Discogenic pain: Who cares?

Abstract

Chronic low back pain has a huge impact on daily living and a negative economic and professional effect. It is a matter of debate and concern for all health professionals involved, particularly spine surgeons. Recent discoveries on the innervation and biochemical properties of the intervertebral disc clarify the role of this structure as a possible cause of chronic low back pain. However, multiple causes may be present in the same patient making the diagnosis a challenging process. Discogenic pain is defined as a chronic low back pain induced by a degenerative disc disease. There are no specific characteristics of discogenic pain, although it has a higher incidence in younger age, it is usually localized medially in the back, worsens with axial loading and improves with recumbence. In the last decades we have assisted the emergence of multiple treatment techniques. However, neither the conservative treatment nor the interventional management has strong evidence in treating discogenic pain. Randomized control clinical trials are sought to improve patient outcome. Meanwhile, we believe each patient should be approached on an individual base. Discogenic pain: we care.

 

Share and Cite:

Lavrador, J. , Simas, N. , Oliveira, E. , Teixeira, J. , Simão, D. and Livraghi, S. (2013) Discogenic pain: Who cares?. Health, 5, 1929-1937. doi: 10.4236/health.2013.511261.

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1] Balagué, F., Mannion, A.F., Pellisé, F. and Cedraschi, C. (2012) Non-specific low back pain. Lancet, 379, 482-491.
http://dx.doi.org/10.1016/S0140-6736(11)60610-7
[2] Andersson, G.B. (1999) Epidemiological features of chronic low back pain. Lancet, 354, 581-585.
http://dx.doi.org/10.1016/S0140-6736(99)01312-4
[3] Dagenais, S., Caro, J. and Haldeman, S. (2008) A systematic review of low back pain cost of illness studies in the United States and internationally. The Spine Journal, 8, 8-20. http://dx.doi.org/10.1016/j.spinee.2007.10.005
[4] Maniadakis, N. and Gray, A. (2000) The economic burden of back pain in the UK. Pain, 84, 95-103.
http://dx.doi.org/10.1016/S0304-3959(99)00187-6
[5] Garcia-Cosamaló, J., Valle, M., Calavia, M., GarcíaSuárez, O., López-Muniz, A., Otero, J. and Veja, J. (2010) Intervertebral disc, sensory nerves and neurotrophins: Who is who in discogenic pain? Journal of Anatomy, 217, 1-15.
[6] Ulrich, D. (1995) Color atlas of embryology: General embryology—Resegmentation of axial organs. Thieme.
[7] Pickering, P. and Robert, H. (1974) Gray’s anatomy: Embryology. Courage Books, 1149-1214.
[8] Kallewaard, J.W., Terheggen, M.A., Groen, G.J., Sluijter, M.E., Derby, R., Kapural, L., Mekhail, N. and van Kleef, M. (2010) Discogenic low back pain. Pain Practice, 10, 560-579. http://dx.doi.org/10.1111/j.1533-2500.2010.00408.x
[9] Cohen, S.P., Larkin, T.M., Barna, S.A., Palmer, W.E., Hecht, A.C. and Stojanovic, M.P. (2005) Lumbar discography: A comprehensive review of outcome studies, diagnostic accuracy, and principles. Regional Anesthesia and Pain Medicine, 30, 163-183.
http://dx.doi.org/10.1016/j.rapm.2004.10.006
[10] Edgar, M.A. (2007) The nerve supply of the lumbar intervertebral disc. The Bone & Joint Journal, 89, 1135-1139. http://dx.doi.org/10.1302/0301-620X.89B9.18939
[11] Raj, P.P. (2008) Intervertebral disc: Anatomy-physiology-pathophysiology-treatment. Pain Practice, 8, 18-44.
http://dx.doi.org/10.1111/j.1533-2500.2007.00171.x
[12] Johnson, W.E., Patterson, A.M., Eisenstein, S.M. and Roberts, S. (2007) The presence of pleiotrophin in the human intervertebral disc is associated with increased vascularization: An immunohistologic study. Spine (Phila Pa 1976), 32, 1295-1302.
[13] Taylor, J.R. (1975) Growth of human intervertebral discs and vertebral bodies. Journal of Anatomy, 120, 49-68.
