اسکولیوز

اسکولیوز

اسلاید 1: اسكوليوز

اسلاید 2: تعريف اسكوليوزانحراف جانبي ستون فقرات

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اسلاید 4: عللايديوپاتيك نوروماسكولارمادرزادينوروفيبروماتوزبيماريهاي مزانشيمي (مارفان “ اهلر دانلوس “ )ارتريت روماتويد نوجوانانتروما (شكستگي , بدنبال لامينكتومي , توراكوپلاستي )استوكوندروديستروفيها ( دوارفيسم , استوژنز ايمپرفكتا , اكوندروپلازي )

اسلاید 5: ادامه عللعفونت بيماريهاي متابوليك ( دوارفيسم ,هوموسيستونوري )

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اسلاید 7: پره والانس و شيوع جنسي2-3 درصد هرچه درجه قوس بالاتر باشد در دخترها شايع تر است و به 4 برابر ميرسد .

اسلاید 8: ارثScoliosis Is a single gen disorder .?

اسلاید 9: Natural historyمرگ و مير درمان نشده ها 100 درصد بالاتر است .شايع ترين علت مرگ كورپولمونال است .Nachemson : 130 pat. For 38 years found that 100% more mortality according to general population (16 from 20 mortality was due to corpulmonal , 37% LBP , only 3 pat. Were idioscoliosis .

اسلاید 10: ايا مرگ زودرس داريم ؟ داريم , ولي در ايديواسكوليوز نداريم .

اسلاید 11: كمر درد در اسكوليوزها ؟انسيدانس در جمعيت عمومي 80-60% است .در اسكوليوزها 86 % است .البته شيوع درد روزانه در اسكوليوزها شايعتر از جمعيت عمومي است .در قوسهاي لومبار و توراكولومباردرد كمر شايعتر است .شدت درد با شدت قوس ارتباطي ندارد .ارتروز در راديوگرافي اسكوليوزها با افزايش سن به 90% ميرسد .

اسلاید 12: فونكسيون ريهفقط در قوسهاي توراسيك ارتباط مستقيم دارد .سيگار و hypokyphosis با عملكرد ريه ارتباط دارد .

اسلاید 13: حاملگيمشخص نيست كه حاملگي موجب افزايش شدت قوس شود .ولي توصيه شده حاملگي زير 20 سالگي رخ ندهد .در قوسهاي متوسط انديكاسيون سزارين نمى باشد .

اسلاید 14: ترمينولوژي(اصطلاحات )Cervical curve : apex between C1 & C6cervicothoracic curve :apex between C7 & T1thoracic curve :apex between T2 & T11thoracolumbar curve :apex between t12 & L1Lumbar curve :apex between L2& L4

اسلاید 15: بررسي و معاينهمعاينه پوست (برهنه )تست خم شدن به جلو دردweb گردني در سندرم ترنر , كاو عميق در سندرم مارفان , بزرگي كبد و طحال در موكوپلي ساكاريدوزها .معاينه بلوغ

اسلاید 16: School screening test10-14 سالگيروش تست .حساسيت تست : 100%اختصاصي تست : % 45

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اسلاید 20: راديوگرافيAP اولين به صورت AP است .ايستاده و گاهي نشسته ,حافظ گنادها بجز در اولين راديوگرافي بكار ميرود .گرافي لاترال هم بصورت ايستاده است .

اسلاید 21: گرافي ap ايستاده

اسلاید 22: گرافي لاترال

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اسلاید 24: اثر راديوگرافي بر بافتهاپستان , مغز استخوان , گنادها , تيرويد AP or PA (5-10 )

اسلاید 25: درمان اسكوليوزتحريك الكتريكيتحت نظر ارتوزعمل جراحي

اسلاید 26: تحريك الكتريكيامروزه ديگر انديكاسيون ندارد .بعضي تنها مورد انرا در بيماران نيازمند بريس ميدانند كه بدليلي امكان استفاده از بريس ندارند .

اسلاید 27: observationدر قوسهاي زير 20 درجه كاربرد دارد .قوسهاي زير 20 در سنين كودكي هر 6-12 ماه گرافي APقوسهاي زير 20 در سنين نوجواني هر 3-4 ماه گرافي AP قوسهاي زير 20 در سنين بعد از بلوغ احتياج به اقدام خاص ندارد .

اسلاید 28: بريسقوسهاي 20-29 درجه اي كه پيشرفت داشته باشند .(5 درجه در طي 6 ماه )قوسهاي 45-30 در اولين برخورد .پيش نيازهاي ارتوز : 1- حداقل 12 ماه از رشد اسكلتي مانده باشد . 2- ريسر 3 يا كمتر باشد 3- رينگ اپوقيزي باز ياشد . 4- بيش از 6 ماه از منارك نگذشته باشد .

اسلاید 29: كونتراانديكاسيونهاي بريسبلوغ اسكلتيلوردوز توراسيكقوس بالاي 45 درجه

اسلاید 30: انواع بريس

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اسلاید 37: هرني ديسكال

اسلاید 38: اناتومي

اسلاید 39: تغذيه ديسكفاقد عروق خوني است .از طريق بخش متخلخل مركزي end plate به روش انتشار تغذيه ميگردد .

