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- 1. Disorders of theback Jesse Noel V. Conjares, MD, MOrtho, FPOA 1
- 2. Disorders of theback Clinical manifestations of a back problem pain Neurologic compromise (paresthesia, power loss, pee and pooh-pooh problems) Deformity 2
- 3. Back Pain • 2ndmost common symptom prompting a patient to visit a physician (next to upper respiratory infections) • Most prevalent among the 25-45 year age group with no gender predilection 3
- 4. Back Pain Main pointsto be considered by a physician in determining etiology AGE Children- developmental disorders, infections, primary tumors Young adults- lumbar disc herniation, spondylolisthesis, acute fractures, infections Older adults- spinal stenosis, metastatic disease, osteoporotic vertebral body fractures 4
- 5. Back Pain ONSET Acute- fractures,infection, disc herniation, inflammatory arthritis, muscle strain Gradual- inflammatory and non-inflammatory arthritis, Potts disease, malignancy, spinal stenosis AGGRAVATING AND RELIEVING FACTORS Aggravated by motion and position(mechanical)- motion segment pathology Persistent- infection, malignancy, inflammatory arthritis ASSOCIATED NEUROLOGIC COMPROMISE Predominantly back pain vs. unilateral leg pain Sensory, motor, autonomic deficits Positive nerve root tension signs 5
- 6. Back Pain SYSTEMIC SIGNSAND SYMPTOMS Eye, heart, urinary tract involvement- spondyloarthropathy Appendicular joint – inflammatory and non- inflammatory arthritis Primary extraspinal malignancy- metastatic spinal disease Manifestations of an infection- vertebral osteomyelitis, Potts disease, discitis System-specific laboratory findings 6
- 7. Back Pain REFERRED PAINFROM ADJACENT ORGAN Cardiovascular- heart disease, aortic aneurysm Urinary tract- pyelonephritis, urolithiasis Digestive tract- pancreatitis, cholecystitis, acute appendicitis, colo-rectal malignancy Reproductive tract- ovarian malignancy, pelvic inflammatory disease Sacroiliitis and hip arthritis PSYCHOGENIC Esp. in chronic, recurrent cases, litigation & compensation issues Special tests can evaluate 7
- 8. Imaging Diagnostic in mostcases. Plain radiographs CAT scan MRI Central Dexa Bone Densitometry Directed by symptoms from history and findings on PE Collaborated by pertinent positive and negative lab results 8
- 9. Laboratory tests To rulein or rule out: malignancy, infection, inflammatory arthritis Cbc with differential count, ESR, CRP, ASO Serum RF, anti-ccp, ANA, HLA-B27 Serum electrolytes Serum alkaline phosphatase, acid phosphatase Prostatic-specific antigen in males Serum electrophoresis 9
- 10. Laboratory tests BIOPSY CT scan-guided BONESCAN Metastatic spine disease To search for more accessible sites for biopsy in cases of metastatic disease 10
- 11. LABORATORY TESTS ELECTROMYOGRAPHY-NERVE CONDUCTION VELOCITY(EMG-NCV) Objective documentation of a patient’s subjective complaint of leg pain Confirms nerve root pathology 11
- 12. What needs tobe managed in spine disorders • Primary disorder • Instability of the spine • Neurologic compromise 12
- 13. Goal of intervention Acomfortable and functional patient 13
- 14. Principles of management Conservativemanagement usually suffices for the majority of cases. 14
- 15. Conservative management Directed atspecific etiology Short-term pain relief • Oral meds: Analgesics, NSAIDS, muscle relaxants, oral steroids, bone density improvement • Epidural steroids with fluoroscopic guidance • 3-day bed rest • Physical therapy – heating modalities (hot moist pack, ultrasound, microwave, lasers) – TENS – Flexibility, strengthening, balance training 15
- 16. Conservative management Long-term • Patienteducation and assurance • Back school and hygiene – Behavior modification – Activity restriction – Orthotic use • Home exercise program 16
- 17. USING YOUR BACK •Back wants to be upright with maintenance of the normal curves.
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- 19. USING YOUR BACK •Lying on a flat firm surface. Pillows under thighs. • Using a stepboard. Mirror at eye level. • Adjusting distance from steering wheel.
- 20. USING YOUR BACK •Do not use back as a lever. Use lower extremities. • Use proper footwork in sports. Turn whole body. • Use a stool or reacher instead of stretching the back eliminating the normal curves.
