Anatomy & Background
The intervertebral disc is a fibrocartilaginous structure found between the bodies of the vertebra. There is a disc between each pair of vertebra in the lumbar spine.
Think of this disc as being a jelly doughnut: there are the outer fibrous rings that surround a soft inside. The outer annular rings are thinnest posterior and lateral. Most disc herniations occur here due to the weakness of the disc wall. The disc functions as a cushion, allows for movement, and serves as a cartilaginous joint between adjacent vertebrae.
Inflammation, damage or degeneration of a disc can cause a range of symptoms that vary based on the severity of the problem. The lumbar fourth and fifth (L4-L5), and lumbar fifth and sacrum (L5-S1) levels have the highest rate of disc degeneration and herniation.
Degenerative Disc Disease
Degenerative disc disease is not an actual disease but is the term used to describe the progression of changes, gradual wear-and-tear, and dysfunction associated with symptoms secondary to disc degeneration. Degeneration of the disc is normal with aging but can be accelerated in certain situations as a result of trauma, repetitive strain or injury and musculo-skeletal imbalances like scoliosis. Disc degeneration itself is not a problem, but the associated conditions that may develop as it progresses can be symptomatic and debilitating.
Stages of Disc Degeneration
The progression of disc degeneration can be classified in the following phases:
- he annular rings of the disc begin to tear and with that irritation of the facet joints at the corresponding spinal level may occur.
- A loss of joint mobility, localized back pain, muscle spasms, and a loss of movement especially extension or backward motions.
- A loss of disc fluid with dehydration and disc narrowing. The facet joints and capsule may develop laxity resulting in instability.
- A patient will present with pain, sharp catching, giving way, a shift in spinal alignment and loss of motion.
- The body reacts to the instability by laying down bone in the form of osteophytes to stabilize the spine. This increase in bone formation can result in Stenosis.
- Back pain will usually decrease, but remain present in a less severe form. Individuals may develop stenotic-like symptoms in the legs, with weakness and difficulty walking and standing for extended periods of time.
- Aging is the most common cause of disc degeneration. As the body ages the discs start to lose fluid and dehydrate. The discs start to narrow and lose their height, compromising their ability to absorb shock and stress.
- The outer fibrous annular rings may begin to crack and tear, weakening the disc walls.
- Individuals who smoke, are obese, or are involved in activities that require heavy labor are more likely to develop disc degeneration.
- A sudden fall or trauma to the spine or disc may begin the degenerative process.
- A disc herniation may initiate the stages of disc degeneration. Unlike muscles, there is minimal blood supply to the discs, so they lack reparative ability.
- Please note: Many times, people suffering from DDD do not show symptoms.
- When symptoms are present, chronic low back pain, with or without radiation to the hips, and aching pain in the buttocks or the backs of the thighs, may be seen with walking.
- Muscle spasms in the back, extending to the buttock area.
- Other symptoms include pain that is generally made worse with sitting, bending, lifting and twisting.
- Stenosis will develop in the later stages, with decreased ability to walk and stand for extended periods of time. Individuals can develop weakness, which may necessitate surgery.
Treating Degenerative Disc Disease
Treatment of lumbar degenerative disc disease or injury will depend on the severity of the condition. When treating acute back problems:
- Rest. Avoid the activities that produce the pain (bending, lifting, twisting, turning, bending backwards, etc).
- Anti-inflammatory drugs and other pain medications.
- Apply ice in acute cases to the lumbar spine to help reduce pain and associated muscle spasm. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
- Moist heat may be helpful to reduce pain and improve any feelings of stiffness.
- An exercise regiment designed specifically to address the cause of the symptoms associated with the degenerative disc disease and improve joint mobility, spinal alignment, posture, and range of motion.
- The use of a brace or other form of support may be necessary to reduce stress on the facet joints, muscles and lumbar spine.
- Steroidal medication to reduce inflammation in moderate to severe conditions.
- Physical therapy for back and disc problems must remain conservative at the beginning to avoid aggravating the condition. Your therapist should emphasize rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has been reduced, a program of stretching and strengthening will be started to restore flexibility to the joints and muscles involved, while improving strength and stability of the spine. Each program will be based on the structure causing the problem and symptoms. A program not tailored to the specific problem may aggravate symptoms
In mild cases patients found that rest, ice and medication were enough to reduce the pain. Once the pain is reduced, physical therapy is recommended to develop a series of stretching and strengthening exercises to prevent re-occurrence of the injury. Return to activity should be gradual to prevent a flare up of symptoms.
Moderate to Severe Cases
If the problem persists, consult with your health care provider. Your physician should perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.
In addition to performing a thorough examination your physician may order the following tests to make a more concise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infection present.
- MRI to determine any soft tissue involvement including visualization of the discs, spinal cord and nerve roots.
- CT scans, which can give a cross section view of the spinal structures.
- EMG, which is used to determine nerve involvement or damage.
Medications to Consider
Your physician may recommend several medication options individually or in combination to reduce the pain, inflammation and muscle spasm that may be associated with disc injuries.
- Over the counter medications for mild to moderate pain.
- Narcotics, if over the counter medications are not effective your physician may prescribe stronger pain medication.
- Anti-inflammatory drugs or prescription NSAIDS to reduce inflammation following acute injury.
- Muscle relaxers to reduce acute muscle spasm.
- Nerve pain medication by prescription, designed specifically to reduce pain from nerve damage.
- Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
Severe or Non-responsive Disc Degenerative Conditions
In the case of conditions that do not respond to conservative care, surgery may be indicated. If you continue to experience some of the following symptoms:
- Increase in radiating or radicular pain
- Pain or nerve damage that gets worse
- The development of or an increase in weakness
- Increase in numbness or tingling
- Loss of bowel and bladder control
- Stenotic symptoms with the inability to stand or walk for extended periods of time and weakness of the lower extremities.
Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
- Caudal Epidural Injections
- Facet Joint Injections
- Interlaminar Caudal Epidural Steroid Injections
- Transforaminal Epidural Injections
- Selective Nerve Root Blocks
- Medial Branch Blocks
- Endoscopic Decompression
- Endoscopic Foraminotomy
- Percutaneous Decompression
- IDET Intradiscal Eletrothermal Therapy
- Selective Endoscopic Discectomy
- Spinal Cord Stimulator
- Radiofrequency Ablation
- Epidural Lysis of Adhesions