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166
14 Dege nerative Cervical Spine Disorders
Matz PG, Anderson PA, Gro MW, et al; Joint Section on Disorders of the Spine and Pe-
ripheral Nerves of the American Association of Neurological Surgeons and Congress
of Neurological Surgeons. Cervical laminoplasty for the treatment of cervical degenerat ive m yelop at h y. J Neurosu rg Spin e 2009;11(2):15 7–16 9
Matz PG, Holly LT, Gro MW, et al; Joint Section on Disorders of the Spine and Peripheral
Ner ves of th e American Association of Neu r ological Surgeon s an d Congress of Neu rological Sur geon s. Ind icat ion s for an terior cer vical decom p ression for t h e t reatm ent of
cer vical degen erat ive radicu lop athy. J Neu rosu r g Spin e 200 9;11(2):174–18 2
Sin gh K, Na n d ya la SV, Ma rq u ez- La r a A, Fin e b e rg SJ. Ep id e m io lo g ic a l t r e n d s in t h e u t ili-
zation of bone m orphogenetic protein in spinal fusions from 2002 to 2011. Spine
2014;39(6):491–496
15 Degenerative Thoracic Spine
Co n d i t i o n s
15.1 General Considerations
I. In t r o d u ct ion .
A. Th or a cic p a in m ay b e d u e t o s eve r a l d i e r e n t e t iolo gie s (Table 15.1).
1. The incidence is ~ 15%.
2. It frequently presents in the fourth to sixth decade of life.
3. Clinical presentation:
a. May be either radicular or myelopathic.
(1) The thoracic canal is relatively small.
(2) Subtle myelopathic symptom s are signi cant.
(3) Radiculopathy involves radiating pain around the associated rib.
B. Dia gn o s is:
1. Thoracic disk herniation is frequently seen on magnetic resonance imaging (MRI).
a. MRI is most useful because of the wide eld of view.
(1) Provides inform ation regarding the status of disk degeneration and
spinal canal im pingem ent (Fig. 15.1).
(2) High false-positive rate.
(3) Also useful in ruling out infections and tum ors.
b. Computed tomography (CT) with myelography:
(1) More accurate assessm ent of spinal cord im pingement (Fig. 15.2).
(2) Invasive imaging study.
2. Thoracic stenosis:
a. Ossi cation of posterior longitudinal ligament.
(1) Com m on in Asian populations.
a
Fig. 15.1 (a) T2 -we ig h t e d sa g it t a l m a g n e t ic re so n a n ce im a g in g (MRI) d e m o n st r at e s a he r n ia t e d d is k a t T1 2 –
L1 . (b) A T2-weighted axial MRI d em onstrates a left paracent ral disk herniation with foraminal impinge m e nt.
b
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15 Dege nerative Thoracic Spine Conditions
Ta b l e 1 5 . 1 Di e re ntial diagno sis of t h o racic pain
Ca t e g o r y Et i o l o g i e s
Card iova scula r Ang ina p ect oris
Myo card ial in fa rc t io n
Mit ra l va lve p ro la pse
Perica rd itis
Ao r t i c a n e u r y s m
Pulmo nary Pneum on ia
Carcino m a
Pne um ot horax
Pulm onary em bo lus
Pulm onary e usion
Me d ias t ina l Eso ph a g it is
Tu m o r s
In t r a -a b d o m in a l He p at it is
Ab s ce s s
Ch o le c ys t it is
Gast ro in t est ina l Pe pt ic u lce r d ise a se
Hiat a l h e rnia
Pancreat it is
Re t r o p e r i t o n e a l P y e lo n e p h r i t is
Ure t e ra l st on e
An e u r y sm
Neuro logical In t r a sp in a l c ys t / t u m o r
Dem yelinat ing disease
Tr a n s v e r s e m y e l i t i s
In fe ct io us Ost e om ye lit is
Diskit is
Ep i d u r a l a b s c e s s
Tu b e r c u l o s i s
15 Dege nerative Thoracic Sp ine Conditions 169
Ca t e g o r y Et i o l o g i e s
Tr a u m a t i c C o m p r e s s i o n f r a c t u r e s
Rib fr a ct u r e s
Neo p la stic Met ast at ic d isease
Mu lt ip le m ye lo m a
In t r a d ura l t u m o rs
Me t ab olic Ost e op o ro sis
Osteom alacia
Pag et ’s d isease
Misce llan e o us He rp e s zo st er
In a m m at o ry d is ea se
Polym yalgia rhe u m at ica
Fi g . 1 5 . 2 Com puted tom ographic m yelography of the disk herniation in Fi g . 1 5 . 1 , demonstrating
e acement of the spinal cord.
170
15 Degenerative Thoracic Spine Conditions
b. Ossi cation of ligamentum avum.
(1) Posterior spinal cord compression.
(2) Treated with posterior thoracic decompression.
c. Spondylosis.
II. Tr e at m e n t o f t h oracic d isk d ise ase .
A. Co n se r vat ive m od a lit ie s.
1. Nonsteroidal anti-in ammatory drugs.
2. Exercise program.
3. Muscle strengthening and cardiovascular tness.
4. Physical therapy and modalities as necessary.
5. Conservative treatment should be tried for at least 6 months in patients
without myelopathy.
