Overview of some degenerative spine conditions by Prof. Enric Cáceres.

1. EFORT – JOINT EFFORTS
Degenerative Spine Conditions
Enric Càceres
Head of Orthopaedics Department
Chair of Autonomous University of Barcelona
Associate Professor of Johns Hopkins University

2. EFORT – JOINT EFFORTS
Spine 2
36 years old male patient assist to emergency room for a sudden
episode with sever pain started three days ago and localized at
right limb irradiated to buttock, posterior face of the thigh, leg,
heel and plantar region of the foot
He also get lost partial sensibility of lateral border of the foot.

3. EFORT – JOINT EFFORTS
Spine2
He complains low back pain three weeks ago without leg pain
Physical examination shows pain at few degrees of elevation of
painful limb and an abolition of Achilles in reflex examination

4. EFORT – JOINT EFFORTS
Spine2

5. EFORT – JOINT EFFORTS
Spine2
IQ: Which is your first diagnoses in agreement with this clinical
history and radiology?
DQ: Which treatment do you choose initially?
CC: Describe nerve root compression level ?
Which is the most useful conservative treatment for this patient
EQ: What image diagnostic test shoud you request?

6. EFORT – JOINT EFFORTS
Spine2 MRI two weeks later without clinical improvement

7. EFORT – JOINT EFFORTS
Spine2

8. EFORT – JOINT EFFORTS
Spine 2
IQ: Do you think that the treatment needs to be changed?
DQ: What is your opinion about epidural injection?
CC: Do you request new tests?
When do you decide a surgical treatment?
If the patient improve your pain and rest asymptomatic, what is
your behavior?
EQ: Simply describe differences between T1 and T2 in MRI

9. EFORT – JOINT EFFORTS
Spine2 : MRI Four months later

10. EFORT – JOINT EFFORTS
Lumbar Disk herniation
General overview
A.Incidence
80% of people has some episode of low back
pain in your life, but only 2-3% has true
sciatica
A.Age
Average starting age 35 years old
Unusual before 20 and after 60 years
Less frequent in old people , more common
associated with stenosis
C. Sex
Similar in both sex but delayed one decadeSimilar in both sex but delayed one decade
in femalesin females

11. EFORT – JOINT EFFORTS
Lumbar disk herniation
Anatomy
1) L4-L5 more frequent than L5-S1
less frequent in thoracic or high lumbar level
2) frecuently posterolateral
3) Central location will cause lumbar pain without
sciatica
4) Foraminal location more frequent in elderly people
and hight levels (L3-L4)
5) intradural location very unusual

12. EFORT – JOINT EFFORTS

13. EFORT – JOINT EFFORTS
Lumbar disk herniation
Clinical features:
Radiculopathy
a. leg pain > lumbar pain
b. Dermatomal distribution
c. Increase sitting positions and forward bending
d. Improve with bed rest

14. EFORT – JOINT EFFORTS
Lumbar disk herniation

15. EFORT – JOINT EFFORTS
Lumbar disk herniation

16. EFORT – JOINT EFFORTS
Lumbar disk herniation
 Diagnostic imaging
1. symptoms correlated physical examination
is the most important thing.
2 .Plain radiographs are not often helpful .
. Provide global overview of spine alignment
. Rule out other sources of nerve root
dysfunction (spondylolisthesis, infection, tumor
3. CT
a. Not routinely used in LDH
. Used to visualize bony anatomy more
thab soft tissue

17. EFORT – JOINT EFFORTS
Lumbar disk herniation

18. EFORT – JOINT EFFORTS
Lumbar disk herniation
Nonsurgical treatment :
 LDH has a favorable prognosis
 90% report improvement of symptoms ( natural
history)
1) short rest (3-5 days)
2) NSAIDs ( more effective than placebo)
3) Physical therapy ( extremely beneficial)
4) Epidural steroid injections (50% avoided surgery)
Patient who failed to improve with nonsurgical
treatment will probably need surgery.
Surgical treatment provided an increase in quality of life
in comparison to continued nonsurgical treatment.

