DDD, herniations part 1 Flashcards
radiology of DDD
decreased disc height osteophyte formation endplate sclerosis vacuum phenomenon subluxation (retrolisthesis)
spondylosis deformans are marked by what?
osteophytes
what part of the disc is associated with spondylosis deformans
outer disc
intervertebral chondrosis is marked by what?
reduced IVD space
what part of the disc is associated with intervertebral chondrosis?
inner disc
what is intervertebral disc osteochondrosis?
primary degeneration of the nucleus pulposus
loss of disc height with minimal osteophytes
intervertebral disc osteochrondrosis has what radiographic feature?
Knutson’s vacuum phenomenon
what is knutson’s vacuum phenomenon?
radiolucent collections of nitrogen gas within annular fissures
where is vacuum phenomenon best seen?
anterior margin of IVD on extension films
normally seen in synovial extremity joints under slight distraction
what is spondylosis deformans?
degeneration of the annulus with prominent osteophytes
what is osteophytosis due to?
breakdown at the site of attachment of the outer annular fibers, including Sharpey’s fibers to the vertebral margin
in osteophytosis, how do the osteophytes grow?
develop at the stressed areas of the ALL and keep going horizontally
what ligaments does osteophytosis sterss?
vertebral attachment of ALL
does osteophytosis fuse?
not usually
what are the common signs and symptoms of cervical spondylotic myelopathy?
clumsy or weak hands leg weakness or stiffness neck stiffness pain in shoulders or arms unsteady gait atrophy of hand musculature hyperrefleia lhermitte's sign sensory loss
what are intercalary ossicles?
annulus degeneration
NOT fractured osteophytes
what does endplate sclerosis indicate?
infraction, compression and necrosis of stressed subchondral bone trabeculae
modic type 1 (which MRI? what does it indicate?)
dark T1
bright T2
indicates inflammation (bone marrow edema)
modic type 2 (which MRI? what does it indicate?)
bright T1
bright T2
indicates fat
modic type 3 (which MRI? what does it indicate?)
dark T1
dark T2
indicates sclerosis
what needs to be present to be considered modic changes?
DDD
what does it indicate when no modic changes to modic type 1?
more likely hypermobile
what does it indicate when modic type 1 goes to modic type 2?
more stable
modic type 2 going to modic type 1 or modic type 2 going to no modic indicates what?
unstable or infection
type one modic changes are more common in what part of the spine?
cervical
type 2 modic changes are more common in what part of the spine?
lumbars
Schmorl’s nodes
abrupt, focal, radiolucent IVD displacement into the cancellous bone of the adjacent vertebra
who do schmorl’s nodes typically occur in?
young children, little significance
if in adults, could represent clinically significant endplate infractions/fractures
criteria to be scheuermann’s disease
at least 3 vertebra with disc space narrowing
endplate irregularity
wedging of 5 degrees or more
who normally gets scheuermann’s disease?
adolescent onset (13-17)
what disease may result in pain, cosmetic deformity and premature DDD?
scheuermann’s disease
what is juvenile discogenic disease?
thoracolumbar scheuermann’s disease
what is the etiology of juvenile discogenic disease?
appears to be failure of embryologic vascular channels, centrum defects, and notochord clefts to disappear, leaving endplate defects
juvenile discogenic disease produces what pathologies?
early degeneration
segmental dysfunction
associated pathology in facet joint
posterior subluxations are primarily associated with what?
DDD (principally the annulus)
anterior subluxation are primarily associated with what?
posterior joint arthrosis (degenerative spondylolisthesis
describe degeneration of the cervical spine
most common at C5/6 decreased disc height posterior and anterior vertebral body osteophyte formation posterior joint arthrosis uncovertebral arthrosis intercalary ossicles
describe uncovertebral degeneration
within 3-7th cervical levels most commonly middle to lower cervical spine bulbous osteophytes (frontal projection) pseudofracture (lateral projection) may encroach IVF
describe zygapophyseal degeneration (facet arthrosis)
where?
x ray findings
where is neurological involvement demonstrated?
