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الكلية كلية الطب
القسم الجراحة
المرحلة 5
أستاذ المادة جميل تحسين محسن كاظم
5/18/2011 8:16:39 PM
the back
symptoms
1. pain: it is sudden or gradual, constant or intermittent.
sciatica this term refers to pain radiating from the buttock into the thigh & calf along the distribution of the sciatic nerve, it results from any pathology in the spine like infection degenerative disorders, disc prolapse, tumors, inflammation …
2. stiffness, limitation of the spine movements.
3. deformity.
4. neurological symptoms, numbness, parasthesia, weakness or urinary symptoms.
signs
i. while the patient standing:
? look: for scar, shape& posture there may be a list (lateral deviation of the spine) or scoliosis (lateral curvature of the spine) or kyphosis (dorsal curvature of the spine), kyphos this term refer to sharp dorsal curvature.
? feel: for tenderness, spinous process, interspinous ligaments.
? move: flexion, extension, lateral flexion & rotation.
ii. while the patient lying prone: feel for tenderness, any step, power of the hamstring muscle, the femoral stretch test.
iii. while the patient supine:
? straight leg rising test, this test is performed by rising the leg with the knee extended if the patient feels pain in the back, buttock, thigh & calf the test is positive, the pain occur because rising the straight leg will cause stretching of the sciatic nerve roots, when the patient start to experience pain dorsiflexion of the ankle will increase the severity of the pain because this add more stretch on the roots.
? neurological examination, in the lower limbs by testing muscle power, tone reflexes& sensation.
imaging these include plain x-ray (ap& lateral), isotope scan, ct scan, mri, discography.
spinal deformities
? scoliosis
it is an apparent lateral curvature of the spine, because it is actually triplane deformity (in anteroposterior, lateral & axial planes).
types of the scoliosis
i. postural scoliosis it is a secondary or compensatory scoliosis because it occurs to compensate to some other conditions outside the spine like short leg or pelvic tilt from hip contracture so when the patient stand the pelvis droping to the short side & spine compensate by tilting to the other side, when the patient site the effect of the underlying cause will be eliminated & the scoliosis will be corrected, other causes of postural scoliosis is muscle spasm from disc prolapse called sciatic scoliosis.
ii. structural scoliosis it a non correctable deformity & consists of lateral deviation of the spine(scoliosis) forward deviation of the spine (lordosis) & rotation of the vertebra at the apex of the curve in the axial plane, so it is triplane deformity, initially the deformity can be corrected but with time it become fixed & will not corrected by changing the posture, once the deformity established it will increase in severity throughout the growth period of the child, severe curves of the thoracic spine causing chest deformities that affect the cardiopulmonary function. sometimes there are secondary curves which appear above or below the structural curve to compensate for the deformity.
?
to differentiate between the postural & structural (fixed) scoliosis we ask the patient to bend forward, if the deformity disappear the curve is postural but if it increase it is structural.
clinical features the patient complain from deformity of the spine, rib hump, prominent hip, asymmetrical shoulders, later there may be backache or cardiopulmonary dysfunction.
on examination we look whether the deformity is compensated or not, if we draw a line from the occiput & it pass through the midline (anal cleft) the structural scoliosis is compensated if it not passes through the anal cleft it is not compensated.
imaging
? x-ray: the x-ray film should be full length showing the entire spine & it should in erect position, the film will show:
1. deformity & whether there are one or more primary curves or one primary and other compensatory curve.
2. the degree of the curve can be assessed by determining the uppermost vertebra & the lowermost vertebra of the curve then by drawing a line along the upper border of the upper vertebra & a line along the lower border of the
?
lower vertebra, the angle subtended by the lines is the angle of the curvature (cobb’s angle).
3. assessment the skeletal maturity, by determining the degree of ossification of the iliac apophysis, called risser’s sign,(if less than 25% ossified its type i ,25-50% its type ii, 50-75% its type iii, 75-100% its type iv, fusion of the apophysis to the ilium is type v) as the structural scoliosis will increase during the growth period & stop progression after skeletal maturity.
