India-Orth16.How Will You Objectively Confirm Your Diagnosis Of Prolapse Disc?
I Will Like To Go For An Mri With Contrast Enhancement Which Will Show The Prolapse Of Disc Along With Extrusion Of Nucleus Pulposus Material Going Beyond The Borders Of Annulus Fibrosus And Thus Narrowing Lateral Foraminal Structure From Where The Nerve Passes.
Even Contrast Myelogram Also Gives The Idea Of Areas Of Thecal Sac Compression
17.What Are Red Flag Signs?
Red Flag Signs Are The Symptoms And Signs Which Warrants Further Extensive Work Up For Investigations And Due Consideration For An Surgical Alternative
A)Fracture
B)Tumor /Infection
C)Progressive Neurological Deterioration
D)Bladder Bowel Involvement
E)Major Motor Weakness
What Are The Types Of Disc Herniations?
There Are Following Types Of Disc Herniations
A)Central
B)Paracentral
C)Lateral Or Foraminal
D)Far Lateral Or Extraforaminal
Of All Of Above The Paracentral Disc Herniation Is The Commonest One Compressing The Traversing Nerve Root.
While In Lateral Or Far Lateral Disc It Is The Exiting Nerve Root Which Gets Compressed By The Disc .
18.Which Is The Common Neurological Involvement In Slipped Disc At L5-S1 Level And Why?
Generally When There Is Sliipage Of Intervertebral Disc , It Is Posterolateral As That Is The Weak Area Not Covered By Posterior Longitudinal Ligament.
Now There Are Two Types Of Nerve Exits At One Level
A)One Is Called Exiting Nerve Root Which Exits The Segmental Level Above The Disc Just Below The Pedicles
B)Another Is The Traversing Nerve Root Which Exits One Level Below
So At The Time Of Disc Protrusion It Is The Traversing Nerve Root Which Gets Compressed Commonly Rather Than The Exiting Nerve Root(Exception Lateral And Far Lateral Disc Herniation)
So In L5-S1 Disc Prolapse It Is The Involvement Of S1 Nerve Root And Not The L5 Nerve Root.
19.What Is The Neurological Manifestation Of L4-L5 Disc Prolapse ?
Sensory—Altered Sensation In Lateral Half Of The Leg With Dorsum Of Foot
Motor---Weak Extensors Of Toes
Reflexes---No Exact Reflexology Is Possible But Some Books Have Mentioned About Elicitation Of Peroneal Reflex
20.What Are The Features For Si Joint Pain And How Will You Confirm Your Diagnosis?
For Sacroiliac Dysfunction One Has To Look For Following Features
A)Unilateral Dull Aching Pain On Buttocks Generally Not Going Beyond Knee
B)Pain On Standing, Sitting For A Long Time, Running, Jumping, Bending Etc
C)Prone Stretch Test, Flexion –Abduction-External Rotation Test Positive., Straight Leg Test Positive, Gaenslens Test Positive( Not A Single Test Is Sensitive And Specific Hence One Has To Perform All The Tests)
The Diagnostic For Si Joint Pain Is The Diagnostic Local Anaesthetic Block Under Flouroscopy.
21.What Is Piriformis Syndrome?
It Is The Unique Condition In Which One Has The Symptoms Signs Of Sciatic Nerve Compression By Piriformis Muscle In The Posterior Hip Region
Patient Has Symptoms Of Nerve Compression On Getting The Provocative Measures Like Stretching The Piriformis On Internally Rotating The Hip Joint.
There Is Also Deep Tenderness In The Gluteal Region.
22.How Shall You Diagnose Myofacial Pain?
Pain Which Is Localized With Muscle Tenderness With Limited Flexion And Extension And Without Any Radiation Helps In Diagnosing Myofacial Type Of Pain
23.What Is Fibromyalgia?
Key Features Of Fibromyalgia
A)Generally Seen In Women
B)Widespread Myalgia And Arthralgia
C)Fatigue
D)Unrefreshed Sleep
E)Psychological Involvement
F)Multiple Tender Points
G)Somatic Symptoms
24.What Is Spinal Stensosis And How Will You Clinically Diagnose It?
Spinal Stenosis Is The Pathological Entity Of The Spine In Which There Is Anatomical Or Functional Narrowing Of Osteoligamentous Structures Of Vertebral Canal/ Or Transverse Foraminal Canal Causing Direct Compression Of Dural Sac Or Indirect Compromise Of Dural Sac, Nerve Roots Or Vasculature Enough To Cause Neurological Symptoms/Signs.
Clinically Patient Will Have Pain On Walking Because The Vascular Supply To The Nerves Gets Compromised During Exertion By Surrounding Compressive Pathologies As A Result Nervous Tissue Is Starved Of Oxygen.
There Will Be Pain On Extension Because Of More Narrowing Of Spinal Canal And Some Relief On Flexion Because Of Relative Widening Of Spinal Canal On Flexion
There Will Be Radiating Pain With Neurological Claudication
It Has To Be Differentiaed With Vascular Claudication In Which There Will Be Vascular Compromise Of The Lower Limb With Cramps As The Main Feature .
25.Will You Prefer Nsaids In Neuropathic Pain?
My Preference Shall Be More For The Drugs Which Are Acting At The Level Of Nervous Tissue Either Peripherally Or Centrally Because In Neuropathic Pain There Occurs The Pathologic Process In The Nerve Tissue Itself Either Defective Conduction Or Sensitization.
