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Degenerative disease of the spine

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The degenerative disc and spine disease.

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Degenerative disease of the spine

  1. 1. DEGENERATIVE SPINE DISEASES K mohamed rafi
  2. 2. TOPICS  ANATOMY  INVESTIGATION  BACK PAIN  CLINICAL FEATURES-WADDELL SIGN  SPINAL STENOSIS  DEGENERATIVE DISC DISEASE  SPONDYLOSIS/SPONDYOLISTHESI S  MANAGEMENT
  3. 3. ANATOMY  INVESTIGATION  BACK PAIN  CLINICAL FEATURES-WADDELL SIGN  SPINAL STENOSIS  DEGENERATIVE DISC DISEASE  SPONDYLOSIS/SPONDYOLISTHESIS  MANAGEMENT  POST OPERATIVE DISEASES
  4. 4. Anatomy Elsevier items and derived items © 2006 by Elsevier Inc.
  5. 5. Intervertebral Discs  Intervertebral Discs  23 narrow spongy shock absorbers which fit between the 24 separate bones of your spine  Each disc has a strong fibrous outer casing - called the annulus fibrosus - and a soft, squashy, jelly-like interior called the nucleus pulposus - which is reinforced with strands of fibre.
  6. 6. Intervertebral Discs  Intervertebral discs have very little in the way of nerve supply and contain no blood. They are made up largely of water.  As we get older the amount of fluid in your discs will diminish. Although any disc in the entire spine can prolapse or burst, the most common ones to which this happens are the lowest two, that is between the fourth and fifth lumbar vertebrae and between the fifth lumbar and the top of the
  7. 7. Nucleus Pulposus  Type II collagen strand hydrophilic proteoglycan  Water content70 ~ 90%  Confine fluid within the annulus  Convert load into tensile strain on the annular fibers and vertebral end-plate
  8. 8. Annulus Fibrosus  Outer boundary of the disc  More than 60 distinct, concentric layer of overlapping lamellae of type I collagen  Fibers are oriented 30-degree angle to the disc space  Helicoid pattern  Resist tensile, torsional, and radial stress  Attached to the cartilaginous and bony end-plate at the periphery of the vertebra
  9. 9. Vital Functions  Restricted intervertebral joint motion  Contribution to stability  Resistence to axial, rotational, and bending load  Preservation of anatomic relationship Biochemical Composition  Water : 65 ~ 90% wet wt.  Collagen : 15 ~ 65% dry wt.  Proteoglycan : 10 ~ 60% dry wt.  Other matrix protein : 15 ~ 45% dry wt.
  10. 10. Vertebral End-Plate  Cartilaginous and osseous component  Nutritional support for the nucleus  Passive diffusion
  11. 11. Spine Motion Segment  Three joint complex  Intervertebral disc + 2 facet joint  Ligamentous structure, vertebral body
  12. 12. Facet Joint  Synovial joint  Rich innervation with sensory nerve fiber  Same pathologic process as other large synovial joint  Load share 18% of the lumbar spine
  13. 13.  ANATOMY INVESTIGATIO N  BACK PAIN  CLINICAL FEATURES-WADDELL SIGN  SPINAL STENOSIS  DEGENERATIVE DISC DISEASE  SPONDYLOSIS/SPONDYOLISTHESI
  14. 14. IMAGING  PLAIN X RAY  MRI  CT  MYELOGRAM  DISCOGRAM  ELECTROMYOGRAM
  15. 15. Plain Films  Beneficial in determining basic structure, integrity, and alignment of spinal motion segments  Whether a spinal disorder is acute or chronic can frequently be determined on plain films ◦ adaptive changes (bony proliferation, endplate remodeling)  Congenital of developmental disorders can be identified  May be of particular benefit in patient under age 20 or over age 50  In most situations should be initial imaging study ordered  Routine films include antero-posterior, lateral, and oblique projections  Specialized views may be additionally ordered ◦ e.g. Coned down lateral view of lumbosacral junction to evaluate L5-S1 disc space
