Discogenic Lumbar Pain

DISEASE/DISORDER:

Definition

Discogenic lumbar pain (DLP) is a separate entity in the differential diagnosis of low back pain. It is thought to originate from late degenerative disk disease (DDD) and internal disc disruption. ³¹ DLP symptoms are distinct from those occurring as a result of spinal deformity or radiculopathies.

Etiology

• Strong familial predisposition to DLP
• DDD is associated with advanced age, male sex, and smoking
• Associated with particular occupations:
  • Sitting positions and vibratory forces may expose disks to stresses, favoring DLP (truck drivers, manual laborers).
    • Intradiscal pressures increase during sitting.¹
  • Physically strenuous activities and repetitive motion may contribute to disk degeneration and facilitate annular injury.

Epidemiology including risk factors and primary prevention

Primarily adults between the ages of 20 and 50 years.

Patho-anatomy/Physiology

The intervertebral disc (IVD) is the medium between two vertebrae in the vertebral column. The IVD is composed of the following:

• Nucleus Pulposus
  • Inner aspect composed of water and proteoglycans in a type II collagen network.
  • Aids in distributing weight to annulus fibrosus and vertebral endplates as well as height conservation.

• Outer Annulus Fibrosus
  • Surrounds the nucleus pulposus.
  • Type I collagen
  • The nerve supply to the annulus is derived from the sinuvertebral nerve and a branch from the lumbar sympathetic chain.

• Endplates of Hyaline Cartilage

Early degenerative changes can involve subtle changes and disruption to the matrix of the nucleus pulposus and inner annulus fibrosus initially without symptoms. A shift in the balance of anabolic and catabolic activities can predispose to accelerated degeneration and promote an inflammatory cascade and biochemical response irritating nociceptive nerve endings of the outer annulus. The development of radial fissures is thought to be related to shear forces, axial loads and compression of the disc leading to vertebral endplate fractures, further disrupting the integrity of the intervertebral disc.

Pain, therefore, occurs from chemical irritation of nerve endings in the outer annulus from annular or endplate disruption. Higher proportions of inflammatory markers such as lactate, growth factors, macrophages, and granulation tissue occur. Mediators such as nitric oxide, leukotrienes, and prostaglandin E are involved in direct nociceptive stimulation leading to pain.

Furthermore, chronic low back pain can result in pain perception dysfunction of the central nervous system, with central sensitization considered to play an important role.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

New onset/acute:
Pain lasting less than 6 weeks.

Subacute:
Pain lasting between 6 and 12 weeks.

Chronic/stable:
Pain persisting beyond 12 weeks.

Specific secondary or associated conditions and complications

• Spondylolysis
• Spondylolisthesis
• Facet arthropathy/facet syndrome
• Myofascial pain syndrome
• Vertebral Fractures

ESSENTIALS OF ASSESSMENT

History

The typical mechanism of many low back injuries is the result of cumulative trauma, and not the result of a single exposure to a high-force load. Such trauma places sub-failure magnitude loads on the spine. These include repeated small loads, such as bending or sustained loads, such as sitting. In particular, injury to the disc has been shown to result from repetitive motion at the end range, which can reduce failure tolerance over time.³

Discogenic pain is most commonly described as centralized low back pain usually without referral beyond the buttocks. Occasionally patients describe a bandlike referral pattern.³⁹ DLP is typically exacerbated by lumbar flexion. However, this presentation can be variable depending on the site of disc pathology. Pain is described to be axial in nature rather than radicular leg pain. Pain may refer to the buttocks, but generally does not extend below the gluteal folds. Pain is frequently exacerbated by sitting more than standing and relieved by lying down.

