Patient Education

Anatomy of the vertebral Column?

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The vertebral column comprises 33 vertebrae divided into five sections :

  1. seven cervical,
  2. 12 thoracic
  3. five lumbar
  4. five sacral
  5. 4 coccygeal

The sacral and coccygeal vertebrae are fused, which typically allows for 24 mobile segments. The cervical and lumbar segments develop lordosis as an erect posture is acquired. The thoracic and sacral segments maintain kyphotic postures, and serve as attachment points for the rib cage and pelvic girdle.

In general, each mobile vertebral body increases in size when moving from cranial to caudal.

A typical vertebra comprises an anterior body and a posterior arch that enclose the vertebral canal. The neural arch is composed of two pedicles laterally and two laminae posteriorly that are united to form the spinous process. To either side of the arch of the vertebral body is a transverse process and superior and inferior articular processes. The articular processes articulate with adjacent vertebrae to form synovial joints. The relative orientation of the articular processes accounts for the degree of flexion, extension, or rotation possible in each segment of the vertebral column. The spinous and transverse processes serve as levers for the numerous muscles attached to them.

The length of the vertebral column averages 72 cm in men and 7 to 10 cm less in women. The vertebral canal extends throughout the length of the column and provides protection for the spinal cord, conus medullaris, and cauda equina.

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Lumbar or low back pain?

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Axial back/lumbar pain occurs at some point in the lives of most people. Appropriate treatment for what can be at times excruciating pain generally should begin with evaluation for significant spinal pathology. This pathology being absent, a brief (1 to 3 days) period of bed rest with institution of an antiinflammatory regimen and rapid progression to an active exercise regimen with an anticipated return to full activity should be expected and encouraged. Generally, patients treated in this manner improve significantly in 4 to 8 weeks. Diagnostic studies, including radiographs, often are unnecessary because they add little information. More sophisticated imaging with CT scans and MRI or other studies have even less utility initially. An overdependence on the diagnosis of disc herniation occurred with early use of these diagnostic studies, which show disc herniations in 20% to 36% of normal volunteers.

When to get x-ray/MRI done?

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  1. Age >50 years
  2. Significant trauma
  3. Neuromuscular deficits
  4. Unexplained weight loss (10 lb in 6 months)
  5. Suspicion of ankylosing spondylitis
  6. Drug or alcohol abuse
  7. History of cancer
  8. Use of corticosteroids
  9. Temperature ≥37.8°C (≥100°F)
  10. Recent visit (≤1 month) for same problem and no improvement
  11. Patient seeking compensation for back pain

Patients should understand that persistence of some pain does not indicate treatment failure, necessitating further measures; however, it is important for treating physicians to recognize that the longer a patient is limited by pain, the less likely he or she is to return to full activity. When a patient is out of work for 6 months, there is only a 50% chance that he or she will return to his or her previous job.

For patients who do not respond to treatment regimens, early recognition that other issues may be involved is essential. Careful reassessment of complaints and reexamination for new information or findings and inconsistencies are necessary. Many studies of occupational back pain have revealed that depression, occupational mental stress, job satisfaction, intensity of concentration, anxiety, and marital status can be related to complaints of pain and disability. The role of these factors as causal or consequential of the symptoms remains an area of continued study; however, there is some evidence that the psychological stresses occur before complaints of pain in some patients. Severe nerve compression shown by MRI or CT correlates with symptoms of distal leg pain; however, mild-to-moderate nerve compression , disc degeneration or bulging, and central stenosis do not correlate significantly with specific pain patterns.

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Cervical Disc Disease/Prolapse?

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Introduction:

Herniation of the cervical intervertebral disc with spinal cord compression has been identified since Key detailed the pathological findings of two cases of cord compression by “intervertebral substance” in 1838. Mixter and Barr reported lumbar disc herniation in 1934 and included four cervical disc protrusions.

Prevelance:

In an epidemiological study of cervical disc rupture, it was more common in men by a ratio of 1.4 : 1. Factors associated with the injury were frequent heavy lifting on the job, cigarette smoking, and frequent diving from a board. The use of vibrating equipment and time spent in motor vehicles were not positively associated with this problem. Studies reported that 40% of people in Sweden were sometimes affected by neck pain during their lives. Patients with cervical disc disease also are likely to have lumbar disc disease. MRI has shown increasing cervical disc degeneration with age.

Cause of pain:

The pathophysiology of cervical disc disease is the same as degenerative disc disease in other areas of the spine. Physiological changes in the nucleus are followed by progressive annular degeneration. Frank extrusion of nuclear material can occur as a complication of this normal degenerative process. Studies postulated that hydraulic pressure on the disc rather than excessive motion produces traumatic disc herniation. As the disc degeneration proceeds, hypermobility of the segment can result in instability or degenerative arthritic changes or both. In contrast to those in the lumbar spine, these hypertrophic changes are predominantly at the uncovertebral joint (uncinate process). Hypertrophic changes eventually develop around the facet joints and vertebral bodies. As in lumbar disease, progressive stiffening of the cervical spine and loss of motion are the usual result in the end stages. Hypertrophic spurring anteriorly occasionally results in dysphagia. Studies identified the production of increased amounts of matrix metalloproteinases, nitric oxide, prostaglandin E2, and interleukin-6 in disc material removed from cervical disc hernias. They suggested that these products are involved in the biochemistry of disc degeneration. These substances also are implicated in pain production. These findings are similar to findings in the lumbar spine.

The classic approach to discs in this region has been posteriorly (from the back) with laminectomy. Surgery showed that simple anterior disc excision without fusion can give results similar to anterior cervical disc excision with anterior interbody fusion. More recently, Yamamoto et al. reported the long-term (2 to 13 years) results of anterior cervical disc excision without fusion. They noted 81% improvement in patients with soft disc hernias, but only 47% improvement in patients with spondylosis; 49% had neck and scapular pain as new postoperative symptoms for the first 4 weeks after surgery . Spontaneous fusion was noted in 79% at 29 months. Currently, anterior cervical discectomy with fusion is the procedure of choice when the disc is removed anteriorly to avoid disc space collapse, prevent painful and abnormal cervical motion, and speed intervertebral fusion. Foraminotomy is the procedure of choice when the disc fragment can be removed posteriorly.

Signs and Symptoms

The signs and symptoms of intervertebral disc disease are best separated into symptoms related to the spine itself, symptoms related to nerve root compression, and symptoms of myelopathy.

Several authors reported that when the disc is punctured anteriorly for the purpose of discography, pain is noted in the neck and shoulder. Complaints of neck pain, medial scapular pain, and shoulder pain are probably related to primary pain around the disc and spine. Anatomical studies have indicated cervical disc and ligamentous innervations. This has been inferred to be similar in the cervical spine to that of the lumbar spine with its sinu-vertebral nerve. Tamura noted cranial symptoms, such as headache, vertigo, tinnitus, and ocular problems, associated with C3-4 root sleeve defects on myelography.

Symptoms of root compression usually are associated with pain radiating into the arm or chest with numbness in the fingers and motor weakness. Cervical disc disease also can mimic cardiac disease with chest and arm pain. Usually the radicular symptoms are intermittent and combined with more frequent neck and shoulder pain.

The signs of midline cervical spinal cord compression (myelopathy) are unique and varied. The pain is poorly localized and aching in nature; pain may be only a minor complaint. Occasional sharp pain or generalized tingling may be described with neck extension. The pain can be in the shoulder and pelvic girdles; it is occasionally associated with a generalized feeling of weakness in the lower extremities and a feeling of instability.

In patients with predominant cervical spondylosis, symptoms of vertebral artery compression also may be found, including dizziness, tinnitus, intermittent blurring of vision, and occasional episodes of retroocular pain. The signs of lateral root pressure from a disc or osteophytes are predominantly neurological . By evaluating multiple motor groups, multiple levels of deep tendon reflexes, and sensory abnormalities, the level of the lesion can be localized as accurately as any other lesion in the nervous system. The multiple innervation of muscles sometimes can lead to confusion in determining the exact root involved. For this reason, MRI or other studies done for imaging confirmation of the clinical impression usually are helpful

Care should be taken in the examination of the extremity when radicular problems are encountered to rule out more distal compression syndromes in the upper extremities, such as thoracic outlet syndrome, carpal tunnel syndrome, and cubital tunnel syndrome. The lower extremities should be examined with special attention to long tract signs indicating myelopathy.

Cervical paraspinal spasm and limitation of neck motion are frequent findings of cervical spine disease, but do not indicate a specific pathological process. Special maneuvers involving neck motion can be helpful in the selection of conservative treatment and identification of pathological processes. The distraction test, which involves the examiner placing the hands on the occiput and jaw and distracting the cervical spine in the neutral position, can relieve root compression pain, but also can increase pain caused by ligamentous injury. Neck extension and flexion with or without traction can be helpful in selecting conservative therapies.

Patients relieved of pain with the neck extended, with or without traction, usually have hyperextension syndromes with ligamentous injury posteriorly, whereas patients relieved of pain with distraction and neck flexion are more likely to have nerve root compression caused by a soft ruptured disc or more likely hypertrophic spurs in the neural foramina. Pain usually is increased in any condition with compression.

The signs of midline disc herniation are those of spinal cord compression. If the lesion is high in the cervical region, paresthesias, weakness, atrophy, and occasionally fasciculations may occur in the hands. A Hoffman sign (upper cervical spinal cord) or the inverted radial reflex (typically indicating C5-6 pathology) also may be present.

Differential Diagnosis

The differential diagnosis of cervical disc disease is best separated into extrinsic and intrinsic factors. Extrinsic factors generally include disease processes extrinsic to the neck resulting in symptoms similar to primary neck problems. Included in this group are tumors of the chest; nerve compression syndromes distal to the spine; degenerative processes, such as shoulder and upper extremity arthritis; temporomandibular joint syndrome; and lesions around the shoulder, such as acute and chronic rotator cuff tears and impingement syndromes. Intrinsic problems primarily consist of lesions directly associated with the cervical spine, the most common being cervical disc degeneration with concomitant disc herniation or later development of hypertrophic arthritis. Congenital factors, such as spinal stenosis in the cervical region, also may produce symptoms. Primary and secondary tumors of the cervical spine and fractures of the cervical vertebrae also should be considered as intrinsic lesions.

Cervical disc disease is devided into four groups:

  1. unilateral soft disc protrusion with nerve root compression
  2. foraminal spur, or hard disc, with nerve root compression
  3. medial soft disc protrusion with spinal cord compression
  4. transverse ridge or cervical spondylosis with spinal cord compression.

Soft disc herniations usually affect one level, whereas hard disc herniations can affect multiple levels. Central lesions usually result in cord compression symptoms, and lateral lesions usually result in radicular symptoms.

The soft disc herniations occurred at the C6 interspace (70%) , C5 interspace (24%). Only six occurred at the C7 interspace. Foraminal spurs also were found predominantly at the C6 interspace (48%). The C5 interspace (39%) and C7 interspace (13%) accounted for the remaining levels where foraminal spurs were found. Investigators also noted the incidence of medial soft disc protrusion with myelopathy to be rare (14 of 246 patients).

