion
mismatch and hypoxemia. There is also cardiovascular involvement in the form of raised right heart pressures, mitral valve
prolapse or congenital heart disease. Thus a careful pre-anaesthetic evaluation and optimization should be done. Intraoperatively
temperature and fluid balance, positioning, spinal cord integrity testing and blood conservation techniques are to be kept in mind.
Postoperatively, intensive respiratory therapy and pain management are prime concerns.
Keywords Scoliosis; Deformity, Spine; Monitoring, Spinal cord; Defect, Restrictive.
Introduction Table 1 Etiologic classification of scoliosis
Scoliosis is a complex deformity of the spine and 1. Idiopathic (genetic) scoliosis (approximately 70% of all cases
of scoliosis; classified by age of onset)
anaesthesia for scoliosis surgery can be challenging, with
several aspects to be kept in mind simultaneously. A brief 2. Congenital scoliosis (probably not genetic)
review is presented to highlight important aspects of the Vertebral
pre-anaesthesia evaluation and anaesthesia management. Open- with posterior spinal defect
With neurologic deficit (e.g., myelomeningocele)
Definition Closed- no posterior element defect
Scoliosis is a complex deformity of the spine re- With neurological deficit (e.g., diastematomy
sulting in lateral curvature and rotation of the vertebrae elia with spina bifida)
as well as a deformity of the rib cage1. There is usually Without neurological deficit (e.g., hemivertebra,
secondary involvement of the respiratory, cardiovascu- unilateral unsegmented bar)
lar and neurologic systems. Extravertebral (e.g., congenital rib fusions)
3. Neuromuscular scoliosis
Classification Neuropathic forms
The initial classification was given by Schulthess Lower motor neuron disease (e.g., poliomyelitis)
W 2. He classified scoliosis by the region involved.
Upper motor neuron disease (e.g., cerebral palsy)
1. Cervico thoracic Others (e.g., syringomyelia)
2. Thoracic Myopathic forms
3. Thoracolumbar Progressive (e.g., muscular dystrophy)
Static (e.g., amyotonia congenita)
4. Lumbar
Others (e.g., Friedrich’s ataxia, unilateral amalia)
5. Combined double primary
4. Neurofibromatosis (Von Recklinghausen’s disease)
The etiologic classification was introduced by the 5. Mesenchymal disorders
Terminology Committee of the Scoliosis Research Soci- Congenital (e.g., Marfan’s syndrome,
ety in 19693, that is shown in Table 1. Morquio’s disease, amyoplasia
congenita, various types of dwarfism)
Epidemiology Acquired (e.g., rheumatoid arthritis, Still’s disease)
Scoliosis can develop at any age, but tends to be- Others (e.g., Scheurmann’s disease, osteogenesis imperfecta)
come clinically evident during periods of rapid somatic 6. Trauma
growth. It’s reported prevalence in the general population Vertebral (e.g., fracture, irradiation, surgery)
varies from 0.3 – 15.3% 4-6. However the prevalence is Extravertebral (e.g., burns, thoracic surgery)
less than 3% for curves more than 10o and less than 0.3%
1. MD, DNB, Assistant Professor, 2. MD, DA, Professor and Head, Dept of Anesthesia, Kasturba Medical College, Mangalore,
Correspondence to: Anand H.Kulkarni, C 3-20, KMC Staff Quarters, Lighthouse Hill Road, Mangalore -575003. Karnataka, India.
E-mail: kulkarnianandh16@yahoo.co.in Accepted for publication on:20.10.07
486
2. Anand H. Kulkarni et al. Scoliosis and anaesthesia
for curves more than 30 o. It is more common in adoles-
cents and has a female to male ratio of about 3:1 7.
75 -90% of cases of scoliosis are of the idiopathic
type, out of which the adolescent type is most common.
Remaining 10 – 25% cases belong to various other eti-
ologies1.
Measurement of severity
The Cobb’s method of measurement, recom-
mended by the Terminology Committee of the Scoliosis
Research Society, consists of three steps.
