Natural History of the Aging Spine Jean-Pierre C. Farcy, MD. Frank J. Schwab, MD. NICE  Spine Course 2007
Stages Of Human Development
 
Importance of the Sagittal Plane <ul><li>The Thoracic Curve </li></ul><ul><li>The Sacral Curve </li></ul>Two Structural Cu...
Importance of the sagittal plane The four curves in the sagittal plane endure 16 (4x4) times more resistance to load than ...
The Spine Range of Motion (ROM) <ul><li>250 degrees between the two extremes </li></ul><ul><ul><li>In hyperextension </li>...
The Spine Range of Motion (ROM)
The PELVIS <ul><li>The discovery in Ethiopia by Latimer of the anthropoid fossil (1974) parts belonging to “Lucy” substant...
Pelvic Differences in Association with Spine Curvatures <ul><li>The permanence of “status erectus” requires a modification...
Pelvic Differences in Association with Spine Curvatures <ul><li>Pelvis and spine are so intimately associated that it is  ...
Chimpanzee. Lucy. Homosapien.
Relationship Between PI and Lumbar Lordosis <ul><li>High PI angle   </li></ul><ul><ul><li>High lordosis angle </li></ul></...
Pelvic Incidence
 
The Spine As A Whole   <ul><li>Is a very flexible structure </li></ul><ul><ul><li>Multi segments structure  </li></ul></ul...
This sketch shows that resistance to loads depends on  muscle strength. Muscle tone of the same muscle groups insure balan...
The load sharing of the posterior muscles from the spine to pelvis and femoral bone carry the lion’s share.
Schematics of Spine and Body Balance Schematic of spine and body balance
<ul><li>Discs </li></ul><ul><ul><li>Must keep their anatomical integrity.  </li></ul></ul><ul><ul><li>Must keep their heig...
How to Maintain Good Posture and Good Balance <ul><li>Muscle distribution In the back </li></ul><ul><ul><li>From Lumbar sp...
Global Alignment <ul><li>Stability cone   </li></ul><ul><li>Prof. J. Dubousset </li></ul><ul><ul><li>If center of gravity ...
Morphotypes <ul><li>Throughout Darwinian evolution it took thousands years for the homo-erectus to stand and walk erected....
The Sacrum Inclination  Bernhardt M Bridwell KH. Segmental analysis of the sagittal plane alignment of the mormal thoracic...
 
End of growth Disc degeneration begins around age 35 Facet degeneration begins around  age 50 Unstable spine Stable spine ...
Progressive Degenerative Process  <ul><li>Affects all structures causing </li></ul><ul><ul><li>The pelvis to gain retro-ve...
Age Related Changes 21-40y Group 41-60y Group >60y Group Pelvic Parameters: Sacral Slope decrease Pelvic Tilt increase Spi...
Throughout Human Life <ul><li>Irregardless of the position of sacrum and pelvis from   </li></ul><ul><ul><li>More vertical...
The Final Result  <ul><li>Depends upon  muscle tone, mass and strength to balance the spine delaying the degenerative proc...
The Degenerative Process <ul><li>In association with a decreased lordosis  </li></ul><ul><ul><li>An increased pelvic tilt ...
The Degenerative Process 75 year old female Can be invalidating and painful With  signs of radiological deformity
Conclusion <ul><li>Short of defining the aging process </li></ul><ul><li>With regard to spine, it affects all anatomical e...
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Spine Natural History Through Human Life

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Spine Natural History Through Human Life

