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Lumbar Discogenic Pain

Original Editors - Jon Ford as part of the STOPS Project.

Top Contributors - Evan Thomas, Admin, Jon Ford, Anne-Laure Vanherwegen, Kim Jackson, Lucinda hampton, WikiSysop, 127.0.0.1, Rachael Lowe and Wanda van Niekerk

Description

Lumbar discogenic pain is a common cause of low back pain, accounting for approximately 28 to 40% of low back pain cases. It is pain that originates from the intervertebral discs in the lumbar (lower) region of the spine.

The intervertebral disc consists of three main parts:

  1. The nucleus pulposus - a gelatinous inner core
  2. The annulus fibrosus - an outer ring of fibrous tissue that surrounds the nucleus pulposus
  3. Two endplates of hyaline cartilage

Discogenic pain occurs when there is damage or degeneration to these disc structures, particularly the annulus fibrosus. This can lead to the release of nociceptive molecules and growth factors, resulting in nerve ingrowth into the disc.

Key features associated with lumbar discogenic pain include:

  • Pain aggravated by prolonged sitting (>60 minutes)
  • Pain worsened by lifting, forward bending, and moving from sitting to standing
  • Symptoms exacerbated by coughing or sneezing
  • A history of working in jobs involving heavy manual handling
  • Pain that is worse in the morning or the day after an injury

Patients often report pain radiating into the buttock and leg, which can be unilateral or bilateral, but without radicular pain. Many patients also experience sitting intolerance.

It's important to note that the severity of pain doesn't necessarily correlate with degenerative changes visible on imaging. Diagnosis typically involves a combination of clinical features, patient history, physical examination, and in some cases, specialized tests like discography.

Treatment options for lumbar discogenic pain can include conservative approaches like physical therapy, medication, and lifestyle modifications, as well as more invasive procedures in some cases. The effectiveness of treatments can vary between individuals, and a personalized approach is often necessary.[1].[2].[3]

Clinically Relevant Anatomy

The intervertebral disc (IVD) is the principal joint between two vertebrae in the vertebral column.
Each IVD is composed of three structures:

  1. The nucleus pulposus (NP), a gelatinous inner part;
  2. The annulus fibrosus (AF), an outer ring of fibrous tissue that encloses the nucleus pulposus;
  3. Two endplates of hyaline cartilage.[2] 

For an detailed read see Intervertebral Disc

Epidemiology

  • Lumbar disc disease is very common, with a high prevalence even in asymptomatic individuals.
  • Intervertebral disc anomalies are found in 25% of people under 60 years old, and over 50% in those above 60.
  • Discogenic pain accounts for approximately 28 to 40% of low back pain cases.
  • When a specific source of back pain can be identified, discogenic pain is one of the most significant causes, with a prevalence of 39%.[4]

Etiology

  • There is a strong familial predisposition to discogenic pain.
  • Risk factors include advanced age, male sex, and smoking.
  • Certain occupations increase the risk, particularly those involving:
    • Prolonged sitting positions
    • Exposure to vibratory forces
    • Physically strenuous activities
    • Repetitive motions
  • Truck drivers are specifically mentioned as being at higher risk.
  • Intradiscal pressures increase during sitting, which may contribute to disc degeneration.
  • The primary cause is intervertebral disc degeneration, which is described as an aberrant, cell-mediated response to progressive structural failure.
  • Outcomes of degeneration can include annular fissures, disc herniation, endplate damage, collapse of the annulus, and disc narrowing.

It's important to note that the presence of disc degeneration or lesions doesn't necessarily mean they are the cause of pain, as these changes are also common in asymptomatic individuals. The correlation between clinical presentation and imaging findings is crucial for accurate diagnosis.[2].[1]

Characteristics/Clinical Presentation

Repeated extension in lying: a common mechanical loading strategy
Repeated extension in lying: a common mechanical loading strategy

Clinical presentation of lumbar discogenic pain typically includes:

  1. Low back pain, often chronic
  2. Pain radiating into buttock and leg (uni- or bilateral), without radicular symptoms
  3. Sitting intolerance
  4. Pain aggravated by prolonged sitting (>60 minutes)
  5. Symptoms worsened by lifting, forward bending, and sit-to-stand movements
  6. Pain exacerbated by coughing or sneezing
  7. Symptoms worse in the morning or day after injury onset
  8. Possible directional preference (certain movements or positions alleviate or worsen symptoms)
  9. History of working in jobs with heavy manual handling
  10. Mechanism of injury often associated with flexion/rotation and/or compression loading

It's important to note that the clinical presentation can vary between patients and may not always include all these features.[5].[1][6] [7][2][8]

Differential Diagnosis

Differential diagnoses for lumbar discogenic pain include:

