Degenerative spine disease by Dr. Shikher Shrestha, FCPS, NEUROSURGERY, NINAS, Nepal
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Transcript of Degenerative spine disease by Dr. Shikher Shrestha, FCPS, NEUROSURGERY, NINAS, Nepal
Degenerative Spine Disease
Shikher ShresthaNINAS
Problem Statement
2002 survey
26% americans – low back pain and 14% - neck pain
890 million office visits due to back pain
2005 -
JAMA - $86 billion health expenditures in spine related problems
Anatomy and Physiology of Spine Degeneration
Kirkaldy- Willis three-joint complex Theory
spine – at each level composed of three joints complex that are affected in degenerative process
This comprise of intervertebral disc and two zygapophyseal joints (dorsal articulating joints)
Degeneration of any one joint leads to degeneration of the other two, initiating a casacade that leads to spinal degenerative disease
Pathology.. Disc Degeneration..
Components of disc
nucleus pulposussemigelatinous structure situated near the
centerremnant of notochord; composed of
mucopolysaccharide + salt + water
annulus fibrosismultilayered circular structures that
surrounds the pulposuscomposed of fibrocartilaginous lamellae;
stiffer than nucleus
cartilagenous end plates
Mechanism of disc degeneration
Part of natural aging process
Repetitive loading results in forces that foster degeneration
Aging dessication collagen and proteoglycans are replaced with fibrous tissue
Continued Axial pressure
less compliant annulus develops circumferential tears most frequently in dorsolateral aspect
tears enlarge and develop into radial tears
herniation of nucleus pulposus
Relative dorsal location of nucleus pulposus and presence of posterior longitudinal ligament lead to classical dorsolateral disc herniation
Circumferential bulge of annulus due to annular tear loss of disc height and osteophyte formation at the attachment of the annulus to vertebral body narrowing of central canal and neural foramen
Dorsal joint degeneration
Articulating facets from superior and inferior vertebral segments
Joints – composed of cartilage, synovial membrane and capsule
Aging synovial reaction, fibrillation of articular cartilage, osteophyte formation laxity of joint capsule
Leads to subluxation of joint
Osteophyte spinal canal and lateral recess stenosis
Combine Three-joint complex Degeneration
Individual aging process of disc and dorsal facet joints are interlaced to contribute to the clinical manifestation of spondylosis
Disc degeneration loss of disc height subluxation of dorsal joints
This compounds to natural process of facet joint degeneration
Subluxation of rostral vertebral body ventrally with respect to the caudal vertebral body (spondylolisthesis)
This results in further narrowing of neural foramina lateral nerve root entrapment
Three stages of Degenerative Spine Disease
Dysfunction stage
Destabilization stage
Restabilization stage
Dysfunction stage..
Characterized by synovial reaction in dorsal joint and small tears in the intervertebral discs
Minor or absent clinical symptoms that are best treated conservatively
Destabilization Stage..
Kirkaldy-Willis defines this stage as
greater degeneration in the three-joint complex, manifesting as laxity and subluxation in the dorsal joints and progressive disc degeneration
Abnormal spinal motion
Natural mobility of the spine lost
Compounded by advanced disc degeneration and disc height reduction lead to spondylolisthesis
Rx – core strengthening and flexibility program to stabilize and normalize dysfunctional motion segment
Restabilization Stage
Instability is reduced via osteophyte formation secondary to a prior increased joint laxity and loss of disc interspace height
Resolution of symptoms can occur due to gradually decreased spinal motion
There may be radiculopathy from spinal nerve entrapment or claudication symptoms from central canal and lateral recess stenosis
CT Myelographyeffective alternative to MRI for assessing neural
elements, central or foraminal stenosis
MRIgold standard for evaluation spinal canal stenosissoft tissue surrounding spinal canal, discs,
ligamentum flavum and facet joints visualizedhypertrophy of PLL, ligamentum flavum and facet
hypertrophy can be localized specifically
Discographymore invasive diagnostic strategycan be done if clinical presentation does not match the
findings in other imaging modalityuseful to identify and characterize diseaseinvolves injecting contrast material into the disc in question
normal cervical disc tolerates 0.2-0.5 ml fluid whereas a degenerated disc can accept 0.5-1.5 ml fluid
if the pain produced following contrast injection is concordant with the typical pain experienced by the patient pathological
Treatment Options
Non operative management
natural course of spinal stenosis – 47% patients with neurogenic claudication and radiculopathy symptomatic improvement without intervention
Reason – progressive disc dehydration shrinking of disk decrease in root compression
