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Intervertebral discs provide support and cushioning against mechanical loads. Changes secondary to aging
and degeneration lead to loss of this important function. This also sets the stage in some for disc-related pain.
Various therapeutic modalities have been attempted with minimal long-term success to alleviate the poorly
described disc-related pain. To better understand the pain originating from the disc, this article attempts to
explore the anatomy of the disc and the different perturbations that occur following aging and degeneration.
There is a great deal of similarity among the discs in different levels. They all consist of a nucleus pulposus,
surrounded by the annulus fibrosus, whose outer layers integrate with the endplate and the ligaments to
strengthen and provide support. The spinal arteries provide the nutrient supply, and the lack thereof seems
to be a hallmark of degeneration and aging. The nerve supply is provided by the sympathetic chain and from
the recurrent sino vertebral nerve, but only the outermost layers of the annulus contain the sensory nerve
fibers. There also appears to be some genetic variation in the rate and degree of synthesis and breakdown
in the primary structural components of the disc, increasing the predisposition for disc-related pain. This
review will also briefly discuss the evidence that has accumulated regarding the occurrence of such
pathologic changes from a genetic and ergonomic perspective.
Published by Elsevier Inc.
Gross anatomy
There are a total of 23 discs in the entire length of the spinal
cord. When the height of all the discs (approximately 8-10
mm in height and 4 cm in diameter) are considered, they
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Techniques in Regional Anesthesia and Pain Management, Vol 13, No 2, April 2009
ity from the head, upper extremities, and torso to the lower
extremities. The discs play a key role in maintaining the
proper spatial orientation of the bony anatomy, such as the
vertebral bodies and facet joints, and consequently also
allow adequate room for passage of the neural roots.7
Cartilaginous endplates
The most cephalad and caudal regions of the intervertebral
discs are the cartilaginous endplates. They have approximately 1-mm-thick horizontal layer of hyaline cartilage
forming an important morphologically and functionally distinct junction between the annulus and the vertebral body.
The composition of the endplate varies slightly in the area
adjacent to the annulus. Here it is primarily composed of
collagen fibers that are continuous with the disc and lay
parallel and horizontal to the adjacent vertebral bodies;
however, the area immediately adjacent to the osseous vertebral body is made up of primarily hyaline cartilage and is
less adherent and more prone for separation during trauma.8
Early in life, the endplates are highly vascularized, but the
degree of vascularity wanes dramatically over the course of
the first year, and there are essentially no blood vessels
present by the third decade, increasing the predisposition for
degeneration.4
Annulus fibrosus
The annulus is composed of a series of 15-25 lamellae, or
concentric rings of collagen. Within each lamella, the collagen fibers lie parallel and are oriented at approximately
Shankar et al
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60 to the vertical axis. Each adjacent lamellar fiber alternates to the left and right in relation to its direction from the
vertical axis. The outermost layers of the annulus tend to be
most dense and resistant to tensile forces. These layers are
firmly attached to the endplates and the vertebral bodies and
are reinforced by the posterior and anterior longitudinal
ligaments (Figure 2). These fibers are most dense posteriorly or anteriorlaterally in close approximation to the posterior and anterior longitudinal ligaments.9,10 These outermost layers of the annulus also contain the sensory nerve
fibers.
The areas between the lamellae are filled with elastin,
which may allow the disc to return to its original position
following flexion or extension. As elastin fibers extend
radially from one lamella to the next, they may also play a
role in binding the lamellae together. The cells within the
annulus are aligned parallel to the collagen fibers. They tend
to be thin, elongated, and fibroblast-like, most notably in the
outer dense region. The annular cells tend to become more
oval as one moves inward toward the nucleus pulposus and
the collagen fibers tend to become less dense and more
loosely organized. A thin, fibrous band of tissue, referred to
as the transitional zone, surrounds the nucleus pulposus.
Thin extensive cytoplasmic projections (some greater than
30 mm) can be found in cells of both the nucleus pulposus
and the annulus. This feature is unique to the intervertebral
discs and is not found in cells of articular cartilage. The
function of these intradiscal projections remains unknown,
but it has been hypothesized that they could play a role in
the communication of mechanical strain.11
Nucleus pulposus
The nucleus pulposus differs from the annulus in that the
vast majority of it is much less dense and nearly the consistency of a gel. It contains a more solidified central region
composed of loosely organized thin, type II collagen and
irregularly shaped radially organized elastin. These hold the
gel-like area, which contains proteoglycan molecules (especially aggrecan) that have hydrophilic chondroitin and keratin sulfate attached to them. This glycoaminoglycan arrangement binds water molecules and gives the nucleus a
much higher composition of water contributing to its consistency (Figure 3). Other proteoglycans include versican,
biglycan, decorin, fibromodulin, and lumican. Other than
versican, whose function is not yet clear, and aggrecan, all
the other small proteoglycans are involved in the repair of
the extracellular matrix.12
Matrix
The extracellular matrix is composed primarily of collagen
and aggrecan. The discs collagen framework serves as an
anchor, attaching to the vertebral bodies and providing the
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Techniques in Regional Anesthesia and Pain Management, Vol 13, No 2, April 2009
cellular processes that regulate the synthesis and turnover of
extracellular components, such as collagen and proteoglycans.
