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Spinal and spinal cord

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Relief of discomfort with meds and spinal manipulation. Bed rest beyond 4 ... 2.saddle anesthesia. 3.significant motor weakness. 4.Low back pain and sciatica ... – PowerPoint PPT presentation

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Title: Spinal and spinal cord


1
Spinal and spinal cord
  • ???????
  • Hsinglin

2
Low back pain and radiculopathy
  • Imaging studies and further testing not helpful
    the first 4 weeks
  • Relief of discomfort with meds and spinal
    manipulation
  • Bed rest beyond 4 days may be more harmful
  • 89-90 low back pain improve within 1 month

3
  • 80 sciatica eventually recover
  • 1 have nerve-root symptoms
  • 1-3 have lumber disc herniation
  • 85 no specific diagnosis made

4
definitions/classifications
  • Radiculopathy dysfunction of nerve root ( pain,
    sensory disturbances, weakness)
  • Mechanical low back pain strain of paraspinal
    muscles, ligament, irritation of facet joints

5
Initial assessment of patient
  • History
  • age, weight loss, cancer or infection, used of
    drug, during of S/S, trauma, cauda equina
    syndrome, work status
  • PE
  • fever, vertebral tenderness, limited range of
    spinal cord
  • Dorsiflexation of ankle and big toe L5, 4
  • Achilles reflex S1
  • Light touch
  • SLR text

6
Further evaluation of patients
  • EMG neuropathy, myopathy, myelopathy,
    unreliable lt 3-4 weeks
  • SEPs (somatosensory evoked potential) spinal
    stenosis, or spinal myelopathy
  • NCVs (nerve conduction velocity) entrapment
    neuropathies that mimic radiculopathy

7
LS X-ray recommendation
  • age gt70yrs, or lt20 yrs
  • systemically ill patients
  • temp. 38C
  • History of maligancy
  • Recent infection
  • Cauda equina syndrome
  • Heavy alcohol or drug abusers
  • DM

8
  • Immunosupressed patients (steroid)
  • Recent trauma
  • Recent urinary tract or spinal surgery
  • Unrelenting pain at rest
  • Persistent pain more than 4 weeks
  • Unexplained weight loss

9
Treatment
  • Conservative treatment
  • 1.activity modification
  • Bed rest no more than 4 days
  • Activity modification heavy lifting, total body
    vibration, asymmetric postures, sustained for
    long periods
  • Exercise walking, bicycling, or swimming

10
  • 2.analgesics
  • Panadol and NSAIDs
  • Opioids
  • 3.muscle relaxants
  • no effect
  • 4.education
  • condition will subside
  • 5.spinal manipulation therapy
  • acute low back pain without radiculopathy in 1st
    month, not used in severe or progressive
    neurologic deficit

11
  • Epidural injection no change in the need for
    surgery, short-term relief of radicular pain when
    control on oral medications is inadequate or not
    surgical candidates.

12
Cauda equina syndrome
  • Midline, most common at L4-5
  • 1.sphincter retension
  • A. urinary retension
  • B. Urinary and fecal incontinence
  • C. Anal sphincter tone
  • 2.saddle anesthesia
  • 3.significant motor weakness
  • 4.Low back pain and sciatica
  • 5.Bilateral absence of achilles reflex
  • 6.Sexual dysfunction

13
Surgical treatment
  • Patients with lt4-8 weeks
  • A urgent treatment (e.g. cauda equina syndrome,
    progressive neurologic deficit)
  • B inability to control pain with medicine
  • Patient with gt4-8 weeks
  • Severe and disabling and not improvement with
    time, correlated with findings on PH and PE.

14
Type of surgery
  • Lumbar spinal fusion fracture/dislocation or
    instability resulting from tumor or infection
  • Instrumentation as an adjunct to fusion
    increasing the fusion rate
  • Pedicle screw-rod fixation utilize following
    laminectomy, shorter length of fixation segment,
    rigid fixation of all 3 columns

15
  • Posterior lumber interbody fusion bilateral
    laminectomy and aggressive discetomy followed by
    bone grafts

16
Intervertebral disc herniation
  • Lumbar disc herniation
  • Posteriorly, one side, compressing a nerve root,
    severe radicular pain
  • Characteristics findings
  • Symptoms start with back pain, days after weeks
    yeilds radicular pain with reduction of back pain
  • Pain relief upon flexing the knee and thigh
  • Position change

17
  • Bladder symptoms difficulty voiding, straining,
    or urine retention
  • Exacerbation with coughing, sneezing, straining
    at the stool
  • Radiculopathy
  • A.pain radiating down LE
  • B.motor weakness
  • C.dermatomal sensory changes
  • D.reflex changes

18
  • Straight leg raising test lt60, L5 and S1

19
  • Spondylosis no-specific degenerative process of
    the spine
  • Spondylolisthesis anterior subluxation of one
    vertebral body on another
  • Grade 1-4
  • Spondylolysis alternative term for isthmic
    spondylolisthesis

20
Spinal stenosis
  • Narrowing of the AP dimension of spinal canal
  • In the lumbar region neurogenic claudication
  • In the cervical region myelopathy and ataxia
  • In the spinal region rare

21
Spinal trauma
  • Uncommon in children
  • The fatality rate is higher with pediatric spinal
    injuries than with adults (opposite to the
    situation with head injury)

22
  • Complete lesion
  • no preservation of any motor or sensory function
    more than 3 segments below the level of the
    injury
  • Persistence of complete spinal cord injury beyond
    24 hours no distal function will recover

23
  • Incomplete lesion
  • Any residual motor or sensory function more than
    3 segments below the level of the injury.
  • Signs of incomplete lesion
  • Sensation or voluntary movement in the Legs
  • Sacral sparing
  • Central cord syndrome
  • Bown-Sequard syndrome
  • Anterior and posterior cord syndrome

24
Spinal shock
  • A. interruption of sympathetics
  • 1. Loss of vascular tone
  • 2. Leaves parasympathetics causing bradycardia
  • B. Loss of muscle tone result venous pooling
  • C. True hypovolemia

25
Initial management of spinal cord injury
  • Cause of death aspiration and shock
  • SCI
  • Significant trauma
  • Loss of consciousness
  • Minor trauma with spinal pain
  • Associated findings suggestive of SCI
  • Abdominal breathing
  • priapism

26
Management in the hospital
  • 1. Immobilization
  • Hypotension maintain SBPgt90mmhg
  • Dopamine, careful hydration, atropine for
    bradycardia associated with hypotension
  • Oxygenation
  • NG tube decompression
  • Indwelling foley
  • Temperature regulation

27
  • Electrolytes
  • Medical management specific to spinal cord injury
  • methylprednisolone given with 8 hours of injury
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