  16. 16. 16  MRI with Gadolinium contrast:  Gadolinium is contrast material allowing enhancement of intrathecal nerve roots  Utilization:  Assessment of post-operative spine---most frequent use  Identifying tumors / infection within / surrounding spinal cord  Diagnosis of radiculitis  Post-operatively can take 2-6 months for reduction of mass effect on posterior disc and anterior epidural soft tissues which can resemble pre-operative studies  Only indications in immediate post-operative period:  Hemorrhage  Disc infection
  17. 17. Electromyography  Radicular pain
  18. 18. 18  . Myelogram:  Procedure of injecting contrast material into the spinal canal with imaging via plain radiographs versus CT  In past, considered the gold standard for evaluation of the spinal canal and neurological compression  With potential complications, as well as advent of MRI and CT, is less utilized:  More common: Headache, nausea / vomiting  Less common: Seizure, pain, neurological change, anaphylaxis  Myelogram alone is rarely indicated
  19. 19. 19  . CT with myelogram:  Can demonstrate much better anatomical detail than myelogram alone  Utilized for:  Demonstrating anatomical detail in multi-level disease in pre- operative state  Determining nerve root compression etiology of disc versus osteophyte  Surgical screening tool if equivocal MRI or CT
  20. 20. 20  . Discography (Diagnostic disc injection):  Less utilized as initial diagnostic tool due to high incidence of false positives as well as advent of MRI  Utilizations:  Diagnose internal disc derangement with normal MRI / myelo  Determine symptomatic level in multi-level disease  Criteria for response:  Volume of contrast material accepted by the disc, with normals of 0.5 to 1.5 cc  Resistance of disc to injection  Production of pain---MOST SIGNIFICANT  Usually followed by CT to evaluate internal architecture, but also may utilize MRI  As outcome predictor of those with pain response received benefit from surgery  52 % of those with structural change received surgical benefit
  21. 21. Discography
  22. 22.  ANATOMY  INVESTIGATION BACK PAIN  CLINICAL FEATURES-WADDELL SIGN  SPINAL STENOSIS  DEGENERATIVE DISC DISEASE  SPONDYLOSIS/SPONDYOLISTHESIS  MANAGEMENT  POST OPERATIVE DISEASES
  23. 23. What is “back pain”?  From the American Academy of Orthopaedic Surgeons: It is a loosely defined diagnosis that may refer to multiple patterns of pain with complex issues surrounding its diagnosis and treatment. There is a paucity of evidence from the literature regarding its cause, management and prognosis. The difficulty of managing patients with low back pain stems from the fact that there often is very little association between physical findings and the patient’s pain and disability.
  24. 24. Causes of Backache Common causes • Back muscle sprain • Prolapsed lumber intervertebral disc • Obesity • Poor posture • Facet joint arthritis • Unaccustomed activities • Occupational causes
  25. 25. Uncommon causes 1.Congenital causes • Scoliosis • Spondylolisthesis • Spina bifida • Spondylolysis 2.Infective conditons • Osteomyelitis • Tuberculosis 3.Traumatic causes • Vertebral body injuries, posterior arch fractures • Muscle sprain/strain • Prolapsed disc 4.Inflammatory causes • Rheumatoid arthritis • Ankylosing spondylitis
  26. 26. 5.Neoplasms • Benign-osteoid osteoma • Malignant-secondaries, multiple myeloma, etc. 6.Metabolic causes • Osteoporosis • Osteomalacia 7.Degenerative conditions • Osteoarthritis • Lumbar spondylosis 8.Referred pain from • Gynaecological diseases • Genitourinary diseases • Gastrointestinal conditions, etc.