disc with tensile strength. The matrix of the nucleus pulposus and the endplate are formed of collagen II (synthesized
by chondrocyte-like cells), proteoglycans, and noncollagenous proteins. Type I and type II collagen fibrils for the
annulus fibrosus are produced by fibroblast-like cells. Proteoglycans are aggregated together by hyaluronic acid and
further by collagen II and collagen IX.13
Aggrecan, containing highly anionic glycosaminoglycans, is the major proteoglycan of the disc. Its components,
chondroitin and keratin sulfate, retain water due to their
osmotic pressure and hence maintain tissue hydration. The
nucleus has a higher concentration of proteoglycans (and
consequently a higher degree of hydration) than the annulus.
Although aggrecan in the articular cartilage contains some
keratin sulfate, the disc aggrecan has far more. In addition,
the disc aggrecan has a higher degree of variability in its
composition, with many smaller, more degraded and less
aggregated molecules.
The matrix is dynamic and constantly in a state of flux.
Its constituents are continually being broken down by proteinases, such as the matrix metalloproteinase (MMP) and
aggrecanases synthesized by disc cells. The discs mechanical properties are determined by the quality and integrity of
the matrix. Homeostasis is maintained within the disc by
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Nutrient exchange
A consistent supply of essential nutrients and oxygen as
well as a means for removal of metabolic end products such
as lactate is required to support the aerobic metabolism
needed to synthesize collagen and proteoglycans, thus enabling optimal cellular function. Most of the discs blood
supply is usually limited to the outer annulus. Given this
fact, the nearest source of blood to the overwhelming majority of adult disc tissues is located in the subchondral
regions of the vertebral bodies. With this tenuous blood
supply, the disc depends solely upon bulk fluid flow for the
transport of large molecules and diffusion for the transport
of small molecules into and out of the disc. These molecules
may traverse a substantial distance, perhaps as far as 20 mm
from the blood source to the center of the disc. The molecules transported must extravasate from the capillaries into
the subchondral bone, cross the vertebral endplate, and then
travel through the extracellular matrix of the disc to center.
This journey must then be traversed in reverse for the
removal of metabolic waste. Rajasakaran and coworkers
tracked diffusion with a gadolinium-enhanced lumbar MRI.
They found that molecules took 2 hours to cross the endplate from the vertebral body and 4 hours to accumulate to
any significant degree in the center of the disc.15 When one
considers the number of different tissues traversed as well
as the sheer distance, it is amazing that any exchange of
nutrients and wastes in the disc takes place via diffusion or
bulk flow.
Electrochemical events as well as mechanical barriers
dictate the velocity of the discs tissuefluid exchange.16
Mechanical barriers would include fibrous tissues near
and within the disc as well as the vertebral endplates. The
potent negative charges exerted by proteoglycans to attract and bind water is a type of electrochemical force.
Proteoglycan-induced increased binding of water improves the compressive strength of the nucleus. Spinal
loading and unloading may influence proteoglycan activity in the disc, which may in turn account for the large
degree of variation in the nucleuss compressive strength
from 630 to 2900 lbs.17
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Physiological changes
When the nuclear region of the young, healthy disc is
analyzed with a T2-weighted magnetic resonance (MR)
imaging, a diurnal variation becomes apparent. The signal
intensity, which correlates with a higher concentration of
water, is elevated in the morning hours after lying down for
several hours overnight and is lower in the evening (correlating with less hydration) after several hours of standing or
sitting in the upright position. This indicates that loading
and unloading the spine appears to create gradients that
influence the degree of tissuefluid exchange. A 19.3-mm
average increase in total body height and an average disc
volume increase of 1300 mm3 in young, healthy females
after lying recumbent for several hours was reported.18
Similarly a 0.9-mm loss in the height of a disc during the
span of a day in healthy adults was documented.19 Yet
another study reported that degenerative discs and nondegenerated discs in subjects over 35 years of age did not
exhibit appreciable diurnal variations.20 The absence of
significant diurnal variations in older and degenerated discs
supports the findings of Rajasekaran and coworkers, who
conclude that any degree of inability to perform fluid exchange is a key element of degenerative disc disease.15
Pressure transmission
As previously discussed, the hydraulic mechanism needed to
both transmit and absorb forces through the disc is primarily
dependent on the degree to which the nucleus is hydrated as
well as the structural integrity of the annulus and the vertebral
endplate. The primary function of the nucleus is to decrease
stress on the vertebral endplate. The vertebral endplate and
annulus both contain and restrain the force of the nucleus.
