The Intervertebral DiscThe Intervertebral Disc( IVD )( IVD )( IVD )( IVD )
Review and new science !!Review and new science !!
US Statistics and $US Statistics and $US Statistics and $US Statistics and $
About 6 million cases of IVD related diseases / yearAbout 6 million cases of IVD related diseases / yearAbout 6 million cases of IVD related diseases / yearAbout 6 million cases of IVD related diseases / year Annual incidence : 5 % of populationAnnual incidence : 5 % of population 2 4 million workers out at any time2 4 million workers out at any time 2.4 million workers out at any time2.4 million workers out at any time Lifetime incidence 60Lifetime incidence 60--90 %90 % 30 million visits to MD/DC/DO annually30 million visits to MD/DC/DO annually 30 million visits to MD/DC/DO annually30 million visits to MD/DC/DO annually 600,000 back surgeries / year USA600,000 back surgeries / year USA t 10t 10 15 billi $ rk p d 2015 billi $ rk p d 20 3030 costs: 10costs: 10--15 billion $ non workmans comp and 2015 billion $ non workmans comp and 20--30 30
billion $ workmans comp annuallybillion $ workmans comp annually
Pt presentationsPt presentationsPt presentationsPt presentations
LBPLBP LBPLBP Radiating pain a] radicular b] nonradicularRadiating pain a] radicular b] nonradicular
O h i k h iO h i k h i Other sx, i.e. weakness, paresthesias, Other sx, i.e. weakness, paresthesias, dysesthesiasdysesthesias
ANATOMY and PHYSIOLOGYANATOMY and PHYSIOLOGYANATOMY and PHYSIOLOGYANATOMY and PHYSIOLOGY
Healthy spine IVDs = 25 % of column heightHealthy spine IVDs = 25 % of column height Healthy spine IVDs 25 % of column heightHealthy spine IVDs 25 % of column height Outer disc Outer disc –– annulus fibrosus; high amount of annulus fibrosus; high amount of
type I collagen less proteoglycans low watertype I collagen less proteoglycans low watertype I collagen, less proteoglycans, low water type I collagen, less proteoglycans, low water content: strong, tough, sheer resistant.content: strong, tough, sheer resistant.I diI di l l II lll l II ll Inner disc Inner disc –– nucleus pulposus; type II collagen, nucleus pulposus; type II collagen, high proteoglycans, 88 % water; distributes high proteoglycans, 88 % water; distributes
l id il id ipressures evenly, avoids compression.pressures evenly, avoids compression.
ANATOMYANATOMYANATOMYANATOMY
ANATOMY and PHYSIOLOGYANATOMY and PHYSIOLOGYANATOMY and PHYSIOLOGYANATOMY and PHYSIOLOGY
Blood supply: capillaries terminate at vert.Blood supply: capillaries terminate at vert.Blood supply: capillaries terminate at vert. Blood supply: capillaries terminate at vert. endplates so nutrition [ and meds, etc] reach endplates so nutrition [ and meds, etc] reach only by diffusion. IMPORTANT: blood cells do only by diffusion. IMPORTANT: blood cells do y yy ynot normally enter the disc !not normally enter the disc !
Disc aging leads to decreased water contentDisc aging leads to decreased water content--g gg gdiffusion decreases, aging worsens, classic diffusion decreases, aging worsens, classic vicious circle !vicious circle !
Converts to fibrocartilageConverts to fibrocartilage-- loss of elasticity and loss of elasticity and loss of resistance to compression.loss of resistance to compression.
MORE ANATOMYMORE ANATOMYMORE ANATOMYMORE ANATOMY
Anterior annular fibers are bolstered byAnterior annular fibers are bolstered by Anterior annular fibers are bolstered by Anterior annular fibers are bolstered by powerful anterior longtitudinal ligament (ALL)powerful anterior longtitudinal ligament (ALL)
Posterior longtitudinal ligament is narrower andPosterior longtitudinal ligament is narrower and Posterior longtitudinal ligament is narrower and Posterior longtitudinal ligament is narrower and more shallow; provides only week midline more shallow; provides only week midline reinforcement esp at L4reinforcement esp at L4 5 and L55 and L5 S where discS where discreinforcement esp. at L4reinforcement esp. at L4--5 and L55 and L5--S, where disc S, where disc pressures are also greatest.pressures are also greatest.
