Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6052_Библиотеки_им_академика_М_И_Перельмана.pdf
118 III Degenerative Spinal Conditions
2. Nonaggregating PGs or PGs that cannot bind to hyaluronic acid increase
G. Homeostasis of intervertebral disk metabolism
1. Anabolic cells and matrix production
a. Growth factors
(1) Transforming growth factor-beta (TGF-, beta fibroblast growth
factor (FGF), insulin-like growth factor-1 (IGF), platelet derived
growth factor (PDGF), bone morphogenetic protein-2 (BMP),
BMP-4, BMP-7
(2) IGF-1, epidermal growth factor (EGF), FGF, and TGF- stimulate
matrix synthesis
(3) FGF promotes proliferation of chondrocytes in degenerative disks
(4) IGF-1 stimulates proteoglycan synthesis in cells of nucleus
(5) BMPs such as BMP-2, BMP-7, latent membrane protein (LMP)-1,
and so on have shown to up-regulate PG synthesis in vitro and
vivo
2. Catabolic
a. Enzymatic degradation of the matrix
(1) Proteinases matrix metalloproteinases (MMPs)
(a) Collagenase, gelatinase, stromelysin
(2) Proinflammatory cytokines and free radicals increase in degen-
erative disks.
(a) Nitric oxide, prostaglandin E
2
(PGE
2
), interleukin (IL)-6 in-
creased in degenerated disks
(b) Phopholipase A
2
, Tumor Necrosis Factor (TNF)-, and IL-1
increased in herniated disks and radiculopathy
b. Cytokine blockers such as interleukin-1, tumor necrosis factor
blockers, tissue inhibitors of metalloproteinases can up-regulate PG
synthesis by blocking catabolic processes.
H. Nutrition by diffusion through the end plates (Fig. 10–3)
1. Blood supply to end plates and outer annulus decreases with aging.
a. Lactate concentration increases.
b. pH decreases.
c. Cellular metabolism affected with decreased nutrition (Fig. 10–4)
I. Biologic strategies for intervertebral disk degeneration (IVD) repair or re-
generation
1. Growth factors
a. BMPs
b. Blocking cytokine pathways
2. Therapeutic gene transfer
a. Viral
b. Nonviral
3. Cell transplantation
a. IVD cells
b. Chondrocytes
c. Mesenchymal stem cells
4. Cells and matrix transplantation
J. Biologic disk regeneration
1. Increases the synthesis and content of PG and collagen
Chapter 10 Biochemical Aspects of Intervertebral Disk Degeneration 119
2. May improve biomechanical properties of the disk or the motion seg-
ment in early stages of disk degeneration
a. If disk degeneration is severe and the posterior structures are com-
promised, may not be effective
b. Use of growth factor stimulation (osteogenetic protein-1) to restore
nucleus height and metabolic function (Masuda et al)
3. May not address pain perception
K. Potential limitations or unanswered questions of growth factor for IVD
repair
1. Duration of therapeutic effect in vivo
2. Optimal dosage
3. Optimal delivery system
a. Injection
b. Prolonged delivery systems
Figure 10–3 Diagram demonstrating the diffusion of nutrients into the intervertebral disk space.
120 III Degenerative Spinal Conditions
c. Carriers
d. Multiple proteins
4. Effect of biomechanical stresses on disk metabolism and influence of
growth factors on cells
5. Combination treatment with pain-relieving procedures
a. Chemonucleolysis
b. Intradiscal electrothermal therapy
Suggested Reading
An HS, Anderson PA, Haughton VM, et al. Introduction: disk degeneration: summary. Spine
2004;9:2677–2678
An H, Takegami K, Kamada H, et al. Intradiscal administration of osteogenic protein-1 increases interver-
tebral disk height and proteoglycan content in the nucleus pulposus in normal adolescent rabbits. Spine
2005;30:25–30
Figure 10–4 Therapeutic Approach for Repair of Intervertebral Disk Degeneration
Protein injection
(single or multiple)
Gene therapy
(prolonged exposure)
▼
▼
Early
Intermediate
Progressive
Tissue-engineering
and/or
Gene therapy
Chapter 10 Biochemical Aspects of Intervertebral Disk Degeneration 121
Masuda K, Aota Y, Muehleman C, et al. A novel rabbit model of mild, progressive, disk degeneration by
an annulus needle puncture: correlation between the degree of disk injury and radiological and histo-
logical appearances of disk degeneration. Spine 2005;30:5–14
Natarajan RN, Williams JR, Andersson GB. Modeling changes in intervertebral disk mechanics with de-
generation. J Bone Joint Surg Am 2006;88(Suppl 2):36–40
Roberts S, Evans H, Trivedi J, et al. Histology and pathology of the human intervertebral disk. J Bone Joint
Surg Am 2006;88(Suppl 2):10–14
Takegami K, An H, Kumano F, et al. Osteogenic protein-1 is most effective in stimulating nucleus pulpo-
sus and annulus fibrosus cells to repair their matrix after chondroitinase abc–induced in vitro chemonu-
cleolysis. Spine J 2005;5:231–238
11
Degenerative Cervical Spine
Disorders: Surgical and
Nonsurgical Treatment
Cervical Degenerative Disease
I. Clinical categories
A. Discogenic axial pain with or without referred pain
B. Disc herniation
1. Myelopathy
2. Radiculopathy
C. Cervical spondylosis
1. Radiculopathy (foraminal stenosis)
2. Myelopathy
II. History and examination
A. Cervical radiculopathy
1. Dermatomal pain distribution (Fig. 11–1)
a. Spurling’s sign
(1) Pain exacerbated by neck extension and rotation toward the
symptomatic side
b. Shoulder abduction relief sign
(1) Pain ameliorated by neck flexion and shoulder raise
2. Neurological findings (nerve root distribution)
a. Numbness
b. Paresthesias
c. Weakness
d. Hyporeflexia
B. Cervical myelopathy
1. Pain is usually absent.
a. Discomfort varies from a dull ache to sharp pain.
