HSS dx and surgery for spine

90

herniated lumbar disc

herniate disc or muscle strain

• OA
• spinal stenosis
• spndylolisthesis (slipping of one vert body on the next)

• 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

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

extension - so walking up hill is painful, leaning over a shopping cart gives relief

• fracture of pars interarticularis, can lead to spondylolisthesis
• seen in growth spurts and pts > 40 y/o

• failed conservative treatment
• intractable pain
• worsening neuro signs
• 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

• w/o or w little -- less successful
• w -- more likely surgery will be useful

• discectomy
• laminectomy / otomy
• foraminectomy / otomy

laminectomy, because pt is prone for so long

• elim motion from single to multiple unstable spinal segments
• ALIF, PLIF, XLIF

maintain motion of the vertebral segment, resurrect collapsed vertebral bodies 

• total disc replacement 
• kypoplasty

• microdiscectomy or discectomy -- HNP, relieve pressure on nerve root
• others (the bone-cutting ones) -- releive pressure, esp from stenosis

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

• to stabilize spine
• maintain lordosis in a pt who's losing it
• release and correct scoliosis`

• 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

instability caused byspondylolisthesis, DDD, or stenosis

• 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

• 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

• 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

vertebral compression fracture (VCF) - due to collapse of vert body, decreased bone density, or tumors in vert bodies

• pts w young/healthy bones
• VCF 2/2 accident/trauma
• spine curvature not due to OP

DDD

• ant approach
• full discectomy
• wedges are cut in sup and inf vert bodies
• disc space is filled w endplates and a spreader

total disc replacement

up to 6 months

• up to 12 months
• 2 or more yrs

up to 40% non-union

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

employment etc

• distress
• hypervigilance
• catastrophising
• fear avoidance beliefs
• low self efficacy

signs it's pathological / cancer

• specific
• measurable
• achievable
• realistic
• timely

• Oswestry Disability Index
• Neck Disability Index
• Roland Morris Disability Questionnaire
• Patients Specific Functional Scale
• Fear Avoidance Behavioral Questionnaire (work and physical activity)

• 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

• I: transfers/gait training, activity modification, equipment, modalities prn
• III: flexibility, progress stability, manual nerve glides (consider irritability)

• II: initial stab therex, submax CV training, stairs/transfers, manual - STM/MFR
• IV: advanced stabilization, functional/sports specific training

• 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

• 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

• 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

• QUADRUPED OR SUPPORTED STANDING (DO SHOULDER FLEXION, HORIZ ABD, EXT)
• SEATED OR STANDING
• PRONE (ADVANCED)
• whoops!

• 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

• static postural cues: lumbo-pelvic proprioception
• dynamic postural cues: quadurped rocking, hip hinge, LP disassociation

• soft tissue mobs
• LE mobs
• thoric mobs

and MD communication