ALL and PLLALL and PLLALL and PLLALL and PLL
ALL and PLLALL and PLLALL and PLLALL and PLL
More AnatomyMore AnatomyMore AnatomyMore Anatomy
Innervation: [ important to ‘discogenic pain’] twoInnervation: [ important to ‘discogenic pain’] twoInnervation: [ important to discogenic pain ] two Innervation: [ important to discogenic pain ] two routesroutes
One enters adjacent dorsal nerve root segmentally as One enters adjacent dorsal nerve root segmentally as j g yj g ythe root exits thru the neural foramenthe root exits thru the neural foramen
Other route is nonOther route is non--segmental ascending thru the segmental ascending thru the g gg ganterior paravertebral sympathetic chain.anterior paravertebral sympathetic chain.
J Bone Joint Surg. Br. 2008: Apr, 90(4)1135J Bone Joint Surg. Br. 2008: Apr, 90(4)1135--99 Discogenic pain Discogenic pain –– ‘visceral pain’ hypothesis‘visceral pain’ hypothesis
NEW PARADIGMSNEW PARADIGMSNEW PARADIGMSNEW PARADIGMS
In fairly recent several new research findings have In fairly recent several new research findings have y gy gchanged our understanding of disc disease and related changed our understanding of disc disease and related back pain and radiculopathy. These results will likely back pain and radiculopathy. These results will likely l d t m r m rk d hl d t m r m rk d hlead to more marked changes.lead to more marked changes.
Three areas in particular are of interest: the genetics of Three areas in particular are of interest: the genetics of disc diseases; probable role of infection in some discdisc diseases; probable role of infection in some discdisc diseases; probable role of infection in some disc disc diseases; probable role of infection in some disc pathologies; and the role of the immune system, pathologies; and the role of the immune system, particularly in radicular pain.particularly in radicular pain.
We will visit this information as we examine disc We will visit this information as we examine disc pathologies.pathologies.
DISC DEGENERATIONDISC DEGENERATIONDISC DEGENERATIONDISC DEGENERATION
Disc degeneration: loss of ‘bright signal’ on T2Disc degeneration: loss of ‘bright signal’ on T2 Disc degeneration: loss of bright signal on T2 Disc degeneration: loss of bright signal on T2 indicates dessicationindicates dessication-- loss of water in the loss of water in the nucleusnucleusnucleusnucleus
Leads to loss of disc heightLeads to loss of disc heightT f l d h l d h fT f l d h l d h f Transfers load to the annulus and the facet Transfers load to the annulus and the facet joints.joints.
Degenerative disc disease [ DDD ] is Degenerative disc disease [ DDD ] is multifactorial but genetics has major rolemultifactorial but genetics has major role
NL vs. DESSICATEDNL vs. DESSICATEDNL vs. DESSICATEDNL vs. DESSICATED
dessicationdessication dessicationdessication
TWINE SPINE STUDYTWINE SPINE STUDYTWINE SPINE STUDYTWINE SPINE STUDY
Finnish study of identical twinsFinnish study of identical twins-- followed for years withfollowed for years withFinnish study of identical twinsFinnish study of identical twins followed for years with followed for years with thorough exams and histories include work and thorough exams and histories include work and recreation, etcrecreation, etc
Approx 60% of DDD was genetic/familial, the Approx 60% of DDD was genetic/familial, the remainder occupational, recreational etcremainder occupational, recreational etc
Loss of disc height correlated with heavy lifting but Loss of disc height correlated with heavy lifting but NOT with dessication itself !NOT with dessication itself !
