Lumbosacral Discogenic Pain Syndrome 

Updated: Aug 19, 2016
Author: Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM; Chief Editor: Craig C Young, MD 

Overview

Background

Spinal abnormalities are more common in athletes than in non-athletes in the general population. Any spinal injury pattern can be observed in athletes who are subjected to trauma. Athletes are susceptible to degenerative disc changes at an early age because of the repetitive loading activities involved in sports.

Back pain is second only to the common cold as a cause of lost time from work and results in more lost productivity than any other medical condition. It has been estimated to result in 175.8 million days of restricted activity annually in the United States, and at any given time, 2.4 million Americans are disabled secondary to low back pain. Of these 2.4 million Americans, one half are chronically disabled. Data from the National Ambulatory Medical Care Survey from 1989-1990 revealed that there were almost 15 million office visits for low back pain, ranking this as the fifth reason for all physician visits.

In most industrialized nations, the lifetime prevalence of back pain exceeds 70%, and in the United States, a 15-20% 1-year prevalence rate has been estimated.[1] In 1990, 400,000 industrial low back injuries resulting in disability occurred in the United States. In 1985, a prospective Swedish study of adults aged 20-65 years conducted over an 18-month period reported over 7,500 work absences related to acute low back pain. Of these episodes, 57% of workers recovered within 1 week, 90% in 6 weeks, and 95% after 12 weeks. In 1987, Deyo reported a slower recovery rate in the United States, with only 33.2% of patients recovering in less than 1 month, 33% recovering in 1-5 months, and 32.7% taking longer than 6 months to recover. Finally, recurrence rates from 60-85% have been reported during the first 2 years following an acute back injury.

Frymoyer reported that 40% of patients experience leg pain in association with back pain; a much lower percentage reported numbness and weakness; and only 1% of adult respondents in the United States reported symptoms indicative of true sciatica. Herniated discs occur primarily in the second through the fifth decades of life and have a slight male preponderance. The L4-5 disc has been shown to be the most commonly herniated disc, resulting an L5 radiculopathy. The L5-S1 disc is a close second in frequency of herniation. Translating the frequency of back pain into economic terms emphasizes the magnitude of the problem. Lower back injuries account for approximately 22% of compensable workplace injuries, but they account for 31% of compensation payments. In the United States, the direct costs of spinal disorders were estimated to be in excess of $23 billion during 1990.This represented an increase of nearly 47% over the estimated costs in 1984.

Epidemiology

Frequency

United States

Overall, imaging signs of degeneration of the lumbosacral discs correlate closely with age. Approximately 20% of teens aged 11-16 years will begin to have mild signs, whereas 10% of 50-year-olds and 60% of 70-year-olds will have signs of severe degeneration.[2]

Thoracolumbar spinal abnormalities are more common in athletes than in nonathletes in the general population. Studies investigating spinal injuries in athletes are largely limited to those injuries that are severe enough to limit participation. Many athletes report injuries that allow for continued competition, and they participate with chronic low back pain.

Nearly 50% of college football linemen experience low back pain during a typical season, while 10-27% of all college football players experience lumbar spinal symptoms.

The rate of lumbar spinal injury in gymnasts has been directly related to the level of competition. Evidence from magnetic resonance imaging (MRI) scans that support this relationship is found in 9% of pre-elite, 43% of elite, and 63% of Olympic level gymnasts.[3, 4]

Noncontact sports, such as golf and cycling, are also associated with increased low back pain, largely related to repetitive forces or long-term postures.

Functional Anatomy

The lumbar spine has an average of 5 vertebrae (normal range 4-6), with an intervertebral disc interposed between adjacent vertebral bodies. A cartilaginous endplate exists between the disc and the adjacent vertebral bodies and is considered part of the disc.

The disc itself is comprised of a central nucleus pulposus surrounded peripherally by the annulus fibrosis. In healthy young adults, the nucleus is a semifluid mass of mucoid material. The nucleus is comprised of approximately 70-90% water in a young healthy disc, but this percentage generally decreases with age. The primary nuclear constituents include glycosaminoglycans, proteoglycans, and collagen. Type II collagen predominates in the nucleus. Proteoglycans are the largest molecules in the body and possess an enormous capacity to attract water through oncotic forces. These forces increase their weight by 250% and result in a gel-like composition. Biomechanically, the nucleus can display properties of either a solid or a liquid substance, depending on the transmitted loads and its posture.

The annulus fibrosis consists of 10-20 type I concentric collagen fiber layers that surround the nucleus. The layers are arranged in an alternating orientation of parallel fibers lying approximately 65 º from the vertical.

