DEGENERATIVE DISC DISEASE
Many patients diagnosed with degenerative disc disease wonder what this
diagnosis means for them. Some may define the term "degenerative" as a
process that worsens over time; others will define the term "disease" as
a destructive process uninhibited by treatment.
Although the term degenerative usually signifies a process which worsens
with age, one can feel confident that in most cases the associated pain
with the degenerative process lessens over time. As we age proteins inside
the disc eventually dry up, and the discs become stiffer; in many people
these results in less pain by the time they are in their sixties. Also of
note, is that degenerative disc disease is not a disease at all, but rather
a degenerative condition in which your discs lose their flexibility and
ability to cushion your spine. This condition may eventually lead to pain
that is quite variable in nature and severity.
The lumbar disc is a unique and well-designed structure in the spine. It is
strong enough to resist terrific forces in multiple different planes of motion,
yet it is still very mobile. Everything you do during the day - once you stand
upright - begins to test the spine's ability to support your body weight. Over
time, these repeated daily stresses and minor injuries can add up and begin to
affect the discs in your spine. Minor injuries to the disc may occur and not
cause pain at the time of the injury. However, as they add up, the disc eventually
begins to suffer from the wear and tear - it begins to degenerate.
Pathophysiology
In order to understand your symptoms and treatment choices, you should start with an
understanding of the general anatomy of your lumbar spine (lower back). This includes
becoming familiar with the various parts that make up the spine and how these parts
work together (Please review "Basic Back Anatomy").
With degenerative disc disease, the main problem lies within one or more of the
intervertebral discs. There is a disc between each of the vertebra in your spine.
The intervertebral discs are designed to absorb pressure and keep the spine flexible
by acting as cushions during body movement similar to shock absorbers. Without the
cushion effect of the discs, the vertebrae in your spine would not be able to absorb
stresses, or provide the movement needed to bend and twist.
Normal intervertebral discs are well hydrated, the nucleus containing 80-85% water and
the annulus about 80%. The water content gives the nucleus a spongy quality and allows
it to absorb spinal stress. Excessive pressure or injuries to the disc can cause injury
to the annulus - the outer ring of tough ligament material that holds the vertebrae together.
Generally, the annulus is the first portion of the disc that seems to be injured. Small
tears show up as in the ligament material of the annulus. These tears heal by scar tissue
which is not as strong as normal ligament tissue. Over time, as more scar tissue forms, the
annulus becomes weaker; the disc becomes more and more dehydrated and denitrified. If the
disc had a normal blood supply, this water and nutrient loss would be replaced and reparative
changes noted. Unfortunately, the disc does not have a direct blood supply and thus its
reparative powers are diminished.
Because of water and nutrient loss, the discs lose some of their ability to act as a cushion.
This can lead to even more stress on the annulus and still more tears as the cycle repeats
itself. As the nucleus loses its water content it collapses, allowing the two vertebrae above
and below to move closer to one another. This results in a narrowing of the disc space between
the two vertebrae and creates multiple anatomical changes. With less space available, the nerve
roots in the neuroforamen may become compressed, causing them to swell and signal pain. Facet
joints located at the back of the spine are forced to shift which may lead to facet syndrome.
The disc itself is weakened and may lose its ability to absorb stress and provide support
eventually leading to disc bulging or herniation. Pieces of the damaged disc may also break
off and cause irritation of the nerves.
Bone spurs, sometimes called osteophytes, may begin to form around the disc space. These bones
spurs can also form around the facet joints and are thought to be due to the body's response to
try to stop the excess motion at the spinal segment. The bone spurs can become a problem if they
start to grow into the spinal canal and press into your spinal cord and nerves. Hypertrophy or
enlargement of the ligaments and facets occur as they try to compensate for the additional stress
noted above. This over-growth causes the spinal canal to narrow (spinal stenosis), which can
compress the spinal cord and nerves causing pain.
