Degenerative Disc Disease of the Lumbar Spine

Degenerative Disc Disease (DDD) is a gradual process that may compromise the spine. Although DDD is relatively common, its effects are usually not severe enough to warrant medical attention. In this discussion we address Degenerative Disc Disease in the lumbar spine.

Degenerative Changes to a Disc

Degenerative changes in the spine are often referred to those that cause the loss of normal structure and/or function. The intervertebral disc is one structure prone to the degenerative changes associated with wear and tear aging, even misuse (e.g. smoking).

Long before Degenerative Disc Disease can be seen radiographically, biochemical and histologic (structural) changes occur. Some of these changes are not unlike those associated with osteoarthritis.

Over time the collagen (protein) structure of the annulus fibrosus weakens and may become structurally unsound. Additionally, water and proteoglycan (PG) content decreases. PGs are molecules that attract water. These changes are linked and may lead to the disc’s inability to handle mechanical stress. Understanding the lumbar spine carries a large portion of the body’s weight; the stress from motion may result in a disc problem (e.g. herniation).

Non-Operative Treatment: Yesterday vs. Today

DDD is a disorder that may cause low back pain. It is interesting to note that although 80% of adults will experience back pain, only 1-2% will need lumbar spine surgery!

In the past some physicians prescribed long courses of bedrest and/or lumbar traction for their patients with low back pain. However, that is not the attitude today. During the acute phase, bedrest may be recommended for a few days, but beyond that experts advocate stretching, flexion and extension exercises, and no/low impact aerobics. Of course, each patient is different and therefore so is their treatment plan.

Therapeutic Exercise

In some patients, the pain response may limit their flexibility. Prescribed stretching exercises can improve flexibility of the trunk muscles. Flexion exercises may help to widen the intervertebral foramen. The intervertebral (between the vertebrae) foramen are small canals through which the nerve roots exit the spinal cord. The intervertebral foramen are located on the left and right sides of the spinal column.

Extension exercises, such as the McKenzie method, focuses on the muscles and ligaments. These exercises help maintain the spine’s natural lordotic curve, important to good .

Aerobics (no/low impact) offers many benefits including improved muscular endurance, coordination, strength, strong abdominal muscles, and weight loss. Strong abdominal muscles work like a brace (or corset) to reduce the loads to the lumbar spine. It is also known that aerobics help to combat anxiety and depression. The loads on the discs during walking are only slightly greater than when lying down. Walking, bicycling, and swimming are forms of aerobic exercise a physician may suggest.

Acupuncture

Acupuncture, a type of alternative medicine, has been shown to control pain. It has been suggested that acupuncture stimulates the production of endorphins, acetylcholine, and serotonin. However, acupuncture should be combined with an exercise program for many of the reasons outlined in prior paragraphs.

Drug Therapy

During the acute phase of low back pain, drugs may be prescribed. Some of these may include narcotics, acetaminophen, anti-inflammatory agents, muscle relaxants, and anti-depressants. Narcotics are used on a short-term basis partially due to their addiction potential. When low back pain is caused by muscle spasm, a muscle relaxant may be prescribed. These drugs have sedative effects. Depression can be a factor in chronic low back pain. Anti-depressant drugs have analgesic properties and may improve sleep.

Manipulation

Today manipulation is performed by Chiropractors and Physical Therapists. For patients without radiculopathy (pain stemming from a spinal nerve root), manipulation may be effective during the first month. Thereafter, benefits are unproven. Manipulation is believed to be effective because of its effect on spinal mobility. Acute low back pain, chronic low back pain, and DDD without nerve compression may respond to manipulation.

The First Six Weeks

Usually during the first six weeks, acute low back pain is treated with a couple of days of bedrest (slightly longer with herniated disc) and appropriate medication. Muscle relaxants are seldom used for longer than one week. Early ambulation is encouraged to increase circulation (aids healing), improve flexibility, and build strength.

