Curvesday Thursday: Degenerative Disc Disease

Degenerative disc disease is one of the most common causes of low back pain and neck pain, and also one of the most misunderstood. Simply put, degenerative disc disease describes the symptoms of pain and possibly radiating weakness or numbness stemming from a degenerated disc in the spine. While the definition sounds simple, many patients diagnosed with degenerative disc disease are left wondering exactly what this diagnosis means for them.

Common questions often include:

  • If I have this much pain in my thirties, how much worse will it become with age?
  • Will the disease become a crippling condition? Will I end up in a wheelchair?
  • Should I restrict my activities? Can I still play sports?
  • Will the disease spread to other parts of the spine?
  • Will the degenerated disc(s) cause any permanent damage?
  • Is surgery inevitable?

A diagnosis of “degenerative disc disease” is alarming to many patients because it sounds like a progressive, threatening disease. However, it is not really a disease, and it is not strictly degenerative.

For most people the term degenerative understandably implies that the symptoms will get worse with age. However, the term does not apply to the symptoms, but rather describes the process of the disc degenerating over time.

While it is true that the disc degeneration is likely to progress over time, the pain from degenerative disc disease usually does not get worse and in fact usually gets better given enough time.

Another source of confusion is probably created by the term disease, which is actually a misnomer. Degenerative disc disease is not really a disease at all, but rather a degenerative condition that at times can produce pain from a damaged disc.

Disc degeneration is actually a natural part of aging, and over time all people will exhibit changes in their discs consistent with a greater or lesser degree of degeneration. However, not all people will develop symptoms. In fact, degenerative disc disease is quite variable in its nature and severity.

Generally, the pain associated with degenerative disc disease is thought to stem from two main factors:

  1. Inflammation
    The proteins contained within the disc space can cause a lot of inflammation, and as a general rule inflammation will cause pain.
  2. Abnormal micromotion instability
    If the annulus – the outer rings of the intervertebral disc – degenerates and wears down, it is not as effective in resisting motion in the spine. This condition has been termed “micromotion” instability because it is usually not associated with gross instability (such as a slipped vertebral body or spondylolisthesis).

Both the inflammation and micromotion instability can cause lower back or neck muscle spasms. The muscle spasm is the body’s attempt to stabilize the spine. It is a reflex, and although the body’s response of muscle spasm is not necessary for the safety of the nerve roots, it can be quite painful. The muscle spasms associated with the instability are thought to cause the flare-ups of intense pain often associated with degenerative disc disease

The two findings most correlated with a pathological disc (a degenerating disc that is painful) are:

  • Cartilaginous end plate erosion
  • Disc space collapse

Like other joints in the body, each vertebral segment is a joint that has cartilage in it. In between the vertebral body and the disc space is a layer of cartilage, which is known as the cartilaginous end plate.

The cartilaginous end plate is the source of disc nutrition. If it becomes eroded, it is thought that the disc is likely to go through a degenerative cascade leading to the inflammation and micromotion instability, which in turn causes pain. As it goes through the process, the disc space will collapse.

MRI findings of spinal degeneration are not specific causes of back pain. Typical MRI findings may include:

  • Disc dehydration, also called disc desiccation, and often referred to as a dark disc or black disc, because a disc with less water in it looks dark on an MRI scan
  • Annular tears
  • Disc bulges

These findings may or may not be the cause of the patient’s low back pain. It is well known that the results of surgically fusing a spine with these findings will be less reliable than fusing a disc space that has disc space collapse and cartilaginous end plate erosion.

There are several symptoms that are fairly consistent for people with lower back pain or neck pain from degenerative disc disease, including:

  • Pain that is usually related to activity and will flare up at times but then return to a low-grade pain level, or the pain will go away entirely
  • The amount of chronic pain—referred to as the patient’s baseline level of pain—is quite variable between individuals and can range from almost no pain/just a nagging level of irritation, to severe and disabling pain
  • Severe episodes of back or neck pain that will generally last from a few days to a few months before returning to the individual’s baseline level of chronic pain
  • Chronic pain that is completely disabling from degenerative disc disease does happen in some cases, but is relatively rare.
  • Activities that involve bending, lifting, and twisting will usually make the patient’s pain worse
  • Certain positions will usually make the pain worse. For example, for lumbar degenerative disc pain, the pain is generally made worse with sitting, since in the seated position the lumbosacral discs are loaded three times more than standing
  • Walking, and even running, may actually feel better than prolonged sitting or standing
  • Patients will generally feel better if they can change positions frequently
  • Patients with lumbar DDD will generally feel better lying in a reclining position (such as with legs propped up in a recliner), or lying down with a pillow under the knees, since these positions relieve stress on the lumbar disc space

The goals for treatment of degenerative disc disease usually include a combination of three areas: pain control; exercise and rehabilitation; lifestyle modifications.

  1. Pain Control
    The focus of this part of treatment is on achieving enough pain reduction to enable the patient to pursue a specific exercise and rehabilitation program. Pain from a degenerated or collapsed disc is usually caused by both instability and inflammation, so both of these causes of pain should be addressed. For most people treatment is nonsurgical and may include one or a combination of many medical, alternative, and/or self care approaches. Often a patient needs to take a trial and error approach to find which types of treatment work best.
  2. Exercise and Rehabilitation
    The goals of exercise are both to help the back heal and to prevent or reduce further recurrences of pain. For people with symptomatic degenerative disc disease, exercises are usually best done under the guidance of a physical therapist or other appropriately trained healthcare professional. A side benefit of exercise is that it can also help reduce pain naturally, as it releases endorphins that serve as the body’s natural pain reliever. Exercise is best done in a controlled progressive manner and with the help of a trained health professional, such as a physiatrist, physical therapist, or chiropractor.
  3. Lifestyle Modifications
    The focus of this part of treatment is education and resources to help the patient develop a healthier lifestyle. Often, people can make lifestyle changes that aim at both avoiding stress on the spine and supporting the spine through the right ergonomics and posture.

    In addition, many people can benefit from the following changes:

    • Avoid nicotine
    • Avoid excess alcohol
    • Incorporate movement into one’s daily routine and avoid staying in one position for too long. For example, stand up and stretch and walk around every 20 to 30 minutes instead of sitting for a prolonged period.
    • Drink plenty of water
    • For lower back pain from DDD, most patients can benefit from a gentle hamstring stretching routine

Sources: http://www.spine-health.com/video/degenerative-disc-disease-interactive-video

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