Pain Conditions Treated

Degenerative disc disease is a condition that is commonly misunderstood. A degenerated disc is not actually a disease—it is part of the normal aging of the spine. When a spinal disc degenerates, it loses its ability to function efficiently as part of the spinal joint, which in turn can lead to back pain and possibly pain that radiates through the extremities.

Degenerative disc disease describes a group of symptoms that may result from the gradual wear and tear of spinal discs or from an acute spinal injury. 

Degenerated disc disease is typically associated with aging. As you age, your discs can degenerate and become problematic. Degenerative disc disease involves the intervertebral discs, which is the cushion between your vertebrae in your spine. They help your back carry weight and allow complex motions of the spine while maintaining its stability.

As you age, the discs can lose flexibility, elasticity, and shock absorbing characteristics. They also become thinner as they dehydrate. When all that happens, the discs change from a supple state that allows fluid movement to a stiff and rigid state that restricts your movement and causes pain. Developing degenerative disc disease is a gradual process. Although most degenerative disc disease patients respond well to non-surgical treatments, such as cortisone injections, some patients do need surgery. Surgery should be considered only after you’ve tried several months of non-surgical treatment

Diagnosing Degenerative Disc Disease

The following process is typically used to diagnose degenerative disc disease:

• A medical history is collected that details current and past symptoms of neck or back pain, including when the pain started, how often pain occurs, where pain is felt, and the severity of pain and its impact on mobility. A medical history may also include information on sleep and dietary habits, exercise and activity level, and how symptoms are eased or worsened by activity or posture.
• A physical exam is conducted, which may include feeling along the spine for abnormalities (palpation), a reflex test, and/or a range of motion test that includes bending the spine forward, backward, or to the side.
• An imaging test may be ordered in some cases to find or confirm disc degeneration in the spinal column. An MRI scan is usually used for suspected disc degeneration, which can show disc dehydration, tears or fissures in the disc, or a herniated disc. A dehydrated disc may be referred to as a dark disc or black disc, because it looks darker on an MRI scan.

   

It is important to note that the amount of pain does not correlate to the amount of disc degeneration. Severely degenerated discs may not produce much pain at all, and discs with little degeneration can produce severe pain—a handful of studies have found prevalent disc degeneration in people not experiencing any disc pain.

For this reason, a diagnosis of degenerative disc disease should always rely on a combination of a medical history, a physical exam, and any imaging tests ordered.

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.

A degenerating spinal disc does not always lead to pain or other symptoms. Because the disc itself has very little innervation, pain usually occurs when the degenerating disc affects other structures in the spine (such as muscles, joint, or nerve roots).

Pain associated with degenerative disc disease generally stems from two main factors:

1. Inflammation. Inflammatory proteins from the disc space interior can leak out as the disc degenerates, causing swelling in the surrounding spinal structures. This inflammation can produce muscle tension, muscle spasms, and local tenderness in the back or neck. If a nerve root becomes inflamed, pain and numbness may radiate into the arm and shoulder (called a cervical radiculopathy in cases of cervical disc degeneration), or into the hips or leg (called a lumbar radiculopathy, in cases of lumbar disc degeneration).
2. Abnormal micro-motion instability. The cushioning and support a disc typically provides decreases as the disc’s outer layer (the annulus fibrosis) degenerates, leading to small, unnatural motions between vertebrae. These micro-motions can cause tension and irritation in the surrounding muscles, joints, and/or nerve roots as the spinal segment becomes progressively more unstable, causing intermittent episodes of more intense pain.

Both inflammation and micro-motion instability can cause lower back or neck muscle spasms. The muscle spasm is the body’s attempt to stabilize the spine. Muscle tension and spasms can be quite painful, and are thought to cause the flare-ups of intense pain associated with degenerative disc disease.

What Happens in The Spine During Disc Degeneration?

Degenerative disc disease primarily concerns a spinal disc, but will most likely impact other parts of the spine as well. The two findings most correlated with a painful disc are:

• Cartilaginous Endplate Erosion. Like other joints in the body, each vertebral segment is a joint that has cartilage in it. In between a spinal disc and each vertebral body is a layer of cartilage known as the endplate. The endplate sandwiches the spinal disc and acts as a gatekeeper for oxygen and nutrients entering and leaving the disc. As the disc wears down and the endplate begins to erode, this flow of nutrition is compromised, which can hasten disc degeneration. As the disc goes through this process, the disc space will collapse.
• Disc space collapse. As a disc degenerates the disc space will collapse, placing undue strain on the surrounding muscles as they support the spine and shortening the space between vertebrae, leading to additional micro-motion and spinal instability.

The degenerative processes typically progress gradually rather than all at once. Endplate erosion and disc space collapse can add to spinal instability, tension in the surrounding muscles, and both local and nerve root pain.

What Are the Symptoms?

You’ll probably feel a sharp or constant pain in your back and neck. Your exact symptoms depend on where the weak disk is and other changes it has caused.

