Orthopedics 5th year, 6th lecture (Dr. Hamid)

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