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MD, PhD, LLB

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2

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26 Vertebra

23 Disc 24x2 facet joints

23x2 endplates

(29)x2 nerveroots

Ligaments

3

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Morphology, anatomy, histology, physiology,biochemistry, neurology, pathology, biomechanics, &functions

Disc, body, endplate, facet, ligament & capsule

Aging spine

Degenerative spine diseases

Degenerative disc diseases

4

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5

Changes in NP proteoglycan, water, collagen II, cell density cell death, collagen I

Disc morphology changes

Inappropriate response to load

Intervertebral discdegeneration

Changes in AF & endplate vascular & neural invasion endplate vascularity,fracture

Genetic factorsAge, Nutrition

Environmentalfactors

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Disc degeneration

Loss of discheight & abnormal load distribution

Spondylotic changes of the body & facet joint

Facet joint hypertrophy & Capsular laxity instability

Hypertrophy of ligamentum flavum, ossification

Ossification of posterior longitudinal ligament

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7

Capsular laxity Instability Internal disruption

Subluxation Lateral nerve Disc resorptionentrapment

Synovitis Dysfunction Circumferential tears

Continuing Herniation Radial tearsdegeneration

Enlargement of One level stenosis Osteophytes

articular processes

Multilevel spondylosisand stenosis

Facet DiscKirkkaldy_Willis (1982)Three stages of spinal degeneration

Dysfunction

Instability

Stabilization

Intermittent axial pain

Persistent back & leg pain

Leg pain neurological deficit

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8

Morphology Physiology Function

Disc Content

changes

Motion & load

Vertebral body Osteoporoticchanges

Load function

Endplate Sclerosis

osteophyte

vascularity

Marrow changes

Load function

Facet &capsule

HypertrophySubluxation

Cartilage contentchange

Motion & load

Ligament Hypertrophy

elasticity

Content

changes

Motion & load

Spinal cord &root

changes changes Functionchanges

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Imaging of spine degeneration

9

Vacuum discSpondylotic changes

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Traction spur instabilityOsteophyte

Marginal syndesmophyte

spondyloarthropathy Non-marginal syndesmophyte diffuse idiopathic skeletal hyperostosis

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Schmorl node

Endplate & marrow changes Cord signal changes inT1 & T2-weighted

Internuclear cleftOPLL

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Pain

Neurodeficit

Defor

mity

Insta

bility

RadiculopathyMyelopathy

SpondylolisthesisScoliosisKyphosis

Abnormal loadAbnormal motionof spinal segment

Axial painRadicular painReferred pain

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SInstability

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Degenerative disc diseases

Axial pain / radiculopathy / myelopathy caused

by , disc degeneration, disc herniation orspondylotic changes

Facet joint arthritis

Spinal stenosis

Spondylolisthesis, scoliosis, kyphosis Ossification of PLL, OYL

14

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Symptom/sign Pain

AxialRadicularReferred

Spondylosis, facetNerve rootEnthesitis, visceral

Radiology

X-rayF/E viewsOblique viewCTMRI

EMGLAB

RadiculopathyMyelopathy HNP, stenosisCSM, OPLL, OYL

Deformity Scoliosis,listhesis,

kyphosisInstability Abnormal spinal

motion segment

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HNP CSM OPLL OYL

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sspondylosis Sspondylolyticspondylolisthesis

Spars defect Sdegen.scoliosis

SNormal SHNP SStenosis SOYL

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Treatment of degenerative spine

18

Pain

Neurodeficit

Defor-

mity

Insta-

bility

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Back or neck pain

Non-radicular back or neck painAcute (4 wk), subacute & chronic

Back or neck pain with radiculopathyAcute, subacute & chronic (>12 wk)

Another specific spinal causes

19

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Treatment options

Medications

Acute, subacute, chronic

Non-medications

Acute, subacute, chronic

Intervention techniques

Subacute, chronic

Surgery

Chronic

20

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Surgical treatment

Indications

Cauda equina syndrome

Progressive myelopathy or radiculopathy

Severe myelopathy or radiculopathy

Correct deformity

Unstable spine Failure conservative treatment

at least 3 months for mechanical pain

21

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SDecompression SDecompression + fusion + stabilization

SDecompression + reduction +fusion + stabilization

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Evidence summary

23

Treatment ofback pain Acute Chronicnonradicular Chronic radicular

Medications AcetaminophenNSAIDsMuscle relaxant

Acetaminophen , NSAIDs, Opioids,Antidepressants , Anticonvulsants

Nonmedications

Superficial heat,Stay activeEducation

Multidisciplinary Rx., exercise,manipulation, massage, acupuncture

Interventiontechniques

Medial branchblock ()

ChemonucleolysisEpidural steroid (HNP)

Spinal cord stimulation(failed back)

Surgery Total discreplacement

DiscectomyDecompressionFusionInterspinous spacer

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Hx.A 60-year-old male presented withprogressive difficulty on walking and handusing for 6 months.

