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Posted by on Oct 16, 2015 in patient education | 0 comments

Lumbar disc herniation

Spinal disorders and the pain associated with them account for a significant portion of disability at work, with most complaints occurring in the lumbar region. Men are more frequently affected. It is essentially a disease of the middle aged, unless precipitated by trauma. L4/5 and L5/S1 disc account for 90% of the cases, with each level affected about equally. L3/4 disc accounts for the majority of the remaining herniations.

Symptoms:
In the acute presentation, symptoms often follow trauma or an injury to the disc produced by a sudden spinal strain, such as lifting heavy weights. There is acute low back pain, and, in the event of nerve root compression, radiating pain, paresthesias, and motor weakness. Severe bilateral root dysfunction may produce bowel and bladder incontinence and sexual dysfunction. If the leg pain is not immediately experienced, it usually appears over ensuing hours with associated paresthesias.

The leg pain is usually worse and in dermatomal fashion. The back pain is thought to be secondary to activation of the sinu-vertebral nerves to the annulus, which share a central pathway with the nerve roots.

Chronic form is characterized by chronic intermittent exacerbations of back ache, usually without leg pain initially. The backache usually subsides with rest and conservative measures, only to reoccur. The leg pain may be as well localized as in the acute form.

The pain , unlike the pain due to tumors, is usually subsides to some extent and with recumbency; the pain is aggravated by increased activities, bending forwards, coughing, sneezing, and straining at stools. Prolonged sitting increases the intradiscal pressure and the pain.

Signs:
On examination, the patient presents with findings of axial pain and radiculopathy.
a) The paraspinal muscles are often in spasm, particularly on the side opposite the leg pain, and are tender to palpation. The patient leans away from the side of leg pain with the hip and knee flexed in an effort to reduce the leg pain.

Spinal movements are restricted due to pain.
Lateral bending towards the side of leg pain closes the intervertebral foramen, compressing the nerve root, and worsens the pain.

The straight leg raising test and the crossed straight leg ( contra lateral leg) raising stretches the sciatic nerve and L5 and S1 root pain get worse.

The reverse straight leg (femoral stretch test) raising stretches the femoral nerve and reproduce the leg pain in the distribution of the affected nerve root contributing to the femoral nerve(L2,3 or 4).

b) Neurological examination may detect the motor, sensory, and reflex impairment (LMN type).
In the lumbar region, the nerve roots exit through the intervertebral foramen caudal to their corresponding vertebral pedicle (e.g.: the L5 root exits at L5/S1 intervertebral foramen); the majority of disc herniations, being posterolateral, compress the root that exits at the intervertebral foramen below the level of the involved disc (L5 root in L4/5/ posterolateral disc herniation). In the less commoner lateral herniation, the root, that exits the foramen at the level of the involved disc, is affected (L5 root in L5/S1 lateral disc herniation).

L5 radiculopathy may present with pain, and paresthesia/numbness along the posterolateral aspect of the leg down to the great toe; weakness of extensor hallusis longus and dorsiflexion may be noted.

S1 radiculopathy may present with pain, and paresthesia/numbness along the posterior aspect of the leg down to the lateral aspect of the heel and foot; weakness of ankle plantar flexion may be detected. Ankle jerk may be absent.

L4 radiculopathy (as in the posterolateral disc herniation at L3/4) may present with pain and paresthesia/numbness along the anterolateral thigh and below the knee to the medial aspect the leg and foot; weakness of quadriceps and knee extension may be noted.

L3 radiculopathy the pain and paresthesia may be localized over the anteromedial thigh and in L2 the distribution is over the groin. Both L2 and L3 radiculopathies may cause quadriceps weakness.

Large central discs may cause bilateral symptoms or cauda equina syndrome. characterized by asymmetric pain and paresthesias in the perineum and down the back or front of the thighs and legs. Sensory disturbances may be limited to the backs of the thighs, buttocks, anus, and perineum, so called saddle anesthesia. paralysis of the bladder and rectum with associated incontinence may occur if the compression is low and affects the sacral roots bilaterally.

Diagnosis

MRI is the imaging modality when evaluating the lumbar spine. It enables visualization of the conus and cauda equine and helps to rule out neoplasia and other intradural lesions.
Its multiplanar capabilities make it suitable for visualising far lateral disc herniations as well as the paravertebral structures. It appears to correlate more accurately with surgical findings at a rate of 90% compared with 77% for CT imaging.

