We see a lot of people with acute low back pain in our clinic, in fact low...
'Wear and Tear' on the spine
Many people who have back pain arrive at our practice after being told by their doctor that they have ‘wear and tear’ in their spine, or that it’s because ‘it’s part of getting older’. Often they will have had an x-ray or a MRI showing that ‘some of the discs in the back are wearing out’. In this posting we will tell you what this means, why it happens and what to do next.
The intervertebral discs and vertebrae form the principle joints in your spine, at each level of the spine there is one intervertebral disc and two ‘facet joints’. Their structure and their relationship are designed to allow the spine to move and to cope with the loads we place on our backs over the course of a lifetime (1). Each disc is made up of three elements;
- Nucleus propulsus – this is the more fluid centre of the disc, it is said to have the consistency of toothpaste. It’s main function is to dissipate force by its fluid nature, a bit like a water balloon if you squeeze it then it will move in any direction.
- Annulus fibrosis – this part of the disc is made up of tough collagen fibres, precisely arranged in ways to resist the pressures placed upon it by the movement of the nucleus proplusus.
- Vertebral endplate – these form the top and bottom of the disc and are mostly cartilage, they are extremely tough and are the barrier between the nucleus and the vertebrae.
Only the outer few millimetres of the annulus has nerves that transmit sensation and pain. (1, 2). As we get older the vast majority of us begin to show changes in these structures, leading to a change in how they perform their tasks. The nucleus of the disc becomes less fluid, elastic and ‘spongy’, changes to its structure make it much ‘drier’ and therefore less able to cope with the forces exerted upon it. This results in the annulus having to take up more of the strain, resulting in damage. This damage creates ‘fissures’ in the annulus allowing the nucleus to move more freely to exert pressure on the outside of the disc (where the nerves that transmit pain are located), this is how ‘bulging discs’ occur. These changes also lead to an increase in the amount of pain producing nerves around the disc. (3). The facet joints also show changes, they begin to lose their cartilage and instead deposit bone to compensate, this is the process that leads to osteoarthritis in various joints of the body.
These changes are often referred to as ‘degenerative joint disease’, however the changes seen are actually the body reacting and adapting to the stresses exerted upon it over the course of our lifetime (1, 2). It would be natural to assume that if you have more of the changes described above then this would correlate to more pain and dysfunction. However this is not the case, the same structural changes are seen in people with and without pain with the majority of people showing the changes by the time they reach 50 (4). This means that if you have back or neck pain and your x-ray or MRI shows that there is some bony change in your spine it may not be the cause of the pain. These changes do however lead to stiffness and a reduction in the range of motion of the spine, which even if you are not in pain may be quite a hindrance to daily tasks. Manual therapy such as osteopathy, coupled with carefully prescribed exercise advice can help with this type of problem.
What is not a natural adaption to getting older is a loss of disc height, however this is commonly described as being so when found on MRIs. The disc only loses height due to a chemical change (usually seen after damage to the endplate) resulting in the nucleus being unable to retain water, this means the fluid leaks out into the annulus (causing further damage) resulting in the effect of an underinflated tyre and loss of height. This subsequently changes the way the facet joints move, making it more likely that they can become dysfunctional and painful. The increased ability of the fluid to move around means that if the correct forces are applied to the disc then it can rupture causing severe pain in the back and along any nerve that is affected by the rupture. If this type of change was to do with aging then it would be seen in a more general pattern in the spine, however it is not uncommon to see this in only one or two discs in the back (1). As this is type of problem is generally a localised one it often shows improvement from manual therapy such osteopathy (5).
What is our experience as osteopaths? In our clinic we commonly see patients who have back pain, they then get a MRI or an x-ray which shows ‘wear and tear’ or ‘worn discs’ and are told that it is just part of aging, and to accept it. Often this is not the full picture and can lead to an incorrect assumption that nothing can be done. We find it to be much more productive to take an individualised approach to each case, considering the person’s age, occupation, previous injuries etc. This, coupled with a thorough physical examination and the results of the x-ray/MRI can lead to a much clearer picture of what may be done to reduce the pain and return the person to normal activities. Often our patients acheive a full recovery or at the very least we can control their pain through manual treatment, exercise and advice specific to their situation.
In cases where there is significant structural changes in the spine it is commonly possible to alter the function of the the unaffected areas, such as the midback, hips etc and acheive a reduction in pain levels and increased movement. Each patient's situation is different, only after a thorough assessment is it possible to know what the best course of action may be.
Do you want to know what is causing your pain and if we can help? Why not take advantage of our new patient consultation introductory offer to get you started towards a tailor made recovery plan for only £19.
Are you in a lot of pain and want to get better as soon as possible? If so the why not book in for a new patient consultation, with treatment on the day, for £60.
1 - Bogduk, N., (2005). Clinical anatomy of the lumbar spine and sacrum. 4th ed. New York: Churchill Livingstone.
2 - Levangie, P. and Norkin, C. (2005). Joint Structure and Function: A Comprehensive Analysis (4th ed). F. A. Davis, Philadelphia.
3 – Urban, J., Roberts, S., (2003). Degeneration of the intervertebral disc. Arthritis Research and Therapy, 5(3), pp120-130.
4 – Brinjikji, W. et al (2014). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Available at; http://www.ajnr.org/content/36/4/811.
5 - Choi, J et al (2014). The Effects of Manual Therapy Using Joint Mobilization and Flexion-distraction Techniques on Chronic Low Back Pain and Disc Heights, available at; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4155230/