Ortho by Dr Riwa Flashcards
1
Q
Plexus Brachialis - Major Branches
A
- Musculocutaneus nerve ( C5, 6, 7) - M. Biceps brachii, brachialis,
- Axillary nerve (C5,6) M. deltoidius, regimental badge sign
- Median nerve (C5 -T1) - All flexors of the forearm except 1.5
- Radial nerve( C5-T1) - All extensors
- Ulnar nerve ( C8-T1) - 1.5 Flexors, all intrigate muscles of the hand
2
Q
Median Nerve (C5-T1)- motor/sensory
A
- Motor
all flexors of the forarm except F.carpii ulnaris and half of F. digitotum proundus
Lateral two lumbriccals and thenar muscles except Adductor polices - Sensory:
supplies palmar aspect of the lateral 3.5 fingers
3
Q
Median course
A
- *Anterior compartment of arm *
Anteromendial, **with brachial artery ** - *Forearm *
all flexors exept F carpii ulnaris and F digitorum profundus - *Hand *
through Carpal Tunnel
supplies lateral two lumbricals - *Terminal branches *
Anterior interosseous nerve
palmar cutaneus branch
recurrent branch - supplies thenar musles
4
Q
Median Nerve Injury - Elbow (supracondylar fractur of the humerus)
A
Motor: All motor lost
Sensory: lost
Classical Sign: Hand of benediction( when pat makes a fist) and Thenar wasting
Symptoms worse with rotation (pronation) of forarm
5
Q
Median Nerve Injury - Wrist
(Laceration, Carpal tunnel syndrom)
A
Motor: Lumbricalis and thenar lost - thenar wasting
Sensory: Similar to injury at elbow except no sensory loss over thenar muscle
6
Q
Median nerve injury - test anterior interosseous nerve
A
- Ok-sign
7
Q
Carpal tunnel syndrom - cause
A
- idiopatic -mc
- inflammatory - RA/OA
- posttraumatic
- pregnancy
- endocrine (Myxedema/Acromegaly)
- Gout
- repititive wrist movements
8
Q
Carpal tunnel syndrom -symptomes
A
- Hand and wrist pain
- Paraesthesia
- Hyposthesia
- Patient wakes up at night with burning/aching, has to shake hand to restore sensation- CLASSICAL-IMPORTANT FOR EXAM
- Late signs- Thenar atrophy and weakness of thumb
9
Q
Carpal tunnel syndrom - Examination
A
- Thenar wasting
- Phalens sign ( flexion of the wrist produces symptomes)
- Tinel sign ( tapping of the wrist produces tingeling)
- NCS - BEST TEST
10
Q
Carpal tunnel syndrom - MX
A
First : splint/wrist bands
If not working: steroid infections
Best/final: Surgery to relase the flexor retinaculum
11
Q
Radial nerve ( C5-T1) - Motor supply
A
Most commonly injured nerve
best prognosis post injury.
Motor:
- Axilla : long head of triceps (first elbow extensor)
- Spiral groove : lateral and medial head of triceps, Anconeus
- After piercing the intermuscular septum : Extensor carpi radialis (first wrist extensor)
- divides into-Posterior interosseous nerve (major motor nerve) which extends thumb & fingers and a superficial branch
12
Q
Radial nerve ( C5-T1) - Sensory supply
A
13
Q
Radial nerve injury - Axilla
A
- Saturday night palsy/ crutch palsy
- all sensory & motor function loss
- Wrist drop classical seen
14
Q
Radial nerve injury - Radial groove
A
- Fracture of the humerus
MOTOR
* Triceps retained
* Extension of fingers and wrist lost ( Wrist drop)
SENSORY
* Arm and forearm retained
* sensation lost on dorsal lateral 3.5 fingers
15
Q
Radial nerve injury -forearm superficial branch
A
- Laceration/stabbing
MOTOR - none
SENSORY - sensation lost on dorsal lateral 3.5 fingers
16
Q
Radial nerve injury - forearm deep branch
A
- Fracture of the radial headm posterior dislocation of the radius
MOTOR - Majority of thr muscles in posterior forarm efected
** NO wrist drop **- Extensor carpi radialis not effected Posterior interosseous nerve
SENSORY
* none
17
Q
Ulnar nerve injury - Compression Pisohammat ligament (eg cyst)
A
- loss of sensation over fingers and hypothenar muscle wasting.
