Degenerative conditions

1. DEGENERATIVE DISEASE OF
JOINTS AND SPINE
PRESENTER: DR.ABDULMAJID H. SAID (RESIDENT)
FACILITATOR: DR.ANTHONY ASSEY (SENIOR LECTURER & CONSULTATNT
SPINE & OT )

2. Degenerative joints disease
• Degenerative joint disease, also known as osteoarthritis (OA), is a
common “wear and tear” disease.
• Most of the people who have OA are older than age 45,and women
are more commonly affected than men.

3. Definition
• Is a chronic joint disorder in which there is progressive softening and
disintegration of articular cartilage accompanied by new growth of
cartilage and bone at the joint margins (osteophytes), and capsular
fibrosis

4. • As defined by the American College of Rheumatology (ACR),OA is a
heterogenous group of condition that leads to joint signs and
symptoms which are associated with defective integrity of articular
cartilage in addition to related changes in the underlying bone at the
joint margins.

5. Epidemiology
• Age > 65years
80% have radiographic features.
25-30% have symptoms
• More common in women
• Weight bearing joints e.g knee & hip joints
• Familial tendency

6. Commonly affects
• Hips
• Kness
• Feet
• Spine
• Hands (Interphalangeal joints)

7. Uncommonly affected joints
• Shoulder
• Wrist
• Elbow
• Metacarpophalangeal joint
• TMJ
• Ankle

8. • picture

9. ETIOLOGY
• PRIMARY/IIDIOPATHIC:
• SECONDARY
 Local or systemic factors

10. Major risk factors

12. Pathophysiology

13. Progressive loss of articular cartilage thickness
Subarticular cyst formation and sclerosis;
Re-modelling of the bone ends and osteophyte formation;
Synovial irritation; and
Capsular fibrosis.

14. Pathology and pathogenesis

15. Pathogenesis
• Initiated by a mixture of systemic predisposing factors interacting
with local mechanical influences that affect the site and severity of
the OA changes, but the changes themselves are chemically
mediated.

16. • A lot of current work revolves around the generation of local cytokines and
proteolytic enzymes within the joint, and cell signalling pathways that link
chondrocyte activity to changes in the subchondral bone, synovium and
capsule
• The early changes in cartilage appear to result from collagenase enzymes
disrupting the integrity of the type II collagen matrix which encloses the
hydrophilic proteoglycans, leading to swelling and softening; subsequently,
more proteolysis and damage to proteoglycans, as well as collagen, results
in the fissuring and loss of volume.
• It is less clear how the changes at the tidemark and in subchondral bone
are mediated, where increased calcification and angiogenesis are switched
on, and trabecular thickening is seen, perhaps in part as a result of
subchondral micro-fractures of trabeculae

17. Clinical Features
• Pain
Activity & weight bearing
Variable over time
Only one or few joints involved
• Morning stiffness only brief < 30 minutes
• Restricted functionality
Capsular thickening
Blocking by osteophytes

18. Clinical findings in knee O/A
• Targets patella-femoral & medial tibio-femoral compartments of knee
• Pain is localized to anterior or medial aspect of knee & upper tibia
• Jerky gait
• Varus deformity
• Joint line &/or periarticular tenderness
• Weakness and wasting of quadriceps muscle.
• Restricted extension & flexion
• Bony swelling around joint

19. Clinical Findings in Hip joint
• Targets mostly superior aspect & less commonly medial aspect of
joint.
• Pain is maximally deep in groin area.
• Antalgic gait.
• Weakness & wasting of muscles (quadriceps & gluteal)
• Pain & restricted internal rotation with flexion.

20. Differential diagnosis

21. Investigations
• Plain X-ray
Joint space narrowing
Subchondral sclerosis

22. • Blood test
FBC-NORMAL
ESR-NORMAL
CRP-NORMAL
RHEUMATOID FACTOR – NEGATIVE
• SYNOVIAL FLUID ANALYSIS
Viscous with low turbidity
CPPD & Calcium phosphate

23. Management
• Non-pharmacotherapy
• Pharmacotherapy
• Surgical Interventions

24. Non-pharmacotherapy
• Exercises
Aerobic conditioning
Muscle strengthening exercises
• Reduction of adverse mechanical factors
Weight loss
Pacing of activities
Appropriate foot wear

25. Pharmacotherapy

28. DEGENERATIVE DISEASE OF THE
SPINE

29. Introduction.
• Can be defined as a gradual Loss of normal stuctural function of the
spine over time.
• Caused mainly by aging, but also tumours, arthritis or infection.
• Leading to structural failure and compression of the neural structures
within the spinal canal, discs and neuro foramen.

