Updated: 10/9/2017

Discogenic Back Pain

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Questions
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https://upload.orthobullets.com/topic/2036/images/Xray - AP - provacative disk_moved.jpg
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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Questions (6)
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(OBQ12.170) Which of the following procedures has been found to lead to accelerated disc degeneration and the development of reactive endplate changes? Review Topic

QID: 4530
1

Provocative discography

86%

(3658/4233)

2

Lumbar myelogram

1%

(60/4233)

3

Cervical myelogram

1%

(24/4233)

4

Lumbar transforaminal epidural steroid injections

10%

(436/4233)

5

Lumbar spinal anesthesia

1%

(29/4233)

L 1

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SUBMIT RESPONSE 1

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(SBQ09SP.1) A 45-year-old construction worker presents to your office with a chief complaint of 3 weeks of low back pain. He states the pain started while he was at work and he now has a difficult time working a full day. He reports the pain is worse with activity but he cannot describe any certain positions that make it worse. He denies any recent history of fever, night sweats, or weight loss. He reports normal bowel and bladder function and denies symptoms radiating into his buttocks or legs. On physical exam he has 5/5 strength in his lower extremities, a normal sensory and reflex exam. Forward flexion of the lumbar spine elicits pain in his lower back. He is able to touch his knees when bending forward, but is unable to touch his toes secondary to pain. What is the most appropriate next step in management? Review Topic

QID: 3364
1

Lumbar spine x-rays

22%

(360/1617)

2

Lumbar spine MRI

1%

(24/1617)

3

Lumbar discography

0%

(4/1617)

4

Oral methylprednisoline taper

0%

(3/1617)

5

Physical therapy and NSAIDs

75%

(1214/1617)

L 4

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SUBMIT RESPONSE 5
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