DJD - General
Can be: |
Primary |
No specific cause can be identified |
Secondary |
Trauma/infection/developmental anomaly |
Poor correlations between radiographic findings and symptoms |
Target sites
Weight bearing joints |
AC Joints |
1st CMC |
DIPs and PIPs |
1st MTP |
In Lx, common in L4/L5, L3/L4 |
S&S
Moderate, achy pain |
Stiffness |
Occasional swelling |
Crepitus |
Reduced ROM |
Normal Bloodwork |
+ve Spurlings, Shoulder abduction , +ve cervical distraction |
Aggravated by extension, ipsilateral lateral flexion |
Consider myelopathy |
DDD - Findings
Decreased disc height (puts extra pressure on facet joints due to lack of impact absorption) |
Osteophyte formation |
Endplate sclerosis |
Vacuum phenomenon |
Subluxation |
Subchrondal cysts |
Consider MRI if conservative care does not improve symptoms after 3-6 weeks |
Annulus disease: - disc height remains the same - weakened Annulus pulls on VB - osteophyte formation
Vacuum phenomenon: Area of nitrogen gas in annular fibres when injured
- Microtrauma in annulus = annular tears, seperation of annulus from vb endpplate
Presentation
- Radioculopathy/Encroachment due to posterior osteophytes, facet and uncovertebral joint arthrosis, thickened bulging ligamentum flavum and a decreased in disc height |
- Age (>50 yo) |
- Flexion of the neck relieves arm pain |
- Not trauma related |
- X-ray Changes |
- pain relieved by rest, aggravated by activity |
- Muscle hypertonicity locally |
- Tender over the involve segment |
- Pain may refer over butt/hip/thigh |
- Reduced ROM |
- Gradual stiffness and loss of ROM |
- Pain with ipsilateral LF / Ext |
- +ve Kemps, +ve Yeomans +ve SLR +ve Braggards +ve Slump |
- +ve Valsalva |
- Assess for: Foot hyperpronation
Breathing
LCS
Hip abductor weakness |
- SMR changes - MYELOPATHY (UMNL - Clonus, Babinski, Hoffman, L'hermittes, Increased reflexes, Stiffness on gait/posture) |
DDD on X-ray
Osteophyte formation on the left image
Vacuum phenomenon circled on the right image
DDD DDX
Cx |
Disc lesion |
SOL |
Tumour |
TOS |
Inflammatory arthropathy |
Rotator Cuff pathology |
Heroes Zoster |
Peripheral nerve entrapment syndrome |
CRPS |
Lx |
Disc lesion |
Strain/sprain |
Stenosis |
DISH |
Fibromyalgia |
Hip OA |
Spondylolisthesis |
F#/Compression f# |
Infection |
Neoplasm |
RA/Rheumatologicadisease |
Viscerosomatic referral - AA, GI, GU |
Hemispheric Spondylosclerosis
A semicircle shaped sclerosis at the endplate on the vertebral body - can be similar to blastic mets
However, blastic mets are more likely to occur in the middle of the vertebral body and would be irregular
Red Flags
- Hx of trauma |
- Corticosteroid use |
- Osteoporosis |
- Prior hx of cancer |
- Unexplained weight loss |
- Fever |
- Chills |
- Recent infection/surgery |
- S&S of CES/myelopathy |
DDD Management
US |
Electrical stimulation |
Traction for radiculopathy |
Myofascial release of CX and shoulder girdle |
CX and TX mobilisation/SMT (can be contraindicated by centtral /lateral recess stenosis |
Mckenzies in direction of centralisation |
Nerve mobilisation (gentle and slow) |
Home exercises for: LS, Traps, cervical rotators |
Cervical support pillow |
Avoid prolonged cervical extension , rotation, lateral flexion and axial loading , reading posture |
Big Three exercises |
Postural advice/breathing exercises |
Referral to specialist - if fails to show improvement, persistent motor weakness, progressive neuro deficit or myelopathy |
Phases of disc degeneration
Phase I |
Phase II |
Phase III |
- Dysfunctional phase |
- Unstable Phase |
- Stabilisation |
- Tears on the outer annulus by repetitive microtrauma |
- Loss of mechanial integrity of the tri-joint complex |
- Further disc resorption, disc space narrowing, disc fibrosis |
- Interrupts blood supply to disc |
- In Disc, multiple annular tears occurs, Internal disc disruption, resorption/loss of disc space height |
- Endplate destruction |
- Impairs nutritional supply and waste removal |
- In zygapophyseals - cartilage degeneration, capsular laxity, subluxation |
- Osteophyte formation |
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Biomechanical - segmental instability |
- More likely to have discogenic pain |
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Modic Changes
Type 1: |
Marrow oedema - pain generator - Converts to Type II |
Type 2: |
Occurs within 3-6 mths to 1 year. Fatty degeneration of subchondral marrow - chronic |
Type 3: |
Rare - extensive bony sclerosis |
Causes |
Local instability + inflammation, biomechanical changes to DDD |
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Genetics |
Type 1 Hyposignal on T1, Hypersignal on T2
Type 2 Hypersignal on both
Type 3 Hyposignal on both