Medical
symptomatic relief to reduction in inflammation
NSAIDsNarcotics to supplement masks
degenerative process until it progresses and improves spontaneously
muscle relaxants – shows some benefitSystemic oral steroids – anti inflammatory
effects may reduce nerve root irritation
Physical reconditioning via physical therapist – strengthen core musclesFlexibility exercise to help preserve normal motion
Epidural steroid injections – short term benefit
Facet joint injection (long acting anesthetic and steroids)33% patients reported >50% pain relief – result
consistent with placebo also; hence controversial
key to efficacy is proper selection of patients with facet syndrome
Facet syndrome defined as pain in the hips and buttocks area, cramping thigh pain, and back stiffness that is worse in the morning, without lower extremity paresthesia
Spinal Manipulative Therapy (SMT) by chiropractors, physical therapists and osteopathic physicians
3 main types of manipulations – therapeutic massage, mobilization and manipulative procedures
Hypothesis – neck or back pain is caused by either a limited range of motion or abnormal dorsal intervertebral joint motion
SMT “resets” the joint by extending the joint beyond the passive range of motion, into the “paraphysiologic range of motion”
Operative Treatment
May correlate with the extent of disease progression
Discectomy
ventral or dorsal approachCervical Spine:
ventral approach often utilized in cervical spine
Ventral – performed through a paramedian incisionrequires little muscle splitting low amount of postoperative
pain and morbiditycomplicationsdysphagia secondary to retraction of esophagus (1-79%
cases)damage to recurrent laryngeal n. vocal cord palsy improves with time
Dorsal approach in cervical spineeffective in eliminating unilateral n. root
compressionforaminotomies with or without discectomyrequires muscle splitting variable post
operative pain
simple foraminotomies and discectomies do not require fusion
minimally invasive techniques to reduce amount of muscle dissection shown to have up to 97% success rate alleviating radiculopathy symptoms
Lumbar spine
categorized as anterior and posterior approachposterior approach more often utilized
involves unilateral muscle dissection exposing the lamina hemilaminectomy removal of herniated disc
The Spine Patient Outcomes Research Trial (SPORT) – prospective, randomized trial evaluating lumbar discectomies against nonoperative treatment
conclusion – patients undergoing lumbar discectomies enjoyed reduction of pain, improvements in physical functioning, and a greater improvement in their disability index than conservative mgmt grp.
Laminectomy
Decompress spine via the removal of lamina and spinous process
Applied for multilevel reduction of spinal canal stenosis
Effective in cervical canal stenosis with spondolytic myelopathy and ossification of posterior longitudinal ligament
Development of postoperative kyphosis in 14-47% cases
This led to use of cervical laminectomy combined with fusion and laminoplasty decreased incidence of postoperative kyphosis
Laminectomy in lumbar spine involves removal of lamina and medial facetectomy to eliminate lateral recess stenosis
Laminoplasty
Detachment of lamina on only one side by creating a trough, and thinning the lamina on the contralateral side to allow for “hinging” at the attached lamina site
Detached lamina elevated and secured using small bone graft to maintain the decompressed state
Preservation of posterior element effectively decompress the spinal canal without the consequences of fusion such as loss of range of motion and adjacent segment degeneration
Laminoplasty – 27% improvement in preventing the incidence of postoperative kyphosis
Fusion
Debated topic
None of the study provides class I evidence to indicate clear benefit
Consideration to perform fusion is based on the need to create stability in an unstable region of the spine
A review of 13 class II and III studies comparing outcome of anterior cervical discectomies with or without fusion performed by Matz et. Al. Demonstrated no clinically significant advantage of including fusion
Although no class I or II evidence to support the use of cervical laminectomy with fusion, there is class III evidence that fusion reduces postoperative kyphosis
A great deal controversy regarding fusion in lumbar spine
Indicated typically in Kirkaldy-Willis second stage, where maximum destabilization is present
Lumbar fusion can be used to augment the transition of the second to third stage of restabilization.
Autograft bone is used either in the dorsolateral spaces or the interspaces to facilitate bony fusion while the construct immobilizes the spinal segment.
There are no clear data to support the presumption that fusion results in better outcomes compared to simple laminectomy alone.
Oswestry disability Index (ODI)
Modic change – vertebral body marrow change
Thank you!!!