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Understanding pathophysiology and patho biochemistry of disc

disease and radiculopathy and monitoring of sciatica

Satishchandra gore

GORE SYSTEM

www.drgoreonline.com

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Present day acts of omission

1. History listen

2. Dermatomes

3. Palpation

4. Mackenzie’s test

5. Discography

6. Staging of sciatica

7. Sub sets of sciatica

8. Detect Confirm and monitor sciatica

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PM R. 2011 Jun;3(6 Suppl 1):S12-7. Identifying inflammatory targets for biologic therapies for spine pain.

Jacobs LJ1, Vo N, Kang JD.

• Costs -spine-related conditions- enormous - trending upward.

• Current methods employed to treat inflammatory-mediated pain are targeted at alleviating symptoms, rather than correcting the underlying cause of disease.

• Biologic therapies that address the underlying cause of pain could potentially decrease the costs associated with treating spine pathology.

• Biochemical basis for inflammatory-mediated intervertebral disk, facet joint, and nerve pain exists.

• With rapid advances in biomedical technology, these interventions may be available for clinical use in the near future.

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S. Rajasekaran , K. Venkatadass, J. Naresh Babu , K. Ganesh, Ajoy P. Shetty Pharmacological enhancement of disc diffusion and differentiation of healthy, ageing and degenerated

discs Results from in-vivo serial post-contrast MRI studies in 365 human lumbar discs . Eur Spine J (2008) 17:626–643

• Irrespective of age of patient

• ‘Healthy discs’ structurally intact and functionally normal. Normal normal.

• ‘Ageing discs’ structurally intact but with reduced diffusion. There is generally lack of distinction or a cleavage plane between nucleus and annulus.

• ‘Degenerated discs’ structural failure and abnormal diffusion.

• Commonest early structural failure is an Annular tear. Late structural failure can be progressive derangement of the nucleus and annulus.

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What makes pain “visible” : nerve supply

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Intervertebral disc, sensory nerves and neurotrophins: who is who in discogenic pain?

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Nat Rev Rheumatol. 2014 Jan;10(1):44-56. Epub 2013 Oct 29.Role of cytokines in intervertebral disc degeneration: pain and disc content.

Risbud MV, Shapiro IM.

• Degeneration of the intervertebral discs (IVDs) is a major contributor to back, neck and radicular pain.

• IVD degeneration is characterized by increases in levels of the proinflammatory cytokines TNF, IL-1α, IL-1β, IL-6 and IL-17 secreted by the IVD cells

• imbalance in catabolic and anabolic responses --degeneration of IVD tissues-herniation and radicular pain.

• chemokines from degenerating discs- infiltration and activation of immune cells-amplifying the inflammatory cascade. Leukocyte migration into the IVD is accompanied by the appearance of microvasculature tissue and nerve fibres.

• Furthermore, neurogenic factors, generated by both disc and immune cells, induce expression of pain-associated cation channels in the dorsal root ganglion.

• Depolarization of these ion channels is likely to promote discogenic and radicular pain, and reinforce the cytokine-mediated degenerative cascade.

• Taken together, an enhanced understanding of the contribution of cytokines and immune cells to these catabolic, angiogenic and nociceptive processes could provide new targets for the treatment of symptomatic disc disease.

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Clin Biomech (Bristol, Avon). 2010 Dec;25(10):961-71Healing of a painful intervertebral disc should not be confused with reversing

disc degeneration: implications for physical therapies for discogenic back pain.

• Intervertebral discs deteriorate over many years, from the nucleus outwards, to an extent that is influenced by genetic inheritance and metabolite transport.

• Degeneration is often painful because nerves in the peripheral anulus or vertebral endplate can be sensitised by inflammatory-like changes arising from contact with blood or displaced nucleus pulposus.

• Surgically-removed human discs show an active inflammatory process proceeding from the outside-in, and animal studies confirm that effective healing occurs only in the outer anulus and endplate, where cell density and metabolite transport are greatest.

• Healing of the disc periphery has the potential to relieve discogenic pain, by re-establishing a physical barrier between nucleus pulposus and nerves, and reducing inflammation.

• Disc Fx modality of disc repair

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Pain Physician. 2007 Jan;10(1):147-64.Systematic review of discography as a diagnostic test for spinal pain: an update.

Buenaventura RM1, Shah RV, Patel V, Benyamin R, Singh V.

There is strong evidence supporting the role of discography in identifying that subset of patients with lumbar discogenic pain , moderate in cervical discogenic pain and limited in thoracic discogenic pain.

Discography is a useful imaging and pain evaluation tool in identifying a subset of patients with chronic spinal pain secondary to intervertebral disc disorders.

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In vivo visualization paradigm

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Nucleus and its effects

Effects of nucleus pulposus on nerve root neural activity, mechanosensitivity, axonal morphology, and sodium channel expression.

