Natural history of aging spine 2015

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