Degenerative disc disease is one of the most common causes of low back pain and neck pain, and also one of the most misunderstood.
Simply put, degenerative disc disease describes the symptoms of pain and possibly radiating weakness or numbness stemming from a degenerated disc in the spine. While the definition sounds simple, many patients diagnosed with degenerative disc disease are left wondering exactly what this diagnosis means for them.
Degenerative Disc Disease Video
Common questions often include:
- If I have this much pain in my thirties, how much worse will it become with age?
- Will the disease become a crippling condition? Will I end up in a wheelchair
- Should I restrict my activities? Can I still play sports?
- Will the disease spread to other parts of the spine?
- Will the degenerated disc(s) cause any permanent damage?
- Is surgery inevitable?
Degenerative disc disease is a misnomer
A diagnosis of “degenerative disc disease” is alarming to many patients because it sounds like a progressive, threatening disease. However, it is not really a disease, and it is not strictly degenerative.
For most people the term degenerative understandably implies that the symptoms will get worse with age. However, the term does not apply to the symptoms, but rather describes the process of the disc degenerating over time.
While it is true that the disc degeneration is likely to progress over time, the pain from degenerative disc disease usually does not get worse and in fact usually gets better given enough time. The degenerative cascade theory explains how this process works.
Another source of confusion is probably created by the term disease, which is actually a misnomer. Degenerative disc disease is not really a disease at all, but rather a degenerative condition that at times can produce pain from a damaged disc.
Disc degeneration is actually a natural part of aging, and over time all people will exhibit changes in their discs consistent with a greater or lesser degree of degeneration. However, not all people will develop symptoms. In fact, degenerative disc disease is quite variable in its nature and severity.
Medical practitioners disagree
Many patients are confused about degenerative disc disease because medical professionals are not in agreement about what the diagnosis means.
In practical terms, this means that few health professionals agree on what does and does not constitute a diagnosis of degenerative disc disease, or when a degenerated disc is the cause of the patient’s pain. Even medical textbooks don’t usually attempt to give an accurate description. Therefore, while many practitioners believe that degenerative disc disease is a common cause of low back pain and neck pain, few agree on the implications.
While much is up for debate, a few aspects of the condition are known. This article provides in-depth information about aspects of degenerative disc disease based on commonly accepted principles, such as how a degenerated disc causes pain, and common symptoms and treatments.
It is important to note that disc degeneration can lead to or hasten the onset of additional spinal conditions, such as:
- Spinal stenosis, a form of spinal degeneration that leads to nerve root or spinal cord pinching.
- Osteoarthritis in the spine, e.g. joint changes in the facet joints in the back of the spine that occur as a result of disc degeneration.
- Spondylolisthesis. If the facet joints degenerate enough, they can become mechanically ineffective, causing one vertebral body to slip forward on another.
Pain from Degenerative Disc Disease
Generally, the pain associated with degenerative disc disease is thought to stem from two main factors:
1. Inflammation
The proteins contained within the disc space can cause a lot of inflammation, and as a general rule inflammation will cause pain.
In the lumbar disc space, the low back pain can radiate into the hips. The associated pain can also travel down the back of the leg (also called sciatica, or radiculopathy), and possibly into the foot and toes.
In the cervical disc space, the neck pain may be local or may radiate into the arm, shoulder and possibly into the hand (a cervical radiculopathy).
2. Abnormal micromotion instability
If the annulus – the outer rings of the intervertebral disc – degenerates and wears down, it is not as effective in resisting motion in the spine. This condition has been termed “micromotion” instability because it is usually not associated with gross instability (such as a slipped vertebral body or spondylolisthesis).
Both the inflammation and micromotion instability can cause lower back or neck muscle spasms. The muscle spasm is the body’s attempt to stabilize the spine. It is a reflex, and although the body’s response of muscle spasm is not necessary for the safety of the nerve roots, it can be quite painful.
The muscle spasms associated with the instability are thought to cause the flare-ups of intense pain often associated with degenerative disc disease.
Symptomatic degenerative disc
The two findings most correlated with a pathological disc (a degenerating disc that is painful) are:
- Cartilaginous end plate erosion
- Disc space collapse
Like other joints in the body, each vertebral segment is a joint that has cartilage in it. In between the vertebral body and the disc space is a layer of cartilage, which is known as the cartilaginous end plate.
The cartilaginous end plate is the source of disc nutrition. If it becomes eroded, it is thought that the disc is likely to go through a degenerative cascade leading to the inflammation and micromotion instability, which in turn causes pain. As it goes through the process, the disc space will collapse.