http://www.aaos.org/Research/committee/research/http://www.aaos.org/Research/committee/research/Kappa/KD2008_Battie.pdfKappa/KD2008_Battie.pdf
DDDDDDDDDDDD
Dessicated disc more compressible, lacks resiliency to Dessicated disc more compressible, lacks resiliency to p , yp , y‘spring back’ from loads‘spring back’ from loads
May lose disc height and ‘bulge’ circumferentiallyMay lose disc height and ‘bulge’ circumferentially This may cause direct mechanical problems: This may cause direct mechanical problems:
compression of nerve root, narrowing of canal, i.e. compression of nerve root, narrowing of canal, i.e. spinal stenosisspinal stenosisspinal stenosisspinal stenosis
Increased load on facet jointsIncreased load on facet joints-- facet DJD, which may facet DJD, which may be symptomatic, and with ligament hypertrophy, be symptomatic, and with ligament hypertrophy, y p , g yp p y,y p , g yp p y,contribute to stenosiscontribute to stenosis
DDDDDD
DDD / SPINAL STENOSISDDD / SPINAL STENOSISDDD / SPINAL STENOSISDDD / SPINAL STENOSIS
Majority of deg. discs are asymptomatic at any given Majority of deg. discs are asymptomatic at any given j y g y p y gj y g y p y gtime unless facet DJD or spinal stenosis [ SS] is time unless facet DJD or spinal stenosis [ SS] is presentpresent
Classic stenosis symptoms bilateral leg pain andClassic stenosis symptoms bilateral leg pain and Classic stenosis symptoms bilateral leg pain and Classic stenosis symptoms bilateral leg pain and paresthesias, and eventually weakness.paresthesias, and eventually weakness.
Genetic factors prominent and includes naturally Genetic factors prominent and includes naturally l / h di l M b l il ll / h di l M b l il lnarrow canal / short pedicles. May be multilevel.narrow canal / short pedicles. May be multilevel.
Pain relieved by flexion/leaning forward Pain relieved by flexion/leaning forward –– i.e. on i.e. on grocery cart. Obviously sx greatest when upright and grocery cart. Obviously sx greatest when upright and g y bv y g w p gg y bv y g w p gactiveactive
SSSSSSSS
Positional changesPositional changes Positional changesPositional changes
SPINAL STENOSISSPINAL STENOSISSPINAL STENOSISSPINAL STENOSIS
RX: NSAIDS acetaminophen restrictedRX: NSAIDS acetaminophen restricted RX: NSAIDS, acetaminophen, restricted RX: NSAIDS, acetaminophen, restricted activity, exercises, lumbar brace, ? medsactivity, exercises, lumbar brace, ? meds
Manipulation exercise self care +/Manipulation exercise self care +/ medsmeds Manipulation,exercise, self care, +/Manipulation,exercise, self care, +/-- medsmeds Generally is progressive, often slowlyGenerally is progressive, often slowly Intervention with injections, lumbar epidural Intervention with injections, lumbar epidural
steroids [ LESI ] may help and can often steroids [ LESI ] may help and can often postpone need for surgery postpone need for surgery
Surgery often inevitable for someSurgery often inevitable for someg yg y
SPINAL STENOSISSPINAL STENOSISand HNP SURGERYand HNP SURGERY
Surgery now favors ‘less is more’ approachSurgery now favors ‘less is more’ approach Surgery now favors less is more approachSurgery now favors less is more approach Broad decompression may seem intuitive but Broad decompression may seem intuitive but
results are no better problems greaterresults are no better problems greaterresults are no better, problems greaterresults are no better, problems greater Some cases can now be done by ‘endoscopic’ Some cases can now be done by ‘endoscopic’
percutaneous meanspercutaneous means Dr. Anthony Yeung, spine surgeon at Desert Dr. Anthony Yeung, spine surgeon at Desert
Institute for Spine Care in Arizona Institute for Spine Care in Arizona
SPINAL STENOSISSPINAL STENOSISand HNP SURGERYand HNP SURGERY
YESS systemYESS system YESS systemYESS system
SPINAL STENOSISSPINAL STENOSISand HNP SURGERYand HNP SURGERY
Approach; pt awake same day surgeryApproach; pt awake same day surgery Approach; pt awake, same day surgeryApproach; pt awake, same day surgery
SSSSSSSS
SS L4SS L4--55SS L4SS L4 55
SS L4SS L4--55SS L4SS L4 55
DISCOGENIC PAINDISCOGENIC PAINDISCOGENIC PAINDISCOGENIC PAIN
DDD with LBPDDD with LBP-- etiology is problematicetiology is problematicgy pgy p Disc does have intrinsic innervation from the nerve Disc does have intrinsic innervation from the nerve
root and the sympathetic chain, these may mediate pain root and the sympathetic chain, these may mediate pain in many casesin many cases
If level is not obvious, discometrics [ through large If level is not obvious, discometrics [ through large bore needle] may identify the level if surgerybore needle] may identify the level if surgerybore needle] may identify the level if surgery bore needle] may identify the level if surgery contemplated.contemplated.
