Degenerative disc disease

In one minute

Degenerative disc disease is the medical name for discs that have dried out, lost height and developed cracks with age. It is not really a disease: on MRI (magnetic resonance imaging) it is present in about a third of pain-free 20-year-olds and almost everyone over 80. In post-Soviet medicine the same findings were, and often still are, called osteochondrosis (остеохондроз), a diagnosis many adults in the region were given for back pain. Most back pain in a degenerated spine has no single identifiable source and settles with movement and time. A minority of people have a treatable cause that the degeneration produced: a herniated disc pressing a nerve, a narrowed canal, an unstable slipped vertebra. This page explains what the MRI words mean, which findings matter, and why surgery for worn discs alone is rarely the right answer.

What it is

A healthy disc is a ring of fibres around a gel core that is mostly water. With age the core loses water and its ability to hold pressure, the disc thins, the ring cracks (annular fissures), the vertebral edges grow spurs, and the facet joints behind take more load and develop arthritis. The findings are so common that a 2015 systematic review of 33 studies in 3,110 people with no back pain found disc degeneration in 37% at age 20 and 96% at 80, disc bulges in 30% and 84%, protrusions in 29% and 43%, and annular fissures in 19% and 29%. Degeneration is the background against which the specific conditions on this site occur; it is not itself a diagnosis that explains pain.

What patients were told: osteochondrosis

If you were examined in Uzbekistan, Russia or a neighbouring country, your report may read "остеохондроз поясничного отдела" and you may have been told your spine is worn out or your vertebrae are crumbling. Soviet and then post-Soviet spine medicine adopted the term as an umbrella for the whole spectrum of degenerative change and the many pain syndromes attributed to it, including reflex muscle and vascular syndromes that, as a 2012 review by Russian spine surgeons itself notes, do not fit the international classification of diseases. The international term for the same MRI findings is degenerative disc disease, and that is the term this page uses. Nobody who used the term was misleading you; it describes real MRI findings. The problem is that it lumps normal ageing, harmless findings and treatable compression into one word and then treats the word.

Causes and risk factors

Age is the dominant factor. The Lancet series on low back pain names physically demanding jobs, smoking, obesity and physical or mental comorbidity as the factors most associated with reporting back pain, and low socioeconomic status with disabling pain. The North American Spine Society (NASS) low back pain guideline lists a previous episode as a predictor of another. What the evidence does not support is the folk model of a spine worn out by sitting, by carrying children or by cold: the same MRI changes appear with age in people who have no pain at all.

How it develops

As the core loses water, the disc can no longer spread load evenly; the ring bears it instead and fissures, and the vertebral endplates (the thin plates of bone and cartilage between disc and vertebra) crack. On MRI this can show as Modic changes: type 1, a fluid-like inflammatory signal in the bone next to the endplate, and type 2, fatty replacement of that bone. Together these can produce what is called discogenic pain: a deep, central low back pain, worse with sitting and bending, without leg pain. Meanwhile the loss of height narrows the exit tunnels and loads the facet joints, and the segment may become loose or slip; those are the pathways to the conditions that can be operated on.

Symptoms

Most people with degenerated discs have no symptoms. When pain does occur, it is typically a dull, central low back ache, worse after sitting, on getting up from a chair or bending forward, and eased by walking or lying down; flare-ups lasting days to weeks separated by quieter periods are the usual course. Pain that spreads into the buttock or thigh without going below the knee is still back pain. Pain shooting below the knee, numbness or weakness means a nerve is involved and belongs on the sciatica page. Leg heaviness on walking that settles on sitting belongs on the spinal stenosis page. Back pain with long morning stiffness in a younger person raises the separate question of inflammatory spine disease, which NICE (the English guideline body) lists among the diagnoses to exclude.

Diagnosis

The task is not to find degeneration, which is a given, but to decide whether the pain has a specific source. History and examination look for the red flags above, for nerve involvement, for inflammatory features, and for what the NASS guideline recommends assessing as predictors of chronic pain: pain severity, functional impairment, and psychosocial and workplace factors.

Imaging is used sparingly. NICE advises against routine imaging for low back pain outside specialist care; the NASS guideline finds insufficient evidence that imaging findings correlate with the presence of low back pain, or that they change treatment decisions. MRI is reserved for pain that has not improved after conservative care, for nerve symptoms and for red flags.

Reading the report:

Modic changes deserve a word because they are the finding most linked with pain. A systematic review of 77 studies found them in a median of 43% of patients with non-specific back pain or sciatica and 6% of people outside clinics, with an association with pain in seven of ten studies, and it warns that they also occur in people with no pain. NASS grades as high the evidence that provocative discography (injecting the disc to see whether it reproduces the pain) correlates with moderate to severe degeneration and endplate changes, but the test is invasive and painful and its role in choosing patients for surgery is disputed.

