LUMBAR DISC PAIN

DIAGNOSTIC TEST
 Straight leg raising test
The straight leg raising test is very important for diagnosis. The method
is let the patient lie supine ,lift the extending leg slowly until the pain
occur again.
 Crossed straight leg raising test
 Cauda Equina Syndrome:
In some cases, the disc prolapsed midline and compress the cauda
equina severly, the patient may complain intense pain, severe muscle
weakness or paralysis, even urinary retention. The decompression
operation is needed to be done as soon as possible.
 Lumbar Spinal Stenosis:
extension pain
LUMBAR STENOSIS:
 Present independently
 Intermittent Claudication,
 low back pain when extend lumbar spine

DIFFERENTIAL DIAGNOSIS
 Tumor
1.Extradural:metastatic(from breast ,prostate),multiple myeloma
2.Intradural: neurofibromas ,meningiomas,ependymomas et al.
 Infection
Discitis,osteomyelitis,tuberculosis

TREATMENT
1. Conservative Management
2. Operation
 indication: the severe pain affect the patient’s life and conservative
management at least half a year fail ,the neural symptoms progress fast
 method: laminectomy and disc remove, PLIF.
 complications
FACET SYNDROME
disc degeneration → abnormal motion→ abnormal burden →arthritis →pain
CLINICAL FINDINGS:
Low back pain
Muscle stiffness
Locking during stoop or straighten back after bending
Pain may radiate to buttock and posterior leg

CAUDA EQUINA SYNDROME:in some cases the disc prolapsed midline and
compress the cauda quina severly,the patient may complain intense
pain,severe muscle weakness or paralysis ,even urinary retention.the
decompression operation needs to be done asap.
Trendelenburg’s sign
We might see the pelvis drop on the unsupported side if we ask a person to
stand briefly on the limb .when dislocation exists, the hip abductors are weak.
So the child is unable to maintain a level pelvis in unilateral stance ,which is
called a positive Trendelenburg sign.
CLUBFOOT
 Most common congenital deformity.
 Talipes Equinovarus is another name, or Talipes
 Babies who are born with clubfoot have one foot or both feet pointing
down and in. Their toes point toward the opposite leg, and the bottom
of their feet face inward. In some cases, it looks like the baby’s foot is
upside down.
FLATFOOT is often a complex disorder, with diverse symptoms and varying
degrees of deformity and disability. There are several types of flatfoot, all of
which have one characteristic in common—partial or total collapse (loss) of the
arch.
SCOLIOSIS occurs relatively frequently in the general population, the causes is
classified as followed: congenital, idiopathic, neuromuscular.
Idiopathic scoliosis is most common.
The Adams forward bend test demonstrates the rotational component of
scoliosis. It is performed by observing the patient from the back while he or she
bends forward at the waist until the spine becomes parallel to the horizontal
plane.
Cobb method used to measure scoliosis spine curvature
“No - man ’ s - land ” is the zone from the middle of the palm to just beyond
the PIP joint , where in the superficialis and profundus lie ensheathed together
and where recovery of glide is so difficult after wounding.
“ Mallet ” finger (“ baseball ” or “ drop ” finger )
due to division or attenuation often extensor to the distal phalanx . A distal
joint that can be passively but not actively extended is diagnostic .
The injury most commonly results from sudden forceful flexion of the digit
when it is held in rigid extension . Either the extensor is partially or completely
ruptured or the dorsal lip of the bone is avulsed . Less frequently , the injury is
due to direct trauma such as a laceration or a crush force .
Tendon rupture , subluxation , and drift .
The most frequent rupture of a healthy tendon is that of the distal joint
extensor of one of the fingers as a result of sudden forceful flexion ( see mallet
finger , above ), or avulsion of the profundus from the distal phalanx in violent
flexion .
The most common subluxations and drifts of ten - dons are twofold :
1.volar drift of the intrinsic tendons as they pass the PIP joint of the fingers ,
causing the “ buttonhole ” deformity ( see above );
2.ulnar drift of the extrinsic middle extensors ( central slips ) as they pass the
MP joints . The latter may result from trauma that divides or attenuates the
lateral expansion ( sagittal band ) or the extensor hood on the radial side of the
central slip .

The proximal digital pulleys in the distal palm , causing trigger finger or
thumb ( stenosing flexor tenosynovitis ). There is local tenderness of the
pulley ; pain , which may be referred to the PT joint ; and locking of the digit in
flexion with a painful jog as it goes into extension.

