Definitions of Abbreviations for New People

[GJZH]

Chirogeek has posted some excellent new studies for us all to read, but some may need some explanation of the abbreviations so I thought I would post the definitons here for all to read...again...

Definitions provided below for Charite, PLIF, ALIF, TLIF, discectomy, IDET
PLIF, ALIF and TLIF Procedures

http://www.scoliosisassociates.com/s...-tlif-alif-041

Spinal fusion is a surgical procedure in which two or more vertebrae are joined or fused together. Fusion surgeries typically require the use of bone graft to facilitate fusion. This involves taking small amounts of bone from the patient’s pelvic bone (autograft), or from a donor (allograft), and then packing it between the vertebrae in order to “fuse” them together. This bone graft, along with a biomechanical spacer implant, will take the place of the intervertebral disc, which is entirely removed in the process. Spinal fusion surgery is a common treatment for such spinal disorders as spondylolisthesis, scoliosis, severe disc degeneration, or spinal fractures. Fusion surgery is usually considered only after extensive non-operative therapies have failed. Three common fusion surgeries available at our practice include PLIF, ALIF and TLIF.

PLIF
PLIF stands for Posterior Lumbar Interbody Fusion. In this fusion technique, the vertebrae are reached through an incision in the patient’s back (posterior). The PLIF procedure involves three basic steps:


Pre-operative planning and templating. Before the surgery, the surgeon uses MRI and CAT scans to determine what size implant(s) the patient needs.
Preparing the disc space. Depending on the number of levels to be fused, a 3-6 inch incision is made in the patient’s back and the spinal muscles are retracted (or separated) to allow access to the vertebral disc. The surgeon then carefully removes the lamina (laminectomy) to be able to see and access the nerve roots. The facet joints, which lie directly over the nerve roots, may be trimmed to allow more room for the nerve roots. The surgeon then removes the affected disc and surrounding tissue and prepares bone surfaces of adjacent vertebrae for fusion.
Implants inserted. Once the disc space is prepared, bone graft, allograft or BMP with a cage, is inserted into the disc space to promote fusion between the vertebrae. Additional instrumentation (such as rods or screws) may also be used at this time to further stabilize the spine.

TLIF

TLIF stands for Transforaminal Lumbar Interbody Fusion. This fusion surgery is a refinement of the PLIF procedure and has recently gained popularity as a surgical treatment for conditions affecting the lumbar spine. The TLIF technique involves approaching the spine in a similar manner as the PLIF approach but more from the side of the spinal canal through a midline incision in the patient’s back. This approach greatly reduces the amount of surgical muscle dissection and minimizes the nerve manipulation required to access the vertebrae, discs and nerves. The TLIF approach is the preferred method at our practice for interbody fusion as it is generally less traumatic to the spine, is safer for the nerves, and allows for minimal access and endoscopic techniques to be used for spinal fusion.

As with PLIF and ALIF, disc material is removed from the spine and replaced with bone graft (along with cages, screws, or rods if necessary) inserted into the disc space. The instrumentation helps facilitate fusion while adding strength and stability to the spine. We currently use many state of the art cage technologies including those made of bone, titanium, polymer, and even bioresorbable materials.

ALIF

ALIF stands for Anterior Lumbar Interbody Fusion. This procedure is similar to PLIF, however it is done from the front (anterior) of the body, usually through a 3-5 inch incision in the lower abdominal area or on the side. This incision may involve cutting through, and later repairing, the muscles in the lower abdomen.

At our practice, a mini open ALIF approach is available that preserves the muscles and allows access to the front of the spine through a very small incision. This approach maintains abdominal muscle strength and function and is oftentimes used to fuse the L5-S1 disc space.

Once the incision is made and the vertebrae are accessed, and after the abdominal muscles and blood vessels have been retracted, the disc material is removed. The surgeon then inserts bone graft (and anterior interbody cages, rods, or screws if necessary) to stabilized the spine and facilitate fusion.

Minimal Access
We routinely do several types of spinal procedures utilizing minimal access techniques. The development of these techniques originated with the application of endoscopy during microdiscectomy surgery for herniated lumbar discs. It has now been applied to fusion surgeries. Ask a member of our clinical team to see if this might be right for you.

After Fusion Surgery
Recovery time is different for every patient. However, most patients are up and walking by the end of the first day after surgery. Most patients can expect to stay in the hospital for 3-5 days depending on their condition. Once released from the hospital, patients who have undergone a PLIF, ALIF, or TLIF procedures are given a prescription for pain medications to be taken if needed, as well as a detailed post-operative activity plan to help ease recovery and return to a healthy life.

Case Example of Degenerative Spondylolisthesis treated with TLIF





This 58 year old woman had degenerative spondylolisthesis at the L4/5 level as shown on the x-ray and MRI above. She had difficulty walking distances and back and leg pain. She was treated with laminectomy and fusion with instrumentation.

