Spinal and spinal cord

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Spinal and spinal cord

  1. 1. Spinal and spinal cordSpinal and spinal cord 外傷科主治醫師外傷科主治醫師 HsinglinHsinglin
  2. 2. Low back pain and radiculopathyLow back pain and radiculopathy  Imaging studies and further testing notImaging studies and further testing not helpful the first 4 weekshelpful the first 4 weeks  Relief of discomfort with meds and spinalRelief of discomfort with meds and spinal manipulationmanipulation  Bed rest beyond 4 days may be moreBed rest beyond 4 days may be more harmfulharmful  89-90% low back pain improve within 189-90% low back pain improve within 1 monthmonth
  3. 3.  80% sciatica eventually recover80% sciatica eventually recover  1% have nerve-root symptoms1% have nerve-root symptoms  1-3% have lumber disc herniation1-3% have lumber disc herniation  85% no specific diagnosis made85% no specific diagnosis made
  4. 4. definitions/classificationsdefinitions/classifications  Radiculopathy : dysfunction of nerve rootRadiculopathy : dysfunction of nerve root ( pain, sensory disturbances, weakness)( pain, sensory disturbances, weakness)  Mechanical low back pain : strain ofMechanical low back pain : strain of paraspinal muscles, ligament, irritation ofparaspinal muscles, ligament, irritation of facet jointsfacet joints
  5. 5. Initial assessment of patientInitial assessment of patient  History :History : – age, weight loss, cancer or infection, used of drug,age, weight loss, cancer or infection, used of drug, during of S/S, trauma, cauda equina syndrome, workduring of S/S, trauma, cauda equina syndrome, work statusstatus  PE :PE : – fever, vertebral tenderness, limited range of spinal cordfever, vertebral tenderness, limited range of spinal cord Dorsiflexation of ankle and big toe – L5, 4Dorsiflexation of ankle and big toe – L5, 4 Achilles reflex – S1Achilles reflex – S1 Light touchLight touch SLR textSLR text
  6. 6. Further evaluation of patientsFurther evaluation of patients  EMG : neuropathy, myopathy, myelopathy,EMG : neuropathy, myopathy, myelopathy, unreliable < 3-4 weeksunreliable < 3-4 weeks  SEPs (somatosensory evoked potential):SEPs (somatosensory evoked potential): spinal stenosis, or spinal myelopathyspinal stenosis, or spinal myelopathy  NCVs (nerve conduction velocity):NCVs (nerve conduction velocity): entrapment neuropathies that mimicentrapment neuropathies that mimic radiculopathyradiculopathy
  7. 7. LS X-ray recommendationLS X-ray recommendation  age >70yrs, or <20 yrsage >70yrs, or <20 yrs  systemically ill patientssystemically ill patients  temp. 38temp. 38°C°C  History of maligancyHistory of maligancy  Recent infectionRecent infection  Cauda equina syndromeCauda equina syndrome  Heavy alcohol or drug abusersHeavy alcohol or drug abusers  DMDM
  8. 8.  Immunosupressed patients (steroid)Immunosupressed patients (steroid)  Recent traumaRecent trauma  Recent urinary tract or spinal surgeryRecent urinary tract or spinal surgery  Unrelenting pain at restUnrelenting pain at rest  Persistent pain more than 4 weeksPersistent pain more than 4 weeks  Unexplained weight lossUnexplained weight loss
  9. 9. TreatmentTreatment  Conservative treatment :Conservative treatment : – 1.activity modification:1.activity modification: » Bed rest : no more than 4 daysBed rest : no more than 4 days » Activity modification : heavy lifting, total bodyActivity modification : heavy lifting, total body vibration, asymmetric postures, sustained for longvibration, asymmetric postures, sustained for long periodsperiods » Exercise : walking, bicycling, or swimmingExercise : walking, bicycling, or swimming
  10. 10.  2.analgesics :2.analgesics : – Panadol and NSAIDsPanadol and NSAIDs – OpioidsOpioids  3.muscle relaxants :3.muscle relaxants : – no effectno effect  4.education:4.education: – condition will subsidecondition will subside  5.spinal manipulation therapy:5.spinal manipulation therapy: – acute low back pain without radiculopathy in 1acute low back pain without radiculopathy in 1stst month,month, not used in severe or progressive neurologic deficitnot used in severe or progressive neurologic deficit
  11. 11. – Epidural injection: no change in the need forEpidural injection: no change in the need for surgery, short-term relief of radicular painsurgery, short-term relief of radicular pain when control on oral medications is inadequatewhen control on oral medications is inadequate or not surgical candidates.or not surgical candidates.
  12. 12. Cauda equina syndromeCauda equina syndrome  Midline, most common at L4-5Midline, most common at L4-5  1.sphincter retension :1.sphincter retension : – A. urinary retensionA. urinary retension – B. Urinary and fecal incontinenceB. Urinary and fecal incontinence – C. Anal sphincter toneC. Anal sphincter tone  2.saddle anesthesia2.saddle anesthesia  3.significant motor weakness3.significant motor weakness  4.Low back pain and sciatica4.Low back pain and sciatica  5.Bilateral absence of achilles reflex5.Bilateral absence of achilles reflex  6.Sexual dysfunction6.Sexual dysfunction
  13. 13. Surgical treatmentSurgical treatment  Patients with <4-8 weeksPatients with <4-8 weeks – A: urgent treatment (e.g. cauda equinaA: urgent treatment (e.g. cauda equina syndrome, progressive neurologic deficit)syndrome, progressive neurologic deficit) – B: inability to control pain with medicineB: inability to control pain with medicine  Patient with >4-8 weeksPatient with >4-8 weeks – Severe and disabling and not improvement withSevere and disabling and not improvement with time, correlated with findings on PH and PE.time, correlated with findings on PH and PE.
