degenerative spine diseases
DESCRIPTION
A Class for Foreign MD Students. Degenerative Spine Diseases. 王 跃 MD, PhD. Dr. Yue Wang. Department of Orthopedic Surgery The First Affiliated Hospital, college of Medicine, ZheJiang University. 浙江大学医学院附属第一医院骨科. Contents. Anatomy of the Intervertebral Disc - PowerPoint PPT PresentationTRANSCRIPT
Degenerative Spine DiseasesDegenerative Spine Diseases
Dr. Yue Wang Dr. Yue Wang
Department of Orthopedic SurgeryDepartment of Orthopedic Surgery
The First Affiliated Hospital, college of Medicine, ZheJiang UniversityThe First Affiliated Hospital, college of Medicine, ZheJiang University
A Class for Foreign MD StudentsA Class for Foreign MD StudentsA Class for Foreign MD StudentsA Class for Foreign MD Students
浙江大学医学院附属第一医院骨科
王 跃 王 跃 MD, PhDMD, PhD
Anatomy of the Intervertebral Disc Overview of Spine Degeneration Lumbar Disc Herniation Cervical Spondylosis Lumbar Spinal Stenosis
ContentsContents
Anatomy of the intervertebral discAnatomy of the intervertebral disc
The Intervertebral DiscTwo major components
Annulus fibrosis: thick, fibrous “radial tire” called lamellae
Nucleus pulposus: ball-like gel
The disc
The discThe disc
The disc is the largest The disc is the largest
avascular organ in the avascular organ in the
human body!human body!
Take about 80% loads Take about 80% loads
in the spine!in the spine!
Spine Degeneration A process involving structural changes of
affected joints and intervertebral disc, with thickening of joint capsule, ligaments, appositional bone formation in response to long term mechanical forces.
Epidemiology Very common: By age 50, 95% of people show
radiographic evidence of lumbar disc degeneration. Yet, only a small portion of them have symptoms.
Degenerative changes of the discDegenerative changes of the disc
Pathological changes Water and proteoglycan content decreases
Collagen fibers of AF become distorted
Tears may occur in the lamellae
Results in: Decreased disc height and volume
Decreased resistance to loads
Risk factors
Increasing age; Heredity plays an important role;
Twin studies revealing similar incidence despite different occupations, socioeconomic status
Smoking; Occupation/leisure activity likely does not play a
major role; Body habitus;
Pathophysiology
Decreased water content in nucleus
pulposus Causes loss of disc height, causing facet joints to
override each other;
Facet joints respond with hypertrophy and
osteophyte formation;
Can lead to compression of neurological
structures, and/or to abnormal movement which
worsens the cycle;
Degenerative changes of the Degenerative changes of the vertebral bodyvertebral body
Sclerosis: Increased bone formation at the endplates Reduced nutrition supply Reduced ability to absorb
loads Osteophytes: Formation of
small bony spurs
Degenerative changes of the Degenerative changes of the facet jointfacet joint
Degenerative Changes Cartilage lining loses
water content Cartilage wears away Facets override each
other Leads to abnormal
function of motion segment
Degenerative changes of the Degenerative changes of the ligamentsligaments
Degenerative Changes Partial ruptures, necrosis
and calcifications
Negatively impact function
of motion segment
Clinical implications
Axial pain – neck or back Due to inflammation surrounding diseased
structures or to instability of the spine
Neurologic compression Compresses laterally to nerve root
Radiculopathy Compresses centrally in canal
In cervical spine: myelopathy In lumbar spine: neurogenic claudication or cauda
equina syndrome
Back pain
80% adults will have episode back pain;
Most improve over time, therefore initial rest
period (short) followed by early mobilization, PT,
NSAIDS, lifestyle modification is the treatment;
90% are not associated with specific discernable
cause! (Idiopathic back pain);
Back pain
Red flags (fevers, night sweats, neurological
symptoms, weight loss, cancer), severe pain
not improving warrant further imaging.
Guidelines published on when to image, types
of conservative treatment
Xray, MRI
Radiculopathy
Arm pain; leg pain, sciatica;
Due to compression lateral to the spinal cord in
cervical spine, distal or lateral to nerver root/cauda
equina in lumbar spine;
Thoracic radiculopathy rare
Most common is C5/6, then C6/7;
In L spine most common is L5/S1 then L4/5;
Radiculopathy – clinical
Pain is the most
prominent, along
dermatome of
affected root;
Lumbar disc herniationLumbar disc herniation
With disruption of the anulus, the soft nucleus With disruption of the anulus, the soft nucleus
was pushed through (herniated) the annulus.was pushed through (herniated) the annulus.
Herniation occurs through a tear in the anulus Herniation occurs through a tear in the anulus
fibrosus. fibrosus.
Most common at L4/5 and L5/S1 levels, and Most common at L4/5 and L5/S1 levels, and
then L3/4 level;then L3/4 level;
Herniated disc at upper L spine is rare.Herniated disc at upper L spine is rare.
