|
Click Here to View Animation
The lumbar disc serves many functions. It has a “shock absorber” function between the lumbar vertebrae. It also facilitates range of motion of the lower back (i.e. flexion, extension, rotation and lateral bending) and acts as a spacer between the vertebrae which allows for the individual nerve roots to pass through their respective exit hole (Foramina). The lumbar disc is composed of two parts, the nucleus polposus (central jelly like material) and the annulus fibrosus (thick outer layer that surrounds the center). This unique arrangement is what allows the disc to serve its function.
The term degenerative disc disease is a diagnosis that encompasses a wide variety of conditions that basically result from a dysfunction of the lumbar disc. Disc degeneration may be age related, activity related (i.e. repetitive abnormal stresses to the low back), or sometimes may be triggered by a traumatic event (accident) that caused the vertebrae, disc or both to be injured (i.e. a burst fracture). Regardless of the mechanism, the end result of degenerative disc disease may present as different symptoms in different patients.
Signs and Symptoms of Degenerative
Disc Disease
Moderate to severe low back pain is a common presenting symptom of degenerative disc disease. The disc itself has nerve fibers supplying the outer surface of the disc and they are thought to be part of the reason that patients have pain from isolated disc degeneration or internal disc derangement (IDD, discogenic pain). Mild or extreme low back pain may also be coming from arthritis at the posterior facet joints that may be part of the degenerative cascade. Leg pain (sciatica) may also accompany low back pain when the degenerative process causes direct pressure on the nerve roots (lumbar stenosis, disc herniation or foraminal stenosis) or results in instability (spondylolisthesis).
Diagnosis of Degenerative Disc Disease
The testing to confirm degenerative disc disease as the cause of the symptoms may be extensive. It is difficult to pinpoint exactly where the pain is coming from. X-rays, MRI (magnetic resonance imaging), CT (computed tomography) scan and discograms may be used as a part of the diagnostic work up and are individually tailored depending on the patient history and physical exam.
Degenerative Disc Disease Treatment
The mainstay of treatment for isolated low back pain stemming from degenerative disc disease is non-operative. All modalities should be exhausted prior to considering surgical intervention. Anti-inflammatory medications, physical therapy, injections, chiropractic treatment, acupuncture and alternative medicine may and should be utilized prior to consideration of surgery for low back pain that comes from degenerative disc disease. For those patients who have tried everything and exhausted non-operative attempts, surgery may be appropriate if the patient’s diagnostic studies and symptoms are consistent.
Different surgical options are available depending on the patient symptoms, physical status, health and diagnostic studies. Lumbar fusion is currently the gold standard for the treatment of low back pain stemming from degenerative disc disease. Different surgical techniques are available. Minimally invasive and minimal access spine surgery has made great progress in the past 10 years and allows for smaller incisions, less blood loss, and at times less post operative pain compared to traditional open approaches. It is important to note that long term studies have not shown definitive long term advantages of minimally invasive spinal approaches. It is also important for patients to realize that not all spinal conditions are amenable to minimally invasive approaches. Anterior lumbar interbody fusion (ALIF) combined with a posterolateral spinal fusion or transforaminal lumbar interbody fusion (TLIF) combined with a posterolateral spinal fusion are both techniques that are utilized depending on individual patients. Artificial disc replacement (total disc replacement) has been evolving as a possible alternative for the treatment of isolated discogenic pain. Artificial disc replacement is still in its relative infancy in the united states and may be a reasonable alternative for fusion in a select group of patients. Further U.S. long term studies are necessary to make an adequate assessment as to the long term results and, most importantly, safety of this evolving procedure.
Regardless of the technical options that are available to the surgeon for treatment of back pain from degenerative disc disease, patient selection is probably the single most important predictor of surgical outcome. It is important for patients to be aware that surgical outcomes vary and to understand that surgery for back pain is for the most part elective in terms of quality of life improvement. As always it is important to seek the advice of a board certified and preferably fellowship trained spine surgeon (orthopedic surgeon or a neurosurgeon) in order to get all the best options for maximizing a good outcome. We are fortunate to have several excellent spine surgeons in the Princeton and central New Jersey area and access to a surgeon with these qualifications is recommended. |
