Spine- Thoracolumbar V- Persistent IDDs Flashcards
What is persistent IDD also known as?
- degenerative disc disease (DDD)
- Age-related Disc Changes (although not always due to age)
how can disc changes allow herniations?
Gradually develops over time due to numerous variables
Where is persistent IDD most common?
Lumbar region
What percentage of IDDs are symptomatic?
1-3%
Persistent IDD is the cause of 5% of what condition?
LBP
What age group is persistent IDD most prevalent in?
30-50 year olds
What segment is 95% of persistent IDD located in?
L4-S1
What is the etiology of persistent IDD?
- acute IDD
- Mixed findings with age
- Lower strength
- Sedentary lifestyle
- Heavier Occupational Lifting
- Smoking
- Genetics
Why can lower strength lead to persistent IDD?
Less stabilization, acute restraints take on more of the load progressively
What can a sedentary lifestyle lead to persistent IDD?
Structures break down with disuse; wont keep its integrity
Acute IDD is the only back condition that is _______?
Genetic
What is lumbar IDD associated with?
Age-related disc changes in cervical region
What percentage of persistent IDD is inheritance?
65-85% but can be modified by diet and lifestyle
What is persistent IDD NOT from?
- Routine loading/physical activities
- prolonged driving
What is beneficial for persistent IDD?
Routine loading
What is the pathogenesis of persistent IDD?
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
Why does persistent inflammation lead to persistent IDD?
- 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
What happens per the miller classifications once changes occur to the disc?
Persistent herniations and nuclear migration gradually develop
What are the categories of herniation per Miller?
- Protrusion (bulge)
- Extrusion
- Free Sequestration
What is a protrusion? (bulge)
- nucleus migrates but remains contained in annulus
What is the most common herniation?
Protrusion (bulge)
What is an extrusion?
- Nucleus migrates thru the outer annulus
What is free sequestration?
- Nucleus migrates and breaks away from annulus
What will develop where the nucleus migrates into the vertebral body?
Schmorl’s Nodes
Why can the disc with persistent IDD be not bright white on an x-ray?
persistent inflammation; not the same as an acute
Why can the initial changes of disc height and integrity as well as narrowing lead to instability/hypermobility?
- Joint space narrowing, greater load on facets
- stenosis may develop due to the neural foramen narrowing
What planes will joint hypermobility present in with persistent IDD?
sagittal and frontal plane motions, NOT in the transverse plane
What happens with later changes due to narrowing with persistent IDD?
- greater age related joint changes
- can less prior instability due to associated stiffening of joint
What is multiple levels of IDD?
Spondylosis
What allows the tissues to adapt without symptoms for some time?
SLOW change
What percentage of changes have a lack of symptoms with imaging?
2/3
What benefit is mechanical diagnosis and therapy (McKenzie)?
Short term benefit
What is mechanical diagnosis and therapy better for?
Placebo for pain but NOT function
What is mechanical diagnosis and therapy NOT superior to?
- Education
- Manual therapy and motion exercises
- Stabilization exercises
What do we need to consider even if imaging shows disc changes?
The primary driver of symptoms from the development of other conditions
- Instability?
- Stenosis?
- Age-related Joint Changes?
- Combinations?
What is a negative outcome predictor for acute and persistent IDD?
Peripheralizaiton
What does peripheralization have a significant association with?
- mental distress/depression
- pain behaviors
- somatisation
- fear of work
- non-organic signs
When is there worse outcomes regarding symptoms with acute AND persistent IDD?
symptoms present more than six months prior to any treatment, including surgery
What medications have conflicting and unclear benefits with acute and persistent IDD?
NSAIDS, muscle relaxants, acetaminophen
What can be prescribed for a large inflammatory response?
Steroid dose pack
What benefit do epidural injections have with persistent and acute IDD?
Short term but not long term relief or functional changes
What can benefit the potential infection source for IDD?
Antibiotic treatment
Waiting an average of 4 and a half months on surgery did what?
- did NOT minimize benefits of surgery
What can be better with surgery vs PT?
Earlier and improved benefit, particularly with severe acute IDD
What should we know about PT vs surgery?
Slower but the same overall outcomes without surgery after two years
What kind of surgery can help IDD?
- Spinal decompression
- laminectomy, partial discectomy
What can indicate a spinal decompression surgery?
- persistent and/or worsening radiculopathy
- symptoms unresponsive to non-surgical treatments
What surgery can be done with hypermobility/instability?
- Lumbar fusion
- Total disc replacement (TDR) with persistent IDD
Whats the difference between a lumbar fusion and PT?
- no difference in long-term outcomes with pain, health status, satisfaction, or disability
What is a Lumbar fusion not additive to?
- Laminectomy or discectomy
What can a lumbar fusion lead to?
Adjacent joint hypermobility/instability
What does a TDR with persistent IDD do with the segments?
Leads to a better load distribution across segments
When is a TDR a safe an effective treatment?
MORE than 5 years postoperatively
What is the difference between a TDR and PT?
- 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
