Written and peer-reviewed by physicians—but use at your own risk. Read our disclaimer.

banner image

amboss

Trusted medical answers—in seconds.

Get access to 1,000+ medical articles with instant search
and clinical tools.

Try free for 5 days

Degenerative disc disease

Last updated: January 19, 2021

Summary

Degenerative disc disease refers to a variety of pathologies involving displacement of disc material into the spinal canal, such as protrusion, herniation, and sequestration. Degenerative disc disease results in mechanical compression of either the spinal cord or a nerve root. The most common symptoms of disc disease are radicular pain in the dermatome of the compressed nerve root, muscle weakness, and loss of deep tendon reflexes in the indicator muscles. The location of the lesion can often be determined using the patient's neurological deficits. In most cases of lumbosacral disc disease, L5 nerve compression is present, which leads to reduced sensitivity in the lateral leg, dorsum of the foot, and weakness in extending the big toe. A protruded/herniated disc on MRI confirms the diagnosis. Conus medullaris syndrome and cauda equina syndrome are severe forms of disc herniation that may present with paresis, sensory deficits, and urinary and bowel incontinence. They require urgent decompression via surgical intervention. Most spinal disc herniations, however, can be treated conservatively with analgesia and by maintaining physical activity.

Definition

Epidemiology

  • Age: most common at 30–50 years
  • Sex: > [1]
  • Approx. 80% of all Americans suffer from significant back pain at some point in their lives. [2]
  • Disc herniation is the cause of back pain in roughly 5% of cases.

Epidemiological data refers to the US, unless otherwise specified.

Pathophysiology

Clinical features

General clinical features

A sudden decrease in pain concomitant with an increase in the degree of paralysis can be a warning sign of neuronal death.

Common radiculopathies

Overview of radiculopathies
Radiculopathy Level of lesion Sensory deficits Motor deficits Reduction of reflexes
C3/4 radiculopathy
  • C2–C4
  • Shoulder and neck area
  • None
C5 radiculopathy
  • C4–C5
C6 radiculopathy
  • C5–C6
  • From upper lateral elbow over radial forearm up to thumb and radial side of index finger
C7 radiculopathy
  • C6–C7
  • Palmar: fingers II–IV (II ulnar half, III entirely, IV radial half)
  • Dorsal: medial forearm up to fingers II–IV
  • Triceps and wrist flexors, finger extensors
C8 radiculopathy
  • C7–C8
  • Finger flexors
  • None
L3 radiculopathy
  • L2–L3
L4 radiculopathy
  • L3–L4
  • Extending from distal anterolateral thigh area over patella up to inner side of lower leg
L5 radiculopathy
  • L4–L5
  • Lateral sides of thigh and knee, anterolateral lower leg, dorsum of foot, big toe
S1 radiculopathy
  • Dorsolateral thigh, dorsolateral lower leg, lateral foot

S2 radiculopathy, S3 radiculopathy, S4 radiculopathy

  • Posterior aspect of thigh and lower leg (S2), perineum (S3S4), perianal (S4)
  • None

Subtypes and variants

Spinal cord compression

Other types of degenerative disc disease

Overview of conus medullaris syndrome and cauda equina syndrome
Syndrome Etiology Onset Pain Motor symptoms Sensory symptoms Urogenital and rectal symptoms
Conus medullaris syndrome
  • Sudden, bilateral
  • Symmetric, bilateral perianal numbness
  • Sensory dissociation
Cauda equina syndrome
  • Damage to or compression of the cauda equina with nerve fibers of L3–S5 (below L2)
  • Gradual, unilateral
  • Saddle anesthesia: lack of sensitivity in the dermatomes S3–S5, affecting the areas around the anus, genitalia, and inner thighs (may be asymmetric)
  • Asymmetric, unilateral numbness and/or paresthesia in lower limb dermatomes

Conus medullaris syndrome and cauda equina syndrome are medical emergencies requiring immediate surgical intervention.

