spine 2554
TRANSCRIPT
-
8/13/2019 Spine 2554
1/39
MD, PhD, LLB
-
8/13/2019 Spine 2554
2/39
2
-
8/13/2019 Spine 2554
3/39
26 Vertebra
23 Disc 24x2 facet joints
23x2 endplates
(29)x2 nerveroots
Ligaments
3
-
8/13/2019 Spine 2554
4/39
Morphology, anatomy, histology, physiology,biochemistry, neurology, pathology, biomechanics, &functions
Disc, body, endplate, facet, ligament & capsule
Aging spine
Degenerative spine diseases
Degenerative disc diseases
4
-
8/13/2019 Spine 2554
5/39
5
Changes in NP proteoglycan, water, collagen II, cell density cell death, collagen I
Disc morphology changes
Inappropriate response to load
Intervertebral discdegeneration
Changes in AF & endplate vascular & neural invasion endplate vascularity,fracture
Genetic factorsAge, Nutrition
Environmentalfactors
-
8/13/2019 Spine 2554
6/39
Disc degeneration
Loss of discheight & 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
-
8/13/2019 Spine 2554
7/39
7
Capsular laxity Instability Internal disruption
Subluxation Lateral nerve Disc resorptionentrapment
Synovitis Dysfunction Circumferential tears
Continuing Herniation Radial tearsdegeneration
Enlargement of One level stenosis Osteophytes
articular processes
Multilevel spondylosisand stenosis
Facet DiscKirkkaldy_Willis (1982)Three stages of spinal degeneration
Dysfunction
Instability
Stabilization
Intermittent axial pain
Persistent back & leg pain
Leg pain neurological deficit
-
8/13/2019 Spine 2554
8/39
8
Morphology Physiology Function
Disc Content
changes
Motion & load
Vertebral body Osteoporoticchanges
Load function
Endplate Sclerosis
osteophyte
vascularity
Marrow changes
Load function
Facet &capsule
HypertrophySubluxation
Cartilage contentchange
Motion & load
Ligament Hypertrophy
elasticity
Content
changes
Motion & load
Spinal cord &root
changes changes Functionchanges
-
8/13/2019 Spine 2554
9/39
Imaging of spine degeneration
9
Vacuum discSpondylotic changes
-
8/13/2019 Spine 2554
10/39
10
Traction spur instabilityOsteophyte
Marginal syndesmophyte
spondyloarthropathy Non-marginal syndesmophyte diffuse idiopathic skeletal hyperostosis
-
8/13/2019 Spine 2554
11/39
11
Schmorl node
Endplate & marrow changes Cord signal changes inT1 & T2-weighted
Internuclear cleftOPLL
-
8/13/2019 Spine 2554
12/39
12
Pain
Neurodeficit
Defor
mity
Insta
bility
RadiculopathyMyelopathy
SpondylolisthesisScoliosisKyphosis
Abnormal loadAbnormal motionof spinal segment
Axial painRadicular painReferred pain
-
8/13/2019 Spine 2554
13/39
13
SInstability
-
8/13/2019 Spine 2554
14/39
Degenerative disc diseases
Axial pain / radiculopathy / myelopathy caused
by , disc degeneration, disc herniation orspondylotic changes
Facet joint arthritis
Spinal stenosis
Spondylolisthesis, scoliosis, kyphosis Ossification of PLL, OYL
14
-
8/13/2019 Spine 2554
15/39
15
Symptom/sign Pain
AxialRadicularReferred
Spondylosis, facetNerve rootEnthesitis, visceral
Radiology
X-rayF/E viewsOblique viewCTMRI
EMGLAB
RadiculopathyMyelopathy HNP, stenosisCSM, OPLL, OYL
Deformity Scoliosis,listhesis,
kyphosisInstability Abnormal spinal
motion segment
-
8/13/2019 Spine 2554
16/39
16
HNP CSM OPLL OYL
-
8/13/2019 Spine 2554
17/39
17
sspondylosis Sspondylolyticspondylolisthesis
Spars defect Sdegen.scoliosis
SNormal SHNP SStenosis SOYL
-
8/13/2019 Spine 2554
18/39
Treatment of degenerative spine
18
Pain
Neurodeficit
Defor-
mity
Insta-
bility
-
8/13/2019 Spine 2554
19/39
Back or neck pain
Non-radicular back or neck painAcute (4 wk), subacute & chronic
Back or neck pain with radiculopathyAcute, subacute & chronic (>12 wk)
Another specific spinal causes
19
-
8/13/2019 Spine 2554
20/39
Treatment options
Medications
Acute, subacute, chronic
Non-medications
Acute, subacute, chronic
Intervention techniques
Subacute, chronic
Surgery
Chronic
20
-
8/13/2019 Spine 2554
21/39
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
21
-
8/13/2019 Spine 2554
22/39
22
SDecompression SDecompression + fusion + stabilization
SDecompression + reduction +fusion + stabilization
-
8/13/2019 Spine 2554
23/39
Evidence summary
23
Treatment ofback pain Acute Chronicnonradicular Chronic radicular
Medications AcetaminophenNSAIDsMuscle relaxant
Acetaminophen , NSAIDs, Opioids,Antidepressants , Anticonvulsants
Nonmedications
Superficial heat,Stay activeEducation
Multidisciplinary Rx., exercise,manipulation, massage, acupuncture
Interventiontechniques
Medial branchblock ()
ChemonucleolysisEpidural steroid (HNP)
Spinal cord stimulation(failed back)
Surgery Total discreplacement
DiscectomyDecompressionFusionInterspinous spacer
-
8/13/2019 Spine 2554
24/39
-
8/13/2019 Spine 2554
25/39
Hx.A 60-year-old male presented withprogressive difficulty on walking and handusing for 6 months.