[14] Urgan, J.P.G., Roberts, S. and Ralphs, J.R. (2000) The nucleus of the intervertebral disc from development to degeneration. Integrative and Comparative Biology: Oxford Journals, 40, 53-61.
[15] Hormel, S.E. and Eyre, D.R. (1991) Collagen in the ageing human intervertebral disc: An increase in covalently bound fluorophores and chromophores. Biochimica et Biophysica Acta (BBA)—Protein Structure and Molecular Enzymology, 1078, 243-250.
[16] Coventry, M.B., Ghormley, R.K. and Kernohan J.W. (1945) The intervertebral disc: Its microscopic anatomy and pathology; anatomy, development and physiology. The Journal of Bone & Joint Surgery, 27, 105-112.
[17] Thompson, J.P., Pearce, R.H., Schechter, M.T., Adams, M.E., Tsang, I.K.Y. and Bishop, P.B. (1990) Preliminary evaluation of a scheme for grading the gross morphology of the human intervertebral disc. Spine, 15, 411-415.
[18] Vernon-Roberts, B. (1992) Age related and degenerative pathology of the intervertebral discs and apophyseal joints. In: Jayson, M.I.V., Ed., The Lumbar Spine and Back Pain, Churchill Livingstone, London, 17-41.
[19] Ishihara, H. and Urban, J.P., (1999) Effects of low oxygen concentrations and metabolic inhibitors on proteoglycan and protein synthesis rates in the intervertebral disc. Journal of Orthopaedic Research, 17, 829-835.
http://dx.doi.org/10.1002/jor.1100170607
[20] Kauppila, L.I., McAlindon, T., Evans, S., Wilson, P.W., Kiel, D. and Felson, D.T. (1997) Disc degeneration/back pain and calcification of the abdominal aorta. A 25-year follow-up study in Framingham. Spine, 22, 1642-1647.
http://dx.doi.org/10.1097/00007632-199707150-00023
[21] Kauppila, L.I. (1997) Prevalence of stenotic changes in arteries supplying the lumbar spine. A postmortem angiographic study on 140 subjects. Annals of the Rheumatic Diseases, 56, 591-595.
http://dx.doi.org/10.1136/ard.56.10.591
[22] Holm, S. and Nachemson, A. (1983) Variations in the nutrition of the canine intervertebral disc induced by motion. Spine, 8, 866-874.
http://dx.doi.org/10.1097/00007632-198311000-00009
[23] Akmal, M., Kesani, A., Anand, B., Singh, A., Wiseman, M. and Goodship, A. (2004) Effect of nicotine on spinal disc cells: A cellular mechanism for disc degeneration. Spine, 29, 568-575.
http://dx.doi.org/10.1097/01.BRS.0000101422.36419.D8
[24] Oda, H., Matsuzaki, H., Tokuhashi, Y., Wakabayashi, K., Uematsu, Y. and Iwahashi, M. (2004) Degeneration of intervertebral discs due to smoking: Experimental assessment in a rat-smoking model. Journal of Orthopaedic Science, 9, 135-141.
http://dx.doi.org/10.1007/s00776-003-0759-y
[25] Cassinelli, E.H., Hall, R.A. and Kang, J.D. (2001) Biochemistry of intervertebral disc degeneration and the potential for gene therapy applications. The Spine Journal, 1, 205-214. http://dx.doi.org/10.1016/S1529-9430(01)00021-3
[26] Kroeber, M.W., Unglaub, F., Wang, H., Schmid, C., Thomsen, M., Nerlich, A. and Richter, W. (2002) New in vivo animal model to create intervertebral disc degeneration and to investigate the effects of therapeutic strategies to stimulate disc regeneration. Spine, 27, 2684-2690.
http://dx.doi.org/10.1097/00007632-200212010-00007
[27] Rousseau, M.A., Ulrich, J.A., Bass, E.C., Rodriguez, A.G., Liu, J.J. and Lotz, J.C.(2007) Stab incision for inducing intervertebral disc degeneration in the rat. Spine, 32, 17-24. http://dx.doi.org/10.1097/01.brs.0000251013.07656.45
[28] Boos, N., Semmer, N., Elfering, A., Schade, V., Gal, I., Zanetti, M., Kissling, R., Buchegger, N., Hodler, J. and Main, C.J. (2000) Natural history of individuals with asymptomatic disc abnormalities in magnetic resonance imaging: Predictors of low back pain-related medical consultation and work incapacity. Spine, 25, 1484-1492.
