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Degenerative Disc Disease & Lumbar Canal Stenosis

DDD is part of the natural process of growing older. A major back injury or fracture can make the changes happen even faster. Disc degeneration follows a predictable pattern. First, the nucleus (the center of the disc) begins to lose its ability to absorb water, then it becomes thick and fibrous, as a result, isn't able to absorb shock as well. Tears appear around the annulus (the outer shell of the disc). The combination of damage to the intervertebral discs, the development of bone spurs, and a gradual thickening of the ligaments that support the spine contribute to degenerative arthritis of the lumbar spine. Over time these changes can also lead to narrowing, or stenosis, of the spinal canal.

Narrowing of the lumbar spinal canal pinches the nerves that control muscle power and sensation in the legs. These changes also can diminish the ability of the spine to carry the load of the upper body. They can lead to the forward slippage of one vertebra on another. This slippage, called "Degenerative Spondylolisthesis," can cause both back and leg pain.

However, not everyone who has degenerative changes in their lumbar spine has pain. Many people who have "normal" backs have MRIs that show disc herniations, degenerative changes, and narrowed spinal canals. Every patient is different, and it is important to realize that not everyone develops symptoms as a result of degenerative disc disease.

COMMON SYMPTOMS include:
Typically patients with DDD/ lumbar spinal stenosis have a long history of pain in the back, buttocks or legs that gradually becomes worse. The symptoms are usually worsened by standing or walking upright. Walking for a certain distance results in an achy pain, tightness, heaviness and a sense of weakness in the buttocks and/or legs (Claudication). These symptoms are generally relieved by sitting down or leaning forward. With age the pain-free distance traveled keeps on decreasing. Although patients are unable to walk for very long, they may be able to ride an exercise bicycle for much longer. Some patients also find that it is easier to walk while leaning forward on a shopping cart. Sometimes the pinched nerves become inflamed and cause pain in the buttocks and/or legs- Sciatica. People complain of back pain and stiffness, especially towards the end of the day.

Warning Signs You Need Immediate Help
• Pain is getting worse
• Disabling pain
• Leg weakness, pain, numbness, or tingling
• Loss of bowel or bladder control

Risk Factors/Prevention
DDD/Lumbar spinal stenosis is usually caused by the wear-and-tear changes of aging. It usually affects middle-aged and older adults. People who are born with narrower spinal canals are more likely to develop this problem early in life.
The best way to avoid the symptoms of lumbar spinal stenosis is to stay as physically fit as possible. Regular exercise can improve endurance and keep the muscles that support the spine strong. Avoiding weight gain can decrease the load that the lumbar spine has to carry. Patients should also avoid cigarette smoking. Both the smoke and the nicotine cause the spine to degenerate faster than normal

DIAGNOSIS
The diagnosis of degenerative disc disease begins with a complete physical examination of the body, with special attention paid to the back and lower extremities.

X-RAYS
If DDD, the x-rays will often show a narrowing of the spaces between the vertebral bodies. Bone spurs begin to form around the edges of the vertebral bodies and also around the edges of the facet joints, the space available for the nerve roots starts to shrink.

MRI or a CT Scan  
A MRI scan is very useful for determining where disc herniations have occurred and where the nerve roots are being compressed. A CT scan is often used to evaluate the bony anatomy in the spine, which can show how much space is available the nerve roots and within the neuroforamen and spinal canal



                                           X-Ray and MRI findings in DDD/LCS

Discography
This is a specialized X-ray test in which dye is injected into one or more discs. The dye is seen on X-ray and can give some information about the health of the disc or discs.

TREATMENT
GOAL OF TREATMENT - to ease pain and other symptoms so the patient can resume normal activities as soon as possible. Non-Operative Treatment: Yesterday vs. Today
It is interesting to note that although 80% of adults will experience back pain, only 1-2% will need lumbar spine surgery. In the past some physicians prescribed long courses of bed rest and/or lumbar (low back) traction for their patients with low back pain. However, that is not the attitude today. During the acute phase, bed rest may be recommended for a few days, but beyond that experts advocate stretching, flexion and extension exercises, and no/low impact aerobics. Of course, each patient is different and therefore so is their treatment plan.

