Degenerative disc disease - Ask Dr. P

What Causes Low Back Pain?

by Pain Doc | May 29, 2020 | Low Back Pain

Low back pain continues to be a problem for many people. If not you, then most likely several people you know: neighbors, co-workers, friends and relatives. That’s what the statistics tell us.

Since it is so prevalent throughout the world, “what causes low back pain?” is a question millions of people want answered. Is it normal and expected as we age? Is it genetic? Will you need to get surgery? As you can expect, the answer is different for different people. First of all, the pain is not identical from person to person. Some people get low back pain on the right side; some get it on the left side. Some get low back pain into the hip.

In this post, I will do my best to help you understand what causes low back pain and at the end of the article provide you a tool to pinpoint what is causing your particular low pain.

The Lumbar Spine and Its Significance

Your low back or lumbar spine engineering-wise is your body’s lynch-pin– along with your pelvis, it connects your upper body to your lower body and is tasked with balancing and moving your torso. If you injure your low back it can put you out of commission: any attempt at moving places a load on your low back and makes pain worse. In extreme cases it is even painful to take in a deep breath! Acute low back pain can instantly stop a 250 pound football player in his tracks; that’s the power it has.

While most cases of low back pain self-resolve over a few days, about 20% of them become chronic, or recurring. For some, it strikes every couple of months; for others, it’s enough to impede their daily activities and quality of life. In fact, low back pain is said to be the number one reason for lost work days (disability) in industrialized nations, and therefore lost productivity.

The reason why low back pain is so prevalent is a societal phenomenon, made possible by evolution. You see, humans are the only bi-pedal animal on the planet. Dancing bears and meerkats don’t count because although they can walk a few steps their pelvic design is still quadri-pedal (walking on four limbs). When nature selected homo sapiens to be bi-pedal, it freed up his arms to carry things–heavy things. Carrying and lifting things and bending the low back places a tremendous load on the lumbar spine, and like any machine, the components bearing the most stress will be the first to break down.

Secondly, the invention of the chair and desk. When our ancient ancestors roamed the plains and forests 30,000 years ago there weren’t any chairs around to sit in for hours, placing pressure on the low back and weakening the postural muscles of the spine. Today, many jobs require sitting at a desk in front of a computer, doing just that. Also, food these days is abundant and much less nutritious causing humans to gain excess weight, placing constant stress on the low back throughout the day.

Causes of Low Back Pain

The vast majority of low back pain cases are mechanical in nature; meaning caused by a breakdown of some physical component of the lumbar spine. These components are the muscles, fascia (muscle sheath), ligaments and tendons; vertebrae, vertebral joints, and discs (which are technically ligaments). If the dysfunction causes compression of nerve roots, then nerve pain is involved, which usually means shooting / radiating pain and/ or numbness down the buttock to lower extremity; sometimes as far down to the sole of the foot.

Here are the main categories of mechanical low back pain:

Congenital Malformations

Sometimes there are abnormalities in the development of the spinal column which interfere with proper movement and balance placing excess stress on soft tissues and sometimes nerves, generating pain or constant stiffness and aches, and loss of range of motion/flexibility. Examples include fused vertebrae (two adjacent vertebrae fused together instead of forming a joint); scoliosis; spina bifida, pars defect, hyperkyphosis (hunchback); and hyperlordosis (swayback).

Injuries

Low back pain is often due to injuries to tissues: sprains to ligaments; ruptured intervertebral discs from a herniated or prolapsed nucleus pulposus (jelly-like shock absorbing substance in all discs); strains (tears, small and large) to muscles and tendons; muscle spasms, and fractures. These can be traumatic from a specific incident such as a sports injury, or can be cumulative over time, often years, from performing a certain movement repeatedly or sitting/slouching causing gradual degenerative disc disease. With acute tissue injury, the inflammatory response is initiated, which is responsible for the pain generation.

