DEGENERATIVE DISC DISEASE, PIVD

1. Moderator : Dr Munin Borgohain
(Professor and HOD)
Presenter: Dr Imran Hussain Kabir
(2nd Year PGT)

2. ANATOMY OF SPINE

3. INTERVERTEBRAL DISC

5. • Annular tear :
1.Radial tear
2.Circumferential tear
3.Peripheral rim tear
• Facet joint degeneration:
-Thinning of facet cartilage causes capsular ligament laxity.
- As the disease progresses, increased stress applied posteriorly.
- which accelerates Facet Osteoarthrosis.

6. • Changes in nucleus pulposus and vertebral end plates signals the
molecular degenerative process.
• Nucleus pulposus(Notochordal cells) believed to stimulate and
maintain regenerative process.
• Notochordal cells stimulte proteoglycan production, release of
soluble mediators.
• Dissapearance of Notochordal cells remove necessary stimulus to disc
health.
• Disk enzymes including cathepsin, lysozyme, aggrecanase and MMPs
participates in disk degeneration process.

7. 1. AGING:
• conc of cells declines
• Rate of synthesis and conc of Proteoglycans decreases.
• Conc of Chondroitin sulfate falls( leads to increase KS/CS)
• Collagen type2 replaced by type1, vulnerable to calcification.
• Noncollagenous protiens increase.
• Nucleus becomes solid, dry and granular.

8. 2. GENETIC FACTORS:
• Stongest factors leads to symptomatic DDD.

9. 3. MECHANICAL FACTORS:
• Vibration:
- when matches resonant frequency of lumbar spine(4-6Hz)
• Torsion:
- Due to criss cross arrangement of fibres in annulus.
- For fibres to incur damage, they must be elongated by >4% of their
resting length
- It requires an axial rotation of >3 degree

10. • COMPRESSION:
- Excessive loading leads to
reducing gene expression of all
anabolic protiens.
- Excessive compression results in
endplate fracture leads to
degeneration.
-Schmorl’s nodes ( disc protrussion
into adjacent vertebral bodies),
seen in adolescent kyphosis

11. 4. NUTRITION:
- Disc relies on diffusion for its nutrition.
- Pumps water and nutrients into the disc.
-Calcification of endplates occludes the vascular opennings
-Smoking cause constriction of arterioles or anoxia(CoHb) ,
A/w disc herniation.
- Atheromatous lesions lead to insufficient blood supply.
5. METABOLIC DISORDER:
-Interfering matrix synthesis or diposition of foreign materials
-Diabetes mellitus
-Alkaptonuria

12. 6. LOW GRADE INFECTION:
- Propionibacterium acne
7. NEUROGENIC INFLAMMATION:
-Antidromic release of substance P produce degeneration
8. AUTOIMMUNE THEORY

13. • LOSS OF PROTEOGLYCAN:
- Reduce GAGs and water holding capacity
-Reduce osmotic pressure of disc capacity
• LOSS OF COLLAGEN FIBERS:
-Type2 collagen more denatured, replaced by type1.
• INCREASE FIBRONECTIN:
-Downregulate aggrecan synthesis, upregulate MMPs.
• ENZYMATIC ACTIVITY:
-Cathepsin, MMPs, aggrecanase.

14. CLINICAL PRESENTATION :
• Pain in neck,loss of sensation in upper limbs, weakness of discrete
muscle groups.
• localize axially to neck and paraspinal region involving trapezius.
• Sudden, acute,intense, radicular pain seen with disc herniation.
• wide based gait with frequent loss of balance.
• Sensory findings- loss of proprioception, difficulty in buttoning
clothes, changed handwriting , dropping objects.
• Hyperreflexia suggests spinal cord compression with UMN signs.

16. DIFFERENTIAL DIAGNOSIS:
• Multiple sclerosis
• NPH
• Transverse myelitis
• CNS tumour
• Meningitis/encephalitis
• Peripheral nerve compression disorder
• Myelopathy due to Vit B12 deficiency
• ALS
• GBS

17. IMAGING:
• Plain radiograph: AP, Lateral,
Flexion-extension views.
• MRI: cord pathologies and
compression.
• CT Myelography: patient who
can’t undergo MRI

18. CONSERVATIVE MANAGEMENT:
• Lifestyle modification, short period of immobilization
• Short period of rest, ice,
• Anti inflammatory (NSAIDs, COX-2 Inhibitors, Glucocorticoids)
• Gabapantine, Amitriptyline, Nortriptyline for radicular pains
• Physiotherapy
• Trigger point injction, epidural injection,
• Medial branch block, RFA

19. INDICATIONS :
• Failure of non operative pain management
• Increasing and significant neurologic deficit
• Cervical myelopathy
ANTERIOR CERVICAL SPINE SURGERY:
1. Anterior cervical discectomy and fusion(ACDF)
2. Anterior cervical corpectomy and fusion (ACCF)
3. Cervical discectomy with arthroplasy
- Hybrid procedures using a combination of ACDF and ACCF are common
- The success(Decompression) and fusion rates after single level ACDF are high,
commonly done in younger patients

20. - For multilevel fusions and decompression, success rates are good,
- But the rate of non union increases with increase in the number of
levels.
- Anterior cervical corpectomy and fusion allows wider decompression.