  27. 27. Common causes of acute low backache • Improper posture • Sudden twist • Faulty weight lifting • Bending • Sudden weight lifting • Faulty sitting
  28. 28. Differential Diagnosis for back Pain 20 yrsAnkylosing spondylitis Pyogenic sacroiliitis Herpes zoster Osteoid osteoma Vertebral sarcoidosis Rheumatoid arthritis Osteoblastoma Sickle cell disease Scoliosis Lyme disease 30 yrs 40 yrsOsteoarthritis DISH Osteomyelitis/Disciitis Paget’s Chordoma Sarcoma Osteoporosis/fracture Metastases
  29. 29. DDx. Age 50 and over  More metastases: ◦ Lung cancer ◦ Breast cancer ◦ Prostate cancer  Spinal stenosis  Rheumatoid diseases  Abdominal aneurysm  Multiple myeloma
  30. 30. Lumbar strain or sprain – 77% Degenerative Disk Disease – 10% Herniated Disk – 4% Compression Fracture – 4% Spinal Stenosis – 3% Spondylolisthesis – 2% cancer infection
  31. 31. Additional Categories . Neuropathic pain  Radiculopathy . Central Pain States  Spinal stenosis  Radiculopathy: disease of nerve roots ◦ Radiculitis: inflammation of nerve roots ◦ Pain, motor and sensory abnormalities  Plexopathy defined as involvement of 2 or more roots
  32. 32. Risk Factors for Low Back Pain  Gender ◦ Weak association with female sex ◦ Increased risk in pregnancy ◦ Stronger relation to occupation than sex ◦ Sciatica and disc operations more common in men  Height and weight ◦ Possible increased risk with height ◦ Weak correlation with weight
  33. 33. Other Risk Factors for LBP  Smoking ◦ Inhibits metabolic processes in the disc ◦ Weak relation with heavy smoking  Postural deformities ◦ Poor correlation  History of back pain ◦ Increased risk of recurrence ◦ Previous surgery possible factor  Epidural fibrosis  Recurrent disc herniation  Spondylodiscitis  Arachnoiditis
  34. 34. Structural Basis of LBP  Largest amount of scientific data ◦ Facet joints ◦ Discogenic pain ◦ Sacroiliac joint  Smallest amount of scientific data ◦ Myofascial pain ◦ Ligament pain ◦ Trigger point pain
  35. 35.  ANATOMY  INVESTIGATION  BACK PAIN CLINICAL FEATURES- WADDELL SIGN  SPINAL STENOSIS  DEGENERATIVE DISC DISEASE  SPONDYLOSIS/SPONDYOLISTHESIS  MANAGEMENT  POST OPERATIVE DISEASES
  36. 36. Waddell’s Signs  Dr. Gordon Waddell is an orthopedic surgeon from Glasgow, Scotland  Specializes in LBP and its disabilities  Developed tests to help identify LBP that is non-physiologic or possible malingering
  37. 37. Waddell’s Signs  To aid in assessing functional (nonorganic) disorders  5 signs: ◦ Tenderness ◦ Simulation (pressure or rotation) ◦ Distraction ◦ Regional disturbance (nonanatomic) ◦ Overreaction  Significant if 3 or more positive
  38. 38. Waddell’s Signs 1. Pain on simulated tests for axial loading – pushing down on the head 2. Pain with passive rotation of the shoulders and pelvis in the same plane 3. Superficial tenderness 4. Non-dermatomal sensory loss 5. Overreaction during physical exam 6. Straight leg raise that improves with distraction 7. Non-painful sitting SLR but painful supine SLR
  39. 39. Some Definitions  Sprain – torn or detached ligament  Strain – torn muscle  Radiculopathy – pain & neurological deficit caused by injury to a nerve root (radix=root)  Sciatica – pain that radiates down posterior or lateral leg; a type of radiculopathy
  40. 40.  ANATOMY  INVESTIGATION  BACK PAIN  CLINICAL FEATURES-WADDELL SIGN SPINAL STENOSIS  DEGENERATIVE DISC DISEASE  SPONDYLOSIS/SPONDYOLISTHESIS  MANAGEMENT
  41. 41. Spinal Stenosis
  42. 42. Cervical • congenital • acquired Lumbar • congenital • acquired Central Foraminal Lateral recess Entranc e Mid Exit myelopathy Radiculopathy
  43. 43. Spinal Stenosis  Local, segmental, or generalized narrowing of the central spinal canal, the lateral recesses, or the neural foramina by bony or soft tissue elements  Resultant narrowing may encroach upon the neural structures
  44. 44. 45 Spinal Stenosis  Clinical:  CONGENITAL OR DEGENERATIVE  Most common complaint is leg pain limiting walking  Neurogenic / Pseudoclaudication = pain in lower extremities with gait  Relief can occur with:  stopping activity  sitting, stooping or bending forward  Common are complaints of weakness and numbness of extremities  Usually becomes symptomatic in 6th decade
  45. 45. Spinal Stenosis  Degenerative changes that most commonly cause stenosis include osteophytes of the vertebral body endplates, uncinate processes, or facet joints and hypertrophy of the ligamentum flavum and anterior facet capsule  Initial size of spinal canal important factor whether degenerative changes will cause neural impingement or compression
  46. 46. Cervical Stenosis  MRI superior  Can evaluate cervical spine completely  Can determine accurate size of central spinal canal  Best predictor of the clinical course of myelopathic patients has been MRI studies ◦ higher signal intensity within cord with decreased cord volume seems to have poorer prognosis
