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.

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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.

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Child Abuse

Child abuse most often occurs under 3 years of age, and if it is not recognized and reported, repeat abuse may occur in 40% of the cases. Death can occur in up to 5% of cases.

Risk factors for Child Abuse include:

  • Being the first born child
  • Single Parent
  • Stepchild
  • Disabled Child
  • Parents were abused

It is important to rule out osteogenesis imperfecta and metabolic bone disease.

femurfx

Suspect Child abuse if:

  • There is a fractured femur in an infant before walking age
    • The most common orthopaedic injury associated with child abuse is a femur fracture
  • Multiple fractures in different stages of healing
    • Callus and periosteal reaction is seen
  • Unwitnessed spiral fracture
    • Spiral fractures are not a good criteria because most of them are accidental
  • Multiple soft tissue bruising
    • Skin lesions are the most common
    • Bone fracture is the second most common

skin lesions

  • Corner fracture
    • Metapheseal fracture especially in the distal femur and proximal tibia
    • Child abuse should be considered when health care providers see cornercornerfx fractures in children before they are of walking age.
  • Posterior rib fracture from a squeezing injury
  • If there is a transepiphyseal separation in the humerus
    • In Newborns
      • The olecranon moves posteriorly
      • Looks like an elbow dislocation
    • Older Child
      • Separation of the distal humerus usually occurs in younger ages

Discrepancy in the history is a clue. It is hard to explain the injury and match it with the given mechanism of the injury. Injuries in abuse mostly occur at the humerus, tibia, and femur (more in the diaphysis). When child abuse is suspected in a patient it is important to recognize the symptoms, be non-judgmental, and obtain a skeletal survey. If you suspect abuse and a skeletal survey is negative, obtain a bone scan to verify. Then consult protective services. The most frequent cause of long-term morbidity in an abused child is a head injury.

Lead Poisoning

Lead poisoning can occur when lead builds up within the body, usually over a long period of time. Young children are vulnerable to lead poisoning and it is important to be aware of this due to lead poisoning being a factor in mental and physical development. Lead poisoning is a medical condition caused by increased levels of lead within the body that interferes with the normal processes of the body and is particularly toxic to children. This occurs because lead and calcium compete for the protein that is important for body functions, especially the nervous system. The lead can displace the calcium from that protein so the calcium will not be able to function properly.

bonelines

When simplifying the signs and symptoms of lead poisoning, we use the acronym “LEAD”. L represents the lines on the gingiva and long bones; E stands for Encephalopathy and erythrocyte (RBC) basophilic stippling (disease, damage, or malfunction of the brain), A signifies abdominal colic and anemia, and D which stands for drop foot and drop wrist.

Lead inhibits the enzymes that are needed to make Heme—preventing the production of hemoglobin. This causes basophilic stippling of the cells due to lead inhibiting the ribosomal RNA degradation. The red blood cells (RBC) will retain aggregates of ribosomal RNA that causes the stippling of the cells.

RNA

Lead poisoning will present itself with a “lead line” in the gingiva (gums) called the Burton’s line. This gray-blue line is visible at the margin of the gum at the base of the teeth. The long bones will also have lead lines in the metaphysis that appear like white bands on an x-ray because the lead is collected within these white bands. The width and density of these lines reflects chronic exposure.

 

At the RBC level, you will find anemia and basophilic stippling of the red blood cells.

dropfootwrist

The patient will also have encephalopathy associated with headache and memory loss. Lead poisoning may also cause abdominal colic—pain, cramps, and constipation. Another condition that may occur due to lead poisoning is “foot drop”. The patient may experience permanent damage to the central nervous system and the peripheral nerves.