? ct scan & mri: these used if there is cord compression.
prognosis the risk factors for curve progression depend on
1. age at presentation high risk of progression if it starts before the age of 12 years.
2. risser’s sign high risk for risser’s 0-1.
3. severity of the curve high risk for curves more than 20 degrees.
4. gender female at higher risk than male.
types of structural scoliosis:
the structural scoliosis is divided into 3 types:
a. idiopathic scoliosis.
b. osteopathic scoliosis.
c. neuropathic & myopathic scoliosis.
idiopathic scoliosis
it’s the most common of all scoliosis account for 80% of the scoliosis, there is family tendency, the incidence is 3/1000 of the population, and the idiopathic scoliosis is subdivided according to age group into adolescent, juvenile & infantile.
causes of idiopathic scoliosis the causes are unknown certain factors can be blamed:
1. family history, is present but presentation is variable
2. hormonal factor may play role like melatonin.
3. brainstem disorder.
4. disorder of proprioception.
5. abnormal content of the calcium in the paraspinal muscles & abnormal increase in the level of calmodulin (which is a calcium binding protein that regulate intracellular calcium binding).
? adolescent idiopathic scoliosis
presenting at the age of 10 years & over. more than 90% of the cases girls, usually the curve is right thoracic (convex to right).
treatment the aim of treatment (1) to prevent the deformity becoming progressive (2) to correct unacceptable deformity.
initially we observe the patient every 4 months & we examine the patient clinically & radiologically with measurement of the curve before we decide between the conservative & operative treatment.
? if the curve is less than 20 degrees, no treatment is required because it either resolves or remains unchanged.
? if the curve 20-30 degrees & it is balanced & not progressive, no treatment is required.
? if the curve 20-30 degrees & it is progressive, it needs brace (milwaukeein thoracic curve) & batson brace in the lumbar curve.
operative treatment: is indicated in the following cases (1) if the curve more than 30 degrees & progressive (2) if the curve is progressive in brace (3) if it present before puberty with risser’s 0-1. (4) unacceptable deformity.
the aim of surgery is to correct the deformity & fuse the primary curve by either posterior approach or anterior approach.
? juvenile idiopathic scoliosis
it is uncommon, usually presented at the age of 4-9 years, the characteristic features of the scoliosis is similar to adolescent scoliosis, the prognosis is worse than adolescent type because the younger age group.
treatment by brace until the child is 10 years old when surgery is likely to succeed.
? infantile idiopathic scoliosis
usually presented before the age of 3 years, it affects boys more than girls. the curve is left thoracic curve (convex to left).
treatment more than 90% will correct spontaneously, but if it progress we use plaster cast until the child become old enough to use brace.
osteopathic (congenital) scoliosis
this type of scoliosis is due to congenital anomaly of the vertebra (hemivertebra, wedge vertebra, unilateral unsegmented vertebra or fused vertebra, fused ribs).
it is usually mild but it may progress to severe curves, before operation we have to do mri o f the spine to exclude dysraphism or diastematomyelia which is a fibrous or bony ridge that extend posteriorly from the vertebral body splitting the spinal cord, if this ridge present it should be resected before correcting the scoliosis.
neuropathic & myopathic scoliosis
it is due neuromuscular disorders like poliomyelitis, cerebral palsy, syringiomyelia, muscular dystrophy. the scoliosis results from unbalanced paralysis of the spinal muscles, the paralytic curve is long & convex toward the weak muscles.
treatment mild curves require no treatment, moderate curves are treated similar to idiopathic scoliosis, severe curve require stabilization of the entire paralytic segment. there is risk of cardiopulmonary compromise especially with severe curves.