Degenerative Changes

Joints wear out over time. Most doctors will tell patients their condition is from “normal” wear and tear. But that’s not accurate. For some people, joints deteriorate at an abnormally fast rate, mainly due to lifestyle factors under their control. I’ve seen X-rays of 60 year-olds look much better than 30 year-olds, on many occasions.

Factors that promote lumbar spine degeneration include:

Being overweight
Genetic predisposition
Sedentary lifestyle/ lack of physical activity
Sitting frequently (airline pilot, police officer, truckers, data entry)
Heavy labor job
Contact sports, especially football
Occupation or recreation that involve hard landings (basketball, gymnastics, parachuting, etc.)
Previous injuries/accidents such as falls and car accidents
Poor diet (your body needs proper nutrients to heal tissues)
Smoking (smoking reduces oxygen to cells and may trigger inflammation)

Doctors use three terms to describe spinal degeneration:

Spondylosis when referring to the vertebrae as a whole;
Degenerative joint disease or DJD if referring to the vertebral joints: facet joints and intervertebral joints; and
Degenerative disc disease or DDD if referring to the intervertebral discs

In all cases, the joint surfaces of the vertebrae lose their smooth borders and form jagged bone spurs called osteophytes. You can have a lot of osteophytes in your spine and not feel pain at all. In fact, if you are over age 40 you probably have them yourself. But if the osteophytes get big enough to narrow the openings where nerves pass through, called foramen, problems start. This narrowing of the foramen is called spinal stenosis and can occur with the intervertebral foramen (IVFs), the small holes formed by adjacent vertebrae which nerve roots pass through; and also the central canal where the spinal cord and cauda equina reside. This can lead to shooting pain down one or both legs; numbness and tingling in the legs, and leg muscle weakness, atrophy and loss of sensation.

Since osteophytes do not resorb (shrink) and only get bigger with time the only option is spinal decompression surgery which involves shaving off the osteophytes to make more room for the nerves.

And there is another problem: when spinal discs degenerate, they lose height (this is part of the reason why most people get shorter as they age). A healthy L5-S1 disc can be in excess of 1 cm thick while a degenerated one can be just 2-3 mm thick. When this happens, the posterior and anterior longitudinal ligaments that run down the front and back of your vertebral column slacken, or buckle, at those levels. Like osteophytes, buckled ligaments can cause stenosis, compressing or irritating nerves and causing the same neurological symptoms.

When the degenerative changes involve deterioration of cartilage, you have bone on bone contact. The cartilage in your spine is located in the encapsulated facet joints, located behind the vertebral bodies. This triggers inflammation, which leads to osteoarthritis. It’s the same process as osteoarthritis of the knees and hips, occurring in the spine.

Like knee osteoarthritis, people with spinal OA will feel burning pain in their lumbar spine especially when standing, and stiffness which is worse upon waking in the morning. Osteoarthritis is a chronic, degenerative disease that is best managed by lifestyle modification (anti-inflammatory diet, exercises, stress reduction). Those with severe cases sometimes elect to use prescription anti-inflammatory medication.

Non-Mechanical Causes of Low Back Pain

Less than 1% of low back pain cases are due to other factors, most of which are “red flag” cases that require immediate medical attention. These include pelvic tumors, kidney stones, metastatic cancer (usually from prostate cancer), infection, and endometriosis. A brain tumor is capable of causing sciatica-like symptoms if it affects the sensory neurons that go to the leg. While rare, if you have low back pain that does not improve with physical therapy or rest, it is a good idea to see your doctor and get some tests done to rule out these conditions.

Summary and Main Take Aways

If you have low back pain, chances are very good it will go away with rest. Apply ice for the first 1 to 2 days. If severe, you can try taking over the counter anti-inflammatory medications (NSAIDs) such as Motrin or Ibuprofen to knock down some of the pain. And if you are lucky to have a cryotherapy center near you, you can do a couple of visits to shorten the healing time.

