Rotatorna manšeta je tetivno mišićna ovojnica koju sačinjavaju četiri mišića: subskapularis, supraspinatus, infraspinatus i teres minor. Sva četiri mišića polaze s lopatice i hvataju se na koštane izbočine nadlaktične kosti (Sl.1). Rotatorna manšeta ključna je struktura ramena. Glavna funkcija manšete je dinamička stabilizacija glave nadlaktične kosti. Oštećenje jednog od navedena četiri mišića bitno smanjuje funkciju ramena, odnosno ruke. Zbog svog položaja i funkcije najčešeće dolazi do oštećenja tetive supraspinatusa (oko 90%), izolirano ili u kombinaciji sa infraspinatusom. Tetiva subskapularisa puno rjeđe je podložena oštećenjima, pogotovo izoliranoj rupturi. Oštećenje tetiva manšete uključuje upalu tetiva (tendinits, tendinozu), parcijalnu i potpunu rupturu tetive. Upala tetiva zahtjeva konzervativno liječenje a ruptura u većini slučajeva operacijsko liječenje.
Rupture nastaju kao posljedica ozljede te trošenja i degeneracije tetiva u osoba starije životne dobi. Kod sportaša ili osoba koje se bavi sportom, pogotovo aktivnostima iznad glave (tenis, rukomet, bacački sportovi i dr) rupture tetiva susreću se u ranijoj životnoj dobi, čak i u dvadesetim godinama života. Najčešće su to parcijalne rupture koje vremenom postaju potpune. Razlog nastanka ruptura u ranijoj životnoj dobi je preopterećenje. Kod veće oštećene tetive i manja ozljeda može dovesti do potpune rupture. Svježu rupturu tetiva manšete treba odmah operirati. Razlog? Dolazi do skraćenja, retrakcije tetive te je kasnija rekonstrukcija često nemoguća.
Pacijenti se žale na bol u ramenu, često s vanjske strane nadlaktice, pogotovo kod obavljanja poslova iznad razine ramena te slabost ruke. Poslove ispod razine ramena obavljaju bez većih poteškoća. Često navode da im je i plahta noću teška. Bol se javlja noću i ne dozvoljava spavanje na bolesnom ramenu. Kod akutnih ozljeda bolesnik ne može odignuti ruku od tijela.
Dijagnostika
Ultrazvučni pregled ramena upotpunjuje kliničku sliku bolesnika. Ultrazvukom je moguće s velikom vjerojatnosti naći rupturiranu tetivu te odrediti veličinu rupture. Potpuna rupture manšete bez većih poteškoća se utvrđuje ultrazvukom. Poteškoće stvaraju parcijalne, djelomične rupture pri čemu je oštećena samo jedna strana tetive i to obično zglobna strana tetive. Pod parcijalnom rupturom se podrazumjeva da je jedan dio debljine tetive oštećen, rupturiran. O veličini rupture ovisi i način liječenja.
Magnetska rezonancija omogućava prikaz cijele tetive i mišića pri čemu se može vidjeti mjesto i veličina rupture te stanje mišića. MR omogućava uvid u veličinu retrakcije tetive te promjene koje se događaju u rupturiranom mišiću, tzv. masna degeneracija pri čemu mišićne niti se zamjenjuju masnim tkivom.
Liječenje
Bolesnici koji nemaju većih poteškoća, a starije su životne dobi ne trebaju operaciju. Njima se savjetuje da izbjegavaju veće opterećenje preko dana te da uzimaju nesteroidne protuupalne lijekove. Kod svih ostali bolesnika se preporuča operacija. Ovisno o veličini i tipu rupture ovisi vrsta operacije.
U bolnici Akromion rutinski se izvodi artroskopska rekonstrukcija manšete.
Kod parcijalne rupture, najčešće je ruptura tetive supraspinatusa, radi se čišćenje, debridement puknutog dijela tetive ako je defekt do 10-20% debljine tetive, ako je defekt veći i zauzima veću površinu neophodna je fiksacija tetive za kost.
Operacijske tehnike koje stoje na raspolaganju operateru mogu se podijeliti na dvije grupe; otvorene i artroskopske. Otvorene operacijske tehnike tehnički su manje zahtjevne ali daju slabiji pregled i pristup tkivu rotatorne manšete, te uvjetuju nešto duži rehabilitacijski tijek radi potrebe cijeljenja tkiva kroz koja se pristupalo na mjesto puknuća tetiva. Standardno se izvode tehnike šivanja rupturirane tetive i fiksacije za kost koncima provučenim kroz tunele probušene u regiji velikog tuberkula ili se koriste koštana sidra. Artroskopski zahvati rekonstrukcije tetiva rupturirane rotatorne manšete zahtijevaju bolju tehnološku opremljenost operacijskog tima te iskustvo operatera. Artroskopska metoda daje bolju vizualizaciju oštećenog tkiva, bolju mogućnost mobilizacije krajeva oštećene tetive i brži rehabilitacijski tijek i oporavak bolesnika.
Prof. Nikola Čičak sa svojim timom objavio je i uveo rutinsku kliničku praksu metodu artroskopske transosealne fiksacije rotatorne manšete koja imitira otvorenu tehniku rekonstrukcije tetive rotatorne manšete kombinacijom koštanog sidra i formiranja koštanog tunela kroz koji se provlači konac za fiksaciju tetive (Sl.4). Ova metoda omogućava optimalni kontakt tetive i kosti čime se stvaraju uvjeti za čvršću fiksaciju i brže cjeljenje rekonstruirane tetive za kost.
Otvorene metode se koriste kada se radi o masivnoj rupturi rotatorne manšete, kada je nemoguća otvorena ili artroskopska rekonstrukcija. U takvim slučajevima se radi transpozicija okolnih mišića, mišića latisimus dorzi kod rupture supraspinatusa i infraspinatusa a veliki pektoralni mišić kod izolirane rupture tetive subskapularisa. U uznapredovalim slučajevima kod bolesnika kod kojih se razvila artropatija ramena kao posljedica masivne rupture rotatorne manšete ugrađuje se obrnuta (reverse) proteza ramena. Indikacija za ovaj tip proteze je životna dob bolesnika iznad 70 godina te pseudoparaliza ruke (nemogućnost odmicanja ruke od tijela).
Rehabilitacija
Nakon operacije, artroskopske rekonstrukcije manšete, bolesnik nosi ortozu za rame 3-4 tjedna. Dan nakon operacije se započinje s fizikalnom terapijom, izvode se lagani pokreti rukom uz pomoć druge ruke ili fizioterapeuta. Prvih 6 tjedana ne smije se aktivno odmaknuti ruka od tijela. Za to vrijeme nastoji se postići puna pasivna pokretljivost ruke. Jačanje mišića rotatorne manšete započinje s 8 tjedana od operacije. Obično se bolesnici počinju koristiti rukom 2-3 tjedna iza operacije. Puno opterećenje ruke se dozvoljava nakon 4 mjeseca
utorak, 30. lipnja 2009.
nedjelja, 28. lipnja 2009.
