Degenerative disc disease (DDD) is part of the natural process of growing older. As we age, our intervertebral discs lose their flexibility, elasticity, and shock absorbing characteristics. The outer fibers that surround the disc, called the annulus fibrosis, become brittle and are more easily torn. At the same time, the soft gel-like center of the disc, called the nucleus pulposus, starts to dry out and shrink. The combination of damage to the intervertebral discs, the development of bone spurs and the gradual thickening of the ligaments that support the spine can all contribute to degenerative arthritis of the lumbar spine.

To a certain degree, this process happens to everyone. However, not everyone who has degenerative changes in their lumbar spine has pain. Many people who have “normal” backs have MRIs that show disc herniations, degenerative changes, and narrowed spinal canals. Every patient is different, and it is important to realize that not everyone develops symptoms as a result of degenerative disc disease.

When degenerative disc disease becomes painful or symptomatic, it can cause several different symptoms due to the compression of the nerve roots. Depending on where your degenerative disc is located, it could cause

• Back pain

• Radiating leg pain

• Neck pain

• Radiating arm pain

• Degenerative Disc Disease

These symptoms are caused by the fact that worn out discs are a source of pain because they do not function as well as they once did, and as they shrink, the space available for the nerve roots also shrinks. As the discs between the intervertebral bodies start to wear out, the entire lumbar spine becomes less flexible. The result can be back pain and stiffness, especially towards the end of the day.

The diagnosis of degenerative disc disease begins with a complete physical examination. Your doctor will examine your back for flexibility, range of motion, and the presence of certain signs that suggest your nerve roots are being affected by degenerative changes in your back. This often involves testing the strength of your muscles and your reflexes to make sure that they are still working normally. You will often be asked to fill out a diagram that asks you where your symptoms of pain, numbness, tingling and weakness are occurring.

A series of x-rays is also usually ordered for a patient with back pain. If degenerative disc disease is present, the x-rays will often show a narrowing of the spaces between the vertebral bodies, which indicates the disc has become very thin or has collapsed. Bone spurs also can form around the edges of the vertebral bodies and also around the edges of the facet joints in the spine. These bone spurs can be seen on an x-ray, and are also called osteophytes. As the disc collapses and bone spurs form, the space available for the nerve roots starts to shrink. The nerve roots exit the spinal canal through a bony tunnel called the neural foramen, and it is at this point that the nerve roots are especially vulnerable to compression.

In many situations, doctors will order a MRI or a CT scan (CAT scan) to evaluate the degenerative changes in the lumbar spine more completely. A MRI is very useful for determining where disc herniations have occurred and where the nerve roots are being compressed. A CT scan is often used to evaluate the bony anatomy in the spine, which can show how much space is available for the nerve roots and within the neural foramina and spinal canal.

Your doctor will discuss with you the treatment options appropriate for your diagnosis.

For most people who do not have evidence of nerve root compression with muscle weakness, conservative, non-surgical therapies, such as medication, rest, exercise and physical therapy, are typically recommended.

Surgery is offered only after conservative treatment has have failed to adequately relieve the symptoms of pain, numbness and weakness over a significant period of time.

The benefits of spine surgery, however, must be weighed against the risks. Your surgeon will be able to discuss the risks and benefits of surgery with you, and the likely results of operative versus non-operative treatment.

Herniation describes an abnormality of the intervertebral disc that is also known as a “slipped,” “ruptured” or “bulging” disc. This process occurs when the inner core (nucleus pulposus) of the intervertebral disc bulges out through the outer layer of ligaments that surround the disc (annulus fibrosis). This tear in the annulus fibrosis causes pain in the back at the point of herniation. If the protruding disc presses on a spinal nerve, the pain may spread to the area of the body that is served by that nerve.

Usually, the main symptom is sharp, acute pain. In some cases, there may be a previous history of localized low back pain, with pain also extending down the leg served by the affected nerve. This pain is usually described as a deep, sharp pain, which gets worse as it moves down the affected leg. The onset of pain with a herniated disc may occur suddenly or it may be preceded by a tearing or snapping sensation in the spine, which may be attributed to a sudden rupture in the annulus fibrosis.

