discogenic low back pain treatment agrasen hospital gondia vidarbha dr sandeep c agrawal

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

www,agrasenortho.com

http://www.drsandeepagrawal.com/

http://www.agrasenortho.com

http://www.drsandeepagrawal.com

http://agrasenortho.com


InterVertebral Disc




Causes of Back Pain

25-40% Back Pain (Discogenic Back Pain)

Muscles,Tendons,Ligamaents




RED FLAGS

Discogenic Back Pain




Degenerated Disc

Annuloplasty Disc Decompression

Chemonucleolysis




Ventral ramus, sympathetic chain, dorsal root ganglion




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




Biochemical Change After Stress

• Matrix protein loss • Loss of hydrostatic pressure • Bulking of annular lamellae

• Annulus wall shear stress ↑, Tear

• Axial back pain & dysfunction




• 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




• 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




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




Provocative Discogram




• 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%.




Surgery for back pain;MRI…

• Clinical correlation is must • Discography is very helpful

Remember: FBSS 30%

Re-surgery; failure & risk




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)




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)




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




Patients Without Loss of Disc Height

• No facet joint or end plate changes • Dark disc, annular tear




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




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




• 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




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)




Thermal energy: 65ºC for 17 minutes •Collagen shrinkage •Destruction of nociceptive fibers




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 (+)




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




Complications

• Discitis • Nerve root injury • Catheter breakage • Cauda equina syndrome




General Concept of IDET

• IDET should be considered as

“Experimental Procedure”

• Maybe useful in highly selected patient




Biaculoplasty (Cooled RF)




Disc Herniation; Discectomy




Hydrodiscectomy (Spine jet®)




Laser and RF Plasma




Percutaneous Nucleotomy




Dekompressor




Ozone Neucleolysis




Intervertebral Disc Surgery

• Three classical surgical steps

conservative!treatment

percutaneous!surgeries

open!surgeries

fusion!surgeries

I

II

III




Brothers

• Lumbar spinal stenosis • Lumbar disc Herniation • Discogenic Low Back Pain




Future of Non surgical Treatment




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.




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. !




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




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.



discogenic low back pain treatment agrasen hospital gondia vidarbha dr sandeep c agrawal

Health & Medicine