Degenerative Disc Disease: What's in a Name?

Michele C. Battié, PhD; Anand B. Joshi, MPH, MD; Laura E. Gibbons, PhD

Disclosures

Spine. 2019;44(21):1523-1529. 

In This Article

Discussion

It has been said that the stage of development of a field can be judged by the clarity of its concepts. From this perspective, despite the longstanding and growing use of the term degenerative disc disease since its introduction as early as the 1940s,[13] our study results reveal a grossly underdeveloped concept, with greatly varying, disparate definitions found in the health sciences literature. Such inconsistencies pose major challenges to clear, accurate communication in medicine and science, and to advancing related knowledge. They also create confusion and misconceptions among clinicians, patients, and the general public.

Definitions ranged from disc desiccation (low signal intensity on T2-weighted MRI), a typical finding in adults, regardless of the presence of symptoms, to specific symptomatic conditions, such as disc herniation with concordant radiculopathy. Moreover, there was no one definition that was used in the majority of publications. This variability was seen within the disciplines and countries from which the related research originated, with the greatest systematic differences observed when referring to degenerative disc disease in the context of cervical versus lumbar regions, as well as between surgical and other disciplines. While the term is used in many clinical and basic science disciplines, it is particularly common among spine surgeons and had become the most common rationale for lumbar spine fusion in the United States during the decade ending in 2008.[14]

A recent survey of experienced clinicians in the UK from an established spine research society also revealed controversies related to clinical use of the term degenerative disc disease.[15] Of the participating clinicians, 18% stated that they did not use the term, with some proposing avoiding such labels that may engender fear. Others claimed patients need to be given a diagnosis and degenerative disc disease offers an alternative to "non-specific low back pain." Indeed, degenerative disc disease, despite the lack of clarity of its definition, has served as a dominant, longstanding pathophysiological model of low back pain under a biomedical framework.[2,16] Yet, limited progress has been made over prior decades in prevention and effective treatment of low back pain under either biomedical or biopsychosocial frameworks.[17] Certainly, muddled concepts and the failure to create a common language in medicine and science have contributed to the stagnation. The case of degenerative disc disease is particularly notable because of its widespread use, the clear confusion as to its meaning, and the consequences of its use. However, similar problems with variable, nonstandardized definitions, nomenclature, and measurement are attracting increasing attention for other common spinal conditions as well, such as lumbar spinal stenosis, endplate pathology, paraspinal muscle changes, and low back pain in general.[1,18–20]

A strength of the current review of case definitions is the identification and inclusion of all publications with degenerative disc disease in the title from a systematic search of major health sciences search engines to sample definitions used. Similarly, identifying all publications from the Scopus search with the term in the title, keywords, or abstract provided a highly relevant indicator of temporal trends in growth in its usage relative to growth in spine-related articles in general. With respect to limitations, we placed definitions in categories reflecting the diversity observed during the review. However, other, perhaps more refined, categorizations could have been used.

The benefits and harms of clinical use of the term degenerative disc disease may be debated.[6,15,16] However, there is little doubt that the use of the term has led to miscommunication and misconceptions among clinicians, patients, the general public, and policy makers. It has also clouded research on disc degeneration and other specific, diverse clinical phenotypes studied under the rubric of degenerative disc disease, and their role in symptomatic spinal conditions.[6] Replacing the term with more precise case definitions or phenotypes under study would be a substantial advance to facilitate accurate communication and allow clearer comparisons and syntheses of related study results to move the field forward.

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