Lumbar Discogenic Pain

Definition/Description

Detailed structure of the intervertebral disc (adapted from Bogduk 2005)

Discogenic pain is responsible for approximately 28% to 40% of all patients with low back pain. [1]

The pain may be related to different types of pain that come from the muscles, bones, or joints in the spine rather than the discs or other structures in the spine. Degenerating discs can release damaging molecules and growth factors that cause nerves to grow into the disc. [2]

Discogenic pain is pain caused by stimulation of pain-sensitive afferent nerves within the annulus fibrosus and is a distinct condition from radiculopathy associated with disc herniation. [3]

Clinically Relevant Anatomy

The intervertebral disc (IVD) is the main joint between the two vertebrae in the spine. Each IVD consists of three structures:

1. The nucleus pulposus (NP) has a gelatinous interior;
2. annulus fibrosus (AF) the outer ring of fibrous tissue surrounding the nucleus pulposus;
3. Two endplates of hyaline cartilage. [2]

The endplates serve as the interface between the intervertebral disc and the vertebrae, covering the upper and lower layers of the annulus fibrosus and nucleus pulposus. The cells in the outer region of the annulus fibrosus are fibroblast-like cells that line the fibers parallel to the collagen and those There are chondrocyte-like cells in the annulus fibrosus.

The nucleus pulposus consists of randomly arranged collagen fibers and radially organized elastin fibers surrounded by a highly hydrated aggrecan-containing gel. There are a small number of chondrocyte-like cells in the nucleus pulposus [2].

Intervertebral discs mechanically resemble thick-walled fiber-reinforced pressure vessels, absorbing strain energy and transferring loads to the spine. The outer fibrous annulus provides structural stability because the vessel wall has a family of layered concentric laminar collagen fibers In different orientations (between 45° and 65° from the spinal axis), it is primarily a tensile member.

The nucleus pulposus is mainly composed of hydrophilic proteoglycans; it absorbs water and compresses the disc, it also distributes weight to the annulus fibrosus and vertebral endplates and maintains disc height. The graded properties of the intervertebral disc change with degeneration, which can be visualized Morphological biochemical and mechanical [4]

Discogenic pain is attributed to degenerative changes in the intervertebral discs due to aging or trauma. A healthy intervertebral disc in an adult has scattered nerves, mostly confined to the outer layer. A degenerated disc has nerves that pass through deeper intradiscal structures to the inside One-third of the ring and nucleus. These nerves contain nociceptive neurotransmitters and initiate the production of cytokines that fire noxious messages from within the disc. [1]

Epidemiology/ Etiology

Discogenic pain is a type of low back pain caused by chemically or mechanically damaged intervertebral discs. [2]

This damage can find its origin in traumatic events as well as in aging-induced deterioration. High levels of pro-inflammatory mediators (cytokines) were found in patients treated for discogenic low back pain. Production of these pro-inflammatory mediators occurs in the nucleus The medulla of the intervertebral disc is often regarded as the main cause of discogenic low back pain. [1]

Characteristics/Clinical Presentation

There is extensive literature supporting the underlying mechanisms of these features as indicators of discogenic pain. Although this has not been validated, it is clinically meaningful that combining these features with radiological criteria would increase diagnostic certainty.

The symptoms of lumbar discogenic pain are not experienced in exactly the same way by every patient. Most patients with chronic low back pain often report that the pain radiates to the buttocks and legs. This pain can be unilateral or bilateral, but there is no radicular pain. These patients may also develop sitting intolerance. [5]

An important mechanism behind the diagnosis of discogenic pain is directional preference resulting from migration of the nucleus pulposus. Mechanical loading strategies (MLS) such as repetitive motion and sustained positioning can induce proximal motion and can terminate distal symptoms. it has been The researchers note that the underlying mechanism of this response is caused by a reduction or migration of a painful and abnormally displaced nucleus pulposus to a more central position in the lumbar disc, thereby reducing pain. [1][4][2]

Related to centralization is direction preference, the direction of the MLS that leads to centralization. [6][2]

Patients with directional preference due to discogenic pain can be diagnosed with reducible discogenic pain (RDP). [7]

Confident diagnosis can be obtained by assessing response to MLS CT/MRI/disc findings and other clinical features. Based on this diagnosis, a treatment plan can be developed.

