Lumbar Degenerative Disc Disease

Lumbar Degenerative Disc Disease

Defining LDDD

• LDDD is the degeneration of the disks within the lumbar portion of the spine. In simpler terms, the tissue separating the vertebrae of the lower spine are breaking down. This does not always result in pain.

• The tissue separating the vertebrae of the spine are called disks. They provide cushion during motion. Pain signals come from the outer layer of the disk, known as the annulus fibrosus.

• Degeneration of the disks is a normal part of aging. When it does result in pain, the pain may be aching, stabbing, and or soreness. It may be localized to one specific point on the lower back, or the pain may radiate throughout the back. It is also common for the pain to radiate down the legs.

Identify Causes and Risk Factors

• LDDD can affect young to middle age people, but it most commonly occurs around the age of 40. Everyone experiences some degeneration with age and the risk continues to increase with age.

• The pain is caused by strain on muscles and inflammation to the site.

• Degeneration may be accelerated by an injury and lifestyle factors, but it can also be related to genetics. Certain genes have been identified that put people at a higher risk for developing LDDD.

• Excessive strain on the back caused by sports, frequent heavy lifting, and labor intensive jobs can increase the risk.

• Other risk factors include musculoskeletal disorders, prolonged sitting, poor posture, obesity, nicotine intake, and weak core muscles.

Diagnostics

• The doctor will need to know the medical history and do a physical exam.

• Radiography is used to visualize gross anatomic disk changes relating to the height of the disk, sclerosis of the end plates, and osteophytic ridging.

• Computed tomography (CT) scanning can be used to identify disk changes such as diffuse annular disk bulge, sclerosis, and herniations.

• An MRI is very effective at detecting disk pathology. It allows doctors to visualize hard and soft tissues. An MRI almost always identifies abnormalities, but those are not necessarily the cause of the pain because most people have some version of an abnormality (for example, my tailbone does not look normal).

  • MRIs are usually not ordered, because many patients recover after 6 weeks of physical therapy.

• MRIs and CTs often have false positives.

• Other conditions will need to be ruled out. These include cauda equina syndrome, infection, tumor, and trauma.

• If cancer is suspected, lab studies will be done to determine the complete blood count, ESR, and alkaline phosphatase levels.

• If the cause is related to rheumatology, tests for antinuclear antibody, rheumatoid factor, uric acid, and HLA-B27 will be done.

Treatment Options (Medical and Alternative)

• Symptoms may alleviate on their own as the spine begins to stabilize.

• The majority of people recover without surgery.

Medications

• Non-steroidal anti-inflammatory drugs (NSAIDs)

  • This is the initial drug class of choice because it helps with pain and inflammation. These drugs are not recommended for long term use.

  • Common forms include ibuprofen, aspirin, ketoprofen, flurbiprofen, naproxen, etodolac, diclofenac, sulindac, and diflunisal.

  • Ketorolac can be as effective as taking an opioid. It cannot be used for more than 5 days.

• Corticosteroids can be given to decrease inflammation. An example would be prednisone.

• Skeletal muscle relaxants such as orphenadrine and cyclobenzaprine can be used.

• Opioids may be used for temporary, severe pain.

Physical Therapy (PT)

• PT should be started quickly after a diagnosis and should be continued for at least 6 weeks. PT will also be expected if a surgery is done.

• PT for LDDD involves training in proper body mechanics and lumbar ergonomics. The goal is to learn how to maintain a neutral spine position throughout daily activities.

• Physical therapists can use manual techniques to increase soft tissue pliability when myofascial tightness is present.

• Athletes may receive a more specialized PT where they learn how to maintain a neutral spine during specific motions that may be used in their sport.

• Stretching of the low back, hips, pelvis, and hamstring muscles will be needed.

• Strengthening exercises should be done to build up lower back and core muscles. These muscles maintain a healthy posture and support the spine.

• Low impact aerobic exercises are encouraged. Examples include walking, swimming, water aerobics, stationary biking, and running on an elliptical.

• Weight loss is beneficial because too much weight can pull disks out of alignment.

• Yoga is a beneficial form of exercise. One study showed that long-term yoga slows down the natural aging process that occurs in intervertebral disks.

Steroid Injections

• The steroid is inserted into the epidural space.

• The doctor will wait two weeks after the injection to assess progress and determine if another injection is needed.

• This may alleviate pain for a few weeks or up to a year.

Surgical Interventions

• Lumbar spinal fusion

  • Two vertebrae are grafted together so that motion no longer occurs at the site of pain.

  • Recovery can take up to a year.

  • Physical therapy should be started at 6 weeks but one study showed that it is more beneficial for physical therapy to start 2 weeks after the surgery.

• Artificial Disk Replacement

  • This is an alternative to lumbar spinal fusion. It is a newer procedure, but patient outcomes are proving to be beneficial.

  • The procedure involves the removal of the spinal disk and replacing it with an artificial disk device. The artificial disk can be made of metal or surgical grade plastic (polyethylene).

  • Recovery can take up to 6 months. The procedure has better patient outcomes, less pain after, and lower complication rates. It also allows for motion in between the lumbar joints.

  • There is a risk for dislocation of the replacement disk.

Therapy

• Pain Reprocessing Therapy

Preventing Flare-Ups

• Don’t sit for prolonged periods of time without standing up or changing positions. When sitting down, a reclined position is beneficial.

• Going on walks can alleviate stiffness.

• Avoid prolonged bed rest.

Other

• Bone fusion with bone morphogenetic proteins

  • These proteins stimulate the growth of new bone

• Heating or ice therapy

• Radiofrequency ablation involves destroying nerve roots with radiofrequency waves.

  • Provides several months of relief

  • Nerves can grow back, but the pain might not return.

• Acupuncture stimulates healing by increasing blood flow. It may also cause the release of endorphins which limit pain.

• Chiropractic care

• Electrical stimulation (TENS unit)

• An ultrasound can be used to reduce muscle spasms and stiffness and improve blood circulation.

Current Research and Trials

• Studies on the inhibition of molecular mediators of degeneration are promising.

• Research is being done on regeneration strategies of the disk (2020): gene therapies, biomolecule therapies, stem cell therapies, injectable cell delivery gels

  • In one study, stem cell therapy decreased pain for two years.

• Intradiskal electrothermal therapy is a minimally invasive surgical procedure that is still in clinical trials. The procedure involves applying heat to a portion of the disk through a catheter with a temperature controlled heating coil.

  • The procedure damages the nerves, shrinks collagen, and stiffens the disk tissue.

  • Pain relief is not immediate and the pain may get worse during the first two days, but overall the procedure is effective at relieving pain.

  • Contraindications include accelerated disk degeneration and end plate formation.

• Injecting hydrogel into spinal discs

  • called Hydrafil

  • Quick and effective in relieving pain