Common signs include pain that:

• Is in your lower back, buttocks, or upper thighs
• Comes and goes. It can be nagging or severe, and can last from a few days to a few months.
• Feels worse when you sit, and better when you move and walk
• Feels worse when you bend, lift, or twist
• Gets better when you change positions or lie down
• In some cases, degenerative disk disease can lead to numbness and tingling in your arms and legs. It can also cause your leg muscles to become weak. This means the damaged disks may be affecting the nerves near your spine.

Degenerative disc disease is frequently the cause of low back pain, especially in young adults.

Although this condition can cause lower back pain symptoms over a long period of time, the good news is that the pain is usually manageable with various conservative treatment options (meaning back care that doesn’t involve surgery).

Low Back Pain and Degenerative Disc Disease Treatment Goals

The vast majority of people with degenerative disc disease experience low back pain symptoms that flare up periodically, but don’t get worse over time. For those people, the main goals for managing lower back pain caused by degenerative disc disease are usually:

• Achieving enough pain relief to be able to engage in lower back pain exercises and a rehabilitation program
• Preventing the application of excess stress on the disc through proper ergonomics and posture
• Trying to manage the low back pain and maintaining an ability to function enough at home and at work.

Most types of surgery for ongoing, debilitating pain and loss of function from degenerative disc disease are fairly extensive, so it is usually in the best interest of most patients to manage their low back pain using non-surgical approaches and self-care. Over time, the low back pain and other symptoms of degenerative disc disease will usually subside. This happens because the disc starts to become stiffer with age, and a stiffer disc stabilizes the motion segment and thus reduces pain. However, this is a very slow process that occurs over many years.

Lower Back Pain Treatment for Degenerative Disc Disease

Pain from degenerative disc disease is caused by a combination of instability at the motion segment and inflammation from the degenerated discs. Both the instability and the inflammation have to be addressed for the back pain treatment to be effective.

The treatments for degenerative disc disease are either passive (done to the patient) or active (done by the patient). Usually, a combination of treatments is used to help control the symptoms. Passive treatments are rarely effective on their own—some active component, such as exercise, is almost always required.

Passive treatments for low back pain from degenerative disc disease may include:

• Pain medication. Typical pain medications used to treat the low back pain include acetaminophen, NSAIDs, oral steroids, narcotic drugs, and muscle relaxants. Each type of medication has strengths, limitations, and risks, and the patient’s particular low back problem and overall health will determine which pain reliever, if any, is indicated.
• Chiropractic manipulation. Manual manipulation by a chiropractor or other qualified health professional is thought to provide lower back pain relief by taking pressure off sensitive neurological tissue, increasing range of motion, restoring blood flow, reducing muscle tension, and creating a series of chemical reactions in the body (such as endorphin release) that act as natural painkillers.
• Epidural injections. An epidural injection into the spine delivers steroids that can provide low back pain relief by decreasing inflammation in the painful area.
• TENS units. These devices deliver mild electrical stimulation that overrides the painful signals sent to the lower back.
• Ultrasound. For acute back pain in the low back, ultrasound may be used to warm the area, which in turn brings blood flow and healing nutrients to the area.
• Massage. Therapeutic low back massage is thought to provide low back pain relief by improving blood flow, reducing muscle stiffness, increasing range of motion, and raising endorphin levels in the body.

   

In addition, heat and/or ice therapy, acupuncture, behavioral therapy, and other therapies often provide enough low back pain relief to allow the patient to progress with his or her exercise and rehabilitation program.

Active Lower Back Pain Treatments

Some active treatments for lower back pain can include:

• Exercise. For the vast majority of patients, the only way to achieve long-term healing is active exercise, which usually includes a combination of strengthening, stretching and low-impact aerobic exercise.
• Quitting smoking. For patients who smoke, doctors recommend quitting smoking to improve blood circulation and healing. Chronic tobacco use is closely linked to chronic pain in the lower back.
• Weight loss. Losing weight can reduce low back pain in overweight people by lessening the amount of stress on the low back’s muscles and ligaments.
• Ergonomics. Proper lifting techniques, ergonomic furniture, supportive footwear, and avoiding static posture for prolonged periods of time can help take pressure off the low back.

Degenerated Disc Disease Treatment: Why Choose Bay State Pain Associates

• Our pain specialists use high-precision diagnostic techniques that allow them to identify the location and degree of disc degeneration with high accuracy.
• Cervical, lumbar and thoracic degenerative disc disease, as well as bulging and herniated discs, are some of the disc-related conditions our specialists are experienced in treating.
• If you are a candidate for nonsurgical or minimally invasive spine treatment, our experts will try these approaches first before considering surgery for degenerative disc disease.
• Skilled in complex spine revision surgeries, our specialists also work with patients who had prior spine surgery that didn’t resolve their pain.
• If degenerative disc disease leads to or worsens spinal stenosis, or radiculopathy, our pain experts can help address these conditions as well.

Treatment for degenerative disc disease typically starts with nonsurgical methods that may provide sufficient symptom relief. When you request an appointment with one of our pain specialists, he will carefully examine you and your MRI scans to determine which treatment approach will best meet your health goals.

