MD, PhD, LLB

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Vertebra 23 Disc 24x2 facet joints 23x2 endplates (29)x2 nerve roots Ligaments

Morphology, anatomy, histology, physiology, biochemistry, neurology, pathology, biomechanics, & functions Disc, body, endplate, facet, ligament & capsule
Aging spine Degenerative spine diseases Degenerative disc diseases
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Intervertebral disc degeneration

Genetic factors Age, Nutrition Environmental factors

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

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

Disc morphology changes

Inappropriate response to load

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Disc degeneration

Loss of disc height & 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

Kirkkaldy_Willis (1982) Dysfunction Three stages of spinal degeneration

Synovitis Dysfunction

Facet

Disc

Circumferential tears

Continuing degeneration
Instability

Herniation

Radial tears
Intermittent axial pain

Capsular laxity Subluxation

Stabilization

Instability Lateral nerve entrapment

Internal disruption Disc resorption

Persistent back & leg pain

Enlargement of articular processes

One level stenosis

Osteophytes

Multilevel spondylosis and stenosis Leg pain neurological deficit

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 Disc

Morphology

Physiology Content changes Osteoporotic changes

vascularity Marrow changes

Function Motion & load Load function Load function

Vertebral body Endplate Facet & capsule Ligament Spinal cord & root Sclerosis osteophyte Hypertrophy Subluxation Hypertrophy elasticity changes

Cartilage content Motion & load change

Content changes changes

Motion & load Function changes

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Imaging of spine degeneration

Spondylotic changes

Vacuum disc
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Osteophyte

Traction spur instability

Marginal syndesmophyte spondyloarthropathy

Non-marginal syndesmophyte diffuse idiopathic skeletal hyperostosis

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Internuclear cleft

Schmorl node

OPLL

Endplate & marrow changes

Cord signal changes in T1 & T2-weighted

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Axial pain Radicular pain Referred pain

Neuro deficit

Radiculopathy Myelopathy
Spondylolisthesis Scoliosis Kyphosis

Abnormal load Abnormal motion of spinal segment

Pain
Defor mity
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Insta bility

SInstability

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Degenerative disc diseases

Axial pain / radiculopathy / myelopathy caused by , disc degeneration, disc herniation or spondylotic changes Facet joint arthritis Spinal stenosis Spondylolisthesis, scoliosis, kyphosis Ossification of PLL, OYL

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Symptom/sign Pain Axial Radicular Referred Radiculopathy Myelopathy Deformity

Instability

Spondylosis, facet Nerve root Radiology Enthesitis, visceral X-ray F/E views HNP, stenosis Oblique view CSM, OPLL, OYL CT Scoliosis, MRI listhesis, EMG kyphosis LAB Abnormal spinal motion segment
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HNP

CSM

OPLL

OYL

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sspondylosis

Sspondylolytic spondylolisthesis

Spars defect

Sdegen. scoliosis

SNormal

SHNP

SStenosis

SOYL
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Treatment of degenerative spine

Neuro deficit

Pain
Instability Deformity
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Back or neck pain

Non-radicular back or neck pain

Acute (4 wk), subacute & chronic

Back or neck pain with radiculopathy

Acute, subacute & chronic (>12 wk)

Another specific spinal causes

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Treatment options

Medications

Acute, subacute, chronic Acute, subacute, chronic Subacute, chronic

Non-medications

Intervention techniques

Surgery

Chronic
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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

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SDecompression

SDecompression + fusion + stabilization

SDecompression + reduction +fusion + stabilization

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Evidence summary
Treatment of back pain Medications

Acute
Acetaminophen NSAIDs Muscle relaxant Superficial heat, Stay active Education

Chronic nonradicular

Chronic radicular

Acetaminophen , NSAIDs, Opioids, Antidepressants , Anticonvulsants Multidisciplinary Rx., exercise, manipulation, massage, acupuncture Medial branch block () Chemonucleolysis Epidural steroid (HNP) Spinal cord stimulation (failed back) Discectomy Decompression Fusion Interspinous spacer
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Non medications Intervention techniques

Surgery

Total disc replacement

( )
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Case

Hx. A 60-year-old male presented with progressive difficulty on walking and hand using for 6 months. PE. Spastic gait, Lhermittes sign +, Grip release
+, Finger escape+, scapulohumeral reflex + 3+ 3+ Hoffmans sign+, Babinski -, clonus 3+ 3+ 3+ 3+ Decreased pinprick L5 Rt 1+ 1+ EHL gr IV Rt

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26

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

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

a
After Sx.

