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Degenerative Spine Conditions

Overview of some degenerative spine conditions by Prof. Enric Cáceres.

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Degenerative Spine Conditions

  1. 1. EFORT – JOINT EFFORTS Degenerative Spine Conditions Enric Càceres Head of Orthopaedics Department Chair of Autonomous University of Barcelona Associate Professor of Johns Hopkins University
  2. 2. EFORT – JOINT EFFORTS Spine 2 36 years old male patient assist to emergency room for a sudden episode with sever pain started three days ago and localized at right limb irradiated to buttock, posterior face of the thigh, leg, heel and plantar region of the foot He also get lost partial sensibility of lateral border of the foot.
  3. 3. EFORT – JOINT EFFORTS Spine2 He complains low back pain three weeks ago without leg pain Physical examination shows pain at few degrees of elevation of painful limb and an abolition of Achilles in reflex examination
  4. 4. EFORT – JOINT EFFORTS Spine2
  5. 5. EFORT – JOINT EFFORTS Spine2 IQ: Which is your first diagnoses in agreement with this clinical history and radiology? DQ: Which treatment do you choose initially? CC: Describe nerve root compression level ? Which is the most useful conservative treatment for this patient EQ: What image diagnostic test shoud you request?
  6. 6. EFORT – JOINT EFFORTS Spine2 MRI two weeks later without clinical improvement
  7. 7. EFORT – JOINT EFFORTS Spine2
  8. 8. EFORT – JOINT EFFORTS Spine 2 IQ: Do you think that the treatment needs to be changed? DQ: What is your opinion about epidural injection? CC: Do you request new tests? When do you decide a surgical treatment? If the patient improve your pain and rest asymptomatic, what is your behavior? EQ: Simply describe differences between T1 and T2 in MRI
  9. 9. EFORT – JOINT EFFORTS Spine2 : MRI Four months later
  10. 10. EFORT – JOINT EFFORTS Lumbar Disk herniation General overview A.Incidence 80% of people has some episode of low back pain in your life, but only 2-3% has true sciatica A.Age Average starting age 35 years old Unusual before 20 and after 60 years Less frequent in old people , more common associated with stenosis C. Sex Similar in both sex but delayed one decadeSimilar in both sex but delayed one decade in femalesin females
  11. 11. EFORT – JOINT EFFORTS Lumbar disk herniation Anatomy 1) L4-L5 more frequent than L5-S1 less frequent in thoracic or high lumbar level 2) frecuently posterolateral 3) Central location will cause lumbar pain without sciatica 4) Foraminal location more frequent in elderly people and hight levels (L3-L4) 5) intradural location very unusual
  13. 13. EFORT – JOINT EFFORTS Lumbar disk herniation Clinical features: Radiculopathy a. leg pain > lumbar pain b. Dermatomal distribution c. Increase sitting positions and forward bending d. Improve with bed rest
  14. 14. EFORT – JOINT EFFORTS Lumbar disk herniation
  15. 15. EFORT – JOINT EFFORTS Lumbar disk herniation
  16. 16. EFORT – JOINT EFFORTS Lumbar disk herniation  Diagnostic imaging 1. symptoms correlated physical examination is the most important thing. 2 .Plain radiographs are not often helpful . . Provide global overview of spine alignment . Rule out other sources of nerve root dysfunction (spondylolisthesis, infection, tumor 3. CT a. Not routinely used in LDH . Used to visualize bony anatomy more thab soft tissue
  17. 17. EFORT – JOINT EFFORTS Lumbar disk herniation
  18. 18. EFORT – JOINT EFFORTS Lumbar disk herniation Nonsurgical treatment :  LDH has a favorable prognosis  90% report improvement of symptoms ( natural history) 1) short rest (3-5 days) 2) NSAIDs ( more effective than placebo) 3) Physical therapy ( extremely beneficial) 4) Epidural steroid injections (50% avoided surgery) Patient who failed to improve with nonsurgical treatment will probably need surgery. Surgical treatment provided an increase in quality of life in comparison to continued nonsurgical treatment.
