Lumbar Degenerative Disk Disease Treatment & Management
- Author: Rajeev K Patel, MD; Chief Editor: Stephen Kishner, MD, MHA more...
Physical rehabilitation with active patient participation is a key approach to treatment of patients with diskogenic pain. Physical therapy programs prescribed specifically to address the primary site of injury and secondary sites of dysfunction can provide a means of treatment, with or without adjunct medications, therapeutic procedures, or surgical intervention.
Relative rest, which restricts all occupational and avocational activities, for up to the first 2 days after an acute episode, may be indicated to help calm initial pain. Rest for longer periods has not been shown to be beneficial and can cause deconditioning, loss of bone density, decreased intradiskal nutrition, loss of muscle strength and flexibility, and increased segmental stiffness. Passive modalities are valuable during the initial 48 hours of relative rest to aid in pain relief, but protracted courses of passive treatments become counterproductive, as they place patient in a dependent role instead of an active one.
Education is one of the most important components of any back-care program and should include an explanation of the natural history of acute, subacute, and chronic disk injury. The physical rehabilitation program should also include training in proper body mechanics and lumber ergonomics during various functional, occupational, and avocational activities. Manual techniques may be applied to increase soft tissue pliability when secondary myofascial tightness is present. If the aforementioned measures are appropriate and completed, an active, dynamic rehabilitation program to stabilize the lumbar spine may be started on an outpatient basis. In addition, rehabilitation of other associated components of the functional kinetic chain may be appropriate, as these structures may also be affected.
Dynamic lumbar-spine stabilization programs are aimed at maintaining a neutral spine position throughout various daily activities. An extension bias commonly is used to help reduce intradiskal pressure. This position allows for balanced segmental force distribution between the disk and zygapophyseal joints, it provides functional stability with axial loading to help minimize the chance for acute dynamic overload upon the disks, it minimizes tension on ligaments and fascia planes, and it decreases symptoms. Repetition is key to increasing flexibility, building endurance, and developing the required muscle motor engrams that subconsciously activate a series of key multimuscular contractions to maintain the lumbar spine in a neutral position throughout static and dynamic activities.
For athletes, the aforementioned program can be progressively combined with sport-specific plyometrics to help the lumbar spine maintain neutral position during high-intensity, unpredictable, reaction-intensive sports. Rehabilitation of athletes should also train them to maintain a neutral spine position in sport-specific motions. These component motions should then be grouped into a new, safe spine-stable movement. Cardiovascular training is an important adjunct to comprehensive rehabilitation programs because it provides endurance necessary to prevent fatigue of the muscles that stabilize the spine.
Occupational therapy can be an important adjunct in the rehabilitation process when generalized muscular deconditioning has created adverse effects on strength, endurance, and flexibility of the upper extremities and/or impairment in activities of daily living (ADLs).
An occupational therapist often provides this portion of the rehabilitation program. Essential elements consist of ensuring proper ergonomics at the work site, which may involve simply reconfiguring a desktop and/or workstation, or it may require complex solutions. Another aspect involves rehabilitation before the patient resumes full-time duties. After the offending source of pain is resolved, the patient typically has deconditioning and may require activity-specific reconditioning to prevent new or recurring injury.
Recreation therapy may have a role in assisting the patient to resume avocational activities, possibly with adaptations in technique or with the use of adaptive equipment.
Medical causes of LBP include the spondyloarthropathies (eg, enteric arthropathy, Reiter syndrome, ankylosing spondylitis, psoriatic arthritis), Marfan syndrome, fibromyalgia, myofascial pain syndrome, diskitis, and neoplastic disease.
Available surgical approaches include anterior, posterior, or combined procedures; interbody fusion with allograft autologous bone or threaded titanium cage; and intertransverse process in situ fusion with or without instrumentation. The introduction of disk arthroplasty has been proposed as a possible surgical option in those patients who would like to maintain as much segmental motion as possible.
The rate of surgical treatment for LDDD in the United States more than doubled during the first decade of the 21st century, according to a study by Yoshihara and Yoneoka. Using Nationwide Inpatient Sample data from patients aged 18 years or older with lumbar/lumbosacral DDD, the investigators found that between 2000 and 2009, the population-adjusted incidence of LDDD surgery increased 2.4-fold. More specifically, the incidence of combined anterior and posterior lumbar fusion (APLF) rose three-fold, while that for posterior lumbar interbody fusion/posterolateral lumbar fusion (PLIF/PLF) increased 2.8-fold. In contrast, the incidence of total disk replacement (TDR) did not significantly rise.
Of the more than 380,000 patients who underwent LDDD surgery between 2000 and 2009, according to the study, the majority (67.9%) were treated with PLIF/PLF, while 16.8% underwent anterior lumbar interbody fusion (ALIF), 13.6% were treated with APLF, and 1.8% underwent TDR. While TDR was more commonly performed in younger patients than in older ones, the opposite was true for PLIF/PLF. Regionally, it was found that LDDD surgery was more frequently performed in the Midwestern and Southern United States than it was in the Northeast.
Effectiveness of surgery
To date, no prospective randomized blind study has demonstrated the superiority of any surgical approach or technique. One retrospective study was performed to compare posterolateral fusion with iliac-crest allografting and translaminar facet-screw augmentation, anterior interbody fusion with fibula allografting, posterolateral fusion with pedicle screw-rod fixation, and anterior interbody threaded cage fusion combined with facet-joint fusion and posterolateral fusion. The results suggested that the last procedure may provide superior outcomes.
Other investigators report outcome rates ranging from 39% to 82-93% for various procedures. With respect to disk arthroplasty, the literature is not clear on its definitive role, if any, in the treatment of symptomatic LDDD.
