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Contains the following key public domain (not copyrighted) U.S. Government publication(s) on one CD-ROM in both Microsoft PowerPoint and Adobe Acrobat PDF file formats:
TITLE:
Orthopedic Shoulder Hip and Spine Disorders, 203 Slides
SLIDE TOPICS, SUBTOPICS and CONTENTS:
Learning Objectives Disorders Of The Shoulder Anatomy Of The Shoulder Review Bones
Scapula
Clavicle
Proximal Humerus Bones Scapula Spans ribs 2 to 7 Three main processes Spine Acromion Coracoid
Bones Clavicle Connects the sternum to the acromion "S" shaped
Bones Proximal humerus (parts) Head Anatomic neck Surgical neck (distal to the anatomic neck) Bones Proximal humerus (parts) Greater tuberosity (rotator cuff insertion - supraspinatus, infraspinatus, teres minor) Lesser tuberosity (rotator cuff insertion - subscapularis) Bones Proximal humerus (parts) Intertubercular groove (bicipital groove) – Long head of the biceps Joints Glenohumeral joint Sternoclavicular joint Acromioclavicular joint Scapulothoracic joint Glenohumeral Joint Ball (Humeral head) and socket (Glenoid) Muscles provide the primary support The labrum lines the glenoid cavity and deepens the socket Ligaments - glenohumeral (inferior glenohumeral is the most important), coracohumeral, capsular G-H Joint Sternoclavicular Joint Gliding joint The only bony attachment to the Axial skeleton is the S-C Joint Articular disc interspaced between surfaces Rotates 30 degrees with glenohumeral motion Ligaments - anterior and posterior sternoclavicular, capsular
Dislocations/Separations Prognosis If pt’s age is < 30, redislocation rate is higher…….Surgery If pt’s age is > 30, redislocation rate is lower…..Rehabilitation Dislocations/Separations Dislocations/Separations Dislocations/Separations Anterior Dislocation Mechanism of Injury Forced abduction and rotation Signs/Symptoms – Acute Pain, flattened Deltoid, anterior fullness, natural splinting, short squared shoulder Anterior Dislocation Radiology- True AP, Axillary lateral or West Point and Scapular Y views
Anterior Dislocation Special tests + Anterior drawer/ translation + Apprehension test + Reduction/ release test
Anterior Dislocation Treatment Immediate reduction Ice, rest NSAIDs, ASA, Tylenol® Shoulder Immobilizer or Sling & Swathe PT - early gentle ROM Anterior Dislocation Treatment -- Surgical Arthroscopic Bankhart repair Capsular shift Open Bankhart repair Capsular shift Usually a combination Posterior Dislocation Mechanism of Injury - Fall on the adducted and internally rotated arm
Posterior Dislocation Signs/Symptoms - Severe Acute Pain, Prominent Coracoid Process, Arm will be adducted, internally rotated Posterior Dislocation Radiology- Shoulder series will indicate head of humerus posterior to the labrum Posterior Dislocation
Special tests + Jerk Test + Reduction test
Posterior Dislocation Treatment Immediate reduction Ice, rest NSAIDs, ASA, Tylenol® Shoulder Immobilizer or Sling & Swathe PT - early gentle ROM Posterior Dislocation Treatment – Surgical Arthroscopic Reverse Bankhart repair Capsular shift Open Reverse Bankhart repair Capsular shift Usually a combination Inferior & Multidirectional Dislocation Shoulder examination shows instability in multiple directions Patients often display hyperelasticity (MP joints, elbow, shoulder, etc. ) Inferior & Multidirectional Dislocation Inferior & Multidirectional Dislocation Inferior & Multidirectional Dislocation Inferior & Multidirectional Dislocation Treatment Nonoperative treatment favored If Surgery – Capsular Shift Acromioclavicular Separations
Acromioclavicular injuries (the so-called separated shoulder) can be classified into six types, and treatment is based on the specific type A-C Separations Mechanism of Injury: FOOSH or Fall onto the tip of the shoulder A-C Separations A-C Separations Type I – AC ligament is partially disrupted; coracoclavicular (CC) ligament is intact Type II – AC ligament is completely torn CC ligament is partially torn Type III – AC & CC ligaments are completely torn & there is complete separation of clavicle from the acromion. Types IV – VI are uncommon A-C Separations Signs and Symptoms Pain over A-C joint & lifting of the arm Swelling With