Discogenic Syndromes Overview

Study Notes

Discogenic Syndromes

Causes:
- Disc degeneration is caused by accumulated micro trauma, possibly with an autoimmune reaction.
- Annulus fibrosis tears and fissures do not heal well.
- Activities like flexion and extension with rotation, sudden jolts, and prolonged postures all increase intradiscal pressure.
- This increased pressure causes nuclear material to push out, leading to disc bulge, protrusion, and nerve root irritation or compression.
- While disc degeneration itself might be asymptomatic, a degenerated disc is a weak link susceptible to deterioration under prolonged or repeated load.

Symptoms

Area of Symptoms:
- Location depends on the structures involved: dura, posterior longitudinal ligament (PLL), nerve root sleeve, and nerve root.
- Dura: Pain around the affected area, centrally and paravertebrally.
- PLL: Central or referred pain that isn't clearly defined. Proximal pain is stronger than distal pain.
- Nerve root sleeve: Central pain is more distinct to one side.
- Nerve root: Distal, defined dermatomal pain.
Character of Symptoms:
- Can be deep (non-nerve root) or superficial (nerve root).
- Severe inflammation: pain is unbearable, distressing, and sickening.
- Nerve root involvement: neurological symptoms.
Behaviour of Symptoms:
- Aggravated by: Postures and activities that increase intradiscal pressure (e.g., sneezing, coughing, Valsalva maneuver).
- Eased by: Lying down or reducing pressure.
Protective Deformities:
- Protective muscle spasms can lead to scoliosis, kyphosis, or list.

Perpetuating Factors

Structural:
- Weak abdominal stabilizers can cause increased intra-abdominal pressure.
- Kyphosis, lordosis, and scoliosis can contribute to problems.
- Abnormal gait due to leg length discrepancies.
Ergonomic:
- Poorly designed chairs or tables.
- Insufficient workspace leading to repetitive flexion and rotation activities.
Activities:
- Anything that increases intra-abdominal pressure.
Stress:
- Fatigue and decreased immunity.
Disease:
- Viral infections, Scheuermann's disease, autoimmune diseases, and endplate fractures.

Treatment

Spinal mobilization techniques: Focus on mobilizing the spine, but avoid extension if it's the worst sign.
Lumbar stabilization exercises: Both local and global exercises should be included.
Trigger point treatment: Identify and treat trigger points, even those seemingly unrelated to the primary complaint.
Neural tissue mobilization: Address any restrictions in the nervous system.
Education:
- Educate patients about the pathology of discogenic syndromes.
- Emphasize avoiding postures and activities that increase intradiscal pressure.
- Teach kinetic handling techniques.
- Promote ergonomic practices.

Flat Tyre Syndrome

Cause:
- Disc space narrowing due to degeneration or disc prolapse, with the ligaments and capsule not yet adapting to the change in intervertebral segment height.
History:
- Can have a slow or rapid onset.
- Often precipitated by a sudden jerky accident.
- May have prior episodes that contributed to disc degeneration.
- Acceleration of wear and tear due to job or hobbies.
Symptoms:
- Area: Local or referred depending on structural involvement and instability severity.
- Character: Catching, twingy, stabbing pain that is unexpected with a feeling of weakness in the back.
- Behaviour:
  - Aggravated by prolonged standing, walking, lying, extension exercises, and certain arcs of motion, especially flexion.
  - Extension after flexion is very difficult and painful, requiring hand assistance.
  - Palpation can provoke pain, especially if a step (lysthesis) is present.
  - Eased by stable positions (sitting may aggravate symptoms if there is a disc lesion).
- Protective Deformities: Varies depending on involved structures.
Perpetuating Factors:
- Structural: If multiple levels are involved, trunk stability and overall disc degeneration are important factors.
- Activities & Posture: Activities with quick movements, large ranges of motion, and jarring, especially into extension, can be problematic.
- Stress: Unconscious use of the body.
Treatment:
- Spinal mobilization techniques.
- Spinal stabilization exercises.
- Neural mobility treatment.
- Education: Explain the pathology, avoid jerky, twisting movements, avoid extension postures and activities if there is anterior displacement, emphasize central stability, and educate about cord/cauda equina signs and symptoms.

Juvenile Disc Syndrome

Commonly affects more young men than women.
Symptoms: Mild spinal stiffness, muscle spasm, and painful joint signs that seem out of proportion.
Lumbar Area: Often presents with a flexion deformity that remains even when lying prone.
Palpation: Limited until strong grade IV/V palpation is applied, which elicits significant pain.
Movement Limitations: Marked limitations with flexion and straight leg raise.
Treatment:
- The aim is to reduce pain rather than increase range of motion.