Dr Damian Muñoz

Dr Damian Muñoz
Curso mínima invasiva south beach

domingo, 29 de diciembre de 2013


lunes, 23 de diciembre de 2013

The spine


The spine

Published online

Every year up to a quarter of a million people around the world suffer a spinal-cord injury. These devastating injuries can end lives, rob people of their mobility and burden healthcare systems. As this Outlook shows, advances in medicine and technology are offering new ways to reduce pain and restore mobility.
Researchers are developing a variety of approaches to repairing spinal injuries. Some techniques use stem cells or reprogram existing cells to help the body recreate neurons damaged in an injury (page S4). Regenerative techniques are already helping to mend vertebrae, and replacement discs are being developed that closely mimic their natural components (S7). New drugs can treat pain, improve the level of recovery after an injury, and possibly stimulate biological mechanisms to replace damaged cells (S10). And biomechanical engineer Peter Cripton shows how collecting neck-injury data can trigger ideas for designing better safety devices, such as helmets that protect the head and neck (S13). A growing body of data shows that the consequences of such an injury depend critically on the emergency treatment provided, including medications that limit the damage (S14). If medical action is not enough, the latest technologies could help. Mechanical systems called exoskeletons can help a paraplegic to stand, walk and even climb stairs (S16).
For spine injuries, as with all healthcare, prevention is better than cure. Rehabilitation and prevention specialist Sara Klaas argues that safer behaviour, from avoiding multitasking when driving to eliminating trip hazards, can reduce the chances of an injury and save billions of dollars (S18). Ultimately, a combination of treatments from immediately after an injury to decades beyond can turn a devastated patient into a productive one with a fulfilling life.
We acknowledge the financial support of Mesoblast in producing this Outlook. As always, Naturehas full responsibility for all editorial content.

Author information


  1. Contributing Editor

    • Mike May

jueves, 12 de diciembre de 2013

Lumbar Compression Fracture


Contributor Information and Disclosures
Andrew L Sherman, MD, MS  Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, University of Miami, Leonard A Miller School of Medicine

Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and RehabilitationAmerican Association of Neuromuscular and Electrodiagnostic MedicineAmerican Medical Association, and Association of Academic Physiatrists

Disclosure: Pfizer Honoraria Speaking and teaching
Nizam Razack, MD  FACS, JD, Assistant Professor of Neurological Surgery, Orthopedics, and Rehabilitation, University of Central Florida Medical School; Neurosurgeon, Spine and Brain Neurosurgery Center; Chairman, Department of Neurosurgery, Orlando Regional Medical Center

Nizam Razack, MD is a member of the following medical societies: American Association of Neurological SurgeonsAmerican College of SurgeonsCongress of Neurological SurgeonsFlorida Medical Association, and Society for Neuro-Oncology

Disclosure: Nothing to disclose.
Specialty Editor Board
Curtis W Slipman, MD  Director, University of Pennsylvania Spine Center; Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center

Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and RehabilitationAssociation of Academic PhysiatristsInternational Association for the Study of Pain, and North American Spine Society

Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment
Patrick M Foye, MD  Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and RehabilitationAmerican Association of Neuromuscular and Electrodiagnostic Medicine,Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.
Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.
Chief Editor
Rene Cailliet, MD  Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center

Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine,American Academy of Physical Medicine and RehabilitationAmerican Pain SocietyAssociation of American Medical CollegesInternational Association for the Study of Pain, and Pan American Medical Association

Disclosure: Nothing to disclose.