  47. 47. Midline sagittal diameter less than 12mm considered relative stenosis. Diameter less than 10mm considered absolute stenosis
  48. 48. Cervical Root Syndromes Root Syndromes with Cervical Disc Herniation Disc Space C4-5 C5-6 C6-7 C7-T1 Root affected C5 C6 C7 C8 Muscles affected Deltoid, supraspinatus Biceps, brachioradialis Triceps, wrist extensors Hand intrinsics, interossei Area of pain and sensory loss Shoulder, anterior arm, radial forearm Thumb Thumb, middle fingers 4th, 5th fingers Reflex affected Biceps Biceps, triceps Triceps Triceps
  49. 49. CSS- Myelopathy  Myelopathy – from spinal cord compression. ◦ The term “myelopathy” refers to pathological changes of the spinal cord itself.  Pain and sensory changes in the back of the head, neck, and shoulders.  Performing surgery relatively early (within 1 year of symptom onset) is associated with a substantial improvement in neurologic prognosis  Delay in surgical treatment can result in permanent impairment
  50. 50. CSS - Myelopathy  The goal here is to avoid missing patients who are myelopathic, because once stenosis has evolved to the point that it is compressing (and causing damage to) the spinal cord, the progression of symptoms may be variable…but it is going to progress.
  51. 51.  T2 weighted MRI, sagittal view; This patient has multilevel degenerative changes of the cervical spine. The bottom two arrows show mild stenosis with CSF (white, fluid signal) still flowing around the cord. However, the top arrow is pointing to the C3/4 level where there is severe cervical spinal stenosis, no CSF around the cord (compression), and signal change within the spinal cord itself (indicating damage).
  52. 52. Stenotic Normal
  53. 53. T2- and T1-weighted sagittals at midspine showing spinal canal stenosis from C4/C5/C6 level
  54. 54. Lumbar canal Stenosis  Narrowing of canal increasingly common  1 per 1000 persons older than 65 years  degeneration of vertebral motion segment (intervertebral disk and facet joints
  55. 55. Lumbar Stenosis  Helpful to determine type of stenosis present ◦ developmental ◦ acquired
  56. 56. Lumbar Spinal Stenosis  Remember that the Spinal Cord ends at the Conus Medullaris, which is typically located at the L1/2 interspace in adults. ◦ L1/2 is the lumbar level least likely to be affected by Lumbar Spinal Stenosis.  Thus, Lumbar Spinal Stenosis doesn’t cause myelopathy; when it affects the motor system, lower motor neuron signs are what you’ll find.
  57. 57. Developmental Lumbar Stenosis  Growth disturbance of posterior elements involving pedicles, laminae, and facet joints  Results in decreased volume of central spinal canal or neural foramina  Midline sagittal diameter less than 12mm considered relative stenosis  Diameter less than 10mm considered absolute stenosis
  58. 58. Acquired or Secondary  Secondary (acquired) from degenerative changes, iatrogenic causes, systemic processes, and trauma.  Degenerative changes - central canal and lateral recess stenosis from posterior disc protrusion, zygapophyseal joint and ligamentum flavum hypertrophy, and spondylolisthesis  Iatrogenic - surgical procedures such as laminectomy, fusion, and discectomy. Systemic processes that may be involved in secondary stenosis include Paget disease, fluorosis, acromegaly, neoplasm, and ankylosing spondylitis
  59. 59. Lumbosacral Root Syndromes Root Syndromes with Lumbar Disc Herniation Disc Space L3-4 L4-5 L5-S1 Root Affected L4 L5 S-1 Muscles Affected Quadriceps Peroneal, anterior tibial, extensor hallucis longus Gluteus max, gastroc, plantar flexors toes Area of Pain and Sensory Loss Anterior thigh, medial shin Big toe, dorsum foot Lateral foot, small toe Reflex Affected Knee jerk Posterior tibial (medial hamstring) Ankle jerk Straight Leg Raising May not increase pain Aggravates pain Aggravates pain
  60. 60. Foraminal Stenosis  Important cause of radicular symptoms  If not addressed at surgery, common cause of failed back surgery  Neural foramen is a canal that lengthens at level of lumbar spine
  61. 61. Foraminal Stenosis  Degenerative ridges off posterolateral margin of vertebral body endplate  Size and location of ridges determines operative approach and amount of bone that needs to be removed to decompress neural elements  Facet degenerative changes may also narrow neural foramen
  62. 62. Lateral Recess Stenosis  Lateral region is compartmentalized into entrance zone, mid zone, exit zone, and far-out stenosis
  63. 63. Lateral Recess Stenosis  Lateral recess stenosis (ie, lateral gutter stenosis, subarticular stenosis, subpedicular stenosis, foraminal canal stenosis, intervertebral foramen stenosis) - narrowing (less than 3-4 mm) between the facet superior articulating process (SAP) and posterior vertebral margin - impinge the nerve root and subsequently elicit radicular pain.
