Pathophysiology

Osteoarthritis is a disease of the articular cartilage and underlying subchondral bone. Although the exact etiology of osteoarthritis is not known, one theory is that cartilage matrix turnover is negatively affected by degenerative forces. This disrupts the balance between cartilage synthesis and degradation. Evidence suggests that collagenase, gelatinase, and stromelysin, which are enzymes involved in cartilage degradation, are increased in osteoarthritic joints.1 The cause for this imbalance...

Natural History

The natural history of spinal osteoarthritis is difficult to define. Most patients will present with back or neck pain, the etiology of which can be hard to determine. Some investigators feel that facet joints are a significant pain generator. Facet joints are innervated by branches of the dorsal rami of the same level and, the level above. After the capsule of the facet joint is innervated with nociceptive fibers. However, studies using facet blocks to examine facet joint contribution to...

Clinical Case 3 Atlantoaxial Instability

Figure 13-3 presents images from a CT scan of an 85-year-old woman with severe neck pain and occipital neuralgia. The pain had been progressively worsening during the past 12-month period despite analgesia. Past medical history included hypertension, hypothyroidism, and osteoarthritis resulting in bilateral knee arthroplasties. On physical exam no weakness or evidence of myelopathy was detected. Dynamic imaging revealed a C1-C2 atlantodens interval of 4 mm in neutral, increasing to 5 mm in...

Alendronate Treatment in Rheumatoid Arthritic Patients

In this study,9 BCT analysis was applied to 29 rheumatoid arthritic patients, randomly assigned to be treated or not with either alendronate for their osteoporosis, but most of whom were on some sort of steroidal medication for their rheumatoid arthritis. Results indicated that, after 12 months Vertebral Average Strength strength density density Vertebral Average Strength strength density density FIGURE 9-4 Median percent change in BCT-predicted whole vertebral compressive strength, average...

Assess for Risk of Falls and Fractures

Certain comorbidities associated with the aging population, such as unsteady gait, use of sedative or hypnotic medications, and impaired visual or neuromuscular function may predispose a patient to falls. By identifying patients at particularly high risk for falls early in the course of treatment, it is possible to prevent a subsequent fracture. It is well recognized that the fracture rate TABLE 12-4 Ten-Year Probability for Fracture Based on FRAX Calculations8 Clinical Risk Factors* 10-Year...

Clinical Case 1 Degenerative Lumbar Spondylolisthesis

Figure 13-1 presents lumbar magnetic resonance imaging (MRI) of a 67-year-old woman with a 30-year history of progressive lower back pain. This pain was exacerbated by activity and relieved by rest. She reported no associated radicular symptoms. Past medical history was significant for morbid obesity, diabetes, and osteoarthritis. Physical exam did not reveal a neurological deficit. The patient had failed to improve despite intensive conservative therapy which included high dosage opiates,...

Epidemiology And Risk Factors

Spinal osteoarthritis has been demonstrated through radiographic and cadaver studies to affect every adult age group.2,3 The prevalence of clinical spinal osteoarthritis increases with age, with elderly patients having the highest radiographic and symptomatic prevalence.1,3 There is also a significant gender difference in prevalence. Females are more likely than males to suffer from osteoarthritis in general. The gender difference is exacerbated after menopause and therefore greater in the...

Clinical Practice Guidelines Evaluation

Elderly patients presenting with significant neck or back pain should be evaluated with plain radiographs to look for evidence of facet joint arthrosis. Those presenting with neurological deficit should be evaluated with MRI or CT myelogram to determine the extent and location of neural compromise. MRI offers a noninvasive assessment of soft tissue disease, whereas CT myelograms can provide additional information on bony compression and provide for surgical planning for instrumentation....

Conclusions And Discussion

Spinal osteoarthritis is a progressive and potentially debilitating disease in the elderly. Therapies to date have focused on symptomatic relief. The sequelae of long-standing spinal osteoarthritis can lead to intractable pain FIGURE 13-5 Postoperative radiographs of Case 3 demonstrating C1-C3 fusion. or neurological symptoms. These patients are often referred to the spine specialist. Great care must be taken in decision making in these patients. Many elderly patients are not good surgical...

Facet Joint Procedures

Approximately 20 of low back pain complaints can be attributed to the zygapophyseal joints in the lumbar spine1,19-22 and likely account for even higher rates of pain in the cervical and thoracic spines.19,20,22 Also known as facet or z-joints, these joints become arthritic and potentially painful as with any joint in the body, and consequently, older individuals may be expected to be more likely to respond to facet blocks than younger patients.20,21,23 In fact, in a study of older Australians...