The lumbar vertebrae are the 5 largest and strongest of all vertebrae in the spine. These vertebrae comprise the lower back. They begin at the start of the lumbar curve (ie, the thoracolumbar junction) and extend to the sacrum. The strongest stabilizing muscles of the spine attach to the lumbar vertebrae. Fractures of lumbar vertebrae, therefore, occur in the setting of either severe trauma or pathologic weakening of the bone. Osteoporosis is the underlying cause of many lumbar fractures, especially in postmenopausal women. Osteoporotic spinal fractures are unique in that they may occur without apparent trauma. However, a thorough diagnostic workup is always required to rule out spinal malignancy. The image below reveals a wedge compression fracture. (See Pathophysiology.)
Anteroposterior and lateral radiographs of an L1 oAnteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.
In the past, treatment options for lumbar fractures were quite limited, with bracing and rest prescribed most often. While many patients improved with this regimen, some did not and were left with chronic, disabling pain. Suh and Lyles found that vertebral compression fractures were associated with significant performance impairments in physical, functional, and psychosocial domains in older women.[1]However, medical and surgical options are now available that can relieve the severe pain and disability from these fractures.

Recent studies

In a study of 55 patients with vertebral compression fracture, Rapan et al investigated changes in pain intensity following vertebroplasty (injection of a cement polymer into the fractured vertebral body; see Other Treatment). Treatment was administered to a total of 28 thoracic and 57 lumbar vertebrae; patients in the study had sustained vertebral fractures from spinal metastases or osteoporosis.
Prior to surgery, the patients' average pain score on the Visual Analog Scale (VAS) was 8.36, while 24 hours postsurgery it had fallen to an average of 2.23. At 3-month follow-up, the reduction in the VAS score remained nearly the same. Among the study's patients, 1 serious complication, paraparesis resulting from cement leakage into the spinal canal, occurred. The authors concluded that in patients with vertebral compression fracture who undergo vertebroplasty, the degree of pain reduction that occurs by 24 hours postsurgery predicts the intensity of pain patients will be experiencing 3 months later.[2]


The lumbar spine provides both stability and support, allowing humans to walk upright. Proper function of the lumbar spine requires that it have a normal posture (ie, a normal lumbar curve). Any injury that changes the shape of a lumbar vertebra will alter the lumbar posture, increasing or decreasing the lumbar curve. As the body attempts to compensate for the alteration in the lumbar spine in order to maintain an upright posture, this will tend to distort the curves of the thoracic and cervical spine.
Lumbar compression fractures can be a devastating injury, therefore, for 2 reasons. First, the fracture itself can cause significant pain, and this pain sometimes does not resolve. Second, the fracture can alter the mechanics of the posture. Most often, the result is an increase in thoracic kyphosis, sometimes to the point that the patient cannot stand upright. In trying to maintain their ability to walk, patients with kyphosis report secondary pain in their hips, sacroiliac joints, and spinal joints. These patients are also at risk for falls and accidents, increasing the risk of secondary fractures in the spine and elsewhere.
Fractures in the lumbar spine occur for a number of reasons. In younger patients, fractures are usually due to violent trauma. Car accidents frequently cause flexion and flexion distraction injuries. Jumps or falls from heights cause burst fractures. These fractures can also result in serious neurological injury. In older patients, lumbar compression fractures usually occur in the absence of trauma, or in the context of minor trauma, such as a fall. The most common underlying reason for these fractures in geriatric patients, especially women, is osteoporosis. Other disorders that can contribute to the occurrence of compression fractures include malignancy, infections, and renal disease.

Traumatic fractures

Different types of fractures can occur in the lumbar (or thoracic) spine. Classification of these fractures is based on the 3-column anatomic theory of Denis, which describes anterior, middle, and posterior spinal columns consisting of aspects of the spine and their corresponding ligaments and other soft-tissue elements. The Denis system, however, was created to classify traumatic fractures. A similar classification system does not exist for compression fractures. The main reason to use such a classification is to help determine whether a fracture is stable. Instability in the Denis system implies that damage has occurred to at least 2 of the columns of the lumbar spine.
  • Wedge fractures are the most common type of lumbar fracture and are the typical compression fracture of malignancy or osteoporosis. They occur as a result of an axially directed central compressive force combined with an eccentric compressive force. In pure flexion-compression injuries, the middle column remains intact and acts as a hinge. Although wedge fractures are usually symmetric, 8-14% are asymmetric and are termed lateral wedge fractures.
  • Fractures involving flexion and distraction forces are often due to lap belts in motor vehicle accidents. Commonly, the posterior columns are compromised in these injuries because the ligaments of the posterior elements are disrupted. This type of injury is quite common in young children. Most patients with flexion-distraction injuries remain neurologically intact.
  • Burst fractures result from high-energy axial loads to the spine. Multiple classification systems exist for these fractures. The severity of the deformity, the severity of canal compromise, the extent of loss of vertebral body height, and the degree of neurologic deficit affect the determination of whether these injuries are unstable.
When any of the above injuries occurs with a severe rotational force, the degree of injury and of instability increases.

