By Dave Emond
Doctor: “So we had a look at your x-rays, and it looks like you have degenerative disc disease”.
Patient: “Uh oh, what does that mean?”
Doctor: “Well your discs and vertebrae have been progressively degenerating because of the way you move. This is why you have pain, and it will probably cause even more issues down the line”.
Patient: “So I have a disease, I will always be in pain, and I’m never going to be the same again”.
Ok, so this might seem like an exaggerated dialogue, but it isn’t too far from the truth of what is said in certain healthcare settings. So let's take a deep dive into why we may need to revisit how we frame our diagnoses.
Where does the diagnosis “degenerative disc disease” come from? From a general perspective, there are changes that occur in our joints as we age. You may be more familiar with the term “arthritis” which is often used as a broad term. If we look at the definition of “degeneration”, it is a word used “to characterize progressive and irreversible deterioration and loss of function”. We should explore this a little more.
Photo courtesy of Johns Hopkins Medicine
As we load our joints and tissues, our bodies adapt. So the extra bone we see on an x-ray, or flattened discs we see on an MRI are our body’s attempt at adapting to make us more resilient for future activities. From a mechanical and physiological perspective, load is required for our body to grow and adapt.
It is important to note, the popular narrative of “doing more activity causes arthritis” isn’t always true (1). There is some literature that tells us the prevalence of arthritis or degeneration of tissues may be correlated with increases in sedentary lifestyles - or better put - a lack of physical activity (2). That being said, a lack of movement won’t necessarily lead to arthritis either, but our joints are made to move. This doesn’t change with age, or with x-ray results. So avoidance of movement when given a scary diagnosis like “degenerative disc disease” might not be our best option.
But I digress. There are many factors that may lead to the changes we see in our joints on a radiographic image, but at the end of the day, they are what they are - age related changes. This means these findings are normal, and to be expected. They are not associated with pain or disability. Could they be a cause? Maybe, but it is tough to be certain.
Many asymptomatic individuals (meaning no back pain or disability) have these “age related changes”. A systematic review by Brinjikji et al (3) revealed some interesting statistics on the relationship of back pain, and the chance of finding changes on a patient’s medical image. Let’s have a look at the pertinent findings:
Disc degeneration:
37% of individuals without any history of low back pain showed “disc degeneration” on their medical imaging by the age of 20
The number jumped to 52% (yes, half the population) by the age of 30
The numbers continued to increase in relation to age and reached as high as 96% of individuals by the age of 80
Remember: All of these people with “degenerative discs” have never had any back pain
Disc bulge:
The numbers once again ranged from 30% (20yo) to 84% (80yo)
I remind you, these people have never had back pain
Disc protrusion (herniation):
29% of individuals by 20 had a disc herniation on their MRI
These numbers raised slowly with age, as high as 43% of the population aged 80
Disc protrusions are not as common to see, and in some cases may spontaneously disappear (4)
This is your per-minute reminder that none of these individuals ever had any back pain
What should we be taking away from this study? These individuals might have funky looking x-rays or MRIs, but they’ve never had any issues with back pain, or had any disabilities associated with back pain. They function just fine. And if they develop pain down the line, we can’t attribute it to their images.
Let's revisit the original definition of “degenerative”. If you asked the participants of this study, they would likely tell you they have not “deteriorated”, and are not dealing with a “lack of tissue function”.
Now, we can’t ignore the obvious. What about people who are in pain? Well, the Brinjikji group has a second part to this study and looked into the imaging in individuals with pain. People with low back pain tend to have more image findings than those who don’t (5). This makes the waters a little murkier, but based on the first part of the study, we still aren’t sure if we can attribute the pain to said findings, when they are commonly found in a pain free population.
So I will now ask 2 questions:
What can a patient/person learn from this?
What can a healthcare practitioner learn from this?
As a person, you are much more than your x-ray. You are more than a joint, or a muscle or a body part. If you are diagnosed with something along the lines of “degenerative disc disease”, recognize that your imaging report could have had very similar findings 10 years prior. You might be dealing with common, self-resolving, non-specific low back pain (which lies outside of the 8-15% of back pain that can be attributed to a specific pathoanatomical diagnosis) (6). Your outlook is, more often than not, good.
As a healthcare practitioner, we need to drop the negative, scary, language when we’re educating a patient on the potential causes of their pain. Let's avoid using words like “degenerative”, “wear and tear”, or “weakness”. This sort of language can cause fear, self-doubt and can feed back into the sedentary activity cycle. We need to set our patients up for success through empowerment, and get them exercising again to return to their normal functional levels.
These are normal, age-related changes. These image findings are not associated with the true definition of degeneration, and this isn’t a disease. So maybe it’s time to ditch the “degenerative disc disease” diagnosis. To paraphrase Jordan Feigenbaum, “saying you have degenerative disc disease, is similar to telling someone with wrinkles they have degenerative skin disease”.
References:
Chakravarty EF, Hubert HB, Lingala VB, Zatarain E, Fries JF. Long distance running and knee osteoarthritis: a prospective study. American journal of preventive medicine. 2008 Aug 1;35(2):133-8.
Song J, Lindquist LA, Chang RW, Semanik PA, Ehrlich-Jones LS, Lee J, Sohn MW, Dunlop DD. Sedentary behavior as a risk factor for physical frailty independent of moderate activity: results from the osteoarthritis initiative. American journal of public health. 2015 Jul;105(7):1439-45.
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology. 2015 Apr 1;36(4):811-6.
Splendiani A, Puglielli E, De Amicis R, Barile A, Masciocchi C, Gallucci M. Spontaneous resolution of lumbar disk herniation: predictive signs for prognostic evaluation. Neuroradiology. 2004 Nov 1;46(11):916-22.
Brinjikji W, Diehn FE, Jarvik JG, Carr CM, Kallmes DF, Murad MH, Luetmer PH. MRI findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls: a systematic review and meta-analysis. American Journal of Neuroradiology. 2015 Dec 1;36(12):2394-9.
O'Sullivan P. It's time for change with the management of non-specific chronic low back painBritish Journal of Sports Medicine 2012;46:224-227.