Degenerative Disc Disease, DDD

Segmental motion pain (SRS) refers to a specific mechanical pain condition in the back. One should not therefore confuse it with a normal, non-specific lumbar spine pain. The condition has previously been called chronic disogenous lumbar (KDL) and in English Degenerative disc disease (DDD).

All of these terms describe the same condition. A pain condition in the back that has a mechanical origin.

The pain was triggered mainly in the front part of the movement segment itself, ie. disk.
The pain can also be triggered by the posterior part, ie. e.g. facet.
The pain can also come from degenerative back disorders in the area, for example. disc herniation or spinal stenosis.
Common with SRS about parents had pronounced back problems
Smokers are over-represented among SRS patients
8 out of 100,000 inhabitants / year are operated for SRS
Speaks for and against SRS
Speaking for SRS:
Localized lumbar pain / lumbar soreness in the middle line
Mechanically triggered pain (location dependent)
A heavily localized disk degeneration – preferably only in one level
Modic changes – ie. edema of the bone adjacent to the degenerate disc
Speaks SRS:
General pain or pain in a large area
Absence of variety of pain or in a large area
Absence of variation of the pain due to posture
Semi-sided pain
Excessive pain reactions during examination and various repetitive results
Small or no disk degeneration
General degenerative changes
SRS disk and pain
SRS is only used when talking about a pain condition in the lumbar spine. Similar conditions can occur in the other parts of the vertebrae, but you usually do not get the same type of symptoms.

One does not know for sure why a degenerate disk gives pain. It is believed that this is because the sensory innervation of the disc’s outer casing signals pain. The sensitivity of the disk is usually compared to the femur of the narrow bone. You have so far three different theories as to why you get SRS and you think that these theories work together.

Theory 1 – Declaration of pain SRS:
Lowered liquid content in the counter
Reduced disk height (in the long term can lead to facet joints not matching each other and this leads to osteoarthritis in the long run)
Changed movement pattern due to reduced liquid content and dish height

Changed pattern of movement is detected by the nerves in the outer cover of the disk
Increased registration of the changes is interpreted as pain
Theory 2 – declaration of pain SRS:
Disk degeneration leads to cracking
Along the crack formation, small blood vessels grow into the disk
Small nerves can grow in with the blood vessels into the counter
They grow the nerves and can signal pain from the disk
Theory 3 – Declaration of pain SRS:
It has been possible to see that the end plate (the vertex of the vertebrae against the disc) can cause pain
Symptoms of SRS
It has been seen that patients have very different pronounced pain conditions. Everything from intermittent back pain that is mechanical and well-functioning to patients who have continuous pain and are greatly affected.

You usually get pain that comes in the forest. During the actual forest, the patient has more severe back pain. The patient usually describes it as a back shot and it usually later turns into a more cohesive pain. The pain is often also experienced as a dull pain in the lumbar spine that can be relieved and completely disappear in certain positions. The pain can often be provoked by static work / strain, sitting and standing. Unloading can often be when the patient lies down on the back or on the side and reduces the lumbar spine.

General pain symptoms at SRS
Pain coming in forest
The pain is described as a back shot
The pain is perceived as dull pain around the lower back
The pain can often be relieved in certain positions and especially when the lumbar spine is reduced.
The pain is provoked by static work and strain

Cutting sharp pain during rapid and uncontrolled movements
Fatigue feeling in the lumbar spine and tension in the back and seat muscles
Bone symptom at SRS
Nerve cleavage of a disc hernia that gives radiance in the legs
Nerve compression due to a spinal stenosis that produces radiance in bone
Referred pain that can occur in both legs
The pain in the legs can sometimes change side
Typical of SRS is that the leg pain is weaker than the back pain itself
The pain in the legs is rarely according to the dermatoma, unlike the nerve that has come into being. The pain in the legs can cross several dermatomas and sometimes it can also be as ”pain spots”.

The pain can be experienced along the entire leg next to the actual bipolar
Numbness sensation with altered sensation in the leg with a subjective feeling of swelling.
No perceived muscle power but the legs can give way due to the pain.
Abdominal symptoms at SRS
1/4 experience varying degrees of abdominal symptoms
Pain radiation to one or both groin (often the same groin as the bone radiations are in)
Disturbed bladder function – many feel that they have to empty their bladder often, have to sit down and relax for a long time to be able to empty their bladder. Often have to go toa several times because of difficulty with emptying.
Some patients have to use catheters to drain. One usually finds no bargain at the examination but one believes that the balance between relaxation of the pelvic floor and contraction of the bladder muscle is disturbed due to pain.
SRS can be mistaken for Cauda equina due to the abdominal symptoms.
Erection and orgasm can be made more difficult by SRS.
In the investigation one often finds an interspinal tenderness in one or more segments. There should be a clear difference between where the interspinal tenderness and other segments. You can test the interspinal tenderness by having the patient lie down with raised legs. The therapist gives a definite pressure interspinal level for level. The reason for doing this is because it is easy for the segment segments to spring against.

