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THERAPEUTICS OF LBA

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    THERAPEUTICS OF LBA
1
ARSENICUM ALB
 Weakness    in small of back.
 - Pain and burning in back. [Oxal.




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 ac.]
 - Trembling, twitching, spasms,
 weakness, heaviness, uneasiness
 - Sciatica.
 - Burning pains.
 - Paralysis of lower limbs with
                                       2
 atrophy.
     AESCULUS HIPPOCASTANUM
•   Severe dull backache in lumbo-sacral articulation;
    more or less constant; affecting sacrum and hips.




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•    - Sensation of heaviness and lameness in back.
•    - Paralytic feeling in arms, legs and spine.
•   Back gives out-during
    pregnancy,leucorrhoea,prolapse<walking(sep),stoo
    ping;must sit or lie down
•   For persons with haemorrhoidal tendencies, and
    who suffer with gastric, bilious or catarrhal
    troubles.                                        3
AGARICUS MUSCARIUS
 - Spine sensitive to touch (Ther.); worse mornings.
• - Pain : sore, aching, in lumbar and sacral
   regions; during exertion in the day time; while




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   sitting (Zinc,Rhust,Sep,Cobalt,Cann.i,Berb,Valer).
• - Spinal irritation due to sexual excesses (Kali P)

• Every motion, every turn of body, causes pain in
   spine. Single vertebra sensitive to touch.
• Uncertainty in walking, stumbles over everything
   in the way; feels pain as if beaten, when standing

                                                    4
ARGENTUM MET
       backache; must walk bent, with
 Severe
 oppression of chest.




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                                        5
ARNICA
•   For the bad effects resulting from mechanical injuries;
    even if received years ago.
•    - Sore, lame, bruised feeling all through the body, as if




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    beaten; traumatic affections of muscles.
•    - After injuries with blunt instruments (Symph.).
•   Everything on which he lies seems too hard; complains
    constantly of it and keeps moving from place to place
    in search of a soft spot (the parts rested upon feel sore
    and bruised, Bap., Pyr.; must move continually to
    obtain relief from the pain, Rhus.).
•   Cannot walk erect on account of a bruised sort of
    feeling in pelvic region.
•   Ascending rheumatism(led_descending cact,kalm)           6
BERBERIS VULGARIS
•   Wandering, radiating pains.
•   All Berberis pains radiate, are not worse by




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    pressure, but worse in various attitudes,
    especially standing and active exercise.
•   Stitches in neck and back; worse, respiration.
•    - Numb, bruised sensation.
•    - Tearing, sticking with stiffness, making rising
    difficult, involving hips, nates, limbs, with
    numbness.
•    - Lumbago. [Rhus; Tart. em.]
•    - Post-operative pain in lumbar region              7
BRYONIA
 Painful stiffness in nape of neck.
 - Stitches and stiffness in small of




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  back.
 - From hard water and sudden
  changes of weather
 Pain stitching,tearing
  <night,motion,warmth >rest,lying on
  painful side(puls,ptel),cold
                                         8
BELLADONA
      neck.
 stiff
 - Swelling of glands of neck.




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 - Pain in nape, as if it would break.
 - Pressure on dorsal region most
  painful.
 - Lumbago, with pain in hips and
  thighs.
 <least jar,motion,touch
                                          9
 >rest
CALCAREA CARB
 Pain as if sprained; can scarcely rise;
  from overlifting.




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 - Rheumatism in lumbar region;
  weakness in small of back.
 - Rheumatism of muscles of back
  and shoulder after failiure of rhustox
 <cold air,wet weather,cold
  water,morning
 >Lying on painful side                    10
CALCAREA FLUR
 Chronic  lumbago; aggravated on
  beginning to move, and ameliorated




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  on continued motion.
 - Pain lower part of back, with
  burning.
 When rhustox fails




                                       11
CALCAREA PHOS
 Rheumatic   pain from draught of air,
  with stiffness and dullness of head.




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 - Soreness in sacro-iliac symphysis,
  as if broken. [Aesc]
 Stffness<menstrual period,morning




                                          12
CARBONEUM SULPHURATUM
•     - Sciatica. Flying pains, returning
    regularly for a long time.




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•    - Pain in lower limbs, with cramps and
    formication
•    - pain<morning on waking
•    - Lightning-like pains, with cramps.
•    - Gait unsteady, tottering; worse in dark.
•    - weakness in back in lumbar region
•   Chronic rheumatism, sensitive and cold.
                                                  13
CAUSTICUM
   - Left-sided sciatica, with
 numbness




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 - Rheumatic tearing in limbs; better
 by warmth, especially heat of bed.
 - Unsteady walking and easily
 falling.
 - Cracking and tension in knees;
 stiffness in hollow of knee.
   stiffness on rising from seat         14
CHAMOMILLA
 Insupportable pain in loins and
 hips.




