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CHAPTER
CLINICAL PEARLS
l D
egeneration in the spine is a naturally occurring process l S urgical intervention to treat symptoms that result
that can be understood through the “three-joint complex,” from degenerative spine disease include diskectomy,
which is composed of the intervertebral disk and the two laminectomy, and fusion procedures. Despite continuing
dorsal articulating joints. Degeneration of any one joint controversy surrounding which procedure is most effective
leads to degeneration of the other two, initiating a cascade in providing long-term relief, the authors believe that
that leads to spinal degenerative disease. the best course is to understand the underlying disease
and select the least invasive procedure to target that
l A
detailed history and neurological examination can be
pathological area.
used to isolate the level at which the underlying disease
originate. Understanding the presenting symptoms can l F usion remains a heavily debated topic. Multiple studies
help to understand the degree of degeneration present have been performed to evaluate the benefits of fusion in
and then start to formulate the most efficient treatment the spine, none of which have provided definitive class I
plan. evidence to indicate a clear benefit. However, in addition
to the class II and III evidence showing some benefit in
l C
onservative treatment is a feasible first course of action to
selected patients, spine fusions may be indicated based
treat the clinical manifestations of first-onset degenerative
on the need to create stability in an unstable region of the
spine disease. The most commonly accepted modalities
spine.
range from anti-inflammatory therapy to exercises designed
to increase muscle strength and relieve joint loading.
Back pain is the one of the most common reasons for primary ANATOMY AND PHYSIOLOGY
care physician outpatient visits in the United States. A survey
performed in 2002 reported that approximately 26% of
OF SPINE DEGENERATION
Americans had low back pain and 14% had neck pain.1 In
2002, 890 million office visits were due to back pain. As may
Three-Joint Complex
be expected from these statistics, the cost associated with the An understanding of the process of spinal aging involves an
diagnosis and treatment of spine-related problems is astro- understanding of the relevant anatomy of the affected spine.
nomical. The Journal of the American Medical Association In order to understand the sequence of events that leads to
reported $86 billion in health expenditures in 2005 devoted to degeneration of the spine, efforts have been made to decon-
spine-related problems. This amount was an increase of 65% struct the spine in order to demonstrate the nature of the
from 1997.2 degenerative process, for such a process begins in one segment
The process that leads to the development of neck and of the spine and then spreads to adjacent segments.
back pain can be segmented and categorized into acquired The Kirkaldy-Willis three-joint complex theory decon-
and congenital/developmental processes. This chapter focuses structs the spine into three joints that are affected in the
on the naturally occurring events that lead to degeneration of degenerative process. At each level of the spine there exists the
the spine. “three-joint complex,” composed of the intervertebral disk
487
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488 PART 5 Spine
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CHAPTER 30 Degenerative Spine Disease 489
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490 PART 5 Spine
A B
should be sought as well, including loss of foot/toe hair, skin and dimensions of bony architecture that may be required for
discoloration, and a clinical history of other disorders and risk surgical planning. CT myelography is an effective alternative
factors associated with ischemic vascular disease. to assess the neural elements when magnetic resonance imag-
The degenerative process advances in the destabilization ing (MRI) is either contraindicated (due to medical implants)
stage and involves laxity of the dorsal joints, which, in turn, or would be less efficacious owing to artifact from previous
leads to joint subluxation. This subluxation, combined with instrumentation. CT myelography can detect central as well
advanced disk degeneration resulting in disk desiccation and as foraminal stenosis.
narrowing of the intervertebral space, can lead to slippage of MRI is widely considered the gold standard for the imag-
one vertebral body relative to another, or spondylolisthesis. ing evaluation of spinal canal stenosis (Fig. 30.5). MRI can
Spondylolisthesis manifests as instability of the joints, which, most effectively visualize the soft tissues surrounding the
in turn, leads to abnormal or dysfunctional motion. The result spinal canal, as well as the intervertebral disks, ligamentum
of this process can eventually lead to mechanical back pain. flavum, and facet joints. In degenerative spine disease, the
Mechanical back pain is defined as pain that results from activ- location of disk herniation can be evaluated. The origin of the
ity and is relieved with rest. This pain is attributed to joint spinal canal stenosis, whether from the intervertebral disks,
instability and abnormal motion of one vertebral body upon hypertrophy of the posterior longitudinal ligament or of the
another, which can be the result of the degenerative changes ligamentum flavum, or facet hypertrophy, can be specifically
described previously but can also result from traumatic or localized by MRI.
