• تشوه العمود الفقري / الجنف / استشاري جراحة العمود الفقري في الاردن / علاج مرضى العمود الفقري بطرق جراحية وغير جراحية / جراحة العمود الفقري بالتداخل المحدود / عمليات الديسك / "الديسك" أو الإنزلاق الغضروفي / علاج الديسك / عمليات الديسك / الم الظهر من الديسك / جراحات الديسك / علاج الديسك في الاردن / اطباء الديسك / اطباء الديسك في الاردن / اسباب الديسك / الام الديك / الام العامود الفقري / اسباب الانزلاق الغضروفي / اوجاع الديسك / اعراض الديسك / علاج الديسك / افضل اطباء الديسك في الاردن / اسرع علاج ديسك في الاردن / افضل طبيب لعلاج الانزلاق الغضروفي / افضل طبيب لعلاج انزلاق الغضروفي في الاردن / كسور الفقرات / قوس العمود الفقري عند الكبار / حقائق عن آلام الظهر والديسك / عمليات تحرير العصب / ألم الظهر المزمن علاج ألم الظهر المزمن / لانزلاق الغضروفي / عندي آلام شديدة في أسفل / خدران في اليد / خدران او تنميل اليد / خدران الرجل / خدران الساق / خدران الاطراف / تنميل الاطراف / تنميل اليد / رجوع الديسك

1. InfectionsInfections of the Spineof the Spine
F ihF ih Od hOd h Ab HAb HFreihFreih OdehOdeh Abu HassanAbu Hassan
F.R.C.SF.R.C.S.(.(Eng.), F.R.C.S.(Tr.&Eng.), F.R.C.S.(Tr.& Orth.).Orth.).F.R.C.SF.R.C.S.(.(Eng.), F.R.C.S.(Tr.&Eng.), F.R.C.S.(Tr.& Orth.).Orth.).
ProfessorProfessor of Orthopedicsof Orthopedics
University of Jordan HospitalUniversity of Jordan Hospital -- AmmanAmman
1/15/2011 1Professor Freih Abu hassan -
University of Jordan

2. Hematogenous spread :g p
Endarteriolar circulation at the
vertebral endplates is an areavertebral endplates is an area
predisposed to hematogenous seeding.
in the lumbar spine followed by the thoracic spine.
1/15/2011 2Professor Freih Abu hassan -
University of Jordan

3. 1/15/2011 3Professor Freih Abu hassan -
University of Jordan

4. 1/15/2011 4Professor Freih Abu hassan -
University of Jordan

5. 1-Paraspinal abscess
2-Extraspinal abscesses.
Paralumbar abscesses may point in the
A Fl k t P tit' t i lA- Flank at Petit's triangle,
B- Groin,
C-Buttock,
D- Popliteal fossa,D Popliteal fossa,
E-Perirectal area.
1/15/2011 5Professor Freih Abu hassan -
University of Jordan

6. 1 S ti f ( ki it i1-Septic focus (e.g skin, genitourinary.
2-Invasive procedures.2 Invasive procedures.
3-Patients with spinal cord injury ,
due to chronic UTI and skin ulcersdue to chronic UTI and skin ulcers.
4- immunocompromised .p
5-Penetrating trauma, spinal surgery,
6 Diabetes Rh A steroid use old age6-Diabetes, Rh.A,steroid use, old age,
1/15/2011 6Professor Freih Abu hassan -
University of Jordan

7. A- S aureus 50%A S. aureus. 50% .
B- Gram-negative Escherichia coli and
P d d P t iPseudomonas and Proteus species.
C-Anaerobic organisms.g
1/15/2011 7Professor Freih Abu hassan -
University of Jordan

8. 1-(ESR) and (CRP) high in 90% of patients.1 (ESR) and (CRP) high in 90% of patients.
2- Needle biopsies guided by (CT) or fluoroscopy.
Cultures are positive in 68% to 86% of cases.
When negative
3- Open biopsy, positive in greater than 80% of cases.
samples sent for pathology to exclude
Malignancy Stains for AFB fungal organismsMalignancy,Stains for AFB, fungal organisms,
and pyogens.
1/15/2011 8Professor Freih Abu hassan -
University of Jordan

9. ImagingImaging
1-Plain radiographs
The findings lag 2 to 3 weeks behind theThe findings lag 2 to 3 weeks behind the
onset of symptoms.
A- Osteolysis in the ant. vertebral metaphyseal region,
B- Loss of disk space height,
C- End plate blurringC- End plate blurring,
D- Subchondral reactive bone formation .
1/15/2011 9Professor Freih Abu hassan -
University of Jordan

