Degenerative disc disease

Degenerative disc disease refers to a specific mechanical pain in the back. So you should not confuse it with a common nonspecific low back pain. The condition has previously been referred to as Chronic Discogenic Lumbargia (CDL) and in english Degenerative Disc Disease (DDD).

All of these terms describe the same condition. A back pain that has a mechanical origin.

  • The pain was mainly triggered in the front part of the operating segment itself, ie. disk.
  • The pain can also be triggered by the posterior part, ie. e.g. facet.
  • The pain may also come from degenerative spinal disorders in the area e.g. hernias or spinal stenosis.
  • Usually with DDD if parents have pronounced back problems
  • Smokers are overrepresented among SRS patients
  • 8 out of 100,000 inhabitants / year are operated for DDD

Speaks for and against DDD

Speaks for DDD:

  • Localized low back pain / lumbar tenderness in the midline
  • Mechanically triggerable pain (location dependent)
  • A strongly localized disk degeneration – preferably only at one level
  • Modic changes – ie edema of the bone adjacent to the degenerate disk

Speaking against DDD:

  • General pain or pain in a large area
  • Absence of variation of pain or in a large area
  • Absence of variation in pain depending on posture
  • Half-sided pain
  • Excessive pain reactions during examination and different results when repeated
  • Little or no disc degeneration
  • General degenerative changes

DDD disc and pain
DDD is used only when talking about a pain condition in the lower back. Similar conditions can occur in the other parts of the pusher, but you usually do not get the same type of symptoms.

You do not know for sure why a degenerate disc causes pain. It is believed that this is because the sensory innervation of the disc’s outer casing signals pain. The sensitivity of the counter is usually compared to the oblique of the narrow bone. So far, there are three different theories about why you get DDD and you think these theories work together.

Theory 1 – Pain explanation DDD:

  • Reduced fluid content in the counter
  • Lowered disc height (in the long run may cause facet joints to no longer fit each other and this leads to osteoarthritis in the long run)
  • Changed movement pattern due to lower fluid content and wash height
  • Changed movement patterns are recorded by the nerves in the outer shell of the disc.
  • Increased registration of the changes is interpreted as pain

Theory 2 – Pain explanation DDD:

  • Disc degeneration leads to cracking.
  • Along the crack formation, small blood vessels grow into the disc.
  • Small nerves can grow along with the blood vessels into the disc.
  • The ingrown nerves and can signal pain from the disc.

Theory 3 – Pain explanation DDD:

  • It has been seen that the end plate (the vertebra’s interface to the counter) can cause pain

Symptom DDD
It has been seen that patients have very different pronounced pain states. Everything from intermittent back pain, which is mechanical and well-functioning to patients who have continuous pain and are severely affected.

You usually get pain coming in the forest. During the forest itself, the patient has more severe back pain. The patient usually describes it as a back shot and it will later on to a more cohesive pain. The pain is often also experienced as a lumbar pain in the lumbar spine that can be relieved and completely disappear in certain positions. The pain can often be provoked by static work / strain, sitting and standing. Relief can often be when the patient lies down on the back or side and reduces the lumbar spine.

General pain symptoms at DDD

  • Pain coming in forest
  • The pain is described as a back shot
  • The pain is experienced as a painful pain around the lower back
  • The pain can often be relieved in certain positions and especially when reducing the lumbar spine.
  • The pain is provoked by static work and stress
  • Cutting sharp pain during rapid and uncontrolled movements
  • Fatigue in the lumbar spine and tension in the back and seat muscles

Leg symptoms of DDD

  • Nervous squeezing of a herniated disc that produces radiation in the bones
  • Nerve compression due to a spinal stenosis that produces radiation in the bones
  • Referred pain that can occur in both legs
  • The pain in the legs can sometimes change sides
  • Typical of DDD is that the leg pain is weaker than the back pain itself
  • The pain in the legs is rarely according to the dermatome, unlike nerves that have been pinched. The pain in the legs can cross several dermatomas and sometimes it can even be “pain stains”.
  • The pain can be experienced along the entire leg next to the leg pipe itself
  • Numbness with altered sensation in the leg with a subjective feeling of swelling.
  • No muscular fatigue is experienced, but the legs can give way because of the pain.

Abdominal symptoms at DDD

  • 1/4 experience varying degrees of genital symptoms
  • Pain radiation against one or both groins (often the same groin as the bone radiations are in)
  • Disturbed bladder function – many people feel that they have to empty the bladder often, have to sit down and relax for a long time in order to empty the bladder. Must often go to the toilet several times because of difficulty with the emptying.
  • Some patients have to use a catheter to empty. You usually do not find any findings when examining it, but you believe that the balance between pelvic floor relaxation and contraction of the bladder muscle is disturbed due to pain.
  • DDD can be mistaken for Cauda equina due to the abdominal symptoms.
  • Erection and orgasm can be hampered by DDD.

Clinical examination

The examination often finds an interspinal tenderness in one or more segments. There should be a clear difference between where the interspinal tenderness and other segments are. The interspinal tenderness can be tested by having the patient sideways with raised legs. The therapist provides a definite pressure interspinal level, level by level. The reason you do it sideways is because it is easy for the forefoot segments to spring against.

