Degenerative Disc Disease

Definition/Description

Degenerative disc disease (DDD) represents a broad category of back pain caused by or associated with disc degeneration [1]. It involves the process by which the intervertebral discs lose height and hydration. When this happens, Guangpan cannot complete its main task Function of cushioning and providing movement between vertebrae. While the exact cause is unknown, it is thought to be related to the aging process in which discs become dehydrated, lose their elasticity and collapse. Despite its name, degenerative disc disease is not A disease, but a natural phenomenon that comes with aging [2]. Degenerative disc disease can occur at any level of the spine, but is most common in the cervical and lower lumbar regions. [3][4][5]

Clinically Relevant Anatomy

Lumbar DDD, a condition with the potential to cause low back pain, results from the coexistence of two distinct timescales, the slow dynamics of disc degeneration and the rapid dynamics of pain recurrence. [6]

Lumbar DDD can also mean radiating pain from damaged discs in the spine. The lumbar discs act as shock absorbers between the two vertebrae, allowing the joints and spine to move easily. The outer region of the disc, the annulus fibrosus, surrounds the disc’s soft inner core, the nucleus medulla. As we age, the discs in our spine undergo degenerative changes, but not everyone experiences symptoms from these changes. Neuroinflammation is one such possible cause of pain. When the outer part of a disc ruptures, the inner core leaks out, releasing a protein that stimulates nerves organize. Another cause is that the discs can no longer absorb pressure, causing abnormal movement around the spinal segment and causing back muscles to spasm as they try to stabilize the spine. In some cases, this segment may collapse, causing nerve root compression and radiculopathy. often pain Decreases over time as inflammatory proteins dissipate and the disc collapses into a stable position. [7]

Intervertebral Discs

Intervertebral Discs

Degenerative disc disease is thought to begin with changes in the intervertebral disc and the fibrotic ring of subchondral bone. The degenerative processes fall into three categories: early dysfunction, intermediate instability, and final stabilization.

• Early dysfunction is the beginning of degenerative changes that can occur as early as 20 years.
• Central instability is classified by mild annulus fibrosis, which can cause lumbar pain.
• Final stabilization is where fibrosis develops in the posterior structures and osteophyte formation. Both pain and movement are reduced. [8]

Epidemiology /Etiology

Intervertebral Discs in situ

Degenerative disc disease is so common that it is estimated that at least 30% of people ages 30-50 will experience some degree of disc degeneration, although not all experience pain or receive a formal diagnosis. [9] Pain is often caused by simple wear and tear, which is General aging process. It can also be the result of a lower back sprain.

The process leading to DDD begins with structural changes. Annular fibrosis loses water over time, which makes it increasingly difficult to withstand the daily stress and strain on the spine. The loss of compliance in the disc causes the force to change from The front and middle to the back of the facets cause facet arthritis. It can also cause hypertrophy of the vertebral body adjacent to the degenerated disc. These overgrowths are called bone spurs or osteophytes.

Characteristics/Clinical Presentation

DDD often occurs with other diagnoses, such as:

• idiopathic low-back pain
• lumbar radiculopathy
• myelopathy
• lumbar stenosis
• spondylosis[5]
• osteoarthritis
• Facet joint degeneration [8]

Activities that often increase pain include:

• Sitting for extended periods of time
• Rotating, bending, or lifting

Activities that usually relieve pain include:

• Frequent changes in positions
• Lying down
• Staying active [10]

Differential Diagnosis

Low back pain is common in individuals with DDD [11], with varying degrees of severity between individuals. Pain is usually chronic but can also be chronic with varying episodes of exacerbation [10]

The degree of annular damage is different [3], which is divided into 5 grades. These grades are differentiated by contrast injection.

• Grade 0: no disruption
• Grade 1: Contrast agent enters cartilage endplate through tear
• Grade 2: Contrast agent flows into the bone endplate
• Grade 3: Contrast agent enters the cancellous bone of the vertebra below the endplate
• Grade 4: Complete leakage of contrast agent in cancellous bone.

Diagnostic Procedures

Provocation discography is a diagnostic test used to identify painful discs. A discography combined with a CT scan after a discogram is used to assess the extent of disruption. [3] X-ray findings can also be used to diagnose DDD. Front-back and side views were taken with the presence Osteophytes with narrowing of the intervertebral disc joint space or “vacuum sign” are noted. [12]

Outcome Measures

No unified outcome measurement system has been reported in the literature. The most common form of outcome measure for DDD is the Oswestry Disability Index (ODI) combined with other forms of outcome measures such as: Short Form 36 (or SF-12) Questionnaire Self-Paced Walk Timed Test (TUG) Visual Analogue Scale (VAS) and Roland-Morris Disability Index (RMDI) [13][14].

