History

The term degenerative disc disease (DDD) represents a complicated idea. In one meta-analysis of 402 publications, investigators found the term used to incorporate multiple conditions, including spinal compression, pinched nerve, and back or neck pain. In many cases, disc degenerative disease was equated with disc degeneration regardless of symptoms or with discogenic pain or disc degeneration as a presumed cause of axial pain.1

Degenerative disc disease is most often associated with low back pain. Cervical degenerative disc disease, in contrast, is more often the cause of neck and radiating arm pain. The condition develops when one or more of the cushioning discs in the cervical spine starts to break down due to wear and tear.2

Epidemiology

It is difficult to know just how common degeneration of the spinal discs really is. The condition is often asymptomatic most of the time and, because the definition is so fluid, it is difficult to review the condition across multiple studies.

That said, investigators reviewed a Medicare Claims 5% Limited Data Set representing about upwards of 1.8 million individuals per calendar year to identify the prevalence of degenerative spinal pathologies. The data set included 21,771,202 person-years, with 12,162,068 female and 9,609,134 male person-years, where a person-year is defined as a single Medicare enrollee per calendar year.3

The yearly prevalence of spine degeneration was 27.3 ± 1.7% overall (mean ± standard deviation among years). Furthermore, prevalence of multilevel degenerative disc disease increased from 24.2% in 2005 to 30.1% in 2017.

The incidence of low back pain varies widely among different reports. The condition is the fifth most common cause for the visit to the doctor and affects 7.6 to 37% of patients.4

A significant percentage of patients with degenerative disc disease have MRI asymptomatic lumbar degenerative disease. In a systematic review of 33 articles involving 3110 patients, imaging detected degenerative disease in 37% of asymptomatic patients aged 20 years and in 96% of patients aged 80 years.5

Etiology

Genetics play a large role in the development of degenerative disc disease. Japanese investigators published findings from a case-control study of 24 patients with immediate relatives who had undergone surgery for disc herniation and presented or had a history of low back pain and/or unilateral leg pain in 1998. The data showed that family history of lumbar disc herniation has a significant implication in lumbar degenerative disc disease.6

Degeneration of intervertebral disc tissue starts sooner than degeneration of other muscular and skeletal tissues. There is evidence that approximately 20% of adolescents and young adults display mild signs of the disease.4

Incidence of degenerative disc disease increases with age. Ten percent of men experience degenerative disc disease at the age of 50 years, increasing to 50% at the age of 70 years. In some reports, degenerative disc disease may be present in 90% of people. However, the disease is often asymptomatic.4

Degenerative Disc Disease Risk Factors

Findings from a retrospective case control study of 160,911 patients with degenerative disc disease and 315,225 controls showed significant association between concomitant hip and knee osteoarthritis, obesity, diabetes, and tobacco dependency and the development of degenerative disc disease.7

Other factors include heavy physical labor, inappropriate flexed posture, and lack of physical activity.

Prognosis

The vast majority of people with lower back pain and/or sciatica symptoms from lumbar degenerative disc disease will be able to successfully manage their pain and avoid surgery. More than 90% of those specifically diagnosed with degenerative disc disease will find that their low back pain and other symptoms go away or subside within 3 months.8

The typical symptom profile is that pain increases at times with a painful flare-up that can last several days, weeks, or even a few months, but then usually subsides back to a lower, more tolerable level.

The good news is that degenerative disc disease pain does not tend to progress with age. Even though degeneration often continues, the associated pain tends to subside. In most cases, a degenerated disc will stabilize by age 60 and will no longer be painful.

Degenerative Disc Disease Diagnosis & Presentation

Typically, patients complain of pain radiating down both buttocks and lower extremities. When patients only experience pain with certain movements, it may indicate instability or a degenerative pars fracture. When collecting patient history, the examiner should on the timeline of pain, radiation of pain, and inciting events.