- Sensations over hypothenar eminence are spared
18
Q
Ulnar nerve ( C8-T1)- Sensory Supply
A
19
Q
PATTERNS OF SENSORY LOSS
A
Mononeuropathies
localised sensory disturbance in the area supplied by the damaged nerve
Peripheral neuropathy
symmetrical sensory deficits in a ‘glove and stocking’ distribution in the peripheral limbs, m/c diabetes mellitus & chronic alcohol excess.
Radiculopathy
due to nerve root damage (e.g. compression by a herniated intervertebral disc), -sensory disturbancesin the associated dermatomes.
Spinal cord damage
sensory loss both at and below the level of involvement in a dermatomal pattern
Thalamic lesions (e.g. stroke)
contralateral sensory loss
Myopathies
symmetrical proximal muscle weakness
20
Q
Nerve injury - Clavicular
A
Brachial Plexus - Subclavian artery
21
Q
Nerve injury - anterior GH dislocation
A
N.axillaris
22
Q
Nerve injury - Surgical neck of humerus
A
N.axillaris
23
Q
Nerve injury - Midshaft humerus
A
N.radialis
24
Q
Nerve injury - Clavicular
Nerve injury - medial epicondyle
A
N.ulnaris
25
Nerve injury - greater tuberosity of the humerus
N.axillaris
26
Nerve injury - Supracondylar humerus
Median nerve - brachial artery
27
Nerve injury - Coles
N.median
28
Nerve injury - ERB
Brachial plexus – high: C5 – C6
29
Nerve injury - Klumpke
Brachial plexus – low: C8 – T1
30
Biceps reflex
C5/6
31
Supinator -Brachioradialis reflex
C5/6
32
Triceps reflex
C7
33
Injury Ulnar - at wrist
Sensory
* numbness in the little and ring fingers
Motor
* weakness of abduction of his little finger
* weakness of flexion of the terminal
phalanx of his little and ring fingers
34
Lumbar Plexus
* formed by anterior rami L1-L4 and contributions of T12
* Important Obturator and Femoral nerve
35
Obdurator nerve (L2-4)
* innervates muscles of the medial thigh
* obturator externus, adductor longus,
adductor brevis, adductor magnus and gracilis
36
Femoral nerve (L2-L4)
* innervates muscles of the anterior thigh
* the illiacus, pectineus, sartorius and quadriceps femoris
37
Sacral plexus
* anterior rami S1-S4 and L4-5
* Important Sciatic nerve
38
Sciatic nerve (L4,5, S1-3)
**Tibial portion **
* muscles in the posterior compartment of the
thigh (apart from the short head of the biceps femoris)
* hamstringcomponent of adductor magnus
* muscles in the posterior compartment of the leg and sole of the foot
**Common fibular portion**
* Short head of biceps femoris, all muscles in the
anterior and lateral compartments of the leg and extensor digitorum brevis
* Motor fn- dorsiflexion and eversion
39
Myotomes - upper limb
C4 = shoulder shrugs
C5 = Shoulder abduction and elbow flexion
C6 = Wrist extension
C7 = Elbow extension and wrist flexion
C8 = Thumb extension and fingers flexion
T1 = Finger abduction
40
Myotomes - lower limb
L2 = Hip flexion
L3 = Knee extension
L4 = ankle dorsiflexion
L5 = Big toe extension
S1 = Ankle plantar flexion
S4 = Bladder and rectum motor supply
41
Complication of fractures and fracture healing
* Osteomyelitis
* Haemorrhage – Mostly seen with pelvic fractures
* Vascular/Nerve injuries- Popliteal artery / common peroneal nerve
* Avascular Necrosis- NOF fractures/ scaphoid/ talus
* Malunion / Nonunion
* Compartment Syndrome
42
Compartment Syndrome
* Emergency
* High risk : fractures of elbow/forearm/proximal third of tibia/multiple fractures of hand or foot/ crush injuries / circumferential burns / tight plasters/ infection/ post surgery
* >6h - severe irreversible myonecrosis - **Volkmans ischemic contracture**
43
Compartment Syndrome - Clinic
Pain out of proportion with injury
Paresthesia
Pallor ( may last symptom with Pulselessness)
Paralysis
Pulselessness
44
Compartment Syndrom - RX
* SIGN- passive stretch test
