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Degeneration of a lumbar disc describes a gradual loss of the cushioning properties of the semi-rigid structure (intervertebral disc) that separates and cushions the bony column (vertebrae) in the lumbar spine. The lumbar spine is in the low back between the thoracic spine and the sacrum; it consists of 5 vertebrae, L1 through L5. Greater than 90% of lumbar disc degeneration occurs between the fourth and fifth lumbar vertebrae or between the fifth lumbar and first sacral vertebrae (Hoff 956).
Intervertebral disc degeneration, especially in the lumbar spine, begins most commonly in people in their third and fourth decades of life. Whether the degenerating disc is a cause of back pain is controversial. Doctors who attribute back pain to degenerating discs frequently use the term "degenerative disc disease" (DDD). Intermittent episodes of back pain may occur months or years before more persistent low back pain or leg pain. Pain may be exacerbated by flexion of the lumbar spine during heavy exertion, repetitive bending, twisting, or heavy lifting. However, it has been demonstrated that minor trauma does not cause either serious chronic low back pain and disability or new MRI findings (Carragee, "Minor Trauma"; Carragee, "First-time Episodes").
As in the cervical and thoracic spines, lumbar disc degeneration occurs naturally with aging. Discs have a soft, gelatin-like material in the center (nucleus pulposus) that remains soft because of its high water content (about 80% in the young spine). However, the water content decreases with age, which causes the disc to change appearance on MRI and to lose some of its elasticity, restricting its function as a shock absorber. The disc space narrows as degeneration occurs, placing stress on the other joints of the vertebrae (facet joints), and this degeneration of the facet joints and surrounding soft tissues may lead to chronic low back pain. Disc displacement (herniation) may occur secondary to disc degeneration when the nucleus pulposus protrudes abnormally beyond the fibrous ring into the spinal canal, often pressing on spinal nerves and causing changes in sensory, motor, and reflex function (radiculopathy).
Usually, the precise cause of back pain cannot be identified, but because pain and degeneration coexist, the pain is usually attributed to the degenerative changes. Intermittent pain, but not unrelenting pain, is most characteristic of disc degeneration. In lumbar disc degeneration, pain usually begins in the low back and can radiate to the sacroiliac region and the buttocks. Nerve root irritation may center over the sciatic nerve, producing pain from the low back region down the back of the thigh. This may be indicative of disc herniation.
Several things may contribute to the pain often attributed to degenerative disc disease. The discs may lose water and become less flexible. Small tears in the tough ring of cartilage that makes up the outer disk (annulus fibrosis) may allow the jelly-like material of the nucleus pulposus to protrude from the disc space (herniate) and compress the nerve root. Bone spurs (osteophytes) grow slowly over time, and the spinal canal may narrow and compress the nerves that run through it. Any of these possibilities may cause pain of varying duration and intensity. Symptoms of DDD will generally vary according to the location and degree of vertebral compression and the activity level of the individual. However, symptoms do not always match up with diagnostic evidence. The presence of diseases that affect the spine or adjacent organs may refer pain to the lower back and legs and may complicate diagnosis of disc disease.
Risk: Aging is a risk factor for lumbar disc degeneration. In individuals of all ages undergoing MRI, 30% of those without symptoms showed disc degeneration; among individuals 60 years of age and older, 57% had abnormalities (Patel). Low back pain due to lumbar disc degeneration tends to occur at a younger age in men than in women, but over time males and females are equally afflicted (Patel). The incidence of low back pain related to DDD is highest in individuals around 40 years of age (Patel). The tendency to develop lumbar disc degeneration appears to be genetic in some cases. Smoking has been shown to increase the risk and rate of disc degeneration. Incidence and Prevalence: Over the course of a person's life there is a 60% to 90% chance that an individual will suffer an episode of low back pain; the likelihood that it might occur in any given year is 5%. According to the National Center for Health Statistics, low back pain accounts for 13 million visits to the doctor each year. With 2.4 million people excused from work during any period, low back pain is the single greatest reason for lost productivity in the US (Patel). The precise incidence of lumbar disc degeneration is unknown because of the large number of asymptomatic cases that go unreported. |
Source: Medical Disability Advisor
| History: Individuals may complain of pain in the lower back and buttocks and often describe a related traumatic event.
