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Spinal and spinal cord. 外傷科主治醫師 Hsinglin. 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 .

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spinal and spinal cord

Spinal and spinal cord

外傷科主治醫師

Hsinglin

low back pain and radiculopathy
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
slide3
80% sciatica eventually recover
  • 1% have nerve-root symptoms
  • 1-3% have lumber disc herniation
  • 85% no specific diagnosis made
definitions classifications
definitions/classifications
  • Radiculopathy : dysfunction of nerve root ( pain, sensory disturbances, weakness)
  • Mechanical low back pain : strain of paraspinal muscles, ligament, irritation of facet joints
initial assessment of patient
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

further evaluation of patients
Further evaluation of patients
  • EMG : neuropathy, myopathy, myelopathy, unreliable < 3-4 weeks
  • SEPs (somatosensory evoked potential): spinal stenosis, or spinal myelopathy
  • NCVs (nerve conduction velocity): entrapment neuropathies that mimic radiculopathy
ls x ray recommendation
LS X-ray recommendation
  • age >70yrs, or <20 yrs
  • systemically ill patients
  • temp. 38°C
  • History of maligancy
  • Recent infection
  • Cauda equina syndrome
  • Heavy alcohol or drug abusers
  • DM
slide8
Immunosupressed patients (steroid)
  • Recent trauma
  • Recent urinary tract or spinal surgery
  • Unrelenting pain at rest
  • Persistent pain more than 4 weeks
  • Unexplained weight loss
treatment
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
slide10
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
slide11
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.
cauda equina syndrome
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
surgical treatment
Surgical treatment
  • Patients with <4-8 weeks
    • A: urgent treatment (e.g. cauda equina syndrome, progressive neurologic deficit)
    • B: inability to control pain with medicine
  • Patient with >4-8 weeks
    • Severe and disabling and not improvement with time, correlated with findings on PH and PE.
type of surgery
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
slide15
Posterior lumber interbody fusion : bilateral laminectomy and aggressive discetomy followed by bone grafts
intervertebral disc herniation
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
slide17
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
slide19
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
spinal stenosis
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
spinal trauma
Spinal trauma
  • Uncommon in children
  • The fatality rate is higher with pediatric spinal injuries than with adults (opposite to the situation with head injury)
slide22
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
slide23
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

spinal shock
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
initial management of spinal cord injury
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
management in the hospital
Management in the hospital
  • 1. Immobilization
  • Hypotension: maintain SBP>90mmhg
    • Dopamine, careful hydration, atropine for bradycardia associated with hypotension
  • Oxygenation
  • NG tube decompression
  • Indwelling foley
  • Temperature regulation
slide27
Electrolytes
  • Medical management specific to spinal cord injury :
    • methylprednisolone : given with 8 hours of injury