Bahan Kuliah Degeneratif Spine

8/9/2019 Bahan Kuliah Degeneratif Spine

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Degenerative Disc Disease Low Back Pain

Herniated Nucleus Pulposus

Cervical Spinal StenosisLumbar Spinal Stenosis

WIDIY!"I#$ %I&IN P


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2

Anatomy

!'e Spine Composed o( ))

vertebrae

* + cervical

* ,- t'oracic * . lumbar

* . sacral / 0

cocc12 3(used4 ct to support t'e

trunk and trans(ermuscular load


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3

The Spinal Cord

5longated c1lindrical mass o(nerve tissue occupies t'eupper -6) o( t'e vertebral canal

30-70. cm4

Conus medullaris

conical distal &ilum terminale ,st seg8 cocc12 scensus medullorum Intumescentia cervicalis

3C ) 9 !'8 -4 Intumescentia lumbalis

3!'8 ,: 9 L-4


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4

Segments of the SpinalCord Composed o( ),

segments ;

< cervical

,- t'oracal. lumbalis

. sacralis

, cocc1geus


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5

Intervertebral Disc

• nucleus pulposus

• annulus fibrosus

• hyaline cartilage

end plates


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7


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Degenerative DiscDisease andLow Back Pain


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Degenerative DiscDisease DDD!

>n(ortunatel1? DDD seems to be sorto( a @wastebasket termA W'ile t'ese c'anges are indeed

@degenerative?A t'is 'appens as we ageand is not necessaril1 indicative o( an1signicant underl1ing pat'olog1 or

condition8

!'e maorit1 o( individuals E: wills'ow some t1pe o( degenerative

c'ange3s4 on lumbar imaging8


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DDD

Degeneration o( an individual discspace t1picall1 re(ers to;

,8loss o( disc 'eig't?

-8loss o( water content?

)8brosis?

08end plate sclerosis6de(ects?.8osteop'1te comple2es? etc8


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Degenerative DiscDisease

!'e process is t'oug'tto begin in t'e annulusbrosis wit' c'angesto t'e structure andc'emistr1 o( t'econcentric la1ers

$ver time? t'ese la1erssuFer a loss o( watercontent and proteogl1can?w'ic' c'anges t'e discGs

mec'anical properties?making it less resilientto stress and strain

NormalAnatomy


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!'e process is t'oug'tto begin in t'e annulusbrosis wit' c'angesto t'e structure andc'emistr1 o( t'econcentric la1ers

$ver time? t'ese la1erssuFer a loss o( watercontent and proteogl1can?w'ic' c'anges t'e discGs

mec'anical properties?making it less resilientto stress and strain

DegenerativeAnatomy


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I

II

III

IV

VV

The Aging Disc

!'ompson criteria Loss o( cells Loss o( H-:6 ↓

proteogl1cans

↓ !1pe II6 ↑ !1pe Icollagen

nnular ssures "ec'anical

incompetence Bon1 c'anges


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Degenerative Disease"#acet Arthritis

C'anges in discstructure and (unctioncan lead to c'anges int'e articular (acets?

especiall1'1pertrop'13overgrowt'4?resulting (rom t'e

redirection o(compressive loads(rom t'e anterior andmiddle columns tot'e posterior elements


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Degenerative Disease"#acet Arthritis

&acet Inections nest'etic eFect %elie( ma1 last (or

several mont's or onl1

a (ew weeks? or a (ewda1s


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Degenerative Disease"$steophytes

!'ere ma1 also be'1pertrop'1 o( t'e

vertebral bodiesadacent to t'e

degenerating disct'ese bon1overgrowt's areknown as osteop'1tes

3or bone spurs4


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S1mptoms Low back pain and6or

buttocks pain I( leg pain also e2ists?

t'ere is likel1 anadditional cause? eg?HNP? stenosis? etc

DDD is not usuall1 t'esole diagnosis

t


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egenerat ve scDisease"

