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