(Redirected from Degenerative Disc Disease)
- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Differential Diagnosis
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Rehab and Return to Play
- 11 Complications
- 12 See Also
- 13 References
- Lumbar Disc Herniation (LDH)
- Thoracic Disc Herniation
- Disc Disease
- Disc Herniation
- Herniated Nucleus Pulposus (HNP)
- Degenerative Disc Disease
- LDH with radiculopathy
- Lumbar Intervertebral Disc Herniation (IDH)
- This page refers to all causes of thoraco-lumbar disc disease
- Can be acute or chronic
- As much as 80% of people develop lower back pain during their lifetime
- Nearly all involve L4/5 or L5/S1 levels (need citation)
- Peak incidence 4th, 5th decade of life (need citation)
- Males more common than females by a ratio of 3:1 (need citation)
- Dehydration is known to contribute to degenerative disc disease
- Axial Overloading
- Not all cases are degenerative, insidious disc disease
- Static overloading, as opposed to physiologic and dynamic overloading, put the disc at risk for posterior herniation
- The role of inflammatory signaling in producing nerve pain in LDH has been well-established
- Propionibacterium acnes
- Gram-positive, facultative anaerobic, fastidious bacterium, which may play a central role in LDH
- Normally associated with superficial skin infections, most notably ace
- 2001 study: 53% of patients had gram positive anaeorbes, of which 84% were P. acnes
- Aghazadeh et al: P. acnes DNA correlates to vertebral edema on preoperative MRI
- In rabit models, Chen et al demonstrated the bacteria induced disc degeneration
- Other studies have failed to reproduce these findings and more research is needed
- Cuesta et al: pH of degenerative discs is ~1.0 less than that of healthy discs
- Intervertebral Disc
- Consists of inner nucleus pulposus (NP), outer annulus fibrosis (AF)
- NP: comprised of collagen, proteoglycans, acts to resist axial compression of the spine
- AF: Composed of type I collagen, supports and maintains the NP
- Tearing of AF leads to protrusion of NP
- Posterior Longitudinal Ligament (PLL)
- Helps stabilize discs posteriorly
- Spinal Stenosis
- Cauda Equina Syndrome
- Estimated to occur between 1% - 10% of patients with herniated discs
- General: Physical Exam Back
- Clasically presents as lower back pain
- Patients may endorse radicular features, sensory abnormalities and weakness
- Symptoms may be worse with straining, coughing, sneezing
- May be worse with sitting, improved with standing
- Physical Exam
- Affected dermatome varies based on level of herniation
- Findings based on level of radiculopathy
- L3: Hip adduction weakness
- L4: Knee extension weakness, decreased patellar DTR
- L5: weakened ankle dorsiflexion, inversion, EHL and hip abduction
- S1: Weakned plantarflexion, decreased achilles DTR
- Special Tests
- Straight Leg Test (SLRT): Elevation of leg while supine or seated recreates radicular pain
- Contralateral SLRT: Recreates symptoms by raising contralateral leg
- Lesegue sign: SLRT worse with forced ankle dorsiflexion
- Bowstring sign: During SLRT, apply pressure to tibial nerve in popliteal fossa
- Kernigs Sign: pain reproduced with neck flexion, hip flexion, and leg extension
- Initial screening with a positive straight leg test + 3 out of 4 of the following symptoms is sufficient for clinical diagnosis
- Dermatomal pain, sensory deficits, reflex deficits, and/or motor weakness
- First line imaging: Standard Radiographs Lumbar Spine, Standard Radiographs Thoracic Spine, Flexion Extension Radiographs
- In the absence of red flags, typically recommend that physicians wait 6-12 weeks before ordering
- Findings in the setting of Herniated Disc
- Scoliosis (compensatory)
- Narrowed intervertebral disc space/ loss of disc height
- Traction osteophytes
- Loss of lordosis
- Degenerative spondylosis
- Gold standard to confirm lumbar disc herniation, typically without contrast
- Diagnostic accuracy of 85-97%
- Increased T2-weighted signal from the posterior 10% of the disc diameter
- Diffusion tensor imaging (DTI) can be used to detect microstructural changes in the nerve root