PathoanatomyPathoanatomy Paracentral herniation is most common;Paracentral herniation is most common;
L3/4 DH: affects L4 root;
L4/5 DH: affects L5 root;
L5/S1 DH: affects S1
root;
Paracentral herniation tends to affect Paracentral herniation tends to affect nerve root of one level lower!nerve root of one level lower!
LDH and SciaticaLDH and Sciatica The most classic symptom of a herniated The most classic symptom of a herniated
disc is radicular pain in the lower disc is radicular pain in the lower
extremity following a dermatomal extremity following a dermatomal
distribution: sciatica. distribution: sciatica.
Mechanical compression;Mechanical compression;
Neuroischemia-->inflammation;Neuroischemia-->inflammation;
Neurochemical factors: immune Neurochemical factors: immune
response response
Focal neurologic deficits; Focal neurologic deficits;
LDH and back painLDH and back pain
Most patients with symptomatic disc Most patients with symptomatic disc
herniations present with leg and back herniations present with leg and back
pain. pain.
The disc is almost aneural, so where The disc is almost aneural, so where
is the pain from? is the pain from?
Mechanical alternation? Innervation Mechanical alternation? Innervation
of a long degenerated disc? of a long degenerated disc?
Biochemical irritation?Biochemical irritation?
Classification of LDHClassification of LDH
ProtrusionsProtrusions
ExtrudedExtruded
SequesteredSequestered
long-standing mild to moderate back pain;
May have a specific incident attributable to the
onset of leg and back pain;
Axial back pain is typically present;
Buttock pain: can be referred or radicular in nature
Radicular pain is more typical and often the more
“treatable” of the complaints;
History and symptomsHistory and symptoms
Patterns of radiculopathyPatterns of radiculopathy
S1 radicular pain may radiate to the
back of the calf or the lateral aspect
or sole of the foot;
L5 radicular pain can lead to
symptoms on the dorsum of the
foot;
L4 radiculopathy: above or below
the knee;
L2 and L3 radiculopathy can
produce anterior or medial thigh
and groin pain
Physical Examinations
Inspection:
Abnormal gait: limping, slapping; footdrop;
Alignment of the spine Extension: loss of
lumbar lordosis, scoliosis;
Palpation and Percussion:
Tenderness at multiple levels;
Local percussion;
Paraspinal muscle spasm;
Neurologic Examination (1)
Sensation: (normal, diminished, or absent )
L4 sensory function is tested at the medial ankle;
L5 at the first webspace between the great and
second toes;
S1 at the lateral aspect of the sole of the foot;
Neurologic Examination (2)
Motor examination
L4 involvement most often affects ankle
dorsiflexion (anterior tibialis);
L5 is tested by toe dorsiflexion, particularly the
great toe (extensor hallucis longus), and hip
abduction.
S1 motor function is assessed by testing plantar
flexion;
Manual muscle test (MMT)
Neurologic Examination (3)
Deep tendon reflexes
The patellar tendon reflex may be diminished
or absent with L3 or L4 involvement;
The Achilles tendon reflex is affected primarily
by S1;
There is no specific reflex that reliably reflects
L5 function.
Specific tests
Straight leg raising test
(SLT): reproduce sciatica
at 35-70 degrees; (for L4,
L5 & S1 radiculopathy);
Lasègue maneuver;
The femoral stretch test:
reproduce anterior thigh
pain (for upper root
pathology);
• X-ray: show spinal degenerative changes
but not a herniated disc; rule out obvious
underlying problems;
• CT: relatively less used;
• MRI: The best;
ImagingImaging
MRIMRI
Axial imagesAxial images
Differential diagnosisDifferential diagnosis
The differential diagnosis should be narrowed The differential diagnosis should be narrowed based on history, physical examination, and based on history, physical examination, and selected imaging tests.selected imaging tests.
idiopathic low back pain; sprain or strain; idiopathic low back pain; sprain or strain;
spinal stenosis;spinal stenosis;
Abscess; tuberculosis; Abscess; tuberculosis;
Tumor;Tumor;
Intrinsic nerve problems; Intrinsic nerve problems;
Nonoperative TreatmentNonoperative Treatment
Physiotherapy: Bed rest should be limited to Physiotherapy: Bed rest should be limited to no more than 2 to 3 days; restore strength, no more than 2 to 3 days; restore strength, flexibility, and function;flexibility, and function;
Pharmacologic Treatment: Nonsteroidal anti-Pharmacologic Treatment: Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line inflammatory drugs (NSAIDs) are first-line agents; muscle relaxants; agents; muscle relaxants;
Selective transforaminal steroid injections;Selective transforaminal steroid injections;
• A benign disease: Saal and Saal a 90% good or excellent outcome in patients treated nonoperatively;
• Another study: at 1 year, 33% had good results, 49% had a fair result, and 18% had a poor result. At 4 years, good results were reported in 51%, fair results were reported in 39%, and poor or bad results were reported in 10%.
• 10-year follow-up results: 61% improvement in the predominant symptom, 40% resolution of low back symptoms, and 56% satisfaction rate.