30. • Affects mostly the mobile parts of the spine (cervical and lumbar
spine).

31. Epidermiology.
Degenerative cervical spine disease.
• On the basis of radiologic findings, 90% of men older than 50 years
and 90% of women older than 60 years have evidence of
degenerative changes in the cervical spine.
• Both sexes seem to be affected equally but the presentation is usually
early in males.

32. • No race seem to be more affected by the disease.
• Age seem to be the major factor in cervical spondylosis, with
• 25% of adults under the age of 40,
• 50% of adults over the age of 40, and
• 85% of adults over the age of 60
• Also there is increased incidence those who carry heavy loads on
their heads or shoulders, in dancers and gymnasts, horse back riders.

33. Lumbar degenerative disease.
• Incidence is 27-37% of the asymptomatic lower back pain population.
eg In the United States, 3% of individuals aged 20-29 years and rising
to more than 80% of individuals older than 40 years have lumbar
spondylosis.
• occurs in 6-10% of the general population and has been found to be
as high as 25-60% in athletes.
• The prevalence of radiographic spondylosis increases with age and
become more past the age of 65.

34. • Age is the greatest risk factor, but other possibilities include disc
desiccation, previous injury, joint overload from malalignment and/or
abnormal z-joint orientation, and genetic predisposition.
• Studies evaluating the role of body mass index (BMI), level of activity,
and gender on incidence and severity of lumbar spondylosis do not
show a clear correlation.

35. Pathoanatomy.
Ligaments.
Intricate stack of bones

36. Joints.

37. Degenerative changes.
• Intervertebral disc Changes.
• Vertebral body/ Endplate changes.
• Degenerative changes of the posterior elements.

38. Intervertebral disc changes.
• Includes, Disc buldge, Annular tear, and Herniation.
• Vacuum Phenomenon
• Brought by decrease in water and proteoglycan content in the annulus
fibrosus.
• Collagen fibres becomes distorted.
• Leading to disc tear, decreased disc height and volume, and loss of
resistance to physiological loads.

39. Disc Buldge.
• Generalized or circumferential disc displacement (involving 50% to
100% of the disc circumference) is known as "bulging", and is not
considered a form of herniation.
• Bulging can be symmetrical (displacement of disc material is equal in
all directions) or asymmetrical (frequently associated with scoliosis)

40. Annular tear.
• Disruption of concentric collagenous fibers comprising the anulus
fibrosus.

41. Vertebral body/ Endplate changes.
Modic changes classification consists of 4 types.
• Type 0 - normal disc and vertebral body appearance.
• Type I - presence of bone marrow edema within vertebral body and
hyper-vascularization.
• Type II - fatty replacements of the red bone marrow within vertebral
body.
• Type III - subchondral bone sclerosis.

42. Vertebral osteophites.
• An osteophyte is a fibrocartilage-capped bony outgrowth.
• Can be extraspinal (marginal, central, periosteal, or capsular) or
Vertebral (traction or claw).

43. Degenerative changes of the posterior elements.
• Facet Joints.
• Ligamentum Flavum.
• PLL

44. Facet joints.
• Cartilage lining Losses water content, cartilage wears away, facets
override on each other.
• Leading to abnormal function of motion segment.
• Facet joint Ligaments become thickened and hypertrophic.
• New bone formation around the joint can occur with the development
of osteophytes or “bone spurs.”

45. Ligamentum flavum.
• Loss of elastin fibres which are replaced by collagen fibers.
• Also deposition of Ca2+.
• Ligamentum flavum can lose strength and elasticity, causing it to
thicken and buckle towards the spinal cord and neuroforamina.

46. Posterior Longitudinal ligament.

47. Symptomatic degenerative spine disease.
Axial Pain.
• Muscle spasms.
• Dicogenic pain.
• Degenerated facet.
• Uncovertebral joints.