19. EFORT – JOINT EFFORTS
Control four months after conservative
treatment
RNM: natural history Male
66 a.
Male
34 a.
Male
71 a.
Women
35 a.
Male
43 a.
Male
30 a.
Male
42 y.o.
Male
49 y.o
Male
62 a.
Male
33 a.
HD Image Decrease HD: 4/10
HD desapear: 6/10

20. EFORT – JOINT EFFORTS
Lumbar disk herniation

21. EFORT – JOINT EFFORTS
Spine 1
• 47 years old male.
• Previous disease:
• Apendicectomy.
• Cronic low back pain with buttock and
lower extremities irradiation
• Severe neurogenic claudication six
months ago with impossibility to walk
more than 150 meters

22. EFORT – JOINT EFFORTS
Spine1

23. EFORT – JOINT EFFORTS
Spine1

24. EFORT – JOINT EFFORTS
Spine1

25. EFORT – JOINT EFFORTS
Spine1
•IQ: What do you think is the etiology of claudication?
•DQ: Witch kind of treatment do you choose.
What is the natural history of this pathologic entity?
•CC:Please could you describe surgical treatment
Amount of decompression?+/-Fusion?
+/-Instrumentation? Witch levels?
•EQ: Possible complications of this surgery?
How do you classify this entity?

26. EFORT – JOINT EFFORTS
Spine1

27. EFORT – JOINT EFFORTS
Lumbar spinal stenosis
Overview / epidemiology
A. Definition.
Spinal stenosis simply means a decrease in
the space available for the neural elements,
and , in the lumbar spine, the cauda equina.
It can ocur at different level : the central
canal, the lateral recess or the intervertebral
foramen causing neurological compression .

28. EFORT – JOINT EFFORTS
Lumbar spinal stenosis
Is the final result of a cascade of events.
• The event that begins the process is thought to
be the disk degeneration.
• As the disk heigth decreases, the loading
characteristics of the facet joints are altered.
• Facet joints capsules becomes incompetenet,
leading to capsular, ligamentum flavum, and facet
hypertrophy.
• The final result of this continuum of changes, is a
decrease in the diameter of the spinal canal.

29. EFORT – JOINT EFFORTS

30. EFORT – JOINT EFFORTS
Lumbar spinal stenosis
• Diagnostic imaging:
1.Upright AP, lateral, and flexion-extension radiographs :
amount of lumbar degeneration , vertebral deformity and
instability.
2.EMG may be helpful to distinguish peripheral neuropathy
from LSS.
3.Myelography: useful when deformity exists.
4.CT scan: facet joints hypertrophy, discal vacuum , size of
discal height and foramen height.
5. MRI is currently the recommended advanced imaging
modality to evaluate LSS. Noninvasive technique.

31. EFORT – JOINT EFFORTS
Lumbar spinal stenosis
Treatment
A. Nonsurgical
1) Narcotics, NAIDs, anticonvulsivants
2) LS ortosis
3) Physical therapy: flexion-based lumbar
stabilization program
4) Steroid injections

32. EFORT – JOINT EFFORTS
Lumbar spinal stenosis
B. Surgical treatment
1) Indications:
Caudal equina syndrome
Severe neurologic deficit or impairment
Failure to improve leg pain and neurogenic
claudication after nonsurgical treatment.
Persistent and severe decrease in patient
quality of life .

33. EFORT – JOINT EFFORTS
Natural historyNatural history
- not well understood
- it is typically favorable, with only
15% deteriorating clinically.
- improvement occurs in 30% to 50%
of patients.
Lumbar spinal stenosis

34. EFORT – JOINT EFFORTS
Lumbar spinal stenosis
Preoperative medical evaluation
Elderly patients
Coexisting comorbidities
Save blood preoperative techniques
Self-saver postoperative
Eritropoyetin
Surgical treatment::

35. EFORT – JOINT EFFORTS
Surgical techniques
Laminotomy
Hemilaminectomy
Resection of 50% of the cephaled and
caudad lamina and ligamentum flavum
Laterral decompression into the lateral
recess and into the foramen
Fusión if resection is > 50 % bilateral facets
or complete unilateral facetectomy
Lumbar spinal stenosis

36. EFORT – JOINT EFFORTS

37. EFORT – JOINT EFFORTS

38. EFORT – JOINT EFFORTS
meta-analysis limitations
74/625 meet inclusion criteria (12% relevant)
Nonrandomized studies
3/74 prospective studies
72% good results
No significative evidence between clinical outcome and age,
sex, previous back pain and number of levels.
Patients with a solid arthrodesis have superior clinical
outcomes in comparing with patients with pseudoartrosis.
Surgical treatment in LSS
Results after decompression technique
Lumbar spinal stenosis

