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Lumbar Degenerative Disk Disease Treatment & Management

  • Author: Rajeev K Patel, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
 
Updated: Apr 26, 2016
 

Rehabilitation Program

Physical Therapy

Physical rehabilitation with active patient participation is a key approach to treatment of patients with diskogenic pain. Physical therapy 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 after an acute episode, may be indicated to help calm initial pain. Rest for longer periods has not been shown to be beneficial and can cause deconditioning, loss of bone density, decreased intradiskal 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 an explanation of the natural history of acute, subacute, and chronic disk injury. The physical rehabilitation program should also include training in proper body mechanics and lumber ergonomics during various functional, occupational, and avocational activities. Manual techniques may be applied to increase soft tissue pliability when secondary myofascial tightness is present. If the aforementioned measures are appropriate and completed, an active, dynamic rehabilitation program to stabilize the lumbar spine may be started on an outpatient basis. In addition, rehabilitation of other associated components of the functional kinetic chain may be appropriate, as these structures may also be affected.

Dynamic lumbar-spine stabilization programs are aimed at maintaining a neutral spine position throughout various daily activities. An extension bias commonly is used to help reduce intradiskal pressure. This position allows for balanced segmental force distribution between the disk and zygapophyseal joints, it provides functional stability with axial loading to help minimize the chance for acute dynamic overload upon the disks, it minimizes tension on ligaments and fascia planes, and it 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 progressively combined with sport-specific plyometrics to help the lumbar spine maintain neutral position during high-intensity, unpredictable, reaction-intensive sports. Rehabilitation of athletes should also train them to maintain a neutral spine position in sport-specific motions. These component motions should then be grouped into a new, safe spine-stable movement. Cardiovascular training is an important adjunct to comprehensive rehabilitation programs because it provides endurance necessary to prevent fatigue of the muscles that stabilize the spine.

Occupational Therapy

Occupational therapy 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 (ADLs).

An occupational therapist often 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 and/or workstation, or it may require complex solutions. Another aspect involves rehabilitation before the patient resumes full-time duties. After the offending source of pain is resolved, the patient typically has 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 the use of adaptive equipment.

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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, diskitis, and neoplastic disease.

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Surgical Intervention

Available surgical approaches include anterior, posterior, or combined procedures; interbody fusion with allograft autologous bone or threaded titanium cage; and intertransverse process in situ fusion with or without instrumentation. The introduction of disk arthroplasty has been proposed as a possible surgical option in those patients who would like to maintain as much segmental motion as possible.

The rate of surgical treatment for LDDD in the United States more than doubled during the first decade of the 21st century, according to a study by Yoshihara and Yoneoka. Using Nationwide Inpatient Sample data from patients aged 18 years or older with lumbar/lumbosacral DDD, the investigators found that between 2000 and 2009, the population-adjusted incidence of LDDD surgery increased 2.4-fold. More specifically, the incidence of combined anterior and posterior lumbar fusion (APLF) rose three-fold, while that for posterior lumbar interbody fusion/posterolateral lumbar fusion (PLIF/PLF) increased 2.8-fold. In contrast, the incidence of total disk replacement (TDR) did not significantly rise.[46]

Of the more than 380,000 patients who underwent LDDD surgery between 2000 and 2009, according to the study, the majority (67.9%) were treated with PLIF/PLF, while 16.8% underwent anterior lumbar interbody fusion (ALIF), 13.6% were treated with APLF, and 1.8% underwent TDR. While TDR was more commonly performed in younger patients than in older ones, the opposite was true for PLIF/PLF. Regionally, it was found that LDDD surgery was more frequently performed in the Midwestern and Southern United States than it was in the Northeast.[46]

Effectiveness of surgery

To date, no prospective randomized blind study has demonstrated the superiority of any surgical approach or technique. One retrospective study was performed to compare posterolateral fusion with iliac-crest allografting and translaminar facet-screw augmentation, anterior interbody fusion with fibula allografting, posterolateral fusion with pedicle screw-rod fixation, and anterior interbody threaded cage fusion combined with facet-joint fusion and posterolateral fusion. The results suggested that the last procedure may provide superior outcomes.

Other investigators report outcome rates ranging from 39% to 82-93% for various procedures. With respect to disk arthroplasty, the literature is not clear on its definitive role, if any, in the treatment of symptomatic LDDD.