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

b
4 Mo

c
4 Yr
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2553

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Schmorls nodes

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Level of evidence
Level I II Study (Systematic reviews ;SR) 1. High quality RCTs; Narrow confidence interval 2. SRs of Level I study with consistent results 1. Lesser quality RCT 2. Prospective comparative study
3.

SRs of Level II or Level I study with inconsistent results

III

1. Case control study 2. Retrospective comparative study 3. SRs of Level III Case series Expert opinion

IV V

Center for evidence-based medicine, Oxford, UK

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Overall strength of evidence

Strength of evidence Good evidence Fair evidence Finding from the studies Level I studies Level II studies
Level III, IV studies Inconsistent/insufficient
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Poor evidence

Grading of recommendation
Grading Definition A Strongly recommends Good evidence that intervention improves health outcomes; Benefits > harm B Recommend for some eligible patients At least fair evidence; benefit > harm; low cost C Not recommend or against At least fair evidence; benefit ~ harm D Against interventions At least fair evidence that intervention is ineffective; 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

Small Moderate Large

Decrease VAS (0-100) Improve ODI (0-100) Standard mean difference

5-10 5-10 0.2-0.5

10-20 10-20 0.5-0.8

>20 >20 >0.8

US Preventive Task Force for Grading strength of evidence

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Acute LBP
Treatment
Acetaminophen NSAIDs Muscle relaxants
Stay active, education Manipulation, herbal Superficial heat Bed rest, exercise
Deep heat, , TENS, Acupuncture, support, Back school, ultrasound, Traction

Level of evidence
Good
Fair
Good Poor

Effect size
Smallmoderate
Smallmoderate No effect No-Small

Grading of Recom.
B
B-C
D I

Chou et al., Spine 2009

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Subacute & Chronic LBP

Treatment Level of evidence Effect size Grading of Recom.

Multidisciplinary, Exercise, manipulation massage, acupuncture

NSAIDs ,Acetaminophen

Good-fair
Good-fair Fair Fair
Poor

Moderate
SmallModerate SmallModerate
No benefit Unable to estimate

B
B B-C D
I

opioids

Antidepressants Anticonvulsants Benzodiazepines Acupuncture, back school Traction, mattress Laser, Lumbar support TENS, ultrasound, short wave, biofeedback, traction

Chou et al., Spine 2009

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Interventional techniques for non-radicular back pain

Treatment
Medial branch block

Level of evidence
Fair

Effect size
Smallmoderate Smallmoderate No benefit

Grading of Recom.
B-C

Epidural adhesiolysis (failed back)

Facet joint injection

Fair
Fair

C
D

Intradiscal steriod injection

Local, botulinum, epidural injection SI joint injection Radiofrequency denervation Spinal cord stimulation Intrathecal therapy Coblation nucleoplasty

Fair
Poor Poor No trials

No benefit
Unable to estimate Unable to estimate Unable to estimate

D
I I I
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Interventional techniques for discogenic & radicular back pain

Treatment Level of evidence Effect size
Moderate
Moderate Moderate No effect Unable to estimate Unable to estimate

Grading of Recom.
B
B B C I

Chemonucleolysis
Epidural steriod injection
(caudal>interlaminar>transfo raminal)

Good
Fair Fair Fair Poor

Spinal cord stimulation (for failed back surgery) Intradiscal steriod inj. Epidural steriod injection (for spinal stenosis) IDET, Radiofrequency denervation Coblation nucleoplasty Spinal cord stimulation

No trials

I
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Surgery
Treatment
Micro / open discectomy Stenosis decompression
Interspinous spacer (X-STOP) Full endoscopic disc surgery Other minimally invasive disc surgery Fusion Total disc replacement Nucleus replacement

Level of evidence
Good Good
Fair Fair Fair-poor Fair Fair Poor

Effect size
Moderate Moderate
Moderate Moderate Unable to estimate Moderate Moderate Unable to estimate

Grading of Recom.
B B
B B I B B I
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