Discogenic
low back pain
Straight to the point of care
Last updated: Feb 03, 2022
, Table of Contents
Overview 3
Summary 3
Definition 3
Theory 4
Epidemiology 4
Aetiology 4
Pathophysiology 7
Classification 8
Case history 8
Diagnosis 10
Approach 10
History and exam 18
Risk factors 18
Investigations 21
Differentials 28
Criteria 29
Management 32
Approach 32
Treatment algorithm overview 42
Treatment algorithm 44
Emerging 57
Primary prevention 57
Secondary prevention 57
Patient discussions 57
Follow up 58
Monitoring 58
Complications 59
Prognosis 60
Guidelines 61
Diagnostic guidelines 61
Treatment guidelines 61
References 62
Images 79
Disclaimer 90
,Discogenic low back pain Overview
Summary
Discogenic low back pain is a complex, multi-factorial, clinical condition. It is characterised by low back pain,
with or without the concurrence of radicular lower limb symptoms, in the presence of radiologically-confirmed
OVERVIEW
degenerative disc disease.
Magnetic resonance imaging is the imaging study of choice for degenerative disc disease due to its unique
detail on the representation of the disc status. Other tests may include plain radiographs, computed
tomography scanning, or provocative discography.
Non-surgical treatments include lifestyle measures, followed by the judicious use of medications,
physiotherapy, and therapeutic needling procedures.
Surgical treatment includes decompression of neural structures and, in selected patients, a fusion of the
motion segment.
Definition
A complex, multi-factorial, clinical condition characterised by low back pain with or without the concurrence
of radicular lower limb symptoms in the presence of radiologically-confirmed degenerative disc disease. The
pain is exacerbated by activity, but may be present in certain positions, such as sitting.
Progression of disc degeneration may lead to additional painful manifestations, including loss of disc height
and facet joint arthrosis, disc herniation and nerve root irritation, and hypertrophic changes resulting in spinal
stenosis.[1] [2]
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 03, 2022.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
3
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2022. All rights reserved.
, Discogenic low back pain Theory
Epidemiology
Low back pain (LBP) is a common clinical problem with major socioeconomic importance. Approximately
70% to 85% of adults are affected by LBP at some point during their lifetime.[4] [5] Each year, LBP affects
THEORY
approximately one-third of the adult UK population; however, only approximately 20% of people with LBP will
consult their doctor about it.[6] [7]
Although a number of different spinal anatomical structures (facet joints, intervertebral discs, vertebral
bodies, ligaments, and muscles), as well as other intra-abdominal or lower thoracic pathological causes,
have been identified as possible sources of LBP, the most common cause seems to be a degenerate lumbar
intervertebral disc.[8] [9] [10] [11] [12]
Radiographic evidence of disc degeneration commences as early as the third decade of life. The changes
increase in prevalence and severity with the passage of time by 3% to 4% per annum.[13] [14] However,
there is no clear correlation between symptoms and radiological findings.
Aetiology
Discogenic back pain is associated with the presence of radiologically-confirmed degenerative disc disease.
Multiple studies have identified a complex mechanical and inflammatory process as the main cause of
chronic discogenic pain.[15] [16] [17] [18]
Genetic influences have been found to be more important than the mechanical effects of sporting
endeavours, sitting habits, or occupational factors in the development of disc degeneration, although
occupation-related postures and stresses due to the abnormal loading and lifting mechanics do also seem to
be related.[19] [20] Degenerative disc disease is also associated with increasing age, smoking, the presence
of facet joint tropism and arthritis, abnormal pelvic morphology, and changes in sagittal alignment.
Radicular leg pain associated with degenerative disc disease results from nerve root compression due to
hypertrophied facet joints, disc prolapse, or foraminal narrowing due to loss of disc height or due to instability
at that motion segment.
In many cases, more than one cause of pain is responsible for the patient's symptoms. Therefore, discogenic
back pain remains primarily a diagnosis of exclusion.