In a study of 59 patients suffering from low back pain and 1- or 2-level LDDD, Freudenberger et al compared the effectiveness of ALIF with anterior tension band plating (ALIF-ATB) with that of PLIF with pedicle screw instrumentation. The investigators found that both techniques had similar fusion rates, but that patients who underwent PLIF had greater estimated blood loss and required more surgical time than did patients who were treated with ALIF-ATB.
Consultation of the primary care physician with a nonsurgical spine specialist is appropriate for patients with symptoms lasting longer than 6 weeks secondary to LDDD. Consultation with a spinal surgeon may be appropriate for patients with intractable severe function-limiting symptoms secondary to IDD, at 1 or 2 contiguous levels, for those with symptoms lasting longer than 6 months who have had no relief from nonsurgical approaches, and for persons with abnormal neurologic findings.
New intradiskal techniques are being investigated to ascertain whether they can obviate fusion procedures. With intradiskal electrothermal therapy, a navigable intradiskal catheter is used to heat the posterior annular wall at the nuclear interface corresponding to the 4- to 8-o'clock zone.[48, 49] Temperatures produced in the outer annulus (46-48°C) are sufficient for thermal coagulation of nervous tissue. Temperatures in the nucleus and the annulus (65-75°C) are sufficient for collagen contraction or shrinkage.
Saal and colleagues observed 20% focal nuclear shrinkage (by volume) and 7% total nuclear shrinkage after treatment. Therefore, some authorities postulate that this intervention may cause thermocoagulation of annular nerve fibers. In addition, by means of collagen shrinkage, it may also result in tightening of the fibrous structure of annular tissue that then may enhance structural integrity of a degenerated or damaged disk and possibly stabilize annular fissures. Intradiskal electrothermal therapy showed great promise in initial studies and was touted as being effective at controlling diskogenic axial lumbar back pain. However, a later investigation, a double-blinded, controlled study conducted by Freeman and colleagues, established safety with limited efficacy.
Saal and Saal reported their results in 36 patients who were followed up for 6-13 months.  Improvement in function, lowering of pain scores, and improvement in sitting tolerance times were observed in 75%.
In a clinical trial of 20 patients, Derby reported a mean 2-point decrease on a 10-point visual analog scale ( P < .05) at 6 months.  In addition, 73% reported satisfaction with outcome and indicated that they would repeat the procedure for the same outcome. Although early results are promising with this exciting novel technique, no definitive judgments can be made because only preliminary outcomes with short-term follow-up have been reported to date.
The idea of intradiskal injections and procedures is becoming exciting with new trials of OB1 and other biological therapies being developed in the hopes of being able to regenerate diskal materials and reverse the degenerative cascade underway.
Since their discovery by Marshall Urist, MD at UCLA, bone morphogenetic proteins have been categorized as either growth or differentiation factors and consist of a family of proteins with important regulatory and developmental effects on bone growth and the development of musculoskeletal tissue. These proteins are clinically used by spine surgeons to facilitate bony fusion and obviate the need for autografting.
- Studies have shown that these proteins are capable of controlling the mRNA transcription of cells within human and animal disk models. At the 2002 North American Spine Society (NASS) annual meeting, studies were presented that showed great promise with regard to the development of treatments for degenerative disk disease using bone morphogenic proteins 2 and 7, with augmentation of diseased disks employed at an early stage to offset the degenerative cascade.[53, 54]
- Miyamoto and colleagues showed restoration of disk viscoelastic properties in a rabbit model of degenerative disk disease after injection of osteogenic protein 1 (OP-1). It is hoped that disk regenerative therapy using intradiskal injections of biological pharmaceuticals will become an effective treatment for degenerative disk disease.
Fardon DF, Williams AL, Dohring EJ, Murtagh FR, Gabriel Rothman SL, Sze GK. Lumbar disc nomenclature: version 2.0: Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. Spine J. 2014 Nov 1. 14 (11):2525-45. [Medline]. [Full Text].
Kong MH, Hymanson HJ, Song KY, et al. Kinetic magnetic resonance imaging analysis of abnormal segmental motion of the functional spine unit. J Neurosurg Spine. 2009 Apr. 10(4):357-65. [Medline].
Kirkaldy-Willis WH. The pathology and pathogenesis of low back pain. In: Managing Low Back Pain. New York, NY:. Churchill Livingstone. 1988: 49.
Dean DD, Martel-Pelletier J, Pelletier JP, et al. Evidence for metalloproteinase and metalloproteinase inhibitor imbalance in human osteoarthritic cartilage. J Clin Invest. 1989 Aug. 84(2):678-85. [Medline].
Komiya Y. Immunohistochernical localization of tissue inhibitor of metalloproteinases (TIMP) and stromelysin in human joint synovium. Jpn J Rheum Joint Surg. 1992. 11:59-70.
MacNaul KL, Chartrain N, Lark M, et al. Discoordinate expression of stromelysin, collagenase, and tissue inhibitor of metalloproteinases-1 in rheumatoid human synovial fibroblasts. Synergistic effects of interleukin-1 and tumor necrosis factor-alpha on stromelysin expression. J Biol Chem. 1990 Oct 5. 265(28):17238-45. [Medline].
NCHS. National Center for Health Statistics. Prevalence of Selected Impairment. Hyattsville, MD:. US Department of Health and Human Services. 1984.
National Center for Health Statistics. Vital statistics of the United States. Washington, DC:. Government Printing Office. 1968-1988.
Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine. 1987 Apr. 12(3):264-8. [Medline].
Von Korff M, Deyo RA, Cherkin D, Barlow W. Back pain in primary care: outcomes at 1 year. Spine. 1993 Jun 1. 18(7):855-62. [Medline].
