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Friday, June 20, 2014

What is Degenerative Disc Disease (DDD) of the Low Back (Lumbar Spine)?

Degenerative Disc Disease also known as "DDD" is a very common Spine condition, most of us will experience in our lifetime. The Spinal Discs are our natural "shock-absorbers" between the Vertebrae. After so many cycles of absorbing and distributing the weight of our body, the Discs will eventually shows signs of wear and tear.

                             What is a Spinal Disc?

Before we go into more detail about DDD, lets first take a look at the Spinal Disc and the Anatomy around it, to help us understand why DDD happens. The Image below is a MRI Scan which has been converted into Color to help you see the Anatomy more clearly. The whole body MRI on the left is designed to show you where in the body the Image on the right is taken from.
This Image is Interactive. Just move your Mouse Cursor over the Image and see the Image Tags come alive. Each tag displays text to explain a specific structure. If the Image tags do not display correctly due to slow Browser Speeds, just refresh the page.

Sagittal Lumbar Spine Color MRI of the Spine Anatomy
Interactive Color MRI of the Anatomy of the Low Back (Lumbar Spine)

Now that we have seen the Anatomy of the Low Back, lets talk about DDD.

                  Why do we get Degenerative Disc Disease?

DDD is the result of wear and tear on the Spine due to the combination of our constant exposure to gravity, the Spine's motion, and weight bearing over time. Genetics and small injuries sustained over time can cause DDD at earlier ages then otherwise expected.

Who is at risk to develop DDD at an earlier age?
1. Smokers - due to diminished blood supply and Oxygen to the Disc
2. People with careers which involve long periods of driving (truck drivers, etc.) - due to the vibration
3. People with a Family History of DDD - genetics
4. Patients with Obesity - increased weight on the Disc
5. Patients with a history of significant Spine trauma

Simply put, our Discs are similar to water-filled balloons. At Birth, our Discs are made up of roughly 80% water. So, the proper function of this "shock-absorber" is in good part related to the water content. Starting in the 3rd decade of life, we begin to lose some of the water inside the Disc. At the same time, some of the important proteins in the core of our Disc (called the "Nucleus) diminish as well. These proteins are replaced by tougher fibers called "Collagen" which do not attract and maintain water inside the Disc. This causes the Disc to get firmer and less flexible over time, just like a shock-absorber which wears out in our car. The loss of elasticity also causes the Disc to lose some of its height. This is the main reason why we shrink with age.

                    Is Degenerative Disc Disease Painful?

Only a small percentage of patients who have DDD actually experience ongoing back pain. Most patients only experience mild or intermittent back pain. How is that possible? The answer is likely very complex and has much to do with our individual body chemistry, our ability to tolerate and perceive pain, our overall mental and physical health, etc.
Studies have shown that up to 1/3rd of people in their 40's will have some signs of DDD on an MRI, yet less than 10% of them experienced symptoms.

                          Does DDD cause Bone Spurs?

As the Disc gets firmer and smaller, the Vertebrae next to the Degenerated Disc have to absorb more pressure and force. This causes Bone Spurs to develop. Depending on the location and size of these Bone Spurs, Spinal Nerves can become compressed potentially causing pain, numbness and weakness in the legs. This is called "Spinal Stenosis".

Here is a Color X-Ray which shows the Bone Spurs from DDD. Notice the red tips coming off the Vertebrae. These are the Bone Spurs.

AP Color X-Ray showing Degenerative Disc Disease (DDD) and Bone Spurs

                  What kinds of Symptoms does DDD cause?

As mentioned above, most people who have signs of DDD on X-Rays or MRI Scans do not actually have significant symptoms such as back pain. However for patients who do suffer symptoms, here are some common ones:

1. Low Back Pain, typically in the small of the back, radiating to the sides of the Spine
2. Low Back Pain which is worse with activity
3. Low Back Pain with forward bending
3. Low Back Pain which is worse when having to be in the same position for longer periods of time
4. Stiffness in the low back, often worse in the morning, improved during the day with activity
5. Muscle spasms in the Low Back
6. Loss of mobility in the Low Back
7. Leg pain, numbness and weakness if the DDD causes pinched Spinal Nerves

                        Does DDD cause Joint Pain as well?

Each segment of the Spine is made up of one Spinal Disc in the front of the Spine and two Spine Joints (Facet Joints) on the back of the Spine.

