Lumbar Degenerative Disc Disease

MUHAMMED KOCABIYIK PHYSICAL MEDICINE & REHABILITATION IV. CLASS V. GROUP

 Lumbar (low back) degenerative disc disease (DDD) is a common condition

in aging adults. The intervertebral discs serve as the spines shock absorbers and, as we age, discs gradually dry out, losing strength and resiliency. In most people, these changes are gradual. In fact, many of our patients don't know they have degenerative disc disease. They may only become aware of the condition when being examined for another health problem, or during a routine checkup.

Pathophysiology
Phase I The dysfunctional phase, or phase I, is characterized histologically by
circumferential tears or fissures in the outer annulus. Tears can be accompanied by endplate separation or failure, interrupting blood supply to the disk and impairing nutritional supply and waste removal. Such changes may be the result of repetitive microtrauma. Since the outer one third of the annular wall is innervated, tears or fissures in this area may be painful. Strong experimental evidence suggests that most episodes of LBP are a consequence of disk injury, rather than musculotendinous or ligamentous strain. Circumferential tears may coalesce to form radial tears. The nucleus pulposus may lose its normal water-imbibing abilities as a result of biochemical changes in aggregating proteoglycans.

 Phase II The unstable phase, or phase II, may result from progressive loss of
mechanical integrity of the trijoint complex. Disk-related changes include multiple annular tears (eg, radial, circumferential), internal disk disruption (IDD) and resorption, or loss of disk-space height. Concurrent changes in the zygapophyseal joints include cartilage degeneration, capsular laxity, and subluxation. The biomechanical result of these alterations leads to segmental instability. Clinical syndromes of segmental instability, IDD syndrome, and herniated disk seem to fit in this phase.

Phase III The third and final phase, stabilization, is characterized by further disk
resorption, disk-space narrowing, endplate destruction, disk fibrosis, and osteophyte formation. Diskogenic pain from such disks may have a higher incidence than that of the pain from the disks in phases I and II; however, great variation of phases can be expected in different disks in any given individual and individuals of similar ages vary greatly.

Symptoms
Disc degeneration is a normal part of
aging, and usually is not a problem. However, DDD can cause discs to lose height and become stiff. When disc height is lost, nerve impingement, bone and joint inflammation, and resultant pain can occur. Disc degeneration causes loss of the joint space, similar to arthritis pain and inflammation. In severe cases, pain may be constant.

Diagnosis
Medical history. Questions about symptoms, their severity, and treatments
you have already tried.

Physical examination. Carefully examined for limitations of movement,

problems with balance, and pain. During the exam, looks for loss of reflexes, muscle weakness, loss of sensation or other signs of neurological injury.

Diagnostic tests. Most start with x-rays, which helps to rule out other
problems such a tumor or infection. The films also reveal loss of disc space between the vertebrae. In some cases, a test called Discography confirms the diagnosis. Discography involves injecting contrast dye into the affected disc (or discs) to create a clearer image and temporarily replicate symptoms.

Medications

Initial treatment of lumbar disc disease consists of antiinflammatory medications including ibuprofen (Motrin, Advil) or naproxen (Aleve). These medications can help relieve both the pain and inflammation associated with lumbar disc disease. A short course of oral corticosteroids, such as prednisone, can also be of benefit, but longterm use of corticosteroids is not recommended. Long-term use is associated with serious side effects, such as peptic ulcer disease, swelling and fluid retention, sleep disturbances, confusion or mood changes, and an increased risk of osteoporosis. For lumbar disc disease that causes severe, radiating nerve pain down the leg (sciatica), an epidural injection of corticosteroids may be considered to provide a more prompt antiinflammatory effect. Muscle relaxants, such as cyclobenzaprine (Flexeril), can provide short-term relief for many people. These medications can cause drowsiness and should not be used if driving, working, or consuming alcohol. Additional side effects of muscle relaxants include dry mouth, blurred vision, urine retention, and constipation. Medications that contain narcotic pain relievers, such as codeine, morphine, or oxycodone can also provide relief of the pain associated with lumbar disc disease. These medications should not be continuously administered for chronic pain if alternative treatments can be used. Common side effects include drowsiness, constipation, or nightmares. Caution is advised to take only as prescribed to avoid toxicity of the narcotic or other medications, such as acetaminophen (Tylenol), that narcotic pain relievers may contain.

Nonoperative Treatment

The good news is that most cases of lumbar degenerative disc disease do not require surgery. Many different nonsurgical treatments help relieve symptoms. These include:
Medications, such as an anti-inflammatory to reduce swelling and pain, muscle relaxants to calm spasm, and occasionally narcotic painkillers to alleviate acute pain. Cold/heat therapy, especially during the first 24-48 hours.

Spinal injections (i.e. epidural) may help relieve low back and leg pain.
Physical therapy, which may include gentle massage, stretching, therapeutic exercise, bracing, or traction to decrease pain and increase function. Chiropractic or alternative therapy (i.e. acupuncture). In conjunction with these treatments, our staff will educate you about healthy posture and proper body mechanics.

Acupuncture Treatment Protocols

Treatment Points: Trauma

First needle the empirical points and move the patient's body to a position where the pain begins to appear. Manipulate the needle with reducing method for 1-2 minutes. If the patient responds well, repeat this process a few times then insert auxillary /local points and retain for 15-20 minutes. Empirical Points:

GV 26 - if pain is only on the midline of the back and patient has flexion/extension difficulty SI 3 - if pain is on the posterior-midline and also lateral and/or patient has torso rotation difficulty Yaotongxue - if pain is on either side of the posterior midline, pain above UB 23 UB 40 - acute back pain on the UB meridian, pain below UB 23 UB 37 - in lieu of UB 40 if there is pain and tenderness here and no congestion of blood vessels at UB 40 GV 8 - stiff and/or rigid spine

Treatment Points: Cold/Wind/Damp

GV 3 - expels cold damp UB 23 - expels damp, tonifies the Kidney UB 52 - chronic back pain above UB 23, direct needle towards pain UB 32 - sacral pain UB 54 - expels cold and damp
Treatment Points: Kidney Qi Deficiency

UB 23, GV 3, GV 4, KD 3 - strengthen the Qi of the Kidney

Massage Techniques
Deep Transverse-Friction Techniques A deep transverse-friction technique involves using the thumbs to put pressure on the center of the back and slowly move them towards the sides. This technique reduces the amount of binding between adjacent tissues. This, in turn, localizes the injured muscle fibers to one region. To enhance this technique, consider using softtissue mobilization techniques. This will also help encourage the localization of adjacent muscle fibers. Deep Longitudinal-Stripping Methods In addition to working the area where the pain is located, it is important to reduce tightness in muscles surrounding the pain. Deep longitudinal-stripping methods reduce the amount of tightness in the muscles surrounding the lumbar region. This technique is performed by placing the thumbs in the center of the back, applying pressure and slowly moving upwards. This technique also reduces the hypertonicity, which is increased muscle tension, in the lumbar region.

Static Compression Techniques

Static compression techniques may also help alleviate pain in the lumbar region. This technique is performed by placing pressure on the region and holding the pressure there, until the muscle relaxes. To place pressure, you can use the thumbs, knuckles or other pressure tools. In fact, using the palm of your hand will allow for broad application of pressure along the painful area of the lumbar region.
In addition to massage techniques, stretching is another great way to alleviate pain in the lumbar region of your back. In most cases, you can perform the stretches yourself. However, facilitated stretching with a massage therapist might be necessary, if it is too painful to put pressure on the lumbar region.

Stretching