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รกัษิณา วนิัยธรรมกลุ Ramathibodi 5402132
ผู้ป่วยหญิงไทยหมา้ย อายุ 70 ปีChief complaint : ปวดขาซา้ย 2 เดือนก่อนมารพ.
Present illness : 1 ปีก่อนมารพ. ขณะกำาลังรดนำ$าต้นไม้ ล่ืนล้ม สะโพกขากระแทกพื$น ใชม้อืขวายนัพื$น หลังล้ม เจบ็บรเิวณขอ้
มอืขวา แต่ไมม่าก ไมม่บีวมแดง ไมม่ขีอ้มอืผิดรูป ไมเ่จบ็สะโพก ขา้งขวา ไมไ่ด้ไปพบแพทยห์ลังจากนั$น อาการปวดดีขึ$นเอง ใช้
งานงอเหยยีดขอ้มอืได้สดุตามปกติ
– 2 เดือน ก่อนมารพ. ปวดสะโพกซา้ย รา้วลงขาซา้ย รา้วลงไปถึงน่อง ไมม่ขีาอ่อน แรง ไมม่ขีาชา ไมม่แีผลท่ีเท้า
– อาการปวดเป็นมากขึ$นเวลาเดิน เดินได้ระยะทางสั $นลง เดินได้น้อยกวา่ 5-10 เมตร นัง่พกัประมาณ 5-10 นาที แล้วเดินต่อได้ และตอนก้มหรอืแอ่นหลังจะปวดมากขึ$น
– ตอนนัง่พกัไมค่่อยปวด ไมม่ปีวดกลางคืน– ไมม่เีบื่ออาหาร นำ$าหนักลด– มอีาการกลั$นปัสสาวะไมไ่ด้ เวลาปวดปัสสาวะ จะมปีัสสาวะราดเปียกกางเกงชั $นใน– ถ่ายอุจจาระได้ปกติ
Personal history :
- โรคประจำาตัว HT , DLP
- ไมม่ปีระวติัมะเรง็ในครอบครวั- ไมม่ปีระวติัแพย้าแพอ้าหารPast History
- ปฏิเสธประวติัผ่าตัดก่อนหน้านี$
Physical Examination
– Vital signs : Body temp 37 , BP 150/80 mmHg, PR 80 bpm , RR 20 /min
– GA : A Thai woman , good consciousness
– HEENT : no pale conjunctivae , anicteric sclera
– Heart : full regular pulse, normal s1s2, no murmur
– Lungs : clear and equal both lungs
– Abdomen : soft, not tender
– Abdomen : not distention , normoactive bowel sound , soft, not tender
– Gait : antalgic gait Lt.
– Neck : normal alignment, no tender point, full motion
– Back : Inspection > loss of lordosis, tender area at lower lumbar
– Palpation > no mark pain on percussion , no trigger point
– No radiated pain on extension, SLR test negative, cross SLR test negative
– Hip joint motion : full ROM all direction both sides
– SI joint ( sign of four) : normal
Neurovascular
– Full 2+ Lt.PTA, Lt. dorsalis pedis artery
– Normal capillary refill < 2 sec
– Moter power of left plantar flexion and dorsiflexion gr. V
DTR 2+ allsensory :normal
Level Rt Lt
C5 V V
C6 V V
C7 V V
C8 V V
T1 V V
T2-9 V V
T10-12 V V
L2 V V
L3 lV V
L4 V V
L5 V V
S1 V V
Bladder sphincter
Anal sphincter >> loose sphincter tone
Problem lists
– Lumbosacral radiculopathy
– Bowel & bladder involvement
Differential diagnosis
Mechanical causes
– Spondylolysis
– Compression fracture
– Traumatic fracture
– Alignment disorder ( kyphosis, scoliosis, spondylolisthesis)
Non mechanical cause
- Malignancy
- infection
INVESTIGATION
LS spine AP
LS spine lateral
LS spine flexion - extension
Oblique view
DIAGNOSIS
– Spondylolisthesis WITH cauda equina syndrome
Spondylolisthesis
Spondylolisthesis
– Symptom
– mechanical/ back pain
– most common presenting symptom
– usually relieved with rest and sitting
– neurogenic claudication & leg pain
– second most common symptoms
– defined as buttock and leg pain/discomfort caused by upright walking
– relieved by sitting
– not relieved by standing in one place (as is vascular claudication)
– may be unilateral or bilateral
– same symptoms found with spinal stenosis
– cauda equina syndrome (very rare)
L4 nerve root involvement
– (compressed in foramen with L4/5 DS)weakness to quadriceps
– best seen with sit to stand exam maneuver
– weakness to ankle dorsiflexion (cross over with L5)
– best seen with heel-walk exam maneuver
– decreased patellar reflex
L5 nerve root involvement
– weakness to ankle dorsiflexion (cross over with L4)
– best seen with heel-walk exam maneuver
– weakness to EHL (great toe extension)
– weakness to gluteus medius (hip abduction)
provocative walking test
- have patient walk prolonged distance until onset of buttock and leg pain
- have patient stop but remain standing upright– if pain resolves this is consistent with vascular claudication
- have patient sit
– if pain resolves this is consistent with neurogenic claudication (DS)
Imaging
– recommended views
– weight bearing lumbar AP, lateral neutral, lateral flexion, lateral extension
– findings
– slip evident on lateral xray
– flexion-extension studies
– instability defined as 4 mm of translation or 10° of angulation of motion compared to adjacent motion segment
MRI
indications
– persistent leg pain that has failed nonoperative modalities
– best study to evaluate impingement of neural elements
views
– T2 weighted sagittal and axial images best to look for compression of neurologic elements
Classification
Wiltse-Newman Classification Type I • Dysplastic: a congenital defect in pars
Type II-A • Isthmic - pars fatigue fx
Type II-B • Isthmic - pars elongation due to multiple healed stress fx
Type II-C • Isthmic - pars acute fx Type III • Degenerative: facet instability without a pars
fx
Type IV • Traumatic: acute posterior arch fx other than pars
Type V • Neoplastic: pathologic destruction of pars
Myerding Classification Grade I • < 25%
Grade II • 25-50%
Grade III • 50-75%
Grade IV • 75-100%
Grade V • spondyloptosis
Treatment
Nonoperative
– physical therapy and NSAIDS
– indications
– most patients can be treated nonoperatively
– modalities include
– activity restriction
– NSAIDS
– PT
– epidural steroid injections
– indications
– second line of treatment if non-invasive methods fail
Operative
lumbar wide decompression with instrumented fusion indications
– most common is persistent and incapacitating pain that has failed 6 mos. of nonoperative management and epidural steroid injections
– progressive motor deficit
– cauda equina syndrome
– outcomes
– ~79% have satisfactory outcomes
– improved fusion rates shown with pedicle screws
– improved outcomes with successful arthrodesis
– worse outcomes found in smokers
posterior lumbar decompression alone
– indications
– usually not indicated due to instability associated with spondylolithesis
– only indicated in medically frail patients who cannot tolerate the increased surgical time of performing a fusion
– outcomes
– ~69% treated with decompression alone are satisfied
– ~ 31% have progressive instability
Anterior lumbar interbody fusion (ALIF)
indications
– reserved for revision cases with pseudoarthrosis
– outcomes
– injury to superior hypogastric plexus can cause retrograde ejaculation
References
– http://www.orthobullets.com/spine/2039/degenerative-spondylolisthesis
– http://www.orthobullets.com/spine/2038/adult-isthmic-spondylolisthesis