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[GJZH]

Total Disc Replacement—Charite™ Artificial Disc
The Charité Artificial Disc is a total disc replacement technology that uses two metal alloy endplates and its unique sliding core. This offers the theoretical advantage of allowing the spacer to shift dynamically within the disc space during spinal motion, moving posteriorly with flexion and anteriorly in lumbar extension. Some experts feel this may improve the segmental rotation and decrease the possibility of facet impingement at extremes of motion. This has not yet been clinically demonstrated.

Figure 14: Charité artificial disc

Figure 15a and 15b: Charité Artificial Disc design to mimic normal disc motion

The Charité Artificial Disc was designed to restore disc space height, to restore motion segment flexibility, to prevent disc degeneration at adjacent segments, to reduce or eliminate pain from motion or from nerve compression, and to improve the patient's functional activities. It was designed to be biocompatible and durable. It has a life span of 40 years (85 million cycles).

The Charité Artificial Disc has kinematics that mirror the segmental motion of a normal spine. It is designed to allow anatomic alignment in lordosis, and to allow normal facet joint loading and unloading.

Wear debris, a concern with polyethylene implants in the peripheral joints, has been studied in the Charité, given the implant's proximity to the spinal canal and nerve roots. In a long-term laboratory test of cyclical motion simulating >11 years of use, no wear debris particles were identified. There is minimal deformation of the core, with less than 8% height loss expected in 10 years of use.

Meticulous attention to implantation is required to ensure that the articulating surfaces of the endplates are parallel in order to restore normal biomechanics. Angled prosthetic endplates are available and were designed to produce parallel surfaces while accommodating lumbar lordosis. Different size endplates are available to the surgeon, so the largest size possible can be used to minimize the chance of subsidence into the bone. Care must be exercised by the surgeon to place the implant centrally in both the sagittal and antero-posterior planes.

Figure 16: Charité Artificial Disc is centralized, front view

Figure 17: Charité Artificial Disc is centralized, side view

Rotation must be controlled by the surgeon during implantation. The endplates are inserted , and the polyethylene core placed into position as the disc space is distracted. Core dislocation is a rarely reported complication.

The surgical approach is typically through an anterior retro-peritoneal route. Patient positioning is important so that radiographic confirmation of the implant position can be seen easily by the surgical team. Factors critical for a good result using the Charité are proper patient selection, selecting the correct prosthesis size, and proper prosthesis positioning with the CentreLine Instruments

Several clinical studies have been published documenting the European experience with this disc since 1987. Worldwide experience with this unconstrained anatomic disc replacement is now greater than 10,000 cases.

Cinotti reported on 46 Italian patients in 1996, with 2-5 year follow-up. He saw no implant failures, but did report reoperation in 19% for continued pain and one case of implant dislocation due to wrong size selection. Overall patient satisfaction was 63%.

LeMaire reported his French series in 1997, following 105 patients a mean of 51 months with 79% good outcomes and no device failures.

Zeegers reported 50 patients in 1999 in a Dutch series. He showed 70% good results with 2 year follow-up, but he did report 24 reoperations in 12 patients, none due to device failure.

The US FDA study was launched at the Texas Back Institute with the first US implantation in March 2000. Since that time, 294 patients have been enrolled in the FDA multicenter (14) study. The study was completed in December 2001, and the FDA approved the Charite for single-level L4-5 and L5-S1 implantation as of October 2004.

The study protocol called for a 2:1 randomization of Charite:BAK threaded fusion cages with autogenous bone graft. 196 patients received the Charité Artificial Disc as part of the randomization, with another 71 non-randomized patients receiving the disc as part of the experience portion of the protocol, so that a total of 267 discs were implanted.

Inclusion criteria were age 18-60, single-level L4-5 or L5-S1 symptomatic degenerative disc disease confirmed by discography, Oswestry score >30, VAS score >4/10, failed >6 months of nonoperative care, back and/or leg pain without nerve compression, <3 prior abdominal surgeries, and compliance with the follow-up schedule.

Exclusion criteria included previous fusion, multilevel degeneration, prior fracture in the lower lumbar spine, non-contained HNP, osteoporosis or metabolic bone disease, spondylolisthesis >3 mm, positive straight leg raise, scoliosis >11 mm, spinal tumor, infection, facet joint arthrosis, psychological disorder, and morbid obesity.

Additional exclusions were metal allergy, bone growth stimulator elsewhere in the spine, participation in another study, arachnoiditis, pregnancy, chronic steroid use, or presence of an autoimmune disease.

Figure 18: Front view of implanted Charité Artificial Disc

Figure 19: Side view of implanted Charité Artificial Disc

[GJZH]

Anterior cervical decompression (discectomy)
A cervical disc herniation can be removed through an anterior approach to relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness and tingling. This procedure, called a cervical discectomy, allows the offending disc to be surgically removed.