Chen C, Cavanaugh JM, Song Z, Takebayashi T, Kallakuri S, Wooley PH.

Spine (Phila Pa 1976). 2004 Jan 1;29(1):17-25.

Effect of nucleus pulposus on the neural activity of dorsal root ganglion.

Takebayashi T, Cavanaugh JM, Cüneyt Ozaktay A, Kallakuri S, Chen C.

Spine (Phila Pa 1976). 2001 Apr 15;26(8):940-5.

Application of nucleus pulposus to the nerve root simultaneously reduces blood flow in dorsal root ganglion and corresponding

hindpaw in the rat.

Yabuki S, Igarashi T, Kikuchi S.

Spine (Phila Pa 1976). 2000 Jun 15;25(12):1471-6.

Acute effects of nucleus pulposus on blood flow and endoneurial fluid pressure in rat dorsal root ganglia.

Yabuki S, Kikuchi S, Olmarker K, Myers RR.

Spine (Phila Pa 1976). 1998 Dec 1;23(23):2517-23.

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Prevention of compartment syndrome in dorsal root ganglia caused by exposure to nucleus pulposus.

Yabuki S, Onda A, Kikuchi S, Myers RR.

Spine (Phila Pa 1976). 2001 Apr 15;26(8):870-5.

Chronic effects of the nucleus pulposus applied to nerve roots on ectopic firing and conduction velocity.

Ozawa K, Atsuta Y, Kato T.

Spine (Phila Pa 1976). 2001 Dec 15;26(24):2661-5.

Epidural application of nucleus pulposus enhances nociresponses of rat dorsal horn neurons.

Anzai H, Hamba M, Onda A, Konno S, Kikuchi S.

Spine (Phila Pa 1976). 2002 Feb 1;27(3):E50-5.

Up-regulation of acid-sensing ion channel 3 in dorsal root ganglion neurons following application of nucleus pulposus on nerve root in rats.

Ohtori S, Inoue G, Koshi T, Ito T, Doya H, Saito T, Moriya H, Takahashi K.

Spine (Phila Pa 1976). 2006 Aug 15;31(18):2048-52.

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Outcome of discogenic sciatica& Pain generators

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Back pain presentation axial

Axial back painHorizontal or verticalAssociated spasmPosture induced changes in painAssessing root mobility , where root is sensitised!!

Examination in standing and lying downStatic examination can not bring out dynamic complaintsDynamic in time and locationRed flags: unrelenting , pain at night

Investigations need and interpretation

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Back pain targets I

Annular tear central non healing

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Paraspinal back pain: MB of DR

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Facet bilateral two level for MB of DR

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Conservatively treated massive prolapsed discs: a 7-year follow-up.Benson RT, Tavares SP, Robertson SC, Sharp R, Marshall RW.

Ann R Coll Surg Engl. 2010 Mar;92(2):147-53

A massive disc herniation can pursue a favourable clinical course. If early progress is shown, the long-term prognosis is very good and even massive disc herniations can be treated conservatively.

Who will show the progress?

How will it be shown?

Unanswered questions!!!

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Leg pain 6 questions

Is pain along dermatomes?If yes which root?Is it disc?If yes which disc?Non invasive imagingInvasive imaging

Answering:Where is pain coming from?

Why is it persisting?

L5 S1

knee

calf

24CENTRALISATION

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Limitations of dermatomes: old unreliable dogma etc.

Can be OVERCOME: PALPATE

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Limitations of “mute” imaging

Image symptom paradox

30% either way

Images look same but presentations are different

How to overcome this uncertainty

Deciphering images with added knowledge from our studies. See <- Visualize

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Mechanism of sciatica

Effects of nucleus pulposus on nerve root activity, mechanosensitivity, axonal morphology, sodium channel expression: Chen et al: spine 2004 29:1:17-25

Seven days' exposure of nerve root to nucleus pulposus potential neural conduction block +++ higher intensity of ectopic discharges on compression due to mechanical sensitization of nerve root.

whereas 42 days' exposure resulted in desensitization.

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SciaticaMechano sensitized root : SNRB and PALPATE

for gore sign …

s1L5

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S1

L5

L5

Accepted for publication in IJASS july 2014 special miss spine surgery issue Gore and Nadkarni

PALPATE elicit tenderness AND BLOCK LTDPN at sinus tarsi for L5 or sural for S1 sciatica pain

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Staging of sciatica 3 stages progressive, may jump.Stage 1 of mechano [pressure] sensitization 80% outpatientStage 2 of mechanical compression 15 % SLRStage 3 of nerve dysfunction 5% standard neuroexamination

limitation of Root mobility

Indicates stretch sensitivity

**May improve if it is only Inflammatory And Not mechanical

Change from image and dermatome paradigm to NERVE paradigm : PALPATE

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2 sub sets

LATERAL Knee pain: BE AWARE

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Heel pain: ouch after zzz

Maximum in morning

There is no way bone grows to cause pain!!