Section 8 - Degenerative Diseases

Question 1

What is a Degenerative Disease

Answer 1

Refers to the loss of normal tissue structure and function as a result of the aging process.

Question 2

OsteoArthritis

Answer 2

Degenerative changes cause symptoms in the joints, usually pain. This means that there is an inflammation of the bones and cartilage of a joint due to a degenerative process.

Question 3

Motion Segment

Answer 3

The functional unit of this mechanism. It is hiw tge soine works to create movement.

Question 4

What is the three-joint complex of each motion segment

Answer 4

Comprised of two facet and the intervertebral disc.

Question 5

What are the two important functions of the intervertebral disc (IVD) ?

Answer 5

1. The IVD acts as a shock absorber, taking up much of the compressive (axial) weight of the trunk and upper extremities and distributing it between the vertebral bodies.
2. The IVD acts as a pivot point in the motion segment. It functions as a contained, deformable ball bearing to allow for motion in all degrees of freedom.

Question 6

Identify structures in the following diagram:

Answer 6

1. Annulus Fibrosus
2. Nucleus Pulposus
3. Lamellae

Question 7

The nucleus pulposus is the central gelatinous substance that accounts for about ______ of the IVD.

Answer 7

40% of the IVD

Question 8

Which has more water and proteoglycan content - the nucleus or the annulus of the IVD?

Answer 8

The Nucleus Pulposus has a much greater water and proteoglycan content than does the annulus. At birth it is approximately 90% and gradually decreases to approximately 70% by the age of 50.

Question 9

In which region of the spine is each of these vertebral bodies found?

Answer 9

Top = C3

Bottom = L5

Question 10

Which carries the smallest portion of the compressive load – the cortical shell or the spongy trabecular bone?

Answer 10

The spongy trabecular cancellous bone

Question 11

The endplate is composed of how many layers?

Answer 11

2 layers

1. The inner bony layer
2. The outer cartilaginous, which represents the transition between the disc and the vertebra.

Question 12

The cartilaginous layer is highly porous and nutrition diffuses across this surface from the __________ layer.

Answer 12

The cartilaginous layer is highly porous and nutrition diffuses across this surface from the bony layer.

Question 13

The facet joints are important in stabilizing the spine. Their __________ and __________ affect the mobility of each spinal region.

Answer 13

The facet joints are important in stabilizing the spine. Their anatomic position** and **orientation affect the mobility of each spinal region.

Question 14

The facet joints in the lumbar region are oriented in the __________ plane and limit the __________ in rotation.

Answer 14

The facet joints in the lumbar region are oriented in the sagittal plane and limit the range of motion in rotation

Question 15

Ligaments have many functions including:

•

•

•

•

Answer 15

Ligaments attach bone to bone

• They provide stability to the spine, yet allow for normal spinal motion.
• Ligaments protect the spine and neurological structures from the effects of excessive motion.
• Ligaments do not resist compressive loads and tend to buckle when subjected to them
• Individual spinal ligaments readily resist tensile forces and prevent the motion segment from exceeding its physiologic range of motion.

Question 16

List the seven ligaments that attach the motion segment together.

1.

2.

3.

4.

5.

6.

7.

Answer 16

1. Anterior Longitudinal Ligament - ALL
2. Posterior Longitudinal Ligament - PLL
3. Ligamentum Flavum
4. Facet Capsular Ligament
5. Intertransverse Ligament
6. Interspinous Ligament
7. Supraspinous Ligament

Question 17

Label the following diagram:

Answer 17

A. Intertransverse Ligament

B. Ligamentum Flavum

C. Supraspinous Ligament

D. Interspinous Ligament

E. Facet Capsular Ligament

F. Anterior Longitudinal

G. Posterior Longitudinal Ligament

Question 18

Label the following diagram:

Answer 18

A. Longus Rotatores Lumborum Muscle

B. Lateral Intertransversarius Muscle

C. Interspinalis Lumborum Muscle

D. Brevis Rotatores Lumborum Muscle

Question 19

Fill in the blanks.

Muscles are the _______________that produce _______________through _______________and _______________across a _______________or _______________. Muscles also provide significant _______________and _______________to the spinal column. They resist _______________placed on the body through _______________.

Answer 19

Muscles are the active structures** that produce **spinal movements** through **bending movements and torque across a joint or motion segment. Muscles also provide significant dynamic stability** and **stiffness** to the spinal column. They resist **external loads** placed on the body through **isometric forces.

Question 20

The most significant alterations of the disc are:

•

•

•

•

Answer 20

• Decreased water and proteoglycan content of the nucleus pulposus.
• Decreased water and proteoglycan content of the annulus, though not to the extent of the nucleus.
• Distortion of the collagen fibers of the annulus fibrosus.
• Tears may in the lamellae, due in part to distortion of the collagen fibers, which could result in a loss of annular strength.

Question 21

What are the two most negative effects of sclerosis on the motion segment?

1.

2.

Answer 21

1. Sclerosis decreases the amount of nutrients diffusing across the cartilaginous end plate into the intervertebral disc, resulting in degeneration of the disc.
2. Sclerosis stiffens the end plate and makes it less able to absorb load transferred from the disc.

Question 22

What is another name for traction spurs?

Answer 22

Peripheral Osteophytes

Question 23

Major trauma or repetitive minor trauma may lead to ____________________.

Answer 23

nonspecific synovitis.

