by Dr. Walter M. Bortz II
Q: What is the latest information on degenerative disk disease? My mother has been diagnosed with this and wants to know more about her options. A: Your mother isn't alone in her diagnosis of degenerative disk disease (see Disk Problems). Many commentators say that our species' difficulty with bad backs started when we first stood up on the Serengeti Plain millions of years ago. I have never seen a chimpanzee with a bad back. Maybe they know something we forgot when we decided to walk upright. Degenerative disk disease goes by different names -- herniated or ruptured disk, prolapsed intervertebral disk, etc. Whatever the name, it is a pain in the rear. Its fundamental cause is almost always osteo- or degenerative arthritis, in which the vertebrae of the spine -- usually in the lower lumbar area, but also common in the neck or cervical area -- become irritated from excessive use or injury. The vertebrae then set up an inflammatory effort to heal themselves. As a result, they lay down calcium deposits and often bone spurs as an accompaniment to the healing effort. The pain and stiffness that result are because of the imprecision of this healing process.
It is possible that this process occurs at a single location in the spine, but it also can be pretty generalized. Diagnosis is very easy to make with simple X-rays. But, if the doctor is concerned about nerve pressure, then he or she may order a scan, such as magnetic resonance imaging, to assess the extent of damage more carefully. Laboratory tests are generally not helpful in making the diagnosis, unless there is a worry that some other feature, such as a malignancy (rare), may also be present.
The spinal disks are small sponges that rest between each vertebral body and, in effect, act as shock absorbers. When arthritis or injury acts to compress these disks, the disk tends to bulge out of its usual alignment and may actually rupture. The most common direction for such a rupture to occur is posteriorly. The displaced disk segment can then possibly press on the spinal nerve as it emerges from the spinal cord or on the cord itself.
Several years ago, our daughter Gretchen suffered a ruptured cervical disk during a rear-end car collision. I was a very interested observer during her surgery. I peered over the surgeon's shoulder directly onto her spinal cord, laid bare by the surgery. There on the cord was a dent -- it reminded me of a 9-iron golf divot -- where the ruptured disk had been pressing directly on the delicate nerve tissue. She is fine now.
A ruptured disk causes most of its mischief by pressing on nerve tissue, resulting in a pinched nerve. The type of symptoms that develop as a result of such pressure depend on which nerve and which part of that nerve are involved. Symptoms as diverse as a floppy wrist, an absent knee jerk, a weak fist, a numb foot or sciatica all result from a nerve pinched somewhere along its course.
Many doctors use the straight-leg-raise test to investigate low-back problems. This simply involves lifting the heel of the patient with his or her leg passively extended. This stretches the sciatic nerve, which is located in back of the hip and runs down the back of the leg. This bowing elicits pain -- reliable evidence of a ruptured disk low in the back.
Because this happens so often, you'd think that medical science would have figured out the best response. The truth is we haven't. The first advice always is to do the simple things first. Heat, rest and aspirin are a common prescription unless the pain onset has been abrupt, in which case ice packs may help. Pain relief lies at the heart of the therapeutic program, because the presence of pain makes the situation much worse: Pain induces muscle spasm, which causes more pain, which causes more muscle spasm. Around and around the cycle goes. So pain relief is essential. What should you take for the pain? Anything that works. Try aspirin or Tylenol (acetaminophen) first, then the anti-inflammatory meds, such as ibuprofen. I have certainly written hundreds of prescriptions for the common narcotic codeine for patients with back pain caused by ruptured disks. The trick here, of course, is to get rid of the pain promptly so that the patient's need for the codeine is short-lived.
There now have been several controlled experiments performed on patients with back pain to see which treatment program works best. Bed rest, chiropractic manipulation, intensive physical therapy and simple "do what you feel you can do" strategies were compared. Guess which came out best? Right -- "do what you can do" shortened the course of treatment the most, was the safest and cost the least.
As with our daughter, surgery is the last resort -- always. Once the pain lets off, exercise is the master prescription. I liken the vertebrae of the spine to a tent pole, the stability of which depends upon its supporting wires and guy lines -- in this case, the ligaments, tendons and muscles. When these are kept taut, the spine cannot chatter and become irritated. Healing can take place better in a sturdy back.
I believe I have written earlier about my wife's experience 25 years ago when she was a very tough lady in her early 40s. One afternoon, however, she developed a screeching back pain, which necessitated a shot of narcotics for relief. An X-ray the next morning showed extensive low-back disease with narrowed disks. The doctor's advice: "Oh, Mrs. Bortz, you have a terrible back. You are going to have to take it easy from now on." Since that time, she has run 20 marathons and a half dozen ultramarathons. Now, at age 69, she has no back symptoms whatsoever. I'm sure the X-rays are still rotten, but she has so strengthened her own muscular girdle that no problems present.
So the right approach to degenerative disk disease is conservative management, with exercise as its centerpiece. A visit to a physical therapist or trainer might be an excellent decision.
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