Painful discs.

[oljoha]

Value of MRI and Discography in Determining the Level of Cervical Discectomy and Fusion (http://www.medscape.com/viewarticle/490748?src=mp)

Have a look at the study which the link above leads to (you may have to register). Now, see I have a problem with painful discs. Why on earth would the disc become painful?

You see I believe the painful disc is a symptom. They nociceptors in the disc become sensitized due to other circumstances. In other words - If we look elsewhere we can probably resolve the sensitized state without resorting to surgery.

Evidence for this? Well - one study showed that when there is a painful disc the re are usually more than one painful segment. So why would several discs become painful simultaneously? Do they degenerate at the same rate? Besides the above study is about cervical discs... and degeneration is the norm in the cervical region... Something doesn't add up (in my head).

[nari]

Hi oljoha

You are right - why on earth would discs become painful? why would a bulge produce pain when nerve compression produces only numbness and/or hyperaesthesia or loss of power??
There seems to be a chemical irritant present but as far as I am aware, no-one knows what, exactly. But a prolapsed disc does not mean it is the source of pain in itself!
Degeneration in the spine to some degree is present in asymptomatic people, so you are right - maybe surgery (which has a success rate of about 60%) is not the answer with intractable pain from a 'disc'.
but I don't think anyone really knows why 40% of surgical interventions fail.


Nari

[oljoha]

Nari, one thing that causes a lot of pain is the chemical irritant from within the disc if it gets in contact with the nerve root and this is combined with mechanical irritation. Separately - they're not so bad. The cases I'm thinking of however are those where there are "painful degenerated discs" but no actual prolapse.

To me - 60% is pretty low. In fact - I'm sure they'd get the same results with mock surgery. They got excellent results with mock arthroscopic knee debridements (all 5 cases became pain free (saw documentary on Discovery channel)). Hey, even the anasthesia might even be what's causing the improvement...

[nari]

The 60% is our general success rate, but that of course does not include follow-up at, say, 2 years.

It is not much better than chance, and marginally above placebo???
Not very encouraging.
Then again, there have been studies comparing surgery, physiotherapy, manipulation and doing nothing - the end result is much the same, at 6 months or so....but these studies do not specify WHAT physiotherapy - and that is pretty important!


Nari

[bernard]

Hi all,

It was my intent to go there, oljoha but you did not let me much time to achieve my little animations! :D

[oljoha]

Sry bout that Bernard :oops: Please, I'd love to see your animations though.

[bernard]

I'm working hard on it! A hand on a patient, the other on the keyboard, the right foot on the mouse! :oops:

The left foot is still! :roll:

[nari]

Bernard

You must be getting slack, with the left foot still!!

You need to levitate in order to do all the things you want to... :wink:


Nari

[bernard]

Nari,

I planned to change the standing leg next week. :lol:

[bernard]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7089697

Spine. 1982 Mar-Apr;7(2):97-102. Related Articles, Links


Vertebral end-plate changes with aging of human vertebrae.

Bernick S, Cailliet R.

The present study describes the sequential age changes within the growth and articular layers of the cartilaginous end-plates of vertebrae from humans varying in age from birth to 73 years. There is a gradual reduction in the width of the growth cartilage up to 16-20 years of age. During adulthood and progressing into old age (60-73 years), the end-plates consist of only articular cartilage which undergoes calcification followed by resorption and replacement by bone. Age changes are observed in the arterioles, capillaries, and venules found in the nutrient canals or spaces of the bone adjacent to the cartilage or disc. The calcification of the articular cartilage and vascular changes seen in the older vertebrae would impede the passage of nutrients from the blood to the disc proper. Collagen fibers are observed arising from the older vertebral end-plates to course into the midregion of the disc.

PMID: 7089697 [PubMed - indexed for MEDLINE]

A bit old but it fits the Diane theory?

[Diane]

..but it fits the Diane theory
Bernard, you'll have to remind me which theory that is again..
Diane

[bernard]

Diane,

Age changes are observed in the arterioles, capillaries, and venules found in the nutrient canals or spaces of the bone adjacent to the cartilage or disc. The calcification of the articular cartilage and vascular changes seen in the older vertebrae would impede the passage of nutrients from the blood to the disc proper

More vasculature then more sensitive neural tissues in the disc and annulus.