Confirmatory Imaging

Radiographic evaluation of the cervical spine frequently shows loss of normal cervical lordosis. Disc space narrowing and hypertrophic changes frequently increase with age, but are not indicative of cervical disc rupture. Usually radiographs are most helpful to rule out other problems. Oblique radiographs of the cervical spine may reveal foraminal encroachment.

MRI of the cervical spine has rapidly become the major diagnostic procedure for neck, arm, and shoulder symptoms. MRI should confirm the objective clinical findings. Asymptomatic findings should be expected to increase with the age of the patient. Cervical myelography usually is indicated only after noninvasive evaluation by MRI fails to reveal the cause or level of the lesion. If MRI is inconclusive, electromyography or nerve conduction velocity may be indicated to show active radiculopathy before proceeding with myelography, especially if the history and physical examination are not strongly supportive of the presence of radiculopathy. Cervical myelography usually is more precise than lumbar myelography, regardless of the contrast medium used. Postmyelography CT with block imaging and thin cuts is very helpful.

When a component of dynamic cord compression is present, myelography remains a valuable tool, although dynamic MRI has reduced the role of myelography. Myelography is performed in the same way as for ruptured lumbar discs except that considerable attention must be paid to the flow of the column of contrast medium with the neck in hyperextended, neutral, and flexed positions. One cannot conclude that spinal cord compression is not present until one is certain that the cephalad flow of the medium is not obstructed with the neck acutely hyperextended. The neck should be hyperextended carefully because of the danger of further damage to the spinal cord.

Because symptoms from cervical instability tend to be gradually progressive, they can be suggestive of spinal cord tumor, amyotrophic lateral sclerosis, posterolateral sclerosis, or multiple sclerosis. Cervical dynamic instability can be shown because the cephalad flow of contrast material is blocked between the lamina of the cephalad level and the disc or body of the caudal level. In view of the disturbances of the spinal fluid dynamics, jugular compression should be done during lumbar puncture with the cervical spine in flexed, neutral, and hyperextended positions.

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Molecular basis of Disc Degeneration?

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By any measure, disc disorders are a tremendous problem. In recent years, understanding of disc degeneration has undergone a significant transformation; however, the treatment of disc degeneration with or without herniation and the associated pain is far from satisfactory. The opportunities to improve understanding at a basic science level and a clinical level remain greater for disc disorders than for other areas of orthopaedics. Particularly with respect to clinical applications, much more effort should be made toward defining and understanding the underlying pathophysiological processes, rather than developing additional treatment options. Treatment continues to be limited not by lack of procedures, but by lack of specific diagnoses with reliable natural history data that could be used to assess better and direct current and future treatment applications.

Axial spine pain—whether cervical, thoracic, or lumbar—often is attributed to disc degeneration. This degenerative process does not always cause pain, but it can lead to internal disc derangement (IDD) or disc herniation. Each of these pathological processes has unique clinical findings and treatments. The understanding of disc degeneration and the associated etiological factors has changed markedly over the past several years. Also, efforts to make the distinction between disc degeneration and “degenerative disc disease” have made some progress.

The genetic influence on disc degeneration may be due to a small effect from each of multiple genes or possibly a relatively large effect of a smaller number of genes. To date, several specific gene loci have been identified that are associated with disc degeneration. This association of a specific gene with degenerative disc changes has been confirmed. Other variations in the aggrecan gene, metalloproteinase-3 gene, collagen type IX, and alpha 2 and 3 gene forms also have been associated with disc pathology and symptoms. The understanding of symptoms related to disc herniations has become clearer over time than symptoms related only to disc degeneration.

As medicine advanced as a science, the number of specific diagnoses capable of causing back and leg pain increased dramatically. With the increase in possible causes, different physical maneuvers were devised to isolate the true problem in each patient.

Physicians who treat patients with spinal disorders and spine-related complaints must distinguish the complaint of back pain, which several epidemiological studies reveal to be relatively constant, from disability attributed to back pain. Although back pain as a presenting complaint may account for only 2% of the patients seen by a general practitioner. Women reported back pain more frequently than men. There were no racial differences, but the lower the educational level of adults interviewed, the greater the proportion of adults reporting back pain. This correlation with education level is consistent with the relationship between socioeconomic factors and lumbar pain and disability.

Risks factors:

Identified risk factors for radiographically apparent disc disorders of the lumbar spine include genetic factors, age, gender, smoking, and to a minimal degree occupational exposure, but not socioeconomic factors. In contrast is the importance of socioeconimic factors for the development of low back pain and disability. Job dissatisfaction, physically strenuous work, psychologically stressful work, low educational attainment, and workers' compensation insurance all are associated with low back pain or disability. These data suggest that aggressive treatment between 4 weeks and 6 months is necessary for patients with low back pain. Consideration of socioeconomic factors is an important component of appropriate patient evaluation because there is an inextricable link between an individual's socioeconomic status and his or her health.

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Discography/Discogram?

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Introduction:

Discography has been used since the late 1940s for the experimental and clinical evaluation of disc disease in the cervical and lumbar regions of the spine. Since that time, discography has had a limited but important role in the evaluation of suspected disc pathology.

In 1964, Holt reported that cervical discography had no diagnostic value because pain reproduction and fissuring were features of cervical discs in normal volunteers. Later investigative work by Simmons and Segil showed the importance of discriminating between painful and nonpainful discs, while avoiding pain reproduction and disc morphology as absolute entities. Carrying this idea further, in 1976, Roth introduced analgesic cervical discography with the rationale that when a painful disc is identified, pain relief should occur by injecting a local anesthetic into the disc. He reported a high success rate for anterior disc excision and fusion using this form of precision diagnostic testing.

Why is it different:

The most important aspect of discography is provocative testing for concordant pain (pain that corresponds to a patient's usual pain) to provide information regarding the clinical significance of the disc abnormality. Although difficult to standardize, this testing distinguishes discography from other anatomical imaging techniques. If the patient is unable to distinguish customary pain from any other pain, the procedure is of no value. In patients who have a concordant response without evidence of a radial annular fissure on discography, CT should be considered because some discs that appear normal on discography show disruption on CT scan.

When it should be done:

Indications for lumbar discography include surgical planning of spinal fusion, testing of the structural integrity of an adjacent disc to a known abnormality such as spondylolisthesis or fusion, identifying a painful disc among multiple degenerative discs, ruling out secondary internal disc disruption or suspected lateral or recurrent disc herniation, and determining the primary symptom-producing level when chemonucleolysis is being considered. Thoracic discography is a useful tool in the investigation of thoracic, chest, and upper abdominal pain. Degenerative thoracic disc disease, with or without herniation, has a highly variable clinical presentation, frequently mimicking visceral conditions and causing back or musculoskeletal pain. In the cervical spine, discography is an important adjunct for diagnosing primary discogenic pain and determining which disc is affected and requires surgery. Discography also may be justified in medicolegal situations to establish a more definitive diagnosis even though treatment may not be planned on that disc.

When it should not be done:

Compression of the spinal cord, stenosis of the roots, bleeding disorders, allergy to the injectable material, and active infection are contraindications to diagnostic discography procedures. Although the risk of complications from discography is low, potential problems include discitis, nerve root injury, subarachnoid puncture, chemical meningitis, bleeding, and allergic reactions. In addition, in the cervical region, retropharyngeal and epidural abscess can occur. Pneumothorax is a risk in the cervical and thoracic regions.

A patient's response during the procedure is the most important aspect of the study. Pain alone does not determine if a disc is the cause of the back pain. The concordance of the pain in regard to the quality and location are paramount in determining whether the disc is a true pain generator. A control disc is necessary to validate a positive finding on discography.

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Cervical/ lumbarEpidural steroid Injections?

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Introduction:

Epidural injections in the cervical, thoracic, and lumbosacral spine were developed to diagnose and treat spinal pain. Information obtained from epidural injections can be helpful in confirming pain generators that are responsible for a patient's discomfort. Structural abnormalities do not always cause pain, and diagnostic injections can help to correlate abnormalities seen on imaging studies with associated pain complaints. In addition, epidural injections can provide pain relief during the recovery of disc or nerve root injuries and allow patients to increase their level of physical activity. Because severe pain from an acute disc injury with or without radiculopathy often is time limited, therapeutic injections help to manage pain and may alleviate or decrease the need for oral analgesics.

The efficacy of epidural injections is not reliably known because of the lack of well-controlled studies. Kepes and Duncalf calculated the average favorable response rate obtained with lumbar epidural steroid injections to be 60%, whereas White calculated the favorable response rate to be 75%. Several studies reported the usefulness of transforaminal epidural corticosteroid injections (selective epidural or selective nerve root block) to identify or confirm a specific nerve root as a pain generator when the diagnosis is unclear based on clinical evidence.

Risks associated with the procedure:

Few serious complications occur in patients receiving epidural corticosteroid injections; however, epidural abscess, epidural hematoma, durocutaneous fistula, and Cushing syndrome have been reported as individual case reports. The most adverse immediate reaction during an epidural injection is a vasovagal reaction. Dural puncture has been estimated to occur in 0.5% to 5% of patients having cervical or lumbar epidural steroid injections. The anesthesiology literature reported a 7.5% to 75% incidence of postdural puncture (positional) headaches, with the highest estimates associated with the use of 16-gauge and 18-gauge needles. Headache without dural puncture has been estimated to occur in 2% and is attributed to air injected into the epidural space, increased intrathecal pressure from fluid around the dural sac, and possibly an undetected dural puncture. Some minor, common complaints caused by corticosteroid injected into the epidural space include nonpositional headaches, facial flushing, insomnia, low-grade fever, and transient increased back or lower extremity pain. Epidural corticosteroid injections are contraindicated in the presence of infection at the injection site, systemic infection, bleeding diathesis, uncontrolled diabetes mellitus, and congestive heart failure.

How is it given:

We do epidural corticosteroid injections in a fluoroscopy suite equipped with resuscitative and monitoring equipment. Intravenous access is established in all patients with a 20-gauge angiocatheter placed in the upper extremity. Mild sedation is achieved through intravenous access. We recommend the use of fluoroscopy for diagnostic and therapeutic epidural injections for several reasons. Epidural injections performed without fluoroscopic guidance are not always made into the epidural space or the intended interspace. Even in experienced hands, needle misplacement occurs in 40% of caudal and 30% of lumbar epidural injections when done without fluoroscopic guidance. Accidental intravascular injections also can occur, and the absence of blood return with needle aspiration before injection is an unreliable indicator of this complication. In the presence of anatomical anomalies, such as a midline epidural septum or multiple separate epidural compartments, the desired flow of epidural injectants to the presumed pain generator is restricted and remains undetected without fluoroscopy. In addition, if an injection fails to relieve pain, it would be impossible without fluoroscopy to determine whether the failure was caused by a genuine poor response or by improper needle placement.

When should be given:

Cervical epidural steroid injections have been used with some success to treat cervical spondylosis associated with acute disc disruption and radiculopathies, cervical strain syndromes with associated myofascial pain, postlaminectomy cervical pain, reflex sympathetic dystrophy, postherpetic neuralgia, acute viral brachial plexitis, and muscle contraction headaches.