Parkinsonova bolest
Parkinsonova bolest je bolest poremećaja pokreta zbog smanjenja lučenja kemijske supstancije dopamina u dijelu mozga koji ima važnu ulogu u kontroli voljnih pokreta (bazalni gangliji). Bolest je nazvana po liječniku iz Londona dr. Jamesu Parkinsonu, koji je 1817. godine prvi opisao simptome bolesti.
Ne postoje specifične metode dijagnostike kojima bi se dokazala bolest, pa je potreban detaljan neurološki pregled i obrada kako bi se postavila dijagnoza bolesti.
Za postavljanje dijagnoze potrebno je uzeti temeljitu anamnezu bolesnika, odrediti opći i neurološki status bolesnika te, ukoliko je potrebno, učiniti test levodopom.
Glavni simptomi:
1. tremor (drhtanje) u mirovanju; obično više izražen na jednoj strani tijela
2. rigor (ukočenost mišića ruku, nogu i vrata)
3. bradikinezija (usporenje pokreta)
Za procjenu stupnja težine bolesti koriste se rezultati dobiveni ocjenskim ljestvicama za Parkinsonovu bolest (Hoehn and Yahr Staging of PD; UPDRS) i pomažu u liječenju i prognozi bolesti.
UPDRS (Unified Parkinson Disease Rating Scale) je skala koja se sastoji od tri različite skupine pitanja vezanih uz mentalno stanje, raspoloženje, ponašanje, sposobnost obavljanja svakodnevnih aktivnosti i motoričku aktivnost.
Maksimalni zbroj bodova je 199 što ujedno predstavlja i najteži oblik onesposobljenja zbog bolesti.
Pozitivan odgovor na terapiju levodopom služi za potvrdu dijagnoze bolesti.
Dodatne dijagnostičke pretrage poput kompjutorske tomografije mozga (CT) ili magnetske rezonancije (MR) mogu pomoći isključiti neke neurološke ili vaskularne poremećaje sa sličnim simptomima, no ne i dokazati bolest.
KLINIČKA SLIKA
Bolest se polagano razvija i može proći nekoliko mjeseci, pa i godina prije nego bolesnik ustanovi da ima tegoba.
Tri su glavna simptoma Parkinsonove bolesti:
1. Tremor (drhtanje)
2. Rigor (ukočenost mišića ruku, nogu i vrata)
3. Bradikinezija (usporenje pokreta)
Osim navedena 3 simptoma, javlja se i posturalna nestabilnost (slaba ravnoteža). SParkinsonova bolestimptomi ne moraju biti prisutni istodobno niti se javljati jednakim intenzitetom.
Tremor (drhtanje) je simptom koji javnost često povezuje s Parkinsonovim bolesti iako tek oko 25 % bolesnika doživljava jako slabi tremor ili ga uopće nema. Karakteriziran je ritmičnim podrhtavanjem i nevoljnim pokretima različitih dijelova tijela. Posljedica je ponavljajućih mišićnih kontrakcija. Gubi se u snu i tijekom odmora, a s vremenom se javlja u sve duljim razdobljima. Počinje asimetrično na rukama, prvo jedna pa druga (stereotip - brojanje novca), kasnije noge, donja čeljust, jezik, glava.
Važno je upamtiti da drhtanje može biti različita podrijetla te da nemaju svi bolesnici s drhtanjem Parkinsonovu bolest.
Rigor (ukočenost) je pojačan tonus ili ukočenost u mišićima. Najčešće se javlja u okviru vrata, ramenog obruča, zdjelice, ali i u šakama i stopalima. Rezultat je tipični položaj bolesnika sa Parkinsonovom bolesti - polupognuti položaj trupa sa nogama savijenim u koljenima i rukama savijenim u laktovima. Često je ukočenost odgovorna za izraz lica u obliku maske. Kod nekih bolesnika ukočenost vodi osjećanju boli, posebno u rukama i ramenima. Pojačava se tijekom kretanja.
Bradikinezija znači sporost pokreta. Ovaj simptom u najvećoj mjeri doprinosi funkcionalnom oštećenju bolesnika. Obilježen je kašnjenjem u započinjanju pokreta i smanjenjem amplitude pokreta. Uzrokovan je sporošću u prijenosu nužnih informacija od mozga prema određenim dijelovima tijela. Kada su upute primljene tijelo sporo reagira na njih. Normalni asocirani pokreti (npr. mahanje rukama dok hodamo, treptanje, gestikulacija tijekom razgovora) znatno su smanjeni. Obavljanje uobičajenih dnevnih aktivnosti koje uključuju fine pokrete je usporeno (zakopčavanje gumbi, vezanje cipela, okretanje u krevetu).
Posturalna nestabilnost (slaba ravnoteža) se javlja kao rezultat gubitaka posturalnih refleksa. To su autonomni refleksni mehanizmi koji kontroliraju održavanje uspravnog položaja i štite osobu od padova tijekom promjene položaja. Padanje, tj. gubitak ravnog stanja se u Parkinsonovoj bolesti javlja npr. kod promjene smjera hoda ili sjedanja u stolicu.
Često je prisutna depresija, demencija, smetnje sna, mokrenja i stolice. Javljaju se promjene u rukopisu (mikrografija - veličina slova se smanjuje tijekom pisanja) i govoru (usporeno započinjanje, tiho, monotono, nerazumljivo pričanje). Osim toga često se javljaju i pretjerano znojenje te seboreja kože i vlasišta.
Brzina napredovanja same bolesti razlikuje se od bolesnika do bolesnika. U nekih bolesnika čak i dulje vrijeme bolest ne utječe na sposobnost obavljanja svakodnevnih aktivnosti. Važno je na vrijeme otkriti bolest te je učinkovito liječiti.
Liječenje Parkinsonove bolesti
Liječenje Parkinsonove bolesti je simptomatsko i ne zaustavlja napredovanje bolesti. U liječenju je potrebno individualno pristupiti svakom bolesniku ovisno o dobi i stupnju težine bolesti, a sve u svrhu poboljšanja kvalitete života.
Važna je rana dijagnoza bolesti, uzimanje specifičnih lijekova, način prehrane, tjelovježba.
Liječenje je izrazito uspješno u ranom stadiju kada je simptome moguće kontrolirati jednim lijekom. U uznapredovaloj fazi bolesti potrebna je kombinacija više lijekova različitog mehanizma djelovanja. Za postizanje odgovarajuće doze potrebno je postupno titriranje kroz dulji vremenski period.
Liječenje Parkinsonove bolesti uz primjenu lijekova uključuje i nefarmakološke mjere (tjelovježba, prehrana, suportivne grupe).
Cilj liječenja je postići kontinuiranu stimulaciju dopaminergičkih neurona primjenom antiparkinsonika (lijekova za liječenje Parkinsonove bolesti)
Ne postoje specifične metode dijagnostike kojima bi se dokazala bolest, pa je potreban detaljan neurološki pregled i obrada kako bi se postavila dijagnoza bolesti.
Za postavljanje dijagnoze potrebno je uzeti temeljitu anamnezu bolesnika, odrediti opći i neurološki status bolesnika te, ukoliko je potrebno, učiniti test levodopom.
Glavni simptomi:
1. tremor (drhtanje) u mirovanju; obično više izražen na jednoj strani tijela
2. rigor (ukočenost mišića ruku, nogu i vrata)
3. bradikinezija (usporenje pokreta)
Za procjenu stupnja težine bolesti koriste se rezultati dobiveni ocjenskim ljestvicama za Parkinsonovu bolest (Hoehn and Yahr Staging of PD; UPDRS) i pomažu u liječenju i prognozi bolesti.
