aka Spondylodiscitis and vertebral osteomyelitis overall are relatively infrequent and may present with bimodal distribution: children and adults >50’s
Occasionally considered as two separate entities due to variations in the blood supply of pediatric vs. adult spines
Risk factors/causes: distant site of infection in the body (25-35%), e.g., oropharynx, urogenital infections, bacterial endocarditis, indwelling catheters, florid skin infections furunculosis/abscess, etc.
Iatrogenic:�operative (e.g., discectomy) interventional or diagnostic/therapeutic procedures
Penetrating trauma
Immunocompromised patients
Diabetics
Malnourished patients or patients with low protein
IV drug users
Chronic disease patients, cancer patients etc.
Potential Pathological Sequence
Clinical Presentation
Back pain with or w/o high fever and other “septic” signs. Fever may only present in 50% of children
Exacerbation of pre-existing back pain in post-surgical cases
Neurological complications in advanced cases of vertebral destruction and epidural abscess
Meningitis, septicemia etc.
Labs: Blood tests are unspecific, may or may not indicate elevated ESR/CRP, WBC
Diagnostic imaging is important but
If clinical suspicion is strong, prompt I.V. antibiotics are needed to prevent serious complications
Routes of Infection
Infection routes to the spine are similar to bone in general
3-distinct routes:
1) Hematogenous spread as bacteremia (most common)
2) Adjacent site of infection (e.g., soft tissue abscess)
3)Direct inoculation (e.g., iatrogenic or traumatic)
M/C organism Staph. Aureus
Mycobacterium TB (tuberculous spinal osteomyelitis) aka Pott’s disease can be presented in cases of re-activated or disseminated pulmonary TB
Mechanisms of Spinal Infection
May vary depending on the patients’ age
In children, the IVD receives direct blood supply and can be infected directly spreading to adjacent bone and causing spondylodiscitis
In Adults
The disc is avascular
Pathogens invade adjacent vertebral end-plates via end-arterial supply of the vertebral body that may facilitate infection due to slow, turbulent flow
Organisms may then quickly gain access to disc substance rich in nutrients (discitis) often w/o significant initially visible destruction to the bone
Thus, one of the earliest rad. findings of spinal infection or sudden reduction of disc height
Later end-plate irregularity/sclerosis may develop, subsequently affecting the entire adjacent vertebral bodies
Diagnostic Imaging
Initially, in most cases of MSK complaints, radiography is the 1st imaging step
Initially, X-radiography is often unrewarding and may appear unremarkable for 7-10 days or presents with some subtle soft tissue changes (e.g., obscuration of Psoas shadows etc.)
Some of the earliest x-ray signs of pyogenic spondylodiscitis: sudden reduction of disc height (above arrow) during initial 7-10 days
Subsequently (10-20 days) some end-plate irregularity and adjacent sclerosis may be noted
In more advanced cases, subsequent vertebral destruction and collapse may occur
N.B. Reliable feature to DDx between spinal infection and metastasis is the preservation of disc height in the latter
Note:�sudden disc narrowing with no appreciable spondylosis (above the first image) is suspicious for infection (discitis)
MRI +C is required to evaluate suspected infection
N.B. 50-60% of pyogenic spondylodiscitis occur in the lumbar region
AP & Lateral Lumbar Radiographs
Note severe disc narrowing and adjacent vertebral body destruction at L1-L2 in a 68 -y.o.-female with a known Hx of type 2 DM
Additional imaging modalities should be used to support the Dx
Final Dx: Pyogenic Spondylodiscitis
Sagittal T1 & T2 MRI
Weighted MRI slices of a patient who had laminectomy at L4
MR imaging with gad contrast is the modality of choice for Dx of spinal infection
Early septic changes affecting the disc and adjacent vertebral end-plates are readily demonstrated as a low signal on T1 and high T2/STIR d/t edema and inflammation
T1 FS +C gad images show avid enhancement of the lesion due to granulation tissue around the phlegmon. Peripheral enhancement is also characteristic of an abscess.
