FreihFreih OdehOdeh Abu HassanAbu HassanF.R.C.S.(Eng.), F.R.C.S.(Tr.&F.R.C.S.(Eng.), F.R.C.S.(Tr.& Orth.).Orth.).

Professor of OrthopedicsProfessor of OrthopedicsProfessor of OrthopedicsProfessor of OrthopedicsUniversity of JordanUniversity of Jordan

1/15/2011 1Professor Freih Abuhassan -

University of Jordan

A S iliitiA S iliitiA. SacroiliitisA. SacroiliitisHistoryHistoryyy

•Trauma is very common•Repetitive LS motion--lumbar rotation or axial loadingrotation or axial loading

•Commonly have LLD.y

1/15/2011 2Professor Freih Abuhassan -

University of Jordan

Differential Diagnosis:Differential Diagnosis:

AA FractureFracture

Differential Diagnosis:Differential Diagnosis:

AA-- FractureFracture•TraumaticTraumatic•Insufficiency stress fractures: yelderly patient with osteoporosis

ith t hi t f twithout history of trauma•Fatigue stress fractures: usually•Fatigue stress fractures: usually athletes / soldiers

1/15/2011 3Professor Freih Abuhassan -

University of Jordan

B- Degenerative joint dis.C- Referred painD- Spondyloarthropathies

•RA , AS.

1/15/2011 4Professor Freih Abuhassan -

University of Jordan

1/15/2011 5Professor Freih Abuhassan -

University of Jordan

Diagnostic ToolsDiagnostic ToolsDiagnostic ToolsDiagnostic Tools• X-rays: Up to 25 % of asymptomatic y p y padults over 50 years can have abn.

• MRI / CT: Only if looking for tumor• Bone scan: Good for fractures• Bone scan: Good for fractures

1/15/2011 6Professor Freih Abuhassan -

University of Jordan

TreatmentTreatmentTreatmentTreatment• Medications: NSAIDS• Physical therapy• Correct limb discrepancy• Injection: Fluoroscopy guided• Injection: Fluoroscopy-guided.

1/15/2011 7Professor Freih Abuhassan -

University of Jordan

B. Cauda Equina SyndromeB. Cauda Equina Syndrome

History:History:•Sudden, partial or complete loss of voluntary bladder functionof voluntary bladder function due to massive disc impingement p gon spinal nervesC i l d l f ti•Can include loss of sensation as well as sphincter tonep

1/15/2011 8Professor Freih Abuhassan -

University of Jordan

54-year-old woman presenting with cauda equina.Due to a massive L4-5 disk herniationq

1/15/2011 9Professor Freih Abuhassan -

University of Jordan

•Urgent decompression is g pmandatory for prevention of irreparable / irreversibleirreparable / irreversible bladder damageg

•12 hours is the maximum time i t i ibl hprior to irreversible changes.

1/15/2011 10Professor Freih Abuhassan -

University of Jordan

C DDD and Spondylosis:C DDD and Spondylosis:C. DDD and Spondylosis:C. DDD and Spondylosis:

ClinicalClinical= Up to 75 % of involvement of the Up to 75 % of involvement of the

spine occurs at 2 levels:

L5-S1 and L4-L5

1/15/2011 11Professor Freih Abuhassan -

University of Jordan

1/15/2011 12Professor Freih Abuhassan -

University of Jordan

T t tT t tTreatment:Treatment:M di ti•MedicationsPh i l h•Physical therapy

1/15/2011 13Professor Freih Abuhassan -

University of Jordan

D. Spinal Stenosis:D. Spinal Stenosis:D. Spinal Stenosis:D. Spinal Stenosis:Clinical:Clinical:Clinical:Clinical:

• Results from narrowing of spinal canal g pand / or neural foramina (CONG. OR DEGENERATIVE)DEGENERATIVE)

• Most common complaint is leg pain, li iti lkilimiting walking

• Neurogenic / Pseudo-claudication =g( pain in lower extremities with gait)

1/15/2011 14Professor Freih Abuhassan -

University of Jordan

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1/15/2011 15Professor Freih Abuhassan -

University of Jordan

1/15/2011 16Professor Freih Abuhassan -

University of Jordan

ClassificationA- Congenital

Classificationg

• Developmental • Achondroplasia• Achondroplasia

B- Acquired • Degenerative • SpondylolisthesisSpondylolisthesis• Disc Herniation

&• Degenerative & Disc Herniation• Degenerative & congenitalDegenerative & congenital

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University of Jordan

C Others:C-Others: • Paget's g• Spinal tumour

I f ti (TB)• Infection (TB) • Post-surgeryPost surgery • Trauma

1/15/2011 18Professor Freih Abuhassan -

University of Jordan

•The L4-L5 segment is the most commonly affected followed by thecommonly affected,followed by the L3-L4.

