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.

For a patient who are new to this diagnosis, common questions often include:

• If I have pain from degenerative disc disease in my thirties, how much worse will it become with age?
• Will the degenerative disc 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?
• What can I do to reduce the symptoms from a degenerated disc?
• Is surgery inevitable?

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.

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

Inflammation

The proteins contained within the disc space can cause a lot of inflammation, and as a general rule inflammation will cause pain.

In the lumbar disc space, the low back pain can radiate into the hips. The associated pain can also travel down the back of the leg (also called sciatica, or radiculopathy), and possibly into the foot and toes.

In the cervical disc space, the neck pain may be local or may radiate into the arm, shoulder and possibly into the hand (a cervical radiculopathy).

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.

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

• Pain that is usually more 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
• Severe episodes of back or neck pain that will generally last from a few days to a few months before the patient goes back to his or her baseline level of chronic pain
• 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

Chronic pain that is completely disabling from degenerative disc disease does happen in some cases, but is relatively rare.

Certain types of activity will usually worsen the pain, especially bending, lifting, and twisting.

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.

Most patients with degenerative disc disease will have some underlying chronic low back pain or neck pain, with intermittent episodes of more severe 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”.

In general, the patient’s pain should not be continuous and severe. If it is, then other diagnoses must be considered.

Nonsurgical Treatment

The common course of symptoms for people with degenerative disc disease is symptoms that flare up periodically, but overall the symptoms don’t progress over time.

DDD Treatment Goals

For people with painful flare-ups, the main treatment goals will usually include 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.

The operative solutions, a fusion or artificial disc, are extensive surgeries and patients are usually advised to make a serious effort with nonsurgical treatments for at least 6 months prior to considering surgery.

Surgical Treatment

Anterior Cervical Decompression & Spine Fusion

The majority of the abnormal anatomy producing spinal nerve and/or cord compression is located anteriorly to (in front of) the spinal cord itself. This is only indirectly addressed by a posterior cervical laminectomy. In fact, chronic spinal instability exacerbating the disease process may be caused by cervical laminectomy. In addition, a thick fibrous scar forms at the operative site in the postoperative period, at times replacing the bony compression and reproducing the original symptoms after an extended postoperative period.

Cervical Disc Replacement Surgery

The standard surgical procedure for a disc replacement is an anterior (from the front) approach to the cervical spine. This surgical approach is the same as that presently used for a discectomy and fusion operation. The affected disc is completely removed including any impinging disc fragments or osteophytes (bone spurs). The disc space is distracted (jacked up) to its prior normal disc height to help decompress (relieve pressure) on the nerves. This is important because when a disc becomes worn out, it will typically shrink in its height, which can also contribute to the pinching on the nerves in the neck.