The anterior approach to the cervical spine (from the front of the neck) can provide exposure from C2 down to the cervico-thoracic junction. Spine surgeons often prefer it because it provides good access to the spine through a relatively uncomplicated pathway. All things being equal, the patient tends to have less wound pain from this approach than from a posterior operation.

After a skin incision is made, only one thin vestigial muscle needs to be cut, after which anatomic planes can be followed right down to the spine. The limited amount of muscle division or dissection helps to limit postoperative pain following the spine surgery. The main trouble that patients have after surgery is a sore throat and difficulty swallowing, which produces a sense of a ‘lump in the throat’ caused by the surgical manipulation of the area.

The general procedure for the decompression surgery includes the following:

1. Surgical approach

The skin incision is one to two inches and horizontal, and can be made on the left or right hand side of the neck.

The thin platysma muscle under the skin is then split in line with the skin incision and the plane between the sternocleidomastoid muscle and the strap muscles is then entered.

Next, a plane between the trachea/esophagus and the carotid sheath can be entered.

A thin fascia (flat layers of fibrous tissue) covers the spine (pre-vertebral fascia) which is dissected away from the disc space.

2. Disc removal

A needle is then inserted into the disc space and an x-ray is done to confirm that the surgeon is at the correct level of the spine.

After the correct disc space has been identified on x-ray, the disc is then removed by first cutting the outer annulus fibrosis (fibrous ring around the disc) and removing the nucleus pulposus (the soft inner core of the disc).

3. Dissection

Dissection is carried out from the front to back to a ligament called the posterior longitudinal ligament. Often this ligament is gently removed to allow access to the spinal canal to remove any osteophytes (bone spurs) or disc material that may have extruded through the ligament.

The dissection is often performed using an operating microscope or magnifying loupes to aid with visualization of the smaller anatomic structures.

Possible risks and complications of anterior cervical discectomy surgery may include:

Inadequate symptom relief

Failure of bone graft healing (a.k.a. non-union or pseudarthrosis)

Persistent swallowing or speech disturbance

Nerve root damage

Damage to the spinal cord (about 1 in 10,000)

Bleeding

Infection

Damage to the trachea/esophagus

Also, the small nerve that supplies innervation to the vocal cords (recurrent laryngeal nerve) will sometimes not function for several months after neck surgery because of retraction during the procedure, which can cause temporary hoarseness. Retraction of the esophagus can also produce difficulty with swallowing, which has usually resolved within a few weeks to months.

There is little chance of a recurrent disc herniation because most of the disc is removed with this type of surgery.

An anterior cervical fusion is usually done as part of a cervical discectomy. The insertion of a bone graft into the evacuated disc space serves to prevent disc space collapse and promote a growing together of the two vertebrae into a single unit. This ‘fusion’ prevents local deformity (kyphosis) and serves to maintain adequate room for the nerve roots and spinal cord.

By: Peter F. Ullrich, Jr., MD

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IDET - IDET (Intradiscal Electrothermal Therapy) back surgery animation
IDET is a minimally invasive outpatient back surgery to treat patients with chronic low back pain that is caused by tears or small herniations of their lumbar discs. This animation walks you through the steps involved in an IDET back surgery.

Click on link to see animation...

http://www.spine-health.com/dir/idet.html

[bluebirdy]

GJZH - even us old-timers appreciate a review of the definitions - especially with changes over the years!

My L5-S1 ALIF was almost 9 years ago and I still have questions that maybe you can clear up for me:

1) is anterior lumbar fusion with no hardware still done?

2) my OSS used donor graft for my anterior fusion, but said that autograft would have been used if a posterior approach had been necessary. Why?

3) my OSS was assisted by a laparascopic surgeon who did the abdominal part. How does that differ from today's minimally invasive approaches??

4) what's the latest on nucleoplasty?

thanks, bluebirdy

[GJZH]

My L5-S1 ALIF was almost 9 years ago and I still have questions that maybe you can clear up for me:

1) is anterior lumbar fusion with no hardware still done?

2) my OSS used donor graft for my anterior fusion, but said that autograft would have been used if a posterior approach had been necessary. Why?

3) my OSS was assisted by a laparascopic surgeon who did the abdominal part. How does that differ from today's minimally invasive approaches??

4) what's the latest on nucleoplasty?

Bluebirdy,

(1) I believe ALIF is still done when that is all that is necessary. Some people do not need the hardware in the posterior.....Evidently in your case it has worked well.

I was offered a bone on bone fusion without any hardware of L1 to L5. I declined that surgery after asking about the procedure here and then actually talking to actual patients that had been through the procedure.