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 - Lumbago.
 - Violent rheumatic pains drive him
 out of bed at night; compelled to
 walk about.
 - Burning of soles at night. [Sulph.]
 - Nightly paralytic loss of power in
 the feet, unable to step on them.        15
CIMICIFUGA
•   Spine very sensitive, especially upper part.
•    - Stiffness and contraction in neck and back.




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•    - Rheumatic pains in muscles of back and neck.
•    - Pain in lumbar and sacral region, down thighs,
    and through hips.
•    - Crick in back.
•    - Uneasy, restless feeling in limbs.
•    - Aching in limbs and muscular soreness.
•    - Rheumatism affecting the belly of muscles,
    especially large muscles.
                                                        16
COBALTUM METALLICUM
 Pain in back and sacrum; worse while sitting;
 better, walking or lying.




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 - Weakness in legs and backache after emission

 - Weak knees.

 - Trembling in limbs.

 - Tingling in feet.

 - Foot-sweat, mostly between toes.




                                                   17
COCCULUS

•   - Paralytic pain in small of the back.




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•   - Lameness; worse by bending.
•   - Trembling and pain in limbs
•   - Numb and unsteady.
•   - Knees crack on motion.
•   - Lower limbs very weak.
•   - Inflammatory swelling of knee.
•   - Intensely painful, paralytic drawing.
•   - Limbs straightened out, painful when flexed.   18
DULCAMARA
 <cold in general-cold air,cold wet
  weather




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 >moving about
 - Pain in small of back, as after long
  stooping.
 - Stiffness and lameness across neck
  and shoulders, after getting cold and
  wet.
 - Pain in shin-bones.                    19
GELSEMIUM
 Dull,heavy pain.
 - Complete relaxation of the whole




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 muscular system.
 - Every little exertion causes fatigue.

 - Dull aching in lumbar and sacral region,
 passing upward.
 - Pain in muscles of back, hips, and lower
 extremities, mostly deep-seated.

                                               20
GNAPHALIUM
 Chronic backache in lumbar region; better
  resting on back.




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 - Lumbago with numbness in lower part of back
  and weight in pelvis.
 - Intense pain along the sciatic nerve; numbness
  alternates with pain.
 - Better, drawing limbs up, flexing thigh on
  abdomen
 - Chronic muscular rheumatism of back and
  neck.
                                                     21
KALI CARB
Backache,sweating,weakness
 - Stiffness and paralytic feeling in back.




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 - Burning in spine. [Guaco.]

 - Severe backache during pregnancy, and after
 miscarriage.
 - Back ache so badly while she is walking that
 she feels as if she could lie down on the street
 - Lumbago with sudden sharp pains extending
 up and down back and to thighs.

                                                    22
LACHESIS
 Neuralgia  of coccyx, worse rising
 from sitting posture; must sit




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 perfectly still.
 - Sensation of threads stretched
 from back to arms, legs, eyes, etc.
 - Sciatica, right side, better lying
 down.
 - Pain in tibia (may follow sore
 throat).                                23
LYCOPODIUM
   - Pain in small of backs
 - Numbness, also drawing and




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  tearing in limbs, especially while at
  rest or at night.
 - Sciatica, worse right side. Cannot
  lie on painful side
 Sciatica that comes on
  periodically>warmth,motion
                                          24
NATRUM MUR
 Pain in back, with desire for some firm support.
  [Rhus; Sep.]




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 - Numbness and tingling in fingers and lower
  extremities.
 - Painful contraction of hamstrings. [Caust.]

