What is Degenerative Disc Disease of the Spine?
Degenerative disc disease describes the symptoms of back or neck pain caused by wear-and-tear on a spinal disc. It can also possibly cause radiating weakness, numbness or hot, shooting pains in the arms or legs (radicular pain). Degenerative disc disease typically consists of a low-level chronic pain with intermittent episodes of more severe pain. Degenerative disc disease is one of the most common causes of low back pain and neck pain, and also one of the most misunderstood.
What are the Symptoms?
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. It 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.
What are the Treatments?
For most people, degenerative disc disease can be successfully treated with conservative (meaning non-surgical) care consisting of medication to control inflammation and pain (steroid medications delivered either orally or through an epidural injections), and physical therapy and exercise.
Surgery is only considered when patients have not achieved relief over six months of nonsurgical care and/or are significantly constrained in performing everyday activities.
The ongoing pain, as well as the frequency and intensity of the flares, can be mitigated through a number of non-surgical options:
The first line of treatment is usually to avoid aggravating the condition. Modifying activities to preclude lifting of heavy objects and playing sports that require rotating the back (e.g. golf, basketball, or football) can be a good first step.
In addition, it is also helpful to learn correct ergonomics, such as how to lift heavy objects, how to set up the office chair and workspace, and sleep postures that reduce pressure on the low back.
Common Nonsurgical Treatment
In addition, common nonsurgical treatment options usually include some combination of the following:
Exercise and Physical Therapy
- An exercise program is essential to relieving the pain of lumbar degenerative disc disease and is part of almost every treatment program for lumbar DDD. In general, an exercise program should have several components, including:
- Hamstring stretching, since tightness in the hamstring muscles down the back of the thigh can increase the stress on the back and make the pain caused by a lumbar degenerative disc worse.
- A back strengthening exercise program, such as Dynamic Lumbar Stabilization exercises, where patients are taught to find their ‘natural spine,’ the position in which they feel most comfortable, and to maintain that position.
- Low-impact aerobic conditioning (such as walking, swimming, biking) to ensure adequate flow of nutrients and blood to spine structures, and relieve pressure on the discs.
While it is common for patients to want to rest when the pain flares up, it is usually not advisable to rest for more than a day or two.
Heat and Ice
Applying heat to stiff muscles or joints to increase flexibility and range of motion, or using ice packs to cool down sore muscles or numb the area where painful flares are concentrated.
A range of medications often play a role in a comprehensive treatment plan.
- Non-steroidal anti-inflammatories (e.g., ibuprofen, naproxen, COX-2 inhibitors) and pain relievers like acetaminophen (e.g. Tylenol) help many patients feel good enough to engage in regular activities.
- Stronger prescription medications, such as oral steroids, muscle relaxants, or narcotic pain medications may also be used to manage intense pain episodes on a short-term basis, and some patients may benefit from an epidural steroid injection.
- Not all medications are right for all patients, and patients will need to discuss side effects, and possible factors that would preclude taking them, with their physician.
Spinal manipulation, such as chiropractic manipulation, can relieve low back pain through several means, including taking pressure off sensitive nerves or tissue, increasing range of motion, restoring blood flow, reducing muscle tension, and – as with more active exercise – promoting the release of endorphins within the body to act as natural painkillers.
Epidural Steroid Injections
An injection can provide low back pain relief by delivering medication directly to the painful area in the spine to decrease inflammation.
For the vast majority of people with symptomatic lumbar degenerative disc disease, a combination of nonsurgical treatments suffices to provide enough pain relief and ability to enjoy everyday activities. For a few with the most severe symptoms, however, surgery may be an option to consider.
Patients unable to function because of the pain or who are frustrated with their activity limitations may consider lumbar spinal fusion surgery for symptomatic lumbar degenerative disc disease.
Lumbar Spinal Fusion Surgery
Lumbar fusion surgery is designed to reduce the pain because it stops the motion at a painful motion segment.
Depending on which level of the spine is affected, the fusion will be somewhat different:
- A one-level fusion at the L5-S1 segment and is the most common form of fusion, as the L5-S1 segment is the most likely level to break down for degenerative disc disease. A fusion at this level of the spine does not significantly change the mechanics in the back.
- Fusion of the L4-L5 level does remove some of the normal motion of the spine as this is a major motion segment in the lower back (as opposed to L5-S1, which has limited motion).
- Multi-level fusions for treatment of lumbar DDD are more problematic than a single-level fusion.
- A 2-level fusion may be considered for patients with severe, disabling pain
- 3-level fusions are not generally recommended because back movement is too diminished and altering the muscle composition can in and of itself cause pain (this has been termed fusion disease).
While a single-level fusion is in and of itself a major surgery, a multi-level fusion has significantly more potential risks and complications associated with it and should be considered only in rare instances.
While it is a major surgery, fusion surgery can be an effective option for patients to enhance their activity level and overall quality of life. This potential positive outcome is particularly true now that less invasive surgical techniques are available to decrease post-operative discomfort, preserve more of the normal anatomy of the low back, and result in higher rates of fusion than previous techniques.
Lumbar Artificial Disc Replacement Surgery
A newer surgery to treat pain and disability from lumbar degenerative disc disease is artificial disc replacement. The theory is that replacing the disc, instead of fusing the disc space together, maintains more of the normal motion in the lumbar spine, thereby reducing the chance that adjacent levels of the spine will break down due to increased stress. This procedure is still a new procedure in the US, so long-term efficacy, and potential risks and complications are still relatively unknown.
The major worry with artificial disc replacement is that anything that moves can wear out with time. Many patients getting surgery for DDD are younger than patients that are receiving artificial joints for hips and knees, and although there is less wear and tear on a spinal joint that a major joint like a hip or knee, over the course of a lifetime, there may be considerable risk that these artificial discs will need to be replaced in the future.
Artificial discs are placed through an anterior approach to the spine under the great vessels (aorta and vena cava). After the procedure, these vessels become scarred down onto the spine, making revisions problematic.