hnp - chiang mai university objectives period 1: • ıƒµšclinical characteristic of hnp •...
TRANSCRIPT
6&(1$5,2UTHAIWAN LEKYINGYONG, M.D.
30 June - 2 July 2003
Learning objectives
Period 1:• �¦µ�clinical characteristic of HNP
• �¦µ�type of HNP
• differential diagnosis HNP
Period 2: for management HNP
• physical modality, activity, orthosis andexercise
case�µ¥Å�¥ °µ¥» 37 �eCC: �ª�Á°ª¤µ 3 Á�º°�
• �ª�Á°ª ¦oµª¨��o��µÂ¨³�n°��oµ¥Â��Á�¦È�Ç Á�}�¤µ��¹Ê�Á¦ºÉ°¥�ª�¤µ�Áª¨µ ¥º�, Á�·�Å�¨ (10) �oµª , �´É�¥°�Ç, �°�®�µ¥,Áª¨µ�{µª³�³¤¸°µ�µ¦�ª�Â���µÇ (Å°, �µ¤, Á�n�Ťn�ª�)vas=4 °µ�µ¦��¹Ê�Áª¨µ¥º�Á°¥��ªµ Ťn�µ °n°�¦��o°Á�oµ�oµ¥�{µª³, °»��µ¦³�¨´Ê�Å�o
• ��·Á�°»�´�·Á®�», æ��¦³�Î�µ�ª• °µ�¡ �Î�µ°µ®µ¦• ·��·�´�¦ �¦³��´��¤• �¸É°¥¼n °. Á¤º°� �. Á�¥�¦µ¥
Physical examination
• A thai man with good consciouness, Rt. Lateralbending positon
• not pale• Back: normal alignmentTenderness on extension and Lt. Lateral bending , taut
band at Lt. Paravertebral muscle• SLRT 80/ 70• FAIR test, sign of 4 –ve• Motor: Lt EHL, TA gr.4, others gr.5 all.• Sensory impaired LT, PPS 1st, 2nd , 3rd finger and
dorsal surface of Lt. Foot• DTR 2+ all• Trigger point at Lt. Gluteus maximus
Differential diagnosis
- HNP -MPS gluteus medius
- SCS -Piriformis syndrome
- Nerve sheath tumor - Spondylosis
- Ureteric stone, Renal calculi
- AVN ( idiopathic)
- Spondylolytic spondylolithesis
- Abcess- irritate sciatic n.
Learning objectives
• HNP ¡�. ¤µ�ª• MPS gluteus max., gluteus minimus, quadratus
lumborum, gluteus medius ¡�. ¦�·�µ• piriformis syndrome ¡�. �¦¥µ£¦�r• spondylolytic spondylolithesis ¡. ¥µ¤
Lumbar myelogram
• Herniated disc at L4-5 disc level withcompression of bilateral exiting L5 andtraversing S1 nerve roots
Definite diagnosis
• HNP L4-L5 (shoulder type)
• MPS Lt. Gluteus maximus
Learning objectives
• Classification of disc herniation
• Management of disc herniation
indications for surgery
rehabilitation management
- physical modality
- activity
- exercise
- lumbar corset/support
Contents
• Disc herniation definition: abnormal rupture or protrusion of disc- Particularly in young- middle age man- Cause usually flexion injury- often occurs to one side- Most common L5-S1, L4-5Macnab’s classification- Bulging disc: intact annulus fibrosus- Prolapsed disk: incomplete defect annulus fibrosus- Extruded disk: complete defect annulus fibrosus, intact
posterior longitudinal lig.- Sequestered disk: part of nucleus pulposus is extruded
History- Most pt. Have back pain varied lengths of time- varying combined with back, hip, leg painBack pain: localized to midline LS region, radiaton to SI, high iliac
crest, coccygeal is more indicative of dural irritationButtock: pain is usually one of deep-seated, cramping painThigh :higher lumbar root, sharp pain, anterior thighLeg: L5/S1 root-cramp & vise-like feeling in belly of gastroc/ peroneal
mus., paresthesia in lateral calf (L5) / back of calf (S1)Foot: most common symptom is parethesia than pain- Younger patient may has only leg pain- Aggravated symptom: bending, stooping, lifting, cough, straining
at stool
PE
Back: loss of lordosis, paravertebral muscle spasmsciatic scoliosis: moreobvious on bending forward, limit flexion, extend ( lesser degree than flex)
Lateral flex.increase pain (Shoulder type:when flex to same side, axillarytype:opposite side)
-scoliosis is a reflex mechanism by which the spine flexes away fromsciatic nerve entrapment side by paraspinous muscle contraction
standing with affected hip&knee slighted flexion- +ve SLRT, crossover pain (well-leg raising sign )= lift well-leg, pain crosses
over into symptomaic hip, early sign of HNP, crossed SLRT : lift symptomatic leg & pain in asymptomatic leg, indicative
of disc herniation lying median to nerve root; axillary/ midline- muscle wasting is rarely seen unless symptom> 3mo., very marked wasting
suggests extradural tumor than HNP
• Investigation
Minimal requirement for diagnosis of HNP:plain x-rays and one other diagnostic study (myelography, CT/myelography, CT, MRI
MRI: necessary to plan a surgical procedure
management
I surgery
Indication:
- failure of conservative treatment: at least 6wks- not more than 3 mo.