Normally, functioning discs disperse forces evenly. However,
any compromise of the functional integrity of the nucleus, the
annulus, or the endplate can alter the balance of forces and
decrease disc function.
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Techniques in Regional Anesthesia and Pain Management, Vol 13, No 2, April 2009
similarity among the twins.30,31 Patients who were diagnosed with herniated discs before the age of 21 were four to
five times more likely to have a significant family history
for disc herniation. Patients with significant osteoarthritis of
the extremities have a greater degree of osteoarthritis and
disc degeneration of the spine. Furthermore, there may be a
genetic link between disc degeneration, degenerative scoliosis,
and spondylolisthesis through similar cellular processes.32
In addition to pathologic processes that occur over time
leading to accelerated degeneration of discs, there is also a
nonpathological degeneration that is inherent with the aging
process independent of trauma or predisposing genetic variation. Two key normal processes that occur with natural
disc degeneration are reduced proteoglycan content within
the disc (and consequent decreased hydration and function)
and decreased endplate permeability (and consequent decreased metabolic exchange). Simultaneously, the type II
collagen molecules are replaced by the denser type I collagen molecules in the nucleus. These type I molecules tend
to crosslink and form even denser tissue that further inhibits
exchange of nutrients and metabolic waste. Although these
changes lead to increased disc desiccation, and decreased
function, it is important to note that they do not substantially
decrease disc height, nor do they invoke an extremely painful response. Similar changes also occur in the articular
cartilage. These changes are easily noticed on an MRI in
which the cartilage (or the disc) takes on a darker appearance as they become less hydrated.
Shankar et al
Disc repair
Following disc disruptions, the discs have a very limited
capacity to heal or to restore their structural integrity. The
outer portion of the annulus is vascularized and heals
through an inflammatory process, but the sparse population
of cells in this area does not produce sufficient quantity or
quality of collagen to replace any structural damage. Sufficiently large tears with less access to cells will in fact be
replaced with granulation tissue that lacks the tensile
Figure 6
stenosis.
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strength of collagen. The outer annulus forms only a peripheral scar tissue after a scalpel wound. This makes one
wonder about the safety of performing decompressive or
thermo-ablative procedures on the disc. The collagen turnover time is longer than the average lifespan of humans.
Injuries to the nucleus or the endplate undergo severe degeneration of the disc following decompression.17
The complexities of disc degeneration-induced pain and
the number of variables that are involved likely accounts for
the great degree of variation between different patients and
disc injuries. With the influx of inflammatory mediators into
the annulus, there is a proliferation of blood vessels and
nerves deeper into the disc, which would allow for nociception in areas with no prior innervation.36-38 Additionally, the
influx of inflammatory mediators, such as tumor necrosis
factor, substance P, or interleukins, will lead to hyperalgesia.39,40
Following disc injury, an inflammatory cascade is initiated. This leads to build up of lactic acid, increased secretion of proteolytic enzymes, decreased proteoglycan production, decreased hydration, cell apoptosis, and further
structural breakdown of the intradiscal components. Over
time, there may be a loss of disc height, bulging of the
periphery of the disc with slackening of the supporting
fibrous tissues, and a reduction of the contribution of the
disc to axial forces. This, in turn, causes maldistribution of
forces to the surrounding structures. One to three millimeters of decrement to disc height has the potential to cause
and overload the facet joint, which could lead to facet
hypertrophy and dysfunction. The combination of a hypertrophied facet, bowed annulus, and ligamental hypertrophy
could significantly decrease the cross-sectional area of the
foramen and lead to symptomatic spinal stenosis.7
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Techniques in Regional Anesthesia and Pain Management, Vol 13, No 2, April 2009
plate trauma may also be associated with Schmorls nodes
or even bone marrow edema in nearby vertebral bodies.48
Peripheral rim lesions in the outer most annulus are
thought to be secondary to trauma. These lesions have been
suggested to correlate with high intensity zones on T2weighted MR imaging that are thought to represent associated hemorrhage or edema.
Conclusions
Acknowledgments
We thank Quinn Hogan, MD, for kindly providing the
cryo-microtome pictures, John Joseph, MD, for providing
the MR images, and DeWayne Risley for doing the color
illustrations.
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