A patient with a herniated disc will usually complain of low back pain that may or may not radiate into different parts of the body, such as the leg. They will often demonstrate a limitation in range of motion when asked to bend forward or lean backwards, and they may lean to one side as they try to bend forward. Patients will sometimes walk with a painful gait, flexing the affected leg so as not to put too much weight on the side of the body that hurts. Straight leg raising may be a positive indication of tension on the nerve root.

Abnormalities in the strength and sensation of particular parts of the body that are found with a neurological examination performed by a doctor provide the most objective evidence of nerve root compression. An MRI is the test of choice for diagnosis of a herniated disc, but a CT scan (CAT scan) also may be helpful because it provides better visualization of the bony anatomy of the spinal column that indicates where the source of pressure on the nerve root is located.

Treatment for the vast majority of patients with a herniated disc does not normally include surgery. Most patients will respond to conservative therapy, such as medication, rest and physical therapy. Treatment is most effective when a patient and a doctor have a good relationship and the patient understands the rationale behind the prescribed treatment.

The primary element of conservative treatment is controlled physical activity. Usually treatment will begin with a modification of activity and then a gradual return to protected activities. Sitting, bending, lifting and twisting are not beneficial for this condition because they put a large amount of stress and pressure on the lumbar spine, which may increase the pressure on the affected nerve root. The appropriate use of medication is an important part of conservative treatment. This can include anti-inflammatory drugs, analgesics and muscle relaxants. Your doctor also may recommend an anti-inflammatory spinal injection for the area of the affected nerve root to lessen swelling and irritation caused by the damaged disc.

Surgery is typically recommended only after physical therapy, rest, and medications have failed to adequately relieve the symptoms of pain, numbness and weakness over a significant period of time.

The benefits of spine surgery, however, must be weighed against the risks. Your surgeon will be able to discuss the risks and benefits of surgery with you, and the likely results of operative versus non-operative treatment.

Osteoporosis is a bone condition characterized by decreased bone mass and the subsequent deterioration of bone tissue. Often called “the silent disease”, this progressive condition causes bones to become more porous, thin and brittle, thus more susceptible to fracture. The spine can be particularly vulnerable – vertebral compression fractures may occur in those whose osteoporosis has reached the advanced stage.

Men, women and in rare cases even children can develop osteoporosis; however, the condition is most prevalent in older adults. An estimated 44% of Americans over age 50 – some 44 million people – have been diagnosed with the condition or identified at increased risk for osteoporosis due to low bone mass. Of those diagnosed with osteoporosis, 80% are women.

The exact cause of osteoporosis is unknown; however, there are a number of established risk factors. Age, nutrition, lifestyle and genetics, as well as certain medical conditions and medications, can all play a part.

Age

During childhood and early adulthood, the body creates new bone faster than it can absorb existing bone, a process that starts to reverse around age 30. Bone loss in women speeds up when the production of estrogen slows down, usually between the ages of 45-55. Likewise, men begin to experience bone loss as their production of testosterone declines, generally around age 45-50.

One of the reasons women are more likely to develop osteoporosis, and develop it earlier, is that their bones are typically smaller and lighter than men’s, so there is less bone mass to begin with. People who do not achieve ideal bone thickness when they are young also are more likely to develop the condition.

Nutrition

Bone strength is a product of both bone mass and density. Bone density depends, in part, on the amount of calcium, phosphorus and other minerals the bone contains. Bones deficient in these minerals tend to be weaker with less internal supporting structure, which makes them more porous and fragile.

Excessive dieting or eating disorders, such as anorexia nervosa, may contribute to bone loss. Studies have shown that cola drinks, which contain phosphoric acid, also may interfere with bones’ ability to absorb calcium.

Lifestyle

People who get little or no exercise are at risk for developing osteoporosis. Weight bearing exercises, such as walking, jogging and weight lifting, work muscles and bones against gravity, which helps maintain their strength and density. Smoking increases the loss of bone density, and heavy alcohol consumption may inhibit bone formation.

Genetics

People who have a parent or sibling with osteoporosis have a 60% to 80% chance of developing the condition, as well. People of Asian or European descent are those most likely to develop osteoporosis; people of African descent the least likely.

Small-framed, thin people also are at greater risk. Smaller bones mean less bone mass. And thin people have less body fat – fat cells produce estrogen, which can help prevent bone loss in women after menopause.

