Spine 1.pdf

Regional Orthopaedics First lecture (Back ) 2023 (Total 2 lectures) Dr.Alaa Al-algawy The total cost of low back pain in the United States is greater than $100 billion per year; one third are direct costs for care, with the remaining costs resulting from decreased productivity, lost wages, and...

Regional Orthopaedics First lecture (Back ) 2023 (Total 2 lectures) Dr.Alaa Al-algawy The total cost of low back pain in the United States is greater than $100 billion per year; one third are direct costs for care, with the remaining costs resulting from decreased productivity, lost wages, and absenteeism. Low back pain accounts for more than 15 million patient visits to the physician’s office per year in the United States, second only to the number of patient visits for respiratory infections. Complaints of back pain begin around age 35 years and increase in prevalence up to age 50 years in men and age 60 years in women. Symptoms: Pain, stiffness and deformity of the back. Pain, paraesthesia or weakness of the lower limbs. The mode of onset is so important, (sudden? gradual? After lifting heavy object?) Any other associated illnesses or malaise? Sciatica: it is a radiating pain from buttock to the thigh & calf , more or less in the distribution of the distribution of the sciatic nerve. Stiffness : Sudden & almost complete (after disc prolapse) , continuous & predominantly at morning ( arthritis or ankylosing spondylitis) . Deformity : any shoulder asymmetry ( scoliosis , kyphosis) . Numbness or paraesthesia in the lower limbs: matching which dermatome?aggrevating factor? Standing? Walking? Sitting? With intermittent claudication? Urinary retention or incontinence: can be due to pressure on cauda equina. May be associated with faecal incontinence, urgency, or impotence. Signs: While the patient is standing: Look for any scar? Pigmentation? abnormal hair? Shape & posture of the spine? Feel: any tenderness? Localised to bony prominence or intervertebral spaces or surrounding muscles? Move : flexion , extension, & rotation . Muscle power in the feet is easily tested in standing when ask the patient to stand up on toes (planti flexion) then to rock back on his heel (dorsi flexion ) and compare between both tests. Lect./1/ Page (1) While the patient lying prone : Feel the bony outlines, deep tenderness , check the posterior tibial & popliteal pulses, Hamstring power, sensation on the back of the limbs, femoral stretch test: for lumbar root irritation is carried out by flexing the knee & lifting the hip joint into extension. pain may be felt in the front of the thigh & in the back. Signs while the patient lying on his back: * Leg raising test : for lumbosacral root irritation. With knee held absolutely straight , the limb lifted from the couch up to 80-90 degrees (normally) , but you stop once the patient feels pain , usually the pain felt at the buttock and calf ,( pain in the thigh alone is not significant) , the buttock pain can be exaggerated if you do dorsiflexion of the foot , and it can be relieved if you flex the knee( relaxing the sciatic nerve) . Some time raising the leg causes pain in the other side( crossed sciatic tension) that may indicate central disc prolapse. * full neurological exam.of the lower limbs, is carried out. * Peripheral pulses must be examined &look for Trophic changes. Imaging : X-Ray: For the spine: AP,Lat., & oblique views. For the pelvis : AP view. C.T. Scan: Very useful for diagnosis of bony deformities & if combined with myelography it will be useful to show the content of the spinal canal. MRI : invaluable in diagnosis of the pine pathologies. Radio isotopes scanning: may pick up areas of increased activity , suggesting fracture, silent metastasis or a local inflammatory lesion. Vertebral anomalies: Scoliosis: Lateral curvature of the spine, actually it is a triplanar deformity, (lateral, anteroposterior & rotational) component. Postural scoliosis: secondary or compensatory to some condition outside the spine. Such as short leg , pelvic tilt due to hip contracture( when the pat. sits the deformity disappears ) or due to muscles spasm ( sciatic scoliosis). Lect./1/ Page (2) Structural scoliosis: It is a non correctable deformity of the affected spinal segment. An essential component of this is the (vertebral rotation), the spinous processes swing round towards the concavity curve. Causes of scoliosis: 1- Idiopathic (most of the cases) . 2- Osteopathic ( due to bony anomalies). 3- Neuropathic (associated with some muscles dystrophy). 4- Miscellaneous group of connective tissue disorders. Clinical features: 1- Deformity: is the most important sign: s.t. not easily discovered if the there is balanced deformity. Unless you undress the patient or ask him to bend forward. 