26. DJD of Spine Flashcards
Rapid Association:
Clinical presentation of DISC HERNIATION
RADICULAR PAIN
(pain along the nerve root distribution)
Rapid Association:
Clinical presentation of DISC DEGENERATION
MECHANICAL BACK PAIN (axial +/- referred)
Rapid Association:
Clinical presentation of SPINAL STENOSIS
NEUROGENIC CLAUDICATION
Rapid Association:
Clinical presentation of DEGENERATIVE SPONDYLOLISTHESIS
MECHANICAL BACK PAIN (axial +/- referred)
RADICULAR PAIN
Rapid Association:
Clinical presentation of DEGENERATIVE SCOLIOSIS
MECHANICAL BACK PAIN (axial +/- referred)
RADICULAR PAIN
The intervertebral discs are comprised of these 2 structures
nucleus pulposus + annulus fibrosis
What is the nucleus pulposus?
function?
composition?
how does this compare to the annulus fibrosis?
shock absorber of the spine
made of aggrecan (proteoglycans)+H2O in a matrix of Type II collagen and elastin fibers
(N looks like it has 2 parallel sticks..don’t judge)
Annulus fibrosis - Type I collagen fibers
What is the purpose of the end plates on the vertebral bodies?
how do they change during one’s lifetime?
serves as the growth plate for the vertebral bodies.
thick during infancy
thin during adulthood; becomes an avascular layer of hyaline cartilage
What happens if there is a loss of hydrostatic pressure in the disc?
example?
hydrostatic pressure normally collapses the small vessels.
A loss of hydrostatic pressure results in patent vessels that release NGF, which stimulates ingrowth of small, non-myelinated nerve fibers (nociceptive fibers) into the previously anervated areas of the disc - may be reaon why people experience axial pain.
examples: disc degeneration
How does the intervertebral discs change during one’s lifetime?
be specific about nucleous pulposis and annulus fibrosis
infants:
- nucleus: 90% water
- annulus: rich in proteoglycans
over time: loss of water and proteoglycans
adults:
- nucleus: smaller with altered biomechanics (results in increased forces on the annulus)
- annulus: stiffer, weaker
what are 2 factors that play a role in the natural aging process of the intervertebral discs
- idiopathic loss of blood supply to the endplate
-
non-enzyatic glycation - reduced sugars bind to collagen proteins and causes them to become more brittle + sticky -> disc becomes thicker, more fibrous
- Also results in a yellowish brown color
how does disc degeneration occur? (3 steps)
what influences the progression of this? (4)
How does it present itself?
What is the outcome of disc degeneration?
- structural damage to end plate
- microfracture of endplate
- rupture of inner annulus and subsequent buldging of annulus into the nucleuos pulposis
factors:
- genetics
- smoking
- occupation
- obesity
clinical presentation: MECHANICAL PAIN (axial + referrred)
outcome: degenerative sciolosis
Wht are the 3 types of disc herniation?
Who does it normally affect?
What usually causes it?
What are the 2 locations that it can occur?
What is the clinical presentation of disc herniation?
3 types:
- protrusion/prolapse - herniated portion remains covered with a thin layer of peripheral annulus
- extrusion – herniated portion ruptures thorugh the full thickness of the annulus and lies under the posterior longintudinal ligament or directly under the dural sac or nerve root
- sequestration – herniated portion fragments away from the originating disc
USUALLY AFFECTS YOUNG ADULTS
Causes:
- sudden violent trauma to a normal annulus
- less severe trauma (bending, lifting) to a degenerated annulus
Locations
- Postero-lateral
- lateral
Clinical presentation:
- RADICULAR PAIN (pain along the nerve root distribution)
POSTERIO-LATERAL disc herniation (Herniated Nucleus Pulposus)
Why does it happen here?
What does it affect?
What does it cause?
YOUNG adults
Posterio-lateral HNP common site due to thinness of annulus there
Affect: TRAVERSING NERVE ROOT
- cervical spine: no traversing nerve root in the cervical spine, nerve roots exit above thier corresponding vertebrae. Thus C4/C5 HNP -> C5 compression
- lumbar spine: remember that lumbar roots exit below their corresponding vertebrae. Thus, L4/L5 HNP in the posteriolateral corner results in L5 compression (weakness when walking on heels) - confusing but look at the diagram and it’ll make sense.
LATERAL disc herniation (Herniated Nucleus Pulposus)
What does it affect?
What does it cause?
- affects EXITING nerve root
- L4/L5 HNP -> L4 nerve root compression
Who does spinal stenosis usually affect?
Why does it occur?
What is the clinical presentation of it?
how do you test for it?
How do you treat it?
- elderly
- occurs as a result of the spine’s attempt to restabilize the disc degeneration by forming osteophytes around the margin of the disc and facet joints, leading to hypertrophy of the facet joints and osteophytes along the margin of the collapsed disc space
- Clinical presentation: neurogenic claudication – back and leg pain precipitated by standing for short periods of time (10-15min) but is relieved promptly by bending forward; shopping cart sign
- Test: bicycle test - rarely provokes neuroenic claudication
- Treatment
- non-op/conservative: spinal epidural steroid injections due to presence of multiple comorbidities
- decompression - laminectomy only if non-op treatment failed
What does this patient suffer from?
Spinal Stenosis (narrowing of the spinal canal)
typical shopping cart sign: neurogenic claudication – back and leg pain precipitated by standing for short periods of time (10-15min) but is relieved promptly by bending forward
Who does Degenerative scoliosis usually affect?
Where is it most common? (1)
What is it caused by? (2-3)
What is the clinical prsentation of it? (3)
- middle aged or elderly
- common in the lumbar spine
- caused by lateral listhesis + wedging/lateral tilt of the vertebra and slight rotation of the vertebral body
- Clinical presentation
- activity-related mechanical back pain (axial + referred)
- radicular pain
- spinal stenosis
A 35-year-male presents with pain radiating down the left leg, worse in the anterior leg distal to the knee. On physical exam, he is unable to go from a sitting position to a standing position with a single leg on the left, whereas he has no difficulty on the right. His patellar reflex is absent on the left, and 2+ on the right. Which of the following clinical scenarios would best produce this pattern of symptoms
Left L4-5 foraminal herniated nucleus pulposus
A 71-year-old male presents with bilateral leg pain for the last two years. His pain is exacerbated when walking and is relieved when his sits or bends forward. He notes occasional periods where his legs feel weak, but motor examination reveals 5/5 motor strength throughout his bilateral lower extremities. He has diminished sensation on the medial aspect of his feet bilaterally. Management thus far has included NSAIDS with occasional narcotic usage, physical therapy, and two epidural steroid injections. He feels his pain is substantially worse than it was one year ago. What does he have and what is the most appropriate management at this time?
He has degenerative spondylolisthesis
Posterior L4-5 decompression with instrumented fusion of L4-5
is this helpful?
hopefully.