Nontraumatic fractures

In osteoporosis, osteoclastic activity exceeds osteoblastic activity, resulting in a generalized decrease in bone density. The osteoporosis weakens the bone to the point that even a minor fall on the tailbone, causing an axial load or flexion, results in one or more compression fractures. The fracture is usually wedge shaped. Without correction, a wedge fracture invariably increases the degree of kyphosis.
Malignancies that result in spinal fractures are most commonly metastases rather than primary bone cancers. Primary cancers that often spread to the spine via hematologic dissemination include cancers of the prostate, kidneys, breasts, and lungs. Melanoma is a less common but more aggressive cause of spinal metastasis. The most common primary cancer of the spine is multiple myeloma, but others, including a variety of sarcomas,[3] can also manifest as a spinal fracture. Nonmalignant lesions that can cause fractures include aneurysmal bone cyst and hemangioma.
Spinal infections usually start in the lumbar intervertebral disk. From the disk, the infection spreads to bone, resulting in osteomyelitis. Severe pain is the hallmark symptom. The exception is spinal tuberculosis or Pott disease. In this case, the disk spaces are typically spared and a compression fracture may be the initial manifestation that leads to its discovery.



United States

Most fractures of the lumbar spine that require operative treatment occur at the thoracolumbar junction. These injuries are primarily traumatic in origin. Most nontraumatic lumbar fractures are osteoporotic in origin. These are almost invariably wedge-type compression fractures. The National Osteoporosis Foundation (NOF) estimates that currently, 10 million individuals in the United States have osteoporosis, and 34 million more have low bone mass.[4] In 2005, osteoporosis was responsible for more than 2 million fractures; approximately 547,000 of those were vertebral fractures. Approximately one third of osteoporotic vertebral injuries are lumbar, one third are thoracolumbar, and one third are thoracic in origin. Additionally, 75% of women older than 65 years who have scoliosis have at least 1 osteoporotic wedge fracture.


  • Mortality from a lumbar fracture is rare; however, morbidity can be significant.
  • In elderly patients with acute osteoporotic fractures, pain and prolonged bed rest can lead to multiple secondary medical complications.
  • In younger persons, neurologic damage from traumatic spine injuries can result in problems such as loss of lower extremity strength and sensation and loss of bowel and bladder control.


Osteoporosis occurs primarily in postmenopausal women. Type 1 osteoporosis occurs in women aged 51-65 years and is associated with wrist and vertebral fractures. Estrogen deficiency is the main etiologic factor. Type 2 osteoporosis (senile type) is observed in women and men older than 75 years, in a 2:1 ratio of women to men.


In young and middle-aged adults, most lumbar fractures are traumatic in origin. High-velocity falls can cause burst fractures, and seat-belt injuries can cause wedge fractures. As stated above, women 51-65 years old develop type 1 osteoporosis. After age 75 years, men also begin to develop type 2 osteoporosis.