M l ff t d thMen are more commnly affected thanwomen, because their spinal o e , because t e sp acanals are narrower at the L3-L5 le elslevels.

1/15/2011 19Professor Freih Abuhassan -

University of Jordan

PathophysiologyPathophysiologyNarrowing of the central canal and/orintervertebral foraminaintervertebral foraminais due to:1 Ann lar b lging1.Annular bulging 2.Bone spur formation2.Bone spur formation 3.Facet joint enlargement4.Ligamentous hypertrophy

1/15/2011 20Professor Freih Abuhassan -

University of Jordan

=Relief can occur with:=Relief can occur with:– stopping activitypp g y– sitting, stooping or bending

forward complaints of weakness and=complaints of weakness and numbness of extremities

1/15/2011 21Professor Freih Abuhassan -

University of Jordan

DiagnosisDiagnosisDiagnosisDiagnosisCT d MRICT and MRI

1/15/2011 22Professor Freih Abuhassan -

University of Jordan

Activity Vascular Claudication Neurogenic ClaudicationClaudication

Walking Distal- proximal pain; lf i

Proximal- distal thigh i

a gcalf pain pain

Uphill Symptoms developUphill Walking

Symptoms develop sooner Symptoms develop later

Rest relief with standing relief with sitting or bending

Bicycling Symptoms develop No symptoms

Lying Flat Relief May increase symptoms

1/15/2011 23Professor Freih Abuhassan -

University of Jordan

TreatmentTreatmentTreatmentTreatment• Medications• Physical therapy

•Surgical decompression

Indications:Indications:1. Severe neurological symptoms 2 failed conservative treatment + impaired ADL2. failed conservative treatment + impaired ADL

1/15/2011 24Professor Freih Abuhassan -

University of Jordan

EE Disc herniationDisc herniationE. E. Disc herniationDisc herniationCli i lCli i lClinical:Clinical:• LBP associated leg symptomsg y p• Positions can induce radicular symptoms

• Posterolateral disc pathology why?= Area where annular fibers least protected by PLL= Greatest shear forces occur with forward or lateral

bend

1/15/2011 25Professor Freih Abuhassan -

University of Jordan

• Central disc pathologyU ll i h LBP l i hUsually with LBP only without radicular symptoms, unless a large y p , gdefect is present

1/15/2011 26Professor Freih Abuhassan -

University of Jordan

1/15/2011 27Professor Freih Abuhassan -

University of Jordan

T t tT t t•• TreatmentTreatment• Conservative treatment:• Conservative treatment:> 90 % success rate of symptom resolution with non-operative managementmanagement

1/15/2011 28Professor Freih Abuhassan -

University of Jordan

TreatmentTreatmentM di ti•MedicationsPh i l th•Physical therapy

•Injections•Injections

S•Surgery1/15/2011 29

Professor Freih Abuhassan -University of Jordan

F. Pars Interarticularis DefectsF. Pars Interarticularis DefectsSpondylolysis:Spondylolysis:

• Anatomic defect in the bony pars interarticularis within the laminainterarticularis within the lamina

• May be uni- or bilateral• Can be congenital or induced• Usually without clinical symptoms with• Usually without clinical symptoms with

incidental findings on radiographs

1/15/2011 30Professor Freih Abuhassan -

University of Jordan

SpondylolisthesisSpondylolisthesisp yp y•Progression of spondylolysis with separation

G d i d I IV»Grades assigned I-IV »Most common levels are»Most common levels areL5-S1 (70 %)L5 S1 (70 %) L4-L5 (25 %)( )

1/15/2011 31Professor Freih Abuhassan -

University of Jordan

SpondylolisthesisSpondylolisthesisSpondylolisthesisSpondylolisthesis•May be asymptomatic, but y y p ,can result in

»DDDR di l h»Radiculopathy

1/15/2011 32Professor Freih Abuhassan -

University of Jordan

1/15/2011 33Professor Freih Abuhassan -

University of Jordan

1/15/2011 34Professor Freih Abuhassan -

University of Jordan

TreatmentTreatmentTreatmentTreatment•MedicationMedication•Physical TherapyPhysical Therapy•InjectionsInjections

•Surgery•Surgery

1/15/2011 35Professor Freih Abuhassan -

University of Jordan

1/15/2011 36Professor Freih Abuhassan -

University of Jordan

1/15/2011 37Professor Freih Abuhassan -

University of Jordan

1/15/2011 38Professor Freih Abuhassan -

University of Jordan