In Such Scenarios Nsaids Are Not Of Much Help Unlike In Nociceptive Variety Of Pain Where There Is Actual Or Potential Tissue Damage Present With An Inflammation.
So My Preference In Neuropathic Pain Will Be Drugs Of Classes Like Antidepressants, Anticonvulsants, Gabapentins,Serotonin –Norepinephrine Reuptake Inhibitors Etc.
26.What According To You Are The Controversies In The Field Of Back Pain Management?
Back Pain Management Has Remained Very Controversial Right From The Begiining As There Were So Many Theories Postulated For The Back Pain With Neither Having A Sound And Fullproof As To The Exact Nature Pinpointing The Cause Of Back Pain In A Given Patient.
Controversies Have Surrounded The Use Of Rest In Back Pain ,Use Of Traction, Use Of Braces, Use Of Alternative Therapies Like Chiropractise, Massage, Lasers, Electotherapy, Ozone Etc
As Far As Surgical Aspect Is Concerned One School Of Thought Believes In Fusion Of Spine To Eliminate Any Motion Between The Spine Segments But Now According To Recent Trend Another School Of Thought Has Started Beleiving In Keeping The Spine Mobile As Fusion Transfers The Loads To The Mobile Segments Which In Itself Becomes The Cause Of Back Pain..
The Latest Finding Of The Nerves Which Transmits Disc Pain Apart From Somatic Nerves Is The Pain Transmission Through The Sympathetic Fibres So In Such Cases Interventional Pain Practise By Giving Diagnostic Blocks Have Brought About Revolution In Diagnosing Exact Cause Of Back Pain.
27.How Will You Clinically Test Lumbar Instability?
Always Study The Spine In Neutral , Flexed And Lordotic Postures.
Eliminate Gravity By Proximal And Distal Trunk Supports.
Make Trunk Horizontal That Is To Examine Both In Supine And Prone Position To Maximise Shear Forces To Test The Instability Component Of Vertebra.
29.Is There Any Role Of EMG In Back Pain?
Electromyographic Studies Have A Place To Rule Out Whether The Pain Is Due To Nerve Root Involvement Or Due To Peripheral Neuropathy Or Due To Muscle Tissue Itself Like In Myopathies.
It Also Has The Prognostic Values
30. What Is The Difference Between Williams And Mckenzie Exercises For Back Pain?
Williams Flexion Exercises Described By Dr Paul Williams In 1937 Were Developed To Moderate The Balance Between Paraspinal Extensor Groups Of The Lumbar Spine And Abdominal Or Flexor Group In The Same Region.These Exercises Hope To Provide An Overall Increase In Trunk Stability In The Lumbar Region By Developing Core Muscle Groups In Abdomen, Posterior Hip Musculature And Posterior Thighs.
In Contrast Mc Kenzie Exercises Are For The Restoration Of Lumbar Lordosis Via Extension Based Treatment Of Acute Low Back Pain And Hence They Are Often Used In Discogenic Pain To Avoid Positioning In The Flexion Which Exacerbates The Pain.
31.How Shall You Differentiate A Pathological Compression Fracture From An Osteoporotic Fracture?
Clinically One Has To Take Into Account The History Of
A)Recent Trauma, Low Energy Falls
B)Prior History Of Cancer
C)H/O Weight Loss, Loss Of Appetite
D)Restpain , Night Pain
E)H/O Fever
Mr Findings In Osteoprotic Lesions
A)A Low Signal Intensity Band On T1 And T2 Weighted Images
B)Spared Normal Bone Marrow Signal Intensity
C)Multiple Compression Fractures
Mr Finding In Metastatic Lesions
A)Conves Posterior Vertebral Body
B)Involvement Of Pedicles And Posterior Elements
C)Epidural Mass That May Encase Neural Elements
D)A Focal Paraspinal Mass
E)Other Spinal Metastatic Lesions.
32.What Is The Difference Between Myelopathy And Radiculopathy?
Simply Said Myelopathy Is A Disease Of The Spinal Cord And Radiculopathy Is A Disease Of Nerve Roots.
The Pathophysiology Of Myelopathy Is Thought To Be Ischaemia From Spinal Cord Compression And If It Occurs On A Chronic Basis That Leads To Irreversible Changes And Ultimately Cord Dysfunction.
The Presentation Of Myelopathy Can Be Subtle. In Case Of Cervical Myelopathy Patient Can Have Bilateral Hand Numbness, Motor Weakness, Gait Abnormalities, Bladder Bowel Dysfunction. Findings May Include Positive Babinski, Hyperreflexia,Etc
The Pathophysiology In Radiculopahty Is Compression Of The Nerve Root Which Leads To Pain And Motor Weakness.The Location Of Pain Is Dermatomal And Motor Weakness Is In A Segemental Pattern.
Mri Is The Investigation Of Choice In Both The Conditions.
33.What Is Sciwora?
Sciwora Is Spinal Cord Injury Without Radiological Abnormality That Means There Are Symptoms And Signs Of Spinal Cord Injury Without Any Demonstrable Injury To Bony Or Ligamentous Spinal Column And Without Any Demonstration Of Instability On X Rays, Myelogram Or Ct Scan.
It Most Commonly Occurs In Children Aged 9 Years Of Younger At The Level Of Upper Or Lower Cervical Spine.
Now With The Advent Of Mri One Can Pinpoint Spinal Cord Damages Prognosis Is Guarded.