Lets take a look at another Color MRI of the Low Back (Lumbar Spine) to see the relationship between the Spinal Disc and the Spinal Joints (Facet Joints). This Image is also Interactive.

Axial Lumbar Spine Color MRI showing Lumbar Spine Anatomy
Interactive Color MRI showing the Spine Anatomy as a Horizontal Slice across the Low Back
What you saw in the Image above shows that the Disc and Facet Joints form a Triangle. When the Disc-part of the Triangle degenerates, more weight and mobility is transferred to the other two sides of the Triangle, which causes more stress on the Facet Joints. Like most joints in the Body, the Facet Joints are prone to degeneration and Arthritis. In this situation, both the Discs and Facet Joints can become a source of back pain. This can make a precise location and source of the Back Pain difficult. Sometimes more than part of our Spine's Anatomy causes symptoms of Back Pain.

                               How is DDD diagnosed?

Doctors typically use a combination of the patient's history, physical examination and Radiology Images (X-Ray, CAT Scan, MRI) to make the diagnosis of DDD. While the Radiology Images can show DDD easily, it can be difficult for doctors to determine that what the Images show is the actual source of the patient's pain. The patient history and physical exam can help narrow things down.

Here is what DDD can look like on a Color converted X-Ray. The red arrow points to a degenerated Disc. This Image is also Interactive.

Lateral Lumbar Spine Color X-Ray showing Degenerative Disc Disease (DDD)
Interactive Color X-Ray of the Low Back showing DDD
Next we can take a look at a Color Converted MRI of the Low Back to see what DDD looks like on an MRI. Notice how the Degenerated Disc has lost most of its height. This Image is also Interactive.

Interactive Color MRI of the Low Back (Lumbar Spine) showing DDD
Here is a Color MRI which shows a Disc suffering from DDD (red arrows) of the Low Back (Lumbar Spine) from the front. You can see some of the Organs such as the Kidneys (green) next to the Spine.

                                   How is DDD treated?

Depending on the severity of the DDD and how it impacts on a patient's quality of life, non-surgical and surgical options exist.

I. Nonsurgical Options:

a. Weight Loss
    Overweight patients can get some benefit from weight loss by reducing the weight loaded on the 
    Spine. In combination with exercise which can benefit the Spine Muscles, weight loss can be a
    significant "self-help" form of treatment for DDD.

b. Tobacco Cessation
    Nicotine reduces blood flow and Oxygen to the Spine and Spine Muscles. Stopping the Nicotine in
    combination with exercise can be another "self-help" method for patients with DDD.

c. Alternative Medicine
    Chiropractic Care can help by restoring and maintaining the mobility of the Spine which is often  
    lost due to muscle spasms and pain related to DDD.
    Acupuncture and Massage Therapy can also help control the pain and spasticity of the muscles in
    Alternative Medicine can open a window of opportunity to help patients become more active.

d. Physical Therapy (PT) and Spine Exercises
    PT often offers specific interventions such as Ultrasound treatments, Spine Traction, Manual
   Therapy and Exercises to help patients with DDD. The goals of PT treatments are to maintain and
   restore the Spine's function, maintain muscle balance, Spine stability, and mobility.

e. Self Help Tools
    These devices range from back braces and supports to ergonomic chairs, mattresses, pillows and
    inversion tables amongst others. It is generally best to research each item and read reviews.

f. Medications
   Medications used to treat pain related to DDD often involve Non-Steroid Anti-Inflammatory Drugs
   (NSAIDS, e.g. Ibuprofen, Naproxen Sodium, etc.), Muscle Relaxants, Pain Killers (Narcotic
   Medications, e.g. Codeine, Hydrocodone, Oxycodone, etc.), Topical Medications (pain relieving
   creams, e.g. Capsaicin, etc.), low dose Antidepressants, etc.

g. Spine Injections
   Pain Specialists (Anesthesiologists, Physiatrists, etc.) often use steroid based injections to help with
   pain related to DDD. Their effectiveness is often based on the origin of the pain which can be
   multifactorial in DDD. Aside from the Degenerated Disc, the Spine Joints (Facet Joints), Spine 
   Muscles, Ligaments, and Spinal Nerves can become a source of pain.
   Here are some commonly performed Spine Injections:
   1. Epidural Steroid Injections
   2. Facet Joint Injections
   3. Muscle Blocks
   4. Discogram

Here is a Color MRI of an Epidural Injection. This Image is also Interactive.