Physical Examination

On observation, the patient may be more comfortable standing than sitting. There is often para-midline tenderness. Range of motion of the lumbar spine may be reduced in all planes due to pain depending on the site of disc pathology with lumbar flexion presenting most often. Further examination may demonstrate an antalgic gait. Strength, sensation and reflexes are usually normal. Provocative maneuvers for neural tension including straight leg raise or slump test may lead to exacerbation of lower back or buttock pain. Nonorganic signs or “Waddell Signs” should be taken into consideration to detect psychological distress and to help identify patients who may require detailed psychosocial assessment. Furthermore, the nonorganic signs appear to help in identification of patients likely to have a poor result from surgery due to the psychogenic component leading to symptom magnification and central sensitization. ⁵⁰

Functional Assessment Tools ^{44, 45, 46, 47, 48, 49}

Many scoring systems are used to evaluate low back pain in patients with the emphasis of measuring the level of functional disability. Most frequently used functional assessment scales and or scoring systems for low back pain is the Oswestry Disability Index (ODI) and Roland-Morris Disability Questionnaire (RMQ).

Oswestry Disability Index (ODI)

• Questionnaire that examines perceived level of disability in acute and chronic population of low back pain sufferers in 10 domains of everyday activities of daily living
  • 10 Domains: Pain Intensity, Lifting, Walking, Standing, Social Life, Employment/Homemaking, Personal Care, Sitting, Sleeping, Traveling
• Scoring: 0-5 by degree of difficulty translated into a percentage score
• Score Interpretation: 0 (no disability) to 100 (maximum disability) ⁴⁶
  • 0-20: Minimal Disability
  • 20-40: Moderate Disability
  • 40-60: Severe Disability
  • 80-100: Bedbound

Roland-Morris Disability Questionnaire

• 24 items reflecting execution of daily physical activities and functions that may be affected by LBP.
  • Includes: Mobility, Work, Sleeping, Recreation, Dressing/Grooming, Standing, Mood and Appetite
• Scores greater than 13 have shown significant disability associated with an unfavorable outcome.

Medical Outcomes Study Short-Form 36

• Generic 36 points measuring health status and outcomes from patients point of view in 8 scales measuring physical and mental health
  • Limitations in physical activities because of physical health problems, limitations in usual role activities (physical and emotional), bodily pain, general health perceptions, vitality, limitations in social activities, mental health

Quebec Back Pain and Disability Scale

• 6 domains of activity affected by back pain with a total of 20 items
  • Bed/Rest, Sitting/Standing, Ambulation, Movement, Bending/Stooping, and Handling of Large/Heavy Objects
• Scoring: 0-5 indicating level of difficulty translated into a percentage score

Waddell Disability Index

• 9 Questions
  • Help/Avoidance of lifting heavy, sitting limited to less than 1.5 hours, Traveling less than 1.5 hours, Standing in place less than 1.5 hours, Walking less than 1.5 hours, Sleep Disturbance, Regularly Missing Social Activities, Sexual Activity, Aid with Footwear
• Scoring: Yes or No; Minimum 0; Maximum 9
  • Greater score = greater disability

Imaging Modalities

Non-Invasive Imaging and Lab Studies

Generally, laboratory studies are non-diagnostic, but may be required for work-up of systemic inflammatory disease, infection, or malignancy including complete blood count (CBC) with differential, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and blood cultures.

• Plain Films
  • Can demonstrate disc space narrowing consistent with degenerative disc changes, and can rule out instability (flexion and extension views) from spondylolysis and/or spondylolisthesis. ⁷

• CT Scan
  • Can better visualize bony elements such as when a bone spur is pressing on a nerve. ⁷