In a study of 59 patients suffering from low back pain and 1- or 2-level LDDD, Freudenberger et al compared the effectiveness of ALIF with anterior tension band plating (ALIF-ATB) with that of PLIF with pedicle screw instrumentation.[47] The investigators found that both techniques had similar fusion rates, but that patients who underwent PLIF had greater estimated blood loss and required more surgical time than did patients who were treated with ALIF-ATB.

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Consultations

Consultation of the primary care physician with a nonsurgical spine specialist is appropriate for patients with symptoms lasting longer than 6 weeks secondary to LDDD. Consultation with a spinal surgeon may be appropriate for patients with intractable severe function-limiting symptoms secondary to IDD, at 1 or 2 contiguous levels, for those with symptoms lasting longer than 6 months who have had no relief from nonsurgical approaches, and for persons with abnormal neurologic findings.

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Other Treatment

New intradiskal techniques are being investigated to ascertain whether they can obviate fusion procedures. With intradiskal electrothermal therapy, a navigable intradiskal catheter is used to heat the posterior annular wall at the nuclear interface corresponding to the 4- to 8-o'clock zone.[48, 49] Temperatures produced in the outer annulus (46-48°C) are sufficient for thermal coagulation of nervous tissue. Temperatures in the nucleus and the annulus (65-75°C) are sufficient for collagen contraction or shrinkage.

Saal and colleagues observed 20% focal nuclear shrinkage (by volume) and 7% total nuclear shrinkage after treatment.[50] Therefore, some authorities postulate that this intervention may cause thermocoagulation of annular nerve fibers. In addition, by means of collagen shrinkage, it may also result in tightening of the fibrous structure of annular tissue that then may enhance structural integrity of a degenerated or damaged disk and possibly stabilize annular fissures. Intradiskal electrothermal therapy showed great promise in initial studies and was touted as being effective at controlling diskogenic axial lumbar back pain. However, a later investigation, a double-blinded, controlled study conducted by Freeman and colleagues, established safety with limited efficacy.[51]

  • Saal and Saal reported their results in 36 patients who were followed up for 6-13 months. [50] Improvement in function, lowering of pain scores, and improvement in sitting tolerance times were observed in 75%.
  • In a clinical trial of 20 patients, Derby reported a mean 2-point decrease on a 10-point visual analog scale ( P < .05) at 6 months. [52] In addition, 73% reported satisfaction with outcome and indicated that they would repeat the procedure for the same outcome. Although early results are promising with this exciting novel technique, no definitive judgments can be made because only preliminary outcomes with short-term follow-up have been reported to date.
  • The idea of intradiskal injections and procedures is becoming exciting with new trials of OB1 and other biological therapies being developed in the hopes of being able to regenerate diskal materials and reverse the degenerative cascade underway.
  • Since their discovery by Marshall Urist, MD at UCLA, bone morphogenetic proteins have been categorized as either growth or differentiation factors and consist of a family of proteins with important regulatory and developmental effects on bone growth and the development of musculoskeletal tissue. These proteins are clinically used by spine surgeons to facilitate bony fusion and obviate the need for autografting.
    • Studies have shown that these proteins are capable of controlling the mRNA transcription of cells within human and animal disk models. At the 2002 North American Spine Society (NASS) annual meeting, studies were presented that showed great promise with regard to the development of treatments for degenerative disk disease using bone morphogenic proteins 2 and 7, with augmentation of diseased disks employed at an early stage to offset the degenerative cascade.[53, 54]
    • Miyamoto and colleagues showed restoration of disk viscoelastic properties in a rabbit model of degenerative disk disease after injection of osteogenic protein 1 (OP-1). It is hoped that disk regenerative therapy using intradiskal injections of biological pharmaceuticals will become an effective treatment for degenerative disk disease.[55]
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Contributor Information and Disclosures
Author

Rajeev K Patel, MD Assistant Professor, Department of Orthopedics, University of Rochester; Consulting Surgeon, Strong Health Spine Center, Strong Memorial Health System

Rajeev K Patel, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, North American Spine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Curtis W Slipman, MD Director, University of Pennsylvania Spine Center; Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center

Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the Study of Pain, North American Spine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Additional Contributors

J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR Senior Associate Dean, Associate Dean of Clinical Medicine, Consultant in Sports Medicine, Assistant Vice President of Program Development, Division of Health Sciences, DeBusk College of Osteopathic Medicine; Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Manipulative Medicine, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, American Osteopathic Academy of Sports Medicine

Disclosure: Nothing to disclose.

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