More than 25 years-ago, Kirkaldy-Willis et al presented the concept of a cascade of spinal motion segment degeneration invoking progressive wear of the. Instability of the Lumbar Spine. KIRKALDY-WILLIS, W., H. *; FARFAN, H., F. **. Section Editor(s): CALANDRUCCIO, ROCCO A. M.D.. Clinical Orthopaedics and . Prominence in this small group have been William Kirkaldy-Willis, Harry Farfan, and Henk Verbiest. It was Kirkaldy-Willis who first conceptualized and published .
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In this illustration disruption of the posterior annulus of the disc has occurred. Post- artificial disc surgery rotational instability.
The entire process can and is adversely affected by factors such as cigarette smokingenvironmental pollutants and lack of exercise. Black Dot- The dural sac kirkalvy the pia and arachnoid layers, the nerve roots of the cauda equina and the exiting nerve roots. On the other hand the collagen itself may have not formed normally at birth due to congenital enzymatic deficiencies.
Blue Dot- The facet or zygoapophyseal joint. In the degenerative kirkalry disc degeneration leads to segmental dysfunction and stress is then directed to the facet joints. A segment includes adjacent vertebrae and the intervertebral disc between them. Shown, to the left, is such a segment. It is only through the understanding of lumbar spine pathophysiology and its clinical correlates that specific rational treatment for patients becomes possible.
The pathophysiology of degenerative disease of the lumbar spine.
Iatrogenically Produced Facet Problems Low back pain secondary to facet degeneration is a common phenomenon. Progressive kjrkaldy and tearing of the disc initiates the cascade: This can progress to the point of true segmental instability. From left-to-right the figures above provided by William Kirkaldy-Willis show the results of progressive degeneration.
This work created a format by which these observations could be related to clinical diagnosis and subsequent rational patient therapy.
Note that the interior of the disc nucleus pulposus is distinct from it enveloping tough collagenous layered capsule annulus fibrosis. In this example radial tears are kikraldy in the posterior annulus.
The Facet Zygoapophyseal Joints In the degenerative williz disc degeneration leads to segmental dysfunction and stress is then directed to the facet joints. Low back pain secondary to facet degeneration is a common phenomenon. In this case, as shown on the right CT image the mass is a calcified chondroma. This process basically causes loss of segmental stability.
A degenerative spondylolisthesis has developed at L In genomic situations i. This section, on the Clinical Cascade, begins with a depiction of the basic elements of a spinal segment. This is a case of a 52 year old female with underlying genomic spine disease.
Post- chemonucleolysis collapse of the disc interspace. Back pain secondary to stress induced on the fact joints by medical procedures is uncommon but of great concern because it reflects lack of understanding by treating physicians.
Tribute to William H. Kirkaldy-Willis (1914-2006)
Lesions such as this are often synovial cysts or chondromas from the degenerated facet. This can be on willix congenital genomic basis as well as a result of the process of aging as well as acquired insult and injury i. To the right is an actual specimen provided by Harry Farfan demonstrating the beginning of degenerative changes.
This mass has been chronically compressing and distorting the dural sac.
The Degenerative and Clinical Cascades Anatomy and Pathophysiology
Normal Spinal Anatomy This section, on the Clinical Cascade, begins with a depiction of the basic elements kirkalldy a spinal segment. Facet degeneration then occurs in association with facet enlargement hypertrophy with subsequent erosion of the articular surfaces leading to other pathologic changes. The facets are markedly degenerated, mechanically incompetent, eroded and contain fluid effusion.
Rational therapy requires making a specific diagnosis first. In Harry Farfan pointed out, on the basis of his research, that: Juvenile Discogenic Disease disc nutrition may be poor because of the existing endplate abnormalities and premature disc collagen deterioration. The term disc is a biologic term. With this loss of segmental loss of support is the development of segmental dysfunction. HIZ tears have been directly correlated with low back pain.
Partial removal of the superior vertebrae allows a better appreciation of the normal anatomy, particularly the relationship of an exiting nerve root to the intervertebral disc.
The MRI image in the center shows the degenerated facet joints and suggests a mass on the left side of the image compromising the central spinal canal.