Discogenic Pain Discogenic pain ispain originating (romt'e disc itsel( aninternall1 disrupted

disc ma1 result in discmaterial causingc'emical irritation o(nerve bers


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Diagnosis Patient e2amination ra1 "%I

C!? in some cases? torule out ot'er diagnosis

Discograp'1

Nonoperative care

%est (or acute? lowback pain NSID medication P'1sical t'erap1

52ercise6walking

Low7impact aerobics !runk strengt'ening


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Surgical care &ailure o( nonoperative treatment

"inimum o( E weeks

&usion%emoval o( disc and replacement wit' bone

gra(t? or a cage7lled bone gra(t? or a bonegra(t substitute nterior approac' Posterior approac' Combined approac'

rt'roplast1 rticulating disc replacement


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Taking a history in a pt% with LBP

5valuation o( patients wit' LBPs'ould be geared towardsidentication o( t'ose patients wit'

a potentiall1 serious underl1ingetiolog18 Cancer

In(ection 9 osteom1elitis? abscess? etc8 &racture Cauda 5uina S1ndrome


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Things that sho&ld raise a'red (ag)

Previous d2 o( cancer? une2plainedweig't loss

Immunosuppression? d2 o( steroid

use? d2 o( IM drug abuse? D2 o(skin6ot'er in(ection3s4

D2 o( recent (alls or trauma

3including surger14 Bladder d1s(unction or (ecal

incontinence? @saddle anest'esiaA?leg weakness

Pain t'at doesnGt improve wit' rest


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$ther things to check with LBP

Social (actors are important to askabout8 5mplo1ment status

n1 pending litigation Mitals can give clues 3(ever wit'

in(ection? etc48

%outine labs are usuall1 suFicient8 Oood p'1sical e2am s'ould pick up

neurological compromise? i( present8

Pal ation o( t'e s ine lookin (or


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*adiography

Currentl1? radiograp'ic imaging isnot recommended (or patients wit'no @red agsA on 'istor1 and

p'1sical i( t'e1 'ave 'ad s1mptomsless t'an 0 weeks duration8

I( red ags present? or persistent

s1mptoms be1ond 0 weeks?radiograp'ic evaluation isrecommended8

!'en re(erral as6i( appropriate8


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+erniated,&cle&sP&lpos&s


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Concept

Intervertebral discs can be t'oug'to(? conceptuall1? kind o( like a @ell1donut8A !'e outside is t'e annulus

brosus? and t'e inside @ell1A is t'emore water1 nucleus pulposus8


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Intervertebral discs act as s'ockabsorbers between t'e vertebralbodies8

=ust like ell1 donuts 'ave a @weak spotAw'ere t'e ell1 suirts out i( 1ousueeQe t'em? t'e annulus o( discs is

weak posteriorl1 w'ere t'e nucleuspulposus can 'erniate t'roug'? causings1mptoms8


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Presentation

!'e classic presentation o(Herniated Nucleus Pulposus 3HNP4?bot' (or cervical and lumbar spine?

is radiculopat'18 !'e disc 'erniation impinges upon a

nerve root? causing c'aracteristic pain8 !'oracic disc 'ernations are muc'?

muc' rarer8


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L&mbar +,P

@SciaticaA is t'e classicradiculopat'1 o( lumbar HNP?t'oug' t'e e2act presentation

depends upon t'e nerve root3s4involved8

"otor weakness can occur? w'ic'again is representative o( t'e nerveroot3s4 involved8 L0 9 uadriceps 3knee e2tension4 L. 9 tibialis anterior 3(oot dorsie2ion4

S, 9 gastrocnemius 3(oot plantar


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L&mbar +,P - when tooperate

!'e natural 'istor1 o( 'erniateddiscs is to resolve over time8

I( conservative management canadeuatel1 treat a patientGs pain?t'is is t'e pre(erred course o( action8

I( conservative management (ails to

adeuatel1 control pain? surger1 canbe per(ormed 3o(ten times on anoutpatient basis48


