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Functional Medicine® Assessment

🔴 Notice: As part of our Acute Injury Treatment Practice, we now offer Functional Medicine Integrative Assessments and Treatments within our clinical scope for chronic degenerative disorders.  We first evaluate personal history, current nutrition, activity behaviors, toxic exposures, psychological and emotional factors, in tandem genetics.  We then can offer Functional Medicine Treatments in conjunction with our modern protocols.  Learn More

Functional Medicine Explained

Spinal Arthritis Diagnostic Imaging Approach Part I

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Degenerative Arthritis

  • Spinal Arthritis:
  • Spondylosis aka Degenerative disease of the spine represents an evolution of changes affecting most mobile spinal segments beginning with:
  • Intervertebral disc (IVD) dehydration (desiccation) and degeneration aka Degenerative Disc Disease (DDD) with an abnormal increase in mechanical stress and degeneration of posterior elements affecting 4-mobile synovial articulations ( true osteoarthritis)
  • 2-Facets in the L/S & 2-Facets & 2-Uncovertebral joints in the C/S
  • Imaging plays a significant role in the diagnosis, grading, and evaluation of neurological complications (e.g., spondylotic myelopathy/radiculopathy)
  • X-radiography with AP, Lateral & Oblique spinal views provides Dx and classification of Spondylosis
  • MR imaging may help to evaluate the degree of neurological changes associated with degenerative spinal canal and neural foraminal stenosis
  • Spinal motion segment:
  • 2-adjacent vertebrae
  • IVD (fibrocartilage)
  • 2-facets (synovial)
  • Pathology: loss of disc height increases mechanical stress on mobile elements
  • Ligamentous laxity/local instability
  • Spinal osteophytes aka spondylophytes & bony facet/uncinate proliferation
  • Disc herniation and often disc-osteophyte complex
  • Ligamentum flavum “hypertrophy” or thickening due to buckling
  • Loss of normal lordosis with or w/o reversal or kyphosis
  • Vertebral canal & neural foraminal stenosis

Neutral lateral cervical radiograph: note mild to moderate disc narrowing and spondylophyte formation at C5-6 & C6-C7 (most common levels affected by cervical spondylosis). Straightening or flattening with mild reversal of cervical lordosis. Some mild facet proliferation is noted at the above levels

  • On radiographs: evaluate for disc height (mild, moderate or severe) loss
  • End-plate sclerosis & spondylophytes; mild, moderate or severe
  • Facet and uncinate irregularity, hypertrophy/degeneration; mild, moderate or severe
  • Note degenerative instability aka degenerative spondylolisthesis/retrolisthesis
  • Normal or lost lordosis vs. degenerative kyphosis
  • Key Dx: correlate with a clinical presentation: neck/back pain with or w/o neurological disturbance ( myelopathy vs. radiculopathy or both)
  • Uncinate processes undergo degeneration/proliferation resulting in uncovertebral arthrosis
  • Early findings present with mild bone proliferation along the cortical margin (white and black arrows) if compared to normal uncinate (orange arrow)
  • Later, more extensive bone proliferation extending into and narrowing vertebral canal and neural osseous foramina (IVF’s) may be noted. The latter may contribute to spinal/IVF stenosis and potential neurological changes
  • Posterior oblique views may help further
  • AP lower cervical (a) and posterior oblique (b) views
  • Note mild uncinated process proliferation with neural foraminal narrowing (arrows)
  • Typically if less than a third of IVF becomes narrowed, patients may present w/o significant neurological signs
  • Lumbar spondylosis is evaluated with AP and lateral views with additional AP L5-S1 spot view to examine lumbosacral junction
  • Typical features include disc height loss/degeneration
  • Intra-discal gas (vacuum) phenomenon (blue arrow) along with spondylophytes
  • Degenerative spondylolisthesis and/or retrolisthesis (green arrow) may follow disc and facet degeneration and can be graded by the Meyerding classification
  • In most cases, degenerative spondylolisthesis rarely progresses beyond Grade 2
  • Lumbar facet degeneration seen as bone proliferation/sclerosis and IVF narrowing
  • MR imaging w/o gad C is an effective modality to evaluate clinical signs of spondylosis & associated neurological complications with pre-surgical evaluation
  • Case: 50-y.o Fe with neck pain. Case b-45-y.o.M (top a b images). MRI reveals: loss of disc hydration or desiccation, spondylophytes and disc herniation w/o neurological changes
  • (Bottom images) Left: preoperative and right postoperative MRI slices of the patient presented with clinical signs of cervical spondylotic myelopathy. Note disc herniation, ligam flavum hypertrophy and canal stenosis (left)
  • Sagittal MRI slice of lumbar DDD manifested with disc desiccation and posterior herniation effacing thecal sac
  • Correlating sagittal and axial slices will be more informative to evaluate canal stenosis and potential degree of neurological involvement (above-bottom images)

Diffuse Idiopathic Skeletal Hyperostosis (DISH) aka Forestier disease

  • Flowing degenerative ossification of ALL
  • M/c Thoracic spine. 2nd m/c-cervical spine
  • Dx by imaging only. X-radiography is sufficient
  • CT w/o contrast helps with Dx of Fx
  • Men>women. Pts>60-y.o. Extensive DISH shows 49% association with type 2DM
  • Complications: Chalk (carrot) stick Fx. Unstable 3-column Fx requiring surgical fusion
  • Sagittal reconstructed CT scan slice in bone window
  • Chalk stick Fx at C5-C6 in the patient with DISH and OPLL

Spinal Arthritis

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