Back Pain Problem PowerPoint Presentation

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Degenerative Spine Diseases Dr. Yue Wang Department of Orthopedic Surgery The First Affiliated Hospital, college of Medicine, ZheJiang University A Class for Foreign MD Students 浙江大学医学院附属第一医院骨科 王 跃 MD, PhD

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

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Anatomy of the intervertebral disc The Intervertebral Disc Two major components Annulus fibrosis: thick, fibrous “radial tire” called lamellae Nucleus pulposus: ball-like gel

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The disc

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The disc The disc is the largest avascular organ in the human body! Take about 80% loads in the spine!

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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.

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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

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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;

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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;

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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

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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

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Degenerative changes of the ligaments Degenerative Changes Partial ruptures, necrosis and calcifications Negatively impact function of motion segment

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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

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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);

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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

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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;

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

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

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Pathoanatomy 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 nerve root of one level lower!

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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;

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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?

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Classification of LDH Protrusions Extruded Sequestered

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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 symptoms

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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

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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;

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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;

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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;

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Manual muscle test (MMT)

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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.

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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);

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

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MRI

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Axial images

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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;

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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;

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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 History

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Operative Treatment Indications progressive neurologic deficit; cauda equina syndrome; failure of appropriate nonoperative treatment;

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Discectomy Release ligamentum Resect lamina Remove disc tissues Inspect neural foramen

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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 spondylosis

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Patients usually present with one or more of: Axial neck pain Radicular arm pain Myelopathy Neurapraxia of upper extremities Cervical disc herniation Non-specific symptoms: dizzying, nausea, head ache, upper back pain;

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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

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Typical surgery: ACDF Anterior cervical decompression and fusion (ACDF); Anterior discectomy; Bone graft or cage; Instrumentation;

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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 compression, including:

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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

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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

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Surgery Laminectomy Laminaplasty

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Cervical spondylosis

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After decompression

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A narrowing of the spinal canal; 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;

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Three shapes of the spinal canal The narrowed canal

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Classification Central stenosis; Lateral recess stenosis; Foramen stenosis;

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

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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)

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Imaging: X-ray

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Imaging: CT

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Imaging: MRI

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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

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Operative treatment: laminectomy

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The Rock Mountain, 2012