Epidural extension/abscess can also be successfully detected my MRI
N.B. 50% of epidural abscess cases present with neurological signs
STIR & T1 FS +C Gad Sagittal MRI
Marked septic collection and edema affecting L4-5 disc and vertebral body with some epidural extension and paraspinal soft tissue edema. Avid contrast enhancement is noted surrounding low signal foci within the bone and disc tissue, some gad. Enhancement is noted in posterior paraspinal muscles and dural spaces
Management: Dx of spondylodiscitis requires prompt I.V antibiotics. If instability and neurological complications develop referral to a Neurosurgeon is required
MRI Unavailable or Contraindicated
Bone scintigraphy is very sensitive but non-specific for spinal infection but overall is of great value d/t higher sensitivity than x-rays and relatively low cost.
An area of increased flow with radiopharmaceutical uptake is characteristic but not specific sign of spondylodiscitis
If neurological signs are present and MRI is contraindicated than CT myelography may be used
TB Osteomyelitis aka Pott’s Disease
TB osteomyelitis is increasing d/t HIV and other immunocompromised states. Extrapulmonary TB m/c affects the spine and especially the thoracic spine (60%)
Radiographic Pathology:�TB bacillus infects the vertebral body and often spreads subligamentously. “Cold” paraspinal abscess collection may develop and spreads along fascial planes, e.g., Psoas abscess. Disc spaces are preserved until v. late and skip areas are noted helping to DDx TB from pyogenic infection. Severe vertebral destruction aka Gibbus deformity may develop (>60-degree sometimes) and may become permanent. Neurologic and many regional complications may develop
Imagingapproach:�CXR with spinal x-rays 1st step that may be unrewarding but may potentially reveal VB destruction w/o disc narrowing. CT scanning is more superior than x-rays. MRI with gad C is a modality of choice
Headaches are a real pain (insert eye-roll here). Many individuals suffer from them, and there are a variety of causes, symptoms, and treatment options. For some, they are a rare occurrence, while others deal with them weekly or even daily. They can range from minor inconveniences to full-fledged life-changing afflictions.
The first step in treating headaches is to understand the type of headache you are experiencing. Some people think they have a migraine when in fact, they are suffering from a tension headache. While tension headaches are more common, it’s estimated by the Migraine Research Foundation that 1 in 4 U.S. Households include someone with a migraine.
Determining which headache is being dealt with takes a bit of research. Individuals suffering from headaches need to ask themselves these questions to determine if they are having a migraine or experiencing a tension headache.
When in life did the headaches begin? According to the Mayo Clinic, migraines start in adolescence or early adulthood. In contrast, tension headaches can start at any time in a person’s life. If an adult just began suffering from headaches, they are most likely tension headaches.
Where does it hurt? The location of the pain is a vital indicator of the type of headache. Migraines typically occur on one side of the head. Tension headaches affect both sides of the head and can produce a feeling of pressure in the forehead area.
What kind of pain is it? If it is a dull pain, a feeling of pressure, or tenderness around the scalp, it’s most likely a tension headache. If, on the other hand, the pain is throbbing or pulsing pain, it could be a migraine. Both headaches can offer up severe pain, just different types.
Are there any other symptoms?Migraines typically come with symptoms beyond head pain. Nausea, light and sound sensitivity, bright flashing or sparkling lights, pins and needle sensations down one or both arms, or dizziness are common. Individuals who don’t experience any of these symptoms are most likely dealing with a tension headache.
Can you function? While painful and frustrating, many people with a tension headache can still perform their jobs, drive, read, and deal with daily life. A migraine is a different story. Lying in a dark, quiet room with a sleep mask on until the headache passes is how most people handle migraines. If the headache is life-disrupting, it could very well be a migraine.
Do regular painkillers work? Tension headaches can often be relieved by over-the-counter pain medications. Migraines don’t budge with these treatments. Once a migraine is in full force, the sufferer must ride it out. If a headache reacts well to a couple of non-prescription painkillers, it’s most likely a tension headache.
Most individuals will, unfortunately, deal with a headache at one point in their lives. It’s important to note that tension headaches are much more common than migraines, but that doesn’t rule out the possibility of a headache being a migraine. The answers to the above questions give insight into the type of headache occurring and how best to handle the treatment proactively. No matter the type of headache, if the pain is severe, or begins after a head injury, seek medical treatment immediately.