The pain is often brought on by activity and relieved with rest. Pain relief may come from lying on the side with the knees bent in the fetal position. Individual may report that the episodes of pain have become more frequent and intense. The individual may describe a sense of stiffness, weakness, tingling in the legs (paresthesias), or instability between acute episodes of pain. A family history of disc degeneration may be reported. A complete history of current and prior illnesses should be taken. Physical exam: The exam is often unremarkable. Limited range of motion is usually noted in both forward flexion and extension. Palpation of the lumbar spine may cause pain. The neuromuscular exam is directed at excluding any symptoms or signs of spinal nerve involvement. Tests: Plain x-rays will show the narrowing of the disc space and some osteophyte formation on the vertebral bodies as examples of age-related changes. These changes are usually not the cause of the symptoms. Further testing is not indicated unless there are signs of spinal nerve irritation or systemic disease. MRI studies are currently the gold standard for defining disc disease; it can rule out serious causes of back pain such as spinal cancer or infection. Discography is a controversial test with no clear demonstration in the literature that it can reliably identify the source of back pain or lead to an effective treatment. Flexion-extension plain x-rays are used to detect spinal instability, which is uncommon and, when seen, almost always occurs in elderly women. For those rare patients with instability proved by x-rays, spine fusion is usually an effective treatment. |
Source: Medical Disability Advisor
| Conservative treatment with medication such as nonsteroidal anti-inflammatory agents (NSAIDs), aspirin (if tolerated), and perhaps a lumbar support corset is usually all that is needed to relieve pain. Intermittent rest may actually be counterproductive to pain relief. It is important for the individual to understand the role of body mechanics in lumbar disc disease. Exercises to improve posture, mobility, and strength and a few manipulative treatments to the back are sometimes helpful. The treatment regimen should include aerobic exercise, since decreased aerobic fitness is a risk factor for recurrence of symptoms.
Surgery is uncommonly performed but may be indicated in cases of chronic disc degeneration with significant back pain and degeneration limited to one or two disc levels. The individual must be made aware that surgery does not provide a cure and, at best, may relieve some of the back and leg symptoms. In highly selected cases of back pain that have not responded to conservative measures in patients without psychosocial confounders, fusion of the affected vertebrae is sometimes performed, although demonstration of effectiveness is lacking in the literature.
Discectomy is not a consideration for disc degeneration. Discectomy is only indicated for disc herniations with nerve root compression. |
Source: Medical Disability Advisor
| Lumbar disc degeneration is chronic and irreversible. Acute episodes of back pain may resolve in a few weeks. Much of the outcome depends on the activity level of the individual. In general, individuals with heavy jobs have more difficulty functioning during episodes of back pain than individuals with light jobs. The prognosis is very good following conservative treatment in a large majority of individuals. Almost half of those afflicted with low back pain will be free of discomfort within 1 week, and 90% will recover between 6 and 12 weeks (Patel). Estimates vary somewhat, but within 2 years of an episode, 60% to 85% will experience a recurrence (Patel). However, individuals who do not follow a treatment regimen that includes strength-building exercises tend to have a poorer outcome, with more frequent and prolonged recurrence of back pain. If back pain attributed to degenerative disc disease has kept a person from working for over a year, there is only a 25% chance that the person will return, and after 2 years, that likelihood essentially drops to zero (Patel).
According to one prospective, observational study, among individuals with acute low back pain, the outcomes are similar whether they receive care from chiropractors, primary care practitioners, or orthopedic surgeons (Carey). |
Source: Medical Disability Advisor
| Note on research and authorship Individuals with degeneration of the lumbar intervertebral disc may benefit from rehabilitation to decrease pain and regain mobility and strength of the spine. It should be recognized that degeneration of a disc is a natural component of aging and may or may not cause symptoms. Therapy to reduce symptoms, followed by spinal exercises, may be sufficient for mild cases. More involved rehabilitation is required for severe symptoms. Passive intervention should be time-limited. Active exercise should be started as soon as tolerated. Rehabilitation will be based upon the duration of time from the onset of symptoms. The goal of rehabilitation is to promote an active lifestyle and regular participation in an exercise program (Malmivaara).
Acute Phase (up to 1 week): Recovery may be improved by a few sessions of manipulation, followed by instruction on safe postures and positions. The individual should be encouraged to resume activities that can be tolerated (Bigos).
Subacute Phase (2 to 12 weeks): A therapist should instruct the individual in an exercise program that will help maintain the individual's well-being. Physical therapy will include modalities such as moist heat and electrical stimulation to control pain in order to promote physical activity. The individual may also benefit from spinal injections for pain control. During this phase, the workplace should undergo an ergonomic evaluation so that changes may be implemented to assist the employee in returning to work. Toward the later stages of this phase, if the individual shows a lack of or slow progress, a health psychologist should evaluate the individual to determine whether or not there are signs of psychological distress secondary to the injury (Kendall). There is evidence that a multidisciplinary treatment approach can be effective in treating these individuals and returning them to a full level of activity (Loisel).
Chronic Phase (more than 12 weeks): The individual should continue to be educated in functional exercises and proper body mechanics. A short course of cognitive pain management may be beneficial. There is evidence that, as with those in the subacute phase, those in the chronic phase may recover through a multidisciplinary treatment approach, returning to a full level of activity. An ergonomic evaluation with modifications may enable the individual's return to work and reduce the risk of re-injury. Vocational services should be available for individuals who cannot return to their previous job title or do not have a job to which to return (van Tulder). |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical | |
| Physical Therapist | | Up to 12 visits within 6 weeks | | | | | | | | Physical Therapist | | Daily up to 6 weeks ‡ ‡ | | | | | | | | Occupational Therapist | | Daily up to 6 weeks ‡ ‡ | | | | | | | | Chiropractor | | Up to 3 visits within first week of onset | | | | | | | | Psychologist | | Up to 2 visits within 6 weeks of onset | | | | | | | | Psychologist | | Up to 12 visits within 6 weeks ‡ ‡ | | | | | | | | Ergonomist | | Up to 2 visits within 8 weeks | | | | | | | | Vocational Counselor | | Up to 3 visits within 6 weeks ‡ ‡ | | | | | | | | Surgical ‡ | |
| Physical Therapist | | Up to 6 visits within 6 weeks | |
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| ‡ Note on Surgical Guidelines: Rehab usually begins after tissue healing, about 6 to 8 weeks after surgery.