Frymoyer JW. Epidemiology: the magnitude of the problem. In: Wiesel SW, Weinstein JN, Herkowitz HH, Dvorak J, eds. The Lumbar Spine. 2nd ed. Philadelphia, PA: WB Saunders Co. 1996.
Luo X, Pietrobon R, Sun SX. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine. 2004 Jan 1. 29(1):79-86.
Gautschi OP, Smoll NR, Corniola MV, et al. Sex differences in lumbar degenerative disc disease. Clin Neurol Neurosurg. 2016 Apr 8. 145:52-57. [Medline].
Bogduk N. Degenerative joint disease of the spine. Radiol Clin North Am. 2012 Jul. 50(4):613-28. [Medline].
Ayturk UM, Gadomski B, Schuldt D, Patel V, Puttlitz CM. Modeling degenerative disk disease in the lumbar spine: a combined experimental, constitutive, and computational approach. J Biomech Eng. 2012 Oct. 134(10):101003. [Medline].
D'Anastasi M, Birkenmaier C, Schmidt GP, Wegener B, Reiser MF, Baur-Melnyk A. Correlation between vacuum phenomenon on CT and fluid on MRI in degenerative disks. AJR Am J Roentgenol. 2011 Nov. 197(5):1182-9. [Medline].
Barrey C, Ene B, Louis-Tisserand G, Montana P, Perrin G, Simon E. Vascular Anatomy in the Lumbar Spine Investigated by Three-Dimensional Computed Tomography Angiography: The Concept of a Vascular Window. World Neurosurg. 2012 Apr 2. [Medline].
Lee SU, Lee JI, Butts K, et al. Changes in posterior lumbar disk contour abnormality with flexion-extension movement in subjects with low back pain and degenerative disk disease. PM R. 2009 Jun. 1(6):541-6. [Medline].
Panagiotacopulos ND, Pope MH, Krag MH, Block R. Water content in human intervertebral discs, I: Measurement by magnetic resonance imaging. Spine. 1987 Nov. 12(9):912-7. [Medline].
Watanabe A, Benneker LM, Boesch C, et al. Classification of intervertebral disk degeneration with axial T2 mapping. AJR Am J Roentgenol. 2007 Oct. 189(4):936-42. [Medline].
Smith BM, Hurwitz EL, Solsberg D, et al. Interobserver reliability of detecting lumbar intervertebral disc high- intensity zone on magnetic resonance imaging and association of high- intensity zone with pain and anular disruption. Spine. 1998 Oct 1. 23(19):2074-80. [Medline].
Aprill C, Bogduk N. High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging. Br J Radiol. 1992 May. 65(773):361-9. [Medline].
Schiebler ML, Grenier N, Fallon M, et al. Normal and degenerated intervertebral disk: in vivo and in vitro MR imaging with histopathologic correlation. AJR Am J Roentgenol. 1991 Jul. 157(1):93-7. [Medline].
Grenier N, Grossman RI, Schiebler ML, et al. Degenerative lumbar disk disease: pitfalls and usefulness of MR imaging in detection of vacuum phenomenon. Radiology. 1987 Sep. 164(3):861-5. [Medline].
de Roos A, Kressel H, Spritzer C, Dalinka M. MR imaging of marrow changes adjacent to end plates in degenerative lumbar disk disease. AJR Am J Roentgenol. 1987 Sep. 149(3):531-4. [Medline].
Modic MT, Steinberg PM, Ross JS, Carter JR. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology. 1988 Jan. 166(1 Pt 1):193-9. [Medline].
Quint U, Wilke HJ. Grading of degenerative disk disease and functional impairment: imaging versus patho-anatomical findings. Eur Spine J. 2008 Dec. 17(12):1705-13. [Medline].
Schellhas KP, Pollei SR, Gundry CR, Heithoff KB. Lumbar disc high-intensity zone. Correlation of magnetic resonance imaging and discography. Spine. 1996 Jan 1. 21(1):79-86. [Medline].
Walsh TR, Weinstein JN, Spratt KF, et al. Lumbar discography in normal subjects. A controlled, prospective study. J Bone Joint Surg [Am]. 1990 Aug. 72(7):1081-8. [Medline].
Scuderi GJ, Brusovanik GV, Golish SR, et al. A critical evaluation of discography in patients with lumbar intervertebral disc disease. Spine J. 2008 Jul-Aug. 8(4):624-9. [Medline].
Robecchi A, Capra R. L'idrocortisone (composto F): prime esperienze cliniche in campo reumatologico. Minerva Med. 1952. 98:1259-63.
Swerdlow M, Sayle-Creer WS. A study of extradural medication in the relief of the lumbosciatic syndrome. Anaesthesia. 1970 Jul. 25(3):341-5. [Medline].
Winnie AP, Hartman JT, Meyers HL Jr, et al. Pain clinic, II: intradural and extradural corticosteroids for sciatica. Anesth Analg. 1972 Nov-Dec. 51(6):990-1003. [Medline].
Rosenberg SK, Grabinsky A, Kooser C, et al. Effectiveness of transforaminal epidural steroid injections in low back pain: a one year experience. Pain Physician. 2002 Jul. 5(3):266-70. [Medline].
Manchikanti L, Staats PS, Singh V, et al. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2003 Jan. 6(1):3-81. [Medline].
Riew KD, Yin Y, Gilula L, et al. Can nerve root injections obviate the need for operative treatment of lumbar radicular pain? A prospective, randomized, controlled, double-blind study. Presented at the 14th Annual North American Spine Society Meeting. Chicago, IL, October 20-23, 1999.
Kraemer J, Ludwig J, Bickert U, et al. Lumbar epidural perineural injection: a new technique. Eur Spine J. 1997. 6(5):357-61. [Medline].
Karppinen J, Malmivaara A, Kurunlahti M, et al. Periradicular infiltration for sciatica: a randomized controlled trial. Spine. 2001 May 1. 26(9):1059-67. [Medline].