• Magnetic Resonance Imaging (MRI) is the optimal investigation
  • Imaging is not indicated unless more than 6 weeks have passed or a red flag is present in the history or physical examination
  • Findings may not correlate well with symptom severity or surgical indication or outcome; however, findings of a high intensity zone could potentially be specific and predictive of a symptomatic disk with severe annular tear.
  • Vertebral body endplate signal intensity changes can be seen on MRI in the setting of degenerative disc disease of the lumbar spine.
  • These signal intensity changes were first described and classified by Modic et al in 1988 and have been since referred to as Modic changes.⁴
  • Three types of Modic changes are identified:
    • Modic Type I: represent bone marrow edema and inflammation and appear hypointense on T1-weighted imaging (T1WI) and hyperintense on T2-weighted imaging (T2WI).
    • Modic Type II: are associated with fatty replacement of normal hematopoietic bone marrow and appear hyperintense on T1WI and isointense or slightly hyperintense on T2WI.
    • Modic Type III changes represent subchondral bone sclerosis and appear hypointense on both T1WI and T2WI.
• The Pfirmann Grading System ^{6, 37}
  • Assesses degenerated intervertebral discs by MRI for the asymmetry in disc structure, distinction of the nucleus and the annulus, signal intensity of intervertebral discs and height of intervertebral discs and assigns grade I to V for disc degeneration.
  • Functional imaging techniques such as MR spectroscopy, T1p calculation, T2 relaxation time measurement, diffusion quantitative imaging, and radio nucleotide imaging provide measurement of some of the degenerative features.^{7, 31}

Invasive Imaging

• Provocative Discography (PD)
  • Provocative discography is a diagnostic procedure used primarily to confirm a discogenic source as the primary pain generator in a patient. The information obtained from the test is used to rule out or plan treatment whether interventional or surgical. The following are ideal situations to use this test:
    • More than one abnormal intervertebral disc and the primary pain generator is in question. ⁵¹
    • Determining potential for morbidity when surgical treatment is questioned (i.e. spinal fusion) with emphasis in determining if the disc adjacent to the proposed instrumented segment is painful or disrupted. ⁵¹
  • Assesses for pain concordant with DLP after injection of radiographically corroborated levels with saline or contrast.
  • High sensitivity but low specificity for discogenic pain.
  • Potential high false-positive rate.
  • The Derby Criteria area well described method for interpreting discography A pain level of 7 or higher during injection, pain reproduction at a pressure less than 50 mmHg above opening pressure, injected contrast volume of 3.5 mL or less, and a pain-free control disk at an adjacent level indicate a positive discography.^{8,9, 37}
  • A nucleogram performed after discography which shows an annular tear of grade III or higher on the Modified Dallas Discogram Description Scale confirms the diagnosis of internal disc disruption. ³⁷
  • Use of provocative discography is controversial as individuals undergoing this procedure are found to have increased risk of disc herniations, loss of disc height and endplate changes.

Social and Familial Factors

Although genetic and demographic characteristics are primary risk factors for DLP, socioeconomic factors are important risk factors for pain and disability.¹⁵

Poor prognosis in low Back Pain (LBP) and disability are associated with job dissatisfaction, physically strenuous work, psychologically stressful work, low education level, and litigation or other secondary gain and lack of effective insurance coverage.

Good social support is associated with less pain and disability.¹⁵

Familial predisposition to DLP may be relevant in prevention and screening.

• Families with 2 or more subjects with DLP at risk.
• In pre-employment screenings, subjects from predisposed families could be redirected to work activities with lower abnormal functional stresses and protective ergonomic measures.¹⁶

CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

The ideal approach to intervention of discogenic back pain remains in question given the multifactorial nature of the disease process and lack of proper non-invasive diagnostic strategy. This is in contrary to spinal surgical approaches that are effective in clear cut spinal deformities, radicular pain from herniation, spinal stenosis and spondylolisthesis and other spinal conditions. Current treatment options range from conservative to surgical and interventional/regenerative approaches.

Lower back pain treatment in general focuses initially on non-operative management including physiotherapy, the use of non-narcotic pain medication, progressive core strengthening, utilizing proper body mechanics, maintaining mobility, and psychological therapies including cognitive-behavior therapy (CBT) if indicated. Other modalities such as acupuncture and dry needling have shown effectiveness in this pathology as compared to no treatment. Guidelines currently advise avoiding opioid use due to the risk of abuse, misuse and hyperalgesia. Interventional and regenerative medicine approaches may surpass surgical interventions once adequate safety, reliability and efficacy are demonstrated in studies.

