Extern conference

รกัษิณา วนิัยธรรมกลุ Ramathibodi 5402132

ผู้ป่วยหญิงไทยหมา้ย อายุ 70 ปีChief complaint : ปวดขาซา้ย 2 เดือนก่อนมารพ.

Present illness : 1 ปีก่อนมารพ. ขณะกำาลังรดนำ$าต้นไม้ ล่ืนล้ม สะโพกขากระแทกพื$น ใชม้อืขวายนัพื$น หลังล้ม เจบ็บรเิวณขอ้

มอืขวา แต่ไมม่าก ไมม่บีวมแดง ไมม่ขีอ้มอืผิดรูป ไมเ่จบ็สะโพก ขา้งขวา ไมไ่ด้ไปพบแพทยห์ลังจากนั$น อาการปวดดีขึ$นเอง ใช้

งานงอเหยยีดขอ้มอืได้สดุตามปกติ

– 2 เดือน ก่อนมารพ. ปวดสะโพกซา้ย รา้วลงขาซา้ย รา้วลงไปถึงน่อง ไมม่ขีาอ่อน แรง ไมม่ขีาชา ไมม่แีผลท่ีเท้า

– อาการปวดเป็นมากขึ$นเวลาเดิน เดินได้ระยะทางสั $นลง เดินได้น้อยกวา่ 5-10 เมตร นัง่พกัประมาณ 5-10 นาที แล้วเดินต่อได้ และตอนก้มหรอืแอ่นหลังจะปวดมากขึ$น

– ตอนนัง่พกัไมค่่อยปวด ไมม่ปีวดกลางคืน– ไมม่เีบื่ออาหาร นำ$าหนักลด– มอีาการกลั$นปัสสาวะไมไ่ด้ เวลาปวดปัสสาวะ จะมปีัสสาวะราดเปียกกางเกงชั $นใน– ถ่ายอุจจาระได้ปกติ

Personal history :

- โรคประจำาตัว HT , DLP

- ไมม่ปีระวติัมะเรง็ในครอบครวั- ไมม่ปีระวติัแพย้าแพอ้าหารPast History

- ปฏิเสธประวติัผ่าตัดก่อนหน้านี$

Physical Examination

– Vital signs : Body temp 37 , BP 150/80 mmHg, PR 80 bpm , RR 20 /min

– GA : A Thai woman , good consciousness

– HEENT : no pale conjunctivae , anicteric sclera

– Heart : full regular pulse, normal s1s2, no murmur

– Lungs : clear and equal both lungs

– Abdomen : soft, not tender

– Abdomen : not distention , normoactive bowel sound , soft, not tender

– Gait : antalgic gait Lt.

– Neck : normal alignment, no tender point, full motion

– Back : Inspection > loss of lordosis, tender area at lower lumbar

– Palpation > no mark pain on percussion , no trigger point

– No radiated pain on extension, SLR test negative, cross SLR test negative

– Hip joint motion : full ROM all direction both sides

– SI joint ( sign of four) : normal

Neurovascular

– Full 2+ Lt.PTA, Lt. dorsalis pedis artery

– Normal capillary refill < 2 sec

– Moter power of left plantar flexion and dorsiflexion gr. V

DTR 2+ allsensory :normal

Level Rt Lt

C5 V V

C6 V V

C7 V V

C8 V V

T1 V V

T2-9 V V

T10-12 V V

L2 V V

L3 lV V

L4 V V

L5 V V

S1 V V

Bladder sphincter

Anal sphincter >> loose sphincter tone

Problem lists

– Lumbosacral radiculopathy

– Bowel & bladder involvement

Differential diagnosis

Mechanical causes

– Spondylolysis

– Compression fracture

– Traumatic fracture

– Alignment disorder ( kyphosis, scoliosis, spondylolisthesis)

Non mechanical cause

- Malignancy

- infection

INVESTIGATION

LS spine AP

LS spine lateral

LS spine flexion - extension

Oblique view

DIAGNOSIS

– Spondylolisthesis WITH cauda equina syndrome

Spondylolisthesis

Spondylolisthesis

– Symptom

– mechanical/ back pain

– most common presenting symptom

– usually relieved with rest and sitting

– neurogenic claudication & leg pain

– second most common symptoms

– defined as buttock and leg pain/discomfort caused by upright walking

– relieved by sitting

– not relieved by standing in one place (as is vascular claudication)

– may be unilateral or bilateral

– same symptoms found with spinal stenosis

– cauda equina syndrome (very rare)

L4 nerve root involvement

– (compressed in foramen with L4/5 DS)weakness to quadriceps

– best seen with sit to stand exam maneuver

– weakness to ankle dorsiflexion (cross over with L5)

– best seen with heel-walk exam maneuver

– decreased patellar reflex

L5 nerve root involvement

– weakness to ankle dorsiflexion (cross over with L4)

– best seen with heel-walk exam maneuver

– weakness to EHL (great toe extension)

– weakness to gluteus medius (hip abduction)

provocative walking test

- have patient walk prolonged distance until onset of buttock and leg pain

- have patient stop but remain standing upright– if pain resolves this is consistent with vascular claudication

- have patient sit

– if pain resolves this is consistent with neurogenic claudication (DS)

Imaging

– recommended views

– weight bearing lumbar AP, lateral neutral, lateral flexion, lateral extension

– findings

– slip evident on lateral xray

– flexion-extension studies

– instability defined as 4 mm of translation or 10° of angulation of motion compared to adjacent motion segment

MRI

indications

– persistent leg pain that has failed nonoperative modalities

– best study to evaluate impingement of neural elements

views

– T2 weighted sagittal and axial images best to look for compression of neurologic elements

Classification

Wiltse-Newman Classification Type I  • Dysplastic: a congenital defect in pars  

 Type II-A  • Isthmic - pars fatigue fx  

 Type II-B  • Isthmic - pars elongation due to multiple healed stress fx

 

 Type II-C  • Isthmic - pars acute fx   Type III  • Degenerative: facet instability without a pars

fx 

 Type IV  • Traumatic: acute posterior arch fx other than pars

 

 Type V  • Neoplastic: pathologic destruction of pars

Myerding Classification Grade I • < 25%  

 Grade II • 25-50%  

 Grade III • 50-75%  

 Grade IV • 75-100%  

 Grade V  • spondyloptosis

Treatment

Nonoperative

– physical therapy and NSAIDS

– indications

– most patients can be treated nonoperatively

– modalities include

– activity restriction

– NSAIDS

– PT

– epidural steroid injections

– indications

– second line of treatment if non-invasive methods fail

Operative

lumbar wide decompression with instrumented fusion indications

– most common is persistent and incapacitating pain that has failed 6 mos. of nonoperative management and epidural steroid injections

– progressive motor deficit

– cauda equina syndrome

– outcomes

– ~79% have satisfactory outcomes

– improved fusion rates shown with pedicle screws

– improved outcomes with successful arthrodesis

– worse outcomes found in smokers

posterior lumbar decompression alone

– indications

– usually not indicated due to instability associated with spondylolithesis

– only indicated in medically frail patients who cannot tolerate the increased surgical time of performing a fusion

– outcomes

– ~69% treated with decompression alone are satisfied

– ~ 31% have progressive instability

Anterior lumbar interbody fusion (ALIF)

indications

– reserved for revision cases with pseudoarthrosis

– outcomes

– injury to superior hypogastric plexus can cause retrograde ejaculation

References

– http://www.orthobullets.com/spine/2039/degenerative-spondylolisthesis

– http://www.orthobullets.com/spine/2038/adult-isthmic-spondylolisthesis