Cervicothoracic Spine V Flashcards
What is acute internal disc derangement due to?
Trauma
What is acute internal disc derangement?
Annular end plate tear
Acute herniations (LEAST COMMON)
Disc changes due to numerous variables allow herniations to ____________ develop over time
Gradually
Most common internal disc derangement type is?
Chronic or persistent
What are the components of the intervertebral disc?
Annulus (inner and outer)
Nucleus pulposus
End plate
Body
What is the most innervated part of the annulus?
The outer annuluus
What collagen type is greater in the outer annulus? Why?
Type I to resist tension
What type of collagen increases into the nucleus of the annulus? Why?
Type II to resist compression
What does the annulus stabilize like?
A ligament
Are the annulus and nucleus very distinct in a healthy disc?
No
The annulus has concentric rings with ______ fibers?
Layered/overlapping
The annulus is avascular so it depends on what?
Diffusion
Depends on movement compression and decompression
Can compression produce tension and vice versa?
YES
think of a water balloon sides get tense with force
tension can create compression (ex- rotating towel and hands get closer)
The majority of fibers in the annulus are where?
deeply embedded into end plate
What does the nucleus do?
Resists compression
high # of GAGs for hydrostatic pressure
What is the nucleus made up of?
Dense connective tissue
Does the nucleus have innervation?
No avascular and aneural
Do the annulus and nucleus move as a unit?
Yes normally
Movement can cause deformation but not migration of nucleus
Is the vertebral end place innervated? Vascular?
Highly innervated and vascularized
What does the vertebral end plate do?
assists with nutrient diffusion for disc
What does the vertebral end plate cover?
Covers nucleus and MOST of annulus
What types of cartilage is the vertebral end plate made up of?
Articular cartilage (Type II) towards vertebral body
Fibrocartilage (Type I) towards disc
What type of collagen is the vertebral body?
Bone - type I collagen
Is persistent or acute IDD more common?
Persistent
Where is IDD rare?
Thoracic spine (<1% all disc herniations)
C2-6 region due to stability from U joints
Where is the most common area for IDD on the disc? Why?
Posterolateral portion of disc
Weaker thinner and more vertical with less oblique annular fibers
What are the most common structures involved with acute IDD? less common?
Outer annular tearing and end plate avulsion
Less commonly inner annular tearing and nucleus pulposus herniation
Disc structures are _________ once damaged
Immunoreactive
What kind of immune response do we expect with IDD?
Large auto immune inflammatory response
What happens with the inflammatory response with IDD?
Excessive osmotic pressure or static fluid pressure in and around disc and spinal nerve
Radiculopathy/radicular s&s
extended inflammatory phase
(static fluid consists of increased inflammatory chemicals that sensitizes spinal nerve and structures to pressure/tension )
What are some typical postlateral IDD symptoms?
Dull achy spinal pain
radiculopathy
referred pain
Why is the pain with postlat IDD dull and achy
Highly innervated outer annulus so very painful
What are the characteristics of radiculopathy with postlat IDD?
Possible segmental paresthesias within 24 hours into distal extremity
What does the presence of coldness with postlat IDD indicate?
Circulatory compromise
What are some typical postlat IDD symptoms?
Decreased pain upon unloading (lying down)
Increased neck pain and paresthesias looking down
Increased pain in AM due to pooling of swelling while sleeping
What would we find in our scan for postlat IDD?
all ROM may increase pain
FLX and possibly contralateral SB/Rot likely limited and increases extremity and spinal pain
Ext and possibly ipsilateral sb/rot less limited
Why would flexion and contralateral SB/Rot increase pain with postlat IDD?
Pressure pushing swelling toward sensitized spinal nerve
tension on annulus and endplate tear and dura
Why would ext and ipislateral sb/rot be less limited with postlat IDD?
May increase spinal pain due to increased hydrostatic pressure on disc with high osmotic pressure
May decrease pain esp with repetition by moving swelling away from spinal nerve
What is the centralization of symptoms?
