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Increasing Gradients of Compressive Stress Can Lead to Annular Delamination, Collapse, and IVD Degeneration

delamination, annulus

A ISSLS Prize-winning study 1 examined how increasing gradients of compressive stress within the intervertebral disc (IVD) contributed to the progress of dis degeneration. The research findings suggest that an increased grade of disc degeneration created decreased nucleus pressure and compressive annulus stress, but anterior annular stress gradients increased by approximately 75 percent, and by 108 percent in the posterior annulus—findings that are clinically significant.

The neural arch may provide a stress-shield for the degenerating disc during mechanical loading, but delamination and collapse of the annulus are most likely caused not by loading, but by increasing gradients of compressive stress, leading to advanced disc degeneration, despite the stress-shield.

 

The Study

Using 191 motion segments from 42 cadavers of varied ages, researchers measured the intradiscal stresses under 1 kN of compression. A pressure transducer was pulled along the midsagittal diameter of the disc to measure the intradiscal stresses. Stress gradients in the annulus were quantified using a formula that averaged the rate of increase in compressive stress between the area of maximum stress in the anterior or posterior annuls, and the nucleus. Measurements were compared before and after applied creep-loading, as well as in flexed or erect postures. A scale of 1to 4 was used to describe the amount of macroscopic disc degeneration observed.

 

Results

An increase of disc degeneration from 2 to 4 decreased by 68 percent the amount of pressure in the nucleus, and compressive stress in the annulus was decreased by 48-64 percent, depending on the simulated posture of the segment and the location of the disc. However, anterior annular stress gradients showed an average 75 percent increase in the flexion position, and posterior annular stress gradients increased 108 percent in upright posture.

 

Conclusion

The neural-arch provides stress-shielding, but compressive stress gradients are significantly increased with an increasing grade of disc degeneration. Adjacent lamellae are sheared by the stress gradients, which may contribute to the delamination and collapse of the annulus.

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Lumbar Disc Herniation and Resorption – What does the literature say?

A professional lumbar spine model with a flexible and totally dynamic herniating (or prolapse) nucleus pulposus.

Lumbar disc herniation is a very common condition which often generates pain and disability. It is a physiological process that starts from the inside out as the nucleus pushes radially into the annulus fibrosus. But not all disc herniations cause pain, and many of them don’t cause long-term disability.

The literature has been quite varied in answering questions surrounding resorption rate. Yes, many disc herniations resorb, and it is believed to be due to the anaerobic and avascular nature of the nucleus pulposus. Once the material extends beyond the annular outskirts, the immune system identifies it as foreign and macrophages begin to chew it up.

But not all lumbar disc herniations are equal while some respond to manual therapy and some do not. Some cases require surgery to remove the offending material.

In a recent meta-analysis titled: ‘Incidence of spontaneous resorption of lumbar disc herniation’ 1 a group of authors looked at 11 cohort studies but found only a very limited number of high-quality papers on the subject. What they found was the phenomenon of lumbar disc herniation resorption to be 66.66% and suggested that conservative treatment may be a first line approach to reduce costs associated with unnecessary surgical bills.


Disc herniations are quite varied in nature, and this is likely why there is such variability in the outcomes reported regarding resorption and pain. As a spine modeling company which continuously invests in the property characteristics of materials, we have found that subtle changes to the nucleus pulposus make-up and annulus fibrosus tensile properties have a significant impact on the biomechanical behaviour of our lumbar disc herniation model.

Many mechanically anatomical variations exist which can cause a wide spread of varying symptoms. These symptoms are likely related to the type of herniations with some more central within the spinal canal and others are more lateral. Further to that, Depending on the severity, an astute clinician can be relatively accurate in the anatomical location to help in the mechanical management of lumbar disc herniation.

flexion, lumbar, model, pain, relief

Flexion lumbar loading

 

 

To see how a spine surgeon uses the model to explain a lumbar disc herniation while referencing an MRI, we present Iona Collins of fixmyspine below.

 

 

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Degenerative disc and impact on flexibility

Degenerative disc, flexibility, model

Aging and Degenerative Disc Changes of the IVD’s Impact on Spinal Flexibility

A publication reviewed several studies involving the biomechanics of the intervertebral discs (IVD) with macroscopic changes associated with degenerative disc disease with the aim of finding out how spinal flexibility was affected by dehydration, tears, fissures, osteophytes, and the inevitable collapse of the intervertebral space. The studies under review used cadavers and did not contribute to information about how degenerative disc disease may cause symptomatic back pain. However, the review can contribute to the understanding of disc degeneration disease and its progression, as well as offer insight into what surgical treatments could be beneficial in improving flexibility and spinal functionality in patients.

