Acute to Persistent IDD - Done Flashcards
What is another name for persistent internal disc derangement?
- Degenerative disc disease
- Age- related disc changes (although not always due to age)
What is the incidence/ prevalence of persistent IDD?
1-3% of patients (directly related to the disc)
Disc changes that are formed by numerous variables allow for what to happen
Herniations (nuclear migration) to gradually develop over time
Chronic or persistent IDD is more or less common than acute IDD?
More common and is the most prevalent IDD and more often not the source of pain
Where is persistent IDD most commonly located and in what population?
- Most commonly in the lumbar region (95% at L5-S1)
- Only 1-3% of IDDs are symptomatic
- Persistent IDD is the source of pain in less than 5% of LBP
- Mostly 30-50 year olds
What is the etiology of persistent IDD?
- Acute IDD
- Mixed findings with age
- Lower strength
- Sedentary life style
- Heavier occupational lifting
- Smoking
- Genetics
Lumbar IDD is associated with what other issue?
Age-related disc changes in the cervical region
65-85% of genes are from inheritance but can be modified by what?
Diet and lifestyle
What etiologies do not lead to IDD?
- Not from routine loading/ physical activities
- Routine loading was beneficial
- Not from prolonged driving
What is the pathogenesis of the persistent IDD/ how are the disc and adjacent structures changing?
- Inflammation
- End plate changes
- Less GAGs
- Annulus break down
- Fibrotic changes
- Disc height loss
- Foramen narrowing
- Excessive stress that leads to hypermobility, stenosis, etc.
- Infection in the disc
- Fatty deposits
What is a gradual pathogenesis of persistent IDD (think getting sick)?
Persistent Inflammation
In- growth of nociceptive fibers from acute IDD healing can lead to what?
Nociplastic pain
What does persistent inflammation bring?
Excessive and destructive proteins (amyloidosis) and a low-grade infection likely enters the disc
What are the other gradual pathogenesis of persistent IDD?
- Less GAGs so more fibrotic and dehydrated nucleus
- More acidic disc that kills disc cells and limits proliferation
- Annular disorganization
- Thinning and loss of cartilage at the end plates
- Increased inflammation and fatty deposits in vertebrae (modic changes)
- Now persistent herniations and nuclear migration gradually developing per the miller classifications once changes occur with the disc
What are the categories of herniation?
- Protrusion
- Extrusion
- Free Sequestration
What is protrusion?
- Tongue pushing on cheek
- Nucleus migrates but remains contained in annulus
What is extrusion?
- Tongue pushing through hole in cheek
- Nucleus migrates through the outer annulus
What is free sequestration?
- Tongue getting cut off
- Nucleus migrates and breaks away from annulus
What is the most common type of herniation?
Protrusion
Where do schmorl’s nodes typically develop?
Likely develop where the nucleus migrates into the vertebral body as well
Narrowing is initially caused by what?
Changes related to loss of disc height and integrity
What might you find with narrowing?
- Instabiligy may develop
- Joint hypermobility noted during sagittal and frontal plane motions but not in the transverse plane
Joint space narrowing leads to what?
- Contributes to initial instability
- Greater load bearing on facets
Neural foramen narrowing leads to what?
Stenosis potentially developing
What are later changes that may come from narrowing?
- Greater age-related joint changes
- Can lessen prior instability due to associated stiffening of joint
Slow changes allow for tissues to what?
Adapt without symptoms for some time as indicated by lack of symptoms with imaged changes in 2/3 of individuals
Gradual onset with symptoms may be like what?
Acute signs and symptoms if inflamed … consider other conditions that may develop and other respective signs and symptoms
Mechanical diagnosis and therapy is an Rx that provides what?
- A short term benefit
- Better than placebo for pain but not for function
Mechanical therapy is not superior to what?
- Education
- Manual therapy and motion exercises
- Stabilization exercises
What do you need to consider when choosing an Rx for your patient with persistent IDD?
Need to consider primary driver of symptoms from the development of other conditions even if imaging shows disc changes (instability? stenosis? age related joint changes? combination?)
What is the negative outcome predictor of both acute and persistent IDD?
Peripheralization
Peripheralization has a significant association with what?
- Mental distress/ depression
- Pain behaviors
- Somatisation (aka nociplastic pain) … conversion of anxiety into bodily symptoms
- Fear of work
- Non-organic signs (ex: tumor)
There are worse outcomes for both acute and persistent IDD when symptoms present longer than what?
Six months prior to any treatment including surgery
What oral medications might you see with IDD?
NSAIDS, Muscle relaxants, and acetaminophen
Are oral medications beneficial for IDD?
- Conflicting and unclear benefits
- May be prescribed a steroid dose pack for large inflammatory response
What is an epidural injection used for with IDD?
Short term but not long term relief or functional changes
Why might antibiotics be used for IDD?
Antibiotic treatment benefits the potential infection source
What is the benefit of surgery for IDD?
- Waiting an average of 4.5 months on surgery did not minimize benefits of surgery
- Some studies demonstrated earlier and improved benefit with surgery versus PT, particularly with severe acute IDD
- Slower but the same overall outcomes without surgery after two years
What kind of surgeries might be done?
Spinal decompression such as a laminectomy or a partial discectomy (you will lose stability with these!!)
What are indications of spinal decompressions?
- Persistent and/ or worsening radiculopathy
- Use when symptoms are unresponsive to surgical treatments
What surgeries can you preform when hypermobility/ instability is present?
- Lumbar fusion
- Total disc replacement (TDR) with persistent IDD
Are lumbar fusions beneficial?
- No difference versus PT in long term outcomes with pain, health status, satisfaction, or disability
- Not additive to laminectomy or discectomy
- May lead to adjacent joint hypermobility/ instability
Are total disc replacements (TDR) with persistent IDDs beneficial?
- Better load distribution across segments
- Safe and effective treatment more than 5 years postoperatively
- At 2 years follow up, no difference compared to PT alone without radiculopathy for in return to work, life satisfaction, fear avoidance behavior, drug use, back performance