Potential sites of impingement
Central disc herniation/posterior osteophyte |
Lateral disc herniation/uncinate hypertrophy |
Facet Hypertrophy |
Thickening of the Ligamentum Flavum |
Management
X-Ray/MRI for further investigations |
- Mobilisation |
- PIR into the direction that does not cause peripheralisation |
- Nerve Mobilisation - flossing & Tensioning |
- Ice |
- NSAID |
- Anti- inflammatory nutritional advice |
- Trp therapy |
- Stabilisation exercises (if cervical) |
- Sensorimotor Training |
- Aerobic Exercise and Weight Training |
- Graded Exposure for fear and pain provoking activities |
Stenosis
Locations |
Spinal stenosis, Central canal |
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Foraminal |
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Lateral Recess Stenosis |
Measurements |
Normal = >15mm |
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Stenosis = 13mm |
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Definite Narrowing = <10mm |
Causes |
Posterior Bulges, herniations, osteophytes, ligamentum flavum |
MRI |
Grade 1: loss of <50% of subarachnoid space without cord deformity |
Grade 2: Denotes spinal cord deformity without signal change |
Grade 3: Spinal cord signal change at site of compression |
- MRI rules out non-degenerative causes of stenosis - tumour, syrinx, MND, MS |
CT myelography: Differentiation of osseous and SOL |
MRI/ CT Axial Gold Standard
Mainly affects the L5 NR
Types of Stenosis
- Congenital (short pedicles/small canal diameter) |
- Acquired: Trauma, Disc Lesion, Spondy, Tumour, Bone disease, Abscess, Hematoma, Arthritis |
Symptoms
Insidious Onset >50y |
LBP, numbness, tingling, radicular pain |
Bilateral leg + low back symptoms - relieved by bending forward + sitting |
Worse with extension, walking downhill + standing for long periods |
Chronic compression on the spinal cord - loss of fine motor skills of the hand, lower extremity pain, paresthesia, numbness, weakness, gait and balance disturbances, difficulty walking, loss of bowel/bladder control |
Face not usually affected |
If presence of fasciculations, atrophy, signs of denervation - consider ALS |
Trefoil Canal A triangular shape on MRI due to the narrowing of the canal
Clinical Findings
- Decreased Cx ROM (extension can induce symptoms) |
- +ve L'hermittes, +ve Spurlings, +ve Cx distraction +ve Valsalva if central cord |
- Mix of LMNL + UMNL signs (myelopathy) |
- UL and LL SMR should be done (long tract signs) |
- +ve Kemps (anything that requires extension) |
- +ve SLR (if foraminal/lateral recess stenosis) |
- Assess for vascular claudication: 5 Ps : Pulsenessless, paralysis, paresthesia, palor and pain
Pt report symptoms - provoked by walking, relieved by standing |
DDx
- ALS, MS (younger patient), PLS (cranial nerve involvement) |
- Vitamin B12 deficiency |
- Tumour |
- Abscess |
- Neoplasm |
- Syringomyelia |
- Arnold-Chiari |
- Vascular disease |
- Cord infarction |
- Radiation myelopathy |
- Encephalitis |
- Drug use |
- DDD/DJD |
- Mechanical LBP |
- Myofascial pain |
- F# |
- Hip pathology |
- Rheumatological disease |
Management
- No myelopathy or significant NR involvement, conservative care is considered |
- SMT/mobilisation (if more than moderate degenerative changes) |
- Nerve mobilisation (home exercises) and cervical traction (reduce nerve adherance, facilitate nerve gliding, reduce intaneural swelling and improve axoplasmic flow) |
- Heat, massage, US, electrical stimulation |
- Stretching, STW of cervical and shoulder girdle musculature |
- Cx strengthening |
- Surgical referral if: |
- Rapid deterioration |
- Significant disability |
- >3mm instability on flex/ext views |
- Abnormal findings on neurodiagnostic testing |
- Significant concave cord deformity |
Criteria for successful management :
Lower initial VAS and disability score
Younger age
Radicular symptoms described as pain rather than paresthesia/weakness
Higher BMI
Cervical Myelopathy
Weakness, stiffness/clumsiness in the hands |
Urinary urgency - bladder + bowel incontinence in late stages |
Clinical S&S |
Clonus |
+ve L'Hermitte's |
UMNL signs below lesion |
LMNL at level of compression |
Loss of vibration and joint position sense - Hands more than feet |
+ve Babinskis + Hoffmans |
Hyperreflexia in the legs, gait changes, difficulty with tasks that require dexterity/fine movement |
Weakness in the legs, difficulty walking (spastic gait) |
- If presence of fasciculations, atrophy/denervation - ALS should be considered
Management
- MRI |
- Check for Tumours, Central Disc Herniations, Atlanto-axial subluxation (in neck) |
- Usually caused by cx spondylosis |
- Immediate Neurosurgical evaluation |
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