Symptoms
In trying to understand the symptoms associated with degenerative disc disease it is important
to understand the term Diskogenic Pain. Diskogenic pain is a term back specialists use when
referring to pain caused by a damaged intervertebral disc. As the disc begins to degenerate,
there is some evidence that the disc itself becomes painful. Movements that place stress on the
disc can result in back pain that appears to come from the disc. This is similar to any other
body part that is injured, such as a broken bone, or even a cut in the skin. When these types of
injuries are held still there is no pain. However, if you move a broken bone, or the skin around
a cut, it causes pain.
Diskogenic pain usually causes pain felt in the lower back. It may also feel like the pain is
coming from your buttock areas and even down into the upper thighs. The experience of feeling
pain in an area away from the cause of the pain - is common in many areas of the body. Examples
include: a person who has gallstones may feel the pain in their shoulder; or a person experiencing
a heart attack may feel pain in the left arm. This is referred to as radiation of the pain. It is
very common for pain produced by spine problems, such as disc problems, to be felt in different
areas of the body, including the back itself.
The symptoms of degenerative disc disease vary from person to person. Many people with deterioration
have no pain, while others may experience pain that is naggingly irritating to severely debilitating.
Interestingly, even though this condition affects people starting in their twenties or thirties, people
in their sixties are less likely to have back pain caused by deteriorated discs. This is thought to be a
result of a decrease in inflammatory proteins within the disc space, the stiffening of the disc and a
decrease of micro-motion.
The typical individual with degenerative disc disease is an active and otherwise
healthy person. Common symptoms include:
• The pain is generally made worse with sitting, since in the seated position the
lumbosacral discs are loaded more than when standing.
• Certain types of activity will usually worsen the pain, especially bending,
lifting and twisting.
• Walking, and even running, may actually feel better than prolonged sitting or standing.
• Patients will generally feel better if they can change positions frequently,
and lying down is usually the best position since this relieves stress on the disc space.
• Most patients will have some underlying chronic low back pain, with intermittent
episodes of severe low back pain. The exact cause of these severe episodes of pain is
not known, but it has been theorized that it is due to abnormal micro-motion in the
degenerated disc that spurs an inflammatory reaction. In an attempt to stabilize the
spine and decrease the micro-motion, the body reacts to the disc pain with muscle spasms.
The reactive spasms are what make patients feel like their back has "gone out".
• The severe episodes of back pain will generally last from a few days to a few months
before the patient goes back to their baseline level of chronic pain. The amount of pain
is quite variable and can range from a nagging level of irritation to severe and disabling pain.
In addition to low back pain, there may be leg pain, numbness and tingling. Even without
pressure on the nerve root (a "pinched nerve"), other structures in the back can refer
pain down the buttocks and into the legs. The nerves can become sensitized with inflammation
from the proteins within the disc space and produce the sensation of numbness/tingling.
Generally, the pain does not go below the knee.
These sensations, although worrisome and annoying, rarely indicate that there is any ongoing
nerve root damage. However, any weakness in the leg muscles (such as foot drop) is an indicator
of some nerve root damage.
How is the diagnosis made?
When you first experience pain, consult your family doctor. Your doctor will take a complete
medical history to understand your symptoms, any prior injuries or conditions, and determine
whether any lifestyle habits are causing the pain. Next, a physical exam is performed to
determine the source of the pain and test for any muscle weakness or numbness. Your doctor
may order one or more of the following imaging studies: X-ray, MRI scan, disco gram, myelogram,
or CT scan to identify a tumor, herniated disc, degenerative disc disease or other conditions
that compress the nerve roots (see section on testing).
NONSURGICAL TREATMENTS
Nonsurgical treatment for degenerative disc disease may include rest and self care. If the
pain persists and becomes chronic, other therapies such as intradiscal decompression, reduction
and stabilization using the DRX 9000 / 9500, Vax-D (see section on Low Back and Neck Pain),
physical therapy that focuses on biomechanical and postural correction, core stabilization,
aquatic therapy, medication, home exercises, hydrotherapy etc.
