Degenerative Disease

1. Degenerative Disease Dr. Sharifa AL-Duraibi

2. Degenerative disc disease Degeneration of one or more intervertebral disc(s) of the spine. Disc degeneration is a disease of aging, and though for most people is not a problem, in certain individuals a degenerated disc can cause severe chronic pain if left untreated.

3. low back pain world wide common complaint among adults. lifetime prevalence in working population up to 80%. 60% experience functional limitation or disability. second most common reason for work disability. despite advances in imaging and surgical techniques LBP prevalence and its cost are relatively unchanged.

4. Pathologic changes Fibrocartilage replaces the gelatinous mucoid material of the nucleus pulposus as the disc changes with age. There may be splits in the annulus fibrosis, permitting herniation of elements of nucleus pulposus.

5. Pathologic changes Shrinkage of the nucleus pulposus that produces prolapse or folding of the annulus with secondary osteophyte formation at the margins of the adjacent vertebral body.

7. Disc pathology vsPain degree of disc injury (size of tear / herniation), nor the degree of nerve root compression correlate with subjective pain or functional disability. Karppinen J. et al. “Severity of Symptoms and Signs in Relation to MRI Findings Among Sciatica Patients.” Spine 2001; 26(7):E149-E154

8. Cervical Radiculopathy

9. Lumbosacral Radiculopathy (Sciatica) Important: A herniated disc at (e.g.) L4-5 may impinge either the L4 or L5 nerve roots!

10. Degenerative Disc (and Facet Joint) Disease Foraminal stenosis Thickening/Buckling of Ligamentum Flavum

12. MRI - Degenerative Disc Disease Age: 20-40 36% have degenerated disc. 5085-95% have degenerated disc. 60-80 98% have degenerated disc. ** <6020% have asymptomatic discherniation. Conclusion: Abnormal findings on MRI frequently DO NOT relate to symptoms (and vice versa) !!

13. MRI – Herniated Disc Levels 85-95% atL4-L5/L5-S1. 5-8% atL3-L4. 2% atL2-L3. 1% atL1-L2/T12-L1. ** Cervical:most common C4-C7. **Thoracic:15% in asymptomatic pts. at multiple levels, not often symptomatic.

14. Anulartear Separations between anular fibers, avulsion of fibers from their vertebral body insertions, or breaks through fibers involving one or many layers of the anular lamellae. The terms 'tear' or 'fissure' does not imply that the lesion is consequent to trauma. In case of a traumatic event the term 'rupture' is appropriate.a

15. Disc herniation Displacement of disc material beyond the limits of the intervertebral disc space. A herniated disc can be contained (covered by outer anulusfibrosus) or uncontained.

16. Disc herniation Focal Herniation Broad based hernia Is a herniated disc less than 90? of the disc circumference. Is a herniated disc in between 90?-180? of the disc circumference.

17. Disc herniation Is the presence of disc tissue 'circumferentially' (180?-360?) beyond the edges of the ring apophyses and is NOTconsidered a form of herniation. Bulging Disc

18. Focal disc herniation Disc Protrusion Disc Extrusion Indicates that the distance between the edges of the disc herniation is less than the distance between the edges of the base. present when the distance between the edges of the disc material is greater the distance at the base.

19. Disc herniation Migration Sequestration indicates displacement of disc material away from the site of extrusion, regardless of whether sequestrated or not. used to indicate that the displaced disc material has lost completely any continuity with the parent disc

20. Axial localisation of herniated discs

21. Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.

22. Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.

23. Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.

24. Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.

25. Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.

26. Protrusion Extrusion Extrusion Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.

27. Protrusion w/ migration + sequestration Protrusion w/ migration Protrusion Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.

28. Lumbar Spinal Stenosis

29. Lumbar Spinal Stenosis Disc bulge, facet hypertrophy and flaval ligament thickening frequently combine to cause central spinal stenosis. Note the trefoil shape of stenotic spinal canal.

30. Lumbar Spinal Stenosis Disc bulge, facet hypertrophy and ligament flavum thickening frequently combine to cause central spinal stenosis Note the trefoil shape of stenotic spinal canal

31. Neural foramen Foraminal Stenosis

33. Cervical Spinal Stenosis

34. case study - annie • 30 y.o. female presents with low back pain. • Pain radiating down right leg. • Initial onset approximately 1 year. • Referred by orthopedic surgeon. • On motrin, previously darvocet, flexeril and valium. • Previous treatments: chiropractic and physical therapy.

35. Diagnostic studies • A-P / lateral Plain Film: Degenerative disc height loss at L4-5 level. • MRI: • L4-L5:Large central disc herniation (9mm in AP X 10mm Broad) effacing the ventral thecal sac and impressing upon the central canal. • This produces moderate canal stenosis. • L5-S1:broad disc bulge with radial tear. • mild effacement upon the ventral thecal sac.

36. Imaging

37. Abnormal Disc <180º > 180º Tear Herniation Bulge 90º–180º < 90º Broad-based Focal Symmetric Asymmetric Waist* No waist Extrusion Protrusion Sequestered Migrated Neither *(In any plane) Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.

38. Schmorl’s Nodes protrusions of the cartilage of the intervertebral disc through the vertebral body endplate and into the adjacent vertebra.

39. Confusing “Spondy-” Terminology Spondylosis= “spondylosisdeformans”= degenerative spine. Spondylitis= Inflamed spine (e.g. ankylosing, pyogenic, etc.). Spondylolysis= Chronic fracture of pars interarticularis with nonunion (“pars defect”). Spondylolisthesis = anterior slippage of vertebra typically resulting from bilateral pars defects. Pseudospondylolisthesis = “degenerative spondylolisthesis” (spondylolisthesis resulting from degenerative disease rather than pars defects)

40. Spondylolysis / Spondylolisthesis

41. current therapies for discogenic pain or disc pathology Medication and limited activity Spinal rehabilitation. Interventional pain management. Spinal surgery.