If the pain lasts more than 4 days, then it usually means something is perpetuating it: perhaps you are not resting it properly; are re-aggravating it; or have some kind of contributing factor such as a rotated vertebra or disc protrusion. These issues can be dealt with by visiting a good physical therapist or chiropractor. You can even do some home exercises and home therapy for low back pain on your own and still get great results.

While most cases of low back pain go away, it doesn’t mean that it will stay away for the rest of your life: 20% of people who get low back pain will experience it again in the future; either from a new injury/event or a flare-up of a pre-existing injury. And remember, some cases become chronic (pain decreases, but the improvement plateaus and remains, with some days worse than others). Your prognosis will depend on what is causing your low back pain (see below for a self-diagnosis tool) and other factors related to your medical history and daily activities.

When dealing with low back pain, besides focusing on reducing the pain think of what things caused it and eliminate those causes as best you can. It may mean:

Getting a stand up desk (standing puts less stress on your low back than sitting)
Losing some weight
Eating a healthier diet
Stopping smoking
Exercising more often
Reducing emotional stress in your life
Improving the ergonomics of your work station
Learning how to lift properly
Getting your back adjusted by a chiropractor periodically to improve joint movement and joint health

And lastly, remember that low back pain should noticeably and progressively improve each day after initial onset. If you notice that pain does not get better with rest, express your concern to your doctor: demand an X-ray, MRI and/or a blood test. Red flag cases like cancer are often misdiagnosed by doctors (dismissed) as general back pain due to spasms because doctors know that the medical literature estimates red flag cases to be 1% or less of all low back pain cases. Remember to be persistent; it is your life you are dealing with.

Below is a low back pain algorithm I created to help you diagnose your particular low back pain so that you can take appropriate action. Use the top one if your low back pain onset was sudden; use the bottom one if the onset was gradual. This is only a guide; always check with you doctor who can examine you, to get an accurate diagnosis.

Chronic Neck Pain or Stiffness? Get Your Neck Curvature checked

by Pain Doc | Feb 27, 2015 | Neck Pain

The cervical spine is the thinnest and most flexible part of the human spine. It is tasked with supporting the weight of the head in the upright position while allowing turning in multiple planes — looking left, right, up, down and behind. It also contains structures directly tied to life sustenance, which is why the neck is a logical target when it comes to martial arts/ self-defense and restraint (and unfortunately, murder).

Given all these vital functions, it is wise to take good care of your cervical spine in a proactive way.

The cervical spine is naturally designed to curve, where the apex is at about the level of the Adam’s apple.

This curve behaves much like a spring in a car’s suspension; or the slight upwards curve you see in any bridge design. Long ago, architects discovered that the load capacity of bridges could be dramatically increased simply by integrating curves or arcs into the design. Like a neck curve, a bridge curve or arc distributes weight over a greater area so that gravity cannot concentrate over one small area and cause structural failure.

neck_xr_flat If the neck curve helps distribute the weight of the head in the upright position, what do you suppose might happen if the curve straightened out or started to bend in the opposite direction like the one to the left?

If you lose your cervical curve over time, which could happen from years of poor posture or trauma like multiple rear-end car collisions, you will probably not notice it until several years pass. The change in biomechanics shifts a greater burden of support to your cervical discs and vertebral end plates. This promotes disc degeneration. The once thick and healthy discs lose fluid content, lose strength, allow the center material to bulge out (herniate, protrude or rupture) and cause bony protuberances called osteophytes to form all around the edges of the vertebrae and facet joints.

For some unfortunate people, the bony projections narrow the passageways where the nerve roots and spinal cord pass through (a condition called spinal stenosis) and neck surgery is necessary to prevent nerve tissue from permanent damage, paralysis and severe paresthesias (numbness, tingling) in both the arms and legs.

So the bottom line: be conscientious about the importance of the health of your cervical spine. Don’t get blind-sided by an MRI diagnosis of “multiple-level, severe degenerative disc disease with advanced neural encroachment.”