Sagitall Color MRI Lumbar Spine Epidural Injection
Interactive Color MRI of a Lumbar Spine Epidural Injection

II. Surgical Options

Surgery is typically only considered as an option if all conservative, less invasive options have been exhausted and a patient's quality of life is significantly impaired.

The surgical options depend in large part on the:

1. Severity of the DDD
2. Number of Discs affected by DDD
3. The Surgeon's certainty that the patient's symptoms are in fact related to DDD
4. The patient's health
5. Which types of surgical options are covered by the patient' insurance
6. Types of Surgeries offered by the Surgeon

Here are two commonly offered Surgeries as a treatment for DDD:

A. Artificial Disc Replacements (ADR)
ADR's replace a Degenerated Disc with an Artificial one. ADR's are typically performed for Discs suffering from moderate to moderate-severe Degeneration. The most severe forms of DDD may involve too much Degeneration of other parts of the Spine Anatomy (Facet Joints, Spinal Nerves, etc.) to be an option for ADR Surgery. The fear is that replacing the Degenerated Disc would not eliminate some of the other potential sources of back pain.
ADR Surgery is most commonly performed through the Abdomen which is the easiest way for Surgeons to gain access to a large part of the Disc. The majority of the diseased Disc is removed prior to the implantation of the ADR.
Two ADRs are currently FDA approved in the U.S. (Prodisc-L, Charite), however numerous other ones are either in development in the U.S. or available overseas.
The goal of ADR Surgery is to maintain some of the mobility of the diseased Disc segment.

Here are some Images of ADRs implanted in the Low Back (Lumbar Spine). The bottom Disc has been surgically fused, while the two Discs above are replaced by ADRs. This Image is Interactive.

Lateral Lumbar Spine Color X-Ray of Artificial Disc Replacements
Interactive Color X-Ray of a 2-Level Artificial Disc Replacement
Here is a Color X-Ray which shows the mobility of an ADR. This Image is also Interactive.

Interactive Color X-Ray showing the mobility of an Artificial Disc Replacement
B. Lumbar Fusion Surgery:

Lumbar Fusion Surgery aims to remove the motion at a diseased Disc segment, since this motion is abnormal and thought to be painful. While Fusion Surgeries have been performed for over 100 years, the technology used for this Surgery has vastly expanded in the last decade. New, less traumatic approaches to the Spine, improved designs of the Spine Implants, and materials which can improve the chances for a complete bone fusion have given Surgeons more options and optimism.

Here are some Color X-Ray Images of Lumbar Fusion Surgery. The first Image is taken from the front. This Image is Interactive.

AP Color X-Ray Lumbar Spine Fusion Surgery
Interactive Color X-Ray of a Lumbar Fusion from a front view (AP)

Here is the side-view Image. This Image is also Interactive.

Lateral Color X-Ray of a Lumbar Fusion Surgery
Interactive Color X-Ray of a Lumbar Fusion from a side view
There are a number of less commonly utilized but emerging technologies which show promise as treatments for DDD. For early stages of DDD, Stem Cell Injections into the Disc are gaining ground.
Also, minimally invasive treatments such as "Interspinous Process Devices" are offering alternatives to the more conventional Fusion Surgeries. However, Surgeons must determine which technology and technique is in the best interest of patients to allow patients to make informed decisions on their care.

Here are some related Blog Topics from recent MMI Blogs:

1. What is Spinal Stenosis? Shown and explained with Color MRI Images
2. What is a Spinal Fusion Surgery of the Low Back (Lumbar Spine)? Shown and explained with
    Color X-Ray Images
3. What is a "Spondylolisthesis" of the Low Back (Lumbar Spine)? Shown and explained with Color
   X-Ray and Color MRI Images.
4. What are Artificial Disc Replacements of the Low Back? Shown and Explained with Color X-Ray Images 
5. Disc Herniations of the Low Back (Lumbar Spine) shown and explained with Color MRI Images
6. What is Sciatica? Shown and Explained with Color X-Ray and Color MRI Images
7. What is an Epidural Injection? Shown and explained with Color MRI Images
8. Lumbar Facet Joint Injection for Low Back Pain shown on a Color MRI
9. What is a Spinal Discogram Injection? Shown and Explained with Color MRI Images

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