Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Pyogenic Spinal Infection Acute pyogenic infection of the spine is uncommon , diagnosis and treatment are often unnecessarily delayed. The elderly, chronically ill and immunodeficient patients are at greatest risk. It might follow surgery in renal system. Tuberculosis of spine: The spine is the most commonest site of skeletal tuberculosis and the most dangerous . It is blood – born infection settled in the vertebral bodies , bone destruction and caseation follow with spread of the infection to the adjacent disc space and adjacent vertebrae. As the vertebral bodies collapse , a sharp angulation or (kyphos) develops. Caseation and cold abscess formation may extend to the neighboring vertebrae or escape into paravertebral soft tissue . There is risk of spinal cord damage due to pressure by the abscess or displaced bone or ischemia from spinal artery thrombosis. Clinically there is long history of ill health and back ache ; the deformity is some time the dominant feature or the patient presented with cold abscess pointing in the groin ; or with parasthesia and weakness of the legs . The characteristic feature in late cases is an angular thoracic kyphosis . Pott`s paraplegia is the most dangerous complication of spinal tuberculosis . Imaging : X- ray , the entire spine should be x- rayed to detect any infection in other vertebrae . Earliest sign is local osteoporosis of two adjacent vertebrae and narrowing of intervertebral disc space ; then there will be bone destruction and collapse of the adjacent vertebral bodies lead to angular deformity. Para spinal soft tissue shadow may be due to para vertebral abscess . CT and MRI is very helpful Investigation : Mantoux test is +ve ; ESR is high Differential diagnosis : 1 - pyogenic infection . 2- malignant disease . Treatment : the aim of treatment is: 1- to eradicate the disease . 2- to prevent or correct the deformity . 3-to prevent or treat the major complication , mainly paraplegia . The way of treatment will be by anti T.B chemotherapy and surgical drainage of the pus collection ; surgical curration of the diseased bone ; anterior spinal fusion and bone grafting sometimes used . Intervertebral disc prolapse The spine is a non-homogeneous complex-shape consist of 24 vertebrae, separated by intervertebral discs with numerous muscles and ligaments attached to them. Intervertebral discs act as a kind of cushion to soften the impacts caused by the movement of body. The intervertebral discs make up about one fourth of entire length of the vertebral column. The discs absorb the stress and strain transmitted to the vertebral column. The intervertebral disc is a structure composed of the gelatenus nucleous pulposus at the center surrounded by annulus fibrosus . Sever stress and degeneration of the disc may lead to herniation of the gelatinus nucleus pulposus through the anulus fibrosus back ward so if it is on the right or on the left it will compress the nerve roots leading to rooting pain(sciatica), and if it herniated to the center it will compress the cauda equina leading to cauda equina syndrome and this include: bladder and bowel incontinence , perineal numbness, bilateral sciatica, lower limb weakness, crossed straight-leg raising sign . Cauda equina lesion need urgent MRI and CT scan and operate urgently if a large central disc is revealed. clinical features: Acute disc prolapse may occur at any age, but is uncommon in the very young and the very old. The patient is usually a fit adult aged 20–45 years. Typically, while lifting or stooping he has severe back pain and is unable to straighten up. Either then or a day or two later pain is felt in the buttock and lower limb (sciatica). Both backache and sciatica are made worse by coughing or straining. Later there may be parasthesia or numbness in the leg or foot, and occasionally muscle weakness. Cauda equina compression is rare but may cause urinary retention and perineal numbness. on examination: The patient usually stands with a slight list to one side(‘sciatic scoliosis’). All back movements are restricted, and during forward flexion the list may increase. There is often tenderness in the midline of the low back, and paravertebral muscle spasm. Straight leg raising is restricted and painful on the affected side. Neurological examination may show muscle weakness(and, later, wasting), diminished reflexes and sensory loss corresponding to the affected level. Imaging 1- X-rays : are helpful, not to show an abnormal disc space but to exclude bone disease. After several attacks the disc space may be narrowed and small osteophytes appear. 2- CT and MRI : These are now the preferred methods of spinal imaging. Treatment : symptomatic treatment include: Heat , analgesics, and exercises strengthen muscles, but there are only three ways of treating the prolapse itself – rest, reduction or removal, followed by rehabilitation. Rest: With an acute attack the patient should be kept in bed, with hips and knees slightly flexed. A nonsteroidal anti- inflammatory drug is useful in most of patients. Reduction: Continuous bed rest and traction for 2weeks may reduce the herniation. If the symptoms and signs do not improve during that period, an epidural injection of corticosteroid and local anaesthetic may help. Removal: The indications for operative removal of a prolapse are: (1) a cauda equina compression syndrome , this is an emergency. (2) Neurological deterioration while