Degenerative Disc Disease (DDD): Remedies For Lower Back Osteoarthritis That Provide Relief

By Dr Ken Nakamura+

MRI of Degnerative Disc DiseaseMRI Showing The Lower Back With Healthy Disc Near The Top With The Bottom Four Being Narrowed, Darker in Color With Disc Bulges: Degenerative Disc Disease: Downtown Toronto Chiropractic

Does your X-rays or MRI show Degenerative Disc Disease DDD?

 

Do you have radiating pain or weakness in your leg from degenerative disc disease?

 

Does forward movement aggravate your pain while extension relieves your pain?

 

In this issue of Bodi Empowerment I’ll go over the causes of degenerative disc disease DDD, why you are getting pain, MRI and X-rays views of DDD and finally treatments.

 

Treatments for degenerative disc disease include conservative therapy, disectomy, disc fusion, disc replacement ( disc arthroplasty ).

 

Your doctor told you that you have degenerative disc disease DDD and even showed you the X-rays or MRI so it must be causing your pain right? We now know better, research has proven that the degree of degenerative disease has absolutely nothing to do with pain. [1].

 

You have to be careful that your doctor isn’t diagnosing you based on X-rays and MRI and instead carefully looking at your history and examination. The X-rays and MRI are used to confirm a doctor’s diganosis, not to make a diagnosis.

 

See Also: Is An MRI, CAT Scan or X-ray Best For My Pain

 

You can have severe degenerative disc disease and have mild pain and stiffness. Mean while your neighbour can have mild degenerative disc disease and have severe pain.

 

So, What Is Degenerative Disc Disease

 

Degenerative Disc Disease is the wearing or the breaking down of your disc found between your vertebra.The disc eventually becomes visibly thinner with imaging such as X-rays or MRI. It’s sometimes called osteoarthritis of the disc, or spondylosis. Either way your health practitioner is still talking about the same thing.

 

For example spondylosis of the L45 disc is still degenerative disc disease. Osteoarthritis at the L5S1 disc is still degenerative disc disease.

 

Why Is My Disc Degenerating?

 

Everybody’s disc degenerates. If you inherited certain genes you will have earlier degenerative disc disease. If not you will likely find the visible beginnings of DDD by the time you are forty years old.

 

Just like wrinkles, some of you start to get wrinkles earlier than others but everyone eventually gets a lot of wrinkles with enough time. Similarly, some people start to show the signs of DDD in their twenties, others much later but eventually everybody gets degenerative disc disease. It’s a part of ageing.

 

Disc Ageing?

 

Disc Showing Annulus, Nucleus, and Endplates: Downtown Toronto Chiropractic

 

You need to understand the three basic parts of the disc. The nucleus, annulus and end plate. The nucleus and annulus is akin to an flat onion with jelly in it. The jelly is the nucleus and the onion part is the annulus with many circular layers. Above and below is an endplate. The end plate is like a fine wire mesh on top and the bottom of the disc.

 

The disc gets it’s life giving blood, from tiny blood vessels that go through this wire mesh (end plate) and stop at the disc. These blood vessels comes from the vertebrae above and the vertebrae below through the mesh (end plate) that attaches to the disc. No blood vessels exist in the actual disc the nutrients have to flow into the center of the disc by diffusing through the jelly (nucleus) and the onion (annulus).

 


By 7 years of age, these tiny blood vessels that used to feed the disc no longer penetrate the end plate.[3-5] Which means your discs aren’t getting as much nutrition as they used to. By the time you are 20 years of age the blood vessels no longer exist.

 

This means you are starting the process of degenerative disc disease at 20 years of age, some researchers say in the first 10 years of life,  so that you can see visible changes in many people’s X-rays by the time they are 40 years of age.

 Vertebra Showing The Facets. Pressure is Shifted to the Back of The Annulus and Facets: Degenerative Disc Disease: Downtown Toronto Chiropractic

Your disc is under a lot of pressure from the inside so it can hold up the weight of your body. So picture the annulus and nucleus with substantial pressure on the inside like a balloon with lots of water in it. As you age the decreasing blood flow and lack of nutrients and oxygen makes the cells in the disc start to die. With less cells to produce water retaining molecules the water content of your disc decreases. With less water the pressure in your disc decreases.[6-7]

 

With your disc deflating like a balloon the pressure on the disc gets shifted from the center of the disc to the back of your disc (annulus) and the joints at the back (facets). The shift in pressure eventually causes fissures in the annulus and osteoarthritis in the joints (facets)

 

 Disc Herniation

Lumbar Disc Herniation-Downtown Toronto Chiropractor

 

 

Stage #1 Disc Bulge

  • After a few years to a few decades of pressure shifted toward the back the disc a fissure breaks the many layers of the  annulus so that only a few layers of the annulus left to hold the disc back.
  • This allows the nucleus (jelly) to push through annulus (onion) closer to the edge of the annulus. This is a Disc Bulge ie. nucleus has pushed out toward the edge of the annulus.