CT is a possible alternative for patient unable to undergo MRI, whereas myelography or postmyelographic CT may be more useful in pinpoint stenotic areas

lumbar disclumbar disc

MANAGEMENT

Medical:
The initial management is non-operative, unless the patient presents with significant neurological deficit.

The medical management traditionally involves bed rest and analgesics and anti-inflammatory drugs. Muscle relaxants help in some. TENS helps in about 20% of patients.

Surgical:
With the exception of a cauda equina syndrome and neurological deficit, surgery should not be considered earlier than 6 weeks from onset of symptoms.

Indications for surgery include failure of acceptable pain control by non-operative measures, progressive neurological deficit, and cauda equina syndrome.

The traditional approach to lumbar discectomy is through posterior hemilaminotomy and foraminotomy, either in prone position or ‘knee-elbow’ position, usually under general anesthesia. Use of a microscope helps and has become a routine these days.

Lately, fenestration (microlumbar discectomy – wherein no bone is removed and the disc is approached by excising the ligament flavum at the required level) is increasingly employed with good results. The advantages in addition to minimal disturbance to spines, are less post operative discomfort and less stay in the hospital.

Whichever approach is used, at least 10gms of disc material has to be removed for adequate pain relief.
Complications

Most common intraoperative complications is negative exploration or wrong –level spine surgery.
Then injury to the One of the neural element, dural tear must be avoided. Failure to close the rent produces pseudomeningocele and recurrence of symptoms.

Bacterial discitis .
Life threatening injuries to major vessels e.g.: aorta, vena cava, iliac vessels, bowel perforation has been reported. Very rare complications have been also reported such as blindness, deep vein thrombosis, raised ICP.

OUTCOME

Approximately, 2/3 of the patients with acute sciatica recover within 4 weeks; about 1/3 of them report with recurrence. The main advantage of surgery is to accelerate the time to recovery.
Patients with more than 6 months of symptoms have poorer outcome

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Posted by on Oct 16, 2015 in patient education | 0 comments

Hydrocephalus

This is a condition in which there is abnormal amount/circulation of cerebral spinal fluid (CSF) in the brain cavities called ventricles caused by overproduction or blockage of flow. This results in increased pressure in the brain giving various symptoms stated below. Sometimes it may occur in adults but with normal pressures (normal pressure hydrocephalus).

Who gets it?
Anyone can develop hydrocephalus ranging from the unborn baby to the very old. However it is more common in babies and young children where it usually presents with a rapidly growing head (big head).

Why do some people get it?
Sometimes a cause for the hydrocephalus cannot be found. In the majority of cases however tests are done that helps to find a cause. The causes range from inherited cases (X linked hydrocephalus) to acquired cases. The acquired causes include infections, nutrient deficiencies in the mother (folate deficiency), birth defects, brain cysts and brain tumours. Head injuries and some types of strokes (ventricular bleeds) can also cause hydrocephalus. These ventricular bleeds can occur with vascular abnormalities and trauma which may also happen in premature babies during delivery.

How can I prevent it?
Preventing, identifying and treating infections early in both the mother and the child can prevent those caused by infections especially of the brain (meningitis). Women of reproductive health wishing to have babies should be on a balanced diet and if at risk of an unbalanced diet they should take folate tablets which can be prescribed by their doctors. These tablets should be taken before a woman is pregnant. By the time a woman misses her first period the critical time when folate is required for brain development will be over hence it will be too late. And the baby may be at risk for neural tube defects which may include spina bifida and hydrocephalus. Safety measures to prevent head injury will reduce hydrocephalus cases.

How is it diagnosed?
Children usually present with a head that is growing at a rate that is faster than normal. If this is suspected the head circumference can be measured at a clinic and plotted on a chart to see if it is abnormal. Other symptoms include a bulging fontanel (nhova yakakwirira), seizures, irritability, regression or delays in development. In older children and adults they can present with headaches, difficulty in walking, loss of athletic abilities, decrease in mental capabilities, change in personalities. All age groups can present with vomiting and lethargy. With these symptoms an ultra sound scan of the head can be done is the fontanels are still open. Pictures of the brain can be taken with computer tomography (CT) or magnetic resonance imaging (MRI). The patient is referred to a neurosurgeon (brain surgeon) for further management.

