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Martin Repko, Richard Chaloupka

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1 Martin Repko, Richard Chaloupka
LPB - Low Back Pain Martin Repko, Richard Chaloupka Ortopedická klinika FN Brno-Bohunice

2 Definition: It is tireness, dyscomfort or pain in lower part of back with or without irradiation do one or both lower extremities. Acute 24hours - 3 month Chronical over 3 month Recidiv Ortopedická klinika FN Brno-Bohunice

3 Anatomy Ortopedická klinika FN Brno-Bohunice

4 Pathogenesis 1. Primary functional secondary structural
2. Primary structural Ortopedická klinika FN Brno-Bohunice

5 Pathogenesis vertebrogenic discogenic neurogenic vasogenic myogenic
viscerogenic psychogenic Ortopedická klinika FN Brno-Bohunice

6 Pathogenesis degeneration inflammation tumours fractures
Congenital deformities Metabolic diseases Ortopedická klinika FN Brno-Bohunice

7 Inflammations specific non-specific revmatic -tbc spondylitis
-spondylogenic osteomyelitis revmatic -M.Bechtereev Ortopedická klinika FN Brno-Bohunice

8 Tbc spondylitis Spondylitis ant. -profunda -superficialis
Spondylitis posterior Ortopedická klinika FN Brno-Bohunice

9 X-ray stages of tbc spondylitis
inicial porosis and decreasing of iv spaces florid destruction and vertebral sekvestration reparative sklerotisation and loosening of iv spaces definitive synostosis Ortopedická klinika FN Brno-Bohunice

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14 Complications of tbc spondylitis
absces kyphosis paraplegia Therapy of tbc spondylitis - antituberculotics (9-12 month) - external fixation (brace, orthosis) - surgical therapy Ortopedická klinika FN Brno-Bohunice

15 Diff.dg. of tbc spondylitis
spondylogenic osteomyelitis typhoid and paratyphoid spondylitis Bang´s spondylitis M.Bechtereev systematic bone illnesses spondylitis brucellosis Mb.Paget posttraumatical spinal deformities tumours and metastases spinal gumma Ortopedická klinika FN Brno-Bohunice

16 Differential diagnosis
Tbc spondylitis Slow progression No pain in quiet position Extensive osteoporosis extensive destruction Big paravertebral absces No osteoplastic reaction Osteomyelitis Heavy and rapid progression Pain in quiet position Border osteoprosis only Minimal destruction Minimal absces Heavy osteoplastic reaction Ortopedická klinika FN Brno-Bohunice

17 Spinal osteomyelitis Clinical signs: rapid start fever
neurological signs Evaluation: laboratory (BP, FW, CRP) cultivation X-ray, bone scan, CT, MRI Ortopedická klinika FN Brno-Bohunice

18 osteomyelitis L4/5

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20 Therapy of spondylogenic osteomyelitis
atb – double or multiple combination (initially intravenous aplic.) (long-term-several month) Bed rest External fixation (brace) Biopsy: -craig needle disc. aspiration -open (CT econtroled) Surgical treatment Ortopedická klinika FN Brno-Bohunice

21 Mb. Bechtereev

22 Spinal tumours primary metastatic - spinal: - extradural - intradural
- vertebral: - benign (osteoid osteoma, hemangiom) - malignant (myeloma) metastatic - osteoblastic (prostatic) - osteolytic (lungs, breast, Grawitz, thyroid) Ortopedická klinika FN Brno-Bohunice

23 Spinal tumours -evaluation methods
Imaging methods -X-ray -CT, MRI -bone scan -Contrast-PMG Laboratory -FW, CRP, BP -PSA, Bence-Jones, ALP Ortopedická klinika FN Brno-Bohunice

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26 Metastasis of teratoma testis

27 Metastasis of ca cervicis uteri

28 Therapy of spinal tumours
Paliative -surgical decompression -chemo- and radiotherapy Causal -surgical resection and stabilisation -sanation of primary tumours in metastasis Ortopedická klinika FN Brno-Bohunice

29 Congenital diseases lumbalisation of S1 sacralisation of L5
Bertolotti´s syndroma Ortopedická klinika FN Brno-Bohunice

30 Spondylolisthesis spondylolysis
= interruption of arcus in pars interarticularis spondylolisthesis = bilateral spondylolysis and vertebral body slipping spondyloptosis = slip over 100% pseudoolisthesis = dislocation of whole vertebral body without spondylolysis Ortopedická klinika FN Brno-Bohunice

31 Spondylolysis Spondylolisthesis Spondyloptosis

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33 Spondylolisthesis classification
1. Etiological (Wiltse+Newman+MacNab) dysplastic istmic degenerative traumatic patological 2. According to X-ray measurement (Meyerding) I.gr. Slip to 25% II.gr. Slip % III.gr. Slip % IV.gr. Slip % Ortopedická klinika FN Brno-Bohunice

34 X-ray evaluation Slip -percentage of slip
grades according to Meyerding: % % % % 5. more than 100% = spondyloptosis Slip angle Ortopedická klinika FN Brno-Bohunice

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36 Evaluation of spondylolisthesis
clinical + neurological imaging 1.X-ray (AP, lateral, oblique, bending) 2.bone scan 3.SPECT 4.CT (native, revers, contrast) 5.MRI 6.Contrast - PMG Ortopedická klinika FN Brno-Bohunice

37 Conservative treatment
Indication: - low pain - low slip - no neurological signs Bed rest Brace physiotherapy NSAID Ortopedická klinika FN Brno-Bohunice

38 Indications for surgical therapy
1. Heavy slip 2. Progressive slip 3. Serious pain 4. Neurological signs Ortopedická klinika FN Brno-Bohunice

39 Traumatology of lumbar spine
Mostly in TL junction Ortopedická klinika FN Brno-Bohunice

40 Osteoporosis typ I -postmenopausal typ II - senile Most common causes:
-long-term immobilisation -diets + abusus -medicaments (glukocorticoids) Ortopedická klinika FN Brno-Bohunice

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42 Fr. L1 burst (A type) v.s. osteoporosis

43 Degenerative spinal diseases
Acute lumbago -herniatio of discus -blocage of intervertebral joint Chronical lumbalgia -paravertebral spasmus -irritation of proprioreceptors Lumboischialgia -compression of n.ischiadicus roots Ortopedická klinika FN Brno-Bohunice

44 Degenerative spinal diseases
discus chondrosis osteochondrosis spondylosis spondylarthrosis discus hernia spinal instability Ortopedická klinika FN Brno-Bohunice

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48 Spinal stenosis Primary (congenital) Secondary
lateral (root compression) -CT+MRI central (canal compression) -CT+C-PMG Ortopedická klinika FN Brno-Bohunice

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50 degenerative scoliosis

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52 Degenerative spine evaluation
anamnesis Clinical examination imaging metods (X-ray, bending films, CPMG, CT, MRI, bone scan, discography) Ortopedická klinika FN Brno-Bohunice

53 Conservative treatment
Bed rest Medicaments -peroral -infusions -local Physiotherapy Back school Ortopedická klinika FN Brno-Bohunice

54 PAIN static neurological signs Treatment algoritmus
Hospital evaluation physiotherapy X-ray 4 weeks later Conservative treatment Surgical therapy specialists examination Healing in Healing in physiotherapy failed back healing in Next therapy

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