Type III & higher…there is an obvious and cosmetically displeasing deformity A-C Separations A-C Separations A-C Separations Diagnosis AP Xrays of both shoulders will confirm Type II or higher A-C separations (with & without weights) A-C Separations Type II A-C Separations Treatment Type I & II: Rest & Ice Sling, Sling & Swath, Shoulder Immobilizer or Figure-of-8-clavicle brace X 4-6 Weeks NSAIDs, ASA or Tylenol® Analgesics esp. at night A-C Separations Treatment Type III is controversial – Most are treated nonoperatively with good results A-C Separations Immobilizing devices A-C Separations Surgical repairs Rotator Cuff Syndrome Rotator Cuff Syndrome Rotator Cuff Syndrome Rotator Cuff Syndrome Rotator Cuff Syndrome Rotator Cuff Syndrome PE + Drop-arm test + Lift-off test Rotator Cuff Syndrome Rotator Cuff Syndrome Diagnosis cont’ Rotator Cuff Syndrome Rotator Cuff Syndrome Rotator Cuff Syndrome Treatment: Surgical Arthroscopic Open
Impingement Syndrome Impingement between the rotator cuff tendons and subacromial bursa between the humeral head, greater tuberosity and the acromion occurs when the arm is elevated. This causes inflammation and edema and therefore increased impingement, in a self-perpetuating cycle…… Impingement Syndrome Classification Stage I: Pt’s < 25 with reversible edema & hemorrhage Stage II: Pt’s 25 – 40 with fibrosis, tendonitis & recurring pain with activity Stage III: Pt’s > 45 with bone spurs or osteophytes & rotator cuff tendon rupture Impingement Syndrome Differential Diagnosis Subacromial Bursitis Supraspinatus Tendonitis A-C Arthritis Bicipital Tendonitis Calcific Tendonitis Adhesive Capsulitis Thoracic Outlet Syndrome Subacromial Bursitis Signs and Symptoms Inability to use the arm in the overhead position (Flexed & Internally rotated or Abduction) due to pain, stiffness, weakness & catching Pain with sleeping on the affected side Pain in the acromial area Subacromial Bursitis Physical Exam + Neer Impingement Sign + Hawkins Impingement Sign + Impingement Sign Differential Diagnosis Impingement Test
Subacromial Bursitis Impingement Test – instill 10cc 1% plain local anesthetic into the subacromial space followed by impingement testing
Subacromial Bursitis Complete pain relief supports a diagnosis of impingement syndrome To demonstrate supraspinatus weakness compare using the supraspinatus test – If initially patient was weak but strong post injection then inflammation & fibrosis is consistent vs rotator cuff tear
Subacromial Bursitis TX: Conservative Rest & Ice Avoidance of overhead activities PT (ROM ex’s & Rotator cuff strengthening ex’s) Ultrasound/Phonophoresis/ Iontophoresis NSAIDs, ASA or Tylenol® Corticosteroid injections Subacromial Bursitis Treatment: Surgical Bursectomy Acromioplasty (Decompression) Arthroscopically or Open Supraspinatus Tendonitis Signs and symptoms are identical to subacromial bursitis except the inflammation is within the tendon vs bursa + Supraspinatus test but no weakness Supraspinatus Test Supraspinatus Tendonitis Treatment: Conservative Rest & Ice Avoidance of overhead activities PT (ROM ex’s & Rotator cuff strengthening ex’s) Ultrasound (Phonophoresis or Iontophoresis) NSAIDs, ASA or Tylenol® Corticosteroid injections Supraspinatus Tendonitis Treatment: Surgical Arthroscopic (Debridement & Acromioplasty) Open (Acromioplasty, Debridement & RC repair) Acromioclavicular (A-C) Arthritis/Arthropathy Signs and Symptoms A-C joint tenderness DJD change on Xrays Physical Exam + Cross-body Adduction Diagnosis Lidocaine injection into the A-C Joint Acromioclavicular (A-c) Arthritis/Arthropathy + Cross- Body Adduction Test Acromioclavicular (A-C) Arthritis/Arthropathy Xrays: DJD changes & possible osteolysis or bone cysts Diagnosis: Lidocaine injection into the A-C Joint Acromioclavicular (A-C) Arthritis/Arthropathy Treatment: Conservative Rest & Ice Avoidance of overhead activities PT (ROM ex’s & Rotator cuff strengthening ex’s) Ultrasound (Phonophoresis or Iontophoresis) NSAIDs, ASA or Tylenol® Corticosteroid injections Acromioclavicular (A-C) Arthritis/Arthropathy Treatment: Surgical Open (Acromioplasty & distal clavicle resection using Mumford procedure) Bicipital Tendonitis Signs and Symptoms Pain to palpation over bicipital groove or tendon Physical Exam +Speed’s Test +Yergason’s Test