(2)This is what I found on why surgeons choose autograft or allograft bone...

http://www.spine-health.com/Topics/s...al/cerv03.html

I suspect your surgeon used allograft (donor bone) because with anterior surgery allograft bone seems to heal just as quickly as autograft and he may not have wanted to put you through the pain. I am repeating what I have read here....

Autograft bone for spinal fusion
Autograft bone (patient’s own bone) is harvested from the iliac crest (hip). This technique has been the gold standard since the 1950’s. Autograft bone usually achieves a fusion in 90%-95% of patients.

The principal disadvantage with using autograft bone is that another incision needs to be made over the hip to harvest the bone graft. Possible complications associated with taking out bone graft include:

Graft site chronic pain (which happens 10% to 25% of the time)

Infection

Bleeding

Damage to the lateral femoral cutaneous nerve (a sensory nerve that supplies sensation to the front of the thigh)

Pelvis bone fracture

The chances of a complication increase with the size of the bone graft and patient obesity. For those who opt to use an autograft, many patients find the bone graft harvest site to be more painful than the cervical surgery site itself.



2. Allograft bone for cervical spinal fusion
Allograft bone (a.k.a. ‘bank’ bone or donor bone from a cadaver) eliminates the need to harvest the patient’s own bone. Basically, the donor graft acts as a bone scaffolding onto which the patient’s own bone grows and eventually replaces over years. There are no living cells in the bone graft, so there is little chance of a graft ‘rejection’ like with an organ transplant. However, bone graft healing remains an issue, as there is a somewhat greater likelihood of bone graft failure with allograft compared to autograft.

With allografts, the speed of healing may be slower than an autograft bone fusion. In addition:

In one-level spinal fusions, it yields nearly equivalent fusion rates as autograft bone.

Anterior cervical instrumentation (plates & screws) are commonly employed with allografts to increase fusion rates.

With increasing numbers of levels to be grafted/fused, the differences in fusion rates between allograft and autograft become more significant.

There is a theoretical risk of transmission of an infection from a donor. The risk of contracting a disease such as HIV or hepatitis from an allograft has been estimated to be between 1 in 200,000 to 1 in 1 million. However, with modern procurement and sterilization methods for bone tissue, the risk is essentially moot.

Potential risks and complications of a spinal fusion surgery include:

The principal risk from a spine fusion is that the graft does not heal. In general, allograft bone does not heal quite as well as autograft bone, but both yield good results when used in the anterior cervical spine.

If a graft is used without instrumentation, there is a small chance (1% to 2%) of a graft dislodgment or extrusion. If this happens, another operation is necessary to reinsert the bone graft, and instrumentation (plates) can then be used to hold it in place.

Controversies about spine fusion surgery
While physicians agree on many things about spine fusion surgery, there are some areas that lack consensus. Two such areas are the type of bone used (autograft vs. allograft) and how many levels should be fused.

Type of bone used with fusion surgery
Whether an autograft or allograft is used is based mostly on a combination of the surgeon’s and patient’s preference. Some surgeons still feel most comfortable with autograft as it yields the best fusion rates. Other surgeons have had good results with allograft bone and wish to avoid the postoperative pain and possible complications associated with harvesting a bone graft.

In some instances, it may be more compelling to use a patient’s own bone. There are some situations where it is more difficult to get a solid fusion and using a better bone graft is reasonable. Factors that may make obtaining a solid fusion difficult include:

Revision surgery (previously failed grafts)

Smokers/smokeless tobacco product users

Multiple level fusions

Disease states which inhibit bone healing or which require medications that do so
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Bone graft for spinal lumbar fusion

Bone graft for spinal fusion surgeries may either be harvested from the patient (autologous bone) or from a cadaver (allograft bone).

Autologous bone is harvested from the patient's pelvic bone (iliac crest) and provides the spinal fusion with a calcium scaffolding for the new bone to grow on (conduction). In addition, autologous bone also contains bone-growing cells (osteoblasts) and bone-growing proteins (bone morphogenic proteins).

Allograft bone simply provides a calcium scaffolding and does not have any bone-growing cells or bone-growing proteins. In the lumbar spine, allograft bone is restricted for use in ALIF or PLIF procedures in which bone graft is placed in compression (the compression aids the healing process for the bone). In a posterolateral gutter spine fusion, in which the bone is placed in tension, allograft bone by itself will not heal well (although allograft chips combined with autograft may be used to extend the harvested bone graft).

Autologous bone, in which the bone is harvested from the patient’s body during spine surgery, has the obvious disadvantage of higher post-operative pain. Most of the pain associated with bone graft harvesting is either from too much muscle stripping or from cutting the small sensory nerves (cluneals) that lie in the fat layer over the pelvis (iliac crest). With careful surgical technique, both of these pitfalls may be avoided.

