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www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com
Discogenic Low Back Pain
Dr.Sandeep Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India [email protected]
Visit us at: www.drsandeepagrawal.com
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www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com
InterVertebral Disc
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Causes of Back Pain
25-40% Back Pain (Discogenic Back Pain)
Muscles,Tendons,Ligamaents
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RED FLAGS
Discogenic Back Pain
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Degenerated Disc
Annuloplasty Disc Decompression
Chemonucleolysis
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Ventral ramus, sympathetic chain, dorsal root ganglion
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Discogenic low back pain
• Diagnosis ..primarily with “provocative discography” !
• Type I collagen in Nucleus pulposus and annulus fibrosus is increasingly replaced by type II collagen
• Chondroitin sulfate is replaced by keratan sulfate • Disc is innervated by the sinuvertebral nerve, which is formed
by branches from the ventral nerve root and parasympathetic plexus
• Sinuvertebral nerve innervate anterior aspect of disc and anterior longitudinal ligment
• Free nerve endings of sinuvertebral nerve can penetrate into the deep annulus fibrosus and nucleus pulposus and are immunoreactive for several pain-related neuropepitides
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Biochemical Change After Stress
• Matrix protein loss • Loss of hydrostatic pressure • Bulking of annular lamellae
• Annulus wall shear stress ↑, Tear
• Axial back pain & dysfunction
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• Chemical factors such as phospholipae A2, IL-1 and matrix metalloproteinase may play roles in discogenic pain
• Discogenic pain is nothing to do with mechanoreceptors and nociceptors in the facet joint capsules and synovium
• In DDD, density of sensory nerve will decrease in vertebral end plates and underlying cancellous bone
• Clinically, discogenic pain is characterized by axial low back pain with associated radicular pain, nerve tension sign
• Discogenic pain is deep, aching, and exacerbated by sitting, bending and axial loading
• Refer pain may radiate in a sclerotomal fashion to the S-I joints, buttocks, or posterior thigh and occasionally into the inguinal area with involvement of the L5-S1 disc
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• Patient has mechanical back pain related to posture or motion and has radiographic instability
• Micromotion at the intervertebral segment :role in the pathogenesis of discogenic pain
• Normal MRI highly correlate with negative lumbar discogram and should be presumed to have a nondiscogenic cause of low back pain
• MRI in patient without loss of disc high shows low signal on T1-weighted imaging or annular tear
• Provocative discogram : to confirm diagnosis of discogenic pain when surgery is being considered
• What is the “positive provocative discogram” ? • Some studies : high-pressure pain response suggests chemical
pathway for pain generation and will have better outcome following fusion
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Discogenic Low Back Pain
• Axial low back pain • No instability • Diagnosis
– MRI (dark disc, hyperintensity zone)
– Provocative discogram • Concordant pain • Abnormal disk morphology • Negative control
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Provocative Discogram
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• Provocative discography (+) is the definite diagnosis of DDD • 90% patients will go on to complete pain relief within 2 to 6
weeks • NSAID and antispasmolytic medicine are effective in the
management of acute back pain, but is unclear in chronic pain • Intradiskal electrothermotherapy (IDET) has been proposed as
an option of the treatment • Lumbar fusion surgical procedure of choice for the treatment of
discogenic back pain with poor response to conservative treatment
• Disc excision or decompression procedure are another recommended procedures in treating DDD
• Successful fusion is obtained in 60% to 90% of patients who undergo posterior procedure, but clinical outcomes are satisfactory in only 40% to 70%.
