外伤科主治医师要领

外伤科主治医师要领第一页，编辑于星期六：十五点五十八分。第1页，共28页。LowbackpainandradiculopathyImagingstudiesandfurthertestingnothelpfulthefirst4weeksReliefofdiscomfortwithmedsandspinalmanipulationBedrestbeyond4daysmaybemoreharmful89-90%lowbackpainimprovewithin1month第二页，编辑于星期六：十五点五十八分。第2页，共28页。

80%sciaticaeventuallyrecover1%havenerve-rootsymptoms1-3%havelumberdischerniation85%nospecificdiagnosismade第三页，编辑于星期六：十五点五十八分。第3页，共28页。definitions/classificationsRadiculopathy:dysfunctionofnerveroot(pain,sensorydisturbances,weakness)Mechanicallowbackpain:strainofparaspinalmuscles,ligament,irritationoffacetjoints第四页，编辑于星期六：十五点五十八分。第4页，共28页。InitialassessmentofpatientHistory:age,weightloss,cancerorinfection,usedofdrug,duringofS/S,trauma,caudaequinasyndrome,workstatusPE:fever,vertebraltenderness,limitedrangeofspinalcordDorsiflexationofankleandbigtoe–L5,4Achillesreflex–S1LighttouchSLRtext第五页，编辑于星期六：十五点五十八分。第5页，共28页。FurtherevaluationofpatientsEMG:neuropathy,myopathy,myelopathy,unreliable<3-4weeksSEPs(somatosensoryevokedpotential):spinalstenosis,orspinalmyelopathyNCVs(nerveconductionvelocity):entrapmentneuropathiesthatmimicradiculopathy第六页，编辑于星期六：十五点五十八分。第6页，共28页。LSX-rayrecommendationage>70yrs,or<20yrssystemicallyillpatientstemp.38°CHistoryofmaligancyRecentinfectionCaudaequinasyndromeHeavyalcoholordrugabusersDM第七页，编辑于星期六：十五点五十八分。第7页，共28页。Immunosupressedpatients(steroid)RecenttraumaRecenturinarytractorspinalsurgeryUnrelentingpainatrestPersistentpainmorethan4weeksUnexplainedweightloss第八页，编辑于星期六：十五点五十八分。第8页，共28页。TreatmentConservativetreatment:1.activitymodification:Bedrest:nomorethan4daysActivitymodification:heavylifting,totalbodyvibration,asymmetricpostures,sustainedforlongperiodsExercise:walking,bicycling,orswimming第九页，编辑于星期六：十五点五十八分。第9页，共28页。2.analgesics:PanadolandNSAIDsOpioids3.musclerelaxants:cation:conditionwillsubside5.spinalmanipulationtherapy:acutelowbackpainwithoutradiculopathyin1stmonth,notusedinsevereorprogressiveneurologicdeficit第十页，编辑于星期六：十五点五十八分。第10页，共28页。Epiduralinjection:nochangeintheneedforsurgery,short-termreliefofradicularpainwhencontrolonoralmedicationsisinadequateornotsurgicalcandidates.第十一页，编辑于星期六：十五点五十八分。第11页，共28页。CaudaequinasyndromeMidline,mostcommonatL4-51.sphincterretension:A.urinaryretensionB.UrinaryandfecalincontinenceC.Analsphinctertone2.saddleanesthesia3.significantmotorweakness4.Lowbackpainandsciatica5.Bilateralabsenceofachillesreflex6.Sexualdysfunction第十二页，编辑于星期六：十五点五十八分。第12页，共28页。SurgicaltreatmentPatientswith<4-8weeksA:urgenttreatment(e.g.caudaequinasyndrome,progressiveneurologicdeficit)B:inabilitytocontrolpainwithmedicinePatientwith>4-8weeksSevereanddisablingandnotimprovementwithtime,correlatedwithfindingsonPHandPE.第十三页，编辑于星期六：十五点五十八分。第13页，共28页。TypeofsurgeryLumbarspinalfusion:fracture/dislocationorinstabilityresultingfromtumororinfectionInstrumentationasanadjuncttofusion:increasingthefusionratePediclescrew-rodfixation:utilizefollowinglaminectomy,shorterlengthoffixationsegment,rigidfixationofall3columns第十四页，编辑于星期六：十五点五十八分。第14页，共28页。Posteriorlumberinterbodyfusion:bilaterallaminectomyandaggressivediscetomyfollowedbybonegrafts第十五页，编辑于星期六：十五点五十八分。第15页，共28页。IntervertebraldischerniationLumbardischerniationPosteriorly,oneside,compressinganerveroot,severeradicularpainCharacteristicsfindings:Symptomsstartwithbackpain,daysafterweeksyeildsradicularpainwithreductionofbackpainPainreliefuponflexingthekneeandthighPositionchange第十六页，编辑于星期六：十五点五十八分。第16页，共28页。Bladdersymptoms:difficultyvoiding,straining,orurineretentionExacerbationwithcoughing,sneezing,strainingatthestoolRadiculopathy:A.painradiatingdownLEB.motorweaknessC.dermatomalsensorychangesD.reflexchanges第十七页，编辑于星期六：十五点五十八分。第17页，共28页。Straightlegraisingtest:<60,L5andS1第十八页，编辑于星期六：十五点五十八分。第18页，共28页。Spondylosis:no-specificdegenerativeprocessofthespineSpondylolisthesis:anteriorsubluxationofonevertebralbodyonanotherGrade1-4Spondylolysis:alternativetermforisthmicspondylolisthesis第十九页，编辑于星期六：十五点五十八分。第19页，共28页。SpinalstenosisNarrowingoftheAPdimensionofspinalcanalInthelumbarregion:neurogenicclaudicationInthecervicalregion:myelopathyandataxiaInthespinalregion:rare第二十页，编辑于星期六：十五点五十八分。第20页，共28页。SpinaltraumaUncommoninchildrenThefatalityrateishigherwithpediatricspinalinjuriesthanwithadults(oppositetothesituationwithheadinjury)第二十一页，编辑于星期六：十五点五十八分。第21页，共28页。Completelesion:nopreservationofanymotororsensoryfunctionmorethan3segmentsbelowtheleveloftheinjuryPersistenceofcompletespinalcordinjurybeyond24hours:nodistalfunctionwillrecover第二十二页，编辑于星期六：十五点五十八分。第22页，共28页。Incompletelesion:Anyresidualmotororsensoryfunctionmorethan3segmentsbelowtheleveloftheinjury.Signsofincompletelesion:SensationorvoluntarymovementintheLegsSacralsparingCentralcordsyndromeBown-SequardsyndromeAnteriorandposteriorcordsyndrome第二十三页，编辑于星期六：十五点五十八分。第23页，共28页。SpinalshockA.interruptionofsympathetics1.Lossofvasculartone2.LeavesparasympatheticscausingbradycardiaB.LossofmuscletoneresultvenouspoolingC.Truehypovolemia第二十四页，编辑于星期六：十五点五十八分。第24页，共28页。InitialmanagementofspinalcordinjuryCauseofdeath:aspirationand