? kyphosis
it is an excessive dorsal curvature or straightening out of the cervical or lumbar lordotic curves.
types of kyphosis:
i.postural kyphosis the postural kyphosis usually associated with other postural defects such as flat feet, it is voluntarily correctable, if treatment is needed this require postural training & exercise.
the deformity may be compensatory or secondary to other deformities like hip flexion contracture which lead to increase lumbosacral lordosis that lead to compensatory thoracic kyphosis.
ii.structural kyphosis this fixed & uncorrectable & associated with changes in the shape of the vertebrae.
types of structural kyphosis: it is divided into 3 types according to the age of presentation:
congenital (osteopathic) kyphosis
this results from congenital vertebral anomalies. these are of 2 types:
? type i, (failure of formation). it is the commonest & the worst, this occurs when the anterior part of the vertebral body fail to develop leading to progressive kyphosis with anterior displacement of the vertebral body which may cause cord compression.
treatment this depend on the age & degree of the curve. if the child under 6 years & the curve less than 40 degrees it require posterior fusion, older children & with curves more than 40 degrees require combined anterior & posterior fusion with cord decompression if there is neurological deficient.
? type ii, (failure of segmentation). this result from failure of segmentation of the anterior part of the vertebral body leading to anterior intervertebral bar, with growth this lead to progressive kyphosis.
treatment requires posterior spinal fusion.
adolescent kyphosis (scheuermann’s disease)
the characteristic feature of this deformity is a fixed round-back deformity associated wedging of several adjacent thoracic vertebrae it primarily affects the ring epiphysis of the vertebral end plate.
causes the exact cause is unknown, but several factors can be blamed:
1. defect in the collagen fibers of the cartilaginous end plate, so the cartilaginous end plate will be weaker than normal & will be damaged by pressure of the adjacent intervertebral disc.
2. increase stress on the anterior part of the vertebral bodies from the normal thoracic kyphosis, making damage is greater on the anterior part of the vertebral body leading to wedging of the vertebrae.
clinical features
it present at puberty, it is more in girls than in boys, the patient presented with increase thoracic kyphosis, backache & fatigue.
on examination, there is smooth thoracic curve, compensatory increase in lumbar lordosis, the deformity is fixed & rarely there is spastic paresis of the lower limb.
x-ray there are irregularities of the vertebral end plate of several adjacent thoracic vertebrae (t6-t10), wedging of more than 5% of the vertebrae, structural (fixed) curve of more than 45 degrees. we can measure the degree of the curve by using the cobb’s angle.
differential diagnosis
? postural kyphosis, there is no pain, the deformity is correctable & the x-ray normal.
? t.b of the spine, x-ray shows narrowing of the intervertebral disc with destruction of the adjacent vertebral bodies.
treatment the treatment depend on the degree of the curve & whether the patient is skeletally mature or not:
? if the curve is less than 50 degrees, this need observation by serial radiograph, postural training & extension exercise.
? if the curve 50-75 degrees, if the patient is skeletally immature this require milwaukee brace, if skeletally mature this require surgical stabilization of the spine.
? if the curve more than 75 degrees, the treatment is always surgical. if the curve can be corrected to less than 50 degrees on extension film then posterior spinal fusion & instrumentation. but if it corrected to more than 50 degrees then a combined anterior release & posterior fusion.
kyphosis in elderly
i. postmenopausal osteoporosis:
this result from osteoporotic compression fracture of one or more of the thoracic vertebrae, the patient less than 70 years, women more than male, complain from backache in thoracic spine but also from lumbosacral backache from compensatory increase lumbar lordosis.
x-ray show osteoporosis & wedge compression fracture of the one or more vertebrae.
treatment by treating the underlying cause by calcium supplement, hormone replacement therapy.
ii. senile osteoporosis
it affect male & female, the patient usually above 75 years, the pain & kyphosis are more than postmenopausal type,
x-ray show compression fracture of several vertebrae, we have to exclude multiple myeloma & secondary metastasis.
treatment usually symptomatic.
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .
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