Low Back Pain- Disc Herniation

The spine is comprised of bony vertebrae separated by discs. The neural structures of the spine include the spinal cord (T12-L1), The conus medullaris—which is the lower end of the spinal cord, and the Cauda Equina, which is the division of multiple nerve roots beginning at the level of L1. Conditions of the lumbar spine including disc herniation are a main cause of lower back pain.

needs edits

The lumbar spine (lower back) consists of five vertebrae numbered L1-L5. These vertebrae are attached to the sacrum at the lower end of the spine. The discs between the vertebrae are round cushioning pads which act as shock absorbers. In a normal disc, there are two layers—the inner disc layer, which is comprised of soft gelatinous tissue and known as the Nucleus Pulposus, and the outer disc layer—which is made up of thick strong tissue, which is known as the Annulus Fibrosis. Behind this disc lies the spinal nerve root and the cauda equina. A major disc herniation of the lumbosacral region could affect the nerve roots.

parts

 

In about 95% of all disc herniation cases, the L4-L5 or L5-S1 disc levels are involved. Herniation of the L4-L5 disc will affect the L5 nerve root. Herniation of the L5-S1 disc will affect the S1 nerve root.

spinesections

There are three types of disc herniation:

  1. Protrusion/ Bulge- A bulging disc with intact annular and posterior longitudinal ligament fibers
  2. Disc Herniation
    • Type A—Disruption of inner annular fibers with intact outer annular fibers
    • Type B—Disrupted annulus with tail of disc material extending into the disc space
  3. Sequestration
    • Free fragment without tail extending into disc space
    • Fragment may be reabsorbed spontaneously
    • May get better with the use of an epidural

sequest

There are three typical locations for disc herniation as well:

  1. Central
    • Involves multiple nerve roots
    • Predominantly causes low back pain more than leg pain
    • May cause incontinence of the bladder and bowel
    • Urgent surgical treatment if patient presents with neurological deficits
  2. Posterolateral—usual location, most commonly involving one nerve root (the lower one)
    • For example: L4-L5 posterolateral herniation will involve L5 nerve root
  3. Foraminal
    • Occurs in 8-10% of cases
    • Involves the exiting nerve
    • Example: L4-L5 foraminal herniation will involve the L4 nerve root

Discogenic Back Pain is an internal disc disruption with early disc degeneration. Pain gets worse with flexion and sitting but, gets slightly better with extension. Forward flexion is limited on the exam and there are no radicular symptoms.

Advertisements

Unbelievable Bacteria

One of the ways bacteria enters the body is through an open wound. When an open wound goes straight down to a fractured bone it is called and open fracture. When bacteria gains access to the deeper tissue beneath the open wound, the tissues become contaminated. Preoperative and prophylactic antibiotics are given to the patient to help decrease the infection rate with the hope of killing the bacteria in the contaminated field.

open fx bacteria

Additionally, a special treatment is done during an open fracture to further help prevent infection. This treatment consists of irrigating and washing the wound, as well as debridement of the dead tissue. Once the tissue has been adequately cleaned, the fracture needs to be reduced and stabilized. Three different ways to stabilize the fracture is with a plate, a rod, or an external fixator. The open wound is either left open for a variable amount of time and it is closed later on. At the time of wound closure, a skin graft will be needed. To promote healing of the fracture a bone graft will be needed usually four to six weeks after the injury.

skin graft

A bone graft is obtained from the pelvis as the pelvis has a large reserve of bone that can be utilized. The bone that is harvested is cut into pieces and then added to the fracture where needed. Despite the best care, a certain percentage of open fracture injuries will become infected. When the tissues become infected by bacteria, white blood cells are attracted to the infected site where the bacteria are multiplying and causing inflammation.

multiple bacteria

Bacteria multiply by replicating their DNA and then dividing into two identical bacterial cells. Due to the doubling of bacterial cells, the population of the bacteria grows rapidly. Once at the site of infection, the white blood cells begin to ingest the bacteria. These bacteria however, may survive and multiply within the white blood cells, causing the cells the burst. When this occurs, the bacteria is then released back into the tissues.