 

About Disc Degeneration

Degeneration of the IVD causes mechanical and biochemical changes in the disc and its surrounding structures. The space between the discs can collapse, and proteoglycan and water content can be greatly reduced, contributing to the damage of endplates and osteophytosis. The entire motion segment of the IVD is affected macroscopically and biomechanically by the degenerative process, and this can cause a loss of functionality and mobility that contributes to further progression of disc disease in the spine.

 

How the IVD Works

A properly functioning IVD evenly distributes weight-bearing loads across the spinal segments and allows the spine to suffer intense compressive loads without collapsing or losing its range of motion. Inside each IVD is a nucleus pulposus (NP)—a gelatinous substance with proteoglycans, elastin fibers, and Type II collagen. The NP is enclosed by the annulus fibrosis (AP)—a lamellar structure made up of Type I collagen fibers. The angle of the collagen fibers in the AP (30 degrees), alternates with that of the adjacent lamellae, which contain gel rich in proteoglycan and may be surrounded by connective bundles of collagen. Endplates connect the IVD to the surrounding vertebrae. The NP transitions to the AF in a transitional zone that is indicated by diverse types of tissue, rather than a distinct border. Negatively charged proteoglycans are balanced by positive cations within interstitial fluids, contributing to osmotic pressurization in response to its environment. Because of this, the IVD absorbs copious amounts of water, which helps the nucleus to adjust in reaction to high compressive forces.

The NP is bookended by the endplates and the AF, which allows the resulting hydrostatic pressure to balance any swelling pressure during active loading and at rest so that the disc will not bulge or collapse under compression. The structure of the lamellae in the AF is tension-loaded and assists with bending and shear. Vicious fluids flow through the permeable endplates, which help evenly distribute pressure within the nucleus or annular tension. The AF’s collagen bundles create an elasticity that absorbs compressive loads. The exchange of fluids within the IVD creates a balance between tension and flexibility that is integral to the function of the spinal unit.

Degenerative disc, flexibility, model

Degenerative disc model

 

Effects of Degenerative Disease and Aging on the IVD

 

  • Cellular/matrix alterations—Aging and degenerating IVD exhibit early changes in the endplates which in turn cause changes to the nucleus and annulus. A progressive reduction of cells begins in childhood and continues throughout a lifetime, decreasing and fragmenting the proteoglycan content in the nucleus and surrounding areas. In time, this leads to a reduction of the disc’s ability to repair itself. As the cells lose their ability to synthesize, there is further loss of proteoglycan content. Changes at the cellular level create biochemical alterations throughout the entire matrix. In time, the NP loses the ability to attract and retain adequate water and an increase in fibrous tissue takes place. A similar –though lesser—loss of water and collagen in the AF leads to reduced swelling pressure and contributes to the degenerative state.

 

  • Structural changes—Structural failures including tears and clefts follow (or are perhaps caused by) alterations in the NP and AF. Considered a symptom of degenerative disc disease, these changes are related to, but distinct from, the simple aging process. Endplate separations, radial tears, and rim lesions increase in the aging population, and approximately 50 percent of the cadaver specimens in one study showed evidence of IVD degeneration in subjects over 30. Calcification of the cartilaginous endplates cause biomechanical changes that reduce the flexibility of the endplates and make the IVD vulnerable to fracture, reduced water intake, and a lower solute exchange rate between the disc and vertebrae. Collapse of the intervertebral space occurs often in a degenerated IVD, though disc height reduction is not a common result of simple aging. In addition to a reduction in disc height, osteophytes may form around the affected vertebrae. Studies have suggested that these osteophytes may be the body’s attempt at providing supplemental stabilization in the degenerated spine segment.

 

  • Pain—A common cause of back pain, degenerative disc disease undermines the spine’s structural integrity and creates tension and spasms in the surrounding muscular structure. In severe cases of disc degeneration, disc prolapse, and collapse, radial tears that cause a leakage of collagen and fluids can increase the frequency and amount of back pain. Another common source of back pain is lesions or uneven loading in the endplates. When there is a reduction in disc height, nerve roots located in between the vertebrae may be squeezed or pinched into the space near the capsule joint, causing radicular pain. This type of pain can intensify with activity or prolonged sitting or standing. Facet join arthritis can cause a decrease in cartilage between the apophyseal or zygapophysial joints and may contribute to back pain.

 

  • Changes in Flexibility—When the IVD are in a degenerative state, the entire motion segment(s) can become more rigid and less flexible. Researchers have theorized that the spine loses its flexibility over time, triggered by an initial dysfunction and followed by instability, which leads to an attempt at stabilization. Thus, disc degeneration is a progressive event which is the result of the spine’s attempt to handle physiological loads. However, there is no evidence that shows a definitive connection between reduced range-of-motion therapies (such as surgical implants that inhibit the range-of-motion) and an improvement of disc degeneration.

