Archive for the ‘sports injuries’ Category
Central Cord Syndrome
Central Cord Syndrome (CCS) is an incomplete injury to the cervical cord resulting in more extensive motor weakness in the upper extremities than the lower extremities. The mechanism of injury occurs from a hyperextension injury with pre-existent osteophytic (abnormal bony outgrowth) spurs, without damage to the vertebral column.
Mechanism and Causes of Injury
CCS occurs typically in patients with hyperextension injuries where the spinal cord is squeezed or pinched between anterior cervical spondylotic bone spurs and the posterior intraspinal canal ligament, the ligamentum flavum. The ligamentum flavum is a strong ligament that connects the laminae of the vertebrae. It serves to protect the neural elements and the spinal cord and stabilize the spine so that excessive motion between the vertebral bodies does not occur.
The injury occurs as a result of anterior and posterior compression of the spinal cord, leading to edema, hemorrhage or ischemia to the central portion of the spinal cord. The site of most injuries is in the mid-to-lower cervical cord. Due to the anatomical lamination of the corticospinal tract with the arm fibers medially, and the leg fibers laterally, the arms are affected more so than the legs, resulting in a disproportionate motor impairment.
Symptoms
Patients are typically left with motor weakness of the upper extremities and lesser involvement of the lower extremities. A varying degree of sensory loss below the level of the lesion and bladder symptoms (urinary retention) may both occur.
Incidence
This syndrome more commonly affects patients age 50 and older who have sustained a cervical hyperextension injury.
CCS may occur in patients of any age and is seen in athletes who present with not only hyperextension injuries to their neck but associated ruptured disc(s) with anterior cord compression.
CCS affects males more frequently than females.
Diagnosis
Evaluation of the patient includes a complete history, a thorough neurological exam, MRI and CT of the cervical spine, and cervical spine x-rays including supervised flexion and extension x-rays.
- Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology; can show direct evidence of spinal cord impingement from bone, disc, or hematoma.
- Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads x-rays; can show the shape and size of the spinal canal, its contents, and the structures around it.
- X-ray: Application of radiation to produce a film or picture of a part of the body can show the structure of the vertebrae and the outline of the joints. X-rays of the spine delineate fractures and dislocations, as well as the degree and extent of spondylitic changes. Flexion/extension views assist in evaluation of ligamentous stability.
Surgical Treatment
Acute surgical intervention is not usually necessary unless there is significant cord compression. Prior to the CT-MRI era, surgical intervention was thought to be more harmful because of the risk of injuring a swollen cervical cord and worsening the deficit. However, with advanced imaging technology such as CT and MRI, patients with compression of the spinal cord secondary to traumatic herniated discs and other lesions can be quickly diagnosed and surgically decompressed. In cases with anterior bony ridges and spinal canal narrowing secondary to ligamentous thickening and or stenosis, acute surgery is usually not performed until the patient has made maximum recovery. Reassessment at that time may lead to surgery depending on the underlying cause. If there is significant motor weakness after a period of recovery, or neurological deterioration or spinal instability, then surgical intervention may be considered.
Nonsurgical Treatment
Nonsurgical treatment consists of immobilization of the neck with a cervical orthosis, steroids unless contraindicated, and rehabilitation with physical and occupational therapy.
Outcome
Many patients with CCS make spontaneous recovery of motor function while others experience considerable recovery in the first six weeks post injury.
If the underlying cause is edema, recovery may occur relatively soon after an initial phase of motor paralysis or pareses. Leg function usually returns first, followed by bladder control and then arm function. Hand movement and finger dexterity improves last. If the central lesion is caused by hemorrhage or ischemia, then recovery is less likely and the prognosis is more devastating.
The prognosis for CCS in younger patients is favorable. Within a short time, a majority of younger patients recover and regain the ability to ambulate and perform daily living activities. However, in elderly patients the prognosis is not as favorable, with or without surgical intervention.
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Carpal Tunnel Syndrome, CTS
Carpal tunnel syndrome is a common problem that affects the use of your hand, and is caused by compression of the median nerve at the wrist. It most often occurs when the median nerve in the wrist becomes inflamed after being aggravated by repetitive movements such as typing on a computer keyboard or playing the piano. It also seems to affect professional artists fairly commonly – in particular, sculptors and printmakers.
The “carpal tunnel” is formed by the bones, tendons and ligaments that surround the median nerve. Since the median nerve supplies sensation to the thumb, index and middle finger, and part of the ring finger, and provides motion to the muscles of the thumb and hand, you might notice numbness and weakness in these areas.
Common Symptoms
- Hand and wrist pain
- A burning sensation in the middle and index fingers
- Thumb and finger numbness
- An electric-like shock through the wrist and hand
Thesesymptoms are often exaggerated when the wrist is bent forward. This numbness or pain may be worse at night, and may actually keep you awake. During the day, it may occur more often when you are participating in activities that involve bending of your wrist.
Common Causes of Carpal Tunnel Syndrome
Diseases or conditions that may increase your chances of developing carpal tunnel syndrome include pregnancy, diabetes, menopause, broken or dislocated bones in the wrist, and obesity. Additional causes include repetitive and forceful grasping with the hands, bending of the wrist, and arthritis.
Any repetitive motions that cause significant swelling, thickening or irritation of membranes around the tendons in the carpal tunnel can result in pressure on the median nerve, disrupting transmission of sensations from the hand up to the arm and to the central nervous system.
