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Friday, November 8, 2013

Patient Information: Lumbar (low back) Degenerative Disc Disease explained with Color X-Ray and MRI - Part II

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How do spine specialists diagnose Lumbar Degenerative Disc Disease?

A history and physical exam can be helpful in pointing towards DDD, but imaging studies are typically the best way to make a diagnosis.

1.     History

The patient’s history may point at genetics, smoking, obesity, or physical work, which predispose the patient to DDD. Prior injuries or disc surgery can also be a red flag.

Low-back pain which has gradually gotten worse and causes stiffness and muscle spasms is suggestive of DDD.

2.     Physical Examination

Lack of spinal mobility and pain with forward bending can point towards DDD.

Here are some common examinations done to evaluate a patient for Lumbar DDD:
a.     Range of motion (mobility)
b.     Palpation (touch and pressure) of the spine
c.      Sensation testing of the legs
d.     Muscle (motor) testing of the legs
e.     Reflex testing of the legs
f.       Gait testing

3.     Imaging

a.     X-Rays

This image is an X-Ray of the low-back (lumbar spine) taken from the side. The front of the spine is to the left, the back to the right. A disc has undergone the process of Degenerative Disc Disease (DDD). It has lost much of its height. 

X-Rays provide a good view of the bone anatomy of the spine. It is also useful to evaluate the height of a disc between the vertebrae. The loss of disc height on a plain X-Ray is usually the first indication of DDD. In later stages, the tops and bottoms (endplates) of the vertebrae next to the degenerated disc will appear flatter and may have bone spurs (osteophytes). Similarly, the facet joints in the back of the spine may show enlargement of the bones (articular processes) making up the joint. The facet joint space will also diminish.
 b. MRI

This image is an MRI scan of the low-back (lumbar spine) showing the spine from the side. The front of the spine is to the left, the back to the right. The vertebrae are shown in orange. Normal discs can be seen in green. A Disc has undergone the process of Degenerative Disc Disease (DDD) which is pointed out by the arrow. This disc is much smaller in height than the normal discs. Bone spurs are also forming at the Vertebrae next to the degenerated disc.
MRI imaging can be very useful in evaluating the disc itself to assess the degree of degeneration. The hydration left in the disc can be seen on particular MRI views. The impact of the DDD with on the other structures of the spine such as the Spinal Cord, Spinal Nerves, and Ligaments can be seen directly.
c. Cat Scan
This image is a CT scan of the low-back (lumbar spine) which shows the spine from the side. The front of the spine is to the left. A disc has undergone the process of Degenerative Disc Disease (DDD). It has lost most of its height.
CT scans are best used to evaluate bone anatomy. The disc itself can be difficult to evaluate on a CT scan. However the effect of DDD on the adjacent vertebral bodies and joints (facet joints) can be seen.
               What treatments are offered for Lumbar Degenerative    
               Disc Disease?
DDD does not have to be a painful disease. Many patients have few or occasional symptoms. The following are some treatment options for those who do have symptoms:
1.     Non-Surgical Care

a.     Alternative Health Care
Alternative Health care options can often complement conventional medical care. Massage Therapy, Acupuncture, Meditation exercises and Herbal Remedies can all help with the pain from this condition. Massage Therapy techniques can help with the muscle discomfort of thoracic degenerative disc disease.
b.     Nutrition and Weight Loss
Proper nutrition and weight loss can have a positive impact on many spine conditions. Excess weight on the spine often contributes to the symptoms of pain and spasms (Spine and Obesity).
c.      Chiropractic Care
Chiropractic care including manipulation and adjustments of the spine can help with the pain and spasms from this condition.
d.     Spine Exercises
Spine exercises can help with the muscle pain and tightness from this condition. Exercise also increases the amount of oxygen delivered to the spine which can help with healing. Pilates, Yoga and T’ai Chi can help maintain the spine’s flexibility. Exercising the spine can be a form of “preventative maintenance” over time. The focus should be on spine mobility and stability.
e.     Physical Therapy (PT)
PT has many modalities to offer for this condition. They can range from Manual Therapy and Exercises to Traction and Ultrasound Treatments. PT can be helpful for DDD. Keeping the spine’s mobility, strength and stability are often goals of PT. Spine traction can be a useful treatment in early DDD. As the disease progresses, the disc and its spine segment may stiffen to a point where traction may not be helpful any longer.
f.       Self Help Tools
Self Help Tools are items which can be purchased to help with back pain. They range from Back Braces to Back Mattresses and Ergonomic Devices such as chairs and computer accessories. Sometimes back braces can add stability to the spine. However this must be balanced against relying too much on the brace, which could weaken the muscles over time.
g.     Spine Medications
Similar to other spine conditions, medications which help with spine pain can help with the symptoms of DDD. While there is no “best medication”, the spine specialist can prescribe one or a combination of the medications below. Here are some examples of groups of medications:
1.     Non-Steroid Anti-Inflammatories Drugs(NSAIDS)
2.     Muscle Relaxants
3.     Pain Killers
4.     Nerve Pain Medications
5.     Antidepressants
h.     Injections
Spine injections can frequently be helpful for pain from DDD. In some patients, the disc or spinal nerve becomes inflamed. In this scenario, epidural steroid injections can help relieve the inflammation and pain. In other patients, the spine joints (facet joints) become inflamed when the disc degenerates.
These joints can also be treated with injections. In other patients, the spine muscles become tight and painful. Muscle injections for these chronic spasms may also be effective.
Here are some of the injections used for lumbar DDD:
1.     Lumbar Trigger Point Injections
2.     Lumbar Muscle Blocks
3.     Lumbar Interlaminar ESI
4.     Lumbar Transforaminal ESI
5.     Lumbar Nerve Root Block
6.     Lumbar Facet Joint Injection
7.     Lumbar Medial Branch Block
8.     Lumbar Radiofrequency Rhizotomy of the Facet Joint

2.     Surgical Care
Surgical care for DDD is reserved for patients who have severe symptoms and a poor quality of life. An isolated disc segment may respond better to a surgical treatment than multiple segments of DDD. Here are some potential surgical treatment options of Lumbar DDD:
1.     Minimally Invasive Spine Surgeries:
a.     Mini-Transforaminal Lumbar Interbody Fusion
b.     Axial Lumbar Interbody Fusion
c.      Interlaminar Lumbar Instrumented Fusion
2.  Spine Surgeries
a.     Lumbar Fusion
b.     Lumbar Artificial Disc Replacement
c.      Lumbar Dynamic Stabilization


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