Transcript
The natural history of the
aging spine
The natural history of the
aging spine
George SapkasProfessor in Orthopaedics
George SapkasProfessor in Orthopaedics
Director of theOrthopaedic dpt for Spinal Disorders
&Musculoskeletal Diseases
Metropolitan Hospital
Director of theOrthopaedic dpt for Spinal Disorders
&Musculoskeletal Diseases
Metropolitan Hospital
IntroductionThe spine is a flexible, multi segmented column.
Its functional role is to maintain stability and an upright position as well as providing mobility at he segmental level.
The spine comprises a static changeless element:– The vertebral bodies– An elastic mobile component
Disc Blood Supply
Avascular– Intradisc pressure
higher than arterial pressure
Nutrient Exchange– External diffusion from
peripheral capillaries– Internal diffusion
through cartilaginous endplates
Internal Fluid Cycle
Nocturnal Cycle– Horizontal posture– Water and nutrients move
into disc– Thickness increases
Diurnal Cycle– Vertical posture– Increased pressure forces
water and waste out of disc.– Disc thickness decreases
Disc Compression
Vertical Loading– Nucleus gets
compressed and radiates outward.
– Nucleus pushes on anulus from within.
– Anulus fibers are in tension.
As for every human tissue, aging of the structural components of the spine may be related to a predetermined genetic cell viability and to exposure of the tissues to heavy mechanical forces throughout life.
Whatever the mechanism aging will lead to degenerative changes starting with subtle biochemical alterations followed by micro-structural and finally gross structural changes of the spinal unit.
Aging of :
The disc
The facet joint
The ligaments and muscles
The bone
Aging of the disc
Interverterbral disc space – foramenprogressive stenosis
Lumbar Stenosis-
Developmental
Aging of the facet joint
Aging of ligaments
Aging of muscles
Aging of the bone
Clinical relevance
Spinal Stenosis
Osteoporotic Compression Fractures
Degenerative
Spondylolisthesis
Degenerative Adult Scoliosis
Developmental DDD
Clinical evaluation
Sites of pain origin
Discogram
Facet’s block
Oswestry D.I.
Rolland Morris
SF-36
Functional – Disability questionnaires
LUMBAR DDD
TREATMENT
OPTIONS
Conservative treatment
NSAIDS
Injections - Facet’s Block
Epidural - Caudal injection
Brace
Psychological support
Social support
Rehabilitation programm
When do we operate the degenerative disease ?
1. Pain not responding to conservative treatment, lasting more than 3 months
2. Non improving neurologic deficit
3. Persistence or deterioration of symptoms of intermitent claudication
4. Significant restriction of the common daily working and social activities
Operative treatment
-Options
Neuromonitoring
Navigation system
Decompression without
spondylodesia
Spondylodesia with internal fixationand postero-lateral grafting
The goals are to:a) Restore the height of the
intervertebral disc spaceb) Restore the width of the
intervertebral foramenc) Achieve the maximum
stability and rigidityd) Relocate
the subluxated joints
e) Restore lumbar lordosisf) Restore, close to normal
the loads on the anterior vertebral column
Lumbar interbody spacers - cages
Lumbar stenosis & instability
Posterior decompression & stabilization & interbody spacers
Lumbar degeneration
-instability
Dynamic stabilization
a. Scoliosis
b. Kyphosis
Saggital & Coronal Imbalance
Adult Spinal Deformity
Loss of :• Lumbar Lordosis
(flat back)
and • Sagittal balance
Technical issues
• Osteotomies to restore sagittal balance (e.g. S.P. osteotomies)
• Intervetebral cages
Decompression and stabilization(long)
Decompression and stabilization(long)
• Posterior 3 column stabilization• Intervertebral cages
• Posterior 3 column stabilization• Intervertebral cages
TLIF
Adult degenerative Kyphosis – Scoliosis(+) Parkinson
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