48. Radiculopathy.
• Neuroforamina compression.

50. The abdominal cutaneous reflex:
Upper abdominal reflex: T8/9
Lower abdominal reflex: T10/12
Cremasteric reflex: L1–2 superficial reflex
Anal cutaneous/bulbocavenosus/priapism: S2, 3, 4

51. DTR
Biceps reflex - elbow flex – C5/6
Supinator reflex – wrist ext – C6/7
Triceps reflex – elbow ext – C7/8
Infrapatella – knee ext – L3/4
Achilles – ankle planta flex – S1/S2

52. Melopathy.
• Spinal cord compression.

53. Cervical degenerative disease.
• Axial neck pain - pain localised to the spinal column.
• Cervical radiculopathy - complaints in a dermatomal or myotomal
distribution often occurring in the arms. May be numbness, pain or
loss of function.

55. • Cervical myelopathy - a cluster of complaints and findings due to
intrinsic damage to the spinal cord itself. Numbness, coordination and
gait issues, grip weakness and bowel and bladder complaints with
associated physical findings may be reported.

56. • Central cord syndrome, in which motor and sensory deficits affected
the upper extremities more severely than the lower extremities.
• Brown-Séquard syndrome, which consisted of ipsilateral motor
deficits with contralateral sensory deficits.
• Brachialgia and cord syndrome, which consisted of radicular pain in
the upper extremity along with motor and/ or sensory long-tract
signs.

57. • Transverse lesion syndrome, in which the corticospinal,
spinothalamic, and posterior cord tracts were involved with almost
equal severity and which was associated with the longest duration of
symptoms, suggesting that this category may be an end stage of the
disease.
• Motor system syndrome, in which corticospinal tracts and anterior
horn cells were involved, resulting in spasticity

58. Lumbar degenerative diseases.
• Axial Pain
• Radiculopathy.

59. Sciatica.
• Spinal causes.
• Disc changes.
• Vertebral body changes.
• Posterior Elements changes.
• Trauma & Tumors.
• Non Spinal causes.
• Piriformis syndrome.
• Wallet Sciatica (Credit-carditis)
• Trauma

60. Myelopathy.
Conus medularis syndrome.
• Most distal part of the spinal cord situated at level of L1-L2 vertebral
bodies and comprises of sacral segments S1-S5.
• May present with Saddle anasthesia, Absent Bulbocarvenous reflexes,
and absent anal reflexes.
• LMN- at the level of the lesion.
• UMN- below the level of the lesion.

62. • Saddle Anaesthesia: A loss of feeling or numbness between the legs
and/or back passage and/or genitals.
• Bladder Disturbance: Difficulty controlling urination, loss of sensation.
• Bowel Disturbance: Inability to control bowel movements, a loss of
sensation and/or constipation
• Sexual Problems: Inability to maintain erection or ejaculate, loss of
sensation during intercourse
• Nerve Root Pain: Combination of pain, numbness or weakness in back and
legs and/or changing temperature sensations and/or
• spasms in the lower limbs.

65. Spondylolisthesis
• Spondylolisthesis (also known as anterolisthesis) is defined as an
anterior displacement of a vertebra relative to the vertebra below,
whereas the reverse, i.e. when the superior vertebra slips posterior to
that below, is called retrolisthesis
(Butt and Saifuddin 2005).

66. Grading.

67. Management.

68. IMAGING
Radiograph: AP,Lat,oblique
general findings
degenerative changes of uncovertebral and facet joints
osteophyte formation
disc space narrowing
decreased sagittal diameter
cord compression occurs with canal diameter is < 13mm

69. lateral radiograph
important to look for diameter of spinal canal
• a Pavlov ratio of less than 0.8 suggest a congenitally narrow spinal
canal predisposing to stenosis and cord compression
• sagittal alignment
• C2 to C7 alignment

70. MRI
• views
T2 axial imaging gives needed information on the status of the soft
tissues.
• findings
disc degeneration and herniation
foraminal stenosis with nerve root compression (loss of perineural
fat)
central compression with CSF effacement

71. CT without contrast
• complementary information with an MRI, more useful to evaluate
OPLL and osteophytes
CT myelography
• More invasive than an MRI , excellent information on degree of
spinal cord compression

72. Discography
indications
• controversial and rarely indicated in cervical spondylosis

73. Studies
Nerve conduction studies
• high false negative rate
• may be useful to distinguish peripheral from central processes
Selective nerve root corticosteroid injections
• may help confirm level of radiculopathy in patients with multiple level
disease, and when physical exam findings and EMG fail to localize
level .