if toes/fingers are passively stretched it results in pain in calf or forearm
* Confirmation- Measuring the inter compartmental pressure
* clinical diagnosis
45
Compartment Syndrom - Mx
* Fasciotomy
46
Clavicle Fracture
* Fall onto affected shoulder
* Pat is supporting arm which is in full adduction
47
Clavicle Fracture - Thinks to look for
* Careful NEUROVASCULAR examination
* skin integrity to r/o open fracture
* lung fields to r/o apical lung injury
48
Clavicle Fracture - Classification
* middle third
* lateral third
* medial third
49
Clavicle Fracture - Middle third
* 80%
* Defined by shortening/comminution/angulation
MX
* Broad arm sling to support limb for 2 weeks or untilcomfortable.Regular analgesia as required
50
Clavicle Fracture -Lateral third
* 15%
* Around and lateral to
coracoclavicular Ligaments
Mx
* If undisplaced,no reduction required
* **If displaced,refer**
* Broad arm sling to support limb for 2 weeks or until
comfortable
Regular analgesia as required
51
Clavicle Fracture -medial third
* 5%
* Bony injury alone associated with sternoclavicular
dislocation- look for vascular,injury/neurological injury
Mx
* If Undisplaced,no reduction required
* ** If displaced,urgent referral**
* Broad arm sling to support limb
52
Clavicle Fracture -medial third
Brachial plexus injury
Subclavian vessel injury
Shortening of the shoulder arc
Stiffness of the shoulder joint
Cosmetic side effects
53
Shoulder disslocation - Types
* Anterior- m/c
* Posterior- seen in seizures or electric shock
* Inferior dislocation (luxatio erecta)
* Superior dislocation
54
Shoulder dislocation - Anterior Clinic
* most common of trauma indirect & direct
Clinic
* injured shoulder in slight abduction and
external rotation, SUPPORTED by the normal side
* Presents with pain/ discomfort and inability to move the affected shoulder.
* ALWAYS do a careful neurovascular examination (axillary nerve)
55
Shoulder dislocation - Anterior RX/Mx
Rx
* Xray AP
* CT/MRI post reduction
Mx
* reduction in trauma bay under anaestesia
56
Fracture proximal humerus - Pathopysiology
* common in elderly (osteoporosis) - outstreched arm (low energy)
* High energy - risk of soft tissue and neurovascular complications
* Nerve - axillaris injury M/C
* Aterial - uncommon, higher risk in elderly x
57
Fracture proximal humerus - Rx/Mx
Rx
* X-ray
Mx
* Nonsurgical: in minimal displaced, Sling immobalisation, Pain relief
* Surgical: if multiple part fracture, review by orthop team
58
Adhesive Capsulitis
* = frozen schoulder - functional loss of passiv and active shoulder motion due to inflammatory process
* clinical diagnose
* increased in DM
59
Adhesive Capsulitis - Presentation
* Pain partricularly at night
* Stiffness
* Global reduction in movements
On Examination-
* Global tenderness
* Active movements restricted
* Passive movements-restricted
* Power- normal
* Sensations-normal
60
Adhesive Capsulitis - Management
* Rest during the acute phase
* Analgesics + physiotherapy
* if pain doesn’t subside, Imaging guided injection :
1 ml corticosteroid with 2-5 ml 1% lidocaine
(may be done to divide the thickened ligaments +/-
acromioplasty)
general approach :
* **stiffness present along with pain** = arthroscopy to divide adhesions
* **Pain alone present** = NSAIDS / Steroid injection.
61
Impingement/ Rotator cuff tear
* subacromial impingement M/C cause for shoulder pain ( 4% in <40y, >50% in over 60Y)
62
Impingement/ Rotator cuff tear - Stages
* Subacromial impingement = first stage of rotator cuff disease
* continuum of disease from
Impingement and bursitis
Partial to full-thickness tear
Massive rotator cuff tears
Rotator cuff tear arthropathy
63
Impingement- Symptoms
* Pain-insidious onset,exacerbated by overhead activities and lifting objects away from body.
