Internal disc disruption
It is assumed that Internal Disc Disruption (IDD) is an important cause of low back pain. Crock defined that the affected disc in IDD is rendered painful by changes in its internal structure, while its external appearance remains normal. In particular he reported annular fissures that distort the internal architecture of the disc while the disc externally appears intact and undeformed. This forms the major difference between IDD and disc herniation, which shows a true disruption of the external structure. IDD is not the same as disc degeneration. It’s a condition in which you can speak of a degeneration of the matrix of the nucleus pulposus with radial fissures that penetrate the annulus fibrosus but do not reach the outer lamella.
IDD of the lumbar intervertebral disc is often overlooked as possible diagnosis in chronic low back pain.
Clinically Relevant Anatomy
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Chronic low back pain is the major cause of work-related disability in people under age 45. Only a few of these patients (< 15%) has a discus herniation, which compromise a nerve-root. The majority of this population (85%) suffers from non-neurological back pain and a significant proportion of these patients are assumed to be related to musculoligamentous injury or degenerative changes. Internal disc disruption is a common entity.
30% to 50% of people with chronic low back pain become an IDD diagnosis. In principle, any structure in the spine can be a possible source of pain because it is innervated (rich innervation of the outer third of the annulus fibrosus, extended nerve fibers in the middle third of the annulus).
Most patients experience:
- Diffuse, dull ache
- Deep-seated, burning, lancinating pain in the back
- Movements in the lumbar s pine are slow
- Movements in the lumbar spine are guarded and restricted
Some patients experience:
- Sensation of weak, unstable back
- Referral pain in hips and lower limbs (not uncommon)
Earlier lifting movements with trauma are the cause of the back pain.
Further on, lumbar fusion is de second most common cause of low back pain.
Pain and muscle spasm are less striking and dramatic
In general: nondescript pain and a negative physical examination in a severely apprehensive patient is the most common clinical scenario.
- Disc herniation:
In which the herniated nucleus pulposus is capable of generating back/leg pain when it causes a mechanical compression of the nerve-root.
- Ruptured disc:
Fernston observed that a simple, ruptured disc without herniation can have a clinical presentation similar to herniated nucleus pulposus.
Pain and movement disability are two important clinical signs for IDD. Otherwise, it’s typical that radiology and CT images are normal.
The modern diagnostic imaging has played a role in understanding IDD. This involves the following techniques:
- Plain X-Ray:
o Usually negative
- Computerized Tomograms:
o Lumbar spine and myelograms are essentially normal
o Low-density zones in the annular region of the intervertebral disc (high-quality routine CT scans) may suggest annular pathology
- Magnetic Resonance Imaging (MRI) of Lumbosacral Spine
o Features internal disc morphology and disc hydration (well-hydrated: bright white)
- Lumbar Discogram/Postdiscography computerized tomography
o Physiologic test that explicitly determines whether a disc is painful
Stimulation affected disc: reproduced pain (irrespective of the morphology)
Control: stimulation of 1 or 2 other discs in which reproducing pain will fail
The definitive diagnosis can be established, using two tests:
- Provocation discography which reproduces the pain
- CT discography to demonstrate the internal disruption (reveal grade 3 radial fissures)
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It is very difficult to establish a clinical diagnosis only based on history and physical examination when there are no objective clinical findings. There is no clinical test that can make a distinction between IDD patients and patients with other conditions. The only convincing means to establish this diagnosis is provocation discography.
1) Conservative nonsurgical treatment:
- Intradiscal steroid instillation
- Radiofrequency denervation
- Intradiscal Electrothermal (IDET) Therapy
2) Surgical treatment:
Internal disc disruption can be managed surgically by a fusion. It’s necessary that the surgeon identifies the affected disc. Furthermore he needs to decide the number of levels he wants to fuse, this means: fusion of the anterior interbody only or a combined anteroposterior fusion. He has to determine the necessity for instrumentation as well.
Two important disadvantages of surgical fusion are:
- failure to maintain the height of the intervertebral disc
- less segmental motion on the fused levels
==> contribute cephalocaudal neuroforaminal stenosis and overloading of adjacent disc levels
Crock was the first in describing the anterior lumbar fusion and reported an union rate of 96% and a high return-to-work rate. The success of this management varies between 46% and 86%.
In 60% to 75%, good pain relief is listed. Return-to-work rate is estimated on 68% after an average period of 6 months. Common postoperative complications are: retrograde ejaculation, graft extrusion and pseudoarthrosis.
Physical Therapy Management
Low back pain limits patients in their ADL-activities and their ability to work. Furthermore, it has a negative influence on the quality of life. The main goals of treatment are improving function and quality of life, treat pain and in long term, prevent future back injury and disability.
1) Dynamic lumbar stabilization:
Pelvic positioning is important for postural control of the spine.
=> Achieve musculoligamentous control of lumbar lordosis in flexion and extension movements
3 levels in dynamic lumbar stabilization program:
- Basic level:
Exercises in the supine or prone position
- Intermediate level:
Exercises in kneeling and later on standing position
- Advanced level:
Movements of position transition
=> Each exercise has the aim to develop an isolated co-contraction muscle patterns and stabilize the lumbar spine in its neutral position (= most comfortable position for patient). A strengthening program of abdominal muscles, back extensors and pelvic stabilizers will brace the spine and helps the patient to find and maintain his neutral spine position.
2) McKenzie exercise program:
Some patients do not respond to the mechanical approach of the McKenzie approach such as patients with extruded disc fragments, lumbar stenosis and internal disc disruption.
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add appropriate resources here
Clinical Bottom Line
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Recent Related Research (from Pubmed)
- ↑ 1.0 1.1 1.2 1.3 Schwarzer A.C., Aprill C.N., Derby R. et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 1195;20:1878-1883. Level of evidence: B
- ↑ Crock H.V. Internal disc disruption. A challenge to disc prolapse fifty years on. Spine 1986; 22:650-3 Level of evidence: C
- ↑ DePalma M.J. iSpine – Evidence-Based Interventional Spine Care. New York: Demos Medical Publishing: 2011. Level of evidence: D
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Sehgal N., Fortin J.D. Internal Disc Disruption and Low Back Pain. Pain Physician 2000; 2(3): 1143-157. Level of evidence: A2
- ↑ DePalma M.J., Ketchum J.., Saullo T. What Is the Source of Chronic Low Back Pain and Does Age Play a Role? Pain Medicine 2011; 12: 224–233 Leve of evidence: B
- ↑ DePalma M.J., Ketchum J.M., Saullo T.R. Etiology of Chronic Low Back Pain in Patients Having Undergone Lumbar Fusion. Pain Medicine 2011 APR 11; 12(5): 732-739. Level of evidence: B
Evidence Based Practice
Learn about Evidence Based Practice in this month's members learn topic with book chapters from Practical Evidence-Based Physiotherapy 2012 & Evidence-Based Practice Across the Health Professions 2013