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Well this can be done by subjecting each level of evidence through their own quality control check lists (Table 67. Therapeutic studies are the most common class of study found in orthopedic literature. Here the subjects have an equal chance of being either in the study or control group by chance and not by choice. This criterion focuses on reporting of trial design, analysis, interpretation and participant progress. Systematic Reviews: Unlike unsystematic literature reviews, systematic reviews are more likely to be quoted as evidences30 and they follow the 8 step process: a. This is a quantitative analysis of results across many studies to arrive at the single best estimate of treatment effect. This helps eliminate bias and is an important tool for practitioners while making treatment decisions. Based on these criteria it is observed that only 15 percent of the systematic reviews is correct while a whopping 85 percent gives biased results. Publication Bias Another factor that affects systematic reviews is the publication bias where positive trials are published more frequently than negative trials. In a trial it has been noted that nearly 70 percent of the positive studies were published against the 10 percent of the neutral studies. These checklists provide invaluable source guidance to authors, journals, editorial and readers to critically appraise the published reports. Estimation of the probabilities or magnitudes of each of the health outcomes for each of the treatment methods and finally, 4. Hence due care need to be exercised while communicating facts and figures to the patients. Patient independent model: Here the patient makes the decision based on the facts presented by the clinician. Here the physicians establish a relationship with the patient and their families and both participate in the decision making process with mutual trust. One cannot follow a set pattern as each patient is different and hence different tools and strategies need to be used to communicate 36 namely: נVerbal, written or video information presented in a structured format. It is just as likely to show that effective interventions are underused as to show that ineffective procedures are over-used 854 Miscellaneous 8. Confidence intervals and statistical guidelines, London: British Medical Journal; 1989. Appliances for Communication the following five approaches may be used to communicate to your patients the results of an orthopedic study: נRelative risk. Detailed descriptions about these approaches are outside the scope of this book and the students are advised to refer bigger books on this subject. Note: It is important to note that the same rules do not apply to each patient and different yardstick needs to be used to convince the patients better. A treatise of the Scurvy in Three parts: Containing an inquiry into the Nature, Causes and Cure of that Disease, Together with a Critical and Chronological View of What Has been published on the subject. The myth of the medical breakthrough: Smallpox, Vaccination and Jenner reconsidered. I will inoculate you with this: with a pox to you: Small pox inoculation, Boston, 1721. Critical appraisal of the orthopedic literature: Therapeutic and economic analysis. The application of decision analysis to the surgical treatment of early osteoarthritis of the wrist. The reporting quality of randomized controlled trials in surgery: A systematic reviewing J Surg 2007; 5-413-22. The reporting of randomized clinical trials using a surgical intervention is in need of immediate improvement: A systematic review. Bias towards publishing positive results in orthopedic and general surgery: A patient safety issue?
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Disk herniation is the most common cause, and occurs especially at the C5-6 and C6-7 levels, affecting the C6 and C7 roots, respectively. The mechanism through which these various disorders cause radicular pain is not known. The pain, which often is attributed to compression, angulation, or stretch of the nerve roots, generally subsides with time even though the anatomic abnormality persists and the root therefore remains distorted. Table 494-2 summarizes the clinical features of the most common cervical radiculopathies. Although there is considerable variation in the clinical findings between different patients, single root involvement can generally be diagnosed by clinical means. Weakness in a myotomal distribution is assessed by evaluating different muscles supplied by the same nerve root but by different peripheral nerves in order to exclude more distal pathology. Motor and sensory function in the lower extremities, and gait, is also evaluated in order to detect evidence of cord compression. The extended neck is rotated and flexed to the side of symptoms, and careful pressure is then applied to the top of the head in a downward direction. An exacerbation of pain or numbness in the extremity supports a diagnosis of cervical root disease. The maneuver should be discontinued if symptoms are reproduced or exacerbated in this way. Plain radiographs of the cervical spine may be abnormal, but such abnormalities are commonly encountered in asymptomatic subjects. Electromyography is often therefore important in showing the functional relevance of any anatomic abnormalities detected by imaging studies. Many patients improve without surgical treatment and can therefore be managed conservatively. Surgical decompression is necessary in patients with severe pain that is unresponsive to 10 to 12 weeks of conservative measures and in those with a progressive neurologic disturbance. Cervical spondylosis is a common cause of dysfunction in patients older than 55 years of age. Typically, there is bulging or herniation of intervertebral disks, with osteophytes and ligamentous hypertrophy, sometimes accompanied by subluxation. The underlying primary pathology is usually