http://dx.doi.org/10.1097/00007632-200006150-00006
[29] Deyo, R.A. and Bass, J.E. (1989) Lifestyle and low-back pain. The influence of smoking and obesity. Spine, 14, 501-506. http://dx.doi.org/10.1097/00007632-198905000-00005
[30] Heliovaara, M. (1989) Risk factors for low back pain and sciatica. Annals of Medicine, 21, 257-264.
http://dx.doi.org/10.3109/07853898909149202
[31] Setton, L.A. and Chen, J. (2006) Mechanobiology of the intervertebral disc and relevance to disc degeneration. The Journal of Bone & Joint Surgery, 88, 52-57.
http://dx.doi.org/10.2106/JBJS.F.00001
[32] Adams, M.A. and Roughley, P.J. (2006) What is intervertebral disc degeneration, and what causes it? Spine, 31, 2151-2161. http://dx.doi.org/10.1097/01.brs.0000231761.73859.2c
[33] Antoniou, J., Steffen, T., Nelson, F., Winterbottom, N., Hollander, A.P., Poole, R.A., Aebi, M. and Alini, M. (1996) The human lumbar intervertebral disc: evidence for changes in the biosynthesis and denaturation of the extracellular matrix with growth, maturation, ageing, and degeneration. Journal of Clinical Investigation, 98, 996-1003. http://dx.doi.org/10.1172/JCI118884
[34] Cloyd, J.M. and Elliott, D.M. (2007) Elastin content correlates with disc degeneration in the annulus fibrosus and nucleus pulposus. Spine, 32, 1826-1831.
http://dx.doi.org/10.1097/BRS.0b013e3181132a9d
[35] Anderson, D.G. and Tannoury, C. (2005) Molecular pathogenic factors in symptomatic disc degeneration. The Spine Journal, 5, 260S-266S.
http://dx.doi.org/10.1016/j.spinee.2005.02.010
[36] Le Maitre, C.L., Pockert, A., Buttle, D.J., Freemont, A.J. and Hoyland, J.A. (2007) Matrix synthesis and degradation in human intervertebral disc degeneration. Biochemical Society Transactions, 35, 652-655.
http://dx.doi.org/10.1042/BST0350652
[37] Orita, S., Miyagi, M., Kobori, S., Gemba, T., Ishikawa, T., Inoue, G., Toyone, T., Aoki, Y., Eguchi, Y., Takahashi, K. and Ohtori, S. (2013) IkB kinase b inhibitor downregulates pain-related neuropeptide production in the sensory neurons innervating injured lumbar intervertebral discs in the dorsal root ganglia of rats. The Spine Journal, 13, 284-288. http://dx.doi.org/10.1016/j.spinee.2013.01.020
[38] Burke, J.G., Watson, R.W., McCormack, D., Dowling, F.E., Walsh, M.G. and Fitzpatrick, J.M. (2002) Intervertebral discs which cause low back pain secrete high levels of proinflammatory mediators. Journal of Bone & Joint Surgery, 84, 196-201.
http://dx.doi.org/10.1302/0301-620X.84B2.12511
[39] Urban, J.P., Smith, S. and Fairbank, J.C. (2004) Nutrition of the intervertebral disc. Spine, 29, 2700-2709.
http://dx.doi.org/10.1097/01.brs.0000146499.97948.52
[40] Adams, M.A. and Roughley, P.J. (2006) What is intervertebral disc degeneration, and what causes it? Spine, 31, 2151-2161.
http://dx.doi.org/10.1097/01.brs.0000231761.73859.2c
[41] Paassilta, P., Lohiniva, J., Goring, H.H., Perala, M., Raina, S.S., Karppinen, J., Hakala, M., Palm, T., Kroger, H., Kaitila, I., Vanharanta, H., Ott, J. and Ala-Kokko, L. (2001) Identification of a novel common genetic risk factor for lumbar disk disease. Journal of the American Medical Association, 285, 1843-1849.
http://dx.doi.org/10.1001/jama.285.14.1843
[42] Kawaguchi, Y., Kanamori, M., Ishihara, H., Ohmori, K., Matsui, H. and Kimura, T. (2002) The association of lumbar disc disease with vitamin-D receptor gene polymerphism. Journal of Bone & Joint Surgery, 84, 2022-2028.