B. Su r ge r y.
1. Indications.
a. Thoracic disk herniation with myelopathy.
b. Thoracic radicular pain without myelopathy that becomes unrelenting
and resistant to conservative treatment for at least 6 months.
2. Surgical techniques.
a. Laminectomy alone may address one- or two-level pathology.
(1) Instrum ented fusion after laminectomy is recom m ended for multilevel
cases or high-risk patients to prevent postoperative kyphosis.
b. Costotransversectomy:
(1) An option in posterolateral herniated disk cases.
c. Most cases require an anterior approach with or without fusion.
(1) Fusion is advocated in patients with the follow ing:
(a) Signi cant back pain.
(b) Evidence of spin al instabilit y.
(c) Iatrogenic instability secondary to rem oval of bone/disk for
decompression.
(d) Kyphotic deform ity.
d. Anterior instrumentation may be used in kyphotic cases.
e. Thoracoscopic diskectomy is an option that may decrease surgical morbidity.
(1) Very surgeon dependent.
(2) Sharp learning curve.
f. Min im a lly inva sive t h oracic app roach es h ave gain ed pop u la r it y.
(1) Retropleural approach: minimizes the need for postoperative chest tube.
Sugg este d Reading
Am a t o V, Gia n n a c h i L, Ir ace C, Co r o n a C. Th o ra ci c s p in a l st e n os is an d m y e lo p a t hy: r ep o r t of
two rare cases and review of the literature. J Neurosurg Sci 2012;56(4):373–378
Hsieh PC, Lee ST, Ch e n JF. Low er th oracic degen erative sp ondylolit h esis w it h con com it ant
lu m bar sp on dylosis. Clin Neurol Ne u rosu rg 201 4;118:21–2 5
Park BC, Min W K, Oh CW, e t al. Su rgical ou t com e of t horacic m yelopat hy secon d a r y t o
ossi cat ion of liga m en t u m avu m . Join t Bon e Spin e 2007;74(6):600–60 5
16 Lumbar Disk Disease:
Patho g e ne sis and Tre atm e nt Optio ns
16.1 General Considerations
I. In t r o d u ct ion .
A. In cid e n ce .
1. Eighty percent of the population will experience back pain.
2. Two to 3% will experience concomitant lower extremity radiculopathy.
B. Age :
1. Mean age of onset is 35 years.
2. Unusual in patients under 20 years and over 60 years of age.
3. Herniated disks in children are rare.
a. Slippage of an entire disk and vertebral end plate or “slipped vertebral
apophyses” may mimic a herniated disk.
4. Herniated disk in the elderly is also uncommon.
a. May be associated with spinal stenosis.
C. Ge n d e r r at io is a p p r o x im a t ely e qu al.
1. Females typically present a decade later.
D. Nat ural h ist or y of low back pain and ra d icu lopat hy:
1. Low back pain resolution:
a. Fifty to 60% recover within 1 week.
b. Ninety- ve percent recover in 3 m onths.
2. Radiculopathy resolution:
a. Fifty percent recover in 1 month.
b. Seventy- ve percent recover in 1 year.
3. Surgical results are better after 1 year and may persist for up to 4 years
(Spine Patient Outcom es Research Trial [SPORT]).
E. Ep id em io lo g ica l r isk fa ct or s:
1. Genetic predisposition.
a. Currently thought to have the most impact on degenerative disk disease,
thanks to contributions by the Twin Spine Study by Battie et al.
2. Cigarette smoking.
3. Depression.
4. Sedentary lifestyle.
5. Obesity.
6. Occupational (theoretical).
a. The Twin Spine Study demonstrated that occupation (repetitive heavy
lifting, driving) had little e ect on disk degeneration.
II. Pat h oge n e sis.
A. In te r ve rt e b r a l d isk ( IVD) d ege n e rat io n (Fig. 16.1).
1. Decreased nutrition to the IVD.
a. End plate sclerosis.
b. Decreased vascularity.
171
172
16 Lum bar Disk Disease: Pat hoge nesis and Treat m ent Options
Fi g . 1 6 . 1 Sch e m a t ic d em on st rat in g th e m orp holo g ica l ch a n g es associa t ed wit h d e g e n e rat io n in t he
int erve rt eb ral disk. Signal in t ensit y (m agnet ic reso n ance im aging) de crea se s as de g e n e ra t io n pro gresses with loss of disk height.
(1) O2 ten sion d e crea ses.
(2) Lactate increases.
(3) pH decreases in the center of the nucleus pulposus.
2. Decreased water content.
a. Normally 88%; decreases to 60% by the eighth decade.
3. Increased likelihood of annular tears with aging.
a. Decreased proteoglycan content of the nucleus pulposus leads to greater
peripheral annular loading and less central nucleus pulposus resistance.
b. An annular tear may cause low back pain without radiculopathy.
(1) This association is still controversial.
c. Nociceptors are found on the outer annulus and posterior longitudinal
ligam ent.
