Degenerative disc disease
Encyclopedia
Degeneration of the intervertebral disc
, often called "degenerative disc disease" (DDD) of the spine
, is a condition that can be painful and can greatly affect the quality of one's life. While disc degeneration is a normal part of aging and for most people is not a problem, for certain individuals a degenerated disc can cause severe constant chronic pain.
sometimes radiates to the hips, or there is pain
in the buttocks
or thigh
s while walking; sporadic tingling
or weakness through the knees may also be evident. Similar pain may be felt or may increase while sitting, bending, lifting, and twisting. Chronic neck pain can also be caused in the upper spine, with pain radiating to the shoulders, arms and hands. Neck pain
may cause interrupted blood supply to the brain resulting in headaches, vertigo and worsened cognitive abilities and memory.
(outer layer of the disc) than others, making discs more susceptible to becoming a source of pain. The scientific community has the opinion that the healing process involved in the repair of trauma to the outer annulus results in the innervation of the resultant scar tissue, and subsequent pain in the disc, as these nerves become inflamed by nucleus pulposus
material. Degenerative disc disease can lead to a chronic debilitating condition and can have a serious negative impact on a person's quality of life. When pain from degenerative disc disease is severe, traditional nonoperative treatment is often ineffective.
and clusters of chondrocytes, suggestive of repair. Inflammation may or may not be present. Histologic examination of disc fragments resected for presumed DDD is routine to exclude malignancy.
Fibrocartilage replaces the gelatinous mucoid material of the nucleus pulposus as the disc changes with age. There may be splits in the annulus fibrosis, permitting herniation of elements of nucleus pulposus. There may also be shrinkage of the nucleus pulposus that produces prolapse or folding of the annulus with secondary osteophyte formation at the margins of the adjacent vertebral body. The pathologic findings in DDD include protrusion, spondylolysis
, and/or subluxation of vertebrae (sponylolisthesis) and spinal stenosis
.
. One or a combination of treatments such as physical therapy
, chiropractic manipulative therapy (CMT) and other chiropractic
treatments, osteopathic manipulation
,vertebrorevitology
, anti-inflammatory medications such as nonsteroidal anti-inflammatory drugs, traction
, or spinal injections often provide adequate relief of these troubling symptoms.
Surgery may be recommended if the conservative treatment options do not provide relief within two to three months. If leg or back pain limits normal activity, if there is weakness or numbness in the legs, if it is difficult to walk or stand, or if medication or physical therapy are ineffective, surgery may be necessary, most often spinal fusion
. There are many surgical options for the treatment of degenerative disc disease. The most common surgical treatments include:
New treatments are emerging that are still in the beginning clinical trial phases. Glucosamine
injections are thought to offer some pain relief for degenerative discs at best, and at worst, do nothing while also not affecting more aggressive treatment options. In the US artificial disc replacement is viewed cautiously as a possible alternative to fusion in carefully selected patients, yet it is widely used in a broader range of cases in Europe, where multi-level disc replacement of the cervical and lumbar spine is common.. Adult stem cell
therapies for disc regeneration are in their infancy. Investigation into mesenchymal stem cell
therapy knife-less fusion of vertebrae in the United States began in 2006.
Intervertebral disc
Intervertebral discs lie between adjacent vertebrae in the spine. Each disc forms a cartilaginous joint to allow slight movement of the vertebrae, and acts as a ligament to hold the vertebrae together.-Structure:...
, often called "degenerative disc disease" (DDD) of the spine
Vertebral column
In human anatomy, the vertebral column is a column usually consisting of 24 articulating vertebrae, and 9 fused vertebrae in the sacrum and the coccyx. It is situated in the dorsal aspect of the torso, separated by intervertebral discs...
, is a condition that can be painful and can greatly affect the quality of one's life. While disc degeneration is a normal part of aging and for most people is not a problem, for certain individuals a degenerated disc can cause severe constant chronic pain.