The pulley over the radial styloid housing the abductor pollicis longus and
extensor pollicis, causing De Quervain ’ s tenosynovitis .
Fractures of the metacarpal and phalangeal bones Such as distal phalanx
tuft of the fingers caught in closing doors and metacarpal shaft fractures of the
ulnar side of the hand ( boxer ’ s fractures ) create an obvious deformity and
are easy to diagnose .
n intraarticular fracture of the base of the thumb metacarpal bone with
subluxation ( displacement ) of the metacarpal leaving a volar pyramidal
shaped fragment attached to the trapezium is called a Bennett fracture .

Dislocations are most common in the PIP joint . Injuries are classified
according to the position of the distal digit as hyperextension , dorsal
displacement , or volar displacement .

Degenerative and Rheumatoid Arthritis

Arthritis of the hand is divided into two categories .
1. Degenerative changes are usually due to some trauma resulting in
damage to the bone or cartilage or to the supporting ligamentous
structures .
2. Rheumatoid arthritis is a systemic disease characterized by synovial
inflammation .
GOUT Gout is a metabolic disorder of uric acid metabolism that affects about
1% of the population ; approximately 50% of patients with gout have cheiragra
( gouty hands ).

Intraoperative neuromonitoring (IONM) is a method of real-time

evaluation of the functional integrity of neural structures used to prevent
potential damage. The method allows to correlate surgical interventions with
neurophysiological changes at a time when damage from surgical trauma can
be avoided or reverted.
All electrophysiological signals have 3 distinct properties:
(1) the amplitude of the response;
(2) the latency（the time of the response from the start of the stimulation）;
(3) the morphology
The IONM of neurosurgery practice uses two techniques called mapping and
monitoring.
The mapping procedure labels the neuroanatomical structure in the surgical
area.
The monitoring techniques continuously assess critical neurological pathways.
COMMON IONM MODALITIES
•Somatosensory Evorked Potentials (SSEPs)
•Motor Evorked Potentials (MEPs)
•Brainstem Auditory Evoked Potentials (BAEPs)
•Electromyography (EMG)
•Electroencephalogram (EEG)
•Bulbocavernosus Reflex (BCR)、H reflex
WARNING CRITERIA-50/10 rule:First,establishes baseline before the
surgery begins. An alarm would be set off if the waveform latency increased by
more than 10% or the amplitude decreased by less than 50% during the
surgery.
Exclude technical factors first.
Then eliminate the effects of anesthesia, body temperature, blood pressure,
etc.

stimulate Zygomatic branch → record in Orbicularis oris and chin muscles

stimulate Mandibular branch → record inFrontalis and orbicularis oculi
muscle
OSTEOCHONDROMA:
Also called bony exostosis, comprise over 45% of benign bone tumors.
Location:metaphyses of long bone, most common sites are distal femur and
proximal tibia
mainly seen in young patients, especially under 20.
ENCHONDROMA: Comprise about 10% of benign tumors.
Common sites: metacarpals, phalangeals, proximal end of humerus.
Patients’ mean age is mid thirties
GIANT CELL TUMOR: This is a benign, sometimes aggressive, bone tumor. It
comprises 5% of bone tumors.
Most common sites are around knees, the epiphsysis area of long bone, but it
may appear in any bone.
Most patients are adults，mainly focus among 20-40.
Symptoms:pain, swelling, pathological fracture.
ANEURYSMAL BONE CYST:Aneurysmal bone cyst (ABC) is an expansile
lesion with blood-filled cystic cavities
ABCs usually occur in long tubular bones (tibia or humerus most commonly)
and the spine (the posterior elements of the vertebrae)
The tumor is a blood-filled cavity with a soft membrane lining the bony
margins, and locally destructive but never metastasize.

UNICAMERAL BONE CYST:Unicameral bone cysts are common lesions of

childhood .
Eighty-five percent occur in the first 2 decades with a 2 : 1 male predominance.

Localization are most common in the proximal humerus and femur.

The lesions are most active during skeletal growth and usually heal
spontaneously at maturity. Unicameral bone cysts often are asymptomatic,
unless a pathological fracture has occurred.
EOSINOPHILIC GRANULOMA:A relatively rare disease, peak incidence is
between 7 and 8 years of age.
Skull is common sites, but may occur in any bone.
Often localized in shaft of long bone and flat bone.
Often self-limited
CHONDROBLASTOMA: a rare neoplasm, typically occurs in patients 10 to 25
years old, with a 2 : 1 male predominance . this tumor represents 1% of all
bone tumors.
The distal femur, proximal humerus, and proximal tibia are the most common
sites of occurrence. In older patients, chondroblastoma has a tendency to
occur in flat bones.
Notice ：occurs in epiphyses
Most patients complain of progressive pain that may mimic a chronic synovitis
or other intraarticular pathological conditions.