  19. 19. EFORT – JOINT EFFORTS Control four months after conservative treatment RNM: natural history Male 66 a. Male 34 a. Male 71 a. Women 35 a. Male 43 a. Male 30 a. Male 42 y.o. Male 49 y.o Male 62 a. Male 33 a. HD Image Decrease HD: 4/10 HD desapear: 6/10
  20. 20. EFORT – JOINT EFFORTS Lumbar disk herniation
  21. 21. EFORT – JOINT EFFORTS Spine 1 • 47 years old male. • Previous disease: • Apendicectomy. • Cronic low back pain with buttock and lower extremities irradiation • Severe neurogenic claudication six months ago with impossibility to walk more than 150 meters
  22. 22. EFORT – JOINT EFFORTS Spine1
  23. 23. EFORT – JOINT EFFORTS Spine1
  24. 24. EFORT – JOINT EFFORTS Spine1
  25. 25. EFORT – JOINT EFFORTS Spine1 •IQ: What do you think is the etiology of claudication? •DQ: Witch kind of treatment do you choose. What is the natural history of this pathologic entity? •CC:Please could you describe surgical treatment Amount of decompression?+/-Fusion? +/-Instrumentation? Witch levels? •EQ: Possible complications of this surgery? How do you classify this entity?
  26. 26. EFORT – JOINT EFFORTS Spine1
  27. 27. EFORT – JOINT EFFORTS Lumbar spinal stenosis Overview / epidemiology A. Definition. Spinal stenosis simply means a decrease in the space available for the neural elements, and , in the lumbar spine, the cauda equina. It can ocur at different level : the central canal, the lateral recess or the intervertebral foramen causing neurological compression .
  28. 28. EFORT – JOINT EFFORTS Lumbar spinal stenosis Is the final result of a cascade of events. • The event that begins the process is thought to be the disk degeneration. • As the disk heigth decreases, the loading characteristics of the facet joints are altered. • Facet joints capsules becomes incompetenet, leading to capsular, ligamentum flavum, and facet hypertrophy. • The final result of this continuum of changes, is a decrease in the diameter of the spinal canal.
  30. 30. EFORT – JOINT EFFORTS Lumbar spinal stenosis • Diagnostic imaging: 1.Upright AP, lateral, and flexion-extension radiographs : amount of lumbar degeneration , vertebral deformity and instability. 2.EMG may be helpful to distinguish peripheral neuropathy from LSS. 3.Myelography: useful when deformity exists. 4.CT scan: facet joints hypertrophy, discal vacuum , size of discal height and foramen height. 5. MRI is currently the recommended advanced imaging modality to evaluate LSS. Noninvasive technique.
  31. 31. EFORT – JOINT EFFORTS Lumbar spinal stenosis Treatment A. Nonsurgical 1) Narcotics, NAIDs, anticonvulsivants 2) LS ortosis 3) Physical therapy: flexion-based lumbar stabilization program 4) Steroid injections
  32. 32. EFORT – JOINT EFFORTS Lumbar spinal stenosis B. Surgical treatment 1) Indications: Caudal equina syndrome Severe neurologic deficit or impairment Failure to improve leg pain and neurogenic claudication after nonsurgical treatment. Persistent and severe decrease in patient quality of life .