[43] Kawaguchi, Y., Osada, R., Kanamori, M., Ishihara, H., Ohmori, K., Matsui, H. and Kimura, T. (1999) Association between an aggrecan gene polymorphism and lumbar disc degeneration. Spine, 24, 2456-2460.
http://dx.doi.org/10.1097/00007632-199912010-00006
[44] Noponen-Hietala, N., Kyllonen, E., Mannikko, M., Ilkko, E., Karppinen, J., Ott, J. and Ala-Kokko, L. (2003) Sequence variations in the collagen IX and XI genes are associated with degenerative lumbar spinal stenosis. Annals of the Rheumatic Diseases, 62, 1208-1214.
http://dx.doi.org/10.1136/ard.2003.008334
[45] Ahn, S.H., Cho, Y.W., Ahn, M.W., Jang, S.H., Sohn, Y.K. and Kim, H.S. (2002) mRNA expression of cytokines and chemokines in herniated lumbar intervertebral discs. Spine, 27, 911-917.
http://dx.doi.org/10.1097/00007632-200205010-00005
[46] Lewin, G.R. and Barde, Y.A. (1996) Physiology of the neurotrophins. Annual Review of Neuroscience, 19, 289-317.
http://dx.doi.org/10.1146/annurev.ne.19.030196.001445
[47] Lu, B., Pang, P.T. and Woo, N.H. (2005) The yin and yang of neurotrophin action. Nature Reviews Neuroscience, 6, 603-614. http://dx.doi.org/10.1038/nrn1726
[48] Richardson, S.M., Doyle, P., Minogue, B.M., Gnanalingham, K. and Hoyland, J.A. (2009) Increased expression of matrix metalloproteinase-10. Nerve growth factor and substance P in the painful degenerated intervertebral disc. Arthritis Research and Therapy, 11, R126.
http://dx.doi.org/10.1186/ar2793
[49] Priestley, J.V., Michael, G.J., Averill, S., Liu, M. and Willmott, N. (2002) Regulation of nociceptive neurons by nerve growth factor and glial cell line derived neurotrophic factor. Canadian Journal of Physiology and Pharmacology, 80, 495-505.
http://dx.doi.org/10.1139/y02-034
[50] Salio, C., Averill, S., Priestley, J.V. and Merighi, A. (2007) Costorage of BDNF and neuropeptides within individual dense-core vesicles in central and peripheral neurons. Developmental Neurobiology, 67, 326-338.
http://dx.doi.org/10.1002/dneu.20358
[51] Freemont, A.J., Watkins, A., Le Maitre, C., Baird, P., Jeziorska, M., Knight, M.T., Ross, E.R., O’Brien, J.P. and Hoyland, J.A. (2002) Nerve growth factor expression and innervation of the painful intervertebral disc. Journal of Pathology, 197, 286-292.
http://dx.doi.org/10.1002/path.1108
[52] Laplante, B.L., Ketchum, J.M., Saullo, T.R. and De Palma, M.J. (2012) Multivariable analysis of the relationship between pain referral patterns and the source of chronic low back pain. Pain Physician, 15, 171-178.
[53] Schwarzer, A.C., Aprill, C.N., Derby, R., Fortin, J., Kine, G. and Bogduk, N. (1995) The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine, 20, 1878-1883.
http://dx.doi.org/10.1097/00007632-199509000-00007
[54] Jensen, M.C., Brant-Zawadzki, Obuchowski, N., Modic, M.T., Malkasian, D. and Ross, J.S. (1994) Magnetic resonance imaging of the lumbar spine in people without back pain. The New England Journal of Medicine, 331, 69-73.
http://dx.doi.org/10.1056/NEJM199407143310201
[55] Emch, T.M. and Modic. M.T. (2011) Imaging of lumbar degenerative disk disease: History and current state. Skeletal Radiology, 40, 1175-1189.
http://dx.doi.org/10.1007/s00256-011-1163-x
[56] Modic, M.T. and Ross, J.S. (2007) Lumbar degenerative disk disease. Radiology, 245, 43-61.
