脊柱-南醫(yī)三院

1、Prof. M. Shantharam ShettyM.S(orth), FRCS, FACSPro Chancellor, Nitte UniversityChairman, Tejasvini Hospital & SSIOTMangaloreBackandneckpainisperhapsoneof thecommonestailmentsaFamilyPhysician/Orthopaedicsurgeon/Physiotherapistfacesineverydaypractice.Today, thehighestliability ofthework hourlossand th

2、e insuranceor GovernmentorPrivatesector paysfor treatment or forworkmen pensation,isforbackpainandrelatedspinaldisorders.Majorityofthebackor neckpainisduetobadposture. Thisisthepenaltywe,humanbeingsarepayingfor evolution to thestraightposture, thoughwearegoingbacktotheoldposture puterization.Examina

3、tionofspineTothe PG ResidentPhysicianOrthopaedicSurgeon-nightmarepuzzleChallengeMostimportantpartofExaminationof spine plete history anditscorrelationsto thediagnosis.Characterof thepainRadicular,relievingoraggravatingfactors, Neurogenicor vascularTrauma lifting,journeyDeformity swelling, coldabsces

4、sNeurologyloss ofpower, sensation,bladderandbowelSex dysfunctionPredisposingdiseaseProstrate, breast,lungs,kidney,thyroidCaseStudyofa26 yearoldfemaleSeverepainintheupperbackThoracicregionradiatingto thechesttillthesternum.Shewent to ortho -costochondritisNeurologist -MRINeuralgia/NeuropathyT5rootNeu

5、rosurgeon MRIshows facetaljointdiseasewith nerve entrapmentAndshesought aDietician,PhysiotherapistPsychiatricopinionShenever cared toseeher family physician whohad seen her growupas a girl.WithaCareful historyWith Pain relieveson restin thenightShehas gained10 kgsofweightin 1 yearThefamily physician

6、 askedher what sizeof bradoyouuse and pleasetry changingthesizeofbraPain disappeared thetime and moneyshespentand theagony of consuming NSAIDsClearlyshowsustheimportanceof takinga carefulcasehistory.Remember, wearecliniciansfirstandtechnicians,surgeons nextspendtimewiththehistoryandhistorytakingOccu

7、pation,posture, familybackgroundandthetypeofpain almostgivesyou adiagnosis.Inthiseraofsophisticatedimaging,littleattentionispaidto clinicalexaminationtherebywemissalesionor over emphasizeone. Remember,MRIsor anyotherimagingmodalitiescanbe15%falsepositiveor 10%falsenegative.Wecannotaffordtomissadiagn

8、osisfor apatientwithasimplebackpainitcanbepathognomonicitcanbe atumour primaryorsecondaryGaitInspectionPalpationMovementsSpecialtestsAthorough NeurologicalexaminationGAITNormal walkingWalking on tip toe (S1)Walking on heel(L5)UnmasksminorflexiondeformitiesAnkylosing spondylitisScheurmanns osteochond

9、rosisStandingwithbackflushagainstthewallHeel,buttock, shoulder andocciputshould alltouchthewallStandingAnteriorAttitudeof the head and neck TorticollisSwellingoverneckWasting of musculatureLimb attitude and deformitySkin changes Scars/sinusesStandingLateralNormalcervical, thoracic andlumbarspineGibb

10、us/Angulation ofspineKyphosisLordosisStandingPosteriorScoliosisListShouldertiltPelvic tiltMusclewastingSkinchanges overspine /hairtuft/pigmentationScars/sinusesSwellingTemperatureTendernessBonystructuresIntervertebraltissuesAlongthespinal processParavertebral muscles and ligamentsParavertebralmuscle

11、spasmStepdeformitySwellingCERVICALSPINEForwardflexion Normal:75to 90degreesExtension Normal:45 degreesRight lateral flexion Normal:45 to60degreesLeftlateral flexion Normal:45 to60degreesRotationto right Normal:75degreesRotationto left Normal:75degreesThoracicandlumbarspineRib cage excursion 7 cmForw

12、ardflexion (Schobers test) Normal: 90 degreesExtension Normal: 30 degreesLateral flexion to left and right Normal: 30 to45degreesRotation to left and right Normal: 45degreesCervicalspine:Compression testDistraction testValsalva testSwallowingtestAdsontestPressdownupon thetop ofptsheadIfthereisincrea