The best results with cervical epidural steroid injections have been in patients with acute disc herniations or well-defined radicular symptoms and in patients with limited myofascial pain. At this time, we do not do cervical transforaminal injections. Of greatest concern are the increasing case reports involving injury to the spinal cord and brainstem after cervical transforaminal injections. These injuries are the result of intraarterial injection into either a reinforcing radicular artery or the vertebral artery, the latter of which is the most common basis of complication. Injection into a radicular artery is an unavoidable complication, but one that can be recognized by using real-time monitoring of a test dose of contrast medium. In the case of intraarterial injection, the procedure should be aborted to avoid injury to the spinal cord.

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Facet Joint Injections?

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The facet joint can be a source of back pain; the exact cause of the pain is unknown. Theories include meniscoid entrapment and extrapment, synovial impingement, chondromalacia facetae, capsular and synovial inflammation, and mechanical injury to the joint capsule. Osteoarthritis is another cause of facet joint pain; however, the incidence of facet joint arthropathy is equal in symptomatic and asymptomatic patients. As with other osteoarthritic joints, radiographic changes correlate poorly with pain.

Although the history and physical examination may suggest that the facet joint is the cause of spine pain, no noninvasive pathognomonic findings distinguish facet joint–mediated pain from other sources of spine pain. Fluoroscopically guided facet joint injections are commonly considered the “gold standard” for isolating or excluding the facet joint as a source of spine or extremity pain.

Clinical suspicion of facet joint pain by a spine specialist remains the major indicator for diagnostic injection, which should be done only in patients who have had pain for more than 4 weeks and only after appropriate conservative measures have failed to provide relief. Facet joint injection procedures may help to focus treatment on a specific spinal segment and provide adequate pain relief to allow progression in therapy. Either intraarticular or medial branch blocks can be used for diagnostic purposes. The only controlled study on the use of intraarticular corticosteroids in the cervical spine found no added benefit from intraarticular betamethasone over bupivacaine.

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Lumbar Canal Stenosis?

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Introduction:

Although symptoms may arise from narrowing of the spinal canal, not all patients with narrowing develop symptoms. In general, the natural history of most forms of spinal stenosis is the insidious development of symptoms. Occasionally, there can be an acute onset of symptoms precipitated by trauma or heavy activity. Many patients have significant radiographic findings with minimal complaints or physical findings. 50% of patients treated nonoperatively reported improved back and leg pain after 8 to 10 years.

Pain relief was noted after 3 months in most patients regardless of treatment, but took 12 months in a few patients. Results in conservatively treated patients deteriorated over time, however, and at 4 years were excellent or fair in 50% of patients treated nonoperatively; 80% of patients treated operatively still had good results. Results were not worse if surgery was done 3 years after failed conservative treatment, and significant deterioration did not occur during the 6 years of follow-up in any of the three groups of patients. Predictors of poor outcomes could not be identified. These authors concluded that conservative treatment is appropriate for patients with moderate pain, 50% of whom have pain relief in less than 3 months, but operative treatment probably is indicated for patients with severe pain and patients in whom conservative treatment fails.

Reported studies suggest that for most patients with spinal stenosis, a stable course can be predicted, with 15% to 50% showing some improvement with nonoperative treatment. Worsening of symptoms despite adequate conservative treatment is an indication for operative treatment.

Clinical Symptoms:

back pain and sciatica is present in 95% and claudication present in 91% of patients. Sensory disturbance in the legs was present in 70%, motor weakness was present in 33%, and voiding disturbance was present in only 12% of patients. Despite the coexistent symptoms, back pain had been present for a median duration of 14 years and sciatica for a median duration of 2 years before presentation. Bilateral leg complaints were present in 42%, and unilateral leg symptoms were present in the other 58%. Distribution of symptoms was L5 in 91%, S1 in 63%, L1-4 in 28%, and S2-5 in 5%. 47% had symptoms specific for two nerve roots, and 35% had monoradiculopathy. Three-level and four-level radicular complaints were recorded in 17% and 1%, respectively. In patients with central spinal stenosis, symptoms usually are bilateral and involve the buttocks and posterior thighs in a nondermatomal distribution. With lateral recess stenosis, symptoms usually are dermatomal because they are related to a specific nerve being compressed. Patients with lateral recess stenosis may have more pain during rest and at night, but more walking tolerance than patients with central stenosis.

Vascular symptoms typically are felt in the upper calf, are relieved after a short rest (5 minutes) while still standing, do not require sitting or bending, and worsen despite walking uphill or riding a stationary bicycle. Neurogenic claudication improves with trunk flexion, stooping, or lying, but may require 20 minutes to improve. Patients often report better endurance walking uphill or up steps and tolerate riding a bicycle better than walking on a treadmill because of the flexed posture that occurs. Pushing a grocery cart also allows spinal flexion, which enhances endurance in most patients with neurogenic claudication.

The gait and posture after walking may reveal a positive “stoop test.” This test is done by asking the patient to walk briskly. As the pain intensifies, the patient may complain of sensory symptoms followed by motor symptoms. If the patient is asked to continue to walk, he or she may assume a stooped posture, and the symptoms may be eased, or if the patient sits in a chair bent forward, the same resolution of symptoms occurs.

Magnetic Resonance Imaging

Investigators have found abnormal findings in 67% of asymptomatic patients evaluated by MRI. In patients older than 60 years, 57% of MRI scans were abnormal, including 36% of patients with herniated nucleus pulposus and 21% with spinal stenosis. MRI is helpful in identifying other disease processes, such as tumors and infections, and is a good noninvasive study for patients with persistent lower extremity complaints after radiographic screening evaluation. MRI should be confirmatory in patients with a consistent history of neurogenic claudication or radiculopathy, but it should not be used as a screening examination because of the high rate of asymptomatic disease. Sagittal T2-weighted images are a good starting point because they give a myelogram-like image. Sagittal T1-weighted images are evaluated with particular attention focused on the foramen. An absence of normal fat around the root indicates foraminal stenosis. Axial images provide a good view of the central spinal canal and its contents on T1- and T2-weighted images. Far-lateral disc protrusions are identified on axial T1-weighted images by obliteration of the normal interval of fat between the disc and nerve root . The foraminal zone is better evaluated with sagittal T1-weighted sequences, which confirm the presence of fat around the nerve root. Spinal deformity, including scoliosis and significant spondylolisthesis, can result in suboptimal imaging by MRI. This is secondary to the curvature of the spine in and out of the plane of the scanner on sagittal sequences and difficulty obtaining true axial cuts. Another disadvantage of MRI is the cost; nonetheless, MRI has become a useful, noninvasive diagnostic tool for the evaluation of patients with extremity complaints.

Nonoperative Treatment

Symptoms of spinal stenosis usually respond favorably to nonoperative management. Despite symptoms of back pain, radiculopathy, or neurogenic claudication, conservative management is successful in most patients. Conservative measures should include rest not exceeding 2 days, pain management with antiinflammatory medications or acetaminophen, and participation in a trunk-stabilization exercise program, along with good aerobic fitness. Other methods should be reserved for patients who are limited by pain and should be used to maximize participation in the exercise program. Traction has no proven benefit in the adult lumbar spine. For a patient with unremitting symptoms of radiculopathy or neurogenic claudication, epidural steroid injections may be useful in alleviating symptoms to allow better participation in physical therapy. Epidural steroids can give significant symptomatic relief, although no scientific study has documented long-term efficacy. If spinal stenosis is present with coexistent degenerative arthritis in the hips or knees, some permanent limitation in activity may be necessary regardless of treatment.

All had spinal stenosis documented by CT or MRI and symptoms of disabling back, buttock, or leg pain. Except for a few patients with acute neurological changes who initially were prescribed 1 to 2 weeks of bed rest, patients were given one course of oral corticosteroids on a 7-day tapered schedule. An epidural steroid injection was given if symptoms persisted, with a repeat injection given if necessary by the transforaminal route at the point of most severe constriction. A third injection was administered only at the treating physician's discretion, usually for flare-ups during follow-up. For less severe symptoms, nonsteroidal antiinflammatory medications were used for 4 to 6 weeks, and this occasionally was repeated. All patients participated in physical therapy that included postural exercises, gentle lumbopelvic mobilization exercises, and a daily flexion lumbar stabilization program. Sustained improvement was reported in 24% and mild improvement in 28%, with 13% definitely worse. Regarding walking, 40% reported improvement, 35% reported no change, and 25% reported worsening at final follow-up.

Epidural Steroid Injection

Spinal stenosis and the resultant mechanical compression of neural elements can cause structural and chemical injury to the nerve roots. Edema and venous congestion of the nerve roots can lead to further compression and ischemic neuritis. This may result in the leakage of neurotoxins, such as phospholipase and leukotriene B, which can lead to increased inflammation and edema. Corticosteroids are potent antiinflammatory medications and result in a decrease in leukocyte migration, the inhibition of cytokines, and membrane stabilization. These actions coupled with their ability to reduce edema provide the rationale for the use of epidural steroid injections in spinal stenosis. Although epidural steroid injections have been used in the treatment of spinal stenosis for many years, no scientifically validated long-term outcomes have been reported to substantiate their use, and most prospective reports show no statistically significant benefit. A meta-analysis showed that epidural steroids have little short-term advantage over placebo for the treatment of leg pain. Studies also are divided on the long-term results and the avoidance of surgery.

Accurate placement of translaminar injections seems to be equally difficult, with successful placement reported in 70%. Complications are infrequent but can occur and include hypercorticism, epidural hematoma, temporary paralysis, retinal hemorrhage, epidural abscess, chemical meningitis, and intracranial air.

The ideal candidate for epidural steroid injection seems to be a patient who has acute radicular symptoms or neurogenic claudication unresponsive to traditional analgesics and rest, with significant impairment in activities of daily living. We have used this technique successfully in our treatment algorithm for neurogenic claudication and radiculopathy.

Operative Treatment

The primary indication for surgery in patients with spinal stenosis is increasing pain that is resistant to conservative measures. Because the primary complaint often is back pain and some leg pain, pain relief after surgery may not be complete. Most series report a 64% to 91% rate of improvement, with 42% in patients with diabetes, but most patients still have some minor complaints, usually referable to the preexisting degenerative arthritis of the spine. Neurological findings, if present, improve inconsistently after surgery. normally 30% had complete improvement in motor symptoms after laminectomy, with 58% regaining grade 4 strength or better at a mean follow-up of 3 years. Reoperation rates vary from 6% to 23%. Prognostic factors include better results with a disc herniation, stenosis at a single level, weakness of less than 6 weeks' duration, monoradiculopathy, and age younger than 65 years. Reversal of neurological consequences of spinal stenosis seems to be a relative indication for surgery unless the symptoms are acute.

A patient's inability to tolerate the restricted lifestyle necessitated by the disease and the failure of a good conservative treatment regimen should be the primary determining factors for surgery in a well-informed patient. The patient should understand the potential for the operation to fail to relieve pain or to worsen it, especially in regard to the axial component of the symptoms. In addition to the general risks of spinal surgery, the severity of symptoms and lifestyle modifications should be considered. Lumbar spinal stenosis does not result in paralysis, only decreased ambulatory capacity, and conservative management is warranted indefinitely in a patient with good function and manageable symptoms. Cervical and thoracic spinal stenoses are associated with painless paralysis in the form of cervical and thoracic myelopathy and require closer attention and follow-up.