Experienced practitioners hypothesize that there may be more than one type of discogenic pain, including nonreducible discogenic pain, discitis, unstable discs, and adolescent discs. [7] (From a pathoanatomical perspective, different morphological and pathophysiological changes may also represent Clinically relevant subgroups, such as endplate alterations, annular tears and changes in inflammatory/immune responses. Practitioners attempting to diagnose discogenic pain should be aware of these possible subgroups and the potential impact on patient performance.

Differential Diagnosis

• Lumbosacral Disc Injury – The cause of lumbosacral disc injury is low back pain (LBP). It is more common than muscle strains or ligament sprains. No clearly identified disc injury as a pain generator. [8]
• Lumbosacral facet syndrome – Zygapophyseal – joints are not the sole or primary cause of LBP and are often mistaken for discogenic pain. The Z-joint is one of the most common sources of low back pain (LBP). [9]
• Lumbosacral radiculopathy – However, radiculopathy is not a cause of back pain and some of the leading causes of acute and chronic low back pain (LBP) are associated with it. The etiology of lumbosacral radiculopathy is nerve root impingement and/or inflammation with neurologic symptoms. supplied by the affected nerve root. [7]
• Lumbar Spondylolisthesis – Lumbar spondylolisthesis most commonly occurs in the lower lumbar region. The cause is minor overuse trauma, specifically repetitive hyperextension of the lumbar spine. If the pars defect is bilateral, it may allow spondylolisthesis, usually L5 over S1, resulting in Spondylolisthesis[6]
• Lumbar spondylolisthesis – The causes of lumbosacral spondylolisthesis are mainly mechanical factors that can initiate or develop lumbar spondylolisthesis. There is also a genetic factor. The most common location is L5 (85%) and can be observed up to L2. Lumbosacral spondylolysis (lumbar spondylolysis) Is the cause of the most common type of spondylolisthesis. [3]

Diagnostic Procedures

Diagnostic procedures can reveal the source of 90% of chronic low back pain. There are two types of low back pain due to internal disc rupture (IDD) (IAD) and internal endplate rupture (IED). The clinically and pathologically seen term IAD is more correct than the term International direct dialing. Lumbar disc herniation without disc herniation accounts for 26%-42% of the causes of chronic low back pain. It causes nociceptive pain syndrome. The source of pain is the innervated outer third of the annulus fibrosus. [10]

Diagnosis and treatment of lumbar discogenic pain due to internal disc rupture (IDD) Internal disc rupture remains a challenge. Magnetic resonance imaging (MRI) can find areas of hyperintensity as an indirect indication of IDD.

However, relatively low sensitivity (26.7% to 59%) and high false positive (24% to 59%) and false negative rates (38%) reduce the value of MRI in screening for painful IDD.

The positive predictive value was as high as 89%. Provocative discography can provide unique information about the source of pain and disc morphology. It can also inform the selection of appropriate treatments for annular tear pain. [5]

A subsequent disc stimulation CT scan is of unique diagnostic value. The clinical manifestations of discogenic pain are not related to degenerative changes. No different from any other back pain. With a prevalence of 39%, it is one of the most important causes of death among patients There are specific sources of back pain. [5]

Outcome Measures

Several tests are available to determine the baseline for patients with lumbar discogenic pain. The questionnaire from the North American Spine Association is a commonly used tool. This has high test-retest and internal reliability. This questionnaire is recommended for [1] The Roland Morris Questionnaire is also a good tool for assessing treatment progress, but the questions in the list only ask about the examination date, they do not consider the overall Situation[4]

The pain visual scale is the instrument of last resort for patients. Patients rate themselves according to how much pain they feel. It is a modified version of the visual analog scale. [2]

Examination

Neurological tests showed that the problem was not caused by a neurological defect. These findings were confirmed by the results of the straight leg raise test, which also showed no signs of possible neurological deficits. [1]

Much of the controversy surrounding discogenic pain arises from confusion and misinformation about the diagnosis. “Disc degeneration” is a poorly defined term, perhaps best described as “an abnormal cell-mediated response to progressive structural failure. A degenerated disc is a Structural failure combined with accelerated or signs of aging”.[1]

Results of degeneration may include annular fissures, herniated discs, endplate damage, annular collapse, and disc narrowing, which in some cases can produce lumbar-related symptoms. Radiological tests such as CT scans and MRIs can image the external and internal morphology of the lesion Intervertebral discs identify this structural failure. However, these isolated changes do not predict the presence or absence of lumbar spine-related symptoms [4], and radiology alone is not recommended for the diagnosis of LBD. [2]. Lumbar discography is suspicious for the location of the IVD nucleus Lumbar pain was induced by injection of radiolucent dye with the aim of eliciting clinical symptoms and revealing morphological abnormalities of the annulus fibrosus. The test is considered positive if the patient’s consistent pain reappears upon stimulation of the suspected painful disc, and Stimulation of adjacent discs did not reproduce the patient’s typical symptoms. Carefully controlled discography is probably the best diagnostic tool for discogenic pain, although it carries significant risks [10] and has a relatively high rate of false positives. [5]