 

See Also: Best Treatments To Help Your Lumbar Disc Herniation

 

Stage #2 Disc Prolapse

 

  • A disc protrusion is like a disc bulge that comes out even more in one focused spot. The disc pushes out as if you had your finger inside a balloon and pushed out.
  • A disc protrusion is when the nucleus has pushed through so many layers of the annulus that only one or two layers of the annulus (onion) and a PLL ligament are holding back the nucleus.
  • Good news: Severely degenerated discs do not prolapse as there isn’t enough pressure within the disc it self for this to happen.

 

Stage #3 Disc Extrusion

 

  • A disc extrusion is when the nucleus breaks through the final layers of the annulus and the PLL ligament and pinches on the nerve (spinal nerve).
  • In most cases your lower back pain is painful but your sciatica is much more worse than your lower back pain.

 

See Also: Best Exercises For Your Herniated Disc

 

Vertical Disc Herniation (Smorl’s Node)

  • Compression of the spine like lifting very heavy weights, and falling onto your buttock will cause Vertical Disc Herniations in the young.
  • When you are young (20 years or under) the annulus is still intact so the weak point becomes the end plate (wire mesh). When you fall down and compress your spine severely the annulus is strong enough to withstand tremendous pressure but your weak link is the end plate. The pressure breaks the end plate pushing the nucleus (jelly) into the vertebra below.
  • When the nucleus herniates (pushes into) into the vertebra there is more space for the nucleus (jelly) so it’s like deflating a balloon.
  • The decrease disc pressure from disc causes a shift of pressure toward the back of the annulus and the joints (facets) just like a normal disc herniation.
  • A Schmorl’s node can be seen on X-ray when the nucleus which has herniated (pushed) into the disc and later on calcifies.

 

See Also: Your Guide To Disc Bulges, Slipped Discs, Disc Herniations, Disc Protrusion, Disc Extrusions

 

Why Is My DDD Painful?

 

Your disc has hardly any pain fibers The only pain (nerve) fibers are on the back outer 1-3 mm of the annulus (onion) and most often aren’t activated unless your disc is injured.[5]

 

Your disc degenerates without any pain until the fissures in the disc reaches the outer annulus where the nerve is. When this happens you likely have pain.

 

Your disc can than progress further to develop a more narrowed disc, fissures in the annulus (onion) and eventually form a disc bulge which often causes pain most of the time.

 

End plate (wire mesh) collapse called a Schmorl’s node is often related to pain, as that pushes your nucleus (jelly) into the vertebra which has many pain fibers.

 

If your disc has substantial degenerative disc disease, nerve (pain) fibers actually start to grow into the annulus (onion) and eventually into the nucleus (jelly) which can cause you lots of pain.[6]

 

Sometimes even disc herniations have nerves grow into them as well, causing pain.

 

Disc Healing

 

Injuries to a disc never heal like a bone can heal after a fracture.[2]

 

Imaging: How To See DDD

#1 X-rays

X-ray of Degnerative Disc Disease DDD: Osteophytes, Narrowed (Thin) Disc: Downtown Toronto Chiropractic

 

You can see degenerative disc disease on X-rays, CT (CAT) scans and MRI. The most important factors are disc narrowing (smaller), ostoephytes (spurs of bone) and disc bulging (seen only on MRI and  CT scans)

 

Often when seen together the radiologist will use the term spondylosis. Most of the time  though it may be used to refer to a narrowed disc alone or the presence of multiple osteophytes.

 

 #2 Magnetic Resonance Imaging (MRI)

 

MRI of Degnerative Disc DiseaseMRI Showing The Lower Back With Healthy Disc Near The Top With The Bottom Four Being Narrowed, Darker in Color With Disc Bulges: Degenerative Disc Disease: Downtown Toronto Chiropractic

An Magnetic Resonance Imaging (MRI) is the most sensitive tool we have to look at degenerative disc disease. You are looking for disc narrowing, bony spurs called osteophytes, bulging discs and how well the disc is functioning.

 

MRI’s have two main settings T1 and T2. The T2 setting shows any tissue that has lots of water in it to show up bright white. The brighter the tissue the more water  there is in the tissue.

 

Normally your disc and spinal cord have a lot of water in it so will show up bright white especially in the nucleus (jelly). As your disc ages, the disc starts to lose water and eventually starts breaking down.  The more water you lose from the disc the blacker the disc looks and the more your disc has degenerated.

 

When your disc has substantial degenerative disc disease your disc will no longer look white on a T2 MRI. It will look black since the water has been completely sucked out the disc. This is called dessication of your disc.