The vertebral endplate is a thin layer of cartilage located between the vertebral body and the intervertebral disc. While normally composed of both hyaline and fibrocartilage in youth, older endplates are virtually entirely fibrocartilage. Because the intervertebral disc is the largest avascular structure in the body, it is dependent on diffusion across the endplate for nutrition and waste removal. The endplate is considered part of the disc because the endplate almost always remains with the disc when the disc is traumatically displaced from the vertebral body.

The principal functions of the disc are to allow movement between vertebral bodies and to transmit loads from one vertebral body to the next. When axial loads are transmitted to the spine, the annulus and nucleus display a complex intertwined role allowing for pressure dispersal. The nucleus has the capacity to sustain and transmit pressure; this function is principally invoked during weight-bearing. In this circumstance, it transmits loads and braces the annulus. The annular lamella is capable of sustaining an axial load on the basis of its bulk. When an axial load is applied to the nucleus, it tends to shorten. The nucleus attempts to radially expand, thereby exerting pressure on the annulus. Annular resistance efficiently opposes this outward pressure, creating a hoop tension effect. The intervertebral disc is so effective at resisting these axial loads that a 40-kg load to a disc causes only 1 mm of vertical compression and only 0.5 mm of radial expansion.

During movement, the annulus acts like a ligament to restrain movements and partially stabilize the interbody joint. The oblique orientation of the annular fibers provides resistance to vertical, horizontal, and sliding movements. The alternation in the direction of the annular fibers in consecutive lamellae causes the annulus to resist twist poorly. When the segment twists one way, the fibers oriented in that direction are placed on stretch while those fibers oriented the opposite direction are placed on slack; therefore, the annulus resists the twisting motion with less than its full complement of fibers.

Sport Specific Biomechanics

Any factor that creates excessive demand can lead to injury. Excessive mechanical loading may occur by repetitive fatigue overload, supramaximal overload, or unexpected overload.[5] Improper technique in activities such as in blocking or tackling, poor body mechanics, or improper training can lead to overload. Unexpected overloads result from falls, collisions, or improper technique. Good coaching, proper technique, and safety measures help to minimize fatigue overload and limit dangerous sport situations.

 

Presentation

History

The history and physical examination findings of the athlete and nonathlete with discogenic or radiculopathic pain are similar.

  • Discogenic pain typically increases with sitting, flexion, coughing, sneezing, or activities that increase intradiscal pressure.

  • Common features of radiculopathy are leg pain in a dermatomal distribution, exacerbation of pain with a sitting position, and amelioration of pain during standing or ambulation. It is typically a flexion, rotation, or combined flexion-rotation injury.[6]

Physical

Physical examination does not yield significant information when dealing with internal disc derangement. Physical examination of the lumbar spine evaluating for discogenic pain should focus on a mechanical and neurologic examination in an attempt to identify the likely source of back pain (ie, mechanical, neurologic, or discogenic).

Causes

Causes of internal disc derangement (IDD) usually involve a series of traumatic events ranging in significance from minor disc injuries to more severe types of injuries. The accumulation of the injuries is generally believed to yield the degenerative nature of the annulus, and the lack of integrity is believed to allow water and protein molecules to escape the confines of the nucleus.

The difference between an asymptomatic degenerative disc and one that hurts has been in question. The nucleus pulposus has no nerve supply; however, the outer third of the annulus is innervated. It receives supply from both the gray ramus laterally and anteriorly and from the sinuvertebral nerve posterior and posterolaterally. The current model holds that in some manner, these annular sensory nerves become sensitized, and any turbulence, such as that caused by twisting or weight-bearing, provokes pain. One possibility is that the nuclear proteins become exposed to the system circulation, allowing an autoimmune reaction to the protein and an intense inflammatory process inside the disc.

 

DDx

 

Workup

Laboratory Studies

Laboratory evaluation is primarily used to identify underlying inflammatory, infectious, neoplastic, or nonspinal causes of low back pain. Such studies may include CBC, rheumatologic screening, and neuroendocrine testing.

Imaging Studies

MRI is the best noninvasive test for detecting IDD. Note, however, that the relationship between MRI depicted IDD and low back pain remains poorly understood.[7]

Generally, MRI demonstrates degenerative changes within the disc, such as annular fissures and reduced signal intensity, indicative of reduced water content. These changes, of course, are not specific for IDD, although discs with IDD do demonstrate degenerative changes. The difficulty is differentiating between a pathologically degenerate disc and a physiologically aging one.

The most specific MRI hallmark for IDD is the high-intensity zone (HIZ). This is a high-intensity signal, usually at the posterior apex of an annular fissure. The significance of the HIZ in regard to discogenic low back pain is still controversial. Aprill and Bogduk initially described the HIZ and reviewed a subset of 41 patients who were also evaluated with CT discography. In this study, the presence of the HIZ was strongly correlated to concordant pain. However, a study by Horton and Daftari involving 63 discs in 25 patients did not support a high correlation of the HIZ with concordant provoked pain.

