The Ideal Patient With Low Back Pain

Low back pain is very common, and the majority of the patients get better with time. The ideal patient will get better with time and has no radiation below the knee, no history of trauma, no fever or chills or weight loss, no bladder or bowel dysfunction, no neurological deficits, and no pathological reflexes.

In order to optimize recovery, management of the patient should consist of early return to activity as tolerated, as the symptoms allow. You will give the patient reassurance with limited analgesia, early range of motion, and muscle relaxants. A healthy patient with an acute onset of non-traumatic low back pain, you do not need early diagnostic imaging before proceeding with the therapeutic treatment. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful, and the symptoms are prolonged. X-rays may not be needed in the first six weeks unless there is a reason for it, such as red flags. In fact, the use of x-rays can lead to better patient satisfaction but doesn’t necessarily lead to better patient outcome. X-rays and MRIs may show changes in the intervertebral discs and may be associated with the patient’s pain, but these changes are also commonly seen in cross-sectional studies of asymptomatic people. There are a lot of false positive MRIs, and you need to correlate the MRI findings with the clinical findings. Don’t rely on the MRI alone! Just because you have MRI changes or disc protrusion, it does not mean that the patient needs surgery!

A nonspecific pain does not require surgery; therefore, it does not require further work-up. There are risk factors associated with low back pain that includes Poor physical fitness; Smoking; History of repetitive bending or stooping on the job and whole-body vibration exposure. If the patient has a simple low back pain, 50% of the patients resolve their pain in one week. Resolution of the acute back pain occurs in 90% of the patients within one month. If the patient has leg pain greater than back pain, then the patient has sciatica. Sciatica means nerve root irritation, probably due to a herniated disc.

The Ideal Patient with Low Back Pain – Everything You Need to Know

The ideal Patient with Low Back Pain – Everything you need to know

Low back pain is very common, and the majority of the patients get better with time. The ideal patient will get better with time and has no radiation below the knee, no history of trauma, no fever or chills or weight loss, no bladder or bowel dysfunction, no neurological deficits, and no pathological reflexes.

In order to optimize recovery, management of the patient should consist of early return to activity as tolerated, as the symptoms allow. You will give the patient reassurance with limited analgesia, early range of motion, and muscle relaxants. A healthy patient with an acute onset of non-traumatic low back pain, you do not need early diagnostic imaging before proceeding with the therapeutic treatment. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful, and the symptoms are prolonged. X-rays may not be needed in the first six weeks unless there is a reason for it, such as red flags. In fact, the use of x-rays can lead to better patient satisfaction but doesn’t necessarily lead to better patient outcome. X-rays and MRIs may show changes in the intervertebral discs and may be associated with the patient’s pain, but these changes are also commonly seen in cross-sectional studies of asymptomatic people. There are a lot of false positive MRIs, and you need to correlate the MRI findings with the clinical findings. Don’t rely on the MRI alone! Just because you have MRI changes or disc protrusion, it does not mean that the patient needs surgery!

A nonspecific pain does not require surgery; therefore, it does not require further work-up. There are risk factors associated with low back pain that includes Poor physical fitness; Smoking; History of repetitive bending or stooping on the job and whole-body vibration exposure. If the patient has a simple low back pain, 50% of the patients resolve their pain in one week. Resolution of the acute back pain occurs in 90% of the patients within one month. If the patient has leg pain greater than back pain, then the patient has sciatica. Sciatica means nerve root irritation, probably due to a herniated disc.