10. 1/15/2011 10Professor Freih Abu hassan -
University of Jordan

11. Long-standing disease causesLong standing disease causes
Vertebral destruction,Vertebral destruction,
collapse, kyphosis, and abscess formation
1/15/2011 11Professor Freih Abu hassan -
University of Jordan

12. 2- Technetium bone scan
86% in diagnosing vertebral osteomyelitis86% in diagnosing vertebral osteomyelitis.
3 CT scans3- CT scans
Enhanced CT scans provide a useful view of
th i l l id tif i f l lthe spinal canal, identifying areas of local
neurologic compromise.
1/15/2011 12Professor Freih Abu hassan -
University of Jordan

13. 4-MR is the imaging 95%
(modality of choice for spinal infections)
T1 loss of details of the nucleus pulposus,
the vertebral end plates, and the associated
metaphyseal region.
T2 hyperintensity of the disk space and
possibly associated epidural abscesses.
1/15/2011 13Professor Freih Abu hassan -
University of Jordan

14. T12-L1 disk space and the entire L1 body have decreased
signal and the end plates are indistinct.
1/15/2011 14Professor Freih Abu hassan -
University of Jordan

15. Vertebral osteomyelitisVertebral osteomyelitis
High signal is seen in the T12-L1 disk space and
the L1 vertebral body on the T2-weighted sagittal sequence.
1/15/2011 15Professor Freih Abu hassan -
University of Jordan

16. 1/15/2011 16Professor Freih Abu hassan -
University of Jordan

17. P t ti di kiti d t litiPostoperative diskitis and osteomyelitis
1/15/2011 17Professor Freih Abu hassan -
University of Jordan

18. 6 W I.V antibiotics + oral antibiotics there after.
Molded total contact braces for the
lumbar and low thoracic spine.lumbar and low thoracic spine.
If cervical osteomyelitis is to beIf cervical osteomyelitis is to be
treated non surgically, a halo vest
h ld b id dshould be considered.
1/15/2011 18Professor Freih Abu hassan -
University of Jordan

19. (1) Open biopsy
(2) Neurologic deficit(2) Neurologic deficit
(3) Vertebral collapse esp. C. spine
(4) Ab(4) Abscess
(5) Failure of medical treatment.( )
1/15/2011 19Professor Freih Abu hassan -
University of Jordan

20. Paraspinal abscessParaspinal abscess
1/15/2011 20Professor Freih Abu hassan -
University of Jordan

21. Paraspinal abscessParaspinal abscess
1/15/2011 21Professor Freih Abu hassan -
University of Jordan

22. Brucellosis of lumbar spine
1/15/2011 22Professor Freih Abu hassan -
University of Jordan

23. The principal mode of spread is hematogenous.
The primary focus lung GIT or GUTThe primary focus lung, GIT, or GUT
1/15/2011 23Professor Freih Abu hassan -
University of Jordan

24. = Slowly progressive spinal painSlowly progressive spinal pain
S t f h i ill= Symptoms of a chronic illness,
fever,malaise, Wt loss,anorexia .e e , a a se, oss,a o e a
1/15/2011 24Professor Freih Abu hassan -
University of Jordan

25. 1/15/2011 25Professor Freih Abu hassan -
University of Jordan

26. 1/15/2011 26Professor Freih Abu hassan -
University of Jordan

27. 1/15/2011 27Professor Freih Abu hassan -
University of Jordan

28. Radiological presentationRadiological presentation
Active & large lesion with abscess.
Multiple levels.
Healing & activity together withHealing & activity together with
sclerotic lesion.
Epidural abscess.
Neurological impairment withoutNeurological impairment without
obvious discrible vertebral lesion.
1/15/2011 28Professor Freih Abu hassan -
University of Jordan

29. Radiographs
= As vertebral osteomyelitis .
E tensi e dest ction= Extensive destruction
There is also a tendency towards preservation
of the intervertebral disks until late in the diseaseof the intervertebral disks until late in the disease.
T.B tends to involve more levels of the spineT.B tends to involve more levels of the spine
than pyogenic processes, and the abscesses
tend to be more extensive.tend to be more extensive.
1/15/2011 29Professor Freih Abu hassan -
University of Jordan

30. 1/15/2011 30Professor Freih Abu hassan -
University of Jordan

31. CT scans
= Extent of vertebral involvement &= Extent of vertebral involvement &
associated soft-tissue masses .
= CT scans cannot distinguish
granulation tissue from abscess
formation.o at o
1/15/2011 31Professor Freih Abu hassan -
University of Jordan

32. MRI scans modality of choice.y
excellent definition ofexcellent definition of
1-The extent of vertebral involvement,
2-Spinal canal compromise,2 Spinal canal compromise,
3-Abscess formation .
4-Distinguish abscesses from granulation T.st gu s abscesses o g a u at o
1/15/2011 32Professor Freih Abu hassan -
University of Jordan