 Greatsensitiveness to pressure

 Coughing <pain




                                                     25
NUXVOM
 Backache in lumbar region.
 - Burning in spine; worse, 3 to 4




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 a.m.
 - Cervico-brachial neuralgia; worse,
 touch.
 - Must situp in order to turn in bed.
 - Bruised pain below scapulae.
 - Sitting is painful.
                                          26

PHOSPHORUS
 Burning  in back; pain as if broken.
 -feeling of intense heat running up




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  the back
 - Weak spine.
 Hot spine
 >heat



                                         27
PHYTOLACCA
 Aching pains in lumbar region; pains streaking
  up and down spine into sacrum.




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 - stand midway b/w bry and rhustox

 Backache-sore lame bruised feeling with constant
  desire to move but motion<
 - Back stiff, especially in morning on rising and
  during damp weather,night
 - Pains fly like electric shocks, shooting,
  lancinating, shifting rapidly. [Puls.; Kali bich.]
 - sciatica-pain run down the outer side of limb.

                                                       28
PULSATILLA
 Shooting pain in the nape and back,
 between shoulders; in sacrum after




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 sitting
 - Drawing, tensive pain in thighs
 and legs, with restlessness,
 sleeplessness and chilliness. Pain in
 limbs, shifting rapidly; tensive pain,
 letting up with a snap.
                                          29
RADIUM BROM
 Aching in back of neck.
 - Pain and lameness in cervical vertebrae,




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 worse dropping head forward, better
 standing, or sitting erect.
 - lumbar and sacral backache, pain
 appears to be in bone, continued motion
 relieves.
 - Backache between shoulders and
 lumbar-sacral region, better after
 walking.                                      30
RHUSTOX
  - Pain and stiffness in small of back; better, motion, or
 lying on something hard; worse, while sitting.
 - Rheumatic pains spread over a large surface at nape




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 of neck, loins, and extremities; better motion. [Agaric.]
 - Tearing down thighs.

 - Sciatica; worse, cold, damp weather, at night.

 - Numbness and formication, after overwork and
 exposure.



                                                         31
RUTA
Pain in nape, back and loins.
 - Backache better pressure and lying on back.




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 - Lumbago worse morning before rising.

 - Spine and limbs feel bruised.

 - Small of back and loins pain.

 - Legs give out on rising from a chair, hips and
 thighs so weak. [Phos.;Con.]
 - Sciatica; worse, lying down at night; pain from
 back down hips and thighs.
 - Hamstrings feel shortened. [Graph.]
                                                      32
SEPIA
 Weakness  in small of back. Pains
 extend into back.




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 - Lower extremities lame and stiff,
 tension as if too short.
 - Heaviness and bruised feeling.
 - Restlessness in all limbs, twitching
 and jerkings night and day.
 - Coldness of legs and feet.
                                           33
STAPHISAGRIA
 Muscles, especially of calves, feel bruised.
 - Backache; worse in morning before




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 rising.
 - Extremities feel beaten and painful.

 - Joints stiff.

 - Crural neuralgia.

 - Dull aching of nates extending to hip-
 joint and small of back.
                                                 34
SULPHUR
 Drawing   pain between shoulders.
 - Stiffness of nape.




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 - Sensation as if vertebrae glided over
 each other.
 - Burning in soles and hands at night.

 - Sweat in armpits, smelling like garlic.

 - Stiffness of knees and ankles.

 - Cannot walk erect; stoop-shouldered.

                                              35
TELLURIUM METALICUM
 Pain in sacrum.
 - - Pain from last cervical to fifth dorsal




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 vertebra, very sensitive; worse touch.
 [Chin.s. ; Phosph.]
 - worse right side, coughing, straining,
 and at night, with sensitive vertebral
 column.
 - Contraction of tendons in bends of
 knees.
                                                36
ZINCUM MET
 Pain in small of back.
 - Cannot bear back touched. [Sul.;




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 Therid.; Cinch.] Tension and stinging
 between shoulders.
 - Spinal irritation.

 - Dull aching about the last dorsal or first
 lumbar vertebrae; worse sitting.
 - Burning along spine. Nape of neck
 weary from writing or any exertion.
                                                 37
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INTERVERTEBRAL DISC PROLAPSE

               PRESENTED BY
  38           DR.ANISHA.K.S
                1.M.D.(MM)
ANATOMY
 The vertebral column is the central
 bony pillar of the body. It supports




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 the skull, pectoral girdle, upper
 limbs, and thoracic cage and, by way
 of the pelvic girdle, transmits body
 weight to the lower limbs. Within its
 cavity lie the spinal cord, the roots of
 the spinal nerves, and the covering
 meninges, to which the vertebral           39

 column gives great protection.
The vertebral column is composed
of 33 vertebrae 7 cervical, 12
thoracic, 5 lumbar, 5 sacral (fused to
form the sacrum), and 4 coccygeal