Abolition of distal and/or spinal pain in a distal to proximal direction in response to repetitive motions or sustained positions
What would you find in your postlat IDD scan?
*resistance and MMT vary
*Possible positive stress tests with compression/distraction/PA pressures
*neuro tests possibly positive depending on severity
-myotomal fatigue
-DTR hyporeflexive
-diminished dermatomes
- positive dural mobility tests
What would we find in our biomechanical exam with postlat IDD?
Possibly positive stability tests
What can be done for acute IDD?
Mechanical diagnosis and therapy
-(mckenzie)
What is directional preference?
A position, motion, and/or factor that alleviates symptoms irrespective of location
What is cervical directional preference?
May be associated with centralization with the addition of decreasing severity and improving function
match up exercise and ADL positions
What can be helpful for acute IDD?
Intermittent traction
MET for tissue proliferation and stabilization particularly of local muscles
What is persistent IDD also known as?
Degenerative Disc Disease
Are age related disc changes always only due to age?
NO
What is the incidence of persistent internal disc derangement?
Lumbar more than cervical
Why is cervical persistent IDD more common?
Largest diameter in lower cervical spine bc of numerous innervations for lateral and posterior cord in brachial plexus
What is the most common site for persistent IDD?
C5,6 and the C6,7
C6 spinal nerve
What is the etiology of persistent IDD?
Acute IDD
sedentary lifestyle
genetics
Is persistent IDD quick or gradual?
Gradual
What happens to cause persistent IDD?
Lost GAGs so more fibrotic
more acidic disc
annular disorganization
modic changed
What are modic changes with persistent IDD? (changes seen on MRI)
Persistent bone marrow edema
- nociceptive fibers that lead to nociceptive pain
- excessive and destructive proteins and a low-grade infection likely enters disc
What does bone marrow do with persistent IDD?
changes from circulatory to fatty type
Now persistent herniations and nuclear migration ____________ develop per the miller classifications
Gradually
What is a protrusion?
Nucleus migrates but remains contained in annulus
What is the most common herniation?
Protrusion (buldge)
What is an extrusion?
Nucleus migrates through the outer annulus
What is free sequestration?
Nucleus migrates and breaks away from annulus
What likely develops where the nucleus migrates into the vertebral body as well?
Schmorl’s Nodes
What develops with persistent iDD?
Instability
disc space narrowing
joint space narrowing (greater load on facets)
foramen narrowing (stenosis may develop)
What are some signs and symptoms of persistent IDD?
Slow change allow tissues to adapt w/o symptoms for some time
Gradual onset of symptoms
- inner annulus is hyponeural and nucleus is aneural so wont produce much pain
What can be prescribed for persistent IDD?
Aggressive nonsurgical treatment
- intermittent traction
- specific therapeutic exercise
-oral anti-inflammatory medication
- pt education
What percentage of people with radiculopathy have good or excellent outcomes at 2 years?
70%
What percentage of people with radiculopathy have only mild symptoms at ~5 years?
90%
What are some CPR for radiculopathy?
Over 54 years old
non dominant UE affected
looking down does not worsen
more than 30 degrees of flexion
What can we do as PTs for radiculopathy?
Intermittent mechanical traction
multi-modal with MT and local muscle training
thoracic thrust manipulation
When is traction most effective for Acute and persistent IDD?
Following CPRs
added to other interventions such as exercise and MT
What is the negative outcome predictor for IDD?
Peripheralization
What is peripheralization associated with?
Mental distress/depression
non-organic signs (tumor)
pain behaviors
somatisation (conversion of anxiety into bodily symptoms)
fear of work
What can doctors do for IDD?
Antibiotics for infection
decompressive surgeries
- laminectomy
- partial disectomy
What can a cervical fusion do?
Increase adjacent segment motion at the levels above and below
What does a total disc replacement do?
unload facets superior to TDR and increased loading at level of TDR
