DEGENERATIVE

Disc
DISEASE
Dr Muhammad Hakim UD41 Ortho HTAN

Anatomy
Pathophysiology
Classification
Clinical

picture

Diagnosis
Treatment

ANATOMY OF SPINE

INTERVERTEBRAL
DISC

Anatomy of the intervertebral disc

The Intervertebral Disc

Two major components

Annulus fibrosis: thick, fibrous

radial tire called lamellae

Nucleus pulposus: ball-like gel

The disc

Pathophysiology
Degenerative

disc disease is a
general term used to describe
changes that can occur along any
area of the spine as you age but is
most common in the lumbar area.
Its not actually a disease but rather a
condition in which your disc
degenerate or lose their flexibility
and ability to cushion your spine.
Familial predisposition for degenerative for degenerative disc
disease.Spine 21.1527-9.1996

The

intervertebral disk undergoes the

most serious age-related changes.
By the third decade of life, the
nucleus pulposusbecomes replaced
with fibrocartilage, and the distinction
between the nucleus and the annulus
becomes blurred.
The proteoglycan, water, and
noncollagenous protein concentrations
decrease, while the collagen
concentration increases.
The increase in collagen concentration
is more pronounced in the nucleus and

Biochemically
Aging

increases the ratio of keratin sulfate to

chondroitin sulfate, and it also changes the
proportion of chondroitin-4-sulfate to chondroitin6-sulfate, with a parallel decrease in water
content.
Proteoglycan synthesis decreases, which
decreases the osmotic swelling and the traffic of
oxygen and nutrients to the disk. Because of this
decreased traffic, breakdown products of link and
noncollagenous proteins stagnate in the disk.
Nonenzymatic glycosylation of these breakdown
products accounts for the brown discoloration of
the aging connective tissues
Eyre DR, Matsui Y, Wu JJ. Collagen polymorphisms of the
intervertebral disc. Biochem Soc Trans 2002;30:844-8

Age related changes :

Disc

dry out and shrink

-The disc made about 80 percent of
water, as we age they slowly lose water.
-This loss of flexibility puts more stress
on the annulus.
Small tears occur in the annulus
-When there are tear in the wall, some
gel like material will come out and
touches the nerves.
-This material has many inflammatory
proteins that can inflame the nerves

 Disc

space get smaller

-due to the loss of water in the disc, the distance
between vertebrae begin to collapse, which is why we
get shorter as we age
Bone spurs grow
-without the disc holding apart the vertebrae, they can
rub on each other and cause abnormal bone growth.
Spinal canal narrows
-The stresses of all the above changes causes the
ligament
and facet joint to be hyperthrophy.
-This overgrowth causes the spinal canal to narrow
which
can compress the spinal cord and nerve which result in
pain.

These

changes are more likely to

occur in people who smoke cigarettes
and those who do heavy physical
work (such as repeated heavy lifting).
People who areobeseare also more
likely to have symptoms of
degenerative disc disease.
A sudden (acute) injury leading to a
herniated disc(such as a fall) may
also begin the degeneration process.

Normal disc

Degenerative disc

Degenerative Changes of
the intervertebral disc
) - DISC BULGE
B. ) - ANNULAR TEAR
C. ) - HERNIATION
A.

A ) DISC BULGE
Generalized or circumferential disc displacement
(involving 50% to 100% of the disc circumference)
is known as bulging, and is not considered a
form of herniation.
Bulging can be symmetrical (displacement of disc
material is equal in all directions) or asymmetrical
(frequently associated with scoliosis)

(Fardon and Milette 2001).

ac. Symmetrical and asymmetrical bulging disc on

transverse CT or MRI scans.
a ) - Normally the intervertebral disc (gray) does not
extend beyond the edges of the ring apophyses
(black line).
b ) - In a symmetrically bulging disc, the disc tissue
extends concentrically beyond the edges of the ring
apophyses (50%100% of disc circumference).
c ) - An asymmetrical bulging disc can be
associated with scoliosis. Bulging discs are not

B ). ANNULAR TEAR
Disruption of concentric collagenous
fibers comprising the anulus fibrosus
MRI Findings
Contrast-enhancing nidus in disc margin
High signal zone at edge of disc which has
low intrinsic signal

TYPES
Concentric tears are circumferential lesions which
are found in the outer layers of the annular wall (Martin et al.
2002). They represent splitting between adjacent lamellae of
the annulus, like onion rings. Concentric tears are most
commonly encountered in the outer annulus fibrosus, and
are believed to be of traumatic origin especially from torsion
overload injuries.

Radial tears

are characterized by an annular tear

which permeates from the deep central part of the disc
(nucleus pulposus) and extends outward toward the annulus,
in either a transverse or cranial-caudal plane.

Transverse tears, also known as peripheral tears

or rim lesions, are horizontal ruptures of fibers, near the
insertion in the bony ring apophyses. Their clinical
significance remains unclear. Transverse tears are believed

CONCENTRIC TEARS
TRANSVERSE
TEARS /
PERIPHERAL
TEARS RIM
LESIONS

RADIAL TEARS

C). DISC HERNIATION

Herniation is defined as a localized
displacement of disc material
(nucleus, cartilage, fragmented
apophyseal bone, fragmented
annular tissue) beyond the limits
of the intervertebral disc space.
(Fardon and Milette 2001).