From the literature it is clear that a single test for diagnosing discogenic pain is not possible and thus the ‘diagnostic accuracy’ approach to assessing the validity of clinical tests is somewhat flawed. [8]

From a clinical perspective, however, many features have long been associated with discogenic pain based on hypothesized and proven causal mechanisms. [9] These characteristics have been identified in a recent Delphi study by international experts [7] and are summarized in the table below:

A generation. Direction preference ii. Prolonged sitting (>60 minutes) can exacerbate symptomiii. Lifting heavy objects aggravates symptoms iv. Forward bending aggravates symptoms v. Symptoms are aggravated by sitting. Coughing/sneezing can aggravate symptoms. work experience Heavy manual processing viii. Injury mechanisms are related to flexion/rotation and/or compressive loadingix. Worse symptoms the next morning or the day after the injury

Medical Management

Minimally invasive treatments bring alternatives to discogenic pain to be more cost-effective and reduce long-term side effects (if possible). The effectiveness of most of these therapies has not been established.

More clinical research is needed to improve the clinical efficacy of minimally invasive treatment of lumbar discogenic pain [5]. Other therapies include nonsteroidal anti-inflammatory drugs (NSAIDs) physical therapy rehabilitation antidepressants antiepileptics and acupuncture Used for low back pain. The effectiveness of these treatments for discogenic pain has not been established. [5]

Thermal Loop Procedure (TAP) was developed to provide a minimally invasive treatment for this complaint. Various techniques are used such as Intradiscal Electrothermal Therapy (IDET) Radiofrequency Plasty and Intradiscal Binatoplasty (IDB). But these treatments Continuation has to do with lack of evidence. [7]

• Intradiscal Electrothermal Therapy (IDET) – This is a minimally invasive treatment option between conservative non-surgical treatment and spinal surgery. Patients with mild disc degeneration can achieve remaining clinical improvement. [8] It may relieve pain in a small percentage of people In patients[5] the procedure appeared to provide adequate symptom progression without additional complications. [9] It also significantly reduces function in 50% of patients with chronic discogenic low back pain. [7]
• Radiofrequency annuloplasty – There is little evidence to support the use of radiofrequency annuloplasty. [7]
• Intradiscal Binatoplasty (IDB) – Clinical benefit observed in the study by Kapural et al. is a result of non-placebo treatment effects given by IDB [6], but little evidence supports the use of IDB in other studies. [7] This should be recommended as an option for patients with Chronic discogenic low back pain. [6]

Other treatments are :

• Dual Ring Pulsed Radiofrequency Disc Method – Continuous P-RF 5/5/60 V for 12 minutes (using Diskit needles) The dual ring pulsed radiofrequency disc method appears to be a safe, minimally invasive treatment option for patients with chronic discogenic low back pain. [3]
• Intradiscal Steroid Injections – This approach has not been shown to determine long-term benefits. [5]
• Intradiscal radiofrequency thermocoagulation – No benefit was found for intradiscal radiofrequency thermocoagulation. [5]
• Spinal fusion – If spinal fusion surgery is performed, the goal is to stop motion at the painful vertebral segment. There are many different methods, but they all involve the following process: first, they add bone graft to a section of the spine; second, they establish a biological response, This results in bone graft growth between the two vertebral elements. This creates bony fusion, causing a fixed bone to replace a movable joint, so it stops that part’s movement. [10]
• Ramus communicans block – A block in the ramus interrupts the transmission of pain information from the intervertebral disc to the central nervous system. [5]
• Disc Cell Transplantation – Disc cell transplantation is in the experimental stage and it has the potential to be useful in the prevention and treatment of discogenic pain. [5] More research is needed.

Physical Therapist Management

In one case study, the therapist chose to introduce left lumbar scoliosis into the treatment. The patient was placed in left decubitus and asked to bend to one side on a pillow. He used a non-weight-bearing position because the patient reported that her symptoms were getting worse After eight repetitions, perform as a weighted side slide.

