Spine- Thoracolumbar V- Persistent IDDs

Question 1

What is persistent IDD also known as?

Answer 1

• degenerative disc disease (DDD)
• Age-related Disc Changes (although not always due to age)

Question 2

how can disc changes allow herniations?

Answer 2

Gradually develops over time due to numerous variables

Question 3

Where is persistent IDD most common?

Answer 3

Lumbar region

Question 4

What percentage of IDDs are symptomatic?

Answer 4

1-3%

Question 5

Persistent IDD is the cause of 5% of what condition?

Answer 5

LBP

Question 6

What age group is persistent IDD most prevalent in?

Answer 6

30-50 year olds

Question 7

What segment is 95% of persistent IDD located in?

Answer 7

L4-S1

Question 8

What is the etiology of persistent IDD?

Answer 8

• acute IDD
• Mixed findings with age
• Lower strength
• Sedentary lifestyle
• Heavier Occupational Lifting
• Smoking
• Genetics

Question 9

Why can lower strength lead to persistent IDD?

Answer 9

Less stabilization, acute restraints take on more of the load progressively

Question 10

What can a sedentary lifestyle lead to persistent IDD?

Answer 10

Structures break down with disuse; wont keep its integrity

Question 11

Acute IDD is the only back condition that is _______?

Answer 11

Genetic

Question 12

What is lumbar IDD associated with?

Answer 12

Age-related disc changes in cervical region

Question 13

What percentage of persistent IDD is inheritance?

Answer 13

65-85% but can be modified by diet and lifestyle

Question 14

What is persistent IDD NOT from?

Answer 14

• Routine loading/physical activities
• prolonged driving

Question 15

What is beneficial for persistent IDD?

Answer 15

Routine loading

Question 16

What is the pathogenesis of persistent IDD?

Answer 16

Gradual
- persistent inflammation
- 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 end plates
- Increased inflammation and fatty deposits in vertebra

Question 17

Why does persistent inflammation lead to persistent IDD?

Answer 17

• in growth of nociceptive fibers from acute iDD > healing can lead to nociplastic pain
• Brings excessive and destructive proteins and a low grade infection enters disc

Question 18

What happens per the miller classifications once changes occur to the disc?

Answer 18

Persistent herniations and nuclear migration gradually develop

Question 19

What are the categories of herniation per Miller?

Answer 19

• Protrusion (bulge)
• Extrusion
• Free Sequestration

Question 20

What is a protrusion? (bulge)

Answer 20

• nucleus migrates but remains contained in annulus

Question 21

What is the most common herniation?

Answer 21

Protrusion (bulge)

Question 22

What is an extrusion?

Answer 22

• Nucleus migrates thru the outer annulus

Question 23

What is free sequestration?

Answer 23

• Nucleus migrates and breaks away from annulus

Question 24

What will develop where the nucleus migrates into the vertebral body?

Answer 24

Schmorl’s Nodes

Question 25

Why can the disc with persistent IDD be not bright white on an x-ray?

Answer 25

persistent inflammation; not the same as an acute

Question 26

Why can the initial changes of disc height and integrity as well as narrowing lead to instability/hypermobility?

Answer 26

- Joint space narrowing, greater load on facets - stenosis may develop due to the neural foramen narrowing

Question 27

What planes will joint hypermobility present in with persistent IDD?

Answer 27

sagittal and frontal plane motions, NOT in the transverse plane

Question 28

What happens with later changes due to narrowing with persistent IDD?

Answer 28

- greater age related joint changes - can less prior instability due to associated stiffening of joint

Question 29

What is multiple levels of IDD?

Answer 29

Spondylosis

Question 30

What allows the tissues to adapt without symptoms for some time?

Answer 30

SLOW change

Question 31

What percentage of changes have a lack of symptoms with imaging?

Answer 31

2/3

Question 32

What benefit is mechanical diagnosis and therapy (McKenzie)?

Answer 32

Short term benefit

Question 33

What is mechanical diagnosis and therapy better for?

Answer 33

Placebo for pain but NOT function

Question 34

What is mechanical diagnosis and therapy NOT superior to?

Answer 34

- Education - Manual therapy and motion exercises - Stabilization exercises

Question 35

What do we need to consider even if imaging shows disc changes?

Answer 35

The primary driver of symptoms from the development of other conditions - Instability? - Stenosis? - Age-related Joint Changes? - Combinations?

Question 36

What is a negative outcome predictor for acute and persistent IDD?

Answer 36

Peripheralizaiton

Question 37

What does peripheralization have a significant association with?

Answer 37

- mental distress/depression - pain behaviors - somatisation - fear of work - non-organic signs

Question 38

When is there worse outcomes regarding symptoms with acute AND persistent IDD?

Answer 38

symptoms present more than six months prior to any treatment, including surgery

Question 39

What medications have conflicting and unclear benefits with acute and persistent IDD?

Answer 39

NSAIDS, muscle relaxants, acetaminophen

Question 40

What can be prescribed for a large inflammatory response?

Answer 40

Steroid dose pack

Question 41

What benefit do epidural injections have with persistent and acute IDD?

Answer 41

Short term but not long term relief or functional changes

Question 42

What can benefit the potential infection source for IDD?

Answer 42

Antibiotic treatment

Question 43

Waiting an average of 4 and a half months on surgery did what?

Answer 43

- did NOT minimize benefits of surgery

Question 44

What can be better with surgery vs PT?

Answer 44

Earlier and improved benefit, particularly with severe acute IDD

Question 45

What should we know about PT vs surgery?

Answer 45

Slower but the same overall outcomes without surgery after two years

Question 46

What kind of surgery can help IDD?

Answer 46

* Spinal decompression - laminectomy, partial discectomy

Question 47

What can indicate a spinal decompression surgery?

Answer 47

- persistent and/or worsening radiculopathy - symptoms unresponsive to non-surgical treatments

Question 48

What surgery can be done with hypermobility/instability?

Answer 48

- Lumbar fusion - Total disc replacement (TDR) with persistent IDD

Question 49

Whats the difference between a lumbar fusion and PT?

Answer 49

* no difference in long-term outcomes with pain, health status, satisfaction, or disability

Question 50

What is a Lumbar fusion not additive to?

Answer 50

- Laminectomy or discectomy

Question 51

What can a lumbar fusion lead to?

Answer 51

Adjacent joint hypermobility/instability

Question 52

What does a TDR with persistent IDD do with the segments?

Answer 52

Leads to a better load distribution across segments

Question 53

When is a TDR a safe an effective treatment?

Answer 53

MORE than 5 years postoperatively

Question 54

What is the difference between a TDR and PT?

Answer 54

- no differences at 2 years follow up compared to PT alone without radiculopathy for in return to work, life satisfaction, fear avoidance behavior, drug use, back performance