Management of Degenerative Disk Disease and Chronic Low Back Pain
Section snippets
The role of disk degeneration in chronic LBP
MRI is not recommended early in the disease course unless red flags or signs of nerve root entrapment are present. The reason is that MRI in acute LBP increases medical costs without giving additional information influencing clinical decision making.15, 16, 17 Furthermore, MRI in the current form is not useful in diagnosing discogenic pain when compared with discography.9 However, discography per se has been found to enhance progression of disk degeneration,18 and therefore recently published
The role of central sensitization in chronic LBP
Nociceptive stimuli from peripheral tissue, such as in the intervertebral disk, are transmitted mainly via the spinothalamic tract to the cerebral cortex. In case of persistent injury, C fibers fire repetitively to the dorsal horn, which may lead to central sensitization.39 Central sensitization is characterized by altered pain sensibility both peripherally and centrally.40 Even although intervertebral disks are the original pain generators in degenerative disk disease, central sensitization
Treatment of chronic LBP
Existing clinical guidelines list several treatment options for chronic LBP, which include pain medication, exercises, behavioral therapy, multidisciplinary rehabilitation, and surgery (Box 1).14, 46 Patient information is not reviewed in detail here. Yet, patient advice is an integral part of care at all stages. Such advice should preferably be given early in the disease course, because 2.5-hour sessions of individual oral education were found to be more effective than no intervention in
Prognostic factors
According to a systematic review, maladaptive pain coping behavior, in addition to baseline disability, is an important prognostic factor for poor recovery of LBP.50 Throughout the past decade, genetic analysis has been used to screen and identify risk factors for various spine-related conditions (eg, disk degeneration),108, 109, 110, 111, 112 and to prognosticate the development of disease progression (eg, scoliosis).113, 114, 115
Summary
Conservative decisions in the treatment of degenerative disk disease are based on interventions made for patients with chronic LBP. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic LBP. However, the effect sizes of these treatments are modest. Furthermore, these therapies work best in a multidisciplinary rehabilitation context. Pain medication is needed for most patients with degenerative
References (137)
Epidemiological features of chronic low-back pain
Lancet
(1999)- et al.
A systematic review of low back pain cost of illness studies in the United States and internationally
Spine J
(2008) - et al.
Discogenic pain
Pain
(2004) - et al.
Artifacts in T1 rho-weighted imaging: compensation for B(1) and B(0) field imperfections
J Magn Reson
(2007) - et al.
Central sensitization: a generator of pain hypersensitivity by central neural plasticity
J Pain
(2009) - et al.
Functional imaging of brain responses to pain. A review and meta-analysis (2000)
Neurophysiol Clin
(2000) - et al.
Affective components and intensity of pain correlate with structural differences in gray matter in chronic back pain patients
Pain
(2006) - et al.
Pain is associated with regional grey matter reduction in the general population
Pain
(2011) - et al.
Etiological theories and treatments for chronic back pain. II. Psychological models and interventions
Pain
(1984) - et al.
Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis
Lancet
(2010)
Regenerative effects of transplanting mesenchymal stem cells embedded in atelocollagen to the degenerated intervertebral disc
Biomaterials
Transplantation of mesenchymal stem cells embedded in Atelocollagen gel to the intervertebral disc: a potential therapeutic model for disc degeneration
Biomaterials
Mesenchymal stem cells arrest intervertebral disc degeneration through chondrocytic differentiation and stimulation of endogenous cells
Mol Ther
A randomized placebo-controlled trial of intradiscal methylene blue injection for the treatment of chronic discogenic low back pain
Pain
Descriptive epidemiology of low-back pain and its related medical care in the United States
Spine
Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey
Spine
Burden of illness of chronic low back pain in Sweden: a cross-sectional, retrospective study in primary care setting
Spine
Costs of back pain in Germany
Eur J Pain
Low back pain
N Engl J Med
Systematic review of lumbar discography as a diagnostic test for chronic low back pain
Pain Physician
Why does acute back pain become chronic?
BMJ
Nonsurgical management of acute and chronic low back pain
J Am Acad Orthop Surg
Burned-out discs stop hurting: fact or fiction?