Surgical options include:

  1. Laminectomy
  2. Microdecompression
  3. Decompression
  4. Over the roof decompression
  5. Foraminotomy
  6. Fenestration
  7. laminotomy
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Lumbar disc disease?

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Signs and Symptoms

Although back pain is common from the second decade of life on, intervertebral disc disease and disc herniation are most prominent in otherwise healthy people in the third and fourth decades of life. Most people relate their back and leg pain to a traumatic incident, but close questioning frequently reveals that the patient has had intermittent episodes of back pain for many months or even years before the onset of severe leg pain. In many instances, the back pain is relatively fleeting and is relieved by rest. This pain often is brought on by heavy exertion, repetitive bending, twisting, or heavy lifting. In other instances, an inciting event cannot be elicited. The pain usually begins in the lower back, radiating to the sacroiliac region and buttocks. The pain can radiate down the posterior thigh. Back and posterior thigh pain of this type can be elicited from many areas of the spine, including the facet joints, longitudinal ligaments, and periosteum of the vertebra. Radicular pain usually extends below the knee and follows the dermatome of the involved nerve root.

The usual history of lumbar disc herniation is of repetitive lower back and buttock pain, relieved by a short period of rest. This pain is suddenly exacerbated, often by a flexion episode, with the appearance of leg pain. Most radicular pain from nerve root compression caused by a herniated nucleus pulposus is evidenced by leg pain equal to, or in many cases greater than, the degree of back pain. The pain from disc herniation usually varies, increasing with activity, especially sitting. The pain can be decreased by rest, especially in the semi-Fowler position, and can be exacerbated by straining, sneezing, or coughing.

Other symptoms of disc herniation include weakness and paresthesias. In most patients, the weakness is intermittent, varies with activity, and is localized to the neurological level of involvement. Paresthesias also vary and are limited to the dermatome of the involved nerve root. Whenever these complaints are generalized, the diagnosis of a simple unilateral disc herniation should be questioned.

Numbness and weakness in the involved leg and occasionally pain in the groin or testicle can be associated with a high or midline lumbar disc herniation. If a fragment is large, or the herniation is high, symptoms of pressure on the entire cauda equina can occur with development of cauda equina syndrome. These symptoms include numbness and weakness in both legs, rectal pain, numbness in the perineum, and paralysis of the sphincters. This diagnosis should be the primary consideration in patients who complain of sudden loss of bowel or bladder control. Whenever the diagnosis of cauda equina syndrome is caused by an acute midline herniation, evaluation and treatment should be aggressive.

The physical findings with disc disease vary because of the time intervals involved. Usually patients with acute pain show evidence of marked paraspinal spasm that is sustained during walking or motion. A scoliosis or a list in the lumbar spine may be present, and in many patients the normal lumbar lordosis is lost. As the acute episode subsides, the degree of spasm diminishes remarkably, and the loss of normal lumbar lordosis may be the only telltale sign. Point tenderness may be present over the spinous process at the level of the disc involved, and pain may extend laterally in some patients.

If there is nerve root irritation, it centers over the length of the sciatic nerve, in the sciatic notch, and more distally in the knee space. In addition, stretch of the sciatic nerve at the knee should reproduce buttock, thigh, and leg pain (i.e., pain distal to the knee).

Occasionally, if leg pain is significant, the patient leans back from an upright sitting position and assumes the tripod position to relieve the pain. This is referred to as the “flip sign.” Contralateral leg pain produced by straight leg raising should be regarded as pathognomonic of a herniated intervertebral disc.

Massive extrusion of a disc involving the entire diameter of the lumbar canal or a large midline extrusion can produce pain in the back, legs, and occasionally perineum.

The combination of saddle anesthesia, bilateral ankle areflexia, and bladder symptoms constituted the most consistent symptoms of cauda equina syndrome caused by massive intervertebral disc extrusion at any lumbar level.

More than 95% of the ruptures of the lumbar intervertebral discs occur at L4 or L5. Ruptures at higher levels in many patients are not associated with a positive straight leg raising test.

Often the neurological signs associated with disc disease vary over time. If the patient has been up and walking for a period of time, the neurological findings may be much more pronounced than if he or she has been at bed rest for several days, decreasing the pressure on the nerve root and allowing the nerve to resume its normal function. In addition, various conservative treatments can change the physical signs of disc disease.

Comparative bilateral examination of a patient with back and leg pain is essential in finding a clear-cut pattern of signs and symptoms. The evaluation commonly may change. Adverse changes in the examination may warrant more aggressive therapy, whereas improvement of the symptoms or signs should signal a resolution of the problem.

Although the predominant cause of back and leg pain in healthy individuals usually is lumbar disc disease, one must be extremely cautious to avoid a misdiagnosis, particularly given the high incidence of disc herniations present in asymptomatic patients as discussed previously. A full physical examination must be completed before making a presumptive diagnosis of herniated disc disease. Common diseases that can mimic disc disease include ankylosing spondylitis, multiple myeloma, vascular insufficiency, arthritis of the hip, osteoporosis with stress fractures, extradural tumors, peripheral neuropathy, and herpes zoster. Infrequent but reported causes of sciatica not related to disc hernia include synovial cysts, rupture of the medial head of the gastrocnemius, sacroiliac joint dysfunction, lesions in the sacrum and pelvis, and fracture of the ischial tuberosity.

Confirmatory Imaging

Although the diagnosis of a herniated lumbar disc should be suspected from the history and physical examination, imaging studies are necessary to rule out other causes, such as a tumor or infection. Plain radiographs are of limited use in the diagnosis because they do not show disc herniations or other intraspinal lesions, but they can show infection, tumors, or other anomalies and should be obtained, especially if surgery is planned. Currently, the most useful test for diagnosing a herniated lumbar disc is MRI .Since the advent of MRI, myelography is used much less frequently, although in some situations it may help to show subtle lesions. When myelography is used, it should be followed with a CT scan.

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Lumbar disc surgery?

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Microdiscectomy

Micro lumbar disc excision has replaced the standard open laminectomy as the procedure of choice for herniated lumbar disc. This procedure can be done on an outpatient basis and allows better lighting, magnification, and angle of view with a much smaller exposure. Because of the limited dissection required, there is less postoperative pain and a shorter postoperative stay.

The procedure is performed with the patient prone (face down). A specialized frame can be used, or the patient can be positioned on chest rolls. The microscope can be used from skin incision to closure. The initial dissection can be done under direct vision, however. A lateral radiograph is taken to confirm the level, and fluoroscopy is needed for placement of tubular retractors if this type of microdiscectomy is chosen.

Endoscopic Techniques

Endoscopic techniques have been developed with the purported advantage of shortened hospital stay and faster return to activity. These techniques generally are variations of the microdiscectomy technique using an endoscope rather than the microscope and different types of retractors. This remains another alternative technique. The basic principles remain the same as with microdiscectomy but here sequential dilatators are used and muscle splitting is minimal.

Rarely, disc herniation has been reported to be intradural. An extremely large disc that cannot be dissected from the dura or the persistence of an intradural mass after dissection of the disc should alert one to this potential problem. Excision of an intradural disc requires a transdural approach, which increases the risk of complications from CSF leak and intradural scarring

Results of Surgery for Disc Herniation

Good results range from 46% to 97%. Complications range from none to more than 10%. The reoperation rate ranges from 4% to more than 20%. A comparison between techniques also reveals similar results. There is no particular technique of discectomy that yields consistently superior results. Technical procedural differences are of minimal importance with regard to outcome.

Several points stand out in the analysis of the results of lumbar disc surgery.

Complications of Disc Excision

The complications associated with standard disc excision and micro lumbar disc excision are similar. A thromboembolism rate of 1%, a postoperative infection rate of 3.2%, and a deep disc space infection rate of 1.1%. Postoperative cauda equina lesions develops rarely. Laceration of the major vascular structures also has been described as a rare complication of this operation. Reported cases of bowel injury as a complication are also there. . The major complication in his surgery may be worsening neuropathy postoperatively. There might be disc space infection and or wound infection. Dural tears with CSF leaks, pseudomeningocele formation, CSF fistula formation, and meningitis also are possible, but are more likely after reoperation. The complications of micro lumbar disc excision seem to be less than with standard laminectomy.

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Nonoperative Treatment Of neck pain?

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Most patients with symptomatic cervical disc herniations respond well to nonoperative treatment, including some patients with nonprogressive radicular weakness. Reasonably good evidence shows that acute disc herniations decrease in size over time in the cervical region. Many conservative treatment methods for neck pain are used for multiple diagnoses. The primary purpose of the cervical spine and associated musculature is to support and mobilize the head, while providing a conduit for the nervous system.

The forces on the cervical spine are much smaller than on the lower spinal levels. The cervical spine is vulnerable to muscular tension forces, postural fatigue, and excessive motion. Most nonoperative treatments focus on one or more of these factors.

The best primary treatment is short periods of rest, massage, ice, and antiinflammatory agents with active mobilization as soon as possible. The position of the neck for comfort is essential for relief of pain. The position of greatest relief may suggest the offending pathological process or mechanism of injury. Patients with hyperflexion injuries usually are more comfortable with the neck in extension over a small roll under the neck. No specific position indicates lateral disc herniation, although most patients tolerate the neutral position best. Patients with spondylosis (hard disc) are most comfortable with the neck in flexion.

Cervical traction can be helpful in selected patients. Care must be exercised in instructing the patient in the proper use of traction. It should be applied to the head in the position of maximal pain relief. Traction never should be continued if it increases pain. The weights should rarely exceed 10 lb (weight of the head). The proper head halter and duration of traction sessions should be chosen to prevent irritation of the temporomandibular joint. Traction applied by a patient-controlled pneumatic force, which is more mobile than halter-type units, avoids irritation of the temporomandibular joint. For extension traction, the patient is supine, and the head is allowed to extend gently off the examining table or bed. For flexion, the same procedure is repeated in the prone position. The patient continues the exercise in the position that is most comfortable for 5 to 10 minutes several times daily.

The postural aspects of neck pain can be treated with more frequent changes in position and ergonomic changes in the work area to prevent fatigue and encourage good posture. Techniques to minimize or relieve tension also are helpful.

Cervical braces usually limit excessive motion. Similar to traction, they should be tailored to the most comfortable neck position. They may be most helpful for patients who are very active.

Neck and shoulder exercises are most beneficial as the acute pain subsides. Isometric exercises are helpful in the acute phase. Occasionally, shoulder problems, such as adhesive capsulitis, may be found concomitantly with cervical spondylosis; complete immobilization of the painful extremity should be avoided.

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Nonoperative Treatment Of low back pain?