Symptoms
With symptomatic degenerative disc disease, chronic low back painBack pain
Back pain is pain felt in the back that usually originates from the muscles, nerves, bones, joints or other structures in the spine.The pain can often be divided into neck pain, upper back pain, lower back pain or tailbone pain...
sometimes radiates to the hips, or there is pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
in the buttocks
Buttocks
The buttocks are two rounded portions of the anatomy, located on the posterior of the pelvic region of apes and humans, and many other bipeds or quadrupeds, and comprise a layer of fat superimposed on the gluteus maximus and gluteus medius muscles. Physiologically, the buttocks enable weight to...
or thigh
Thigh
In humans the thigh is the area between the pelvis and the knee. Anatomically, it is part of the lower limb.The single bone in the thigh is called the femur...
s while walking; sporadic tingling
Paresthesia
Paresthesia , spelled "paraesthesia" in British English, is a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep"...
or weakness through the knees may also be evident. Similar pain may be felt or may increase while sitting, bending, lifting, and twisting. Chronic neck pain can also be caused in the upper spine, with pain radiating to the shoulders, arms and hands. Neck pain
Neck pain
Neck pain is a common problem, with two-thirds of the population having neck pain at some point in their lives.Neck pain, although felt in the neck, can be caused by numerous other spinal problems. Neck pain may arise due to muscular tightness in both the neck and upper back, or pinching of the...
may cause interrupted blood supply to the brain resulting in headaches, vertigo and worsened cognitive abilities and memory.
Understanding disc pain
After an injury, some discs become painful because of inflammation. Some people have nerve endings that penetrate more deeply into the annulus fibrosusAnnulus fibrosus disci intervertebralis
Each intervertebral fibrocartilage is composed, at its circumference, of laminæ of fibrous tissue and fibrocartilage, forming the annulus fibrosus.-Spelling notes:...
(outer layer of the disc) than others, making discs more susceptible to becoming a source of pain. The scientific community has the opinion that the healing process involved in the repair of trauma to the outer annulus results in the innervation of the resultant scar tissue, and subsequent pain in the disc, as these nerves become inflamed by nucleus pulposus
Nucleus pulposus
Nucleus pulposus is the jelly-like substance in the middle of the spinal disc. It is the remnant of the notochord . It functions to distribute hydraulic pressure in all directions within each disc under compressive loads. The nucleus pulposus consists of chondrocyte-like cells, collagen fibrils,...
material. Degenerative disc disease can lead to a chronic debilitating condition and can have a serious negative impact on a person's quality of life. When pain from degenerative disc disease is severe, traditional nonoperative treatment is often ineffective.
Pathologic changes
Degenerative discs typically show degenerative fibrocartilageFibrocartilage
White fibrocartilage consists of a mixture of white fibrous tissue and cartilaginous tissue in various proportions. It owes its flexibility and toughness to the former of these constituents, and its elasticity to the latter...
and clusters of chondrocytes, suggestive of repair. Inflammation may or may not be present. Histologic examination of disc fragments resected for presumed DDD is routine to exclude malignancy.
Fibrocartilage replaces the gelatinous mucoid material of the nucleus pulposus as the disc changes with age. There may be splits in the annulus fibrosis, permitting herniation of elements of nucleus pulposus. There may also be shrinkage of the nucleus pulposus that produces prolapse or folding of the annulus with secondary osteophyte formation at the margins of the adjacent vertebral body. The pathologic findings in DDD include protrusion, spondylolysis
Spondylolysis
Spondylolysis is a defect of a vertebra. More specifically it is defined as a defect in the pars interarticularis of the vertebral arch. The great majority of cases occur in the lowest of the lumbar vertebrae , but spondylolysis may also occur in the other lumbar vertebrae, as well as in the...
, and/or subluxation of vertebrae (sponylolisthesis) and spinal stenosis
Spinal stenosis
Lumbar spinal stenosis is a medical condition in which the spinal canal narrows and compresses the spinal cord and nerves at the level of the lumbar vertebra. This is usually due to the common occurrence of spinal degeneration that occurs with aging. It can also sometimes be caused by spinal disc...
.
Treatment options
Often, degenerative disc disease can be successfully treated without surgerySurgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
. One or a combination of treatments such as physical therapy
Physical therapy
Physical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
, chiropractic manipulative therapy (CMT) and other chiropractic
Chiropractic
Chiropractic is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. It is generally categorized as complementary and alternative medicine...
treatments, osteopathic manipulation
Osteopathic Manipulative Medicine
Osteopathic Manipulative Medicine is the application of the distinct osteopathic philosophy, structural diagnosis and use of Osteopathic Manipulative Technique in the diagnosis and management of the patient. OMM takes into account the physical and mental health of a patient, and how either aspect...