Stenosis in the Lumbar Spine

An active 90-year-old man was referred to the spine surgery clinic with a long history of worsening bilateral buttock pain and decreased walking tolerance. He was otherwise in excellent health, but noted a burning pain in his buttocks with radiation down the posterior and lateral thighs after ambulating more than about 50 yards. The pain quickly improved with rest, and would not occur if he had a shopping cart to lean on while ambulating. Descending stairs or inclines would aggravate symptoms...

Facet Devices

The anatomy and functional interrelationships are complex. The 3-D sliding synovial articulation is difficult to replicate. Physiologically, the facets have nociceptive and propriocep-tive input that is vital to the proper function of the motion segment. The resulting chemical and mechanical pain generation is difficult to treat surgically. Kinematically complex, facet joints engage in coupled shear and sliding, as well as rotational load sharing, all of which...

Discuss Treatment Clinical Challenges and Future Treatments

This patient had failed conservative therapy, but had multiple medical comorbidities. Despite this, operative intervention was felt to be of benefit as the patient's current state of obesity and deconditioning prevented any further meaningful physiotherapy or exercise program. The patient was treated with decompressive laminectomies L3-L5 with complete L3-L4 and L4-L5 facetec-tomies. Bilateral placement of L3-L5 pedicle screws and right-sided L3-L4 and L4-L5 transforaminal interbody fusions...

Comparing Teriparatide and Alendronate for Treatment of Osteoporosis

Teriparatide and alendronate increase bone mineral density through opposite effects on bone remodeling, namely via anabolic and antiresorptive actions, respectively. In this study8, two randomly assigned groups of postmenopausal osteoporotic women (N 28 teriparatide N 25 alendronate) who had quantitative CT scans of the spine at baseline and postbaseline (6 months and 18 months) were analyzed with BCT for L3 vertebral compressive strength. At 18 months, patients in both treatment groups had...

Diagnosis Of Osteoporosis

Although a good clinical understanding of osteoporosis takes into account the pathophysiology of bone remodeling, mineralization changes, and variable bone quality of the patient, the diagnosis of osteoporosis until recently FIGURE 12-1 Receptor activator of nuclear factor-iB (RANK) on the osteoclast precursor's surface interacts with its ligand (RANKL), expressed by the osteoblasts and stromal cells, thereby activating the differentiation of the osteoclast precursor to activated osteoclast and...

Contraindications

It is often easier to define patients who are not good candidates for a given procedure than to accurately define those who would be suitable. To some extent, the same can be said for lumbar disc arthroplasty. In recent years, much attention has turned toward defining and understanding the established contraindications for TDR, and this, in turn, has generated some controversy. In an epidemiological study to investigate the contraindications to lumbar total disc arthroplasty in their patient...

Clinical Case Examples

Sciatica Healing Plan

MC, a 66-year-old woman with medical contraindications to open surgery, was treated with SRS for a spinal schwannoma. She initially presented with a chronic cough and generalized weakness. Routine laboratory studies showed pancytopenia, and flow cytometry was consistent with acute lymphocytic leukemia. The diagnosis was confirmed by bone marrow biopsy. While undergoing chemotherapy in December 2008, she developed lower back pain with subjective right leg weakness. A 10-by 7-mm epidural lesion,...

Needle Insertion Techniques

There are four common ways to insert a needle finger pressing insertion, pinching needle insertion, pinching skin insertion, and tight skin insertion. The skin at the insertion site is cleaned with an alcohol pad. The needle insertion angle can be perpendicular, oblique, or horizontal to the skin surface with various depths, depending on the location of the acupuncture points, the medical conditions being treated, and the patient's general health. Finger pressing insertion. This technique is...

Other Implant Types Figure 547

Interspinous Implant Titanium

There are a variety of other implants with comparable biomechanical effects. Most of them are implanted through a posterior midline approach. Coflex (Paradigm Spine, New York, NY, USA) This is a U-shaped titanium implant with two bendable wings on its cranial and caudal parts. The Coflex is a dynamic extension stopper that acts like a spring in such a way that extension leads to an elastic compression of the U (Figure 54-9). It is either used as an adjunct to open decompression in spinal...

The Role of Deformity in the Clinical Presentation

Early studies indicated that the incidence of back pain in adult scoliosis patients is about the same as in age-matched controls. Kostuik found a 60 incidence of back pain in adult patients with scoliosis, which was similar to that noted in patients without spinal deformity22. In other studies, patients with adult scoliosis were found to have more severe back pain as compared to controls, especially if the curve progressed beyond 45 degrees23. In more recent studies, Weinstein et al. have...