MRI findings of spinal degeneration are not specific causes of back pain. Typical MRI findings may include:
- Disc dehydration, also called disc desiccation, and often referred to as a dark disc or black disc, because a disc with less water in it looks dark on an MRI scan
- Annular tears
- Disc bulges
These findings may or may not be the cause of the patient’s low back pain. It is well known that the results of surgically fusing a spine with these findings will be less reliable than fusing a disc space that has disc space collapse and cartilaginous end plate erosion.
Common Symptoms of Degenerative Disc Disease
There are several symptoms that are fairly consistent for people with lower back pain or neck pain from degenerative disc disease, including:
- Pain that is usually related to activity and will flare up at times but then return to a low-grade pain level, or the pain will go away entirely
- The amount of chronic pain—referred to as the patient’s baseline level of pain—is quite variable between individuals and can range from almost no pain/just a nagging level of irritation, to severe and disabling pain
- Severe episodes of back or neck pain that will generally last from a few days to a few months before returning to the individual’s baseline level of chronic pain
- Chronic pain that is completely disabling from degenerative disc disease does happen in some cases, but is relatively rare
- Activities that involve bending, lifting, and twisting will usually make the patient’s pain worse
- Certain positions will usually make the pain worse. For example, for lumbar degenerative disc pain, the pain is generally made worse with sitting, since in the seated position the lumbosacral discs are loaded three times more than standing
- Walking, and even running, may actually feel better than prolonged sitting or standing
- Patients will generally feel better if they can change positions frequently
- Patients with lumbar DDD will generally feel better lying in a reclining position (such as with legs propped up in a recliner), or lying down with a pillow under the knees, since these positions relieve stress on the lumbar disc space
Severe degenerative disc disease pain
Most patients with degenerative disc disease will have some underlying chronic low back pain or neck pain, with intermittent episodes of more severe pain. The exact cause of these severe episodes of pain is not known, but it has been theorized that it is due to abnormal micromotion in the degenerated disc that spurs an inflammatory reaction. In an attempt to stabilize the spine and decrease the micromotion, the body reacts to the disc pain with muscle spasms. The reactive spasms are what make patients feel like their back has “gone out.”
In general, the patient’s pain should not be continuous and severe. If it is, then other diagnoses must be considered.
Specific lumbar and cervical DDD symptoms
Degenerative disc disease most commonly occurs in the cervical spine (neck) or the lumbar spine (lower back), as these areas of the spine have the most motion and therefore are most susceptible to wear and tear.
As a final note, it is helpful for patients to know that the amount of pain does not correlate to the amount of damage in the spine. Severely degenerated discs may not produce much pain at all, and discs with little degeneration can produce severe pain. What this means for patients is that even if they are experiencing severe pain, it does not necessarily mean that there is something seriously wrong with their spine and does not necessarily mean that they need surgery to repair any damage.
Degenerative Disc Disease Treatment Guidelines
The goals for treatment of degenerative disc disease usually include a combination of three areas: pain control; exercise and rehabilitation; lifestyle modifications.
Pain Control
The focus of this part of treatment is on achieving enough pain reduction to enable the patient to pursue a specific exercise and rehabilitation program. Pain from a degenerated or collapsed disc is usually caused by both instability and inflammation, so both of these causes of pain should be addressed.
For most people treatment is nonsurgical and may include one or a combination of many medical, alternative, and/or self care approaches. Often a patient needs to take a trial and error approach to find which types of treatment work best.
The operative solutions, a fusion or artificial disc, are extensive surgeries and patients are usually advised to make a serious effort with nonsurgical treatments for at least 6 months prior to considering surgery.
Exercise and Rehabilitation
The goals of exercise are both to help the back heal and to prevent or reduce further recurrences of pain. For people with symptomatic degenerative disc disease, exercises are usually best done under the guidance of a physical therapist or other appropriately trained healthcare professional. A side benefit of exercise is that it can also help reduce pain naturally, as it releases endorphins that serve as the body’s natural pain reliever.
Exercise is best done in a controlled progressive manner and with the help of a trained health professional, such as a physiatrist, physical therapist, or chiropractor.
Lifestyle Modifications
The focus of this part of treatment is education and resources to help the patient develop a healthier lifestyle. Often, people can make lifestyle changes that aim at both avoiding stress on the spine and supporting the spine through the right ergonomics and posture.
In addition, many people can benefit from the following changes:
- Avoid nicotine
- Avoid excess alcohol
- Incorporate movement into one’s daily routine and avoid staying in one position for too long. For example, stand up and stretch and walk around every 20 to 30 minutes instead of sitting for a prolonged period.
- Drink plenty of water
For lower back pain from DDD, most patients can benefit from a gentle hamstring stretching routine. There are many options in each of the above three areas.