Carreon found that the Oswestry Disability Index was a good primary outcome measure for lumbar fusion and non-surgical interventions for various symptomatic degenerative spinal conditions [15], but further research is needed.

Examination

The patient’s medical history is an invaluable tool in identifying the disc as the source of the injury. Patients may have a history of chronic low back pain as well as hip symptoms and spinal stiffness that worsen with activity and tenderness in the area involved. [12]

Mood and anxiety disorders are associated with neurological deficits [16] and are more common in patients with lumbar or cervical disc herniation than in those without. However, no relationship was found between pain severity and mood or anxiety disorders. These diseases may be Diagnosis using the Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders

MRI is the most commonly used method to specifically evaluate disc degeneration. Delineation of disc hydration and morphology based on proton density water content and chemical environmental MRI. Pfirrmann et al. Design a Grading System for Intervertebral Disc Degeneration Based on MRI Signal Intensity This useful grading system of nuclear ring structure distinction and intervertebral disc height [17] has been accepted and applied clinically.

The revised system includes 8 grades of lumbar disc degeneration. [18] Sagittal T2-weighted images are used for classification as they provide a comprehensive perception of disc architecture and good tissue differentiation. 8 grades represent progression from normal disc to severe disc Grade 1 corresponds to no disc degeneration and grade 8 corresponds to advanced degeneration. In addition to the 8-level table, there is also an image reference panel. [18]

Medical management

For patients with chronic low back pain due to disc degeneration, the preferred treatment option is conservative management with physical therapy and drug therapy. [19]

Conservative treatment includes rest, adequate exercise stimulation, regular physical activity, muscle strengthening, pain medication, physical therapy rehabilitation programs, and lifestyle modifications such as weight loss. [20] Drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) And acetaminophen (such as Tylenol) help patients feel confident enough to carry out daily activities. Stronger prescription medications, such as oral steroid muscle relaxants or narcotic pain relievers, may also be used for short-term control of severe pain episodes, some Patients may benefit from epidural steroid injections. Epidural steroid injections can relieve low back pain by delivering medication directly to the painful area to reduce inflammation.

[21]

Animal experiments with mesenchymal stem cells have demonstrated successful results. [20][3] Surgical interventions include disc replacement and lumbar fusion[3][20] to relieve chronic low back pain. [twenty two]

Intervertebral assisted motion devices (DIAMs) are another surgical management option for the treatment of DDD. DIAM is a polyester-encased silicone interspinous dynamic stabilization device that unloads the anterior column and reestablishes the functional integrity of the posterior column Pillar. This device is designed for preservation of functional spinal units. [twenty three]

Lumbar total disc replacement (TDR) is an option in cases where patients do not respond to nonsurgical treatments. Patients with symptomatic single-level lumbar DDD who had failed at least 6 months of nonsurgical treatment were randomly assigned to Investigational TDR device (also known as: TDR activL device) or FDA-approved control device. After a 2-year study, these devices were found to be safe and effective in treating symptomatic lumbar DDD. [twenty four]

Physical Therapy management

One of the main purposes of physical therapy is to relieve pain. Using a variety of physical modalities, including heat and cold applied traction spinal manipulation [25] [26] [27] exercise programs and electrical stimulation such as “TENS” and “pulsed radiofrequency (PRF)” Treatment [28] and lifestyle changes (such as weight loss and smoking cessation) [29] Among exercise methods, McKenzie core strengthening and core stabilization exercises with no-load movement-promoting exercises are effective in reducing pain in degenerative disc disease. [30]

Spinal manipulation Spinal manipulation is traditionally used to relieve low back pain, but the effects are usually only temporary. HVLA (High Speed Low Amplitude) is a procedure that includes many different techniques and may involve initial preparation of the joint and its The surrounding tissue adopts methods such as stretching and assisted movement. Both load forces and moments are applied to the joint, and it moves to its end range of voluntary motion. The pulse is then applied, and the payload is the sum of the force applied by the therapist plus the inertial force The forces generated by the movement of body parts and the internal tension generated by the client’s muscular reactions. [31]

This technique immediately improved self-perceived pain in spinal flexion and hip flexion during passive SLR testing [32], but Paige et al. reported only modest improvements in pain and (transient) minor musculoskeletal injuries [33] Can Patients with LBP considered as a treatment option need to be screened for possible serious pathology. There are two reasons for this: some conditions, such as fractures, can affect the mechanical integrity of the spine and make SMT distinctly dangerous. not recognized in other contexts Circumstances delayed initiation of more appropriate care. For example, early detection and treatment of spinal malignancies are important to prevent the spread of metastatic disease and the development of further complications such as spinal cord compression. Applications where any SMT exists Red flags are considered contraindications to SMT until further investigation excludes other conditions.

