Discogenic Low Back Pain

Dr. Craig Best

What is discogenic low back pain?

Lumbar intervertebral discs are a common cause of chronic low back pain. A fissure (tear) in the outer fibrous portion of the disc, the annulus fibrosus, can allow some of the inner liquid portion, the nucleus pulposus, to leak out. This can lead to chronic inflammation, ingrowth of nerves into the disc, and increased sensitization and subsequent pain coming from the disc. The gold standard method for diagnosis of discogenic low back pain is via provocative lumbar discography.

What are common features of discogenic low back pain?

Patients with discogenic low back pain typically complain of deep and aching pain that can become sharp with movement, an inability to sit for prolonged periods of time, temporary relief with change of position, and low back more than leg pain. This type of low back pain commonly begins with a lifting and/or twisting injury, such as those commonly encountered in the workers’ compensation setting.

How is discogenic low back pain diagnosed?

Discogenic low back pain is typically diagnosed via a combination of findings from the history, physical examination, and MRI findings. However, we must also be mindful that >60% of people without any low back pain whatsoever will have disc changes on advanced imaging and, as such, we cannot rely too heavily on imaging findings to formulate a diagnosis. MRI findings such as a high intensity zone (HIZ) or Modic changes have a high specificity (87% and 70%, respectively) for discogenic low back pain. In the end, though, the gold standard for diagnosis of discogenic low back pain remains provocative lumbar discography.

What is lumbar discography?

Provocative lumbar discography is the gold standard diagnostic test to precisely confirm or exclude the intervertebral disc as a source of chronic low back pain. Using fluoroscopic (x-ray) guidance, needles are placed within two or more discs and pressurized using contrast dye. Based on patient response (i.e. whether the patient’s typical low back pain is reproduced or not) and imaging findings such as fissures (tears) within the disc(s), a diagnosis of discogenic low back pain can be confirmed or ruled out as a source of chronic low back pain.

Who is a candidate for lumbar discography?

Patients who have been experiencing low back pain for greater than 3 months, have tried and failed conservative management (medications, physical therapy, chiropractic), and for whom non-invasive diagnostic tests (x-ray, MRI) have failed to precisely diagnose the source of low back pain.

Why is lumbar discography performed?

Low back pain is a very common cause of musculoskeletal disability, but “low back pain” is not a diagnosis. There are distinct anatomic spinal structures that can potentially generate pain. Studies have shown that the intervertebral discs are the main pain generating structure in 40-70% of cases of low back pain. In patients younger than 60 years of age, the disc is the most common cause of low back pain, followed by the sacroiliac joint then the facet joint. In patients older than 60 years of age, the facet joint is the most cause of low back pain, followed by the disc then the sacroiliac joint. As such, provocative lumbar discography is an important tool to precisely diagnose pain emanating from the lumbar intervertebral discs. 

Does lumbar discography contribute to disc degeneration?

Despite concerns raised by some physicians that lumbar discography contributes to higher rates of disc degeneration, a recent review of the safety and overall diagnostic value of provocative lumbar discography concluded that it is a safe and helpful diagnostic test when performed by properly trained physicians using strict procedural guidelines as outlined by the Spine Intervention Society.

What are the potential benefits of diagnosing discogenic low back pain using lumbar discography?

First, in patients who eventually go on to have lumbar fusion surgery for management of their discogenic low back pain, there is an 88% chance of success with a positive discogram compared to just a 50% chance of success with a negative discogram. Second, when lumbar discography identifies the source of a patient’s low back pain earlier in his or her course, it can save the patient from potentially excessive and unnecessary testing and treatment. For example, if a patient undergoes provocative lumbar discography and the test is negative, the intervertebral disc is essentially ruled out as a source of low back pain. As such, there would be no need for lumbar fusion surgery and the diagnostic focus can then turn to other potential sources of low back pain (facet joint, sacroiliac joint, etc.). Conversely, if a patient undergoes provocative lumbar discography and the test identifies a painful disc, there is now no need for further diagnostic injections (lumbar medial branch blocks, sacroiliac joint injections, etc.) and the focus can proceed to treatment. Lastly, it can potentially provide peace of mind by having a precise diagnosis of one’s low back pain.

How is discogenic low back pain treated?

Traditional treatment options for management of discogenic low back pain include analgesic medications, physical therapy, lumbar epidural steroid injections, and lumbar fusion surgery. In addition, a new, non-surgical treatment option now exists called intradiscal platelet rich plasma (PRP) injections may now be considered for management of discogenic low back pain.

What is platelet-rich plasma (PRP)?

Platelet-rich plasma is component of the patient’s own blood. It is rich in growth factors and can also signal an increased healing response to a damaged tissue. It is used to treat a variety of painful musculoskeletal conditions.

How does intradiscal PRP work?

After the painful disc(s) is/are identified via provocative lumbar discography, the PRP solution is then injected into the problematic disc(s) using x-ray (fluoroscopic) guidance. The PRP solution then stimulates the body’s healing response. As the disc heals, the patient’s pain and overall function improves.

What are the results of intradiscal PRP?

There are now multiple studies demonstrating that, in properly selected patients, intradiscal PRP injections can provide significant improvements in pain and function. Patient satisfaction scores are consistently favorable in those who have undergone intradiscal PRP.

References

Schwarzer et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 1995; 20:1878–83.

DePalma et al. What is the source of chronic low back pain and does age play a role? Pain Med 2011;12:224–33.

Carragee et al. Does discography cause accelerated progression of degeneration changes in the lumbar disc: A ten-year matched cohort study. Spine 2009;34:2338–45.

Cuellar et al. Does provocative discography cause clinically important injury to the lumbar intervertebral disc? A 10-year matched cohort study. Spine J 2016;16: 273–80.

McCormick et al. Diagnostic value, prognostic value, and safety of provocation discography. Pain Medicine 2018;19:3-8.

Tuakli-Wosornu et al. Lumbar intradiskal platelet-rich plasma (PRP) injections: a prospective, double-blind, randomized controlled study. PM R 2016;8:1-10.

Levi et al. Intradiscal platelet-rich plasma injection for chronic discogenic low back pain: preliminary results from a prospective trial. Pain Med 2016;17:1010-22.

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