If you send us images, include the written report and the side-view images; tell us whether the pain stays in the back or travels into the leg, and for how long it has been there.

Treatment without surgery

This is the treatment. The 2017 American College of Physicians (ACP) guideline states that most acute and subacute back pain improves regardless of treatment and recommends non-drug measures first: heat, massage, manipulation or acupuncture for a new episode, and for chronic pain exercise, multidisciplinary rehabilitation, mindfulness-based stress reduction, tai chi, yoga and motor control exercise. NICE adds a supervised group exercise programme, manual therapy only alongside exercise, and a push to return to normal activity and work; it advises against belts, traction, TENS (transcutaneous electrical nerve stimulation), ultrasound and acupuncture. NASS grades structured back school and short-term heat as effective.

Medication is second line and short: NSAIDs (non-steroidal anti-inflammatory drugs), which NICE, NASS and the ACP all list as the first-line drug, at the lowest effective dose for the shortest time in NICE's words, or muscle relaxants as an alternative for a new episode in the ACP guideline. NICE advises against paracetamol alone, opioids for chronic back pain, antidepressants and gabapentinoids; NASS finds oral steroids ineffective. The doctor decides on any course.

What the evidence does not support: injections into the disc (NASS finds intradiscal steroids give short-term improvement only in patients with Modic changes and insufficient evidence otherwise; platelet-rich plasma, bone marrow concentrate and methylene blue carry insufficient evidence), spinal injections for back pain without leg pain (NICE advises against them), and the courses of chondroprotectors, vitamin drips and machine physiotherapy that many patients in the region have already been through; none of the guidelines cited on this page recommends them. Radiofrequency denervation of the small facet joint nerves has a place when the pain is shown to come from those joints; see the facet joint syndrome page.

When surgery is considered

Surgery is considered for what degeneration produces, not for degeneration itself: a disc fragment on a nerve, a canal or foramen too tight for the root, an unstable slipped vertebra. Each has its own page and its own indications.

For back pain alone, the trials are sobering. Three randomised trials in Norway and the United Kingdom compared fusion with a rehabilitation programme of exercise and cognitive behavioural therapy in 473 patients with at least a year of back pain; at an average of 11 years the difference in disability was 0.7 points on a 100-point scale, which is no difference. NICE tells doctors not to offer fusion for low back pain outside a research trial and not to offer disc replacement. NASS found no studies able to answer whether surgery beats non-surgical care for non-specific low back pain. Fusion for a single, severely degenerated, unstable level after a year or more of proper rehabilitation is a choice some patients make with open eyes; it is not a treatment for osteochondrosis.

Surgical options

• For a herniated fragment with leg pain: endoscopic lumbar discectomy.
• For a narrowed canal or foramen: endoscopic lumbar decompression or endoscopic foraminotomy.
• For an unstable or slipping segment with pain that has resisted rehabilitation: fusion, which joins the two vertebrae with an interbody cage and screws. We perform it fully endoscopically (endoscopic lumbar fusion); open spinal fusion remains the right tool for some anatomies.
• Disc replacement: NICE advises against it for low back pain.
• Percutaneous disc procedures marketed as disc restoration (ozone, laser, nucleoplasty): no guideline cited on this page supports them.

How we treat it at spine.uz

What we say when the report says osteochondrosis

Send your MRI on Telegram or WhatsApp. The remote opinion is free; a doctor from the team replies by voice within 48 hours and tells you, plainly, whether your images show ageing that needs exercise and time or a specific problem that needs treatment. The in-person consultation and any operation are paid.

When there is a surgical target, we treat it through a 7 mm incision, most often under local anaesthesia with sedation rather than general anaesthesia; the anaesthetist and surgeon decide per patient. Decompression uses no screws or implants; fusion, where indicated, is done endoscopically with a cage and percutaneous screws. Most patients walk on the day of surgery and go home within 24 hours. We are Tashkent's first endoscopic spine team, five surgeons operating as one team, with 27,600+ endoscopic and spine operations and a complication rate well below 1% in our own series. You leave with a written team conclusion, including when the conclusion is that no operation is needed.

Recovery and outcomes

Most new episodes of back pain recover quickly; recurrence is common, and a small proportion of people develop persistent, disabling pain, with high initial pain, distress and pain at several body sites as the main predictors. In the 11-year follow-up of the fusion trials, outcomes of the rehabilitation group did not deteriorate over time, which is the strongest argument for investing in exercise rather than waiting for a final solution. Where a specific target was treated, recovery follows that condition's page.

Living with it and prevention

Move every day; the spine that is used ages better than the spine that is rested. Build strength in the hips and trunk, keep weight down, stop smoking, sleep enough, and stay at work. Do not collect MRI scans; the pictures will get worse with every decade whether or not you hurt, and knowing that is protective. Treat a flare-up as a flare-up, not as a verdict.