  64. 64. Entrance Zone  The entrance zone - medial to the pedicle and SAP – stenosis from facet joint SAP hypertrophy.  Other causes - developmentally short pedicle and facet joint morphology, as well as osteophytosis  Disc prolapse anterior to the nerve root  The lumbar nerve root compressed below SAP retains the same segmental number as the involved vertebral level (eg, L5 nerve root is impinged by L5 SAP).
  65. 65. Mid Zone  Mid zone extends from the medial to the lateral pedicle edge. Mid-zone stenosis arises from osteophytosis under the pars interarticularis and bursal or fibrocartilaginous hypertrophy at a spondylolytic defect
  66. 66. Exit Zone  Exit-zone stenosis involves an area surrounding the foramen and arises from facet joint hypertrophy and subluxation, as well as superior disc margin osteophytosis. Such stenosis may impinge the exiting spinal nerve
  67. 67. Extra-canalicular Stenosis  Far-out (extracanalicular) stenosis entails compression lateral to the exit zone  Occurs with far lateral vertebral body endplate osteophytosis and when the sacral ala and L5 transverse process impinge on the L5 spinal nerve
  68. 68. Synovial Cysts from Facet Arthrosis
  69. 69. Central Canal Stenosis
  70. 70. Lateral Recess Stenosis
  71. 71. Foraminal Stenosis
  72. 72. MR – T2W CER SPINE[SAG] OPLL
  73. 73. AXIAL
  74. 74. CT LS SPINE L F CALCIFICATION
  75. 75. CT – CER SPINE
  76. 76.  ANATOMY  INVESTIGATION  BACK PAIN  CLINICAL FEATURES-WADDELL SIGN  SPINAL STENOSIS DEGENERATIVE DISC DISEASE  SPONDYLOSIS/SPONDYOLISTHESIS  MANAGEMENT  POST OPERATIVE DISEASES
  77. 77. Definition  Degenerative Disk Disease – gradual degeneration of the disk between vertebrae, due to loss of fluid and tiny cracks, part of normal aging process
  78. 78. Degenerative Disc Disease (DDD)  Unfortunately, DDD seems to be sort of a “wastebasket term” that is often used to describe age-related changes on MRI, etc. ◦ While these changes are indeed “degenerative,” this happens as we age and is not necessarily indicative of any significant underlying pathology or condition. ◦ The majority of individuals > 60 will show some type of degenerative change(s) on
  79. 79. DDD  Degeneration of an individual disc space typically refers to  loss of disc height,  loss of water content,  fibrosis, end plate sclerosis/defects,  osteophyte complexes, etc.
  80. 80. Degenerative Disc Disease  Plain films of limited value ◦ associated changes include decreased disc height, bony sclerosis, gas or calcification within disc space, and endplate hyperostosis  MRI and CT provide excellent delineation of disc herniation  Process that begins in second or third decade and progresses
  81. 81. Etiology Degeneration Facet arthropathy Segmental instability spinal stenosis foraminal stenosisNERVE PAIN
  82. 82. Intervertebral Disc Cellular and Biochemical Change  Decrease proteoglycan content  Loss of negative charged proteoglycan side chain  Water loss within the nucleus pulposus  Decrease hydrostatic property  Loss of disc height  Uneven stress distribution on the annulus
  83. 83. Degenerative Disc Disease  On T2 MRI, signal intensity of disc is related to state of hydration of nucleus pulposus  Gradual desiccation into more solid fibrocartilaginous structure with aging and degeneration ◦ loss of signal intensity
  84. 84. Spinal MRI – Disc disease Nomenclature
  85. 85. Spinal Structures (Sagittal)  Cord  Disc – signal, height and contour  Vertebral bodies and spinous processes  Nerve roots and neural foramina  Central canal  Ligaments (ALL, PLL, interspinous)  Epidural space
  86. 86. Spinal Structures (Axial)  Nerve roots and neural foramina  Cord  Disc contour  Vertebral bodies  Central canal  Lateral recesses  Ligaments (ligamentum flavum)  Epidural space  Facet joints
  87. 87. Normal Discs  Well hydrated nucleus ◦ Intermediate signal on T1, high signal on T2  Annulus fibrosus ◦ Low signal intensity on all sequences  Posterior margins are mildly concave, or flat in upper lumbar spine  May be minimally convex at lumbosacral junction
  88. 88. Degenerative Disc Disease  Asymptomatic patients of all ages can show disc abnormalities on MRI  do we differentiate pain generating lesions from non-pain generators?