39. EFORT – JOINT EFFORTS
88 patients 2,8 a 6,8 years
Surgical treatment
Long term results after laminectomy
Results 1 year Follow-up
Poor 11% 43%
Severe pain 7% 30%
Reoperated 6% 17%
Basic functional
impairment
8% 35%
Walking < 15 meters 8% 21%
Lumbar spinal stenosis

40. EFORT – JOINT EFFORTS
Age >75 years increase number of complications
x 9 .
More than 3 co-morbidities: increase hospital
stay 25%, increase cost 36% and 75% cases
need assisted living.
Surgical treatment in LSS
- Comorbidities and results
Lumbar spinal stenosis

41. EFORT – JOINT EFFORTS
 Prospective Randomized Comparative
Decompression versus decompression and
uninstrumented fusion
Lumbar spinal stenosis
Results Fusion Non fusion
Excellent 44% 8%
Good 52% 36%
Fair 4% 48%
Poor 0% 8%
Slipage increase
(Preop-postop)
0,5mm 2,6mm
p:0,002

42. EFORT – JOINT EFFORTS
what black disc means?
MRI image corresponding with a degenerative disk disease degree IV
Pfirmann 2001

43. EFORT – JOINT EFFORTS
it’s a pathology?
-Participates in the degenerative and
physiologic cascade starting from 30
years old
- When appear in a precocious time in
young people could be symptomatic

44. EFORT – JOINT EFFORTS
Modic changes
• Standard non invasive tool
• Degenerative changes (Modic)
T1 T2
MODIC I EDEMA
Decrease signal Increase signal
MODIC II FAT DEGENERATION
Increase signal Increase signal
MODIC III ESCLEROSIS
Decrease signal Decrease signal
Modic MT, Radiology. 1988;166:193-9

45. EFORT – JOINT EFFORTS
MRI: - HIZMRI: - HIZ
HIZ:Hight Intensity Zone in T2 localized
annulus posterior or posterolateral layer
Aprill, Bogduck, 1992

46. EFORT – JOINT EFFORTS
MRI - HIZ
- Disk tear lesion predictor
- Contends vascularizated granulamotous tissue
- highlight with Gadolinium
- strong relationship whit positive discography
-…not always with clinical significance
MRI CT+Discoghraphy CT+Discography

47. EFORT – JOINT EFFORTS
Discography ????
-Discriminative test
-Useful in diagnosis of lumbar pain with suspicious
discal source
- No prediction surgical success

48. EFORT – JOINT EFFORTS
Clinical significance black disc
(Disc degneration degreeIV)
• Clinical picture of
discogenic lumbar pain
no radicular pain
psicologic and social normal behavior
• Image:
disc degeneration = or >IV degree
HIZ +
absence of another structural pathology
• Discriminative test
discography
• Reject other pain generator
facet injection

49. EFORT – JOINT EFFORTS
Treatment
Surgical
Treatment??
- IDET ( 3 studies: non effective)
- TDR (total disk replacement)
- Dynamic stabilization
- Segmentary circumferential fusion
- Information

50. EFORT – JOINT EFFORTS
Aim :Cancel pain generator
Circumferential fusion Total disc replacement

51. EFORT – JOINT EFFORTS
 Dark diskDark disk
Symptomatic in young patientsSymptomatic in young patients
Agreement: Patient / Diagnosis / TreatmentAgreement: Patient / Diagnosis / Treatment
Non consents related treatmentNon consents related treatment
 Lumbar disk herniationLumbar disk herniation
Positive tension singsPositive tension sings
Specific radicular painSpecific radicular pain
Good results with Nonsurgical treatmentGood results with Nonsurgical treatment
Partial diskectomyPartial diskectomy
 Lumbar spinal stenosisLumbar spinal stenosis
Favorable Natural historyFavorable Natural history
High incidence complications after surgical treatmentHigh incidence complications after surgical treatment
 Differential diagnosisDifferential diagnosis
Sumary

52. EFORT – JOINT EFFORTS
Degenerative Spine Disease
Enric Càceres
Head of Orthopaedics Department
Chair of Autonomous University of Barcelona
Associate Professor of Johns Hopkins University