When to seek treatment?
When you notice any of the above symptoms or become pregnant please visit a doctor. Early treatment is advised to have better outcome.

What treatment is available?
The goal of treatment is to eliminate the cause if possible +/- provide alternate routes for the flow of CSF (brain water). Brain tumours can be removed surgically and infections treated with medicine. If there is a clear blockage to flow of CSF it can be unblocked or an alternate pathway opened up by endoscopic ventriculostomy. This is where a small hole is made in the skull and instruments introduced through the hole to open up channels for better flow of CSF. When this is not feasible CSF can be diverted to the veins, chest cavity or more commonly the abdomen through the use of shunts. These are small tubes that are inserted into the ventricles (brain cavities) and channelled below the skin usually into the abdominal cavity. The main problems with a shunt are that it can be blocked or infected, which may warrant revision of the shunt.

Will an affected person have a normal life?
Outlook depends on the cause, associated conditions and time to treatment. It ranges from a near normal life to severe disability and mental retardation. Half of babies with hydrocephalus will have normal intelligence. Most will have problems with vision and memory. The other problems may be related to the associated condition and causes.

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Posted by on Oct 16, 2015 in patient education | 0 comments

Headache

A headache is one of the commonest illness and reasons for visiting a doctor or clinic. Almost everyone experiences a headache at some point and most headaches will respond to simple painkillers , drinking extra water ,rest or other simple measures .

There are many different types of headache, most headaches are not caused by serious or sinister conditions .In certain circumstances however , a headache can be in fact a symptom of a serious or life threatening illness .

What are the different types of headache?
Headaches can be primary, or they can be secondary which means they are related to a separate illness.
Your doctor can generally tell the likely cause of your headache from talking to you and examining you. Once he or she has discovered the cause then you will be able to decide how to reduce or stop the headaches. This may involve taking medication only when you get the headaches, taking daily medication to prevent them or, sometimes, stopping medication you are already taking.

Very occasionally, headaches need further investigation to rule out more serious underlying causes.

Primary headaches
The most common types of headache are tension-type headaches and migraines.

Tension-type headaches
Tension-type headaches are usually felt as a band or across the forehead. They can last for several days. They can be uncomfortable and tiring, but they do not usually disturb sleep. Most people can carry on working with a tension-type headache..Tension-type headaches tend to worsen as the day goes on and are often mildest in the morning.
Tension-type headaches are thought to be caused by tightness in the muscles at the back of the neck and over the scalp. The underlying causes include anything which makes those muscles tense. This includes both physical and mental tension. Tiredness, stress, anxiety and an awkward sleeping position can make them worse. Working long hours bent over a computer may trigger them. Some people get tension-type headaches if they drink too much caffeine or alcohol, if they don’t drink enough water or if they go for a long time between meals and become tired and hungry. Occasionally, tension-type headaches can be caused by poor vision, particularly if reading in low light for long periods

What is the treatment for tension-type headaches?
Tension-type headaches usually respond to simple painkillers and extra water intake. However, the best approach is to treat the underlying cause ( if identifiable). Changes in lifestyle can help – such as having less caffeine, drinking more water and adequate sleep. So, too, can a sensible diet in which you eat regularly and have a good balance of slow-release energy foods rather than lots of sugars. Reducing the number of pillows you sleep on can sometimes help, particularly if you sleep on more than two pillows.

Migraines
A typical migraine is one-sided and throbbing. Indeed, headaches that are one-sided, headaches that throb and headaches that make you feel sick are more likely to be migraines than anything else. Migraines are often severe enough to be disabling.

Migraines can last a few hours to three days. They are often made worse by movement or sound. Patients often feel sick (nausea) or vomit, even if the pain is not severe. Often patients find bright light and even TV make the headache worse. Most people with migraines have 1-2 attacks a month.

people with migraine can have warning symptoms (aura) occur before the migraine, commonly consisting of flashing lights .Some people actually lose half of their vision completely. Others experience tingling or weakness on one side of the body, or slurring of speech. These warning symptoms can last for up to an hour, and are generally followed by a headache. Migraines can be triggered by stress, hunger, certain foods such as chocolate and red wine, tiredness, and lack of body fluid (dehydration). What is the treatment for migraines?