Bicipital Tendonitis + Speed’s Test Bicipital Tendonitis + Yergason’s Test Bicipital Tendonitis Treatment: Conservative Rest & Ice Avoidance of overhead activities PT (ROM ex’s & Rotator cuff strengthening ex’s) Ultrasound (Phonophoresis or Iontophoresis) NSAIDs, ASA or Tylenol® Corticosteroid injections (BEWARE!) Bicipital Tendonitis Treatment: Surgical Arthroscopic Open Calcific Tendonitis Signs and Symptoms Localized tenderness Associated with impingement from increased size of the tendon
Calcific Tendonitis Diagnosis Xrays Calcific Tendonitis Treatment: Nonoperative Physical therapy Needling calcification with local anesthetic Radiotherapy Treatment: Operative Surgical excision
Adhesive Capsulitis “Frozen Shoulder” Idiopathic loss of both active and passive motion Most commonly affects patients between 40 & 60 Most common risk factor is DM Type I
Adhesive Capsulitis Patients typically have 2 phases “freezing” phase with pain & progressive loss of motion “thawing” phase of decreasing discomfort associated with a slow but steady improvement in range-of-motion Adhesive Capsulitis Physical Exam -- reveals significant reduction in both active & passive range-of-motion, at least 50%, when compared with the opposite normal shoulder Motion is painful, especially at the extremes Pain & tenderness are common at the deltoid insertion Adhesive Capsulitis Treatment NSAIDs Non-narcotic analgesics Moist Heat Stretching program 3-4 x daily ? Consider a corticosteroid injection Thoracic Outlet Syndrome Thoracic outlet syndrome - compression of a portion of the brachial plexus, most commonly the lower portion [C8, T1], and the axillary artery Thoracic Outlet Syndrome Etiology Compression by the scalene muscles/first rib on the lateral cord of the brachial plexus and the subclavian artery Thoracic Outlet Syndrome Signs/Symptoms Related to overuse- paresthesias to hand and arm, pain in upper extremity and neck, weakness of extremity, drooping of shoulder girdle, clear correlation with posture and position
Thoracic Outlet Syndrome Diagnosis Adson's Maneuver Wright's Test Roos Test Thoracic Outlet Syndrome Adson's maneuver - shoulder extension and head rotation to the ipsilateral side while holding a breath leads to loss of the radial pulse Thoracic Outlet Syndrome Modified Adson's (Wright's) test Shoulder extension, abduction to 90 degrees, and external rotation with the head rotated to the contralateral side leads to loss of the radial pulse Thoracic Outlet Syndrome Roos test ‑ the arms elevated past 90 degrees and the hands opened and closed rapidly 15 times leads to cramping/tingling of the hands (claudication) Thoracic Outlet Syndrome Treatment options Nonoperative - physical therapy, postural training Operative - first rib resection, others Summary Steps in the general examination of the anterior shoulder Mechanisms of injury, clinical signs and symptoms, diagnostic tests, and treatment for common shoulder disorders
Common Orthopedic Hip Disorders Learning Objective Identify the etiology, clinical presentation, laboratory and radiologic studies, evaluation and treatment for the following hip conditions: Aseptic/Avascular Necrosis or Osteonecrosis Fractures and Dislocations Slipped Capital Femoral Epiphysis Legg-Calve-Perthes Disease Disorders Of The Hip Aseptic Necrosis (AVN or Osteonecrosis) Fractures & Dislocations Slipped Capital Femoral Epiphysis (SCFE) Legg-Calve-Perthes Disease Osteonecrosis Also commonly referred to as avascular necrosis (AVN)
Represents death of bony tissue Osteonecrosis Most common site involved is the hip (femoral head)
Death of subchondral bone leads to collapse of overlying cartilage and flattening of the femoral head (crescent sign)
Crescent Sign Crescent Sign Osteonecrosis Treatment Options Activity modification NSAIDs, Tylenol® or ASA Cane or Crutches Total hip arthroplasty for advanced cases Controversial Core decompression Vascularized fibula graft Osteonecrosis Osteonecrosis
