Dear Izzy54,
Thank you for your question on degenerative disc disease and
degenerative facet?s disease. As usual, any information I provide is
no substitute for direct medical advice.
Let me start by describing what a spinal disc is. The disc acts as a
?shock absorber? between two vertebral bodies and allows the spinal
column to move. The disc is made up of two main parts: the annulus
and the nucleus pulposis. The annulus is a tough, fibrous layer that
forms a ring around the nucleus pulposis. The nucleus pulposis is a
gel-like substance. The nucleus pulposis is the shock absorber and
the annulus keeps the nucleus in place. A ?herniated disc? occurs
when the annulus ruptures, usually due to excessive force, and allows
a portion of the nucleus pulposis to escape, often causing compression
on the spinal cord or a nerve root originating from the spinal cord,
resulting in symptoms such as sciatica (pain running down the backs of
the legs). You can see a picture of the anatomy of a disc here
(viewed from the front and a little above):
http://www.lowbackpain.com/img_spinalDiskNerves.jpg
A good picture of various disc problems, including disc degeneration
and herniation, can be seen at this location:
http://www.augustaortho.com/images/spine_178.jpg
You can visit this site as well:
http://www.emba.uvm.edu/~iatridis/research/ivd.jpg
The image on the left is a normal lumbar disc. The one on the right
is an image of degenerative disc disease.
In terms of treatment, a multimodality approach is generally
preferred, including occupational and physical therapy, medical, and,
sometimes, surgical. Details can be found at the e-medicine site
above. I have reproduced them here for convenience:
?Rehabilitation Program:
? Physical Therapy: Physical rehabilitation with active patient
participation is a key approach to treatment of patients with
discogenic pain. Physical therapy (PT) programs prescribed
specifically to address the primary site of injury and secondary sites
of dysfunction can provide a means of treatment, with or without
adjunct medications, therapeutic procedures, or surgical intervention.
Relative rest, which restricts all occupational and avocational
activities, for up to the first 2 days following an acute episode, may
be indicated to help calm initial pain symptoms. Rest for longer
periods of time has not been shown to be beneficial and can cause
deconditioning, loss of bone density, decreased intradiscal nutrition,
loss of muscle strength and flexibility, and increased segmental
stiffness. Passive modalities are valuable during the initial 48 hours
of relative rest to aid in pain relief, but protracted courses of
passive treatments become counterproductive, as they place patient in
a dependent role instead of an active one.
Education is one of the most important components of any back care
program and should include explanation of the natural history of
acute, subacute, and chronic disc injury. In addition, the physical
rehabilitation program should include training in proper body
mechanics and lumber ergonomics during various functional,
occupational, and avocational activities. Manual techniques may be
employed to increase soft tissue pliability when secondary myofascial
tightness is present. If the aforementioned measures are appropriate
and completed, then an active dynamic outpatient lumbar spine
stabilization rehabilitation program may be initiated. In addition,
rehabilitation of other associated components of the functional
kinetic chain may be appropriate, as these structures also may be
affected.
Dynamic lumbar spine stabilization rehabilitation programs are aimed
at maintaining neutral spine position throughout various daily
activities. An extension bias commonly is employed to help reduce
intradiscal pressure. This position (1) allows for balanced segmental
force distribution between the disc and zygapophyseal joints, (2)
provides functional stability with axial loading to help minimize the
chance for acute dynamic overload upon the discs, (3) minimizes
tension on ligaments and fascia planes, and (4) decreases symptoms.
Repetition is key to increasing flexibility, building endurance, and
developing the required muscle motor engrams that subconsciously
activate a series of key multimuscular contractions to maintain the
lumbar spine in a neutral position throughout static and dynamic
activities.
For athletes, the aforementioned program can be combined
progressively with sport-specific plyometrics to help the lumbar spine
maintain neutral position during high-intensity, unpredictable,
reaction-intensive sports. Rehabilitation of athletes also should
feature training them in maintaining neutral spine position in
individual sport-specific motions; then, subsequently, these component
motions should be grouped into a new safe spine stable movement.
Cardiovascular fitness training is an important adjunct to
comprehensive rehabilitation programs, as it provides endurance
necessary to prevent fatigue of the muscles that stabilize the spine.