However, recent studies have revealed a new However, recent studies have revealed a new ,,explanation of LBP in a significant minority of these explanation of LBP in a significant minority of these discsdiscs
DISCOGENIC PAINDISCOGENIC PAINDISCOGENIC PAINDISCOGENIC PAIN
Modic type 1 end plate changesModic type 1 end plate changes Modic type 1 end plate changesModic type 1 end plate changes
DISCOGENIC PAINDISCOGENIC PAINDISCOGENIC PAINDISCOGENIC PAIN
These changes are seen in 6 % of populationThese changes are seen in 6 % of populationThese changes are seen in 6 % of population These changes are seen in 6 % of population and in 35and in 35--40% of LBP pts.40% of LBP pts.
The changes are similar to those due to discThe changes are similar to those due to discThe changes are similar to those due to disc The changes are similar to those due to disc infectionsinfections
Tissue excised from half of the patients withTissue excised from half of the patients withTissue excised from half of the patients with Tissue excised from half of the patients with such changes showed signs of chronic infx, 80% such changes showed signs of chronic infx, 80% of those grew Propionibacterium acnes, a of those grew Propionibacterium acnes, a g pg pbacterium associated with acne and also found bacterium associated with acne and also found in the oral cavity.in the oral cavity.
DISCOGENIC PAINDISCOGENIC PAINDISCOGENIC PAINDISCOGENIC PAIN
Randomized double blind study gave a commonRandomized double blind study gave a commonRandomized double blind study gave a common Randomized double blind study gave a common antibiotic for just over 3 monthsantibiotic for just over 3 months
Study has been replicated at other centersStudy has been replicated at other centersy py p All were patients with LBP longer than 6 months All were patients with LBP longer than 6 months 80% had reduction of pain; half of those were80% had reduction of pain; half of those were 80% had reduction of pain; half of those were 80% had reduction of pain; half of those were
essentially pain freeessentially pain free This may be effective rx for many chronic LBP patientsThis may be effective rx for many chronic LBP patientsy y py y p ? Mechanism of effectiveness of ozone Rx? Mechanism of effectiveness of ozone Rx
ANNULAR TEARSANNULAR TEARSHNPsHNPs
The other common disc pathology is disruptionThe other common disc pathology is disruption The other common disc pathology is disruption The other common disc pathology is disruption of the annulus of the discof the annulus of the disc
This varies in degree from very minor to veryThis varies in degree from very minor to very This varies in degree from very minor to very This varies in degree from very minor to very large disruptions with major extrusion of the large disruptions with major extrusion of the nucleus pulposusnucleus pulposusnucleus pulposusnucleus pulposus
Can occur at any age; many mechanisms of Can occur at any age; many mechanisms of i ji jinjuryinjury
LBP but most often with radicular painLBP but most often with radicular pain
ANNULAR TEARSANNULAR TEARSHNPsHNPs
Even tiny annular tears can be associated with severe Even tiny annular tears can be associated with severe yypain pain –– severe nerve root painsevere nerve root pain
Recent studies have revealed a new paradigm of this Recent studies have revealed a new paradigm of this mechanismmechanism
Excised HNP material was found to have high levels of Excised HNP material was found to have high levels of certain molecules involved in immune responsescertain molecules involved in immune responsescertain molecules involved in immune responsescertain molecules involved in immune responses
Two of these, Interleukin 17, IL 17, and Tumor Two of these, Interleukin 17, IL 17, and Tumor Necrosis Factor Alpha, TNFNecrosis Factor Alpha, TNF--A, play major roles in A, play major roles in p ,p , , p y j, p y jinflammation esp in patients with autoinflammation esp in patients with auto--immune immune diseases such as RA and SLEdiseases such as RA and SLE
ANNULAR TEARS IMMUNE ANNULAR TEARS IMMUNE RESPONSERESPONSE
