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Updated: Aug 30 2021

Discogenic Back Pain

Images - AP - provacative disk_moved.jpg
  • summary
    • Discogenic Back pain is a common cause of axial low back pain without radicular symptoms caused by intervertebral disc degeneration.
    • Diagnosis is made by a combination of history, physical examination, and MRI studies. 
    • Treatment is usually NSAIDS, physical therapy, cognitive therapy and lifestyle modifications.
  • Etiology
    • Mechanism
      • 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, cognitive therapy, lifestyle modifications
        • indications
          • treatment of choice of majority of patients with low back pain in the abscence of leg pain
        • outcomes
          • no statisically significant difference in ODI at short (1 year) or long term (10 years) for patients treated with cognitive and exercise therapy compared to lumbar diskectomy with fusion 
    • 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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