Degenerative spine: diagnosis and medical treatment

2021-07-20 12:01 AM

Because the spine is subjected to multiple loads that occur continuously, it leads to morphological changes including degenerative changes in the intervertebral discs, vertebral bodies, and the posterior spinous processes and cartilage damage

Degenerative spondylolisthesis conditions involve a gradual loss of normal structure and function of the spine over time. They are most often caused by aging, but can also be the result of a tumor, infection, or arthritis. Pressure on the spinal cord and nerve roots due to degeneration can be caused by:

Slipped or herniated disc.

Spinal stenosis, or narrowing of the spinal canal.

Osteoarthritis, or breakdown of cartilage in spinal joints.

Spondylolisthesis is a fairly common disease in the elderly, related to the degenerative process. Because the spine is subjected to multiple loads occurring continuously, it leads to morphological changes including degenerative changes in the intervertebral discs, vertebral bodies and in the posterior spinous processes and damage to the cartilage of the spine. facet cartilage discs on vertebral stones, intervertebral discs and articular cartilage of posterior spine, grow spines - bone beaks in vertebral body chains

Spondylolisthesis usually progresses slowly, manifested by a gradual increase in symptoms: pain, stiffness, and limited range of motion.

Degenerative sites in the spine:

Cervical spondylosis: degeneration occurs mainly in the C5, C6, and C7 vertebrae and rarely occurs in the higher segments.

Degeneration of the vertebrae in the back (thoracic spine): uncommon.

Lumbar spondylolisthesis: in some elderly patients, bone spurs may develop along the entire length of the spine (Forestier uses the term “ankylosing hyperostosis” to refer to this severe case).

Degeneration of posterior interspinous articular cartilage: seen in patients > 40 years old, usually in the cervical and lumbar spine.

General clinical and paraclinical symptoms

Localized paraspinal muscle pain originates from paraspinal ligaments, joint capsules.

Contraction of the muscles near the spine.

Nerve root pain may be due to root compression of the spinal nerve or maybe merely pain propagating along the nerve associated with the primary local lesion.

Tests: usually nothing special.

Diagnostic imaging methods:

Conventional radiographs: need to be taken in the following positions: straight, inclined, 3/4 right and left (especially with cervical spine). Typical radiographic images of spondylolisthesis include intervertebral disc stenosis, subchondral thickening, and collapse of subchondral areas, neoplastic osteophytes.

Computed tomography, magnetic resonance, contrast-enhanced myelography: depending on the technique, it helps to clearly detect bone, disc, and software damage that causes neurological symptoms due to degenerative spinal injuries.

Electromyography: valuable in diagnosing pinched nerve damage.

Diagnosis and identification of the most common locations of spinal degeneration in clinical practice

Lumbar spondylolisthesis (CSTL)

There are three clinical forms of lumbar spondylosis depending on the extent of disc damage.

Acute low back pain:

Seen at the age of 30 - 40. The pain occurs after an excessively strong movement, suddenly and in the wrong position (holding, calving, carrying, pushing, falling...).

Pain is usually in the lumbar spine. Pain may be bilateral, but not contagious. Limited range of motion and difficulty in performing spinal movements, often without neurological signs.

May be accompanied by spasticity of the paraspinal muscles in the morning and relieved after exercise.

Physical examination: pain on palpation of the lumbar region. Reflex, sensory, motor, and other neurologic findings are normal.

Some patients may progress to chronic back pain.

Chronic low back pain: when low back pain persists for more than 3 months.

Risk factors include: carrying heavy loads, turning, body vibration (motorcycle riding, long car sitting), obesity, excessive physical exercise.

Usually occurs between the ages of 30 and 50.

Dull pain in the low back, not spreading far, pain increased when moving, changing weather, pain reduced when resting.

The spine can be partially deformed and limit some bending, leaning...

Lumbar spine pain - sciatica due to herniated disc:

Occurs when the annulus is torn and the nucleus pulposus protrudes into the spinal canal, pressing on the roots of a spinal nerve or on the spinal cord.

Usually occurs in people between 35 and 45 years of age, more men than women.

Sudden pain, pain spreading down the buttocks, on the back outside the thigh, usually ending at the toe, depending on the compression position, increasing when coughing, sneezing, pushing.

Examination revealed scoliosis, Lasegue sign, Valleix sign, positive bell rope pulling on the affected side, mildly reduced tendon reflexes, muscle atrophy, possibly circular muscle disorder.

X-ray signs:

Conventional X-ray: there are often common signs of spondylolisthesis: disc stenosis, bone spurs, conjunctival foramen stenosis.

MRI scan: clearly see the degenerative and herniated state of the disc, the position of the disc compressing the nerve.

Computed tomography can also detect lesions.

Degeneracy of the ancient wave column

Degeneration can occur in all cervical vertebrae, but the location in C5 - C6 or C6 - C7 is most common.

Symptom:

Neck pain: sometimes radiates to the shoulders and arms. Numbness in an area of ​​the arm, forearm, and finger.

Limit movement of the neck movements.

Headache: from the occipital region, spreading to the temples, forehead or behind the eyes, without neurological signs.

Barré - cervical sympathomimetic syndrome: headache, dizziness, tinnitus, dizziness, blurred vision. Dysphagia in the back of the throat, difficulty swallowing.

Cervical spinal cord compression syndrome: in rare cases, the bone spurs at the back of the vertebral body press on the anterior part of the marrow, patients have signs of spastic hemiplegia or progressive extremities.