In posterolateral gutter spine fusion and PLIF procedures, a single incision can be used for the spinal fusion surgery and to harvest the bone from the pelvis (iliac crest). The pelvis can be approached through a plane that has no nerves or blood vessels, and only the top portion of the crest needs to be stripped of its muscles (gluteal muscles). Use of this surgical technique minimizes the blood loss and post-operative pain associated with bone graft harvesting.

Bone harvested for ALIF procedures is done through a separate incision (one inch to two inches long) over the iliac crest. Again, only the very top portion of the iliac crest needs to be removed and the soft cancellous (spongy) bone from in between the cortical (hard) layers of bone is scooped out.

Scooping the bone out of the pelvic bone does not result in a lot of pain because there are no nerve fibers inside the bone. However, care must be taken to avoid the sensory nerve in this region (lateral femoral cutaneous nerve) as damage to this nerve can produce pain and numbness in the front of the thigh (meralgia parasthetica). In general, this approach should be associated with minimal post-operative pain or discomfort because limited soft tissue stripping is needed.

There are currently several products on the market and in development that act either as a bone graft extender or substitute. Demineralized bone matrix (bone that has had the calcium removed) has been available for the past several years. It carries some of the bone morphogenic proteins that the body uses to induce bone formation. There are also calcium hydroxyappetite products or coral, both of which have structures similar to bone and act as scaffolding for new bone.

There has been a lot of excitement among spine surgeons awaiting the new bone morphogenic protein products that are expected to be strong inducers of bone growth (osteoinductive). These new products will be relatively expensive, but will probably be able to grow bone even better than the patient’s own bone and bone graft harvesting may no longer be necessary.




3) My OSS was assisted by a laparascopic surgeon who did the abdominal part. How does that differ from today's minimally invasive approaches??

I am not certain I know how to answer this question, but maybe someone else does and will come along and answer it for you....

[GJZH]

4) what's the latest on nucleoplasty? I found this study of nucleoplasty, but I think it is still not popular on the board, but not real certain....best to ask it of others publicly....The results of the study are probably dependent on who is doing the study as well...

Abstract ID: A-38
Abstract Title: The Efficacy of Nucleoplasty™ in the Treatment of Contained Herniated Lumbar Intervertebral Discs
Authors: Provenzano D1, Dellapiazza D2, Gaughan J3, Kabazie A4
Ohio Valley General Hospital1, Ohio Valley General Hospital2, Temple University School of Medicine3, The Western Pennsylvania Hospital4
Poster Type:

ABSTRACT BODY
Introduction: Sixty to 80% of adults will experience low back pain, the leading cause of both time lost from work and permanent disability in North America.(1) Technologies for percutaneous disc procedures have been introduced to treat both low back and radicular pain. Disc nucleoplasty™ utilizing coblation technology™ was FDA cleared in 2001 and to date greater than 35,000 procedures have been performed. Safety and efficacy data published on this technique are relatively scarce. To assess the safety and efficacy profile of nucleoplasty, we performed a retrospective review.

Materials and Methods: Following IRB approval, a retrospective review was performed of perioperative clinical records and procedure notes of all patients who underwent nucleoplasty from 2001 to 2004 by the senior author (AJK). Assessment of long-term safety and efficacy occurred via a prospective telephone follow-up. Previously, some patients received conservative therapy including modalities such as opioid and non-opioid medications, physical therapy and epidural steroids. Patients were divided into three groups based on length of follow-up: less than 6 months, 6 months to 1 year, and greater than 1 year. A clinically important reduction in pain was considered to be ≥30% on a 0 to 10 verbal numerical rating scale.(2)

Results: 121 patients (133 procedure levels) underwent nucleoplasty from 2001 to 2004 with a mean duration of symptoms of 1276 ± 1454 (s.d.) days and a mean follow-up of 511 ± 571 days. The mean age was 40 ± 11 years (64 males & 57 females). Prior to the procedure 75% of patients had constant pain. The primary pain was axial lumbar spine in 91 (75%), radicular in 16 (13%), and both in 14 (12%) patients. No difference in outcome was noted among the areas of primary pain. 43% of patients were associated with workers compensation claims with no statistically significant difference in improvement compared to non-workers compensation patients. 69 patients (57%, 95% CI 48%-66%) had ≥30% pain relief and 53 patients (44%, 95% CI 35%-53%) had ≥50% pain relief. Pain relief achieved did not decrease with time. There was no difference in pain reduction between the three time frame groups. No complications were associated with this procedure including discitis or neurological injury.

Discussion: Over 500,000 percutaneous decompressions for herniated discs have been performed in the last 20 years, often allowing patients to avoid a more invasive technique.(3) The nucleoplasty procedure is a safe technique providing an improvement in verbal numerical rating scales. Future studies on nucleoplasty would benefit from randomized controlled studies with direct comparison to conservative therapy, other percutaneous disc decompression technologies, and microdiscectomy. In addition, defining selection criteria is warranted.

