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spine Orthopedic

Date post: 07-May-2015
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Spine and orthopedic surgery
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Page 1: spine Orthopedic
Page 2: spine Orthopedic

Cervical spine

Consist of 7 vertebra

8 nerves

Give two plexuses

Cervical plexus ( C1-C5) brachial plexus ( C5-T1)Phernic ( C3,C4,C5) mucocutanous n (C5-C7)

Lesser occipital (C2) axillary n (C5-C6)

Supraclaviclular ( C3,C4) median n (C5-T1)

radial N (C5-T1)

ulnar n (C8-T1)

Page 3: spine Orthopedic

Cervical spine

History * acute traumaHistory of Falling down , vehicle accident .

Any patient unconious form after heard injury you should assumed it as cervical spine injury.

ABC, WAIT FOR help , x –ray frontal & lateral

Page 4: spine Orthopedic

Cervical spine

History * PAIN :- analysis of pain

Acute ,sub acute ,chronic

Onset ,duration , character , severity ,radiation ,reliving ,aggravating factor

At end of day /at night , other joint affected

*Weakness in upper limb

*Paraesthesia

Page 5: spine Orthopedic

Cervical spine

History

Pain and difficulty turning the head and neck, examples are:

→ Disease of atlanto-occipital joints produces pain radiating to the occiput.

→ Spondylosis of the middle and lower cervical spines causes pain radiating to the upper border of trapezius, interscapular region, and the arms.

→ Irritation of the C6 & C7 nerve roots can give rise to referred pain in the interscapular region, radial fingers, and thumb.

→ Irritation of C8 can cause pain on the ulnar side of forearm, ring, and little fingers.

Page 6: spine Orthopedic
Page 7: spine Orthopedic

Cervical spine

Physical examination:

Look

Observe the posture of the head and neck and note any abnormality and deformity, e.g. loss of lordosis.

Feel

→ The midline spinous processes

→ The paraspinal soft tissues

→ The supraclavicular fossae – for cervical ribs or enlarged lymph nodes

→ The anterior neck structures including the thyroid

Page 8: spine Orthopedic

Move: → Assess active movements:

o forward flexionPut your chin on your chest

o Extensionlook upwards at the ceiling as far back as you can

o Lateral flexionPut your ear onto your shoulder

o Lateral rotationLook over your right/left shoulder

Page 9: spine Orthopedic

→occiput to wall test → Gently perform passive movements if there are

reduced active movements and see if the end of the range has a sudden or gradual resistance and whether it is pain or stiffness that restricts movements

Page 10: spine Orthopedic

Cervical spinePhysical examination – Cont. ( Neuro exam):

MovementC5- shoulder abductionC6 – elbow flexion wrist extension

C7- wrist flexionREFLEXES:-Deltoid (C5)BICEPS (C6)TRICEPS (C7)

Sensory C2,C3 neck shoulderC3,C4 shoulder posteriorARM Medially T1Laterally C5 ,C6FOR ARMT1 MEDIALLY C6 laterallyHANDLateral C6Middle finger C7MEDIALLY C8

Page 11: spine Orthopedic

Thoracic spine( T1-T12)

History

→ Commonly, localized spinal pain, examples are: Ankylosing spondylitis produces pain in the thoracolumbar region Acute thoracic spinal pain may be due to vertebral prolapse due to

malignancy, or infection; especially if there was systemic upset or fever is present

→ Less commonly, symptoms of paraparesis including sensory loss, leg weakness, and loss of bladder or bowel control

Page 12: spine Orthopedic

Thoracic spine

Physical examination:

Look With the patient standing, inspect posture from behind, the side and the

front, noting any deformity, e.g. rib hump or abnormal curvature. Feel → The midline spinous processes → The paraspinal soft tissues → If there is increased prominence of one or more spinous processes

implying anterior wedge-shaped collapse of the vertebral body – often related to osteoporosis.

Move Ask the patient to sit with arms crossed, and to twist round and look at you.