74. INDICATIONS
Evaluate degree of spinal
cord and nerve root compression
FINDINGS
effacement of CSF indicates functional stenosis
spinal cord signal changes
seen as bright signal on T2 images (myelomalacia)
signal changes on T1-weighted images correlate with a poorer prognosis following
surgical decompression
compression ratio of < 0.4 carries poor prognosis

75. • LABS
Focused :eg
Lipid profile,RFT,LFT,SICKLING,RBS,UA

76. General education on spine health
Driving
smoking cessation
Avoid lifting
professional athletes
Weight management

77. Physical therapy/Orthotics
•
Aims of Physical therapy
1.To reduce pain
2.To increase muscle strength and length
3.To increase joint ROM

78. Physical Therapy Modalities:1st Line
• 1.Exercise therapy
2.Ice/ Heat therapy
3.Manual therapy
4.Traction
5.Electrotherapy
Splints and Orthotics
Types of spinal orthotics:CO,CTO,CTLO

79. Pharmacotherapy
Multi-modal pain management
WHO Pain LAdder
Commonly Used medications
NSAIDS:Diclofenac
STEROIDS:Prednisolone
CALCIUM SUPPLEMENTS
VITAMINS:Vitamin B Complex containing 1,6 and 12
MUSCLE RELAXANTS eg Baclofen
ANXIOLYTICS/ANTI-CONVULSANTS: eg Pregabalin,Gabapentin
CAFERGOT+ERGOTAMINE
•

80. Surgery and follow-up reviews
Operative
surgical decompression, restoration of lordosis, stabilization
indications
significant functional impairment and
1-2 level disease
lordotic, neutral or kyphotic alignment
techniques
appropriate procedure depends on
cervical alignment
 number of stenotic levels
location of compression
medical conditions e.g., goiter

81. Anterior Decompression and Fusion (ACDF)
indications
mainstay of treatment in most patients with single or two level disease
fixed cervical kyphosis of > 10 degrees
anterior procedure can correct kyphosis
compression arising from 2 or fewer disc segments
pathology is anterior (OPLL, soft discs, disc osteophyte complexes)
approach
uses Smith-Robinson anterior approach
corpectomy and strut graft may be required for multilevel spondylosis

82. Laminoplasty
indications
gaining in popularity
useful when maintaining motion is desired
avoids complications of fusion so may be indicated in
patients at high risk of pseudoarthrosis
contraindications
cervical kyphosis
> 13 degrees is a contraindication to posterior
decompression

83. Laminectomy with posterior fusion
indications
• multilevel compression with kyphosis of < 10 degrees
• > 13 degrees of fixed kyphosis is a contraindication for a posterior procedure
• in flexible kyphotic spine, posterior decompression and fusion may be indicated if
kyphotic deformity can be corrected prior to instrumentation
contraindications
• fixed kyphosis of > 10 degrees is a contraindication to posterior decompression
• will not adequately decompress spinal cord as it is "bowstringing" anterior

84. anterior cervical discectomy and fusion
indications
• persistent and disabling pain that has failed nonoperative modalities
• progressive and significant neurologic deficits .
posterior foraminotomy
indications
• foraminal soft disc herniation causing single level radiculopathy ideal
• may be used in osteophytic foraminal narrowing
cervical total disc replacement
indications (controversial)
• single level disease with minimal arthrosis of the facets .

85. Techniques
Anterior Cervical Discectomy and Fusion (ACDF)
approach
• uses Smith-Robinson anterior approach
techniques
• decompression
• placement of bone graft increases disk height and decompresses the neural foramen through
indirect decompression
• corpectomy and strut graft may be required for multilevel spondylosis
• fixation --- anterior plating functions to increase fusion rates and preserve position of interbody
cage or strut graft .

86. Posterior foraminotomy
approach
• posterior approach
technique
• if anterior disc herniation is to be removed, then superior portion of
inferior pedicle should be removed .

87. Total disc replacement
approach
• uses Smith-Robinson anterior approach
Patient Follow Plan:To review progress of care and to identify
complications