Medical Conditions and Medications

Several medical conditions, including hyperthyroidism, Cushing’s syndrome and hyperparathyroidism, increase the risk of osteoporosis. Some medications also may contribute to bone thinning. They include

• Corticosteroids (for treating asthma and chronic obstructive pulmonary disease)

• Endometriosis medications

• Aromatase inhibitors (for treating breast cancer)

• Thyroid replacement medications

• Antacids containing aluminum (if overused)

• What Are The Symptoms of Osteoporosis?

Unfortunately, the reason osteoporosis is called the “silent disease” is that it has no physical symptoms in its early stages. As the condition progresses, the following symptoms that indicate weakening bones may occur

• Lower back or neck pain

• Bone pain or tenderness

• Curved backbone or stooped posture (“dowager’s hump”)

• Gradual loss of height

• Fractures from minor trauma, especially in the hip, spine or wrists

Early diagnosis is critical. If you believe you are at risk for osteoporosis or have experienced any of the above symptoms, contact your physician. He or she will make a diagnosis based on your medical history, a physical examination and a bone density test – a painless, accurate and non-invasive procedure that measures bone thickness.

Although there is no cure for osteoporosis, there are a variety of treatment options that have the potential to reduce, stop or even reverse bone loss. Even small changes in diet, exercise and medication may help prevent the more serious consequences of the condition, such as broken bones. There also are a number of osteoporosis prevention and/or treatment medications currently approved by the U.S. Food and Drug Administration.

Consult with your physician to determine which treatment plan is best for you, and follow the program he or she recommends to rebuild and maintain bone health.

Spondylolisthesis occurs when one vertebra slips forward on the adjacent vertebrae. The condition may be congenital (hereditary), or the result of physical stresses on the spine or spinal degeneration. It may produce both a gradual deformity of the lower spine and also a narrowing of the vertebral canal, and can cause back pain, leg pain and other symptoms.

There are five types of spondylolisthesis

Type I is called dysplastic spondylolisthesis and is secondary to a congenital defect of either the superior sacral or inferior L5 facets or both with gradual slipping of the L5 vertebra.

Type II, isthmic or spondylolytic, in which the lesion is in the isthmus or pars interarticularis, has the greatest clinical importance in persons under the age of 50. If a defect in the pars interarticularis can be identified but no slipping has occurred, the condition is termed spondylolysis. If one vertebra has slipped forward on the other (horizontal translation), it is considered spondylolisthesis.

Type II can be divided into three subcategories

Type II A is sometimes called Lytic or stress spondylolisthesis and is most likely caused by recurrent microfractures caused by hyperextension. It is also called a “stress fracture” of the pars interarticularis and is much more common in males

Type II B probably also occurs from microfractures in the pars. However, in contrast to Type II A, the pars interarticularii remain intact but stretched out as the fractures fill in with new bone

Type II C is very rare and is caused by an acute fracture of the pars. Nuclear imaging may be needed to establish a diagnosis

Type III is a degenerative spondylolisthesis, and occurs as a result of the degeneration of the lumbar facet joints. The alteration in these joints can allow forward or backward vertebral displacement. This type of spondylolisthesis is most often seen in older patients. In Type III, degenerative spondylolisthesis there is no pars defect and the vertebral slippage is never greater than 30%.

Type IV, traumatic spondylolisthesis, is associated with acute fracture of a posterior element (pedicle, lamina or facets) other than the pars interarticularis.

Type V, pathologic spondylolisthesis, occurs because of a structural weakness of the bone secondary to a disease process such as a tumor or other bone disorder.

The narrowing of the spinal canal, called spinal stenosis, can happen as a result of the degeneration of both the facet joints and the intervertebral discs. In this condition, bone spurs, called osteophytes, which develop because of the excessive load on the intervertebral disc, grow into the spinal canal.

The facet joints also enlarge as they become arthritic, which contributes to a decrease in the space available for the nerve roots. The ligaments of the spinal column, especially the ligamentum flavum, become stiff, less flexible and thicker with age, which also contributes to spinal stenosis. These processes narrow the spinal canal and may begin to impinge and put pressure on the nerves roots and spinal cord, creating the symptoms of spinal stenosis.

Stenosis may occur in the central spinal canal (central stenosis) where the spinal cord or cauda equina are located, in the tract where the nerve root exits the central canal (lateral recess stenosis) or in the lateral foramen (foraminal stenosis) where the individual nerve roots exit out to the body.

