Degenerative Disc Disease explained by Grant Cooper MD, Princeton Spine & Joint Center:
One of the things that I’ve noticed over the last 10 years or so is that when patients come in and they’ve been given a diagnosis of degenerative disc disease, they come in with a heaviness and they say, ‘Doc, I have degenerative disc disease, so I don’t know what you can do for me.’ And I’ve realized over the years that there’s a lot of emotional baggage that comes with those words, degenerative disc disease. And part of that is that I’ve realized that almost no one really understands what they’re talking about when they come in and they say those words to me. So I thought it’d be helpful if we sort of unpack that term so we understand what is degenerative disc disease.
Degenerative discs is when the disc actually starts to dry out. The discs themselves are a cushion so that the bones aren’t rubbing on each other and they are filled with fluid. And as we all get older it’s normal for the discs to start to lose some of that fluid so that by the time someone is 50, certainly by the time they’re 60, everyone’s going to have degenerative discs. That’s something that you’re going to see on an MRI on someone as they get a little bit older. But as I just said, everyone’s going to get that so clearly it doesn’t always cause pain. In fact, it usually doesn’t. People are walking around all the time with degenerative discs and no pain. So degenerative disc disease is a term that comes in to say, look, when those degenerative discs are painful, then we’ll call it degenerative disc disease.
The reality is that when people have chronic lower back pain, so we’re going to define that as people that have had back pain for longer than three months, and when those people are older than 18 years of age, then 40% of the time that back pain is coming from their disc. And as the discs get older and you start to see that kind of wear and tear on it, we can call it degenerative disc disease But what’s actually causing the pain in somebody that has painful degenerative disc disease is when there’s a tear on the inside of the disc. It’s called an annular tear.
And so basically as we said before, the disc is a cushion between the bones. The way I think of it as like a jelly donut. There’s the inner jelly which is actually full of inflammatory proteins. It’s what gives the cushion to the disc, the cushioning. And then in the outer third of the crust of the disc called the annulus fibrosis. They are nerve fibers and when discs cause back pain is because there’s been a tear and some of that jelly has extravasated out and gets gone out into the outer third of the annulus and it starts irritating those neuro fibers. It’s called an annular tear. And when does cause pain, that’s what’s actually happening to cause the pain. Now that can happen in an 18 year old and someone with a lot of fluid in their discs and no degeneration really of note other than the annular tear. And it can happen in someone who’s 30, 50, 80, 90, 100. So when someone has a tear like that that’s causing pain, it’s the inflammation that’s irritating those nerve fibers that’s actually causing the pain from the disc.
Inflammation is a protein response. The way that I like to think about it is that it’s like a fire. There are two ways that you can put out a fire, right? One is you clear away the sticks and clear where the fodder from around the fire and the fire has a tendency to take care of itself. So in a surgeon’s world, that is surgery, right? You’re literally moving around the structure. You’re moving bones, you’re moving discs. In my world that tends to be more physical therapy, Pilates, posture, yoga, manipulations, trying to get all the muscles to take the pressure off of the back so that the back can basically calm down and heal itself.
Sometimes you take some water and you dump it on the fire. A lot of our day, as an interventional spine doctor, we are that fire hose. We’re basically taking a needle, we’re going under fluoroscopy or under an x ray and we’re delivering anti inflammatory medication around the inflamed spot, in this case the disc. The nice thing about that is the water goes on the fire. The fire tends to go out. But the limitation of that is that even when the fire goes out, the water invariably turns off, right? And so when the water turns off, it doesn’t mean that the fire is going to come back, but it doesn’t mean that it’s not either. So when somebody uses injections as an anti inflammatory to take away the inflammation, it’s really important that we think of that as more of a window of opportunity t hat enables someone to go learn some exercises and work on the mechanics, so that you start taking the pressure off of the disc so that as the water goes away, the fire doesn’t come back in 3, 6, 9, 12 months or whatever. And that’s the basic way that we tend to approach degenerative disc disease non-surgically, is to either think of it mechanically and think about how we’re going to unload the disc through exercise and ergonomics and, and your daily activities, or we’re going to use some interventional modalities to take away the inflammation from around the disc and then couple that to doing some exercises to make sure that we’re not sitting back here and having to worry about taking away the inflammation again. And then there are, there are some ancillary things that could get talked about, but that’s the main evidence-based way of approaching degenerative disc disease non-surgically.