Thomas E, Cyteval C, Abiad L, et al. Efficacy of transforaminal versus interspinous corticosteroid injectionin discal radiculalgia - a prospective, randomised, double-blind study. Clin Rheumatol. 2003 Oct. 22(4-5):299-304. [Medline].
Buttermann GR. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. J Bone Joint Surg Am. 2004 Apr. 86-A(4):670-9. [Medline].
Weiner BK, Fraser RD. Foraminal injection for lateral lumbar disc herniation. J Bone Joint Surg Br. 1997 Sep. 79(5):804-7. [Medline].
Lutz GE, Vad VB, Wisneski RJ. Fluoroscopic transforaminal lumbar epidural steroids: an outcome study. Arch Phys Med Rehabil. 1998 Nov. 79(11):1362-6. [Medline].
Wang JC, Lin E, Brodke DS, et al. Epidural injections for the treatment of symptomatic lumbar herniated discs. J Spinal Disord Tech. 2002 Aug. 15(4):269-72. [Medline].
Coppes MH, Marani E, Thomeer RT, Groen GJ. Innervation of "painful" lumbar discs. Spine. 1997 Oct 15. 22(20):2342-9; discussion 2349-50. [Medline].
Weinstein J, Claverie W, Gibson S. The pain of discography. Spine. 1988 Dec. 13(12):1344-8. [Medline].
Yoshihara H, Yoneoka D. National trends in the surgical treatment for lumbar degenerative disc disease: US, 2000-2009. Spine J. 2014 Oct 1. [Medline].
Freudenberger C, Lindley EM, Beard DW, et al. Posterior versus anterior lumbar interbody fusion with anterior tension band plating: retrospective analysis. Orthopedics. 2009 Jul. 32(7):[Medline].
Kapural L, Mekhail N. Novel intradiscal biacuplasty (IDB) for the treatment of lumbar discogenic pain. Pain Pract. 2007 Jun. 7(2):130-4. [Medline].
Kapural L, Ng A, Dalton J, et al. Intervertebral disc biacuplasty for the treatment of lumbar discogenic pain: results of a six-month follow-up. Pain Med. 2008 Jan-Feb. 9(1):60-7. [Medline].
Saal JS, Saal JA. A novel approach to painful internal disc derangement: collagen modulation with a thermal percutaneous navigable intradiscal catheter: a prospective trial. Proceedings of the 13th Annual Meeting of the North American Spine Society. 1998.
Freeman BJ, Fraser RD, Cain CM. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine. 2005 Nov 1. 30(21):2369-77; discussion 2378. [Medline].
Derby R, Eek B, Ryan DP. Intradiscal electrothermal annuloplasty. Presented at 13th Annual Meeting North American Spine Society 13th Annual Meeting. San Francisco, CA, October 28-31, 1998.
Moon SH, Lee HM, Park MS. Bone morphogenic protein-2 facilitates expression of chondrogenic not osteogenic phenotype in human intervertebral disc cells. Program and abstracts of the 17th Annual Meeting of the North American Spine Soc. 2002.
Ahn N, Imai Y, An H. Effect of nutrient concentration and OP-1 on the metabolism of intervertebral disc: In vitro organ culture study. Program and abstracts of the 17th Annual Meeting of the North American Spine Soc. 2002.
Miyamoto K, Masuda K, Kim JG. Intradiscal injections of osteogenic protein-1 restore the viscoelastic properties of degenerated intervertebral discs. Spine J. 2006 Nov-Dec. 6(6):692-703.
Adams MA, McMillan DW, Green TP, Dolan P. Sustained loading generates stress concentrations in lumbar intervertebral discs. Spine. 1996 Feb 15. 21(4):434-8. [Medline].
Adams P, Eyre DR, Muir H. Biochemical aspects of development and ageing of human lumbar intervertebral discs. Rheumatol Rehabil. 1977 Feb. 16(1):22-9. [Medline].
Aguila LA, Piraino DW, Modic MT, et al. The intranuclear cleft of the intervertebral disk: magnetic resonance imaging. Radiology. 1985 Apr. 155(1):155-8. [Medline].
Andersson GB. Epidemiologic aspects on low-back pain in industry. Spine. 1981 Jan-Feb. 6(1):53-60. [Medline].
Andersson GB, Schultz AB, Nachemson AL. Intervertebral disc pressures during traction. Scand J Rehabil Med Suppl. 1983. 9:88-91. [Medline].
Aoki J, Yamamoto I, Kitamura N, et al. End plate of the discovertebral joint: degenerative change in the elderly adult. Radiology. 1987 Aug. 164(2):411-4. [Medline].
Bergquist-Ullman M, Larsson U. Acute low back pain in industry. A controlled prospective study with special reference to therapy and confounding factors. Acta Orthop Scand. 1977. (170):1-117. [Medline].
Bernard TN Jr. Lumbar discography followed by computed tomography. Refining the diagnosis of low-back pain. Spine. 1990 Jul. 15(7):690-707. [Medline].
Biering-Sorensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine. 1984 Mar. 9(2):106-19. [Medline].
Bigos SJ, Battid MC. The impact of spinal disorders in industry. In: Frymoyer JW, ed. The Adult Spine. New York:. Raven Press. 1991.
Blair SN, Piserchia PV, Wilbur CS, Crowder JH. A public health intervention model for work-site health promotion. Impact on exercise and physical fitness in a health promotion plan after 24 months. JAMA. 1986 Feb 21. 255(7):921-6. [Medline].
Block AR, Vanharanta H, Ohnmeiss DD, Guyer RD. Discographic pain report: influence of psychological factors. Spine. 1996 Feb 1. 21(3):334-8. [Medline].