Ischemic Osteonecrosis (More accurate term) aka avascular necrosis AVN: this term describes subarticular (subchondral) bone death
Intramedullary bone infarct: depicts osteonecrosis within the medullary cavity of the bone (above x-ray image)
Causes: m/c: trauma, systemic corticosteroids, diabetes, vasculitis in SLE. The list is long. Other vital causes: Sickle cell disease, Gaucher disease, alcohol, caisson disease, SCFE, LCP, etc.
Pathology: ischemia and bone infarct with resultant devitalized center surrounded by ischemia and edema with normal bone on the outer periphery (MRI double line sign)
Sub-articular necrotic bone eventually collapses and fragments leading to progressive bone and cartilage destruction and rapidly progressing DJD
Early Dx often missed but crucial to prevent severe DJD
M/C Sites
Hips, shoulders, talus, scaphoid bone. Many peripheral idiopathic AVN sites are known by their eponyms (e.g., Kienbock aka AVN of the lunate bone, Preisier aka scaphoid AVN)
Radiography is insensitive to early AVN and may only present as subtle osteopenia
Some of the early appreciable rad features are increased patchy bone sclerosis followed by sub-articular bone collapse or “crescent sign” signifying stage-3 on Ficat classification (above)
Earliest detection and early intervention can be achieved by MRI (most sensitive modality)
If MRI contraindicated or unavailable, 2nd most sensitive modality is radionuclide bone scan (scintigraphy)
X-ray and CT scanning are of equal value
Coronal MRI Slice
Fluid sensitive, sensitive coronal MRI slice revealing bill ischemic osteonecrosis of the femoral head
MRI findings: l
Tc99-MMDP Radionuclide Bone
Bone scan reveals a central area of photopenia (cold spot) d/t necrotic fragment surrounded by increased osteoblastic activity as increased uptake of Tc-99 MDP in the right hip
The patient is a 30-year-old female with breast cancer and chemotherapy treatment who suddenly presented with right hip pain
Radiographic Progression of AVN
Later stages present with articular collapse, subarticular cysts, increased patchy sclerosis and complete flattening of the femoral head with resultant severe DJD. Rx: THA
Management
Early imaging Dx with MRI or bone scintigraphy is essential
Referral to the Orthopedic surgeon
Core decompression (above) can be used to revascularize the affected bone during earlier stages but produces mixed results
Delayed changes of AVN: THA as IN severe DJD cases
B/L THA
B/L THA in the patient with ischemic osteonecrosis of the right and later left hip
When B/L hip AVN is present, typically consider systemic causes (corticosteroids, diabetes)
Inflammatory Arthritis Affecting the Hip
Consider common systemic inflammatory condition such as RA and AS/EnA
Hip RA may develop in 30% of patients with RA
Key features to DDx inflammatory arthritis vs. DJD is symmetrical/uniform aka concentric joint loss often leading to axial migration and Protrusion Acetabule in advanced cases
Key element between RA vs. AS: the presence of RA bone erosion w/o productive bone changes or enthesitis in AS d/t inflammatory subperiosteal bone proliferation, whiskering/fluffy periostitis (collar-type enthesitis circumferentially affecting head-neck junction)
Dx: Hx, PE, labs: CRP, RH, anti-CCP Ab (RA)
CRP, HLA-B27, RF- (AS)
Septic Arthritis
Gonococcal infections, iatrogenic causes, I.V. drug use, and some others
Routes:�hematogenous, adjacent spread, direct inoculation (e.g., iatrogenic)
Clinically: pain and reduced ROM presented as monoarthritis, generalized signs/symptoms. CBC, ESR, CRP changes. ARthrocentesis and culture are crucial
M/C pathogen Staph. Aureus & Neisseria Gonorrhea
1st step: radiography, often unrewarding in the early stage. Later (4-10 days) indistinctness of the white cortical line at the femoral articular epiphysis, loss of joint space, effusion as a widening of the medial joint area (Waldenstrom sign)
MRI – best at early DX: T1, T2, STIR, T1+C may help with early. Early I.V. antibiotics crucial to prevent rapid joint destruction
