Lower back pain is one of the most common reasons why patients visit their primary care providers. In recent years, it is also a major cause of disability and missed days of work.
There are a variety of causes for back pain, but one of the most common is lumbar degenerative disk disease (DDD). Today’s column focuses on causes and management of lumbar DDD.
What is lumbar disk degeneration?
The lumbar spine is composed of five vertebrae and individual disks. The lumbar vertebrae are large compared to the neck and thoracic spine, and provide the majority of the load-bearing ability for the body.
In spite of this, it still provides significant mobility in terms of forward/backward movement, side-to-side movements and swiveling with the pelvis. Compared to the relatively rigid lumbar vertebrae, the disks contain fluid and provide the ability of the spine to absorb shock and to aid in movement (along with the facet joints).
In degenerative disk disease, the fluid content of the disk is disrupted, resulting in inflammation and (at times) instability. Often, disk degeneration starts from initial disruption and progresses, often as a result of lifestyle factors (such as tobacco consumption or weight gain).
The symptoms of lumbar disk degeneration can vary significantly. In minor cases, patients may have back pain exacerbations that are self-limiting and resolve on their own. In other cases, more severe back pain and tenderness may develop. In cases where the disk bulges into the spinal canal, the nerves may get compressed, resulting in numbness, tingling and in severe cases weakness.
The initial diagnosis of lumbar disk degeneration is based on the clinical location of the pain and the symptoms. Often, this diagnosis is made by a primary care physician.
A physical examination is usually important to evaluate muscle strength, tone, and for associated symptoms such as weight loss, urinary or bowel incontinence — which could suggest more serious pathologies. When the symptoms remain for a period of time, imaging studies such as X-rays or MRI (the gold standard for diagnosing degenerative disk disease) may be required.
Non-surgical Management of DDD
Initial management of DDD is usually without surgery. This includes physical therapy, which may focus on flexibility and range of motion. Building core muscle strength may also be beneficial. Lifestyle changes such as smoking cessation, weight loss and adjusting work activities are also recommended. In many cases, therapy and lifestyle changes can provide patients with substantial pain relief.
When these don’t work, interventional pain management referral may be required. Image-guided injections of steroids are done around the spine or into the joints of the spine to see if this provides pain relief. The idea behind these injections is to reduce inflammation and possibly help with pain control. Steroid injections may be repeated in different parts of the spine over the course of time, to identify which areas are triggers for pain.
Surgical Management of DDD
Surgical management of DDD is usually reserved for three primary cases:
• Severe pain which has been refractory to non-surgical management treatments, including therapy and steroid injections
• Presence of neurologic deficit such as weakness, or severe pain along the distribution of a nerve
• The presence of abnormal movement in the spine caused by damage to the disk
Surgical options for management of DDD range from open surgery to minimally invasive approaches. Endoscopic spine surgery is a more recent advancement, which allows nerve decompression with less tissue disruption and often-times less post-operative pain.
It is important to realize that there is a range of surgical options and the treatments can be tailored to a patient’s specific needs and goals.
The patient and surgeon can work as partners in providing the optimal treatment to suit their goals after surgery.
Dr. Jay Jagannathan is a board-certified neurosurgeon with offices throughout the state of Michigan, including in Troy. He is President of a multi-specialty neurosurgical group, Jagannathan Neurosurgery.