musculoskeletal aging dorothy d. sherwood, md, facp 4/19/2012
TRANSCRIPT
Pathobiology of DJD Degeneration of Cartilage
Chondrocyte: Normal function to create and break down matrix
Proinflammatory cytokines ( IL 1, 6,7,8 and TNF alpha) cause chondrocytes to stop making healthy matrix and increase the breakdown of cartilage
Thickening of subchondral bone,osteophyte formation, hypertrophy, ligamental injuries.
Risk Factors AGE! 50 to 80% of people over 60 have
symptomatic DJD Obesity Genetics Injuries Crystal arthopathies Vitamin D deficiency
Cervical Spine Disease Anatomy:
8 cervical nerves with ventral and dorsal roots Spinal nerve spits into the dorsal ramus and the
ventral ramus Dorsal ramus – posterior neck pain Ventral ramus – Brachial plexus as well as
paraverterbral neck pain Myotome- group of muscles innervated by a spinal
nerve Dermatome- sensory innervation.
Cervical 80 to 90 % of non-traumatic cervical pain is
due to DJD – but DD included Rheumatoid Arthritis Spondyloarthritis Polymyagia Rheumatica Bone Mets/Cord Tumor Infection Multiple Sclerosis
Cervical DJD Stiff neck/cervical strain: c/o neck pain, restricted
ROM, para-spinal muscle tenderness – may or may not have trigger points; no weakness, no sensory symptoms, will have LROM of the neck on exam. Neurological exam normal.
Management: NSAID if tolerated in elderly; low dose hydrocodone if needed for further relief of pain ( sleep interuption ) ; avoid muscle relaxers – don’t work and are very anticholinergic.
Cervical DJD Cervical Spondylosis – DJD
Cervical Spondylitic myelopathy: weakness, impaired coordination, gait impairment, bowel or bladder incontinece, babinsky
Due to cord compression by arthritic changes. Think of it as squeezing the cord
Cervical Radiculopathy: pain, weakness, sensory changes and reflex changes due to pinching the nerve at the cervical foramen
Cervical DJD Physical Exam:
Cervical ROM Muscle palpation Strength, reflexes, sensory, gait, upper motor neuron signs Maneuvers: Spurling, Elvey, Upward Traction
Imaging: X ray Cervical spine: shows curvature, shows position of
vertebra, shows arthritic changes that can be causing pain, metastatic lesion, osteomylitis
MRI Cervical Spine: age >50, immunocompromised, h/o cancer, neurological findings, fever – non-contrast if just looking for DJD changes. Gadolinium in patietns with GFR < 30 causes Nephrogenic Systemic Fibrosis
CT Cervical Spine: looking more for boney problems
Cervical DJD Treatment:
Motor findings: refer to Neurosurgeon of choice Sensory findings: respond well to time…
Steroid taper TCA Gabapentin Narcotics
If safe, NSAID is always indicated ( but not if you are using a steroid taper )
NSAID and Elderly Renal Toxicity
Age is major risk factor after known CKD CHF Hypertension with chronic meds Volume Depletion
GI Toxicity Age H. pylori Steroid use Anticoagulant use Prior h/o bleeding ulcer
Choice: lowest dose, shortest duration, monitor every 3 months for GI and or Renal Toxicity
Use PPI in all patients over age 70
Lumbar Spine Disease Pathophysiology
Loss of Interverterbral disc with degeneration Loat on the Facets Facet hypertrophy Ligament hypertrophy
Lumbar DJD Terminology:
Spondylosis: arthritis Spondylolisthesis: slippage – Grade 1 to 4 Sondylolysis: fracture of the pars interarticularis Spinal Stenosis; squeezing the cord Radiculopathy: nerve root compression
Lumbar Clinical Presentation:
Pain Sensory Loss Weakness Neruogenic Claudication Bowel, Bladder incontinece, Erectile Dysfunction
– Cauda Equina or Conus Medullaris Syndrome ( compression at T11)
Lumbar DJD DD:
Vascular Distal polyneuropathy DJD hip and knee SI Joint pain Inflammatory conditions
Arachnoiditis Chronic Demylinating Polyneuropathy Sarcoidosis Carcinomatous meiningitis Lymes, HSV, HZV< EBV, mycoplasma, TB
Lumbar DJD Evaluation:
Back pain alone of recent onset: NSAID, opiate, follow up in 4 weeks – if still present X ray and ESR – if abnormal MRI
Back pain with neruo findings in patient >50: pain relief – opiate, NSAID not as helpful: if pain only – treat and if not better in 4 weeks – MRI: If weakness – MRI and refer.
Bowel, bladder, ED, sensory level – MRI H/O fever, cancer, weight loss - MRI
Lumbar Treatment modalities
Physical Therapy : No proven benefit, no standard treatment protocol, but everyone does it and patients like it
Injections: may give short term benefit Surgery: depends on the problem – helps in a
young back, dicy at best in an old back
Hip DJD DD: Trochanteric Bursitis, Gluteusmedius Bursitis, DJD,
fracture There are 18 bursas in the hip joint and they can all hurt
Take Home: Hip Joint Pain is anterior groin pain Trochanteric Bursitis is lateral thigh pain Lateral Cutaneous Femoral Nerve Pain – not influenced by
movement Anterior hip or groin pain – usually DJD but r/o osteonecrosis,
abdominal pathology such as hernia, or L2-3 nerve root Posterior pain is almost never the hip – lumbar, SI Joint or
Leriche’s syndrome (vascular disease causing buttock, hip, thigh claudication)
Hip DJD Exam:
FABERE Test Flex Abduct Externally Rotate Extend
Internal and External Rotation Palpation
Knee Pain Medial: meniscal, medial ligament,
Anserine bursitis Lateral: meniscal, lateral ligament, iliotibial
band syndrome Anterior: Patellofemoral syndrome, Patellar
bursitis, Patellar tendonopathy ( jumpers leg ) Osgood Schlutter – tibial pain
Posterior:Arthritis, Bakers Cyst,