(inflamation of synovial membrane)

Question 24

The articular processes begin to override each other as the joint capsules become stretched. This results in…

Answer 24

This results in a malalignment of the joints and abnormal biomechanical function of the motion segment.

Question 25

How do spinal ligaments show the effects of aging?

Answer 25

Spinal ligaments show the effects of aging through ## Footnote - Partial ruptures - Necrosis - Calcification of fibers

Question 26

List 7 changes to the motion segment that may occur due to degenerative disc disease. 1. 2. 3. 4. 5. 6. 7.

Answer 26

1. The disc loses water, causing it to shrink in volume. 2. The disc space begins to narrow. Concurrently, the facet joints begin to override and wear away at the hyaline cartilage surfaces. 3. Compressive loads are transferred away from the nucleus/central end plate interface to the peripheral annulus/vertebral end plate margins. 4. Sclerosis of the central end plate further reduces disc nutrition. 5. The motion segment becomes hypermobile due to the narrowed intervertebral space and overriding of the facets 6. Osteophytes develop in an attempt to stabilize excessive motion. 7. Osteophytes may encroach on neurological structures.

Question 27

Though degenerative disc disease may be found in every spinal level, what are the most frequently affected levels by region?

Answer 27

Cervical 5-6 Lumbar 4-5 Lumbar 5-S1

Question 28

What does "stenosis" mean?

Answer 28

Derived from the Greek *stenos:* narrow, and *osis:* pathological condition. Literally means "the narrowing of a tube."

Question 29

What is the most common form of spinal stenosis?

Answer 29

Acquired degenerative type The most frequently involved regions for degenerative spinal stenosis are in the lower cervical and lower lumbar areas.

Question 30

Label the diagram: A. B. C. D.

Answer 30

A. Central Stenosis B. Thickened Ligamentum Flavum C. Lateral Recess Stenosis D. Foraminal Stenosis

Question 31

Describe the clinical presentation for degenerative lumbar spinal stenosis.

Answer 31

Symptoms appear gradually and back pain is almost always present. There may also be associated buttock and leg pain, usually bilaterally.

Question 32

What is neurogenic claudication and how can it be relieved?

Answer 32

Neurogenic Claudication is a symptom of lumbar spinal stenosis. Neurogenic claudication is brought on by and intensified by walking and standing upright. Symptoms are often relieved when the patient flexes forward and opens more of the spinal canal, thereby relieving the pressure. Sitting and lying down in the fetal position also relieve claudication symptoms.

Question 33

What is the difference between neurogenic claudication and vascular claudication?

Answer 33

Vascular claudication is caused by narrowing of the major arteries supplying blood to the legs. Unlike Neurogenic claudication, symptoms for vascular claudication are relieved by standing and worsened by laying down. Neurogenic - Causes back pain first, followed by pain descending down the legs. Vascular - Pain originates in the lower leg and extends up the leg toward the lower back.

Question 34

What kind of radiographic studies are most commonly used when evaluating lumbar spinal stenosis?

Answer 34

Plain X-ray films (A-P and Lateral) Myelography combined with CT scan MRI

Question 35

What are some of the conservative treatments for mild degenerative lumbar stenosis?

Answer 35

Stretching exercises that increase their flexion motion. -Biking, water walking, and swimming are excellent activities for these individuals. Epidural steroid injections may reduce swelling in neurologic and vascular tissues, thereby improving circulation.

Question 36

What is the most common cause of spinal stenosis in the cervical region?

Answer 36

Degeneration of the three-joint complex is most common cause.

Question 37

What is radiculopathy?

Answer 37

Progressive deterioration of a **nerve root**

Question 38

What is myelopathy?

Answer 38

Progressive deterioration of the **spinal cord**

Question 39

Describe the clinical presentation of a patient with degenerative cervical stenosis.

Answer 39

- May be in 40s or 50s - History of neck trauma preceding, by months or years - Onset of Stenosis symptoms - Radiculopathy of the C5,6,7 nerve root on one side only. Causing diminished sensation, muscle weakness and arm pain. - Myelopathy may lead to altered gait, diminished fine motor coordination, sensory changes, muscle weakness, and in late cases, bowel or bladder dysfunction.

Question 40

Conservative care for degenerative cervical stenosis is generally limited to what kind of patients?

Answer 40

Conservative care generally limited to individuals who suffer from radicular symptoms only.

Question 41

Surgical treatment for degenerative cervical stenosis is generally given to what kind of patients?

Answer 41

Patients with frank myelopathy from degenerative stenosis Individuals with significant deformity and/or instability may be surgical candidates.

Question 42

Describe surgical approaches and techniques used for decompression in the cervical region.

Answer 42

Anterior, Posterior or combined approaches.

Question 43

What is a "laminectomy"?

Answer 43

Laminectomy involves partial or complete removal of the posterior elements, allowing increased space for the neural structures.

Question 44

What is a "laminoplasty"?

Answer 44

Laminoplasty is the surgical reconstruction of the posterior elements that allows for increased canal space but maintains the posterior arch.

Question 45

The cervical facets are oriented in the _________ plane and thus ____ \_\_\_\_ ______ flexion, lateral bending, or rotation very well; they do resist __________ somewhat.

Answer 45

The cervical facets are oriented in the **_coronal_** plane and thus **_do not resist_** flexion, lateral bending, or rotation very well; they do resist flexion somewhat. \*\*This is why the cervical spine has such a substantial range of motion.\*\*\*