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اسلاید 43: تغيرات مفاصل فاست طي عمر مرحله 1 : (dysfunction ) پارگي حلقوي ديسك سينوويت و هيپرموبيليته مفصل فاست (45-15 ).مرحله 2 : (instablity ) پارگي پيشرونده ديسك , تخريب مفصل فاست و سابلوكساسيون ان .(70-35 )سالگي.مرحله 3 : (stablization ) هيپرتروفي اطراف مفصل و انكيلوز كمري .(بالاي 60 سالگي )

اسلاید 44: محل شايع دژنرسانس ديسكL4-L5 & L3-L4

اسلاید 45: علايم باليني هرني ديسكالدرد كمريا گردن, مشخصات درد درد تير كشنده به ساقاسپاسم عصلات كمرياختلال حسي و حركتي اختلال رفلكس عصبيSLR

اسلاید 46: ريسك فاكتورهاي LBPشغل سنگينكار روي وسايط نقليهسيگارتزايمان زياد قد بالاي 180وزن بالاشغل همراه استرس

اسلاید 47: علايم ديسك گردنيعلايم مربوط به خود مهره , از طريق اعصاب sinovertebral بصورت درد گردني و مديال به اسكاپولا و شانه .علايم مربوط به فشار به ريشه عصبي .علايم مربوط به ميولوپاتي كه با lermit sign در MS افتراق ميابد .(در ديسكهاي مياني مشاهده ميشود .)

اسلاید 48: IMAGING IN LOW BACK PAIN

اسلاید 49: Plain Radiographs (X-Rays)Generally not recommended in the first month of symptoms in the absence of “red flags”.The main purpose of plain x-ray is to detect serious underlying structural or pathologic conditions.

اسلاید 50: RED FLAGS (POSSIBLE FRACTURE)Major trauma,such as vehicle accident or fall from height Minor trauma or even strenuous lifting (in older or potentially osteoporotic patient)

اسلاید 51: RED FLAGS (POSSIBLE TUMOR OR INFECTION)Age over 50 or under 20,history of cancerConstitutional symptoms,such as recent fever or chills or unexplained weight lossRisk factors for spinal infection:recent bacterial infection(U.T.I),IV drug abuse,or immunesuppression(from steroids,transplant or HIV)Pain that worsen when supine,severe nighttime pain

اسلاید 52: RED FLAGS (POSSIBLE CAUDA EQUINA SYN.)Saddle anesthesiaRecent onset of bladder dysfunction: (retention,frequency,overflow incontinence)Severe or progressive neurological deficit in lower extremityAnal sphincter laxity,perineal sensory lossMajor motor weakness:quadriceps,ankle plantar flexors,evertors, and dorsiflexors (foot drop)

اسلاید 53: OBLIQUE VIEWSAre rarely indicated and increase both the cost and radiation exposureThe exception would include a young patient with an acute injury or repetitive extension activities, which can result in fracture of the pars interarticularis.

اسلاید 54: Myelography (Myelogram)Largely replaced by MRI Generally not indicated in the evaluation of acute low back pain except in cases where the clinical picture supports a progressive neurologic deficit and the MRI and EMG are nondiagnostic. . Reserved as a preoperative test to correlate examination findings, often in conjunction with a CT scan.

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اسلاید 57: Discography (Discogram)Rarely necessary in the evaluation of acute low back pain and certainly not recommended within the first 3 months of treatment.Patients who have not responded to a well-coordinated rehabilitation program or who have normal or equivocal MRI findings.May have some benefit in localizing a symptomatic disc as the etiology of nonradicular back pain.

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اسلاید 59: Computer Tomography (CT)Provides superior anatomic imaging of the osseous (bony) structures and good resolution for disc herniation.Its sensitivity for detecting disc herniation when used without myelography however is inferior to MRI.

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اسلاید 61: Magnetic Resonance Imaging (MRI)Should not be overusedHas excellent sensitivity in the diagnosis of lumbar disc herniation and is considered the imaging study of choice for root impingement.Its use should therefore be reserved for selected patients.

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اسلاید 63: INDICATIONS OF MRI (IMMEDIATE)Patients with progressive neurologic deficitCauda equina syndromePatients with a suggestive presentation and known history or high risk for malignancy or inflammatory disease.Determining exact levels of pathology in the candidate for a selective nerve root block when physical examination and electrodiagnostic findings are not definitive.