Generally, during the first two to three weeks the acute symptoms subside. Aerobic (no/low impact) exercise may be started three times per week along with daily back exercises. Some patients may be referred to physical therapy or a supervised work-conditioning program.

Beyond Six Weeks

If the symptoms of DDD and low back pain persist despite non-operative treatment, further diagnostic tests may be necessary. These tests may include an MRI, CT Scan, Myelogram, or possibly Discography.

Although most DDD patients with herniation respond well to non-operative treatments, a small percentage do not. Disc herniation is the most common indication for spinal surgery. In fact, 75% of all spinal surgeries are for a herniated disc.

Red Flags

Lumbar herniation causing loss of bowel or bladder control, or major lower extremity deficit, requires immediate surgery. These symptoms (Red Flags) are caused by nerve root compression. Cauda Equina Syndrome is a serious disorder that may be caused by a large central herniation. The cauda equina begins at the end of the spinal cord. The cauda sac is filled with nerves resembling the tail of a horse. When this sac is compressed the patient may present with the following symptoms: low back pain, bilateral lower extremity weakness, radiculopathy (pain from a nerve root), and incontinence.

When these symptoms present, surgery is required immediately. Most herniated discs often do not require surgical intervention and respond quite nicely to non-surgical treatments (within 6 weeks).

Surgical Procedures

The type of surgical procedure(s) is dependent on the patient, the diagnosis, and the goals of surgery.

Surgical removal of an inferior disc may involve a limited laminotomy and partial disc excision. The disc fragments are removed and the nerve is decompressed. Micro-discectomy is often a preferred procedure requiring smaller incisions resulting in reduced scarring and a more rapid recovery.

If the entire disc is removed, spinal column instability may warrant fusion. Patients who are obese, smoke, or who have psychological problems exhibit lower rates of success. Smoking in particular negatively impacts the process of fusion and healing in general. Spinal fusion may be combined with spinal instrumentation, the use of medically designed hardware (e.g. screws, cages).

In Conclusion

Although degenerative disc disease is relatively common in aging adults, it seldom means a surgical sentence. When medical attention is warranted, the majority of patients respond well to non-operative forms of treatment. By eliminating tobacco and maintaining a fitness regiment along with a good diet, most people can enjoy the benefits of a healthy spine.


Links for Research ... Updated Periodically.

Lumbar Herniated Disc

SpineUniverse

Artificial Discs

Guide to Degenerative Diseases of the Cervical Spine

INTRODUCTION

The cervical spine consists of the top 7 vertebrae of the spine. Doctors often refer to these vertebrae as C1 - C7, with the "C" indicating cervical, and the numbers 1-7 indicating the level of the vertebrae. C1 is closest to the skull, while C7 is closest to the thoracic (chest/rib cage) region of the spine.

The cervical spine is particularly susceptible to degenerative problems because of:

* its large range of motion
* its somewhat complex anatomy.

For example, cervical motion segments (i.e. a disc with a vertebra above and below) consist of five "joints" (the intervertebral disc, the two facet joints, and the two uncovertebral joints).

Symptoms

There are several symptoms that may indicate the presence of a degenerative condition in the cervical spine. Symptoms include, neck pain, pain around the back of the shoulder blades, arm complaints (pain, numbness or weakness), and rarely, difficulty with hand dexterity or walking.

The degenerative process may begin in any of the joints in the cervical spine, and over time it may also cause secondary changes in the other joints. For example, an intervertebral disc may be primarily affected. As the disc narrows, the normal movement of that segment is altered, and the adjacent joints (also called ‘osteoarthritis’ or ‘degenerative joint disease’) are subjected to abnormal forces and pressures leading to degenerative arthritis (i.e. inflammation of a joint).

Neck pain as a result of spondylosis (i.e. a degenerative change) is relatively common. The pain may radiate, or spread, into the shoulder blade or down the arm. Patients may have an arm complaint (such as pain or weakness), as the result of nerve root compression from a bone spur.

Dysphagia (i.e. difficulty in swallowing) can result from large anterior osteophytes (i.e. bony growths at the front of the spine), although this is rare.