UPDRS (Unified Parkinson Disease Rating Scale) je skala koja se sastoji od tri različite skupine pitanja vezanih uz mentalno stanje, raspoloženje, ponašanje, sposobnost obavljanja svakodnevnih aktivnosti i motoričku aktivnost.
Maksimalni zbroj bodova je 199 što ujedno predstavlja i najteži oblik onesposobljenja zbog bolesti.
Pozitivan odgovor na terapiju levodopom služi za potvrdu dijagnoze bolesti.
Dodatne dijagnostičke pretrage poput kompjutorske tomografije mozga (CT) ili magnetske rezonancije (MR) mogu pomoći isključiti neke neurološke ili vaskularne poremećaje sa sličnim simptomima, no ne i dokazati bolest.
KLINIČKA SLIKA
Bolest se polagano razvija i može proći nekoliko mjeseci, pa i godina prije nego bolesnik ustanovi da ima tegoba.
Tri su glavna simptoma Parkinsonove bolesti:
1. Tremor (drhtanje)
2. Rigor (ukočenost mišića ruku, nogu i vrata)
3. Bradikinezija (usporenje pokreta)
Osim navedena 3 simptoma, javlja se i posturalna nestabilnost (slaba ravnoteža). SParkinsonova bolestimptomi ne moraju biti prisutni istodobno niti se javljati jednakim intenzitetom.
Tremor (drhtanje) je simptom koji javnost često povezuje s Parkinsonovim bolesti iako tek oko 25 % bolesnika doživljava jako slabi tremor ili ga uopće nema. Karakteriziran je ritmičnim podrhtavanjem i nevoljnim pokretima različitih dijelova tijela. Posljedica je ponavljajućih mišićnih kontrakcija. Gubi se u snu i tijekom odmora, a s vremenom se javlja u sve duljim razdobljima. Počinje asimetrično na rukama, prvo jedna pa druga (stereotip - brojanje novca), kasnije noge, donja čeljust, jezik, glava.
Važno je upamtiti da drhtanje može biti različita podrijetla te da nemaju svi bolesnici s drhtanjem Parkinsonovu bolest.
Rigor (ukočenost) je pojačan tonus ili ukočenost u mišićima. Najčešće se javlja u okviru vrata, ramenog obruča, zdjelice, ali i u šakama i stopalima. Rezultat je tipični položaj bolesnika sa Parkinsonovom bolesti - polupognuti položaj trupa sa nogama savijenim u koljenima i rukama savijenim u laktovima. Često je ukočenost odgovorna za izraz lica u obliku maske. Kod nekih bolesnika ukočenost vodi osjećanju boli, posebno u rukama i ramenima. Pojačava se tijekom kretanja.
Bradikinezija znači sporost pokreta. Ovaj simptom u najvećoj mjeri doprinosi funkcionalnom oštećenju bolesnika. Obilježen je kašnjenjem u započinjanju pokreta i smanjenjem amplitude pokreta. Uzrokovan je sporošću u prijenosu nužnih informacija od mozga prema određenim dijelovima tijela. Kada su upute primljene tijelo sporo reagira na njih. Normalni asocirani pokreti (npr. mahanje rukama dok hodamo, treptanje, gestikulacija tijekom razgovora) znatno su smanjeni. Obavljanje uobičajenih dnevnih aktivnosti koje uključuju fine pokrete je usporeno (zakopčavanje gumbi, vezanje cipela, okretanje u krevetu).
Posturalna nestabilnost (slaba ravnoteža) se javlja kao rezultat gubitaka posturalnih refleksa. To su autonomni refleksni mehanizmi koji kontroliraju održavanje uspravnog položaja i štite osobu od padova tijekom promjene položaja. Padanje, tj. gubitak ravnog stanja se u Parkinsonovoj bolesti javlja npr. kod promjene smjera hoda ili sjedanja u stolicu.
Često je prisutna depresija, demencija, smetnje sna, mokrenja i stolice. Javljaju se promjene u rukopisu (mikrografija - veličina slova se smanjuje tijekom pisanja) i govoru (usporeno započinjanje, tiho, monotono, nerazumljivo pričanje). Osim toga često se javljaju i pretjerano znojenje te seboreja kože i vlasišta.
Brzina napredovanja same bolesti razlikuje se od bolesnika do bolesnika. U nekih bolesnika čak i dulje vrijeme bolest ne utječe na sposobnost obavljanja svakodnevnih aktivnosti. Važno je na vrijeme otkriti bolest te je učinkovito liječiti.
Liječenje Parkinsonove bolesti
Liječenje Parkinsonove bolesti je simptomatsko i ne zaustavlja napredovanje bolesti. U liječenju je potrebno individualno pristupiti svakom bolesniku ovisno o dobi i stupnju težine bolesti, a sve u svrhu poboljšanja kvalitete života.
Važna je rana dijagnoza bolesti, uzimanje specifičnih lijekova, način prehrane, tjelovježba.
Liječenje je izrazito uspješno u ranom stadiju kada je simptome moguće kontrolirati jednim lijekom. U uznapredovaloj fazi bolesti potrebna je kombinacija više lijekova različitog mehanizma djelovanja. Za postizanje odgovarajuće doze potrebno je postupno titriranje kroz dulji vremenski period.
Liječenje Parkinsonove bolesti uz primjenu lijekova uključuje i nefarmakološke mjere (tjelovježba, prehrana, suportivne grupe).
Cilj liječenja je postići kontinuiranu stimulaciju dopaminergičkih neurona primjenom antiparkinsonika (lijekova za liječenje Parkinsonove bolesti)
subota, 27. lipnja 2009.
Discus hernia
Predstavlja izbijanje jezgre diska kroz raskinuti prsten diska, što znači da je degeneracija diska dosegla vrhunac. Od tog su trenutka nadaIje moguće stalne tegobe. Prsten može popustiti na bilo kojemu mjestu. Međutim, zbog statičko-dinamičkih i strukturnih posebnosti u slabinskom dijelu kičmenog stuba hernija se najčešće pojavljuje na stražnjem dijelu diska. Dakle, izbočenje jezgre diska straga najčešći je oblik hernije i na tome je dijelu kičmenog stuba stražnja bočna hernija vrlo značajna jer tuda prolaze korijeni živaca. Na kičmenom stubu se straga nalazi stražnja uzdužna sveza koja je prilično jaka i ne dopušta ispade, pa je ondje hernija rijetka. Najčešće hernija nastaje straga desno ili lijevo (dorzo-lateralno), jer je ondje najneotpornije mjesto (locus minoris resistentiae). Na tome mjestu disk nije ojačan svezama. Osim toga, istraživanja pokazuju da u tom području u prstenu diska ostaju rupice od zakržljalih krvnih žila. Na tome je mjestu onemogućeno ili otežano i odmicanje korijena živca. Zato se upravo ondje često pojavljuju znakovi pritiska na korijen živca. Pri tom mogu biti pogođeni jedan do dva korijena živca jer ih pritišće pulpozno tkivo jezgre ispalo kroz stražnju stijenku ili ih tako izbočeno tkivo rasteže i vuče. Nastane li hernija u predjelu intervertebralnog otvora, ona može biti vrlo mala a ipak pokazivati znakove pritiska. Tamo je, naime, prostor uzak, a znakovi nastaju samo zbog pritiska na jedan određeni korijen živca. Prsten može napuknuti do vanjskih slojeva, s tim što vanjski slojevi ostanu čitavi, te se tkivo izboči van, ali ne ispadne izvan granice diska. U tom se slučaju hernija može vratiti na svoje prijašnje mjesto, dakle reponirati. To nazivamo protruzijom hernije diska. Ako se ona reponira, prestaju i znakovi kompresije. Ako se prsten i rastegne, hernija se ipak može povući ako istisnuto tkivo još ima vezu s diskom. Međutim, ako te veze nema i ako se tkivo odvoji od diska, ono se više ne može vratiti u prijašnji položaj, pa nastane tzv. sekvestar diska. Pukne li prsten diska, kažemo da je nastao prolaps. U slučaju da je prolaps tolikog intenziteta da probije lig.longitudinalae posterior, govorimo o extrusio disci. 