Migraines tend to improve with rest, sleep, darkness and quiet. Drinking water can help if you don’t feel sick, and simple painkillers such as paracetamol and ibuprofen can be effective. Many people find that they are not, and have special migraine medication prescribed by their doctor. These medications consist of tablets which you take when you have a migraine, and you take them as early as possible in the pain .

Cluster headaches
Cluster headaches are very severe headaches , sometimes called ‘suicide headaches’. They occur in clusters, often every day for a number of days or even weeks. Then they disappear for months on end. They are uncommon, and tend to occur particularly in adult male smokers. They are severe, one-sided headaches, which are really very disabling. Patients often have a red watery eye on the affected side, a stuffy runny nose and a droopy eyelid.
Cluster headaches usually require treatment from your doctor

Chronic daily headaches
Chronic daily headache or chronic tension-type headache is usually caused by muscle tension in the back of the neck and affects women more often than men. Chronic means that the condition is persistent and ongoing. These headaches can be started by neck injuries or tiredness and may be made worse by medication overuse . A headache that occurs almost every day for three months or more is called a chronic daily headache.

What is the treatment for chronic daily headaches?
This type of headache is best treated by physiotherapy, avoiding painkillers and occasionally by certain antidepressant medications . Using painkillers regularly for chronic daily headache is likely to make things worse, as you may also develop a medication-induced headache

What are the different types of secondary headache?
Sometimes headaches have underlying causes, and treatment of the headache involves treating the cause. People often worry that headaches are caused by serious disease, or by high blood pressure. Both of these are extremely uncommon causes of headache – indeed high blood pressure usually causes no symptoms at all.

Headaches due to referred pain
Some headaches can be caused by pain in some other part of the head, such as tooth or ear pain, pain in the jaw joint and pains in the neck.

Sinusitis is a common cause. The headache of sinusitis is often felt at the front of the head and also in the face or teeth. Often the face feels tender to pressure, particularly just below the eyes and beside the nose. You may have a stuffy nose and the pain is often worse when you bend forwards. Acute sinusitis is the type that comes on quickly in association with a cold or sudden allergy. You may have a temperature and be producing a lot of mucus.
Acute glaucoma can cause severe headache . In this condition the pressure inside the eyes goes up suddenly and this causes a sudden very severe headache behind the eye. The eyeball can feel very hard to touch, the eye is red, the front of the eye (cornea) can look cloudy and the vision is usually blurred.
What types of headache are serious or dangerous?
All headaches are unpleasant , however a few headaches are signs of serious underlying problems.
Dangerous headaches tend to occur suddenly, and to become progressively worse over time. They include the following:

Bleeding around the brain (subarachnoid hemorrhage)
Subarachnoid hemorrhage is a very serious condition which occurs when a small blood vessel bursts on the surface of the brain. Patients develop a severe ‘thunderclap’ headache and stiff neck and may become unconscious. This headache is usually described as “ the worst headache of my life” .A person who suffers such a headache should be rushed to a hospital urgently .

Meningitis and brain infections
Meningitis is infection of the tissues around and on the surface of the brain . . Brain infections can be caused by germs called bacteria, viruses or fungi . They cause a severe, disabling headache. Usually patients are sick and cannot bear bright light . Often they have a stiff painful neck .brain infections are serious and life threatening illnesses.

Brain tumours
Brain tumour is a very uncommon cause of headaches. Usually the headache of brain tumours is present on waking in the morning, is worse on sitting up, and gets steadily worse from day to day, never easing and never disappearing. It can sometimes be worse on coughing and sneezing (as can sinus headaches and migraines).such a headache should be investigated early .

When should I be worried about a headache?
Most headaches don’t have a serious underlying cause. However, healthcare professionals are trained to ask you about the signs and symptoms that might suggest your headache needs further investigation, just to make sure it’s nothing serious.