congenital causes. The treatment for mechanical back pain Diskography is a more invasive diagnostic strategy. At
includes restoration of stability to the segment through fusion times, when the clinical presentation does not match the find-
and fixation. ings on the aforementioned routine imaging techniques, or
indeterminate findings on standard imaging modalities are
present, some feel that diskography may be used to identify
DIAGNOSTIC FINDINGS and characterize the disease. Diskography involves injecting
contrast material into the intervertebral disks in question. The
The initial evaluation of back and leg pain begins with static amount of contrast agent tolerated by a disk is an indication
plain radiographs (Fig. 30.3). Static radiographs provide an of degeneration. A normal cervical disk may tolerate 0.2 to
evaluation of spinal alignment and the intervertebral disk 0.5 mL of fluid, whereas a degenerated disk can accept 0.5 to
spaces. An assessment of an affected intervertebral space serves 1.5 mL of fluid.10 If the pain produced following contrast
to provide a rough estimation of the extent of disk degenera- injection is concordant with the typical pain experienced by
tion, and therefore desiccation, that is present at a given level. the patient, the injected level is considered by some to be the
Static radiographs consisting of flexion and extension views of pathological segment. Disk pressure at which pain is elicited
the cervical or lumbar spine can reveal loss of normal align- is also used to predict the pathological level, because damaged
ment during motion. Such may be indicative of dorsal, or even disks allegedly produce pain at lower pressures than normal
ventral, joint instability. disks.11 The effectiveness of diskography to predict positive
Computed tomography (CT) provides a very useful evalu- surgical outcomes is controversial at best, with varying predic-
ation of the bony anatomy (Fig. 30.4). CT is effective in tive reliability. One of the greatest criticisms of diskography
evaluating for bony osteophytes, presence of calcification, is that the grading system employs a subjective criterion for
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CHAPTER 30 Degenerative Spine Disease 491
A B
FIGURE 30.4 Computed tomography (CT) of the cervical and lumbar spine. CT scans are effective for evaluating bony structure in the spine.
In the CT scan of the cervical spine (A), a single-level ventral fusion with plating has been performed. CT is more effective compared to
magnetic resonance imaging (MRI) for evaluating instrumentation due to the lack of artifact on CT imaging. Successful fusion can also
be effectively evaluated by CT imaging by observing whether the interbody graft is consistent with the vertebral bodies above and below.
Careful assessment of the bony anatomy is required when instrumentation is planned. Autofusion of the spine as seen in the lumbar spine
(B) at the L1-L2 level can be detected on CT and provides useful information prior to surgical intervention.
A B
pain, and therefore can be skewed, depending on the patient stenosis is unclear, it has been postulated that progressive disk
and the examiner. It is emphasized that diskography should be dehydration may lead to shrinking of the disk and a decrease
used with the understanding that it does not provide clinically in nerve root compression.13
proven diagnostic utility. Medical treatment of degenerative spine disease ranges
from symptomatic relief to reduction of inflammation. Nar-
cotics can be effective for controlling back or extremity pain,
but these drugs represent short-term resolutions, because they
TREATMENT OPTIONS only postpone the inevitable course of the degenerative dis-
ease, whether it is toward improvement or further worsening
Nonoperative Management of symptoms.