Natural HistoryNatural History
Operative TreatmentOperative Treatment
Indications
progressive neurologic deficit;
cauda equina syndrome;
failure of appropriate nonoperative
treatment;
DiscectomyDiscectomy
Release ligamentum
Release ligamentum
Resect laminaResect lamina
Remove disc tissues
Remove disc tissues
Inspect neural foramen
Inspect neural foramen
Cervical discs similar to lumbar discs, but: Nucleus pulpous smaller Discs better supported on lateral margins
Most cervical disc herniations occur in postero-lateral margins
Cervical spondylosisCervical spondylosis
Patients usually present with one or more of: Axial neck pain
Radicular arm pain
Myelopathy
Neurapraxia of upper extremities
Cervical disc herniationCervical disc herniation
Non-specific symptoms: dizzying, nausea, head
ache, upper back pain;
Treatment of radiculopathy
Nonoperative Treatment Cervical radiculopathy often resolves without surgery Conservative methods include PT and anti-
inflammatory medicines
Indications for surgery Continued pain or progressive neurological deficit
indicate need for surgery Anterior and posterior approaches may be used Fusion with or without instrumentation may be done
Typical surgery: ACDF
Anterior cervical decompression and fusion (ACDF);
Anterior discectomy; Bone graft or cage; Instrumentation;
Myelopathy (1)Myelopathy (1)
Hand dysfunction Distal often more affected
Difficulty with buttons, handwriting Otherwise, extensor pattern ‘pyramidal pattern’
Triceps, wrist extension Leg dysfunction
Balance difficulty Staggering gait Tandem gait difficulty very early finding
A group of symptoms resulting from spinal cord A group of symptoms resulting from spinal cord compression, including:compression, including: A group of symptoms resulting from spinal cord A group of symptoms resulting from spinal cord compression, including:compression, including:
Myelopathy (2)Myelopathy (2)
Sensory disturbance
Often bilateral hand difficulty, sensory level as
disease is more severeait
Upper motor neuron signs
Babinski response, hyperreflexia, Hoffman’s
sign, increased tone, stiff gait
Degenerative myelopathy – natural history
Typically that of worsening;
Stepwise in 50%, progressive in 50%;
Therefore, patients with myelopathy are usually
treated surgically;
Surgery typically performed in expedited fashion; Relative to rate of deterioration
Lost neurological function is often not regained – the
reason to perform early surgery
Surgery
LaminectomyLaminectomy LaminaplastyLaminaplasty
Cervical spondylosisCervical spondylosis
After decompressionAfter decompression
A narrowing of the spinal canal;
Lumbar spine stenosis (LSS)Lumbar spine stenosis (LSS)
one of the most common conditions in the elderly;
Can occur in asymptomatic individuals: Radiographic stenosis is common;
in adults older than 65, LSS is the most common reason to undergo lumbar spine surgery;
Three shapes of the Three shapes of the spinal canalspinal canal
The narrowed canal
ClassificationClassification
Central stenosis;
Lateral recess stenosis;
Foramen stenosis;
Clinical presentationClinical presentation
Most commonly present with leg pain:
neurogenic claudication or radicular leg
pain; Low back pain, common;
Bowel and bladder incontinence, uncommon;
Neurogenic claudicationNeurogenic claudication Spinal stenosis compressing central lumbar spine below Spinal stenosis compressing central lumbar spine below
level of spinal cord may cause neurogenic claudication;level of spinal cord may cause neurogenic claudication; Walking induced leg symptoms of heaviness, numbness, Walking induced leg symptoms of heaviness, numbness,
pain, cramping, burning or weakness;pain, cramping, burning or weakness; Leaning forward posture while walking; (why?)Leaning forward posture while walking; (why?) Relieved by sitting;Relieved by sitting; Differential diagnosisDifferential diagnosis
Peripheral neuropathyPeripheral neuropathy Stocking pattern, diabetes Stocking pattern, diabetes
vascular claudicationvascular claudication Look for nail changes, hair loss, pulses on feetLook for nail changes, hair loss, pulses on feet
Typically occurs in older age groups (>65yrs)Typically occurs in older age groups (>65yrs)
Imaging: X-rayImaging: X-ray
Imaging: MRIImaging: MRI
TreatmentTreatment
Rarely progresses to severe deficits, is more of Rarely progresses to severe deficits, is more of a pain syndromea pain syndrome
initial treatment is conservativeinitial treatment is conservative Weight loss, smoking cessation, physiotherapyWeight loss, smoking cessation, physiotherapy Decompressive surgery considered:Decompressive surgery considered:
if trial of 3 months conservative therapy fails, AND if trial of 3 months conservative therapy fails, AND disability is bad enough that patient wishes to disability is bad enough that patient wishes to consider surgery, AND patient factors (medical consider surgery, AND patient factors (medical comorbidities) are such that surgery can be comorbidities) are such that surgery can be performedperformed
Operative treatment: Operative treatment: laminectomylaminectomy
The Rock Mountain, 2012