Core stability strength training is designed to enhance core stability by strengthening and improving the coordination between the abdominal and back muscles. [34] Stabilization exercises will increase the patient’s ability to resist higher loads on the degenerated disc [35]. this is a key element Prevent and treat injury as muscle tissue loses 1 kg per year after age 40. [36] Post-dynamic stabilization programs will significantly improve pain and disability. [37] [38] Training 1–3 times per week can reduce pain and Once the pain subsides and the patient is able to resume their work and hobbies/activities and is able to stop analgesics, it should continue [39].

Perform exercises to reduce pain and ensure stability by strengthening the hip extensors, hip flexor abs, and sacrospinalis muscles. [40] Other important exercises include engaging the pelvic musculature to restore body symmetry, such as the back extensors and abdominal muscle. The Williams Method recommends stretching the back extensors and strengthening the abdominal muscles to relieve some of the stress placed on the lumbar discs. [41] [42]

An example Williams flexion exercise program follows:

• Pelvic Tilt – Lie on your back with your knees bent, press your back into the floor and hold this position for up to 10 seconds.

• Single or double Knee to chest – Lying on the back with knees bent, one is pulled up to chest level and held for up to 10 seconds.This can be done with one or two knees at a time.

• Partial crunches – Start in a pelvic tilt position and lift your shoulders off the ground. Hold for 2-10 seconds per repetition

• Hamstring stretch

• Hip Flexor stretch

• Squats – Done correctly this is a great overall exercise that works the full body and trunk control recruitment and lower back strength.

Core stability exercises are recommended in conjunction with these exercises. Motivating and engaging the transverse abdominis is key to creating a stable base for performing other exercises, including strength exercises. [43]

Exercises can be performed to: Curls Side Planks Tummy Planks Bridge and alternate leg and arm lifts in a four-point kneeling position. This can be done to lift opposite arms and legs at the same time. The spine should remain neutral during these exercises The position has no compensatory movements and the pelvis does not tilt. [43] Balance and coordination exercises related to individual sports can also be added to the program. [43] [44]

For patients with degenerative disc disease, adding behavioral therapy to the treatment plan is also recommended due to the psychological impact of the disease, as patients may associate ongoing pain and long-term degeneration with their back becoming increasingly weak . This additional therapy has Has been shown to give better results. [8] These false thoughts often induce a fear of movement and may lead to avoidance of spinal movements. [35] Education and advice can also improve patient compliance [45] by helping them overcome their fears and adapt their coping Strategy. Staying active and physically active did not adversely affect their spines [8], and doing low-intensity aerobic exercise actually benefits the spine by increasing nutrients and blood flow to spinal structures and reducing pressure on the intervertebral discs. Single positions for extended periods of time should also be avoided as much as possible. Back care is a lifelong process and patients should be encouraged to maintain regular activity. [35][8]

Do stretches to move the pressure on the disc forward. Some exercises are:

• Hollowing the back
• Making a sphinx posture
• Gym ball exercises

Physiotherapy should aim to promote peridiscal healing by stimulating cells to facilitate metabolite transport and prevent adhesions and re-injury. This approach has the potential to speed up pain relief around the disc, even if it doesn’t reverse age-related degeneration Changes in the nucleus [46]

In the conservative management of discogenic back pain, the use of low-level laser therapy is another possible option with positive clinical outcomes of more than 90%, with lasting benefits not only in the short term but also in the long term. In their study, Ip and Fu conducted three Treatments were given weekly for a period of 12 weeks. Significant improvement was seen in 49 of 50 patients on the Oswestry Disability Index score [47], but this requires more research.

Clinical Bottom Line

DDD is a condition in which the intervertebral discs lose height and water, so the discs cannot perform their primary function. While the exact cause of DDD is unknown, it is thought to be primarily related to the aging process. the most common position The processes are located in the cervical and lower lumbar regions of the spine.

Diagnosis is made by x-ray, and to accurately identify painful discs, a provocative discography test is used. A common outcome measure is the Oswestry Disability Index combined with questionnaires such as the VAS and SF-36.

Various concepts of medical management are used to treat DDD. Surgical techniques may be considered when pain persists despite conservative treatment efforts. A few examples of surgical treatments are:

• DIAM interspinous spacer[48][49]
• Disc arthroplasty
• Lumbar spinal fusion
• Total disc replacement

However, the preferred treatment option is conservative management, including physical therapy and pain medication. The goal of physical therapy is to relieve pain to increase overall strength and core stability, and to inform and advise patients about the disease so that they can subsequently Effective self-management over the long term.