1. Locating the superior end vertebra.
2. Locating the inferior end vertebra.
3. Drawing intersecting perpendicular lines from the
superior surface of the superior end vertebra and from
the inferior surface of the inferior end vertebra. Fig.1 Cobb’s method: measurement of severity.
The angle of deviation of these perpendicular lines
from straight line is the angle of the curve (Fig1). If the Pre anaesthetic assessment
end plates are obscured pedicles can be used instead for I. Airway assessment: Airway difficulties may be
quantification 8. The draw back of the Cobb’s method is anticipated when the scoliosis involves the upper
that it measures a complex deformity in only two dimen- thoracic or cervical spine. Also devices like halo
sions. Nevertheless it maintains a uniform method of traction may interfere with securing the airway.
measurement. Some disorders like Duchenne muscular dystrophy
Surgery is performed when the Cobb’s angle ex- may lead to tongue hypertrophy.
ceeds 50o in the thoracic spine and 40o in the lumbar II. Respiratory system: Assessment of the pulmo-
spine. The goal of surgery is to stop the progression of nary system must focus on evidence of pre existing
cardiopulmonary disease. If untreated, idiopathic scolio- lung injury or pulmonary disease, pneumonia and
sis is often fatal in the fourth or fifth decades of life as a 10
severity of scoliosis . Factors associated with post-
result of pulmonary hypertension or respiratory failure9 . operative mechanical ventilation requirements in-
The severity of scoliosis and clinical implications are as clude pre-existing neuromuscular disease, severe
in Table 2. restrictive pulmonary dysfunction with a vital
Table 2 Severity of scoliosis and clinical correlation7 : capacity(VC) of <35% predicted, congenital heart
Cobb’s angle Clinical manifestations defects, right ventricular failure,obesity, anterior tho-
-1 9
( degrees) racic spine surgery and blood loss of >30ml.kg .
<10 No symptoms Scoliosis results in reduced VC, reduced functional
>25 Increase in pulmonary artery pressure residual capacity (FRC), and restrictive pulmonary
>40 Consider surgical intervention disease pattern characterized by increased respira-
>70 Significant decrease in lung volume tory rate and decreased tidal volume. The severity
>100 Dyspnea on exertion of pulmonary impairment is influenced by the scolio-
o
>120 Alveolar hypoventilation, chronic respiratory sis angle (>70 ), number of vertebra involved (7 or
failure.
more), cephalad location of the curvature and de-
Treatment options: gree of loss seen in the thoracic kyphosis. Pulmo-
I. Non surgical – braces, traction, plaster applications nary impairment is manifested by a decreased arte-
9.
rial oxygen tension due to pulmonary shunting There
II. Surgical- posterior approaches, anterior ap-
is significant controversy regarding the degree of
proaches, combined/staged procedures
487
3. Indian Journal of Anaesthesia, December 2007
improvement in pulmonary function after scoliosis way obstruction, which may be a result of chronic
surgery. One study found that patients with an an- airway inflammation secondary to poor clearance
14
terior component to correction had worse pulmo- of secretions . Significant displacement or rotation
nary function testing variables at 3 months but im- of the trachea or main stem bronchi may cause
15
proved function at 2 years. Patients who had poste- mechanical airway obstruction . In severe restric-
rior correction only had a trend for improved func- tive defects, there is decrease in inspiratory capac-
tion at 3 months but no significant difference from ity and also ineffective ventilatory patterns which
11
the anterior or combined group at 2 years . Scolio- rely on increase in frequency of respiration rather
sis surgery is more likely to have immediate pulmo- than increase in tidal volume, which increases the
o
nary complications if the curvature is >60 . Reduced work of breathing and promotes respiratory muscle
VC is the first manifestation of restrictive lung dis- fatigue in response to exercise. They also have a
16
ease. As the disease progresses gas exchange is decreased response to carbon dioxide . When the
o
affected by ventilation-perfusion mismatch, alveo- Cobb’s angle is 100 patients are at an increased
lar hypoventilation, an increased dead space and an risk of developing chronic respiratory failure and
increased alveolar- arterial gradient. Prolonged pe- pulmonary hypertension. The pulmonary hyperten-
riods of hypoxemia result in pulmonary hyperten- sion is a product of chronic atelectasis, chronic hy-
17
sion, hypercapnia and eventual respiratory failure. poxemia and chronic hypercapnia . Scoliosis of neu-
Surgery for scoliosis is performed to slow disease romuscular dysfunction etiology usually starts from
10
progression and prevent complications . Scoliosis early infancy, when the chest wall is very compli-
may limit the function of the respiratory muscles ant, and the distortion of the thorax is severe. Also
i.e., intercostals may be overstretched or unable to the lung growth is severely impaired. Moreover the
stretch due to intercostal space changes, putting potential for complications is higher because of prob-
them at a mechanical disadvantage. Moreover, the lems like chronic recurrent aspiration and
7
effectiveness of the muscles may be hampered by pneumonias due to impaired secretion clearance .