‡ ‡ As part of multidisciplinary intervention (work condition). |
| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| The condition may progress to a symptomatic lumbar disc herniation. Severe degeneration may cause degenerative spinal stenosis with compression of the motor fibers of the nerve root and may result in weakness or paralysis of the affected muscle group, along with loss of muscle tone and atrophy. |
Source: Medical Disability Advisor
| Temporary work restrictions should include avoidance of heavy lifting, twisting motions, prolonged sitting or standing, and activities that involve heavy vibration (such as driving large vehicles and using construction equipment such as jackhammers). Individuals may benefit from rest periods, including an opportunity to lie down during such breaks. Use of pain medication and muscle relaxants can affect dexterity and alertness. Safety issues will need to be evaluated. Work-hardening programs and worksite evaluations are beneficial to many individuals and may allow for earlier return from disability. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual complain of pain in the lower back and buttocks? Is it brought on by activity and relieved with rest? Is it episodic or unrelenting and progressive?
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Do certain activities or postures cause individual's pain?
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Were x-rays done? Was degeneration confirmed?
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Was MRI performed?
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Were conditions such as tumors, infections, osteoarthritis, rheumatoid arthritis, fractures, or a narrowing of the spinal canal (spinal stenosis) ruled out?
Regarding treatment:
- Did individual respond to conservative therapy?
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Is individual taking nonsteroidal anti-inflammatory drugs? Muscle relaxants? Opioids?
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Does individual have a home-exercise program that includes some aerobic activity?
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How long has individual had intractable back pain?
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Is individual a candidate for surgery?
Regarding prognosis:
- Is individual active in physical therapy?
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Was individual trained in proper body mechanics and lifting?
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Has individual incorporated exercises that improve posture, flexibility, and strength into the home-exercise program?
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Are chronic conditions such as severe scoliosis, a narrowed spinal canal, osteoporosis, or osteoarthritis present?
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Does individual report a change in symptoms?
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Source: Medical Disability Advisor
| Bigos, S., et al. "Acute Low Back Problems in Adults." Clinical Practice Guidelines. 14th ed. Rockville, MD: Agency for Healthcare Policy Research (AHCPR), 1994.Carey, T. S., et al. "The Outcomes and Costs of Care for Acute Low Back Pain Among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons." New England Journal of Medicine National Center for Biotechnology Information. National Library of Medicine. 16 Dec. 2008 <PMID: 7666878>. Carragee, E., et al. "Are First-time Episodes of Serious Low Back Pain Illness Associated with New MRI Findings?" Spine 6 6 (2006): 624-635. Carragee, E., et al. "Does Minor Trauma Cause Serious Low Back Pain Illness?" Spine 31 25 (2006): 2942-2949. Hoff, Julian T. "Intervertebral Disc Disease." Current Surgical Diagnosis & Treatment. Eds. L. W. Way and Gerald M. Doherty. 11th ed. New York: McGraw-Hill, 2004. 952-958. Kendall, N., S. J. Linton, and C. J. Main, eds. "Guide to Assessing Psychological Yellow Flags in Acute Low Back Pain." Risk Factors for Long-Term Disabilities and Work Loss. Wellington, New Zealand: The National Health Committee, 1997. Loisel, P., et al. "A Population-based, Randomized Clinical Trial on Back Pain Management." Spine 22 24 (1997): 2911-2918. National Center for Biotechnology Information. National Library of Medicine. 19 Dec. 2004 <PMID: 9431627>. Malmivaara, A., et al. "The Treatment of Acute Low Back Pain--Bed Rest, Exercises, or Ordinary Activity?" New England Journal of Medicine 332 6 (1995): 351-355. National Center for Biotechnology Information. National Library of Medicine. 19 Dec. 2004 <PMID: 7823996>. Patel, Rajeev K., and Curtis W. Slipman. "Lumbar Degenerative Disc Disease." eMedicine. Eds. J. Michael Wieting, et al. 1 Oct. 2004. Medscape. 10 Sep. 2004 <http://emedicine.com/pmr/topic67.htm>. van Tulder, M. W., et al. "Behavioral Treatment for Chronic Low Back Pain: A Systematic Review within the Framework of the Cochrane Back Review Group." Spine 26 3 (2001): 270-281. National Center for Biotechnology Information. National Library of Medicine. 19 Dec. 2004 <PMID: 11224863>. Williams, Keith D., and Ashley L. Park. "Lumbar Disc Disease." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beatty. 11th ed. Philadelphia: Mosby Elsevier, 2008. 2199-2216. |
Source: Medical Disability Advisor
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