Razlikujemo pokretni i nepokretni (fiksirani) prolaps. Pokretni prolaps (iskliznuće) može, na primjer nakon liječenja fizikalnim metodama (ekstenzija, ležanje) ili manipulacije na kralješnici, skliznuti u svoje staro ležište. Tako i tegobe popuštaju. Međutim, ako je prolaps fiksiran, to je nemoguće jer više nema veze s diskom pa on u novom ležištu uskoro sraste s okolinom, i to stvarajući ožiljak. Unatoč tome, i u takvim je primjerima moguće spontano izlječenje, i to na tri načina: 1. Ispalo tkivo svojim pritiskom troši (razgrađuje) susjedne koštane tvorevine, nastaju udubine na razgrađenim dijelovima kosti u koje se to tkivo može uvući, tvoreći tako sekvestar (odvojeni ili odumrli dio diska). Pritisak tako prestaje, pa se i bolovi smanje ili čak prestanu. 2. Sekvestar se može pomaknuti u tzv. nijemo područje, gdje nema pritiska na živac. 3. Sekvestar se može rastvoriti, tj. resorbirati, što se, čini se, najčešće događa.
Razlikujemo pokretni i nepokretni (fiksirani) prolaps. Pokretni prolaps (iskliznuće) može, na primjer nakon liječenja fizikalnim metodama (ekstenzija, ležanje) ili manipulacije na kralješnici, skliznuti u svoje staro ležište. Tako i tegobe popuštaju. Međutim, ako je prolaps fiksiran, to je nemoguće jer više nema veze s diskom pa on u novom ležištu uskoro sraste s okolinom, i to stvarajući ožiljak. Unatoč tome, i u takvim je primjerima moguće spontano izlječenje, i to na tri načina: 1. Ispalo tkivo svojim pritiskom troši (razgrađuje) susjedne koštane tvorevine, nastaju udubine na razgrađenim dijelovima kosti u koje se to tkivo može uvući, tvoreći tako sekvestar (odvojeni ili odumrli dio diska). Pritisak tako prestaje, pa se i bolovi smanje ili čak prestanu. 2. Sekvestar se može pomaknuti u tzv. nijemo područje, gdje nema pritiska na živac. 3. Sekvestar se može rastvoriti, tj. resorbirati, što se, čini se, najčešće događa.
Prava ispadanja tkiva sa strane i sprijeda ne samo što su rjeđa nego izazivaju i manje tegoba nego ispadanje tkiva unatrag, jer ondje nema mogućnosti oštećenja korijena živca. Govorimo tada o “nijemim” ispadanjima (nijemim hernijama) jer ne izazivaju bolove u živcu (neuralgiju) ni druge podražaje. Ostaju subjektivno neprimjetni, a obično ne pogađaju ni tkiva na drugim organima. Tegobe se mogu očekivati samo ako zbog ispadanja nastane suženje diska, a time i sekundarne promjene na tkivima između pršljenova.
četvrtak, 25. lipnja 2009.
Tennis elbow
Tennis elbow
Published by Bupa's health information team, June 2007.
This factsheet is for people who have tennis elbow, or who would like information about it.
Tennis elbow is the common name for a painful condition affecting the outside part of the elbow. Tennis elbow is most common in people aged between 35 and 55. Depending on the severity, it can take from two months to two years to heal fully.
What is tennis elbow?
The medical term for tennis elbow is lateral epicondylitis because it affects the outside of the elbow bone called the lateral epicondyle. The cause of the problem is damage to a tendon that joins the extensor muscles of the forearm to the upper arm bone (humerus). This tendon is called the common extensor tendon (see diagram).
The elbow joint
Tendon damage can occur after a single incident, such as lifting something very heavy, causing a tear in the tendon. But the most common cause is repeated overuse of the arm.
This overuse causes tiny tears (called microtears) in the tendon. You will make this worse if you continue doing the activity that triggered the pain and if you don't rest your arm. If you continue aggravating the injury you may get a more serious tear or even rupture your tendon.
Causes and risk factors
Playing tennis three times in a week when you haven't played for some time is the sort of overuse that could cause tennis elbow. But most people who develop tennis elbow have not been playing tennis. A range of different activities that involve repeated hand, wrist and forearm movements can be the cause. These include:
* using a computer mouse (especially if you have poor arm and neck posture)
* using a computer keyboard
* using vibrating equipment, such as strimmers
* using scissors or shears
* gardening
* manual occupations that involve repetitive twisting and lifting of the wrist - including plumbing, bricklaying and use of a screwdriver
* playing musical instruments such as the violin
Symptoms
The main symptom is pain and tenderness on the outside of the elbow and sometimes in the muscles on top of the forearm. Tennis elbow usually affects the arm of your dominant hand (right arm if you are right-handed) because this is the arm you use the most.
The symptoms usually develop gradually. The pain may go away after a day or so. But if you repeat the activity that triggered the pain, it may get worse as you will increase the damage to your tendon. The pain may become constant and even interrupt your sleep.
Other symptoms include:
* your affected arm feels stiff in the morning and painful when you turn door handles or shake hands
* your affected arm feels weak and heavy
* pain or stiffness in other parts of your affected arm, or your shoulder or neck, as your body tries to compensate for the weakness in your elbow
When to see your doctor
If you have severe elbow pain, can't move the joint or have any loss of feeling, you should seek medical treatment urgently.
Most people with mild symptoms of tennis elbow can try home treatments (see Home treatment). But if your symptoms don't improve after a couple of weeks, you should see your GP or physiotherapist.
Diagnosis
Your GP can usually diagnose tennis elbow from examining your arm and hearing about how your symptoms developed. An X-ray is rarely needed, but your GP may recommend having one to rule out other conditions, such as arthritis, that can cause elbow pain.
For severe tennis elbow that has failed to heal with normal treatment, your GP might suggest an MRI scan or ultrasound. These give images of the soft tissues, including muscles and tendons, inside your arm.
Treatment
To make a full recovery, you need to change the way you use your arm so that your tendon is rested and has time to heal. Exactly how you do this depends on how you came to have tennis elbow and how severe it is.
