DEGENERATIVE DISCOGENIC SYNDROME
International Publicized Data
GMCD Instructional Course Lecture
Dr. med. Guy M.C. Declerck MD (GMCD)
Medical FRCS-, FRCS Ed Orth-, M Ch Orth-, PhD-studies
Spinal Surgical and Research Fellow, Perth, Western Australia
Spinal Orthopaedic Surgeon and Surgical Instructor
Consultant R&D Innovative & Restorative Spinal Technologies
President International Association of Andullation Technology (IAAT)
Translation: Filip Vanhaecke PhD
Illustrative expertise and page layout: Lennart Benoot, Mincko, Halle, Flanders, Belgium
Review scientific literature: Medical Consulting Advice, Ostend, Flanders, Belgium
Support: International Association of Andullation Therapy (IAAT)
Legal advice: Anthony De Zutter, kornukopia.be
Dedication to the Colombian Family Gloria Rúa Meneses and her sons Andres David and Juan Camilo Hinestroza, both representing Colombia’s National Waterpolo Team. For their friendship and hospitality. April 2014.
Relying on the work of giants is the lifeblood of scientific research. Indeed, if I have seen further, it is by standing on the shoulders of giants. One might even say that I have always depended
on the kindness of strangers in this regard (*).
The continuous support by professor BA Kakulas (Neuropathology), professor JR Taylor (Spinal Anatomy and Human Biology), and Sir George M Bedbrook (Spinal Orthopaedic and Rehabilitation Surgeon) made it possible to analyse 27539 post-mortem human spines, normal and pathological, in the Department of Neuropathology, Royal Perth Hospital/University Western Australia, Perth.
Note: in order not to disturb easy reading of the underneath scientifically based chapters, only a few authors are mentioned in the text where dr. Guy considered it essential. Their names are placed between brackets. Further information on their individual research can be read in the last chapter ‘Literature Encyclopedia’.
(*) Mirsky Steve. Technology is making it harder for word thieves to earn outrageous fortunes. Scientific American, February 2014, p. 64
Following thorough clinical, laboratory and radiological investigations, an evident, clear-cut and undeniable pathology will only be found in maximum 20 % of patients suffering from low back pain. Spinal infections, poliomyelitis, tumors, metastases, thoracolumbar fractures, metabolic and rheumatoid diseases, abdominal pathologies etc ... are disabling conditions. Their diagnosis should not be missed because the causing mechanisms are crippling. For each of these serious conditions, therapeutic approaches are available.
Scientific medical research is only at the beginning of understanding that the synergetic degenerative mechanisms between the nucleus pulposus (NP), the endplates (EP) and the annulus fibrosus (AF) of the intervertebral disc (IVD) [see: ‘Structure of the Intervertebral Disc’] are responsible for an important public health issue. Surgical investigations by Kuslich (1991) and Barrick (2000) showed clear evidence that the intervertebral disc is the culprit for a very large portion of LBP. Indeed, approximately 80 % of all chronic LBP patients show nothing but investigational evidence of IVD degeneration. The author defines symptoms and signs of chronic low back pain linked to the - benign - degenerative changes in the IVD as degenerative discogenic syndrome.
Benign acute (ALBP) and benign chronic low back pain (CLBP) are not diseases. Both conditions simply are symptomatic manifestations related to an underlying condition which is difficult to comprehend because of an unique interrelation of various aetiological factors. Benign LBP results from an extraordinary - and as yet still not understood - interplay between genetic background, declining nutrition of the IVD, biochemical aging and degenerating processes in the IVD and disturbed daily biomechanical loading patterns on the IVD.
Fig. 2. Typical illustration of the normally evolving degenerative processes in the lumbar intervertebral discs.
The information is based on a review and analysis of 23,539 postmortem lumbar spines by dr. med. Guy Declerck at the Department of NeuroMuscular Pathology at the University of Perth.
The Colombian sculptor Alonso Ríos Vanagas (www.alonsoriosescultor.com) depicted the typical details in the nucleus pulposus, the endplates, and the annulus fibrosus at the L4-L4 IVD level.
There exists no relationship at all between symptoms of low back pain and potential ‘abnormal’ radiological features. All human beings will age and may develop degenerative changes in their lumbar intervertebral discs without any associated pain at all. Then something special must happen to cause pain!
The complex ongoings and synergetic degenerative mechanisms in the IVDs are as yet not understood. But chronic LBP remains an area of deep concern. The effect of LBP on the quality of life has far reaching consequences. LBP is the most common cause of disability and loss of mobility. Some LBP sufferers even become suicidal. As most of us already experienced, the medical professionals as well are awaiting a logic and universally acceptable explanation. Socioeconomic factors are not at all the reasons why structural defects occur in the annulus fibrosus and the endplates of a degenerating IVD but are known to be important risk factors for intensifying the pain and the related disability.