Diagnosing Carpal Tunnel Syndrome
It is important to seek medical assistance when you first notice persistent symptoms. Do not wait for the pain to become intolerable.
Before your doctor can recommend a course of treatment, he or she will perform a thorough evaluation of your condition, including a medical history, physical examination and diagnostic tests. Your doctor will document your symptoms and ask about the extent to which these symptoms affect your daily living. The physical examination will include an assessment of sensation, strength and reflexes in your hand.
If conservative treatment such as medication or physical therapy does not provide sufficient relief, your doctor may perform diagnostic studies to determine if surgery is an effective option. These diagnostic studies may include:
- X-ray: An x-ray will show the bones of the wrist and determine if any abnormalities may be contributing to carpal tunnel syndrome or another disorder.
- Electromyogram and Nerve Conduction Studies (EMG/NCS): These tests primarily study how the nerves and muscles are working together. They measure the electrical impulse along nerve roots, peripheral nerves and muscle tissue.
Conservative (Nonsurgical) Treatments
The main purpose of conservative treatment is to reduce or eliminate repetitive injury to the median nerve. In some cases, carpal tunnel syndrome can be treated by immobilizing the wrist in a splint to minimize or stop pressure on the nerves. If that does not work, patients are sometimes prescribed anti-inflammatory medications or cortisone injections in the wrist to reduce swelling. Your doctor may suggest specific types of hand and wrist exercises, which may be helpful. Treatment for carpal tunnel syndrome may include rest, the use of a wrist splint during sleep, or physical therapy. Conservative treatment methods may continue for up to eight weeks.
Only a small percentage of patients require surgery. Factors leading to surgery include the presence of persistent neurological symptoms and lack of response to conservative treatment.
If you experience severe pain that cannot be relieved through rest, rehabilitation or nonsurgical treatment, you may be a candidate for one of several surgical procedures that can be performed to relieve pressure on the median nerve. The most common procedure is called carpal tunnel release, which can be performed using an open incision or endoscopic techniques.
The open incision procedure or carpal tunnel release, involves the doctor opening your wrist and cutting the ligament at the bottom of the wrist to relieve pressure. The endoscopic carpal tunnel release procedure involves making a smaller incision and using a miniaturized camera to assist the neurosurgeon in viewing the carpal tunnel. The possibility of nerve injury is slightly higher with endoscopic surgery, but the patient’s recovery and return to work is quicker.
After surgery, a dressing will be applied to your hand. You should leave this secured in place until your first office visit following surgery. You may need bandages on one or both wrists depending on your surgery. If this is the case, you may require extra assistance at home with everyday activities. Your stitches can be removed about 10-14 days after surgery. Make sure you avoid repetitive use of the hand for four weeks after surgery and avoid getting the stitches wet. You will notice that the pain and numbness begins to improve after surgery, but you may have tenderness in the area of the incision for several months.
Recurrence of symptoms after surgery for carpal tunnel syndrome is rare, occurring in less than 5 percent of patients. A majority of patients recover completely. To avoid injuring yourself again, it may help to change the way you perform repetitive movements, the frequency with which you perform the movements, and the amount of time you rest between periods when you must perform these movements.
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Regenerative Medicine
Administering undifferentiated stem cells to an injured disc has made adult stem cell regenerative medicine in spine a reality. Adult stem cell regenerative medicine holds the promise of stabilizing or even reversing the degenerative changes associated with aging or following traumatic injury. Current clinical use of stem cells is very limited, in part by the cumbersome approval process. The use of concentrated bone marrow aspirate (BMC) as a “stem cell” preparation is currently the simplest and safest way of utilizing the regenerative potential for mesenchymal stem cells (MSCs) to promote tissue regeneration. In fact, stem cells concentrated from bone marrow have been shown to stimulate the formation of bone, cartilage, ligament and tendon, and dermal tissues.
Conservative treatment options for lumbar and cervical pain associated with discogenic disc disease (Pfirrmann Grades 3-6) are limited. Treatment options include pain medication, steroids, physical therapy, and chiropractic care. Reversal of disc pathology has not been achieved with current available treatment modalities. Failure of these nonoperative treatments may leave surgical intervention as a treatment option.
The goal of utilizing MSCs is to not only potentially provide pain relief from the painful degenerative disc, but to reverse the degenerative process. There are three methods for placing MSCs into the painful nucleus pulposus.
The use of allogeneic mesenchymal precursor cells (MPCs) is currently being evaluated as a part of an FDA Phase I clinical trial. Extracted from donors and expanded in number by tissue culture, this process isolates and grows the stem cells into pure MPCs which are injected into the nucleus pulposus. This technology does not have FDA approval.
Utilizing expanded, autologous MSCs for injection into the painful disc is the second method. Federal regulations require the approval of an Investigational New Drug application supported by prospective, randomized clinical trials for the use of expanded autologous MSCs. The FDA has not approved this technology.
The third method involves autologous point of care therapy. This technology does not require FDA approval. The patient’s own MSCs are directly injected into the nucleus pulposus of the symptomatic degenerated disc(s) using standardized two needle discography technique. This requires fluoroscopic visualization and 2-3cc of MSCs are slowly injected into the symptomatic nucleus pulposus.
There have been no complications associated with the iliac crest aspiration or disc injection. Thus far no patient in the study has undergone spine surgery following treatment. Results obtained with this technique suggest its potential clinical efficacy in the treatment of moderate to severe degenerative disc disease. These results require verification with longer follow-up and randomized prospective studies.
For more information regarding treatment options please visit our websites at http://www.becomepainfree.com
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