- 21. USING YOUR BACK •Sit less often. • Lie down. • Stand up and shift positions regularly. • Walk in comfortable flat rubber-soled footwear.
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- 24. Principles of management Surgeryto address progressive neurologic deficit, deformity and failure of conservative management. 24
- 25. Neurologic compromise Compromise maybe secondary to: • Traumatic transection • Physical compression or compression of blood supply – Canal malalignment – Fracture fragment comminution – Disc herniation – Degenerative stenosis – Tumor – Abcess formation 25
- 26. Addressing neurologic compromise Decompression •Fracture reduction • Fragment removal • Debridement of infected tissue and abcess • Tumor excision 26
- 27. Addressing neurologic compromise •Anterior decompression – Corpectomy – Discectomy – Distraction plates • Posterior decompression – Laminectomy and laminotomy – Facetectomy and foraminotomy – Discectomy 27
- 28. Stabilizing the spine Arthrodesis •Fusing the motion segment to facilitate bone or fracture healing to eliminate movement permanently Instrumentation • Holds the bone fragments in place until fusion becomes complete • Increases the fusion rate 28
- 29. Stabilizing the spine Arthrodesis Waysof bridging the bone gap • Use of autologous bone grafts • Use of allografts • Use of bone graft substitutes – Demineralized bone matrix – Calcium sulfate tablets – Hydroxyapatite – Bone growth factors – Biodegradable and non-biodegradable polymers 29
- 30. Arthrodesis Use of autologousbone grafts 30
- 31. Arthrodesis Use of allografts •Freeze dried irradiated cadaver bone (bone chips, portions of long bone)
- 32. Arthrodesis Use of bonesubstitutes • Demineralized bone matrix, calcium sulfate tablets, hydroxyapatite powder, bone morphogenetic protein, polymers
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- 34. Kinds of spineinstrumentation What segment is being stabilized cervical, thoracic, lumbar Where it is placed Anterior vs posterior Several different types Rods and hooks Plates and screws Rods and screws Interlaminar wiring Interspinous wiring Interbody fusion cages 34
- 35. Spinal rods andhooks 35
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- 41. Overview of SpineDisorders • Muscle strain • Degenerative spine disease • Lumbar disc herniation • Spine trauma • Deformity • Spine infection • Spine tumor • Spondyloarthropathy 41
- 42. Muscle strain, discherniation, degenerative spine disease 42
- 43. 33 vertebrae ofthe bony spine 24 movable • 7 cervical • 12 thoracic • 5 lumbar 14 fused • 5 fused sacral • 4 fused coccygeal • 2 primary curves • 2 secondary curves • 72-75 cm in length – ¼ are IV discs
- 44. Motion segment • 3JOINTS – INTERVERTEBRAL DISC- (synarthroses=bone-con. tissue-bone); cartilage joint – 2 FACET /APOPHYSEAL JOINTS (diarthroses=bone-joint capsule-bone); synovial joint • Pedicles – Half the height of corresponding body forming a superior and inferior notch – Adjacent inferior and superior notches form the intervertebral foramen thru neural and vascular structures pass
- 45. Intervertebral disc • “circular life preserver with a beach ball at the center”
- 46. Intervertebral disc Central nucleus –High water & proteoglycan (hydrophilic)=glycosaminoglycans(GAGs) + water – GAGs- chondroitin-4-sulfate, chondroitin-6-sulfate, hyaluronate, keratan sulfate – Lower collagen (type II-better for compression) content – Exerts pressure radially against the annulus and endplate on weight- bearing
- 47. Intervertebral disc Peripheral annulus –Higher collagen fibers (type I-higher resistance to tension) arranged concentric lamellae – Attached to the vertebral cartilaginous endplates, epiphyseal ring (Sharpey’s fibers), vertebral body periosteum, longitudinal ligaments – On weight-bearing, fibers become horizontal 47
- 48. Motion segment stabilizers Intervertebraldisc Nucleus polposus Annulus fibrosus 6 ligaments ALL PLL Ligamentum flavum Intertransverse ligament Interspinous ligament Supraspinous ligament Facet joint capsule 48
- 49. Extrinsic back extensors quadratuslumborum Intrinsic back extensors erector spinae transversospinalis 49 Motion segment stabilizers
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- 52. USING YOUR BACKAS A TYPE 3 LEVER Torque=magnitude of Force x perpendicular distance to axis of rotation
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- 54. Muscle strain Back extensorsneed to exert a lot more force to maintain the extensor torque greater than the flexion torque of your slouched body. Fatigue sets in leading to microtears- strain Most common cause of low back pain. 54 Quadratus lumborum
