Abra Valley College
Abra Valley College
Abra Valley College
COLLEGE OF NURSING
NCM 116
JOINT
DISORDERS
GROUP-6
PREPARED BY:
VALERA ALDEMAR G.
BOSQUE DEXIE MAE D.
ANGALA EARLYN MAY P.
RAMOS ALLYZA ASHLEY B.
BSN-3
OSTEOARTHRITIS
INTRODUCTION
Osteoarthritis (OA) is a degenerative joint disease and the most common type of arthritis. Some people
call it degenerative joint disease or “wear and tear” arthritis. This condition is gradual loss of cartilage
between joints and the formation of osteophytes or outgrowth at the margins of the joints. This is what
causes pain and can lead to joint damage.
Once pain and loss of movement function become chronic, people with osteoarthritis often experience
restrictions in participating in meaningful activities, and decreased well-being. In some cases it also
causes reduced function and disability some people are no longer able to do daily tasks or work.
The most commonly affected parts of the body are the hands, knees, hips, and spine, As the damage of
soft tissues in the joint progresses, pain, swelling, and loss of joint motion develops.
Many factors can contribute to developing osteoarthritis, like the history of joint injury or overuse, older
age and being overweight. While this condition is not part of the normal aging process, it is common in
older adults with aging as a risk factors.
According to Maegan Wagner osteoarthritis affects more in woman than in men.
By 40 years of age, 90% of the population has degenerative joint changes in their weight-bearing joints.
• CAUSES/RISK FACTORS
Osteoarthritis happens when the cartilage and other tissues within the joint break down or have a
change in their structure. This does not happen because of simple wear and tear on the joints.
Instead, changes in the tissue can trigger the breakdown, which usually happens gradually over time.
Certain factors more likely to develop the disease are:
1. AGING.
o The aging changes observed in the cells and extra cellular matrix of joint tissues likely
increase the susceptibility of older adults to osteoarthritis. Aged chondrocytes responds
poorly to growth factor stimulation and so are unable to maintain homeostasis in the
articular cartilage.
2. BEING OVERWEIGHT OR OBESE.
o Extra weight puts more stress on joints, particularly weight-bearing joints like the hips
and knees. This stress increases the risk of osteoarthritis in that joint. Also, obesity may
also have metabolic effects that increase the risk of osteoarthritis.
3. BONE DEFORMITIES.
o Some people are born with malformed joints or defective cartilage.
4. HISTORY OF INJURY OR SURGERY TO A JOINT.
o History of joint injury represents an important risk factor for posttraumatic osteoarthritis
and is a significant contributor to the rapidly growing percentage of the population with
osteoarthritis.
5. OVERUSE FROM REPETITIVE MOVEMENTS OF THE JOINT.
o Injury or overuse, such as knee bending and repetitive stress on a joint, can damage a
joint and increase the risk of osteoarthritis in that joint.
6. GENDER.
o Women are more likely to develop osteoarthritis than men, especially after age 50.
7. FAMILY HISTORY.
o People who have family members with osteoarthritis are more likely to develop
osteoarthritis.
8. RACE.
o Some Asian populations have lower risk for OA.
9. CERTAIN METABOLIC DISEASES.
o These include diabetes and a condition in which your body has too much iron
(hemochromatosis).
A. ASSESSMENT
History taking to the patient.
o The history should address the character the gender, age, lifestyle, location, severity, factors
that aggravate or relieve pain, and time (new-onset or recurrent)
Assess pain thoroughly.
o A comprehensive assessment will help us to identifying the underlying cause of pain and the
effectiveness of treatment.
Assess factors that cause pain.
o Pain in osteoarthritis may be associated with specific movements of affected joints.
Assess the patient’s existing knowledge about the disease.
o Evaluating the patient’s understanding and how the patient perceives the management of
osteoarthritis, this will allow us healthcare providers to plan appropriate care and provide
correct patient education.
Assess vital signs of the patient.
o This will help us health care provider detect or monitor medical problems of the patient.
Assess the patient’s weight and body mass index (BMI).
o Obesity increases the mechanical stress in a weight-bearing joint.
Assess the both hands.
o Bony enlargements and shape changes in the finger joints can happen over time.
Assess the knees.
o When walking or moving, you may hear a grinding or scaping noise. Over time, muscle and
ligament weakness can cause the knee to buckle.