All work was completed at Western Pennsylvania Hospital.

1. Garfin, et al. 1997. Orthopaedic Knowledge Update: Spine. Rosemont: American Academy of Orthopaedic Surgerons.
2. Farrar, et al. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149-158.
3. Reddy, et al. New approach to the management of acute disc herniation. Pain Physician. 2005;8:385-389.

ATTACHED FILES
Reg Anesth Pain Med 2006; 30(3):A-38

[mariah]

Thanks for all this information, however I have a question. I was up most of the night due to pain so am not comprehending too clearly. In plain language could you please tell me, did the patients have significant pain relief after having nucleoplasty? Thank you

[GJZH]

What is RSD?

Reflex Sympathetic Dystrophy Syndrome (RSD) - also known as Complex Regional Pain Syndrome (CRPS) - is a chronic neurological syndrome characterized by:

severe burning pain
pathological changes in bone and skin
excessive sweating
tissue swelling
extreme sensitivity to touch


[For a complete description of RSD/CRPS symptoms, please read the Diagnosis section of the Clinical Practice Guidelines section of this website].

There are Two Types of CRPS - Type I and Type II.

CRPS Type I (also referred to as RSD) - cases in which the nerve injury cannot be immediately identified
CRPS Type II (also referred to as Causalgia) - cases in which a distinct "major" nerve injury has occurred
RSD/CRPS is best described in terms of an injury to a nerve or soft tissue (e.g. broken bone) that does not follow the normal healing path
RSD/CRPS development does not appear to depend on the magnitude of the injury. The sympathetic nervous system seems to assume an abnormal function after an injury
Since there is no single laboratory test to diagnose RSD/CRPS, the physician must assess and document both subjective complaints (medical history) and, if present, objective findings (physical examination).


Criteria for Diagnosing

Complex Regional Pain Syndrome Type I (RSD)

The presence of an initiating noxious event, or a cause of immobilization
Continuing pain, allodynia, or hyperalgesia with which the pain is disproportionate to any inciting event
Evidence at some time of edema, changes in skin blood flow (skin color changes, skin temperature changes more than 1.1°C difference from the homologous body part), or abnormal sudomotor activity in the region of the pain
This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction

Complex Regional Pain Syndrome Type II (Causalgia)

The presence of continuing pain, allodynia, or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerve
Evidence at some time of edema, changes in skin blood flow (skin color changes, skin temperature changes more than 1.1°C difference from the homologous body part), or abnormal sudomotor activity in the region of pain
This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction.

[GJZH]

http://www.spine-health.com/topics/c...w_degen01.html

Common degenerative disc disease questions
Degenerative disc disease is one of the most common causes of low back pain, and also one of the most misunderstood. Many patients diagnosed with low back pain caused by degenerative disc disease are left wondering exactly what this diagnosis means for them. Common questions that are often on patients’ minds include:

If I have low back pain from degenerative disc disease in my thirties, how much worse will it become with age?

Will the degenerative disc disease become a crippling condition? Will I end up in a wheelchair?

Should I restrict my activities?

Can I still play sports?

Will the degenerative disc disease spread to other parts of the spine?

Will the low back pain from degenerative disc disease cause any permanent damage?

Degenerative disc disease is a misnomer
A large part of many patients’ confusion is that the term “degenerative disc disease” sounds like a progressive, very threatening condition. However, this condition is not strictly degenerative and is not really a disease:

Part of the confusion probably comes from the term "degenerative", which implies to most people that the symptoms will get worse with age. The term applies to the disc degenerating, but does not apply to the symptoms. While it is true that the disc degeneration is likely to progress over time, the low back pain from degenerative disc disease usually does not get worse and in fact usually gets better over time.

Another source of confusion is probably created by the term "disease", which is actually a misnomer. Degenerative disc disease is not really a disease at all, but rather a degenerative condition that at times can produce pain from a damaged disc.

Disc degeneration is a natural part of aging and over time all people will exhibit changes in their discs consistent with a greater or lesser degree of degeneration. However, not all people will develop symptoms. In fact, degenerative disc disease is quite variable in its nature and severity.

Medical practitioners disagree on degenerative disc disease
Finally, many patients are confused about degenerative disc disease because many medical professionals don’t agree on what the phrase describes. In practical terms, this means that few practitioners agree on what does and does not constitute a diagnosis of degenerative disc disease. Even medical textbooks don’t usually attempt to give an accurate description. Therefore, while many practitioners believe that degenerative disc disease is a common cause of low back pain in young adults, very few agree on the implications.

While there is still a lot of debate in the medical community about degenerative disc disease, a few aspects of the condition are known. This article will discuss aspects of degenerative disc disease that are more commonly accepted, such as the theory of the degenerative cascade, as well as some areas of theory that are still a source of debate in the medical community.

