Degenerative disk disease

Last updated: May 18, 2022

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Degenerative disk disease refers to a group of conditions in which disk material is displaced into the spinal canal. The condition can be asymptomatic or manifest as radiculopathy (due to compression of a spinal nerve root) or myelopathy (due to compression of the spinal cord). The site of nerve or cord compression can often be determined based on the patient's neurological deficits. Radiculopathy manifests with radicular pain, motor weakness, and loss of deep tendon reflexes in the dermatome and myotome territory of the compressed nerve root. Myelopathy is a medical emergency that typically manifests with motor weakness, sensory abnormalities (e.g., saddle anesthesia), and bowel and/or bladder disturbances. MRI findings consistent with physical exam findings confirm the diagnosis. Conservative management with analgesics and physiotherapy may be sufficient for isolated acute radiculopathy without severe paresis. Urgent surgical decompression is required for patients with spinal cord compression, conus medullaris syndrome, or cauda equina syndrome to prevent permanent neurological damage.

  • Age: most common at 30–50 years
  • Sex: > [1]
  • Approx. 80% of all Americans suffer from significant back pain at some point in their lives. [2]
  • Disk herniation is the cause of back pain in roughly 5% of cases.

Epidemiological data refers to the US, unless otherwise specified.

Intervertebral disks usually protrude/herniate posterolaterally, as the posterior longitudinal ligament is thinner than the anterior longitudinal ligament.

Degenerative disk disease may be asymptomatic and detected incidentally (e.g., on imaging performed for an unrelated condition). Examination findings vary depending on the location and severity of nerve root compression. [4][5]

As dermatomal territories often overlap (except in autonomous sensory zones) and muscles are often supplied by several myotomes, sensory and motor deficits may be absent or minimal if a single spinal root is compressed.

The affected nerve root is typically the one below the level of disk herniation (i.e., C4–C5 disk herniation leads to C5 radiculopathy; L4–L5 disk herniation leads to L5 radiculopathy).

Cervical radiculopathy [8]

Symptoms

  • Neck pain commonly associated with radiculopathy
  • Can manifest with difficulty with fine motor skills
  • Can be accompanied by headache and/or shoulder pain

Examination findings

May be normal or demonstrate specific motor or sensory deficits depending on the nerve root affected

Overview of cervical radiculopathies [9]
Radiculopathy Causative disk Sensory deficits Motor deficits Reduction of reflexes
C3/4 radiculopathy
  • C2–C4
  • Shoulder and neck area
  • None
C5 radiculopathy
  • C4–C5
C6 radiculopathy
  • C5–C6
  • From the upper lateral elbow over the radial forearm up to the thumb and radial side of index finger
C7 radiculopathy
  • C6–C7
  • Palmar: fingers II–IV (II ulnar half, III entirely, IV radial half)
  • Dorsal: medial forearm up to fingers II–IV
  • Triceps, wrist flexors, and finger extensors
C8 radiculopathy
  • C7–T1
  • Finger flexors
  • None

Provocative maneuvers

Lumbosacral radiculopathy [3]

Symptoms

Worsening of low back pain with lumbar flexion (e.g., on sitting) is suggestive of lumbar disk herniation, while improvement of pain with lumbar flexion is suggestive of lumbar spinal stenosis. [3]

Examination findings

May be normal or show specific motor or sensory deficits, depending on the affected nerve root

Overview of lumbosacral radiculopathies [9]
Radiculopathy Causative disk Sensory deficits Motor deficits Reduction of reflexes
L3 radiculopathy
  • L2–L3
  • Anterolateral area of the thigh
L4 radiculopathy
  • L3–L4
L5 radiculopathy
  • L4–L5
  • Lateral aspect of the thigh and knee, anterolateral aspect of the leg, dorsum of the foot, and the big toe
S1 radiculopathy
  • Dorsolateral aspect of thigh and leg, and the lateral aspect of the foot

S2 radiculopathy, S3 radiculopathy, S4 radiculopathy

  • None

Back pain associated with bowel or bladder dysfunction is concerning for spinal cord compression, cauda equina syndrome, and conus medullaris syndrome.

