disc pathology and non-surgical decompression

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disc pathology and non-surgical decompression
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reuben henderson, d.o.

• 1993 - michigan state university college of
  osteopathic medicine
• internship flint osteopathic and st. lawrence
  hospitals 1994 1995
• pmr residency university of michigan 2001
• private practice 2004 pmr

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low back pain world wide

• common complaint among adults
• lifetime prevalence in working population up to
  80
• 60 experience functional limitation or
  disability
• second most common reason for work disability
• despite advances in imaging and surgical
  techniques LBP prevalence and its cost are
  relatively unchanged

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back pain causes

• de-conditioning
• sprain/strain
• spondylolithesis
• spondylosis
• facet syndrome
• disc herniation

• disc bulge
• spinal stenosis
• biomechanical
• inflammatory
• infection
• cancer

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recent research on DDD

• 1. heredity may be largely responsible for
  degeneration/herniation of intervertebral disc.
• 2. genetic influences have been confirmed by the
  identification of several gene forms associated
  with disc degeneration.
• 1. Kenneth M C Cheung, How has genetics research
  altered understanding of degenerative disc
  disease implications for intervertebral disc
  regeneration. European Cells and Materials Vol.
  16 Suppl. 4, 2008 (page 8)
• 2. Yingang Zang, Advances in susceptibility
  genetics of intervertebral degenerative disc
  disease. Int J Biol Sci 2008 4283-290

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intervertebral disc
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vascular supply to the disc space from the
cartilaginous endplate

• 1. segmental radicular artery
• 2. interosseous artery
• 3. capillary tuft
• 4. disc anulus

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neurological innervation of posterior spinal
column

• 1. ascending branch of the sinuvertebral nerve
• 2. dorsal root ganglion
• 3. descending branch of the sinuvertebral nerve
• 4. disc anulus
• 5. posterior longitudinal ligament

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• disc degeneration

• changes in hydrostatic pressure
• lack of oxygen
• lack of glucose
• changes in pH levels
• death of proteoglycans

Urban JPG, McMullin JF, "Swelling pressure of
the lumbar intervertebral discs influence of
age, spinal level, composition and degeneration."
Spine 1988, 13179-187 Handa T, et al. "Effects
of hydrostatic pressure on Matrix Synthesis and
MMP production in the human lumbar intervertebral
disc." Spine 1997 221085 -1091 Classification
of Age-Related Changes in Lumbar Intervertebral
Discs 2002 Volvo Award in Basic Science" Spine
2002 Volume 27, Number 23, pp 2631-2644
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proteoglycan structures
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ProteoglycaN structures
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annular tears

• rim lesion
• concentric tear
• radial tear

Osti OL, Vernon-Roberts B, et al. Annular Tears
Disc Degeneration J Bone Joint Surg. Br
1992 74-B678-82 Gordon SJ, Yang KH, Mayer PJ,
et al Mechanism of disc rupture. A preliminary
report. Spine 16450-456, 1991
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disc pathology vs pain

• degree of disc injury (size of tear /
  herniation), nor the degree of nerve root
  compression correlate with subjective pain or
  functional disability

• Karppinen J. et al. Severity of Symptoms and
  Signs in Relation to MRI Findings Among Sciatica
  Patients. Spine 2001 26(7)E149-E154

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internal disruption

• Crock HV, Internal disc disruption.   A challenge
  to disc prolapse fifty years on. Spine 1986
  11650-3

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current therapies for discogenic pain or disc
pathology

• medication and limited activity

• spinal rehabilitation

• interventional pain management

• spinal surgery

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non-surgical decompression

• non-invasive procedure designed to target
  underlying disc pathology
• improve nutrient exchange
• create environment for healing

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non-surgical decompression
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goals of treatment

• actively distract and passively retract the spine
  in order to affect intervertebral disc space
• reduce intradiscal pressures
• increase fluid and nutrient exchange
• promote disc regeneration
• retract nucleic material of bulging or herniated
  disc

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guarding reflex

• traction causes natural guarding reflex
• muscles contract or spasm to prevent distraction
  in order to protect the spine
• traction devices are rarely able to bypass or
  overpower reflex contractions and achieve
  distraction of the disc space

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biofeedback response
designed to monitor patient response and adjust
tensions in order to bypass reflex muscle
contractions
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negative intradiscal pressure
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decompressive patient MRI
September 16, 2006
January 08, 2007
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disc regeneration

• controlled distraction in vivo study of
  rabbit-spine model showed

• significant increase in disc thickness
• signs of tissue regeneration
• decrease in apoptotic (dead) cells in the annulus
  and cartilage endplates
• increase in protein-expressing cells