Conservative management plays a significant role in the man- Nonsteroidal anti-inflammatory medications have been
agement of degenerative spine disease. Studies of the natu- shown to be effective in providing relief for acute back pain.14
ral course of spinal stenosis have shown that up to 47% of Narcotic medication can be used to supplement those drugs
patients with symptoms of lumbar spinal stenosis, including when there is more severe pain, but the effectiveness of nar-
neurogenic claudication and radiculopathy, had improvement cotics only serves to mask the degenerative process until it
of symptoms without any intervention.12 Although the physi- progresses or improves spontaneously. Furthermore, nar-
ology of spontaneous improvement of symptoms of spinal cotic medications often contribute to the perpetuation of the
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492 PART 5 Spine
cyclical process leading to the development of a chronic pain of SMT stems from the hypothesis that neck or back pain is
syndrome in patients who do not improve. Their use, there- caused by either a limited range of motion or abnormal dorsal
fore, should be very carefully considered. intervertebral joint motion. A natural joint motion consists
Other medical treatments include muscle relaxants. Mus- of an active range of motion, followed by a passive range of
cle relaxants have shown benefit for the treatment of acute motion that can be reached with external mobilization. A dys-
neck and back pain.15 Systemic oral steroids have also been functional joint leads to pain because it is unable to reach the
utilized for the treatment of radicular pain. Some think that entire range of motion. SMT “resets” the joint by extending
the anti-inflammatory effects may reduce nerve root irritation, the joint beyond the passive range of motion, into the “para-
although several studies have not demonstrated a proven clini- physiological range of motion.” This stresses the joint to its
cal effect.16-18 limit, just short of joint disruption. At this point, joint cavita-
A critical tool for nonoperative management of degen- tion occurs, and the often encountered sounds of joint mobili-
erative spine disease is physical reconditioning, often via the zation, which are likely the result of gas released into the joint
employment of a physical therapist. The goal associated with space,22 occur. The effectiveness of spinal manipulation has
the application of self-induced physical focuses in order to been questioned, and definitive clinical studies that show sig-
strengthen core muscle groups is to help alleviate pathological nificant long-term improvement are lacking. Clinical evidence
loading of the affected dysfunctional joints. Flexibility exer- indicates that there may be short-term relief for the manage-
cises play an integral role as well. Improving segmental flexi- ment of low back pain, but there is no evidence of significance
bility at adjacent segments can diminish pain and help preserve that demonstrates efficacy.23 One of the difficulties associated
normal motion. with assessing the effectiveness of SMT is related to the fact
Epidural steroid injections (ESIs) have been shown to be that there exists no universal treatment strategy—the types
effective, particularly for radicular pain. The anti-inflammatory and numbers of treatments administered vary most dramati-
effects of the steroids are likely to be effective against the che- cally across the board.
moinflammatory responses emanating from a herniated disk.
As expected from its mechanism of action, the effects of ESIs
are usually acute and, hence, short term in nature. Because
Operative Treatment
they do not alter the overall progression of the spine degenera- Surgical treatment options for degenerative spine disease
tion, their temporary clinical benefits are limited, and there- range widely in complexity and may correlate with the extent
fore, they serve best when used to supplement the use of an of disease progression. Via the matching of the clinical evalu-
alternative conservative treatment, such as physical therapy. ation with imaging findings, the disease can be isolated and
Facet joint injections remain a controversial mode the most appropriate nonsurgical or surgical approach chosen
of treatment for back pain. Injections are composed of a and employed.
long-acting local anesthetic, combined with steroids. Stud- In the initial stage of spinal degeneration, disk desiccation
ies have reported no evidence of clinical improvement of leads to predominantly dorsolateral disk herniations causing
back pain,19 with only 33% of patients reporting greater radicular symptoms (Fig. 30.6). Single-level disk herniations
than a 50% relief of pain.20 This approximates results that can be treated nonoperatively or with cervical or lumbar dis-
are consistent with the placebo effect. The key to the effi- kectomy. The latter are relatively “simple” operations that are
cacy of facet injections may reside in the proper selection of associated with a relatively high degree of short-term success.
patients with the so-called facet syndrome. Lippitt defined Long-term success is more variable.
the manifestations of the facet syndrome as “pain in the More complex pathological processes may require surgical
hips and buttocks area, cramping thigh pain, and back stiff- decompression via laminectomy or surgical stabilization. The
ness that is worse in the morning, without lower extremity options are myriad. The decision to fuse should not be taken
paresthesias.” One of the alleged key signs associated with lightly, however. A failed instrumented lumbar fusion often
the facet syndrome is the observation that the pain is exac- results in further surgery and chronic pain. Such patients are
erbated with lumbar spine extension.21 A factor that may very difficult to manage moving forward.
confound the efficacy of facet joint injections is the likeli-
hood that injected material may leak out of the facet joint.