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The number and variety of nonoperative therapies for back and leg pain are diverse and overwhelming. Treatments range from simple rest to expensive traction apparatus. All of these therapies are reported with glowing accounts of miraculous “cures”; few have been evaluated scientifically. In addition, the natural history of lumbar disc herniation is characterized by exacerbations and remissions with eventual improvement of extremity complaints in most cases. Finally, several distinct symptom complexes seem to be associated with disc disease. Few, if any, studies have isolated the response to specific and anatomically distinct diagnoses. The simplest treatment for acute back pain is rest. 2 days of bed rest were better than a longer period. Biomechanical studies indicate that lying in a semi-Fowler position (i.e., on the side with the hips and knees flexed) with a pillow between the legs should relieve most pressure on the disc and nerve roots. Muscle spasm can be controlled by the application of ice, preferably with a massage over the muscles in spasm. Pain relief and antiinflammatory effect can be achieved with nonsteroidal antiinflammatory drugs (NSAIDs). Most acute exacerbations of back pain respond quickly to this therapy. As the pain diminishes, the patient should be encouraged to begin isometric abdominal and lower extremity exercises. Walking within the limits of comfort also is encouraged. Sitting, especially riding in a car, is discouraged.

Numerous medications have been used with various results in subacute and chronic back and leg pain syndromes. The current trend seems to be moving away from the use of strong narcotics and muscle relaxants in the outpatient treatment of these syndromes. This is especially true in the instances of chronic back and leg pain where drug habituation and increased depression are frequent. Oral steroids used briefly can be beneficial as potent antiinflammatory agents. The many types of NSAIDs also are helpful when aspirin is not tolerated or is of little help. Numerous NSAIDs are available for the treatment of low back pain. When depression is prominent, mood elevators such as nortriptyline can be beneficial in reducing sleep disturbance and anxiety without increasing depression. Nortriptyline also decreases the need for narcotic medication.

Physical therapy should be used judiciously. The exercises should be fitted to the symptoms and not forced as an absolute group of activities. Patients with acute back and thigh pain eased by passive extension of the spine in the prone position can benefit from extension exercises rather than flexion exercises. Improvement in symptoms with extension indicates a good prognosis with conservative care. Patients whose pain is increased by passive extension may be improved by flexion exercises. These exercises should not be forced in the face of increased pain. This may avoid further disc extrusion. Any exercise that increases pain should be discontinued. Lower extremity exercises can increase strength and relieve stress on the back, but they also can exacerbate lower extremity arthritis. The true benefit of such treatments may be in the promotion of good posture and body mechanics rather than of strength. Hansen et al. compared intensive, dynamic back muscle exercises, conventional physiotherapy (manual traction, flexibility, isometric and coordination exercises, and ergonomics counseling), and placebo-control treatment in a randomized, observer blind trial. Regardless of the method used, patients who completed therapy reported a decrease in pain. Physiotherapy seemed to have better results in men, however, and intensive back exercises gave better results in women. Patients with strenuous physical occupations responded better to physiotherapy, whereas patients with sedentary occupations responded better to intensive back exercises.

Numerous treatment methods have been advanced for the treatment of back pain. Some patients respond to the use of transcutaneous electrical nerve stimulation. Others do well with traction varying from skin traction in bed with 5 to 8 lb to body inversion with forces of more than 100 lb. Back braces or corsets may be helpful to other patients. Ultrasound and diathermy are other treatments used in acute back pain. The scientific efficacy of many of these treatments has not been proved.

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What are the normal ligaments of knee?

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There are four main ligaments in the knee that can become injured. During injury, a knee ligament may be stretched (sprained), or sometimes torn (ruptured). Ligament rupture can be partial (just some of the fibres that make up the ligament are torn) or complete (the ligament is torn through completely). Knee ligament injuries can cause pain, swelling, tenderness, bruising and reduced movement of your knee. Your knee joint may feel unstable and you may walk with a limp. Treatment of a knee ligament injury can depend on a number of things including which ligament is injured and how sporty and active you are.

There are four bones around the area of the knee joint: the thigh bone (femur), the main shin bone (tibia), the outer shin bone (fibula) and the knee cap (patella). But the main movements of the knee joint are between the femur, the tibia and the patella. Tough connective tissue (articular cartilage) lines the ends of the tibia and femur and the back of the patella around the knee joint. The articular cartilage reduces friction between the bones of the knee joint and helps smooth movement between them.

Each knee joint also contains an inner and outer meniscus (a medial and lateral meniscus). These are thick rubbery pads of cartilage tissue. They are C-shaped and become thinner towards the middle of the joint. The menisci cartilages sit on top of, and are in addition to, the usual thin layer of articular cartilage which covers the top of the tibia. The menisci act like shock absorbers to absorb the impact of the upper leg on the lower leg. They also help to improve smooth movement and stability of the knee.

There are four ligaments around the knee joint. A ligament is a tough strip of connective tissue that joins one bone to another bone around a joint. The knee joint ligaments help to stabilise and support the knee when it is moved into different positions.

Each ligament has a different job to do:

  • The medial collateral ligament (MCL) is one of the ligaments on the outside of the knee joint. It runs between the femur and the tibia on the inner side of the knee. It helps to protect and stabilise the knee joint against any blows or forces that may be directed on to the outer side of the knee. It helps to limit the amount that the knee moves from side to side.
  • The lateral collateral ligament (LCL) is the other main ligament on the outside of the knee joint. It runs between the femur and the fibula on the outer side of the knee. It helps to protect and stabilise the knee joint against any blows or forces that may be directed on to the inner side of the knee. This ligament also helps to limit the amount the knee moves from side to side.
  • The anterior cruciate ligament (ACL) is one of the ligaments inside the knee joint. It runs diagonally connecting the anterior (front) of the tibia to the posterior (back) of the femur. This ligament helps to stabilise the knee joint by controlling backward and forward movements of the knee. It stops the tibia bone from moving forwards in front of the femur.
  • The posterior cruciate ligament (PCL) is the other ligament inside the knee joint. It also runs diagonally across the knee connecting the back (posterior) of the tibia to the front (anterior) of the femur. The ACL and PCL cross each other inside the knee joint and some people call them the cross ligaments. The PCL helps to control the forward and backward movements of the knee.

The knee joint is surrounded by a protective joint capsule. This is lined by a special membrane called the synovial membrane. The synovial membrane produces synovial fluid which helps to lubricate and reduce friction within the knee joint. There are also muscles that help to support the knee joint. The main ones are the thigh muscles (quadriceps) and rear thigh muscles (hamstrings) in the legs.

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What is a knee ligament injury?

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The ligaments around the knee are strong. However, sometimes they can become injured. They may be stretched (sprained), or sometimes torn (ruptured). A ligament rupture can be partial (just some of the fibres that make up the ligament are torn) or complete (the ligament is torn through completely). The majority of knee ligament injuries are sprains and not tears and they tend to settle down quickly.

There are a number of different things that can cause injury to the ligaments in your knee:

  • You may have a direct blow to your knee or knock into something with your knee.
  • Your knee may be moved outside of its usual range of movement. For example, this can happen during a fall, if you land awkwardly during sport, or after a sudden movement.
Medial collateral ligament injury

Injuries to the MCL can happen in almost any sport and can affect people of all age groups. They often happen when your leg is stretched out in front of you and the outer side of your knee is knocked at the same time - for example, during a rugby or football tackle.

Lateral collateral ligament injury

Injuries to the LCL are less common than injuries to the MCL. This is because your other leg usually protects against injury to the inner side of your knee. (It is usually a direct blow to the inner side of your knee that causes an LCL injury.) But, this ligament injury can sometimes happen if one leg is stretched out in front of you and doesn't have the other leg for protection - for example, during a rugby or football tackle.

Anterior cruciate ligament injury

ACL injuries most often occur during sports such as football, basketball, skiing and tennis. The injury often happens if you land on your leg and then quickly pivot or twist your knee in the opposite direction.

Women are more likely than men to injure their ACL although it is not certain why this is. About half of people with an ACL injury also have injury to their meniscus or another ligament in the same knee.

Posterior cruciate ligament injury

Injuries to this ligament are not as common as ACL injuries. This is because the PCL is wider and stronger than the ACL. There are a number of ways that the PCL can become injured. For example, it may be injured during a car accident if the front of your bent knee hits the dashboard. It may also be injured from falling on to your bent knee. Your PCL can also be injured if your knee is hit from the front whilst your leg is stretched out in front of you with your foot on the ground - for example, during a game of football.

At first, some people with a PCL injury may not have much in the way of symptoms (see below). It may take a while for you to realise that there is a problem. For example, you may later notice pain that comes on when going up and down stairs or when starting a run; or, your knee may feel unstable when walking on uneven ground

What are the symptoms of a knee ligament injury?

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If you have injured one or more of the ligaments in your knee, the symptoms are likely to be similar regardless of the ligament that is injured. The severity of the symptoms depends on the degree of the injury to the ligament. For example, a ligament that is completely torn may produce more in the way of symptoms than a ligament that is just stretched (sprained).

Symptoms can include:

  • A popping sound, or a popping or snapping feeling at the time of injury can sometimes be heard if a ligament is completely torn.
  • Swelling of your knee. When a ligament is injured, there may be some bleeding inside your knee joint from the damaged ligament. This can lead to knee swelling. The degree of swelling will depend on the severity of the injury. Minor ligament sprains may cause little in the way of swelling, whereas completely torn ligaments may lead to a lot of knee swelling.
  • Pain in your knee. Again, the degree of pain can depend on the severity of the knee injury.
  • Tenderness around your knee on touching. This may be mild tenderness over the actual ligament in minor sprains, or more generalised and severe tenderness if a ligament is torn.
  • Not being able to use or move your knee normally. In complete ligament tears, movement can be severely reduced, whereas in more minor sprains, you may have a relatively good amount of knee movement.
  • A feeling that your knee is unstable or perhaps giving way if you try to stand on it. This may cause you to limp. Again, this depends on how severe the ligament injury is. You may be able to stand if you only have a minor sprain.
  • Bruising around your knee can sometimes appear, although not always. It may take some time for bruising to develop.

How is a knee ligament injury diagnosed?

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If you feel that you may have a knee ligament injury, you should see a doctor. Your doctor will usually start by asking you questions about the injury, what happened and where you are feeling any pain. They may then examine your knee to look for signs of swelling of your knee joint. They may also move your leg into different positions to test your knee ligaments. From this examination, they may be able to get an idea of the possible injury that you have.

If your doctor is concerned that you may have a more serious knee ligament injury, they may refer you for further tests such as an ultrasound scan or an MRI scan. Such tests should be able to show up any tears or rupture of your ligaments. Sometimes, an X-ray of your knee may be suggested.

If you have a lot of swelling of your knee after your injury, doctors may sometimes suggest draining off some of the fluid that is causing the swelling in your knee. To do this, a needle can be used to pierce the skin around your knee and the fluid can be drained off into a syringe attached to the needle. Special precautions are taken to keep the area and the procedure sterile so as not to introduce infection into your knee joint.

What is the treatment for a knee ligament injury?