Boden SD, Davis DO, Dina TS, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg [Am]. 1990 Mar. 72(3):403-8. [Medline].
Bogduk N. The innervation of the lumbar spine. Spine. 1983 Apr. 8(3):286-93. [Medline].
Bogduk N, Modic MT. Lumbar discography. Spine. 1996 Feb 1. 21(3):402-4. [Medline].
Bogduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine. 2nd ed. London: Churchill Livingstone. 1991:161.
Bogduk N, Tynan W, Wilson AS. The nerve supply to the human lumbar intervertebral discs. J Anat. 1981 Jan. 132(Pt 1):39-56. [Medline].
Brickley-Parsons D, Glimcher MJ. Is the chemistry of collagen in intervertebral discs an expression of Wolff''s Law? A study of the human lumbar spine. Spine. 1984 Mar. 9(2):148-63. [Medline].
Bush K, Cowan N, Katz DE, Gishen P. The natural history of sciatica associated with disc pathology: a prospective study with clinical and independent radiologic follow-up. Spine. 1992 Oct. 17(10):1205-12. [Medline].
Butler D, Trafimow JH, Andersson GB, et al. Discs degenerate before facets. Spine. 1990 Feb. 15(2):111-3. [Medline].
Butt WP. Lumbar discography. J Can Assoc Radiol. 1964. 14:172.
Cady LD Jr, Thomas PC, Karwasky RJ. Program for increasing health and physical fitness of fire fighters. J Occup Med. 1985 Feb. 27(2):110-4. [Medline].
Cady LD Jr, Thomas PC, Karwasky RJ. Program for increasing health and physical fitness of fire fighters. J Occup Med. 1985 Feb. 27(2):110-4. [Medline].
Cats-Baril WL, Frymoyer JW. The economics of spinal disorders. In: Frymoyer JW, ed. The Adult Spine: Principles of Practice. New York, NY: Raven Press. 1991.
Colhoun E, McCall IW, Williams L, Cassar Pullicino VN. Provocation discography as a guide to planning operations on the spine. J Bone Joint Surg [Br]. 1988 Mar. 70(2):267-71. [Medline].
Coventry MB, Ghormley RK, Kernohan JW. The intervertebral disc: its microscopic anatomy and pathology, III: pathologic changes in the intervertebral disc. J Bone Joint Surg. 1945. 27(1):460.
Crook HV. Internal disc disruption. In: Frymover JW, ed. The Adult Spine: Principles and Practice. New York, NY: Raven. 1991: 2015.
DePalma AF, Rothman RH. The Invertebral Disc. Philadelphia, PA:. WB Saunders. 1970.
Derby R, Eek B, Van Peteghern PK, Ryan DP. Somatic referred pain patterns resulting from direct in vivo intradiscal thermal stimulation. Presented at Combined meeting of the International Spinal Injection Society and the Australian Faculty of Musculoskeletal Medicine Combined Meeting. Sydney, Australia,. September 26-27, 1998.
Deyo RA, Bass JE. Lifestyle and low-back pain. The influence of smoking and obesity. Spine. 1989 May. 14(5):501-6. [Medline].
Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988 May-Jun. 3(3):230-8. [Medline].
Dixon ASJ. Diagnosis of low back pain: sorting the complainers. In: Jayson M, ed. The Lumbar Spine and Back Pain. New York, NY:. Grune and Stratton. 1976.
Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine. 1997 May 15. 22(10):1115-22. [Medline].
Fordyce WE, Brockway JA, Bergman JA, Spengler D. Acute back pain: a control-group comparison of behavioral vs traditional management methods. J Behav Med. 1986 Apr. 9(2):127-40. [Medline].
Forssell MZ. The back school. Spine. 1981 Jan-Feb. 6(1):104-6. [Medline].
Freemont AJ, Peacock TE, Goupille P, et al. Nerve ingrowth into diseased intervertebral disc in chronic back pain. Lancet. 1997 Jul 19. 350(9072):178-81. [Medline].
Fry J. Back pain and soft tissue rheumatism. In: Colloquium Proceedings of Advisory Services. London, England:. 1995.
Frymoyer JW. Back pain and sciatica. N Engl J Med. 1988 Feb 4. 318(5):291-300. [Medline].
Frymoyer JW, Pope MH, Clements JH, et al. Risk factors in low-back pain: an epidemiological survey. J Bone Joint Surg [Am]. 1983 Feb. 65(2):213-8. [Medline].
Gonzalez VM, Goeppinger J, Lorig K. Four psychosocial theories and their application to patient education and clinical practice. Arthritis Care Res. 1990 Sep. 3(3):132-43. [Medline].
Gower WE, Pedrini V. Age-related variations in proteinpolysaccharides from human nucleus pulposus, annulus fibrosus, and costal cartilage. J Bone Joint Surg [Am]. 1969 Sep. 51(6):1154-62. [Medline].
Grenier N, Greselle JF, Vital JM, et al. Normal and disrupted lumbar longitudinal ligaments: correlative MR and anatomic study. Radiology. 1989 Apr. 171(1):197-205. [Medline].
Hadler NM. The predicament of backache. J Occup Med. 1988 May. 30(5):449-50. [Medline].
Hazard RG, Fenwick JW, Kalisch SM, et al. Functional restoration with behavioral support: a one-year prospective study of patients with chronic low-back pain. Spine. 1989 Feb. 14(2):157-61. [Medline].
Heliovaara M. Risk factors for low back pain and sciatica. Ann Med. 1989 Aug. 21(4):257-64. [Medline].
HHS. Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A report of the Surgeon General. Washington, DC:. Government Printing Office. 1989.
