Discogenic Back Pain - Spine

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, 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