limiting the ability of the thorax to expand. The dis- Preoperatively respiratory function should be as-
tortion of the thoracic cage makes the respiratory sessed by a thorough history, focusing on functional
system much less compliant, thus increasing the impairment and effort tolerance, physical examina-
work of breathing even when the lungs themselves tion and appropriate investigations. Respiratory func-
12
are healthy . Scoliosis has generally been associ- tion should be optimized by treating any reversible
ated with the development of restrictive lung defect cause of pulmonary dysfunction like infection by
manifested by a decrease in total lung capacity physiotherapy and bronchodilator therapy as indi-
(TLC) on pulmonary function testing. Infantile and cated. Preoperative incentive spirometry is advis-
juvenile scoliosis are more likely to be associated able before thoracotomy for anterior approach cor-
with true lung hypoplasia because the thoracic de- rections.
formity is present during the period of rapid lung III. Cardiovascular system: The cardiovascular
13
growth and development . In adolescent scoliosis, changes associated with scoliosis are less common
in contrast, the decrease in TLC is more likely to but more serious than the changes in the respira-
reflect the impaired chest wall mechanics that pre- tory system and share a common etiology. The al-
7
vent normal inflation of the lungs . Long standing teration in the cardiovascular system is related pri-
hypoinflation and atelectasis leads to further reduc- marily to the changes in the structure of the medi-
tion of lung volume. The decreased TLC is often astinum and secondarily to the effects of chronic
associated with increased residual volume (RV), respiratory insufficiency on the function of the car-
resulting in very high RV /TLC ratio reflecting the diac system. The primary changes are related to
dysfunction of expiratory muscles, which do not al- structure of the mediastinum following scoliotic
7
low full exhalation . In severe cases of scoliosis, curves. The effect is a restrictive pericarditis with
flow-volume loops may show evidence of lower air- a possible secondary pericardial effusion. Limited
488
4. Anand H. Kulkarni et al. Scoliosis and anaesthesia
cardiac filling decreases any potential increases in Table 3 Suggested preoperative investigations be-
18
cardiac output . In response to exercise, the al- fore major spine surgery9
ready elevated pulmonary artery pressure increases. M i n i mu m Optional
Moreover the displacement or compression of the investigations investigations
Respiratory Plain chest X-ray PFT (bronchodilator
heart due to thoracic deformity may not allow an system reversibility)
increase in stroke volume necessary during exer- ABG Pulmonary diffusion
7 capacity
cise . Eventually even normal filling can be impaired Spirometry(FEV1,FVC)
and the cardiac output at rest can be impaired. At Cardiovascular ECG Dobutamine
stress echo
this point cardiac reserves are limited and may not system
Echo Dipyridamole/thallium
able to withstand the increased haemodynamic de- scintigraphy
mand of major surgery. Echocardiography and stress Blood Complete blood count Liver function tests
Clotting profile
testing, either physical or pharmacologic, can be Cross match
done to determine the performance of the myocar- Urea/electrolytes
dium. In addition to mechanical impairment of myo- IV. Neurologic system: A detailed neurologic evalua-
cardium, there can be cardiovascular pathology sec- tion and documentation is important because of medi-
ondary to the chronic insufficiency of the respira- colegal issues. Moreover, patients who have preex-
tory system. Pulmonary hypertension is the natural isting neurologic deficits are at an increased risk of
18
evolution from chronic hypoxemia . Other factors developing spinal cord injury during scoliosis surgery.