Higuchi M, Kaneda K, Abe K. Postnatal histogenesis of the cartilage plate of the spinal column: electron microscopic observations. Spine. 1982 Mar-Apr. 7(2):89-96. [Medline].
Hirsch C, Ingelmark BE, Miller M. The anatomical basis for low back pain. Acra Orthop Scand. 1963. 23:1-17.
Hopwood MB, Abram SE. Factors associated with failure of lumbar epidural steroids. Reg Anesth. 1993 Jul-Aug. 18(4):238-43. [Medline].
Horlocker TT, Wedel DJ, Offord KP. Does preoperative antiplatelet therapy increase the risk of hemorrhagic complications associated with regional anesthesia?. Anesth Analg. 1990 Jun. 70(6):631-4. [Medline].
Hurri H. The Swedish back school in chronic low back pain, I: benefits. Scand J Rehabil Med. 1989. 21(1):33-40. [Medline].
Hurri H. The Swedish back school in chronic low back pain, II: factors predicting the outcome. Scand J Rehabil Med. 1989. 21(1):41-4. [Medline].
Ito M, Incorvaia KM, Yu SF, et al. Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. Spine. 1998 Jun 1. 23(11):1252-8; discussion 1259-60. [Medline].
Jackson HC 2d, Winkelmann RK, Bickel WH. Nerve endings in the human lumbar spinal column and related structures. J Bone Joint Surg [Am]. 1966 Oct. 48(7):1272-81. [Medline].
Jaffray D, O''Brien JP. Isolated intervertebral disc resorption. A source of mechanical and inflammatory back pain. Spine. 1986 May. 11(4):397-401. [Medline].
Jamison RN, Raymond SA, Slawsby EA, et al. Opioid therapy for chronic noncancer back pain: a randomized prospective study. Spine. 1998 Dec 1. 23(23):2591-600. [Medline].
Jamison RN, VadeBoncouer T, Ferrante FM. Low back pain patients unresponsive to an epidural steroid injection: identifying predictive factors. Clin J Pain. 1991 Dec. 7(4):311-7. [Medline].
Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14. 331(2):69-73. [Medline].
Kambin P, Zhou L. History and current status of percutaneous arthroscopic disc surgery. Spine. 1996 Dec 15. 21(24 Suppl):57S-61S. [Medline].
Kawakami M. Histochemical and immunohistochemical demonstrations of nerve fibers on human paraspinal soft tissue [Japanese]. J Wakayama Med Soc. 1989. 40:621-30.
Kieffer SA, Sherry RG, Wellenstein DE, King RB. Bulging lumbar intervertebral disk: myelographic differentiation from herniated disk with nerve root compression. AJR Am J Roentgenol. 1982 Apr. 138(4):709-16. [Medline].
Klaber Moffett JA, Chase SM, Portek I, Ennis JR. A controlled, prospective study to evaluate the effectiveness of a back school in the relief of chronic low back pain. Spine. 1986 Mar. 11(2):120-2. [Medline].
Koeller W, Muehlhaus S, Meier W, Hartmann F. Biomechanical properties of human intervertebral discs subjected to axial dynamic compression: influence of age and degeneration. J Biomech. 1986. 19(10):807-16. [Medline].
Kostuik JP, Harrington I, Alexander D, et al. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg [Am]. 1986 Mar. 68(3):386-91. [Medline].
Kummel BM. Nonorganic signs of significance in low back pain. Spine. 1996 May 1. 21(9):1077-81. [Medline].
Kuslich SD, Ahern JW, Dowdle JD. The BAK method of lumbar interbody fusion-2 year follow-up results: Proceedings of the 11th Annual Meeting of the North American Spine Society. Lippincott Williams and Wilkins;. 1996.
Kuslich SD, Ahern JW, Garner MD. An in-vivo, prospective analysis of tissue sensitivity of lumbar spinal tissues: Proceedings of the 12th Annual Meeting of the North American Spine Society. Lippincott Williams and Wilkins;. 1997.
Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Orthop Clin North Am. 1991 Apr. 22(2):181-7. [Medline].
Lacroix JM, Powell J, Lloyd GJ, et al. Low-back pain. Factors of value in predicting outcome. Spine. 1990 Jun. 15(6):495-9. [Medline].
Lee CK, Vessa P, Lee JK. Chronic disabling low back pain syndrome caused by internal disc derangements. The results of disc excision and posterior lumbar interbody fusion. Spine. 1995 Feb 1. 20(3):356-61. [Medline].
Lipson SJ, Muir H. Experimental intervertebral disc degeneration: morphologic and proteoglycan changes over time. Arthritis Rheum. 1981 Jan. 24(1):12-21. [Medline].
Malinsky J. The ontogenetic development of nerve terminations in the intervertebral discs of man. (Histology of intervertebral discs, 11th communication). Acta Anat (Basel). 1959. 38:96-113. [Medline].
Manson JE, Tosteson H, Ridker PM, et al. The primary prevention of myocardial infarction. N Engl J Med. 1992 May 21. 326(21):1406-16. [Medline].
Mayer TG, Gatchel R, Mayer H, et al. A prospective two-year study of functional restoration in industrial low back pain injury: an objective assessment procedure. JAMA. 1989. 258:1763.
Mayer TG, Gatchel RJ, Kishino N, et al. Objective assessment of spine function following industrial injury: a prospective study with comparison group and one-year follow-up. Spine. 1985 Jul-Aug. 10(6):482-93. [Medline].
McCarron RF, Wimpee MW, Hudkins PG, Laros GS. The inflammatory effect of nucleus pulposus: a possible element in the pathogenesis of low-back pain. Spine. 1987 Oct. 12(8):760-4. [Medline].
McCoy CE, Selby D, Henderson R, et al. Patients avoiding surgery: pathology and one-year life status follow-up. Spine. 1991 Jun. 16(6 Suppl):S198-200. [Medline].