Other types of bacteria can also produce a thick capsule that prevents them from being engulfed. Engulfed bacteria may also produce toxins used to destroy cells that try to attack them. Bacteria can also hide in dead bone or bone cells. When this happens, antibiotics and white blood cells are unable to reach the bacteria, since the dead bone has no blood supply. In addition to the bacteria hiding in the bone, the bacteria grow rapidly.

engulf

During this growth period, the bacteria communicate with one another through a process known as quorum sensing. Quorum sensing is the use of a chemical signals from one bacteria to another. As the bacterial population grows, the concentration of the chemical signal. Once the concentration of the chemical signal reaches a certain threshold, the bacteria then begin their attack. The bacteria will attack the tissues causing it to break down and die which can lead to an abscess formation. The abscess must be drained and evacuated, followed by antibiotic treatment.

bacteria communuity

Antibiotics can kill bacteria in several different ways. One way is by disrupting the cell wall which ruptures the bacteria. Another way, is by preventing DNA replication by blocking the unwinding of the DNA. A third way is by inhibiting the ribosomes from making proteins needed for the cellular structure and function. The last way is by blocking the enzymes that produce folate. Folate is needed for DNA synthesis, and without it the cell will die.

When hardware is used to stabilize the fracture, the story can become much more complex.

 

Stiff Knee

Extension contracture of the knee can result from different causes, but it usually occurs from trauma. The patient is unable to bend the knee to a functional level.

stiffknee1.png

Trauma will cause adhesions inside the knee, fibrosis, and shortening of the knee ligaments.

There will also be adhesions and shortening of the quadriceps muscles.

stiffknee2.png

Treatment

Treatment will usually begin with therapy. The first surgical option will include an arthroscopy and the release of any adhesions. The second surgical option that may be considered as a quadricepsplasty (Thompson or Judet) or a combination of treatments.

An example of a combination treatment plan would be a modified Judet quadricepsplasty with the release of the quadriceps muscle from the femur and a release of the adhesions that are located inside the knee.

After surgery the surgeon can usually achieve 90° plus flexion.

Finger Fractures

Fractures to the fingers and hands are common. Mallet finger is a deformity caused from a blow to the finger at the DIP joint. Patient is unable to straighten the DIP due to avulsion injury.

finger1.png

Most often mallet finger injuries can be treated without surgery. Treatment is given by applying a splint to immobilize the fingertip in extension. Movement should be allowed in the PIP joint. Surgery may be necessary if more than 50% of the joint is involved or there is subluxation of the joint to restore the function of the extensor tendon.

finger2.png

Middle and proximal phalangeal fractures:

finger3.png

The normal relaxed cascade of the hand should form a straight alignment of the fingers.  When holding a relaxed cascade, the fingers should normally point towards the region of the scaphoid. Malrotation of the finger will cause the affected finger to deviate from its normal rotational direction.

finger4.JPG

Treatment:

If there is no rotational deformity, the finger is treated by buddy taping the injured finger to the adjacent normal finger for 2-3 weeks. If rotational deformity is present, a digital block is given and the fracture is reduced in a volar splint. The MCP is held in 70 degrees of flexion for proximal phalanx fractures for 2-3 weeks. The splint holds the DIP and PIP in 0 degrees extension in middle phalanx fractures. Then buddy tape for additional 2 weeks.

finger5

Metacarpal fractures:

The wrist should be immobilized in 20 degrees extension and the MCP in 60-70 degrees of flexion.

finger6

The fingers should be kept free in order to check for rotation. Finger fractures means stiffness of the fingers.

Indication for surgery:

  • Rotational deformity
  • Open fracture
  • Multiple unstable fractures
  • Significant angulation or deformity.
  • Articular displacement
  • Metacarpal shortening especially with the middle and index fingers.

If the fracture is displaced or unstable, closed reduction and K-wire is an option for fixation.

finger7.png

Plating is another option for fixation however it is rare.

finger8.png

In phalanx fractures treated by ORIF, adhesions of the extensor tendon may occur. Patient may have decreased range of motion of the PIP which is called extrinsic tightness.

The patient will have greater passive PIP flexion with MP extension compared to when MP is flexed.