Archives October 2021

The spinal discs are designed to meet the structural and dynamic needs of the spine. Discs are strong enough to manage multiple planes of motion. The disc has several functions, including serving as an integral part of the joint at each spinal motion segment.

Over time, spinal discs tend to undergo complex structural, mechanical, and chemical changes and may become a source of pain. Even slight changes of disc nutrition and motion may cause a healthy, pristine disc to begin degenerating.

Aging may make the spinal disc more rigid and flat. As the structure changes, the disc becomes more susceptible to becoming a source of pain. Most people over 60 years old will have degenerative changes in the discs, but only a very small percent of people will experience pain. This article explains the process of disc degeneration.

Spinal Disc Anatomy and Function

Each spinal disc is one part of each of the motion segments that run along the length of the spinal column. The discs act as shock absorbers between the bony vertebral bodies; the flexibility of the discs allows the spine to resist multiple planes of motion created by various types of forces.

The intervertebral disc is comprised of a series of fibrous bands that form a tough outer layer and soft material with toothpaste consistency that forms a soft inner layer.

Annulus fibrosus

The disc’s outer layer is called the annulus fibrosus, named for the fibrous tissue that composes the layer. The fibers and water content of the annulus fibrosus exist in gradients. From the outer edge moving inwards, collagen type I fiber content decreases while protein and water content increases.

Nucleus pulposus

The inner material contained in the disc is called the nucleus pulposus, named for the pulp-like or gel-like soft consistency of this layer.

Blood supply to the spinal disc

Blood vessels that supply nutrients to the disc lie in the endplates above and below it, rather than penetrating the disc itself. Low blood supply limits nutrient delivery and slows the immune system response, particularly to tissues and cells damaged by age or injury.

Nerve endings in the spinal disc

In a healthy disc structure, nerves to the disc space only penetrate into the very outer edge of the annulus fibrosus.

If a tear in the annulus fibrosus reaches the outer edge, the nerves there can become sensitized and cause significant spine pain. With continued degradation, the nerve fibers on the periphery of the disc will actually grow further into the disc space. The growth of nerves may be associated with pain from a degenerating disc.

If the nucleus pulposus, which contains a great deal of inflammatory proteins, leaks out of the disc and touches a nerve root, that nerve root can become inflamed and cause pain that radiates down a leg (sciatica or lumbar radiculopathy) or down an arm (cervical radiculopathy).

Discs degenerate in several ways over time.

• Elastin fiber content increases, especially in the inner edge of the annulus fibrosus.
• Osmotic pressure needed to maintain high water content in the nucleus decreases.
• Water content decreases, from 80% at birth to as low as 66% in the sixth decade of life.
• Disc height decreases.

High water content gives the disc its spongy quality and shock-absorbing ability. With age and degeneration, the disc gradually loses its ability to absorb shock and its flexibility.

Other characteristics of aging, dehydrating disc include:

• Yellowing of the nucleus pulposus
• Small fractures in the adjacent bones
• Thickening of the adjacent bones
• Thinning of the cartilaginous endplates
• Fewer blood vessels in the endplates

As the blood vessels that serve the disc decrease in number, the build-up of cellular waste grows. The build-up in the disc can decrease pH to as low as 6.3, making the interior of the disc more acidic and risking further cellular damage with age and with stress.

The degenerating disc can cause structural changes nearby, such as the narrowing of a nerve pathway which causes spinal stenosis and may result in radicular pain.

Degenerative Disc Disease Pain

While disc degeneration does not necessarily cause pain, research has shown that disc degeneration is strongly associated with cases of low back pain. Pain may be debilitating in nature and restrict mobility.

Disc pain may be caused by several factors acting simultaneously, usually involving nerves that penetrate deep into the disc’s outer edge or involving the instability of the disc after an injury.

• Inflammation. The proteins in the disc interior cause inflammation if they come into contact with nearby muscles, joints, and nerve roots. Inflammation can cause pain, increased muscle tension, muscle spasms, and tenderness around the affected disc, as well as sharp, shooting pains in the leg or in the arm if a nerve root is affected (sciatica, or cervical radiculopathy respectively.)
• Disc space collapse. Decreasing disc height and water content place undue strain on the joints and muscles that support the vertebrae. In some cases, a collapsed disc space can cause a nerve root to become pinched or irritated, leading to pain in the arm or leg.
• Excessive micro-motions. Decreased cushioning and support from the disc may lead to a relative increase in motion between two vertebrae. This excess motion typically causes muscle spasms and pain may irritate the joints and nerve roots and can result in the formation of bone spurs.