contributing to pulmonary hypertension are that the Prepoerative considerations for patients undergo-
number of vascular units per unit volume of lung is ing major reconstructive spinal surgery are summa-
19
lesser than in normal lungs .Also in the compressed rized in Table 4.
lung regions, the alveoli become smaller than at re- Table 4 Preoperative considerations for patients
sidual volume, leading to blood flow in extra alveo- undergoing major reconstructive spinal surgery22
20
lar vessels which have a higher resistance . Even- Problem C o mme n t
tually right ventricular strain and failure will evolve Respiratory
from increased work of right sided cardiac output. Reduction in total lung Reduction worse with increas
capacity and vital -ing deformity. If vital capac
Detection of any right ventricular dysfunction should capacity -ity <40% predicted postop
be a stronger indication for complete cardiac evalu- -erative ventilation likely.
18
ation . Patients with idiopathic scoliosis also have A further decrease in the vital
capacity of up to 40% may
been found to have a high incidence of mitral valve occur postoperatively: recov-
prolapse (up to 25%). It may indicate a common ery may take up to 2
months.
basis for both the entities, namely a collagen disor- Increasing V/Q mismatch Hypoxemia more likely
7
der . Moreover the incidence of scoliosis is higher Cardiovascular
Increase in pulmonary Independent of severity of
in patients with congenital heart disease than in nor- vascular resistance scoliosis
mal subjects. Hence the patients should be evalu- Increase in incidence of High index of suspicion
congenital heart disease
ated for the presence of congenital heart disease and mitral valve
like ventricular or atrial septal defects, patent duc- regurgitation
21 Neurological
tus arteriosus, tetralogy of Fallot . Assessment of Variable preoperative Careful preoperative docu
the cardiovascular system should be done keeping deficit mentation
all above in mind. Minimum investigations include Musculoskeletal
Muscular dystrophy Abnormal response to muscle
an electrocardiogram and echocardiography to as- relaxants
sess left ventricular function and pulmonary artery Respiratory impairment Postoperative ventilation may
be required
pressures. Dobutamine stress echo may be used to Nutrition
assess cardiac function in those with limited effort Malnourishment Likely in patients with meta
-static carcinoma
tolerance9 . The preoperative investigations suggested
are as in Table 3. Anaesthesia technique
I. Premedication: It is advisable to avoid use of nar-
489
5. Indian Journal of Anaesthesia, December 2007
cotics or heavy sedation as premedication in pres- capnography, esophageal stethoscope and a tem-
ence of pulmonary function impairment. perature probe. Also a urinary catheter should be
Bronchodilators may be used as part of optimiza- placed and urine output measured. The prolonged
tion of lung function preoperatively.Antisialogogues anaesthesia in unusual positions, combined with sig-
may be of value in procedures where a fibre- optic nificant blood loss, haemodynamic effects of tho-
intubation is planned or when prone or lateral posi- racic surgery and possible need for deliberate hy-
tion is required to minimize secretions and avoid potension mandate an invasive arterial line. Also
wetting of the tape securing the endotracheal tube. serial blood gas measurements may be done where
In those at risk of aspiration H2 blocking agents or required. CVP values are not reliable in the prone
proton pump inhibitors may be administered with or 23
position or with an open chest .
without sodium citrate.
