SPINAL CHAPTER, NESON DEGENERATIVE SPINAL DISEASE PRABIN SHRESTHA ANISH M SINGH B&B HOSPITAL
INTRODUCTION DEGENERATIVE SPINAL DISEASE Gradual loss of normal structure and function of spine with time Also called degenerative disc disease Usually caused by Age, wear and tear effect
DEGENERATIVE SPINAL DISEASE Not considered as disease/ Not rapidly progressing Progresses with age Occurs due to daily stresses Aggravated by minor injuries Also aggravated by other pathologiesmajor trauma, tumors, osteoporosis, arthritis etc
DEGENERATIVE SPINAL DISEASE Normal disc- elastic, glue or jelly like, gelatinous, mucoid, not breakable, well hydrated-=80% water Abnormal disc- dehydrated, fibrous, less elastic, calcified, easily breakable in pieces Not problematic in majority of cases In some can create severe pain and disability
CORD / NERVE COMPRESSION Leads to Disc herniation Spinal canal stenosis Leads to spinal cord and nerve compression Leads to Radiculopathy and/or Myelopathy
GRADING OF DEGENERATED SPINE Complex No uniformity 42 different systems
GRADING
SPINAL DEGENERATION
PHASES Phase 1: Minor loss of normal spine balance and spinal curvature. The surrounding structures muscles, nerves, discs and joints more stressed. No Pain, reversible Phase 2: Narrowing of the discs and deformation in the bones. Foraminal/canal stenosis and pain starts. Reversible.
PHASES Phase 3: Nerve damage and deformation of the bones and discs. Significant physical and mental stress due to pain. Partially reversible. Phase 4: Damage is permanent, nerve damage and deformation. Irreversible. Management of pain and discomfort.
CX SPINE DEGENERATION
PATHOLOGY-DEGENERATION Predominantly involves lumbar spine and cervical spine Osteoarthritis cartilage breakdown and joint inflammation and pain Spondylitis, subluxation, listhesis Reduced mobility of spine and pain
PATHOLOGY Disc degeneration Dehydration, less elastic and herniation Hypertrophy of Yellow ligament, PLL Spinal canal /foramen stenosis Radiculopathy and myelopathy and chronic pain
DEGENERATIVE SPONDYLOLISTHESIS Occurs after >60 yrs Women>Men Most Common at L4-5 Severe facet joint disease Hypertrophic facets and foraminal stenosis Subluxation of vertebrae Spinal canal stenosis
CLINICAL PRESENTATION Pain, local or radiating Local pain is due to Osteoarthritis Spinal deformity Limited motion Muscle spasm
CLINICAL PRESENTATION Radiating Pain, due to Radiculopathy Myelopathy claudication Neurological deficit Motor/sensory deficit Bowel/bladder involvement Sexual dysfunction
CLINICAL PRESENTATION Symptoms depend not only on the degree of degeneration but also on Level of degeneration, pressure or stress on the spinal column and involvement of spinal cord and/or nerve roots Aggravated by posture- sitting, lifting, bending, twisting etc
DEGENERATED SPINE 30-35% becomes symptomatic About 10% develops chronic pain and becomes severely disabled
IDEAL SITTING POSTURE The ideal sitting posture can be illustrated as a straight line through the ear canal, shoulder joint, thorax/ribs, pelvis and the hips
BODY POSTURE
Sway Back Posture
WITH AGE
BAD SITTING POSTURE
DIAGNOSIS S/S X-ray Osteoporosis Degenerative signs- narrow disc spaces, osteophytes, Deformity Dynamic x-ray shows instability Oblique x-ray shows foraminal stenosis