,vertebrorevitology
Vertebrorevitology
-Definition and essence of the method:Definition and essence of the methodVertebrorevitology – is a method of backbone’s diseases treatment with the aim to optimize conditions for activation of reparative...
, anti-inflammatory medications such as nonsteroidal anti-inflammatory drugs, traction
Traction (orthopedics)
In orthopedic medicine, traction refers to the set of mechanisms for straightening broken bones or relieving pressure on the spine and skeletal system.There are two types of traction: skin traction and skeletal traction....
, or spinal injections often provide adequate relief of these troubling symptoms.
Surgery may be recommended if the conservative treatment options do not provide relief within two to three months. If leg or back pain limits normal activity, if there is weakness or numbness in the legs, if it is difficult to walk or stand, or if medication or physical therapy are ineffective, surgery may be necessary, most often spinal fusion
Spinal fusion
Spinal fusion, also known as spondylodesis or spondylosyndesis, is a surgical technique used to join two or more vertebrae. Supplementary bone tissue, either from the patient or a donor , is used in conjunction with the body's natural bone growth processes to fuse the vertebrae.Fusing of the...
. There are many surgical options for the treatment of degenerative disc disease. The most common surgical treatments include:
- Anterior cervical discectomyDiscectomyA Discectomy is the surgical removal of herniated disc material that presses on a nerve root or the spinal cord. The procedure involves removing the central portion of an intervertebral disc, the nucleus pulposus, which causes pain by stressing the spinal cord or radiating nerves...
and fusion: A procedure that reaches the cervical spine (neck) through a small incision in the front of the neck. The intervertebral disc is removed and replaced with a small plug of bone or other graft substitute, and in time, that will fuse the vertebrae.
- Cervical corpectomyCorpectomyA corpectomy is a surgical procedure that involves removing part of the vertebral body , usually as a way to decompress the spinal cord and nerves. Corpectomy is often performed in association with some form of discectomy....
: A procedure that removes a portion of the vertebra and adjacent intervertebral discs to allow for decompression of the cervical spinal cord and spinal nerves. A bone graft, and in some cases a metal plate and screws, is used to stabilize the spine.
- Dynamic Stabilisation: Following a discectomy, a stabilisation implant is implanted with a 'dynamic' component. This can be with the use Pedicle screws (such as Dynesys or a flexable rod) or an interspinous spacer with bands (such as a Wallis ligament). These devices off load pressure from the disc by rerouting pressure through the posterior part of the spinal column. Like a fusion, these implants allow maintain mobility to the segent by allowing flexion and extension.
- FacetectomyFacetectomyFacetectomy is a surgical procedure which involves decompression of a spinal nerve root. For example, it can be performed in severely resistant cases of cervical rhizalgia, where the cervical nerve roots within the intervertebral foramina are decompressed....
: A procedure that removes a part of the facetZygapophysial jointA zygapophysial joint is a synovial joint between the superior articular process of one vertebra and the inferior articular process of the vertebra directly above it...
to increase the space.
- ForaminotomyForaminotomyForaminotomy is a medical operation used to relieve pressure on nerves that are being compressed by the intervertebral foramina, the passages through the bones of the vertebrae of the spine that pass nerve bundles to the body from the spinal cord....
: A procedure that enlarges the vertebral foramenVertebral foramenIn a typical vertebra, the vertebral foramen is the foramen formed by the anterior segment , and the posterior part, the vertebral arch....
to increase the size of the nerve pathway. This surgery can be done alone or with a laminotomy.
- Intervertebral disc annuloplasty (IDET)Intervertebral disc annuloplastyThe term intervertebral disc annuloplasty indicates any procedure aimed at repairing the annulus of a bulging intervertebral disc before it herniates.-Intradiscal electrothermal annuloplasty:...
: A procedure wherein the disc is heated to 90°C for 15 minutes in an effort to seal the disc and perhaps deaden nerves irritated by the degeneration.
- Intervertebral disc arthroplastyIntervertebral disc arthroplastyArtificial Disc Replacement , or Total Disc Replacement , is a type of arthroplasty. It is a surgical procedure in which degenerated intervertebral discs in the spinal column are replaced with artificial devices in the lumbar or cervical spine...
