Degenerative Disc Disease by Dr. BBT

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JIANGSU UNIVERSITY

JIANGBIN HOSPITAL

DEPARTMENT OF ORTHOPEDICS No. 2,

Subject: Degenerative Disc Disease

Supervisor: Dr. Huang Yonghui

Performed by: Dr. Bidhya Bhusan Tamrakar

MS student in Orthopedics First Year

2012 February 27



Degenerative diseaes of the spine

Introduction

Pain due to degenerative disease of the cervical and lumbar spine is very

common in the general population. A wide variety of terms is used

describing this, including lumbago, wear and tear, spondylosis and a

slipped disc. What is clear is that parts of the spine are subject to a series

of changes in both the intervertebral disc and the adjacent vertebrae. They

are associated with local pain and may be associated with the

compression of the spinal cord or nerve root. It is also apparent that thesechanges occur with age. MRI scanning has provided excellent evidence

of this disc degeneration, with loss of water content, these changing often

without associated pain. Thinning of the annulus and the appearance of

radial slits allow the nucleus to bulge —and may eventually rupture

through causing disc prolapse. Progressive collapse of the disc space may

allow additional movement, putting extra strain on the apophyseal joints,

in which secondary degenerative changes occur with associated

ligamentous hypertrophy. Osteophyte formation, due to calcification of

the bulging peripheral fibres of the annulus, leads to further narrowing of the spinal, or root exit, canal.

Neurological involvement can therefore occur due to cord, cauda

equina or toot compression by soft disc, ligamentous hypertrophy or

osteophyte formation.

Cervical degenerative disease

Two patterns emerge.

1. Cervical radiculopathy. Neck and radicular pain in the arm with,



on examination, signs of a lower motor neuron lesion usually affecting

C6 or C7. Functional changes and pins and needles may be apparent, the

arm pain being the predominant symptom.

2. Cervical myelopathy. Pain and stiffness in the neck with a grittyfeeling in the tips of the fingers. Patients will complain of stiffness and a

loss of dexterity, with unsteadiness of gait.

The symptoms are usually slowly progressive with, on examination, signs

of an upper motor neuron lesion with a glove and stocking distribution

sensory loss. The neck pain may not be a major feature. Examination will

usually reveal a restricted range of cervical spine movement.

Commonly seen in the midcervical region, signs of radiculopathy at the

affected level may be superimposed. Presence of the deltoid jerk suggestscompression above the C4/5 level.

Investigation

Following a careful history and examination to define the pattern of

neurological compromise and the clinically affected level, plain X-rays in

flexion and extension with an MRI represent the investigations of choice.

Cervical myelography is rarely performed, but CT myelography may be

helpful if MRI is not available.

Plain X-rays provide details of the bony architecture and evidence of

osteophyte formation. Instability can be seen and measured. MRI in

sagittal and axial views allows detailed study of the spinal cord —

including changes within the cord itself — together with views of the

exiting nerve roots and root canals. MRI does not provide ‘dynamic’

information about the cervical spine and should be used in conjunction

with plain X-rays in flexion and extension.

Differential diagnosis

For cervical radiculopathy the diagnosis is usually apparent. The

differential includes cervical rib, producing a T1 syndrome, ulnar or

median nerve entrapment syndromes, metastatic disease in the cervical

spine, or even direct brachial plexus involvement via an apical lung

tumour (Pancoast syndrome).

For patients with a myelopathy, clearly other causes of spinal cord

compromise rarely occur, but should be considered. These include anintraspinal tumor, infection or instability associated with conditions such



as rheumatoid arthritis. Beware the tumor at the level of the foramen

magnum leading to wasting of the small hand muscles.

Management

Radiculopathy. In over 75 per cent of patients the symptoms will resolve

with conservative measures, including rest, analgesia, the use of a

cervical collar and physiotherapy by an experienced therapist. Physical

therapies are becoming increasingly specialized and appropriately timed

treatments will usually produce good results.

Care should be taken with cervical collars. A short-term support can

become a long-term crutch. Their length of use should be avoided.

Surgery is indicated according to the duration and severity of the pain, physical signs, the radiological appearances and most importantly the

patient’s wishes. A good history with physical signs and corresponding

radiological changes, and providing a good decompression is achieved,

will produce good results.