Slipped Capital Femoral Epiphysis (SCFE)
Important to diagnose but easily missed potentially leading to Ischemic Osteonecrosis of the femoral head aka AVN
Presents typically in overweight children (more often boys), age over eight years. Greater incidence in African-American boys
1st step: radiography, especially look for a widened physeal growth plate (so-called pre-slip). Later, slip and disturbed Klein’s line (above image). MRI – best modality for early Dx and early intervention
The frog lateral view often demonstrates the medial slip better than the AP view
Clinically Limping Child or Adolescent
M>F (10-18 years). African-Americans are at greater risk. 20% of cases of SCFE are B/L. Complications: AVN >>DJD
Radiography:�AP pelvis, spot, and frog leg may reveal slippage as Klein line failed to cross through the lateral aspect of the femoral head
Additional features: physis may appear widened
MRI w/o gad, is required for the earliest Dx and prevention of complications (AVN)
Normal and Abnormal Klein Line
Consistent with SCFE. The physis is also widened. Dx: SCFE
Urgent referral to the Pediatric Orthopedic surgeon
Subtle Changes in Left Hip
Note suspected subtle changes in the left hip that may require MR examination to confirm the Dx
Delay in care may result in major complications
Perthes’ Disease
aka Legg-Calves-Perthes Disease (LCP)
Refers to Osteochondritis of the femoral head with osteonecrosis likely d/t disturbed vascularization of the femoral head
Presents typically in children (more often boys) aged under eight years as atraumatic “limping child.” 15% may have B/L Perthe’s
Imaging steps: 1st step x-radiography, followed by MRI especially in stage 1 (early) w/o x-ray abnormalities
Unspecific signs: joint effusion with Waldenstrome sign+ (>2-mm increase in medial joint space compared to the opposite side). Past approach: Fluoroscopic Arthrography (replaced by MRI)
Pathologic-Radiologic Correlation: in well-established cases, the femoral head characteristically becomes sclerotic, flattened and fragmented due to avascular necrosis (AVN). Later on, an occasional Coxa Magna changes may develop (>10% femoral head enlargement)
Management: symptoms control, bracing. Boys at younger ate show better prognosis d/t more immaturity and better chances of bone/cartilage repair mechanisms. In advanced cases, operative care: osteotomy, hip arthroplasty in adulthood if advanced DJD develops
Common Neoplasms & Other Conditions Affecting Hip/Pelvis
M/C hip & pelvis neoplasms in adults: bone metastasis ( above far left), 2nd m/c Multiple Myeloma (M/C primary bone malignancy in adults). Tips: remember Red Marrow distribution. Less frequent: Chondrosarcoma
Paget’s disease of bone (above-bottom left image) is m/c detected in the pelvis and Femurs
Children and young adults ‘limping child’ benign neoplasms: Fibrous Dysplasia (above middle image), Solitary Bone Cyst (21%), Osteoid Osteoma, Chondroblastoma. Malignant pediatric neoplasms: m/c Ewing Sarcoma (above middle right and bottom images) vs. Osteosarcoma. >2y.o-consider Neuroblastoma
Imaging: 1st step: radiography followed by MRI are most appropriate.
If Mets are suspected: Tc99 bone scintigraphy is most sensitive
Multiple Myeloma
Multiple Myeloma in a 75-y.o male (AP pelvis view)
Chondrosarcoma in a 60-y.o male (axial and coronal reconstructed CT+C slices in the bone window)
When we think of chiropractic care, our minds automatically jump to treatment for�work injuries, or issues stemming from aging. While spinal manipulations and other chiropractic treatment are�highly valuable in those situations, they are not the beginning and end of what chiropractic care can accomplish.�Here are four key�ways chiropractic care safeguards the whole family.
Adults who embrace the benefits of a chiropractor should consider treatment for their entire family, as it can provide unique benefits to each member regarding total wellness and quality of life.
