degenerative disc disease basic ppt

1. LUMBAR
DEGENERATIVE
DISC DISEASE

4. INTERVERTEBRAL DISC
• Hydrostatic, load bearing structure
between the vertebral bodies
• Nucleus pulposus + annulus
fibrosus
• No blood supply
• Largest avascular structure in the
body

5. NUCLEUS PULPOSUS
• Type II collagen strand + hydrophilic
proteoglycan
• Water content 70 ~ 90%
• Confine fluid within the annulus
• Convert load into tensile strain on the
annular fibers and vertebral end-plate
• Chondrocytes manufacture the matrix
component

6. ANNULUS FIBROSUS
• Outer boundary of the disc
• More than 60 distinct, concentric
layer of overlapping lamellae of type
I collagen
• Fibers are oriented 30-degree angle
to the disc space in a helicoid
pattern
• Resist tensile, torsional, and radial
stress
• Attached to the cartilaginous and
bony end-plate at the periphery of
the vertebra

7. FACET JOINT
• Synovial joint
• Rich innervation with sensory
nerve fiber
• Same pathologic process as other
large synovial joint
• Load share 18% of the lumbar
spine

8. BIPEDALISM

9. Eccentric / torsional loading / recurrent microtrauma
circumferential and radial tears in
annular fibers
Coalescence of circumferential
tears into radial tears
nuclear material to migrate out
annular tears may cause
endplate separation
loss of nuclear nutrition and
hydration
disk height decreases
biomechanical axis of loading shifts posteriorly
posterior articulations bear greater weight distribution
compensation - hypertrophy of the facets and bony
overgrowth (osteophytes)
progressive foraminal and central canal narrowing
Lumbar canal stenosis
Disc prolapse

11. KIRKALDY WILLIS STAGES
1.DYSFUNCTION- outer annular tears and separation of
the endplate, cartilage destruction, and facet synovial
reaction
2.INSTABILITY- disk resorption and loss of disk space
height occur, Facet capsular laxity
3.RESTABILIZATION- osteophyte formation and stenosis

12. CAUSATION OF DISCOGENIC PAIN
• Inflammatory
• Biochemical
• Vascular
• Mechanical compression

13. Prevalence of Disc Degeneration in Normal Individuals

14. • Pain, radiating from the back or buttock into the leg
• Numbness and weakness
• Sharp, lancinating, shooting/radiating down the leg posteriorly below
the knee
• Coughing, Valsalva maneuver  increase intradiscal pressure 
increase pain
• Sitting position, driving  out of lordosis  increase intradiscal
pressure  increase pain
CLINICAL PRESENTATION

15. ROOT TENSION SIGNS
• Straight-leg raising : L5, S1 root
• Contralateral SLR : sequestrated or extruded disc
• Femoral stretching, reverse SLR : L3, L4 root
NEUROLOGICAL EXAMINATION
CAUDA EQUINA SYNDROME- saddle anesthesia, urinary retention,
severe/progressive neurologic deficit in lower extremity
CLINICAL PRESENTATION

16. 1. WHEN TO TREAT?
2. HOW TO TREAT?

17. INDICATIONS FOR SURGICAL INTERVENTION
1. Progressive neurological deficit
2. Persistent pain in spite of conservative management (6weeks-3months)
3. Persistent or worsening intermittent claudication
4. Cauda equina syndrome
Ideal candidate- history, physical examination and radiographic findings are
consistent with one another- Clinico-radiological concordance

18. CONSERVATIVE MANAGEMENT OPTIONS
1. Analgesics- NSAIDs/ Muscle relaxants/ Opioids
2. Use of steroids controversial
3. Physiotherapy
4. Epidural steroid injections

19. EVOLUTION OF TRADITIONAL SURGICAL CONCEPTS
1. Decompression
2. Fusion
3. Deformity correction

20. LAMINECTOMY
LAMINECTOMY AND DISCECTOMY
INSTABILITY
1. HEMILAMINECTOMY
2. FENESTRATION
3. FORAMINOTOMY
4. MICRODISCECTOMY
FUSION PROCEDURES
1. PEDICLE SCREW FIXATION
2. PLIF/TLIF
3. ANTERIOR FIXATION

21. MOTION PRESERVATION
MINIMALLY INVASIVE SPINE SURGERY- Serial dilator/ Endoscopic

22. MOTION PRESERVATION
ARTIFICAL DISC (ARTHROPASTY)

23. • Defined as pain that persists or reoccurs after one or more
surgical procedure on the lumbo-sacral spine
• Upto 10% of patient who undergo back surgery
• Most common causes- patient selection and diagnosis,
nerve scarring, recurrence at same/another level
• A proper history is more cost-effective than any diagnostic
procedure
FAILED BACK SURGERY SYNDROME

27. BOTTOMLINE
• Treat the patient, not the scans
• Identify the source of pain
• Individualization of therapy
• Motion preservation

28. THANK YOU!