Conservative Treatments

• Includes oral non-narcotic analgesics, physiotherapy, psychotherapy and acupuncture/dry needling, judicious use of spinal orthoses.
• Remains the first line approach in treatment algorithm.
• These strategies including CBT and acupuncture/dry needling have demonstrated good results with some comparative to surgical treatments.
• McKenzie Method of Mechanical Diagnosis and Therapy, although commonly used for lower back pain, has limited evidence for its efficacy. ^42,43

Surgical Interventions

No significant superiority when compared with multidisciplinary biopsychosocial rehabilitation, physical therapy or epidural injections. Primarily indicated for failed conservative therapy.

Fusion Surgery

• Thought to stabilize the painful disc and prevent recurring discogenic pain.
• Disadvantages include adjacent segment disorder that can accelerate degeneration due to excess loading on discs adjacent to the procedure.

Total Disc Arthroplasty

• Less risk of adjacent segment disorder.
• Increased risk of heterotopic ossification and operation risk.
• Best for spinal levels where mobility is needed (cervical).

Minimally Invasive Interventions

Intradiscal Biacuplasty or Radiofrequency

• Outpatient, thermal annular procedure (TAP) utilizing heat or cooled radiofrequency ablation of nociceptive nerves.
• Desai and colleagues compared intradiscal biacuplasty and conventional medical management together demonstrating long-term clinical effectiveness of combination therapy in pain, function, disability and satisfaction. ³²
• In a 2017 systematic review, level 1 evidence was demonstrated that percutaneous biacuplasty is efficacious in treatment of chronic, refractory discogenic pain. ³⁴
• No significant RCT data of these interventions exist to demonstrate proper efficacy for the treatment discogenic back pain.

Intradiscal Electrothermal Annuloplasty (IDEA)

• Thermocoagulation across posterior aspect of disc at the nuclear-annular junction.
• Ablates disc nociceptors, promote remodeling and decrease inflammatory mediators.
• Lack of RCT data exists to determine the efficacy of IDEA in the treatment of discogenic back pain.

Intradiscal Methylene Blue

• Previous studies showed reduction in pain severity and improvement in disability scores.
• Conflicting results in literature and more studies will be needed to confirm its efficacy. ³⁵
• The RCT results published in 2019 by Kallewaard et al. determined there is no greater efficacy for utilization of intradiscal methylene blue injections for chronic discogenic lumbar back pain in comparison to isotonic saline hydrochloride. ⁵²

Percutaneous Disc Decompression

• Procedure aimed to remove excess material to reduce intradiscal pressure to relieve the internal disc nociceptors or spinal nerve roots.
• Further literature on a larger scale needed, currently there is no evidence demonstrating efficacy for discogenic back pain.

Epidural Injection Therapy

• May have potential benefit on a case by case basis (i.e. Patients with inflammatory end plate changes have a better benefit).
• Shown in literature to be superior to fusion and disc arthroplasty. ^38,41

Regenerative Medicine

Stem Cell Therapy for Intervertebral Disc Regeneration ^{28, 29, 31, 35, 36, 38}

• Includes mesenchymal stem cells derived from bone marrow aspirate or adipose tissue, platelet rich plasma (PRP) and chondrocytes.
• Stem cell-based treatments of DDD are promising, but further clinical studies are warranted. ²⁹
• Current in vitro and in vivo studies show that stem cells have the capacity to repair degenerative disks.
• Repair occurs by differentiation toward chondrocyte-like cells, which are capable of producing proteoglycans and type II collagen.
• Mesenchymal stem cells derived from bone marrow or adipose tissue have the advantage for stem cell therapy on source, safety, and tolerance.
• Recently, a study shows that percutaneous injection of autologous bone marrow concentrate cells significantly reduced DLP through 12 months. ²⁸

Intervertebral Disc Repair or Implant Biomaterials

• Developed for annulus closures and nucleus pulposus replacement especially after discectomy.
• Risk for reherniation and adjacent tissue damage remains a set-back for many of the biomaterials.
• Total-disc tissue-engineered replacements are being developed to promote integration of the vertebral endplate while reducing herniation risk ³¹

GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

There continues to be a lack of clarity on treatment recommendations for discogenic back pain in general. Regenerative therapies and intervertebral disc repair, biomaterials, intradiscal procedures and spinal cord stimulation may show promising results as research in this area continues on a larger scale. For now, first line therapies continue to be conservative in nature and surgical interventions as second-line or adjunctive treatment options.