under conservative treatment. (3) persistent disabling pain and signs of sciatic tension after 2– 3 weeks of conservative treatment. The two operations most widely performed are laminotomy and microdiscectomy. Spondylolysis It is defect in the neural arch ( paras interarticularis) of the 5th or 4th lumber vertebra, it predispose to spondylolisthesis. It might follow injuries ( fibrous non union of fracture or stress fracture) or congenital. X-ray in oblique view would shows the defect. Most of cases need no treatment, belt, analgesia for short time and physiotherapy may used some times. Spondylolisthesis forward displacement of one vertebra over other vertebra ‘Spondylolisthesis’ means forward translation of one segment of the spine upon another. The shift is nearly always between L4 and L5, or between L5 and the sacrum, ( fig. . ). Normal discs, laminae and facets constitute a locking mechanism that prevents each vertebra from moving forwards on the one below. Forward shift (or slip) occurs only when this mechanism has failed. Classification: six types: Dysplastic (20 per cent) The superior sacral facets are congenitally defective. Lytic or isthmic (50 per cent) In this, the commonest variety, there are defects in the pars inter articularis (spondylolysis), or repeated breaking and healing may lead to elongation of the pars. Degenerative (25 per cent) Degenerative changes in the facet joints and the discs. Post-traumatic (Unusual fractures). Pathological Bone destruction (e.g. due to tuberculosis or neoplasm) may lead to vertebral slipping. Postoperative (iatropathic) occasionally, excessive operative removal of bone in decompression operations. Clinical features Backache is the usual presenting symptom; it is often intermittent, coming on after exercise or strain. Sciatica may occur in one or both legs. On examination the buttocks look flat, the sacrum appears to extend to the waist and transverse loin creases are seen. A ‘step’ can often be felt when the fingers are run down the spine. In children the condition is painless but the mother may notice protruded abdomen .In old age intermittent claudication may occur due to associated spinal stenosis. Imaging : X-ray: 1- lateral view show the forward shift of the upper part of the spinal column on the stable vertebra below. 2- oblique views which is the best view to see the gap in the pars interarticularis (decapitated Scotty dog) sign. In doubtful cases, CT may be helpful. Treatment: Conservative treatment, analgesic antiinflammatory drugs, avoiding lifting weights, using lumber built. Operative treatment is indicated: (1) if the symptoms are disabling. (2) if the slip is more than 50 per cent and progressing. (3) if neurological compression is significant. Surgical treatment carried out by reduction, internal fixation and spinal fusion Spinal stenosis The term spinal stenosis is used to describe abnormal narrowing of the central canal, the lateral recesses or the intervertebral foramina to the point where the neural elements are compromised. When this occurs the patient develops neurological symptoms and signs in the lower limbs called neural claudication. The causes of spinal stenosis are: 1- congenital. 2- chronic disc protrusion. 3- osteoarthritis of the facet joints. 4- spondylolisthesis. Clinical features The patient, usually aged over 50, complains of aching, heaviness, numbness and parasthesia in the thighs and legs; it comes on after standing upright or walking for 5–10 minutes, and is consistently relieved by sitting, squatting or leaning against a wall to flex the spine (hence the term ‘spinal claudication’). The patient may prefer walking uphill, which flexes the spine (and maximizes the spinal canal capacity), to downhill, which extends it. Imaging X-rays will usually show features of disc degeneration and proliferative osteoarthritis or degenerative spondylolisthesis. Measurement of the spinal canal can be carried out on plain films, but more reliable information is obtained from myelography, CT and MRI. The MRI and CT is the reliable and safe imaging nowadays. Treatment: Conservative measures, including instruction in spinal posture, reduce weight may suffice. Most patients are prepared to put up with their symptoms and simply avoid uncomfortable postures. If discomfort is marked and activities such as standing and walking are severely restricted, operative decompression is almost always successful (laminactomy). Spondylosis Spondylosis is osteoarthritis of spine, it is very common. It result from degenerative changes, previous injuries and spinal diseases. There is scleroses of facet joints, reduction of joint space and osteophytes formation which might compress the spinal canal and nerve roots. Spondylosis may cause chronic backache after activities or early morning, spinal stenosis or radiculopathy. X-ray shows osteoarthritis changes in posterior facets joints and reduction in intervertebral disc space. The treatment depend on the severity of the symptoms and disability, in the mild cases treatment is unnecessary, analgesia, belt and physiotherapy may be used in moderate symptoms, rarely surgery used in treatment of severe cases. Coccydynia Coccydynia is chronic painful condition in the region of the coccyx, the pain persist for many weeks or months , after local injury. There is local tenderness, other causes of pain in this region should be excluded. It is self limiting condition, analgesia and local steroid injection may used .