122
◆
Chapter 11 Degenerative Cervical Spine Disorders 123
2. Symptoms
a. Wide, ataxic gait pattern
b. Poor hand dexterity
(1) Buttoning shirt
(2) Writing
(3) Holding onto a coffee mug
3. Physical exam findings
a. Hyperreflexia
b. Positive Hoffman’s sign
c. Positive Babinski
Figure 11–1 Neck pain and referred pain from the cervical zygapophyseal joints.
124 III Degenerative Spinal Conditions
d. Positive Lhermitte’s sign
e. Myelopathic hand syndrome
(1) Thenar atrophy
(2) Positive finger escape sign
(3) Positive grip release test
(4) Dysdiadochokinesia
(a) Loss of coordination and dexterity of the hands during
rapid movement (Table 11–1)
III. Radiographic imaging (Figs. 11–2, 11–3)
A. Plain radiographs
1. Anteroposterior, lateral, and oblique views
a. Overall alignment
(1) Patients with spondylosis will have a loss of lordosis or spondy-
lolisthesis
b. Narrowing of the intervertebral disc space
c. Degenerative changes in the zygapophyseal joints and the presence
of osteophytes
d. Foraminal narrowing observed on the oblique views (Fig. 11– 4).
B. Myelography and computed tomography myelography
1. Modality of choice for those who cannot undergo magnetic resonance
imaging (MRI)
2. Good for postoperative imaging if instrumentation present
3. Disadvantage is procedure invasiveness
C. MRI
1. Imaging modality of choice for cervical disc disease
2. Good for evaluating space available for the cord
a. Less than 13 mm is relative stenosis.
b. Less than 10 mm is critical stenosis.
3. Particularly useful to rule out spinal cord lesions such as sy-
ringomyelia, tumors, and myelomalacia
4. Correlation with clinical symptoms is critical as the false-positive rate
is high.
Table 11–1 Demographics of Cervical Spine Disease
Cervical Spondylosis Disk Herniation
Age 50 50
Sex Male female Male female
Onset Insidious Acute
Location of pain Neck and arm Arm
Neck stiffness Yes No
Weakness Yes Yes or no
Myelopathy More common Less common
Dermatomal distribution Multiple Single
Chapter 11 Degenerative Cervical Spine Disorders 125
Figure 11–3 Cross-sectional view of a cervical vertebra. The neuroforamen is divided into three
areas: the medial zone, the middle zone, and the lateral zone. (From An HS. Principles and Tech-
niques of Spine Surgery. Baltimore: Williams and Wilkins; 1998. Reprinted with permission.)
Figure 11–2 Schematic of an axial cut through the cervical spine. The shaded area in section I rep-
resents the lamina that is removed in a laminectomy. Section II represents the bone removed to
perform a thorough foraminotomy.
126 III Degenerative Spinal Conditions
IV. Differential diagnosis
A. Trauma
1. Cervical sprain
2. Traumatic neuritis (brachial plexus)
3. Posttraumatic instability
B. Tumors
1. Superior sulcus tumor with C8 radiculopathy and Horner’s syndrome
2. Spinal cord tumors
3. Metastatic disease
4. Primary bone tumors
C. Inflammatory conditions
1. Rheumatoid arthritis
2. Ankylosing spondylitis
D. Infections
1. Discitis
Figure 11–4 An oblique cervical spine radiograph demonstrating neuroforaminal stenosis sec-
ondary to osteophyte formation at the uncinate processes.
Chapter 11 Degenerative Cervical Spine Disorders 127
2. Osteomyelitis
3. Soft tissue abscess
4. Shoulder disorders
a. Rotator cuff tears
b. Impingement syndrome
E. Neurological conditions
F. Demyelinating disease (Guillain-Barré syndrome)
G. Amyotrophic lateral sclerosis
H. Others
1. Thoracic outlet syndrome
2. Reflex sympathetic dystrophy
3. Angina pectoris
4. Peripheral nerve entrapments
V. Treatment for cervical radiculopathy
A. Conservative treatment: 70 to 80% successful outcome expected with 2 to
3 months of conservative treatment
1. Acute phase (first 2 weeks)
a. Nonsteroidal antiinflammatory medications
b. Oral steroids
c. Short-term analgesics
d. Ice or heat application
e. Activity modification
(1) Soft collar
(2) Home traction
2. Intermediate healing phase (3 to 4 weeks)
a. Stretching and isometric exercises
b. Physical therapy
(1) Modalities if the patient is not improving
c. Epidural steroids may be considered for persistent radicular pain.
3. Rehabilitation phase (4 weeks)
a. Cardiovascular conditioning
b. Vigorous strengthening exercise program
B. Operative indications
1. Progressive signs of root or cord dysfunction
2. Failure of conservative treatment in relieving radicular pain or neuro-
logical deficits
3. Axial pain without radiculopathy should be treated conservatively as
long as possible as surgical results are less predictable.
VI. Surgical techniques
A. Anterior cervical surgery
1. Indications
a. Central soft disc herniation
b. Bilateral radiculopathy at the same level
c. Unilateral soft disc or foraminal stenosis
(1) Anterior approach is preferred in patients with significant neck
pain in addition to radiculopathy.