VI. Positioning: Patient positioning for surgery varies
II. Induction: Routine induction by the intravenous depending on the level of spine to be operated upon
route is common. Alternatively an inhalational in- and nature of proposed surgery. Repositioning may
duction may be used guided by the patient’s condi-
be required intraoperatively. Peripheral nerves, eyes,
tion. Use of succinylcholine may be associated with
genitals and bony points should be padded and pro-
a hyperkalemic response in presence of myopathies
tected. Intraoperative imaging is often required, thus
or denervation. It may also cause malignant hyper-
the surgical site should be placed away from the
thermia in certain syndromes like King- Denborough,
table’s central support area. Prone positioning re-
central core disease, adenylate kinase deficiency
20
etc . Therefore it may be prudent to avoid succi- quires an uncompressed abdomen. Anterior ap-
nylcholine in these cases and use nondepolarising proaches to thoracic spine are via a thoracotomy
neuromuscular blocking agents for intubation. with the patient supported in the lateral position.
Anterior approach to the lumbar spine necessitates
III. Intubation: Anterior approaches to spine may ne- laparotomy.
cessitate the use of a double lumen tube for lung
isolation to enable access to the anterior spine. This VII.Malignant hyperthermia: Malignant hyperther-
may be difficult in cases where there is involve- mia is a rare pharmacogenetic myopathy affecting
24
ment of upper thoracic or cervical spine by the humans .Affected patients are susceptible to acute
scoliosis since distortion of the tracheobronchial tree hyperthermia which may be triggered by potent in-
25
is a common accompaniment. On the other hand a halational anaesthetics or succinyl choline . There
single lumen tube may be used, allowing more lim- are several published reports of myopathies associ-
ited intraopertive lung retraction, after discussion ated with malignant hyperthermia and several of
with the surgeon. In posterior approaches a single these syndromes have skeletal abnormalities includ-
20
lumen tube is used. ing scoliosis .It is critically important to be alert for
IV. Maintenance: A stable anaesthetic depth is re- early evidence of malignant hyperthermia like rise
quired to enable proper interpretation of somato in body temperature, elevated heart rate, ventricu-
sensory evoked potentials (SSEPs) or motor evoked lar arrhythmias or hypercapnia. The key to success-
potentials (MEPs). Either a nitrous oxide-narcotic- ful management of malignant hyperthermia is im-
inhalation agent technique may be employed or an mediate cessation of triggering agents, 100% oxy-
intravenous technique using propofol may be used. gen, cooling, supportive respiratory, cardiovascular
Non-depolarizing neuromuscular blocking agents are and acid-base procedures; and drugs like dantrolene
20
used to maintain relaxation. When MEPs are to be which lower free ionized intracellular calcium .
recorded it is advisable to use atracurium by con- VIII.Spinal cord monitoring: The cervical and lum-
tinuous infusion and maintain a constant depth of bar ganglionic areas of the spinal cord are meta-
block by neuromuscular monitoring. Intravenous flu- bolically more active and the number and size of
ids should be warmed and a warming mattress de- the cervical and lumbar feeders are greater than
vice is preferable. those in the thoracic cord and thus the thoracic cir-
V. Intraoperative monitoring: Minimum monitoring culation is described as“water shed”. This critical
should include ECG, NIBP, pulse oximetry, zone extends from T4 to T9 where the vascular
490
6. Anand H. Kulkarni et al. Scoliosis and anaesthesia
supply is least generous and special care should be aesthetic agents may suppress SSEP signals, cer-
26
taken during surgery .Distraction of the spine, tain patient conditions like neuromuscular degenera-
placement of pedicle screws and bony decompres- tion may make SSEPs impossible to obtain; and
sion are intraoperative events in which the spinal anterior cord injury may go completely undetected
27
cord or nerves may suffer injury . Above and be- in spite of SSEP monitoring. A wake-up test should
low the auto- regulation range, spinal cord blood flow be planned for well in advance and discussed with
depends on perfusion pressure. Spinal cord injury the patient in the pre-anaesthesia visit. Because of
due to above reasons leads to loss of auto regula- neuromonitoring concerns a predominantly nitrous
tion. In this situation hypotension may further com- oxide and narcotic technique is typically used. Small
promise spinal cord blood flow and compound the doses of volatile anaesthetics, if used, should be dis-
injury. Spinal cord blood flow is also highly sensitive continued an hour before wake-up is anticipated.
