How to manage degenerative disc disease?

Management of Degenerative Disc Disease

Stabilizing exercises are the most effective first-line treatment for degenerative disc disease, showing a 17% reduction in clinical symptoms compared to mobilizing exercises which actually increased symptoms by 10%. 1

Initial Assessment and Conservative Management

Physical Therapy Approach

• Stabilizing exercises should be prioritized over mobilizing exercises for patients with degenerative disc disease 1
• Structured physical therapy programs should include:
  • Core strengthening exercises
  • Postural training
  • Proper body mechanics education
  • Activity modification techniques

Pain Management

• First-line medications:
  • NSAIDs/COXIBs at maximum tolerated doses for 2-4 weeks
    • Naproxen (375-1100 mg/day)
    • Diclofenac (150 mg/day)
    • Ibuprofen (1800 mg/day)
  • Acetaminophen for patients who cannot tolerate NSAIDs
• Second-line therapy:
  • Duloxetine for chronic pain

Lifestyle Modifications

• Weight management to reduce axial loading on the spine
• Ergonomic modifications at work and home
• Avoidance of activities that exacerbate symptoms
• Soft consistency diet with nutritious fluids may be necessary during symptomatic periods

Imaging Considerations

• MRI without contrast is the gold standard for evaluating neuroforaminal stenosis 2
• Imaging should be considered after a trial of conservative therapy 3
• Remember that asymptomatic degenerative changes are common, and imaging findings don't always correlate with symptoms 2

When to Consider Surgery

Surgery should be considered in patients with:

• Moderate to severe spinal stenosis who have failed conservative management for at least 6 weeks 2
• Disabling radicular pain preventing normal everyday activities 2
• Severe spinal stenosis with multiple disc herniations and subluxation 2
• Progressive neurological deficits

Surgical Options

• Lumbar laminectomy with adequate decompression of neural elements
• Foraminotomy to address foraminal stenosis
• Fusion with instrumentation if instability is present 2

Emerging Treatments

Several promising biological therapies are being developed to address the underlying pathophysiology of disc degeneration:

• Growth factor injections 4, 5
• Stem cell therapies to repopulate degenerated discs 4, 5
• Gene therapy to modify the degenerative process 4, 5
• Tissue engineering approaches 4

Important Considerations

• Approximately 80% of patients experience symptom resolution with conservative treatment 2
• The degenerative cascade is initiated by an imbalance between catabolic and anabolic processes in the intervertebral discs 6
• Delayed surgical intervention in severe cases can lead to irreversible neurological damage 2
• Long-term outcomes of fusion may include acceleration of degenerative processes at adjacent levels 7
• Disc arthroplasty shows equivalent long-term outcomes to fusion without accelerating adjacent degeneration, though concerns remain about wear debris and facet joint arthrosis 7

Follow-up Recommendations

• Regular clinical and functional assessments after treatment initiation
• Follow-up every 4-6 weeks initially
• For surgical patients, radiographic evaluation at 12 months post-surgery
• CT without contrast to assess osseous fusion if fusion was performed 2

Remember that understanding the pathophysiology of degenerative disc disease is crucial for developing effective treatment strategies that address the underlying degenerative process rather than just managing symptoms.