* night pain
64
Impingement - Physical examination
* Strength-usually normal
* Painful Arc Test-pain with arm abducted in scapular plane from 60° to 120°
* Active and passive movements usually full
65
Impingement - Rx/Mx
Rx
* X-ray - initially
* US - Next
* MRI - Best
Mx
* Anagesics+ Physio- initial
* Trial of steroid injections- next
* Arthroscopic decompression - best
66
Rotator Cuff Tear
* one or more of the rotator cuff tendons is
torn --> tendon becomes partially or
completely detached from the head of the
humerus.
* Most tears occur in the supraspinatus tendon
Cause :
* injury
* wear (degeneration).
Types
* Partial thickness tear
* Full thickness tear
67
Rotator Cuff Tear - Symptomes
* Pain at rest and at night, particularly if lying on the affected shoulder
* Pain with movement
* Weakness when lifting or rotating your arm
68
Rotator Cuff Tear - Examination
* Active movements weak
* Passive movements normal
* Impingement+ Power weak
* often supraspinatus weakness( Jobes test/empty cane)
69
Rotator Cuff Tear - Rx/Mx
Rx
* First-xray
* Next-usg
* Best-MRI
Mx
* Analgesics+ rest
* Steroid injection
* Surgery
70
Fracture Midshaft humerus
* common fracture caused by twisting force following a fall
Clinic
* Severe pain/ deformity +/- wrist drop
* Check for : radial nerve
Investigation:
* X-ray
Treatment:
* Undisplaced: reduce and place a U-Slab, always check for radial nerve post reduction
* Displaced: surgery
71
Fracture Supracondylar
* m/c fracture in children around the elbow
* FOOSH = Fall on outstreched hand
* Hyper extention
72
Fracture Supracondylar - Clinic
* pain/ deformity
* always check for the integrity of the triangle
* Check: median/ulnar/radial nerve and brachial artery
73
Fracture Supracondylar - Types
74
Fracture Supracondylar - Rx/Mx
Rx
* Xray
Mx
* Rx = hyperflexion of the elbow
* then apply collar and cuff
* Cast only if displacement
75
Biceps tendon rupture
* proximal ruptur more common (90%)
Cause:
* Injury
* overuse due to age or repetitive oberhead movement ( tennis / swimming)
76
Biceps tendon rupture - Clinic
* painful pop
* pain
* weakness especially in supination
77
Biceps tendon rupture - Examination
Distal rupture:
* varying degree of proximal retraction of the muscle belly-“reverse Popeye sign”
* change in contour of the muscle, proximally
* medial ecchymosis
Proximal
* popeye sign
* change in contour of the muscle, proximally
* medial ecchymosis
78
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Biceps tendon rupture - Rx/Mx
Rx
* mostly pysical exam
* Xray
* MRI
Mx
* Older, limited use - proximal -conservative( rice and Nsaids)
* young, athletes- proximal - surgical repair
79
Pulled elbow
* children 3-5
* subluxation/dislocation of the radial head ( not stable in ligaments)
* axial traction and pronation of hand ( lifted with their wrist)
80
Pulled elbow- clinic
* pain
* refusal to use affected arm
* affected arm in flexion and pronation
* child will refuse supination
81
Pulled elbow - Rx/Mx
Rx
* clinical
* may Xray for conformation
Mx
* Reduction = Elbow flexion and supination under analgesia
* Hyperpronation/supination and pronation alternation
82
Flow chart - Child not using upper limb
83
Lateral epicondylitis - Tennis Elbow
* wrist extensor ( externsor carpi radialis brevis)
* 40-60a
* carpenter, gardener, computer, vioinist, dentist
84
Lateral epicondylitis - Clinic
* pain - outer elbow
* Rest pain/night pain
* pain during gripping and hand movements
* lateral tenderness
* wrist extension by extend arm reproduces pain
85
Lateral epicondylitis - Mx
* 6-24 month self limiting
* lifestyle modifications
* Nsaids/rice
* brace ( counterforce)
* Physiotherapy
* Stereoids with severe pain
86
Medial epicondylitis
* golfers elbow, forehand tennis elbow
* flexor origin
* reverse dumbell eexercise
87
Fracture of the forearm
* Monteggia
* Galeazzi
Both requiere surgery
88
Montaggia Fracture
Fracture of the proximal
third of the ulna with fracture of the
radial head and dislocation of the
proximal radio-ulnar joint.
89
Galezzi Fracture
Fracture of the distal third of
the radius with dislocation of the DRUJ.
