Acetaminophen (such as Tylenol) is a medication that is usually given to ease the pain in IVDD patients. It works by decreasing the brain’s perception of pain. Unlike the other non-steroidal anti-inflammatory drugs, acetaminophen does not usually treat the inflammation in degenerated disc. NSAIDs, or non-steroidal anti-inflammatory drugs, are some of the pain medications that help to decrease the inflammation in the lower back that is usually associated with the lumbar degenerative disc disease. Anti-inflammatory medicines consists of corticosteroids or NSAIDS that is used to treat the spinal pain(in case of inflammation).
Generally NSAIDs are preferred than corticosteroids as NSAIDs have similar analgesic and anti-inflammatory effects. NSAIDs are generally used to treat low back pain from degenerative disc disease include: Ibuprofen, Naproxen, COX-2 inhibitors. Muscle relaxants usually work by having an sedative effect on the whole body. Generally, the muscle relaxants are prescribed early in a case of low back pain to relieve the pain caused by muscle spasms.Invasive Treatment: To treat IVDD patients surgically, it should be based on different factors, such as neurological signs, severity of pain, the type of compression lesion and its (their) response to the conservative treatment. Surgeries are usually done to remove the compressive lesions or structures such as herniated disc and hypertrophic ligaments, but neither of this surgeries are helpful to increase the lifespan of the degenerated disc or in its regeneration (MoattarRazaRizvi,2017).
Interventional surgery for disc herniation is one of the most widely used, effective treatment available for back pain that emerges within the broad scope of disc degeneration.Interventional procedures for IVDD include epidural steroid injections and surgical procedures, such as disectomy, fusion, and total disc replacement.
Various techniques are available to treat IVDD-related compression. Direct decompressive procedures include ventral slot (cervical disc disease), inverted cone slot (cervical spondylomyelopathy – CSM), dorsal laminectomy (Degenerative lumbosacral stenosis -DLSS) and haemilaminectomy (thoracolumbar disc disease), pediculotomy, corpectomy. Curettage or fenestration (nuclectomy) of the diseased disc or adjacent discs which may cause future disease is commonly performed.
These surgical procedures all lead to altered biomechanics of the spinal segment: Decompressive surgery without disc stabilization results in spinal instability, which may lead to recurrence of clinical signs, while stabilization prevents degeneration of the decompressed spinal segment, it is associated with degeneration of the adjacent spinal segments.
A novel, biocompatible, hydrogel NPP (nucleus pulposus prosthesis) has recently been developed. It is implanted in dry form, enabling insertion of the NPP through a small annular opening. After insertion, the prosthesis is allowed to expand in situ and reaches its final dimensions within 18 hours of placement. The prosthesis fills up the entire NP cavity created after nuclectomy (confinement), which is essential to achieve a physiological distribution of stress in the disc and to minimize the risk of implant migration.
An ideal therapeutic strategy would be to replace, regenerate, or augment the intervertebral disc cell population, correcting the matrix insufficiencies and restoring normal segment biomechanics. Biological restoration through the use of autologous disc chondrocyte transplantation, offers a potential functional integration of disc metabolism and mechanics.
It directly addresses the decreased number of viable chondrocytes and disc cells within the diseased disc space, in the past decade- cellular therapy has gained significant attention for addressing the regeneration of the disc by controlling cell loss and proteoglycans components. Cell-based therapy can be performed using different types differentiated cells, such as NP cells, AF cells, Cartilagenous chondrocytes and progenitor cells. The choice of cells depends on certain practical issues such as accessibility, abundance and safety concerns that include tumorigenesisand immunogenicity.the avascular nature of the IVD creates an acidic, hypertonic, hypoglycemic and hypoxic microenvironment forming a barrier for exogenous cells to survive.
Cell therapy offers better treatment by directly injecting cells into degenerated discs to slow (the degeneration) or might help in regeneration. Transplanted cells are thought to produce for example extracellular matrix constituents including collagens and proteoglycans to restore the functional integrity of degenerated IVDs (Meisel et al., 2007). Various cell sources have been considered for IVD cell therapy e.g. autologous disc cells and articular chondrocytes (Zhang et al., 2011.
Autologous disc derived cell transplantation is technically beneficial and biologically applicable for repairing disc damage and reducing the disc degeneration. Adipose tissue provides an alternative source of regenerative cells, which are able to differentiate into a nucleus pulposus-like phenotype when exposed to environmental factors similar to disc, and offer the inherent advantage of availability without the need for transporting, culturing, and expanding the cells.
Stem cell therapy
Stem cell therapies are gaining attention in many neurologic, cardiac, blood diseases and IVDD is no exception. stem cells are undifferentiated, multi-potent cells mainly present in the bone marrow but also found in many other tissues which are highly accessible and have ability to self-renew, proliferate, chondrocytes, and they possess immune-modulatory properties. Stem cells particularly adult mesenchymal stem cells, are seen to be a good alternative and attractive cell choice for regeneration of the IVD.
Notochordal cell-based therapy
Current treatments such as conservative therapy, spinal fusion and disc arthroplasty aim to ease the pain, without addressing the underlying cause of IVD degeneration. Regenerative therapies are promising, but have shown limited regenerative effects. Another cell type of interest is the notochordal cell (NC), a remnant of the embryonic notochord which is present in the young IVD, but disappears in humans around the age of 10. NC disappearance coincides with the onset of IVD degeneration, suggesting a role for NCs in maintaining a healthy IVD (de Vries, S.A.H,2016 Nov 21)
Growth factor therapy
Growth factors are substances, often proteins,that regulate the cellular processes such as growth, differentiation, migration and apoptosis through autocrine or paracrine signaling. Upon their binding to the cell surface receptors, an intracellular cascade takes place that activates or represses specific genes, ultimately resulting in a biological effect. Growth factors that are being tested in vitro as well as in vivo for regenerative therapies for the IVD, include bone morphogenic proteins (BMPs), growth and differentiation factor 5 (GDF-5) and transforming growth factor beta 1 (TGFβ-1).Bone morphogenic proteins (BMPs), a class of proteins belonging to the transforming growth factor β (TGFβ) superfamily, are known to influence chondrogenesis. BMP-2 and BMP-7, otherwise known as osteogenic protein-1 (OP-1), have shown promising results in relation to IVD regeneration.
Gene-based therapy was first proposed by Friedmann and Roblin. It can be done either by in vivo gene therapy using vectors with appropriate genes, or through ex vivo gene therapy using the target cells, which are removed, cultured, genetically altered in vitro, and then re-implanted. These vectors are classified into two different types, viral vectors and non-viral vectors. These viruses are very competent vectors. For significant gene therapy, research has used viral vectors such as retrovirus, lentivirus, adenovirus, and adeno-associated virus. Adenovirus-based vectors are largely used for gene therapy – helping in high level transient gene expression in both in vitro and in vivo models.
Non-viral vectors have been designed to deliver transgene messages while attempting to avoid the negative aspects of viral based systems ,including viral mutagenicity, systemic viral infections and viral protein immunogenicity (Wiethoff CM and Middaugh CR,2003).Examples of non-delivery systems include cationic liposomes, DNA -polymer conjugates and mechanical administration of naked DNA. But Non-viral delivery systems have not yet widely been used in IVD studies. Although gene transfer vectors are essential in gene therapy , but no single vector system will be suitable for all the required applications.