Non-surgical Spinal Decompression (NSSD)
The idea of disc decompression in the absence of surgery has garnered much attention in the last 10 years, but not all the notoriety has been positive or without controversy. Like any new technology it has had many supporters and just as many detractors, or so it seems. Whenever a new therapy or treatment for an age-old problem such as spine pain is developed, it seems there is a knee jerk reflex that occurs within the clinical community that further triggers a series of events.
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One of the first occurrences might be described as an over-exuberance toward the product with early users and/or adopters of the technology falling prey to overstating the worth of the product without any real substantive research to support the claims, and all too often, based on profit potential. This can, and often does lead to mounting skepticism over the value of the product and can often overshadow the true benefits derived from using the product. What inevitably happens is that this early enthusiasm for a technology is met with an equal and opposite sentiment in the form of extreme criticism by those who feel that either the product is not what it is touted to be, or that the claims made on behalf of the product are not valid.
As clinicians, we can all think of a product, device, intervention or a piece of technology that had early expectations of significantly improving the treatment capability of a vexing health problem but, instead, became mired in controversy with resultant discrediting. There are few conditions that are as ubiquitous and costly to treat as lumbar degenerative disc disease (LDDD) so when a new technology purported to have a high case resolution rate for this condition comes along, it raises the attention level and suspicions of many groups or stakeholders—not the least of which are the entrepreneurs (both clinical and non clinical) who seek to profit from the vast treatment dollar potential. As I researched the history or evolution of this non-surgical spinal decompression (NSSD) technology, I couldn’t help but feel that there is untapped value in this modality, but some early unscrupulous hype has not helped this technology find it’s true place in the treatment of spinal pain and dysfunction. This clinical report will focus less on the marketing/ manufacturer’s claims surrounding NSSD and more on the available evidence for effectiveness, as well as the biologic plausibility supporting this intervention.
Degenerative Disc Disease (DDD)
The aging of the human spine, combined with micro- and macro-trauma to the spinal structures help explain some of the changes seen in cadavers as well as various forms of imaging of the live spine. There appears to be a natural degeneration that is temporal but which can be accelerated by postural changes brought about by redistribution of the biomechanical forces secondary to injury or simply changes in body habitus. We will confine our discussion to the lumbar spine for the purposes of this report but the same applies to the cervical spine and, less so, to the thoracic spine. Degeneration is universal to the structures that comprise the motion segment (functional unit) as defined by the composition of the two adjacent vertebral bodies along with the interposed intervertebral disc. The disc and two zygapophyseal (facet joints) at the same level function as a tri-joint complex. It is generally accepted that the majority (up to 90%) of the spinal loading occurs in the anterior portion of the spine when sitting and a little less when standing. As relative degeneration occurs, there is a shift from anterior to posterior loading or transmission of forces during dynamic motion to the point of parity. The disc acts to provide static stability to the functional spinal unit while dynamic stability is provided by ligaments and local muscles acting in an orchestrated manner—depending on spine position, functional anatomy and level of force required by the activity. The histologic and morphologic integrity of the spine are maintained by these structures. At any given time, there is a critical threshold for shear and compression forces of any given motion or functional segment, above which injury will occur. Recurrent or persistent forces above threshold levels lead to the breakdown of the motion segment—especially the disc and facet joints. The degenerative casacade has been described by Kirkaldy-Willis and has been a widely accepted model of spinal segment pathophysiology.1 In this model, the author describes a three-phase continuum that is based on a transitional process.
A brief description of the spinal disc is in order for a better understanding of the pathology that NSSD attempts to treat. The intervertebral disc has three major parts to it: the nucleus pulposus, the annulus fibrous and end plates. The nucleus contains the gel-like material (water and muchopolysaccharides) which provide viscosity when perturbed. Surrounding the nucleus pulposus, is the annulas fibrosus which, as its name implies, consists of collagen-based annular lamina which radiate outward and contain the nuclear material under normal physiologic loading. The outermost lamellae attach to the vertebral bodies via Sharpey’s fibers, while the innermost lamellae attach to the endplates. Under spinal compression, the nucleus pressurizes and applies hydraulic forces to the end plates vertically and the inner annulus laterally. The annular fibers become tense and can bulge outward as a result. Loss of nuclear material appears to lead to loss of disc height which has implications for facet loading, shear stiffness and ligament mechanics.2