Bilateral hip involvement is very common (50% to 80%), so one needs to rule this out and follow over time in patients with what appears to be unilateral hip ON Osteonecrosis Etiologies Idiopathic (Chandler’s Disease) Post-traumatic Steroid-induced Alcohol-induced Dysbarism (Caisson’s Disease) Storage diseases (such as Gaucher’s Disease) Osteonecrosis Evaluation Careful history for risk factors (to assess etiology) Physical examination Decreased joint range of motion Clinical Suspicion Femoral Neck Fracture Garden Classification Type I -- incomplete or valgus impacted fracture
Femoral Neck Fracture Type II -- complete fracture without displacement Femoral Neck Fracture
Type III -- complete fracture with partial displacement of fracture fragments Femoral Neck Fracture Type IV -- complete fracture with total displacement of the fragments which allows the femoral head to rotate back into anatomic position
Femoral Neck Fracture
Types I & II = nondisplaced Types III & IV = displaced Femoral Neck Fracture Signs and Symptoms Inability to bear weight
Femoral Neck Fracture Affected leg appears shortened and is externally rotated from the contraction of the iliopsoas and gluteus maximus muscles Femoral Neck Fracture Tx Principles Nondisplaced fx’s should be internally stabilized with lag screws or pins placed parallel Femoral Neck Fracture Tx Principles Displaced fractures Closed/open reduction and internal fixation in younger patients Primary prosthetic replacement in older patients Femoral Neck Fracture Complications associated with femoral neck fractures: Loss of fixation Infection Non-Union Osteonecrosis Dislocation Prosthetic loosening Pain related to acetabular erosion Hip Dislocations Posterior-most common Ortho Emergency -- due to risk of AVN, early DJD or Vascular insufficiency Hip Dislocations Hip Dislocations Clinical findings: Shortened limb Internally rotated Adducted Hip Dislocations Tx: Reduction using Allis maneuver (Both Anterior & Posterior dislocations) Hip Dislocations If Irreducible or recurrent dislocations: ORIF -- THR Slipped Capital Femoral Epiphysis (SCFE) Femoral head remains in the acetabulum and the neck displaces through the growth plate in the anterior direction Caused by weakness of the perichondrial ring and a slip through the hypertrophic zone of the developing growth plate Slipped Capital Femoral Epiphysis (SCFE) SCFE most commonly seen in obese adolescent boys Most common with a + FMHX Slipped Capital Femoral Epiphysis (SCFE)
Bilateral is not uncommon Assoc with hypothyroidism & renal disease Slipped Capital Femoral Epiphysis (SCFE) Presents with hip or knee pain and an externally rotated LE with decreased ROM of the hip especially internal rotation Slipped Capital Femoral Epiphysis (SCFE) Slipped Capital Femoral Epiphysis (SCFE) Slip is classified based on the degree of slippage and best seen on the frog-leg lateral view Grade I -- 0 to 33% Grade II -- >33 to 50% Grade III -- > 50% Slipped Capital Femoral Epiphysis (SCFE) Frog-Leg View Slipped Capital Femoral Epiphysis (SCFE)
Tx: Pinning across the capital femoral epiphysis to prevent further slippage Slipped Capital Femoral Epiphysis (SCFE) Legg-Calve-Perthes Disease Noninflammatory deformity of the WB surface of the femoral head Results from a vascular insult or abnormality Legg-Calve-Perthes Disease Vascular insult leads to osteonecrosis of the proximal femoral epiphysis Most common in boys 4 - 8 years old Legg-Calve-Perthes Disease Pain in hip or knee Decreased ROM esp. Abduction & Internal Rotation Can occur bilaterally Legg-Calve-Perthes Disease Pathologic process include Necrosis of bone
Legg-Calve-Perthes Disease X-ray findings vary with the stage of disease 2 most common staging systems are Caterall Salter-Thompson Legg-Calve-Perthes Disease Salter-Thompson Stage A -- No involvement of the lateral pillar of the femoral head; prognosis generally good Stage B -- Lateral pillar of the femoral head is involved; prognosis generally poor Legg-Calve-Perthes Disease Caterall Stage I -- 25% of the femoral head in the anterior central region is involved Stage II -- 50% of the femoral head including the anterior lateral region is involved Legg-Calve-Perthes Disease Caterall Stage III -- Approx. 75% of femoral head involved with formation of a large sequestrum; large medial pillar usually uninvolved Stage IV -- Entire femoral head involved, with widespread collapse of epiphysis Legg-Calve-Perthes Disease Crescent sign represents a pathologic fracture with collapse of subchondral bone in the resorbing femoral head Legg-Calve-Perthes Disease Legg-Calve-Perthes Disease Treatment Goal: To maintain the sphericity of the femoral head Treatment for Caterall Stage I & II or Salter-Thompson Stage A is usually observation