90
Greenstick Fracture - definition
* incomplete fracture, in which on cortex is broken and bending of the opsite side
* kids
Investigation
* Xray
Treatment:
* Closed reduction
* Suitable for local anaest, manipulation and plaster
* Plaster for 4-6 weeks
91
Fracture types distal radius
intrarticular : Bartons fracture
Extra- articular: Colles/ smith fracture
92
Colles fracture
*extraarticular
* distal end of the radius (2cm)
* commenly in postmenopausal women
* mechanism = FOOSH +wrist extension
93
Colles fracture - Management
Colles Cast
* below the elbow
* Hand is mid pronation and ulnar
deviation.
* wrist joint will be in palmar
flexion = HAND SHAKING CAST
* high displacement: K-wires/open reduction using plates
* **repeated X-rays are recommended at 1, 2 and 6 weeks to verify proper healing.**
94
# 1.
Colles fracture - Complication
* M/C stiffness of fingers.
* 2nd m/c dinner fork deformity.
* Others
- Damage to the median nerve
- Rupture of extensor pollicis longus tendon
- Non-union (extremely rare)
95
Colles vs Smith- Xray
96
Colles vs Smith
97
Smith - Fracture
* extra articular fracture
* Distal end of radius – volar / ventral displacement
* Mechanism of injury = FOOSH + wrist in flexion
* Deformity = Garden spade deformity
* Management – POP cast below elbow / Surgery using plate fixation.
98
Bartons fracture
* intra-articular fracture
* fragment can be dorsally or ventrally displaced
* Needs surgical management
99
Scaphoid Fracture
* Common after Foosh injury
* Blood supply from distal to proximal > any # in the waist can lead to AVN
100
Scaphoid Fracture - Clinic
* Pain/Tenderness in anatomical snuffbox
* Pain/tenderness on axial compression
101
Scaphoid Fracture - Rx/Mx
Rx
* X ray followed by Mri
Mx
* Thimb spica cast for 4-6 weeks
* If on initial Xray no # but symptoms apply cast and retest in 1 week
102
De Quervains Tendosynovitis
Cause
* Cumulated injuries/ overuse
Effected tendons
* Extensor pollicis brevis and Abductor pollicis longus
RX
* Finkelstein Test - Localize pain at the base of the thumb
MX
* Splinting of the hand at night
* NSAIDs
* Steroid injections
103
Mallet finger
Cause:
* injury to the finger extensor
* tear of tendon/ distal avulsion
* Hyperextension/hyperflexion injury
(Ball hits distal phalanx)
Mx
* Mallet finger splint (hyperflexion of the distal interphalangeal joint for 6 weeks)
104
Trigger finger
**Epidermiology/Pathophysio**
* problem of the flexor tendons-locking tendon in flexion with difficulty of extension
* f>m, older, more in DM
* Affected pully: A1
* m/c Flexor digitorum profundus, ring finger
**Cause **
* trauma/DM/ Autoimmune conditions like RH/SLE
**Examination **
* inflammation
**Mx**
* initial: Rest, splinting, Nsaids, steroid
* Corticosteroids
* surgical release
105
Pelvic Fractures - Unstable
106
Pelvic Fracture - Clinical evaluation
* follow Atls protocoll
* neurovasc status of limb
* pelvic instability - length discrepancy with internal or external rotation
* peritoneum for open injuries
* Rule out vaginal or rectum involvement
107
Pelvic fractures - Complications
* Massive hemorrhage due to rupture of the venous plexus in the posterior pelvis/ large vessel injury
* Neurological injury- damage to lumbosacral plexus /nerve roots
* Genitourinary/gastrointestinal injury
* DVT/PE/Fat embolism
108
Pelvic fractures - Rx/Mx
Rx
* Xray
Mx
* Stable: strict bed rest
* unstable: Aplly pelvic binder
* may require ex fix before surgical exploration
109
Coxa vara/ valga
110
Shoulder pain differentials
111
Common shoulder conditions
112
Evaluation of Subacromial Impingement/Cuff Pathology
113
Comparison of important causes of hip pain in chidren
114
L4 ( Motor/reflex/sensory)
Motor : ankkle dorsi flexion deficit ( tibialis ant)
Reflex: patella reflex defizit
Sensory: medial leg, medial big toe
115
L5 ( Motor/reflex/sensory)
Motor: big toe, dorsiflexion deficit
Reflex: ankle reflex
Sensory: dorsum foot, anteroir lower leg big toe
116
Osgood schlatter
* children who play active sport
Symptoms
* pain with physical activity
Signs
* palpable lump below the knee
* red inflammed skin over tibial tuberosity
* sometime quadriceps loose strenght and bulk
117
Osgood schlatter - Mx
* rest
* ice
* Physio
* Analgesics
118
Proximal femoral fracture - Epi/Pathothology
* M/c in elderly, rare in young( high energy trauma)
* displaced : non ambulatory, shortend leg + external rotation
* Impacted or stress fracture: my weight bearing, more groin pain/pain on axial compression
119
Proximal femoral fracture Rx/Mx
Rx
* Xray
Mx
* Surgery: DCS/DHS/Nailing/Hemi/THR
120
Knee injuries
121
ACL- Anatomy
* runs from posterior femur to anterior tibia. Has two bundles- AM/PL
* prevent anterior tibial translation and internal tibial rotation.