Some distortion of the spinal canal will occur in virtually every person as they age, but the severity of the symptoms will depend on the size of a person’s spinal canal and the encroachment on the neural elements. The rate of deterioration varies greatly from person to person, and not everyone will feel symptoms.

Spinal stenosis may be caused by a number of processes that decrease the amount of space in the spinal canal available for the neural elements. Degenerative causes are the most common, but there are a few unusual causes of stenosis. These include calcium pyrophosphate crystal deposition, amyloid deposition, and intradural spinal tumors.

Some people with degenerative disease of the lumbosacral spine may be totally asymptomatic, some may complain of mild discomfort in the low back, and others may not even be able to walk.

Patients who have significant spinal stenosis typically will begin to notice pain in the buttocks, thigh or leg that develops with standing or walking, and improves with rest. In some cases, a patient will complain of leg pain and weakness without having any back pain. More severe symptoms of the disorder include numbness, a tingling sensation and/or weakness in the lower extremities.

Certain positions can alleviate the symptoms of spinal stenosis by increasing the amount of space available for the nerves. These positions usually involve flexion of the lumbar spine and forward bending. Any position that flexes the lumbar spine is often associated with resolution of symptoms. For instance, patients with spinal stenosis can ride a bike and walk up an incline or flight of stairs without any pain. They can also often walk for extended distances if they have something to lean on, like a shopping cart. However, if they are walking down an incline or flight of stairs, or if they have to give up the shopping cart, their symptoms often reappear.

The presentation and severity of the symptoms of spinal stenosis depends on the several factors, including the original width of the spinal canal, the susceptibility of the nerves involved, and the unique functional demands of the patient and the pain tolerance of each individual.

The diagnosis of spinal stenosis begins with a complete history and physical examination. The doctor will determine what symptoms are present, what makes them better or worse, and how long they have been present. A physical examination is essential for determining how severe the condition is, and whether or not it is causing weakness or numbness in certain parts of the body.

Abnormalities in the strength and sensation of particular parts of the body that are found with a neurological examination provide the most objective evidence of chronic nerve root compression caused by spinal stenosis. Routine radiographs of the lumbar spine are very helpful in determining the amount of degeneration that is present in the spine, which gives an indirect indication of whether or not spinal stenosis is present. These S-rays are also used to determine if certain parts of the spine are unstable, which may be contributing to the symptoms of stenosis.

A computed tomography (CT or CAT) scan provides excellent visualization of the bony anatomy of the spinal column and is an indispensable tool for determining where the stenosis is located. This test is often performed in conjunction with a myelogram, which involves injecting dye into the space occupied by the spinal cord and nerve roots to determine how well the cerebrospinal fluid is able to travel along the nerve roots. An EMG or electromyographic test may help to determine which nerve root in particular is not working normally in the situation where several nerve roots may be involved.

Your doctor will be able to discuss with you what your diagnosis means in terms of treatment options. For most people who do not have evidence of nerve root compression with muscle weakness, the first line of therapy includes non-steroidal anti-inflammatory drugs and physical therapy.

Surgery is offered only after physical therapy, rest, and medications have failed to adequately relieve the symptoms of pain, numbness and weakness over a significant period of time.

The benefits of spine surgery, however, must be weighed against the risks. Your surgeon will be able to discuss the risks and benefits of surgery with you, and the likely results of operative versus non-operative treatment.

Spinal fractures occur when the normal vertebral body is “squashed”, or compressed in height. When the load on a vertebra exceeds its stability or inherent strength, the bone can collapse. Pain, limited mobility, height loss and spinal deformity are often the result. In severe cases, part of the vertebral body may protrude into the spinal canal and put pressure on the spinal cord and nerves. Organ function, including that of the bowel or bladder, also may be compromised.

Vertebral compression fractures can happen for a number of reasons: trauma from a fall or a car accident; bone thinning due to osteoporosis or even the spread of a tumor into the spine.

Knowing how to prevent, recognize and treat vertebral compression fractures is critical for maintaining good spinal health. Here is some information to help you learn more about this type of spinal injury.

Osteoporosis

There is no one single cause; however, the vast majority of vertebral compression fractures are the result of osteoporosis, a condition that causes bones to progressively become more thin and fragile. When bones are brittle, even everyday activities and minor traumas, such as lifting a laundry basket, missing a step, or even coughing or sneezing, can cause these tiny fractures.