It is amazing that we have possibility to restore a normal hydration with these growing. The human being try to repair the failing disc with vessels to augment nutrition and hydration.

It fails because posture do not follow this behavior?

[Shirl]

I am finding this thread very interesting guy's. I suffer from DDD and many other spine problems. Like I said very interesting thoughts here.

I do know before I had my lumbar fusion L4-S1 I had the problem of disc fluid "leaking" onto the nerve and have to say that was very painful!!!!!!!

I think this is a great topic about "Disc Pain." I believe bernard and Doug went around with this one?

Shirl :)

[bernard]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11725235

Spine. 2001 Dec 1;26(23):2550-7.

Immunohistochemical detection of Schwann cells in innervated and vascularized human intervertebral discs.

Johnson WE, Evans H, Menage J, Eisenstein SM, El Haj A, Roberts S.

J.P. O'Brien Laboratory, Centre for Spinal Studies, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG, United Kingdom. w.e.b.johnson@keele.ac.uk

STUDY DESIGN: The ingrowth of nerves, blood vessels, and Schwann cells into human intervertebral discs was examined using immunohistochemistry for cell-type-specific markers. OBJECTIVES: To determine whether Schwann cells may contribute to disc innervation, and to assess the relation between disc innervation and vascularization. SUMMARY OF BACKGROUND DATA: Intervertebral disc degeneration was associated previously with ingrowth of blood vessels and nerves. Schwann cells are known to play an important role in regulating nerve growth and survival in other tissues, but they have not been examined in human pathologic intervertebral discs. METHODS: Serial sections of human intervertebral discs were immunostained for the neuronal markers (neurofilament 200, peripherin, protein gene product 9.5), for the Schwann cell marker (glial fibrillary acidic protein), and for the endothelial cell marker (CD34). RESULTS: Glial fibrillary acidic protein-immunopositive cells colocalized with nerves in degenerate discs, but were absent or rarely observed in nondegenerate, aneural discs. These also were seen in the disc matrix, independently of nerves. Much of the nerve and Schwann cell ingrowth was found in vascularized areas of disc tissue, where the lamellar structure of the anulus fibrosus was disrupted. Blood vessels were observed deeper into the discs than nerves or Schwann cells. CONCLUSIONS: The appearance of glial fibrillary acidic protein-immunopositive cells in diseased intervertebral discs was closely associated with nerve ingrowth. This novel finding suggests that Schwann cells have a role to play in regulating disc innervation and nerve function in the disc. Because blood vessels were observed furthermost into the disc, it is possible that degenerate disc vascularization occurs before innervation.

PMID: 11725235 [PubMed - indexed for MEDLINE]

One more point to Diane! :D

[oljoha]

Diane,
More vasculature then more sensitive neural tissues in the disc and annulus.

It is amazing that we have possibility to restore a normal hydration with these growing. The human being try to repair the failing disc with vessels to augment nutrition and hydration.

It fails because posture do not follow this behavior?

All these nerves stem from either the neural plexus of the ALL or PLL. Now if this plexus is irritated then these nerves (inside the disc) will also be irritated. If you mobilise the ALL (extension) you could be influencing this plexus and thus causing a decrease in pain. Shit I'm tired should not be writing...

And yes ... this topic was on disc pain - not nerve root pain (disc material leaking onto the nerve root).

[bernard]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15456054

Stud Health Technol Inform. 2002;88:321-5.
Muscular modelling: relationship between postural default and spine overloading.

Pomero V, Vital JM, Lavaste F, Imbert G, Skalli W.

Laboratoire de Biomecanique, ENSAM, Paris, France.

