Degenerative Disc Disease
Degenerative disc disease is a catchall phrase for a number of structural changes of the spine, such as lossof disc height, disc bulges, and impingement of nerves in the spine, among other changes. Certain healthcare providers and their patients typically presume that such changes of the spine are the cause of back pain. As such, it is one of the most commonly used diagnoses to explain back pain. Degenerative disc disease is also one of the most common reasons for undergoing spine surgeries1 and interventional procedures.2
Given how frequently the diagnosis is made in clinical practice, and given how commonly it is used as a reason to proceed with spine surgery or interventional procedures, it is important for patients to know that the diagnosis of degenerative disc disease is a controversial diagnosis within the healthcare community. There is by no means agreement that it is understood accurately across all healthcare providers. There is also no agreement that it should be diagnosed as often as it is.
Common misunderstandings of degenerative disc disease
Degenerative disc disease is commonly misunderstood. Given its name, patients with a diagnosis of degenerative disc disease often believe that they have a condition that is deteriorating their spine and which is inevitably going to get worse. Despite what its name implies, however, it is neither a disease nor a condition that inevitably worsens.
It is not considered a disease because degenerative changes of the spine are normal and common in the general population. By mid-adulthood, most people will have degenerative changes of the spine. Most degenerative changes are not painful. These facts are consistent findings in research.
Powell, et al.,3 had 302 women with no history of back pain undergo MRI scans of the lumbar spine. More than a third of women aged 18 to 40 had at least one degenerative disc. The percentage was higher for those older than 40 years of age.
Jensen, et al.,4 essentially repeated this study with 98 men and women who had no history of back pain. 64% of the sample had degenerative changes at one disc and 38% of the sample had degenerative changes at more than one disc.
Takatalo, et al.,5 performed essentially the same study on a much larger sample of 558 young men and women ages 20-22. They found that almost half of the young men and women had at least one degenerative disc.
The results of these studies show that degenerative disc disease is common and it is commonly not painful. Indeed, most of the time, degenerative changes of the spine are not painful.
Degenerative disc disease is therefore no longer considered a disease. The name is a misnomer and degenerative changes of the spine might better be thought of as a normal condition. Upwards of half of all adults (or more) have it and most of these people have no pain.
Moreover, degenerative changes of the spine do not inevitably get worse. Numerous studies over the years have shown that, while degenerative changes of the spine can get worse, most of the time they remain the same or get better.
Symmons, et al.,6 reviewed X-rays of 742 women aged 45 or older and then repeated the X-rays 8 to 11 years later. They divided the women into two groups, those with back pain and those without back pain. They found that 40% of those with back pain had degenerative disc disease, which did not get worse. They also found that 70% of the women without back pain had degenerative disc disease, which did not get worse.
Using MRI scans on a repeated basis, Matsubara, et al.,7 followed 32 patients with herniated discs in their lumbar spine. They found that, over the course of a year, 62% of disc herniations spontaneously reduced in size. The remaining 38% herniations did not progressively worsen.
Using repeated MRI scans over time, Hutton, et al.,8 reviewed two groups of patients with lumbar-related endplate changes. Endplate changes are another type of degenerative change in the spine. The first group was 36 patients with a low level of endplate changes and the second group was 22 patients with a more advanced stage of such changes. In the first group, half remained the same; a little less than half got worse; and two patients reversed back to normal. In the second group with the more advanced changes, most remained the same; some got better and none got worse.
Humphreys, et al.,9 looked at still other degenerative changes of the spine. They found that foraminal stenosis did narrow with age but found no progression of disc height, lordosis, or reduced width of the central canal.
In clinical practice, healthcare providers often attribute the progression of degenerative changes of the spine to injuries and accidents. However, even injuries and accidents do not inevitably lead to a progression of degenerative changes. Carragee, et al.,10 gave MRI’s to 200 working adults without any history of low back pain and then repeated the scans every six months for five years. They also kept track of different injuries and accidents that occurred in the intervening five years. Examples of what they tracked were sports and lifting injuries, traffic accidents, slips and falls. They found that, as long as the injury or accident was not severe enough to cause bone fracture or joint dislocation, everyday accidents and injuries did not cause pre-existing degenerative disc disease to worsen.