 

 

Conclusions

Research into the biomechanics of the IVD systems clarifies some aspects of degenerative disc disease but offers little insight into the specific causes of lower back pain. Degenerative changes of the IVD systems cause changes to the functionality of the spine, with some inconclusive evidence of a loss of flexibility and increasing stiffening over time.  Further studies of the effects of disc degeneration and a possible link to spinal instability are recommended.

 

 

 

 

 

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Study Indicates Pain Signals Can be Transmitted from the Peripheral Sensory Nerves to the CNS

pain, model

A research study of GABAergic communication within rodent peripheral sensory ganglia demonstrated that somatosensory pain signals can be transmitted from the peripheral sensory nerves to the central nervous system (CNS). The study further found that necessary proteins required in GABA synthesis were released by sensory neurons and triggered by depolarization. By infusing the sensory ganglia with GABA or GABA reuptake inhibitors, the researchers could significantly reduce or alleviate acute inflammatory or neuropathic pain and nociception in the rodent subjects. They were also able to cause or exacerbate peripherally-induced nociception by GABA-receptor antagonists to sensory ganglia. The study demonstrated that chronic peripheral-induced nociception could be reduced in vivo by chemogenomic or optogenetic depolarization of the GABAergic root ganglion neurons. This indicates a need for further research into peripheral somatosensory ganglia as a potential site of therapeutic pain remediation.

 

Background

Peripheral nerves create pain to convey information to the brain and central nervous symptoms about damage that may be occurring in the body. Healthy nerves send signals from the origin of the impending damage to the spinal cord. There, peripheral somatosensory signals are analyzed within the synapses. It is believed that, prior to their interaction with the spinal cord, nerve fibers do not receive input from the synapses and that cell bodies are unnecessary to the propagation of action potential (AP) to the spinal cord from its periphery. Some chronic pain conditions could be caused or exacerbated by the somatic sensory neurons stimulating peripheral excitation. The researchers involved in this study examined local GABAergic transmission within the DRG to more fully understand why GABA receptors are present in sensory neuron somata and from where any possible activators of the transmitters may originate.

 

Results

In the in vivo study of rodent peripheral sensory ganglia, the researchers’ data determined that GABA is most likely produced in various sub-types of dorsal root ganglion (DRG) neuron. This observation supports the theory that many different sizes and types of DRG neurons may, upon stimulation, be released. In addition, every type of small-diameter DRG neuron may respond to GABA, which satellite glia will remove from the extra satellite space. This release could also signal and set base GABA levels.

Both GABA and the GABA reuptake inhibitor NO711 produce an antinociceptive effect when administered locally in vivo to DRG. When GABA receptor antagonists are similarly delivered, peripherally-induced pain is exacerbated and a nocifensive behavior occurs—even without applied painful stimuli. The results of this observation indicate a healthy endogenous GABAergic inhibition within DRG, though it is still unknown whether the afferent fiber transmission occurs only within the peripheral segments of the DRG.

Previous evidence of cross-excitation within the sensory ganglia and the abundance of neurotransmitter receptors expressed within the somatic and perisomatic sensory neuron sites could point to complex integration of peripheral somatosensory information within the DRG. This study adds a possible new theory of pain to the previously proposed “gate-control” idea.

The research study indicates a potential for the use of focally-applied GABA mimetics or GAT1 inhibitors targeting DRG as a means of pain relief. This idea corresponds with recent studies that concluded that direct stimulation of DRGs through implanted stimulation devices provided relief in people who suffered from neuropathic pain. The authors of this study postulate that the DRG neuromodulation effect works due to the peripheral ganglionic gate and that peripherally-acting GABA mimetics could be used to affect long-term pain relief in pain sufferers.

 

 

 

 

 

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Cavitation – Practitioner Experience Best Indicator of Success

cavitation, spine, joints

Practitioner Experience Best Indicator of Success in Cervical Spine Manipulation Cavitation

 

Cervical spine studies have historically indicated that manipulation (and the generation of cavitation) by a qualified practitioner is the most effective means of treatment for neck pain, far exceeding placebos or exercise. Though there are various definitions and modalities of cervical manipulation, in general, treatment involves the use of applied force in a single direction perpendicular to the affected cervical joint surface. The widely-accepted indicator of the success of any manipulation is an audible “pop” or other sound produced by the joint’s cavitation, regardless of which technique is applied in the manipulation.