  89. 89. Vertebral End-Plate  Become thinner and hyalinized  Decrease permeability  Inhibit nucleus metabolism  Disc space narrowing  Osteophyte formation at the end-plate and annular junction  Marrow change with increased axial loading  Subluxation and instability
  90. 90. Tears of the Annulus  Most of these tears are not visible on MR imaging  Some have granulation tissue and edema, leading to high intensity on T2 images = High Intensity Zones (HIZ)  Known pain generators  Usually seen in the posterior annulus of lower lumbar discs  Globular or horizontal lines of increased dignal intensity on T2 and post-contrast T1
  91. 91. HIZ
  92. 92. Terminology  Diffuse annular bulge  Broad-based protrusion (focal disc bulge)  Focal disc protrusion  Disc extrusion,migration  Disc sequestration
  93. 93. Diffuse Disc Bulge  Symmetric and circumferential bulge more than 2 mm in all directions  Also called a diffuse annular bulge  This is considered a “normal” finding in the aging spine
  94. 94. Broad-Based Protrusion (Or Focal Disc Bulge)  Asymmetric bulge involving more than 90° of the disc circumference
  95. 95. Focal Disc Protrusion  Focal, asymmetric extension of disc  The base is broader than any other dimension  Usually asymptomatic  These are contained by the PLL
  96. 96. Disc Extrusion  Usually symptomatic  AP diameter is greater than base  Maintains contact with parent disc  Not contained by the PLL
  97. 97. Migration - Sequestration  Migration indicates displacement of disc materialaway from the site of extrusion,  Sequestration is used to indicate that the displaceddisc material has lost completely any continuity withthe parent disc
  98. 98. Disc Sequestration  Loss of continuity between extruded disc and parent disc  Usually symptomatic
  99. 99. Further Grading  Subjective division into small, moderate or large ◦ Protrusions and extrusions can be measured, but reliability is questionable  What is happening to neural elements? ◦ Effacement ◦ Compression ◦ Displacement  Note: a small herniation in a small canal may be more significant than a large herniation in a spacious canal
  100. 100. Location of Disc Abnormalities  Central  Paracentral  Foraminal  Extraforaminal  Anterior
  101. 101. Clinical Correlation  1/3 or more of asymptomatic people have disc abnormalities on MRI  Only 1% of asymptomatic patients have extrusion on MRI  90% of lumbar disc abnormalities are central or paracentral
  102. 102. Modic Type I
  103. 103. Modic Type II
  104. 104. Modic Type III
  105. 105. MRI of Lumbar HNP
  106. 106.  ANATOMY  INVESTIGATION  BACK PAIN  CLINICAL FEATURES-WADDELL SIGN  SPINAL STENOSIS  DEGENERATIVE DISC DISEASE SPONDYLOSIS/SPO NDYOLISTHESIS  MANAGEMENT  POST OPERATIVE DISEASES
  107. 107. Spondylolisthesis -Definitions  Spondylolisthesis - anterior or posterior slipping or displacement of one vertebra over another
  108. 108. SPONDYLOLISTHESIS  Slipping of one vertebra with respect to other.  Types: (Wiltse) congenital isthmic degenerative traumatic pathologic post surgical  Usually assosciated with spondylolysis( which is fibrous cleft within pars interarticularis)  Prevalence : 4% of population  Location : L5-S1 >L4-L5 usually bilateral
  109. 109. ISTHMIC TYPE  MC type  Lesion in pars interarticularis  Subtypes : 1.lytic --- fatigue # of pars interarticularis. 2.intact but elongated P.A 3.acute # of P.A  Separation of two halves of vertebrae anterior half--- ( body, pedicle & superior articular facet ) posterior half--- ( lamina & inf articular facet )
  110. 110. CONGENITAL(DYSPLASTIC) Dysplasia of superior articular facet of sacrum PATHOLOGIC Pathologic # or bare softening. Ex: pagets disease or osteogenisis imperfecta DEGENERATIVE Ex: osteo arthritis Posterior facet joints became unstable and sublocate TRAUMATIC/POST SURGICAL Rare.
