1. اسكوليوز

2. تعريف اسكوليوز
انحراف جانبي ستون فقرات

4. علل ايديوپاتيك نوروماسكولار مادرزادي نوروفيبروماتوز
بيماريهاي مزانشيمي (مارفان “ اهلر دانلوس “ )
ارتريت روماتويد نوجوانان
تروما (شكستگي , بدنبال لامينكتومي , توراكوپلاستي )
استوكوندروديستروفيها ( دوارفيسم , استوژنز ايمپرفكتا , اكوندروپلازي )

5. ادامه علل
عفونت
بيماريهاي متابوليك ( دوارفيسم ,هوموسيستونوري )

7. پره والانس و شيوع جنسي 2-3 درصد
2-3 درصد
هرچه درجه قوس بالاتر باشد در دخترها شايع تر است و به 4 برابر ميرسد .

8. ارث
Scoliosis Is a single gen disorder .?

9. Natural history مرگ 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 .

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

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 .

12. فونكسيون ريه فقط در قوسهاي توراسيك ارتباط مستقيم دارد .
سيگار و hypokyphosis با عملكرد ريه ارتباط دارد .

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

14. ترمينولوژي(اصطلاحات )
Cervical curve : apex between C1 & C6
cervicothoracic curve :apex between C7 & T1
thoracic curve :apex between T2 & T11
thoracolumbar curve :apex between t12 & L1
Lumbar curve :apex between L2& L4

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

16. School screening test 10-14 سالگي روش تست . حساسيت تست : 100%
سالگي
روش تست .
حساسيت تست : 100%
اختصاصي تست : % 45

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

21. گرافي ap ايستاده

22. گرافي لاترال

24. اثر راديوگرافي بر بافتها
پستان , مغز استخوان , گنادها , تيرويد
AP or PA (5-10 )

25. درمان اسكوليوز
تحريك الكتريكي
تحت نظر
ارتوز
عمل جراحي

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

27. observation در قوسهاي زير 20 درجه كاربرد دارد .
در قوسهاي زير 20 درجه كاربرد دارد .
قوسهاي زير 20 در سنين كودكي هر 6-12 ماه گرافي AP
قوسهاي زير 20 در سنين نوجواني هر ماه گرافي AP
قوسهاي زير 20 در سنين بعد از بلوغ احتياج به اقدام خاص ندارد .

28. بريس قوسهاي 20-29 درجه اي كه پيشرفت داشته باشند .(5 درجه در طي 6 ماه )
قوسهاي 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 .

29. كونتراانديكاسيونهاي بريس
بلوغ اسكلتي
لوردوز توراسيك
قوس بالاي 45 درجه

30. انواع بريس

37. هرني ديسكال

38. اناتومي

39. تغذيه ديسك فاقد عروق خوني است .
از طريق بخش متخلخل مركزي end plate به روش انتشار تغذيه ميگردد .

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 )

44. محل شايع دژنرسانس ديسك
L4-L5 & L3-L4

45. علايم باليني هرني ديسكال
درد كمريا گردن, مشخصات درد
درد تير كشنده به ساق
اسپاسم عصلات كمري
اختلال حسي و حركتي
اختلال رفلكس عصبي
SLR

46. ريسك فاكتورهاي LBP شغل سنگين كار روي وسايط نقليه سيگارت زايمان زياد
قد بالاي 180
وزن بالا
شغل همراه استرس

47. علايم ديسك گردني
علايم 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 .)

48. IMAGING IN LOW BACK PAIN

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.

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)

51. RED FLAGS (POSSIBLE TUMOR OR INFECTION)
Age over 50 or under 20,history of cancer
Constitutional symptoms,such as recent fever or chills or unexplained weight loss
Risk 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

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

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

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.

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.

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.

61. Magnetic Resonance Imaging (MRI)
Should not be overused
Has 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.

63. INDICATIONS OF MRI (IMMEDIATE)
Patients with progressive neurologic deficit
Cauda equina syndrome
Patients 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.

67. TREATMENT OPTIONS
NON OPERATIVE TREATMENT
OPERATIVE TREATMENT

68. TREATMENT OPTIONS
NON OPERATIVE TREATMENT
OPERATIVE TREATMENT

69. NON OPERATIVE TREATMENT
REST
DRUGS
EXERCISES
PHYSICAL THERAPY MODALITIES
INJECTIONS

72. APPROPRIATE DIAGNOSTIC TOOLS NEEDED

73. TREATMENT OPTIONS
NON OPERATIVE TREATMENT
OPERATIVE TREATMENT

74. NON OPERATIVE TREATMENT
REST
DRUGS
EXERCISES
PHYSICAL THERAPY MODALITIES
INJECTIONS

75. REST
DECONDITIONING 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

76. DRUGS ACETAMINOPHEN Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Muscle Relaxants
Opioid Analgesics
Oral Steroids
Colchicine
Anti-Depressant Medications

77. Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Are a reasonable first-line medication
Theoretically 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 patient
Prolonged use of these medications(greater than 4 weeks) should be avoided

78. Muscle Relaxants
Muscle relaxants can be used as short-term adjunctive medications
Benzodiazepines (except low dose diazepam) do not appear to be helpful or indicated in patients with acute low back pain
Commonly experienced undesirable side effects include drowsiness and fatigue
Prescribed prior to bedtime to take advantage of their sedating effects and reduce daytime sedation.

79. Anti-Depressant Medications
Generally not necessary in the treatment of acute low back pain
Tricyclic antidepressants, and in particular amitriptyline, have been well studied and supported as useful analgesics in patients with pain of neurogenic origin
They can be helpful as adjuncts for pain and sleep if used at bed time
Doses should begin low and slowly increased to minimize side effects

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

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 pain
Success rates range greatly due to many factors including electrode placement, chronicity of the problem, and previous treatments
Documentation of greater than 50% reduction in pain with a treatment trial may help substantiate its true beneficial effects as opposed to a placebo response.

82. Electrical Stimulation
High 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 strengthening
It may often be combined with ice or heat to enhance its analgesic effects.

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

84. Ultrasound(cont.)
The use of ultrasound is contraindicated over a previous laminectomy or peripheral nerve secondary to alterations in membrane stability
It 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.

85. Superficial Heat
Superficial heat can produce heating effects at a depth limited to 1-2cm
It has been found to be helpful in diminishing pain and decreasing local muscle spasm
should be used as an adjunct to facilitate an active exercise program
It is most often used during the acute phases of treatment when the reduction of pain and inflammation are the primary goals

86. Cryotherapy
Ice packs or cryotherapy are generally more effective in terms of depth of penetration than other superficial thermal modalities
This is helpful in reducing local metabolism, inflammation, and pain
The 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.

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