Injury Prevention For The Whole Family
The best way to treat an injury is to avoid an injury. It sounds simple, but many individuals don’t think of their health this way. Chiropractic for each family member means that their spines will be well-maintained, aligned, joints are looser, and necks are relaxed. For younger family members, this means sliding into third base won’t pull a muscle, studying for that exam won’t cause headaches, and taking out the trash won’t hurt their backs (even though they may still gripe about it).
For the older family members, chiropractic treatment for prevention helps avoid workplace injuries, minimizes strains and sprains from gardening or other “weekend warrior” activities, and even aids in sleeping and stress relief.
Chiropractic care also helps every family member.
Increases Flexibility
As mentioned above, chiropractic treatment helps keep joints loose, and the entire body functioning properly. Flexibility is critical in performing physical activity, �lessening growing pains,�aging gracefully, and avoiding disease and injury. Spinal manipulation coupled with at-home exercises make it easy for each family member to be as limber as possible.
Enhances Healing
A wide variety of health issues, from headaches and backaches to immune diseases and digestive problems,�can be addressed through chiropractic care. That’s because, instead of treating the symptoms of an issue, chiropractors aim toward the cause of the problem. No matter what a person’s age, if they are dealing with issues caused by spinal misalignment or stiff muscles and joints, consulting with a chiropractor for treatment can speed up the healing process, decrease downtime, and lessen the chance of the issue recurring.
Reduces Performance Issues
Most individuals crave to perform at the highest level possible. Some examples are scoring�well on a test,�playing the best basketball game, driving safely, excelling at job duties, hiking a trail, and�giving a speech. We all want to do our best and be successful.
The holistic approach of chiropractic care helps us function at top performance. While pain takes the focus away from performing�well, and drugs can cause fuzziness and loss of concentration, chiropractic treatments give relief without side effects.�No matter a person’s age, chiropractic care helps his or her body be higher-functioning and ready for life’s challenges, regardless of the form they take.
Chiropractic care benefits patients of a wide array of ages�in a variety of ways. Family members should carefully consider the positive, long-lasting aspects of chiropractic treatment for themselves, their spouses, and children. A commitment to such treatment can decrease injury and performance issues, and increase flexibility, confidence, and success.
Macroscopic & Microscopic Appearance of Normal vs. Damaged Articular Hyaline Cartilage by DJD
Hip Osteoarthritis (OA) aka Osteoarthrosis
Symptomatic and potentially disabling DJD
Progressive damage and loss of the articular cartilage causing denudation and eburnation of articular bone
Cystic changes, osteophytes, and gradual joint destruction
Develops d/t repeated joint loading and microtrauma
Obesity, metabolic/genetic factors
Secondary Causes: trauma, FAI syndrome, osteonecrosis, pyrophosphate crystal deposition, previous inflammatory arthritis, Slipped Capital Femoral Epiphysis, Leg-Calves-Perthes disease in children, etc.
Hip OA, 2nd m/c after knee OA. Women>men
88-100 symptomatic cases per 100000
Radiography is the Modality of Choice for the Dx and Grading of DJD
Special imaging is not required unless other complicating factors exist
The acetabular-femoral joint is divided into superior, axial and medial compartments/spaces
Normal joint space at the superior compartment should be 3-4-mm on the AP hip/pelvis view
Understanding the pattern of hip joint narrowing/migration helps with the DDx of DJD vs. Inflammatory arthritis
In DJD, m/c hip narrowing is superior-lateral (non-uniform) vs. inflammatory axial (uniform)
AP Hip Radiograph Demonstrates DJD
With a non-uniform loss of joint space (superior migration), large subcortical cysts and subchondral sclerosis
Radiographic features:
Like with any DJD changes: radiography will reveal L.O.S.S.
L: loss of joint space (non-uniform or asymmetrical)
O: osteophytes aka bony proliferation/spurs
S: Subchondral sclerosis/thickening
S: Subcortical aka subchondral cysts “geodes.”
Hip migration is m/c superior resulting in a “tilt deformity.”
