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Some consequences of disc degeneration

I’ve heard doctors say that the presence or absence of lumbar disc degeneration (LDD) is unimportant when it comes to clinically evaluating patients with low back pain (LBP). This sentiment likely comes from knowledge that many patients with LDD do not experience LBP. However, just because LDD doesn’t correspond well with pain may not be the best way to understand the clinical importance. In short, thinking of LDD as an incidental finding may be a relatively simplistic way of thinking it because it fails to answer the questions of, why it exists, how is it compensated for, and how does it impact available treatment strategies.

Researchers at the Palmer Center for Chiropractic Research conducted a study reporting the prevalence of radiographic findings in individuals with chronic low back pain [1]. The article discusses some of the physiological ramifications LDD and the potential importance to clinicians and patients. Recent evidence suggests that LDD can contribute to LBP [2], a patient’s recovery potential [3], and may be important when considering treatment and rehabilitation plans.

Two recent studies found that moderate to severe LDD or the presence of multi-level narrowing found a relationship with LBP [4,5]. So, it appears that patients with more severe forms of LDD may be more likely to experience pain. That still doesn’t mean LDD is directly responsible for pain in these patients. However, LDD appears to create a chain of circumstances that may contribute to LBP and how patients can respond to care.

Here is some LDD related physiology to consider.

• Disc narrowing reduces the cross sectional area of the spinal canal and intervertebral foramina, thereby increasing the risk for canal stenosis and radicular compression [6].

• Disc narrowing contributes to zygapophyseal degeneration by changing the relative positions of joints and altering biomechanical loading [6,7].

• Disc narrowing approximates vertebral joint surfaces and causes motion segment laxity [6,8-10].

• Multifidus atrophy, fiber type change and fatty infiltration are associated with LDD [11,12] and specific exercises have been shown to stimulate regrowth [13,14].

• Moderate to severely degenerated discs lack structural integrity within the annulus and diffuse fluid slowly compared to normal or mildly degenerated discs. This altered physiology suggests discs with moderate to severe degeneration are not able to tolerate weight training or sustained static positions as well [3].

Given this information, it is valuable for me to understand whether LDD is mild, moderate, or severe in in the patients I treat or consult with. Combining this information with the diagnosis and other clinical factors helps me develop treatments targeted at abnormal physiological processes, treatment recommendations, lifestyle suggestions, and prescribe preventive or rehabilitative exercise / activities supported by research evidence.

Reference List
1. Vining R, Potocki E, McLean I, Seidman M, Morgenthal AP, Goertz C: Prevelance of radiographic findings in individuals with chronic low back pain screened for a randomized clinical trial: secondary analysis. Journal of Manipulative and Physiological Therapeutics 2014, Accepted for publication.
2. Videman T, Battie MC, Gibbons LE, Maravilla K, Manninen H, Kaprio J: Associations between back pain history and lumbar MRI findings. Spine (Phila Pa 1976 ) 2003, 28(6): 582-588.
3. Beattie PF: Current understanding of lumbar intervertebral disc degeneration: a review with emphasis upon etiology, pathophysiology, and lumbar magnetic resonance imaging findings. J Orthop Sports Phys Ther 2008, 38(6): 329-340.
4. de Schepper EI, Damen J, van Meurs JB, Ginai AZ, Popham M, Hofman A, Koes BW, Bierma-Zeinstra SM: The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic features. Spine (Phila Pa 1976 ) 2010, 35(5): 531-536.
5. Hicks GE, Morone N, Weiner DK: Degenerative lumbar disc and facet disease in older adults: prevalence and clinical correlates. Spine 2009, 34(12): 1301-1306.
6. Modic MT, Ross JS: Lumbar degenerative disk disease. Radiology 2007, 245(1): 43-61.
7. Fujiwara A, Lim TH, An HS, Tanaka N, Jeon CH, Andersson GB, Haughton VM: The effect of disc degeneration and facet joint osteoarthritis on the segmental flexibility of the lumbar spine. Spine (Phila Pa 1976 ) 2000, 25(23): 3036-3044.
8. Zhao F, Pollintine P, Hole BD, Dolan P, Adams MA: Discogenic origins of spinal instability. Spine 2005, 30(23): 2621-2630.
9. Mimura M, Panjabi MM, Oxland TR, Crisco JJ, Yamamoto I, Vasavada A: Disc degeneration affects the multidirectional flexibility of the lumbar spine. Spine (Phila Pa 1976 ) 1994, 19(12): 1371-1380.
10. Passias PG, Wang S, Kozanek M, Xia Q, Li W, Grottkau B, Wood KB, Li G: Segmental lumbar rotation in patients with discogenic low back pain during functional weight-bearing activities. J Bone Joint Surg Am 2011, 93(1): 29-37.
11. Kalichman L, Hodges P, Li L, Guermazi A, Hunter DJ: Changes in paraspinal muscles and their association with low back pain and spinal degeneration: CT study. Eur Spine J 2010, 19(7): 1136-1144.
12. Yoshihara K, Shirai Y, Nakayama Y, Uesaka S: Histochemical changes in the multifidus muscle in patients with lumbar intervertebral disc herniation. Spine (Phila Pa 1976 ) 2001, 26(6): 622-626.
13. Danneels LA, Cools AM, Vanderstraeten GG, Cambier DC, Witvrouw EE, Bourgois J, De Cuyper HJ: The effects of three different training modalities on the cross-sectional area of the paravertebral muscles. Scand J Med Sci Sports 2001, 11(6): 335-341.
14. Hides JA, Stanton WR, McMahon S, Sims K, Richardson CA: Effect of stabilization training on multifidus muscle cross-sectional area among young elite cricketers with low back pain. J Orthop Sports Phys Ther 2008, 38(3): 101-108.

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