Diagnosing the Problem

When a patient with a degenerative disorder of the cervical spine is examined by a doctor, one or more symptoms are likely to be apparent. The doctor will ask the patient many questions to gain a detailed history of the condition. A thorough evaluation of the patient will be conducted, including several types of tests, so as to accurately identify the problem.

A neurologic examination will be done to rule out a neurologic deficit. A shoulder examination will also probably be done to ensure that the symptoms are indeed originating from the neck.

Various diagnostic tools may be used, including:

X-rays

X-rays are useful for identifying such problems as:

* narrowing of the intervertebral disc space
* anterior osteophytes (i.e. bony spurs)
* spondylosis (i.e. arthritis) of the facet joints
* osteophytes from the uncovertebral joints

Computed Tomography

Computed tomography (CT) can highlight the bony changes associated with degenerative spondylosis (arthritis). Osteophytes can be observed and evaluated as well. However, CT does not provide for optimal evaluation of discs (although it may sometimes show disc herniations).

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is a powerful tool in the assessment of patients with cervical spondylosis. Images from MRI's can help doctors to identify disc herniations, osteophytes and joint arthrosis. MRI is best suited for soft disc herniations, but often times more information is needed.

Myelogram/CT

This is the "gold standard". It is often utilized in complex cases involving multi-level disease, or suboptimal MRI images. It is very useful in delineating bone spurs from safe disc herniations.

Discography

As in the lumbar and thoracic spine, cervical discography (see figure) remains controversial. Although the discogram may add to the clinician's knowledge, it should not be used by itself to predicate treatment.

Facet Blocks

Facet blocks in the cervical spine are subject to the same criticisms as facet blocks used elsewhere. There is little scientific documentation to validate their use. Repeating the test and comparing results at different levels probably gives much more useful information than carrying out facet blocks at one or more levels at one point in time. The do aid physicians in determining the "pain generator".

Treatment Options

After the doctor has conducted the necessary tests to identify the problem in the cervical spine, a treatment plan will then be developed. Various treatment options are available, and can be subdivided into two categories:

* Non operative treatment
* Operative treatment.

Nonoperative Treatment

Nonoperative treatment of cervical degenerative disease provides good to excellent results in over 75% of patients. A multidisciplinary approach includes:

* Immobilization - can be achieved using a collar or braces; most beneficial during acute exacerbations of pain by reducing motion at the symptomatic levels.

* Physical therapy and manipulation (chiropractic) - can be useful in decreasing muscle spasms that can contribute to symptoms; this is where heat, electrical stimulation, and exercise have their maximum benefit.

* Medications - including painkillers, nonsteroidal anti-inflammatories, and muscle relaxants. In many cases, nonoperative treatment can provide good long-term results.

Operative Treatment

A surgeon is likely to consider a surgical treatment of a cervical degenerative problem if one or more of the following criteria are met:

* Non operative treatments have been tried and failed
* The disorder is causing spinal cord dysfunction
* The disorder is causing prolonged arm pain or weakness

The surgical procedure proposed for these patients is removing the bone spur and possible fusion of two or more cervical vertebrae. In most instances, the preferred approach is an anterior (i.e. from the front) interbody fusion. Using the anterior approach, a surgeon can perform a complete discectomy (i.e. removal of the disc between two vertebrae), and then seek to restore the normal disc space height and normal lordosis (i.e. the concave curve in the cervical spine) by implanting a carefully sculpted graft. A titanium plate may be utilized to improve the rate of fusion and avoid a neck brace.

A posterior approach (from the back of the spine) is often considered when a cervical disc has herniated laterally (i.e. sideways).

Conclusion

Cervical spine degenerative disorders can be diagnosed more accurately and treated more effectively today than even five or ten years ago. Under the guidance and treatment of an expert medical team, most patients can now hope to see a very significant improvement in their condition.


Links for Research ... Updated Periodically

Cervical Epidural Injection

Artificial Disc Surgery in the Cervical Spine