122
ACL - Injury
Contact : football, basketball, netball
non-contact: post a jump
123
ACL- Injury- Symptoms
* Pain/audible pop
* swelling
* Instability - esp when climbing down the stairs/running ets
* LAchmans test and anterior drawer test positiv
124
ACL Injury - Rx/Mx
RX
* MRI
MX
* rest
* ice
* Surgical repair
* Physio
125
Meniscal injury
126
Meniscal injury
* walking/squatting
* trauma( twisting while leg is bent)
* wear and tear (older people)
127
Meniscal injury - Symptoms
* pain
* Swelling, typical delayed
* catch/locking of the knee
* Instability or the knee “giving way”
* Restricted range of motion
* Mc Murry +
128
Meniscal injury - Rx/Mx
RX
* MRI
Mx
* depend on location and zone involed
* rest
* ice
* Physio
* Surgery
*
129
Genu varum/valgum
130
Ankle injury
* sprain or fracture
131
Ankle injury- Symptoms
* pain
* swelling
* sprain: can weight bear
* fracture: no weight bearing
* watch out for displaced fractures can lead to neurovascular injuries
132
Ankle injury
* sprain - rice
* Fracture - cast boot , if displaced surgery
133
Ottowa Rule
Bony tenderness:
* along distal 6 cm of the posterior edge of fibula or tip of lateral malleolus
* along distal 6 cm of the posterior edge of tibia/tip of medial malleolus
* at the base of 5th metatarsal
* at the navicular
* Inability to bear weight both immediately after injury and for 4 steps during an initial evaluation
134
Achilles tendon injury
* overuse injury
* strain/partial tear or complete tear
RF
* overuse
* history of previous injury
* obesity
* family history
* Muscle and tendon stiffness
135
Achilles tendon injury- Symptoms
Tendinopathy
* pain
* swelling
Tear
* shot feeling
* Thopson test - no plantar flexion of the foot being observed
136
Achilles tendon injury- Mx
Initial: RICE
Splinting with ankle in plantar flexion
Definitiv: surgery
137
Spine- Acute lower back pain
* injury
* overuse
138
Spine- Acute lower back pain- Symptoms
* pain
* tenderness
* inability to do daily task
* Can radiate- down legs or be associated with tingeling or numbness
139
Lower back pain - Red flags
Tumour
* History of cancer
* Weight loss
* Night pain
* Age >40 or <15 years
Fracture
* History of trauma
* Risk factors for fragility fracture
Infection
* Fever >38.0°C
* Night sweats/chills
* Immunosuppression
* Intravenous drugs
* Concomitant infection
Cauda equina syndrome
* Urinary retention
* Saddle anaesthesia
* Worsening neurology – flaccid paralysis
140
Lower back pain - Rx/Mx
* Unless red flags, no radiological evaluation
* if red flag: Xray, MRI
MX
* no red flags: Analgesics/continue normal activity/Physio
* First line analgesics: Paracetamol
* second line : Nsaids
* Third : codein
141
Cervical spondylosis
* natural degenerative process of the cervical motion segment --> cervical radiculopathy, cervical myelopathy, or axial neck pain.
RX
* plain radiographs of the cervical spine
Mx
* observation, medical management, or surgical management
* depending on the severity and chronicity of pain, presence of instability or,presence of neurological deficits