PE. Spastic gait, Lhermittes sign +, Grip release+, Finger escape+, scapulohumeral reflex +

Hoffmans sign+,

Babinski -, clonus

Decreased pinprick L5 Rt

EHL gr IV Rt

25

Case

3+

3+ 3+

3+

3+ 3+

1+ 1+

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After Sx.

4 Mo

4 Yr

a

b

c

(a-b)/b X 100 = 15%

(b-c)/c X 100 = 15%

(a-c)/a X 100 = 25%

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Schmorlsnodes

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Level of evidence

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Level Study (Systematic reviews ;SR)

I 1. High quality RCTs; Narrow confidence interval2. SRs of Level I study with consistent results

II 1. Lesser quality RCT

2. Prospective comparative study3. SRs of Level II or Level I study with inconsistent results

III 1. Case control study2. Retrospective comparative study

3. SRs of Level IIIIV Case series

V Expert opinion

Center for evidence-based medicine, Oxford, UK

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Overall strength of evidence

32

Strength ofevidence

Finding from thestudies

Good evidence Level I studies

Fair evidence Level II studies

Poor evidence Level III, IV studiesInconsistent/insufficient

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Grading of recommendation

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Grading DefinitionA Strongly recommends

Good evidence that intervention improveshealth outcomes; Benefits > harm

BRecommend for some eligible patientsAt least fair evidence; benefit > harm; low cost

C Not recommend or againstAt least fair evidence; benefit ~ harm

D Against interventionsAt least fair evidence that intervention isineffective; harm > benefit

I Insufficient evidence to recommend or against

US Preventive Task Force for Grading strength of evidence

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Effect size of treatment

No effect, small, moderate, large effect

34

Small Moderate Large

Decrease VAS (0-100) 5-10 10-20 >20

Improve ODI (0-100) 5-10 10-20 >20

Standard meandifference

0.2-0.5 0.5-0.8 >0.8

US Preventive Task Force for Grading strength of evidence

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Acute LBP

35

TreatmentLevel ofevidence

Effectsize

Grading ofRecom.

Acetaminophen NSAIDsMuscle relaxants

GoodSmall-

moderateB

Stay active, educationManipulation, herbalSuperficial heat

FairSmall-

moderateB-C

Bed rest, exercise Good No effect D

Deep heat, , TENS,Acupuncture, support,Back school, ultrasound,Traction

Poor No-Small I

Chou et al., Spine 2009

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Subacute & Chronic LBP

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Treatment Level ofevidence Effectsize Grading ofRecom.

Multidisciplinary, Exercise,manipulation massage,acupuncture

Good-fair Moderate B

NSAIDs ,Acetaminophenopioids

Good-fair Small-Moderate

B

Antidepressants AnticonvulsantsBenzodiazepinesAcupuncture, back school

FairSmall-

ModerateB-C

Traction, mattress Fair No benefit D

Laser, Lumbar support TENS,ultrasound, short wave,biofeedback, traction

PoorUnable toestimate

I

Chou et al., Spine 2009

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Interventional techniques fornon-radicular back pain

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Treatment Level ofevidence

Effectsize

Grading ofRecom.

Medial branch block FairSmall-

moderateB-C

Epidural adhesiolysis (failed back) FairSmall-

moderate C

Facet joint injection Fair No benefit D

Intradiscal steriod injection Fair No benefit D

Local, botulinum, epidural injection Poor

Unable to

estimate I

SI joint injectionRadiofrequency denervation

PoorUnable toestimate

I

Spinal cord stimulationIntrathecal therapyCoblation nucleoplasty

No trialsUnable toestimate

I

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Surgery

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Treatment Level ofevidence Effectsize Grading ofRecom.

Micro / open discectomy Good Moderate B

Stenosis decompression Good Moderate B

Interspinous spacer (X-STOP) Fair Moderate B

Full endoscopic disc surgery Fair Moderate B

Other minimally invasive disc

surgery

Fair-poorUnable to

estimate

I

Fusion Fair Moderate B

Total disc replacement Fair Moderate B

Nucleus replacement PoorUnable to

ti t

I