- 55. Degenerative Changes Disc- lossof disc height • loss of water content • loss of proteoglycans which maintain disc hydration Facet joints- degenerative arthritis • Osteophyte formation • Joint capsule thickening Ligamentum flavum • thickening 55
- 56. Degenerative changes END RESULT: BACKPAIN +/- NUMBNESS/PARESTHESIAS OF LEGS – Narrowing of the neural foramen and spinal canal – Compression of neural elements – Instability of the motion segment – Diagnosis is RAYUMA. • SPINAL STENOSIS • DEGENERATIVE OSTEOARTHRITIS • SPONDYLOSIS 56
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- 58. Disc herniation • Improperback use exceeding tensile strength of fibers • Tears=back pain • Healing of tear=symptom relief but weaker disc
- 59. Disc herniation • Continuedimproper back use • Tears getting bigger • Unable to hold “beach ball in the middle” • Strong PLL posteriorly • Beach ball “slips” posterolaterally
- 60. Disc herniation • Nerveroot compression (SCIATICA) – Pain – Paresthesias – Power loss • Exaggerated pain when nerve put in tension clinically
- 61. Disc herniation CLINICAL TESTS •Lhermitte’s- flexing head, coughing, sneezing, shock-like sensation down extremities • Brudzinski’s- flexing head, px adducts and flexes knee • Kernig’s sign (bent leg) • Laseague’s sign (straight-leg)- sensitive • Fajerstajn’s (crossed straight- leg raising)- specific
- 62. Management for discherniation and spinal stenosis Conservative management Surgery to decompress and stabilize
- 63. Spine fractures (acute trauma,osteoporotic)
- 64. Spine fractures 2 majorgroups: Acute, high-energy trauma, young age group stabilize patient at scene, transport to hospital Chronic osteoporotic fractures in the elderly 64
- 65. Relevant anatomy inacute spine trauma 3 column theory of stability (Denis) of the thoracolumbar spine Anterior column: ALL, anterior half vertebral body, anterior annulus fibrosus Middle column: Posterior half vertebral body, posterior annulus fibrosus, PLL Posterior column: Facet joints and capsule, pedicle, lamina, ligamentum flavum, interspinous ligament, supraspinous ligament 65
- 66. Vertebral column fractures Classifiedaccording to the mechanism of injury to the middle column 1. Wedge compression 2. Burst 3. Chance fracture (GQ Chance, 1948) 4. Flexion-distraction 5. Translational 66
- 67. Chance fracture • Lapbeltflexion injury with horizontal avulsion of 2 or 3 columns with axis of rotation in front of vertebral column • ½ with abdominal injuries • May have neurologic compromise • Should be checked in a young px after a VA 67
- 68. Determinants of instability McAfeeet al. (1983) • Progressive neurological deficit • Greater than 20° of kyphosis • Greater than 50% loss of vertebral body height • Retropulsed bone fragments within the neural canal 68
- 69. Management of AcuteSpine Fractures Stabilize the patient and the spine at the scene of accident. Determine stability of the fracture and neurologic compromise.
- 70. Conservative management forstable fractures. Brace wear for 3 months Analgesics Progressive strengthening after brace Surgery for unstable fractures. decompression and fusion 70 Management of Acute Spine Fractures
- 71. Osteoporotic compression fractures Osteoporosis=low bone mass At risk: post-menopausal elderly women with small frame white or asian cigarette smoking low calcium diet eating disorders sedentary lifestyle high glucocorticosteroid state hyperthyroidism 71
- 72. Osteoporotic compression fractures Lowenergy or cumulative trauma Clinically manifests as chronic pain, kyphotic deformity, loss of height, and rarely neurologic compromise. Pain from spine deformity causing deformation of pain-innervated structures like the peripheral annulus, facet joint capsule, and ligaments and muscle spasms. 72
- 73. Conservative management for osteoporoticfractures • Orthotic use • Pharmacologic intervention – Analgesia – Calcitonin nasal spray – Bone density improvement • biphosphonates • Strengthening of back muscles • Improvement of flexibility • Activity modification and functional lifestyle 73
- 74. Anti-osteoporosis regimen • Adequatecalcium intake (non-fat milk, seafoods, supplements) • Adequate vitamin D levels (sunlight exposure 30 min/day, supplements) • Weight-bearing exercise (brisk walking) • For post-menopausal patients: – Hormone replacement therapy – Estrogen analog therapy 74
- 75. Surgical intervention for osteoporoticvertebral fractures Minimally invasive for pain • Vertebroplasty • Balloon kyphoplasty Open surgery for neurologic compromise • Decompression • Stabilization 75
- 76. Percutaneous vertebroplasty 76 Recent randomizedtrials show no difference with placebo.
