5.4.2016 Ortopedická klinika FN Brno-Bohunice LPB - Low Back Pain Martin Repko, Richard Chaloupka 5.4.2016 Definition: It is tireness, dyscomfort or pain in lower part of back with or without irradiation to one or both lower extremities.  Acute 24 hours - 3 month  Chronical over 3 months  Ortopedická klinika FN Brno-Bohunice 5.4.2016 Anatomy Ortopedická klinika FN Brno-Bohunice 5.4.2016 Pathogenesis 1. Primary functional secondary structural 2. Primary structural Ortopedická klinika FN Brno-Bohunice 5.4.2016 Pathogenesis  vertebrogenic  discogenic  neurogenic  vasogenic  myogenic  viscerogenic  psychogenic Ortopedická klinika FN Brno-Bohunice 5.4.2016 Pathogenesis  degeneration  inflammation  tumours  fractures  Congenital deformities  Metabolic diseases Ortopedická klinika FN Brno-Bohunice 5.4.2016 Inflammations  specific -tbc spondylitis  non-specific -spondylogenic osteomyelitis  reumatic -M.Bechtereev, reumatoid arthritis Ortopedická klinika FN Brno-Bohunice 5.4.2016 Tbc spondylitis  Spondylitis ant. -profunda -superficialis  Spondylitis posterior Ortopedická klinika FN Brno-Bohunice 5.4.2016 X-ray stages of tbc spondylitis  inicial porosis and decreasing of iv spaces  florid destruction and vertebral sekvestration  reparative sklerotisation and loosening of iv spaces  definitive synostosis Ortopedická klinika FN Brno-Bohunice 5.4.2016 5.4.2016 5.4.2016 5.4.2016 5.4.2016 Complications of tbc spondylitis  absces  kyphosis  paraplegia Therapy of tbc spondylitis - antituberculotics (9-12 month) - external fixation (brace, orthosis) - surgical therapy Ortopedická klinika FN Brno-Bohunice 5.4.2016 Diff.dg. of tbc spondylitis  spondylogenic osteomyelitis  typhoid and paratyphoid spondylitis  Bang´s spondylitis  M.Bechtereev  systematic bone illnesses  spondylitis brucellosis  M.Paget  posttraumatic spinal deformities  tumours and metastases  spinal gumma Ortopedická klinika FN Brno-Bohunice 5.4.2016 Differential diagnosis Tbc spondylitis  Slow progression  No pain in quiet position  Extensive osteoporosis  extensive destruction  Big paravertebral absces  No osteoplastic reaction Osteomyelitis  Heavy and rapid progression  Pain in quiet position  Border osteoprosis only  Minimal destruction  Minimal absces  Heavy osteoplastic reaction Ortopedická klinika FN Brno-Bohunice 5.4.2016 Spinal osteomyelitis Clinical signs:  rapid start  fever  neurological signs Evaluation:  laboratory (leucocytes, ESR, CRP)  cultivation  X-ray, bone scan, CT, MRI Ortopedická klinika FN Brno-Bohunice 5.4.2016 osteomyelitis L4/5 5.4.2016 5.4.2016 Therapy of spondylogenic osteomyelitis  atb – double or multiple combination (initially intravenous aplic.) (long-term-several months)  Bed rest  External fixation (brace)  Biopsy: -craig needle disc. aspiration -open (CT econtroled)  Surgical treatment Ortopedická klinika FN Brno-Bohunice 5.4.2016 Mb. Bechtereev 5.4.2016 Spinal tumours  primary - spinal: - extradural - intradural - vertebral: - benign (osteoid osteoma, hemangiom) - malignant (myeloma)  metastatic - osteoblastic (prostatic) - osteolytic (lungs, breast, Grawitz, thyroid) Ortopedická klinika FN Brno-Bohunice 5.4.2016 Spinal tumours -evaluation methods  Imaging methods -X-ray -CT, MRI -bone scan -(Contrast-PMG)  Laboratory -ESR, CRP, BP -PSA, Bence-Jones, ALP Ortopedická klinika FN Brno-Bohunice 5.4.2016 5.4.2016 5.4.2016 Metastasis of teratoma testis 5.4.2016 Metastasis of ca cervicis uteri 5.4.2016 