 

#3 Discography

Discography

Discography involves injections to try and give you pain in the disc that you think is causing you pain. It’s for people that haven’t responded to non-surgical care and is usually used for planning lumbar fusion surgery.

 

If your doctor tells you that you need to have a discography you should have serious concerns. First if you don’t get the surgery it may accelerate disc degeneration and 25% of people are found to have a disc problem when they actually don’t.[9-10]  That’s a huge rate of mistakes.

 

Remember they are using discography to decide whether they are going to do surgery.

Prevent Degenerative Disc Disease

Your mom and dad are the main cause. In other words genetics. Smoking and manual labour are not as important factors for Degenerative Disc Disease. Your parents played the most meaningful part.

 

The genes that you inherited influence the size, shape and make-up of the vertebrae and disc but also how resilient your disc is.

 

Studies show that if there is a family history of DDD in patients who are diagnosed with a herniated disc before age 21. (Remember you end up with disc herniations as a part of the DDD process)

 

The minor factors which puts you at risk for degenerative disc disease are frequent bending and twisting, and whole body vibration, [11] smoking from nicotine and impaired blood flow to the disc [12-15] and association of plaques in the arteries called atherosclerosis in the main artery in the lower back [16]

 

Heavy lifting is associated with disc prolapse but not other areas of degenerative disc disease

Treatment

The golden rule is always try non-surgical care first. Spinal manipulation by a chiropractor, McKenzie approach and lower back stabilization exercises have been shown to relieve pain.[17-18]

 

Traction and spinal decompression has not been shown to be effective for treating degenerative disc disease.

#1 Fusion Surgery (Arthrodesis)

 

Spinal fusion surgery involves removing the nucleus and most of the annulus. Bone from the pelvis is transplanted where your disc was so that the two vertebrae become one.

 

Sometimes spinal fusion surgery is effective for treatment of pain but increases the rate of degeneration in the adjacent vertebrae, usually significantly within 10 years after the surgery.[19-21]

 

If your surgeon isn’t telling you this that is a yellow flag. Your surgeon should freely tell you all the pros and cons of fusion surgery.

 

Danger: Bone Morphogenetic Protein (BMP) is sometimes used instead of taking some of your own hip bone to fill in the space vertebrae for fusion. Instead they use BMP as a bone graft substitute.

 

In 2008, the FDA published a public health notification about potentially life-threatening complications associated with use of BMP in cervical spine fusion [25].

 

In Europe this is the gold standard for disc replacement. What’s troubling is that two studies found that there was no advantage of fusion over exercise therapy and cognitive therapy in the short and long term.[26]

 

#2 Total Disc Replacement

 

Total Disc Replacement is a type of surgery where you take out the offending disc and replace it with an artificial disc.  There are concerns about the long-term durability of polyethylene.[22-23] Claims about prevention of adjacent veretebra wear and tear are not clear yet.

 

Several studies also report that there is complete loss of motion at the operated level from the bones fusing the artificial segment on its own or need for a second surgery.[27] Furthermore not one study demonstrates that artificial disc reduces degeneration at vertebrae adjacent to it.

 

Deaths have occured due to blood clots or bleeding from blood vessels being injured following the surgery.

 

Tell us what you think in the comments below and like us on Facebook. I will answer all questions in the comments section here at this downtown Toronto Chiropractic clinic.

 

 

References

 

1. Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. Journal of Bone and Joint Surgery—Series A. 1990;72(8):1178–1184.

2. Adams MA & Roughley PJ, What is intervertebral disc degeneration, and what causes it?, Spine 2006; 31(18): 2151-2161.

3. Taylor JR , Growth of human intervertebral discs and vertebral bodies. J Anat. 1975 Sep; 120(Pt 1):49-68.

4. Holm S, Maroudas A, Urban JPG, et al. Nutrition of the intervertebral disc. Solute transport and metabolism. Connect Tiss Res. 1981;8:101–119. doi: 10.3109/03008208109152130.

5. Maximilian Rudert and Bemhard Tillmann, Lymph and blood supply of the human intervertebral disc Cadaver study of correlations to discitis Acta Ofthop Sand 1993; 64 (1): 37-40

6. García-Cosamalón J, del Valle ME, Calavia MG, et al. Intervertebral disc, sensory nerves and neurotrophins: who is who in discogenic pain? Journal of Anatomy. 2010;217(1):1–15.

7. Sowa G, Vadalà G, Studer R, et al. Characterization of intervertebral disc aging: longitudinal analysis of a rabbit model by magnetic resonance imaging, histology, and gene expression. Spine.2008;33(17):1821–1828.

8. Prescher A. Anatomy and pathology of the aging spine.European Journal of Radiology. 1998;27(3):181–195.

9. Carragee EJ, Tanner CM, Khurana S, et al. The rates of false-positive lumbar discography in select patients without low back symptoms. Spine. 2000;25(11):1373–1381.