Dislocation of the Hip

Dislocation of the Hip

Hip dislocation can be either a simple dislocation or it can be a fracture dislocation which involves the posterior wall of the acetabulum or the femoral head. Dislocation of the hip can be two types: posterior dislocation (most common type) or anterior dislocation (rare). hipPosition of the hip during the impact decides the injury. In posterior dislocation of the hip, which is the commonest type, the lower limb will be flexed, adducted, and internally rotated. Anterior hip dislocation is rare. It could be a superior anterior hip dislocation. The limb will be extended, abducted, and externally rotated. With an anterior inferior dislocation (obturator type), the extremity will be flexed, abducted, and externally rotated. Hip fractures are different than hip dislocations. Notice that the affected extremity is shortened and externally rotated with a hip fracture. Hip dislocation of any type is an emergency. It must be reduced in less than 6 hours of injury. After reduction of the hip, get a CT scan. Although x-ray is helpful, a CT scan clearly outlines the bony injury. Check the CT scan for congruous reduction, for absence of fracture, and absence of marginal impaction in the acetabulum (with posterior wall fracture, check for marginal impaction). Marginal impaction is more common in posterior acetabular wall fractures and could lead to instability. hip diDisplaced or comminuted posterior wall fracture could lead to arthritis. Make sure that you have good congruous reduction with no loose bodies or important fractures present. Check for fractures of the acetabulum and the size of the fragment. The size of the posterior wall fracture has an effect on the stability of the hip joint. If congruous reduction of the hip is not obtained, perform open reduction urgently. Open reduction can be done through an anterior approach or a posterior approach. Hip dislocation with or without associated fracture can cause complications. The risk of avascular necrosis depends on the interval between the injury and reduction of the dislocation. Urgent reduction of hip dislocation is mandatory to avoid AVN and interruption of the blood supply which leads to collapse of the femoral head. Reduce the hip and recheck the sciatic nerve function. Always reduce the hip early. Closed reduction should be done in less than 6 hours. hip disWhen injury occurs to the sciatic nerve due to posterior hip dislocation, the common peroneal nerve is usually affected, causing weakness in dorsiflexion of the ankle and loss of toe extension. Injury can occur in varying degrees of severity and it can be missed. Check for foot drop. Movement of the toes may be misleading. Movement of the toes may appear as dorsiflexion, however this really is the result of plantar flexion. Documenting the injury is important to avoid medical legal problems. Injury to the sciatic nerve usually occurs from the dislocation and not from the reduction of the hip. The longer the wait for the reduction of the dislocation, the more the patient is predisposed to sciatic nerve injury. The length of time a hip remains dislocated influences the incidence and the severity of a major sciatic nerve injury. Patient recovery of the sciatic nerve occurs in 60-70% of patients. The patient usually requires an anti-foot drop splint to prevent equinus of the ankle. hip dThere is approximately 10% incidence of sciatic nerve palsy from posterior hip dislocation. Neurologic examination at the time of injury is usually difficult, however, it is extremely necessary. Check for sensation on the top of the foot. In posterior dislocation of the hip, always look for injuries in the knee such as with a dashboard injury. The force of the injury is usually transmitted from the knee to the hip. There may be an associated posterior cruciate ligament (PCL) injury or a meniscal tear. Examine the knee for injuries and an MRI of the knee may be needed. In cases of high energy trauma, always look at the chest. There might be a tear of the aorta. Check for widening of the mediastinum on chest x-rays. There is concern of deceleration injury involving the aorta. You may apply advanced trauma life support (ATLS) protocol. More flexion, internal rotation, and adduction favors pure dislocation of the hip. Less flexion, internal rotation, and adduction favors fracture dislocation of the hip. Hip dislocation may be associated with acetabular fracture or fracture of the femoral head (Pipkin fracture). hip dislWith Pipkin fracture, as the femoral head dislocates, it hits the posterior wall of the acetabulum and the femoral head fractures. This may be different from an anterior hip dislocation. Anterior hip dislocation will cause impaction of the femoral head or indentation fractures. Classically, Pipkin fracture is a posterior dislocation of the hip and fracture of the femoral head. To treat this, do emergency closed reduction of the hip within 6 hours. Closed reduction is done to avoid avascular necrosis (AVN) of the hip. Reduction of the hip joint and mobilization of the patient with protected weight-bearing crutches for 4-6 weeks. After closed reduction, when the patient has an associated fracture, assess the hip stability, especially if the fragment is not too large. The hip is usually stable if the fragment size of the acetabulum is less than 20%. More than 40%, the hip is unstable. Between 20%-40% fragment size, the hip stability is undetermined. When there is an associated acetabular fracture, the best method to assess the stability of the hip is by examination of the patient under general anesthesia utilizing fluoroscopy. Asses the posterior wall stability with the obturator oblique view. Hip will be in flexion, adduction, and add axial load. hip disloCheck the medial clear space for opening (opening of the medial clear space suggests instability of the posterior wall fracture. Irreducible isolated posterior dislocation; do emergency surgical treatment to reduce the hip. If there is an associated acetabular fracture or femoral head fracture, do urgent closed reduction of the hip dislocation followed by stabilization of either of the fractures if needed according to the protocol. For a posterior hip dislocation with posterior acetabular wall fracture, you must assess the stability of the hip joint by examination under anesthesia after closed reduction. After closed reduction, if the dislocation is not congruent, do open reduction and fixation urgently. For a Pipkin femoral head fracture, do headless screw fixation.