Lumbosacral Facet Joint Syndrome Lumbosacral Radiculopathy Lumbosacral Spondylolisthesis Lumbosacral Spondylolysis Paraspinal Muscle sprain or strain Ligament sprain or strain

Accurate diagnosis requires a detailed history, careful physical exam, and appropriate imaging. The clinical presentation of lumbar discogenic pain can be similar to other types of back pain, making differentiation challenging. A comprehensive assessment is crucial to rule out other potential causes and confirm discogenic pain as the source..[4]

Diagnostic Procedures

Diagnostic procedures for lumbar discogenic pain include:

  1. Detailed patient history
  2. Physical examination
  3. Neurological tests
  4. Straight Leg Raise test
  5. Imaging (MRI, CT scan) to assess disc morphology
  6. Provocative lumbar discography (controversial but considered best available tool)
  7. Pain provocation tests (e.g., pressure on spinous process)
  8. Lumbar overpressure test
  9. Assessment of directional preference

No single test is definitive. Diagnosis typically involves combining clinical features, patient history, physical examination findings, and imaging results.[9][5]

Outcome Measures

Several tests can be used to determine the bottom line for patients with lumbar discogenic pain. The questionnaire from The North American spine society is a frequently used instrument. This has a high test-retest reliability and internal reliability. This questionnaire is recommended to be used for monitoring of individual patient’s progress during treatment.[1]
The Roland Morris questionnaire is also a good instrument to evaluate the progress during treatment but the questions on the list only ask about the situation on the date of examination, they do not consider the whole situation.[6]

The pain visual numeric is the last frequently used instrument for patients. The patients score their selves themselves by the amount of pain they are feeling. It is a modified version of the visual analogue scale.[2]

Examination

The examination for discogenic back pain involves several components:

1.Patient history: This is crucial, as discogenic low back pain typically increases when sitting, flexing the back, coughing, or sneezing - activities that generally increase intradiscal pressure.

2.Physical examination: While there's no definitive method to determine discogenic pain, some clinicians consider:

  • Biphasic straightening from flexion
  • Pain from pressure on the spinous process
  • Lumbar overpressure test: The therapist pushes downwards on the patient's shoulders while they sit on the examination table. A positive test provokes pain.

3. Provocative tests:

  • The patient can make a rounded back to provoke the anterior part of the disc
  • A hollow back can be used to provoke the posterior part of the disc

4. Imaging: Additional examination such as MRI and CT is often needed to determine discogenic low back pain.

5. Diagnostic procedures: Lumbar discography may be used, where radiolucent dye is injected into the suspected painful disc to provoke clinical symptoms and reveal morphological abnormalities.

6. Differential diagnosis: It's important to rule out other causes of low back pain, such as facet joint syndrome, radiculopathy, spondylolisthesis, spondylolysis, and muscle or ligament strains.

7. Neurological examination: This includes tests like straight leg raising for lower back issues.

8. Outcome measures: Tools like the North American Spine Society questionnaire, Roland Morris questionnaire, and pain visual numeric scale may be used to assess and monitor the condition.

  • It's important to note that a single definitive test for diagnosing discogenic pain is not possible, and the diagnosis often relies on a combination of these examination methods.[1][6][9][10][8][5]

From a clinical perspective however, a number of features have long been associated with discogenic pain based on hypothetical and proven causal mechanisms.[11]
These features have been identified in a recent Delphi study of international expertsand are summarised in the following table:

i. Directional preference
ii. Symptoms being aggravated by prolonged sitting (>60 minutes)
iii. Symptoms being aggravated by lifting
iv. Symptoms being aggravated by forward bending
v. Symptoms being aggravated by sit to stand
vi. Symptoms being aggravated by cough/sneeze
vii. History of working in a job with heavy manual handling
viii. The mechanism of injury being associated with flexion/rotation and/or compression loading
ix. Symptoms much worse the next morning or day after onset of injury

Medical Management

Minimally invasive treatments bring alternatives for discogenic pain in order to cost-effectiveness and less long-term side effects (if possible). Effectiveness of most of these therapies is yet to be established.