Pain from degenerative disc disease
Low back pain from a degenerated disc
The lumbar disc is a unique and well-designed structure in the spine. It is strong enough to resist terrific forces in multiple different planes of motion, yet it is still very mobile. The disc has several functions, including acting as a shock absorber between the vertebral bodies.

The lumbar disc has been likened to a jelly donut. It is comprised of a series of bands that form a tough outer layer and soft, jelly-like material contained within:

Annulus fibrosus—the disc’s firm, tough outer layer
Nerves to the disc space only penetrate into the very outer portion of the annulus fibrosus. Even though there is little innervation to the disc, it can become a significant source of back pain if a tear in the annulus reaches the outer portion and the nerves become sensitized. With continued degeneration, the nerves on the periphery of the disc will actually grow further into the disc space and become a source of pain.

Nucleus pulposus—the jelly-like inner disc material
The nucleus pulposus contains a great deal of very inflammatory proteins. If this inner disc material comes in contact with a nerve root, it will inflame the nerve root and create pain down the leg (sciatica or radiculopathy). In the same manner, if any of the inflammatory proteins within the disc space leak out to the outer annulus and touch the pain fibers in this area, it can create a lot of low back pain.

Source of the pain
Generally, the pain associated with degenerative disc disease is thought to stem from two different factors:

Inflammation

Abnormal micromotion instability

The proteins in the disc space can cause a lot of inflammation, and inflammation in the disc space can lead to low back pain radiating to the hips. The associated pain can also travel down the back of the legs.

If the annulus—the outer rings of the intervertebral disc - becomes damaged or worn down, it is not as effective in resisting motion in the spine. This condition has been termed “micromotion” instability because it is usually not associated with gross instability (such as a slipped vertebral body or spondylolisthesis).

Both the inflammation and micromotion instability can cause muscular spasm in the low back. The muscle spasm is the body’s attempt to stabilize the low back. It is a reflex, and although the body’s response of muscle spasm is not necessary for the safety of the nerve roots, it can be quite painful.

The "degenerative cascade" of a degenerating disc
There is minimal blood supply to the disc, and blood is what brings healing nutrients and oxygen to damaged structures in the body. This means that the spinal disc lacks any significant reparative powers. Unlike muscles, which have good blood supply, once a spinal disc is injured it cannot repair itself.

Stages of degenerative disc disease
In the 1970’s, Kirkaldy-Willis first described the "degenerative cascade" of degenerative disc disease. He postulated that after an individual suffers a torsional (twisting) injury to the disc, the disc would degenerate in three general stages.

First, there is significant dysfunction caused by the acute back pain of the injury.

Next, there is a long phase of relative instability at that particular vertebral segment and the patient will be prone to intermittent bouts of back pain.

Finally, the body re-stabilizes the segment and the patient experiences fewer episodes of back pain.

Based on the observation that demographic studies show less back pain from degenerative disc disease in elderly adults (over 60 years) than in younger adults (30 to 50 year-olds), he also concluded that this process happened over a period of 20 to 30 years. Although elderly patients may have pain from facet osteoarthritis, it is uncommon for them to have disc problems.

While this summary is a simplification of Kirkaldy-Willis’s extensive work, it lays the framework for what is known today. We do know that lumbar disc degeneration is a very common and natural process, and only in limited cases does it become painful.

Degenerative disc disease and low back pain
The natural history of lumbar degenerative disc disease is relatively benign. The pain tends to be intermittent, and although at times the pain may seem to be getting worse, the painful symptoms are generally not progressive. While the disc degeneration will progress, the low back pain and other symptoms do not tend to get worse with the progression of the degeneration.

Many patients worry that if they are have a lot of low back pain when they are only 35 years old, the pain will become much worse and they may be in a wheelchair by the time they’re in their sixties. However, if patients can find a way to manage their back pain and maintain their function, the natural history is really quite favorable. With continued disc degeneration, all the inflammatory proteins within the disc space will eventually burn out, and the disc will usually become stiffer, thus decreasing micro-motion. In fact, someone who is 65 years old is actually less likely to have discogenic back pain than someone who is 35 years old.

Degenerative disc disease: the natural degenerative process
Normal disc degeneration with age
When we are born, the disc is comprised of about 80% water, which gives it its spongy quality and allows it to function as a shock absorber. As we age, the water content decreases and the disc becomes less capable of acting as a shock absorber (see Figure 1).

The proteins within the disc space also change composition, and mos`t of us will develop tears into the annulus fibrosus (the outer hard core of the disc). Most people will have some level of disc degeneration by their sixth decade, yet most do not have back pain (see Figure 2).