McNally DS, Shackleford IM, Goodship AE, Mulholland RC. In vivo stress measurement can predict pain on discography. Spine. 1996 Nov 15. 21(22):2580-7. [Medline].
Medical Economics. Physician Desk Reference. 54th ed. Montvale, NJ:. Medical Economics Company Inc. 2000.
Merriam WF, Quinnell RC, Stockdale HR, Willis DS. The effect of postural changes on the inferred pressures within the nucleus pulposus during lumbar discography. Spine. 1984 May-Jun. 9(4):405-8. [Medline].
Miller JA, Schmatz C, Schultz AB. Lumbar disc degeneration: correlation with age, sex, and spine level in 600 autopsy specimens. Spine. 1988 Feb. 13(2):173-8. [Medline].
Modic MT, Masaryk TJ, Ross JS. Imaging of degenerative disk disease. Radiology. 1988 Jul. 168(1):177-86. [Medline].
Nachemson A, Morris JM. In vivo measurements of intradiscal pressure: discometery, a method for the determination of pressure in the lower lumbar discs. J Bone Joint Surg Am. 1964 Jul. 46:1077-92. [Medline].
Nakamura S, Takahashi K, Takahashi Y, et al. Origin of nerves supplying the posterior portion of lumbar intervertebral discs in rats. Spine. 1996 Apr 15. 21(8):917-24. [Medline].
Ohnmeiss DD, Vanharanta H, Ekholm J. Degree of disc disruption and lower extremity pain. Spine. 1997 Jul 15. 22(14):1600-5. [Medline].
Palmgren T, Gronblad M, Virri J, et al. Immunohistochemical demonstration of sensory and autonomic nerve terminals in herniated lumbar disc tissue. Spine. 1996 Jun 1. 21(11):1301-6. [Medline].
Parker LM, Murrell SE, Boden SD, Horton WC. The outcome of posterolateral fusion in highly selected patients with discogenic low back pain. Spine. 1996 Aug 15. 21(16):1909-16; discussion 1916-7. [Medline].
Plowman SA. Physical activity, physical fitness, and low back pain. In: Holloszy JO, ed. Exercise and Sport Science Review. Vol 20. Philadelphia, PA:. Lippincott Williams and Wilkins. 1992.
Praemer A, Furrier S, Rice DP. Musculoskeletal Conditions in the United States. Rosemont, IL:. American Association of Orthopaedic Surgeons. 1992: 23-33.
Pritzker KP. Aging and degeneration in the lumbar intervertebral disc. Orthop Clin North Am. 1977 Jan. 8(1):66-77. [Medline].
Quebec Task Force on Spinal Disorders. Scientific approach to the assessment and management of activity-related spinal disorders: a monograph for clinicians. Spine. 1987 Sep. 12(7 Suppl):S1-59. [Medline].
Resnick D. Degenerative diseases of the vertebral column. Radiology. 1985 Jul. 156(1):3-14. [Medline].
Resnick D, Niwayama G, Guerra J Jr, et al. Spinal vacuum phenomena: anatomical study and review. Radiology. 1981 May. 139(2):341-8. [Medline].
Ricketson R, Simmons JW, Hauser BO. The prolapsed intervertebral disc. The high-intensity zone with discography correlation. Spine. 1996 Dec 1. 21(23):2758-62. [Medline].
Ross JS, Modic MT, Masaryk TJ. Tears of the anulus fibrosus: assessment with Gd-DTPA-enhanced MR imaging. AJNR Am J Neuroradiol. 1989 Nov-Dec. 10(6):1251-4. [Medline].
Rowe ML. Low back pain in industry. A position paper. J Occup Med. 1969 Apr. 11(4):161-9. [Medline].
Saal JA, Saal JS. Intradiscal electrothermal treatment for chronic discogenic low back pain: prospective outcome study with a minimum 2-year follow-up. Spine. 2002 May 1. 27(9):966-73; discussion 973-4.
Saal JA, Saal JS, Ashley J. Thermal characteristics of the lumbar disc: evaluation of a novel approach to targeted intra discal thermal therapy. Presented at the 13th Annual Meeting of the North American Spine Society. San Francisco, CA, October 28-31, 1998.
Saifuddin A, Braithwaite I, White J, et al. The value of lumbar spine magnetic resonance imaging in the demonstration of anular tears. Spine. 1998 Feb 15. 23(4):453-7. [Medline].
Salkever DS. Morbidity costs: national estimates and economic determinants. NCHSR Research Summary Series. October 1985. Washington, DC:. US Department of Health and Human Services. 1986.
Schellhas KP. HIZ lesions. Spine. 1997 Jul 1. 22(13):1538. [Medline].
Schnebel B, Kingston S, Watkins R, Dillin W. Comparison of MRI to contrast CT in the diagnosis of spinal stenosis. Spine. 1989 Mar. 14(3):332-7. [Medline].
Schneiderman G, Flannigan B, Kingston S, et al. Magnetic resonance imaging in the diagnosis of disc degeneration: correlation with discography. Spine. 1987 Apr. 12(3):276-81. [Medline].
Schwarzer AC, Aprill CN, Derby R, et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine. 1995 Sep 1. 20(17):1878-83. [Medline].
Selby DK. The structural degenerative cascade: the lumbar spine. In: White AH, Schofferman JA, eds. Spine Care: Diagnosis Conservative Treatment. St Louis:. Mosby. 1995: 8-26.
Sether LA, Yu S, Haughton VM, Fischer ME. Intervertebral disk: normal age-related changes in MR signal intensity. Radiology. 1990 Nov. 177(2):385-8. [Medline].
