Spinal and spinal cordSpinal and spinal cord

外傷科主治醫師 外傷科主治醫師 HsinglinHsinglin

Low back pain and radiculopathyLow back pain and radiculopathy

Imaging studies and further testing not Imaging studies and further testing not helpful the first 4 weeks helpful the first 4 weeks

Relief of discomfort with meds and spinal Relief of discomfort with meds and spinal manipulationmanipulation

Bed rest beyond 4 days may be more Bed rest beyond 4 days may be more harmful harmful

89-90% low back pain improve within 1 89-90% low back pain improve within 1 month month

80% sciatica eventually recover80% sciatica eventually recover 1% have nerve-root symptoms1% have nerve-root symptoms 1-3% have lumber disc herniation1-3% have lumber disc herniation 85% no specific diagnosis made85% no specific diagnosis made

definitions/classificationsdefinitions/classifications

Radiculopathy : dysfunction of nerve root ( Radiculopathy : dysfunction of nerve root ( pain, sensory disturbances, weakness) pain, sensory disturbances, weakness)

Mechanical low back pain : strain of paraspiMechanical low back pain : strain of paraspinal muscles, ligament, irritation of facet joinnal muscles, ligament, irritation of facet jointsts

Initial assessment of patientInitial assessment of patient

History : History : – age, weight loss, cancer or infection, used of drug, duriage, weight loss, cancer or infection, used of drug, duri

ng of S/S, trauma, cauda equina syndrome, work statusng of S/S, trauma, cauda equina syndrome, work status

PE : PE : – fever, vertebral tenderness, limited range of spinal cordfever, vertebral tenderness, limited range of spinal cord

Dorsiflexation of ankle and big toe – L5, 4Dorsiflexation of ankle and big toe – L5, 4

Achilles reflex – S1Achilles reflex – S1

Light touchLight touch

SLR textSLR text

Further evaluation of patients Further evaluation of patients

EMG : neuropathy, myopathy, myelopathy, EMG : neuropathy, myopathy, myelopathy, unreliable < 3-4 weeksunreliable < 3-4 weeks

SEPs (somatosensory evoked potential): spiSEPs (somatosensory evoked potential): spinal stenosis, or spinal myelopathynal stenosis, or spinal myelopathy

NCVs (nerve conduction velocity): entrapmNCVs (nerve conduction velocity): entrapment neuropathies that mimic radiculopathyent neuropathies that mimic radiculopathy

LS X-ray recommendation LS X-ray recommendation

age >70yrs, or <20 yrsage >70yrs, or <20 yrs systemically ill patientssystemically ill patients temp. 38temp. 38°C°C History of maligancyHistory of maligancy Recent infectionRecent infection Cauda equina syndrome Cauda equina syndrome Heavy alcohol or drug abusersHeavy alcohol or drug abusers DMDM

Immunosupressed patients (steroid)Immunosupressed patients (steroid) Recent traumaRecent trauma Recent urinary tract or spinal surgeryRecent urinary tract or spinal surgery Unrelenting pain at restUnrelenting pain at rest Persistent pain more than 4 weeksPersistent pain more than 4 weeks Unexplained weight lossUnexplained weight loss

TreatmentTreatment

Conservative treatment : Conservative treatment : – 1.activity modification:1.activity modification:

» Bed rest : no more than 4 daysBed rest : no more than 4 days

» Activity modification : heavy lifting, total body Activity modification : heavy lifting, total body vibration, asymmetric postures, sustained for long vibration, asymmetric postures, sustained for long periodsperiods

» Exercise : walking, bicycling, or swimmingExercise : walking, bicycling, or swimming

2.analgesics :2.analgesics :– Panadol and NSAIDsPanadol and NSAIDs– OpioidsOpioids

3.muscle relaxants : 3.muscle relaxants : – no effectno effect

4.education: 4.education: – condition will subsidecondition will subside

5.spinal manipulation therapy: 5.spinal manipulation therapy: – acute low back pain without radiculopathy in 1acute low back pain without radiculopathy in 1stst month, month,

not used in severe or progressive neurologic deficitnot used in severe or progressive neurologic deficit

– Epidural injection: no change in the need for suEpidural injection: no change in the need for surgery, short-term relief of radicular pain when crgery, short-term relief of radicular pain when control on oral medications is inadequate or not ontrol on oral medications is inadequate or not surgical candidates.surgical candidates.

Cauda equina syndromeCauda equina syndrome

Midline, most common at L4-5Midline, most common at L4-5 1.sphincter retension : 1.sphincter retension :

– A. urinary retensionA. urinary retension– B. Urinary and fecal incontinenceB. Urinary and fecal incontinence– C. Anal sphincter toneC. Anal sphincter tone

2.saddle anesthesia 2.saddle anesthesia 3.significant motor weakness3.significant motor weakness 4.Low back pain and sciatica4.Low back pain and sciatica 5.Bilateral absence of achilles reflex 5.Bilateral absence of achilles reflex 6.Sexual dysfunction6.Sexual dysfunction

Surgical treatmentSurgical treatment

Patients with <4-8 weeksPatients with <4-8 weeks– A: urgent treatment (e.g. cauda equina syndromA: urgent treatment (e.g. cauda equina syndrom

e, progressive neurologic deficit)e, progressive neurologic deficit)– B: inability to control pain with medicineB: inability to control pain with medicine

Patient with >4-8 weeksPatient with >4-8 weeks– Severe and disabling and not improvement with Severe and disabling and not improvement with

time, correlated with findings on PH and PE.time, correlated with findings on PH and PE.