Magnetic Resonance Imaging (MRI scan) has contributed a great deal to our understanding of lumbar degenerative disc disease and the natural degenerative process. With the advent of MRI technology, good anatomic detail of the disc can be imaged and correlated with the individual’s back pain. Through studies with MRI scans, it was found that:

A large number of young patients with chronic low back pain had evidence of disc degeneration on their MRI scans, and;

Up to 30% of young healthy adults with no back pain had disc degeneration on their MRI scans.

Therefore, degeneration on an MRI scan cannot be used as the sole diagnostic tool for lumbar degenerative disc disease. Disc degeneration present on an MRI scan is not synonymous with a diagnosis of degenerative disc disease and low back pain. The MRI findings need to be corroborated by the findings of the patient’s history and physical exam.

[GJZH]

Degenerative Disc Disease (Continued)


Pain from degenerative disc diseaseIt is not exactly clear why some degenerated discs are painful and some are not. As with many common causes of back pain, there is probably a variety of reasons that discs can become painful. Some theories about pain from degenerative disc disease are:

If a disc is injured or degenerated, it may become painful because of the resultant instability from the disc injury, which in turn can lead to an inflammatory reaction which results in low back pain.

Some people seem to have nerve endings that penetrate more deeply into the outer annulus than others, and this is thought to make the degenerated disc more susceptible to becoming a pain generator.

MRI findings without significant degenerative disc disease
The two findings most correlated with a pathological disc—a degenerating disc that is painful—are:

Disc space collapse

Cartilagenous end plate corrosion

The cartilagenous end plate is the source of disc nutrition. If this becomes eroded, the disc is likely to go through a degenerative cascade leading to the inflammation and micromotion instability, which in turn causes pain. As it goes through the process, the disc space will collapse.

MRI findings of disc dehydration (often referred to as a dark disc, because a disc with less water in it looks dark on an MRI scan), annular tears, or disc bulges are not specific causes of low back pain. These findings may or may not be the cause of the patient’s low back pain. It is well known that the results of surgically fusing a spine with these findings will be much more unreliable than fusing a disc space that has disc space collapse and cartilagenous endplate erosion.


Common symptoms of degenerative disc disease
Along with MRI scan results that show disc degeneration, there are some common symptoms that are fairly consistent for people with low back pain from degenerative disc disease.

The typical individual with degenerative disc disease is an active and otherwise healthy person who is in their thirties or forties. In general, the patient’s pain should not be continuous and severe. If it is, then other diagnoses must be considered. Degenerative disc disease pain is usually more related to activity and will flare up at times but then return to a low grade pain level or the pain will go away entirely.

Common symptoms of degenerative disc disease include:

The low back pain is generally made worse with sitting, since in the seated position the lumbosacral discs are loaded three times more than standing.

Certain types of activity will usually worsen the low back pain, especially bending, lifting and twisting.

Walking, and even running, may actually feel better than prolonged sitting or standing.

Patients will generally feel better if they can change positions frequently, and lying down is usually the best position since this relieves stress on the disc space.

Types of pain from degenerative disc disease
Most patients with degenerative disc disease will have some underlying chronic low back pain, with intermittent episodes of severe low back pain. The exact cause of these severe episodes of pain is not known, but it has been theorized that it is due to abnormal micro-motion in the degenerated disc that spurs an inflammatory reaction. In an attempt to stabilize the spine and decrease the micro-motion, the body reacts to the disc pain with muscle spasms. The reactive spasms are what make patients feel like their back has "gone out".

The severe episodes of low back pain from degenerative disc disease will generally last from a few days to a few months before the patient goes back to their baseline level of chronic pain. The amount of chronic pain is quite variable and can range from a nagging level of irritation to severe and disabling pain, although severe, disabling pain is quite rare.

In addition to low back pain from degenerative disc disease, there may be leg pain, numbness and tingling. Even without pressure on the nerve root (a "pinched nerve"), other structures in the back can refer pain down the rear and into the legs. The nerves can become sensitized with inflammation from the proteins within the disc space and produce the sensation of numbness/tingling. Generally, the pain does not go below the knee.
These sensations, although worrisome and annoying, rarely indicate that there is any ongoing nerve root damage. However, any weakness in the leg muscles (such as foot drop) is an indicator of some nerve root damage.

Chronic pain versus acute pain
One very important tenet in chronic pain is that the level and extent of pain does not equal tissue damage. Severely degenerated discs may not produce much pain at all, and discs with little degeneration can produce severe pain.

In this manner, chronic pain is very different from acute pain. With acute pain, the severity of pain directly correlates to the level of tissue damage. This provides us with a protective reflex, such as the reflex to remove your hand immediately if you put it on something hot.

In chronic pain, the pain does not have the same meaning—it is not protective and does not mean there is any ongoing tissue damage.

By: Peter F. Ullrich, Jr, MD