to PaCO2 alterations during induced hypotension28 . Two or three twitches on a train-of-four are suffi-
The risks of spinal cord damage and methods to cient to allow the patient to move his or her toes.
minimize the risks are as given in Table 5. The inci- After discontinuation of nitrous oxide and ventila-
dence of post operative neurologic injury is estimated tion with 100% oxygen, the patient should be able
29
at 1.84% .SSEPs, MEPs and the “wake-up” tests to follow commands to move their toes within ten
are commonly used to help safeguard spinal cord minutes. It is not advisable to reverse neuro muscu-
and nerve root function during surgery. lar blockade or narcotics to speed a wake-up test
Table 5 Risks of spinal cord damage 22 because this may result in violent movements that
can damage instrumentation or hurt the patient. Also
Risk related to:
the sympathetic discharge accompanying narcotic
Length and type of surgical procedure reversal may further compromise spinal cord blood
Spinal cord perfusion pressure flow. As soon as satisfactory movement is observed,
Underlying spinal pathology anaesthesia is reestablished. A successful wake-up
Pressure on neural tissue during surgery test suggests an intact cortex and spinal cord.
Risk minimized by: B . SSEP: They are a type of sensory evoked response.
Careful positioning It provides the ability to monitor functional integrity
Maintaining SCPP of sensory pathways in the anaesthetized patient
SCPP = MAP – CSFP undergoing surgical procedures which place the
CSFP can be reduced by CSF drainage spinal cord at risk. It is recorded after electrical
MAP manipulated by anaesthetist stimulation of a peripheral mixed nerve. Stimulation
?keep systolic blood pressure > 90 mmHg is by surface electrodes placed on the skin above
Drugs the nerve. A square wave stimulus of 50-250 micro
Methylprednisolone given less than 8 hours after insult sec duration, strength 20-50 mA, stimulation rate 1-
NMDA antagonists (ketamine, magnesium) 6 Hz is commonly used. Sites of stimulation are
Prevention of hematoma formation
common peroneal nerve at knee or posterior tibial
nerve at ankle. For best results an anaesthetic tech-
Careful hemostasis
nique that does not markedly depress the SSEP
Stop anti-platelet medication preoperatively
should be chosen and the physiologic status of the
Withhold heparin immediately postoperatively
patient should remain constant during periods of
(CSFP, cerebrospinal fluid pressure; MAP, mean arterial pressure; 31
NMDA, N-methyl-D-aspartate; SCPP, spinal cord perfusion pres-
potential surgical injury .The blood supply to the
sure)
motor tracts is derived from the anterior spinal ar-
tery. It is therefore possible for significant motor
A. Wake-up test: It was first described by Vauzelle,
30 deficit to develop post-operatively in patients with
Stagnara et al in 1973 . It is a gross test of spinal 32
intact SSEPs throughout surgery . All anaesthetic
motor function. It remains the most reliable assess-
drugs affect SSEPs. Generally they tend to increase
ment of the intact spine for several reasons. An-
latency and decrease amplitude. Exceptions are ni-
491
7. Indian Journal of Anaesthesia, December 2007
trous oxide, ketamine and midazolam which do not A. Reducing blood loss
affect latency. Etomidate has been reported to in- 1. When patients are placed prone intraabdominal
crease amplitude. The use of inhaled agents upto 1 pressure should be minimized. This leads to a re-
MAC may not significantly affect SSEP monitor- duced epidural venous pressure and thus the venous
ing. Bolus doses of opioids or sedatives or sudden surgical bleed.
increase in concentration of anaesthetic agents al-
2. Hypotensive anaesthesia is considered a reason-
ter SSEPs. Therefore the best anaesthetic technique ably safe and effective method for reducing blood
is one that provides smooth and continuous anaes- loss by up to 58% during spine surgery .Mean
42,43
31
thetic effect avoiding bolus dosing . Physiologic arterial pressure is typically maintained at 60-65mm
factors influencing SSEPs include blood pressure, of Hg. Hypotensive anaesthesia can be achieved
44
temperature and blood gas tensions. When mean by the use of inhalational agents , sodium nitroprus-
arterial pressure falls to below the lower limit of 45
side , ganglion blocking drugs e.g.trimethaphan ,
46
47
auto- regulation there is progressive decrease of calcium channel blockers e.g. nicardipine , beta
33 48
amplitude with no change in latency . Hypother- blockers e.g. propranolol, esmolol, labetalol , nitro-
49 50
mia causes increase in latency and decrease in glycerin , fenoldopam etc.