Type of surgeryType of surgery

Lumbar spinal fusion : fracture/dislocation Lumbar spinal fusion : fracture/dislocation or instability resulting from tumor or infectior instability resulting from tumor or infectionon

Instrumentation as an adjunct to fusion : incInstrumentation as an adjunct to fusion : increasing the fusion ratereasing the fusion rate

Pedicle screw-rod fixation : utilize followinPedicle screw-rod fixation : utilize following laminectomy, shorter length of fixation seg laminectomy, shorter length of fixation segment, rigid fixation of all 3 columns gment, rigid fixation of all 3 columns

Posterior lumber interbody fusion : bilateral Posterior lumber interbody fusion : bilateral laminectomy and aggressive discetomy folllaminectomy and aggressive discetomy followed by bone grafts owed by bone grafts

Intervertebral disc herniationIntervertebral disc herniation

Lumbar disc herniationLumbar disc herniation– Posteriorly, one side, compressing a nerve root, Posteriorly, one side, compressing a nerve root,

severe radicular painsevere radicular pain Characteristics findings : Characteristics findings :

– Symptoms start with back pain, days after weekSymptoms start with back pain, days after weeks yeilds radicular pain with reduction of back ps yeilds radicular pain with reduction of back painain

– Pain relief upon flexing the knee and thighPain relief upon flexing the knee and thigh– Position changePosition change

– Bladder symptoms : difficulty voiding, straininBladder symptoms : difficulty voiding, straining, or urine retentiong, or urine retention

– Exacerbation with coughing, sneezing, straininExacerbation with coughing, sneezing, straining at the stoolg at the stool

» Radiculopathy : Radiculopathy :

» A.pain radiating down LEA.pain radiating down LE

» B.motor weaknessB.motor weakness

» C.dermatomal sensory changesC.dermatomal sensory changes

» D.reflex changesD.reflex changes

Straight leg raising test : <60, L5 and S1Straight leg raising test : <60, L5 and S1

Spondylosis : no-specific degenerative procSpondylosis : no-specific degenerative process of the spineess of the spine

Spondylolisthesis : anterior subluxation of oSpondylolisthesis : anterior subluxation of one vertebral body on anotherne vertebral body on another– Grade 1-4Grade 1-4

Spondylolysis : alternative term for isthmic Spondylolysis : alternative term for isthmic spondylolisthesis spondylolisthesis

Spinal stenosisSpinal stenosis

Narrowing of the AP dimension of spinal caNarrowing of the AP dimension of spinal canalnal

In the lumbar region : neurogenic claudicatiIn the lumbar region : neurogenic claudicationon

In the cervical region : myelopathy and ataxIn the cervical region : myelopathy and ataxiaia

In the spinal region : rareIn the spinal region : rare

Spinal trauma Spinal trauma

Uncommon in childrenUncommon in children The fatality rate is higher with pediatric The fatality rate is higher with pediatric

spinal injuries than with adults (opposite to spinal injuries than with adults (opposite to the situation with head injury)the situation with head injury)

Complete lesion : Complete lesion : – no preservation of any motor or sensory no preservation of any motor or sensory

function more than 3 segments below the level function more than 3 segments below the level of the injuryof the injury

– Persistence of complete spinal cord injury Persistence of complete spinal cord injury beyond 24 hours : no distal function will beyond 24 hours : no distal function will recoverrecover

Incomplete lesion:Incomplete lesion:– Any residual motor or sensory function more thAny residual motor or sensory function more th

an 3 segments below the level of the injury.an 3 segments below the level of the injury.– Signs of incomplete lesion :Signs of incomplete lesion :

» Sensation or voluntary movement in the LegsSensation or voluntary movement in the Legs

» Sacral sparingSacral sparing

Central cord syndromeCentral cord syndrome

Bown-Sequard syndromeBown-Sequard syndrome

Anterior and posterior cord syndromeAnterior and posterior cord syndrome

Spinal shockSpinal shock

A. interruption of sympatheticsA. interruption of sympathetics– 1. Loss of vascular tone1. Loss of vascular tone– 2. Leaves parasympathetics causing bradycardi2. Leaves parasympathetics causing bradycardi

a a B. Loss of muscle tone result venous poolinB. Loss of muscle tone result venous poolin

gg C. True hypovolemia C. True hypovolemia

Initial management of spinal cord Initial management of spinal cord injuryinjury

Cause of death : aspiration and shockCause of death : aspiration and shock SCI : SCI :

– Significant traumaSignificant trauma– Loss of consciousnessLoss of consciousness– Minor trauma with spinal painMinor trauma with spinal pain– Associated findings suggestive of SCI : Associated findings suggestive of SCI :

» Abdominal breathingAbdominal breathing

» priapismpriapism

Management in the hospital Management in the hospital

1. Immobilization1. Immobilization Hypotension: maintain SBP>90mmhgHypotension: maintain SBP>90mmhg

– Dopamine, careful hydration, atropine for bradyDopamine, careful hydration, atropine for bradycardia associated with hypotensioncardia associated with hypotension

OxygenationOxygenation NG tube decompressionNG tube decompression Indwelling foleyIndwelling foley Temperature regulationTemperature regulation

Electrolytes Electrolytes Medical management specific to spinal cord Medical management specific to spinal cord

injury :injury :– methylprednisolone : given with 8 hours of injmethylprednisolone : given with 8 hours of inj

uryury