Case 15 Spndylolisthesis


Case 15
                                                Spndylolisthesis
Age –Young                           What happened ?                    Any history of trauma ?
                                               
Symptoms –                            Gait disturbances , Numbness in lower extremities , Cauda Equina , Muscle weaknesses


Introduction ownself
Exposure – whole body
Hand scrubbing
Look- Standing Patient

Comment on Lumbar Corset
Attitude of the body
Look
Alignment       -           Front        Both shoulders and Pelvis are leveled,
                                                     No wasting of Quadriceps muscles
                                                      Patella facing forward and at equal height
Leg, foot and toes look normal with normal        
overlying skin
                                    Side           Elbows straight overlying greater trochanter
                                                       Transverse Loin Creases
     Knee Straight
      Foot Arches maintained  
                                    Back               
Short Kyphosis present at LS junction
Lumbar spine scoliosis due to paraspinal muscle spasm / Lumbar spine flattened / lumbar spine too short
Prominent Buttocks
 Stepping at L5 –S1 + ,
 Normal overlying skin on back with no dimpling , tuft of hair
  and swelling
  Calf symmetrical with normal overlying skin
  Heel has – Normal varus
 Feel
Temperature – Normal
Superficial Palpation – Paraspinal Muscle spasm +
Bony Palpation – Stepping L 5 – S 1
Tenderness at 5th Lumbar Spine
Movement – Global Reduction in movement

Gait                                         Normal / Foot Drop Gait , Disturbance +
Tip toe , heel walking ,

Squating                                  heel at the same level

Standing –      Special tests -Trendelenburg test

Lie down Patient
SLR – decrease to < 60 degrees bilaterally not true nerve root sign                                                
Movement                               Hip / Knee / Ankle / Toes                   
LLD
                                   
Neurovascular Assessment

Sensory Examination             L 2 – S 5   
Motor Examination  -               Global muscle weakness
Power of the Muscles –                      
                                    Supine             Quadriceps ,
TA / EHL /EDC / TP / Peronei
                                                Lateral             Abductor /Adductor
Prone               Gastrosoleus / FHL/FDC /Hamstring/Gluteal Maixums /Medius/Minimus


Reflexes

Vascular Examination – DPA / PTA on supine position












Investigations
Radiographs
CT Scan
MRI


Discussion
Types – Wiltse, Newman and Mc Nab
1)Congenital – Dysplasia S1 Superior Facet
                      a)Lytic – Fatigue Fractura Pars articularis
                      b)Elongated But intact      Pars articularis
                      c)Acute Fracture
2)Degenerative – Facet Arthrosis leading to Subluxation of L 4 – 5
3)Traumatic – patient don’t survive usually
4)Pathological – degenerative or localized bone disease
5)Post Surgical

Myerding Classification
Based on quartiles
Radiographs –
Slip angle is Measured
Scottie dog appearance can be observed .
Risk factors for progression
Young age
Female
Presence of Spina Bifida
Wedging of Vertebral Body
Round anterior dome of Sacrum
Hyperlordosis



Comments

Post a Comment

Popular posts from this blog

Outline of Treatment of Spinal Tuberculosis

Image
 Tuberculosis     In general , Rest and Nutrition                                 Chemotherapy                                Surgery if needed .                                    Dorsal Spine - Approach to surgery     A bit ambiguous      Many prefer to do Anterior Transpleural. Some choose Anterolateral/posterolateral extrapleural                and posterolateral approaches      Posterolateral Approach(Martin 1970)      Dura exposed by Hemilaminectomy first and then operation extended laterally to remove posterior         ends of 2 to 4 ribs, corresponding transverse process and pedicles.      He thinks  Anterolateral approach a very risky one.     Approach to Atlanto-occipital and Atlanto-axial joint         Numerous structures on the way anteriorly     Supine position, Neck on 5-10 degrees hyperextension ,Trachesostomy done     Transoral Anterior Approach           Uvula, Soft palate bissected , Hypopharynx packed, 5 cm long incision given, Flaps                                 
Read more

COXA VARA

Image
Coxa Vara Painless limp, LLD gradually worsening ,  Unilateral or bilateral in 30-50 % cases Prominent trochanters Pelvic Tilt- LLD  Trendelenburg test or delaye trendelenburg test + ve B/L waddling  High Greater trochnater - supratrochanteric shortening,  Decreased abduction, (decrease in articular trochanteric distance ) and internal rotation (due to decreased anteversion) may have out toeing r/o cervical instability causing limping  Types of Coxa Vara  https://quizlet.com/au/304405013/coxa-vara-flash-cards/ Mangement      Depends on Hilgenreiner Angle (HEA ) https://www.orthobullets.com/pediatrics/4041/developmental-coxa-vara  > 60 degrees - wait and watch    45-60 degrees - wait and watch  Goals of surgery      Neck shaft angle  (more or equal ) to 140.              degrees     Correct version      Ossification and healing of inferomedial.               fragment      Restore ATD (Articulo-trochanteric            distance    AND abductor mechanism                 (length -tension
Read more

Paediatric Supracondylar Humerus Fracture

Image
Supracondylar Fracture  Patient Presentation         Age 6-10 years         MOI - Fall on outstretched hand with elbow on extension, breaks.   Olecranon serves as the fulcrum      and the stress concentrates in distal humerus. Anteriorly the perisoteum hinges.     Pain , swelling, deformity, bruising      Deformity (usually S shaped ) , skin puckering      Compartment syndrome         Blood vessels spasm/ contusion/ tear/ thrombosis     If capillary refill present , hand arm Dunlop traction done.      No role of Angiography , further delays the treatment.      Nerve Injuries, proximal fragment spike hits nerve.             3a Posteromedial displacement - Radial Nerve involvement             3b Posterolateral displacement - Median Nerve involvement     Gartland and Wilkins Classification      Extension type fracture      1. Undisplaced Fracture      2. Displaced Fracture , posterior cortex is.                intact     3. Displaced fracture, posterior cortex breaks      Flexion type occ
Read more

Hind Foot amputation

Image
Boyd Amputation -Tibiocalcaneal arthodesis, heel pad preserved. ( https://www.semanticscholar.org/ ) ( Modifizierte Pirogoff-Amputation | SpringerLink ) Pirgoff Amputation  Amputation at ankle. part of calcanuem left in the stump , Calcaneum cut vertically.  Advantages  long lever arm , self suspension , good proprioception , end wt bearing.  Disadvantages  poor cosmesis , too long to use standard foot , no possibility of prosthetic foot fitting 
Read more

Timing and Outcome of Surgery in Hip Fractures

Hip Joint Ball and Socket joint. Hip fracture is any fracture involving Interochanteric region head, neck or acetabulum. 310,000 Hip fractures in the United State in 2003     1/3 rd - receive a hip replacement.     10.3 - 15.2 billion dollars / year Elderly – Vast Majority  Co-morbidities Femoral Neck Fracture Fracture Healing is delayed due to          - I ntracapusular neck- No Cambium layer          - Synovial fluid clears out haematoma and inhibits fracture union          - Haematoma causes pressure on head Mechanism of injury  • Directly on lateral hip • Twisting mechanism • Fatigue or insufficiency fracture, then fall • In younger - RTA /  fall from a height Risk Factors of Hip Fractures   • Osteoporosis and Falls   Lifetime risk -17.5 percent for women : 6 percent for men  • Average -   women 77 years old  :  men 72 years old • Low socioeconomic status • Cardiovascular diseas
Read more