- Bladder & bowel involvement
- Increasing neurological deficit
II conservative treatment1. Unloading spine
• Rest until pain start to abate (approximately48 hrs)
• Corset/brace
Indications:
- patient who is recovering after bed rest and return to work quickly
- An older patient
- Postoperative support
• Modification of work and activities
2. Antiinflammatory drugs
3. Analgesics
4. Traction ( intermittent 25%BW 20-30 min)
5. Heat/cold
6. Exercise ( modified Willium exercise - back pain, Mc Kenzie exercise -leg pain)
Spondylolytic spondylolithesis
spondylolysis: anatomic defect , causes discontinuityin pars interarticularis
- May be unilateral or bilateral
- Often found in radiological studies, with noclinical significance
Spondylolithesis: forward/ backward translationsubluxation of body of superior vertebrae upon itsadjacent inferior vertebrae
- usually forward slipping of L5 vertebra on sacrum
-Wiltse et al. classified spondylolithesis• Dysplastic: congenital abnormal of upper
sacrum/arch of L5,• Isthmic: lesion of pars interarticularis• Degenerative: progressive intersegmental
instability, female>male, age >=40 yrs• Traumatic: fracture/ dislocation of facet joint,
allowing forward displacement• Pathological: loss of stability secondary to
pathological destruction
• Symptoms- major symptom- LBP (intermittent dull aching
pain)- Often radiate into sacroiliac region, also into
thighs• PE- limited ROM back- Palpable “ledge” at upper aspect of listhesis- Limited hamstring extensibility
Lumbar SCS
: narrowing of spinal canal, nerve root canals/tunnelsof intervertebral foramina
- A-P diameter < 10 mm-12 mm was consideredpathological
- Normal LS canal is narrowest in A-P diameter at3rd and 4th vertebrae
- Central canal is usually narrowing from yellowligament
- Lateral canal is usually narrowing fromosteophyte/ facet
• Symptom- back pain, sciatica, claudication, thigh and
leg pain,HNP SCS
Age 40-50 >50Duration short longLevel usually 1 level several level- pain relief by supine, squatting
Piriformis syndrome
: compression of extraspinal n., forming the sciatic n.by piriformis muscle
• Postulated etiologies of piriformis synd.• Sacroiliac disease that causes piriformis muscle
contraction• Inflammatory disease of muscle, tendon/ fascia
of piriformis• Degenerative deformities of bony component of
notch• Abnormal of neurovascular bundle as they cause
through tunnel• Direct trauma to gluteal region of sacroiliac joint
• Symtom and sign- pain/paresthesia may be present along the entire
distribution/ segment of sciatic nerve- Motor deficit may co-exist with subtle atrophy- Predominant symptom, pain at sacral and gluteal
area, increase with sitting and walking, decreasefrom supine position
- Test: FAIR position (hip flex, adduct, internalrotate)
- -treat& Dx: injection of anestheic& steroid intopiriformis bursa/ muscle (direction: via vaginallyat insertion into tender muscle/ via gluteal muscleat sacral notch (located tender spot by PR)
• Treatment
- stretching piriformis
- Pelvic tilting exercise
- NSAIDs
- Steroid injection
Myofascial pain syndrome
� *OXWHXV�PHGLXV��µÁ®�»�µ¦�ª�®¨� �OXPEDJR���n°¥�ªnµ *OXWHXV�0D[��*OXWHXV�PLQLPXV��SDLQ�DW�ORZHU�OXPEDU�DQG�LVFKLXP��UHIHU��LOLDF�FUHVW��6,�MRLQW��LVFKLXP��SRVWHURODWHUDO�RI�WKLJK��VDFUXP• Gluteus maximus
- pain at lower lumbar , aggravate by walking with forward bending ,sitting and extend back from flexion position
- refer pain to sacrum, above ischeal tuberosity, coccyx, gluteal cleft
• Gluteus minimus
- may be antalgic gait
- refer pain like sciatic n. lesion (pseudosciatica)