Jarvik, at al,11 performed essentially the same study on 123 Veteran's Affairs (VA) patients over a three-year period. Their subjects had no recent history of back pain at the beginning of the study. Over the course of the three years, 67% of their sample reported having an onset of back pain. Upon MRI scanning, only 9% showed evidence of adverse change in their spine – whether it was onset of degenerative disc disease or progression of a pre-existing degenerative disc disease.
Scientific certainty is based on different investigators coming to the same finding. What all these studies show is that degenerative changes of the spine can get worse, but it is far from inevitable that they will get worse. These studies also show that the name ‘degenerative disc disease’ is a misnomer and leads to misunderstanding of the condition.
Controversy in the use of the diagnosis of degenerative disc disease
In clinical practice, the diagnosis of degenerative disc disease is a common explanation for why a patient has back or neck pain. Healthcare providers commonly use X-ray, CT or MRI scans to find evidence of degenerative changes. Once found, they use the results of these tests to explain the cause of pain. The diagnosis also forms the basis of treatment decisions. Procedures like spine surgeries and epidural steroid injections aim to modify degenerative changes in the spine. Many healthcare providers and patients confidently proceed with these kinds of procedures in the belief that the MRI or CT scan has identified the cause of pain – degenerative disc changes in the spine.
The confidence seems well founded. The pain is in the back or neck and so it seems reasonable to look for some type of structural abnormality in the spine. If a CT or MRI scan shows degenerative changes in the spine, then the pain must be caused by the degenerative changes. Patients and healthcare providers, particularly spine surgeons and interventional pain physicians, understand the cause of back pain in this manner.
There is, however, no way to be certain that degenerative changes of the spine are the cause of back or neck pain in any particular individual.
When a patient with back pain presents to a healthcare provider, and the patient undergoes a scan, such as an MRI, one of three types of findings will occur. The scan might show a normal spine, as far as degenerative changes go. This type of finding happens up to half the time.12 Another possibility, of course, is that the scan shows degenerative changes of the spine. Sometimes, the changes are not in the right place to possibly cause the pain (i.e., the degenerative disc is in the mid-back, for instance, when the pain is in the low back). These are considered ‘incidental’ findings. Incidental findings of non-painful degenerative changes are common, as many if not most adults have degenerative changes in their spine, whether they have pain or not. If, however, the scan shows degenerative changes in a place that could be the cause of pain, healthcare providers often conclude that the degenerative changes are the cause of pain. They subsequently proceed to treat the degenerative disc through interventional or surgical procedures.
How confident should they be? How do they know that these findings aren’t incidental too? What if the degenerative changes are in fact non-painful, like the other ones that so often occur, and the true cause of pain is something else entirely? Just because they are in the right location to possibly cause pain, doesn’t prove that they are in fact causing the pain. There is no way to reliably identify when a disc is painful through any of the available scans.
Because of this problem, discography has become more widely used in recent years. Discography is a procedure that attempts to provoke pain and, by doing so, identify degenerative discs. The procedure is controversial because of its unreliability – it can too often identify degenerative discs as painful when they really aren’t or otherwise fail to find the true cause of pain. Despite its common use, professional and governmental organizations recommend against using it.13, 14
As a result, there is no way to know for certain when a degenerative change of the spine is painful or not, even when they are found on a scan.
Research, too, consistently finds that the presence of degenerative findings on scans cannot fully explain why pain occurs. In a recent review of this research, Endean, et al.15 found statistically significant correlations between degenerative changes of the spine and having back pain. After all, sometimes, degenerative changes of the spine are painful. However, the associations were weak because, as described above, they are also sometimes not painful. So, what this means is that back pain is only partly attributable to the presence of degenerative changes of the spine. There must be other reasons for back pain and imaging scans do not identify them. As such, these investigators did not recommend using findings from scans as the sole means of determining why an individual has pain.