Assess the hips.
o You might feel pain and stiffness in the hip joint or in the groin, inner thigh, or buttocks.
Sometimes, the pain from arthritis in the hip can radiate (spread) to the knees. Over time, you
may not be able to move your hip as far as you did in the past.
Assess the spine.
o You may feel stiffness and pain in the neck or lower back. As changes in the spine happen,
some people develop spinal stenosis, which can lead to other symptoms.
B. ANALYSIS/NURSING DIAGNOSIS
Chronic pain related to joint stiffness as evidence by guarding behavior.
Impaired physical mobility related to muscle weakness as evidence by sedentary lifestyle.
DIAGNOSTIC TEST
X-rays. Cartilage doesn't show up on X-ray images, but cartilage loss is revealed by a narrowing
of the space between the bones in your joint. An X-ray can also show bone spurs around a joint.
Magnetic resonance imaging (MRI). An Magnetic resonance imaging (MRI) uses radio waves
and a strong magnetic field to produce detailed images of bone and soft tissues, including
cartilage.
Blood tests. Although there's no blood test for osteoarthritis, certain tests can help rule out other
causes of joint pain, such as rheumatoid arthritis.
Joint fluid analysis. Your doctor might use a needle to draw fluid from an affected joint. The
fluid is then tested for inflammation and to determine whether your pain is caused by gout or an
infection rather than osteoarthritis.
TREATMENT/MANAGEMENT
There is no cure for osteoarthritis, so doctors usually treat osteoarthritis symptoms with various
therapies, which may include:
Physical therapy. A physical therapist can show you exercises to strengthen the muscles around
your joint, increase your flexibility and reduce pain. Regular gentle exercise that you do on your
own, such as swimming or walking, can be equally effective.
Occupational therapy. An occupational therapist can help you discover ways to do everyday
tasks without putting extra stress on your already painful joint. For example, a toothbrush with a
large grip could make brushing your teeth easier if you have osteoarthritis in your hands. A
bench in your shower could help relieve the pain of standing if you have knee osteoarthritis.
Transcutaneous electrical nerve stimulation (TENS). This uses a low-voltage electrical
current to relieve pain. It provides short-term relief for some people with knee and hip
osteoarthritis.
PHARMACOLOGICAL MANAGEMENT
Osteoarthritis can't be reversed, but treatments can reduce pain and help you move better.
Acetaminophen. Acetaminophen (Tylenol) has been shown to help some people with
osteoarthritis who have mild to moderate pain. Taking more than the recommended dose of
acetaminophen can cause liver damage.
Nonsteroidal anti-inflammatory drugs (NSAIDs). Over-the-counter nonsteroidal anti-
inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB) and Naproxen Sodium
(Aleve), taken at the recommended doses, typically relieve osteoarthritis pain.
Duloxetine (Cymbalta). Normally used as an antidepressant, this medication is also approved to
treat chronic pain, including osteoarthritis pain.
SURGICAL MANAGEMENT
Arthroscopic Lavage techniques. Arthroscopic lavage include lavage and debridement of the
knee (e.g., shaving of rough cartilage or smoothening of the degenerated meniscus). In theory,
arthroscopy for OA should relieve symptoms by removing the debris and inflammatory
cytokines that cause synovitis.
Joint arthroplasty. Joint arthroplasty is a well-accepted, safe, and cost-effective method for
treatment of advanced knee OA. Owing to its irreversible nature, joint arthroplasty is
recommended only in patients for whom other treatment modalities have failed or are
contraindicated.
Total knee arthroplasty(TKA). Total knee arthroplasty advanced knee osteoarthritis, with more
than one compartment involved and failure of conservative treatments, TKA has been shown to
be a highly effective treatment that results in substantial improvement in patient functioning and
health-related quality of life .
PROGNOSIS
In 2019, about 528 million people worldwide were living with osteoarthritis; an increase of 113%
since 1990 (1).
About 73% of people living with osteoarthritis are older than 55 years, and 60% are female (1).
With a prevalence of 365 million, the knee is the most frequently affected joint, followed by the hip
and the hand (2).
344 million people living with osteoarthritis experience severity levels (moderate or severe) that
could benefit from rehabilitation (3).
With ageing populations and increasing rates of obesity and injury, the prevalence of osteoarthritis is
expected to continue to increase globally. Osteoarthritis is not an evitable consequence of ageing.