More clinical studies are needed to improve the clinical efficacy of minimally invasive treatments for lumbar discogenic pain.[5]  Additional therapies, including nonsteroidal anti-inflammatory drugs (NSAID’s), physical therapy, rehabilitation, antidepressants, antiepileptic’s and acupuncture have been used for low back pain. The effectiveness of these treatments for discogenic pain is yet to be established.[5]

Thermal annular procedures (TAPs) have been developed in an effort to provide a minimally invasive treatment for this complaint. Multiple techniques such as intradiscal electrothermal therapy (IDET), radiofrequency annuloplasty and intradiscal biacuplasty (IDB) were used.
However, these treatments continue to be controversially associated with a lack of evidence.[8] 

  • Intradiscal electrothermal therapy (IDET) - This is a minimally invasive treatment option between conservative nonoperative management and spinal surgery. Remaining clinical improvements can be realized in patients with mild disc degeneration.[10] It may offer some pain relief for a small group of patients.[5] This procedure appears to offer sufficiently symptom progress without additional complications.[11] It also offers functionally significant relief in 50% of chronic discogenic low back pain patients.[8] 
  • Radiofrequency annuloplasty - There is minimal evidence supporting the use of radiofrequency annuloplasty.[8] 
  • Intradiscal biacuplasty (IDB) - The clinical benefits observed in the study of Kapural et al. are the result of non-placebo treatment effects given by IDB,[7]but there is minimal evidence supporting the use of IDB in other studies.[8] This should be recommended as a selection method for patients with chronic discogenic low back pain.[7] 

Other treatments are :

  • Bi-annular pulsed radiofrequency disc method - The bi-annular pulsed radiofrequency disc method with consecutive P-RF 5/5/60 V, 12-min (with Diskit needle), appears to be a safe, minimally invasive treatment option for patients with chronic discogenic low back pain.[3] 
  • Intradiscal steroid injections - This method has not been proved to determine long-term benefits.[5] 
  • Intradiscal radiofrequency thermocoagulation - No benefits have been found for the intradiscal radiofrequency thermocoagulation.[5] 
  • Spinal fusion - If a spinal fusion surgery is performed, its aim is to stop the motion at a painful vertebral segment. There are many different approaches but they all involve the following process: firstly they add bone graft to a segment of the spine, secondly, they set up a biological response that causes the bone graft to grow between two vertebral elements. This creates a bone fusion which leads to one fixed bone replacing a mobile joint, so it will stop the motion at that segment.[9] 
  • Ramus communicans block - A block in the ramus communicans is able to interrupt the passage of painful information from the discs to the central nervous system.[5]
  • Disc cell transplantation - Disc cell transplantation is in the experimental stage, it has the potential to become useful for the prevention and treatment of discogenic pain.[5] More research is needed.

Physical Therapist Management

Physical therapist management for lumbar discogenic pain typically includes:

  1. Conservative treatment for acute or subacute disc injuries
  2. Reducing muscular guarding
  3. Improving segmental motion
  4. Correcting mechanical faults
  5. Developing a home exercise program
  6. Lumbar stabilization exercises as treatment progresses
  7. Back stretch exercises
  8. Education on helpful mechanical loading strategies (MLSs)
  9. Postural advice
  10. Lumbar taping techniques in some cases
  11. Therapist-applied forces when appropriate[8]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Fukui S et al. Intradiscal Pulsed Radiofrequency for Chronic Lumbar Discogenic Low Back Pain: A One Year Prospective Outcome Study Using Discoblock for Diagnosis. Pain Physician 2013.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 José García-Cosamalón et al. Intervertebral disc, sensory nerves and neurotrophins: who is who in discogenic pain? J Anat. 2010 July; 217(1): 1–15.
  3. ↑ 3.0 3.1 Bogduk, N. (2012). Clinical and radiological anatomy of the lumbar spine. New York, Churchill Livingstone.
  4. ↑ 4.0 4.1 Pathak S, Conermann T. Lumbosacral discogenic syndrome.Available: https://www.ncbi.nlm.nih.gov/sites/books/NBK560537/(accessed 1.4.2025)
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 Zhou Y, Abdi S. Diagnosis and minimally invasive treatment of lumbar discogenic pain--a review of the literature. Clin J Pain. 2006 Jun;22(5):468-81.
  6. ↑ 6.0 6.1 6.2 Schultz et al. Mechanical profiling of intervertebral discs. J Biomech. 2009 May.
  7. ↑ 7.0 7.1 7.2 McKenzie, R. and S. May (2003). The lumbar spine: mechanical diagnosis and therapy. New Zealand, Orthopedic Physical Therapy Products.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 Chan, A. Y., J. J. Ford, et al. (2013). Preliminary evidence for the features of non-reducible discogenic low back pain: survey of an international physiotherapy expert panel with the Delphi technique. Physiotherapy.
  9. ↑ 9.0 9.1 9.2 Bao-Gan Peng. Pathophysiology, diagnosis, and treatment of discogenic low back pain. World J Orthop. 2013 April 18; 4(2): 42–52.
  10. ↑ 10.0 10.1 Robert E Windsor. Lumbosacral Disc Injuries. Medscape. 2013 June 3.
  11. ↑ 11.0 11.1 Gerard A Malanga, Lumbosacral Facet Syndrome.Medscape. 2013 april 5.
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