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Self-help Treatment

For the first 48-72 hours think of:

  • Paying the PRICE - Protect, Rest, Ice, Compression, Elevation; and
  • Do no HARM - no Heat, Alcohol, Running or Massage.
Paying the PRICE:
  • P rotect your injured knee from further injury.
  • Rest your affected knee for 48-72 hours following injury. Consider the use of crutches to keep the weight off your injured knee. However, many doctors say that you should actually not keep your injured knee immobile for too long. You can usually start some exercises to help keep your knee joint moving and mobile. Start these as soon as you can tolerate the exercises without them causing too much pain. You can ask your doctor when you can start to move your knee joint and what exercises you should do.
  • Ice should be applied as soon as possible after your knee injury - for 10-30 minutes. Less than 10 minutes has little effect. More than 30 minutes may damage the skin. Make an ice pack by wrapping ice cubes in a plastic bag or towel. (Do not put ice directly next to skin, as it may cause ice-burn.) A bag of frozen peas is an alternative. Gently press the ice pack on to your injured knee. The cold from the ice is thought to reduce blood flow to the damaged ligament. This may limit pain and inflammation. After the first application, some doctors recommend reapplying for 15 minutes every two hours (during daytime) for the first 48-72 hours. Do not leave ice on while asleep.
  • Compression with a bandage will limit swelling, and help to rest your knee joint. A tubular compression bandage can be used. Mild pressure that is not uncomfortable or too tight, and does not stop blood flow, is ideal. A pharmacist will advise on the correct size. Remove before going to sleep. You may be advised to remove the bandage for good after 48 hours. This is because the bandage may limit movement of the joint which should normally be moving more freely after this time. However, bandages of the knee are sometimes kept on for longer to help keep swelling down and to keep the affected knee more comfortable. Ask your doctor what is best in your case.
  • Elevation aims to limit and reduce any swelling. For example, keep your foot on the affected side up on a chair when you are sitting. It may be easier to lie on a sofa and to put your foot on some cushions. When you are in bed, put your foot on a pillow. The aim is that your affected knee should be above the level of your heart.

Avoid HARM for 72 hours after injury. That is, avoid:

  • Heat - for example, hot baths, saunas, heat packs. Heat has the opposite effect to ice on the blood flow. That is, it encourages blood flow. So, heat should be avoided when inflammation is developing. However, after about 72 hours, no further inflammation is likely to develop and heat may then be soothing.
  • Alcoholic drinks, which can increase bleeding and swelling and decrease healing.
  • Running or any other form of exercise which may cause further damage.
  • Massage, which may increase bleeding and swelling. However, as with heat, after about 72 hours, gentle massage may be soothing.
Medication
  • Paracetamol and codeine: paracetamol is useful to ease pain. It is best to take paracetamol regularly, for a few days or so, rather than every now and then. An adult dose is two 500 mg tablets, four times a day. If the pain is more severe, a doctor may prescribe codeine, which is more powerful, but can make some people drowsy and constipated.
  • Anti-inflammatory painkillers: these drugs are also called non-steroidal anti-inflammatory drugs (NSAIDs). They relieve pain and may also limit inflammation and swelling. There are many types and brands. You can buy two types (aspirin and ibuprofen) at pharmacies, without a prescription. You need a prescription for the others. Side-effects sometimes occur with anti-inflammatory painkillers. Stomach pain, and bleeding from the stomach, are the most serious. Some people with asthma, high blood pressure, kidney failure, bad indigestion and heart failure may not be able to take anti-inflammatory painkillers. So, check with your doctor or pharmacist before taking them in order to make sure they are suitable for you.
    Also, if you are having surgery to repair a torn ACL , it is thought that, theoretically, NSAIDs may not be a good idea to take for a long period of time after the surgery because they may have an effect on the success of the surgery.
  • Rub-on (topical) anti-inflammatory painkillers: again, there are various types and brands of topical anti-inflammatory painkillers. You can buy one containing ibuprofen, without a prescription, at pharmacies . You need a prescription for the others. There is debate as to how effective rub-on anti-inflammatory painkillers are compared with tablets. Some studies suggest that they may be as good as tablets for treating sprains. Some studies suggest they may not be as good. However, the amount of the medication that gets into the bloodstream is much less than with tablets, and there is less risk of side-effects

Surgery for knee ligament injury?

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Sometimes surgery may be suggested after a knee ligament injury. This is more likely if:

  • You are someone who does a lot of sport or you are a very active person and you have injured your ACL.
  • You have injured more than one knee ligament, or you have injured a knee ligament and have also injured another part of your knee.
  • You have ruptured your LCL.

Surgery is most commonly suggested to repair ACL injuries. However, it is fair to say that the best way to treat a torn ACL is still debated. Physiotherapy and other measures may be all that is needed by some and may prevent the need for an operation. The decision about whether or not to use surgery depends on:

  • Each individual person.
  • The activities and sports that you do.
  • How active your lifestyle is in general.
  • Your underlying health.
  • Any other knee injuries that you may also have.

You may want to discuss the pros and cons of surgery with your doctor.

If surgery is carried out to repair a torn ACL, your doctor will usually advise that you wait some weeks after your initial injury. This is so that:

  • Any swelling has had a chance to go down.
  • You have got more movement back in your knee.
  • You have built up the strength in the muscles of your thighs that help to support your knee joint.

Your doctor may refer you for physiotherapy to help to prepare you for surgery.

The ACL ligament cannot simply be stitched back together. Instead, surgery to reconstruct, or rebuild, the ACL is usually carried out. Most often, part of a tendon, or tendons, from somewhere else in your body is used to reconstruct your ACL. For example, the following may be used:

  • Part of the tendon at the bottom of your kneecap (your patellar tendon).
  • Part of the tendon that attaches your kneecap to the quadriceps muscle at the front of your thigh (your quadriceps tendon).
  • Part of the tendons that run from the back of your knee up the back of your thigh (your hamstring tendons).
  • Sometimes, tendons from someone else (a donor) may also be used to repair your ACL.

The tendon is fixed in place inside your knee joint, using staples or screws. Once fixed in place, over time, a new ligament should grow over the tendon that has been used. Keyhole surgery is usually used to reconstruct your ACL.

There is currently some debate as to the best way to treat PCL injury - with surgery, or without surgery. You may like to discuss this with your doctor. If surgery is carried out, as with surgery for ACL injury, the damaged ligament is replaced using a tendon, or tendons, from elsewhere in your body, or using a donor tendon. Surgery is not often needed for MCL injuries.

How long does a knee ligament injury take to heal?

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This will depend on which knee ligament you have injured and also how severe your injury is. Also, if you have injured more than one ligament in your knee, recovery may take longer.

If you have surgery to repair your ACL, it usually takes around six months before your knee has recovered enough for you to return to your previous sporting activities. However, in some people, it may be longer. In general, surgery to reconstruct an ACL has good results in around 8-9 out of 10 people. If your PCL has been treated using surgery, it can take between 9 and 12 months before complete recovery.

After a stretch injury (sprain) or partial tear to the MCL, the ligament has completely healed in most people after three months. If there is a complete tear, recovery may take a little longer but most people are back to their usual activities after 6-9 months.

Knee Replacement Surgery?

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Who Needs Knee Replacement Surgery?

You and your doctor may consider knee replacement surgery if you have a stiff, painful knee that makes it difficult to perform even the simplest of activities, and other treatments are no longer working. This surgery is generally reserved for people over age 50 years of age.

What Happens During Knee Replacement Surgery?

Once you are under general anesthesia (meaning you are temporarily put to sleep) or spinal/epiduralanesthesia (numb below the waist), an 8- to 12-inch cut is made in the front of the knee. The damaged part of the joint is removed from the surface of the bones, and the surfaces are then shaped to hold a metal or plastic artificial joint. The artificial joint is attached to the thigh bone, shin and knee cap either with cement or a special material. When fit together, the attached artificial parts form the joint, relying on the surrounding muscles and ligaments for support and function.

What Are Recent Advances in Knee Replacement Surgery ?

Minimally invasive surgery has revolutionized knee replacement surgery as well as many fields of medicine. Its key characteristic is that it uses specialized techniques and instruments to enable the surgeon to perform major surgery without a large incision.

Minimally invasive knee joint replacement requires a much smaller incision, 3 to 5 inches, versus the standard approach and incision. The smaller, less invasive approaches result in less tissue damage by allowing the surgeon to work between the fibers of the quadriceps muscles instead of requiring an incision through the tendon. It may lead to less pain, decreased recovery time and better motion due to less scar tissue formation.

Currently this less invasive procedure is performed by only a small percentage of orthopedic surgeons in North America. Researchers continue looking at the short-term and long-term benefits of minimally invasive versus traditional knee replacement surgery.

What Happens After Knee Replacement Surgery?

The average hospital stay after knee joint replacement is usually three to five days. The vast majority of people who undergo knee joint replacement surgery have dramatic improvement. This improvement is most notable one month or more after surgery. The pain caused by the damaged joint is relieved when the new gliding surface is constructed during surgery.

After knee joint replacement, people are standing and moving the joint the day after surgery. At first, you may walk with the help of parallel bars, and then a walking device -- such as crutches, walker, or cane -- will be used until your knee is able to support your full body weight. After about six weeks, most people are walking comfortably with minimal assistance. Once muscle strength is restored with physical therapy, people who have had knee joint replacement surgery can enjoy most activities (except running and jumping).

How Long Will I Need Physical Therapy After Knee Replacement?

After knee replacement surgery, you are usually sent home or to a rehabilitation facility, depending on your condition at that time. If you are sent to a facility, the average rehabilitation stay is approximately seven to ten days. If you are sent directly home from the hospital, your doctor will usually have a physical therapist come to treat you at home. Your doctor also may have you go to an outpatient physical therapy facility as the final stage of the rehabilitation process. Outpatient therapy may last from one to two months, depending on your progress.

Remember, every person is different and the course of rehabilitation will be determined on an individual basis with the assistance of your doctor and physical therapist.

What Precautions Should I Take After Knee Replacement Surgery?

After knee replacement surgery, you should not pivot or twist on the involved leg for at least six weeks. Also during this time, when lying in bed, you should keep the involved knee as straight as possible. Kneeling and squatting also should be avoided soon after knee joint replacement surgery.

Your physical therapist will provide you with techniques and adaptive equipment that will help you follow guidelines and precautions while performing daily activities. Remember, not following the given precautions could result in the dislocation of your newly replaced joint.

How Can I Manage at Home During Recovery?

The following tips should make your recovery at home easier.

  • Stair climbing should be kept to a minimum. Make the necessary arrangements so that you will only have to go up and down the steps once or twice a day.
  • A firm, straight-back chair is extremely helpful in adhering to these joint precautions. Recliners should not be used.
  • To help avoid falls, all throw rugs should be removed from the floor and rooms should be kept free of unnecessary debris.
  • Enthusiastic pets should be kept far away until you have healed.

You should ask your doctor before returning to such activities as driving, sexual activity, and exercise

Is Knee Replacement Surgery Safe?

Knee joint replacements have been performed for years and surgical techniques are being improved all the time. As with all surgeries, however, there are risks. Since you will not be able to move around much at first, blood clots are a particular concern. Your doctor will give you blood thinners to help prevent this. Infection and bleeding also are possible, as are the risks associated with using general anesthesia. Other less common concerns that you and your doctor must watch out for include the following:

  • Pieces of fat in the bone marrow may become loose, enter the bloodstream and get into the lungs, which can cause very serious breathing problems.
  • Nerves in the knee area may be injured from swelling or pressure and can cause some numbness.
  • Other bones may be broken during the surgery, which may require a longer hospital stay.
  • The replacement parts may become loose or break.
How Long Will My New Knee Joint Last?