  1. 1. Natural History of the Aging Spine Jean-Pierre C. Farcy, MD. Frank J. Schwab, MD. NICE Spine Course 2007
  2. 2. Stages Of Human Development
  3. 4. Importance of the Sagittal Plane <ul><li>The Thoracic Curve </li></ul><ul><li>The Sacral Curve </li></ul>Two Structural Curves In Kyphosis Two Non-Structural Curves In Lordosis <ul><li>The Cervical Curve </li></ul><ul><li>The Lumbar Curve </li></ul>Vary with pelvic / hip posture stabilized at ambulation age Quantified by the Pelvic Incidence (PI)
  4. 5. Importance of the sagittal plane The four curves in the sagittal plane endure 16 (4x4) times more resistance to load than possible in a straight spine.
  5. 6. The Spine Range of Motion (ROM) <ul><li>250 degrees between the two extremes </li></ul><ul><ul><li>In hyperextension </li></ul></ul><ul><ul><li>In flexion </li></ul></ul><ul><li>Most of the ROM is </li></ul><ul><ul><li>In the Cervical Spine 105 º </li></ul></ul><ul><ul><li>And in the Lumbar Spine 95 ° </li></ul></ul>
  6. 7. The Spine Range of Motion (ROM)
  7. 8. The PELVIS <ul><li>The discovery in Ethiopia by Latimer of the anthropoid fossil (1974) parts belonging to “Lucy” substantiates the premise that the creature walked upright. Lucy’s pelvis is different from the other semi-erectus creatures and it appears that the differences are crucial to maintain the standing position permanently. </li></ul>
  8. 9. Pelvic Differences in Association with Spine Curvatures <ul><li>The permanence of “status erectus” requires a modification of the pelvis enabling a lumbo-sacral curvature which is only made possible by a curvature of the spine above the pelvis. </li></ul>
  9. 10. Pelvic Differences in Association with Spine Curvatures <ul><li>Pelvis and spine are so intimately associated that it is impossible to dissociate spine from the pelvis in any study. </li></ul><ul><li>Both are intimate structures which function together with the input of loads and forces that body mobility requires insuring the proper balance of the whole body. </li></ul>
  10. 11. Chimpanzee. Lucy. Homosapien.
  11. 12. Relationship Between PI and Lumbar Lordosis <ul><li>High PI angle </li></ul><ul><ul><li>High lordosis angle </li></ul></ul><ul><ul><li>Less vertebrae involved in the lordosis. </li></ul></ul><ul><ul><li>Less rigidity in the SI joint </li></ul></ul><ul><li>Low PI angle </li></ul><ul><ul><li>Lower lordosis angle </li></ul></ul><ul><ul><li>More vertebrae involved in the lordosis. </li></ul></ul><ul><ul><li>More rigidity in the SI joint </li></ul></ul>
  12. 13. Pelvic Incidence
  13. 15. The Spine As A Whole <ul><li>Is a very flexible structure </li></ul><ul><ul><li>Multi segments structure </li></ul></ul><ul><ul><li>Division of stress application </li></ul></ul><ul><ul><li>Increasing segmental and multisegmental stiffness will affect balance. </li></ul></ul><ul><li>Is a very stable structure </li></ul><ul><ul><li>Muscle tone, strength and mass insure stability </li></ul></ul><ul><ul><li>Stability depend on them so does balance. </li></ul></ul>
  14. 16. This sketch shows that resistance to loads depends on muscle strength. Muscle tone of the same muscle groups insure balance. Loss of muscle mass in aging places the balance system at risk of failure.
  15. 17. The load sharing of the posterior muscles from the spine to pelvis and femoral bone carry the lion’s share.
  16. 18. Schematics of Spine and Body Balance Schematic of spine and body balance
  17. 19. <ul><li>Discs </li></ul><ul><ul><li>Must keep their anatomical integrity. </li></ul></ul><ul><ul><li>Must keep their heights, hydration and chemical components. </li></ul></ul><ul><li>Ligaments </li></ul><ul><ul><li>Must keep their strength and elasticity. </li></ul></ul><ul><li>Bones </li></ul><ul><ul><li>Must keep their mineral mass. </li></ul></ul>How to Maintain Good Posture and Good Balance