Many of the symptoms that arise from bony spurs pressing on the vertebral arteries, especially in the upper neck, include dizziness, lightheadedness, headache, and transient ischemic attacks.

Cervical spondylosis can cause all three syndromes: spinal nerve root compression, spinal cord compression, and spinal artery compression.

Diagnose:

Mainly based on X-ray images, computed tomography or magnetic resonance imaging similar to those presented in lumbar spondylosis.

Differential diagnosis

Other causes of low back pain (see table 1)

Board. Causes of low back pain

Mechanical cause

Indirect causes

Due to organ disease

Injury to ligaments, tendons in the lumbar region

Cancer

diseases of the viscera in the pelvis

Spinal stenosis

Infection

Kidney disease

Complications of osteoporosis compensating for vertebral collapse

Inflammation of the vertebral disc

aortic aneurysm

Spondylolisthesis

Scheuermann disease

Gastrointestinal disease

Fracture due to trauma

Paget's disease of the bone

Congenital disease

Other causes of cervical spine pain (see table)

Board. Causes of cervical spine pain

Ankylosing spondylitis.

Joint diseases Ankylosing spondylitis.

Rheumatoid arthritis.

Fibromyalgia (fibromyalgia).

Muscle pain due to other joint diseases.

Injury

Broken bones dislocated joints.

Software damage.

Injuries in the neck region

Muscle pain.

Inflammation of the bone.

Infectious discitis.

Congenital diseases of the cervical spine.

Diseases of the bones

 Paget disease.

Osteomalacia.

Osteoporosis.

Metastatic cancer.

Neuromuscular disorders

Meningitis.

Cerebral palsy and other spastic diseases.

Paralysis of muscles in the neck region due to other injuries.

Non-drug treatments

Rest, avoid strenuous movements, especially bending movements to carry heavy objects.

Physiotherapy: effective in relieving pain, correcting poor posture and maintaining muscle nutrition at the edge of joints, treating tendon and muscle pain associated with

Heat treatment: ultrasound, infrared, hot compress, mineral spring therapy, mud are highly effective.

Stretching the spine, blocking the interphalangeal joints, acupuncture, massage.

Exercise: for chronic low back pain (swimming...).

Drug therapies

Analgesics: choose one of the drugs according to the World Health Organization analgesic ladder (paracetamol, Efferalgan), Efferalgan codeine, morphine. For example, take 0.5g paracetamol tablets with a dose of 1 - 3g/day. Depending on the pain, adjust the dose accordingly.

Non-steroidal anti-inflammatory drugs: choose one of the following drugs (note absolutely do not combine drugs in the group because they do not increase the therapeutic effect but have many side effects):

Diclofenac (Voltaren) 50mg x 2 tablets / day divided into 2 or 75mg 1 tablet / day after a full meal.

75mg/day intramuscular injection can be used for the first 2-3 days when the patient is in great pain, then switch to oral.

Meloxicam (Mobic) tablet 7.5mg x 2 tablets/day after eating or as an intramuscular injection 15mg/day x 2-3 days if the patient has a lot of pain, then switch to oral route.

Piroxicam (Felden) 20mg tablet or tube, take 1 tablet per day after eating or inject 1 ampoule per day intramuscularly in the first 2-3 days when the patient has a lot of pain, then switch to oral route.

Celecoxib (Celebrex) 200mg tablets, dose 1 to 2 tablets / day after a full meal. Should not be used in patients with a history of cardiovascular disease and with greater caution in the elderly.

Muscle relaxants: mydocalm 150mg x 3 tablets/day divided into 3 in case of severe muscle spasticity or mydocalm 50mg orally 4 tablets/day in 2 divided doses or Myonal 50mg x 3 tablets/day in 3 divided doses in case of mild or moderate muscle spasticity.

Antidepressants: sometimes indicated when patients have low back pain accompanied by anxiety, depression. For example, amitriptyline 25mg, take 1-2 tablets/day, Dogmatil 50mg x 1-3 tablets/day.

Epidural injection: when sciatica is present. Hydrocortisone acetate 125mg/5ml: 3 injections each time 5-7 days apart.

Treatment of spinal pain caused by posterior degenerative joint disease: injection of corticosteroids such as DepoMedrol 40mg (methylprednisolone acetate), Diprospan (betamethasone dipropionate) injection 1-2 doses 1-2 weeks apart, do not inject more than 3 times a year. In order to inject accurately, the procedure should be performed under the light curtain.

Disease-Modifying Osteoarthritis Drugs (DMOADs) are a slow-acting group of drugs, after a long time (average 1 month) and this effect is maintained even after stopping treatment (after several weeks to 2-3 months). The drug is well-tolerated, with very few side effects.

Glucosamine sulfate: use orally 1.5g/day as 250mg tablet orally 4 tablets/day x 6-8 weeks or 1.5g pack take 1 pack/day x 4-6 weeks or longer depending on response.

Chondroitin sulfate.

Combination of glucosamine and chondroitin.

Diacerhein 50mg orally 1-2 tablets/day.

Surgical treatment

When clinically indicated in the following cases:

Horsetail syndrome.

Wrist syndrome with severe compression of the cervical spine cannot be resolved by medical treatment.

Disc herniation is associated with persistent sciatica pain.

Manifestations of spinal stenosis with progressive neurological signs.

Prevention

Patient education: avoid overloading the spine by movement and weight, avoid sudden strong movements (heavy lifting, twisting...).

Adjust weight to ideal weight.

Detection and repair of skeletal and spinal deformities in adults and children.

Avoid rickets in children.