Treatment for tennis elbow includes the following.
* Reduce inflammation and pain. Your GP may prescribe medicines to reduce inflammation. Your physiotherapist may try various techniques to reduce the pain. These may include acupuncture, ultrasound, deep tissue massage and correcting posture. For tennis elbow that has failed to heal with normal treatment, a doctor may suggest a steroid injection, which can help relieve pain and inflammation.
* Activity modification. Your physiotherapist can advise you on how to improve your posture, or improve your technique at sports and other activities to help prevent further injuries. This may involve having a workstation assessment if your tennis elbow is due to your work.
* Rehabilitation. This involves strengthening exercises, such as a structured loading programme of the tendon as well as stretching. Your physiotherapist will be able to advise you on this.
* Arm brace or tape. This can alter where the tendon works from and allow the inflammation to settle.
Home treatment
You can treat your symptoms yourself if you have mild tennis elbow. The most important part of the treatment is to rest your injured tendon by stopping or changing the activity that is causing the problem. To relieve your symptoms, you can do the following.
* Apply an ice pack - to reduce the pain and swelling. Immerse your arm in ice for 10 minutes or use an ice pack (a bag of frozen peas will do) for 10 to 30 minutes. Don't apply the ice directly to your skin because it can cause cold injury - place a cloth between the ice your skin. Repeat every couple of hours as needed for the next 48 hours, allowing your arm to warm up between ice sessions.
* Take anti-inflammatory medicine - such as ibuprofen, according to the directions on the packet, up to the maximum daily dose. Ibuprofen is not suitable for people who have stomach ulcers, or for some people with asthma. If in doubt, ask your pharmacist or doctor for advice. Ibuprofen belongs to a group of drugs called non-steroidal anti-inflammatory drugs (NSAIDs). Always read the patient information leaflet that comes with your medicine. Other types of NSAIDs may be more appropriate for some people.
* Wear an arm brace - this is a form of strapping that you can wear around your forearm and elbow to help restrict the movement of your tendon. You can buy arm braces from some physiotherapists, larger pharmacies and sports shops. Your physiotherapist will be able to advise you on how to use it.
* Modify technique - when doing a manual task you can't avoid, use a tool with a smaller grip. If available, you should contact your employer's occupational health advisers. They can give advice on how to change your daily activity at work to allow your arm to heal.
Other treatments
Your GP can prescribe stronger types or doses of NSAIDs than those you can buy from your pharmacist. He or she may refer you to a sports medicine doctor, a rheumatologist or a physiotherapist.
Surgery may be an option if the tendon is severely damaged, or if there has been no improvement after many months of rest and rehabilitation. However, very few people need surgery.
Prevention
Tennis elbow is an overuse injury, so it can be prevented. A few sensible precautions include:
* warm up for activity with five minutes of gentle movements - this allows time for your muscles to adjust to the extra stresses and strains
* try not to do the same activity for long periods of time - take regular breaks
* seek advice early from your doctor or physiotherapist if you notice a problem
To prevent an old tennis elbow injury from coming back, you should:
* cut down on the type of activity causing the problem
* give yourself proper rest between sessions
* don't play sport if your arm is painful
Published by Bupa's health information team, June 2007.
This factsheet is for people who have tennis elbow, or who would like information about it.
Tennis elbow is the common name for a painful condition affecting the outside part of the elbow. Tennis elbow is most common in people aged between 35 and 55. Depending on the severity, it can take from two months to two years to heal fully.
What is tennis elbow?
The medical term for tennis elbow is lateral epicondylitis because it affects the outside of the elbow bone called the lateral epicondyle. The cause of the problem is damage to a tendon that joins the extensor muscles of the forearm to the upper arm bone (humerus). This tendon is called the common extensor tendon (see diagram).
The elbow joint
Tendon damage can occur after a single incident, such as lifting something very heavy, causing a tear in the tendon. But the most common cause is repeated overuse of the arm.
This overuse causes tiny tears (called microtears) in the tendon. You will make this worse if you continue doing the activity that triggered the pain and if you don't rest your arm. If you continue aggravating the injury you may get a more serious tear or even rupture your tendon.
Causes and risk factors
Playing tennis three times in a week when you haven't played for some time is the sort of overuse that could cause tennis elbow. But most people who develop tennis elbow have not been playing tennis. A range of different activities that involve repeated hand, wrist and forearm movements can be the cause. These include:
* using a computer mouse (especially if you have poor arm and neck posture)
* using a computer keyboard
* using vibrating equipment, such as strimmers
* using scissors or shears
* gardening
* manual occupations that involve repetitive twisting and lifting of the wrist - including plumbing, bricklaying and use of a screwdriver
* playing musical instruments such as the violin
Symptoms
The main symptom is pain and tenderness on the outside of the elbow and sometimes in the muscles on top of the forearm. Tennis elbow usually affects the arm of your dominant hand (right arm if you are right-handed) because this is the arm you use the most.
The symptoms usually develop gradually. The pain may go away after a day or so. But if you repeat the activity that triggered the pain, it may get worse as you will increase the damage to your tendon. The pain may become constant and even interrupt your sleep.
Other symptoms include:
* your affected arm feels stiff in the morning and painful when you turn door handles or shake hands
* your affected arm feels weak and heavy
* pain or stiffness in other parts of your affected arm, or your shoulder or neck, as your body tries to compensate for the weakness in your elbow
When to see your doctor
If you have severe elbow pain, can't move the joint or have any loss of feeling, you should seek medical treatment urgently.
Most people with mild symptoms of tennis elbow can try home treatments (see Home treatment). But if your symptoms don't improve after a couple of weeks, you should see your GP or physiotherapist.
Diagnosis
Your GP can usually diagnose tennis elbow from examining your arm and hearing about how your symptoms developed. An X-ray is rarely needed, but your GP may recommend having one to rule out other conditions, such as arthritis, that can cause elbow pain.
For severe tennis elbow that has failed to heal with normal treatment, your GP might suggest an MRI scan or ultrasound. These give images of the soft tissues, including muscles and tendons, inside your arm.
Treatment
To make a full recovery, you need to change the way you use your arm so that your tendon is rested and has time to heal. Exactly how you do this depends on how you came to have tennis elbow and how severe it is.
Treatment for tennis elbow includes the following.
* Reduce inflammation and pain. Your GP may prescribe medicines to reduce inflammation. Your physiotherapist may try various techniques to reduce the pain. These may include acupuncture, ultrasound, deep tissue massage and correcting posture. For tennis elbow that has failed to heal with normal treatment, a doctor may suggest a steroid injection, which can help relieve pain and inflammation.
* Activity modification. Your physiotherapist can advise you on how to improve your posture, or improve your technique at sports and other activities to help prevent further injuries. This may involve having a workstation assessment if your tennis elbow is due to your work.
* Rehabilitation. This involves strengthening exercises, such as a structured loading programme of the tendon as well as stretching. Your physiotherapist will be able to advise you on this.
* Arm brace or tape. This can alter where the tendon works from and allow the inflammation to settle.
Home treatment
You can treat your symptoms yourself if you have mild tennis elbow. The most important part of the treatment is to rest your injured tendon by stopping or changing the activity that is causing the problem. To relieve your symptoms, you can do the following.