One can also see in a clinical examination that the patient has a reluctance or pain at an extension of the back. Often they only want to make a short extension movement. Lateral reflections are usually not a problem as long as they do not have to perform it at a high speed, then it can pain and chop in the back. Bending forward is usually no problem down, but on the way up, they may want to relieve their hands and often make the movement slow.

The therapist can also push against the patient’s crista edges as the patient stands up. If stabbing pain occurs, it strengthens suspicion of SRS.

Interspinal palpation pain
Reluctance or inability to extend the lumbar spine due to pain
Rapid lateral inflexions produce stabbing pain
Therapist presses over the patient’s crista edges
X-ray examination – SRS
At SRS there is no specific X-ray finding. This has been a problem for the diagnosis of SRS to be accepted.

Plain X-ray
You can see through the X-ray if the patient’s mechanical pain instead depends on eg. and spondylolists. One can also see if there are lowered disks, deposits on the vertebral body or different types of slips of the vertebrae (degenerative list, side sliding, translation).

Looking for:

Lowered disk height
Magnetic Resonance (MR)
An MRI is very good at checking the disc degeneration and is usually necessary to determine an SRS. What one is trying to see on an MRI is how well the degenerated disk is (black disk), lowered liquid content in the disk, lowered disk height, modic changes. Are these changes visible and there is some relationship to the disk.

Looking for:

Degenerate disk
Lowered liquid content in the counter
Lowered disk height
Modic changes
Natural Process
There are currently not so many studies on natural processes and SRS. You have so far been able to see that the pain decreases with age. It is believed that this is because the degenerative changes can sometimes heal the pains and the aches thus decrease or completely cease. Often the disc degeneration becomes so pronounced that the vertebrae eventually grow together, also called spontaneous fusion. One has previously thought that the aches tend to be gone within 5-10 years, but it has been seen that it often takes longer than that and that the degeneration can also take place in another area and thus get pain in a new place.

Conservative treatment
As SRS is seen as a mechanical pain condition, it tries to strengthen the local mechanical strength. This is done by training the small back muscles, the multifids and the oblique abdominal muscles (transversus abdominis). It is believed today that these are important for stabilizing the lumbar spine mechanically and it is believed that by strengthening these, it will be able to compensate for the lack of function in the segment or reduce the pain.

One also tries to reduce the provocative factors such as unnecessarily heavy or biomechanically less good load. Reduce static load and try to get the patient to reduce his sedentary over time. If the patient smokes then they also try to stop it, as it increases the disk degeneration.

You also go through various coping strategies to be able to handle their pain better and, above all, reduce or counteract any movement loss. A movement injury usually does not reduce the symptoms regardless, but usually leads to tense and stiff muscles, which in turn gives pain.

Traction has also been able to see a good effect from the treatment of SRS. However, the result is usually short-lived and the pain comes back either immediately after the actual traction is completed or that one can get a residual effect – unclear how long.

In some cases, analgesics may have to be used to reduce the patient’s pain. One should try to avoid treating with ”drugs” with habituation risk and instead use NSAIDs.

Centrally acting analgesics together with anti-inflammatory drugs are often as far as possible with SRS patients.

Stabilizing exercise
Reduce static and heavy load
Try to be physically active in everyday life
Coping strategies
Stop smoking
Analgesics – Attempt to stick to NSAIDs
Surgical treatment
Surgical treatment is the last option when neither natural course nor conservative treatment worked well enough. Ideally, you want the patient’s lifestyle to be so on the passport that is up that operation is considered the last resort. In an operation, it is important to emphasize that the patient may not be quite good but only better. One should try to avoid incorrect expectations in order to minimize the risk of disappointment.

Set operation – fusion
In the case of a rig operation, it is desired that the mobility should completely cease between the vertebrae operation and the movement segment itself. It can be anything from one segment to several. You use screws, braces or plates to lock the vertebrae together during the healing process. This is called instrumentation and is necessary to improve bone healing. It has also been seen that instrumentation makes the healing process faster and that one does not even need corset. Postoperatively, it is important to be able to mobilize the patient to reduce complications and an instrumented fusion is therefore the most common method today.

After a rig operation, there is an increased risk of being able to get pain and other symptoms in segments adjacent to the rig operation. This is called ”Adjacent segment disease”. About 20% of all patients undergoing surgery receive symptomatic pain. It is important to keep in mind that the patients who were operated on have previously had painful degenerative changes. It has been seen that this ”Adjacent segment disease” often occurs where a rig operation occurs over more levels than three. The reason for this is that so much movement is locked that the load on the above as well as underlying vertebrae increases. The spine causes fewer vertebrae to perform the same movement.

Disk prosthesis – Total disc replacement
Disk prostheses have existed since the 1970s with varying results and different types of materials. The problem with disc prostheses is often that the ”pillows” themselves are not left in the desired location or that they sink into the leg.

Result SRS and surgery
In a study at Spine center in Stockholm, a 1-2 year follow-up saw that:

65-75% of patients reported ”painless” or ”much better”.
15-20% of patients stated ”slightly better”
In a study 18 years ago (Fritzell, 2001) stated

29% that they have become painless or much better.
It is believed that the improvement of the result is due to the fact that one is better at today

Select suitable patients
The surgical technique improved
The implants have been developed
The rehabilitation is today more ambitious