Patient with Lumbar Spondylosis and Diskogenic Pain

Abstract

Diskogenic low back pain (LBP), defined as pain that originates from a damaged vertebral disk, is a common cause of LBP. It is characterized by a three-phase cascade of degeneration marked by dysfunction, instability, and stabilization. A distinct pathologic characteristic of the disks from patients with diskogenic LBP has been found to be the formation of the zones of vascularized granulation tissue, with extensive innervation extending from the outer layer of the annulus fibrosus into the nucleus pulposus along a torn fissure. In addition, there appears to be an association between microbial infection and symptomatic disk degeneration. Low-virulence microorganisms, in particular Propionibacterium acnes, might be causing a chronic low-grade infection in the lower intervertebral disks in some patients. The diagnosis of diskogenic pain is primarily based on clinical manifestations, physical examinations, imaging studies, and provocative diskography. Diskogenic pain should be differentiated from other axial back pain conditions, such as facet arthropathy, sacroiliac joint pain, myofascial strain and pain, vertebral compression fracture, and other, less common conditions. Treatment options should be tailored to individual needs. Early and gradual physical and behavioral therapies are encouraged. Pharmacologic therapy, composed primarily of analgesics, nonsteroidal antiinflammatory drugs, muscle relaxants, and antidepressants, may have modest positive effects. A subset of patients with Modic type I changes in magnetic resonance imaging may benefit antibiotic therapy directed at the infected disks by P. acnes and other low-virulence microorganisms. There is evidence that supports the use of epidural steroid injections and intradiskal injections (methylene blue, ozone, steroids) for diskogenic pain. Additional options include intradiskal biacuplasty, gray ramus communicans nerve blocks/radiofrequency ablation, and intradiskal stem cell injections for disk repair/regeneration, all of which have gained support in clinical trials. These treatment modalities have shown promise to provide equal or even better outcomes compared with surgical spinal fusion or total disk replacement with an artificial disk. This review contains 2 figures and 149 references. Keywords: collagen, diskogenic low back pain (LBP), herniation, intervertebral disk, spondylosis