- High rate of abnormal findings in asymptomatic individuals
- Indications for obtaining MRI
- Pain lasting >6-12 weeks not responding to normal conservative therapy
- Presence of red flags
- Represent pathologic changes to the vertebral body
- Type 1: vascular developments in the vertebral body including inflammation and edema
- correlate significantly with degree of degenerative disc disease
- Type 2: fatty replacement of the vertebral bone marrow
- Type 3: fractures or changes of the trabecular bone of the vertebrae
- With myelography, diagnostically equivalent to MRI for lumbar disc herniation
- Useful in patients who can not receive MRI
- Central prolapse
- Associated with back pain only, cauda equina syndrome
- Posterolateral (paracentral)
- Represents >90% of cases due to weak PLL
- Affects descending or lower nerve root
- Foraminal (far lateral, extraforaminal)
- Less common, affecting 5-10% of cases
- Affects exiting or upper nerve root
- Can affect both upper and lower nerve root
- Protrusion: eccentric bulging, intact annulus
- Extrusion: disc material herniates through annulus, remains continuous with disc space
- Sequestered fragment: disc material herniates through annulus, no longer continuous with disc space
- Gugliotta et al: equivalent medium- and long-term outcomes for conservative and surgical treatment of LDH
- Other studies have demonstrated improved 1- and 2-year outcomes in the surgical treated group when compared to conservatively managed patients
- Disc herniation >6.31 mm likely to benefit from surgical intervention
- Surgery: Improved short term, unclear medium- and long-term benefits
- One study found that microdiscectomy of L4-5 LDH resulted in superior patient reported outcomes compared to non-operative management
- 90% of patients will improve at 3 months with non-operative care (need citation)
- Herniated disc is reabsorbed over time and decreases in size
- Treatment of choice for the majority of patients
- Very brief period of rest following by increasing activity as tolerated
- Physical Therapy
- Corticosteroid Injection (CSI)
- Widely varied success rates from 20% to 95%
- Thought to be due be more beneficial in acutely herniated discs, where a true inflammatory response is occurring.
- Provide short term improvement in radicular pain, sensory symptoms
- Likely do not reduce rate of surgical intervention, provide any functional benefit
- Disc herniation <6.23 mm more likely to do well with CSI
- Spinal Traction
- One small study showed improvement in 28 day outcomes, however no control arm
- Spinal Manipulation Therapy
- Consider chiropractor, massage therapy
- Platelet Rich Plasma (PRP)
- Several studies have reported improvement in clinical scores 1 month post PRP injection
- Predictors of good surgical outcome
- Factors that do not affect surgical outcome
- Motor deficit
- Vertebral level or side of herniation
- Presence of type I modic changes
- Microdiscectomy: laminotomy, discectomy
- Percutaneous lumbar foraminoplasty
- Far lateral microdiscectomy
- Open Discectomy
Rehab and Return to Play
- Emphasis on core strengthening, extension exercises
Return to Play
- Athletes with herniated lumbar disks should rest 6 to 12 weeks following surgical treatment, while those with spinal fusion should wait 1 year to return to activity
- Cauda Equina Syndrome (CES)
- Rare, devastating
- Risk factors for dveloping CES: diabetes, acute onset of symptoms, L3-L4 involvement, sequestrated discs (fully separated NP from AF), superiorly migrated discs, posterior herniation, primary canal stenosis, and greater canal compromise
- Dural Tear
- Rate of 1-17%
- Increases hospitilization cost, wound dehiscience, post op infection, worsening function, nerve injury
- Recurrent herniation risk factors
- Pre-operative disc height index
- Older age
- Disc protrusion
- Disc sequestration
- Longer duration of sick leave
- Workers’ compensation
- Greater preoperative symptom severity
- Diabetes Mellitus
- Vascular injury (vena cava or aorta)
- Sports Medicine Review Back Pain: https://www.sportsmedreview.com/by-joint/back/
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