: also called Artificial Disc Replacement (ADR), or Total Disc Replacement (TDR), is a type of arthroplastyArthroplastyArthroplasty is an operative procedure of orthopedic surgery performed, in which the arthritic or dysfunctional joint surface is replaced with something better or by remodeling or realigning the joint by osteotomy or some other procedure.-Background:Previously, a popular form of arthroplasty was...
. It is a surgical procedure in which degenerated intervertebral discIntervertebral discIntervertebral discs lie between adjacent vertebrae in the spine. Each disc forms a cartilaginous joint to allow slight movement of the vertebrae, and acts as a ligament to hold the vertebrae together.-Structure:...
s in the spinal column are replaced with artificial ones in the lumbar (lower) or cervical (upper) spine.
- LaminoplastyLaminoplastyLaminoplasty is a surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The procedure involves cutting the lamina on both sides of the affected vertebrae and then "swinging" the freed flap of bone open thus relieving the pressure on the spinal cord...
: A procedure that reaches the cervical spine from the back of the neck. The spinal canal is then reconstructed to make more room for the spinal cord.
- LaminotomyLaminotomyA laminotomy is a neurosurgical procedure that removes part of a lamina of the vertebral arch in order to decompress the corresponding spinal cord and/or spinal nerve root....
: A procedure that removes only a small portion of the laminaLamina of the vertebral archThe laminæ are two broad plates, extending dorsally and medially from the pedicles, fusing to complete the roof of the vertebral arch.Their upper borders and the lower parts of their anterior surfaces are rough for the attachment of the ligamenta flava....
to relieve pressure on the nerve roots.
- Micro-discectomy: A procedure that removes a disc through a very small incision using a microscope.
- Percutaneous disc decompression: A procedure that reduces or eliminates a small portion of the bulging disc through a needle inserted into the disc, minimally invasive.
- Percutaneous Laser Disc-Decompression (PLDD): Based on this small study population, it can be concluded that PLDD may be an effective treatment for disco-genic back pain with minimal natural recurrence.
- Spinal decompressionSpinal decompressionSpinal decompression is a term that describes the relief of pressure on one or many pinched nerves of the spinal column.Spinal decompression can be achieved both surgically and non-surgically and is used to treat conditions that result in chronic back pain such as disc bulge, disc herniation,...
: A non-invasive procedure that enlarges the Intra Vertebral Foramen (IVF) by aiding in the rehydration of the spinal discs.
- Spinal laminectomyLaminectomyLaminectomy is a spine operation to remove the portion of the vertebral bone called the lamina. There are many variations of laminectomy. In the most minimal form small skin incisions are made, back muscles are pushed aside rather than cut, and the parts of the vertebra adjacent to the lamina are...
: A procedure for treating spinal stenosisSpinal stenosisLumbar spinal stenosis is a medical condition in which the spinal canal narrows and compresses the spinal cord and nerves at the level of the lumbar vertebra. This is usually due to the common occurrence of spinal degeneration that occurs with aging. It can also sometimes be caused by spinal disc...
by relieving pressure on the spinal cord. A part of the lamina is removed or trimmed to widen the spinal canal and create more space for the spinal nerves.
New treatments are emerging that are still in the beginning clinical trial phases. Glucosamine
Glucosamine
Glucosamine is an amino sugar and a prominent precursor in the biochemical synthesis of glycosylated proteins and lipids. Glucosamine is part of the structure of the polysaccharides chitosan and chitin, which compose the exoskeletons of crustaceans and other arthropods, cell walls in fungi and...
injections are thought to offer some pain relief for degenerative discs at best, and at worst, do nothing while also not affecting more aggressive treatment options. In the US artificial disc replacement is viewed cautiously as a possible alternative to fusion in carefully selected patients, yet it is widely used in a broader range of cases in Europe, where multi-level disc replacement of the cervical and lumbar spine is common.. Adult stem cell
Adult stem cell
Adult stem cells are undifferentiated cells, found throughout the body after embryonic development, that multiply by cell division to replenish dying cells and regenerate damaged tissues...
therapies for disc regeneration are in their infancy. Investigation into mesenchymal stem cell
Mesenchymal stem cell
Mesenchymal stem cells, or MSCs, are multipotent stem cells that can differentiate into a variety of cell types, including: osteoblasts , chondrocytes and adipocytes...
therapy knife-less fusion of vertebrae in the United States began in 2006.