Shulenberger CC. Ergonomic intervention for the prevention and treatment of spinal disorders. In: White AH, Schofferman JH, eds. Spine Care: Diagnosis and Conservative Treatment. St Louis, MO:. Mosby. 1995: 472-85.
Slipman CW. Discography. In: Gonzalez E, ed. Acute Low Back Pain: Assessment and Management. New York, NY:. Demos Vermande. 1998.
Sobel DF, Zyroff J, Thorne RP. Diskogenic vertebral sclerosis: MR imaging. J Comput Assist Tomogr. 1987 Sep-Oct. 11(5):855-8. [Medline].
Sponseller PD, Hobbs W, Riley LH III, Pyeritz RE. The thoracolumbar spine in Marfan syndrome. J Bone Joint Surg Am. 1995 Jun. 77(6):867-76. [Medline].
Svensson HO, Vedin A, Wilhelmsson C. Low-back pain in relation to other diseases and cardiovascular risk factors. Spine. 1983 Apr. 8(3):277-85. [Medline].
Troup JD, Martin JW, Lloyd DC. Back pain in industry. A prospective survey. Spine. 1981 Jan-Feb. 6(1):61-9. [Medline].
Urban JP, Holm S, Maroudas A, Nachemson A. Nutrition of the intervertebral disk: an in vivo study of solute transport. Clin Orthop. 1977 Nov-Dec. (129):101-14. [Medline].
US Food and Drug Administration. FDA News Release. FDA clears Cymbalta to treat chronic musculoskeletal pain. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm232708.htm. Accessed: November 5, 2010.
Valkenburg HA, Haanen HM. The epidemiology of low back pain. In: White AA, Gordon SL, eds. American Academy of Orthopaedic Surgeons Symposium. St Louis:. Mosby. 1982.
Vamvanij V, Fredrickson BE, Thorpe JM, et al. Surgical treatment of internal disc disruption: an outcome study of four fusion techniques. J Spinal Disord. 1998 Oct. 11(5):375-82. [Medline].
Vernon-Roberts B, Pirie CJ. Degenerative changes in the intervertebral discs of the lumbar spine and their sequelae. Rheumatol Rehabil. 1977 Feb. 16(1):13-21. [Medline].
Viner N. Intractable sciatica-the sacral injections- an effective method of giving relief. Can Med Assoc J. 1925. 15:630-4.
Waddell G. 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine. 1987 Sep. 12(7):632-44. [Medline].
Waddell G, Bircher M, Finlayson D, Main CJ. Symptoms and signs: physical disease or illness behaviour?. Br Med J (Clin Res Ed). 1984 Sep 22. 289(6447):739-41. [Medline].
Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine. 1980 Mar-Apr. 5(2):117-25. [Medline].
Weinstein J. Report of the 1985 ISSLS Traveling Fellowship. Mechanisms of spinal pain. The dorsal root ganglion and its role as a mediator of low-back pain. Spine. 1986 Dec. 11(10):999-1001. [Medline].
Wetzel FT, LaRocca SH, Lowery GL, Aprill CN. The treatment of lumbar spinal pain syndromes diagnosed by discography: lumbar arthrodesis. Spine. 1994 Apr 1. 19(7):792-800. [Medline].
White A, Mattmiller A, White L. Back School and Other Conservative Approaches to Low Back Pain. St Louis, MO:. Mosby. 1983.
White AA III, Gordon SL. Synopsis: workshop on idiopathic low-back pain. Spine. 1982 Mar-Apr. 7(2):141-9. [Medline].
White AH. The socioeconomic cascade. In: White AH, Schoffermand JA, eds. Spine Care: Diagnosis and Conservative Treatment. St Louis, MO:. Mosby. 1995; 27-34.
White AW. Low back pain in men receiving workmen''s compensation. Can Med Assoc J. 1966 Jul 9. 95(2):50-6. [Medline].
White L. Back School State of the Art Reviews. Philadelphia, PA:. Hanley and Belfus. 1991.
Wiesel SW, Tsourmas N, Feffer HL, et al. A study of computer-assisted tomography, I: the incidence of positive CAT scans in an asymptomatic group of patients. Spine. 1984 Sep. 9(6):549-51. [Medline].
Williams AL, Haughton VM, Meyer GA, Ho KC. Computed tomographic appearance of the bulging annulus. Radiology. 1982 Feb. 142(2):403-8. [Medline].
Wiltse LL. The history of spinal disorders. In: Frymoyer JW, ed. The Adult Spine: Principles and Practice. 2nd ed. Philadelphia, PA:. Lippincott-Raven. 1997: 3-40.
Woo SL, Buckwalter JA. AAOS/NIH/ORS workshop. Injury and repair of the musculoskeletal soft tissues. Savannah, GA, June 18-20, 1987. J Orthop Res. 1988. 6(6):907-31. [Medline].
Yu S, Haughton VM, Sether LA, et al. Criteria for classifying normal and degenerated lumbar intervertebral disks. Radiology. 1989 Feb. 170(2):523-6. [Medline].
Yu SW, Haughton VM, Lynch KL, et al. Fibrous structure in the intervertebral disk: correlation of MR appearance with anatomic sections. AJNR Am J Neuroradiol. 1989 Sep-Oct. 10(5):1105-10. [Medline].
Yu SW, Haughton VM, Sether LA, Wagner M. Anulus fibrosus in bulging intervertebral disks. Radiology. 1988 Dec. 169(3):761-3. [Medline].
Yu SW, Haughton VM, Sether LA, Wagner M. Comparison of MR and diskography in detecting radial tears of the anulus: a postmortem study. AJNR Am J Neuroradiol. 1989 Sep-Oct. 10(5):1077-81. [Medline].
Zdeblick TA. A prospective, randomized study of lumbar fusion. Preliminary results. Spine. 1993 Jun 15. 18(8):983-91. [Medline].