Pain may range from mild to severe and may become worse with certain positions, such as prolonged standing or sitting, or with certain movements, such as twisting or bending the spine. The process of how a disc degenerates has been studied and is thought to follow a typical pattern that occurs over a long period of time- several years or decades.

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Sciatica is a term used to describe nerve pain in the leg that is caused by irritation and/or compression of the sciatic nerve. Sciatica originates in the lower back, radiates deep into the buttock, and travels down the leg.

What Does Sciatica Feel Like?

The symptoms of sciatica are commonly felt along the path of the large sciatic nerve. Sciatica is often characterized by one or more of the following features:

• Pain. Sciatica pain is typically felt like a constant burning sensation or a shooting pain starting in the lower back or buttock and radiating down the front or back of the thigh and leg and/or feet.
• Numbness. Sciatica pain may be accompanied by numbness in the back of the leg. Sometimes, tingling and/or weakness may also be present.
• One-sided symptoms. Sciatica typically affects one leg. The condition often results in a feeling of heaviness in the affected leg. Rarely, both legs may be affected together.
• Posture-induced symptoms. Sciatica symptoms may feel worse while sitting, trying to stand up, bending the spine forward, twisting the spine, lying down, and/or while coughing. The symptoms may be relieved by walking or applying a heat pack over the rear pelvic region.

It is important to note that any type of lower back pain or radiating leg pain is not sciatica. Sciatica is specific to pain that originates from the sciatic nerve.

Sciatica Is the Symptom of an Underlying Medical Condition

Sciatica is a term used to describe a set of symptoms caused by an underlying medical condition; it is not a medical diagnosis.

Common medical conditions that may cause sciatica include¹:

• A herniated lumbar disc
• Lumbar spinal stenosis
• Lumbar degenerative disc disease, general degenerative changes in vertebrae or discs
• Spondylolisthesis
• Muscle spasm and/or inflammation of the lumbar and/or pelvic muscles
• Sacroiliac joint dysfunction

Rarely, tumors, blood clots, or other conditions in the lower spine may cause sciatica.

The sciatic nerve is the largest single nerve in the body and is formed by the union of 5 nerve roots in the lumbar and sacral spine. There are 2 sciatic nerves in the body—the right and left nerves, supplying the corresponding lower limb.

A few anatomical characteristics of the sciatic nerve include:

• Origin. Starting at the level of the spinal segment L4, the sciatic nerve is formed by the merging of spinal nerves roots from L4 to S3. The emerging nerve roots converge into a single sciatic nerve making it large and bulky, typically up to 2cms in diameter.
• Path. After its individual contributions end, the sciatic nerve exits the pelvis through the greater sciatic foramen, below the piriformis muscle. The nerve then runs along the back of the thigh, into the leg, and finally ends in the foot.
• Branches. The sciatic nerve branches into 2 main divisions behind the knee—the tibial nerve and the common peroneal nerve. The tibial nerve courses down and supplies the back of the leg and the sole of the foot. The common peroneal nerve supplies the front of the leg and foot.

Rarely, the sciatic nerve may split into 2 nerves near the sciatic foramen, which merge again into a single nerve.

The specific sciatica symptoms largely depend on the nerve root that is pinched. For example, an L5 nerve impingement can cause pain in the back of the thigh and weakness in lifting the big toe and the ankle.

The Course of Sciatica

Often, a particular event or injury does not cause sciatica—rather it tends to develop over time. Sciatica affects 10% to 40% of the population, typically around the age of 40 years. Sciatica is found to be common in certain types of occupations where physically strenuous positions are used, such as machine operators or truck drivers. Specifically, people who often bend their spine forward or sideways or raise their arms frequently above the shoulder level may be at risk of sciatica.

The vast majority of people who experience sciatica typically get better within 4 to 6 weeks with nonsurgical sciatica treatments. If severe neurological deficits are present, recovery may take longer. An estimated 33% of people, however, may have persistent symptoms up to 1 year. When severe nerve compression is present with progressive symptoms, surgery may be indicated.

When Sciatica Is Serious

Certain symptoms of sciatica may indicate a serious medical condition, such as cauda equina syndrome, infection, or spinal tumors. These symptoms may include, but are not limited to:

• Progressive neurological symptoms, such as leg weakness
• Symptoms in both legs
• Bowel and/or bladder dysfunction
• Sexual dysfunction

It is advised to seek medical attention immediately if such symptoms develop. Sciatica that occurs after an accident or trauma, or if it develops in tandem with other symptoms like fever or loss of appetite, also causes for prompt medical evaluation.

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