B18 Spinal Degeneration

Question 1

What is the story of the progression of disc degeneration and how it affects the facets?

Answer 1

1. Annular fibers tear which may or may not cause Sx
2. Disc begins to degenerate — loses hydrostatic properties and flattens out
3. Load shifts to facets and leads to DJD and possible facet syndrome (which may or may not cause Sx)

Question 2

What is the structural degenerative cascade of the disc

Answer 2

• Micro trauma from eccentric and torsional loading
• Leads to circumferential tears of inner and then outer annular fibers
• Fibers separate from vertebral endplate and blood supply and nutrition is interrupted to the IVD
• Proteoglycan breakdown, loss of hydrostatic properties, and disc heigh loss

Question 3

The nucleus pulpous becomes more susceptible to degradation with what 2 things?

Answer 3

Smoking and vibration

Question 4

Why is spinal degeneration by itself often NOT an appropriate Dx in most cases?

Answer 4

Often patients achieve complete resolution of Sx while the spinal degeneration remains unchanged.

Question 5

Describe the degenerative cascade as explained by Kirkaldy-Willis and Burton in 1992 and include possible dx in each stage

Answer 5

1. Dysfunction phase: no sx, derangement, herniation, facet syndrome
2. Instability phase: no sx, degenerative spondylolisthesis, structural instab
3. Stabilization phase: no sx, osteophyte radicular syndromes, degenerative facet syndrome, osteoarthritis, spinal stenosis

Question 6

If degenerative joint or degenerative disc disease is the cause of pain, what is diagnosis is used?

Answer 6

Osteoarthritis
Spondylitis
Degenerative joint disease
Degenerative disc disease

Question 7

What is the association between osteoarthritis symptoms and osteoarthritis radiographic changes in the hip according to Birrell’s 2005 hip study?

Answer 7

Mild/moderate changes are very frequent and not related to pain. Severe changes is rare, but strongly related*

*Except in young males where there is a weaker correlation.

In other words: treat the patient, NOT the xray

Question 8

What are the possible roles of degeneration in a patient’s case?

Answer 8

• it may be underlying factor that amplifies Sx or makes patient more susceptible to injury
• it may affect duration of care
• it may affect management strategy

Question 9

What are the 4 scenarios when degeneration may be the primary diagnosis?

Answer 9

1. Spinal stenosis
2. Instability
3. Spondylotic compression of nerve root
4. Osteoarthritis

Other times you can cite it as a co-factor e.g. “cervical facet syndrome and joint dysfunction complicated by moderate DJD”

Question 10

List the 4 degeneration scenarios that can be the primary diagnosis for the CERVICAL spine in order of commonality:

Answer 10

1 spur/osteophyte
2 stenosis
3 instability
4 osteoarthritis

Question 11

What does spondylotic compression refer to?

Answer 11

Spur/osteophyte

Question 12

List the 4 degeneration scenarios that can be the primary diagnosis for the LUMBAR spine in order of commonality:

Answer 12

1 spinal stenosis
2 instability
3 osteoarthritis
4 spondylotic compression of NR

Question 13

What are some signs and Sx associated with cervical osteoarthritis?

Answer 13

• Neck pain, sometimes scapular ache
• SX worse in the AM, PM and with activity
• Chronic FHP (forward head position)
• Reduced global ROM
• Associated with morning stiffness lasting <30 minutes
• If atlas involved, head rotation reduced due to stabbing pain
• Radiographic evidence of degeneration

Question 14

Tell me about the reduced global ROM that someone with cervical osteoarthritis might have

Answer 14

Painless stiffness and crepitus that spares flexion

Question 15

What are some unusual Sx of cervical osteoarthritis?

Answer 15

• Cervicogenic dizziness/vertigo
• Dysphagia
• pupillary signs
• ear symptoms relieved by traction
• pseudoangina