summary Discogenic back pain is a common etiology of axial low back pain without radicular symptoms and is caused by intervertebral disc degeneration Diagnosis is made by a combination of history, physical examination, and MRI Treatment is usually NSAIDs, physical therapy, cognitive therapy, and lifestyle modifications Etiology Mechanism disc characteristics are modified by bone morphogenetic 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 negative Imaging Radiographs first diagnostic study to evaluate for disc degeneration MRI identifies degenerative discs without significant stenosis or herniation Provocative discography criteria for a positive test: concordant pain response abnormal disc morphology on fluoroscopy and post-discography CT negative control levels in the lumbar spine outcomes studies have shown that provocative discography leads to accelerated disc degeneration, including: increased incidence of lumbar disc herniation loss of disc height endplate changes Treatment Nonoperative NSAIDs, physical therapy, cognitive therapy, and lifestyle modifications indications majority of patients with low back pain in the absence of leg pain outcomes no statistically significant difference in ODI at short- (1-year) or long-term (10-year) follow-up for patients treated with cognitive and exercise therapy compared to lumbar discectomy with fusion Operative lumbar discectomy with fusion indications controversial outcomes poor results when lumbar fusion is performed for discogenic back pain that is 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 originate from facet joint or subtle instability of prosthesis if the implant is in a good position, posterior stabilization alone is recommended dislocation of polyethylene inlay treat with either revision arthroplasty or revision to arthrodesis