  111. 111. MEYERDING CLASSIFICATION  Lateral X Ray- Measurement of the distance from the posterior edge of the superior vertebral body to the posterior edge of the adjacent inferior vertebral body. Distance is reported as % of the total superior vertebral body length.  Grade I ----- 0-25% Grade II ----- 25-50% Grade III ----- 50-75% Grade IV ------ 75-100%  >100% ----- spondyloptosis ( vertebra completely falls off the supporting vertebra)
  112. 112. IMAGING FEATURES X-RAY: 1. LATERAL: Anterior displacement 2. OBLIQUE: Defect in pars interarticularis In normal vertebra P.I appears like a “scotty dog” i. If the appearance is that of scotty dog wearing a collar , the defect is the isthmus (P.I) ----- Spondylolysis ii. If the head of the scotty dog is separated from the neck ---- Spondylolisthesis 3. AP : Napolean hat sign
  113. 113. CT : •Pars interarticularis defect has to be located at pedicle level ;has irregular margins & adjacent sclerosis. (IV disc level = apophyseal joint ) •Elongated AP diameter of spinal canal. MRI: •Pars interarticularis defect •Forward displacement •Cord signal changes.
  114. 114. Facet (Zygapophysial) Joint Pain  Lumbar facet joints recognized as a source ◦ Facet syndrome: lumbosacral pain with or without sciatica ◦ Pain after rotary movement or twisting ◦ Low back pain with radiation to thighs and buttocks ◦ Poor clinical correlation with imaging or exam
  115. 115. Facet Joint Pain  Definitive diagnosis requires diagnostic blocks  Lumbosacral facet joints - 15 to 45% of cases of low back pain  Cervical facet joints - 54 to 67% of cases of neck pain ◦ Common with “whiplash”  Validity, specificity and sensitivity of diagnostic facet joint nerve blocks are considered to be strong
  116. 116. MRI
  117. 117. MRI
  118. 118. MRI Lateral Recess Stenosis
  119. 119. MRI
  120. 120. MRI
  121. 121.  ANATOMY  INVESTIGATION  BACK PAIN  CLINICAL FEATURES-WADDELL SIGN  SPINAL STENOSIS  DEGENERATIVE DISC DISEASE  SPONDYLOSIS/SPONDYOLISTHESI S MANAGEMENT  POST OPERATIVE DISEASES
  122. 122. Backache MANAGEMENT  Conservative  Surgery
  123. 123. Backache CONSERVATIVE MANAGEMENT:  Good posture  Bed rest on hard bed  IFT,SWD,TENS,IPT  L.S belt application  Exercises  Stress therapy
  124. 124. Interventions/Nonsurgical Management  Williams position (Semi-fowler’s with knees flexed; this takes pressure off lower back)  Firm mattress, or backboard under soft mattress  Exercise  Drug therapy  Heat and/or ice therapy  Diet therapy (weight control to help reduce chronic back pain) (Continued)Elsevier items and derived items © 2006 by Elsevier Inc.
  125. 125. POSTURE:  The neck has a slight natural curve, which sits on top of the two curves in the middle and lower back.  Correct posture maintains all three curves and prevents undue stress and strain by distributing body weight evenly
  126. 126. STANDING POSTURE  In correct, fully erect posture, a line dropped from the ear will go through the tip of the shoulder, the middle of the hip, the back of the kneecap and the front of the anklebone.
  127. 127. SITTING POSTURE  When sitting in any position, the three back curves need to be maintained.  If you cannot sit without slouching forward or backward, you need to support yourself with hands and arms or lean against a wall or chair back.
  128. 128. SITTING POSTURE
  129. 129. SITTING POSTURE:
  130. 130. LYING POSTURE:  Avoid propping head or upper body up on an arm and hand.  Head should remain relaxed. Legs should be together.