Specific Rest
Immediately after a back injury, rest is often all your back needs to feel better. Rest is used to take
the pressure off your spine and the muscles around it. You should rest in a comfortable position on a
firm mattress. Placing a pillow under your knees can also help relieve pain. Do not stay in bed for
several days! Bed rest for more than two or three days can weaken the back muscles, making the problem
worse instead of better. Even though you may still feel some pain, a gradual return to normal activities
is good for your muscles. In most cases of sudden back pain, the sooner you start moving again, the
sooner your back pain will improve. Ice and heat may also be utilized and one should start performing
some basic low back stretching exercises (see section under "Basic back stretching exercises”).
Self Care
Using correct posture and keeping your spine in alignment are the most important things you can do for
your back. You may need to make adjustments to your daily standing, sitting, and sleeping habits. You
may also need to learn proper ways to lift and bend. Your workspace may need to be rearranged to keep
your spine from being under stress.
Stress is the number one obstacle to pain control. Pain increases when you are tense and stressed.
Relaxation exercises are one way of reclaiming control of your body. Deep breathing, visualization,
and other relaxation techniques can help you to better manage the pain you live with.
Intradiscal Decompression
Spinal experts have known and taught for decades that discs, in a compressed, anaerobic state find it
next to impossible to heal. However, through intradiscal decompression, negative pressure is created
inside the disc. In real simple terms, this negative pressure increases the diffusion rate of vitamins,
minerals, oxygen, water and other collagen precursors that are needed to rebuild the collagen matrix of
the disc. This process assists in the healing process of the disc (Please see the Low Back and Neck pain
section of our website).
Physical Therapy
Postural asymmetries across the pelvic girdle, hips, spine, rib cage and shoulder complex will be assessed
and treated in association with the work done on the DRX 9000. This type of in-depth biomechanical assessment
allows accurate diagnosis of any underlying structural issues that may be contributing to a patient's often
complicated and chronic problem. Exercise and work patterns will also be assessed and changed as necessary.
Other types of treatments may include:
Modalities - alternating heat and ice, massage, ultrasounds, and electric stimulation
Bracing - ranging from a simple corset to a rigid plastic body jacket
Flexibility and Strength Training - this is achieved through exercises, posture retraining, stretching, etc.
Posture Training - learning how to stand, sit, and move properly; incorrect posture can contribute to back pain
Core Stabilization
Aquatic Therapy
Aquatic Therapy is a system of exercises and activities designed to utilize water’s unique healing benefits.
In the rehabilitation process, the buoyancy of water helps to reduce joint compression. Following injury or
surgery, range of motion and weight bearing exercises can be initiated more quickly without causing undue
stress to the healing tissues and bone. The high density of water also creates increased resistance against
movement, thus providing more feedback and increased effectiveness of strengthening exercises. Aquatic therapy
has been proven as an effective treatment and rehabilitation medium for many health conditions.
Exercise
Exercise is vital to recovery and to maintaining a healthy spine. Consider it part of
long-term health management and risk reduction. Regular exercise is the most basic way
to combat back problems. However, if you an acute injury to the spine talk to your doctor
or physical therapist before you start an exercise routine. You need to make sure the
exercises you choose are effective and safe for your particular case.
Why exercise? Scientific studies have shown that people who exercise regularly have far
fewer problems with their back. It helps strengthen the muscles in your back that correspond
with your spine. It can reduce your risk of falls and injuries. It can strengthen your abdomen
(your belly), arms, and legs, which reduces back strain. Stretching reduces risk of muscle
spasms. In addition, weight bearing exercises help prevent loss of bone mass caused by
osteoporosis, reducing your risk of compression fractures. Aerobic exercise, the type that
gets your heart pumping and pulse rate up, has been shown to be a good pain reliever as well.