Osteoporosis-related compression fractures can occur anywhere in the spine, but are most often found in the lower vertebrae of the upper back. The vertebral bone tends to collapse toward the front of the spine, creating wedge-shaped vertebrae that cause the spine to curve forward (kyphosis), eventually leading to the “dowager’s hump” frequently associated with the advanced stage of the disease. Learn more about osteoporosis.

Tumors

Tumors growing in or near the spine are another cause of compression fractures. Doctors frequently monitor those diagnosed with certain types of cancer, including multiple myeloma or lymphoma, for spinal breakage. Tumors also may spread to the spine as a result of cancer in other organs and areas of the body, such as the breasts, lungs and intestines.

Trauma

People with strong, healthy bones also can sustain compression fractures from a hard fall or blow to the back or torso. Vertebrae can withstand a good deal of shock; however, if the force on the spine is too great, they can break.

The primary physical symptoms of vertebral fracture include one or more of the following

• Sudden onset of back pain

• Increase in pain when standing or walking

• Variable pain relief when lying down

• Limited spinal mobility

• Weakness or numbness in the affected areas

• Height loss

• Deformity and disability

• Shortness of breath

These additional symptoms signal the possibility of multiple vertebral fractures

• Hunched back (“dowager’s hump”)

• Bulging abdomen

• Gastrointestinal problems – crowding of the internal organs can be a serious side effect of multiple compression fractures

• Shortness of breath – it’s possible for the torso to become so compressed that it’s difficult to breathe

• Hip pain (hip fracture)

If you think you may have a compression fracture, see a doctor. (To find one near you, visit our Physician Locator.) Here are some questions your doctor may ask

• How long have you been in pain? Was the onset sudden or gradual?

• Where is the pain located? What is the intensity?

• Does the pain radiate to other parts of the body?

• In what positions is the pain better or worse?

• Is the pain getting worse or better over time?

Your doctor also may recommend one or more of the following diagnostic tests

• A spinal X-ray to determine the presence of a fracture

• An MRI to check for the age of the fracture and other abnormalities in the soft tissues, including nerves and ligaments

• A nuclear bone scan, another test that can determine the presence and/or age of a fracture

• DEXA scan

Treatment of compression fractures includes measures to alleviate the pain, stabilize and repair the fracture, and diagnose the underlying cause of the breakage.

Non-Surgical Measures

Non-surgical treatment options your doctor may recommend include

• Medications to relieve bone, muscle and nerve pain

• A reduction in activity or bed rest

• A spinal brace to limit motion

• Medication to stabilize or improve bone density

• Physical therapy

• Epidural spinal injection

• External soft bracing

• Surgical Options

If compression fractures fail to heal or if pain persists despite non-surgical measures, your doctor may recommend surgery as the next step toward relief. Surgical procedures for treating vertebral compression fractures are usually minimally invasive.

The best way to avoid vertebral compression fractures is to begin taking preventive measures toward building a strong back and spine early in life. But, even if you didn’t, it’s never too late to start! Here are a few tips:

Exercise – Exercise, especially strength/resistance training and/or lifting weights regularly, can help build strong bones. Engaging in some form of cardiovascular exercise and strength training at least three times a week can help combat bone loss, and the earlier you start exercising and strength training the better. Strong muscles also help you maintain balance to avoid falls and other accidents.

Eat Right – Eat a nutrient-rich, balanced diet, with sufficient intake of calcium, Vitamin D and phosphorus. Avoid smoking and excessive alcohol use; smoking contributes to bone density loss and too much alcohol inhibits bone formation. If possible, maintain a healthy weight – additional pounds place excess strain on the back.

Stay Hydrated – Drink between six and eight cups or water a day to keep the body well hydrated. Water helps reduce stiffness and contributes to overall spine health. Learn how to maintain bone density for a healthy spine.

Practice Good Posture – Maintaining a “neutral spine” is the foundation of good posture. In a neutral spine, the natural curves of the spine (the concave, or lordotic, curves, and the convex, or kyphotic, curves) are in proper balance. The spine is neither rounded forward nor arched back too much.

Proper posture keeps your bones properly aligned and alleviates excess stress on your musculoskeletal systems, allowing your muscles, joints, and ligaments to work as intended.