Orthopaedic inpatients spinal cord

Indication of decompression surgery ( disc prolapse )

X improvement w/ conservative surgery

Increase in neurological deficit

Bldder + bowel symptoms

Objective findings consistent w/ repeated symptoms

Surgical management for prolapsed disc

Disectomy: w/ partial laminectomy → disc excision for pain relief —> lower rate of return of physical signs of weakness

Microdisectomy: disc excisaion w/ small incisions under endoscope

Indications for lumbar spine stenosis

Intervertebral disc loses fluid content —> bulges into canal

Spinal facet joints enlarge w/ arthritis —> bulges into canal

—> stenosis of spine —> narrowing of canal

Symptoms: low back pain

—> neurogenic claudication ( pins + needles / numb in legs )

—> leg cramps

—> leg weakness

description of laminectomy

Removal of piece of lamina to lower pressure on spinal root/ cord

Indications for spinal fusion surgery

Instability: secondary segmental instability/ degenerative disc disease/ unstable traumatic fractures/ spondylolisthesis

Congenital/ acquired deformity: scoliosis/ kyphosis/ spondylolisthesis

Others: osteomyelitis/ TB/ neoplasm

Description of spinal fusion

removal of disc + place cage in disc place + place pedicle screws posteriorly —> minimise movement at that level for bone fusion to happen

Artificial disc replacement ( alternative to spinal fusion ) description

Artificial disc provides proper intervertberal spacing to preserve motion segment —> contraindication: severe facet degeneration

Post op physio management

Immobilisation of spine w/ thoracolumbosacro orthosis —> worn for majority of the day

—> presentation: supine w/ bed flat + adequate analgesia

Stage 1: soft tissue prep

Stage 2: instrumentation

Education: back care

Surgical complications for spinal surgery

Dural tear

haematoma formation

wrong site surgery/ inadequate decompression

respiratory

DVT

Infection

Hardware failure

principles of medical management of spinal trauma

Spine stability: ability of spine to withstand load w/o pain/ neurological damage/ deformity

—> potential to increase neurological compromise + spine deformity ( thoracic kyphosis )

Mechanisms more likely to be unstable #: flexion/ flexion + rotation/ hyper E if neural arch fractured

Neurological involvement: unstable spinal fractures —> greater risk

—> higher prevalence in: young + high energy trauma / elderly w/ low energy trauma + degenerative canal narrowing

Patient factors: comorbidities/ anaesthetic risk/ previous level of function/ bone quality

Medical assessment of spinal trauma

Clinical examination:

palpation: tenderness/ spinous process step

Neurological exam

Radiology:

X rays: AP/ Lateral/ Area specific / under load: flexion + extension; erect or stadnding

CT scan: spine #s

MRI scan: ligamentous disruption

Alignment used for radiology cervical spine

Anterior vertebral line

Posterior vertebral line

Spinolaminar line

Posterior spinal line

Type of cervical spine # types + MOI

Fracture type: anterior wedge/ burst

MOI:

Vertebral arch #: hyperE

fracture dislocation: flexion rotation

Burst #: vertical compression

Crush #: flexion

Stable + unstable cervical # Mx

Stable: brace —> lower risk of spinal deformity + pain relief

e.g. soft collar/ philadelphia / bivalved CTLSO/ Minerva

Unstable:initial: skeletal traction w/ skull tongs/ operative fixation/ halo thoracic vest

Type of thoracic spine # types + MOI + Mx + lumbar # Mx

Mostly stable bc rib cage support —> Mx: TLSO e.g. Jewett/ cash brace

Unstable: high velocity injury —> Mx: operative fixation

MOI: flexion —> vertebral body crush fracture / osteoporotic crush # ( pathological )

Lumbar # Mx: unstable: operative fixation/ stable: lumbar brace

Complications of spinal fractures

Neurological injury

Circulatory: DVT/ postural hypotension

Skin/ pressure injuries

Respiratory complications

Infections

physio management of spinal injury initial

Pain Mx:

elective surgery: impact of chronic pain

Trauma: pain from spine trauma + surgery

Neurological Ax

Wound

Impact of pain on respiratory/ mobility function

Subjective questions for physio Mx of spinal injury

Pain: location + severity at rest + w/ movement

—> post surgery + impact on radicular pain

Sensation: areas of altered sensation + patterns

Power: changes to muscle strength compared to before the operation

Patient goals

Objective Ax for physio Mx of spinal injury

Check sensation: light touch + systematic Ax of dermatomes

Check power: MMT ( modified for position + pain ) + grading

Muscle activation

Mobility

Neurological Ax purpose + components

purpose: establish baseline of normal sensation + strength

Light touch sensation in LL dermatomes

Muscle power in restrictions of pain

Reflexes

Post op physio Mx for disectomy + laminectomy

Neurological Ax

Circulation( static glute + quad + heel slides + knee/ ankle pumps ) + respiratory exercises ( incentive spirometry + deep breathing )

Bed mobility: log rolling technique

Msk exercises: muscle activation + gentle spine mobility

SOOB as pain tolerated

Mobilise on doctors orders + progress to independence

Education: back care, lifting restrictions—> reduce risk of re-herniation , ergonomic advice

Out-patient department referral for muscle stability, neural mobilisation, progression

Scoliosis post-op physio Mx

Spine precautions bwt unstable bwt first + 2nd stage procedures

Fusion across mulitple levels —> higher pain associated

Significant + immediate changes to overall posture + biomechanics + balance + reactions + gait

Higher chance of circulation, pressure, visual complications

Impact of blood loss on mobility —> check haemoglobin count before mobilisation

Back care education

Physio Mx for post spinal fusion

Variable use of post- op bracing for early protection to spinal fusion

Neurological monitoring

Circulation + respiratory exercises

Mobility: posture + muscle activation —> gentle early ROM spine exercises

Education: graduated return to activity inc walking/ posture + back care/ smoking cessation

Discharge considerations for post spinal fusion

Longer stay bc more painful than decompression surgeries

—> ensure abilities in activities match home environment + supports in place

Respiratory Mx considerations

Considerations

Time physio respiratory Mx in time w/ pain relief

Support incision site for painful activities

Why need respiratory Mx: pain from spinal # reduces tidal volume + issues w/ sputum clearance + immobilisation

—> techniques to raise inspiratory effort + sputum clearance

—> positioning: sitting up/ out of bed/ mobilisation —> prevent complications

Neural mobility exercise

Stage 1: large through range DF + PF + hip abduction + adduction in neurtral

progression: PF/ DF in small amount of SLR on pillow

Stage 2: through range knee extension in some hip F

Stage 3: continue techniques + progress through degrees of hip flexion

Aim: pain + symptom relief + limit scarring in intra/ extraneural tissue

Circulation Ax considertions

AX for DVT —> calf pain/ swelling/ tenderness/ redness/ temp changes

—> inform medical team + document Ax + whom you told

Skin/ pressure injury prevention

Use appropriate equipment

Pressure relieving air mattress/ cushions

Spinal turn beds: facilitate maintenance of spinal precautions + pressure relief

Remove braces for skin checks + pressure relief

Mobilisation