Diskectomy
This leaking may result in direct nerve root block or diffu-
sion of anesthetic material into the paraspinous soft tissues. Diskectomy procedures can be typically categorized into ven-
Such “leakage” would obviously skew outcomes. Neverthe- tral and dorsal approaches. In the cervical spine, the ventral
less, facet joint injection persists as a popular therapeutic approach is often utilized because of its ability to decom-
and diagnostic modality. press broad-based disk herniations. The ventral approach is
One of the less understood therapies patients have often performed through a paramedian incision that requires little
attempted prior to their presentation to a spine specialist is muscle splitting, which leads to a relatively low amount of
spinal manipulative therapy (SMT). SMT is primarily pro- postoperative pain and morbidity. The most commonly
vided by chiropractors, but can also be administered by physi- encountered postoperative complication is dysphagia second-
cal therapists and osteopathic physicians. Manipulation can ary to retraction of the esophagus, which has been shown
be categorized into three main types of therapies: therapeutic to occur in anywhere from 1% to 79% of cases following
massage, mobilization, and manipulative procedures. These anterior cervical procedures, but dramatically improves in the
manipulation techniques range from the application of pres- majority of cases.24 The other main consideration of the ven-
sure isolated to the paraspinal musculature to maneuvers that tral cervical approach, and possibly a contraindication to the
stress the spinal joints and ligaments. The therapeutic benefit approach, is damage to the recurrent laryngeal nerve resulting
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CHAPTER 30 Degenerative Spine Disease 493
A B
A B C
FIGURE 30.7 Sagittal magnetic resonance imaging (MRI) of the cervical spine (A) indicating multilevel stenosis primarly from disk herniations.
A three-level anterior diskectomy and fusion procedure was performed. Postoperative radiographs (B and C) show a three-level fusion with
ventral plating.
in vocal cord paralysis. This paralysis has also been shown to is removed. The Spine Patient Outcomes Research Trial
improve with time in the majority of cases25 (Fig. 30.7). (SPORT) was a prospective, randomized trial that evaluated
The dorsal approach to the cervical spine has also been lumbar diskectomies against nonoperative treatment.27 This
shown to be effective in eliminating unilateral nerve root com- trial concluded that patients undergoing lumbar diskectomies
pression. The technique is effective for eliminating postero- enjoyed reduction of pain, improvements in physical function-
lateral disk herniations either through foraminotomies with ing, and a greater improvement in their disability index than
or without a diskectomy procedure. The dorsal approach patients undergoing conservative treatment. Given the pres-
eliminates the morbidity associated with the ventral approach, ence of the cauda equina in the lumbar region as opposed to
mainly dysphagia, and risk to the ventral neurovascular struc- the spinal cord present in the cervical region, the posterior
tures, but requires muscle splitting, which can add a variable approach is more versatile in the sense that even more cen-
amount of postoperative pain. Simple foraminotomies and tralized disk herniations can be decompressed owing to the
diskectomies also do not require fusion, theoretically decreas- amount of manipulation that can be tolerated by the thecal
ing risk of adjacent segment degeneration. Minimally inva- sac.
sive techniques have been developed to reduce the amount of
muscle dissection carried out and have shown to have up to a
Laminectomy
97% success rate alleviating radiculopathy symptoms.26
Diskectomy procedures in the lumbar spine can also be Laminectomies decompress the spine via the removal of the
categorized into anterior and posterior approaches, although lamina and spinous process. Laminectomy can be applied
unlike the cervical spine, the posterior approach is the more equally in the cervical, thoracic, and lumbar spine, typically
often utilized. Lumbar diskectomies involve a unilateral for multilevel reduction of spinal canal stenosis. In the cervi-
muscle dissection exposing the lamina of the given level to cal spine, multilevel laminectomy has been shown to be effec-
allow a hemilaminectomy, through which the herniated disk tive particularly for canal decompression resulting in cervical
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494 PART 5 Spine
A B C
FIGURE 30.8 Multilevel cervical stenosis viewed on sagittal magnetic resonance imaging (MRI) (A). Laminectomies were performed from the
C3 to C6 levels and fused with lateral mass screws. Postoperative lateral and anteroposterior (AP) radiographs are shown (B and C).