Legg-Calve-Perthes Disease Tx for Caterall Stage III & IV or Salter-Thompson Stage B is early ROM followed by containment of the femoral head within the acetabulum using an abduction brace or surgery Summary Etiology, clinical presentation, laboratory and radiologic studies, evaluation and treatment for the following hip conditions: Aseptic/Avascular Necrosis or Osteonecrosis Fractures and Dislocations Slipped Capital Femoral Epiphysis Legg-Calve-Perthes Disease
Common Orthopedic Conditions of the Spine Learning Objective Given a scenario describing a patient with symptoms suggestive of an orthopedic or musculoskeletal condition, formulate a treatment plan after ordering and interpreting diagnostic tests and making a preliminary diagnosis. Learning Objective Identify the etiology, clinical presentation, lab/radiologic studies, evaluation, and treatment for the following spine conditions: Back Strain/Sprain Ankylosing Spondylitis Cauda Equina Learning Objective Identify the etiology, clinical presentation, lab/radiologic studies, evaluation, and treatment for the following spine conditions: Herniated Nucleus Pulposus (HNP) Spinal Stenosis Kyphosis/Scoliosis Low Back Pain (LBP): Spondylolysis, Spondylolisthesis
Disorders Of The Back/Spine Back Strain/Sprain Ankylosing Spondylitis Cauda Equina Herniated Nucleus Pulposus (HNP) Spinal Stenosis Kyphosis/Scoliosis Low Back Pain (LBP): Spondylolysis, Spondylolisthesis Back Strain/Sprain LBP is the most frequent cause of lost work time and disability in adults <45 years Most symptoms of limited duration 85% of patients improve and returning to work within 1 month Back Strain/Sprain The 4% of patients whose symptoms persist longer than 6 months generate 85% to 90% of the costs to society for treating low back pain Back Strain/Sprain By strict definition, a low back sprain is an injury to the paravertebral spinal muscles. However, the term also is used to describe ligamentous injuries of the facet joints or annulus fibrosus Back Strain/Sprain Repeated lifting and twisting or operating vibrating equipment most often precipitates a back sprain Back Strain/Sprain Other risk factors include poor fitness, poor work satisfaction, smoking, and hypochondriasis Recurrent episodes are separated by many months or years; more frequent recurrences suggest degenerative disk disease Back Strain/Sprain – Clinical Symptoms Patients report the acute onset of low back pain, often following a lifting episode Lifting may be a trivial event, such as leaning over to pick up a piece of paper Pain often radiates into the buttocks and posterior thighs Back Strain/Sprain – Clinical Symptoms Patients may have difficulty standing erect, may need to change position frequently for comfort Condition often first occurs in the young adult years
Back Strain/Sprain Clinical Symptoms - First Major Episode May show signs of nonorganic behavior, such as exaggerated responses, generalized hypersensitivity to light touch, or facial grimacing Physical Examination PE reveals diffuse tenderness in the low back or sacroiliac region ROM of the lumbar spine, particularly flexion, is typically reduced and elicits pain Physical Examination The degree of lumbar flexion and the ease with which the patient can extend the spine are good parameters by which to evaluate progress The motor and sensory function of the lumbosacral nerve roots and lower extremity reflexes are normal Back Strain/Sprain Diagnostic Tests Plain radiographs usually are not helpful for patients with acute low back strain, as they typically show changes appropriate for their age Back Strain/Sprain Diagnostic Tests (cont’) Adolescents/young adults, have little or no disk space narrowing. Adults older than age 30 years, have variable disc space narrowing and/or spurs Back Strain/Sprain Diagnosis For patients with atypical symptoms, such as pain