What is the degenerative cascade

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The term degenerative cascade was introduced by Dr. Kirkaldy-Willis to explain the typical progression of lumbar spine degeneration. This process is conceptualized in terms of a three-joint complex composed of the intervertebral disc and two zygoapophyseal joints that comprise a functional spinal unit, the smallest anatomic unit of the spinal column that demonstrates its basic functional characteristics. The progression of degenerative changes involving the three-joint complex is conceptualized in terms of three phases: dysfunction, instability, and stabilization.

In the first phase, dysfunction, minor trauma or unusual activity leads to back pain. Segmental spinal muscles become tender and spastic. Circumferential tears in the annulus and degeneration of the nucleus occur. Synovitis and cartilage degeneration in the facet joints develop. Disc material may herniate into the spinal canal through an annular tear.

In the second phase, instability, progressive facet capsule laxity and internal disc disruption lead to segmental instability. Degenerative spondylolisthesis and dynamic lateral nerve root entrapment may develop during this phase.

In the third phase, stabilization, osteophytes develop around and within the facet joints and intervertebral disc. The ligamentum flavum may thicken and cause narrowing of the spinal canal. Central spinal stenosis and fixed lateral nerve root entrapment may occur (Fig. 45-3).

PHASE

FACET JOINTS

DISC

Synovitis hypomobility

Continuing degeneration

Capsular laxity

Dysfunction

Herniation

Instability Degenerative spondylolisthesis

Circumferential tears

Radial tears

Internal disruption

Figure 45-3. The degenerative cascade. Interactions between the facet joints and intervertebral disc during the three phases of degenerative spondylosis. (Adapted from Kirkaldy-Willis WH, Bernard TH. Managing Low Back Pain. 4th ed. Philadelphia: Churchill Livingstone; 1999. Fig. 13-2 on p. 250.)

Subluxation

Enlargement of articular processes

Instability Degenerative spondylolisthesis

Subluxation

Enlargement of articular processes

Disc resorption

Osteophytes

Disc resorption

Osteophytes

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