Carpal Tunnel Syndrome Treatment

Carpal Tunnel Syndrome Treatment

Pain, numbness, and paresthesia in the palmar aspect of the thumb, index, and long finger (median nerve distribution). Symptoms of carpal tunnel syndrome occur more at night. These symptoms wake the patient up from sleep, causing the patient to shake the hand in attempt to resolve these symptoms. carPercussion of the volar wrist crease produces electric sensation distally to the fingers. Phalen’s maneuver is performed by flexing the wrist for 60 seconds. This will increase the carpal tunnel pressure temporarily and produce the symptoms. If the test is positive, the patient will have numbness and tingling in the hand and wrist. The Positive Compression Test (Durkan’s Test) is the most sensitive test. The examiner places even pressure with two thumbs directly over the patients median nerve in the carpal tunnel for about 30 seconds. Reproduction of symptoms in the distribution of the median nerve means that the test is positive for carpal tunnel syndrome. Self-administered hand diagram is extremely helpful (most specific test for carpal tunnel syndrome). The patient should highlight the areas where they are experiencing the symptoms. The patient may complain of thenar atrophy, weakness, or clumsiness of the hand. The patient’s history and examination is an indication for carpal tunnel syndrome. carpCarpal tunnel syndrome is a clinical diagnosis. Carpal tunnel syndrome can be treated by anti-inflammatory medication or activity modification. Activity modification includes avoiding activities that aggravate the symptoms. It can also be treated with neutral wrist splints. It can help night time symptoms because it lowers the carpal tunnel pressure. Functional wrist splints (30o extension) will aggravate carpal tunnel syndrome because it increases the carpal tunnel pressure. At 3 months, 50% of patients will improve with splints. At 18 months, more patients will improve with splints. Sometimes, I use Vitamin B6. There is really no proof that vitamin B6 and physical therapy have any significant effect on improvement of carpal tunnel symptoms. Steroid injections are used for the treatment and for diagnosis of carpal tunnel syndrome if clinical examination or electro-diagnostic test is not clear. If the patient temporarily improves from injection, then the patient will definitely improve from surgery. For steroid injection, mark the intersection of the palmaris longus tendon and the distal palmar crease. Next, go 1 cm proximal and 1 cm ulnar to that site, this will be the point of injection. Use a 25 gauge needle with desired steroid and 1 mL of 1% lidocaine. caPut the needle at a 45o to the skin of the wrist. Direct the needle towards the base of the thumb and advance the needle distally and slowly. The physician should warn the patient before the injection that if any feeling of numbness, paresthesia, or severe pain exists to let the physician know about it. Injection gives 80% transient improvement and 22% of the patients will be symptom free 1 year after injection. Carpal tunnel release surgery can be open or endoscopic. Surgery is usually done when there is persistence of the symptoms and failure of nonoperative treatment. The injection is a good prognosis for improvement after surgery when the splint no longer works, and when steroid injection only gives temporary improvement (injection is a good prognosis for improvement from surgery). The median nerve is much like a truck passing through a tunnel. The truck (nerve) should be able to pass through the tunnel with ease and without friction. If the tunnel is narrow then the nerve (truck) cannot pass. If you want the nerve to pass, then widen the tunnel. The tunnel is widened by cutting the transverse carpal ligament, as seen in this example. The American Academy of Orthopedic Surgeons (AAOS) recommends doing electrodiagnostic studies before performing carpal tunnel release surgery. Graham stated, that if the patient has a strong history and clinical examination for the diagnosis of carpal tunnel syndrome, then the electrodiagnostic test is unlikely to change the clinical diagnosis. Endoscopic procedure will give a better early rehab. carpaThe result is the same as with an open release, however incomplete release is a complication of the endoscopic procedure. The pinch strength returns to normal by 6 weeks. The grip strength returns to normal by 12 weeks. At one year, 20% of patients with severe carpal tunnel symptoms will continue to have symptoms. Revision carpal tunnel usually occurs when there is incomplete release. 25% will have no relief. Only 25% will have complete relief. The recurrent motor branch of the median nerve can be injured during the surgery. I want to talk about the anatomy and the variation in distribution of this nerve. After passing through the carpal tunnel, the median nerve gives a branch on the radial side called the recurrent motor branch. The recurrent motor branch is an important nerve supply to the thenar muscles. The recurrent motor branch of the median nerve has multiple variations of the nerve: 30% are subligamentous with recurrent innervation and 20% are transligamentous with recurrent innervation. If this nerve is injured, the patient will get progressive thenar atrophy due to that injury. It is important to cut the transverse carpal ligament far ulnarly to avoid cutting the recurrent motor branch of the median nerve. If you see a patient after carpal tunnel release and that patient has progressive thenar atrophy, this can be explained by the fact that there is an injury to an unrecognized transligamentous motor branch of the median nerve.