Herniated lumbosacral disks commonly cause radiculopathy below the level of the herniated disk (e.g., L4–L5 disk herniation results in L5 radiculopathy). However, a far lateral disk herniation can cause radiculopathy above the level of the disk (e.g., L4–L5 far lateral disk herniation resulting in L4 radiculopathy). [12]

Provocative maneuvers

Leg raising maneuvers are used to screen for lumbosacral radiculopathy

Degenerative disk disease is diagnosed on the basis of characteristic clinical features in conjunction with abnormal imaging.

Approach [13][14][15]

See also “Management of acute back pain” and “Compressive spinal emergencies.”

MRI spine without IV contrast [8][13][16]

A diagnosis of degenerative disk disease should not be made based on imaging alone; up to 30% of asymptomatic individuals have abnormal disk appearances on MRI. [16]

Other imaging modalities

CT myelogram [13][14][15]

X-ray spine [14][15]

Additional investigations

See “Acute back pain” for details on the distinguishing characteristics and management of the underlying etiology.

The differential diagnoses listed here are not exhaustive.

Approach

Urgently obtain an MRI and consult neurosurgery to evaluate any of the following red flags for acute back pain associated with DDD: new or progressive neurological deficits, especially motor weakness, saddle anesthesia, and/or bowel, bladder, or sexual dysfunction; intractable or progressive pain; recent spinal surgery.

Conservative management [8][17][18]

About 90% of lumbar disk herniations with acute radiculopathy start to improve within 6 weeks and resolve by 12 weeks with conservative management. [23]

Surgery [8][18]

See also “Urgent spinal causes of back pain.”

Overview

The following table outlines common symptoms following compression of the spinal cord or cauda equina. Patients may also present with symptoms of incomplete spinal cord syndromes depending on the location of the herniated disk.

Overview of compressive spinal emergencies [25]
Compressive myelopathies Cauda equina syndrome
Spinal cord compression Conus medullaris syndrome
Etiology
  • Damage to or compression of the cauda equina (nerve fibers L3–S5) located below L2
  • Common causes include large posteromedial disk herniation, trauma, and tumors.
Onset
  • Variable, bilateral
  • Sudden, bilateral
  • Gradual, typically unilateral
Pain
  • Localized neck or back pain
Motor symptoms
Sensory symptoms
  • Loss or reduction of all sensation below the affected level of the spinal cord
  • Symmetric bilateral perianal numbness
  • Sensory dissociation
  • Saddle anesthesia: lack of sensitivity in the dermatomes S3–S5, affecting the areas around the anus, genitalia, and inner thighs (may be asymmetric)
  • Asymmetric unilateral numbness and/or paresthesia in lower limb dermatomes
Urogenital and rectal symptoms
  • Sphincter dysfunction with urinary or bowel urgency, retention, or incontinence

Spinal cord compression, conus medullaris syndrome, and cauda equina syndrome are medical emergencies that have the potential to cause permanent neurological damage. [28]

Cauda equina syndrome typically manifests with lower motor neuron signs. Spinal cord compression and conus medullaris manifest with a combination of lower motor neuron signs (at the level of compression) and upper motor neuron signs (below the level of compression).

Management

Consider empiric management of other urgent spinal causes of acute back pain, e.g., vertebral osteomyelitis, vertebral fracture, or spinal epidural abscess as directed by clinical suspicion.

  • Obtain an urgent MRI spine without contrast.
  • Consult neurosurgery for urgent surgical decompression.
  • Document the patient's current neurological deficits and reassess frequently. [29]
  • Obtain bladder scan to evaluate postvoid residual and insert Foley catheter for patients with urinary retention.
  • Administer analgesics (preferably NSAIDs, see “Pain management”). [28][30]
  • Treat the underlying cause.
  • Admit the patient for frequent neurological examinations and definitive management.

Treatment of acute spinal cord compression varies based on the underlying etiology and may include decompressive surgery (e.g., for disk herniation) or IV steroids and radiation therapy (for malignant compression).

Initiate immediate management of back pain with new neurological symptoms in patients with back pain and new motor weakness, saddle anesthesia, and/or bowel/bladder dysfunction.

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