Another thing that is introduced is the lateral planar movement by repeating the rotation to the right from the left bent position. This joint movement completely eliminated the patient’s pain and restored a considerable range of motion in the sagittal plane after another standing test. this The treatment is equivalent to flexion-rotation mobilization, with the notable difference that in the latter approach the motion comes from below. The patient also did some homework during treatment. She was sent home and instructed in posture dos and don’ts, and Repeat right turns in left decubitus position 6-8 times a day. [5]

Treatment of all possible types of discogenic pain is complex and beyond the scope of this article. There are many different treatments, but not all of them have been proven to be effective. Some examples of possible treatments for low back pain are acupuncture, anti-inflammatory drugs, physical therapy Rehabilitation Antidepressants Antiepileptics and Complementary Therapies. Some treatments have been shown to be effective, but only in specific patient groups, and they have not always shown long-term benefits. Intradiscal steroid injections and intradiscal electrothermal therapy are well known Example of this problem. Furthermore, no clear benefit of intradiscal radiofrequency thermocoagulation was found. [5]

In carefully identified cases of RDP, a regime can be applied whereby regular participants apply helpful MLS educational postural advice lumbar taping techniques, and in some cases force applied by the therapist.

To assess the response to MLS, you need to be careful. A recent randomized controlled trial of treatment-reducible discogenic pain used the following criteria. Respond positively to at least 10 repetitive movements or a period of sustained positioning by:

• At least a 50% increase in the possible range of motion of the MLS during application or
• Lumbar spine range of motion increased by at least 50% in any movement after application OR
• Increased intersegmental motion observed during lumbar active range of motion testing after application or
• Improvement in rest pain [10] lasting at least 1 minute after application (at least 1 point improvement on a numerical rating scale or symptom concentration) or
• Abnormal reduction in observed lateral shift posture persisting for at least 1 minute after application [7]

The table below summarizes the key components of an effective treatment regimen for RDP:

Treatment Protocol Components Rationale Determine if there is clinical evidence of inflammation (at least 2: nocturnal waking symptoms due to persistent early morning pain symptoms > 60 minutes) McKenzie method is used primarily for mechanical problems and inflammation if present Specific management is required to assess associated MLS and identify key asterisks in the absence of inflammation. Identification of the most effective MLS for treatment Interpretation of treatment time frames and recovery expectations with respect to RDP regimens. get participants involved Course of treatment is critical for effective specific treatment Inflammation management (if applicable) including information sheets Lumbar taping Pharmacy consultation recommended for over-the-counter NSAIDs and walking program Posture/Mobility NSAIDs and subclinical mobility in neutral spinal position can prevent excessive and counterproductive inflammatory responses In the absence of inflammation, provide appropriate doses of relevant MLS and reassess asterisks. Additional hypothesis testing provides assignments Apply the relevant MLS regularly as practice. Self-management of RDP through the home application of MLS is an important part of the McKenzie Method providing lumbar rolling posture education, a walking program, and lumbar taping in a neutral lumbar position. these strategies Described in the information sheet Participant education about postural control is an important part of the McKenzie method

The application of the MLS needs to be carefully executed according to the following criteria:

• Ensuring correct starting position
• Clear and specific descriptions of participants
• Physiotherapist carefully observes performance of MLS participant
• Provide verbal and tactile feedback to participants during and after MLS
• In most cases, participants were instructed to perform MLS until the onset of pain. If the pain episode progresses further into the MLS range during application, the trial physical therapist encourages the participant to advance the movement to the new pain onset point with a view to ending the possible range
• Closely monitor symptom response, including centralization during and after MLS

MLS is usually recommended as a home exercise with 6-10 repetitions every 1-2 hours (carefully monitor the patient’s response to symptoms). Patients with true RDP tend to respond rapidly within a few days. If this does not occur, the accuracy of the diagnosis should be considered.

DPM is rarely used alone to treat discogenic pain, but is used in combination with other treatments, including manual therapy, motor control training and functional restoration. In the presence of significant psychosocial and neurophysiological factors, the administration of DPM should Carefully weigh other therapeutic approaches (e.g. cognitive-behavioral approaches to graded activity neurophysiological education). [6][3][1][4][2][10]

Key Research

Adams, M. and P. Roughley (2006). What is disc degeneration and its causes? Spine 31(18):2151-2161

Maurer P Block JE Squillante D. Intradiscal electrothermal therapy (IDET) effectively relieves symptoms in patients with discogenic low back pain. J Spinal Disorders Tech. Year 2008