外伤科主治医师要领.ppt

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 80%sciatica eventually recover 1%have nerve-root symptoms 1-3%have lumber disc herniation 85%no specific diagnosis made 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 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 EMG:neuropathy,myopathy,myelopathy,unreliable 70yrs,or 20 yrs systemically ill patients temp.38 C History of maligancy Recent infection Cauda equina syndrome Heavy alcohol or drug abusers DM 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 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 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 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 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 Patients with 4-8 weeks Severe and disabling and not improvement with time,correlated with findings on PH and PE.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 Posterior lumber interbody fusion:bilateral laminectomy and aggressive discetomy followed by bone grafts 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 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 Straight leg raising test:90mmhg Dopamine,careful hydration,atropine for bradycardia associated with hypotension Oxygenation NG tube decompression Indwelling foley Temperature regulation Electrolytes Medical management specific to spinal cord injury:methylprednisolone:given with 8 hours of injury