orthopedics 5th year, 6th lecture (dr. hamid)
TRANSCRIPT
Prolapsed Intervertebral Discs
Pathology • 1-Chronic-Normal aging-disc degeneration-
displacement of facet joint--2ndary effect-aquired SS
2-Acute disc herneation-pain---Effects of pressure on the nerve root
-Compressive • -Deformation-str,& fun, changes
• Clinical picture
Clinical picture
Imaging• X-ray• MRI• CT scans with or without myelography -intolerant to MRI -Unsuitable for MRI• gadolinium-enhanced MRI This will help to delineate which part of the
previous operation site is disc and which is epidural fibrosis (the latter enhancing).
DDXGood general condition,mild N/D,-veInvestigation,normalCSF,+veMRI,on.off,1-2
level, neither young nor old DDX-----Acute muscular&ST strain------inflammatory ----Infection -----Vertebral and nerve Tumor
treatment
• REST-• Reduce-traction• Remove • Rehablitate
rest
• First attack• • Any attack, early period• • 75 to 80% respond• • Principle – rest – 3wks
• GENTLE MASSAGE• G Helps to loosen tight muscles in spasm.• H Psychological well being effect
• BRACES & CORSETS• B Helps to restrict movements• H Sense of well being• S Prevails tortional movements• Not to be used for more than 3 wks.
• Anti inflammatory• Analgesics• Muscle relaxant• Small doses of diazepam to relieve
apprehension• Medicines for constipation
• PRECAUTIONS• P Straining• S Wt lifting • W Jerky movements• J Torsion of back• T Forward flexion
• EPIDURAL BLOCK• Very valuable• Immediate relief from pain• Should not have neurological deficit• SLR should be more than 45o• Should not have bilateral signs
Indications for diskectomy -Progressive Neurological deficit• Failure of conservative treatment-refractory• Significant motor deficit • Severe incapacitating pain - does not
respond to any form of treatment• Cauda equina syndrome
surgical treatment-lamenectomy--partial lamenectomy-fenstraion-tailor-percutanous--endoscopic-spinoscope--Microdisectomy-LASER---disc replacement
• PRINCIPLES OF SURGERY• Decompress the root• Prevent further extrusion• Avoid too much scarring• Minimum handling of muscles• Least excision of bone• Early mobilization• Early discharge
• THE LAMINECTOMY• T Today there is no indication to
laminectomy• in PID• i May create instability• M Involves lot of scarring & morbidity• I Cannot return to work early• C Introduces restrictions on life
• THE FENESTRATION• The approach is good and adequate• Unilateral exposure• Minimum damage• Ligamentum flavum removed• Contiguous margins of laminae• removed.• 2/3 upper lamina and 1/3 lower lamina• removed.
• MICROLUMBAR DISCECTOMY• Best ,Short paramedian incision – less
than one inch• Bone is not touched• The approach is through lateral half of
lig.flavum.• Good illumination,
magnificationVisualisation• Meticulous haemostasis• Same day mobilisation• Discharge within 24 hours
Complications
-mechanical intraop;• dural tear• nerve root injury• vascular injury • epidural haematomas.
• -early postop• Superficial wound infections• Discitis • Haematoma• -late postop• Non-union• Instability• deformity
Persistent post operative back pain and sciatica
Back Pain
• 70-80% of population at least once• 13% of sickness absences• most common cause of work-related disability• most expensive cause of work-related disability• 7% chronic pain• Men= women• Most common between 30-50 yrs
Epidemiology
Risk Factors
• Heavy lifting
• Bodily vibration
• Obesity
• High risk occupations :miscellaneous labor, warehouse work, and nursing
AetiologyConginetal--Kyphoscoliosis
--Spina bifida
--Spondylolisthesis
Acquired
TraumaticVertebral fractures
Ligamentous injury
Joint strains
Muscle tears
Infective Osteomyelitis-acute and chronicTB,Discitis
Inflammatory
Ankylosing spondyolitis
Rheumatology disorders
Neoplastic
Primary tumors
Secondary tumors
Degenerative
Osteoarthritis
Spondylosis
Metabolic
Osteoporosis
Osteomalacia
Endocrine
Cushing's -osteoporosis
Idiopathic
Paget's disease
Scheuermann's disease
Psychogenic
Psychosomatic backache
Visceral
Penetrating peptic ulcer
Carcinoma of the pancreas
Carcinoma of the rectum
Vascular
Aortic aneurysm
Acute aortic dissection
Renal
Carcinoma of the kidney
Renal calculus
Inflammatory kidney disease
Gynaecological
Uterine tumors
Pelvic inflammatory disease
Endometriosis
Approach to diagnosis
• -Transiet back ache following musc,activity• -sudden acute pain &scitica • -intermittent low back pain• --pain+claudication• -sever constant, localized pain