Let’s have a look a the causes of low back pain and how it could be related to degenerative disc disease and herniated discs.
- common complaint among adults
- lifetime prevalence in working population up to 80%
- 60% experience functional limitation or disability
- second most common reason for work disability
- despite advances in imaging and surgical techniques LBP prevalence and its cost are relatively unchanged
- 90% people age >50 have Degenerative Disc Disease
- Large disc herniation does NOT always need surgery
- Neurologic loss is NOT an absolute indication for surgery
- Small disc bulge is NOT always normal
- Surgery does not have an 80% success rate
- Conservative treatment is reversible. Surgery is not.
Causes of low back pain - Click to enlarge
Back pain causes:
- Spasm
- Sprain/strain
- Biomechanical
- Disc herniation
- Disc bulge
- Degenerative osteoarthritis
- Facet syndrome
- Spondylolithesis
- Spinal stenosis
- Osteoporosis
- Inflammatory
- Infection
- Cancer
Normal Vs Disc Degeneration - Clic to enlarge
Disc degeneration (arthrosis)
- Changes in hydrostatic pressure
- Lack of oxygen
- Lack of glucose
- Changes in pH levels
- Death of proteoglycans
If the cells of the disc failed to get proper nutrients – such as oxygen, or glucose – or if the pH level of the disc drops (because waste is not being diffused out of the disc and it becomes anaerobic), disc cells would die and stop producing the vital proteoglycan aggregates. The disc loses its water content (dehydrates) and loses its hydrostatic pressure (osmotic pressure).
Symptoms of lumbar disc disease are the result of either herniation of the nucleus pulposus through a mechanically weak annulus fibrosis or from tearing of the annulus itself. This can lead to Radiculopathy from nerve root compression and/or Radiculitis – an inflammatory process affecting nerve roots or the spinal cord. Herniation is thought to be the result of a defect in the annulus fibrosis, most likely the result of excessive stress applied to the disc.
Herniated disc
Three types of annular tears:
- Rim lesion – horizontal tearing of the very outer fibers of the disc near their attachments into the ring apophysis;
- Concentric tear – splitting apart of the lamellae of the annulus in a circumferential direction
- Radial tear – horizontal or obliquely horizontal tears
If you have a herniated disc, you should carefully read the following:
A health problem as serious needs to be taken care of by a competent health professional. Such a condition when poorly managed can have a disastrous effect on your health for the rest of your days.
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Herniated disc click to enlarge
The facts about herniated discs:
- Herniated Discs are not all inherently painful
- Most bulging discs are not symptomatic
- A bulging disc may be as painful as an herniated disc
- Surgery or non-surgical spinal decompression is required to correct an herniated disc
- In most cases, surgery actually offers poor curative results for an herniated disc
- Herniated Discs does notworsen with time but the disc does end up with degenerative disc disease.
- Most herniated discs won’t resolve on their own. The pain may subside because of posture and structural compensation
- Herniated discs cannot be diagnosed with an x-ray. You need an MRI
- Herniated discs are not always due to injury
- Herniated discs can happen because of a spinal rotational decompensation caused by a pelvis misalignment
- Medical treatment is not necessary for most herniated discs
- Many disc pain conditions are misdiagnosed
If I were to gather a group of middle age folks (45 average age) who have NEVER had back pain before and shoot MRIs on them all, here’s what we would find:
- 38% would have disc bulges,
- 37% disc protrusions (aka: contained herniations),
- 11% disc extrusions (aka: non-contained herniations),
- 0% disc sequestrations (aka: free fragments) and
- 4% nerve root compression by the disc herniation.
A more shocking statistic is that 60% of asymptomatic middle aged people would have findings of disc bulge or worse (protrusion, extrusion) on MRI!
Disc herniation, the leading cause of lombosciatica, is a result of a long and silent degenerative disc which will decompensate more or less abruptly on the occasion of an effort, sometimes minimal.
The lombosciatica almost never an “accident” occurring on a perfectly healthy spine.
References:
1. Jensen MC, et al. “MRI imaging of the lumbar spine in people without back pain.” N Engl J Med – 1994; 331:369-373
2. Boden SD et al. “Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation.” J Bone Joint Surg Am 1990; 72A:403-408
3. Weishaupt D et al. “MRI of the lumbar spine: Prevalence of intervertebral disc extrusion and sequestration, nerve root compression and plate abnormalities, and osteoarthritis of the fact joints in Asymptomatic Volunteers.” Radiology – 1998; 209:661-666
4. Boos N, et al. “1995 Volvo Award in clinical science: The diagnostic accuracy of MRI, work perception, and psychosocial factors in identifying symptomatic disc herniations.” Spine – 1995; 20:2613-2625
5. Powell MC, et al. “Prevalence of lumbar disc degeneration observed by magnetic resonance in symptomless women.” Lancer – 1986; 2:1366-7
6. Boos N, et al. “Natural history of individuals with asymptomatic disc abnormalities in MRI: Predictors of low back pain-related medical consultation and work incapacity.” Spine 2000; 25:1484
7. Borenstein G, Boden SD, Wiesel SW, et al. “The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic individuals: A 7-year follow-up study. J Bone Joint [am] 2001; 83:320-34
8. Wiesel SW, et al. “A study of computer-associated tomography: I. The incidence of positive CAT scans in asymptomatic group of patients.” Spine 1984;9:549-51
11. Wood KB, et al. ‘Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individual s.’ J Bone Joint Surg Am. 1995 Nov;77(11):1631-8
20. Jarvik JJ, et al. “The longitudinal assessment of imaging and disability of the back (LAIDBack) Study.” Spine 2001;26: 1158-66.
25. Boden SD, et al. “Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatci Subjects.” J Bone Joint Surg [AM] 1990; 72:403-408
26. Fraser RD, Sandhu A, Gogan WJ. ‘Magnetic resonance imaging findings 10 years after treatment for lumbar disc herniation.’ Spine 1995 Mar 15;20(6):710-4. “The findings of this study indicate that long-term improvement of a patient’s symptoms after treatment of disc herniation may occur with or without resolution of the hernia. This and the similar morphologic findings in the different groups is consistent with the 10-year clinical results after the treatment of disc herniation reported by Weber.”
27. Masui T, et al. ‘Natural History of Patients with Lumbar Disc Herniation Observed by Magnetic Resonance Imaging for Minimum 7 Years.’ J Spinal Disord Tech. 2005 Apr;18(2):121-126. “Clinical outcome did not depend on the size of herniation or the grade of degeneration of the intervertebral disc in the minimum 7-year follow-up.”
517. Giuliano V, et al. ‘The use of flexion and extension MR in the evaluation of cervical spine trauma: initial experience in 100 trauma patients compared with 100 normal subjects.’ Emerg Radiol. 2002 Nov;9(5):249-53.
