HSS dx and surgery for spine

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shmvii
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220204
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HSS dx and surgery for spine
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2013-05-19 09:10:51
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spring 2013
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spring 2013
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  1. for what percent of people is back pain acute, fading in days or weeks?
    90
  2. low back pain that worsens with sitting may indicate ___
    herniated lumbar disc
  3. acute onset of lower back pain may suggest __ or __
    herniate disc or muscle strain
  4. gradual onset LBP fits w __ __ __
    • OA
    • spinal stenosis
    • spndylolisthesis (slipping of one vert body on the next)
  5. HNP def
    • herniated nucleus pulposus
    • -- due to sudden r chronic overloading of ant aspect of intervertebral disc --> weakening and bulging of post wall --> nerve compression --> pain, weakness, neuro changes, loss of B & B
  6. DDD
    degen disc disease - a result of micro-trauma to the annulus, or natural aging process --> loss of disc ht, flexibility, elasticity, shock absorption --> pain, loss of ROM, spinal stenosis
  7. stenosis pain increases in what pos?
    extension - so walking up hill is painful, leaning over a shopping cart gives relief
  8. spondylolysis
    • fracture of pars interarticularis, can lead to spondylolisthesis
    • seen in growth spurts and pts > 40 y/o
  9. 4 LBP criteria for surgery
    • failed conservative treatment
    • intractable pain
    • worsening neuro signs
    • cauda equina syndrome
  10. cauda equina syndrome
    injury to lower spinal chord causing symptoms such as leg weakness, perineal numbness, loss of B&B

    can result from spinal shock, can cause permanent neuro damage if untreated

    C.E. starts around L2
  11. spine surgery indications - pain w/wo radicular symptoms?
    • w/o or w little -- less successful
    • w -- more likely surgery will be useful
  12. decompression surgery is to relieve pressure on the spinal cord or nerve roots. name 5 procedures
    • discectomy
    • laminectomy / otomy
    • foraminectomy / otomy
  13. which procedure requires taping the eyes?
    laminectomy, because pt is prone for so long
  14. basic goal fo fusion surgery, and the 3 types
    • elim motion from single to multiple unstable spinal segments
    • ALIF, PLIF, XLIF
  15. replacement / refortifying surgery -- what is it, name 2 types
    maintain motion of the vertebral segment, resurrect collapsed vertebral bodies 

    • total disc replacement 
    • kypoplasty
  16. microdiscectomy, laminotomy / ectomy, foraminotomy / ectomy -- what are they for?
    • microdiscectomy or discectomy -- HNP, relieve pressure on nerve root
    • others (the bone-cutting ones) -- releive pressure, esp from stenosis
  17. BMP
    bone morphogenic protein -- a lab component you can use instead of bone in ALIF -- but can only do this once bc body will build up antibodies once it's introduced
  18. ALIF anterior lumbar interbody fusion -- for what?
    • to stabilize spine
    • maintain lordosis in a pt who's losing it
    • release and correct scoliosis`
  19. ALIF, basic technique
    • get to the spine via the belly
    • put a wedge in the ant disc space to spread out the vert and promote lordosis
    • make burr holes in vert bodies above and below to create bleed, and then the space is filled w bone from iliac crest or fom BMP