? Occupational Therapy: Occupational therapy (OT) can be an
important adjunct in the rehabilitation process when generalized
muscular deconditioning has created adverse effects on strength,
endurance, and flexibility of the upper extremities and/or impairment
in activities of daily living (ADL).
Often an occupational therapist provides this portion of the
rehabilitation program. Essential elements consist of ensuring proper
ergonomics at the work site, which may involve simply reconfiguring a
desktop/workstation, or it may require more complex solutions. Another
aspect involves rehabilitation prior to reentry to full-time duties.
Once the offending source of pain has been brought to resolution, the
patient typically has sustained deconditioning and may require
activity-specific reconditioning to prevent new or recurring injury.
? Recreational Therapy: Recreation therapy may have a role in
assisting the patient to resume avocational activities, possibly with
adaptations in technique or with adaptive equipment.
Medical Issues/Complications: Medical causes of LBP include the
spondyloarthropathies (eg, enteric arthropathy, Reiter syndrome,
ankylosing spondylitis, psoriatic arthritis), Marfan syndrome,
fibromyalgia, myofascial pain syndrome, discitis, and neoplastic
disease.
Surgical Intervention: Available surgical approaches include anterior,
posterior, or combined procedure; interbody fusion with allograft
autologous bone or threaded titanium cage; and intertransverse process
in situ fusion with or without instrumentation.
? To date, no prospective randomized blind study has demonstrated
superiority of any surgical approach or technique. One retrospective
study comparing (1) posterolateral fusion (PF) with iliac crest
allograft and translaminar facet screw augmentation, (2) anterior
interbody fusion with fibula allograft, (3) PF with pedicle screw rod
fixation, and (4) anterior interbody threaded cage fusion combined
with facet joint fusion with PF suggests the latter procedure may
provide superior outcomes.
? Other investigators report outcomes for various procedures ranging
from 39% to as high as 82-93%.
Consultations: Consultation of the primary care physician with a
nonsurgical spine specialist is appropriate for patients with
symptomatology of longer than 6 weeks' duration secondary to LDDD.
Consultation of a spine surgeon may be appropriate for patients with
intractable severe function-limiting symptomatology secondary to
internal disc disruption, at either 1 or 2 contiguous levels, or of
greater than 6 months' duration who have had no relief from
non-surgical approaches and for persons with abnormal neurologic
findings.
Other Treatment (injection, manipulation, etc.): New intradiscal
techniques are being investigated to ascertain whether they can
obviate the need for a fusion procedure. Intradiscal electrothermal
therapy uses a navigable intradiscal catheter to heat the posterior
annular wall at the nuclear interface corresponding to the 4-8 o'clock
zone. Temperatures produced in the outer annulus (46-48°C) are
sufficient for thermal coagulation of nervous tissue. Temperatures
within the nucleus and the annulus (65-75°C) are sufficient to result
in collagen contraction or shrinkage.
Saal et al observed 20% focal nuclear shrinkage (by volume) and 7%
total nuclear shrinkage following treatment. Thus, some authorities
postulate that this intervention may thermocoagulate annular nerve
fibers and, through collagen shrinkage, also may result in tightening
of the fibrous structure of annular tissue that then may enhance
structural integrity of a degenerated or damaged disc and possibly
stabilize annular fissures. Two recent clinical trials illustrate the
promise for this procedure.
? Saal and Saal reported their results for 36 patients with
follow-up visits for 6-13 months. Improvement in function, lowering of
pain scores, and improvement in sitting tolerance times were observed
in 75% of patients.
? In a second small clinical trial involving 20 patients, Derby
reported a mean 2-point decrease on a 10-point VAS (p <0.05) at 6
months. In addition, 73% reported satisfaction with outcome and
indicated that they would repeat the procedure for the same outcome.
While early results are promising with this exciting novel technique,
no definitive judgments can be made since only preliminary outcome
studies with short-term follow-up have been reported to date.?
A good resource to start with the overall nature of degenerative disc
disease can be found at e-medicine:
http://www.emedicine.com/pmr/topic67.htm
This site, updated in early February, 2005, discusses the disease
process of degenerative disc disease, which primarily occurs in the
lumbar (lower) spine:
?Posterior elements of the lumbar spinal functional unit typically
bear less weight than anterior elements in all positions. Anterior
elements bear over 90% of forces transmitted through the lumbar spine
in sitting; during standing, this portion decreases to approximately
80%. As the degenerative process progresses, relative
anterior-to-posterior force transmission approaches parity. The spine
functions best within a realm of static and dynamic stability. Bony
architecture and associated specialized soft tissue structures,
especially the intervertebral disc, provide static stability. Dynamic
stability, however, is accomplished through a system of muscular and
ligamentous supports acting in concert during various functional,
occupational, and avocational activities.
