Internal disc disruption
Original Editors - Alexander Chan
Top Contributors - Alexander Chan, Dorien De Strijcker
Definition/Description[edit | edit source]
Internal disc disruption, first proposed by Crock (1970), has been defined as lumbar spinal pain, with or without referred pain, stemming from an intervertebral disc, caused by internal disruption of the normal structural and biochemical integrity of the symptomatic disk.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Crock (1970) postulated that traumatic damage to the vertebral end plate could cause an irritant substance to drain into the spinal canal and/or vertebral body. This could initiate an autoimmune response, causing an internal process of disc degradation, which would lead to annular tearing and irritation of the free nerve endings in the outer third of the annulus fibrosis.
Clinically Relevant Anatomy[edit | edit source]
Click on the link for more specific details about intervertebral disc.
Epidemiology /Etiology[edit | edit source]
Internal disc disruption is a subgroup of discogenic pain. The epidemiology/etiology of discogenic pain can be found here andhere.
The prevalence of IDD has been estimated to be 39% (95% CI: 29% to 49%) in ninety-two patients with chronic LBP.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In a more recent study, it has been estimated at 42% (95% confidence interval [CI] = 35% to 49%).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Characteristics/Clinical Presentation[edit | edit source]
Crock’s (1986) description of IDD included the following features:
- Intractable back pain with aggravation of pain and low of spinal motion with any physical exercises
- Leg pain
- Loss of energy
- Marked weight loss
- Profound depressionCite error: Invalid
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In the IASP’s Classification of Chronic Pain, IDD has the features of:
- lumbar spinal pain, with or without referred pain in the lower limb girdle or lower limb;
- aggravated by movements that stress the symptomatic diskCite error: Invalid
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According to Sehgal (2000), most of the patient’s experience:
- diffuse, dull ache
- a deep-seated, burning, lancinating pain in the back
- a sensation of a weak, unstable back
- referral of pain into the hips and lower limbs is not uncommon.
- a varying degree of sitting intolerance
- lumbar spine movements are slow, guarded and restricted
- a history of lifting trauma precedes the back pain in acute cases
- pain and muscle spasm are less dramatic and more nondescript in persistent casesCite error: Invalid
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Differential Diagnosis[edit | edit source]
- 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 pulposusCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
- Degenerative disc disease:
The intervertebral disc transitions from being asymptomatic to pain generating as a result of degenerative changes. Although altered disc morphology may be asymptomatic, various mechanisms that may give rise to a symptomatic degenerate disc exist.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Diagnostic Procedures[edit | edit source]
Physical examination alone is insufficient to establish a diagnosis of IDD. Diagnostic imaging, however, has contributed to the understanding of IDD.
Plain Xrays and Computerized Tomograms (CT) are generally normal.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Magnetic Resonance Imaging (MRI) of the lumbosacral spine can identify areas where there are changes to signal intensity, with a loss of signal intensity correlating with abnormal disc morphology on discography.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Provocative discography is physiologic test that explicitly determines whether a disc is painful. The disc suspected of causing pain is injected with radiolucent dye. The aim is to provoke clinical symptoms and reveal morphological abnormalities in the annulus fibrosis.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleThe test is considered positive if the individual’s concordant pain is reproduced upon stimulating the suspected painful disc, and injection of adjacent discs does not reproduce the typical symptoms.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In asymptomatic individuals, discography is not painful, but is frequently painful in those with low back pain. A post-discography CT scan can be used to evaluate the extent of internal disruption within the disc.
Despite the clinical use of discography, its utility has been questioned due to high false positive rates.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It is also associated with procedural risks, is expensive, and can be difficult to access.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Discography has also been shown to result in accelerated disc degeneration compared to match-controls.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The criteria for diagnosing IDD from the International Association for the Study of Pain’s Taxonomy Working Group is:
1. Lumbar spinal pain, with or without referred pain in the lower limb girdle or lower limb
2. Aggravated by movements that stress the symptomatic disc
3. Diagnostic criteria for lumbar discogenic pain must be satisfied including either:
a) Selective anesthetization of the putatively symptomatic intervertebral disc completely relieves accustomed pain, or save that whatever pain persists can be ascribed to some other coexisting source or cause
b) Provocative discography of the putatively symptomatic disc reproduces the patient’s accustomed pain, but not at least two adjacent discs, and the pain cannot be ascribed to some other source innervated by the same segments as the symptomatic disc
4. CT-discography must demonstrate a grade 3 or greater grade of annular disruption
Outcome Measures[edit | edit source]
add links to outcome measures here (also see Outcome Measures Database)
Examination[edit | edit source]
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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The only convincing means to establish IDD is provocative discography as described above.
Medical Management
[edit | edit source]
1) Pharmacological management
Pharmacological management if for analgesic purposes and may include the use of Acetaminophen (Paracetamol), non-steroidal anti-inflammatories, muscle relaxants, or opioids.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
2) Minimally invasive interventional procedures:
- Intradiscal steroid injection
- Radiofrequency denervation
- Intradiscal Electrothermal (IDET) Therapy
3) Surgical treatment:
Internal disc disruption can be managed surgically by fusing the vertebrae at the level of disc disruption.
Disadvantages of surgical fusion include:
- failure to maintain the height of the intervertebral disc
- less segmental motion at the fused levels, which may contribute cephalocaudal neuroforaminal stenosis and overloading of adjacent disc levels Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Physical Therapy Management
[edit | edit source]
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 stabilisation (core stability):
Traditionally core stability has referred to the active component to the stabilizing system. This includes local muscles that provide segmental stability (eg transversus abdominis, lumbar multifidus) and/or the global muscles (eg rectus abdominis, erector spinae) that enable trunk movement/torque generation and assistance in stability in more physically demanding tasks.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This is discussed in more detail here.
2) Mechanical Diagnosis and Therapy (McKenzie Method) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title:
The McKenzie method utilizes the patient’s response to repeated lumbar movements to assess which movements reduce the individual’s most peripheral symptoms. These movements are then combined into an individualized exercise regimen. This is discussed in more detail here
Key Research[edit | edit source]
Resources
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Clinical Bottom Line[edit | edit source]
Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