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decompression research

• 71 of 778 cases were successful in reducing pain
  to a 0-1 on a 0-5 pain scale.
• 86 of 219 patients demonstrated success
  according to Oswestry Pain Scale 84 remained
  pain-free at 90 day follow up.
• 91 of 14 patients with radiculopathy and
  abnormal sensory function demonstrated improved
  neurological function.
• 50 -100 reduction of pain was reported in 19
  out of 23 pts with ruptured intervertebral discs
  and 20 out of 27 with facet arthrosis

• Earl Gose, et al., Vertebral Axial
  Decompression Therapy for Pain Associated with
  Herniated or Degenerative Discs or Facet
  Sysdrome An Outcome Study." Journal of
  Neurological Research, Vol 20, 13179-187
• Thomas Gionis, MD, et al., Spinal
  Decompression" Orthopaedic Technology Review.
  2004
• Frank Tilaro, M.D., et al., Vertebral Axial
  Decompression on Sensory Nerve Disfunction"
  Journal of Neuro-imaging, 1998 Volume 8, Number
  2
• Shealy, et al., New Concepts in Back Pain
  Management. Decompression, Reduction and
  Stabilization. Pain Management. 1998 239-257

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decompression research
Objective To determine the effectiveness of
Spinal Decompression Lumbar Disc
Pathology Design Retrospective Chart
Review Setting Multi-Center Outpatient
Treatment Patients A consecutive sample of 778
Lumbar Cases Intervention 10 25 Sessions on
Non-surgiacal Decompression System Outcome
Measures Changes in visual Analog Scale over
time Improvements in Mobility Improvements
in Functioning
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decompression research
Objective To determine changes in pre and post
MRIs after undergoing non-surgical
decompression Design Retrospective Chart
Review Setting Outpatient Treatment
Center Patients A Sample of 20 Lumbar
Cases Intervention 20 sessions of Non-surgical
decompression for 18 patients 40 sessions for
2 patients Outcome Measures Changes in MRIs pre
and post treatment
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DECOMPRESSION RESEARCH
Objective To determine the effectiveness of
Spinal Decompression on Cervical and Lumbar
Disc Pathology Design Retrospective Chart
Review Setting Outpatient Treatment Center
Westminster, MD Patients A consecutive sample
of 156 Lumbar patients and 37 cervical
patients Intervention 20 25 Sessions on FDA
Cleared (K051013) Decompression Table Outcome
Measures Changes in visual Analog Scale over
time Improvements in Activities of Daily
Living Improvements in Functioning
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lumbar improvement in V.A.S.

• Reduction in Mean from 5.8 to 0.8 V.A.S.
• Same improvement noted for both post surgical and
  non-post surgical patients

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lumbar activities of daily living

• Improvements in Average A.D.L. Component Scores

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decompressive research

• SUNY research foundation
• randomized, double-blind, controlled trial
• subjective VAS pain and oswestry measurements
• objective pre and post MRIs

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decompressive research

• Greater Baltimore Medical Center
• Randomized Controlled Trials SpineMED vs
  conventional traction
• Subjective VAS pain and Oswestry Measurements

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case study - annie

• 30 y.o. female presents with low back pain
• pain radiating down right leg
• initial onset approximately 1 year
• referred by orthopedic surgeon
• on motrin, previously darvocet, flexeril and
  valium
• previous treatments chiropractic and physical
  therapy

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findings

• ROM decreased in the lumbar spine to flexion,
  rotation and side bending
• Strength right side 4/5 for L4-L5 innervated
  muscles
• FABER test positive on the right
• Reflexes ¼ and symmetrical
• SLR negative

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diagnostic studies

• A-P / lateral Plain Film
• degenerative disc height loss at L4-5 level
• MRI
• L4-L5 large central disc herniation (9mm in AP X
  10mm Broad) effacing the ventral thecal sac and
  impressing upon the central canal.
• This produces moderate canal stenosis.
• L5-S1 broad disc bulge with radial tear.
• mild effacement upon the ventral thecal sac.

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imaging
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case 1 outcome

• VISIT 6
• gt pain reduced4 to 1
• VISIT 10
• gt pain reduced 1 to 0
• gt core exercises initiated
• VISIT 20
• gt pain stabilized 1

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case 1 outcome

• VISIT 24
• gt Pain stable at 1
• gt Released to home exercise program
• gt Inversion table recommended

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post spineMED findings

• ROM full in the lumbar spine to flexion,
  rotation and side bending
• strength 5-5 for the bilateral lower extremity
• FABER test negative bilaterally
• reflexes ¼ and symmetrical
• SLR negative

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post spineMED imaging

• MRI
• L4-5 now measures only 1 or 2 mm in AP dimension
  x 9 mm broad with only mild narrowing of thecal
  sac
• L5-S1 diffuse disc bulge, no radial tear or
  thecal sac effacement

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conclusion

• non-surgical decompression can significantly
  improved the clincal outcome of patients with
  discogenic pain
• in treating over 300 patients
• no incidence of injury, some incidence of
  residual pain
• many successful outcomes
• mostly lasting results healing

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intervertebral disc