The objectives of the study are to describe and use a muscular model to compare spinal loads and muscles recruitments between an unbalanced subject (patient) and a normal volunteer. Data collection was performed and imputed into the muscular model: from sagittal X-rays, together with plantar foot pressure measurements, external loads for the L3/L4 level were calculated. Using MRI of the thoraco-lumbar region and muscular testing, a personalized muscular model was constructed. The main results are as follow: external loads for the unbalanced subject were higher because of the postural default, especially for flexion moment. Running the model, simulations showed a higher erector spinae group activation for the patient. This induced a significant difference in joint compression. Setting the maximum admissible stress of the extensor muscles of the patient to an equivalent level as the one found for the volunteer to maintain the posture, a second simulation was performed. Joint compression was reduced, but postero-anterior shear and flexion moment increased drastically. The model suggests that either the muscular system needed a stronger activation, yielding a higher joint compression and probably a muscle fatigue in such an activation level, or the spinal loads increased to a higher and probably dangerous level.

PMID: 15456054 [PubMed - indexed for MEDLINE]

[bernard]

Anterior thoracic posture increases thoracolumbar disc loading. (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15168237)

Eur Spine J. 2005 Apr;14(3):234-42. Epub 2004 May 27. Related Articles, (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=15168237) Links (javascript:PopUpMenu2_Set(Menu15168237);)
Harrison DE (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Harrison+DE%22%5BAuthor%5D), Colloca CJ (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Colloca+CJ%22%5BAuthor%5D), Harrison DD (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Harrison+DD%22%5BAuthor%5D), Janik TJ (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Janik+TJ%22%5BAuthor%5D), Haas JW (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Haas+JW%22%5BAuthor%5D), Keller TS (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Keller+TS%22%5BAuthor%5D).

Ruby Mountain Chiropractic Center, 123 Second Street, Elko, NV, 89801, USA. cbpdcs@idealspine.com

In the absence of external forces, the largest contributor to intervertebral disc (IVD) loads and stresses is trunk muscular activity. The relationship between trunk posture, spine geometry, extensor muscle activity, and the loads and stresses acting on the IVD is not well understood. The objective of this study was to characterize changes in thoracolumbar disc loads and extensor muscle forces following anterior translation of the thoracic spine in the upright posture. Vertebral body geometries (C2 to S1) and the location of the femoral head and acetabulum centroids were obtained by digitizing lateral, full-spine radiographs of 13 men and five women volunteers without previous history of back pain. Two standing, lateral, full-spine radiographic views were obtained for each subject: a neutral-posture lateral radiograph and a radiograph during anterior translation of the thorax relative to the pelvis (while keeping T1 aligned over T12). Extensor muscle loads, and compression and shear stresses acting on the IVDs, were calculated for each posture using a previously validated biomechanical model. Comparing vertebral centroids for the neutral posture to the anterior posture, subjects were able to anterior translate +101.5 mm+/-33.0 mm (C7-hip axis), +81.5 mm+/-39.2 mm (C7-S1) (vertebral centroid of C7 compared with a vertical line through the vertebral centroid of S1), and +58.9 mm+/-19.1 mm (T12-S1). In the anterior translated posture, disc loads and stresses were significantly increased for all levels below T9. Increases in IVD compressive loads and shear loads, and the corresponding stresses, were most marked at the L5-S1 level and L3-L4 level, respectively. The extensor muscle loads required to maintain static equilibrium in the upright posture increased from 147.2 N (mean, neutral posture) to 667.1 N (mean, translated posture) at L5-S1. Compressive loads on the anterior and posterior L5-S1 disc nearly doubled in the anterior translated posture. Anterior translation of the thorax resulted in significantly increased loads and stresses acting on the thoracolumbar spine. This posture is common in lumbar spinal disorders and could contribute to lumbar disc pathologies, progression of L5-S1 spondylolisthesis deformities, and poor outcomes after lumbar spine surgery. In conclusion, anterior trunk translation in the standing subject increases extensor muscle activity and loads and stresses acting on the intervertebral disc in the lower thoracic and lumbar regions.

Publication Types:

Historical Article

PMID: 15168237 [PubMed - indexed for MEDLINE]

[bernard]

I worked last week with an mechanics engineer and something great went out this discussion.
The IVD (intervertebral disc) is a very strong thing but it has some limitations at use.

http://www.algoless.com/flash/lumbar_002.swf

If we agree that it was perfectly designed (?), we may assume, as a start, that disc is a well defined volume with few allowed variations.