Radiographic Presentation of Hip OA May Vary Depending On Severity
Mild OA: mild reduction of joint space often w/o marked osteophytes and cystic changes
During further changes, collar osteophytes may affect femoral head-neck junction with more significant joint space loss and subchondral bone sclerosis (eburnation)
Cyst formation will often occur along the acetabular and femoral head subarticular/subchondral bone “geodes” and usually filled with joint fluid and some intra-articular gas
Subchondral cysts may occasionally be very large and DDx from neoplasms or infection or other pathology
Coronal Reconstructed CT Slices in Bone Window
Note moderate joint narrowing that appears non-uniform
Sub-chondral cysts formation (geodes) are noted along the acetabular and femoral head subchondral bone
Other features include collar osteophytes along head-neck junction
Dx: DJD of moderate intensity
Referral to the Orthopedic surgeon will be helpful for this patient
AP Pelvis (below the first image), AP Hip Spot (below the second image) CT Coronal Slice
Note multiple subchondral cysts, severe non-uniform joint narrowing (superior-lateral) and subchondral sclerosis with osteophytes
Advanced hip arthrosis
Severe DJD, Left Hip
When reading radiological reports pay particular attention to the grading of hip OA
Most severe (advanced) OA cases require total hip arthroplasty (THA)
Refer your patients to the Orthopedic surgeon for a consultation
Most mild cases are a good candidate for conservative care
Hip Arthroplasty aka Hip Replacement
Can be total or hemiarthroplasty
THA can be metal on metal, metal on polyethylene and ceramic on ceramic
A hybrid acetabular component with polyethylene and metal backing is also used (above right image)
THA can be cemented (above right image) and non-cemented (above-left image)
Non-cemented arthroplasty is used on younger patients utilizing porous metallic parts allowing good fusion and bone ingrowth into the prosthesis
Failed THA May Develop
Most develop within the first year and require revision
Femoral stem may fracture (above left)
Postsurgical infection (above right)
Fracture adjacent to the prosthesis (stress riser)
Particle disease
Femoroacetabular Impingement Syndrome
(FAI): abnormality of normal morphology of the hip leading to eventual� cartilage damage and premature DJD
Clinically:�hip/groin pain aggravated by sitting (e.g., hip flexed & externally rotated). Activity related pain on axial loading esp. with hip flexion (e.g., walking uphill)
Pincer-type�acetabulum: > in middle age women potentially� many causes
CAM-type deformity:�> in men in 20-50 m/c 30s
Mixed type (pincer-CAM) is most frequent
Up until the 90s, FAI was not well-recognized
FAI Syndrome
CAM-type FAI syndrome
Radiography can be a reliable Dx tool
X-radiography findings:�osseous bump on the lateral aspect of femoral head-neck junction. Pistol-grip deformity. Loss of normal head sphericity. Associated features: os acetabule, synovial herniation pit (Pit’s pit). Evidence of DJD in advanced cases
MRI and MR arthrography (most accurate Dx of labral tear) can aid the diagnosis of labral tear and other changes of FAI
Referral to the Orthopedic surgeon is necessary to prevent DJD progression and repair labral abnormalities. Late Dx may lead to irreversible changes of DJD
AP Pelvis: B/L CAM-type FAI syndrome
Pincer-Type FAI with Acetabula Over-Coverage
Key radiographic signs: “Cross-over sign” and abnormal center-edge and Alfa-angle evaluation methods
Dx of FAI
Center-edge angle (above the first image) and Alfa-angle (above the second image)
B/L CAM-type FAI with os acetabule�(above right image)
MR Arthrography
Labral tear and CAM-type FAI syndrome on axial (above left) and coronal T2 W (above right) MR arthrography
Note acetabula labral tear. Referral to an orthopedic surgeon is required. For more information:
Throbbing, dull and achy, sharp and excruciating. All of these words can be used to describe lower back pain.
Unfortunately, lower back pain is a common occurrence in adults. According to the American Chiropractic Association, low back pain is the single leading cause of disability worldwide, with millions of reported cases�every year.
What Treatment Should You Seek If You Experience Pain in Your Lower Back?
The good news is that it often heals on its own. A few days of over-the-counter pain meds, ice,�and taking it easy, and you could be back to normal.