I’ve seen such cases where patients were oblivious to what was developing inside their necks. They dismissed their neck stiffness and aches to “getting older” or simple muscle strain. When massage and chiropractic provided only temporary relief, they had a cervical MRI done which revealed the formidable origin behind these symptoms, and the next step was neck surgery. Neck surgery of this nature involves removing the damaged disc, shaving off the osteophytes and inserting a bone graft to promote fusion of adjacent vertebrae.

Prevention is the best approach. You don’t have to have neck problems to start preventive measures. In fact, the vast majority of patients who have early to moderate stage degenerative disc disease have no complaints. It’s like a cavity — you don’t feel anything as the pit erodes the tooth enamel, but as soon as it hits a nerve, you will definitely be aware of its presence. But by that time, you’ll need invasive procedures. In the case of a cavity, it means either a filling or tooth extraction; in the case of a cervical disc, it might mean cervical decompression surgery.

Below is a video that summarizes the importance of maintaining a healthy cervical curve (“lordosis”) and exercises to maintain or restore your neck curve so that it can better withstand the physical demands placed on it and hopefully preclude the need to visit an orthopedic surgeon years down the road.

Also, make sure to check out this site’s Self-Care for Neck Pain video, which demonstrates home care procedures for managing musculoskeletal neck pain and/or stiffness.

Risk Factors for Disc Bulges and Degenerative Disc Disease

by Pain Doc | May 17, 2011 | Uncategorized

I’ve been fielding a lot of questions about bulging discs lately. Here are some of the questions I get:

Can you heal a bulging disc?
Is a bulging disc hereditary?
How to treat a bulging disk?

The short answer to the first question is “yes” if the bulge is not severe and the body still has in place the mechanisms to keep the disc living and healthy (see below).

The other answer to the first question is “no” if the disc bulge is the result of breakdown of the nutrient-delivery mechanism to the disc. If this is the case, it is a matter of time before the disc totally degenerates. Physical therapy, chiropractic, spinal decompression and exercises can slow it down, but one cannot do these things indefinitely and often enough to stop the progression.

It’s important to know that your spinal discs are mostly avascular; meaning, don’t have a direct blood supply. Discs get their nutrients (water, oxygen, glucose, minerals, vitamins) via slow absorption from the capillaries directly underneath the vertebral end plates. At the end of the day, your discs flatten from the effects of gravity. As you sleep, they soak up fluids and expand, so that by the time you wake up in the morning you are at least 5 mm taller than when you first went to bed. This is called the diurnal cycle of fluid movement in and out of the disc and is the major means of nutrient delivery.

At the center of the disc is the nucleus, which has tiny cells that make the proteoglycan molecules responsible for attracting and holding onto water. This maintains a hydrostatic pressure that allows the disc to bear about 80% of the weight applied to its spinal level. These cells, similar to chondrocytes that make collagen in the joints, are the most active when the pressure in the disc is about 3 atmospheres. If the pressure is higher (obese individuals, those who carry heavy weight frequently at work) or lower, the cells make less of these molecules, putting the disc at greater risk of drying out. Injuries to the internal part of the disc or vertebral bodies can increase the volume of the nucleus, drastically reducing its hydrostatic pressure and slowing down proteoglycan synthesis. This is one of the pathways of degenerative disc disease, or DDD as the posterior (facet) joints, which are not designed for bearing much weight take on the responsibility of the disc and quickly wear down, forming the familiar osteophytes (bone spurs) seen on X-ray and MRI studies.

Here are the basic risk factors for developing DDD/ bulging discs:

1) History of Structural Damage to the Disc or Vertebra

Single event trauma to the spine resulting in damage to the vertebral end plates . An example would be a parachuter landing hard on the ground on his feet. This can cause a small injury, or even a significant compression fracture to the bony end plates– the surfaces to which the disc attaches. This is bad news, because nutrients to the disc (blood, oxygen, glucose) traverse through these end plates from the top and bottom of the disc. If it is damaged, the area calcifies and “shuts the gate,” depriving the disc of critical nutrients needed to stay healthy. This sets the stage for a slow procession of degeneration over the years which will have phases of back pain, stiffness, disc bulging, stenosis, and in severe cases leg pain, leg weakness and altered sensation.

