Patients commonly express the belief that their chronic back or neck pain is a progressive condition that will unavoidably lead to greater and greater pain and disability. They’ve been told that they have degenerative disc disease and that it is the cause of their pain. It was found on their MRI scan of the spine. Since the cause of their pain is called ‘degenerative,’ they understandably believe that it’s inevitable that they are going to get worse. Their future, it seems, holds nothing but increasing pain and impairment.
Sometimes, healthcare providers believe that degenerative disc disease is inevitably degenerative too. Commonly, patients tell me that they’ve been told by their healthcare provider that they will end up in a wheelchair someday or that the provider is surprised the patient can walk upright given the extent of the findings of degenerative disc disease that’s evident on the MRI scan. Such comments by healthcare providers seem to indicate that they too believe that degenerative disc disease is inevitably degenerative, progressively leading to a worsening of pain and disability.
What is the natural course of degenerative disc disease?
How confident should we be in this belief that degenerative disc disease is inevitably degenerative? What does science tell us about what happens to so-called degenerative changes of the spine over time? In healthcare, studies of what happens to health conditions over time when left untreated are called natural history studies. Such studies simply track a condition over time to see what its natural trajectory is– whether the condition tends to get better or worse. It would be helpful to look at natural history studies of the conditions that fall under the category of degenerative disc disease. We'd then know what the natural trajectory is for such conditions.
Degenerative disc disease is a catchall phrase for a number of conditions of the spine. These conditions are typically evident on CT and MRI scans. They are a loss of disc height, disc bulges and herniations, annular tears, endplate changes, osteophyte complexes, neuroforaminal stenosis, and central canal stenosis, among others.
Let’s look at what happens to these conditions over time. Many chronic back or neck pain patients have such degenerative changes in their spine as evidenced by MRI or CT scans and it will be helpful to know something about what typically happens to them if you have them. Contrary to popular belief, we will find that the changes to the spine that we call degenerative disc disease are not inevitably degenerative.
When patients review this research, they tend to be a little surprised. They have long thought of their condition as inevitably progressive and it can take a little bit of time to get used to the idea that their condition is not as degenerative as they had thought it to be. Moreover, they are frequently a little skeptical. One of the most common exceptions to the review of this research goes something like, ‘Well, Doc, I’ve been told that my degenerative disc disease is very severe… Severe or advanced degenerative disc disease is going to get worse. How could it not?’ That is to say, a common belief about degenerative disc disease is not only that it is inevitably degenerative, but that the more advanced it is the more progressive it will be. Another way to put it is the belief that the worst or most advanced stages of degenerative disc disease will always tend to lead to the most severe pain and disability. So, let’s review what science tells us about what happens to the most advanced or worst degenerative changes over time too.
Specifically, with our review of natural history studies of degenerative disc disease, we want to determine the answers to two questions:
- Do degenerative changes to the spine inevitably worsen?
- What happens to the most severe degenerative changes?
Natural history studies of degenerative disc disease
Symmons, et al., (1991) were some of the first investigators to look at these questions. They took X-rays of 742 women aged 45 or older and then repeated the X-rays 8 to 11 years later. They broke women into two groups, those with back pain and those without back pain. They found degenerative changes in both groups. They also found that degenerative disc disease progressed most often in those with back pain. Over the study period, they found that almost 60% of women with back pain had a progression of their degenerative disc disease; whereas, a little more than 30% of women without back pain had a progression of their degenerative disc disease. Notice, however, that progression of degenerative disc disease is not inevitable. The remaining 40% of those with back pain had degenerative disc disease that did not get worse. The remaining 70% of the women without back pain had degenerative disc disease that did not get worse.
This study relied on X-rays, rather than more accurate CT or MRI scans. Is there evidence of the same findings with CT or MRI scans?
Using MRI scans on a repeated basis, Matsubara, et al., (1995) followed 32 patients with herniated discs in their lumbar spine over the course of a year. They found that 62% of the disc herniations spontaneously reduced in size and the remaining 38% of herniations did not get worse. In this study, we see a significant degenerative disc problem – herniations – tending to get better the majority of the time. Even when disc herniations failed to get better, they did not tend to get worse. Here, we find that the disc herniations are not inevitably degenerative.
These researchers also found data that pertains to the severity of disc herniations. Contrary to the popular belief that the worst problems tend to become more problematic, they found that the larger the disc herniation, the more it reduced.
Another spinal condition that falls under the category of degenerative disc disease are endplate changes. Hutton, et al., (2011) reviewed two groups of patients with lumbar-related endplate changes who had had MRI’s repeated over time. The first group was 36 patients with a minimal level of endplate changes. The second group was 22 patients with a more advanced stage of such changes. Of the first group with less significant endplate changes, half remained the same; a little less than half got worse; and two patients reversed back to normal. Of the second group with the more advanced changes, most remained the same; some got better and none got worse.
Here again, we see two important facts about this specific type of degenerative change. First, in its least advanced stage, sometime it does get worse, but only less than half the time. Thus, we really can’t say it is inevitable that it gets worse. Second, contrary to the notion that the more severe spine problems always lead to more severe consequences, we see that the advanced stages of endplate changes generally stay the same. Sometimes it gets better, but they don’t tend to get worse.