Animal and in vitro cell culture study models still remain the basis for analyzing the degenerative processes in the intervertebral disc. It has overwhelmingly been shown that there exists a close relationship between biology and biomechanics of the IVD in the bipedal humans. It’s called ‘the mechanobiology of the IVD’ (Adams). To paraphrase the politician Winston Churchill, it is quite possible that in a few years’ time the reasons for chronic low back pain no longer will be ‘a riddle, wrapped in a mystery, inside an enigma’
As long as the exact pain causing mechanisms are not known, the human brain will be left open to all kind of explanatory fantasies. It all depends where the medical and paramedical staff received part or all of their clinical (and surgical) training. During his lifetime, the author has heard as many explanations as institutes he visited and worked in! Because only a few experts start understanding the important relationship between biomechanics and biochemistry in the pathogenesis of chronic LBP, the mismatch of opinions will remain fantastic, extremely confusing and contradictory.
Low back pain is not something which simply passes by as a meaningless event. Once a first episode of LBP has occurred, new episodes of LBP always must be anticipated. LBP is the manifestation of an underlying phenomenon which will never spontaneously nor definitely disappear.
A first episode of LBP may settle in approximately 30 % of patients at three months from its origin. When a period of LBP continues for more than 3 months, it is defined as chronic LBP. Overall, up to 75 % of LBP sufferers still experience some (slight) symptoms at one year following an acute LBP attack.
LBP may continue as a fluctuating condition over time with frequent relapses or exacerbations. Intermittent CLBP is the term used when pain free periods of varying duration alternate with short acute LBP attacks (Fig. 5a). Undulating CLBP means that the ever present LBP is accompanied by up and down going symptoms (Fig. 5b). Strangely enough and irrespective of the type of treatment, as many as 90 % of recurrent acute episodes of LBP will improve spontaneously in about 6 weeks. LBP suites the definition of ‘perpetuum mobile’.
Fig. 5a. The course of chronic intermittent low back pain. Each time, the recurring attacks of LBP are followed by pain free periods. (Illustration by Natacha Monstrey)
Fig. 5b. The course of chronic undulating low back pain. The LBP complaints present an up and down going pattern. There are no pain free periods. (Illustration by Natacha Monstrey)
Disability is defined as restricted functioning, limitation of activities and decreased participation in life situations. The degenerative discogenic syndrome (DDS) related to the degenerative processes in the intervertebral disc is not crippling. It represents the most common cause of restrictions on activity in individuals between 20 and 50 years of age, especially in men. Benign acute LBP and benign chronic LBP are only temporarily disabling.
Disability related to LBP in soldiers during World War I counted for 0,23 %. They returned to duties after two weeks. Disability increased 400 % during World War II (1,07 %) and sick leave was two months. Disability due to LBP varies enormously but continues to grow exponentially. Both disability and sick leave depend on the country of origin, the social background and the daytime. By the end of the 20th century up to 12 % of the population in the high income countries was temporarily disabled by LBP (Cassidy).
Prevalence is the percentage of individuals in a given population who have the complaints related to an underlying condition during a specified period of time. The incidence is the percentage of individuals in a given population who will develop a disease during a specified period of time.
Epidemiological studies since the 1970s repeatedly recognized that benign low back pain (LBP) is one of the most prevalent conditions of the human race. LBP is widespread, temporarily disabling, but not invalidating nor crippling, costly and responsible for exorbitant levels of work absenteeism and significant productivity losses. An overall evaluation of the huge amount of published figures points out that the prevalence of benign LBP is similar in low-income, middle-income, and high-income countries. The prevalence of LBP in schoolchildren and adolescents approaches that seen in adults. Eight out of ten (80 %!) individuals will - at some stage in their lives - have suffered at least one episode of significant benign LBP. As many as 40 % in a normal population have experienced some degree of LBP in the past year.
In the younger populations benign LBP seems to be the only major source of pain. However, the prevalence peaks between the ages 35 and 55 years. In industrialised countries, approximately 25 % of these adults report LBP occurring in the past 3 months. In a small part of the world, Flanders in Belgium, this figure corresponds to over 1,5 million individuals and in the USA to approximately 54 million individuals. The prevalence of LBP in the elderly older than 65 years of age is not known with certainty but is lower than in the younger population groups.
How long will patients worldwide continue to tell that they are not taken seriously, that the medical personnel doesn’t believe them, and answer that they are simply faking their signs and symptoms?