    done in lumbar or cervical spine
  20. PLIF - what's it for?
    instability caused byspondylolisthesis, DDD, or stenosis
  21. basics of PLIF procedure
    • remove lamina to get to disc space
    • open the space and pack it w bone graft or cages, then screw stuff into vert bodies above and below
    • can do this lumbar or cervical
  22. ups and downs fo PLIF
    • benefits: direct access to spine (ALIF gives this too), can address multiple issues at once, less risk of going thru a blood vessel (compared to ALIF)
    • drawbacks: disrupts major back muslces, manipulates nervs, can lead to pain and sensory changes
  23. XLIF - extreme lateral interbody fusion - basic description
    • like the ALIF, but less invasive -- done in sidelying, goes thru psoas
    • no laminectoym or foramenctomy needed
    • smaller incisions, easier on the pt, 
    • BUT - possible thigh or groin pain or numbness
  24. kyphoplasty - to treat what?
    vertebral compression fracture (VCF) - due to collapse of vert body, decreased bone density, or tumors in vert bodies
  25. contraind for kyphoplasty
    • pts w young/healthy bones
    • VCF 2/2 accident/trauma
    • spine curvature not due to OP
  26. total disc replacement is to treat what?
    DDD
  27. total disc replacement basic procedure
    • ant approach
    • full discectomy
    • wedges are cut in sup and inf vert bodies
    • disc space is filled w endplates and a spreader
  28. dural tear is a risk in which procedure?
    total disc replacement
  29. discectomy of 1 level, how long is there a risk of reherniation
    up to 6 months
  30. decompression or fusion of 1 level, how long is there risk of reinjury?
    for > 1 level?
    • up to 12 months
    • 2 or more yrs
  31. impact of smoking on boney reunion?
    up to 40% non-union
  32. how does the muldifidus present after a one level fusion?
    reduction of cross sectional area (% varies a lot, but he says it'll feel like a divot w jelly in it under yr finger)

    • stability is decreased in forward bending after a 1 level fusion
    • and for standign after a 2 level
    • axial rotatation - spinal stability is decreased even after a hemifacetectomy
  33. blue flag
    employment etc
  34. yellw flags
    • distress
    • hypervigilance
    • catastrophising
    • fear avoidance beliefs
    • low self efficacy
  35. red flags
    signs it's pathological / cancer
  36. S.M.A.R.T. goals
    • specific
    • measurable
    • achievable
    • realistic
    • timely
  37. 5 researched and good functional outcome tests
    • Oswestry Disability Index
    • Neck Disability Index
    • Roland Morris Disability Questionnaire
    • Patients Specific Functional Scale
    • Fear Avoidance Behavioral Questionnaire (work and physical activity)
  38. Of the 4 phases, in which do we see the pts, and what are the goals in these phases?
    • I: pt edu (BLT, ADL), HEP, pain control, log roll
    • III: maximize function, RTW,

    • but FYI
    • II: improve activity tolerance, pain control
    • IV: return to pre-op fxn and light recreation
  39. phase I and III interventions
    • I: transfers/gait training, activity modification, equipment, modalities prn
    • III: flexibility, progress stability, manual nerve glides (consider irritability)
  40. phases II and IV interventions
    • II: initial stab therex, submax CV training, stairs/transfers, manual - STM/MFR
    • IV: advanced stabilization, functional/sports specific training
  41. criteria for progression in the 4 stages
    • I: pain <4/10, mod disability, tolerate upright > 30 min, indep w transfers
    • II: pain well controlled, min/mod disability, upright >45 min
    • III: min pain, min disability, return to work, tolerate therex in multiple pos
    • IV: goals achieved, min disability, close to full fxn
  42. lumbar stability progression
    • specific stability in supine/sidelying/prone/quadruped: simple motions w ab-set
    • closed chain stability: side plank, bridge, quadruped foot slides
    • open chain stability:  dead bugs, scotty dog
    • functional training: work hardening
  43. cranio-cervical flexion - method of doing this exercise and measuring the flexion
    • lay pt supine with a blood pressure cuff under the neck, set to 20 mmHg, and have pt do CCF 22-30mmHg in 2 mm increments, holding each level 10 sec w 10 sec rest
    • norm: get to 26-30 wo compensation
  44. cervical stability progression
    • QUADRUPED OR SUPPORTED STANDING (DO SHOULDER FLEXION, HORIZ ABD, EXT)
    • SEATED OR STANDING
    • PRONE (ADVANCED)
    • whoops!
  45. soreness rules of porgression
    • no soreness: progres
    • soreness improves w warm up: stay at same level
    • soreness that doesn't improve w warm up: go back one level/modality/day off
    • soreness that persists >48 hrs or is signif: call MD
  46. 4 cues for neuromuscular re-edu
    • static postural cues: lumbo-pelvic proprioception
    • dynamic postural cues: quadurped rocking, hip hinge, LP disassociation
  47. 3 manual interventions
    • soft tissue mobs
    • LE mobs
    • thoric mobs

    and MD communication

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