33. Laboratory findings are nonspecificLaboratory findings are nonspecific.
Most patients ha e an ele ated ESRMost patients have an elevated ESR;
the WBC count is highly variable.
1/15/2011 33Professor Freih Abu hassan -
University of Jordan

34. TREATMENTTREATMENTTREATMENTTREATMENT
Chemotherapy is the mainstay,
particularly for early disease, but
increasing resistant to therapy isincreasing resistant to therapy is
a cause of concern.
1/15/2011 34Professor Freih Abu hassan -
University of Jordan

35. O ti t t tO ti t t tOperative treatmentOperative treatment
S i l t &Surgery is complementary &
supplementary to chemotherapy.pp y py
Indications Neurological deficitIndications -Neurological deficit
-Large abscess
P i d i &-Progressive destruction &
Kyphosis
I bili-Instability
1/15/2011 35Professor Freih Abu hassan -
University of Jordan

36. SurgerySurgerySurgerySurgery
EarlierEarlier
-Only focal debridement and-Only focal debridement and
drainage of abscessdrainage of abscess
-Long bed restg
1/15/2011 36Professor Freih Abu hassan -
University of Jordan

37. SurgerySurgery
CurrentlyCurrently
-Radical debridement & reconstruction
-Prevention & correction of kyphosis
-InstrumentationInstrumentation
-Give stability for early mobilisation
1/15/2011 37Professor Freih Abu hassan -
University of Jordan

38. INSTRUMENTATIONINSTRUMENTATIONINSTRUMENTATIONINSTRUMENTATION
(Newer concept)(Newer concept)
Anterior
P t iPosterior
Combined
adv:-(1)Protect graft
(2)Encourage fusion( ) g
(3)Prevent & correct kyphosis
(4)Gives stability(4)Gives stability
(5)Early mobilisation
1/15/2011 38Professor Freih Abu hassan -
University of Jordan

39. Anterior InstrumentationAnterior InstrumentationAnterior InstrumentationAnterior Instrumentation
(One stage surgery)(One stage surgery)
After radical debridement
With graft or cage
Indications
2 segment involved with kyphosis
(P t El t h ld b i t t)(Post. Element should be intact)
1/15/2011 39Professor Freih Abu hassan -
University of Jordan

40. Posterior InstrumentationPosterior Instrumentation
((one stage surgery)one stage surgery)
Indications:
- Post.elelment involvement
- Epidural abscessEpidural abscess
- Tuberculoma
- Both element involvement
(postero-lat approach)(postero-lat approach)
1/15/2011 40Professor Freih Abu hassan -
University of Jordan

41. Posterior fusion and instrumentation stabilized the
spine after anterior L1 corpectomy and T12-L2 strut
graft for the patient with L1 osteomyelitis
1/15/2011 41Professor Freih Abu hassan -
University of Jordan

42. T.B.of spine in childenT.B.of spine in childenpp
(Newer concept)(Newer concept)
Early surgical intervention-
* Children bet. 5-15 yearsy
* >2 segment involvement
* Preexisting kyphosis > 30*Preexisting kyphosis > 30
Surgery-Surgery-
Anterior surgery with fusion and
second stage post fusion with/second stage post.fusion with/
without instrumentation
1/15/2011 42Professor Freih Abu hassan -
University of Jordan

43. Tuberculosis of spine in 13-year-old girl.
1/15/2011 43Professor Freih Abu hassan -
University of Jordan

44. Late casesLate casesLate casesLate cases
(Newer concept)(Newer concept)
Reconstruction of ant. column with
ftgraft
Shortening of posterior column with
fusionfusion
P t i i t t tiPosterior instrumentation
1/15/2011 44Professor Freih Abu hassan -
University of Jordan

45. Endoscopic spine surgeryEndoscopic spine surgeryEndoscopic spine surgeryEndoscopic spine surgery
(Newer concept)(Newer concept)
MINIMALLY INVASIVE
* DebridementDebridement
* Decompression
* Interbody fusion
* Instrumentation ???* Instrumentation ???
1/15/2011 45Professor Freih Abu hassan -
University of Jordan

46. USG guided procedureUSG guided procedure
USG guided drainage of abscess
it b tti th tcavity by putting catheter
1/15/2011 46Professor Freih Abu hassan -
University of Jordan

47. MMMessageMessage
Be radical where indicated for
* Prevention of deformityPrevention of deformity
* Prevention of complications
* Early mobilisation with help of
current conceptscurrent concepts
1/15/2011 47Professor Freih Abu hassan -
University of Jordan

48. 1/15/2011 48Professor Freih Abu hassan -
University of Jordan