* Apply an ice pack - to reduce the pain and swelling. Immerse your arm in ice for 10 minutes or use an ice pack (a bag of frozen peas will do) for 10 to 30 minutes. Don't apply the ice directly to your skin because it can cause cold injury - place a cloth between the ice your skin. Repeat every couple of hours as needed for the next 48 hours, allowing your arm to warm up between ice sessions.
* Take anti-inflammatory medicine - such as ibuprofen, according to the directions on the packet, up to the maximum daily dose. Ibuprofen is not suitable for people who have stomach ulcers, or for some people with asthma. If in doubt, ask your pharmacist or doctor for advice. Ibuprofen belongs to a group of drugs called non-steroidal anti-inflammatory drugs (NSAIDs). Always read the patient information leaflet that comes with your medicine. Other types of NSAIDs may be more appropriate for some people.
* Wear an arm brace - this is a form of strapping that you can wear around your forearm and elbow to help restrict the movement of your tendon. You can buy arm braces from some physiotherapists, larger pharmacies and sports shops. Your physiotherapist will be able to advise you on how to use it.
* Modify technique - when doing a manual task you can't avoid, use a tool with a smaller grip. If available, you should contact your employer's occupational health advisers. They can give advice on how to change your daily activity at work to allow your arm to heal.
Other treatments
Your GP can prescribe stronger types or doses of NSAIDs than those you can buy from your pharmacist. He or she may refer you to a sports medicine doctor, a rheumatologist or a physiotherapist.
Surgery may be an option if the tendon is severely damaged, or if there has been no improvement after many months of rest and rehabilitation. However, very few people need surgery.
Prevention
Tennis elbow is an overuse injury, so it can be prevented. A few sensible precautions include:
* warm up for activity with five minutes of gentle movements - this allows time for your muscles to adjust to the extra stresses and strains
* try not to do the same activity for long periods of time - take regular breaks
* seek advice early from your doctor or physiotherapist if you notice a problem
To prevent an old tennis elbow injury from coming back, you should:
* cut down on the type of activity causing the problem
* give yourself proper rest between sessions
* don't play sport if your arm is painful
LOW BACK PAIN
Almost everyone will experience low back pain at some point in their lives. This pain can vary from mild to severe. It can be short-lived or long-lasting. However it happens, low back pain can make many everyday activities difficult to do.
Anatomy
Understanding your spine and how it works can help you understand why you have low back pain.
Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine.
Vertebrae
Parts of the lumbar spine.
These bones connect to create a canal that protects the spinal cord. The spinal column is made up of three sections that create three natural curves in your back: the curves of the neck area (cervical), chest area (thoracic), and lower back (lumbar). The lower section of your spine (sacrum and coccyx) is made up of vertebrae that are fused together.
Five lumbar vertebrae connect the upper spine to the pelvis.
Spinal Cord and Nerves
These "electrical cables" travel through the spinal canal carrying messages between your brain and muscles. Nerves branch out from the spinal cord through openings in the vertebrae.
Muscles and Ligaments
These provide support and stability for your spine and upper body. Strong ligaments connect your vertebrae and help keep the spinal column in position.
Facet Joints
Between vertebrae are small joints that help your spine move.
Intervertebral Disks
Intervertebral disks sit in between the vertebrae.
When you walk or run, the disks act as shock absorbers and prevent the vertebrae from bumping against one another. They work with your facet joints to help your spine move, twist, and bend.
Intervertebral disks are flat and round, and about a half inch thick. They are made up of two components.
Annulus fibrosus. This is the tough, flexible outer ring of the disk. It helps connect to the vertebrae.
Nucleus pulposus. This is the soft, jelly-like center of the annulus fibrosus. It gives the disk its shock-absorbing capabilities.
Healthy intervertebral disk (cross-section view).
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Description
Back pain is different from one person to the next. The pain can have a slow onset or come on suddenly. The pain may be intermittent or constant. In most cases, back pain resolves on its own within a few weeks.
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Cause
Lumbar ligament tear.
There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.
As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger — and can make us prone to back pain, especially if we overdo our activities.
These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in her back!
Over-activity
One of the more common causes of low back pain is muscle soreness from over-activity. Muscles and ligament fibers can be overstretched or injured.
This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this "stiffness" and soreness in the low back — and other areas of the body — that usually goes away within a few days.
Disk Injury
Some people develop low back pain that does not go away within days. This may mean there is an injury to a disk.
Disk tear. Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood.
Disk herniation. Another common type of disk injury is a "slipped" or herniated disc.
Herniated disk.
A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain.
Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is sciatica.
A herniated disk often occurs with lifting, pulling, bending, or twisting movements.
Disk degeneration.
Disk Degeneration
With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints in the vertebrae to rub against one another. Pain and stiffness result.
This "wear and tear" on the facet joints is referred to as osteoarthritis. It can lead to further back problems, including spinal stenosis.
Spondylolisthesis.
Degenerative Spondylolisthesis
(Spon-dee-low-lis-THEE-sis). Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.
Spinal Stenosis
Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves.
Spinal stenosis.
When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth - called spurs - can lead to a narrowing of the spinal canal. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal.
Scoliosis
This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly leg symptoms, if pressure on the nerves is involved.
Additional Causes
There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position, you should consult your primary care doctor.
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Symptoms
Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain.
Most people find that reclining or lying down will improve low back pain, no matter the underlying cause.
People with low back pain may experience some of the following:
* Back pain may be worse with bending and lifting.
* Sitting may worsen pain.
* Standing and walking may worsen pain
* Back pain comes and goes, and often follows an up and down course with good days and bad days.
* Pain may extend from the back into the buttock or outer hip area, but not down the leg.
* Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain.
Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.
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Tests and Diagnosis
Medical History and Physical Examination
After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain.
Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.
Imaging Tests
Other tests which may help your doctor confirm your diagnosis include:
X-rays. Although they only visualize bones, simple X-rays can help determine if you have the most obvious causes of back pain. It will show broken bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves.
Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible in an MRI scan.
Computerized axial tomography (CAT) scans. If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three-dimensional X-ray and focuses on the bones.
Bone scan. A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection.
Bone density test. If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.
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Treatment
In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.
Nonsurgical Treatment
Medications. Several medications may be used to help relieve your pain.
* Aspirin or acetaminophen can relieve pain with few side effects.
* Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
* Narcotic pain medications, such as codeine or morphine, may help.
* Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.
Physical medicine. Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do.
* Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.
* Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
* Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.
* Traction is often used, but without scientific evidence for effectiveness.
* Other exercise-based programs, such as Pilates or yoga are helpful for some patients.
Surgical Treatment
Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.
In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.
Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply can not be treated with surgery.
Spinal Fusion. This is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a bad curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is if the painful spine segments do not move, they should not hurt.
Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals.
The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.
The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.
Disc Replacement. This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.
The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.
The surgery is done through your abdomen, usually on the lower two disks of the spine.
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Prevention
It may not be possible to prevent low back pain. We cannot avoid the normal wear and tear on our spines that goes along with aging. But there are things we can do to lessen the impact of low back problems. Having a healthy lifestyle is a good start.
Exercise
Combine aerobic exercise, like walking or swimming, with specific exercises to keep the muscles in your back and abdomen strong and flexible.
