Degenerative Disc Disease (Neck/Lumbar)
Julie Adkins and Jill C. Cash
Definition
A.Degenerative disc disease is a general term for the gradual deterioration of the discs between the vertebrae of the spine that can occur naturally or through a twisting injury where portions of the disc may tear, resulting in thinner and more fragile cartilage. Any level of the spine can be affected. The disc itself has very few nerve endings and no blood supply. The disc has no way to repair itself and the pain created by the damaged disc can either be a chronic condition or have periodic flare-ups.
Incidence
A.In the United States, back pain is the second leading symptom that prompts visits to a healthcare provider. As many as 80% of adults experience at least one episode of back pain during their lifetime, and 5% experience chronic problems with their back. Cervical degenerative disc disease is much less common than disc degeneration of the lumbar spine. After a patient reaches the age of 60, some level of disc degeneration is a normal finding rather than an exception.
Pathogenesis
The degenerative changes of the spine can be subdivided into three stages:
A.Dysfunction: May involve outer annular tears, separation of the endplate, cartilage destruction, and facet synovial reaction.
B.Instability: Disc resorption and loss of disc space height, possibly leading to subluxation.
C.Restabilization: Progressive changes leading to osteophyte formation or bone spurs and stenosis.
Predisposing Factors
A.Injury/inflammation.
B.Age related, occurs more commonly as one ages.
C.Slight genetic component.
Common Complaints
A.Pain that is usually related to activity; flare-ups at times but then returns to a low-grade pain level or pain will go away entirely. Cervical disc degeneration is most frequently felt as a stiff neck. Lumbar symptoms may include local tenderness, hypomobility, and painful extension of the lumbar back.
B.Muscle spasms of the neck, arms, or shoulders due to cervical nerve inflammation or impingement. Lumbar symptoms may include a giving away or catch in the back,
pain with standing and/or flexion.
C.Headache, muscle tenderness, stiffness, and reduced movement. Pain in buttocks or upper thighs.
Other Signs and Symptoms
A.Paresthesia of upper extremities and hands with decreased strength and hand grip.
B.Referred pain to hips, knees, ankles, and feet
C.Progression to chronic pain (pain lasting over 3 months).
Potential Complications
A.Presence of bowel and bladder symptoms.
B.Cauda equina syndrome.
C.Disability.
Subjective Data
A.When did the pain begin?
B.Ask the patient what activity brought about or preceded the episode. Was there an injury that could be related to the pain? Activity modification?
C.Have the patient rate the pain on a scale of 0 to 10, with 0 being no pain, or on the visual analogue scale, a series of faces of varying intensity.
D.Does the pain radiate to any other point of the body?
E.What factors make the pain better or worse?
F.Ask if the patient has had any problems with bladder or bowels.
G.Ask the patient to list all medications currently being taken, including over-the-counter (OTC) and herbal. Any current modalities tried?
H.Ask the patient if there is any family history of osteoporosis or degenerative disc disease.
Physical Examination
A.Vital signs: Weight, blood pressure, temperature, pulse, respirations. Notice red flags such as weight loss, fever, elevated pulse.
B.Start with a general physical examination to determine the source of the problem, dependent on where there is pain—neck, lower back, arms, legs, and so forth.
C.Inspect:
1.Inspect general appearance, skin rashes, or deformities.
2.Observe gait, assistive device use.
D.Palpate:
1.Assess the motion of spine and neck. Assess for pain with twisting, bending, or moving.
2.Assess muscle strength or weakness.
3.Palpate areas of tenderness or muscle spasms.
4.Sensory changes—assess increased or decreased sensation associated with point of tenderness.
5.Check deep tendon reflexes (DTRs).
6.Assess motor skills such as toe or heel walk.
E.Auscultate:
1.Auscultate carotid arteries.
2.Auscultate abdomen.
3.Conduct a complete heart exam.
4.Conduct a complete lung exam.
Diagnostic Tests
A.X-ray of affected area may reveal a decrease in the height space between disc, bone spurs, sclerosis, facet hypertrophy (enlargement), and instability during flexion or extension of limbs. X-ray will show fracture, infections, or tumors if suspected.
B.MRI or CT scan is used for more severe causes, such as loss of water in a disc, stenosis, or herniated disc, as well as to rule out differential diagnoses.
Differential Diagnoses
A.Degenerative disc disease.
B.Infection.
C.Fracture.
D.Tumor.
Plan
A.General interventions:
1.Initial decisions are made according to the seriousness of the findings. Some problems need immediate attention, possibly even surgery. The vast majority of problems, however, do not require immediate surgery.
B.Patient teaching:
1.Educate the patient about avoiding actions that aggravate the condition:
a.Modify activities to avoid lifting heavy objects and playing sports or other activities that require rotating the back or neck.
b.Teach correct ergonomics, such as how to lift heavy objects, how to sit in a chair, and how to correct sleep postures.
2.Nonsurgical interventions:
a.Rest.
b.An exercise program or physical therapy that may strengthen the back and avoid further inflammation or injury.
c.Alternating heat and ice to the affected site.
C.Pharmaceutical therapy:
1.Mild pain medications can reduce inflammation and pain. These medications will not stop degeneration, but they will help with pain control:
a.Nonsteroidal anti-inflammatory drugs (NSAIDs) block the inflammatory response in joints. Use can decrease renal function, and excessive use can lead to kidney problems.
b.Nonnarcotic pain relievers: Most commonly used are Tylenol and aspirin, but they must be avoided in patients with gastrointestinal disorders or liver problems.
c.Narcotic pain medications: Narcotics relieve pain by acting as a numbing anesthetic to the central nervous system. Narcotics can cause many side effects such as nausea, vomiting, constipation, sedation, or drowsiness. Precautions about falls are paramount with these types of medications.
d.Muscle relaxants can help relieve pain but have been shown to be only marginally effective. There is a significant risk for drowsiness and falls. Fall precautions and driving restrictions must be advised while using narcotics and muscle relaxants.
Follow-Up
A.Follow-up is determined by the patient’s response to conservative measures for pain relief, impact on activities of daily living (ADLs), ability to carry out work duties, or worsening of symptoms.
Consultation/Referral
A.Physical therapy: May include modalities of heat and ice, massage, ultrasound, and electric stimulation. Other treatments may include bracing, flexibility and strength training, pool therapy, and/or posture training.
B.Referral for epidural steroid injections: A combination of steroid and a local anesthetic given through the back into the epidural space. Injections are used when conservative treatments options have failed. Referral should be made to a pain control specialist for epidural steroid injections.
C.Referral to a neurosurgeon if immediate, emergent findings are found on evaluation or if symptoms last over 6 months without any relief.
Individual Considerations
A.Geriatrics:
1.Assess current living conditions, support systems, transportation issues, and impact on ADL. Educate the patient to enhance an understanding of the disease process and review possible treatment options available.
2.Assess all medications the patient is currently taking for interactions and review precautions with the patient regarding pain control medications used.
3.Review assistance that is available to avoid aggravating activities. Implement education for back posture, ergonomics with table computers and laptops/electronic tablets, lifting precautions, and abdominal muscle strengthening.
4.When prescribing pain medications or muscle relaxants, discuss ways to avoid falls and injuries, noting side effects of medications, such as drowsiness that may occur when performing ADLs. Acupuncture and/or corticosteroid injections might be beneficial. Radiofrequency denervation most often does not alleviate pain from intervertebral discs.
5.Special considerations are needed if surgery is necessary: Family support, rehabilitation, transportation, and home healthcare.