MC lower lumbar, middle cervical and upper throacic spine
xray is characterized by increased radiodensity and irregularity, hypertrophic changes, and osteophytes
neurological involvement is demonstrated on axial imaged of CT and MRI
baastrup’s disease
when the spinouses can touch (kissing spine disease)
how can chiro help in degeneration?
assist function
how can pharma help in degeneration?
decrease inflammation
how can surgery help in degeneration?
joint replacement
how can social support help in degeneration?
decrease stress, increase social function
how can physiotherapy help in degeneration?
increase circulation, decrease pain
where is the source of pain in degeneration?
distention of joint capsule contracture of joint capsule muscle spasms periosteal elevation direct pressure on subchondral bone
what are the consequences of degeneration?
loss of muscle strenght decreased ROM limited function crepitus joint effusion depression/anxiety
what is DISH?
exuberant hypertrophic changes involving the anterior vertebral body margins
symptoms/signs of DISH
very common males over 50 incidence among diabetics may be asymptomatic neck stiffness dysphagia in 20% hoarseness
where does DISH occur?
ALL of middle and lower thoracic, upper lumbar and lower cervical regions
define entheseopathy
pathological osseous proliferation at tendon or ligament insertion
it is degenerative and inflammatory
what are the radiographic signs you would see with DISH
flowing ossification of the anterior vertebral body margins with ankylosis
preservation of disc height (or minimal evidence of disease)
absence of sacroiliits (excludes AS)
what is OPLL?
ossification of the PLL, seen as a radiolucent line along the posterior aspect of the vertebral bodies
what can OPLL be associated with?
DISH, but doesn’t have to
what can OPLLr result in?
loss of sagittal diameter of spinal canal, with resultant myelopathy
OPLL is present in __% of DISH patients.
40-50%
what are signs and symptoms of OPLL?
abnormalities are insidious
sensory and motor disturbances in the legs
progressive difficulty walking
paresthesias and diminished tactile senses over gradually increasing areas
what is a common treatment of OPLL?
laminectomy
if you see someone who has OPLL, what do you do?
send them for a neurosurgical consult
MR, CT
do NOT adjust
what are indications for imaging (MRI)?
true radicular symptoms evidence of NR irritation failed conservative treatment surgical candidate red flags
prevalence of disc herniations are similar in who?
low back pain and radiculopathy patients
radiculopathy patients are more likely to have what?
extrusions and nerve root compression
is there a correlation between severity of disease and function and apin?
no
who usually has a better sense of health?
patients who were blinded
red flags for potentially serious conditions
features of cauda equina syndrome significant trauma weight loss history of cancer fever IV drug use steroid use patient age over 50 years severe, unremitting night-time pain pain that gets worse when patient is lying down
what aer the most common complaints of people with herniations?
back pain
worse with sneezing, flexion, sitting and bowel function
only __% of back pain patients suffer from a disc herniation
5%
what is the prevalence of herniations among the asymptomatic patients?
20-35%
what are some predictive factors of herniations if they don’t have symptoms?
lesion size and direction
canal size, ligamentum flavum hypertrophy
temporal/phase of herniation
what is the prognosis of a herniation?
good
what is the most serious complication of a herniation?
cauda equina syndrome
what is cauda equina syndrome?
one of the most serious complications of disc herniations
herniated discs do what to nerves that cause cauda equina syndrome?
compress multime nerve roots
what are the symptoms of cauda equina syndrome? what do you do?
altered bowel and bladder function impotence saddle paresthesia progressive muscle atrophy immediate neurosurgical consultation
what are some examples of aggressive management of disc herniations?
percutaneous discectomy microdiscectomy discectomy (MC) laminectomy chemonucleolysis
surgery foe a disc herniation is considered if…
there is cauda equina syndrome
lack of progress with conservative care
muscle atrophy
too much pain
what are some forms of conservative care for disc herniations?
chiropractic limited bed rest drugs injections physical therapy acupuncture
midline disc herniations in the cervical spine cause what?
myelopathies
lateral disc herniations in the cervical spine cause what?
compresses the NR below
midline/paracentral herniations in the lumbar spine do what?
compress NR below
foraminal disc herniation in lumbars involve what?
compression of the nerve root at the same level
what is the best imaging for disc herniations?
MRI
what is the function of the IVD?
nucleus and annulus work together to dampen forces
what does proper function of the disc depend on?
integrity of the compoenets of the disc
stability of annulus
hydration of nucleus
separation offered by endplates
describe the pathway that leads to injury of the nucleus of a disc?
decreased oxygen–>decreased chondrocytes–>decreased proteoglycans–>decreased water–>increased annular stress–>increased annular fissures
the natural cohesion of the nucleus is denatured by what?
endplate fractures and blood exposure
what are the contents of the spinal canal?
thecal sac (cord, cauda equina) epidural fat internal vertebral plexus ligamentum flavum PLL
