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Cheatography

DJD & DDD Cheat Sheet (DRAFT) by

Degenerative Joint disease & Degenerative Disc Disease in imaging

This is a draft cheat sheet. It is a work in progress and is not finished yet.

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
 
Biomec­hanical - segmental instab­ility
- More likely to have discogenic pain
 

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
 
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
 
Foraminal
 
Lateral Recess Stenosis
Measur­ements
Normal = >15mm
 
Stenosis = 13mm
 
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