1、Spinal and spinal cord,外傷科主治(zh zh)醫師 Hsinglin,第一页，共二十八页。,Low back pain and radiculopathy,Imaging studies and further testing not helpful the first 4 weeks Relief of discomfort with meds and spinal manipulationBed rest beyond 4 days may be more harmful 89-90%low back pain improve within 1 month,第二页，
2、共二十八页。,80%sciatica eventually recover1%have nerve-root symptoms1-3%have lumber disc herniation85%no specific diagnosis made,第三页，共二十八页。,definitions/classifications,Radiculopathy:dysfunction of nerve root(pain,sensory disturbances,weakness)Mechanical low back pain:strain of paraspinal muscles,ligament
3、,irritation of facet joints,第四页，共二十八页。,Initial assessment of patient,History:age,weight loss,cancer or infection,used of drug,during of S/S,trauma,cauda equina syndrome,work statusPE:fever,vertebral tenderness,limited range of spinal cord Dorsiflexation of ankle and big toe L5,4 Achilles reflex S1 L
4、ight touch SLR text,第五页，共二十八页。,Further evaluation of patients,EMG:neuropathy,myopathy,myelopathy,unreliable 3-4 weeksSEPs(somatosensory evoked potential):spinal stenosis,or spinal myelopathyNCVs(nerve conduction velocity):entrapment neuropathies that mimic radiculopathy,第六页，共二十八页。,LS X-ray recommend
5、ation,age 70yrs,or 20 yrssystemically ill patientstemp.38CHistory of maligancyRecent infectionCauda equina syndrome Heavy alcohol or drug abusersDM,第七页，共二十八页。,Immunosupressed patients(steroid)Recent traumaRecent urinary tract or spinal surgeryUnrelenting pain at restPersistent pain more than 4 weeks
6、Unexplained weight loss,第八页，共二十八页。,Treatment,Conservative treatment:1.activity modification:Bed rest:no more than 4 daysActivity modification:heavy lifting,total body vibration,asymmetric postures,sustained for long periodsExercise:walking,bicycling,or swimming,第九页，共二十八页。,2.analgesics:Panadol and NS
7、AIDs Opioids3.muscle relaxants:no effect4.education:condition will subside5.spinal manipulation therapy:acute low back pain without radiculopathy in 1st month,not used in severe or progressive neurologic deficit,第十页，共二十八页。,Epidural injection:no change in the need for surgery,short-term relief of rad
8、icular pain when control on oral medications is inadequate or not surgical candidates.,第十一页，共二十八页。,Cauda equina syndrome,Midline,most common at L4-51.sphincter retension:A.urinary retensionB.Urinary and fecal incontinenceC.Anal sphincter tone2.saddle anesthesia 3.significant motor weakness4.Low back
9、 pain and sciatica5.Bilateral absence of achilles reflex 6.Sexual dysfunction,第十二页，共二十八页。,Surgical treatment,Patients with 4-8 weeksSevere and disabling and not improvement with time,correlated with findings on PH and PE.,第十三页，共二十八页。,Type of surgery,Lumbar spinal fusion:fracture/dislocation or insta
10、bility resulting from tumor or infectionInstrumentation as an adjunct to fusion:increasing the fusion ratePedicle screw-rod fixation:utilize following laminectomy,shorter length of fixation segment,rigid fixation of all 3 columns,第十四页，共二十八页。,Posterior lumber interbody fusion:bilateral laminectomy an
11、d aggressive discetomy followed by bone grafts,第十五页，共二十八页。,Intervertebral disc herniation,Lumbar disc herniationPosteriorly,one side,compressing a nerve root,severe radicular painCharacteristics findings:Symptoms start with back pain,days after weeks yeilds radicular pain with reduction of back pain
12、Pain relief upon flexing the knee and thighPosition change,第十六页，共二十八页。,Bladder symptoms:difficulty voiding,straining,or urine retentionExacerbation with coughing,sneezing,straining at the stoolRadiculopathy:A.pain radiating down LEB.motor weaknessC.dermatomal sensory changesD.reflex changes,第十七页，共二十
13、八页。,Straight leg raising test:60,L5 and S1,第十八页，共二十八页。,Spondylosis:no-specific degenerative process of the spineSpondylolisthesis:anterior subluxation of one vertebral body on anotherGrade 1-4Spondylolysis:alternative term for isthmic spondylolisthesis,第十九页，共二十八页。,Spinal stenosis,Narrowing of the AP
14、 dimension of spinal canalIn the lumbar region:neurogenic claudicationIn the cervical region:myelopathy and ataxiaIn the spinal region:rare,第二十页，共二十八页。,Spinal trauma,Uncommon in childrenThe fatality rate is higher with pediatric spinal injuries than with adults(opposite to the situation with head in
15、jury),第二十一页，共二十八页。,Complete lesion:no preservation of any motor or sensory function more than 3 segments below the level of the injuryPersistence of complete spinal cord injury beyond 24 hours:no distal function will recover,第二十二页，共二十八页。,Incomplete lesion:Any residual motor or sensory function more
16、than 3 segments below the level of the injury.Signs of incomplete lesion:Sensation or voluntary movement in the LegsSacral sparingCentral cord syndromeBown-Sequard syndromeAnterior and posterior cord syndrome,第二十三页，共二十八页。,Spinal shock,A.interruption of sympathetics1.Loss of vascular tone2.Leaves parasympathetics causing bradycardia B.Loss of muscle tone result venous poolingC.True hypovolemia,第二十四页，共二十八页。,Initial management of spinal cord injury,Cause of death:aspiration and shockSCI:Significant