degenerative disease of the intervertebral disks. This is followed by reactive hyperostosis, with osteophyte formation related to the disk and adjacent vertebral bodies, as well as the facet joints and joints of Luschka. Other associated pathologic factors include thickening of the ligamentum flavum, disk herniation, and a congenitally narrow spinal canal. Ischemia of the cord or roots from compression or distortion of small blood vessels may contribute to the neurologic deficit. The lateral syndrome is characterized primarily by radicular pain and focal neurologic deficits that reflect root dysfunction; gait is usually unaffected. By contrast, the medial syndrome is associated with signs of cord involvement, and especially with pyramidal tract findings in the legs and a gait disturbance. Thus, pain in the neck may be accompanied by a root deficit in one arm, clumsy hand, spastic paraparesis, and gait disturbance. Sudden quadriplegia or paraplegia after trivial injuries or a fall in an elderly person is often also due to spondylotic myelopathy. Patients with cervical dystonia often have severe degenerative disease of the spine and are at greater risk of developing spondylotic myelopathy. Examination often reveals a lower motor neuron deficit in one or both upper limbs, and a pyramidal tract deficit in the legs. Sensory changes are also present in a distribution that depends upon the site of involvement. When sensory findings are inconspicuous, the differential diagnosis of spondylotic myelopathy includes amyotrophic lateral sclerosis.
Primary tumors of the spine and spinal cord are uncommon and are overshadowed by the more frequent occurrence of secondary tumors including lymphoma, myeloma, and cancer. Among the features suggesting malignancy are constant unremitting pain in atypical or multiple sites, pain that is unrelated to activity or posture, the presence of systemic or constitutional symptoms, and an elevated erythrocyte sedimentation rate, especially in patients aged 55 years or older. Examination Examination commonly reveals spasm of the paraspinal muscles and limitation of spinal movements. Focal tenderness over a spinous process suggests vertebral involvement by tumor or infection. Neurologic examination is important, and the presence of any deficits mandates further evaluation. General physical examination is also important in patients with back pain and should include rectal and pelvic examination. When pain is referred to the back and relates to visceral disease, abdominal palpation may reproduce it. Imaging studies of the neck or back are required when clinical examination reveals a likely cause, such as a fracture, or when pain does not respond to conservative measures over several weeks. They are important in patients at particular risk for a neoplastic or infectious cause for pain. Further evaluation will depend upon the nature and extent of the underlying pathology. Electrophysiologic studies, particularly electromyography and nerve conduction studies, are sometimes helpful in showing the functional significance of anatomical abnormalities and are additionally important as a means of diagnosing a radiculopathy. Acute pain may relate to developing scoliosis, disk disease, or spondylolisthesis. Acute hemorrhage may require evacuation, and infection requires antimicrobial therapy and, in some instances, drainage. Even in the absence of confirmatory evidence, a trial of antituberculous therapy may be necessary in those at high risk of spinal tuberculosis, such as the elderly, the immunocompromised, and those who have come from high-risk areas such as the Indian subcontinent. Patients with ankylosing spondylosis may respond to nonsteroidal anti-inflammatory agents, and should also participate in a vigorous activity program to maintain spinal movement. In the absence of clinical or imaging findings that suggest substantial underlying structural disease, patients with acute pain are treated symptomatically. There is no agreement as to the optimum duration of bed rest for back pain, but 2 or 3 days is usually adequate. Many patients with chronic neck or back pain have no surgically remedial lesion, and a multidisciplinary approach is then necessary to ensure that symptoms eventually resolve and that patients are successfully rehabilitated. This may include the use of analgesic, nonsteroidal anti-inflammatory agents, or tricyclic drugs (taken at night), but patients should be encouraged to remain active. The chronic neck pain that sometimes follows whiplash injury has been attributed by some to psychological factors or related to pending litigation, but doubt can be cast on this view, which should not influence management. Aminoff the intervertebral disk that is placed between two adjacent intervertebral bodies consist of a soft, gelatinous, inner nucleus pulposus (a remnant of the notochord) that serves as a shock absorber between adjacent vertebral bodies. With advancing years, the nucleus becomes harder, less resilient, and more susceptible to trauma. Tears tend consequently to develop in the annulus, through which a portion of the nucleus pulposus may herniate. Herniation is generally in a lateral direction and may lead to compression of the nerve roots as they enter the intervertebral foramina, but sometimes occurs centrally, so that either the spinal cord or cauda equina is compressed. In some instances, the protruded disk material loses its continuity with the nucleus pulposus, and becomes a free fragment within the spinal canal. The early recognition of thoracic disk herniations is important, however, because there is only limited space in the thoracic portion of the spinal canal and delay in diagnosis may lead to an irreversible myelopathy. It does not necessarily affect the entire dermatomal territory and may be poorly localized by patients. Patients with cervical disk herniations generally hold their neck stiffly and are most comfortable when recumbent.