Drug Therapy
During the acute phase drugs may be prescribed. Some may include anti-inflammatory agents, muscle relaxants, narcotics, and anti-depressants. Narcotics are used on a short-term basis partly due to their addiction potential. When low back pain is caused by muscle spasm, a muscle relaxant may be prescribed. These drugs have sedative effects. Depression can be a factor in chronic low back pain. Anti-depressant drugs have analgesic properties and may improve sleep

Therapeutic Exercises
Acupressure
Manipulation
Pain Management Techniques :--  Epidural Steroid Injections (ESI)
                                                           Nerve Root Blocks
                                                           Facet Blocks and Rhizotomy


First Six Weeks
Usually during the first six weeks, acute low back pain is treated with bed rest for a couple of days & appropriate medication. Muscle relaxants are seldom used for longer than one week. Early ambulation is encouraged to increase circulation (aids healing), improve flexibility, and build strength. Generally, during the first two to three weeks, acute symptoms subside. Aerobic (no/low impact) exercise may be started three times per week along with daily back exercises. Some patients may be referred to physical therapy or a supervised work-conditioning program.

Beyond Six Weeks
if the symptoms of DDD/LCS and low back pain persist, further diagnostic tests may be necessary. These tests may include an MRI, CT scan, myelogram, or possibly discography.

Although most degenerative disc disease patients with herniation respond well to non-surgical treatment, a small percentage does not. Disc herniation is the most common indication for spinal surgery. In fact, 75% of all spinal surgeries are for a herniated disc.

SURGERY
In general, surgery is only considered as a last resort if all attempts at non-surgical therapies are unsuccessful and if the overall potential benefits of surgery are greater than the potential risks.
The main types of surgery for degenerative disc problems include
Lumbar Laminectomy
Discectomy
  -> Standard Discectomy
  -> Micro discectomy
  -> Endoscopic discectomy

• Fusion

 -> Posterior Fusion Techniques
     - Poster lateral fusion with Instrumentation
     - Post. Interbody Fusion (PLIF)
     - TLIF
 -> Anterior Interbody Fusion

Fusion eliminates motion and prevents the slippage or curvature from worsening after surgery, which would cause more back and/or leg pain. Your surgeon may use screws and rods to hold the spine in place while the body heals the bone together. Using screws and rods increases the rate of fusion and enables the patient to get out of the postoperative brace sooner. Overall the results of surgery are good to excellent. Most patients are able to resume a normal lifestyle after a period of recovery from surgery.

What's New?
There are two areas of research that have changed the way patients with spinal stenosis are treated. First, surgeons have developed ways to perform decompression procedures through smaller incisions (Minimally Invasive Spine Surgery). These techniques cause less pain after the operation and allow quicker return to normal activities. These new techniques are as effective and safe as the traditional procedures. Surgeons are also beginning to use manufactured bone-forming proteins (Bone substitutes) to fuse the Spine. Now days surgeons are shifting to soft stabilization or flexible stabilization of Spine alternative to fusion, it is called as Dynamic stabilization. Dynamic stabilization uses flexible materials to stabilize the affected lumbar region while preserving the natural anatomy of the spine. It is intended to alter the load bearing pattern of the motion segment and to control any abnormal motion while leaving the spinal segment mobile.

How we do it?
At Orthopedic`n`Spine Center Jalandhar, patients are evaluated for their problems and individualized treatment protocol is formulated. Most of the patients get relief with medication and physiotherapy. Patients who do not get relief with conservative treatment are evaluated for pain management techniques. Surgery is offered to a very few patient's; as a last resort. Each patient is evaluated on his own merits and the surgery most suitable for his condition is suggested. Most of the surgical procedures carried are Minimally Invasive and patients have a very short hospital stay.


This information is for educational purposes only and should not be relied upon as medical advice. It has not been designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient.

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