However, those who continue to deal with the pain after a few weeks’ time may choose to look for other solutions. This is also true for people who experience repeated flare-ups, or chronic lower back pain.
One of the best and most popular options is chiropractic care.
Why?�
First of all, chiropractic care doesn’t focus solely on the pain but helps the body heal itself. Chiropractors understand the bones,�muscles, discs, and nerves�in the back, and can figure out the reason for the pain.
From there, they can create a customized treatment plan from compresses to spinal manipulation to exercises that help heal the area and reduces the pain.
Second, It’s A Drug-Free Solution.
Because of its healing, therapeutic approach, chiropractic treatment tends to the source of the pain, instead of simply dulling it. Spine Universe estimates 6 to 12 treatments are typically needed to treat low back pain, but each person’s requirement may vary.
Throughout these�treatments, spinal alignment begins�to balance the other parts of a person’s back and helps correct the issue causing the pain. Also, spinal manipulation helps improve mobility and function in many cases, whereas drugs alone do not.
Finally, Chiropractic Care for Lower Back Pain Also Helps Minimize Relapses
Patients who experience lower back pain never want to deal with it again, but�it can flare up periodically. According to the National Institute of Neurological Disorders and Stroke, roughly 20% of those who suffer from low back pain will eventually deal with it chronically. This can cause frustration, primarily when it affects mobility.
Before you run screaming in horror to the medicine cabinet, one of the best reasons to participate in chiropractic treatment is that it helps reduce the chance of a recurrence. By working on the total body and getting it in the best shape possible, the patient is stronger and more balanced to handle their workload and other strenuous activities. Chiropractors also impart advice on how to minimize the chances of re-aggravating the lower back.
Millions of people suffer from back pain each year, and some never visit a chiropractor. Those who do choose chiropractic treatment are privy to treatment that reduces their pain, increases healing, shortens their downtime and lessens their chances of a recurrence. If over the counter medication and ice packs haven’t worked within a few days, it’s time to make an appointment for a consultation with a licensed chiropractor. You will be happy you did.
X-radiography pitfalls: some undisplaced Garden 1 & 2 Fxs may be missed d/t pre-existing DJD and osteophytes along the femoral head-neck junction that may overly the Fx line
Fx line is incomplete and too small/subtle especially if the study is read by non-radiologists
Incomplete Fxs if left untreated will not heal and likely to progress to complete Fxs
AP hip spot view: note valgus deformity of the head (above yellow arrow) with a small/subtle line of sclerosis in the sub-capital region representing Garden 1 Fx. MRI may help with Dx of subtle radiographic Fxs. If MRI contraindicated, Tc 99 radionuclide bone scan may help demonstrate high uptake of the radiopharmaceutical in Fx (below image)
Above – Tc99 Radionuclide Bone Scan Reveals Left Subcapital Femoral Neck Fx
Garden 2 complete undisplaced (above green arrows) Fx
AP hip: Garden 3 complete partially displaced Fx (above the first image)
AP pelvis: complete displaced Garden 4 Fx (above the second image)
Clinical pearls: in some cases of Garden 4 Fx, DDx may be difficult to differentiate from OSP vs. pathologic fx d/t to bone Mets of Multiple myeloma (MM)
Management: depends on patients age and activity level
Garden 3 & 4� require total hip arthroplasty in patients <85-y.o.
Garden 1 & 2 may be treated with closed reduction of fx and open capsule and 3-cannulated fixating screws
Pre-existing DJD may require total arthroplasty
Occasionally observation may be performed on patients who are not active and significant risks of surgery and depends on surgical centers
m/c Rx of Garden 1 & 2 undisplaced Fx with 3-screws. Screws proximity depends on the bone quality and Fx type
THA aka hip replacement: cemented THA with bone cement (above the first image) vs. non-cemented (biologic) that is used mostly in younger patients
2-types: metal on metal vs. metal on polyethylene
The femoral angle of the prosthesis should have slight valgus but never >140 degrees
The non-cemented component uses porous metal allowing the bone to integrate sometimes coating in bone cement from osteoconduction
THA has good outcome and prognosis
Occasionally cement failure, fractures, and infections may complicate this procedure
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