Improving diagnostic methods will further aid in precisely defining specific pathologies associated with this condition. Discography continues to be invasive in nature and primarily a method for those who are planned to undergo surgical intervention although with the risk of accelerated intervertebral disc degeneration. The need for an alternative noninvasive diagnostic method remains to be an area of focus to aid in localizing the pain generator and selecting an adequate therapeutic approach.

Diagnostic Gaps

Magnetic Resonance Imaging (MRI)

• MRI and the Pfirrmann scoring is widely used to grade disc degeneration.
• Modic changes are MRI signal-intensity changes in vertebral bone marrow that correlate with disc pathology.
• Type 1 Modic changes with high intensity zones have a high specificity for positive discography.
• Currently, MRI findings only show a moderate effectiveness in fully identifying the pain generator.
• Literature has consistently demonstrated a high prevalence of asymptomatic spinal changes and the low predictive value of signs in low back pain. Therefore, systematic clinical and radiological correlation is warranted. ⁵³
• New MRI sequences such as T1p are currently being investigated along with serum biomarkers to be a useful clinical tool in diagnosis of lower back pain ³¹

Provocative Discography (PD)

• Use of provocative discography is controversial and presents a large gap in evidence-based knowledge given the invasive technique, risk of accelerated degeneration and demonstration of high false positives.
• Specificity of producing concordant pain by stimulating an anatomic site has not been proven in PD.
  • In presence of chronic pain, there is increased responsiveness to normative innocuous stimuli. Furthermore, hyperalgesia of uninjured tissue occurs around an area of injury leading to a high false positive rate.
  • Stimulation of structures proximal to a lesion may mimic patient’s usual pain.
  • Psychogenic pain may also be simulated by anatomical stimulation. Therefore, it cannot be assumed that reported reproduction of pain by stimulation of an anatomic structure implicates the disk as the primary pain generator.³⁰
• The lack of consistency of literature for highly efficacious interventions for discogenic back pain limit the degree to which discography findings can lead to improved patient outcomes.

Biomarkers

• Many biomarkers have been described in literature to be used as a diagnostic tool in low back pain although research in this area is ongoing. ³¹

Treatment Gaps

Non-Operative Treatments

• Mesenchymal Stem Cells, Bone Marrow Aspirate, PRP, Chondrocytes
  • There is a need for more high quality studies for the safety, efficacy and reliability of these interventions on a larger scale.

Interventional

• Dorsal Root Ganglion Stimulation/Spinal Cord Stimulation
  • Recent small study of DRG stimulation for discogenic LBP improved level of pain, function and quality of life ³²
  • Small sample size and further research needed to determine the place of spinal cord stimulation in the treatment algorithm.

Surgical Interventions

• Spinal Fusion
  • Small- to moderate-average benefits from surgery versus nonsurgical therapies seen in highly selected patients, and the majority of such patients undergoing surgery do not experience an optimal outcome.
  • In comparing nonsurgical treatment for non-radicular LBP with degenerative disc disease, lumbar inter-body fusion is probably not very effective.
• Total Disc Arthroplasty
  • Known to have less adjacent disc degeneration complications although similar efficacy when compared to spinal fusion.
  • May be replaced with further development and research of intradiscal procedures, regenerative therapies and disc repair/biomaterials.

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Original Version of the Topic:

Alexios Carayannopoulos, DO. Discogenic Lumbar Pain. Publication Date: 2011/11/10.

Previous Revision(s) of the Topic

Alexios Carayannopoulos, DO. Discogenic Lumbar Pain. Publication Date: 04/13/2016.

Author Disclosures

Adeepa D. Singh, MD
Nothing to Disclose

Karen Pechman, MD
Nothing to Disclose

Safwan Zar, MD
Nothing to Disclose