外伤科主治医师要领

Spinal and spinal cordLow back pain and radiculopathyn nImaging studies and further testing not helpful the first 4 weeks n nRelief of discomfort with meds and spinal manipulationn nBed rest beyond 4 days may be more harmful n n89-90%low back pain improve within 1 month n n80%sciatica eventually recovern n1%have nerve-root symptomsn n1-3%have lumber disc herniationn n85%no specific diagnosis madedefinitions/classificationsn nRadiculopathy:dysfunction of nerve root(pain,sensory disturbances,weakness)n nMechanical low back pain:strain of paraspinal muscles,ligament,irritation of facet jointsInitial assessment of patientn nHistory:History:age,weight loss,cancer or infection,used of drug,age,weight loss,cancer or infection,used of drug,during of S/S,trauma,cauda equina syndrome,work during of S/S,trauma,cauda equina syndrome,work statusstatusn nPE:PE:fever,vertebral tenderness,limited range of spinal cordfever,vertebral tenderness,limited range of spinal cord Dorsiflexation of ankle and big toe L5,4 Dorsiflexation of ankle and big toe L5,4 Achilles reflex S1 Achilles reflex S1 Light touch Light touch SLR text SLR textFurther evaluation of patients n nEMG:neuropathy,myopathy,myelopathy,unreliable 70yrs,or 20 yrsn nsystemically ill patientsn ntemp.38Cn nHistory of maligancyn nRecent infectionn nCauda equina syndrome n nHeavy alcohol or drug abusersn nDMn nImmunosupressed patients(steroid)n nRecent trauman nRecent urinary tract or spinal surgeryn nUnrelenting pain at restn nPersistent pain more than 4 weeksn nUnexplained weight lossTreatmentn nConservative 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 swimmingn n2.analgesics:2.analgesics:Panadol and NSAIDs Panadol and NSAIDs Opioids Opioidsn n3.muscle relaxants:3.muscle relaxants:no effectno effectn n4.education:4.education:condition will subsidecondition will subsiden n5.spinal manipulation therapy:5.spinal manipulation therapy:acute low back pain without radiculopathy in 1acute low back pain without radiculopathy in 1st st month,month,not used in severe or progressive neurologic deficitnot used in severe or progressive neurologic deficitEpidural injection:no change in the need for Epidural injection:no change in the need for surgery,short-term relief of radicular pain when surgery,short-term relief of radicular pain when control on oral medications is inadequate or not control on oral medications is inadequate or not surgical candidates.surgical candidates.Cauda equina syndromen nMidline,most common at L4-5Midline,most common at L4-5n n1.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 tonen n2.saddle anesthesia 2.saddle anesthesia n n3.significant motor weakness3.significant motor weaknessn n4.Low back pain and sciatica4.Low back pain and sciatican n5.Bilateral absence of achilles reflex 5.Bilateral absence of achilles reflex n n6.Sexual dysfunction6.Sexual dysfunctionSurgical treatmentn nPatients with 4-8 weeksSevere 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 surgeryn nLumbar spinal fusion:fracture/dislocation or instability resulting from tumor or infectionn nInstrumentation as an adjunct to fusion:increasing the fusion raten nPedicle screw-rod fixation:utilize following laminectomy,shorter length of fixation segment,rigid fixation of all 3 columns n nPosterior lumber interbody fusion:bilateral laminectomy and aggressive discetomy followed by bone grafts Intervertebral disc herniationn nLumbar disc herniationPosteriorly,one side,compressing a nerve root,Posteriorly,one side,compressing a nerve root,severe radicular painsevere radicular painn nCharacteristics findings:Symptoms start with back pain,days after Symptoms start with back pain,days after weeks yeilds radicular pain with reduction of weeks yeilds radicular pain with reduction of back painback painPain relief upon flexing the knee and thighPain relief upon flexing the knee and thighPosition changePosition changeBladder symptoms:difficulty voiding,Bladder symptoms:difficulty voiding,straining,or urine retentionstraining,or urine retentionExacerbation with coughing,sneezing,Exacerbation with coughing,sneezing,straining at the stoolstraining 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 changesn nStraight leg raising test:90mmhgDopamine,careful hydration,atropine for Dopamine,careful hydration,atropine for bradycardia associated with hypotensionbradycardia associated with hypotensionn nOxygenationn nNG tube decompressionn nIndwelling foleyn nTemperature regulationn nElectrolytes n nMedical management specific to spinal cord injury:methylprednisolone:given with 8 hours of methylprednisolone:given with 8 hours of injuryinjury