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(the lower 3 are commonly fused).
Because it is segmented and made
up of vertebrae, joints, and pads of
fibrocartilage called intervertebral
discs, it is a flexible structure. The
intervertebral discs form about one
fourth the length of the column.     40
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INTERVERTEBRAL DISC
 They may be regarded as semi-
 elastic discs, which lie between




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 the rigid bodies of adjacent
 vertebrae .They are thickest in
 the cervical and lumbar regions,
 where the movements of the
 vertebral column are greatest.
 Unfortunately, their resilience is   43

 gradually lost with advancing
 Each disc consists of a peripheral part, the
anulus fibrosus, and a central part, the
nucleus pulposus.
The anulus fibrosus is composed of




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fibrocartilage, in which the collagen fibers are
arranged in concentric layers or sheets.
 The nucleus pulposus in children and
adolescents is an ovoid mass of gelatinous
material containing a large amount of water, a
small number of collagen fibers, and a few
cartilage cells. It is normally under pressure
and situated slightly nearer to the posterior 44
than to the anterior margin of the disc.
 The  upper and lower surfaces of the
  bodies of adjacent vertebrae that abut
  onto the disc are covered with thin plates
  of hyaline cartilage. No discs are found
  between the first two cervical vertebrae




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  or in the sacrum or coccyx.
 Functions:- Their physical
  characteristics permit them to serve as
  shock absorbers when the load on the
  vertebral column is suddenly increased,
  as when one is jumping from a height.
  Their elasticity allows the rigid        45


  vertebrae to move one on the other.
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PATHOLOGY
•   A sudden increase in the compression load
    on the vertebral column causes the




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    semifluid nucleus pulposus to become
    flattened. Sometimes, the outward thrust
    is too great for the anulus fibrosus and it
    ruptures, allowing the nucleus pulposus to
    herniate and protrude into the vertebral
    canal, where it may press on the spinal
    nerve roots, the spinal nerve, or even the
    spinal cord and cause back ache,sciatica.
                                                  49
 There is narrowing of joint space.
  The weakest part of annulus is
 posterolateral part and as a result the




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 nerve root is often compressed in lateral
 part of spinal canal.Central protrusion
 can result in compression of cauda
 equina.



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AETIOLOGY
 1.Traumatic-80%   cases traumatic
  origin




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 2.Increased tension
 3.Degeneration-15% .Disc loses
  elasticity and fluid content.can’t
  resist body wt and liable to herniate.


                                           53
SITE
 1.Lumbosacral  region-L4/5 and
  L5/S1.80% occures at this region.




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 2.Lower cervical region-C5/6 and
  C6/7.19% Occures at this region.
 3.Dorsal region-constitute 1%of all
  disc prolapse


                                        54
    CLINICAL FEATURES
•   A.CERVICAL DISC PROTRUSION
•   Is relatively uncommon.
•   Midline protrusion:-rare,anterior part of the cord




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    is slightly compressed with compression of the
    ant.spinal artery and veins.artery compression
    lead to disturbence of spinothalamic and
    pyramidal tract and some damage of ant horn
    cells.vein-stasis and cong of ant horn cells below
    leison.->s/o disseminated sclerosis/primary
    lateral sclerosis appear.spastic
    paralysis,secondary atrophic changes(ant horn 55
    cell involvement)
•   Lateral protrusion:-common will cause pain and
    stiffness of neck.pain often radiate to scapular
    region and to occiput.Do not involve multiple
    nerve root,but involve the root emerges above
    the corresponding vertebra.




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•   When C6 nerve root is involved pain will be
    complined of at shoulder tip,outer border of
    upper arm and dorsum of forearm.there is
    sensory weakness of lateral border of upper
    arm,forearm.weakness of jerks
•   C7-pain at shoulder tip,back of upper arm and
    forearm,sensory loss,weakness of jerk.
                                                 56
•   B.LUMBAR DISC PROLAPSE
•   1.Pain-lowback ache followed by referred sciatic
    pain.in almost all cases there is initial back ache later
    followed by sciatica.in some cases both occures
    simultaneously.




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•   Onset of pain may be a/c following trauma.
•   Or sub a/c following hrs/days/weeks after trauma
•   Or c/c-habitual back strain and pt complaines of
    increasing pain
•   Pain is usually dull ache/stabing/shooting pain




                                                           57
 Site of pain is usually lower lumbar
  region usually in midline.pain radiate to
  one or both sacroiliac jt,to buttock, or
  distally to lowerlimb.Pain accentuated
  by coughing.




