» » Degenerative Disc Disease
Degenerative Disc Disease
- J. William Bookwalter, III, MD
Degenerative disc disease (DDD) is the normal change of the disc that takes place
with aging. As people age, DDD progresses. Complaints of back pain increase with
age. The changes in the discs increase with age. We believe the two are related.
The purpose of this booklet is to help you understand the problem and what you
need to do to manage it.
Function, Anatomy and Change in the Disc
The disc is a special type of joint that allows you to move in three planes.
It acts like a ball bearing placed between the two vertebral bodies so you
can move forward and backward, side to side and rotate from left to right
and back again. It is located between the two vertebral bodies. There are
two facet joints towards the back and side of the vertebral column that limit
the movement of the discs. Behind the disc and vertebrae is the spinal canal,
which contains the spinal cord and nerve roots. It is these structures that
can be affected by herniations and stenosis or narrowing of the spinal canal.
As
we all age the disc loses its water content and begins to narrow. Imagine
if you will two tin cans separated by a water balloon. Leather straps hold
the cans together causing some pressure on the balloon. You can see that
the cans can move in any plane, but only a little bit,
when the water balloon is very full and pushing the cans
apart against the leather straps. If you take some water
out of the balloon the cans come closer together and
the motion increases. This is what happens as the disc
ages. It loses its water content and the motion of the
disc becomes more eccentric. Fissures and cracks develop
in the disc. Increased motion stresses the ligaments
and joints and causes inflammation. The fissures and
cracks can allow material from the center of the disc
to bulge or herniated out through a thinned annulus or
outer ring. The annulus is normally much thinner in back
than in front.
The first picture below is a normal disc. The second
shows some bulging of the disc because of thinning of
the outer ring and some early fissure formation. The
third shows more advanced fissure formation with a herniation.
The fourth shows a completely herniated fragment. The
final drawing shows a disc that has undergone advanced
degenerative change such as we find in older patients.
The
next picture below shows a real fissure in a disc.
Over time osteophytes
or bone spurs can form:
Bone spurs can narrow the space for the spinal cord
or roots, compressing them. These changes produce pain
of different types.
Symptoms
Back or neck pain are the most common symptoms of DDD.
Other common symptoms are sacroiliac pain, buttock
pain, hip pain, pain in the back of the thigh or along
the side of the hip. Fifty percent of the time there
is an incident that causes the onset of symptoms. The
other fifty percent of the time, no specific event
takes place. Regardless the management is the same.
This is a problem that will not go completely away
and constant management is essential for long-term
control of symptoms.
Management
There are three aspects to management of degenerative
disc disease.
Exercise
Stretching
Aerobic
Behavior modification
Activities
Lifestyle changes
Medications
Anti-inflammatories
Other
Rarely, surgery is indicated
The single most important thing is to develop a regular
routine of both stretching and aerobic exercise. You
should stretch 15 to 30 minutes every day. It is recommended
that you aerobically exercise for 30 to 45 minutes three
or four times a week. Current guidelines for exercise
are 100 minutes of aerobic exercise per week.
Behavior modification takes two forms. In daily life,
you need to identify the things that aggravate your symptoms
and change them. For example, if you sit at a computer
all day, get a countdown timer. Set it for 30 minutes.
Every time it goes off, get up and change your position
for 5 or 10 minutes. Use good lifting mechanics and observe
good postures. The illustration below shows relative
pressures with different postures.
Different postures
exert different forces on the discs. At its most extreme,
you may have to change jobs to accommodate your disc
problem.
The second part of behavior modification is losing
weight and smoking cessation. Obese patients are 80%
more likely to have back problems than their normal weight
counterparts. In addition the fat rolls make it more
difficult to aerobically exercise and interfere with
stretching effectively. Smokers are 400% more likely
to have symptomatic DDD than their non-smoking counterparts.
They are 1000% more likely to develop a chronic pain
syndrome. Nicotine causes the blood vessels throughout
the body to narrow. This reduces the blood flow to all
the tissues. The discs have no direct blood supply and
depend on the osmosis of nutrients in and waste products
out. When the blood flow to adjacent tissues is reduced,
it greatly reduces the nutrients the discs get and the
flow of waste out. This diminished nutrition and waste
product buildup increases the rate at which the discs
degenerate. The effects of the nicotine are not gone
until 3 to 6 months after exposure to nicotine stops.
There is no medicine that makes you younger. Therefore,
there is no medicine that reverses degenerative change.
Unlike a problem such as strep throat where your Doctor
gives you an antibiotic and kills the bacteria and resolves
the problem completely, medications don’t fix this
problem. Medications are an adjunctive treatment. Steroid
and non-steroidal anti-inflammatories help reduce inflammation,
a common problem. Muscle relaxants and non-narcotic pain
medications can help relieve pain and spasm, but are
not a substitute for exercising, behavior modification,
weight loss and smoking cessation.
Recommendations
We will refer you to a physiatrist to begin a rehab program.
In the rehab program, your goals should be to develop
both stretching and aerobic exercise programs and learn
good postural behaviors and lifting mechanics. We may
give you some medications to help diminish inflammation
or spasm. If you are over weight or a smoker, you need
to contact your primary care physician to learn about
strategies to help with either or both. Surgery is
not as a rule a solution for degenerative disc disease.
There are very specific indications for it. We are
always happy to reevaluate you. If you develop weakness,
gait imbalance or loss of bowel or bladder control,
you should seek medical help immediately.
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