at rest or at night or a history of significant trauma, AP and lateral radiographs are necessary These views help to identify or rule out infection, bone tumor (visualize up to T10), fracture, or spondylolisthesis Back Strain/Sprain Differential Diagnosis Ankylosing spondylitis (family history, morning stiffness, limited mobility of lumbar spine) Drug-seeking behavior (exaggerated symptoms, inconsistent and nonphysiologic examination) Extraspinal causes: ovarian cyst, nephrolithiasis / pancreatitis/ ulcer disease Back Strain/Sprain Differential Diagnosis Fracture of the vertebral body (major trauma or minimal trauma with osteoporosis) Herniated nucleus pulposus or ruptured disc (unilateral radicular pain symptoms that extend below the knee and are equal to or greater than the back pain) Back Strain/Sprain Differential Diagnosis Infection [fever, chills, sweats, elevated erythrocyte sedimentation rate (ESR)] Myeloma (night sweats, men older than age 50 years) Back Strain/Sprain-Treatment Focuses on relieving symptoms, short period of bed rest (1 to 2 days) NSAIDs, other non-narcotic pain medications (7 to 14 days) Back Strain/Sprain-Treatment Muscle relaxants may be helpful in the first 3 to 5 days, but narcotic analgesics/sedatives should be avoided Back Strain/Sprain - Treatment Treatment Couple medications with reassurance Once the acute pain has diminished, emphasize aerobic conditioning and strengthening regimens Goal is to assist patient in returning to normal activity within 4 weeks Ankylosing Spondylitis
Ankylosing Spondylitis
Men 3rd to 4th decade of life Insidious onset of back and hip pain Morning stiffness + HLA-B27 Ankylosing Spondylitis
Neurological Syndromes 44 yo F w/ 2 yr h/o LBP but new bilateral sciatica, saddle numbness Onset: p moving furniture PE: distressed; sensory loss L5-S4 (anal area); weakness in feet DF/PF W/U: emergent MRI & surgical referral Cauda Equina Syndrome Distal end of the spinal cord, the conus medullaris, terminates at the Ll-2 level Below this, spinal canal is filled with L2-S4 nerve roots, known as the cauda equina Cauda Equina Syndrome Compression of roots distal to the conus causes paralysis without spasticity RARE : <1-2% of HNP or spinal masses L5/S1 is the most common level Involves bilateral sacral roots Cauda Equina Syndrome A massive central herniation of a lumbar disc that presents with Bilateral sciatica +/- foot weakness Progressive motor weakness and numbness Saddle anesthesia (buttock anesthesia) Loss of bowel and bladder control This represents a surgical emergency!
Herniated Nucleus Pulposus (HNP) of the Lumbar Spine Displacement of the central area of the disc (nucleus) resulting in impingement on a nerve root HNP of the Lumbar Spine Classification based on degree of disc displacement
Most commonly involves the L4-5 disc (L5 nerve root) Disc Pathology
HNP of the Lumbar Spine History Radicular leg pain May also have lower back pain
HNP of the LS – Physical Findings Motor weakness L4 nerve root—tibialis anterior weakness L5 nerve root—extensor hallicis longus weakness S1 nerve root--achilles tendon weakness HNP of the LS – Physical Findings Physical findings cont’d: Asymmetric reflexes Knee jerk (L4) Tibialis Posterior or Medial Hamstring tendon reflex (L5) Ankle jerk (S1) HNP of the Lumbar Spine Sensory findings Light touch Sharp Dull HNP of the Lumbar Spine Positive tension signs Straight Leg Raise (Supine & Sitting) HNP of the Lumbar Spine Diagnostic tests Magnetic resonance imaging (MRI) Myelography Electromyography/nerve conduction studies HNP of the Lumbar Spine Treatment (most sxs resolve with time) Symptomatic Physical therapy NSAIDs, Tylenol or ASA Aerobic conditioning Lumbar epidural steroids Neurological Syndromes 71 yo M w/ long ho LBP & 6 mos. R buttock > calf pain w/ vague numbness
Worse: Standing, walking