Park, et al., (2013) found in a sample of 27 cervical spondylolisthesis patients that only three had a progressive worsening of their condition over a 2-7 year follow-up period. None of the three experienced any significant neurological injury or an increase in their symptoms as a result.
Humphreys, et al., (1998) looked at still other conditions of the spine, which are associated with degenerative disc disease. They found that foraminal stenosis did in fact narrow with age but found no progression of disc height, lordosis, or central canal stenosis. So, here again, we find that degenerative changes of the spine are far from inevitably degenerative.
Regarding the latter, Karadimas, et al., (2013) reviewed the literature on cervical spondyltic myelopathy, or a degenerative narrowing of the spinal cord in the area of the neck, and found that the condition naturally worsened in 20-60% of the cases. Again, we see a significant degenerative condition can get worse, but does not always get worse. Indeed, depending on the study, 40-80% of the time it does not get worse.
Some might counter with a subtle variation of the second question we have been attempting to review, namely that the most advanced degenerative disc disease tends to be more degenerative. They might acknowledge that degenerative disc disease itself may not inevitably become worse. They might even acknowledge that the most advanced stages of such changes don't tend to inevitably get worse. However, they might argue that the most severe degenerative changes to the spine do in fact lead to greater pain and/or a greater decline in functioning. In other words, those with the most severe degenerative disc disease will inevitably experience the greatest pain and disability.
A recent study by Berg, et al., (2013) inadvertently sheds light on this point. They were interested in looking at whether degenerative disc disease correlates with pain and disability in a sample of 170 low back pain patients who had been recommended for disc replacement surgery at either of the two lowest disc levels of the lumbar spine (i.e., L4-5 & L5-S1). Presumably, the degenerative disc disease evident at these two levels was severe enough to have the surgery recommended to them. Interestingly, they found no significant correlation at all between degenerative disc disease and either pain or disability. Even among a subgroup of people with the most severe degenerative changes (the severest of the severe), they still found no correlation. They subsequently added findings of facet arthropathy, another degenerative condition, and with the combination of degenerative disc and facet changes they still found no correlation between such changes and either pain or disability. In other words, neither more severe findings of degenerative disc disease nor a greater amount of such degenerative conditions lead to a worsening of pain or impairment. (This study highlights another interesting question to which we tend to all assume we know the answer – to what extent does degenerative disc disease explain chronic back or neck pain. This question will be taken up in our next blog post).
To summarize, we set out to determine the truth of certain common beliefs that patients have about degenerative disc disease. These beliefs are that degenerative disc disease is inevitably going to worsen, or at the very least the most severe degenerative changes are always going to get worse. By reviewing what the science tells us about degenerative disc disease, we see that neither of these beliefs are true. While degenerative changes do sometimes get worse, they often either remain the same or get better. Also, we see evidence that the worse the degenerative condition is, the more it tends to either stay the same or get better.
Has your healthcare provider ever told you or implied that degenerative disc disease was inevitably going to get worse? Why do you think that this belief continues to be common when the scientific literature doesn't support it?
Berg, L., Hellum, C., Gjertsen, O., Neckelmann, G., Johnsen, L. G., Storheim, K., Brox, J. I., Eide, G. E., & Espeland, A. (2013). Do more MRI findings imply worse disability or more intense low back pain? A cross-sectional study of candidates for lumbar disc prosthesis. Skeletal Radiology, 42(11), 1593-1602.
Humphreys, S. C., Hodges, S. D., Patwardhan, A., Eck, J. C., Covington, L. A., & Sartori, M. (1998). The natural history of the cervical foramen in symptomatic and asymptomatic individuals aged 20-60 years as measured by magnetic resonance imaging: A descriptive approach. Spine, 23, 2180-2184.
Hutton, M. J., Baker, J. H., & Powell, J. M. (2011). Modic vertebral body changes: The natural history as assessed by consecutive magnetic resonance imaging. Spine, 36, 2304-2307.
Karadimas, S. K., Erwin, W. M., Ely, C. G., Dettori, J. R., & Fehlings, M. G. (2013). Pathophysiology and natural history of cervical spondyltic myelopathy. Spine, 38(22S), S21-S36. doi: 10.1097/BRS.0b013e318a7f2c3
Matsubara, Y., Kato, F., Mimatsu, K., Kajino, G., Nakamura, S., & Nitta, H. (1995). Serial changes on MRI in lumbar disc herniations treated conservatively. Neuroradiology, 37, 378-383.
Park, M. S., Moon, S. H. Lee. H. M., Kim, S. W., Kim, T. H., Suh, B. K., & Riew, K. D. (2013). The natural history of degenerative spondylolisthesis of the cervical spine with 2-7year follow-up. Spine, 38(4), E205-E210. doi: 10.1097/BRS.0b013e1827de4fd
Symmons, D. P., van Hemert, A. M., Vandenbroucke, J. P., & Valkenburg, H. A. (1991). A longitudinal study of back pain and radiological changes in the lumbar spines of middle aged women. II. Radiographic findings. Annals of the Rheumatic Diseases, 50, 162-166.
Date of last modification: 3-10-2014
Author: Murray J. McAllister, PsyD