Midline back pain is the hallmark symptom of lumbar compression fractures. The pain is axial, nonradiating, aching, or stabbing in quality and may be severe and disabling. The location of the pain corresponds to the fracture site, as seen on radiographs. In elderly patients with severe osteroporosis, however, there may be no pain at all as the fracture occurs spontaneously.
Young adults may present with severe back pain following an accident, such as a fall or a motor vehicle accident. Lower extremity weakness or numbness are important symptoms of neurologic injury from the fracture.
Vertebral fractures may also cause referred pain. Gibson et al presented a study of 350 patient encounters in 288 patients with 1 or more compression fracture without conus medullaris compromise or spinal nerve compression. They found that nonmidline pain was present in 240 of the 350 encounters. The pain was typically in the ribs, hip, groin, or buttocks. Treatment of the fracture with vertebroplasty (see Other Treatment) resulted in 83% of those patients gaining pain relief.[5]
Alternatively, many compression fractures are painless. Osteoporosis is a silently progressive disease. Osteoporotic compression fractures are often diagnosed when an elderly patient presents with symptoms such as progressive scoliosis or mechanical lower back pain and the physician obtains routine lumbar radiographs.
Finally, patients may present with a known (or unknown) malignancy. Routine spinal screening via magnetic resonance imaging (MRI; if focal or referred pain occurs), or via bone scan (as a survey if pain has not occurred) reveals the pathologic fracture. The most common malignancies leading to spinal involvement in the form of fractures are metastasis and multiple myeloma. Often, the compression fracture is the presenting manifestation that leads to the diagnosis of malignancy. However, patients may also have unexplained fevers, night sweats, past history of malignancy, or weight loss.
Finally, patients who have recently traveled outside of the United States, or who live in the inner city, may have symptoms of infection, such as general malaise, fever, or severely increasing pain. In these patients, osteomyelitis and Pott disease (tuberculosis spondylitis) must be ruled out.


A detailed neurologic examination is essential in all patients presenting with back pain, spine deformity, or traumatic spine injury. Most interventional procedures to alleviate pain in compression fractures are contraindicated in cases of neurologic compromise. Thus, a rectal examination is required to assess for rectal tone and sensation in trauma patients.
Upon inspection of the spine, the patient typically has a kyphotic posture that cannot be corrected. The kyphosis is caused by the wedge shape of the fractured vertebra; the fracture essentially turns the lateral conformation of the vertebra from a square to a triangle.
Hip flexor contractures due to iliopsoas shortening are typically present.
Palpation is important to correlate any reports of pain to the radiographic level of injury. Extreme pain elicited with superficial palpation is often observed in patients with spinal infections. Moderate pain is usually present at the level of the fracture.


The principal underlying cause of lumbar compression fractures is osteoporosis. In women, the leading risk factor for osteoporosis is menopause, or estrogen deficiency. Additional risk factors that may worsen the severity of osteoporosis include cigarette smoking, physical inactivity, use of prednisone and other medications, and poor nutrition. In males, all of the above nonhormonal risk factors apply; however, low testosterone levels also may be associated with compression fractures.
Renal failure and liver failure are both associated with osteopenia. Nutritional deficiencies can decrease bone remodeling and increase osteopenia. Finally, genetics also play a role in the development of compression fractures; osteoporosis can be observed in closely related family members.
Malignancy may manifest initially as a compression fracture. The most common malignancy in the spine is metastasis. Typical malignancies that metastasize to the spine are renal cell, prostate, breast, and lung, although other types can metastasize to the spine on rare occasions. The 2 most common primary spine malignancies are multiple myeloma and lymphoma.
Infection that results in osteomyelitis can also result in a compression fracture. Typically, the most common organisms in a chronic infection are staphylococci or streptococci. Tuberculosis can occur in the spine and is called Pott disease.

