外伤科主治医师要领

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,11/7/2009,#,按一下以編輯母片標題樣式,*,*,*,按一下以編輯母片,第二層,第三層,第四層,第五層,Spinal and spinal cord,外傷科主治醫師,Hsinglin,第一页，共二十八页。,Low back pain and radiculopathy,Imaging studies and further testing not helpful the first 4 weeks,Relief of discomfort with meds and spinal manipulation,Bed rest beyond 4 days may be more harmful,89-90%low back pain improve within 1 month,第二页，共二十八页。,80%sciatica eventually recover,1%have nerve-root symptoms,1-3%have lumber disc herniation,85%no specific diagnosis made,第三页，共二十八页。,definitions/classifications,Radiculopathy:dysfunction of nerve root(pain,sensory disturbances,weakness),Mechanical low back pain:strain of paraspinal muscles,ligament,irritation of facet joints,第四页，共二十八页。,Initial assessment of patient,History:,age,weight loss,cancer or infection,used of drug,during of S/S,trauma,cauda equina syndrome,work status,PE:,fever,vertebral tenderness,limited range of spinal cord,Dorsiflexation of ankle and big toe L5,4,Achilles reflex S1,Light touch,SLR text,第五页，共二十八页。,Further evaluation of patients,EMG:neuropathy,myopathy,myelopathy,unreliable 70yrs,or 20 yrs,systemically ill patients,temp.38,C,History of maligancy,Recent infection,Cauda equina syndrome,Heavy alcohol or drug abusers,DM,第七页，共二十八页。,Immunosupressed patients(steroid),Recent trauma,Recent urinary tract or spinal surgery,Unrelenting pain at rest,Persistent pain more than 4 weeks,Unexplained weight loss,第八页，共二十八页。,Treatment,Conservative treatment:,1.activity modification:,Bed rest:no more than 4 days,Activity modification:heavy lifting,total body vibration,asymmetric postures,sustained for long periods,Exercise:walking,bicycling,or swimming,第九页，共二十八页。,2.analgesics:,Panadol and NSAIDs,Opioids,3.muscle relaxants:,no effect,4.education:,condition will subside,5.spinal manipulation therapy:,acute low back pain without radiculopathy in 1,st,month,not used in severe or progressive neurologic deficit,第十页，共二十八页。,Epiduralinjection:no changeinthe needfor surgery,short-termrelief of radicularpain whencontrolonoral medications is inadequateornot surgical candidates.,第十一,页,页，共,二,二十八,页,页。,Caudaequinasyndrome,Midline,most commonatL4-5,1.sphincterretension:,A.urinary retension,B.Urinary andfecalincontinence,C.Anal sphinctertone,2.saddleanesthesia,3.significant motor weakness,4.Lowback painand sciatica,5.Bilateralabsence of achilles reflex,6.Sexualdysfunction,第十二,页,页，共,二,二十八,页,页。,Surgicaltreatment,Patientswith 4-8weeks,Severeand disablingandnot improvement withtime,correlatedwith findings on PH andPE.,第十三,页,页，共,二,二十八,页,页。,Type of surgery,Lumbarspinal fusion:fracture/dislocation or instability resultingfrom tumor or infection,Instrumentationasanadjuncttofusion:increasing thefusionrate,Pedicle screw-rodfixation:utilizefollowing laminectomy,shorter lengthoffixationsegment,rigidfixationofall3columns,第十四,页,页，共,二,二十八,页,页。,Posteriorlumber interbodyfusion:bilaterallaminectomyand aggressivediscetomy followed by bonegrafts,第十五,页,页，共,二,二十八,页,页。,Intervertebraldisc herniation,Lumbardischerniation,Posteriorly,one side,compressing anerveroot,severe radicularpain,Characteristicsfindings:,Symptomsstartwith backpain,daysafterweeksyeildsradicular painwithreductionofbackpain,Pain reliefupon flexingthe kneeand thigh,Positionchange,第十六,页,页，共,二,二十八,页,页。,Bladder symptoms:difficultyvoiding,straining,or urine retention,Exacerbationwithcoughing,sneezing,strainingatthestool,Radiculopathy:,A.painradiating downLE,B.motor weakness,C.dermatomalsensorychanges,D.reflexchanges,第十七,页,页，共,二,二十八,页,页。,Straightlegraisingtest:90mmhg,Dopamine,careful hydration,atropine for bradycardia associatedwithhypotension,Oxygenation,NG tube decompression,Indwellingfoley,Temperature regulation,第二十六页,，,，共二十八,页,页。,Electrolytes,Medical management specific tospinal cord injury:,methylprednisolone:given with 8 hoursof injury,第二十七页,，,，共二十八,页,页。,内容总结,Spinal andspinal cord。5.spinal manipulationtherapy:。1.sphincterretension:。C.dermatomalsensory changes。Hypotension:maintain SBP90mmhg。Electrolytes,第二十八页,，,，共二十八,页,页。,