Does Disc Degeration lead to Herniation?

Bone Joint J. 2013 Aug;95-B(8):1127-33. doi: 10.1302/0301-620X.95B8.31660.

Do intervertebral discs degenerate before they herniate, or after?

Lama P1, Le Maitre CL, Dolan P, Tarlton JF, Harding IJ, Adams MA.

The belief that an intervertebral disc must degenerate before it can herniate has clinical and medicolegal significance, but lacks scientific validity. We hypothesised that tissue changes in herniated discs differ from those in discs that degenerate without herniation.

Tissues were obtained at surgery from 21 herniated discs and 11 non-herniated discs of similar degeneration as assessed by the Pfirrmann grade. Thin sections were graded histologically, and certain features were quantified using immunofluorescence combined with confocal microscopy and image analysis. Herniated and degenerated tissues were compared separately for each tissue type: nucleus, inner annulus and outer annulus.

Herniated tissues showed significantly greater proteoglycan loss (outer annulus), neovascularisation (annulus), innervation (annulus), cellularity/inflammation (annulus) and expression of matrix-degrading enzymes (inner annulus) than degenerated discs. No significant differences were seen in the nucleus tissue from herniated and degenerated discs.

Degenerative changes start in the nucleus, so it seems unlikely that advanced degeneration caused herniation in 21 of these 32 discs. On the contrary, specific changes in the annulus can be interpreted as the consequences of herniation, when disruption allows local swelling, proteoglycan loss, and the ingrowth of blood vessels, nerves and inflammatory cells. In conclusion, it should not be assumed that degenerative changes always precede disc herniation.

Lumbar Spinal Manipulation and Improved Range of Motion

Spine J. 2014 Mar 6. pii: S1529-9430(14)00239-3. doi: 10.1016/j.spinee.2014.02.038.

Lumbar motion changes in chronic low back pain patients.

Mieritz RM1, Hartvigsen J2, Boyle E3, Jakobsen MD4, Aagaard P5, Bronfort G6.

Several therapies have been used in the treatment of chronic low back pain, including various exercise strategies and spinal manipulative therapy. A common belief is that spinal motion changes in particular ways in direct response to specific interventions, such as exercise or spinal manipulation.

The purpose of this study was to assess changes in lumbar region motion over 12 weeks by evaluating four motion parameters in the sagittal plane and two in the horizontal plane in LBP patients treated with either exercise therapy or spinal manipulation.

199 study participants with low back pain of more than six weeks' duration who had spinal motion measures obtained before and after the period of intervention. Lumbar region spinal kinematics sampled using a six-degree-of-freedom instrumented spatial linkage system.

Trained therapists collected regional lumbar spinal motion data at baseline and at 12 weeks follow up. The lumbar region spinal motion data were analyzed as a total cohort and relative to treatment modality (high-dose, supervised low-tech trunk exercise, spinal manipulative therapy, and a short course of home exercise and self-care advice).

For the cohort as a whole, lumbar region motion parameters were altered over the 12-week period, except for the jerk index parameter. The group receiving spinal manipulation changed significantly in all, and the exercise groups in half, the motion parameters included in the analysis. The spinal manipulation group changed to a smoother motion pattern (reduced jerk index) while the exercise groups did not.

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