When we are in the uterus and in the first few years ofWhen we are in the uterus and in the first few years ofWhen we are in the uterus and in the first few years of When we are in the uterus and in the first few years of life, the immune system learns to recognize our own life, the immune system learns to recognize our own tissuetissue
The nucleus is isolated early in utero and is not The nucleus is isolated early in utero and is not recognized as part of our tissuesrecognized as part of our tissues
Recall that the disc normally has no blood vessels, Recall that the disc normally has no blood vessels, receives nutrients by diffusionreceives nutrients by diffusion
When annulus is torn, our own wbcs then think the When annulus is torn, our own wbcs then think the nucleus is ‘foreign tissue’, an invader nucleus is ‘foreign tissue’, an invader
DISC, IMMUNE RESPONSEDISC, IMMUNE RESPONSEDISC, IMMUNE RESPONSEDISC, IMMUNE RESPONSE
Duke university professor, author of the major study, Duke university professor, author of the major study, y p , j y,y p , j y,Dr. Mohammed Shamji, M.D. , Ph.D.,states;Dr. Mohammed Shamji, M.D. , Ph.D.,states;
“ The center of the disc is immune“ The center of the disc is immune--privileged, since it privileged, since it b d db d dhas never been exposed to the immune system,” and has never been exposed to the immune system,” and
further that ‘when a disc is injured, the body reacts further that ‘when a disc is injured, the body reacts against the invading inner material [ nucleus ] as itagainst the invading inner material [ nucleus ] as itagainst the invading inner material [ nucleus ] as it against the invading inner material [ nucleus ] as it would against any virus or foreign body, and launches a would against any virus or foreign body, and launches a response targeted at destruction. The nerve root, which response targeted at destruction. The nerve root, which i h di di i l bi h di di i l bis present, near the protruding disc material, becomes is present, near the protruding disc material, becomes painfully inflamed, swollen and damaged during the painfully inflamed, swollen and damaged during the cascade of events’. cascade of events’.
DISC, IMMUNE RESPONSEDISC, IMMUNE RESPONSEDISC, IMMUNE RESPONSEDISC, IMMUNE RESPONSE
Arthritis and Rheumatology: 2010Arthritis and Rheumatology: 2010Arthritis and Rheumatology: 2010 Arthritis and Rheumatology: 2010 Jul;62(7):1974Jul;62(7):1974--82; Shamji, et.al. 82; Shamji, et.al. “Proinflammatory cytokine expression profile in “Proinflammatory cytokine expression profile in y y p py y p pdegenerated and herniated human intervertebral degenerated and herniated human intervertebral disc tissues.” disc tissues.”
Journal of Orthopaedic Research, Volume 29, Journal of Orthopaedic Research, Volume 29, Issue 1, pp 1Issue 1, pp 1--7, Jan. 2011. Gabr, et.al. “Effects 7, Jan. 2011. Gabr, et.al. “Effects
f i l kif i l ki 17 i b l di ll i17 i b l di ll iof interleukinof interleukin--17 on intervetebral disc cells in 17 on intervetebral disc cells in vitro.”] vitro.”]
DISC, IMMUNE RESPONSEDISC, IMMUNE RESPONSEDISC, IMMUNE RESPONSEDISC, IMMUNE RESPONSE
Additional experiments with isolated rabbit spinal Additional experiments with isolated rabbit spinal p pp pneurons and aspirated material from nucleus confirm neurons and aspirated material from nucleus confirm thisthis
Explains why corticosteroids helpExplains why corticosteroids help-- they shut down thethey shut down the Explains why corticosteroids helpExplains why corticosteroids help-- they shut down the they shut down the immune responseimmune response
TNFTNF--A is main mediator of nerve root painA is main mediator of nerve root pain TNFTNF--A plays role in immune regulation, but also in A plays role in immune regulation, but also in
diseases including alzheimers, autoimmune disease, diseases including alzheimers, autoimmune disease, inflammatory bowel disease, etc.inflammatory bowel disease, etc.y b w ,y b w ,