Osteoarthritis is more prevalent in older people (about 70% are older than 55), global prevalence is
expected to increase with the ageing of populations.
The prevalence of musculoskeletal complaints was 16.3% (95% CI 8.6-24.0) of the adult population
in a Filipino urban community.
The total prevalence of rheumatic disease is 9.8% (95% CI 8.2-11.4).
According to the DOH the prevalence of Osteoarthritis was 4.1% (95% CI 3.3-4.9) and soft tissue
rheumatism 3.8% (95% CI 2.9-4.8).
The prevalence of rheumatoid arthritis, 0.17% (95% CI 0-9.36), was notably low compared to the
prevalence in other developing countries.
Several key prevention strategies have been proposed to prevent osteoarthritis and control the
disease progression. In particular, reducing overuse of joints (related to workload), and promoting
healthy lifestyles (regular physical activity, maintaining a normal body weight) play an important
role.
The typical onset is in the late 40s to mid-50s, although osteoarthritis may also affect younger
people, including athletes and people who sustain joint injury or trauma. About 60% of people living
with osteoarthritis are women.
REFERENCE:
AskMayoExpert.(2020).Osteoarthritis (adult). Mayoclinic.org
Wagner(2023).Osteoarthritis Nursing Diagnosis & Care Plan.Nurse Together.
World Health Organization(2023). Osteoarthritis.who.int
CDC(2023). Osteoarthritis.cdc.gov
National Institute of Arthritis and Musculoskeletal and Skin Disease(2023). Overview of
Osteoarthritis.niams.nih.gov
National Library of Medicine(2011). Current Surgical Treatment of Knee
Osteoarthritis.ncbi.nlm.nih.gov
GOUT
INTRODUCTION
Gout is the most common type of inflammatory arthritis. It causes sudden and intense attacks of joint
pain, often in the big toe. It can also strike joints in other toes or the ankle or knee. People with
osteoarthritis in their fingers may experience their first gout attack in their finger joints.
It is characterized by sudden, severe attacks of pain, swelling, redness and tenderness in one or more
joints. It can occur suddenly, often waking the person up in the middle of the night with the
sensation that their big toe is on fire. The affected joint is hot, swollen and so tender that even the
weight of the bedsheet on it may seem intolerable.
Men are three times more likely than women to develop gout. It tends to affect men after age 40 and
women after menopause, when they lose the protective effects of estrogen.
CAUSES/RISK FACTORS
Gout occurs when urate crystals accumulate in the joint, causing the inflammation and intense pain gout
attack. Urate crystals can form when there is a high levels of uric acid in the blood. The body produces
uric acid when it breaks down purines substances that are found naturally in the body.
Purines are also found in certain foods, including red meat and organ meats, such as liver. Purine-rich
seafood include anchovies, sardines, mussels, scallops, trout and tuna. Alcoholic beverages, especially
beer and drinks sweetened with fruit sugar (fructose) promote higher level of uric acid.
Normally, uric acid dissolves in the blood and passes through the kidney into the urine. But sometimes
either the body produces too much uric acid or the kidneys excrete too little uric acid. When this
happens, uric acid can build up, forming a sharp, needlelike urate crystals in a joint or surrounding tissue
that cause pain, inflammation and swelling.
Several factors increase the likelihood of the blood uric acid level rising and gout developing. These
include the following:
1. Gender.
o Gout is more common among men than among women.
2. Family history.
o Gout often runs in families and there may be a genetic predisposition to developing
hyperuricemia and gout.
3. Older age.
o Gout rarely occurs in children and is more common among middle-aged adults and the
elderly.
4. Overweight.
o The larger a person is, the more urate they produce each day meaning overweight or obesity
can mean too much urate is produced for the kidneys to process effectively.
5. Purine-rich foods.
o Eating foods that are rich in purines can lead to hyperuricemia and trigger gout.
6. Alcohol.
o A high alcohol intake can increase the risk of hyperuricemia, since alcohol can interfere with
urate excretion.
7. Medications.
o Medical disorders that affect kidney function and therefore the elimination of uric acid can
cause gout. Some medications may also raise the risk of developing gout.
A. ASSESSMENT
Asses pain characteristics and location.
o Gout can be diagnosed during flare when the joint is painful and swollen. It is important to
identify which joints are affected to optimize the treatment plan.