The things which would suggest to your doctor and nurse that your headache might need further investigation include the following. They do not mean that your headache is serious or sinister, but they mean that the doctor or nurse might wish to do some further checks to be sure:

You have had a significant head injury in the previous three months.
Your headaches are worsening and accompanied by high temperature (fever).
Your headaches start extremely suddenly.
You have developed problems with speech and balance as well as headache.
You have developed problems with your memory or changes in your behavior or personality as well as headache.
You are confused or muddled with your headache.
Your headache started when you coughed, sneezed or strained.
Your headache is worse when you sit or stand.
Your headache is associated with red or painful eyes.
Your headaches are not like anything you have ever experienced before.
You have unexplained vomiting with the headache.
You have low immunity – for example, if you have HIV, or are on oral steroid medication or immune suppressing drugs.
You have or have had a type of cancer that can spread through the body.

Summary
Most headaches, whilst unpleasant, are harmless and respond to simple measures. Migraine, tension headache and medication-induced headache are all very common. Headaches are, very rarely, a sign of a serious or sinister underlying condition .

If you have a headache which is unusual for you then you should discuss it with your doctor. You should also talk to your doctor about headaches which are particularly severe or that stop your regular activities, those which are associated with other symptoms like weakness or tingling. Finally, always talk to your doctor if you have an unremitting morning headache which is present for more than three days or is getting gradually worse.

Remember that headaches are less likely to occur in those who:
Manage their stress levels well.
Eat a balanced, regular diet.
Take balanced regular exercise.
Pay attention to posture and core muscles.
Sleep on two pillows or fewer.
Drink plenty of water.
Have plenty of sleep.

Anything that you can do to improve any of these areas of your life will improve your health and well-being and reduce the number of headaches you experience.

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Posted by on Oct 16, 2015 in patient education | 0 comments

Brain tumours

A brain tumour is a mass of abnormally growing cells in the brain or skull. Half of the time it will have spread from somewhere else in the body (metastatic brain tumour). But sometimes it can just start from the brain (primary tumour) the tumours are named from the tissue type where they originate from. Gliomas are the most common primary tumours and have different grades ranging from those that are curable by surgery to those that a very deadly despite any form of treatment. Other types are meningiomas and medulloblastomas.

Who gets a brain tumour?
Anyone can get a brain tumour, but they are more common between 3-12 years and then also between 40-70 year olds. Some types of tumours can be more common in males and others in females.

How can I suspect a brain tumour?
The symptoms for brain tumours are usually not specific and can mimic other diseases. Often these symptoms tend to be caused by the other diseases rather than the brain tumour. Because of this, sometimes brain tumours are overlooked and lead to delay in diagnoses. The symptoms include nausea, vomiting, new onset seizures, weakness or abnormal sensation on one side of the body, loss of coordination, trouble talking, changes in vision or abnormal eye movements, memory or personality changes, ringing in ears or reduced hearing. In children they may present with signs of hydrocephalus. (Refer to article on hydrocephalus). Presence of these signs may prompt taking of images such as Computer tomography scan (CT) or Magnetic resonance scan (MRI). If a brain tumour is suspected the patient is referred to a neurosurgeon (brain surgeon) for further treatment. Sometimes the neurosurgeon may need to do an operation to take a small sample of the tumour before giving a diagnosis of the particular brain tumour.

brain_tumor

How can I prevent brain tumours?
Since the cause of most tumours is not known, not much can be done to prevent them. However avoidance of radiation may reduce the occurrence of tumours that can be induced by radiation (eg meningiomas). Avoidance of smoking will reduce lung cancer and hence metastatic brain cancers. Same applies for UV radiation causing melanomas. Speculations on mobile cellular phones causing brain cancers have not yet been clearly confirmed or refuted.

How is it treated?
Surgery, radiotherapy and chemotherapy and just follow up are the main modalities of treating brain tumours. Often various combinations of the above modalities are employed. Surgery is usually the best when it is possible and can on its own be curable for lower grade tumours. However sometimes complete removal of the tumour may not be possible because of tumour size or its location near deep sensitive brain structures. In such cases a partial resection is done then combined with another modality. Radiotherapy involves use of X-rays to suppress/ kill tumour cells. This however also may damage normal brain tissue depending on the dose and duration of use. Benefit is always weighed against the risks involved. Chemotherapy is the least effective modality except for some specific tumours like lymphomas which respond well. Some tumours if they are small and not causing symptoms may be left alone, but close monitoring is mandatory.

What is the expected outcome for brain tumour?
The outcome depends on age at diagnosis, size of tumour, location and type of tumour, extent of surgery done and other illness the patient has. Prognoses range from cure to death in a few months depending on the above.

 

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