外傷科主治醫(yī)師要領(lǐng)

外傷科主治醫(yī)師要領(lǐng)第一頁，編輯于星期六：十五點五十八分。第1頁，共28頁。LowbackpainandradiculopathyImagingstudiesandfurthertestingnothelpfulthefirst4weeksReliefofdiscomfortwithmedsandspinalmanipulationBedrestbeyond4daysmaybemoreharmful89-90%lowbackpainimprovewithin1month第二頁，編輯于星期六：十五點五十八分。第2頁，共28頁。

80%sciaticaeventuallyrecover1%havenerve-rootsymptoms1-3%havelumberdischerniation85%nospecificdiagnosismade第三頁，編輯于星期六：十五點五十八分。第3頁，共28頁。definitions/classificationsRadiculopathy:dysfunctionofnerveroot(pain,sensorydisturbances,weakness)Mechanicallowbackpain:strainofparaspinalmuscles,ligament,irritationoffacetjoints第四頁，編輯于星期六：十五點五十八分。第4頁，共28頁。InitialassessmentofpatientHistory:age,weightloss,cancerorinfection,usedofdrug,duringofS/S,trauma,caudaequinasyndrome,workstatusPE:fever,vertebraltenderness,limitedrangeofspinalcordDorsiflexationofankleandbigtoe–L5,4Achillesreflex–S1LighttouchSLRtext第五頁，編輯于星期六：十五點五十八分。第5頁，共28頁。FurtherevaluationofpatientsEMG:neuropathy,myopathy,myelopathy,unreliable<3-4weeksSEPs(somatosensoryevokedpotential):spinalstenosis,orspinalmyelopathyNCVs(nerveconductionvelocity):entrapmentneuropathiesthatmimicradiculopathy第六頁，編輯于星期六：十五點五十八分。第6頁，共28頁。LSX-rayrecommendationage>70yrs,or<20yrssystemicallyillpatientstemp.38°CHistoryofmaligancyRecentinfectionCaudaequinasyndromeHeavyalcoholordrugabusersDM第七頁，編輯于星期六：十五點五十八分。第7頁，共28頁。Immunosupressedpatients(steroid)RecenttraumaRecenturinarytractorspinalsurgeryUnrelentingpainatrestPersistentpainmorethan4weeksUnexplainedweightloss第八頁，編輯于星期六：十五點五十八分。第8頁，共28頁。TreatmentConservativetreatment:1.activitymodification:Bedrest:nomorethan4daysActivitymodification:heavylifting,totalbodyvibration,asymmetricpostures,sustainedforlongperiodsExercise:walking,bicycling,orswimming第九頁，編輯于星期六：十五點五十八分。第9頁，共28頁。2.analgesics:PanadolandNSAIDsOpioids3.musclerelaxants:cation:conditionwillsubside5.spinalmanipulationtherapy:acutelowbackpainwithoutradiculopathyin1stmonth,notusedinsevereorprogressiveneurologicdeficit第十頁，編輯于星期六：十五點五十八分。第10頁，共28頁。Epiduralinjection:nochangeintheneedforsurgery,short-termreliefofradicularpainwhencontrolonoralmedicationsisinadequateornotsurgicalcandidates.第十一頁，編輯于星期六：十五點五十八分。第11頁，共28頁。CaudaequinasyndromeMidline,mostcommonatL4-51.sphincterretension:A.urinaryretensionB.UrinaryandfecalincontinenceC.Analsphinctertone2.saddleanesthesia3.significantmotorweakness4.Lowbackpainandsciatica5.Bilateralabsenceofachillesreflex6.Sexualdysfunction第十二頁，編輯于星期六：十五點五十八分。第12頁，共28頁。SurgicaltreatmentPatientswith<4-8weeksA:urgenttreatment(e.g.caudaequinasyndrome,progressiveneurologicdeficit)B:inabilitytocontrolpainwithmedicinePatientwith>4-8weeksSevereanddisablingandnotimprovementwithtime,correlatedwithfindingsonPHandPE.第十三頁，編輯于星期六：十五點五十八分。第13頁，共28頁。TypeofsurgeryLumbarspinalfusion:fracture/dislocationorinstabilityresultingfromtumororinfectionInstrumentationasanadjuncttofusion:increasingthefusionratePediclescrew-rodfixation:utilizefollowinglaminectomy,shorterlengthoffixationsegment,rigidfixationofall3columns第十四頁，編輯于星期六：十五點五十八分。第14頁，共28頁。Posteriorlumberinterbodyfusion:bilaterallaminectomyandaggressivediscetomyfollowedbybonegrafts第十五頁，編輯于星期六：十五點五十八分。第15頁，共28頁。IntervertebraldischerniationLumbardischerniationPosteriorly,oneside,compressinganerveroot,severeradicularpainCharacteristicsfindings:Symptomsstartwithbackpain,daysafterweeksyeildsradicularpainwithreductionofbackpainPainreliefuponflexingthekneeandthighPositionchange第十六頁，編輯于星期六：十五點五十八分。第16頁，共28頁。Bladdersymptoms:difficultyvoiding,straining,orurineretentionExacerbationwithcoughing,sneezing,strainingatthestoolRadiculopathy:A.painradiatingdownLEB.motorweaknessC.dermatomalsensorychangesD.reflexchanges第十七頁，編輯于星期六：十五點五十八分。第17頁，共28頁。Straightlegraisingtest:<60,L5andS1第十八頁，編輯于星期六：十五點五十八分。第18頁，共28頁。Spondylosis:no-specificdegenerativeprocessofthespineSpondylolisthesis:anteriorsubluxationofonevertebralbodyonanotherGrade1-4Spondylolysis:alternativetermforisthmicspondylolisthesis第十九頁，編輯于星期六：十五點五十八分。第19頁，共28頁。SpinalstenosisNarrowingoftheAPdimensionofspinalcanalInthelumbarregion:neurogenicclaudicationInthecervicalregion:myelopathyandataxiaInthespinalregion:rare第二十頁，編輯于星期六：十五點五十八分。第20頁，共28頁。SpinaltraumaUncommoninchildrenThefatalityrateishigherwithpediatricspinalinjuriesthanwithadults(oppositetothesituationwithheadinjury)第二十一頁，編輯于星期六：十五點五十八分。第21頁，共28頁。Completelesion:nopreservationofanymotororsensoryfunctionmorethan3segmentsbelowtheleveloftheinjuryPersistenceofcompletespinalcordinjurybeyond24hours:nodistalfunctionwillrecover第二十二頁，編輯于星期六：十五點五十八分。第22頁，共28頁。Incompletelesion:Anyresidualmotororsensoryfunctionmorethan3segmentsbelowtheleveloftheinjury.Signsofincompletelesion:SensationorvoluntarymovementintheLegsSacralsparingCentralcordsyndromeBown-SequardsyndromeAnteriorandposteriorcordsyndrome第二十三頁，編輯于星期六：十五點五十八分。第23頁，共28頁。SpinalshockA.interruptionofsympathetics1.Lossofvasculartone2.LeavesparasympatheticscausingbradycardiaB.LossofmuscletoneresultvenouspoolingC.Truehypovolemia第二十四頁，編輯于星期六：十五點五十八分。第24頁，共28頁。InitialmanagementofspinalcordinjuryCauseofdeath:aspirationand