A recent study 1 compared the results of four practitioners’ spine manipulation therapies on the relative range of motion (ROM) in four control groups. The subjects of the study—students with no history of neck pain—were analyzed for relative ROM prior to, and after manipulation therapy. Practitioners involved in the study represented a range of experience (1,20, and 20 years) in cervical spine manipulative therapy. They employed “classic” HVLA technique (in which the patient is in an upright, seated position, with shoulders relaxed) on their subjects, who were fitted with spine motion analyzers attached to an adjustable helmet and harness prior to their manipulations. The volunteers—9 women and one man whose average age was 25 years—were manipulated one-to-four times by each of the four practitioners, who were instructed to discontinue the manipulations after achieving cavitation or after four attempts. An independent observer collected kinematics data during the experiment. This data was later analyzed to determine the rate of cavitation occurrence during each practitioner’s C3 and C5 thrust manipulations. The procedures used in the study employed a low magnitude of axial rotation to reduce the risk of potential cervical artery dissection.

The study concluded that there was little relevance in the direction of applied forces in the vertebral manipulation. Rather, the number of years a practitioner had been in practice was a more reliable indicator of kinematic impact on the subjects in the study. The most experienced practitioners most consistently achieved acceleration magnitude and produced cavitation. Their therapies consistently improved neck mobility and relative ROM in their subjects, suggesting that certain kinematics parameters are most likely linked with the occurrence of cavitation for thoracic manipulation.

 

 

 

  1. Assessment of in vivo 3D kinematics of cervical spine manipulation: Influence of practitioner experience and occurrence of cavitation noise
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Fostering Postural Interoceptive Exercises to Help Reduce Neck Pain

posture, awareness, pain, spine model

In a recently accepted Level 1 evidence publication (Jan 31, 2017), a study looked at how postural awareness can make an impact on non-specific neck pain. Non-specific neck pain usually indicates that there isn’t  any pathological problems. Moreover, this usually indicates a degenerative problem associated with the intervertebral discs and/or facet joints.

In their study (Does Postural Awareness Contribute to Exercise-induced Improvements in Neck Pain Intensity? A Secondary Analysis of a Randomized Controlled Trial Evaluating Tai Chi and Neck Exercises) seventy-five subjects were randomly allocated to two groups: a Tai Chi group and conventional neck exercise group. After a period of 12 weeks, neck pain VAS measures decreased significantly in both groups.

The authors speculated that postural awareness played an important role in the positive outcomes.

Postural awareness can be a challenging concept to encourage especially when patients do not know the reason to do so. Dynamic Disc Designs models allow the practitioner to explain why posture is important. This fosters postural awareness through education rather than a dictatorship approach.

Interoceptive consciousness often begins with an understanding of how changing posture can change the stresses on the internal spinal structures.

Whether you are trying to motivate postural interoceptive awareness or explain why certain neck exercises are important to the patient, our models help connect the reasons at to why.

“ Your models have re-established the vital importance of the doctor / client communication relationship, dramatically bridging the gap for both to have a common understanding of the condition, the process ahead, and the targeted outcomes towards health and wellness for life. Simply perfect.” Barry Kluner DC

Postural awareness begins with an understanding of how the spine works. Our viscoelastic models show patients the effect of load and time dependent compression. Changing the angles of the endplates can significantly improve ones posture and the reduction of pressure on sensitive tissues. Teaching a patient as to WHY to improve their posture is a key to helping them reduce their pain.

 

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Migration of Nucleus Pulposus

Treatment strategies related to intervertebral disc displacement often involves extension. Robin McKenzie’s work on centralization of symptoms in the case of disc herniation has been used by many.  Most of the research on migration nucleus pulposus has been previously investigated in the lumbar spine. In a recent study published in PM&R 1 , researchers looked at the cervical spine and wondered if this was a similar case. They hypothesized that cervical extension would centralize and shift the nucleus anterior–away from the associated disc herniation.

They looked at 10 healthy young males with mean age of 22 yrs old and compared neutral to extension position of the cervical discs using MRI. They carefully mapped out the nucleus pulposus and found that in extension the migration nucleus pulposus was anterior and away from the posterior disc margin.

They concluded that moving the cervical spine into extension could be clinically valuable in the case of cervical disc problems.

At Dynamic Disc Designs, we have seen what these researchers have seen! When our handcrafted models (with an annulus and nucleus) are moved into extension, the nucleus can been seen to move anterior. In our lumbar models, the clear L4 vertebra of our Professional LxH Model allows full migration visibility of the nucleus pulposus. This is helpful in the clinical explanation of treatment targets for patients with intervertebral disc problems.

migration nucleus pulposus, lumbar model

Posterior nucleus migration in flexion.

  1.  Kim YH, Kim SI, Park S, Hong SH, Chung SG Effects of Cervical Extension on Deformation of Intervertebral Disk and Migration of Nucleus Pulposus. PM R. 2016 Sep 6. pii: S1934-1482(16)30905-4. doi: 10.1016/j.pmrj.2016.08.027. [Epub ahead of print