Degenerative Disc Disease (DDD)

Describes a process of degeneration to the vertebral disc over a period of time. This insidious process is secondary to wear and tear, trauma and misuse. It results in loss of normal anatomic structure and daily functioning, which leads to discomfort and progressive pain as it accelerates.

Anatomy:
The vertebral “disc” is a structure that lies between the vertebrae in the spine and act as shock absorber, handling the everyday loads placed upon it. The disc is a water-based tissue (collagen) that as it ages begins to lose the water content and becomes less elastic. As this occurs, the inner gel substance (nucleus pulposus) and the outer muscular layer (annulus) begin to dry out causing the tissue to fissure and tear, resulting in progressive degeneration. This leads to the disc becoming unable to handle the stress and perform its normal daily activities of living. The degenerative process begins prior to x-ray findings becoming obvious.

Radiographic findings reveal the disc space becoming narrowed, bones become closer in appearance to one another and “spurs” are noted as the body attempts to reinforce the involved bony structures.

Conservative Treatment:
In years past, physicians recommended strict periods of bed rest until symptoms had resolved. Now the theory has changed to short periods of rest and quick progression of activities as tolerated.

Exercise: When pain allows, stretching exercises should begin in attempt to increase flexibility and strengthen muscle structures as well as help aid in decreasing inflammatory effects. Certain spine diagnosis can be treated effectively with specific physiotherapy (PT) exercise programs, improving strength, posture, abdominal muscles and endurance. Concentrating on an approved chronic spine exercise program will lead to a healthier, less painful future.

Pharmacy: Anti-inflammatory pills will decrease the surrounding inflammatory effects, which correlates with decreased pain as the edema resolves. Steroids are a much more potent anti-inflammatory and may be prescribed in some instances. Muscle relaxers are pills designed to decrease the acute contractures of the muscle fibers (spasms). Contrary to some people’s beliefs, muscle relaxers only help for a few days at most and usually are not prescribed for long periods. Pain medication is prescribed solely to take the edge off and not to rid an individual’s pain. The narcotic aids in breaking the acute pain cycle. Again, only in few instances is this medication intended for prolonged use.

Alternative Providers: Chiropractics; When dealing with neck or back pain and no radiculitis (referred pain into the extremities) manipulation may be of some benefit for the first few weeks, by increasing mobility. After the first month , there is no documented benefit. Acupuncture; Some studies show that acupuncture may increase the production of endorphins, acetylcholine and seratonin, which may help reduce pain. Massage; May help decrease inflammation and pain by loosening fibers, spasms and allowing better flexibility for a quicker return to function. Most physical therapists routinely perform friction massage along with other modalities.

Acute Phase:
When neck or back pain exacerbates, keep in mind that with a conservative approach, the majority of people improve significantly over 4-6 weeks. If pain persists greater than that period or new symptoms develop, then further evaluation and diagnostic testing may be warranted. Knowing your bodies response to injury and treatment will help get you back to activity sooner.

Warning Signs (Red Flags):
Sometimes DDD may allow a disc to herniated which in turn will cause a radicular component to your symptoms. This happens when some of the inner disc gel (nucleus pulposus) causes pressure on a nerve structure. (See Herniated Discs for more information).

Infrequently, if a disc herniation is large it causes a syndrome called “Cauda Equina”. This syndrome represents because of a large central herniation causing pressure on the string like fibers at the latter portion of the spinal cord. These fibers resemble the tail of a horse (Latin termed- Cauda Equina). The pressure could lead to progressive neurological symptoms such as bilateral lower extremity weakness, numbness in the “saddle” distribution, urinary or bowel retention or incontinence. Should these symptoms present, it is a surgical emergency and should be evaluated immediately.

Surgical Procedures:
Each patient and diagnosis should be evaluated differently depending on pathology, severity of symptoms, activity level and response to prior treatments. If conservative measures fail then further procedures can be explored depending on symptoms.

Facet Injections: These are cortisone injections placed directly into the joints in the spine by fluoroscopy (live x-ray). They may decrease the inflammatory effects within the joint and in turn decrease pain.

Radio Frequency Ablation (RFA): If the facet injections are successful but temporary, RFA may be beneficial. This procedure attempts to eliminate pain generated by the nerve within the degenerated disc.

Discogram: A procedure that is performed to help your surgeon specifically isolate the pain generator in your spine.

Fusion: A surgical procedure that attempts to stop motion at a segment of your spine, by preparing the site, introducing bone graft (usually from your pelvic bone) and securing it with screws. When the segment fuses over a period of time, motion is eliminated and the pain resolves.

All surgical procedures need to be discussed at length to tailor a specific procedure for each unique diagnosis and individual. In turn, any procedure has risks that should be discussed at length with your provider.