Subaxial Cervical and Upper Thoracic Spine Fractures in the Elderly

Discoligamentous Injury Mri

Harrod, and Andrew P. White Elderly patients are at increased risk of neurological injuries, including central cord syndrome, due to degenerative stenosis, spondylotic stiffness, and changes in spinal cord morphology and vasculature. Spinal ankylosis increases the risk of unstable fractures, which may not be diagnosed on initial imaging studies such as plain radiographs. For historical reasons, central cord syndrome has traditionally been treated nonoperatively or...

Basic Science

The pathogenesis of lumbar stenosis is an interesting degenerative cascade that eventually leads to the pathognomonic signs and symptoms. In brief, the degenerative cascade begins at the level of the intervertebral disc, which consists of an inner nuclear core called the nucleus pulposus and an outer supporting layer of the disc called the annulus fibrosus. Beginning early in life, the nucleus pulposus loses its vascular supply and depends on diffusion for its nutrient base, which slowly...

Case Studies

Scoliosis Case Studies

Minimally invasive scoliosis surgery relies on three main technologies (1) DLIF XLIF, (2) posterior MIS TLIF, and (3) percutaneous pedicle screw instrumentation. Using a combination of these techniques, deformities of the thoracolumbar spine spanning T10 to the pelvis can be treated. The most common and most straightforward problem is a degenerative scoliosis from L2 to L5 with back pain and neurogenic claudication (Figure 60-8). Using a lateral interbody approach, much of the stenosis can be...

Pharmacologic Treatment

Osteoporosis has been divided into two categories, high-turnover and low-turnover osteoporosis. The pharmacologic agents currently available are commonly divided into antiresorptive and anabolic groups. Antiresorp-tive agents have been developed to address the high-turnover state. These include estrogen, selective estrogen receptor modulators (SERMs), cal-citonin, and bisphosphonates. The anabolic agent, parathyroid hormone, provides active building of bone mass and has been suggested to treat...

Clinical Practice Guidelines

Operative indications for stenosis in the thoracic spine are similar to those in the cervical spine symptoms recalcitrant to nonoperative measures and cases in which myelopathy develops. A 58-year-old woman with no significant past medical history presented to an outside hospital with progressive bilateral lower extremity weakness, right greater than left, and decreased sensation below the nipple line. In addition, she reported 5 out of 10 pain in the midthoracic area, urinary retention, mild...

L5 Dorsal Ramus

Nerve Ganglion

The L5 dorsal ramus is longer than the L1-L4 dorsal rami. It courses the superior border of the ala of the sacrum, lying in the groove formed by the junction of the ala and the superior articular process of the sacrum. It divides into medial and intermediate branches, lacking a lateral branch. The medial branch curves medially around the caudal aspect of the lumbosacral facet joint and ends in the multifidus muscles. The intermediate branch innervates the longissimus thoracis and communicates...

Facet Arthropathy

Ligamentum Flavum Thickening

Degenerative changes of the facet joints in the spine resemble that of other synovial joints in the rest of the body. Although radiography can demonstrate the bone changes associated with osteoarthritis, including joint space narrowing as a result of thinning of articular cartilage, subchondral sclerosis, marginal osteophyte formation, facet hypertrophy, and hyperostosis, these findings are best demonstrated on CT (see Figures 16-2 and 16-3). Very often, gas from vacuum phenomenon can also be...

References

Winlove, Pathophysiology of the intervertebral disc and the challenges for MRI, J. Magn. Reson. Imaging 25 (2007) 419-432. 2. C.Q. Zhao, L.M. Wang, L.S. Jiang, et al., The cell biology of intervertebral disc aging and degeneration, Ageing Res. Rev. 6 (2007) 247-261. 3. A.G. Hadjipavlou, M.N. Tzermiadianos, N. Bogduk, et al., The pathophysiology of disc degeneration a critical review, J. Bone Joint Surg. Br. 90 (2008) 1261-1270. 4. I. A. Stokes, J.C. Iatridis, Mechanical...

Degenerative Mechanics

Osteoarthritic changes at the facet joints can have a cascading effect on a patient's overall spinal health. The facet joints function as the posterolateral articulation between vertebral segments. As such, they bear weight, restrict anterior and posterior movement of the anterior column, and restrict axial rotation. Arthritic changes in these joints can promote abnormal spine mechanics, increasing degeneration. It is commonly held that facet joint arthrosis is a sequela of disc degeneration.4...

Patients with Poor Indications for Dorsal Ramus Rhizotomy

Endoscopic Dorsal Rhizotomy

Patients with lumbosacral radiculopathy whose debilitating leg pain is 1. Multiple-level disc disease with confirmed severe concordant disco-genic pain by evocative diskography, and minimal relief with medial branch blocks 2. Significant motion segment instability or hypermobility 3. Pseudarthrosis following failed fusion 4. FBSS with more leg pain than back pain without known etiology 5. Patients with multiple debilitating painful conditions severe multilevel stenosis including foraminal...