PE. Spastic gait, Lhermittes sign +, Grip release+, Finger escape+, scapulohumeral reflex +
Hoffmans sign+,
Babinski -, clonus
Decreased pinprick L5 Rt
EHL gr IV Rt
25
Case
3+
3+ 3+
3+
3+ 3+
1+ 1+
-
8/13/2019 Spine 2554
26/39
26
-
8/13/2019 Spine 2554
27/39
27
-
8/13/2019 Spine 2554
28/39
28
After Sx.
4 Mo
4 Yr
a
b
c
(a-b)/b X 100 = 15%
(b-c)/c X 100 = 15%
(a-c)/a X 100 = 25%
-
8/13/2019 Spine 2554
29/39
-
8/13/2019 Spine 2554
30/39
30
Schmorlsnodes
-
8/13/2019 Spine 2554
31/39
Level of evidence
31
Level Study (Systematic reviews ;SR)
I 1. High quality RCTs; Narrow confidence interval2. SRs of Level I study with consistent results
II 1. Lesser quality RCT
2. Prospective comparative study3. SRs of Level II or Level I study with inconsistent results
III 1. Case control study2. Retrospective comparative study
3. SRs of Level IIIIV Case series
V Expert opinion
Center for evidence-based medicine, Oxford, UK
-
8/13/2019 Spine 2554
32/39
Overall strength of evidence
32
Strength ofevidence
Finding from thestudies
Good evidence Level I studies
Fair evidence Level II studies
Poor evidence Level III, IV studiesInconsistent/insufficient
-
8/13/2019 Spine 2554
33/39
Grading of recommendation
33
Grading DefinitionA Strongly recommends
Good evidence that intervention improveshealth outcomes; Benefits > harm
BRecommend for some eligible patientsAt least fair evidence; benefit > harm; low cost
C Not recommend or againstAt least fair evidence; benefit ~ harm
D Against interventionsAt least fair evidence that intervention isineffective; harm > benefit
I Insufficient evidence to recommend or against
US Preventive Task Force for Grading strength of evidence
-
8/13/2019 Spine 2554
34/39
Effect size of treatment
No effect, small, moderate, large effect
34
Small Moderate Large
Decrease VAS (0-100) 5-10 10-20 >20
Improve ODI (0-100) 5-10 10-20 >20
Standard meandifference
0.2-0.5 0.5-0.8 >0.8
US Preventive Task Force for Grading strength of evidence
-
8/13/2019 Spine 2554
35/39
Acute LBP
35
TreatmentLevel ofevidence
Effectsize
Grading ofRecom.
Acetaminophen NSAIDsMuscle relaxants
GoodSmall-
moderateB
Stay active, educationManipulation, herbalSuperficial heat
FairSmall-
moderateB-C
Bed rest, exercise Good No effect D
Deep heat, , TENS,Acupuncture, support,Back school, ultrasound,Traction
Poor No-Small I
Chou et al., Spine 2009
-
8/13/2019 Spine 2554
36/39
Subacute & Chronic LBP
36
Treatment Level ofevidence Effectsize Grading ofRecom.
Multidisciplinary, Exercise,manipulation massage,acupuncture
Good-fair Moderate B
NSAIDs ,Acetaminophenopioids
Good-fair Small-Moderate
B
Antidepressants AnticonvulsantsBenzodiazepinesAcupuncture, back school
FairSmall-
ModerateB-C
Traction, mattress Fair No benefit D
Laser, Lumbar support TENS,ultrasound, short wave,biofeedback, traction
PoorUnable toestimate
I
Chou et al., Spine 2009
-
8/13/2019 Spine 2554
37/39
Interventional techniques fornon-radicular back pain
37
Treatment Level ofevidence
Effectsize
Grading ofRecom.
Medial branch block FairSmall-
moderateB-C
Epidural adhesiolysis (failed back) FairSmall-
moderate C
Facet joint injection Fair No benefit D
Intradiscal steriod injection Fair No benefit D
Local, botulinum, epidural injection Poor
Unable to
estimate I
SI joint injectionRadiofrequency denervation
PoorUnable toestimate
I
Spinal cord stimulationIntrathecal therapyCoblation nucleoplasty
No trialsUnable toestimate
I
-
8/13/2019 Spine 2554
38/39
-
8/13/2019 Spine 2554
39/39
Surgery
39
Treatment Level ofevidence Effectsize Grading ofRecom.
Micro / open discectomy Good Moderate B
Stenosis decompression Good Moderate B
Interspinous spacer (X-STOP) Fair Moderate B
Full endoscopic disc surgery Fair Moderate B
Other minimally invasive disc
surgery
Fair-poorUnable to
estimate
I
Fusion Fair Moderate B
Total disc replacement Fair Moderate B
Nucleus replacement PoorUnable to
ti t
I