From the Guidelines
Degenerative lumbar disc disease typically progresses gradually over decades, beginning with biochemical changes in the disc during early adulthood, with most patients experiencing improvement in acute symptoms within 6-12 weeks with conservative management 1. The natural history of degenerative lumbar intervertebral disc disease involves three main phases: dysfunction, instability, and stabilization.
- Initially, microscopic tears develop in the disc annulus, causing inflammatory responses and pain.
- As degeneration advances, the disc loses height and hydration, leading to decreased shock absorption capacity.
- By middle age, many individuals experience some degree of disc degeneration, though not all develop symptoms. Pain patterns often fluctuate, with episodes of acute pain followed by periods of minimal discomfort.
- Long-term outcomes vary significantly - some patients stabilize with minimal ongoing symptoms through natural fusion processes, while others develop chronic pain or neurological complications like stenosis or radiculopathy. Risk factors accelerating degeneration include genetic predisposition, smoking, obesity, occupational factors involving heavy lifting, and previous trauma.
- The correlation between imaging findings and symptoms is often poor, with many individuals having significant radiographic degeneration but minimal symptoms. This natural variability in disease progression explains why many patients can be successfully managed with conservative approaches rather than surgical intervention, as there is no compelling evidence that routine imaging affects treatment decisions or improves outcomes 1. The majority of patients with lumbar disc herniation and radiculopathy experience improvement within the first 4 weeks with noninvasive management, and thus, conservative management is recommended as the initial approach 1.
From the Research
Definition and Prevalence
- Degenerative lumbar intervertebral disc disease is a major cause of chronic low back pain, with the degenerative cascade often initiated by an imbalance between catabolic and anabolic processes in the intervertebral discs 2.
- The majority of individuals with degenerative disc disease are asymptomatic 3.
Natural History
- The natural history of sciatica is associated with a good overall prognosis, while that of discogenic low-back pain is less promising 3.
- Lumbar disc herniation has a favorable prognosis in the majority of circumstances, with a natural history process of disc resorption 4.
- Understanding the natural history of degenerative spondylolisthesis is important to tailor an individualized management plan for each patient 5.
Pathophysiology
- The degenerative process results in disc bulging and loss of nucleus pulposus and water content, and subsequent loss of disc height 2.
- Changes to degenerative cascades in the intervertebral disc cause dysfunction and instability in the lumbar spine 6.
- Loss of stem and progenitor markers, imbalance of the extracellular matrix, increase of inflammation, sensory hyperinnervation, and vascularization have been identified as the onset and progression of disc degeneration 6.
Treatment and Management
- Most patients respond to conservative management and surgical interventions well initially, yet a significant number of patients continue to suffer from chronic low back pain 2.
- A trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication 5.
- Various treatments include pharmacological, rehabilitation, or surgical interventions that aim to relieve pain, but these modalities do not halt the pathologic events of disc degeneration or promote tissue regeneration 6.