Spine (Phila Pa 1976)
Magnetic resonance imaging and low back pain in adults: a diagnostic imaging study of 40-year-old men and women
Spine (Phila Pa 1976)
An updated overview of clinical guidelines for the management of non-specific low back pain in primary care
Eur Spine J
Does early imaging influence management and improve outcome in patients with low back pain? A pragmatic randomised controlled trial
Health Technol Assess
Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial
JAMA
Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome
Radiology
2009 ISSLS Prize Winner: Does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study
Spine (Phila Pa 1976)
Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society
Spine (Phila Pa 1976)
Results of surgery for discogenic low back pain: a randomized study using discography versus discoblock for diagnosis
Spine (Phila Pa 1976)
Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain
Eur Spine J
Prevalence and pattern of lumbar magnetic resonance imaging changes in a population study of one thousand forty-three individuals
Spine (Phila Pa 1976)
The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic features
Spine (Phila Pa 1976)
A population-based study of juvenile disc degeneration and its association with overweight and obesity, low back pain, and diminished functional status
J Bone Joint Surg Am
Does lumbar disc degeneration on MRI associate with low back symptom severity in young Finnish adults?
Spine (Phila Pa 1976)
Narrowing of lumbar spinal canal predicts chronic low back pain more accurately than intervertebral disc degeneration: a magnetic resonance imaging study in young Finnish male conscripts
Mil Med
Magnetic resonance study of disc degeneration in young low-back pain patients
Spine (Phila Pa 1976)
Age-dependent correlation of low-back pain and lumbar disc regeneration
Arch Orthop Trauma Surg
The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males
Eur Spine J
Degenerative MRI changes in patients with chronic low back pain: a systematic review
Spine
What is the source of chronic low back pain and does age play a role?
Pain Med
In vivo 3.0-tesla magnetic resonance T1rho and T2 relaxation mapping in subjects with intervertebral disc degeneration and clinical symptoms
Magn Reson Med
T1rho MRI and discography pressure as novel biomarkers for disc degeneration and low back pain
Spine (Phila Pa 1976)
Assessment of glycosaminoglycan distribution in human lumbar intervertebral discs using chemical exchange saturation transfer at 3 T: feasibility and initial experience
NMR Biomed
Single shot T1rho magnetic resonance imaging of metabolically generated water in vivo
Adv Exp Med Biol
In-vivo intervertebral disc characterization using magnetic resonance spectroscopy and T1rho imaging: association with discography and Oswestry Disability Index and SF-36
Spine (Phila Pa 1976)
Basic science of pain
J Bone Joint Surg Am
Chronic back pain is associated with decreased prefrontal and thalamic gray matter density
J Neurosci
Cited by (72)
Elucidation of effect of spinopelvic parameters in degenerative disc disease
2023, NeurochirurgieRole of AP-2α/TGF-β1/Smad3 axis in rats with intervertebral disc degeneration
2020, Life SciencesCitation Excerpt :IDD can be caused by excessive mechanical loading and a variety of processes which weaken a disc prior to disruption, or damage its healing response, such as the combined impacts of middle age, inadequate metabolite transport, an unfavorable inheritance, and loading history [2]. The gold standard of surgical treatment of IDD is spinal fusion, but this strategy can be accompanied by various negative side effects such as considerable rates of complication and reoperation and adjacent level pathologies [3,4]. Conservative therapies and invasive or interventional strategies in early stage of degeneration function to alleviate symptoms but not maintain the nature state of the disc [5].
Lumbar high-intensity zones on MRI: imaging biomarkers for severe, prolonged low back pain and sciatica in a population-based cohort
2020, Spine JournalCitation Excerpt :Low back pain (LBP) causes functional impairment, diminished quality of life, work disability, potential psychological distress, and increased health-care costs [1–3]. Magnetic resonance imaging (MRI) of the lumbar spine is a useful tool used to identify the potential source of the LBP and to help guide management [4,5]. However there is often discrepancy and critique between the clinical profile and MRI findings [6,7].
A novel in vivo large animal model of lumbar spinal joint degeneration
2018, Spine JournalCitation Excerpt :Degenerative disc disease (DDD) is a common, widespread socioeconomic problem [1]. Innovative therapies such as dynamic stabilization, growth factor injection and other biological therapies, surgical techniques, and tissue engineering strategies aim to treat or slow the progression of DDD [2]. Animal models are often required to evaluate these therapeutic strategies before being introduced into the clinical setting.
This work was supported by an Area of Excellence grant from the University Grants Committee of Hong Kong (AoE/M-04/04).
Disclosure: The investigators have no financial or competing interests in relation to this work.