Improves: Stooping, sitting, forward bending Spinal Stenosis HNP/Spinal Stenosis Comparisons HNP vs Stenosis Age: 30-50 vs >50 Sciatica: Classic for HNP vs Atypical for Stenosis Aggravated: Flexion/Sitting vs Extension & Standing HNP/Spinal Stenosis Comparisons HNP vs Stenosis (cont’) Nerve Tension Signs (SLR): Usual vs Unusual Prognosis: Worse, More Chronic in Stenosis HNP and Spinal StenosisTreatment NSAIDs (COX-2 inhibitors), Tylenol or ASA “Muscle relaxants” Narcotics Tramadol [generic] Corticosteriods (including spinal injections) HNP/Spinal Stenosis Treatment Decompression Laminectomy Foraminotomy Fusion Kyphosis Defined: abnormally increased convexity in the curvature of the thoracic spine as viewed from side Scheuermann’s Disease Hyperkyphosis that does not reverse on attempts at hyperextension Scheuermann’s Disease Most common in adolescent males Scheuermann’s Disease Dx made by X-ray 45 degrees With 5 degrees or more of vertebral wedging at 3 sequential vertebrae Scheuermann’s Disease (cont’) Treatment Observation +/- Bracing Spinal Fusion Scoliosis
Scoliosis - Defined Lateral curvature of the spine of greater than 10 degrees, usually thoracic or lumbar, associated with rotation of the vertebrae and sometimes excessive kyphosis or lordosis Scoliosis Idiopathic scoliosis Lateral deviation and rotation of the spine without an identifiable cause Scoliosis Assoc. rib hump with forward bending Scoliosis Assoc. rib hump with forward bending Scoliosis Curve description – curve described by its apex (position and direction [right or left] that it points to Scoliosis Right thoracic curves -- apex at T7 or T8 (MC) Double major curves -- right thoracic curve with left lumbar curve Left lumbar curves, Right lumbar curves Scoliosis
Scoliosis Curve measurement
Most common method used is Cobb method
Measurements are made on standing PA X-rays Scoliosis Determination of skeletal maturity Risser staging -- based on ossification of iliac crest apophysis Risser staging is graded 0 (least mature) to 5 (most mature) Scoliosis Adolescent idiopathic scoliosis Presents between ages 10 & 18 MC form of idiopathic Scoliosis Curve progression is most likely with Curve > 20 degrees Age at dx < 12 Risser stage of 0 or 1 Scoliosis Approx. 75% with curves of 20 - 30 degrees progress at least 5 degrees Severe curves of 90 degrees or more are assoc. with cardiac & pulmonary impairment Left thoracic curves are rare and require eval of spinal cord with MRI Scoliosis Treatment options include:
Observation
Bracing Scoliosis Surgery Based on likelihood of curve progression Curve Magnitude Age at DX Skeletal Maturity Presence of Menarche Curve progression during observation period Scoliosis Scoliosis Scoliosis Scoliosis Scoliosis Adolescent idiopathic scoliosis is typically not painful, and the child presenting with a painful curvature should be given a thorough w/u Low Back Pain Spondylolysis Defect in pars interarticularis (Unilateral) MC cause of lower back pain in children and adolescents Low Back Pain Spondylolysis Unilateral Pars defect is the result of a fatigue fx from repetitive hyperextension Low Back Pain Most common in gymnasts and football lineman Low Back Pain Low Back Pain Spondylolysis Treatment Modification of activity NSAIDs, Tylenol/ASA Physical therapy Flexibility & strengthening exercises Thoracolumbosacral orthosis Low Back Pain Spondylolisthesis Bilateral Pars Interarticularis defect Forward slippage of one vertebra on another Usually L5-S1 Low Back Pain Most common in children involved in hyperextension activities Low Back Pain Spondylolisthesis Meyer Classification Low Back Pain Spondylolisthesis Treatment Modification of activity NSAIDs, Tylenol, ASA Physical therapy Flexibility & strengthening exercises Thoracolumbosacral orthosis
Low Back Pain Spondylolisthesis Treatment Severe pain not responding to non-operative management requires surgical decompression and/or stabilization
Summary Symptoms suggestive of an orthopedic or musculoskeletal condition, formulation of a treatment plan after ordering and interpreting diagnostic tests, and making a preliminary diagnosis Summary Etiology, clinical presentation, lab/radiologic studies, evaluation, and treatment for the following spine conditions: Back Strain/Sprain Ankylosing Spondylitis Cauda Equina
Summary Etiology, clinical presentation, lab/radiologic studies, evaluation, and treatment for the following spine conditions: Herniated Nucleus Pulposus (HNP) Spinal Stenosis Kyphosis/Scoliosis Low Back Pain (LBP): Spondylolysis, Spondylolisthesis
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