Gadolinium-DTPA enhanced MRI is also being proposed as a viable alternative, showing a signal flare at the site of granulation tissue within a healing or healed full-thickness tear.[8]

Discography is the criterion standard for detecting IDD. It is somewhat invasive but is the only tool for accurately demonstrating whether a disc is painful or not. However, the efficacy of discography is controversial, and proper interpretation requires knowledge of the pathologic condition, an in-depth appreciation of the patient, and proper technique.

 

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

An acute or subacute disc injury should initially be treated conservatively. Conservative care includes physical therapy, anti-inflammatory medication, analgesics, and non–habit-forming sleep aids as necessary.

The emphasis of physical therapy is to reduce muscular guarding, improve segmental motion, reverse or improve mechanical faults, and ultimately improve the function of the injured individual through a home exercise program.

Once muscle guarding and mechanical faults have been improved, the patient is generally started on a lumbar stabilization program, with a trunk and lower extremity stretching program and a graduated conditioning program. The conditioning program emphasizes walking and may, depending on the individual’s history and overall health, emphasize weight training in a lumbar-safe manner.

Recovery Phase

Rehabilitation Program

Physical Therapy

This phase of rehabilitation focuses on the functional biomechanical and soft tissue deficits. Strengthening exercises start in simple planes and progress to complex muscle patterns. A lumbar spine stabilization program is initiated, using coordinated co-contraction of the abdominal and extensor muscles in a neutral posture.

Other Treatment (Injection, manipulation, etc.)

Evidence for epidural injection, one of the most frequent interventions for chronic low back pain, has been highly variable. However, for those with persistent discogenic pain despite a conservative approach, epidural steroid injection may be warranted to provide pain relief to allow for more active participation in conservative treatment. A 2012 meta-analysis of lumbar interlaminar epidural injections in the treatment of radiculitis due to disc herniation, spinal stenosis, or axial pain for nonherniated discogenic pain showed good-to-fair evidence for local anesthetic plus steroid under fluoroscopy. Evidence was best for herniated discs with radicular pain; however, results from one randomized controlled trial and two nonrandomized control studies showed positive effects at 3-, 6-, and 12-month follow-up for this approach to lumbosacral discogenic pain without radiculopathy.[9]

A randomized clinical trial by Desai et al evaluated the effectiveness of intradiscal biacuplasty versus conventional medical management in the treatment of lumbar discogenic pain. The study concluded that intradiscal biacuplasty is more effective than conventional management alone.[10]

Maintenance Phase

Rehabilitation Program

Physical Therapy

The final phase of rehabilitation requires full nonpainful active and passive lumbar range of motion and an appropriate neutral posture during both static and dynamic activities. Sport-specific activities should be reviewed to ensure correct techniques.

 

Medication

Medication Summary

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) can help decrease pain and inflammation. Various oral NSAIDs can be used, and none of these holds a clear distinction as the drug of choice. Choice of NSAID is largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

Similarly, narcotics may be indicated for short-term use to help maintain comfort during the acute phase of the injury. Again, no clear drug of choice exists in this category and treatment should be individualized.

Lee et al compared radicular pain reduction from epidural steroid injections administered using interlaminar, caudal, and transforaminal techniques in patients with lumbosacral intervertebral disc herniation.[11] The investigators examined results from 95 such patients who had experienced no decrease in pain following treatment with analgesics, anti-inflammatory agents, or physical therapy. As measured using the Visual Analog Scale (VAS) pain score, the ratio of successful results was higher for epidural injections administered with the interlaminar or transforaminal techniques than it was for those performed with the caudal technique.

Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Celecoxib (Celebrex)

For arthritis. Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus GI toxicity may be decreased.

Seek lowest dose of celecoxib for each patient.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)

For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of COX, which results in a decrease of prostaglandin synthesis.

Ketoprofen (Orudis, Oruvail, Actron)

For relief of mild to moderate pain and inflammation.

Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease.

Doses >75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.

 

Follow-up

Return to Play

Return to play is an individualized process. No specific time frame exists for a particular injury. Safe return to play is allowed after the appropriate sport-specific rehabilitation program is completed and the athlete demonstrates full pain-free range of motion and proper neutral spine posture with sport-specific activities.

Prevention

Injury prevention is best accomplished through good coaching, proper techniques of sport specific activity, adequate training prior to participation, and appropriate safety measures, including proper protective equipment and adherence to the rules of the game.

Education

Knowledge of proper sport activity techniques, sport rules, and safety measures prevents most sport injuries.