To effect decompression of the nerve root, either an anterior cervical

discectomy approach can be used, or posterior foraminotomy. For soft

disc prolapse causing nerve root compression, an anterior approach is

most frequently used.

Myelopathy. There is much debate about how and when to proceed to

surgery. The aim of the operation is to prevent further deterioration. If

there is improvement, then this is to some extent a bonus and it is

important that the patient and their family are advised of this. Despite

decompression, in 30 per cent of patients there will be further

deterioration, probably due to vascular changes within the cord itself.

Surgical decompression is, therefore, appropriate for those who are

deteriorating, whose symptoms interfere with normal activity; and areaccepting of the risks of the procedure.

The aim is to decompress the spinal cord and maintain or establish

stability. This can be done by an anterior or a posterior approach to the

spine. Anterior approach requires removal of soft disc, osteophytes and

hypertrophied ligaments, often over multiple levels. Fusion, intervertebral

grafts or onlay plates can then be achieved.

A posterior cervical laminectomy provides easy access to decompressthe spine over multiple levels and great care must be taken to avoid spinal



cord injury. The decision between anterior and posterior approaches

depends again on the pathology, the presence of instability and the

experience of the surgeon.

The advantages and disadvantages of the two approaches are consideredin.

Inflammatory disorders involving the cervical spine

Rheumatoid arthritis

This commonly affects the spine and particularly the cervical spine.

Patients often present with stiffness and pain in the neck, and some

patients present with neurological symptoms due to compressive

myelopathy in the neck. Diseases in the joints in turn lead to soft-tissuedestruction and then instability.

The three common abnormalities are:

• atlantoaxial subluxation;

• proximal migration of the odontoid with basilar impression;

• lower cervical spine subluxations.

Investigation with flexion and extension radiographs of the neck and

MRI scan allow assessment of stability and cord compression. A certain

number of patients may require decompression of the spinal cord and

appropriate stabilisation. Anterior decompression (transoral), fusion and

instrumentation may be appropriate with localised disease. This may be

necessary in either the lower or the upper cervical spine.

Ankylosing spondylitis

This is relatively uncommon, but can present with painful stiffness of the

spine. It is more common in males, most of whom will be human

leucocyte antigen (HLA) B27 positive. Other inflammatory markers will

be raised. In general physiotherapy combined with anti-inflammatory

drugs will control symptoms adequately. However, severe deformities

will occasionally be seen and these may require major surgery to the

spine to effect correction. Occasionally patients with ankylosing

spondylitis will present after minor trauma with unstable fractures. These

patients should be assumed to have an unstable injury until this has been

excluded. Surgical stabilisation leads to satisfactory results in most cases.



Thoracic spinal degenerative disease

This is rare. Thoracic disc is the commonest form of degenerative

thoracic disease that requires surgery.

Presentation

More common in males (5:3 ratio) and usually in the lower thoracic

spine, the patients may present with a history of injury but this usually

occurs spontaneously.

Pain may not be a major feature. The symptoms will progress very

rapidly over a few days, or may occur insidiously over years. The

presenting features are those of progressive spinal cord compression with,

initially, often dissociating signs, but if undiagnosed will finally progressto a paraplegia with a sensory level, to loss of sphincter function.

Investigation

Plain X-ray may reveal calcification in the disc at the affected level, with

calcification of the protruding disc visible.

CT scan. As part of a CT myelogram, this will confirm the epidural

compression at the level of the disc prolapse.

MRI scan remains the investigation of choice. Be aware of the level of

the disease and whether it is lateral or central.

Management

Removal of a thoracic disc represents a very different operation to that of

cervical or lumbar disc. The prolapse can be hard and calcified or

occasionally soft and liquid, appearing like pus. The dura may even be

eroded.

A standard laminectomy is dangerous and a lateral or anterior

transthoracic approach is required to excise these lesions.

If truly central, a transthoracic route, with drilling out of the vertebral

body above and below the level of the disc prolapse, will allow piecemeal

removal of the disc and decompression of the spine.

For the laterally placed discs a costotransversectomy with division of

the paravertebral muscles and excision of the rib head provides goodaccess, again drilling away the vertebral bodies above and below the disc



to allow its removal. Check the levels very carefully by preoperative

and/or peroperative imaging and warn the patient, especially about the

risks of paralysis due to surgery.