http://dx.doi.org/10.1148/radiol.2451051706
[57] Aoki, Y., Ohtori, S., Takahashi, K., et al. (2004) Innervation of the lumbar intervertebral disc by nerve growth factor—Dependent neurons related to inflammatory pain. Spine, 29, 1077-1081.
http://dx.doi.org/10.1097/00007632-200405150-00005
[58] Bogduk, N., Aprill, C. and Derby, R. (2013) Lumbar discogenic pain: State-of-the-art review. Pain Medicine, 14, 813-836. http://dx.doi.org/10.1111/pme.12082
[59] Haughton, V. (2011) The “dehydrated” lumbar intervertebral disk on MR, its anatomy, biochemistry and biomechanics. Neuroradiology, 53, 191-194.
http://dx.doi.org/10.1007/s00234-011-0923-6
[60] Pfirrman, C.W., Metzdorf, A., Zanetti, M., Hodler, J. and Boos, N. (2001) Magnetic resonance classification of lumbar intervertebra disc degeneration. Spine, 126, 1873-1878. http://dx.doi.org/10.1097/00007632-200109010-00011
[61] Rhame, R. and Moussa, E. (2008) The modic vertebral endplate and marrow changes pathologic significance and relation to low back pain and segmental instability of the lumbar spine. American Journal Neuroradiology, 29, 838-842. http://dx.doi.org/10.3174/ajnr.A0925
[62] Kuisma, M., Karppinen, J. and Niinimaki, J. (2007) Modic changes in endplates of lumbar vertebral bodies: prevalence and association with low back and sciatic pain among middle-aged male workers. Spine, 31, 1714-1718.
http://dx.doi.org/10.1097/01.brs.0000224167.18483.14
[63] Del Grande, F., Maus, T.P. and Carrino, J. (2012) Imaging the intervertebral disk, age-related changes, herniations and radicular pain. Radiologic Clinics of North America, 50, 629-649. http://dx.doi.org/10.1016/j.rcl.2012.04.014
[64] Sachs, B.L., Vanharante, H., Spivey, M.A. (1987) Dallas discogram description. A new classification of CT/Discography in low back disordes. Spine, 12, 295-298.
http://dx.doi.org/10.1097/00007632-198704000-00018
[65] Boden, S.D., Davis, D.O., Dina, T.S., et al. (1990) Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. Journal of Bone & Joint Surgery, 72, 403-408.
[66] Koes, B.W., van Tulder, M.W. and Peul, W.C. (2007) Diagnosis and treatment of sciatica. British Medical Journal, 334, 1313-1317.
http://dx.doi.org/10.1136/bmj.39223.428495.BE
[67] Luijsterburg, P.A., Verhagen, A.P., Ostelo, R.W., van den Hoogen, H.J., Peul, W.C., Avezaat, C.J. and Koes, B.W. (2008) Physical therapy plus general practitioners’ care versus general practitioners’ care alone for sciatica: A randomised clinical trial with a 12-month follow-up. European Spine Journal, 17, 509-517.
http://dx.doi.org/10.1007/s00586-007-0569-6
[68] Buttermann, G.R. (2004) The effect of spinal steroid injections for degenerative disc disease. Spine, 4, 495-505.
http://dx.doi.org/10.1016/j.spinee.2004.03.024
[69] Saal, J.A. and Saal, J.S. (2000) Intradiscal electrothermal treatment for chronic discogenic low back pain: A prospective outcome study with minimum 1-year follow-up. Spine, 25, 2622-2627.
http://dx.doi.org/10.1097/00007632-200010150-00013
[70] Kapural, L., Mekhail, N., Hicks, D., Kapural, M., Sloan, S., Moghal, N., Ross, J. and Petrinec, D. (2008) Histological changes and temperature distribution studies of a novel bipolar radiofrequency heating system in degenerated and nondegenerated human cadaver lumbar discs. Pain Medicine, 9, 68-75.
http://dx.doi.org/10.1111/j.1526-4637.2007.00410.x
[71] Winn, H.R., Bullock, M., Hovda, D., Schouten, J., Maas, A., Frank, L.A. and Christopher, P.A. (2011) Youmans neurological surgery: Chapter 273—Diagnosis and management of diskogenic lower back pain. Vol. 3, Elsevier Saunders, Philadelphia.

Copyright © 2024 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.