  33. 33. EFORT – JOINT EFFORTS Natural historyNatural history - not well understood - it is typically favorable, with only 15% deteriorating clinically. - improvement occurs in 30% to 50% of patients. Lumbar spinal stenosis
  34. 34. EFORT – JOINT EFFORTS Lumbar spinal stenosis Preoperative medical evaluation Elderly patients Coexisting comorbidities Save blood preoperative techniques Self-saver postoperative Eritropoyetin Surgical treatment::
  35. 35. EFORT – JOINT EFFORTS Surgical techniques Laminotomy Hemilaminectomy Resection of 50% of the cephaled and caudad lamina and ligamentum flavum Laterral decompression into the lateral recess and into the foramen Fusión if resection is > 50 % bilateral facets or complete unilateral facetectomy Lumbar spinal stenosis
  38. 38. EFORT – JOINT EFFORTS meta-analysis limitations 74/625 meet inclusion criteria (12% relevant) Nonrandomized studies 3/74 prospective studies 72% good results No significative evidence between clinical outcome and age, sex, previous back pain and number of levels. Patients with a solid arthrodesis have superior clinical outcomes in comparing with patients with pseudoartrosis. Surgical treatment in LSS Results after decompression technique Lumbar spinal stenosis
  39. 39. EFORT – JOINT EFFORTS 88 patients 2,8 a 6,8 years Surgical treatment Long term results after laminectomy Results 1 year Follow-up Poor 11% 43% Severe pain 7% 30% Reoperated 6% 17% Basic functional impairment 8% 35% Walking < 15 meters 8% 21% Lumbar spinal stenosis
  40. 40. EFORT – JOINT EFFORTS Age >75 years increase number of complications x 9 . More than 3 co-morbidities: increase hospital stay 25%, increase cost 36% and 75% cases need assisted living. Surgical treatment in LSS - Comorbidities and results Lumbar spinal stenosis
  41. 41. EFORT – JOINT EFFORTS  Prospective Randomized Comparative Decompression versus decompression and uninstrumented fusion Lumbar spinal stenosis Results Fusion Non fusion Excellent 44% 8% Good 52% 36% Fair 4% 48% Poor 0% 8% Slipage increase (Preop-postop) 0,5mm 2,6mm p:0,002
  42. 42. EFORT – JOINT EFFORTS what black disc means? MRI image corresponding with a degenerative disk disease degree IV Pfirmann 2001
  43. 43. EFORT – JOINT EFFORTS it’s a pathology? -Participates in the degenerative and physiologic cascade starting from 30 years old - When appear in a precocious time in young people could be symptomatic
  44. 44. EFORT – JOINT EFFORTS Modic changes • Standard non invasive tool • Degenerative changes (Modic) T1 T2 MODIC I EDEMA Decrease signal Increase signal MODIC II FAT DEGENERATION Increase signal Increase signal MODIC III ESCLEROSIS Decrease signal Decrease signal Modic MT, Radiology. 1988;166:193-9
  45. 45. EFORT – JOINT EFFORTS MRI: - HIZMRI: - HIZ HIZ:Hight Intensity Zone in T2 localized annulus posterior or posterolateral layer Aprill, Bogduck, 1992
  46. 46. EFORT – JOINT EFFORTS MRI - HIZ - Disk tear lesion predictor - Contends vascularizated granulamotous tissue - highlight with Gadolinium - strong relationship whit positive discography -…not always with clinical significance MRI CT+Discoghraphy CT+Discography
  47. 47. EFORT – JOINT EFFORTS Discography ???? -Discriminative test -Useful in diagnosis of lumbar pain with suspicious discal source - No prediction surgical success
  48. 48. EFORT – JOINT EFFORTS Clinical significance black disc (Disc degneration degreeIV) • Clinical picture of discogenic lumbar pain no radicular pain psicologic and social normal behavior • Image: disc degeneration = or >IV degree HIZ + absence of another structural pathology • Discriminative test discography • Reject other pain generator facet injection
  49. 49. EFORT – JOINT EFFORTS Treatment Surgical Treatment?? - IDET ( 3 studies: non effective) - TDR (total disk replacement) - Dynamic stabilization - Segmentary circumferential fusion - Information
  50. 50. EFORT – JOINT EFFORTS Aim :Cancel pain generator Circumferential fusion Total disc replacement
  51. 51. EFORT – JOINT EFFORTS  Dark diskDark disk Symptomatic in young patientsSymptomatic in young patients Agreement: Patient / Diagnosis / TreatmentAgreement: Patient / Diagnosis / Treatment Non consents related treatmentNon consents related treatment  Lumbar disk herniationLumbar disk herniation Positive tension singsPositive tension sings Specific radicular painSpecific radicular pain Good results with Nonsurgical treatmentGood results with Nonsurgical treatment Partial diskectomyPartial diskectomy  Lumbar spinal stenosisLumbar spinal stenosis Favorable Natural historyFavorable Natural history High incidence complications after surgical treatmentHigh incidence complications after surgical treatment  Differential diagnosisDifferential diagnosis Sumary
  52. 52. EFORT – JOINT EFFORTS Degenerative Spine Disease Enric Càceres Head of Orthopaedics Department Chair of Autonomous University of Barcelona Associate Professor of Johns Hopkins University