2. SYMPTOMS  Pain  Sciatica  Stiffness  Deformity  Numbness or paraesthesia  Urinary symptoms  Other

3. Signs with the patient standing Look › Skin › Shape and posture Feel › Tenderness Move › Flexion / Extension › Rotation / Lateral flexion

4. Signs with patient lying face downwards › Bony outlines › Tenderness › Sensations and Power › Femoral stretch test Signs with patient lying on his back › Straight leg raising test (sciatic stretch) › Neurological examination of lower limbs › Circulation in the limbs › Rectal examination

6. 0Total paralysis 1Barely detectable contracture 2Not enough to act against gravity 3Strong enough to act against gravity 4Still stronger but less than normal 5Full power

7.  Plain x-rays › AP and lateral views › Oblique views › PA view of S.I. Joint  Computed tomography (with mylography)  MR imaging  Radioisotope scanning  Discography and facet joint arthrography

8. Lifetime incidence ranges from 60 -80% Most cases resolve spontaneously D/Dx: › Simple back pain (non specific low back pain) › Nerve root pain › Possible serious spinal pathology

9.  Presentation 20 - 50 years  Lumbosacral, buttocks and thigh  “Mechanical” pain  Patient well  Specialist referral not required

10.  Vast majority improve within 2 months  Symptomatic Rx with Aspirin/NSAIDs  Bed rest should be limited to 1-2 days  ? Corsets, TENS, Traction  Exercise - Stretching & range of motion active

11.  Pain that persists after 3 months  < 5% of patients with L.B.P develop Ch.L.B.P  Multiple factors › Disc, facet joints, annulus fibrosis, ligaments  Psychosocial factors  Surgery is rarely helpful  Functional restoration programme

12.  Uncommon in very young and the very old  Nerve root pain follows the dermatome of the involved nerve  Pain is generally worse in the leg than in the back  Exacerbation of leg pain by straining, sneezing or coughing  Localised neurological signs

13.  Large midline disc prolapse  Compresses several nerve roots  Sphincter disturbance  Saddle anaesthesia  Prompt surgical intervention

14. Conservative › Bed rest for 48-72 hours › NSAIDs › Epidural steroids › 85% relief rate Surgical treatment › 10-15% of patients ultimately require surgery › More rapid relief but the ultimate end point is the same regardless of treatment

15.  Commonest cause of neurologic leg pain in older patients  Symptoms  Neurogenic claudication - Vascular claudication  Treatment

16.  Presentation under age 20 or onset over 55  Thoracic pain  Past hx of carcinoma, steroids  Unwell, weight loss  Widespread neurology  Structural deformity  Abnormal blood parameters

17.  Forward slippage of one vertebral body on another  Causes › Congenital › Isthmic › Traumatic › Pathologic › Degenerative  Treatment

18. Forward slippage of one vertebral body on another

21. Deformity may occur in either coronal or sagittal plane Scoliosis - Lateral curvature of the spine › Structural › Nonstructural Kyphosis - Sagittal plane deformity in the thoracic or thoracolumbar spine

22. Idiopathic Scoliosis 80% of all scoliosis Adolescent - age 10 or over Juvenile - age 4 to 9 Infantile - age 3 or under

24. Structural scoliosis presenting at or about the onset of puberty and before maturity 80 % of cases of idiopathic scoliosis Mostly (90%) in girls Predictors of progression very young age marked curvature Risser sign

25. Treatment Prevent a mild deformity from becoming severe Correct an existing deformity Nonsurgical treatment Curves between 20-40 when spinal growth is incomplete Curves >30 (Risser 2 or less) even if no progression Surgical treatment Curves >40 in skeletally immature Unbalanced curves between 20 - 40 in skeletally immature Curves >50

27. Due to congenital anomalous vertebral development Hemivertebrae Wedged vertebrae Fused vertebrae Absent or fused ribs Treatment Early fusion in progressive curves

29. Causes Poliomyelitis Cerebral palsy Syringomyelia Friedrich’s ataxia Muscular dystrophies Typical paralytic curve is long, convex towards the side with weaker muscles

30. Treatment Mild curves No treatment Moderate curves with spinal stability As for idiopathic scoliosis Severe curves Fitting a suitable sitting support Surgical stabilization of the entire spinal segment

31.  Postural (Round back)  Compensatory  Structural

32. Causes Postural kyphosisPostradiation kyphosis Scheuermann’s diseaseMetabolic disorders MyelomeningoceleSkeletal dysplasias Traumatic kyphosisTumourous conditions PostsurgicalInfections

33. Excessive thoracic kyphosis (Cobb angle >45° with wedging of 5° or more) of at least 3 adjacent apical vertebrae and vertebral end plate irregularities Aetiology unknown Incidence 1% of general population with slight female dominance

35. Treatment Orthotic treatment Skeletally immature - Milwaukee brace(poor compliance) Surgical (rare) Severe deformity in skeletally mature Severe deformity and neurologic signs