  131. 131. Spinal exercises
  132. 132. BackacheEXERCISES:  Cat Back  Fetal Position  Arm exercises
  133. 133.  Alternate Leg Slides  Alternate Leg Raises
  134. 134. TENS  Transcutaneous electrical nerve stimulation ◦ Endorphin modulated ◦ Altered CNS transmission of pain
  135. 135. Traction  Enlarges foramen  Vacuum effect  PLL traction  Relaxation of spasm  Decreases intradiscal pressures up to 30%
  136. 136. Chiropractic Care  Most common “alternative medicine”  Up to 30% of back pain sufferers  Manipulation under anesthesia
  137. 137. Trigger Point Injections  Myofascial back pain ◦ Responds better to stretching, local modalities  Used when other treatments fail  Anesthetic +/- steroid  Limit the number of injections  Prolotherapysclerosing agent ◦ No scientific evidence
  138. 138. Injection Therapy  Anesthesia plus anti- inflammatory effect  Epidural injection ◦ Good for nerve root irritation ◦ Unclear in mechanical back pain  Effective for facet joint arthropathy, sacroiliac disease  Radiofrequency dorsal rhizotomy
  139. 139. Braces  Indicated with fracture, instability  No evidence to support long term use  Weakening of postural muscles  Do not really immobilize
  140. 140. RELIEVE STRESS  Yoga  Meditation
  141. 141. Surgical Management  Discectomy  Laminectomy  Spinal fusion  Minimally invasive lumbar procedures: ◦ Percutaneous lumbar discectomy ◦ Microdiskectomy ◦ Laser-assisted laparoscopic lumbar diskectomy Elsevier items and derived items © 2006 by Elsevier Inc.
  142. 142. Nucleus Pulposus Replacement
  143. 143. Discectomy  the removal of a herniated disk to relieve pressure on a nerve root  Window in the lamina- retract nerve-removal of herniated disc material-healing by scar tissue - Fenestration discectomy - Endoscopic discectomy
  144. 144. Laminectomy  derived from lumber (lower spine), lamina (part of the spinal canal's bony structure) and - ectomy (removal).  The operation is performed to relieve pressure on one or more spinal nerve roots
  145. 145. Herniated Disc Repair Elsevier items and derived items © 2006 by Elsevier Inc.
  146. 146. Elsevier items and derived items © 2006 by Elsevier Inc.  .
  147. 147. Elsevier items and derived items © 2006 by Elsevier Inc.
  148. 148. TOPICS  ANATOMY  INVESTIGATION  BACK PAIN  CLINICAL FEATURES-WADDELL SIGN  SPINAL STENOSIS  DEGENERATIVE DISC DISEASE  SPONDYLOSIS/SPONDYOLISTHESIS  MANAGEMENT POST OPERATIVE DISEASES
  149. 149. Prior Disc Surgery  If persistent or recurrent symptoms, MRI exam is optimal method to detect presence of discal abnormality  Specificity limited in first six months after surgery  Routinely performed with and without contrast ◦ enhancement of fibrotic material will be pheripheraly
  150. 150. Treatment Failures  Failure to respond to conservative measures (6 weeks)  Progression to involve radiculopathy  Rapidly progressive neurologic symptoms  Chronic pain (> 12 weeks)
  151. 151. Failed Back Syndrome  Present with variety of post-operative findings  Epidural fibrosus  Recurrent disc herniation  Osseus regrowth (stenosis)  Foraminal stenosis  Status of fusion  Infection
  152. 152. Fusion itself can accelerate the severity of adjacent level degeneration as compared with non-fusion. But there was no correlation in the incidence of symptomatic adjacent segment diseases according to the fusion in single level anterior cervical arthrodesis for the degenerative cervical diseases. Adjacent segment disease is more a result of the natural history.
  153. 153.  ANATOMY  INVESTIGATION  BACK PAIN  CLINICAL FEATURES-WADDELL SIGN  SPINAL STENOSIS  DEGENERATIVE DISC DISEASE  SPONDYLOSIS/SPONDYOLISTHESI S  MANAGEMENT
  154. 154.  Image gallery
  155. 155. THANK YOU for this opportunity  Ref  1.ROSS  2.EDELMAN  INTERNET
  • MichaelIkeAZUKAEGOAC

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The degenerative disc and spine disease.

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