Transcript interspspinous-and-super-spinious

INTERSPINOUS PAIN IN THE LUMBAR REGION
A CLINICAL OBSERVATION
DR WILLEM BOSHOFF D.C. (USA)., MSc Med (Wits)
PRESENTED AT
PAIN SA CONGRESS, DURBAN, MAY 2016
CHIROPRACTIC ASSOCIATION CONGRESS, DURBAN, SEPT 2016
THE AUTHOR ACKNOWLEDGES THE ASSISTANCE OF THE SCHOOL OF
ANATOMICAL SCIENCES, FACULTY HEALTH SCIENCES, UNIVERSITY OF
THE WITWATERSRAND, JOHANNESBURG
Introduction
 The Interspinous and Supraspinous ligaments are often neglected
as structures that contribute to spinal pain in the lumbar region.
They are predominantly of a ligamentous-collagen structure, but
play an important role in function of the facets and intervertebral
disc, and also in pain patterns in the lumbar spine
The Wheelbarrow Model
 Extension in the lumbar spine is dependent on elasticity of the
interspinous and supraspinous ligaments.
Kapanji
WHEELBARROW MODEL
( Boshoff )
Medial Nerve Supply
 The medial nerve supply to the interspinous and supraspinous ligaments
is from the post – ganglionic, posterior ramus of the dorsal nerve root.
 The medial nerve also supplies the capsule of the facet, the inter
laminar ligament, associated adjacent muscle structures and the
superficial skin. ( Hiltons law ) The nerve supply to the lumbar
facet capsule originates from the adjacent dorsal root and the
dorsal root of the exiting nerve root above
 To evaluate the possibility of interspinous and supraspinous
involvement, it is important to do lateral XR in the flexion and
extension position with the purpose of viewing opening and closing
of the inter spinous gapping
 The radiographer needs to focus on flexion and extension of the
spine on the pelvis, and not at acetabular level.
In cases where pain persists and symptoms are not responding to conservative
management, the following conditions can be considered as co causes:
Tear drop traction spurring in a 28 year old patient
Kissing Spinous (Baastrups condition).
Note also the tear drop formation from interspinous
spur
Congenitally enlarged spinouses.
Note associated arthritic changes where spinouses
approximate and early calcific changes in the supraspinous
ligament
Calcific changes in the interspinous ( A ) and
supra spinous ( B ) ligaments
A
B
A
B
The Interspinous, Supraspinous and Interlaminar
ligaments were removed from the lumbar spine of a 73
year old cadaver. The purpose of this exercise was to
see if the was a difference in the elastin/collagen ratio of
these ligaments. The Interlaminar ( ligamentum flavum)
ligament was not of specific consequence in this study,
Interestingly, it showed a 50/50 content of
elastin/collagen suggesting that flexibility is reasonably
maintained ( See Tissue Samples )
Tissue Samples of Cadaver
The tissue specimen were stained using the Trichrome
Staining procedure:
Collagen – Blue
Ground substance cartilage, bone and hyaline substances
– Shades of blue
Nuclei, fibroglia, myoglia, neuroglia and fibrin – Red.
Elastin – Pale pink/yellow
Interlaminar ligament
(Ligamentum Flavum)
Note the abundance of the elastin tissue ( wavy pale pink)
in this sample, as compared to the collagen blue
Observed percentage ratio:
Collagen – blue – 30%
Elastin – pale pink 70%
Supraspinous ligament
 Note the more evident appearance of the striated wavy
pale pink elastin tissue
 Observed percentage ratio:
 Collagen – blue – 50%
 Elastin – pale pink – 50%
Interspinous ligament
 Note the concentration of blue/pale blue and the lesser prominent
areas of fragmented pale pink elastin tissue.
 Observed percentage ratio:
 Collagen – blue – 60%
 Elastin – pale pink – 40%
 The limited study suggests that the limitation in the ability to stretch
is greater in the interspinous ligament. The figures represent a
correlation of elastin and collagen presence in the harvested tissue
samples after staining
Typical Case Presentation
 Chronic centralized low back pain
 Not responsive to Rx or conservative management: Chiropractic
care, Physiotherapy, Biokinetics. May also have radicular
symptoms associated to additional nerve root irritation
 Examination reveals some facet pain (degenerative due to lack of
function)
 Inter spinous pain
 There may be an accompanying degenerative disc, and or disc
bulge.
 Very tender inter spinous pain on examination
 -Limited gapping on flex and extension XR
 -Mild response – short term to facet bloc
 Test: - Infiltrate interspinous and supraspinous ligaments with
marcaine. If there is relief and patient moves better, the cause is in
these structures. Periarticular infiltration on the facet joint may give
a similar but false diagnosis (medial nerve )
Treatment
 The intent in treatment would be to restore elasticity into
the affected inter and supraspinous ligaments. The
progressive infiltration of collagen in the degenerating
(lack of exercise/mobility) tissue makes the contribution
of conservative management limited. Theoretically,
removal of the inter spinous ligament, and cutting away
of some of the tissue of the superior and inferior
spinous process, leaving the supra spinous intact, could
allow for a degree of restoration in function in the
“Wheelbarrow Model”. The proposal is to maintain the
supraspinous ligament for added stability. The tissue
samples suggest a higher concentration of elastin,
better than in the interspinous ligament.
 Flexibility stretching exercise and Cx flexion distraction
with adjunct therapies may be the optimal conservative
intrim management suggestion.
Conclusion
 For the present the ideal treatment is still evasive. It is
proposed that the condition may presents in cases of
persisted post-surgical pain and is also a chronic
condition with limited response in conservative
management. This observed phenomenon certainly
lends itself to further investigation in effective
procedural management.
 It is further suggested that the restriction in these
posterior ligaments directly influence function in the
facet joints and may well also affect the intervertebral
disc height leading to degenerative changes in the joint
complex “ Wheel Barrow Model “
THANK YOU
Willem Boshoff