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Surgery for back pain;MRI…
• Clinical correlation is must • Discography is very helpful
Remember: FBSS 30%
Re-surgery; failure & risk
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Discogenic Low Back PainPathoanatomy and Pathophysiology
• Type II collage -> Type I collagen • Chondrotin sulfate -> Keratan
sulfate • Dehydration in nucleus pulposus • Radial tear within the annulus
fibrosus • Disk height loss • Laxity in the peripheral attachment • Free nerve ending (sinuvertebral
nerve)
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Discogenic Low Back PainClinical Features
• Deep, aching, exacerbated by sitting, bending and axial loading
• Referred pain : sacroiliac joints, buttocks, posterior thighs, inguinal area (L5-S1 occasionally)
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Patients with Loss of Disc Height
• End plate sclerosis, mild facet joint arthrosis
• Disc bulging, ligamentum flavum infolding, mild canal and foraminal stenosis
• Positive discograms in 25% patients with mild symptoms
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Patients Without Loss of Disc Height
• No facet joint or end plate changes • Dark disc, annular tear
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Discogenic Low Back PainPrognosis
• Acute back pain – 90% complete relief within 2 to 6 weeks
• Chronic back pain – 40% as discogenic pain
• 5-year follow-up – 68% improve – 24% worsen – 8% remained unchanged
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Discogenic Low Back PainManagement
• Conservative – Medication, physical therapy, exercise
• Intradiscal electrothermal therapy(IDET) • Lumbar fusion
– Mechanoreceptos and nociceptors in the facet joint decrease after interbody fusion
– Posterior • Successful fusion 60% to 90% • Satisfactory outcome 40% to 70%
– Anterior • Successful fusion 80% to 96%
• Artificial disc
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• Posterior procedures – PLIF – TLIF
• ALIF can remove pain fibers and receptors from the annulus fibrosus and nucleus pulposus, eliminate motion across disc, restore disc height and indirectly decompress neuroforamen, avoid posterior muscle disruption – Open – Laparoscopic ALIF
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IDET Intradiscal Electrothermal Annuloplasty• Local anesthesia
• 90 degrees Celsius for 15-17 minutes
• Contract and thicken the collagen fibers
• Cauterize nerve endings
IntraDiscal ElectroThermotherapy ( IDET ) For discogenic pain (axial pain)
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Thermal energy: 65ºC for 17 minutes •Collagen shrinkage •Destruction of nociceptive fibers
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Indications (Saal & Saal)• Axial pain > 6 months • Non-operative care at least 3 months • No psychosocial problems
• SLRT (-)
• Disc height: > 50% preserved
• MRI: no compressive lession
• Provocative discogram (+)
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Results of IDET! highly varied• 70% satisfied result Saal JA. Spine. 2000
• 50% were dissatisfied Davis TT. Spine. 2004
• Not effective Spruit M. Eur Spine J. 2002
• Potentially beneficial in carefully selected patients
Biyani A. Spine. 2003
• Worthwhile in a small proportion of strictly defined patients Pauza KJ. Spine J. 2004
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Complications
• Discitis • Nerve root injury • Catheter breakage • Cauda equina syndrome
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General Concept of IDET
• IDET should be considered as
“Experimental Procedure”
• Maybe useful in highly selected patient
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Biaculoplasty (Cooled RF)
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Disc Herniation; Discectomy
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Hydrodiscectomy (Spine jet®)
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Laser and RF Plasma
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Percutaneous Nucleotomy
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Dekompressor
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Ozone Neucleolysis
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Intervertebral Disc Surgery
• Three classical surgical steps
conservative!treatment
percutaneous!surgeries
open!surgeries
fusion!surgeries
I
II
III
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Brothers
• Lumbar spinal stenosis • Lumbar disc Herniation • Discogenic Low Back Pain
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Future of Non surgical Treatment
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Take Home Message
• Disc contributes 25-40% back pain • Only 10% patients require Intervention • MRI alone does not guarantee the
diagnosis of discogenic pain • Until supported by clinical judgment and
discography • Surgery is indicated in selected cases
specially sequestrated disc and emergent situation
• Non-surgical management is very safe & successful in
most of the patients.
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This presentation is for doctors in general.!. Some graphics and jpeg files are taken from Google Image to heighten the specific points in this presentation. !• If there is any objection/or copyright violation, please inform [email protected] for prompt deletion. !• It is intended for use only by the doctors of orthopaedic surgery.!. Views expressed in this presentation are personal. • .For any confusion please contact the sole author for clarification. !• Every body is allowed to copy or download and use the material best suited to him. !
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Requirements towards the development of a fine personality
1. Clarity of goals and purpose in life 2. Doing beyond expectation 3. Learning from failures 4. Initiatives 5. Enthusiasm 6. Character and personality 7. Self discipline 8. Positive mental attitude 9. Managing 10. Sound physical and mental health 11. Team work 12. Hard work 13. Growing in one’s knowledge and skills 14. Desiring pleasure and excitement
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THE CAN DO ATTITUDE
• You CAN DO everything, but not all at once.
• You CAN DO everything, if it’s important enough for
you to do.
• You CAN DO everything, but you may not be the best
at everything.
• You CAN DO everything, but there will be
limitations.
• You CAN DO everything, but you’ll need help.