21. Arthroplasty preserves motion at the segment maintaining normal
biomechanics.
• COMPLICATIONS of anterior surgery:
- Post op dysphagia
- Hoarseness in voice
-vertebral artery injury
-Implant related problem(Screw plate disengagement, cage
displacement, breakage of implant, failure)
-Graft related problem (Graft resorption,
expulsion,nonunion,migration)

22. POSTERIOR SURGERY
• Preferred in patients with short neck, obesity, barrel chest,h/o
previous anterior cervical surgery.
• Laminectomy or Laminoplasty used for spinal cord decompression
• Laminectomy has been regarded as standard treatment for multilevel
cervical degenerative disease with cord compression.
• Laminoplastyis performed in stable cervical spine with good lordosis
and minimal neck pain
• COMPLICATION:
-Loss of range of motion
-New onset kyphosis
-Neck pain, Delayed C5 nerve palsy.

23. • Midline back pain and referred pain over SI joint and posterior thigh.
• Aggrevated on ambulation
• Pain doesn’t radiate below knee
• Painfull range of motion
• LBP is associated with
- Disc space narrowing
- Radial disc fissure
-Disc prolapse

24. • Plain radiograph shows:
-variable degree of spondylosis
-Disc space collapse
- End plate sclerosis
-Marginal osteophytes
-Facet hypertrophy

25.  MRI : Modic classification of
degenerative end plate and
vertebral body MRI changes
-Type 1 modic changes : Acute
vertebral body and end plate
inflammation
- Type 2 modic changes: End plate
disruption and fatty degeneration
of adjacent vertebral body
- Type 3 modic change : End plate
sclerosis and loss of vertebral
cancellous bone

26. 1. PROVOCATIVE DISCOGRAPHY :
GS in confirming the diagnosis of discogenic pain,
used as a confirmatory test to evaluate the vertebral level
• 2 components:
- Provoke the concordant pain ( awake patient ) by pressurizing the
disc with a contrast materials
- Painless discogram in the adjacent discs.

27. 2. GADOLINIUM-DTPA-ENHANCED MRI :
Gd increases visibility of granulation tissue that forms within healed full thickness
annular tear

28. A. NON SURGICAL MEASURES:
-Responds to >90% patients.
- Comprises multidisciplinary approach:
• Education
• Rehabilitation
• Medications - NSAIDs, COX-2 Inhibitors, Muscle relaxants
• Physiotherapy
• Facet joint injection and medial branch nerve block
• Facet denervation by Radiofrequency dorsal neurotomy
• Intradiscal electrothermal therapy(IDET)

29. B. SURGICAL MEASURES
INDICATION:
-Failure of aggressive conservative treatment
- Prolong chronic pain, disability >1 year
- Advanced disc degeneration ( on MRI) limited to 1or 2 disc levels.
SURGICAL METHODS:
 FUSION (ARTHRODESIS)
 Artificial TDR
 Dynamic Stabilization

30. -Spinal fusion involves use of autograft( ileac crest or
lamina),
allograft, Demineralized bone matrix(DBM),
ceramics,Bone Morphogenic protien(BMP)
 ANTERIOR LUMBER INTERBODY FUSION (ALIF):
- Spine is approached anteriorly
- Removes large portion of annulus and ALL
-Better restoration of disc height
-in standalone procedure ,complication rates high
-High non union rate, revision rate, vessel damage,
retrograde ejaculation

31.  POSTERIOR LUMBER INTERBODY
FUSION(PLIF):
- Inserting a cage filled with bone graft or
bone substitutes with addition of pedicle
instrumentation
-It includes increased need for neural
manipulation, high rates of cage
subsistence, cage
migration,retropropulsion.

32.  TRANSFORAMINAL LUMBER INTERBODY
FUSION:
-Cage is introduced unilaterally through
intervertebral foramen.
-Avoiding exposure of the spinal canal
 EXTREME LATERAL APPROACH
 CIRCUMFERENTIAL FUSION
 BONE MORPHOGENIC PROTEIN(BMP):
-rhBMP used as a substitute for autogenous
iliac crest bone graft
-Induce lumber fusion rate, reduce donor
morbidity.
-rhBMP-2 and rhBMP-7 are used

33. INDICATION:
-Failure of aggressive conservative treatment involving
1 or 2 disc of lower lumber spine.
C/I:
-Lumber spinal stenosis, Facet disease,
old fractures, previous laminectomy,osteoporosis,
infection.
 Unconstrained (Charite): Two concave metal end plates
and an unconstrained biconvex polythylene core
 Semiconstrained(ProDisc): Two metal end plates-
concave polythylene inlay and metal convex articulating
surface

34. DYNAMIC STABILIZATION
INDICATION:
• LBP due to early disc degeneration
• To stabilize degenerative spondylolisthesis or
scoliosis following Decompression
laminectomy
• To protect disc against further degeneration
- Aim is to stabilize while while restricting
painful motion .
-The device most studied are :
• The Graf
• The Dynesys