The overall mechanical effect of these structures maintains the
histologic integrity of the tri-joint complex. Net shear and
compressive forces must be maintained below respective critical minima
to maintain tri-joint articulation integrity. Persistent, recurrent,
nonmechanical, and/or excessive forces to the motion segment beyond
minimal thresholds lead to microtrauma of the disc and facet joints,
triggering and continuing the degenerative process. Degenerative
cascade, described by Kirkaldy-Willis, is the widely accepted
pathophysiologic model describing the degenerative process as it
affects the lumbar spine and individual motion segments. This process
occurs in 3 phases that comprise a continuum with gradual transition,
rather than 3 distinct clearly definable stages.?
What all of this means is that, normally, the front part of the spine
(anterior) bears more than 90% of the downward forces that the spine
encounters during sitting and about 80% during sitting. Degeneration
of the spine occurs, the back (posterior) portion of the spine takes
on more of the load until the front and back each handle roughly 50%
(parity) of the load.
Degenerative disc disease is believed to result from multiple traumas
to the spine (frequent heavy lifting, multiple accidents, obesity,
etc.), which cause microscopic damage to the disc (tears that are too
small to see with the naked eye). This ?microtrauma? results in
cumulative damage to the disc, which causes progression of the
disease. This is the most widely accepted model for how degenerative
disc disease occurs. More details on the three phases of degeneration
can be found at the e-medicine web site above.
Although not directly relevant to your question, but perhaps of
interest to you, one classic example of degenerative disc disease
presenting in younger individuals is that seen in athletes. More
details on this particular presentation and it?s treatment can be
found here from e-medicine:
http://www.emedicine.com/sports/topic68.htm
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Degenerative facet disease is a type of degenerative spine disease
that affects the facet joint. Here?s an article on facet joints,
including pictures of vertebral bodies showing facet joints, so that
you can orient yourself to the anatomy:
http://www.spineuniverse.com/displayarticle.php/article1293.html
The first picture is a view from the right side, the second view is from the back.
The facet functions
A good reference on Lumbosacral facet syndrome can be found here at e-medicine:
http://www.emedicine.com/sports/topic65.htm
Isolating disease of the facet joint as the sole source of a patient?s
low back pain is difficult:
?Authors have concluded that in most cases, facet joints are not the
single or primary cause of LBP [Low Back Pain]. In many cases, facet
pain is mistaken for [discogenic] pain. Thus, many clinicians agree
that correlating historical or physical examination findings with pain
emanating from the facet is a challenge.?
The anatomy of the facet joint helps one understand how it?s
degeneration can lead to pain:
?The facet joints are diarthrodial joints with a synovial lining, the
surfaces of which are covered with hyaline cartilage, which is
susceptible to arthritic changes and arthropathies. Repetitive stress
and osteoarthritic changes to the facet joint can lead to facet
hypertrophy. Like any synovial joint, degeneration, inflammation, and
injury can lead to pain with joint motion, causing restriction of
motion secondary to pain, and thus deconditioning. In addition, facet
arthrosis, particularly trophic changes of the superior facet, can
progress to narrowing of the neural foramen. The neural foramen is
bordered by the superior facet, pars interarticularis, and posterior
portion of the vertebral body. Facet hypertrophy can contribute to
lateral and central lumbar stenosis, which can lead to impingement on
the exiting nerve root. Thus, facet pain can occasionally produce a
pain referral pattern indistinguishable from disk herniation.?
To summarize this, the facet joint includes a fluid pocket (as do the
fingers), which is why people can crack their necks, fingers, and
other joints. Stress to this joint from sports, lifting, etc., can
lead to hypertrophy of the bone (the bone grows larger ? the
equivalent of bone spurs). Because the joint contains many nerves,
such change in the shape of the joint leads to pain and inflammation
(a type of arthritis) and decreased use. This decreased use leads to
deconditioning (arthritis improves with exercise and gets worse with
prolonged rest). The inflammatory process causes the disease to
further progress. This is why (see below) anti-inflammatory
medications can slow the rate of progression of the disease.
