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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

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degenerative spine diseases

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

slide2

Contents

  • Anatomy of the Intervertebral Disc
  • Overview of Spine Degeneration
  • Lumbar Disc Herniation
  • Cervical Spondylosis
  • Lumbar Spinal Stenosis
slide3

Anatomy of the intervertebral disc

The Intervertebral Disc

Two major components

  • Annulus fibrosis: thick, fibrous “radial tire” called lamellae
  • Nucleus pulposus: ball-like gel
the disc1
The disc
  • The disc is the largest avascular organ in the human body!
  • Take about 80% loads in the spine!
spine degeneration
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.
slide7

Degenerative 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
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
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;
slide10

Degenerative changes of the vertebral 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 facet joint
Degenerative changes of the facet joint

Degenerative Changes

  • Cartilage lining loses water content
  • Cartilage wears away
  • Facets override each other
  • Leads to abnormal function of motion segment
slide12

Degenerative changes of the ligaments

  • Degenerative Changes
    • Partial ruptures, necrosis and calcifications
    • Negatively impact function of motion segment
slide13

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
slide14

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);
slide15

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
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
Radiculopathy – clinical

Pain is the most prominent, along dermatome of affected root;

slide18

Lumbar disc herniation

  • With disruption of the anulus, the soft nucleus was pushed through (herniated) the annulus.
  • Herniation occurs through a tear in the anulusfibrosus.
  • Most common at L4/5 and L5/S1 levels, and then L3/4 level;
  • Herniated disc at upper L spine is rare.
slide19

Pathoanatomy

  • Paracentral herniation is most common;
  • Paracentral herniation tends to affect nerve root of one level lower!

L3/4 DH: affects L4 root;

L4/5 DH: affects L5 root;

L5/S1 DH: affects S1 root;

slide20

LDH and Sciatica

  • The most classic symptom of a herniated disc is radicular pain in the lower extremity following a dermatomal distribution: sciatica.
      • Mechanical compression;
      • Neuroischemia-->inflammation;
      • Neurochemical factors: immune response
  • Focal neurologic deficits;
slide21

LDH and back pain

  • Most patients with symptomatic disc herniations present with leg and back pain.
      • The disc is almost aneural, so where is the pain from?
      • Mechanical alternation? Innervation of a long degenerated disc? Biochemical irritation?
slide22

Classification of LDH

Extruded

Sequestered

Protrusions

slide23

History and symptoms

  • 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;
patterns of radiculopathy
Patterns 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
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
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;
slide27

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;
slide29

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.
slide30

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);
slide31

Imaging

  • X-ray: show spinal degenerative changes but not a herniated disc; rule out obvious underlying problems;
  • CT: relatively less used;
  • MRI: The best;
slide34

Differential diagnosis

  • The differential diagnosis should be narrowed based on history, physical examination, and selected imaging tests.
  • idiopathic low back pain; sprain or strain;
  • spinal stenosis;
  • Abscess; tuberculosis;
  • Tumor;
  • Intrinsic nerve problems;
slide35

Nonoperative Treatment

  • Physiotherapy: Bed rest should be limited to no more than 2 to 3 days; restore strength, flexibility, and function;
  • Pharmacologic Treatment: Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line agents; muscle relaxants;
  • Selective transforaminal steroid injections;
slide36

Natural History

  • 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.
slide37

Operative Treatment

  • Indications
        • progressive neurologic deficit;
        • cauda equina syndrome;
        • failure of appropriate nonoperative treatment;
discectomy
Discectomy

Release ligamentum

Inspect neural foramen

Remove disc tissues

Resect lamina

slide39

Cervical spondylosis

  • 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
slide40

Cervical disc herniation

  • Patients usually present with one or more of:
    • Axial neck pain
    • Radicular arm pain
    • Myelopathy
    • Neurapraxia of upper extremities
  • Non-specific symptoms: dizzying, nausea, head ache, upper back pain;
treatment of radiculopathy
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
Typical surgery: ACDF

Anterior cervical decompression and fusion (ACDF);

Anterior discectomy;

Bone graft or cage;

Instrumentation;

myelopathy 1
Myelopathy (1)

A group of symptoms resulting from spinal cord compression, including:

  • 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
slide44

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
slide45

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
Surgery

Laminaplasty

Laminectomy

slide49

Lumbar spine stenosis (LSS)

  • A narrowing of the spinal canal;
  • 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;
slide51

Classification

  • Central stenosis;
  • Lateral recess stenosis;
  • Foramen stenosis;
slide52

Clinical presentation

  • Most commonly present with leg pain: neurogenic claudication or radicular leg pain;
  • Low back pain, common;
  • Bowel and bladder incontinence, uncommon;
slide53

Neurogenic claudication

  • Spinal stenosis compressing central lumbar spine below level of spinal cord may cause neurogenic claudication;
  • Walking induced leg symptoms of heaviness, numbness, pain, cramping, burning or weakness;
  • Leaning forward posture while walking; (why?)
  • Relieved by sitting;
  • Differential diagnosis
    • Peripheral neuropathy
      • Stocking pattern, diabetes
    • vascular claudication
      • Look for nail changes, hair loss, pulses on feet
  • Typically occurs in older age groups (>65yrs)
treatment
Treatment
  • Rarely progresses to severe deficits, is more of a pain syndrome
  • initial treatment is conservative
  • Weight loss, smoking cessation, physiotherapy
  • Decompressive surgery considered:
    • if trial of 3 months conservative therapy fails, AND disability is bad enough that patient wishes to consider surgery, AND patient factors (medical comorbidities) are such that surgery can be performed