What is the treatment approach for degenerative changes?

Treatment Approach for Degenerative Changes

The treatment approach for degenerative changes depends critically on the anatomical location and clinical presentation, with surgical decompression and fusion recommended for symptomatic lumbar stenosis with spondylolisthesis, while peripheral degenerative changes (such as in feet) should be managed conservatively with podiatry assessment, appropriate footwear, orthotics, and NSAIDs. 1, 2

Spinal Degenerative Changes

Lumbar Spine with Stenosis and Spondylolisthesis

Surgical decompression combined with fusion is the definitive treatment for symptomatic stenosis associated with degenerative spondylolisthesis in patients desiring surgical intervention. 1, 3

• The Spine Patient Outcomes Research Trial (SPORT) demonstrated superior outcomes with surgery compared to non-surgical treatment, with benefits sustained for at least 4 years. 1, 3
• Decompression alone risks progression of vertebral misalignment; fusion prevents deformity progression and improves patient outcomes. 1
• Posterolateral lumbar fusion (PLF) supplemented with pedicle screw stabilization should be considered when kyphosis or instability is present. 1, 3
• The specific fusion technique should be individualized based on the patient's anatomical constraints, but PLF remains the recommended standard approach. 1, 3

Cervical Degenerative Myelopathy

• Laminectomy combined with fusion using lateral mass plate fixation and autogenous grafting is effective for cervical stenosis with instability or deformity. 1
• Neurological improvement occurs in approximately 89% of patients following laminoplasty with posterolateral bone graft. 1
• The presence of preoperative myelomalacia on imaging does not predict worse neurological recovery. 1

Common Surgical Complications to Monitor

• Nerve root injury, dural tears, and infection are potential complications requiring vigilant postoperative surveillance. 3
• Pseudarthrosis may develop, necessitating revision surgery in select cases. 1
• C-5 root palsies can occur in cervical procedures but typically resolve spontaneously. 1

Peripheral Degenerative Changes (Feet)

Initial Conservative Management

Refer patients for podiatry assessment, treatment, and monitoring to minimize pain while walking and evaluate specific degenerative changes. 2

• Implement a multidisciplinary approach including podiatrist, occupational therapist, and physiotherapist to address pain and maintain mobility. 2
• Use gait analysis systems when available to assess walking patterns and evaluate therapy effectiveness. 2

Footwear and Orthotic Interventions

• Select footwear that is firm and comfortably fitting, with appropriate length and width, a rounded toe, and a flexible flat sole with heel support. 2
• Apply shock-absorbing insoles to reduce pressure on calcaneal spurs when present. 2
• Regular debridement of hyperkeratosis (callus) prevents increased pressure and pain. 2

Pain Management Protocol

• Apply ice therapy for 10-minute periods through a wet towel to reduce acute pain and inflammation. 2
• Prescribe topical or oral NSAIDs for pain relief, particularly during acute inflammatory episodes. 2
• Consider referral for injection therapies if pain persists despite conservative measures. 2

Follow-up Schedule

• Schedule regular follow-up appointments every 3-6 months based on symptom severity. 2
• Monitor for changes in pain levels, mobility, and development of new deformities or complications. 2
• In patients with decreased bone mineralization, screen for diabetic complications to enable early intervention. 2

Dialysis Access Degenerative Changes

Graft Degeneration and Pseudoaneurysm

Large pseudoaneurysms and progressive graft degeneration require surgical exploration and removal of infected or compromised graft segments to prevent life-threatening hemorrhage. 1

• Degenerative changes within the graft and overlying skin can compromise circulation, leading to incomplete hemostasis upon needle withdrawal and potential graft rupture. 1
• Untreated progression can result in severe hemorrhage, exsanguination, and death. 1
• Large pseudoaneurysms prevent access to adjacent areas for needle placement, further compromising dialysis adequacy. 1

Stenosis Management

• Stenosis detected prior to access thrombosis is more responsive to therapy than post-thrombosis stenosis (50% patency at 24-28 weeks vs. 4 weeks). 1
• Hemodynamically significant venous stenosis should be corrected to prolong access use-life and prevent thrombosis. 1

Osteoarthritis Degenerative Changes

First-Line Conservative Approach

• Implement patient-centered care including exercise therapy, patient education, and weight loss (if appropriate). 1
• For hand osteoarthritis, prescribe orthoses for symptom relief, improved function, and prevention of progression of degenerative changes. 1

Pharmacologic Management

• Use NSAIDs in oral or topical form as second-line therapy after conservative measures. 1
• Avoid opioids except when pain is severe or patients do not respond to, are intolerant of, or have contraindications to NSAIDs. 1

Surgical Consideration

• Consider surgical interventions as third-line care when conservative and pharmacologic strategies fail. 1

Critical Pitfalls to Avoid

• Never perform decompression alone for lumbar stenosis with spondylolisthesis without addressing fusion needs, as this leads to progressive misalignment and symptom recurrence. 1
• Failure to address footwear issues undermines orthotic therapy effectiveness in peripheral degenerative changes. 2
• Do not delay surgical intervention for infected dialysis grafts, as the graft material acts as a foreign body and untreated infection can lead to sepsis and death. 1
• Avoid dismissing large pseudoaneurysms as benign, as they pose hemorrhage risk and limit access for dialysis. 1