2- Backache: not always a presenting symptom. Patient should be completely exposed & examined from front , behind & from the side. Diagnostic feature of fixed (different from mobile or postural) is that it becomes more prominent when ask the pat. to bend forward . X-Rays: Plain X-Ray full length PA &lat. Of spine &iliac crest should be taken with the pat. erect. In PA view can measure the Cobb’s angel of the primary curve,(lines subtended between the first line pass above the uppermost vertebra. & lower line at the lower border of lowermost vertebra. To assess skeletal maturity is very important because there is rapid progression of the curve during skeletal growth while a minimal progression occurs after skeletal maturity. Good prognostic sign is assessment of iliac apophyses which will start ossification extended medially (Riser’s sign) (grades 1-5) . Special tests : Pulmonary function test is important before & after surgery. Prognosis &treatment: Aim is to prevent severe deformity & to stop further progression of the deformity as early as possible. Generally speaking : younger the child , higher the curve ,worse the prognosis. Management it depends on the type of scoliosis: Idiopathic : About 80% of scoliosis, may be seen as infantile ,juvenile and adolescent. Lect/1/ Page (3) Adolescent idiopathic scoliosis : at age of 10 or more. 90% in females, Most of the curves are under 20 degree & resolves spontaneously . But if the curve between 20-30 degrees needs close observation until puperty then if more than 30 degrees needs surgery to correct the angle & fix the curve to prevent more deterioration. During the follow up we can use some pine braces to decrease the progression like (Milwaukee brace & Boston brace). Instruments used in surgery like Harrington rods, with sub laminar wires. Juvenile idiopathic scoliosis ( 4-9 years): Rare but more severe , s.t. need surgical fusion even before puberty. but to use braces to let the pat. Reach the age of 10 years. Infantile idiopathic scoliosis: ( age under 3 years) Rare also but if the deformity is sever it needs serial elongation derotation flexion (EDF) casting under G.A. Until pat grows enough to apply brace und treated as juvenile type. Congenital (Osteopathic scoliosis) : Due to anomalies of vertebrae (fusion or abnormal segmentation) . Neuropathic and myopathic scoliosis : Due to , poliomyelitis , C.P., syringomyelia , Mild curve (less than 20 degrees need no treatment , moderate curve (20-30 degrees) managed like idiopathic type, may needs surgery near or at puberty . Kyphosis: The term kyphosis is used to describe normal & abnormal spine positions, e.g: Normal: gentle rounding of the dorsal spine. Abnormal: excessive dorsal curvature or straightening out of the cervical or lumbar lordotic curves. Kyphosis might be : 1-postural: (round back or drooping shoulder) this is voluntarily correctable; if treatment needed it is an only postural exercise. Lect. /1/ Page (4) 2- Compensatory: secondary to some other deformity like fixed flexion deformity of hip joint, increased lumbosacral lordosis, this is also correctable. 3- Structural kyphosis: is fixed , and associated with changes in the shape of the vertebrae. ( most common is due to osteoporosis , congenital anomalies , Scheuermann’s diseases ( adolescent kyphosis) , ankylosing spondylitis , tuberculous spondylitis , fractures or fracture dislocation of spine. The term (Kyphos or Gibbus) means a sharp posterior angulation due to localized collapse or wedging of one or more vertebrae. It might be due to fracture, congenital anomaly or TB of those vertebrae. Scheuermann’s diseases (adolescent kyphosis): It is a growth disorder of the spine in which the vertebrae become slightly wedged shaped. If this occurs in thoracic spine will cause mild kyphosis. The cause is unknown, but it might be a type of Osteochondritis of the vertebral epiphyseal endplate, where they appear irregularly ossified. Cl/F : Condition start at puberty , in girls twice than occurs in boys, present as smooth thoracic kyphosis . In X-Ray lateral view : the end plate of several vertebrae ( T6-T10 ) appear irregular or fragmented. In severe cases the vertebral body looked wedged anteriorly. Wedging of single vertebra of more than 5 degrees or the overall curve if more than 40 degrees are abnormal. Treatment : Curves up to 40 degrees needs no treatment except back strengthening exercises & postural training. While a curve of 60 degrees or more in older adolescent or young adults may need surgical correction. Kyphosis in adults: Kyphosis of elderly due to degenerative changes of the spine and narrowing of the intervertebral spaces may cause the senile kyphosis or due to senile osteoporosis or due to both conditions. Lect /1 / page (5)