DIAGNOSIS CT scan Bony anomaly of spine MRI Neuronal structures Disc tissues Spinal canal and other soft tissue lesions
DYNAMIC X-RAY
TREATMENT Conservative Rx Analgesics, steroids Epidural steroid Physiotherapy Improves muscle strength Improves spine and muscle flexibility
SURGICAL TREATMENT Discectomy Foraminotomy Laminectomy/ laminoplasty Fusion/fixation Vertebroplasty Corpectomy
DEGENERATIVE SPINAL SURGERY MY EXPERIENCE OF 10 YEARS
NEUROSURGERY IN MY EXPERIENCE Periph N 10% Brain 35% Spine 55%
TYPES OF SPINAL SURGERY, TOTAL 1100 Others 20% Trauma 5% Degen Spine 75%
DEGENERATIVE SPINAL SURGERY TOTAL 850 CASES Lumbar 80% Microdiscectomy 600 Laminectomy 100 Cervical 20% Discectomy 80 laminectomy 70
CERVICAL SPINE Cx spine Degen -150 ACDF- 55% Decom Laminectomy- 45% ACDF Bone graft Titanium cage Bone cement
ACDF WITH BONE CEMENT 65/80 CASES SURGICAL PROCEDURE Total discectomy done under microscope Bone cement (Mehtyl methacralate) powder (Monomer) mixed with Liquid (Plolymer) and semisolid material filled in 5 ml syringe Bone cement poured in the disc space, 2 ml used and packed
HCD C6-7, ACDF WITH BONE CEMENT
BONE CEMENT FIXATION
MIDDLE AGED MALE, HCD C4-5
POST OP
HCD C5-6
CAGE/BONE GRAFT FUSION/ FIXATION Bone graft fusion/ fixation
32/M HCD C5-6-7
RECURRENT HCD, YOUNG FEMALE
OBESITY WITH HCD
POST OP
HCD WITH OPLL
HCD C5-6
POSTERIOR CX DISCECTOMY
YOUNG FEMALE PATIENT WITH SEVERE NECK PAIN AND CX RADICULOPATHY
RESULTS All got better and became symptom free except One case developed central cord syndrome 3/80 ACDF had residual symptoms of myelopathy 2/80 had intraoperative CSF leak One patient had post operative infection One patient had transient hoarseness of voice Not a single case of major neurovascular injury
LUMBAR DEGENERATED SPINE LAMINECTOMY/MICRODISCECTOMY Total 700 cases in last 10 years Occupies 25-30 % of total major surgeries 80% of Degen spine surgery About 4-8 cases/ month
META-ANALYSIS
GENERAL INFORMATION Majority L4-5 then L5-S1 Side- Rt=Lt Sex- M>F Age:14-87 Yrs Recently >80% below 40 yrs of age More young people, More migrant workers Average surgical time- 20-60 min for one level one side
RX PROTOCOL After surgery 1 st day Bed rest/ On Bed physiotherapy Mobilization- from 2 nd day Discharge- 3 rd day Average hospital stay-4 days Normal activities after few days Suture out on 10 th day
HUGE DISC L4-5, YOUNG LADY SURGICAL TIME- 3 HOURS
DISC TISSUES
YOUNG LADY WITH SEVERE LEFT LEG PAIN
HUGE LUMBAR DISC
EXTRADURAL MASS L4-5
HUGE LUMBAR SEQUESTRATED DISC
L4-5 HUGE HLD YOUNG BUDDHIST MONK
HLD WITH OPLL
HUGE HLD
PRE-OP
POST OP
INFLAMED NERVE ROOT
14 YRS OLD BOY
OUTCOME OF MICRODISCECTOMY Residual LBP 7% Residual leg pain 3% Complet e cure 90%
RECURRENCE 4cases 3 males 1 female re-operated Recurrence after 1-2 years of first surgery Better after 2 nd surgery
COMPLICATIONS Infection/discitis/failed back syndrome- 4-5% Dural tear and CSF lick- 1% No major neurological deficits No long term morbidity One mortality- obese lady with multiple medical problem, expired after about1 month of surgery due to liver disease and ascites
CONCLUSION Degen Spinal surgery common procedure Technically easy and safe Case selection most important factor for best outcome Neurological SS MRI findings