Therapy of spinal tumours  Paliative -surgical decompression -chemo- and radiotherapy  Causal -surgical resection and stabilisation -sanation of primary tumours in metastasis Ortopedická klinika FN Brno-Bohunice 5.4.2016 Congenital diseases  lumbalisation of S1  sacralisation of L5  Bertolotti´s syndroma Ortopedická klinika FN Brno-Bohunice 5.4.2016 Spondylolisthesis  spondylolysis = interruption of arcus in pars interarticularis  spondylolisthesis = bilateral spondylolysis and vertebral body slipping  spondyloptosis = slip over 100%  pseudoolisthesis = dislocation of whole vertebral body without spondylolysis Ortopedická klinika FN Brno-Bohunice 5.4.2016 Spondyloptosis Spondylolysis Spondylolisthesis 5.4.2016 5.4.2016 Spondylolisthesis classification 1. Etiological (Wiltse+Newman+MacNab) – dysplastic – istmic – degenerative – traumatic – patological 2. According to X-ray measurement (Meyerding) •I.gr. Slip to 25% •II.gr. Slip 25 - 50% •III.gr. Slip 50 - 75% •IV.gr. Slip 75 - 100%Ortopedická klinika FN Brno-Bohunice 5.4.2016 X-ray evaluation  Slip -percentage of slip grades according to Meyerding: 1. 0-25% 2. 25-50% 3. 50-75% 4. 75-100% 5. more than 100% = spondyloptosis  Slip angle Ortopedická klinika FN Brno-Bohunice 5.4.2016 5.4.2016 Evaluation of spondylolisthesis  clinical + neurological  imaging 1.X-ray (AP, lateral, oblique, bending) 2.bone scan 3.SPECT 4.CT (native, revers, contrast) 5.MRI 6.(Contrast – PMG) Ortopedická klinika FN Brno-Bohunice 5.4.2016 Conservative treatment Indication: - low pain - low slip - no neurological signs  Short bed rest  Brace  physiotherapy  NSAID Ortopedická klinika FN Brno-Bohunice 5.4.2016 Indications for surgical therapy 1. severe slip 2. Progressive slip 3. Serious pain 4. Neurological signs Ortopedická klinika FN Brno-Bohunice 5.4.2016 Traumatology of lumbar spine  Mostly in TL junction Ortopedická klinika FN Brno-Bohunice 5.4.2016 Osteoporosis  typ I -postmenopausal  typ II - senile Most common causes: -long-term immobilisation -diets + abusus -medicaments (glukocorticoids) Ortopedická klinika FN Brno-Bohunice 5.4.2016 5.4.2016 Fr. L1 burst (A type) v.s. osteoporosis 5.4.2016 Degenerative spinal diseases  Acute lumbago -hernia of discus -blocage of intervertebral joint  Chronical lumbalgia -paravertebral spasmus -irritation of proprioreceptors  Lumboischialgia -compression of n. ischiadicus roots Ortopedická klinika FN Brno-Bohunice 5.4.2016 Degenerative spinal diseases  discus chondrosis  =osteochondrosis  spondylosis  spondylarthrosis  discus hernia  spinal instability Ortopedická klinika FN Brno-Bohunice 5.4.2016 5.4.2016 5.4.2016 dis 5.4.2016 Spinal stenosis  Primary (congenital)  Secondary • lateral (root compression) -CT+MRI • central (canal compression) -CT+C-PMG Ortopedická klinika FN Brno-Bohunice 5.4.2016 5.4.2016 degenerative scoliosis 5.4.2016 5.4.2016 Degenerative spine evaluation  anamnesis  Clinical examination  imaging metods (X-ray, bending films, CPMG, CT, MRI, bone scan, discography) Ortopedická klinika FN Brno-Bohunice 5.4.2016 Conservative treatment  Short bed rest  Medicaments -peroral -infusions -local  Physiotherapy  Back school Ortopedická klinika FN Brno-Bohunice 5.4.2016 Treatment algoritmus static physiotherapy X-ray 4 weeks later PAIN neurological signs Hospital evaluation Conservative treatment Surgical therapy Next therapy Healing in specialists examination physiotherapy healing in failed back Healing in