Disc pathology Flashcards
Describe the back pain
1) A common complaint among adults
2) Lifetime prevalence in working population is up to 80%
3) 60%experience functional limitation or disability
4) Second most common reason after circulatory diseases for work disability
- Despite advances in imaging and surgical techniques
LBP prevalence and its cost are relatively unchanged
What are the causes of back pain?
CTI MIND V
1) Congenital: scoliosis/kyphosis/spondylolysis
2) Traumatic: lumbar strain/compression fracture
3) Infectious: pyelonephritis/osteomyelitis/discitis/herpes zoster/spinal or epidural abscess
4) Metabolic: osteoporosis/hyperparathyroidism/Paget’s disease/osteomalacia
5) Inflammatory: ankylosing spondylitis/sacroiliitis/rheumatoid arthritis
6) Neoplastic: multiple myeloma/metastatic disease/lymphoma/leukemia/ osteosarcoma
7) Degenerative: disc herniation/osteoarthritis/facet arthropathy/spinal stenosis
8) Vascular: aortic aneurysm/diabetic neuropathy
9) Visceral: prostatitis/PID/ovarian cyst/endometriosis kidney stones/cholecystitis/ pancreatitis
- The 3 most common causes of back pain are: 1) lumbar strain or sprain 70%, 2) age-related degenerative disorder 10% 3) herniated discs or the disc bulge 4%
What are the different ligaments in the vertebral column?
The vertebral column has many ligaments, including; anterior and posterior longitudinal ligaments, supraspinous, interspinous ligaments, and inferior ligaments and all of these are very important because sometimes the disc nucleus can bulge through these ligaments leading to what’s known as disc, or disc prolapse
What is disc herniation?
Herniation refers to either protrusion, prolapse, or extrusion.
1) Protrusion:
- Bulging of nucleus pulposus through weakened annulus fibrosus, usually posterior or posterolateral
- Can rarely disappear spontaneously
We have two scenarios if the annulus fibrosus is intact:
Mild contained: referred to as a bulge “mostly back pain”
Moderate/Severe contained: referred to as protrusion “back & leg pain”
Dr. emphasized on the fact that protrusion is the term used for an intact annulus fibrosis
NON-CONTAINED: (BACK & LEG PAIN)
2) Prolapse:
- Rupture of nucleus pulposus through the annulus but not the posterior or anterior longitudinal ligament
- Associated with neovascularization at edges of fibrocartilaginous fragments
- Usually in the lumbar region
- May occur in thoracic or cervical disc
3) Extrusion: rupture of nucleus pulposus through the annulus and posterior or anterior longitudinal ligament
4) Sequestration:
Fragmentation of extruded segment may extend into the spinal canal or far from the site of rupture
Clinical symptoms depend on the severity of herniation and the position of the offending disc
Patients may develop cauda equina syndrome in severe cases
What is the cauda equina syndrome?
A serious condition where the nerves and nerve roots at the lower end of the spinal cord get compressed
- Cauda equina syndrome is a surgical emergency, if it’s left untreated the patient could get permanently paralyzed & develop incontinence (as some of the compressed nerves control the bladder)
What are the symptoms of cauda equina?
1) Saddle anesthesia
2) Pain
3) Incontinence
4) Numbness
5) Emergency
What is meant by degenerative disc diseases?
1) Degenerative disc disease is an age-related condition that happens when one or more of the discs between the vertebrae of the spinal column deteriorate or break down, leading to pain, There may be weakness, numbness, and pain that radiates down the leg.
2) DDD is more of a disorder than a disease since it relates to aging
The nucleus pulposus will get dehydrated (aka disc desiccation)
3) DDD leads to microtears in the ligaments and fibers & weakness of the back & numbness and pain
DDD has different degrees of severity
What are the different causes of degenerative disc diseases?
1) Degeneration of proteoglycans which are very important in the background of intervertebral discs
2) Lack of oxygen: oxygen decreases with age because the end arteries supplying the discs will have atherosclerosis (deposition of fibro-fatty plaques in the vessels)
3) Lack of glucose
4) Changes in pH and hydrostatic pressure
What is the pathophysiology behind the degenerative disc diseases?
1) Disc gradually dries out, and loses height and volume.
2) The nucleus pulposes changes from a turgid gelatinous bulb to a brownish dessicated structure.
3) Annulus fibrosis develops fissures parallel to the vertebral
end plates
4) Compressive loads transfer away from the nucleus to the margins
5) Sclerosis of the endplate reduces disc nutrition
6) Facet joints wear away cartilage, and begin to override
7) The motion segment becomes hypermobile
8) Osteophytes (excessive bony process in an attempt to stabilize the back due to the sclerosis) develop to attempt to stabilize the motion segment
9) Osteophytes may encroach on neural structures (causing pain)
- Osteophytes form in response to increased facet apposition and instability
- Pain is not caused by the degeneration itself
- Soft tissue and joint irritation source of nociceptive input
What are the types of annular tears?
1) Rim lesions
2) Concentric tears
3) Radial tears
- Common in sports players, and it might accompany disc degenerative diseases
What are the different signs of disc degeneration?
1) Increase of cell density (chondrocyte proliferation)
2) Granular changes
3) Structural alterations with tears and clefts
4) Increase in acid mucopolysaccharides (mucoid degeneration) with dark blue staining areas surrounding the chondrocytes
What are the therapies for disc-pathologies?
1) Medication and limited activity
2) Spinal rehabilitation
3) Interventional pain management
4) Spinal surgery