34
amplitude .Hyperthermia decreases amplitude and 3. Antifibrinolytic agents e.g. aprotinin inhibits plas-
0 35
causes loss of wave at 42 C . Hypoxia decreases min and kallikrein and preserves platelet function .
51
36
amplitude . An amplitude decrease of 50% or a Urban et al found significantly reduced blood loss in
latency increase of 10% may suggest a correctable major spine surgeries where aprotinin infusion was
41
problem. It is to be confirmed that capnography; used intraoperatively .
pulse oximetry and temperature readings are all
constant for the patient. The blood pressure is to be B. Autologous blood transfusion
raised in attempt to improve spinal cord perfusion. Autologous blood can be made available to the
If hemodilution had been performed it should be patient by 3 methods.
reversed. A wake-up test or anatomic manipulation 1. Preoperative autologous blood donation
may then be performed based on the surgeon’s dis- (PABD): The patient donates blood 3 -5 weeks
cretion37 . before surgery for use intraoperatively. Recombi-
C. MEP: The limitations of the wake- up test led in- nant erythropoietin has been used before major sur-
vestigators to explore the possibility of monitoring gery to rise hemoglobin levels, to reduce allogenic
MEPs38 . Compared to SSEPs, MEPs are markedly blood requirements and facilitate PABD and acute
depressed by almost all anaesthetic agents 39.The normovolemic hemodilution (ANH).
marked influence of anaesthetic drugs on MEPs de- 2. Acute normovolemic hemodilution (ANH): This
mands a rigid anaesthetic protocol. During the MEP is performed immediately before surgery. The re-
recording anaesthesia is maintained by minimum moved blood is replaced by the infusion of colloids
dose of ketamine or etomidate infusion. An alterna- or crystalloids to achieve normovolemia with re-
tive is to use a titrable infusion of droperidol-fenta- duced hematocrit. During surgery blood of a lower
nyl40 . hematocrit is lost. The donated blood may be
IX. Blood conservation: In extensive spine surgeries retransfused once hemostasis is achieved.
-1 41
blood losses are typically 10 to 30 ml.kg . It is 3. Intraoperative cell salvage: Blood lost during
desirable to keep allogenic blood transfusion to a surgery is collected using commercially available
minimum considering the risks of allogenic transfu- equipment and is then anticoagulated, filtered for
sion i.e., hypothermia, impaired coagulation, hyper- clots and debris, centrifuged, resuspended in saline
kalemia, hypocalcaemia, transfusion reactions, acute and reinfused to the patient. Clotting factors need
lung injury, transmitted infections etc. This is ac- to be replaced using fresh frozen plasma. The tech-
complished by techniques to reduce blood loss and nique is unsuitable in the presence of malignancy or
by autologous blood transfusion. infection.
492
8. Anand H. Kulkarni et al. Scoliosis and anaesthesia
53
X. Post operative care: The patients undergoing fects . The use of opioids would not interfere with
scoliosis surgery frequently have preexisting mor- neurologic assessment. However the effects of a
bidity, and surgery imposes several further stresses single intrathecal opioid dose would have a limited
like significant blood loss and fluid shifts, prolonged duration of effect. Other techniques like intrapleu-
anaesthesia, hypothermia etc. After scoliosis cor- ral infusions of local anaesthetics or opioids or both
45
rection preferably all patients should be cared for in have been used .The use of low dose intravenous
an intensive care setting. This is particularly impor- ketamine has demonstrated efficacy with an initial
tant in those with pre existing myelopathy, pulmo- dose of 0.25 mg.kg -1, followed by an infusion of 2-
nary dysfunction, cardio vascular disease, extensive 2.5 mcg.kg -1.min-1 improves pain scores, decreases
spine surgery, airway edema or those who have had nausea, reduces narcotic requirements and is not
10
massive transfusion . Oxygen by mask is given for associated with hallucinations27 .