Repetitive, axial loads to the spine. An axial force is one that travels straight down the spine, while standing. If you are in a job that requires frequent heavy lifting, especially above the shoulders; or requires you to carry 50 or more pounds of gear most of the day, you are placing axial loads on your spine. Similar to #1, it can slowly damage the vertebral end plates and damage the nutrient delivery system to the disc.

2) Hereditary Factors – there are respected studies that strongly suggest a genetic component to DDD. One study showed that there is a 50% greater chance of developing severe disc degeneration in the relatives of past disc surgery patients. Another study found mutations in the genes responsible for the synthesis of proteoglycan molecules, which are responsible for water retention in the disc. If the disc cannot attract and hold onto water, it cannot maintain its hydrostatic pressure. As a result, it loses its ability to distribute weight and slowly dessicates (dries out).

3) Occupation. This is pretty obvious. Those who work with heavy machinery or require heavy lifting are more prone to developing bulging discs.

4) Smoking. Smoking damages the fine blood vessels that the disc depends on to deliver nutrients. It also generates a lot of free radicals, which can damage the disc further. Some surgeons require patients to be “smoke-free” for at least three months prior to surgery.

So, here are the lessons to take here. First, if you have a parent who suffers from bulging discs and degeneration, realize that you have a 50% greater chance of developing them on your own. You may have a mutant gene that is making defective collagen in your disc, making it a ticking time bomb ready to go off in the near future. Your best bet is to minimize the expression of this gene, and a good way to do it is to eat as healthy as you can; ditch the toxins (smoking, excessive alcohol and sugar); avoid getting overweight, and maintain positive thoughts (may affect gene expression to your benefit).

Secondly, avoid unnecessary axial forces to your spine. Stay away from things that involve hard landings on your feet, and don’t lift weights in a way that places pressure to your lower back.

Recommended Back Exercises

by Pain Doc | Jan 18, 2011 | Low Back Pain

I am a firm believer that strengthening and conditioning the core, back and leg muscles is the best way to guard against getting back pain.

If you’re prone to having your back “go out”, then these exercises are the best way to guard against recurrence. Don’t wait until you get degenerative disc disease, because once you reach this point the chances of living a pain- free life take a big nosedive. The reason is that the best exercises for strengthening your back are more risky for those with disc degeneration.

What typically happens is the disc degeneration patient will naturally stay cautious or apprehensive and will avoid back exercises for fear of re-injuring his back. This eventually leads to back muscle weakness and loss of muscle coordination–precursors for back injury and chronic pain.

So, if you don’t have back pain or degenerative joint disease (weak, thinning and/or herniated discs with accompanying bone spurs and cartilage degeneration) consider yourself lucky. Make sure your exercise regimen involves engaging the primary muscles of the trunk primarily, and the whole body, secondarily.

Do functional exercises which force the muscle groups to work synergistically rather independently. Such exercises can mimic common body movements; for example, carrying something on your shoulder while walking.

In strengthening the back, I like to do squats using a 20 lb bar on my back with feet apart in different distances.

Throwing a 12 lb. medicine ball using your whole upper body is another great functional exercise. Get a partner and have him stand 10 feet to your right. Throw the ball to your partner while using your core as well as arms. This simple exercise will strengthen your abs, your paraspinals, arms, and even your leg muscles.

Next, use a Freemotion or similar cable-weight machine where you can raise an arm above your head. With both hands, grip the cable handle and swing it down towards your feet, as though you were chopping wood with an axe. Boy, this is a great exercise as you will feel just about every muscle in your back, arms and chest work together to move the weight.