13、sepain ineithercervicalspineorupperextremity,noteitsexactdistribution.So,wecanlocatetheneurologicallevelAnarrowing of neuralforamen,pressureon thefacetjointsormuscle spasmcancause increasepain uponcompressionPlacetheopen palm ofonehand under theptschin, andtheotherhand isupon occiputThen,gradually l

14、ift (distract)thehead toremove itsweightfromtheneckTodemonstratetheeffectthatnecktraction might have helpin relieving thepain bydecreasingpressureon thejoint capsulesaround thefacetjoints.Askpttohold his breathand bear down as ifheweremoving hisbowelsThen,ask whetherhefeels any increasein painand de

15、scribethelocationThistestincreaseintratechal pressureIfa spaceoccupyinglesion, suchas aherniateddiscor a tumorpresentin cervical canal, ptmaydevelop pain in cervicalspinesecondary toincreasepressureThepain also may radiate tothedermatomedistribution ofcervical spinepathologyDifficultyor painupon swa

16、llowingcansometimescausedbycervicalspinepathologysuchas:BonyprotuberanceBonyosteophytesSofttissue swelling dueto hematomas, infectionortumor in ant portion ofcervical spinePullthearmdownwardsPalpatetheradialpulseTurntheptsheadto thesamesidewhilefeelingtheradialpulseFadingoftheradialpulseindicatespos

17、itivethoracicoutletobstructionStraightlegraisingtestSciaticstretchtestFemoralstretchtestWiththeknee extended, passively flex thehipinorder toliftthelower limbThept willfeel painover theback andradiatingto lowerlimb.Watchthedistribution of pain indicatingtheinvolvednerverootNormally accepted positive

18、 if theangleof elevation is 60degreesCross sciatic tensionindicate severe root irritationFollowingtheSLRtest,drop thelimbforabout10degreestorelievetensionon theirritatednerverootDorsiflextheankleto reproducethestretchingeffectonthenerverootThiswillreproducethesciaticapainlook for lumbar roottensiona

19、sk thepatienttolie proneflexthekneeliftup thehipintoextensionpain may befelt in frontofthethighand thebackDonetoexcludehigherdiscprolapsed (rare)UPPERLIMB1.Tonehypertonia :UMNLnormotoniahypotonia :LMNL2.PowerNerve rootC5C6C7C8T1TestElbow flexionWrist extensionWrist flexionFinger flexionFinger abduct

20、ion3.Reflex-bicepsjerk:C5,C6-tricepsjerk:C7,C8-brachioradialis jerk:C5,C64.SensationC5lateralarmC6lateralforearm-thumb &index fingerC7middle fingerC8ring&little fingerT1medial armLOWERLIMB1.Tonehypertonia :UMNLnormotoniahypotonia :LMNL2.PowerL2L3,4L4L5S1,2Hip flexionKnee extensionDorsiflexionGreat t

21、oeextensionPlantar flexion3.Reflex-knee jerk:L3,L4-ankle jerk:S1,S2-plantar reflex :L5,S1,S24.SensationL1groinL2anterior thighL3anterior kneeL4medial legL5lateralleg-medial offoot dorsumS1lateraloffootdorsum-heelandfoot soleS2posterior legandthighIVDPSpondylolisthesisVertebralcolumn islonger than sp

22、inal cordVertebraand correspondingspinal cordsegmentCervicalvertebraeThoracic1-6Thoracic7-9T10T11T12L1+1+2+3L1& L2L3& L4L5sacralsegmentsDefinition : Lateral curvature of the spine2 broad types of deformity are defined:Postural scoliosisStructural scoliosisThe deformity is secondary or compensatory t

23、osome condition outside the spine.Short legPelvic tilt due to contracture of the hip Local muscle spasm a/w PID may cause askew back (sciatic scoliosis) The curve disappear when the patient sit or onforward flexion.Usually panied by bony abnormality orvertebral rotation.The deformity is fixed and does not disappearwith changes in position.Causes:Idiopathic (most cases)Osteopathic (congenital)Neuropathic ( poliomyelitis, cerebral palsy)Myopathic ( muscular dystrophies)NeurofibromatosisConstitutes about 80% of all cases of scoliosisAge of onset have been used to defined 3groups:Adolescent (