References:[5][6]

Diagnostics

Differential diagnoses

Differential diagnoses of low back pain

Differential diagnoses of low back pain
Common etiologies Typical features Diagnostics Therapy
Musculoskeletal Muscle strain (most common cause of lower back pain)
  • Acute back pain and paravertebral stiffness and difficulty bending after physical exertion (e.g., heavy lifting)
  • No loss of sensory or motor function
  • Straight leg raise test negative
  • Percussion: tenderness over lumbar spine
  • Negative straight leg-raising maneuvers
Spinal stenosis
Spinal disc herniation
  • Conservative
    • Activity continuation, no bed rest
    • NSAIDs
  • Surgical decompression: in case of severe/progressive neurologic deficits
Degenerative spondylolisthesis
Vertebral fractures
  • History of injury
  • Local pain on pressure, percussion, and compression
Malignancy

Bone metastases (extradural metastatic lesions)

Less commonly: intramedullary tumors (e.g., multiple myeloma, ependymomas, astrocytomas, metastases) and intradural-extramedullary (e.g., meningiomas, nerve sheath tumors)

  • MRI (urgent if spinal compression is suspected)
Infectious Spinal epidural abscess
Inflammatory Ankylosing spondylitis
  • Pain mostly at rest
  • Improves with activity
Reactive arthritis
Psoriatic arthritis
Others Abdominal aortic aneurysm
  • Ultrasound (also for follow-up)
  • CT (in case of rupture)
  • Open or endoscopic grafting (tube or Y-prosthesis)
Cauda equina syndrome
  • Surgical decompression
Spinal epidural hematoma
  • Surgical decompression to avoid permanent neurologic dysfunction (laminectomy and evacuation of blood)

Acute spinal cord compression is a medical emergency. Conduct an MRI or CT myelography immediately and decompress the cord via IV steroids and/or surgery as soon as possible.

The differential diagnoses listed here are not exhaustive.

Treatment

Conservative treatment

Up to 80% of all disc herniations are self-limiting and usually resolve within 4 weeks.

Surgical treatment

References

  1. Wang Y-XJ, Griffith JF, Zeng X-J, et al. Prevalence and Sex Difference of Lumbar Disc Space Narrowing in Elderly Chinese Men and Women: Osteoporotic Fractures in Men (Hong Kong) and Osteoporotic Fractures in Women (Hong Kong) Studies. Arthritis & Rheumatism. 2013; 65 (4): p.1004-1010. doi: 10.1002/art.37857 . | Open in Read by QxMD
  2. Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain.. Arch Intern Med. 2009; 169 (3): p.251-8. doi: 10.1001/archinternmed.2008.543 . | Open in Read by QxMD
  3. Bhandutia AK, Winek NC, Tomycz ND, Altman DT. Traumatic Conus Medullaris Syndrome. JBJS Case Connector. 2016; 6 (2): p.e38. doi: 10.2106/jbjs.cc.15.00208 . | Open in Read by QxMD
  4. Brouwers E, van de Meent H, Curt A, Starremans B, Hosman A, Bartels R. Definitions of traumatic conus medullaris and cauda equina syndrome: a systematic literature review. Spinal Cord. 2017; 55 (10): p.886-890. doi: 10.1038/sc.2017.54 . | Open in Read by QxMD
  5. Eisen A, Aminoff MJ, Wilterdink JL. Anatomy and Localization of Spinal Cord Disorders. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/anatomy-and-localization-of-spinal-cord-disorders.Last updated: November 18, 2015. Accessed: July 11, 2017.
  6. Schiff D, Brown P, Shaffrey ME, DeAngelis LM, Eichler AF, Savarese DMF. Treatment and Prognosis of Neoplastic Epidural Spinal Cord Compression, including Cauda Equina Syndrome. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/treatment-and-prognosis-of-neoplastic-epidural-spinal-cord-compression-including-cauda-equina-syndrome.Last updated: June 27, 2017. Accessed: September 14, 2017.