Joint examination.
o Perform a thorough examination of affected joints, assessing for swelling, redness, warmth,
and limited range of motion.
Patient history.
o Obtain a detailed medical history, with a focus of previous gout attacks, family history of
gout, and any existing comorbidities.
Dietary assessment.
o Assess the patient’s dietary habits, particularly the intake of purine rich foods and alcohol, to
identify potential triggers for gout attacks.
Uric acid levels.
o Monitor serum uric acid levels through blood test to determine the extent of hyperuricemia
and guide treatment strategies.
Lifestyle factors.
o Evaluate lifestyle factors such as physical activities, stress levels, and hydration, as they can
influence the frequency and severity of gout attacks.
Medication history.
o Review the patient’s current medications, including any prescribed medications, over-the-
counter drugs, and herbal supplement, as some may exacerbate or contribute gout.
DIAGNOSTIC TEST
X-rays. X-rays can be used to diagnose gout by showing the presence of uric acid crystals within the
joint. If there is suspicion of gout, an X-ray can be used to confirm the diagnosis and determine if
any joint damage is present. X-rays can also be used to monitor the progress of the disease and the
effectiveness of treatments.
Ultrasound. Ultrasound imaging is a non-invasive modality that uses high-frequency sound waves
to create images of the body’s internal structures. It is commonly used in the assessment of gout
because it can detect joint effusions and typhoid (gouty deposits) in joints. It is particularly useful in
the early stages of gout when joint pain is intermittent and clinical signs may not be prominent.
Magnetic resonance imaging (MRI). MRI (Magnetic Resonance Imaging) is a non-invasive
medical imaging technique that uses a combination of magnetic fields and radio waves to create
detailed images of the internal structures of the body. MRI is commonly used in the evaluation of
gout because it can detect joint effusions and typhoid, which are characteristic signs of gout. MRI
can also assist in the differential diagnosis of gout and other forms of arthritis.
CT (computed tomography) scan specifically a dual-energy CT scan. CT (Computed Tomography)
scan is a non-invasive medical imaging technique that uses computers and X-rays to create cross-
sectional images of the body, allowing physicians to view internal structures and organs in great
detail. CT scan is commonly used in the evaluation of gout as it can detect uric acid crystals in joints
and show joint damage caused by gout. It can also help to differentiate gout from other forms of
arthritis.
Other common tests to diagnose gout include:
Blood tests to measure the uric acid in your blood.
Joint aspiration using a needle to remove a sample of fluid from inside a joint.
PHARMACOLOGICAL MANAGEMENT
The healthcare provider might suggest medications to help manage your symptoms, including:
NSAIDs: Over-the-counter (OTC) NSAIDs, like ibuprofen and naproxen, can reduce pain and
swelling during a gout attack. Some people with kidney disease, stomach ulcers and other health
problems shouldn’t take NSAIDs. Talk to your provider before taking NSAIDs.
Colchicine: Colchicine is a prescription medication that can reduce inflammation and pain if it is
taken within 24 hours of a gout attack.
Corticosteroids: Corticosteroids are prescription medications that reduce inflammation. The
heath care provider might prescribe oral (by mouth) pills. They may also inject corticosteroids
into the affected joints or into a muscle near the joint (intramuscularly).
SURGICAL MANAGEMENT
There are three main types of surgery for gout include tophi removal, joint fusion, and joint
replacement.
Tophi removal. Tophi removal involves the removal of the painful, infected, or swollen
growths. The procedure consists of cutting a tophus out while keeping as much of the
surrounding tissue intact as possible.
Joint fusion. Joint fusion involves fusing the bones in a joint together. This surgery may cause a
person to lose some mobility, but it should provide some relief from symptoms such as chronic
pain.
Joint replacement. In this procedure, doctors remove the damaged, painful joint and replace it
with an artificial joint. This procedure can help reduce pain and improve mobility. The most
common location for this surgery is the knee.
PROGNOSIS
With early gout diagnosis, life-long urate-lowering therapy enables most patients to live a normal
life. For many patients with advanced disease, aggressive lowering of the serum urate level can
resolve tophi and improve joint function. Gout is generally more severe in patients whose initial
symptoms appear before age 30 and whose baseline serum uric acid level is >9mg/dL (0.5 mmol/L).
