Thirty-one patients ranging from age 15 to 29 presented with lumbar disc degeneration and/or herniation of three or more levels, documented on MRIs, CT scans, myelograms, and/or discograms. Twenty-two patients had three-level involvements. Six patients had four-level involvements and three had five-level disease. Twenty-one patients had significant disc herniations, nine of which were extruded. These patients were associated with obesity, height of six feet or more, strong family history, pre-existing pathologies, congenital abnormalities, end plate defects and/or excessive cumulative work activities or sports involving heavy axial loading, repetitive bending or rotation of the lumbar spine. There were 21 males and 10 females. 12 patients ranged from 6 feet to 6'6" in height. Nine patients were markedly overweight. Of the 7 teenagers, 4 were 6 feet or more and one weighed 200 pounds since the age of 12. High percentage of patients were involved in unusual heavy activity such as rodeo riding, competitive rowing, weigh/lifting, rugby, etc. Co-existing pathologies such as endplate defects, spondylolisthesis, retrolisthesis, spinal stenosis, congenital fusion, osteoporosis, spondyloepiphyseal dysplasia, reversal or loss of lumbar lordosis were found, in addition to the multi-level disc degeneration. However, osteophyte formation was rarely seen in this young age group.
Initially, all the patients were treated conservatively with rest, back school, physical therapy training and conditioning program, anti-inflammatory medications, epidural injections and braces. When aggressive conservative treatments failed in patients with significant neurological deficit and/or severe leg pain, surgical decompression was directed to the cause of the neurological deficit or to the origin of pain. SeIective nerve root blocks, indwelling epidural blocks, EMG and/or discograms were performed to localize the origin of pain. Two underwent chemonucleolysis with one improved. Two underwent percutaneous nuclectomies and one improved. Five underwent surgical decompressions and discectomies with four improved. In five patients, 4 of whom failed initial procedures, fusions were performed and four improved. Conservative treatments involving back school,-training in good body mechanics, conditioning program and termination of heavy work or athletic activities were useful even in patients requiring surgery. For young patients with multi-level disc disease, nonoperative management is indicated unless there is significant neurological deficit or severe pain not responding to aggressive conservative treatments. |