The above article also ties together disease in the disc and facet as
part of a larger interconnected process:
?If one considers the disk and facet joints as an interdependent
functional spinal unit, degenerative changes within this 3-joint
complex can influence each of the segments. Thus, degeneration of the
disks can lead to loss of disk height, resulting in a relative
increase in facet load found in compression and extension maneuvers.
One theory is that these excessive facet loads cause the inferior
facet to pivot about the pars and stretch the joint capsule, in
addition to causing rostrocaudal [front-to-back] subluxation (ie,
facet malalignment). Thus, some authors postulate that facet joints
undergo osteoarthritic changes in response to disk degeneration
secondary to changes in loading.?
Treatment is similar to that for degenerative disc disease and is
described in the e-medicine article above and here:
Physical Therapy / Rehab:
?Acute Phase:
?
Rehabilitation Program:
_ Physical Therapy: The initial treatment plan for acute facet joint
pain is focused on education, relative rest, pain relief, maintenance
of positions that provide comfort, exercises, and some modalities.
Physical therapy includes instruction on proper posture and body
mechanics in activities of daily living that protect the injured
joints, reduce symptoms, and prevent further injury. Positions that
cause pain are avoided. Bed rest beyond 2 days is not recommended
because this can have detrimental effects on bone, connective tissue,
muscle, and the cardiovascular system. Thus, activity modification,
rather than bed rest, is strongly recommended.
Modalities such as superficial heat and cryotherapy also may help
relax the muscles and reduce pain. In addition, medications such as
nonsteroidal anti-inflammatory drugs (NSAIDs) can also be
administered. At this point, spinal manipulation and mobilization can
also be attempted to reduce pain.
? Other Treatment (injection, manipulation, etc.): Spinal
manipulation is also being used for both short- and long-term pain
relief. Some evidence supports the use of spinal manipulative therapy
combined with a trunk-strengthening program, which may actually reduce
the need for pain medication over the course of a year.
Recovery phase:
?
Rehabilitation Program:
_ Physical Therapy: Once the painful symptoms are controlled during
the acute phase of treatment, stretching and strengthening exercises
of the lumbar spine and associated muscles can be initiated.
Stretching of the hip flexors, hamstrings, hip internal and external
rotators, and lumbar extensors is essential because these muscles may
have been inactive secondary to reduced activity by the patient. In
addition, treatment includes strengthening of the abdominal and
gluteal muscles.
Strengthening maneuvers must emphasize flexion, neutral postures, and
pelvic tilt, all in an effort to reduce compression of the facet
joints. Pelvic tilt maneuvers can help reduce the degree of lumbar
lordosis, and they are to be performed with knees bent while standing,
legs straight while standing, and while sitting. Flexion-based
exercises are avoided if hypermobility or instability is suggested or
if the maneuvers increase LBP. Additional activities can include
stationary bicycling and treadmill ambulation on an incline.
These exercises are eventually incorporated into a more comprehensive
rehabilitation program, which includes spine stabilization exercises.
The goal with these exercises is to teach the patient how to find and
maintain a neutral spine during everyday activities. The neutral spine
position is specific to the individual and is determined by the pelvic
and spine posture that places the least stress on the elements of the
spine and supporting structures. Dynamic lumbar control is also
incorporated to protect the spine from biomechanical stresses,
including tension, compression, torsion, and shear. Spinal
stabilization emphasizes synergistic activation of the trunk and
spinal musculature in the midrange position by strengthening the
abdominal and gluteal muscles and enables the patient to develop the
muscles that support the trunk and spine and, ultimately, diminish the
overall stress on the spine.
? Other Treatment (injection, manipulation, etc.): Three
interventions may be used to treat facet joint pain, although their
efficacy remains in question. The goal of facet injections is
primarily to verify the diagnosis and perhaps reduce pain to
facilitate an active physical therapy program. If prior injections
were helpful and pain recurs, injections can be repeated; however,
they should be limited.
Intra-articular facet joint injection with corticosteroids and a
local anesthetic is one of the interventional procedures performed.
Typically, this is performed under fluoroscopic guidance with contrast
medium. Again, a few randomized trials validate the benefits of this
procedure, and most found similar efficacy between this procedure and
medial branch blocks. The only randomized study on facet injections
questioned its therapeutic value; however, the rate of pain relief has
been reported to be as high as 90% in almost half the patients who
underwent this procedure. Note that this procedure does not eliminate
pain emanating from the other posterior-element structures.