I do not at all agree that chronic LBP sufferers seek compensation on purpose. The patients are ignorant of what’s going on and seek assistance. Therefore, LBP was and always will be a reason for seeking sick leave. LBP suffers are fearful that ‘something’ may go wrong. This feeling is accentuated because most doctors simply have no idea and no clue about the reasons for this benign type but sometimes very intense pain. Is it really possible that a ‘torn spinal muscle’ can cause that amount of pain and for so long? Why do torn (stronger and larger) muscles in the arm or tight do not cause similar pains? Of course, there is that famous ‘disc herniation’ explanation! For most doctors the ‘disc herniation theory’ simply is an excuse and a synonym for ‘a riddle, wrapped in a mystery, inside an enigma’. Doctors are not allowed to say ‘I don’t know!’.
Most caretakers prefer to take no risks. The oath to Hippocrates means that at all times they have to seek the best for their patients. Regarding benign low back pain, this means avoiding a worst outcome by simply doing nothing. This is the attitude by which LBP sufferers are driven. Of course, compensation doctors do exist. They like to get rid of these LBP sufferers as they present unexplainable complaints. There exist no imaging techniques to identify potential cellular and molecular indicators of pain. Electrochemical technology CLARITY visualizing projections, already tested on mouse brains, may present solutions in the future (Chung and Deisseroth).
Although the percentage of individuals who have benign LBP is similar in low-income, middle-income, and high-income countries, chronic low back pain (CLBP) only is epidemic and only has a major societal impact in the developed and industrialised world. No doubt this situation is influenced by the well-structured social security systems with their compensational mechanisms. In countries which as yet are not fully developed, there simply is nothing to gain by staying at home for a benign condition.
In the developed countries CLBP related to intervertebral disc degeneration affects the majority of the population. CLBP is the leading cause of limitation of activities in both sexes. In a given year, up to 15 % of the entire working population will be (temporarily) disabled by LBP. The ensuing economic losses for society are enormous. In the USA and as for 1981, LBP was responsible for 93 million lost working days. Recently it has been calculated that LBP now accounts for 149 million days lost from work.
In all high and middle-income countries, LBP is the second most common reason for sick leave, behind only a common cold. In Belgium 12 % of work absenteeism exceeding 28 days is due to by LBP. Lost working days due to LBP mostly are registered in the work force of companies or industries dealing with housekeeping, cleaning, textile, food and building. Employees in sports clubs, insurance companies, and sectors concentrating on gardening, farming, and agriculture record the least days lost to work. Nobody can rationally explain these figures. In the industrialized countries it seems that the social security systems do not concentrate on reactivating people but simply encourage the LBP sufferers ‘to rest a while’. At least this was the author’s experience while practising in Belgium! He even received letters from these security systems urging not to send the patients back to work. Unfortunately, the author never cooperated with the authorities of these politically driven systems (at least in Belgium).
The economic burden due to LBP is similar to that of the more serious coronary heart diseases. The economic losses due to LBP are higher than those of other major health problems, such as diabetes, Alzheimer disease, and kidney diseases.
Statistics on the impact of low back pain provide figures which repetitively indicate that CLBP of degenerative origin is extremely expensive, costs billions of dollars or euros, and continues to rise. The direct and indirect costs to the individual and to the society may count for 12 % of gross domestic product in a country.
The direct costs which are related to diagnosis and treatment include fees of medical visits, medication, hospitalization, radiology, blood analyses, all kind of devices, the whole gamma of medical and alternative therapies, etc … . Two-thirds of all costs are indirect. These include charges due to reduced or loss of productivity, inactivity, absence from work, loss of work, lost wages, costs of transportation to and from medical and paramedical care providers, all kind of societal supports for the affected individuals, their family and professionals .
In the USA the total cost of LBP to the individuals and the society reached 100 billion $ per year in 1991 and were estimated to value up to 200 billion $ per year in 2005. In 2006, the socialist mutuality in Belgium published amazing figures for this small country. Direct costs per LBP individual in 2006 accounted for 922 euros per year. The total direct medical costs for the whole country were estimated somewhere between 81 and 167 million euros. The sum of direct and indirect costs was between 270 and 1600 million euros (Federaal Kenniscentrum voor de Gezondheidszorg).
The whole society has to compensate for its LBP-members!
Elucidating the molecular mechanisms how intervertebral disc (IVD) cells and their pericellular matrix communicate with each other and how they react on the daily mechanical forces exerted on the lumbar IVDs remains fundamental for developing a cause-directed biological therapy to settle the degenerative changes. Till that moment (in another 10 to 15 years), patients suffering (the attacks of) benign low back pain have no choice but to accept their fate or decide to undergo one of the various physiotherapeutic, injecting or surgical treatments. Finally developing an efficient and universally accepted therapy curing the degenerative disc syndrome remains one of the most exceptional therapeutic challenges in the 21ste century.
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