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اسلاید 67: TREATMENT OPTIONSNON OPERATIVE TREATMENTOPERATIVE TREATMENT

اسلاید 68: TREATMENT OPTIONSNON OPERATIVE TREATMENTOPERATIVE TREATMENT

اسلاید 69: NON OPERATIVE TREATMENTREST DRUGSEXERCISESPHYSICAL THERAPY MODALITIESINJECTIONS

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اسلاید 72: APPROPRIATE DIAGNOSTIC TOOLS NEEDED

اسلاید 73: TREATMENT OPTIONSNON OPERATIVE TREATMENTOPERATIVE TREATMENT

اسلاید 74: NON OPERATIVE TREATMENTREST DRUGSEXERCISESPHYSICAL THERAPY MODALITIESINJECTIONS

اسلاید 75: RESTDECONDITIONING SHOULD BE AVOIDED AT THE ONSET BY LIMITING BED REST AND IMMOBILIZATION(2-3DAYS) LYING IN THE MOST COMFORTABLE POSITION(NOT RESTRICTED TO SEMI-FOWLER OR LATERAL POSITION)MOST PREFER CONTINUATION OF ORDINARY ACTIVITIES WITHIN THE LIMITS PERMITTED BY PAIN AS SOON AS POSSIBLE

اسلاید 76: DRUGS ACETAMINOPHEN Nonsteroidal Anti-inflammatory Drugs (NSAIDs)Muscle RelaxantsOpioid Analgesics Oral SteroidsColchicineAnti-Depressant Medications

اسلاید 77: Nonsteroidal Anti-inflammatory Drugs (NSAIDs)Are a reasonable first-line medicationTheoretically offer additional anti- inflammatory effects(most prominent during the first week after injury)By carefully prescribing therapeutic doses at regular intervals, the analgesic and anti- inflammatory properties of these agents will be best realized by the patientProlonged use of these medications(greater than 4 weeks) should be avoided

اسلاید 78: Muscle RelaxantsMuscle relaxants can be used as short-term adjunctive medicationsBenzodiazepines (except low dose diazepam) do not appear to be helpful or indicated in patients with acute low back painCommonly experienced undesirable side effects include drowsiness and fatiguePrescribed prior to bedtime to take advantage of their sedating effects and reduce daytime sedation.

اسلاید 79: Anti-Depressant MedicationsGenerally not necessary in the treatment of acute low back painTricyclic antidepressants, and in particular amitriptyline, have been well studied and supported as useful analgesics in patients with pain of neurogenic originThey can be helpful as adjuncts for pain and sleep if used at bed timeDoses should begin low and slowly increased to minimize side effects

اسلاید 80: Exercise to Optimize Outcome in Low Back PainImprovement in aerobic fitness can improve blood flow and oxygenation to all tissues including the muscles, bones and ligaments of the spineAerobic exercise may also decrease the psychological impact of low back pain by improving mood,decreasing depression, and increasing pain toleranceActive exercise program that emphasizes restoration of normal lumbosacral motion, trunk strengthening, and instruction in proper body mechanics

اسلاید 81: Transcutaneous Electrical Nerve Stimulation (TENS)It is generally used in chronic pain conditions and not indicated in the initial management of acute low back painSuccess rates range greatly due to many factors including electrode placement, chronicity of the problem, and previous treatmentsDocumentation of greater than 50% reduction in pain with a treatment trial may help substantiate its true beneficial effects as opposed to a placebo response.

اسلاید 82: Electrical StimulationHigh voltage pulsed galvanic stimulation has been used in acute low back pain to reduce muscle spasm and soft tissue edema (swelling)Its Use should be limited to the initial stages of treatment, such as the first week after injury so that patients may quickly progress to more active treatment, which includes a restoration of range of motion and strengtheningIt may often be combined with ice or heat to enhance its analgesic effects.

اسلاید 83: UltrasoundIt has been found to be helpful in improving the distensibility of connective tissue, which facilitates stretchingIt is not indicated in acute inflammatory conditions where it may serve to exacerbate the inflammatory responseIt is best use to improve limitations in segmental spinal range of motion following recurrent or chronic low back pain

اسلاید 84: Ultrasound(cont.)The use of ultrasound is contraindicated over a previous laminectomy or peripheral nerve secondary to alterations in membrane stabilityIt should be discontinued as segmental motion is improved with the patient then moved into an active strengthening program and eventual transference to an independent home exercise program.

اسلاید 85: Superficial HeatSuperficial heat can produce heating effects at a depth limited to 1-2cmIt has been found to be helpful in diminishing pain and decreasing local muscle spasmshould be used as an adjunct to facilitate an active exercise programIt is most often used during the acute phases of treatment when the reduction of pain and inflammation are the primary goals

اسلاید 86: CryotherapyIce packs or cryotherapy are generally more effective in terms of depth of penetration than other superficial thermal modalitiesThis is helpful in reducing local metabolism, inflammation, and painThe analgesic effects of ice result from a decreased nerve conduction velocity along pain fibers and a reduction of the muscle spindle activity responsible for mediating local muscle tone.

اسلاید 87: Cryotherapy(cont.) It is usually most effective in the acute phase of treatmentIt is applied over an area for 15-20 minutes, 3-4 times per day initially and then on an as needed basisPeripheral nerve injury and local frostbite secondary to prolonged cryotherapy has been previously described, emphasizing the need for monitoring of cryotherapy use.