  18. 20. How to Maintain Good Posture and Good Balance <ul><li>Muscle distribution In the back </li></ul><ul><ul><li>From Lumbar spine to pelvis </li></ul></ul><ul><ul><li>From Lumbar spine to femoral bone </li></ul></ul><ul><li>Muscles strength in the back </li></ul><ul><ul><li>Must be sufficient to balance the weight of torso and head. </li></ul></ul><ul><li>Muscle tone </li></ul><ul><ul><li>Must be tuned to respond all proprioceptive commands </li></ul></ul><ul><li>Muscle Mass must be maintained. </li></ul>
  19. 21. Global Alignment <ul><li>Stability cone </li></ul><ul><li>Prof. J. Dubousset </li></ul><ul><ul><li>If center of gravity falls outside the cone then energy consumption rises or person must seek additional support. (Crutch, Cane …) </li></ul></ul>
  20. 22. Morphotypes <ul><li>Throughout Darwinian evolution it took thousands years for the homo-erectus to stand and walk erected. </li></ul><ul><li>In the course of a human life it takes months to come from fetus position to erect position and steady walking ability. </li></ul><ul><li>The settlement of spine/pelvis define a specific morphotype for each individual. </li></ul>
  21. 23. The Sacrum Inclination Bernhardt M Bridwell KH. Segmental analysis of the sagittal plane alignment of the mormal thoracic and lumbar spines and thoraco lumbar junction. Spine 1989;14:717
  22. 25. End of growth Disc degeneration begins around age 35 Facet degeneration begins around age 50 Unstable spine Stable spine ankylosis stenosis spondylo deformity Most often all together Progressive Degenerative Process
  23. 26. Progressive Degenerative Process <ul><li>Affects all structures causing </li></ul><ul><ul><li>The pelvis to gain retro-version </li></ul></ul><ul><ul><ul><li>Sacrum sinks and hips move anteriorly </li></ul></ul></ul><ul><ul><ul><li>Hip hyperextension reserve decreases </li></ul></ul></ul><ul><ul><ul><li>Gravity line moves from behind to front of the hips </li></ul></ul></ul><ul><ul><li>Lumbar lordosis decreases </li></ul></ul><ul><ul><li>Thoracic kyphosis increases </li></ul></ul><ul><li>A vicious circle which can only be delayed but not stopped. </li></ul>
  24. 27. Age Related Changes 21-40y Group 41-60y Group >60y Group Pelvic Parameters: Sacral Slope decrease Pelvic Tilt increase Spinal Parameters: Global Inclination tilt forward GL Parameters: GL - Heels doesn’t change Pelvis move backward Kyphosis increase * Lordosis decrease Age
  25. 28. Throughout Human Life <ul><li>Irregardless of the position of sacrum and pelvis from </li></ul><ul><ul><li>More vertical </li></ul></ul><ul><ul><li>More horizontal </li></ul></ul><ul><ul><li>The amount of vertebrae included in the lumbar lordosis </li></ul></ul><ul><ul><li>The angle of lordosis </li></ul></ul><ul><li>A progressive modification of the pelvic version takes place </li></ul><ul><ul><li>The gravity line moves in front of the hips </li></ul></ul><ul><ul><li>The pelvis sinks in retroversion </li></ul></ul>
  26. 29. The Final Result <ul><li>Depends upon muscle tone, mass and strength to balance the spine delaying the degenerative process </li></ul><ul><li>Genes can influence individual, age-related changes. </li></ul><ul><li>Understanding interactions between genes and the environment may delay the aging process. </li></ul>
  27. 30. The Degenerative Process <ul><li>In association with a decreased lordosis </li></ul><ul><ul><li>An increased pelvic tilt </li></ul></ul><ul><ul><li>An increased upper kyphosis </li></ul></ul>75 years old female Can be smooth, delayed and pain free in spite of progressive signs of radiological deformity
  28. 31. The Degenerative Process 75 year old female Can be invalidating and painful With signs of radiological deformity
  29. 32. Conclusion <ul><li>Short of defining the aging process </li></ul><ul><li>With regard to spine, it affects all anatomical elements. </li></ul><ul><li>It looks like muscles are key in delaying the aging process </li></ul><ul><li>Genes and environment interaction have certainly a role to play … still to be defined </li></ul>

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