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 03, 2022.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2022. All rights reserved.
low back pain
Straight to the point of care
Last updated: Feb 03, 2022
, Table of Contents
Overview 3
Summary 3
Definition 3
Theory 4
Epidemiology 4
Aetiology 4
Pathophysiology 7
Classification 8
Case history 8
Diagnosis 10
Approach 10
History and exam 18
Risk factors 18
Investigations 21
Differentials 28
Criteria 29
Management 32
Approach 32
Treatment algorithm overview 42
Treatment algorithm 44
Emerging 57
Primary prevention 57
Secondary prevention 57
Patient discussions 57
Follow up 58
Monitoring 58
Complications 59
Prognosis 60
Guidelines 61
Diagnostic guidelines 61
Treatment guidelines 61
References 62
Images 79
Disclaimer 90
,Discogenic low back pain Overview
Summary
Discogenic low back pain is a complex, multi-factorial, clinical condition. It is characterised by low back pain,
with or without the concurrence of radicular lower limb symptoms, in the presence of radiologically-confirmed
OVERVIEW
degenerative disc disease.
Magnetic resonance imaging is the imaging study of choice for degenerative disc disease due to its unique
detail on the representation of the disc status. Other tests may include plain radiographs, computed
tomography scanning, or provocative discography.
Non-surgical treatments include lifestyle measures, followed by the judicious use of medications,
physiotherapy, and therapeutic needling procedures.
Surgical treatment includes decompression of neural structures and, in selected patients, a fusion of the
motion segment.
Definition
A complex, multi-factorial, clinical condition characterised by low back pain with or without the concurrence
of radicular lower limb symptoms in the presence of radiologically-confirmed degenerative disc disease. The
pain is exacerbated by activity, but may be present in certain positions, such as sitting.
Progression of disc degeneration may lead to additional painful manifestations, including loss of disc height
and facet joint arthrosis, disc herniation and nerve root irritation, and hypertrophic changes resulting in spinal
stenosis.[1] [2]
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 03, 2022.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
3
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2022. All rights reserved.
, Discogenic low back pain Theory
Epidemiology
Low back pain (LBP) is a common clinical problem with major socioeconomic importance. Approximately
70% to 85% of adults are affected by LBP at some point during their lifetime.[4] [5] Each year, LBP affects
THEORY
approximately one-third of the adult UK population; however, only approximately 20% of people with LBP will
consult their doctor about it.[6] [7]
Although a number of different spinal anatomical structures (facet joints, intervertebral discs, vertebral
bodies, ligaments, and muscles), as well as other intra-abdominal or lower thoracic pathological causes,
have been identified as possible sources of LBP, the most common cause seems to be a degenerate lumbar
intervertebral disc.[8] [9] [10] [11] [12]
Radiographic evidence of disc degeneration commences as early as the third decade of life. The changes
increase in prevalence and severity with the passage of time by 3% to 4% per annum.[13] [14] However,
there is no clear correlation between symptoms and radiological findings.
Aetiology
Discogenic back pain is associated with the presence of radiologically-confirmed degenerative disc disease.
Multiple studies have identified a complex mechanical and inflammatory process as the main cause of
chronic discogenic pain.[15] [16] [17] [18]
Genetic influences have been found to be more important than the mechanical effects of sporting
endeavours, sitting habits, or occupational factors in the development of disc degeneration, although
occupation-related postures and stresses due to the abnormal loading and lifting mechanics do also seem to
be related.[19] [20] Degenerative disc disease is also associated with increasing age, smoking, the presence
of facet joint tropism and arthritis, abnormal pelvic morphology, and changes in sagittal alignment.
Radicular leg pain associated with degenerative disc disease results from nerve root compression due to
hypertrophied facet joints, disc prolapse, or foraminal narrowing due to loss of disc height or due to instability
at that motion segment.
In many cases, more than one cause of pain is responsible for the patient's symptoms. Therefore, discogenic
back pain remains primarily a diagnosis of exclusion.
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 03, 2022.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2022. All rights reserved.
