History and Physical Examination

The cascade of degenerative changes seen in degenerative disk disease can be subdivided into the following three stages:

Dysfunction
Instability
Restabilization

The duration of the stages varies greatly, and distinguishing the signs and symptoms from one stage to the next is difficult.

The dysfunction stage involves outer annular tears and separation of the endplate, cartilage destruction, and facet synovial reaction. The symptoms of dysfunction are low back pain or neck pain, often localized but sometimes referred, and painful movement. The signs are local tenderness, contracted muscles, hypomobility, and painful extension of the back, neck, or both. Results of a neurologic examination are usually normal.

In the instability stage, disk resorption and loss of disk space height occur. Facet capsular laxity may develop, leading to subluxation. The symptoms are those of dysfunction (ie, "giving way" of the back, a "catch" in the back with movement, and pain with standing after flexion). The signs are abnormal movement (ie, during inspection or palpation), including observation of a catch, sway, or shift when standing erect after flexion.

In the stage of restabilization, the progressive degenerative changes lead to osteophyte formation and stenosis. The main symptom is low back pain of decreasing severity. The signs are muscle tenderness, stiffness, reduced movement, and scoliosis.

The release of cytokines plays a key role in all three stages, and this role represents a likely target for future therapeutic interventions.^[9]

Workup

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Media Gallery

Magnetic resonance image of the lumbar spine. This image demonstrates a herniated nucleus pulposus at multiple levels.
Diskogram showing examples of an intact disk and a disrupted disk at the lumbar level.
The process of disk degeneration following internal disk disruption and herniation.
The various forces placed on the disks of the lumbar spine that can result in degenerative changes.

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Author

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.

Coauthor(s)

Grant Stone, DO, MBA Resident Physician, Department of Physical Medicine and Rehabilitation, Louisiana State University School of Medicine in New Orleans

Disclosure: Nothing to disclose.

Edward Babigumira, MD Interventional Spine and Pain Medicine Specialist, Lewes Medical and Surgical Associates, Delaware

Edward Babigumira, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, International Spine Intervention Society

Disclosure: Nothing to disclose.

James Monroe Laborde, MD, MS Clinical Assistant Professor, Department of Orthopedics, Louisiana State University Health Sciences Center and Tulane Medical School; Board of Advisors, Department of Biomedical Engineering, Tulane University; Adjunct Assistant Professor, Department of Physical Medicine and Rehabilitation, Louisiana State University Medical School

James Monroe Laborde, MD, MS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Michael R Voorhies, Jr, MD Resident Physician, Department of Physical Medicine and Rehabilitation, Louisiana State University Health Sciences Center

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.

William O Shaffer, MD Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Kentucky Medical Association, North American Spine Society, Kentucky Orthopaedic Society, International Society for the Study of the Lumbar Spine, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Received royalty from DePuySpine 1997-2007 (not presently) for consulting; Received grant/research funds from DePuySpine 2002-2007 (closed) for sacropelvic instrumentation biomechanical study; Received grant/research funds from DePuyBiologics 2005-2008 (closed) for healos study just closed; Received consulting fee from DePuySpine 2009 for design of offset modification of expedium.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Nuvasive, NLT Spine, RTI, Magellan Health<br/>Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.

Degenerative Disk Disease Clinical Presentation

History and Physical Examination

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