外傷科主治醫(yī)師要領

1、Spinal and spinal cord外傷科主治醫(yī)師 Hsinglin第一頁，共二十八頁。Low back pain and radiculopathyImaging studies and further testing not helpful the first 4 weeks Relief of discomfort with meds and spinal manipulationBed rest beyond 4 days may be more harmful 89-90% low back pain improve within 1 month 第二頁，共二十八頁。 80%

2、 sciatica eventually recover1% have nerve-root symptoms1-3% have lumber disc herniation85% no specific diagnosis made第三頁，共二十八頁。definitions/classificationsRadiculopathy : dysfunction of nerve root ( pain, sensory disturbances, weakness) Mechanical low back pain : strain of paraspinal muscles, ligamen

3、t, irritation of facet joints第四頁，共二十八頁。Initial assessment of patientHistory : age, weight loss, cancer or infection, used of drug, during of S/S, trauma, cauda equina syndrome, work statusPE : fever, vertebral tenderness, limited range of spinal cord Dorsiflexation of ankle and big toe L5, 4 Achille

4、s reflex S1 Light touch SLR text第五頁，共二十八頁。Further evaluation of patients EMG : neuropathy, myopathy, myelopathy, unreliable 70yrs, or 20 yrssystemically ill patientstemp. 38CHistory of maligancyRecent infectionCauda equina syndrome Heavy alcohol or drug abusersDM第七頁，共二十八頁。Immunosupressed patients (s

5、teroid)Recent traumaRecent urinary tract or spinal surgeryUnrelenting pain at restPersistent pain more than 4 weeksUnexplained weight loss第八頁，共二十八頁。TreatmentConservative treatment : 1.activity modification:Bed rest : no more than 4 daysActivity modification : heavy lifting, total body vibration, asy

6、mmetric postures, sustained for long periodsExercise : walking, bicycling, or swimming第九頁，共二十八頁。2.analgesics : Panadol and NSAIDs Opioids3.muscle relaxants : no cation: condition will subside5.spinal manipulation therapy: acute low back pain without radiculopathy in 1st month, not used in

7、 severe or progressive neurologic deficit第十頁，共二十八頁。Epidural injection: no change in the need for surgery, short-term relief of radicular pain when control on oral medications is inadequate or not surgical candidates.第十一頁，共二十八頁。Cauda equina syndromeMidline, most common at L4-51.sphincter retension :

8、A. urinary retensionB. Urinary and fecal incontinenceC. Anal sphincter tone2.saddle anesthesia 3.significant motor weakness4.Low back pain and sciatica5.Bilateral absence of achilles reflex 6.Sexual dysfunction第十二頁，共二十八頁。Surgical treatmentPatients with 4-8 weeksSevere and disabling and not improveme

9、nt with time, correlated with findings on PH and PE.第十三頁，共二十八頁。Type of surgeryLumbar spinal fusion : fracture/dislocation or instability resulting from tumor or infectionInstrumentation as an adjunct to fusion : increasing the fusion ratePedicle screw-rod fixation : utilize following laminectomy, sh

10、orter length of fixation segment, rigid fixation of all 3 columns 第十四頁，共二十八頁。Posterior lumber interbody fusion : bilateral laminectomy and aggressive discetomy followed by bone grafts 第十五頁，共二十八頁。Intervertebral disc herniationLumbar disc herniationPosteriorly, one side, compressing a nerve root, seve

11、re radicular painCharacteristics findings : Symptoms start with back pain, days after weeks yeilds radicular pain with reduction of back painPain relief upon flexing the knee and thighPosition change第十六頁，共二十八頁。Bladder symptoms : difficulty voiding, straining, or urine retentionExacerbation with coug

12、hing, sneezing, straining at the stoolRadiculopathy : A.pain radiating down LEB.motor weaknessC.dermatomal sensory changesD.reflex changes第十七頁，共二十八頁。Straight leg raising test : 90mmhgDopamine, careful hydration, atropine for bradycardia associated with hypotensionOxygenationNG tube decompressionIndwelling foleyTemperature regulation第二十六頁，共二十八頁。Electrolytes Medical management specific to spinal cord injury : methylprednisolone : given with