Lumbar Degenerative Disc Disease

1
Lumbar Degenerative Disc Disease

• Chris Williams, MSIII

2
Lower Back Pain (LBP)

• 85 of US pop will experience an episode
• 2nd most common reason to see MD
• Most common cause of disability if lt45yrs
• 2 types
• Mechanical
• Muscle Strain
• Trauma
• Compressive
• Stenosis
• Herniation

3
Degenerative Disc Disease Herniation

• Represents lt2 of LBP
• More likely at L4-L5 and L5-S1
• Increased risk if overweight
• Less common if lt20 or gt65 yrs

4
Clinical Presentation

• A 30 y/o previously healthy male
• CC My back hurts and its keeping me from
  working.
• Onset 1 week ago no inciting trauma recalled
• Pain is sharp and burning. Radiates to
  posterolateral leg (unilateral)
• Pain is worse with extension of back and sitting
• Gait is not affected

5
Clinical Presentation

• Numbness and tingling along
  
  
  lateral leg, big toe and dorsum
  of foot after 30
  seconds of
  sitting leg extension test
• Bladder/bowel fxn nml
• Lab tests?
• Differential Diagnosis?

6
Lower Limb Dermatomes
7
Management

• Even with radicular symptoms 70 will resolve
  within 4 weeks
• Bed rest for 2 Days (any longer does not improve
  outcome)
• NSAIDs, Toradol, COX-2 inh, Flexeril
• Walking to the point of pain (PT)

• Whitman, JM, Flynn, TW, Childs, JD, et al. A
  comparison between two physical therapy treatment
  programs for patients with lumbar spinal
  stenosis a randomized clinical trial. Spine
  2006 312541.
• Faas A, Chavannes AW, van Eijk JT, Gubbels JW. A
  randomized, placebo-controlled trial of exercise
  therapy in patients with acute low back pain.
  Spine 1993181388-95.
• Gilbert JR, Taylor DW, Hildebrand A, Evans C.
  Clinical trial of common treatments for low back
  pain in family practice. Br Med J Clin Res
  1985291 791-4.

8
Imaging

• Only indicated after 4-6 wks of previously
  mentioned management
• MRI is preferred
• Serves the HP not the other way around
• Disc protrusion is found
  in 80 of asymptomatic
  people over
  age 60
• Does not correlate with
  symptoms or severity

• Jensen, MC, Brant-Zawadzki, MN, Obuchowski, N, et
  al. Magnetic resonance imaging of
  the lumbar spine in people without back pain. N
  Engl J Med 1994 33169.

9
Surgery

• 70 success rate after 4 yrs
• Indications for surgery
• Progressive motor weakness
• Bowel or bladder dysfunction
• Incapacitating nerve root pain despite
  conservative therapy for 4wks
• Recurrent incapacitating pain despite
  conservative treatment

• Atlas, SJ, Keller, RB, Robson, D, et al. Surgical
  and nonsurgical management of lumbar spinal
  stenosis four-year outcomes from the Maine
  lumbar spine study. Spine 2000 25556.

10
Surgical Options

• Hemilaminectomy with excision (decompression)
• Spinal Fusion
  (immobilization)
• Artificial Disc Replacement (reconstruction)
• Not all patients qualify
• Quick recovery
• No long-term studies
  in the US