When joint replacement procedures were first performed in the early 1970s, it was thought that the average artificial joint would last approximately 10 years. We now know that about 85% of the joint implants will last 20 years or more. Improvements in surgical technique and artificial joint materials should make these artificial joints last longer.

Operative Treatment for neck pain/cervical disc prolapse?

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The primary indications for operative treatment of cervical disc disease are

  1. failure of nonoperative pain management.
  2. increasing and significant neurological deficit.
  3. cervical myelopathy.

In most patients, the persistence of pain is the primary indication. The intensity of the persistent pain should be severe enough to interfere consistently with the patient's desired activity and greater than would reasonably be expected after operative treatment. The approach chosen should be determined by the location and type of lesion. Soft lateral discs are easily removed with the posterior (back) approach, whereas soft central or hard discs (central or lateral) probably are best treated with an anterior (front) approach.

Osteophytes that were not removed at surgery frequently have been shown to be reabsorbed at the level of fusion. The use of a graft also prevents the collapse of the disc space and maintains adequate foraminal size.

AFTERTREATMENT

Neurological function is closely monitored after surgery. Discharge is permitted when the patient is ambulatory, which usually is the same day as surgery. Pain should be controlled with oral medication. Radicular pain relief usually is dramatic and prompt, although hypesthesia can persist for weeks or months. The patient is allowed to return to clerical work when comfortable and to manual labor after 6 weeks. As a rule, neither support nor physical therapy is necessary, and the patient's future activity is not restricted. Isometric neck exercises, upper extremity range-of-motion exercises, and posterior shoulder girdle exercises can be useful for patients in whom atrophy or inactivity has been considerable. A soft cervical collar can help relieve immediate postoperative pain.

Results

Operations in cervical surgery are the results better than after the removal of a lateral herniated cervical disc. Mostly patients recover completely but in some cases neurodeficit persist . few patients continued to have arm pain after operation which settle over time. One patient had a recurrent extrusion at the same level. Two other patients had soft extrusions on the opposite side at another level, also requiring a second operation.
Approximately 90% had extremely good results.

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Operative Treatment low back pain/ lumbar spine problem?

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If nonoperative treatment for lumbar disc disease fails, the next consideration is operative treatment. The patient must be certain that the degree of pain and impairment warrants such a step. The surgeon and the patient must realize that disc surgery is not a cure, but may provide symptomatic relief. It neither stops the pathological processes that allowed the herniation to occur nor restores the disc to a normal state. The patient still must practice good posture and body mechanics after surgery. Activities involving repetitive bending, twisting, and lifting with the spine in flexion may have to be curtailed or eliminated. If prolonged relief is to be expected, some permanent modification in the patient's lifestyle may be necessary, although often no specific limitations are applied. The key to good results in disc surgery is appropriate patient selection. The optimal patient is one with predominant (if not only) unilateral leg pain extending below the knee that has been present for at least 6 weeks. The pain should have been decreased by rest, antiinflammatory medication, or even epidural steroids, but should have returned to the initial levels after a minimum of 6 to 8 weeks of conservative care. Some managed care plans now insist on a trial of physiotherapy.

Physical examination should reveal signs of sciatic irritation and possibly objective evidence of localizing neurological impairment. CT, lumbar MRI, or myelography should confirm the level of involvement consistent with the patient's examination.

Surgical disc removal is mandatory and urgent only in cauda equina syndrome. All other disc excisions should be considered elective. The elective status of surgery should allow a thorough evaluation to confirm the diagnosis, level of involvement, and physical and psychological status of the patient. Frequently, if there is a rush to the operating room to relieve pain without proper investigation, the patient and the physician later regret the decision. Regardless of the method chosen to treat a disc rupture surgically, the patient should be aware that the procedure is predominantly for the symptomatic relief of leg pain. Patients with predominantly back pain may not be relieved of their major complaint—back pain.

Few of the patients complained of back pain after disc surgery. Failure to relieve sciatica was proportional to the degree of herniation. The best results of 99.5% complete or partial pain relief were obtained when the disc was free in the canal or sequestered. Incomplete herniation or extrusion of disc material into the canal resulted in complete relief for 82% of patients. Excision of the bulging or protruding disc that had not ruptured through the anulus resulted in complete relief in 63%, and removal of the normal or minimally bulging disc resulted in complete relief in 38%, which is near the stated level for the placebo response. Likewise, the incidence of persistent back pain after surgery was inversely proportional to the degree of herniation. In patients with complete extrusions, the incidence was about 25%, but with minimal bulges or negative explorations the incidence increased to greater than 55%.

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Sacroiliac Joint Pain and injection?

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Introduction:

The sacroiliac joint remains a controversial source of primary low back pain despite validated scientific studies. It often is overlooked as a source of low back pain because its anatomical location makes it difficult to examine in isolation, and many provocative tests place mechanical stresses on contiguous structures. In addition, several other structures may refer pain to the sacroiliac joint.

Sacroiliac joint anatomy and mechanics:

The sacroiliac joint, similar to other synovial joints, moves; however, sacroiliac joint movement is involuntary and is caused by shear, compression, and other indirect forces. Muscles involved with secondary sacroiliac joint motion include the erectae spinae, quadratus lumborum, psoas major and minor, piriformis, latissimus dorsi, obliquus abdominis, and gluteal. Imbalances in any of these muscles as a result of central facilitation may cause them to function in a shortened state that tends to inhibit their antagonists reflexively. Theoretically, dysfunctional movement patterns may result. Postural changes and body weight also can create motion through the sacroiliac joint. Because of the wide range of segmental innervation (L2-S2) of the sacroiliac joint, there are myriad referral zone patterns. In studies of asymptomatic subjects, the most constant referral zone was localized to a 3 × 10 cm area just inferior to the ipsilateral posterior superior iliac spine however, pain may be referred to the buttocks, groin, posterior thigh, calf, and foot.

Cause of pain in sacroiliac joint:

Sacroiliac dysfunction, also called sacroiliac joint mechanical pain or sacroiliac joint syndrome, is the most common painful condition of this joint. The true prevalence of mediated pain from sacroiliac joint dysfunction is unknown; however, several studies indicated that it is more common than expected. Because no specific or pathognomonic historical facts or physical examination tests accurately identify the sacroiliac joint as a source of pain, diagnosis is one of exclusion. Sacroiliac joint dysfunction should be considered, however, if an injury was caused by a direct fall on the buttocks, a rear-end motor vehicle accident with the ipsilateral foot on the brake at the moment of impact, a broadside motor vehicle accident with a blow to the lateral aspect of the pelvic ring, or a fall in a hole with one leg in the hole and the other extended outside.

Lumbar rotation and axial loading that can occur during ballet or ice skating is another common mechanism of injury. Although controversial, the risk of sacroiliac joint dysfunction may be increased in individuals with lumbar fusion or hip pathology.

Other causes include insufficiency stress fractures; fatigue stress fractures; metabolic processes, such as deposition diseases; degenerative joint disease; infection; and inflammatory conditions, such as ankylosing spondylitis, psoriatic arthritis, and Reiter disease. The diagnosis of sacroiliac joint pain can be confirmed if symptoms are reproduced on distention of the joint capsule by provocative injection and subsequently abated with an analgesic block.

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Tubercular Spinal Infection (POTTS SPINE)?

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Introduction:

Tuberculosis was previously the primary cause of infectious spondylitis. Before the advent of effective chemotherapy, time and surgery for paralysis were the only treatment options. Tubercular bone and joint infections currently account for 2% to 3% of all reported cases of M. tuberculosis. Spinal tubercular infections account for one third to one half of the bone and joint infections. The thoracolumbar spine is the most commonly infected area. The incidence of infection seems to increase with age, but males and females are almost equally infected.

Cause of infection:

Pathologically, the infection is characterized by acid-fast–positive, caseating granulomas with or without pus. Tubercles composed of monocytes and epithelioid cells, forming minute masses with central caseation in the presence of Langerhans-type giant cells, are typical on microscopic examination. Abscesses expand, following the path of least resistance, and contain necrotic debris. Skin sinuses form, drain, and heal spontaneously. Bone reaction to the infection varies from intense reaction to no reaction. In the spine, the infection spares the intervertebral discs and spreads beneath the anterior and posterior longitudinal ligaments. Epidural infection is more likely to result in permanent neurological damage.

Signs and symptoms:

Slowly progressive constitutional symptoms are predominant in the early stages of the disease, including weakness, malaise, night sweats, fever, and weight loss. Pain is a late symptom associated with bone collapse and paralysis. Cervical involvement can cause hoarseness because of recurrent laryngeal nerve paralysis, dysphagia, and respiratory stridor (known as Millar asthma). These symptoms may result from anterior abscess formation in the neck. Sudden death has been reported with cervical disease after erosion into the great vessels. Neurological signs usually occur late and may wax and wane. Motor function and rectal tone are good prognostic predictors. Jain et al. calculated that the spinal canal can accommodate 76% encroachment on CT scan without neurological abnormality. investigators reported that 60% to 90% of patients with Pott paraplegia recovered with prolonged bed rest in an open-air hospital.

How to diagnose:

Laboratory studies suggest chronic disease. Findings include anemia, hypoproteinemia, and mild ESR elevation. Skin testing may be helpful, but is not diagnostic. The test is contraindicated in patients with prior tuberculous infection because of the risk of skin slough from an intense reaction and is not useful in patients with suspected reactivation of the disease.

Early radiographic findings include a subtle decrease in one or more disc spaces and localized osteopenia. Later findings include vertebral collapse, called “concertina collapse” by Seddon because of its resemblance to an accordion. Soft-tissue swelling and its late calcification are highly predictable radiographic findings. CT scanning, with or without contrast, allows better evaluation of the pathological process and the degree of neural compromise. MRI permits further delineation of the pathological process. Abscess formation and the presence of bone fragments were the only MRI findings that helped distinguish spinal tuberculosis from neoplasia. None of these tests is confirmatory for tuberculosis, however. Scientist noted that 67Ga scanning was most useful in patients with disseminated tuberculosis.

Definitive diagnosis depends on culture of the organism and requires biopsy of the lesion. Percutaneous techniques with radiographic or CT control usually are adequate. Epithelioid granulomas were seen in 89%, positive acid-fast bacilli cultures in 83%, and positive acid-fast bacilli smears in 52%. Open biopsy may be required if needle biopsy is dangerous or nonproductive or if other open procedures are required.

Delayed diagnosis and missed diagnosis are common. Differential diagnoses include pyogenic and fungal infections, secondary metastatic disease, primary tumors of bone (e.g., osteosarcoma, chondrosarcoma, myeloma, eosinophilic granuloma, and aneurysmal bone cyst), sarcoidosis, giant cell tumors of bone, and bone deformities such as Scheuermann disease. Definitive diagnosis by culture of a biopsy specimen is important because of the toxicity of the chemotherapeutic agents and the length of treatment required. No patient developed paraplegia after surgery.