Nonsurgical Treatment

• Pain control focuses on reducing pain from the damaged disc and helping you return to your daily activities. Methods of pain control may include anti-inflammatory medications, manual manipulation, steroid injections, electrical stimulation, back braces or heat/ice therapy.
• Physical therapy can help stretch and strengthen the right muscles to help the back heal and reduce the frequency of painful flare-ups.
• Lifestyle modifications, such as changing your posture, losing weight or giving up smoking, can sometimes help reduce stress on the damaged disc and slow down further degeneration.

Surgical Options

Surgical options are available for people who experience severe pain or significant loss of function and don’t respond to other treatments. The surgery may involve removal and replacement of the whole or a part of the affected disc (partial or total disc replacement). Another option is disc removal (discectomy) with spinal fusion that reduces the movement in the damaged spine segment.

Surgery to address degenerative disc disease is usually only recommended if pain is severe and nonsurgical treatments, such as pain medications and physical therapy, are ineffective. The goal of surgery is to alter the underlying mechanisms in the spine causing pain, such as excessive micro-motion, inflammation, and/or muscle tension. 

Prior to deciding whether to have surgery for degenerative disc disease, patients should consider the risks and benefits. 

Nonsurgical treatments are typically suggested for no less than 6 to 12 weeks before surgery is considered, although in most cases nonsurgical treatments are used for much longer. It is estimated that only between 10% and 20% of lumbar disc degeneration cases and up to 30% of cervical disc degeneration cases are not successfully treated using nonsurgical methods, and warrant surgery to relieve pain and improve mobility.

There are several factors to consider before opting for surgical treatment if it is recommended, including:

• Recovery process. The recovery period following spinal surgery can consist of a combination of physical therapy, pain medications, or wearing a back or neck brace
• Lifestyle considerations. The everyday lifestyle changes needed for either nonsurgical or surgical treatment may be considerable. In the case of surgery, a long recovery process may require significant time off from work. Additionally, regular physical therapy, and pain management will be required for optimal results.
• Imaging evidence of disc degeneration. Spinal surgery for degenerative disc pain is typically only recommended if an imaging scan correlates to the specific cause of pain, and even then outcomes are not always predictable.

Spinal surgery is always elective, meaning it is the patient’s choice whether or not to have the procedure. A spinal fusion is the most common procedure used for degenerative disc pain. In recent years, artificial disc replacement has become more widely used as devices and surgical methods have improved.

Spinal Fusion for Degenerative Disc Disease

During a spinal fusion surgery, two adjacent vertebrae are grafted together to alter the underlying mechanisms causing pain. A fused joint eliminates instability at a spinal segment, reducing pain caused by micro-motions, muscle tension, and/or inflammation. Joint fusion can also allow for a more thorough decompression of pinched nerves.

A spinal fusion procedure typically consists of the following steps:

• Under general anesthesia, an incision is made to approach the spine. For a cervical fusion, the incision is usually made in the front of the neck. For a lumbar fusion, an incision may be made in the back, front, or side of the body.
• Muscles surrounding the spine are cut away or pushed to the sides to access the spine.
• The degenerating disc is removed from the disc space.
• A bone graft and/or instruments are implanted across the disc space to stabilize the spinal segment and encourage bone growth.
• The spinal muscles are replaced or reattached, and the incision site is closed with sutures.

A fusion surgery sets up the mechanisms for bone growth, and the fusion occurs in the months following the procedure. For this reason, the complete recovery process from a fusion surgery can last up to a year, although a majority of patients are back to their regular activities within six weeks.

Following surgery, use of a back or neck brace may be advised to keep the spine stabilized and to minimize painful movements that can undermine the healing process. Additionally, physical therapy is usually recommended to condition the muscles to better support the spine, and pain medications are prescribed to manage post-surgical pain.

Artificial Disc Replacement Surgery

Degenerative disc pain can also be significantly reduced or eliminated by implanting a device that mimics the natural support and motion of a spinal disc in a procedure called Artificial Disc Replacement (ADR). Unlike a spinal fusion, this procedure is intended to maintain motion at a spinal segment after surgery.

In this procedure:

• The spine is approached through a small incision under general anesthesia. During a cervical ADR, the incision is usually made in the front of the neck; during a lumbar ADR, the incision is usually made in the back directly over the spine.
• The muscles are moved to the side or cut away from the spine.
• The degenerated disc is removed entirely, as is any degenerated portions of the spinal joints or adjacent vertebrae in the disc space.
• The artificial disc is inserted into the disc space using x-ray imaging to guide the device. Some devices also include metal plates that are attached to either vertebrae facing the disc space.
• The muscles surrounding the spine are reattached, and the wound is closed.

Artificial discs are typically made of metal or plastic materials. The recovery process from an artificial disc replacement usually consists of a combination of pain medications, physical therapy, and possibly wearing a back or neck brace. Recovery from this procedure can take up to 6 months.