The high prevalence of metabolic syndrome and cardiovascular disease probably increases mortality
in patients with gout.
Some patients do not improve sufficiently with treatment. The usual reasons includes inadequate
education provided to patients, nonadherence, alcoholism, and mainly undertreatment of the
hyperuricemia by physicians.
REFERENCE:
o Center for Disease Control and Prevention(2020).Gout. mayoclinic.org
5. Obesity.
o Being obese is a risk factor for carpal tunnel syndrome.
6. Workplace factors.
o Working with vibrating tools or on an assembly line that requires repeated movements that
flex the wrist may create pressure on the median nerve.
7. Heredity.
o This is likely an important factor. The carpal tunnel may be naturally smaller in some people,
or there may be anatomic differences that change the amount of space for the nerve and these
traits can run in families.
8. Health conditions.
o Diabetes, rheumatoid arthritis, and thyroid gland imbalance are conditions that are associated
with carpal tunnel syndrome.
A. ASSESSMENT
Ask the patient about nocturnal pain.
o Commonest cause of hand at night.
Take family history.
o Abnormally small size of carpal tunnel runs in families.
Assess the patient’s presenting symptoms.
o Such as pain, numbness, tingling, and weakness in the affected hand and fingers.
Evaluate the patient’s daily tasks.
o Including their ability to perform daily tasks, work-related activities, and hobbies that may be
impacted by CTS.
Assess the patient’s pain level using appropriate pain assessment tools.
Press down or tap along the median nerve of the palm side of the patient wrist and hand.
o This is to see if it causes any tingling into your fingers (Tinel's sign).
Bend and hold the wrists of the patient in a flexed position.
o This is to test for numbness or tingling in your hands.
SURGICAL MANAGEMENT
Surgery may be appropriate if symptoms are severe or don't respond to other treatments. The goal of
carpal tunnel surgery is to relieve pressure by cutting the ligament pressing on the median nerve.
Endoscopic surgery. A surgeon uses a telescope-like device with a tiny camera called an
endoscope. This allows the surgeon to see inside the carpal tunnel. The surgeon cuts the ligament
through one or two small incisions in the hand or wrist. Endoscopic surgery may result in less
pain than does open surgery in the first few days or weeks after surgery.
Open surgery. A surgeon makes a cut, also called an incision, in the palm of the hand over the
carpal tunnel and cuts through the ligament to free the nerve.
PROGNOSIS
Carpal tunnel syndrome (CTS) is one of the most common upper limb compression neuropathies.
CTS account for approximately 90% of all entrapment neuropathies. It is due to an entrapment of
the median nerve in the carpal tunnel at the wrist
The incidence and prevalence varies, 0.125% – 1% and 5 – 16%, depending upon the criteria
used for the diagnosis. It is a condition of middle-aged individuals and affects females more often
than males.
In the first population based study, Stevens and other noted that the mean age at diagnosis was
50 years for men and 51 years for women.
Although unlikely, untreated carpal tunnel syndrome can lead to permanent nerve damage,
disability and loss of hand function.
REFERENCE:
University of Cagayan Valley(2023). Carpal Tunnel Syndrome. Studocu.com
Balido(2024). Carpal Tunnel Syndrome. Scribd.com
National Institutes of Neurological Disorders and Stroke(2023). Carpal Tunnel Syndrome.
Mayoclinic.org
American Academy of Orthopaedic Surgeons(2022). Carpal Tunnel Syndrome.my.cleavelandclinic.org
Johns Hopkins Medicine(2024). Carpal Tunnel Release.hopkinsmedicine.org
8. Psychological conditions.
o People prone to depression and anxiety appear to have a greater risk of back pain. Stress can
cause muscle tension, which can contribute to back pain.
A. ASSESSMENT
Physical Examination.
o The physical examination is not as important as the history in identifying secondary
causes of acute low back pain. Nevertheless, certain aspects of the physical examination
are considered important.
GAIT AND POSTURE.
o Observation of the patient's walk and overall posture is suggested for all patients with
low back pain. Scoliosis may be functional and may indicate underlying muscle spasm or
neurogenic involvement.