the first few hours after extubation and may be re-
quired for longer periods in those with pre existing Conclusion
pulmonary dysfunction. Pulmonary complications Scoliosis, which may be of varied etiology, leads to
(ARDS, pneumonia, atelectasis, pulmonary embo- respiratory involvement characterized by restrictive lung
lism) are the most common post operative compli- disease, ventilation-perfusion maldistribution and hypox-
cations, and vigilant monitoring, incentive spirom- emia. Cardiovascular involvement is usually in the form
etry and aggressive pulmonary toilet are essential of raised right heart pressures, mitral valve prolapse or
for reducing morbidity particularly in those with pre congenital heart disease. Anaesthesia is often needed
existing pulmonary disease. Certain other compli- for corrective orthopaedic surgery, which is very chal-
cations which could occur after scoliosis surgery lenging. A detailed pre-anaesthetic assessment and opti-
are neurologic injury, ileus, pneumothorax, dural mization of the respiratory and cardiovascular systems
tears, urinary complications and syndrome of inap- is imperative. Important intraoperative considerations are
8, 27
propriate ADH secretion . monitoring, temperature and fluid balance maintenance,
XI. Post operative analgesia: Pain management can positioning, spinal cord integrity monitoring and blood
be challenging and pain is of a severe degree in conservation. Post operative intensive care, respiratory
more extensive procedures. A multimodal approach care and pain therapy deserve special mention.
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9:261-266.
ISACON 2007 Diamond Jubilee Year - 2007
55 th
Annual National Conference of Indian Society of Anaesthesiologists
Visakhapatnam, 26th - 29th Dec, 2007 (Organised by ISA Visakhapatnam City Branch)
Hosted by ISA AP State Branch.
Venue : Port Stadium complex, Visakhapatnam
REGISTRATION CHARGES
CATEGORY UPTO UPTO FROM
30.09.07 30.11.07 01.12.07
(REGULAR) (DELAYED) (INCL. SPOT)
Organising Chairperson
ISA Members
Dr. D. Vijay Kumar Rao
Conference Rs. 2000 Rs. 2400 Rs. 3200
H.O.D.,
C.M.E. Rs. 500 Rs. 600 Rs. 700
Andhra Medical College,
Conference + C.M.E. Rs. 2400 Rs. 2900 Rs. 3800 Visakhapatnam.
PG Students Mob. : 98491 16069
Conference Rs. 1500 Rs. 1900 Rs. 2300
C.M.E. Rs. 500 Rs. 600 Rs. 700
Conference + C.M.E. Rs. 1900 Rs. 2400 Rs. 2900 Organising Secretary
Non-ISA Members Dr. V. Kuchela Babu
Conference Rs. 2600 Rs. 3200 Rs. 3900 Dept. of Anaesthesiology,
C.M.E. Rs. 700 Rs. 800 Rs. 900 Seven Hills Hospital
Conference + C.M.E. Rs. 3200 Rs. 3900 Rs. 4700 Rockdale Layout,
Accompanying person Rs. 1200 Rs. 1300 Rs. 1400 Visakhapatnam.
Ph. : 0891-2526655, 6529261
(Children above 5 yrs)
Mob. : 93931 02444
Overseas Delegates US$ 140 US$ 160 US$ 180
Email : kuchelababu@yahoo.com
Overseas Delegates US$ 90 US$ 110 US$ 130 Website : www.isacon2007.com
Accompanying person
Registration is mandatory for all participants (irrespective of the type of participation)
Identity badge is mandatory for entering into conference area including trade exhibition
Payment is only to be made by DD or cash, in favour of 'ISACON 2007' Payable at Visakhapatnam.
Certificate from Principal or H.O.D. is mandatory for Post Graduate students
495