DDD what is it?
degenerative disc disease refers to the natural deterioration of the intervertebral disc structure so they become weak & collapse `
DDD factors which precipitate damage to the intervertebral discs
DDD is often related to aging
…
fax which precipitate damage on top of aging:
- progressive dehydration of the nucleus pulposus
- daily activities causing tears in the annulus fibrosis
- injuries or pathology resulting in instability inc mechanical insults (eg?), iatrogenic injuries (eg?) or systemic metabolic processes (eg?)
DDD pathophysiology?
3 stages:
1) dysfunction - outer annular tears & separation of endplate, cartilage destruction, facet synovial reaction
2) instability - disc resorption & load of disc space height, along w facet capsular laxity, can lead to subluxation & spondylolisthesis
3) restabilisation - degenerative chnages lead to osteophytes formation & canal stenosis
DDD clinical features + OE?
- depends on the region & severity of the disease
- early sx: localised
- severe ->causes instability : pain may become more severe and include radicular leg pain or paraesthesia. +ve lasegue sign (???) SCIATICA
- further progression: worsening muscle tenderness, stiffness, RROM (lumbar region), scoliosis
- OE: may be unremarkable. potential signs inc: local spine tenderness, contracted paraspinal muscles, hypo mobility, painful extension of back or neck….complete neuro exam needed (why?)
DDD differentials ?
cauda equina, infection (eg discitis) or malignancy
DDD investigations ?
NICE says imaging only if: - red flags - radiculopathy + pain > 6 wks - evidence of cord compression - imaging would alter management … - spine x ray if pt has recent trauma or >70yrs - gold standard=MRI spine
DDD management ?
- variable & pt dependent
- acute stage = analgesia (simple then neuropathic), PT, encourage mobility
- > 3m despite analgesia ?=refer to pain clinic
SPINAL STENOSIS what is it? (0 to finals)
narrowing of the spinal canal so u get compression of the cord or roots
- normally affects cervical or lumbar spine
- > 60 yrs due to degenerative chnages
SPINAL STENOSIS types?
- canal stenosis - ??
- lateral stenosis - ??
- foramina stenosis - ??
SPINAL STENOSIS causes?
congenital ss, degerative changes, herniated discs, ligamentum flavum or postirior longitudinal ligament thickening, spinal fracs, spondylolisthesis tumours
SPINAL STENOSIS presentation ?
- sx = gradual onset. severity of them depends on degree of narrowing. subtle w mild compression but severe could present as cauda equina syndrome features
- lumbar spine central stenosis — intermittent neurogenic claudication is the key presenting feature. typical sx: x3?? AKA PSEUDOCLAUDICATION
- sx appear on walking or standing but not at rest. flexion (bending) improves sx (why?)
SPINAL STENOSIS investigations?
- MRI
- investigations to exclude PAD (eg ABPI & CT angio ) when intermittent claudication is present
SPINAL STENOSIS management ?
- exercise
- wt loss
- analgesia
- PT
- decompression surgery
- laminectomy
CAUDA EQUINA SYNDROME what is it? (0 to finals)
nerve roots of the cauda equina are compressed - surgical emergency !!!
CAUDA EQUINA SYNDROME causes?
cord terminates at L2/3 & becomes CE and can become compressed:
- herniated disc
- tumours - mets
- spondylolisthesis
- abscess
- trauma
CAUDA EQUINA red flags?
- bilateral sciatica
- saddle anaesthesia
- ED
- painless urinary retention
- urinary & faecal incontinence
CAUDA EQUINA management ?
- immediate hospital admission
- emergent MRI
- decompression surgery