5 Tips for Flying Back Pain Free


5 Tips for Flying Back Pain Free

By: Stephanie Burke

Flying with Back Pain
With the upcoming holidays, many people are starting to worry about how to manage the pain associated with a long flight.
Collected from many posts on our Forums, here are the top 5 most frequently mentioned tips about how to survive an airplane ride with less pain or discomfort.
  1. Move
    Sitting in the same position for a prolonged period puts a great deal of stress on your spine, so get up and walk and stretch as frequently as possible. Go to the back of the plane and do some gentle stretches - toe raises. Consider bringing a doctor's note and alert the flight crew prior to boarding that you have a back condition and will need to
  2. Schedule Smart
    Try to book a flight for a time of day when the plane is likely to be less full. With no one sitting next to you it will be easier to move and stretch while remaining in a sitting position, and to change sitting positions as needed. It will also be easier to retrieve your belongings from under the seat in front of you without twisting and straining your lower back.
  3. Support your Spine
    Bring a back roll or ask for extra pillows to put behind your back to keep your spine straight and prevent slouching. This will alleviate pain and pressure. If you are on the shorter side, bring something to prop up your feet to keep your knees at a right angle.
  4. Bring the Heat and Chill
    Bring gel packs that can be frozen or heated (or bring one of each). These are great for treating swelling, sore muscles, back pain, and even headaches. Be sure to have the physician's note about your back condition handy in case airport security has issues with the gel pack in your carry-on luggage. Bring a couple of empty Ziploc® baggies as well - these will not be an issue to get through security can be filled with ice once you're at the gate and/or on board the plane.
  5. Pain Medication can Help
    OTC pain killers like acetaminophen and NSAIDs, or prescription drugs like narcotics or muscle relaxants, can help "take the edge" off during and after the flight. Remember, these medications need to build up in your bloodstream, so it is best to take them at least an hour before you anticipate the pain setting in. Again, a letter from your doctor stating your need for any prescribed pain medications will help with possible airport security issues; and always be sure to keep medications in their original bottles.
Using a combination of the tips above should make travel as easy on your back as possible. And remember to try to reduce stress however possible - bring soothing music, a good book, chocolate, do some deep breathing - anything that eases your mind and calm your body will help.

lunes, 9 de diciembre de 2013

Burst Fracture C7

35 year fell on head now with neck pain. What's the diagnosis? 

Burst Fracture

· Burst fractures result from axial loading most often secondary to motor vehicle accidents and falls
· The axial load drives the intervertebral disk into vertebral body below
· Usually produces a comminuted, vertical fracture through the vertebral body
· Fragments may be retropulsed into the spinal canal injuring the cord
· Burst fractures may resemble flexion-teardrop fractures

o In a classical flexion-teardrop fracture, there is an avulsed anterior, inferior triangular bony fragment that is separated from the body and displaced anteriorly

o Both the anterior and posterior ligamentous structures are injured, which may not be the case in a burst fracture

§ Burst fractures, however, can have associated injury to the posterior ligamentous structures, especially if there is a combination of axial loading and flexion at the time of injury

· Clinically
o Neck pain

o Numbness or parasthesia

o Weakness

· Imaging on conventional radiography
o Lateral view of the cervical spine on conventional radiograph should show a comminuted fracture of the vertebral body

o Soft tissue swelling can be recognized by an increase in the prevertebral soft tissue of greater than ½ the AP diameter of the C3 vertebral body at C3 or greater than the full AP diameter of the cervical vertebral body at C6

o The anterior portion of the body will be wedged

o Retropulsion can be inferred if the posterior surface of the vertebral body is convex towards the spinal canal, as the normal cervical vertebral body has a concave posterior surface

o Injury to the posterior ligamentous structures can be inferred by widening of the interspinous distance and forward subluxation of the vertebral body above the fracture

o CT will show the comminuted fracture and the retropulsed fragment

Burst fracture, C7. Lateral view of the cervical spine demonstrates a comminuted vertical fracture
through the body of C7. The posterior surface of C7 is displaced posteriorly toward the spinal canal (red arrow)
while there is slight soft tissue swelling anteriorly (white arrow).
For a larger photo of the same image without the arrows, click here

· Treatment

o Burst fractures may be treated initially with cervical tongs

o The fracture is considered stable if there is no neurologic deficit or if there are no retropulsed fragments

miércoles, 4 de diciembre de 2013

Exam film

lunes, 2 de diciembre de 2013


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