 

This condition usually occurs from exposure to lead based paint, typically used in much older homes. Particles from the lead based paint can be inhaled through the air or from contaminated drinking water, as we have seen recently. Extended exposure can cause serious problems, with children being the most vulnerable. They will commonly show signs of: irritability, fatigue, lower IQ, and lack of attentiveness. The child may show signs of encephalopathy, nausea, vomiting, gait disturbances, and seizures. Exposure in adults is usually occupational related. Adults will experience personality changes, headaches, neuropathy, weakness, foot and wrist drop, and stomach aches. Both children and adults will experience pale skin due to anemia because lead interferes with the normal formation of hemoglobin.

When diagnosing lead poisoning, you have to take into consideration the history of exposure, cm lead levels are usually greater than 5—however, some people use higher numbers. If a complete blood count (CBC) test is done, microcytic anemia will be found and in a peripheral blood smear, you will find basophilic stippling (ribosomes). The serum iron will be normal.

basophil

When treating lead poisoning, the first step will be to eliminate the source of lead contamination. Next, a chelating agent will be used. During this step, various drugs may be used to help remove lead from the body. A chelating agent will bind the lead into a form that the body can excrete. It is used if lead levels are higher than 45µg/dL in children, and more than 70µg/dL in adults. Dimercaprol (oral chelating agent) is used in cases where patients present with encephalopathy. Succimer is used when there aren’t any signs of encephalopathy.

It is also possible to be contaminated by lead due to a bullet penetrating a joint or if it is introduced into the cerebral spinal fluid. This may cause severe synovitis and low grade lead poisoning. This condition is rare, however it can occur. Lead toxicity can also occur due to contamination of the ground water and soil. Lead poisoning can occur due to ingesting food grown in contaminated soil.

Flail Chest

Flail Chest—Everything You Need to Know

In flail chest, three or more ribs are involved in segmental fractures. A segment of the rib cage breaks and then becomes separated or detached from the chest well. It usually requires a significant amount of violent force in order for the ribs to break in this way. Due to the nature of this injury, flail chest could be a life threatening condition.

flail

The fractured segment will sink into the chest with inspiration and expand out of the chest wall with expiration opposite to the normal chest wall mechanics. The segmented rib fractures work independently. If the segmented section moves right, then the rest of the ribs move left, and vice versa. The flail chest moves in the opposite direction of the chest wall. The fractured segment goes in while the rest of the chest goes out—this is called paradoxical breathing.

There may be a pulmonary contusion associated with the flail chest fracture segment, and this contusion could be more significant than the flail segment. There may also be a noticeable chest wall deformity with the presence of air in the subcutaneous tissue (crepitus). Trauma to the chest usually causes scapular fractures or a clavicle fracture.

Symptoms of Flail Chest:

  • Patient will have chest pain and shortness of breath
  • Paradoxical movement of the flail segment
    • The constant movement of the ribs is very painful
    • The broken rib may puncture the lung and cause pneumothorax

pneumo

Images

On an x-ray, it is difficult to see if the fractures are displaced or nondisplaced. A CT scan is probably the best method for visualizing these fractures.

The prognosis varies and it depends on the severity of the condition, however, the death rate ranges between 10-25% usually depending on the pulmonary injury. About 8% of patients who are admitted to the hospital with fractured ribs will have a flail chest.

Treatment

If there is no respiratory compromise and no flail chest segment, observation of the patient will be done. It is important to follow advanced trauma life support (ATLS) principles.

  • Airway
  • Breathing
  • Circulation

The patient’s pain will need to be managed—usually with intercostal nerve blocks. It is essential to avoid the suppression of breathing and if necessary, give the patient positive pressure ventilation (a chest tube if needed).

Surgery

Surgery may help in reducing the duration of the ventilator support and aid in the pulmonary function. The patient will need aggressive pulmonary toilet and physiotherapy.

An open reduction and internal fixation should be done when there is severe pain and displaced ribs, when there is a flail chest segment (three or more consecutive fractured ribs with segmental injury), the rib fractures are associated with failure to wean the patient off of ventilation, and/or when there are open rib fractures.  Usually a plate and screw system is used in addition to early range of motion of the shoulders.