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Introduction
  • Disc degeneration is the cause of pain
  • Controversial but gaining acceptance as distinct cause of low back pain
  • Disc characteristics modified by bone morphogenic proteins 
Presentation
  • Symptoms
    • axial low back pain without radicular symptoms
    • pain exacerbated by
      • bending
      • sitting
      • axial loading
  • Physical exam
    • nerve tension (straight leg raise) signs are negative
Imaging
  • Radiographs
    • plain radiographs are the first diagnostic study to evaluate for disc degeneration
  • MRI
    • shows degenerative discs without significant stenosis or herniation
  • Provocative Diskography 
    • criteria for a positive test
      • must have concordant pain response
      • must have abnormal disc morphology on fluoroscopy and postdiskography CT
      • must have negative control levels in lumbar spine
    • outcomes 
      • studies have show provocative diskography leads to accelerated disc degeneration including  
        • increased incidence of lumbar disc herniations
        • loss of disk height
        • endplate changes
Treatment
  • Nonoperative 
    • NSAIDS, physical therapy, lifestyle modifications
      • indications
        • treatment of choice of majority of patients with low back pain in the abscence of leg pain
  • Operative
    • lumbar diskectomy with fusion
      • indications
        • controversial
      • outcomes
        • poor results when lumbar fusion is performed for discogenic back pain diagnosed with a positive provocative discography
    • lumbar total disc replacement   
      • indications
        • controversial
        • most argue single level disc disease with disease-free facet joints is the only true indication
      • outcomes
        • shown to have better 2-year patient outcomes than fusion
        • lower rates of adjacent segment disease with total disc replacement compared to fusion
      • complications
        • persistent back pain
          • thought to be facet joint in origin or subtle instability of prosthesis
          • if implant in good position, treat with posterior stabilization alone
        • dislocation of polyethylene inlay 
          • treat with either revision arthroplasty or revision to arthrodesis
 
 

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