Inhibited by drugs like Remicaid and Enbrel, which are Inhibited by drugs like Remicaid and Enbrel, which are expensive and potentially dangerousexpensive and potentially dangerous
DISC, IMMUNE RESPONSE RXDISC, IMMUNE RESPONSE RXDISC, IMMUNE RESPONSE RXDISC, IMMUNE RESPONSE RX
If annular tear / HNP not responsive toIf annular tear / HNP not responsive to If annular tear / HNP not responsive to If annular tear / HNP not responsive to conservative care, including chiropractic care, conservative care, including chiropractic care, consider intervention esp in acuteconsider intervention esp in acuteconsider intervention esp in acuteconsider intervention esp in acute
LESI is safe and often very effective. LESI is safe and often very effective. Additionally can ‘hydraulically’ lyse adhesionsAdditionally can ‘hydraulically’ lyse adhesionsAdditionally can hydraulically lyse adhesions Additionally can hydraulically lyse adhesions that form with inflammationthat form with inflammationDi d i l d b dDi d i l d b d Disadvantages include can not be used too Disadvantages include can not be used too frequently so not a ‘maintainence’ med frequently so not a ‘maintainence’ med
DISC, IMMUNE RESPONSE RXDISC, IMMUNE RESPONSE RXTTVINPOCETINEVINPOCETINE
There is a naturally occurring substance that is aThere is a naturally occurring substance that is a There is a naturally occurring substance that is a There is a naturally occurring substance that is a TNFTNF--A inhibitor that is taken orallyA inhibitor that is taken orally
Derived from the plant vinca minor the lesserDerived from the plant vinca minor the lesser Derived from the plant vinca minor, the lesser Derived from the plant vinca minor, the lesser periwinkle plantperiwinkle plantB i di d M d NIHB i di d M d NIH h ih i Being studied at Mayo and NIHBeing studied at Mayo and NIH-- has antihas anti--inflammatory effects of steroids without the side inflammatory effects of steroids without the side ffffeffectseffects
Often very useful to maintain improvementOften very useful to maintain improvement
TNFTNF--A inhibitorA inhibitorTNFTNF A inhibitorA inhibitor
Available at Roy’s Health Foods and NaturalAvailable at Roy’s Health Foods and Natural Available at Roy s Health Foods and Natural Available at Roy s Health Foods and Natural PantryPantry
ANNULAR TEARSANNULAR TEARSHNPsHNPs
spectrumspectrum spectrumspectrum
ANNULAR TEARSANNULAR TEARSANNULAR TEARSANNULAR TEARS
Small tearSmall tear
ANNULAR TEARSANNULAR TEARSANNULAR TEARSANNULAR TEARS
TearTear –– contrast under PLLcontrast under PLL Tear Tear contrast under PLLcontrast under PLL
ANNULAR TEARSANNULAR TEARSANNULAR TEARSANNULAR TEARS
teartear teartear
ANNULAR TEARSANNULAR TEARSANNULAR TEARSANNULAR TEARS
ANNULAR TEARSANNULAR TEARSANNULAR TEARSANNULAR TEARS
ANNULAR TEARANNULAR TEARTTPLL TORNPLL TORN
ANNULAR TEARANNULAR TEARTTPLL TORNPLL TORN
Extruded fragment above and belowExtruded fragment above and below Extruded fragment, above and belowExtruded fragment, above and below
PLL / ‘WEAK SPOTS’PLL / ‘WEAK SPOTS’PLL / WEAK SPOTSPLL / WEAK SPOTS
ANNULAR TEARANNULAR TEARTTPLL TORNPLL TORN
Torn PLL extruded nucleus visible tearTorn PLL extruded nucleus visible tear Torn PLL, extruded nucleus, visible tearTorn PLL, extruded nucleus, visible tear
LUMBAR EPIDURALLUMBAR EPIDURALT TT TSTEROID INJECTION [ LESI ]STEROID INJECTION [ LESI ]
If conservative Rx not working, may actually beIf conservative Rx not working, may actually beIf conservative Rx not working, may actually be If conservative Rx not working, may actually be safer and more conservative than prolonged oral safer and more conservative than prolonged oral medsmeds
Can shut down the immune response processCan shut down the immune response process Can hydraulically lyseCan hydraulically lyse –– break upbreak up –– adhesionsadhesionsCan hydraulically lyse Can hydraulically lyse break up break up adhesions adhesions
between nerve root and dural membranes, and between nerve root and dural membranes, and help prevent them reforminghelp prevent them reformingp p gp p g
LESILESISCARRINGSCARRING
adhesionsadhesions adhesionsadhesions
LESILESILESILESI
LESILESILESILESI