Degenerative Disc Disease Treatment Modalities

September 10, 2019

Degenerative disc disease (DDD) is an age-related condition that occurs when one or more discs between the vertebrae of the spinal column deteriorate, which can lead to back pain. Despite it’s name, this is a natural occurrence that comes with aging due to repeated daily stresses on the spine. The discs (rubbery in quality) between the vertebrae have a very important function.  Intervertebral discs allow for normal flexion and bending of the back and thus act like shock absorbers. Therefore, the intervertebral discs cushion overall stress when the spine moves or bears weight.

In DDD, the most common symptom is back pain, but there may also be weakness, numbness or pain that radiates down the leg if it involves the low back.  Other symptoms include pain with bending, lifting and twisting. First-line treatment is generally conservative. This includes physical therapy, extension-based exercises such as the McKenzie Protocol, acupuncture, weight loss, a short-term back brace, non-steroidal anti-inflammatories drugs such as ibuprofen and/or muscle relaxants.  Proper positioning such as kneeling or reclining can relieve the disc pressure.  Lifestyle modifications including weight loss, smoking cessation and proper positioning can help reduce stress on the spine and slow down further degeneration. Typically, a combination of these will improve many of the symptoms. More invasive treatment such as local facet injections with steroids can also be useful.  This is because with moderate-severe degenerative disc disease, the facet joints start taking more of the load than they are functionally designed to.

A few other treatments such as facet rhizotomy have been shown to temporarily relieve pain. This procedure involves a radiofrequency current that deadens the nerves around the facet joint, thereby preventing the pain signals from reaching the brain. Patient’s that initially respond well to local facet joints may be a candidate for this procedure. On average, pain relief from this can last up to a year.

A newer procedure called intradiscal electrothermal annloplasty (IDET) involves a getting a catheter into the disc and then heating it.  Studies have shown that a possible mechanism of pain reduction is due to the heat allowing the collage to contract, and thus repair the damaged disc.  However, the evidence behind this still remains weak.

Surgical treatment involves removal of the whole or affected disc (termed total discectomy or partial discectomy) with or without spinal fusion. The fusion part of the surgery will furthermore reduce the movement in the damaged spine segment. In recent years, your surgeon can also replace the disc with artificial disc replacement. The long-term effects of these surgeries are yet to be definitely studied.

References:

Deyo RA, Loeser JD, Bigos SJ. Herniated lumbar intervertebral disk. Ann Intern Med 1990; 112:598.

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol 2015; 36:811.

Yin R, Lord EL, Cohen JR, et al. Distribution of Schmorl nodes in the lumbar spine and their relationship with lumbar disk degeneration and range of motion. Spine (Phila Pa 1976) 2015; 40:E49.

Iannuccilli JD, Prince EA, Soares GM. Interventional spine procedures for management of chronic low back pain-a primer. Semin Intervent Radiol. 2013;30(3):307–317. doi:10.1055/s-0033-1353484

Freeman BJ. IDET: a critical appraisal of the evidence. Eur Spine J. 2006;15 Suppl 3(Suppl 3):S448–S457. doi:10.1007/s00586-006-0156-2

Aichmair A, Du JY, Shue J, et al. Microdiscectomy for the treatment of lumbar disc herniation: an evaluation of reoperations and long-term outcomes. Evid Based Spine Care J. 2014;5(2):77–86. doi:10.1055/s-0034-1386750

Cui XD, Li HT, Zhang W, Zhang LL, Luo ZP, Yang HL. Mid- to long-term results of total disc replacement for lumbar degenerative disc disease: a systematic review. J Orthop Surg Res. 2018;13(1):326. Published 2018 Dec 26. doi:10.1186/s13018-018-1032-6

Beatty S. We Need to Talk about Lumbar Total Disc Replacement. Int J Spine Surg. 2018;12(2):201–240. Published 2018 Aug 3. doi:10.14444/5029