Recent practice guidelines developed by the American Pain Society and American College of Physicians took even a stronger stance.16 Unless patients show signs of severe neurological problems, infection or cancer, they recommend against obtaining routine imaging scans, like MRI’s or CT’s, for acute back pain. Numerous countries around the world have come to a similar conclusion.17 A different group of researchers recently recommended against routine use of scans in chronic back pain too.18
These guidelines might initially surprise patients. However, there is significant concern in the healthcare community about the diagnosis of degenerative disc disease by means of imaging scans or discography. The reason is that it can lead to poor outcomes for surgical and interventional procedures.19 After all, if there really is no way to determine when a degenerative change in the spine is truly painful or not, then treatments like back surgeries and interventional procedures are likely to be unnecessary at times. It might also be a reason why such treatments are so often unsuccessful in reducing pain.20, 21, 22, 23, 24, 25
Therapies and Procedures for degenerative disc disease
For degenerative disc disease, the American Pain Society and American College of Physicians recommend the use of anti-inflammatory and antidepressant medications, chiropractic care, physical therapy, cognitive behavioral therapy, and chronic pain rehabilitation programs.26, 27
Conclusion
Degenerative disc disease is a commonly misunderstood and controversial diagnosis. Its name is a misnomer, as it leads to misunderstanding. Degenerative changes of the spine are neither inevitably degenerative nor a disease. It really acts as a catchall phrase for a number of conditions of the spine that are common in the general population and are usually not painful. Sometimes, of course, they can cause pain. However, there is currently no way to determine with any certainty when a degenerative change in the spine is painful or not. Practice guidelines developed by professional and governmental organizations recommend against the routine use of imaging scans and discography to diagnose degenerative disc disease. The reason is that their use can lead to over-diagnosis of degenerative disc disease, which, in turn, leads to unnecessary and unsuccessful treatments.
References
1. Deyo, R. A., Cherkin, D. C., Loeser, J. D., Bigos, S. J., & Ciol, M. A. (1992). Morbidity and mortality in association with operations on the lumbar spine. Journal of Bone and Joint Surgery, 74, 536-543.
2. Friedrich, J. M., & Harrast, M. A. (2010) Lumbar epidural steroid injections: Indications, contraindication, risks, and benefits. Current Sports Medicine Reports, 9, 43-49.
3. Powell, M. C., Szypryt, P., Wilson, M., Symonds, E. M., & Worthington, B. S. (1986). Prevalence of lumbar disc degeneration observed by magnetic resonance in symptomless women. Lancet, 328, 1366-1367
4. Jensen, M. C., Brant-Zawadzki, M. N., Obuchowski, N., Modic, M. T., Malkasian, D., Ross, J. S. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331, 69-73.
5. Takatalo, J., Karppinen, J., Niinimaki, J., Taimela, S., Nayha, S., Jarvelin, M. R., Kyllonen, E., Tervonen, O. (2009). Prevalence of degenerative imaging findings in lumbar magnetic imaging among young adults. Spine, 34, 1716-1721.
6. Symmons, D. P., van Hemert, A. M., Vandenbroucke, J. P., & Valkenburg, H. A. (1991). A longitudinal study of back pain and radiological changes in the lumbar spines of middle aged women. II. Radiographic findings. Annals of the Rheumatic Diseases, 50, 162-166.
7. Matsubara, Y. Kato, F. Mimatsu, K., Kajino, G., Nakamura, S., & Nitta, H. (1995). Serial changes on MRI in lumbar disc herniations treated conservatively. Neuroradiology, 37, 378-383.
8. Hutton, M. J., Baker, J. H., & Powell, J. M. (2011). Modic vertebral body changes: The natural history as assessed by consecutive magnetic resonance imaging. Spine, 36, 2304-2307.