Herniated discs in the cranio-caudal

(vertical) direction through a break in one
or both of the vertebral body endplates
are referred to as intravertebral
herniations (also known as Schmorls
nodes). They are often surrounded by
reactive bone marrow changes.
Nutrient vascular canals may
leave scars in the endplates, which are
weak spots representing a route for the
early formation of intravertebral body
nuclear herniations

Degenerative
Changes of the
Posterior Elements
Most commonly affected
are:
1.Facet Joints
2.Ligamentum
Flavum

Degenerative changes of
the facet joint
Degenerative Changes
Cartilage lining loses
water content
Cartilage wears
away
Facets override
each other
Leads to abnormal
function of motion
segment

2). LIGAMENTUM FLAVUM

Degenerative Changes

Partial ruptures, necrosis

and calcifications

Negatively impact function

of motion segment and can
cause spinal stenosis

MRI of spinal stenosis: arrow points to

the moderately stenotic spinal canal
caused by hypertrophic facets and
ligament flavum

Clinical picture
At

least 30% of people aged 30-50 years oldwill

have some degree of disc space degeneration, although
not all will have pain or ever receive a formal diagnosis.
In fact, after a patient reaches 60, some level of disc
degeneration is a normal finding.
History of recurring or persistent back pain
Occasional buttock pain and referred pain radiating
down the posterior thigh with no radiculopathy
Pain:deep,dull ache in the lower lumbar region
Increased pain with rotation,flexion and side
bending,prolonged sitting/standing/walking
Relief of pain with rest,lateral recumbent position
Leg pain develop as late finding
SLR causes back pain only

Diagnostic Tests

Initially a physical exam consisting of range of

motion, check nerve-related changes, and look for
fractures or infection

Diagnostic test
-Laboratory studies
-Imaging studies
-diagnostic procedure

Laboratory Studies
Inflammatory

causes of low back pain can

be ruled out with tests for acute phase
reactants such as the erythrocyte
sedimentation rate (ESR) and C- reactive
protein level. A complete blood count
should be obtained, including a platelet
count.
Rheumatoid factor testing and
antinuclear antibody testing are good
screening tools for autoimmune
disorders.

Imaging studies

X-rays would show the narrowing between the vertebral

bodies

CT scan shows how much space is available for the

nerve roots to pass through

MRI tests are the most significant diagnostic imaging

that shows disk herniation and compressed nerves

Diagnostic procedure
-Selective nerve root blocks
Transforaminal selective nerve root blocks (SNRBs) have
been used as both subjective diagnostic tools and
therapeutic interventions for lumbar spinal stenotic levels.
When MRI shows evidence of multilevel degenerative disk
disease, SNRBs can be used to determine whether a
specific nerve root is affected. The procedure involves
injection of anesthetic and contrast at the nerve root level
of interest under fluoroscopic guidance. This creates an
area of hypoesthesia in the respective dermatome.
Anderberg et al investigated the correlation of SNRBs with
MRI findings and clinical symptoms in cervical spines with
multilevel degenerative disk disease. The results showed a
60% correlation with the most severe areas of MRI
degeneration. In areas of neurological deficit, dermatomal
radicular pain showed a 28% correlation with SNRB results.
1.Anderberg L, Annertz M, Brandt L, Saveland H. Selective diagnostic cervical nerve root block-correlation with clinical symptoms and MRI-pathology. Acta Neurochir (Wien). Jun
2004;146(6):559-65; discussion 565.

Treatment
Conservative
Modifying daily activities and physical therapy
Chiropractor
Analgesics, NSAIDs and oral steroids are prescribed
to reduce pain
Epidural injections and selective nerve root blocks
are before surgery
Surgery is a last resort for treatment of DDD

Exercise
Different types of exercises are prescribed,
depending on each patient's diagnosis. Floor
exercises consist of abdominal bracing, modified
sit-ups, double-knee-to-chest or low back
stretches, seat lifts, mountain and sag exercises,
knee-to-elbow exercises, hamstring stretches,
extension exercises, and extension flexibility
exercises. Swimming exercises are some of the
best activities. Aerobic exercises improve
endurance if performed regularly (ie, 3
times/wk). Relaxation exercises are good for
relieving muscular tension that may aggravate
back pain.

Chiropractor
Chiropractic

manipulation or spinal
adjustment is done for patient with
back or neck pain.The philosophy is to
return the joints to more normal
motion.Good joint motion is essential
for the health and nutrition of the
discs and joints because it permits the
exchange of nutrient,fluids and waste.

Medication
Nonsteroidal anti-inflammatory drugs
-aspirin,ibuprofen,naproxen and celecoxib are
examples of non steroidal anti-inflammatory drugs
used to reduce inflammation and relieve pain.
Analgesics
-acetaminophen can relieve pain but dont have the
anti-inflammatory effect of NSAIDs.
Steroids
-can be used to reduced swelling and inflammation
of the nerve.steroids have the advantage of
providing almost immediate pain relief within a 24
hour period

Injections
Epidural steroid injections are most commonly used for
therapeutic purposes. The type and dosage of steroid
varies widely. Methylprednisolone (80-120 mg) mixed
with normal saline to achieve a volume of 8-10 mL is an
effective and safe dosage and volume. In some centers,
2-3 injections are given over a 1- to 2-week course, but
long-term results do not appear to be any different from
those achieved with a single injection.
The response to epidural injections is variable, and many
authorities believe the injections are only of short-term
value. Even if a favorable response occurs, no more than
4 injections should be given annually. Immediate pain
relief may be achieved by adding 4-6 mg of preservativefree morphine to the epidural steroid injection.

Surgical theraphy
Diskectomy

Take Home Messages

Know

the natural history of the

disease
Know your patient
Correlate clinical findings and
investigation if needed
Until definitive evidence
available, choose the most costeffective available treatment
option