RANGE OF MOTION.
o The examiner should record the patient's forward flexion, extension, lateral flexion and
lateral rotation of the upper torso. Pain with forward flexion is the most common
response and usually reflects mechanical causes. If pain is induced by back extension,
spinal stenosis should be considered
PALPATION OR PERCUSSION OF THE SPINE.
o Point tenderness over the spine with palpation or percussion may indicate fracture or an
infection involving the spine. Palpating the paraspinous region may help delineate tender
areas or muscle spasm.
HEEL-TOE WALK AND SQUAT AND RISE
o A patient unable to walk heel to toe, and squat and rise may have severe cauda equina
syndrome or neurologic compromise.
PALPATE THE PATIENT TO THE SCIATIC NOTCH
o Tenderness over the sciatic notch with radiation to the leg often indicates irritation of the
sciatic nerve or nerve roots.
STRAIGHT LEG RAISING TEST
o With the patient in the supine position, each leg is raised separately until pain occurs. The
angle between the bed and the leg should be recorded. Pain occurring when the angle is
between 30 and 60 degrees is a provocative sign of nerve root irritation.
REFLEXES AND MOTOR AND SENSORY TESTING
o Testing knee and ankle reflexes in patients with radicular symptoms often helps
determine the level of spinal cord compromise. An altered knee or ankle reflex alone
does not suggest the need for invasive management because this finding is generally
transient and fully reversible
B. ANALYSIS/ NURSING DIAGNOSIS
Chronic pain related to inflammation of the lumbar as evidence by patient consistent lower back pain.
DIAGNOSTIC TEST
Spine X-ray, which uses radiation to produce images of bones.
MRI, -which uses a magnet and radio waves to create pictures of bones, muscles, tendons and
other soft tissues.
CT scan, - which uses X-rays and a computer to create 3D images of bones and soft tissues.
Electromyography (EMG) to test nerves and muscles and check for neuropathy(nerve damage),
which can cause tingling or numbness in your legs. Depending on the cause of pain, health care
provider may also order blood tests or urine tests. Blood tests can detect genetic markers for
some conditions that cause back pain (such as ankylosing spondylitis). Urine tests check for
kidney stones, which cause pain in the flank (the sides of the low back).
SURGICAL MANAGEMENT
Some injuries and conditions need surgical repair. There are several types of surgery for low back
pain, including:
Lumbar spine surgery. Lumbar spine surgery is an invasive treatment that involves the physical
removal, repair, or readjustment of spinal structures to treat injuries, diseases, and/or deformities
affecting the spine between one or more of the lumbar vertebrae (L1-S1) spinal motion
segments.
Lumbar Laminectomy. Lumbar laminectomy is a procedure that involves removing bone to
relieve excess pressure on the spinal nerve(s) in the lower back or lumbar spine. Laminectomy
removes the roof of the vertebrae to allow space for nerves exiting the spine.
Spinal Fusion. The spinal fusion procedure involves placing bone grafts between adjacent spinal
vertebrae to join the two structures together. When appropriate, we may use minimally invasive
surgical techniques.
C. IMPLIMENTATION/INTERVENTION OF CARE OF CLIENTS
A. INDEPENDENT NURSING CARE
• Apply hot and cold compress.
• Pharmacologic pain management as ordered.
• Instruct the patient to report pain before it become severe.
• Educate the patient regarding the disease lower back pain.
• Assist the patient in positioning in the bed or in standing.
• Provide comfort measures like massage, and cool packs)
• Provide comfort and pillows in positioning in the bed.
• Provide gentle exercise.
• Assess the patients pain scale and perception.
PROGNOSIS
Most people with back strains and sprains recover and do not have long-term health issues. But
many people will have another episode within a year.
Some people have chronic back pain that doesn’t get better after several weeks. Older people
with degenerative conditions such as arthritis and osteoporosis may have symptoms that get
worse over time.
Surgery and other treatments are effective at helping people with a range of injuries and
conditions live pain-free.
REFERENCE :
National Institute of Arthritis and Musculoskeletal and Skin Diseases(2022). Back Pain
Symptoms.mayoclinic.org
National Library of Medicine(2012).The prognosis of acute and persistent low-back pain a meta-
analysis.ncbi.nlm.nih.com
Wayne(2024).Acute Pain Nursing Care Plan and Management.nurselabs.com
Hamilton(2023). Lumbar Spine Surgery.spine-health.com
Eisler.(2019).Surgical Treatment Options for Lower Back Pain Relief.ctbackcenter.com