Page 13: spine Orthopedic

Lumbar spineLUMBAR NERVES( L1-L5)

SACRAL NERVES ( S1-S4)

LUMBAR PELUXES ( L1-L4)

illioingunal (L1) , iliohypogastric (L1) , genitofemoral (L1-L2), Femoral (L2-L4)

Obuturator (L2-L4)

SACRA L PELUXES

SCIATIC NERVE (L4 –S3)

1- Common peroneal

2- Tibia

Page 14: spine Orthopedic

Lumbar spineSCITICA :- PAIN extend from buttock , poster-lateral of leg , lateral aspect of foot

Common risk factor :-

1-Herniated disc

2- pregnancy

3-osteoarthritis

4- wrong IM INJECTION

Page 15: spine Orthopedic

Lumbar spine

History

→ Low back pain is an extremely common complaint

→ Sacroilitis produces pain that is referred down both legs to knees

→ Consider abdominal and retroperitoneal pathology, e.g. abdominal aortic aneurysm, pancreatitis, peptic ulcer, renal pathologies.

Page 16: spine Orthopedic

Lumbar spine

Red flag features for acute low back pain:

→ In History: Age < 20 yrs or > 55 years Recent significant trauma (fracture) Pain:

Thoracic (dissecting aneurysm) Non-mechanical (infection/ tumor/pathological fracture) Fever ( infection) Difficult micturition Fecal incontinence Motor weakness Saddle anesthesia Sexual dysfunction Gait change ( cauda equina syndrome) Bilateral sciatica

Page 17: spine Orthopedic

Lumbar spine

Red flag features for acute low back pain:

→ In Past medical History: Cancer ( metastasis.)Previous steroid use (osteoporotic collapse)

→ In Systemic review:

Weight loss/malaise without obvious cause (e.g. cancer)

Page 18: spine Orthopedic

Lumbar spine

Physical examination:

Look

Examine the patient standing. Look for obvious abnormality such as decreased/increased lordosis, obvious scoliosis soft tissue abnormalities such as a hairy patch or lipoma that overlie spina bifida.

Feel

Palpate the spinous processes and the paraspinal tissues. The L4/L5 interspinous space is palpable at the level of iliac crests.

Page 19: spine Orthopedic

Move → Flexion: ask the patient to

try to touch his toes with his legs straight

→ Extension: ask the patient to straighten up and lean back as far as possible

→ Lateral flexion: ask the patient to reach down to each side touching the outside of the leg as far down as possible while keeping the legs straight

Page 20: spine Orthopedic

LUMBER SPINEPhysical examination – Cont. ( Neuro exam):

MovementL2- hip flexionL3 – Knee extention L4-dorsiflexion S1-planterflexion

REFLEXES:-Quadriceps (L3-L4)Achilles (l5-s1)

Sensory

Page 21: spine Orthopedic

Lumbar spinePhysical examination-Cont.:

Special tests: Schober’s test for forward flexion Root compression tests:

Straight leg raise Tibial nerve stretch test Femoral nerve stretch test Flip test

Sacroiliac joints test

Page 22: spine Orthopedic

Lumbar spine

Schober’s test for forward flexion1- Erect position. 2- Select 2 bony points,10cm apart and mark it.3-Maximum flexion on lumbar with fix knee.4-the two points should separate by at least a further

5cm.

Page 23: spine Orthopedic

Schober’s test

Page 24: spine Orthopedic

Straight –Leg raising test

-knee straight,slowly lifted the leg.

-note for any tightness and pain in the buttock (around 80-90 )

-passive dorsiflexion,increase the pain.

-bow-string sign : bending the knee slightly,release the pain.then apply firm pressure behind lateral hamstring,pain will recur.

-

Page 25: spine Orthopedic

• Hematological : erythrocyte sedimentation rate, complete blood count

• Biochemical : C-Reactive protein , Ca level , ALP• Serological : RF , ANA• X- ray• CT scan• MRI• Isotope bone scan• Ultrasound


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