It can also be seen in a clinical examination that the patient has a dislike or pain in the extension of the back. Often they only want to do a brief extension movement. Lateral reflexes are usually not a problem as long as they do not have to perform it at a high speed, then it can pain and chop in the back. Bending forward is usually no problem down, but on the way up they may want to relieve their hands and often make the movement slow.

The therapist can also push against the patient’s cristic edges as the patient stands up. If choking pain occurs, the suspicion of DDD strengthens.

  • Interspinal palpation pain
  • Dislike or inability to extend the lumbar spine due to pain
  • Rapid lateral flexions cause choking pain
  • Therapist presses the patient’s crista edges

X-ray examination – DDD
At DDD there is no specific x-ray finding. This has been a problem for the diagnosis of DDD to be accepted.

Plain X-ray
It is possible to see if the mechanical pain of the patient is due to e.g. and spondylolists. You can also see if there are lowered counters, bearings on the vertebra or various types of vertebrae (degenerative listes, lateral slides, translation).

Checking for:

  • Lowered sink height
  • Pålagring
  • Sliding

Magnetic Resonance (MR)
An MRI is very good for checking disk degeneration and is usually necessary to establish an DDD. What you try to see on an MRI is how degenerate the disk is (black disk), reduced fluid content in the disk, lowered disk height, modic changes. Are these changes visible and there is some relationship to the disc.

Checking for:

  • Degenerated disc
  • Reduced fluid content in the counter
  • Lowered sink height
  • Modic changes
  • Treatment
  • Natural Process

There are currently not many studies on natural processes and DDD. So far, it has been seen that the pain decreases with age. It is believed that this is because the degenerative changes can sometimes cure the pain and the pain thereby diminishes or completely ceases. Often the disk degeneration becomes so pronounced that the vertebrae eventually grow together more together, also called spontaneous fusion. It has previously been thought that the pain usually goes away within 5-10 years, but it has been seen that it often takes longer than that and that the degeneration can also take place in another area and thus cause pain in a new place.

Conservative treatment
Since DDD is seen as a mechanical pain state, it is attempted to strengthen the local mechanical strength. This is done by training the small back muscles, multifids and the oblique abdominal muscles (transversus abdominis). It is now considered that these are important for mechanically stabilizing the lumbar spine and it is believed that by strengthening these it will be able to compensate for lack of function in the segment or reduce the pain.

Attempts are also made to reduce the provocative factors such as unnecessarily heavy or biomechanically less good load. Reduce static load and try to make the patient reduce his sedentary over time. If the patient smokes, they also try to stop it as it increases disk degeneration.

You also go through various coping strategies to better manage your pain and, above all, reduce or counteract any fear of movement. A fear of movement usually does not reduce the symptoms regardless, but mainly leads to tense and stiff muscles, which in turn causes pain.

Traction has also been able to see a good effect of when treating DDD. However, the result is usually short-lived and the pain comes back either immediately after the traction itself is completed or that you can have a lasting effect – unclear how long.

In some cases, analgesics may need to be used to reduce the patient’s pain. One should try to avoid treatment with “drugs” with addiction risk and use NSAIDs instead.

Centrally acting analgesics along with anti-inflammatory are often as far as you can go with DDD patients.

  • Stabilizing exercise
  • Reduce static and heavy loads
  • Try to be physically active in everyday life
  • Traction
  • Coping strategies
  • Stop smoking
  • Analgesics – Try to stick to NSAIDs

Surgical treatment
Surgical treatment is the last option since neither natural treatment nor conservative treatment has worked well enough. Preferably, the patient’s lifestyle should be so affected that surgery is considered the last resort. In an operation, it is important to emphasize that the patient may not be completely healthy but only better. Attempts should be made to avoid erroneous expectations in order to minimize the risk of disappointment.

Steel operation – fusion
In a stele operation, you want the mobility to stop completely between the vertebral stele operation applies and over the movement segment itself. It can be anything from one segment to several. Screws, braces or plates are used to lock the vertebrae together during the healing process. This is called instrumentation and is necessary to improve bone healing. It has also been seen that instrumentation makes the healing process faster and you don’t even need a corset. Postoperatively, it is important to be able to mobilize the patient to reduce complications and an instrumented fusion is therefore the most common method today.

After a surgery, there is an increased risk of being able to get pain and other symptoms in segments adjacent to the surgery. This is called “Adjacent segment disease”. Approximately 20% of everyone who undergoes an operation gets symptomatic pain after. Important to note is that the patients who were operated on have already had painful degenerative changes. It has been seen that this “Adjacent segment disease” often occurs where a staging operation occurs on more levels than three. The reason for this is that you then lock in so much movement that the load on the above as well as the underlying vertebra increases. The spine causes fewer vertebrae to perform the same movement with.

Disc prosthesis – Total disc replacement
Disk prostheses have been around since the 1970s with varying results and different types of materials. The problem with disc prostheses is often that the “pillows” themselves are not left in the desired place or that they sink into the bone.

Results DDD and surgery
In a study at the Spine center in Stockholm, it was seen at a 1-2 year follow-up that:

  • 65-75% of patients stated “pain-free” or “much better”.
  • 15-20% of patients stated “somewhat better”

In a study 18 years ago (Fritzell, 2001) stated

  • 29% that they become painless or much better.

It is believed that the improvement in the result is because you are better at that today at

  • Selecting appropriate patients
  • The surgical technique improved
  • The implants have been developed
  • Rehabilitation is more ambitious today