Disc Degeneration Wayne Cheng, MD, Dept. of Orthopaedic Surgery Basic Science May 13, 2014.
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Transcript of Disc Degeneration Wayne Cheng, MD, Dept. of Orthopaedic Surgery Basic Science May 13, 2014.
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Disc Degeneration
Wayne Cheng, MD,
Dept. of Orthopaedic Surgery
Basic Science
May 13, 2014
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Outline Introduction Anatomy and pathophysiology Clinical presentation Diagnostic studies Treatment options
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.
Too much pain, Too little money
$86 Billion spent on back and neck pain (2005) More U.S. health care dollars are spent treating back and neck
pain than any other medical condition.
Company acquirer Price(million)
Spinecore Stryker 360
Link spine JNJ 325
Spine solution
Synthes 350
Spinal dynamc
Medtronic 270
Total 1.3 billion
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Why Disc?
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PART 1 - NULEUSRESIST COMPRESSION TO 8X BODY WEIGHT
LAMINATIONS OF ANNULUS, LAMINATIONS OF ANNULUS, Angulated & OverlappingAngulated & Overlapping GELGEL
HIGH INTERNAL HIGH INTERNAL PRESSUREPRESSURE
20-24 PLIES AT L5-S1
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NUCLEUS PULPOSUS
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Proteoglycan = Super sponge
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PLIES OR LAMINATIONS OF TIRE
Part 2- ANULUS
LAMINATED CONSTRUCTION OF THE ANNULUS RESISTS MECHANICAL FORCES YET PRESERVES SEGMENTAL MOTION (THE AUTOMOBILE TIRE, WITH ITS HIGH INTERNAL PRESSURE IS QUITE SIMILAR.)
HIGH INTERNAL HIGH INTERNAL AIR PRESSURE AIR PRESSURE MAINTAINS THE MAINTAINS THE INTEGRITY OF INTEGRITY OF THE TIRETHE TIRE
NOTE ANGULATION & NOTE ANGULATION & OPERLAPPING PLIESOPERLAPPING PLIES
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PART 3- ENDPLATE /VASCULAR:ENDPLATE FILTRATION SYSTEM For Transfer of Nutrients and Waste Removal
µ Gµ GLOMERULUSLOMERULUSDUCTDUCT
CARTILAGENOUS END PLATECARTILAGENOUS END PLATE
End-Plate End-Plate BONEBONE
VERTEBRAL SPONGIOSAVERTEBRAL SPONGIOSA
WITHIN WITHIN 1.5 - 2 mm1.5 - 2 mm
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HOW THE DISC DEGENERATES
Of AnnulusOf AnnulusOf GelOf Gel
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THE STRUCTURES OF THE ENDPLATE WORK WITH THE NUCLEUS AS A METABOLIC PUMP
ESCAPE ROUTESESCAPE ROUTESTOXINS BUILD-UPTOXINS BUILD-UP
ANEROBICANEROBIC
NORMAL PATHS FOR NORMAL PATHS FOR DILUTION OF TOXINSDILUTION OF TOXINS
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CHEMICAL CAUSES OF DISCOGENIC PAINOne of The Key Components
Insoluble Portion of Cell Insoluble Portion of Cell MEMBRANE=MEMBRANE=
Phospholipase APhospholipase A2 2 Occurs in High Concentration Occurs in High Concentration
Inside Degenerated Discs And Unfortunately Is A Inside Degenerated Discs And Unfortunately Is A Powerful Naturally Occurring NeurotoxinPowerful Naturally Occurring Neurotoxin
Now SolubleNow Soluble
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CHANGES IN EXTRACELL. MATRIX
Inc Col 1:2Cross link ColProteolytic clevage
Collagen
Aggrecan
Less cell – less PGCS to KSMore Cross linkBreakdown of aggrecan
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OUTER ANNULUS VESSEL & NERVE BELT
* AREAS OF HIGHEST NERVE * AREAS OF HIGHEST NERVE & VESSEL CONCENTRATION, & VESSEL CONCENTRATION, BUT ONLY IN THE OUTER 6 BUT ONLY IN THE OUTER 6 ANNULAR LAYERSANNULAR LAYERS
*
** **
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ANNULAR DEGENERATION, A PRECURSOR TO POTENTIAL INSTABILITY AND PAINDEGENERATED, DEGENERATED,
FIBROTIC NUCLEUSFIBROTIC NUCLEUS
CIRCUMFERENTIAL CIRCUMFERENTIAL TEARSTEARS
EDEMA OF GEL EDEMA OF GEL LAYERSLAYERS
OUTER ANNULUS OUTER ANNULUS TEARSTEARS
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TYPES OF ANNULAR TEARS
RADIAL TEARRADIAL TEAR
CIRCUMFERENTIAL TEARCIRCUMFERENTIAL TEAR
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COMBINED DEGENERATION, LEAKAGE AND GANGLIONIC ATROPHY
This Rare Case of Long-Standing Back and Leg Pain Shows Atrophy Of the Ganglion And Post-Ganglionic Nerve. An Old HNP is Also Seen At the
Midline *
**
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MORE ADVANCED NUCLEUS DEGENERATION
CIRCMFERENTIAL TEARS
OLD HNP
FACET DEGEN
GANGLION
RADIAL TEAR
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MECHANICAL FAILURE
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MECHANICAL FAILURE
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INTRADISCO PRESSURE
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Disc DegenerationControversialYoung patientsMostly mechanical back pain worsen with any activities
Sitting intoleranceMore pain with flexion than extension
?Abnormal psychological profile
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Discogenic pain
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Disc DegenerationBlack discHIZ
HIZ
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Treat patient not x-ray !67Asymptomatic
volunteers: MRI + Herniated disc
<60 yo = 20% >60 yo = 36% >80 yo = 90%
(Boden JBJS 1990)
98 Asymptomatic vol. 36% had normal disc at all
levels
(Jensen NEJM 1994)
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PROVOCATIVE DISCOGRAPHY
NORMAL LEVELNORMAL LEVEL
DEGENERATIVE LEVELDEGENERATIVE LEVEL
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DISCOGRAM Carragee, E Spine dec, 2000 Randomized Symptomatic patients
17/27 (63%) = +
Asymptomatic patients 8/20 (40%) = -
April, C Sine J 2005 Control Asymptomatic, 55 disc,
58% Grade 3 tear, all had negative discogram result.
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Non-Operative TreatmentNSAIDPhysical therapyEpidural steroid injection
Activity modification
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Disc pressure & position Highest sitting with forwarded posture Lower with straight or relaxed with arm rest. Lowest with standing
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OCCUPATIONAL PREVENTION Inclination of backrest to 110 deg, lumbar support, arm rest. Decrease vibration input. Keep object center of mass close to the body
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Motion Preservation-Artificial Discfor Patients w Disc Degeneration
Charite’ (depuy) Prodisc (synthes)
Maverick (Medtronic)
Flexicore (stryker)
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Artificial Disc and Fusion
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Cervical artificial disc
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2 Level cervical artificial disc
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Posterior Dynamic Stabilization
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Progenitor Cells / BMP
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Thank You