The natural chemicals of the body that combat pain - called endorphins - are released during
exercise and actually reduce your pain.
Medications
Your doctor may prescribe pain relievers to include: no steroidal anti-inflammatory
medications (NSAIDs), steroids, non-narcotic analgesics, narcotics or muscle relaxers.
No steroidal anti-inflammatory drugs (NSAIDs) - aspirin, naproxen (Naprosyn, Aleve),
ibuprofen (Motrin, Nuprin, and Advil), celecoxib (Celebrex) are examples of no steroidal
anti-inflammatory drugs used to reduce inflammation and relieve pain. However, be aware
that NSAIDs can decrease renal function and excessive use can lead to kidney problems.
Heavy use of NSAIDs may also lead to GI complications (i.e. ulcers).
Steroids can be used to reduce the swelling and inflammation of the nerves. They are taken
orally (as a Medrol dose pack) or generic prednisone in a tapering dosage over a 5-10 period.
Steroids may also be given as an injection directly into the source of pain. Usually, it takes
24 hours for Steroids to take affect.
Analgesics, such as acetaminophen (Tylenol) can relieve pain but don't
have the anti-inflammatory effects of NSAIDs or steroids.
Narcotic Pain Medications: If you experience severe pain, your health provider might
prescribe a narcotic pain medication such as codeine or morphine. Narcotics relieve
pain by acting as a numbing anesthetic to the central nervous system. The strength and
length of pain relief differs for each drug. Narcotics can cause related side effects
such as nausea, vomiting, constipation, and sedation or drowsiness. These side effects
are predictable and can often be prevented. Common preventative measures include: not
taking sleeping aids or antidepressants in conjunction with narcotics, avoiding alcohol,
increasing fluid intake, eating a high fiber diet, and using a fiber laxative or stool
softener to treat constipation. Remember that narcotics can be addictive if used
excessively or improperly.
Muscle Relaxants (i.e. Flexeril, Skelaxin): If you are having muscle spasms, muscle relaxants can help
relieve pain, but they are only shown to be marginally effective. They also have a significant risk of
drowsiness and depression. Long-term use is not suggested; only 5-10 days is typically recommended.
Holistic Therapies
Some patients want to try holistic therapies such as acupuncture, acupressure, nutritional
supplements, and biofeedback. The effectiveness of these treatments for degenerative disc
disease may aid you in learning coping mechanisms for managing pain as well as improving
your overall health. For resources in your area visit:
National Center for Complementary and Alternative Medicine (NCCAM)
nccam.nih.gov
Ask NOAH About: Alternative (Complementary) Medicine
www.noah-health.org/english/alternative/alternative.html
Whole Health MD www.WholeHealthMD.com
The Natural Pharmacist www.tnp.com
(The Rejuvenation Center does not endorse these sites. They are provided as a resource only.)
SURGICAL TREATMENTS
Surgery is rarely recommended unless you have a proven instability and your symptoms do not
significantly improve with nonsurgical treatments. The goal of surgery is to stop the movement
of the painful motion segment and decompress any spinal nerves. Talk to your doctor about
whether surgery is right for you. Some surgeries specific to degenerative disc disease are:
Interbody Fusion is a surgical procedure in which one or more of the bony vertebrae of the
spine are permanently joined together to provide stability to the spine. Spinal fusion can
be performed at any level of the spine but is most common in the lumbar and cervical regions
where it is most moveable. At each level of the spine, there is a disc space in the front and
paired facet joints in the back (see Basic Back Anatomy). Working together, these structures
define a motion segment and permit range of motion. Two vertebral segments need to be fused
to stop the motion at one segment.
Intradiscal Electro thermal Therapy (IDET) uses a thin catheter to deliver heat directly into
the spinal discs to shrink the tears and fissures in the annulus and thermo-coagulate nerves
to overcome diskogenic back pain.
|