|
(Continued from page 19)
patient should avoid rotation movements as this leads to facet hypertrophy and further stenosis.
Degenerative instability affects the facets or disk. The degeneration can be exacerbated by a congenital malformative failure of the neural arch to form. This can be seen in up to 20% of spine x-rays. Sometimes the instability results in slippage of one bone upon another. If back pain is the only concern management can be accomplished with anti-inflammatories, spine stabilization exercises, aquatics and epidural steroids. Weight loss once again plays a major role. A brace may be indicated for very short-term use. A brace leads to muscle atrophy and further instability and must be accompanied by intensive physical therapy.
TREATMENT OPERATIVE STENOSIS
The treatment of osteoarthritis is either non-surgical as stated above or surgical. If the disease is allowed to run its course, 15% of the people will have a decrease in symptoms, 70% will have no changes, and 15% will have an increase in their symptoms with no severe deterioration. Of those people treated with surgery, 50% will have an improved post-operative course, 40% will have slight to no improvement, and 10% will be worse. Removal of the facet and synovium followed by fusion is the surgical treatment for isolated facet disease.
Stenosis centrally and laterally responds to simple decompression of the lamina with undercutting but preservation of the facets. Stenosis with slippage can respond to simple decompression of the lamina. Depending upon the degeneration and stability, the decompression may be accompanied by an inter-transverse process fusion. Gross instability may require internal fixation.
TREATMENT OPERATIVE DISK DISEASE FIRST TIME
Herniated disk with radicular features, such as pain, tingling or numbness down the leg that fails conservative measures, responds to surgery 95% of the time for non workmen's compensation cases. To get the best possible outcome, the history has to correspond to the anatomical and physical findings. The onset of radicular pain could begin under most circumstances, even without apparent etiology. The major complaint should be of radicular pain. It may or may not be associated with paresthesia or paresis. The radiographic findings should demonstrate disc pathology at the level of the dermatomal or myotomal symptoms. Usually the nerve root involved corresponds to the lower level of the bones involved such that an L5-S1 herniated disc usually affects the S1 nerve root. However, it must be remembered that more lateral herniated discs will affect the nerve root from the upper level. Likewise, the herniated disc could affect both of the nerve roots.
ANNULOPLASTY
The herniated discs do not have to be large, but just "large enough" to deform the nerve root or thecal sac. Disk contained by the annulus may respond to annuloplasty. Annuloplasty may be appropriate for one level pathology, if the disk height is still at least 2/3's of the normal height and the swelling of the adjacent vertebra is classified as modic-1 or less. This involves placing a wire into the disk and heating it up until it gels. The heat destroys the pain sensing nerve fibers that inappropriately grew into inflamed posterior disk. The heat also shrinks the disk taking some pressure off of the nerve root.
(Continued on page 21)
|
|