(1) The posterolateral corner is most susceptible to a tear from exion/
rotation or torsional stresses.
4. Herniation.
a. Types of disk herniation (Table 16.1).
b. Locations.
(1) Most com m on at L4–L5 and L5–S1, less com m on at high lum bar and
thoracic regions.
16 Lum bar Disk Disease: Pat hog e nesis and Treat m ent Options 173
Ta b l e 1 6 . 1 Morp ho lo g y o f d isk h e rn ia t io ns
Ty p e Fi n d i n g s
Prot rusion Broad-b ased disk bulge
Ext r u s io n Dis k h e r n ia t i o n t h r o u g h t h e p o s t e r io r lo n g i t u d in a l l ig a m e n t ;
the fragment is larger than its base but still in continuity
Se q ue st ere d Co m plet e d isp lace m e n t o f t he d isk wit h n o co nt inu it y o f t he
fragm e nt and the intact disk
a
Fi g . 1 6 . 2 ( a ) Sch e m at ic dem o nst rat ing the ana-
tomical orientation of the exiting and traversing
nerve root in relation to the intervertebral disk.
Not e t hat t he e xiting n e r ve root can be a ect ed
only by a far lateral disk herniation. (b) Typically,
posterolateral disk herniations a ect the traversing ne r ve root . A m a g n e t ic reso n a n ce im ag ing
scan shows a posterolateral L5–S1 disk herniation
b
im p ing in g o n t h e le ft S1 n e rve ro ot .
(2) Classically posterolateral with impingem ent of the traversing nerve
below (i.e., L4–L5 herniated nucleus pulposus [HNP] a ects the
traversing L5 nerve root) (Fig. 16.2).
(3) Axillary herniation:
(a) Usually due to cephalad and medial migration of the disk
fragm en t.
(b) Medial ret raction becom es di cult and dangerous (Fig. 16.3).
174
16 Lum bar Disk Disease: Pat hoge nesis and Treat m ent Options
a
b c
d e f
Fi g . 1 6 . 3 Illu st ra t io ns a nd m a g n e t ic re so n an ce im a g in g d e m o n st r a t in g va rio u s t yp e s o f lu m b a r
disk he rniations. (a,b) Left paracent ral L5–S1 disk herniation. (c,d) Sequestered disk fragment that
migrated inferiorly to the level of the S1 pedicle. (e,f) L5–S1 axillary disk herniation.
(4) A sm all central disk herniation may cause back pain without
radiculopathy or cauda equina syndrome.
(5) Extrem e lateral or foram inal herniation:
(a) Impinges upon the exiting nerve root above the disk level.
(b) More com m on in older patients.
(c) Typically found at L3 and L4 (Fig. 16.4).
(6) Intradural herniation is extrem ely rare.
B. Ne r ve r oo t s.
1. Anatomy.
a. Each lumbar nerve root exits below the pedicle and above the disk.
(1) For exam ple, the L5 nerve exits below the L5 pedicle and above the
L5 – S1 d i s k .
b. The dorsal root ganglion lies in the intervertebral foramen inferior to the
pedicle, which may be the main source of pain.
c. Each nerve root has three branches.
(1) Ventral ram us for motor function
16 Lum bar Disk Disease: Pat hog e nesis and Treat m ent Options 175
Fig . 1 6 . 4 An a xia l m a g n e t ic r e s o nance imaging scan demonstrating
a large far lateral disk herniat ion at
L5 – S 1 c a u s i n g i m p i n g e m e n t o n t h e
right L5 nerve root.
(2) Sinuvertebral nerve.
(a) Innervates the outer layer of the posterior annulus brosus.
(b) Anterior part of the annulus brosu s has sym pathetic
innervation, and the a erent bers connect with the
sinuvertebral nerves.
(3) Dorsal ram us branch.
(a) Innervates the facets and posterior muscles.
C. Bio ch e m ic a l p at h olo g y o f d is k h e r n ia t io n .
1. Annulus brosus and nucleus pulposus cells produce the extracellular
matrix.
a. Primarily collagen and proteoglycans.
b. With aging and disk degeneration, the cells die (apoptosis), and the
matrix content is decreased.
c. Both anabolic and catabolic processes maintain the integrity of the
matrix.
(1) Proin am matory cytokines regulate the catabolic processes.
(a) Tumor necrosis factor alpha, interleukin-1, phospholipase A2,
prostaglandins.
(2) Grow th factors regulate the anabolic processes.
(a) Bone morphogenetic protein (BMP).
2. Di usion through the end plates or nutritional pathway is also altered by
degenerative changes.
3. An annular tear or HNP is initially associated with signi cant in ammation.
a. Cytokine leakage through the annular defect may cause radiculopathy.
b. Nucleus pulposus fragments elicit in ammatory and neurotoxic changes
without signi cant mechanical compression.
(1) Rest, anti-in am m atory drugs, or epidural steroids frequently
alleviate the symptoms by decreasing the in ammatory reaction.
4. The HNP fragment elicits signi cant in ammatory reaction and undergoes
subsequent resorption.
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