spondolytic myelopathy, as well as for other pathological dis- region of the spine. In the cervical spine, fusion can be consid-
orders such as ossification of the posterior longitudinal liga- ered for ventral and dorsal approaches. A review of 13 class
ment. Although shown to be effective in improving signs of II and III studies comparing the outcome of anterior cervical
myelopathy, the development of postoperative kyphosis has diskectomies with and without fusion performed by Matz and
been reported to be between 14% and 47%.28 This has led associates, demonstrated that there was no clinically signifi-
to the use of cervical laminectomy combined with fusion and cant advantage of including fusion. Only two class III stud-
laminoplasty. Although all three techniques have been shown ies demonstrated that anterior cervical diskectomy alone had
to be effective in decompressing the spinal canal, laminectomy a short length of hospital stay and operative time.30 Fusion
with fusion and laminoplasty have become more commonplace has become a commonplace procedure with cervical lami-
owing to their reduced incidence of postoperative kyphosis. nectomies owing to the incidence of postoperative kyphosis
Laminoplasty involves detachment of the lamina on only (Fig. 30.8). Although no class I or II evidence exists to sup-
one side by creating a trough, and thinning the lamina on port the use of cervical laminectomy with fusion, there is
the contralateral side to allow for “hinging” at the attached class III evidence to indicate that fusion reduces postoperative
lamina site. This allows the detached lamina to be elevated kyphosis.28,31,32
and secured using small bone grafts to maintain the decom- A great deal of controversy surrounds the indications
pressed state. The preservation of the posterior elements has for fusion in the lumbar spine. The indication for fusion is
been shown to effectively decompress the spinal canal without typically during the end of the second stage of the Kirkaldy-
the consequences of fusion such as loss of range of motion and Willis process, which is the phase of maximal destabilization.
adjacent segment degeneration. In one study, laminoplasty Degeneration of the joint complexes and disk space leads to
was shown to be associated with a 27% improvement in pre- excessive movement of one vertebral body upon another, cre-
venting the incidence of postoperative kyphosis.29 ating mechanical back pain. The pain created is partially axial
Laminectomy in the lumbar spine is most common proce- pain caused by disk degeneration and abnormal joint motion
dure performed by spine and neurological surgeons. Laminec- but can also have a radicular component due to foraminal
tomy alone in the lumbar spine is most effective for neurogenic stenosis and nerve root entrapment during mobility. Lumbar
claudication resulting from spinal stenosis. Lumbar laminec- fusion can be used to augment the transition to the second
tomy involves removal of the lamina as well as performing a stage of spinal degeneration into the third stage, restabiliza-
medial facetectomy to eliminate lateral recess stenosis. tion. Fusion typically involves a laminectomy to decompress
the spinal canal and the lateral recess (Fig. 30.9). Autograft
bone is used either in the dorsolateral spaces or the interspaces
Fusion
to facilitate bony fusion while the construct immobilizes the
Fusion remains a heavily debated topic. Multiple studies have spinal segment. There are no clear data to support the pre-
been performed to evaluate the benefits of fusion in the spine, sumption that fusion results in better outcomes compared
none of which has provided definitive class I evidence to indi- to simple laminectomy alone. A multicenter trial is currently
cate a clear benefit. The consideration to perform a fusion is underway to compare fusion with laminectomy alone for
typically based on the need to create stability in an unstable grade I spondylolisthesis.33
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CHAPTER 30 Degenerative Spine Disease 495
A B
SELECTED KEY REFERENCES Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus non-
operative treatment for lumbar spinal stenosis: four-year
Ghogawala Z. Spinal laminectomy vs. instrumented pedicle screw results of the spine patient outcomes research trial. Spine.
fusion. Available at http://www.spine-slip-study.org/2. 2010;35(14):1329-1338.
Johnsson KE, Rosen I, Uden A. The natural course of lumbar spi- Yong-Hing K, Kirkaldy-Willis WH. The pathophysiology of
nal stenosis. Clin Orthop Relat Res. 1992;279:82-86. degenerative disease of the lumbar spine. Orthop Clin North
Ritchie JH, Fahrni WH. Age changes in lumbar intervertebral Am. 1983;14(3):491-504.
discs. Can J Surg. 1970;13(1):65-71.
Please go to expertconsult.com to view the complete list of
references.
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