2022年医学专题—外伤科主治医师要领(1).ppt

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，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,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 Light 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 recommendation,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 weeksUnexplained 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 NSAIDs 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 radicular 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 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 instability 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 and 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 painPain 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 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 injury),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 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