Proper Lifting
Be sure to lift heavy items with your legs, not your back. Do not bend over to pick something up. Keep your back straight and bend at your knees.
Weight
Maintain a healthy weight. Being overweight puts added stress on your lower back.
Avoid Smoking
Both the smoke and the nicotine cause your spine to age faster than normal.
Proper Posture
Good posture is important for avoiding future problems. A therapist can teach you how to safely stand, sit, and lift.
Anatomy
Understanding your spine and how it works can help you understand why you have low back pain.
Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine.
Vertebrae
Parts of the lumbar spine.
These bones connect to create a canal that protects the spinal cord. The spinal column is made up of three sections that create three natural curves in your back: the curves of the neck area (cervical), chest area (thoracic), and lower back (lumbar). The lower section of your spine (sacrum and coccyx) is made up of vertebrae that are fused together.
Five lumbar vertebrae connect the upper spine to the pelvis.
Spinal Cord and Nerves
These "electrical cables" travel through the spinal canal carrying messages between your brain and muscles. Nerves branch out from the spinal cord through openings in the vertebrae.
Muscles and Ligaments
These provide support and stability for your spine and upper body. Strong ligaments connect your vertebrae and help keep the spinal column in position.
Facet Joints
Between vertebrae are small joints that help your spine move.
Intervertebral Disks
Intervertebral disks sit in between the vertebrae.
When you walk or run, the disks act as shock absorbers and prevent the vertebrae from bumping against one another. They work with your facet joints to help your spine move, twist, and bend.
Intervertebral disks are flat and round, and about a half inch thick. They are made up of two components.
Annulus fibrosus. This is the tough, flexible outer ring of the disk. It helps connect to the vertebrae.
Nucleus pulposus. This is the soft, jelly-like center of the annulus fibrosus. It gives the disk its shock-absorbing capabilities.
Healthy intervertebral disk (cross-section view).
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Description
Back pain is different from one person to the next. The pain can have a slow onset or come on suddenly. The pain may be intermittent or constant. In most cases, back pain resolves on its own within a few weeks.
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Cause
Lumbar ligament tear.
There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.
As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger — and can make us prone to back pain, especially if we overdo our activities.
These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in her back!
Over-activity
One of the more common causes of low back pain is muscle soreness from over-activity. Muscles and ligament fibers can be overstretched or injured.
This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this "stiffness" and soreness in the low back — and other areas of the body — that usually goes away within a few days.
Disk Injury
Some people develop low back pain that does not go away within days. This may mean there is an injury to a disk.
Disk tear. Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood.
Disk herniation. Another common type of disk injury is a "slipped" or herniated disc.
Herniated disk.
A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain.
Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is sciatica.
A herniated disk often occurs with lifting, pulling, bending, or twisting movements.
Disk degeneration.
Disk Degeneration
With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints in the vertebrae to rub against one another. Pain and stiffness result.
This "wear and tear" on the facet joints is referred to as osteoarthritis. It can lead to further back problems, including spinal stenosis.
Spondylolisthesis.
Degenerative Spondylolisthesis
(Spon-dee-low-lis-THEE-sis). Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.
Spinal Stenosis
Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves.
Spinal stenosis.
When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth - called spurs - can lead to a narrowing of the spinal canal. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal.
Scoliosis
This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly leg symptoms, if pressure on the nerves is involved.
Additional Causes
There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position, you should consult your primary care doctor.
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Symptoms
Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain.
Most people find that reclining or lying down will improve low back pain, no matter the underlying cause.
People with low back pain may experience some of the following:
* Back pain may be worse with bending and lifting.
* Sitting may worsen pain.
* Standing and walking may worsen pain
* Back pain comes and goes, and often follows an up and down course with good days and bad days.
* Pain may extend from the back into the buttock or outer hip area, but not down the leg.
* Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain.
Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.
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Tests and Diagnosis
Medical History and Physical Examination
After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain.
Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.
Imaging Tests
Other tests which may help your doctor confirm your diagnosis include:
X-rays. Although they only visualize bones, simple X-rays can help determine if you have the most obvious causes of back pain. It will show broken bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves.
Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible in an MRI scan.
Computerized axial tomography (CAT) scans. If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three-dimensional X-ray and focuses on the bones.
Bone scan. A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection.
Bone density test. If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.
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Treatment
In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.
Nonsurgical Treatment
Medications. Several medications may be used to help relieve your pain.
* Aspirin or acetaminophen can relieve pain with few side effects.
* Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
* Narcotic pain medications, such as codeine or morphine, may help.
* Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.
Physical medicine. Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do.
* Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.
* Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
* Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.
* Traction is often used, but without scientific evidence for effectiveness.
* Other exercise-based programs, such as Pilates or yoga are helpful for some patients.
Surgical Treatment
Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.
In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.
Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply can not be treated with surgery.
Spinal Fusion. This is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a bad curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is if the painful spine segments do not move, they should not hurt.
Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals.
The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.
The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.
Disc Replacement. This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.
The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.
The surgery is done through your abdomen, usually on the lower two disks of the spine.
Top of page
Prevention
It may not be possible to prevent low back pain. We cannot avoid the normal wear and tear on our spines that goes along with aging. But there are things we can do to lessen the impact of low back problems. Having a healthy lifestyle is a good start.
Exercise
Combine aerobic exercise, like walking or swimming, with specific exercises to keep the muscles in your back and abdomen strong and flexible.
Proper Lifting
Be sure to lift heavy items with your legs, not your back. Do not bend over to pick something up. Keep your back straight and bend at your knees.
Weight
Maintain a healthy weight. Being overweight puts added stress on your lower back.
Avoid Smoking
Both the smoke and the nicotine cause your spine to age faster than normal.
Proper Posture
Good posture is important for avoiding future problems. A therapist can teach you how to safely stand, sit, and lift.
srijeda, 24. lipnja 2009.
koljeno- articulatio genus
Koljeni zglob je jedan od zglobova u tijelu koji je najpodložniji povredama. Koljeni zglob čini sastav dvije kosti, femur i tibia. U koljeni zglob ubrajamo ligamente, koji pomažu da zglob ostane čvrst pri pokretima, a to su lig. collaterale mediale i laterale i lig. cruciatum anterius i posterius. Druga važna struktura koljenog zgloba su meniskusi, koji učestvuju u njegovoj stabilizaciji, a to su meniscus medialis i meniscus lateralis. U koljeni zglob također ubrajamo lig. patellae, koji je pet do šest milimetara debela tetiva m. quadriceps femoris-a i koji se proteže preko cijelog koljenog zgloba sve do tuberositas tibiae.
Čahuru pojačavaju mišići, koji služe kao stabilizatori, a to su: m.quadriceps femoris, m.semitendinosus, m.semimembranosus, m.biceps femoris, m.gastrocnemius, m.popliteus, m.adductor magnus, m.sartorius, i m.gracilis.