Better results with regard to deformity, recurrence, development of paralysis, and resolution when radical surgery is performed with chemotherapeutic coverage. The resolution of paraplegia did not depend on surgical intervention. Long-term bed rest, with or without cast immobilization, was ineffective. If the facilities for radical surgery are unavailable, ambulatory chemotherapy is the treatment of choice.

Treatment:

The indications for surgery in the absence of neurological symptoms vary widely. Involvement of more than one vertebra significantly increases the risk of kyphosis and collapse. Open biopsy for diagnosis, débridement, and grafting with or without anterior instrumentation may offer the most direct approach in these patients. Resistance to chemotherapy and recurrence of the disease are other indications for radical surgical treatment. The indications for surgery in early or late disease as severe kyphosis with active disease, signs and symptoms of cord compression, progressive impairment of pulmonary function, and progression of the kyphotic deformity. Primary contraindications to surgery are cardiac and respiratory failure.

Posterior fusion, with or without spinal instrumentation, is indicated after anterior decompression and grafting to prevent late collapse and stress fracture of the graft if more than two vertebrae are involved and if anterior instrumentation is not used. Posterior fusion alone rarely is indicated at this time. High incidences of failure and late progression of kyphotic deformity, with or without fatigue fracture of the fusion, have followed posterior fusion alone. Tricortical iliac crest is the preferred bone graft material for all levels, provided that it is long enough. External immobilization is mandatory whenever débridement and grafting are performed.

Halo (vest, cast, or pelvic) immobilization for 3 months is used after cervical and cervicothoracic procedures. Removable or nonremovable thoracolumbar immobilization is used after thoracic and thoracolumbar procedures until the grafts have completely healed (9 to ≥12 months). Lumbosacropelvic immobilization is used after low lumbar procedures and should be from the hip to the knee of at least one leg for 6 to 8 weeks, followed by thoracolumbosacral immobilization until the graft has healed, and the infection has resolved.

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Disc degeneration (Cervical/lumbar)?

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Stages of Degeneration:

The degenerative process has been divided into three separate stages with relatively distinct findings.

  1. The first stage is dysfunction, which is seen in individuals 15 to 45 years old. It is characterized by circumferential and radial tears in the disc anulus and localized synovitis of the facet joints.
  2. Second stage stage is instability. This stage, found in 35- to 70-year-old patients, is characterized by internal disruption of the disc, progressive disc resorption, degeneration of the facet joints with capsular laxity, subluxation, and joint erosion.
  3. The final stage, present in patients older than 60 years, is stabilization. In this stage, the progressive development of hypertrophic bone around the disc and facet joints leads to segmental stiffening or frank ankylosis.



Each spinal segment degenerates at a different rate. As one level is in the dysfunction stage, another may be entering the stabilization stage. Disc herniation in this scheme is considered a complication of disc degeneration in the dysfunction and instability stages. Spinal stenosis from degenerative arthritis in this scheme is a complication of bony overgrowth compromising neural tissue in the late instability and early stabilization stages.

Diagnosis:

Radiologically a 4-mm collapse of the disc produces sufficient narrowing of the foramen to threaten the nerve.

Prognosis and treatment :

Long-term follow-up studies of lumbar disc herniations documented several principles, the foremost being that generally symptomatic lumbar disc herniation (which is only one of the consequences of disc degeneration) has a favorable outcome in most patients. The primary benefit of surgery was early on in the first year, but that with time the statistical significance of the improvement was lost. The judicious use of epidural steroids also is supported. Nonprogressive neurological deficits (except cauda equina syndrome) can be treated nonoperatively with expected improvement clinically.

If surgery is necessary, it usually can be delayed 6 to 12 weeks to allow adequate opportunity for improvement. Some patients are best treated surgically for lumbar disc herniation. Similar principles are valid regarding cervical disc herniations, which also generally can be treated nonoperatively. The important exception is a patient with cervical myelopathy, who is best treated surgically.

The natural history of degenerative disc disease is one of recurrent episodes of pain followed by periods of significant or complete relief. The memory of painful low back episodes was short.

Before a discussion of diagnostic studies, axial spine pain with radiation to one or more extremities must be considered. It is doubtful if there is any other area of orthopaedics in which accurate diagnosis is as difficult or the proper treatment as challenging as in patients with persistent neck and arm or low back and leg pain.

Surgical treatment can benefit a patient if it corrects a deformity, corrects instability, relieves neural compression, or treats a combination of these problems. Obtaining a history and completing a physical examination to determine a diagnosis that should be supported by other diagnostic studies is a useful approach; conversely, matching the diagnosis and treatment to the results of diagnostic studies, as often can be done in other subspecialties of orthopaedics (e.g., treating extremity pain based on a radiograph that shows a fracture), is fraught with difficulty.

most patients with nonspecific complaints and findings are best treated by physiotherapy. For patients with sigenificant findings, evaluation and treatment by a specialist is appropriate. For a few patients (although they are responsible for a much more significant portion of health care use), a multidisciplinary approach is best.

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Spinal cord injury (SCI)?

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Spinal cord injury is defined as Damage to the spinal cord that causes changes in its function, either temporary or permanent. This may cause loss of muscle function, sensation, or autonomic function in parts of the body supplied by the spinal cord below the level of the lesion.

It can be classified as

  1. Complete Injury: total loss of sensation and muscle function.
  2. Incomplete: some nervous signals are able to travel past the injured area of the cord.

The symptoms can vary from pain or numbness to paralysis to incontinence. The prognosis also ranges widely, from full recovery in rare cases to permanent tetraplegia in injuries at the level of the neck, and paraplegia in lower injuries. Complications that can occur in the short and long term after injury include muscle atrophy, pressure sores, infections, and respiratory problems.


Reason for injury can be car accidents, gunshots, falls, or sports injuries, but it can also result from nontraumatic causes such as infection, insufficient blood flow, and tumors.

The ability to control the limbs after spinal cord injury depends on two factors:

  1. The place of the injury along your spinal cord
  2. The severity of injury to the spinal cord.

Paralysis from a spinal cord injury may be referred to as:

  1. Tetraplegia. Also known as quadriplegia, this means your arms, hands, trunk, legs and pelvic organs are all affected by your spinal cord injury.
  2. Paraplegia. This paralysis affects all or part of the trunk, legs and pelvic organs.

The lowest part of spinal cord that functions normally after injury is referred to as the neurological level of injury. The severity of the injury is often called "the completeness" and is classified as either of the following:


Spinal cord injuries of any kind may result in one or more of the following signs and symptoms:

  1. Loss of movement
  2. Loss of sensation, including the ability to feel heat, cold and touch
  3. Loss of bowel or bladder control
  4. Exaggerated reflex activities or spasms
  5. Changes in sexual function, sexual sensitivity and fertility
  6. Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord
  7. Difficulty breathing, coughing or clearing secretions from your lungs


Signs and symptoms

Emergency signs and symptoms of spinal cord injury after an accident may include:


  1. Extreme back pain or pressure in your neck, head or back
  2. Weakness, incoordination or paralysis in any part of your body
  3. Numbness, tingling or loss of sensation in your hands, fingers, feet or toes
  4. Loss of bladder or bowel control
  5. Difficulty with balance and walking
  6. Impaired breathing after injury
  7. An oddly positioned or twisted neck or back

When to see a doctor

Anyone who experiences significant trauma to his or her head or neck needs immediate medical evaluation for the possibility of a spinal injury. In fact, it's safest to assume that trauma victims have a spinal injury until proven otherwise because:

  1. A serious spinal injury isn't always immediately obvious. If it isn't recognized, more severe injury may occur.
  2. Numbness or paralysis may develop immediately or come on gradually as bleeding or swelling occurs in or around the spinal cord.
  3. The time between injury and treatment can be critical in determining the extent of complications and the amount of recovery.

If you suspect that someone has a back or neck injury:

  1. Don't move the injured person — permanent paralysis and other serious complications may result
  2. Call local emergency medical assistance number
  3. Keep the person still
  4. Place heavy towels on both sides of the neck or hold the head and neck to prevent them from moving until emergency care arrives
  5. Provide basic first aid, such as stopping any bleeding and making the person comfortable, without moving the head or neck

Treatment

Starts with stabilizing the spine and controlling inflammation to prevent further damage (intravenous steroids) . Treatment options may include:

  1. Spinal fracture fixation (pedicle screw stabilization)
  2. Spinal laminectomy (decompression) and fixation.
  3. Spinal corpectomy and stabilization.
  4. Percutaneous pedicle screw stabilization.
  5. Stem cell therapy.

Spinal Fracture Fixation?

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Spinal fracture can be primary due to injury or secondary (pathological- in an already weak bone). Vertebral fixation (also known as "spinal fixation") is surgical procedure in which two or more vertebrae are anchored to each other through a synthetic "vertebral fixation device", with the aim of reducing vertebral mobility and thus avoiding possible damage to the spinal cord and/or spinal roots.


Indications

A vertebral fracture fixation procedure may be indicated in cases of:

  1. vertebral fracture leading to neurological injury.
  2. Vertebral fracture with impending neurological injury.

Types of Fixations: The implants used to achieve vertebral fixation are usually a permanent rigid or semi-rigid prosthesis made of titanium like rods, plates, screws, and various combinations thereof. The surgery may be open or minimally invasive (like minimally invasive transforaminal lumbar interbody fusion or percutaneous fracture stabilization).

The types of fracture fixation may include:

Cervical:
Anterior cervical plating with or without corpectomy.
Anterior cervical cage insertion and plating.
Posterior cervical lateral mass screw fixation and stabilization.
Anterior or posterior stabilization with neurological decompression.
Thoracic:
Percutaneous dorsal fracture stabilization. (minimally invasive)
Open dorsal fracture stabilization.
Thoracic fracture fixation with laminectomy (decompression) and anterior cage support.
Kyphoplasty/vertebroplasty for fractured vertebra.
Anterior transthoracic approach for fracture fixation and anterior column reconstruction (cage)
Lumbar/Lumbo-sacral:
Posterior percutaneous fracture fixation (minimally invasive)
Posterior open spinal fixation with fusion.
Posterior spinal fixation with anterior cage insertion.
Kyphoplasty/vertebroplasty.
Anterior lumbar fixation with corpectomy and mesh cage support.
Axial lumbar interbody fusion .
Direct lateral lumbar interbody fusion.
Lumbo sacral spinal fixation.

Normally the pedicles screws used for posterior stabilization are connected with rods on both the sides, whereas the anterior assembly normally uses a plate and screw mechanism, e.g in cervical spine.

In cases with severe osteoporosis cement augmented screws are also available to increase the hold in weak bone.

Normally after spinal fracture fixation a protective brace is worn for additional support till the fracture heals.

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CONTACT US

Raviprit Orthopaedic and Spine Clinic

Address:   A-71, Near Mother Pride School Sector-93b, Noida - 201304, U.P

O.P.D Timing:  6 PM TO 8 PM (Monday to Saturday)
11 AM TO 1 PM (Sunday)

Email ID:  drhimanshurtyagi@gmail.com

Telephone: +91-9654095717

Artemis Hospital

Address:  Sector 51, Gurgaon, Haryana 122001

O.P.D Timing:  9 AM TO 5 PM (Monday to Saturday)

Email ID:  drhimanshurtyagi@gmail.com

Telephone: +91-9654095717