9. Humphreys, S. C., Hodges, S. D., Patwardhan, A., Eck, J. C., Covington, L. A., & Sartori, M. (1998). The natural history of the cervical foramen in symptomatic and asymptomatic individuals aged 20-60 years as measured by magnetic resonance imaging: A descriptive approach. Spine, 23, 2180-2184.
10. Carragee, E., Alamin, T., Cheng, I., Franklin, T., & Hurwitz, E. (2006). Does minor trauma cause serious low back illness? Spine, 31, 2942-2949.
11. Jarvik, J. G., Hollingsworth, W., Martin, B., Emerson, S. S., Gray, D. T., Overman, S., Robinson, D. Staiger, T., Wessbecher, F., Sullivan, S. D., Kreuter, W., & Deyo, R. A. (2006). Rapid magnetic resonance imaging vs radiographs for patient with low back pain. Journal of the American Medical Association, 289, 2810-2818.
12. Savage, R. A., Whitehouse, G. H., & Roberts, N. (1997). The relationship between magnetic resonance imaging appearance of the lumbar spine and low back pain, age, and occupation in males. European Spine Journal, 6, 106-114.
13. Agency for Healthcare Research and Quality. (2007). Total expenses and percent distribution for selected conditions by type of service: United States, 2009. Washington DC: Government Printing Office. Retrieved from http://guidelines.gov/content.aspx?id=12540.
14. Chou, R. Loeser, J. D., Owens, D. K., Rosenquist, R. W., Atlas, S. J., Baisden, J., Caragee, E. J., Grabois, M., Murphy, D. R., Resnick, D. K., Stanos, S. P., Shaffer, W. O., & Wall, E. R. (2009). Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain. Spine, 34, 1066-1067.
15. Endean, A., Palmer, K. T., & Coggon, D. (2011). Potential of MRI findings to refine case definition for mechanical low back pain in epidemiological studies: A systematic review. Spine, 36, 160-169.
16. Chou, R., Aseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147, 478-491.
17. Koes, B. W., van Tulder, M. W., Ostelo, R., Kim, B. A., & Waddell, G. (2001). Clinical guidelines for the management of low back pain in primary care: An international comparison. Spine, 26, 2504-2513.
18. Chou, D., Samartzis, D., Bellabarba, C., Patel, A., Luk, K., Kisser, J. M., & Skelly, A. C. (2011). Degenerative magnetic resonance imaging changes in patients with chronic low back pain: A systematic review. Spine, 36, S43-S53.
19. Modic, M. T., Obuchowski, N. A., Ross, J. S., Brant-Zawadzki, M. N., Groof, P. N., Mazanec, D. J., & Benzel, E. C. (2005). Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology, 237, 597-604.
20. Arden, N. K., Price, C., Reading, I., Stubbing, J., Hazelgrove, J., Dunne, C., Michel, M., Rogers, P., & Cooper C. (2005). A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology, 44, 1399-1406.
21. Gibson J. N. & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved November 25, 2011, from The Cochrane Library, Wiley Interscience.
22. Mirza, S. K. & Deyo, R. A. (2007). Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine, 32, 816-823.
23. Ng, L., Chaudhary, N., & Sell, P. (2005). The efficacy of corticosteroids in periradicular infiltration in chronic radicular pain: A randomized, double-blind, controlled trial. Spine, 30, 857-862.
24. Staal, J. B., de Bie, R., de Vet, H. C., Hildebrandt, J., & Nelemans, P. (Updated March 30, 2007). Injection therapy for subacute and chronic low back pain. In Cochrane Database of Systematic Reviews, 2008 (3). Retrieved April 22, 2012.
25. van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.
26. Chou, R., Atlas, S. J., Stanos, S. P., & Rosenquist, R. W. (2009). Nonsurgical interventional therapies for low back pain: A review of the evidence for the American Pain Society clinical practice guideline. Spine, 34, 1078-1093.
27. Chou, R. & Huffman, L. H. (2007). Medications for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine, 147, 505-514.
Date of publication: April 27, 2012
Date of last modification: January 29, 2017