Kod pacijenta s bolovima u koljenu, osnovno je odrediti koje su strukture oštećene i u kojem stepenu. Važni su anamnestički podaci o vremenu i načinu povrijeđivanja. Na osnovu dobrog poznavanja ovih znakova može se odrediti koji dio tkiva je oštećen. Kako bi se smanjila mogućnost „izlijetanja“ zglobnih tijela iz svojih prirodnih ležišta, koljeno je okruženo s nekoliko nivoa odbrane. Prvi su svakako mišići, a oni oko koljena uvjerljivo su najjači u cijelom organizmu. Zatim je prisutan cijeli splet vanjskih ligamenata koji okružuju zglob i daju mu dodatnu čvrstoću. Na kraju, tu su i dva unutrašnja ligamenta, zakopana duboko u samom koljenu, a zovemo ih prednja i stražnja križna veza.
U 2003. godini u SAD-u 4,3 miliona ljudi je izostalo sa posla zbog povreda na koljenom zglobu. Prosječno 500.000 operacija na meniskusima se obavi u SAD-u godišnje. Preko 90% tih ljudi ima poboljšanje nakon operacije na koljenom zglobu. Prema podacima Američke akademije ortopedskih hirurga više od 100.000 amerikanaca pokida svoje prednje ukrštene ligamente svake godine. Od 33 povrijeđenih fudbalera, 21 % od toga se nikada nisu vratili na teren nakon operacije ACL-a, dok je kod ostalih 79 % igrača koji su se vratili nakon rehabilitacijske pauze od 9-12 mjeseci pala sposobnost igranja i to za 1/3 sposobnosti.
ANATOMSKA GRAĐA KOLJENOG ZGLOBA
Zglob koljena je spoj dvije kosti, femura i tibiae. U sastav donjeg okrajka femura ulaze dva kondila, spoljni (condylus lateralis) i unutrašnji (condylus medialis), koji na svojoj donjoj strani imaju površinu za zglobljavanje s gornjim krajem tibiae. Kondili su naprijed spojeni zglobnom površinom za čašicu (facies patellaris), a pozadi i dole su odvojeni dubokom, međukondilarnom jamom (fossa intercondylaris). Na površnim, potkožnim stranama kondila nalaze se natkondilne kvržice, spoljna (epicondylus lateralis) i unutrašnja (epicondylus medialis).
Gornji kraj tibiae sastoji se iz dva kondila, medijalnog (condylus medialis) i lateralnog (condylus lateralis), koji na svojim gornjim stranama imaju zglobnu površinu (facies articularis superior) za zglobljavanje sa kondilima femura. Između zglobnih površina kondila tibiae nalaze se središno koštano uzvišenje (eminentia intercondylaris) i dva hrapava polja, prednje (area intercondylaris anterior) i zadnje (area intercondylaris posterior). Na donjoj strani spoljnog kondila tibiae postoji ovalna zglobna površina (facies articularis fibularis) za zglobljavanje s gornjim krajem fibule.
Patella, čašica je sezamoidna kost u tetivi m.quadriceps femoris-a. Ona ima trouglast oblik i od njenog vrha, koji je okrenut nadole, pruža se čašična veza (lig.patellae) koja nastavlja tetivu m.quadriceps femoris-a. Zglobna površina facies articularis na zadnjoj strani čašice podijeljena je uspravnim grebenom u dva polja, od kojih je spoljno veće.
Zglobne površine kondila femura, idući od sprijeda nazad, opisuju luk koji je u svom zadnjem dijelu jače konveksan nego u prednjem, odnosno prečnik krivine prednjeg dijela zglobne površine je veći nego prečnik njenog zadnjeg dijela. Zglobne površine kondila tibiae su veoma plitke. Duž perifernih ivica kondila tibiae nalaze se meniskusi, spoljni (meniscus lateralis – slika 1.) i unutrašnji (meniscus medialis). Meniskusi su fibroznohrskavične tvorevine polumjesečastog oblika, koje omogućuju kondilima tibiae da se prisno priljube uz konveksne zglobne površine kondila femura.
Časica se svojom zglobnom površinom nalazi iznad zglobne površine femura (facies patellaris), u koju ona upada samo kada je koljeno u fleksiji. Prilikom fleksije zgloba koljena, naročito iz stojećeg stava, čašica vrši veoma snažan pritisak na kondile femura, potiskujući ih nazad. Potiskivanje femura nazad spriječavaju ukrštene veze zgloba koljena.
Klizanje čašice naviše i naniže, koje iznosi 5-6 cm, olakšavaju dvije sluzne kese, gornja (bursa suprapatellaris) i donja (bursa infrapatellaris profunda). Gornja sluzna kesa još u diječijem dobu spaja se sa šupljinom zgloba koljena. Između čašične veze (lig.patellae) i tibiae nalazi se masno jastuče (corpus adiposum infrapatellare). Prilikom fleksije zgloba masno jastuče ispunjava mrtvi ugao, prostor između kondila i tetive m.quadriceps femoris-a. Prilikom ekstenzije ono iskače i prominira bočno od čašične veze.
Ukrštene veze zgloba koljena (ligg. cruciata) zaostatak su sagitalne pregrade koja povezuje međukondilarnu jamu femura s interkondilarnim poljima tibiae. Prednja ukrštena veza (lig. cruciatum anterius – slika 1.) silazi od zadnjeg dijela spoljnog kondila femura koso naprijed i unutra i završava se u prednjem međukondilarnom polju tibiae (area intercondylaris anterior), između prednjih krajeva meniskusa. Zadnja ukrštena veza (lig.cruciatum posterius – slika 1.) silazi od prednjeg dijela unutrašnjeg kondila femura koso nazad i upolje i završava se u zadnjem međukondilarnom polju tibiae, iza zadnjih krajeva meniskusa. Zadnjoj ukrštenoj vezi priključuje se vrlo često fibrozni snopić, koji prolazi od zadnjeg dijela spoljnog meniskusa (lig. meniscofemorale posterius).
Zglobna čahura pojačana je prednjim, bočnim i zadnjim vezama. U prednje čahurne veze spadaju lig. patellae i dva krilca čašice, spoljno (retinaculum patellae laterale) i unutrašnje (retinaculum patellae mediale). Krilca spriječavaju bočna pomijeranja čašice i u slučaju njene frakture služe kao pomoćne tetive m.quadriceps femoris-a za dijelimičnu ekstenziju zgloba koljena.
Od bočnih čahurnih veza snažnija je spoljna (lig. collaterale laterale – slika 1.). Ona je u obliku vrpce, odvojena je od zglobne čahure i povezuje epicondylus lateralis femura s glavom fibule. Unutrašnja bočna veza (lig. collaterale mediale – slika 1.) ima oblik trake. Ona je srasla sa zglobnom čahurom i bazom unutrašnjeg meniskusa. Ona se spušta s epicondylus medialis-a femura do unutrašnje strane tijela tibiae.
Zadnju stranu čahure zgloba pojačavaju dvije zatkoljene veze, kosa (lig. popliteum obliquum) i lučna (lig. popliteum arcuatum), koje se međusobno ukrštaju i povezuju kondile tibiae jedne strane sa kondilima femura suprotne strane noge. Donjem dijelu kose veze, koja polazi od unutrašnjeg kondila tibiae, priključuju se rekurentna vlakna tetive m.semimembranosus-a. Lučna zatkoljena veza prebacuje se svojim konkavitetom preko tetive m.popliteus-a. Od njenog donjeg kraja odvaja se nastavak koji silazi do glave fibule.
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