Diagnosis generally starts when the patient complains of pain or loss of function. The healthcare provider will review the patient’s medical history and conduct a physical exam to determine the source of the prom. The physician may further order imaging exams such as X-rays, a magnetic resonance imaging scan (MRI) or computed tomography (CT) scan to get a better look at the discs and bony structures.17

Evaluating the patient’s stride is critical to better assess the daily impact the pain/deficit is causing. Ask the patient to stand from the chair, walk on their heels and toes, then sit on the examination table for testing of strength, reflex, and straight leg testing is one systematic order.9

Diagnostic Workup & Physical Examination Findings

Evaluation of patients with low back pain typically includes anterior-posterior and lateral radiographs of the impacted area. Some physicians will obtain radiographs of the entire spine.9

Investigators recommend against performing an MRI at the initial presentation of suspected acute disc herniations in patients who lack “red flags,” because these patients frequently improve following a 6-week course of physical therapy. The patient can undergo MRI if symptoms persist after physical therapy.

Red flags can include numbness to the perineum; issues controlling the bowel or bladder; infection (particularly in patients with a history of IV drug use); fever; nighttime chills; suspected tumor in those with a history of cancer or new-onset weight loss; and trauma from fall, assault, or collision.

The evaluating physician should focus should be directed to the T2 weighted sagittal, and axial images as these will illustrate any compression of neurologic elements. Over time, both symptomatic and asymptomatic disc herniations will decrease in size on MRI due to stabilization of the disc herniations. Detection of degenerative disc disease or herniated disc disease on MRI does not correlate with the likelihood of chronic pain or the future need for surgery.

A comprehensive examination should also include ruling out non-organic causes of low back pain/symptoms, including psychological causes. In that case, the evaluating physician should consider:

  • Nonspecific description of symptoms or inconsistency, including superficial/non-anatomic sites of tenderness on exam
  • Pain with axial load/rotational movements
  • Negative straight leg raise with patient distraction
  • Non-dermatomal patterns of distribution of symptoms
  • Pain out of proportion on the exam

Differential Diagnoses

As much as 30% mechanical back pain originates in the sacroiliac joint in origin, but physicians often miss this potential diagnosis. Similarly, ankylosing spondylitis can be missed when providers mistakenly assume back the back pain is mechanical.10

Inflammatory disorders, malignancy, pregnancy, trauma, osteoporosis, nerve root compression, radiculopathy, plexopathy, degenerative disc disease, disc herniation, spinal stenosis, sacroiliac joint dysfunction, facet joint injury, and infection are all differential diagnoses for degenerative disc disease. Recognizing the distinguishing between the signs and symptoms of mechanical pain from neuropathic pain is an essential first step in the diagnosis of back pain.

References

  1. Battié MC, Joshi AB, Gibbons LE; ISSLS Degenerative spinal phenotypes group. degenerative disc disease: What is in a name? Spine (Phila Pa 1976). 2019;44(21):1523-1529. doi: 10.1097/BRS.0000000000003103
  2. Shim JH. Cervical degenerative disc disease. SPINE-health. October 6, 2016. Accessed July 21, 2022. 
  3. Parenteau, CS, Lau, EC, Campbell, IC, et al. Prevalence of spine degeneration diagnosis by type, age, gender, and obesity using Medicare data. Sci Rep 2021;11, 5389. doi.org/10.1038/s41598-021-84724-6
  4. Kos N, Gradisnik L, Velnar T. A brief review of the degenerative intervertebral disc diseaseMed Arch. 2019;73(6):421-424. doi: 10.5455/medarh.2019.73.421-424
  5. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-6. doi: 10.3174/ajnr.A4173
  6. Matsui H, Kanamori M, Ishihara H, Yudoh K, Naruse Y, Tsuji H. Familial predisposition for lumbar degenerative disc disease. A case-control study. Spine (Phila Pa 1976). 1998;23(9):1029-34. doi: 10.1097/00007632-199805010-00013
  7. Steelman T, Lewandowski L, Helgeson M, Wilson K, Olsen C, Gwinn D. Population-based risk factors for the development of degenerative disk diseaseClin Spine Surg. 2018;31(8):E409-E412. doi: 10.1097/BSD.0000000000000682
  8. Sellers JT. Living with degenerative disc disease. SPINE-health. June 16, 2014. Accessed July 21, 2022.
  9. Donnally III CJ, Hanna A, Varacallo M. Lumbar Degenerative Disk Disease. [Updated 2022 Mar 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
  10. Barros G, McGrath L, Gelfenbeyn M. Sacroiliac joint dysfunction in patients with low back painFed Pract. 2019;36(8):370-375. PMID: 31456628