10. Carragee EJ, Don AS, Hurwitz EL, Cuellar JM, Carrino J, Herzog R. 2009 ISSLS prize winner: does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study. Spine. 2009;34(21):2338–2345.

11. Lötters F, Burdorf A, Kuiper J, Miedema H. Model for the work-relatedness of low-back pain. Scandinavian Journal of Work, Environment and Health. 2003;29(6):431–440.

12. Battié MC, Videman T. Lumbar disc degeneration: epidemiology and genetics. Journal of Bone and Joint Surgery—Series A. 2006;88(supplement 2):3–9.

13. Battie MC, Videman T, Gill K, et al. 1991 Volvo Award in Clinical Sciences: smoking and lumbar intervertebral disc degeneration: an MRI study of identical twins. Spine.1991;16(9):1015–1021.

14. Oda H, Matsuzaki H, Tokuhashi Y, Wakabayashi K, Uematsu Y, Iwahashi M. Degeneration of intervertebral discs due to smoking: experimental assessment in a rat-smoking model. Journal of Orthopaedic Science. 2004;9(2):135–141.

15. Iwahashi M, Matsuzaki H, Tokuhashi Y, Wakabayashi K, Uematsu Y. Mechanism of intervertebral disc degeneration caused by nicotine in rabbits to explicate intervertebral disc disorders caused by smoking. Spine. 2002;27(13):1396–1401.

16. Kurunlahti M, Tervonen O, Vanharanta H, Ilkko E, Suramo I. Association of atherosclerosis with low back pain and the degree of disc degeneration. Spine. 1999;24(20):2080–2084.

17. Adams MA & Roughley PJ  Spine 2006; 31(18): 2151-2161. What is intervertebral disc degeneration, and what causes it?

18. Beattie P upon etiology, pathophysiology, and lumbar Magnetic Resonance Imaging Journal of Orthopaedic & Sports Physical Therapy 2008; 38(6): 329-340.

19. Song K-J, Choi B-W, Jeon T-S, Lee K-B, Chang H. Adjacent segment degenerative disease: is it due to disease progression or a fusion-associated phenomenon? Comparison between segments adjacent to the fused and non-fused segments. European Spine Journal. 2011;20(11):1940–1945. [PMC free article] [PubMed]

20. Tang S, Rebholz BJ. Does anterior lumbar interbody fusion promote adjacent degeneration in degenerative disc disease? A finite element study. Journal of Orthopaedic Science.2011;16(2):221–228. [PubMed]

21. Wu JC, Liu L, Wen-Cheng H, et al. The incidence of adjacent segment disease requiring surgery after anterior cervicaldiskectomy and fusion: estimation using an 11-year comprehensive nationwidedatabase in Taiwan. Neurosurgery. 2012;70(3):594–601.

22. Delamarter R, Zigler JE, Balderston RA, Cammisa FP, Goldstein JA, Spivak JM. Prospective, randomized, multicenter food and drug administration investigational device exemption study of the ProDisc-L total disc replacement compared with circumferential arthrodesis for the treatment of two-level lumbar degenerative disc disease: results at twenty-four months. Journal of Bone and Joint Surgery—Series A. 2011;93(8):705–715.

23. Harrop JS, Youssef JA, Maltenfort M, et al. Lumbar adjacent segment degeneration and disease after arthrodesis and total disc arthroplasty. Spine. 2008;33(15):1701–1707.

24. Center for Devices and Radiological Health. FDA public health notification: life-threatening complications associated with recombinant human bone morphogenetic protein in cervical spine fusion, 2011.

25 Ritzell P, Hagg O, Wessberg P, Nordwall A. Swedish Lumbar Spine Study Group. Lumbar fusion versus non-surgical treatment for chronic low back pain: a multicentre randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine. 2001;26:2521–32.

26. Guyer RD, McAfee PC, Hochschuler SH, Blumenthal SL, Fedder IL, Ohnmeiss DD, Cunningham BW Prospective randomized study of the Charite artificial disc: data from two investigational centers, Spine J. 2004 Nov-Dec; 4(6 Suppl):252S-259S.

 


Author

Dr Ken Nakamura

Who is Dr. Ken? I’m a father, spouse, chiropractor, and I love what I do! I created Bodi Empowerment to bring you and everyone-else safe and effective methods for self-treatment by basing my articles on research to everything I can. Still many parts will be based on 18 years of experience, seminars, and collaboration with other health experts; which means you will get opinions as well. Sometimes my articles won’t agree with what is currently accepted, but I am not here to please everyone. I’m here to empower you through the knowledge that I give you. Dr. Ken works at Rebalance Sports Medicine in downtown, Toronto.

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