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Cervical +,P

Classic presentation is to @wake upwit' it8A >suall1 no identiable(actor8

Causes pain(ul limitation o( neck motionand s1mptoms corresponding to t'eaFected nerve root3s4

!'e maorit1 o( cervical 'erniated

discs will catc' t'e nerve rootcorresponding to t'e lower vertebrallevel8

52; CE6+ disc 'erniation will impingeu on t'e C+ root8


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Cervical +,P

=ust as is t'e case wit' Lumbar HNP?conservative t'erap1 is t'e mainsta1o( treatment8

Surger1 indicated (or t'ose t'atdonGt improve wit' conservativemanagement? or wit'

new6progressive neurologic decit8


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Cervical Spinal

Stenosis


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Cervical Spinal StenosisCSS!

Stenosis 9 a constriction ornarrowing o( a duct or passage8 Cervical spinal stenosis? t'us? is

narrowing o( t'e spinal canal 3wit'inw'ic' lies t'e cervical spinal cord48 !'is narrowing can be (rom an1 o( a

multitude o( causes8 >suall1? t'oug'? t'is is

re(erring to more c'ronic t1pes o(processes? rat'er t'an acute or suddenones8


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CSS - when it ca&sesproblems.

%adiculopat'1 9 (rom nerve rootcompression8 !'e term @radiculopat'1A re(ers to

disease o( t'e nerve roots L"N signs?pain6paraset'esias8

"1elopat'1 9 (rom spinal cord

compression8 !'e term @m1elopat'1A re(ers to

pat'ological c'anges o( t'e spinal corditsel(8


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CSS / 0yelopathy

!'e goal 'ere is to avoid missingpatients w'o are m1elopat'ic?because once stenosis 'as evolved to

t'e point t'at it is compressing 3andcausing damage to4 t'e spinal cord?t'e progression o( s1mptoms ma1 be

variablebut it is going to progress8


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CSS myelopathy / +istory

Some patients attribute weakness to@getting old?A and because t'e1arenGt 'aving neck pain 3man1

m1elopat'ic patients donGt4? t'e1donGt realiQe t'ereGs a problem t'atneeds addressing8

sk about ne motor movements? likebuttoning buttons? t1ing s'oes? signingc'ecks? 'andwriting c'anges? usingutensils? etc8 @ClumsinessA wit' ne

motor skills is common8


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L&mbar Spinal

Stenosis

L b S i l St i


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L&mbar Spinal StenosisLSS!

=ust as we discussed wit' CervicalSpinal Stenosis? @Lumbar SpinalStenosisA can occur secondar1 to

an1t'ing w'ic' narrows t'e lumbarspinal canal


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L&mbar Spinal Stenosis

%emember t'at t'e Spinal Cord endsat t'e Conus "edullaris? w'ic' ist1picall1 located at t'e L,6-

interspace in adults8 L,6- is t'e lumbar level least likel1 to

be aFected b1 Lumbar Spinal Stenosis8

!'us? Lumbar Spinal StenosisdoesnGt cause m1elopat'1 w'en it

aFects t'e motor s1stem? lowerG


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LSS / presentation

!'e @classicA presentation o(Lumbar Spinal Stenosis is,e&rogenic Cla&dication 3NC4? or

@pseudoclaudication8A 3JE:Ksensitivit1? but 3456 speci7city 48

Oraduall1 progressive back? t'ig'?buttock? and6or leg pain t'at is relievedb1 rest and6or? c'aracteristicall1? ac'ange in posture usuall1 t'roug'

e2ion at t'e 'ips 3sitting or suatting?


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,e&rogenic Cla&dication

Neurogenic Claudication is t'oug'tto arise (rom compression o(?irritation to? or isc'emia o( t'e

lumbosacral nerve roots8

!'is is in contrast to Mascular

Claudication 3MC4? w'ic' issecondar1 to insuFicienc1 o( vascular suppl1 to meet demand o(muscles 3pain is isc'emic? but (rom

muscles48


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Bahan Kuliah Degeneratif Spine