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 Other symptoms-paraesthesia,pins and
  needle sensation etc
 Small protrusion cause severe pain,as
  there is max friction of nerve root
  without much loss of conduction.large-
  less pain,conduction
  diminished,neurological symptoms more    58


  marked
 Commonly    seen in middle age.
 Usually last for 2-6 wks or continue
  longer.
 Serious neurological symptoms may be




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  an indication for surgery.
 Motor weakness more likely to recover
  than sensory




                                          59
CAUDA EQUINA SYNDROME
•   aetiology:-compressive leisons below the
    level of L1 may affect cauda equina or




                                                 www.similima.com
    conus medullaris or both-
    IVDP,neoplasms,spinal
    arachnoditis,lumbar canal stenosis.
•   Symptoms of root involvment-motor
    weakness in the form of LMN paralysis
    affecting glutei ms and ms of lower limb.
•   Sensory –root pain in the distribution of
    sciatic nerve often bilateral.              60
 Sensory   loss in the region of
  perineum,gluteal region and back of
  thighs.(saddle back anesthesia).
 Vesical and rectal incontinence.




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 Impotency in males
 Anal and bulbo cavernous reflex are lost
 Compression of conus medullaris result
  in early loss of sphincteric fn and UMN
  signs of lower limb.

                                         61
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                   62
PHYSICAL SIGNS
 O/E-SPINE
 Attitude-lumbar    scoliosis with convexity




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  to affected side,kyphosis with slight
  flexion hip and knee
 o/p-local deep tenderness is elicited on
  /slightly lateral to the affected spine
 Mvmts-flexion,extension-restricted
 Lateral flexion painful,rotation free and
  painless                                   63
 Knee   jerk diminished in lesion b/w L3-4
 TEST
 -Straight leg rising test-pain <40 degree
  indicate IVDP




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 PSLR-imp to differentiate sciatica from
  d’s of sacroiliac joint.
 Femoral nerve stretch test-IVDP at L2-3
 Naffzigiers test-lhermitte’s sign-cervical
  disc prolapse.

                                           64
   LUMBAR CANAL
STENOSIS
 Elderly
 Gradual   in onset




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 Back pain on standing and walking
  with neurological finding.
 Walking distance is limited.Legs go
  rubbery and tend to give away
 >rest for 5-10 mts,going uphill

                                        65
INVESTIGATIONS
1  .X RAY-AP &LATERAL VIEW
 Pathological narrowing of disc space




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  in 1/3rd cases
 2.Myelography
 3.epidurography
 3discography
 MRI

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                   72
MANAGEMENT
 1.REST-Strict   recumbency for 3 wks
  essential.




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 Corset-less severe cases
 Avoid stooping and lifting heavy wt
 2.TRACTION-enforce rest.min of 1
  hr daily for 3wks


                                         73
OPERATIVE MANAGEMENT
 Epidural  injection of .5% procain to
  reduce IVDP




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 Laminectomy followed by discectomy
  followed by arthrodesis




                                          74
DIFFERENTIAL DIAGNOSIS
 1.Lumbar  spondylosis
 2.Spondylolisthesis




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 3.Ankylosing spondylitis




                             75
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   LOW BACK ACHE


                76
AETIOLOGY
   1
            MECANICAL-
               prolapsed




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        disc,spondylosis,spond
        ylolysis/spondylolisthe
               sis,spnal
          stenosis,congenital
        abnormalities,nonspec
                   ific
                                  77
 INFLAMATO
        RY-
infection,sacro




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 iliitis,AS,arac    METABOLI
     hnoiditis           C-
                   osteoporosis,
                   osteomalacia,
                   hyperparath
                   yroidism,pag
                       et’s ds     78
                        REFERRED
 NEOPLASTIC-            PAIN-Peptic
metastasis,myelo      ulcer,pancreas,b
ma,reticulosis,oste      owel,kidney
        oid                ds,aortic




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osteoma,intrathec     aneurism,endom
    al tumors         etriosis,ovary,ret
                        roperitoneal
                       fibrosis,herpis
                          zoster,hip
                       ds,polymyalgia
                         rheumatica        79
      OTHERS-
    scheuermann’s




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osteochondritis,fibrom
     yalgia,diffuse
  idiopathic skeletal
 hyperostosis(DISH)


                         80
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                           81
               THANK YOU

				
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