Lumbar spine

Degenerative disease of the lumbar spine is almost universal with

increasing age. The disc ages owing to deterioration of the proteoglycan

within the disc, which becomes dehydrated as a result. Therefore the disc

becomes narrower and this in turn narrows the nerve root canals where

the lumbar nerve roots exit from the spinal canal. Secondary changes also

occur in the facet joints with loss of joint space, sclerosis and osteophyte

formation.

Between 70 and 90 per cent of individuals will experience back pain atsome point in their lives. The commonest site of pain in the spine is the

intervertebral disc. Although the central part of the disc has no nerve

supply, the annulus is very sensitive and is often a source of pain.

Degeneration tears often occur in the annulus and these can be a source of

pain.

Neurological symptoms can also occur as a result of degenerative

disease in the spine. Tears of the annulus can allow part of the nucleus

pulposus to herniate through the annulus. The weakest part of the annulusis the postero-lateral corner, and as a result the nerve root is often

compressed in the can also occur and this can result in compression of the

cauda equina which lies in the midline throughout most of the lumbar

spine. This can cause cauda equina compression with loss of bowel and

bladder function. If this occurs, urgent surgical decompression is

indicated.

Another effect of degeneration is that spinal stenosis can occur due to a

combination of narrowing of the disc, osteophyte formation from the

joints and thickening of the ligamentum flavum. The stenosis can either

be central, lateral around the exiting nerve roots or a combination of the

two. Most patients with spinal stenosis are elderly but some patients

present young, and the majority of these has developmental spinal

stenosis where the spinal canal is narrow from birth.

Presenting symptoms

Back pain is usually felt in the lumbar area and may radiate to the

buttocks and the back of the thighs. If the pain is coming from the upper lumbar region, it may radiate to the front of the thigh. Pure back pain very



seldom radiates below the knees. Patients will often complain of spinal

stiffness and of difficulty in the activities of daily living such as picking

things up, shopping, sitting, walking, running and so on. Back pain can

occur in any age group, but beware of the child with back pain because it

is likely that there is some more serious underlying condition (see above).Other features of back pain which are worrying include night pain which

prevents sleep or unremitting pain which cannot be controlled with pain

relief. Spinal tumour or spinal infection must be excluded in these

patients.

Disc prolapse

Disc prolapse occurs most commonly in middle age although it can occur

in adolescence and in the elderly. The typical history is of an episode of

back pain either related to lifting and/or twisting or which occursspontaneously. Eighty per cent of disc prolapses occur in the lumbar

spine, the majority at L5/S1 and at L4/L5. The back pain commonly lasts

for 2—6 weeks and may continue for longer. The back pain will often

improve then but is followed almost immediately by sciatica or nerve root

pain. The pain will usually follow one or more dermatomes, and is often

associated with neurological symptoms, altered sensation and weakness

in the muscles innervated by the compressed nerve roots. Serious

neurological symptoms may he an indication for urgent surgery to

decompress the nerve roots, but in general a period of waiting is best because 90 per cent of patients will have relief of their pain within 6

weeks. Minor degrees of weakness and numbness will usually improve

with time and may resolve completely. Motor weakness is more likely to

recover than sensory change.

Spinal stenosis

Spinal stenosis presents typically in the elderly patient and tends to

develop gradually. The patient may develop back pain, especiallystanding and walking, which is associated with neurological symptoms in

the legs. Patients report pain, weakness and numbness in the legs on

standing or walking, and their walking distance is usually limited. They

may complain that their legs go rubbery or tend to give way. Their

symptoms usually resolve with rest, especially sitting down for 5—10

minutes, and then they can continue. They often report fewer symptoms

going up hill or walking using a rollator or a shopping trolley. The reason

for this is that the spinal canal is made wider with spinal fiexion. This

helps to differentiate these patients from those with vascular claudication

who find it worse uphill. Usually the symptoms of vascular claudication



will be relieved more rapidly.