The long-term benefit of intra-articular injection remains
controversial, and some studies have equivocal results when either
steroids or saline is used for the injection. These joint blocks are
used for spinal pain for which no other cause can be found. If the
patient responds to the first injection, then he or she is a candidate
for a second procedure.
Complications are rare, although tenderness at the injection site is
reported. A few reports have noted spinal block, vasovagal episodes,
and chemical meningitis due to puncturing the dural cuff, but these
reports are rare. Recommend that patients withhold medications that
promote bleeding, such as NSAIDs, warfarin (Coumadin), and aspirin.
Contraindications include bacterial infection, possible pregnancy,
bleeding diathesis, and local anesthetic allergy.
Medial branch block for diagnostic purposes has already been
described, and studies have shown it to be effective in this regard;
however, controversy remains regarding its use as a therapeutic
intervention. Note that such a block also eliminates pain, which may
be emanating from other structures innervated by the medial branch,
such as the multifidus or interspinous muscles or the interspinous
ligaments.
A third intervention involves a medial branch neurotomy through
radiofrequency (rhizotomy), chemical neurolysis, or cryoneurolysis.
Percutaneous radiofrequency neurotomy is a method of denaturing the
nerves that innervate the facet joint through coagulation, thus
conferring temporary relief of pain. Once the axons regenerate, pain
often returns. The therapeutic benefit of this procedure likewise
remains controversial; however, success rates range from 17-90%. Many
of the studies have poor selection criteria, inconsistent techniques,
poor outcome measures, and small sample sizes.
Maintenance Phase:
?
Rehabilitation Program:
_ Physical Therapy: The maintenance phase represents the final phase
of the rehabilitation process. Eccentric muscle-strengthening
exercises, including more dynamic conditioning exercises (eg, with a
large gym ball) are added to the program. Exercises are to be
performed in a functional manner and in functional planes (eg,
standing in multiple planes). For those patients involved spine can be
maintained. The goals of a comprehensive spine rehabilitation program
have been met when pain is controlled, near-full range of motion of
the spine is achieved, symmetrical flexibility is attained, and trunk
control can be maintained in sport or recreational activities.
? Other Treatment (injection, manipulation, etc.): Spinal
manipulation is also being used for both short- and long-term pain
relief. Some evidence supports the use of spinal manipulative therapy
combined with a trunk-strengthening program, which may actually reduce
the need for pain medication over the course of a year.?
The above article also details the various medications being used to
treat degenerative facet disease, including acetaminophen,
anti-inflammatory medications, muscle relaxants, opioid analgesics,
and antidepressants (these are structurally similar to muscle
relaxants).
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For any of these treatments, the ?best? therapy strongly depends on
the individual patient, however, physical therapy and rehab are a
central component in slowing the progression of these diseases.
In terms of pneumococcus infection?s relation to these diseases, an
exhaustive medical literature (and Google) search turned up only a
single reference (a case report) from Brussels in French:
Vandemergel X. Richet M. Gocmen A. Libert P. Sartor JC. Robience YJ.
[Pneumococcal spondylodiscitis. A case report]. [French] Revue
Medicale de Bruxelles. 19(2):73-5, 1998 Apr.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9643086
This article describes a case of disc infection with pneumococcus
bacteria, which may have led to degeneration of the disc. This,
however, has not been documented elsewhere. Case reports are useful
to document rare events and to help generate hypotheses, which can
then be tested independently, so this is certainly not an established
cause of either of the diseases you ask about.
I also searched multiple databases looking for any medications which
may have been described to cause or contribute to degenerative disc or
facet disease with no results. The most likely conclusion is that no
medications have been linked to these disorders, however I would
speculate that any pro-inflammatory medications (these are not usually
prescribed), such as certain immunomodulatory chemotherapeutic agents,
may contribute to the progression of either of these diseases in the
short term.
Further potentially useful information can be found at the following links:
A patient-oriented overview of spine disease:
http://www.spineuniversity.com/public/spinesub.asp?id=36
The Yahoo Back Pain Center has a large amount of patient-oriented information:
http://health.yahoo.com/health/centers/back_pain/index
I hope you found this information useful. Please feel free to ask for
any clarification.
Best,
-welte-ga |
,
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