- 77. Percutaneous balloon kyphoplasty 77 Recentrandomized trials showed good improvement in pain and function scores at 1 month follow-up. No difference with placebo at 1 year.
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- 79. Curves of thespine – Kuba- KYPHOSIS – Liyad- LORDOSIS – Sideways- SCOLIOSIS
- 80. Scoliosis Classified as toetiology • Idiopathic • Congenital • Neuromuscular • Degenerative • Traumatic • Functional Idiopathic scoliosis classified as to age of onset • Infantile • Juvenile • Adolescent • Adult 80
- 81. Scoliosis Asymmetry of theback and on the bend over test warrants spine xrays 81
- 82. Cobb’s angle Risserstage 82
- 83. Scoliosis • Any lateralcurvature of the spine with a Cobb’s angle of less than 15 degrees have a similar chance of progressing as a straight spine. • Less than 30 degrees rare chance of progression after skeletal maturity. Keep a curve below 30 degrees until maturity. • 50 degree curves will progress. 83
- 84. Brace wear guidelines Cobb’sangle Risser 0 Risser 1 to 2 Risser 3, 4 or 5 <25 Observe Observe Observe 25-45 Brace Brace Observe >45 Surgery Surgery Surgery if >50 84 For idiopathic scoliosis, Tachdjian’s Pediatric Orthopedics, 2008
- 85. Brace wear Milwaukee bracefor Apex T8 above Boston brace for Apex below T8 85
- 86. Scoliosis Heart and lungcompromise occur at curves of 90 and 100 degrees. Brace wear is dose-dependent at least 23h/day until skeletal maturity. Juvenile scoliosis (< age 9) has the best bracing results. Congenital and neuromuscular scoliosis progress very fast, are resistant to brace wear and have poor prognosis. 86
- 87. Surgical intervention forscoliosis Prevention of curve progression • Fusion with or without instrumentation • Instrumentation without fusion in young growing patients 87
- 88. Pott’s disease 88 Problems: Instability Neurologic compromise Treatment: •Quadruple anti-TB oral tablets (DOTS) • Full contact orthosis • Same indications for surgery
- 89. Spine tumor Most commontumor of the spine is metastatic. Most common primary malignant tumor of the spine is multiple myeloma. Problems of spinal tumor: tumor removal spinal stabilization neurologic compromise 89
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- 91. Infoposter activity End ofcourse activity 91
- 92. infoposter • Compose andprint an infoposter about selected orthopedics topics and present it for 5 min • Target audience: general public, medical students (scope of ortho), pediatricians and parents (ddh and clubfeet) • 10 groups, 7 members, 1 topic • To be printed on a 2’x 6’ tarpaulin sheet with stand • Choice of members and topic 92
- 93. infoposter • Graded asa long exam • Criteria: 50% content completeness and accuracy, 30% visual impact and creativity, 20% 5 min oral presentation on March 4 • Need to have specific content approved first by the 15th Feb • Posters have to be displayed by 1pm on March 4 in the classroom • Assign a spokesman for the group to speak about the poster (max 5 min) and answer questions 93
- 94. topics 1. Orthopedics (definition,scope, subspecialties, work being done, recruit med students to take up orthopedic residency) 2. Fractures (early recognition, first aid, treatment by doctors not hilots, cast care, rehab) 3. Hand disorder (cumulative trauma disorders like trigger finger, cts, de quervains, causes, recognition, treatment and how to avoid) 94
- 95. topics 4. DM foot(causes, recognition, treatment, prevention) 5. Osteosarcoma or enlarging mass in general (recognition, treatment) 6. Osteoporosis (causes, recognition, consequences, treatment, prevention) 7. Developmental hip dysplasia or clubfoot (causes, recognition, newborn screening, treatment) 95
- 96. topics 8. Sports injuries(injuries when taking up running, recognition, proper shoes, warm-up, training for marathon, diet) 9. Arthritis (differentiate bet osteoarthritis, RA and gout, conservative treatment) 10. Low back pain (when to see a doctor, causes, prevention) 96
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