AGING SPINE Prof. dr Mirza Bišćević Spine department, Orthopedics
Spine - central static column of the body and kinetic chain, - function of stability, mobility, and protection of neural structures (NO COMPRESION of medula and nerve roots) and WITHOUT A PAIN, - physiological sagital curves: cervical lordosis 20-40, thoracic kyphosis 25-40, lumbal lordosis 40-60, sacral kyphosis, in frontal plane curve up to 10. 2
Spine is getting old.
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The lifetime prevalance of back pain is app. 80%, - changes in posture and gait, - aging process: facet joint arthrosis, disc degeneration, osteoporotic fractures, muscle atrophy, - increasingly the sagittal disbalance has gained importance in aging spine.
Life-lasting aging process of the spine might be: - moderately painfull (common) therapy NSAID, excersises, - painless (very seldom), - strongly painfull, w/o motordeficit (not uncomon) more serious medical treatment (intensive phsyical tretament, blocks, open surgery).
Who is at risk??? - immobile work and life style, - long term vehicle drivers, - obesity, - weak lower back and abdominal muscles, - defective posture and body biomechanics (muscle antrophy), - the last months of pregnancy, - high risky sportive activities, - tobacco use, - mental and emotional stess.
Causes of Low Back Pain: Poor posture and LB misuse Muscle spasm Disc hernaition Spondiolistesis Osteoporosis Spinal stenosis Facet pain Rheumatic diseases Spine tumors Infections Prostate problems Muscle sprain Sakroileitis Obstetric diseases Stress Fractures
How does it start? 1. DYSFUNCTION PHASE annular tear, disrupted blood circulation 2. INSTABILTY PHASE reduction in disc height, 3. STABILISATION PHASE disc resorption, end plate destruction, osteophyte formation. N 1 2 3
What we see the first on MRI? Modic Type I changes: decreased signal in the T1 and increased signal in T2 images.
How does it end? 1.STIF SPINE faset/disk arthrosis, 2.A/SIMPTHOMATIC axial/radicular pain, permanent or during loading, 3.EV. OSTEOPOROTIC AND CURVED fish bone vertebras, thoracic hyperkyphosis, lumbal scoliosis instead of lordosis 15
Osteoporosis? - a metabolic disease related to the aging process or adverse effect of some drugs intake vs. age related bone atrophy (equal loss of cortical and cancelous bone, no bone deformations), - pronounced thoracic hyperkyphosis, reduced lumbar lordosis (sleevs on clothes to long), chronic axial pain, respiratory and gastrointestinal disfunction, reduction of vision field, static disbalans, mobility... - asimptomatic until vertebral, radius, or hip fracture appeares, then problematic for treatment, 16
How can we follow aging process? Laboratory, X-ray dynamic X rays, scoliosis X ray, pelvis and knee, CT, MRI, EMG, Bone densitometry, Discography, Myelography, PET, scintigraphy.
When shell we (surgeons) act? - intractable pain more then 6-8 weeks, - urine and faecal incontinence (urgently), - progressive motor or sensory loss, - tumor or abscess, - some spinal fractures, - spondilolistesis or other spine instabilities.
Be avare: - or, we can not stop spine to become old, just can help to be less painfull and more functional. - diagnosis confirmed by radiological tests, and no other specialist can help (last option), - surgery reduces VAS 2-3 times, improves ODI score double, but scores are gradualy worsening during a years!!!, - or, there is no 100% complete pain relife wich will last foreve,
Degenerative lystesis, to intervene, or not? 20
Degenerative scoliosis, or not? Intervene, or not?
Take home message: -aging is not relevant until spine is painless, and there is no clinical signs of compression, - reduction on motion and cosmesis is not an important issue in older pts., - radiological descriptions are not important; or diskus hernia, lystesis, spondylosis, fasetarthrosis, scoliosis are common findings in asimptomatic pts.,
- listen to the patient, and sharpen your senses, - treat complains ONLY if they can be explained by imaging procedures, -spine is not his/her the only problem; reduced general health status and life expectancy with multiple co-morbidities, -other orthopedic problems - generalised arthrosis (hip and knee arthrosis, whole spine involment, etc.),
- fragile soft tissue, osteoporosis; the best treatment in aging spine might be the prevention of severe deformities by medical or early surgical treatment, - if surgery, then appropriate pts. selection, correct diagnosis, good surgical plan and technique, surgical experience.
Good decisions come from experience! Experience comes from bad decisions!!