  14. 14. Type of surgeryType of surgery  Lumbar spinal fusion : fracture/dislocationLumbar spinal fusion : fracture/dislocation or instability resulting from tumor oror instability resulting from tumor or infectioninfection  Instrumentation as an adjunct to fusion :Instrumentation as an adjunct to fusion : increasing the fusion rateincreasing the fusion rate  Pedicle screw-rod fixation : utilizePedicle screw-rod fixation : utilize following laminectomy, shorter length offollowing laminectomy, shorter length of fixation segment, rigid fixation of all 3fixation segment, rigid fixation of all 3 columnscolumns
  15. 15.  Posterior lumber interbody fusion : bilateralPosterior lumber interbody fusion : bilateral laminectomy and aggressive discetomylaminectomy and aggressive discetomy followed by bone graftsfollowed by bone grafts
  16. 16. Intervertebral disc herniationIntervertebral disc herniation  Lumbar disc herniationLumbar disc herniation – Posteriorly, one side, compressing a nerve root,Posteriorly, one side, compressing a nerve root, severe radicular painsevere radicular pain  Characteristics findings :Characteristics findings : – Symptoms start with back pain, days afterSymptoms start with back pain, days after weeks yeilds radicular pain with reduction ofweeks yeilds radicular pain with reduction of back painback pain – Pain relief upon flexing the knee and thighPain relief upon flexing the knee and thigh – Position changePosition change
  17. 17. – Bladder symptoms : difficulty voiding,Bladder symptoms : difficulty voiding, straining, or urine retentionstraining, or urine retention – Exacerbation with coughing, sneezing,Exacerbation with coughing, sneezing, straining at the stoolstraining at the stool » Radiculopathy :Radiculopathy : » A.pain radiating down LEA.pain radiating down LE » B.motor weaknessB.motor weakness » C.dermatomal sensory changesC.dermatomal sensory changes » D.reflex changesD.reflex changes
  18. 18.  Straight leg raising test : <60, L5 and S1Straight leg raising test : <60, L5 and S1
  19. 19.  Spondylosis : no-specific degenerativeSpondylosis : no-specific degenerative process of the spineprocess of the spine  Spondylolisthesis : anterior subluxation ofSpondylolisthesis : anterior subluxation of one vertebral body on anotherone vertebral body on another – Grade 1-4Grade 1-4  Spondylolysis : alternative term for isthmicSpondylolysis : alternative term for isthmic spondylolisthesisspondylolisthesis
  20. 20. Spinal stenosisSpinal stenosis  Narrowing of the AP dimension of spinalNarrowing of the AP dimension of spinal canalcanal  In the lumbar region : neurogenicIn the lumbar region : neurogenic claudicationclaudication  In the cervical region : myelopathy andIn the cervical region : myelopathy and ataxiaataxia  In the spinal region : rareIn the spinal region : rare
  21. 21. Spinal traumaSpinal trauma  Uncommon in childrenUncommon in children  The fatality rate is higher with pediatricThe fatality rate is higher with pediatric spinal injuries than with adults (opposite tospinal injuries than with adults (opposite to the situation with head injury)the situation with head injury)
  22. 22.  Complete lesion :Complete lesion : – no preservation of any motor or sensoryno preservation of any motor or sensory function more than 3 segments below the levelfunction more than 3 segments below the level of the injuryof the injury – Persistence of complete spinal cord injuryPersistence of complete spinal cord injury beyond 24 hours : no distal function willbeyond 24 hours : no distal function will recoverrecover
  23. 23.  Incomplete lesion:Incomplete lesion: – Any residual motor or sensory function moreAny residual motor or sensory function more than 3 segments below the level of the injury.than 3 segments below the level of the injury. – Signs of incomplete lesion :Signs of incomplete lesion : » Sensation or voluntary movement in the LegsSensation or voluntary movement in the Legs » Sacral sparingSacral sparing Central cord syndromeCentral cord syndrome Bown-Sequard syndromeBown-Sequard syndrome Anterior and posterior cord syndromeAnterior and posterior cord syndrome
  24. 24. Spinal shockSpinal shock  A. interruption of sympatheticsA. interruption of sympathetics – 1. Loss of vascular tone1. Loss of vascular tone – 2. Leaves parasympathetics causing2. Leaves parasympathetics causing bradycardiabradycardia  B. Loss of muscle tone result venousB. Loss of muscle tone result venous poolingpooling  C. True hypovolemiaC. True hypovolemia
  25. 25. Initial management of spinal cordInitial management of spinal cord injuryinjury  Cause of death : aspiration and shockCause of death : aspiration and shock  SCI :SCI : – Significant traumaSignificant trauma – Loss of consciousnessLoss of consciousness – Minor trauma with spinal painMinor trauma with spinal pain – Associated findings suggestive of SCI :Associated findings suggestive of SCI : » Abdominal breathingAbdominal breathing » priapismpriapism
  26. 26. Management in the hospitalManagement in the hospital  1. Immobilization1. Immobilization  Hypotension: maintain SBP>90mmhgHypotension: maintain SBP>90mmhg – Dopamine, careful hydration, atropine forDopamine, careful hydration, atropine for bradycardia associated with hypotensionbradycardia associated with hypotension  OxygenationOxygenation  NG tube decompressionNG tube decompression  Indwelling foleyIndwelling foley  Temperature regulationTemperature regulation
  27. 27.  ElectrolytesElectrolytes  Medical management specific to spinal cordMedical management specific to spinal cord injury :injury : – methylprednisolone : given with 8 hours ofmethylprednisolone : given with 8 hours of injuryinjury

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