The low back or lumbar spine has five vertebrae with intervertebral discs located between the adjacent vertebrae that serve as shock absorbers. Each disc has two parts, a soft, gel-like interior (the nucleus pulposus) containing mostly water and a fibrous outer, ring-like structure (the annulus fibrosus) that surrounds and protects the nucleus. Nerve fibers are not present in the nucleus or inner two-thirds of the annulus. However, the outer third of the annulus does have nerve fibers. When you have intervertebral disc problems in the low back it is most often caused by a vertebral abnormality that can be identified by the spine specialist’s diagnostic process, e.g., disc herniation, spondylosis, spinal stenosis, lumbar sprain, etc. The pain the patient experiences from these conditions is caused by an irritation of a spinal nerve root (s) or the spinal cord itself.
The imaging studies sometimes show no evidence of vertebral abnormality, yet the patient is experiencing moderate to debilitating low back pain. This condition is often attributed to the slow deterioration of a disc resulting from age-related changes in the chemical and physical composition of the disc itself. The changes cause inflammation and/or tears or cracks in the disc’s annulus (internal disc disruption) that irritates the nerve fibers in the outer third of the disc’s annular ring. In addition, the gradual leakage of fluid from the disc causes the height of the disc to collapse and the nucleus to become dried and firm. Other contributors to discogenic pain include genetic factors, nutrition and mechanical or traumatic disruption.
Pain or other symptoms of neural pathology may not be present in the early stages of chronic disc degeneration. As the condition advances, discomfort in the low back becomes evident. The discogenic pain, which occurs most frequently in patients between 30 and 65 years of age, differs from other low back pain symptoms in that it is usually a dull ache, sometimes accompanied by unilateral radicular pain in the buttock or thigh, but not in the lower leg and foot (as is the case with sciatic pain).
Patients with low back discogenic syndrome are categorized as having (1) chronic persistent (constant) pain or (2) chronic recurrent (episodic) pain. The later presents as intermittent pain episodes that may last for several weeks or months followed by a brief, pain-free period before reoccurring. Pain in both categories will intensify when the pressure inside the disc (intradiscal pressure) increases, e.g., when the individual engages in strenuous physical activity, sits, bends forward, twists, stands in a stationary position, coughs, or sneezes.
The diagnosis of discogenic pain follows the spine specialist’s examination of the patient, followed by careful analysis of MRI and/or CT scans. In some cases the specialist may use a discogram to confirm the location of the pain and assist in the decision as to whether surgical fusion of the lumbar disc should be undertaken. The minimally invasive discogram procedure is somewhat controversial in that it induces pain in the patient in order to more precisely locate the actual source of the disc pain.
As with most other spine-related abnormalities, there are a number of treatment options for discogenic pain that the spine specialist may consider including conservative treatments such as non-steroidal anti-inflammatory medications, pain medications (including oral steroids), epidural steroid injections, opiods, physical therapy, and spinal bracing. In the event conservative treatments fail to alleviate the pain, or the pain worsens, the specialist may consider using thermal annuloplasty or Intradiscal Electrothermal Annuloplasty to seal cracks in the disc and deaden the nerves. Finally, the specialist may decide to perform endoscopic or traditional open surgery. This usually means that the patient will undergo a lumbar discectomy with fusion. History has shown that when this procedure is performed the cause of the pain is eliminated in 80% or more of cases.
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