Treatment

The majority of patients with back pain can be treated with physical

treatments such as physiotherapy, chiropractic, or the various other

treatments available. Explaining to the patient that they have a

nonprogressive condition which is very common will help them to cope

with the symptoms. Medications such as analgaesics and anti-

inflammatories can also be used. Adjustments to work situations (e.g.

seating) and to day-to-day life (e.g. less driving, more physical activity,

weight loss) are often much more effective that other measures. A small

proportion of patients will develop more severe symptoms which require

more intensive physical treatments such as rehabilitation. Surgery to fuse

or stabilise the spine is a last resort, and should only be used in selected patients where less invasive methods have been used. Combined anterior

—posterior surgery probably has the best results in these patients.

Disc prolapse

Disc prolapse usually resolves within 6 weeks, and simple pain relief may

be all that is required in these patients. Longitudinal studies have

demonstrated that most of these disc prolapses will resolve with time.

Patients with evidence of cauda equina compression must be managed

as an emergency.

Symptoms suggestive of this are:

• very restricted straight leg raising bilaterally;

• numbness in the perineum;

• inability to void or difficulty voiding urine;

• inability to have or difficulty in having bowels open;

• lax anal sphincter;

• severe pain.

Not all of these signs are necessarily present in each patient. Emergency

MRI scanning or, if not available, CT scan or myelogram will confirm the

diagnosis, and treatment is surgical decompression and partialdiscectomy.



In the patient with simple sciatica various options are available.

• Epidural steroid injection — about 30 per cent success rate, low

complication rate, day-case procedure.

• Chemonucleolysis (injection of chymopapain into the disc itself) —

about 70 per cent success rate, day case or overnight stay. Often causes

back pain in the early stages. May take some weeks to be effective.

Low complication rate, occasional anaphylactic reaction to the

chymopapain.

• Laser discectomy (laser coagulation of the disc) — success rate 50—70

per cent, less back pain than chemonucleolysis, day-case procedure,

low complication rate.

• Microdiscectomy — success rate 80—90 per cent. Three per cent long-

term complication rate (e.g. nerve damage, infection, long-term back

pain). Requires hospital admission for a few days. Longer

convalescence.

• Standard discectomy — as for microdiscectomy, but longer scar, longer

in hospital, longer recovery.

There is no reason in most cases why closed techniques cannot beused initially and then open surgery used if other methods fail. In older

individuals associated spinal stenosis is common and open techniques

are more likely to be effective.

Many patients with spinal stenosis are elderly, and nonsurgical methods

of treatment may be better for some. Various treatments have been used

with fairly low success rates such as lumbar corset, epidural injection of

steroids and traction. Physiotherapy with flexion exercises can be helpful

in a minority of patients. Calcitonin has been used with some success for

treating spinal stenosis, particularly in the elderly who may not be fit for surgery. One-hundred international units of calcitonin are given by

intramuscular (i.m.) injection 4 days a week for 4 weeks. Success rates of

20—3 0 per cent have been reported, but to date there has not been a

randomised trial to assess the treatment.

Surgery is effective in about 70 per cent of patients with spinal stenosis.

Decompression of symptomatic nerve roots and central stenosis can give

very effective relief.

Spondylolisthesis



Spondylolisthesis is a common condition and is usually caused either by

spondylolysis or by degenerative change. Spondylolysis is a defect in the

bone in the pars interarticularis, and causes a slip between one vertebra

and another in some cases. It is present in about 6 per cent of the normal

population, is usually asymptomatic and is a common incidental finding.In young individuals presenting with back pain nonoperative measures

such as physiotherapy are usually successful in resolving pain, and

occasionally a plaster jacket can resolve symptoms. Indications for

surgery include non-resolving and serious pain or progressive slip

between the two vertebrae. If the spondylolysis is undisplaced and the

intervertebral disc at that level is normal, direct repair by bone grafting

and internal fixation can be carried out. Otherwise fusion of the motion

segment is required. In children internal fixation is seldom required but in

adults most surgeons use fixation with inter-pedicular screws.

Degenerative spondylolithesis is common in the elderly and occurs

owing to degeneration of the disc and the associated facet joints. It can be

associated with spinal stenosis, and if decompressive surgery is

contemplated, it is usually best to carry out an un-instrumented fusion to

prevent progression of the slip.

Degenerative Disc Disease by Dr. BBT

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