I have three types of cells, osteoblasts that form the bone, osteoclasts which remove the bone and are concerned with remodeling, osteocytes, which are the resting cells. These cells are present in the lamellae, which surround concentrically the How do I start developing? Osteoblasts lay down uncalcified matrix, which is subsequently calcified as true bone. These various osteons amalgamate to form large haversian systems, loosely woven in the medullary bone and densely packed in the cortical shell. Now having known my intrinsic structure, you will be interested to know that I have two major portions, medulla and the cortex. About Medulla Medulla is my softer counterpart and has the dual role of structure and storage. The other important component of the medulla is the marrow between the medullary bone lattices. Initially present throughout, it confines itself to the metaphyseal regions of the long bones and in some flat bones like pelvis, rib, etc. The medulla plays the structural role by its trabecular organization along maximal lines of stress and clearly identifies itself into compression and traction trabeculae. About Cortex Cortex gives me the remarkable strength, which you all admire particularly during compression. I have an epiphysis and epiphysis plate (which disappears with growth), metaphysis and diaphysis. Epiphysis is an expanded portion at the end develops usually under pressure and forms a support for the joint surface. It is easily affected by developmental problems like epiphyseal dysplasias, trauma, overuse, degeneration and damaged blood supply. The result is distorted joints due to avascular necrosis and degenerative changes. It is vulnerable to develop osteomyelitis, dysplasias and tumors resulting in distorted growth and altered bone shapes. Diaphysis is a significant compact cortical bone which is strong in compression and which gives origin to muscles. Remember Parts of a bone נEpiphysis נPhysis (growth plate) נMetaphysis נDiaphysis (5 fused bones) (3-5 fused bones) (12 pairs) Table 2. Axial skeleton forms the upright axis of the body and the appendicular skeleton forms the appendages and girdles that attach them to the axial skeleton. Short bones these are generally cube-shaped and are found in areas where limited movements are required. Flat bones these consist of parallel layers of compact bone separated by a thin layer of cancellous bone tissue. Irregular bones these have a peculiar and irregular shape and are unique in their appearance and functions. Proper exercises, protection against injuries and infection enhance my efficiency in serving you, but there are certain inherent problems in me in which you can do precious little. Congenital problems, hormonal problems, metabolic problems, tumor conditions, etc. Nevertheless, the problem that poses a serious threat to my integrity is injuries due to trauma. As a child, you are more playful and more prone to fall and this breaks me quite often. Though you pride in the fast-paced life of yours, I grieve at my misfortune and at my vulnerability to these vast array of incriminating forces, which overcome me putting you out of action for months. In these, there are three varieties: Syndesmosis: this is characterized by a dense fibrous membrane that binds the articular bone surfaces very closely and tightly to each other. Thus, my duty is to serve you to the best of my ability, so that you lead a healthy skeletal life. Here the adjoining bone margins are united into rigid, jagged interlocking processes. Two varieties are described: Synchondroses: Here hyaline cartilage is posed in between. Symphysis: Here the fibrocartilage is interposed in between and is usually found in the midline of the body.
