Lumbar (Intervertebral) Disc Disorders

para>Symptoms may emerge rapidly after adolescence, leading to significant and chronic LBP.
Pregnancy Considerations

Increased incidence of LBP, sacroiliac dysfunction, and/or sciatica during pregnancy

Geriatric Considerations

Usually multifactorial to include possible disc degeneration, lesions of spine, spondylolisthesis, spinal stenosis, and osteoporotic fractures

ETIOLOGY AND PATHOPHYSIOLOGY

With age, the nucleus pulposus loses ability to support compressive force, shifting weight onto the annulus fibrosis, which subsequently fatigues.
Over time, fibers of the annulus fibrosus lengthen, weaken, and fray with resultant protrusion, extrusion, or sequestration of disc fragments.
Symptomatic degenerative disc disease results from inflammatory irritation of adjacent tissues (ligament, nerve root, and vertebrae) or compression of structures (bulging disc, herniated nucleus pulposus, degenerative changes of the spine).
There is no definitive correlation of radiographic findings and symptomatology.

RISK FACTORS

Smoking, genetics, elevated BMI, inactivity, osteoporosis, trauma, cancer, psychologic disorder (i.e., depression, anxiety)
Occupational risks: prolonged standing, heavy lifting, use of vibrating tools (jackhammer)
Socioeconomic factors do not contribute to risk of initial injury/degeneration but contribute significantly to subsequent degree of disability.

GENERAL PREVENTION

Most episodes of LBP are not preventable.
Modification of occupational risk factors
Management of comorbid conditions
Smoking cessation
Aerobic and core-strengthening exercises

COMMONLY ASSOCIATED CONDITIONS

Obesity
Diabetes mellitus
Osteoarthritis, osteoporosis
Depression/anxiety
Low job satisfaction

DIAGNOSIS

HISTORY

Assess location, onset, aggravating/relieving factors, and associated symptoms. Establish baseline pain level and functional deficits.
Degenerative disc disease usually described as recurrent episodes of pain with periods of complete or near-complete resolution.
Inciting event for pain flare is usually not traumatic; often occurs after exertion (lifting, bending, twisting).
Radicular pain often greater than back pain with disc herniation.
Pain often exaggerated by Valsalva maneuver.
Red flags
- Cauda equina syndrome: saddle anesthesia, bowel or bladder dysfunction, neurologic deficits in bilateral lower extremities
- Expanding lesion (swelling or tumor growth): progressively worsening symptoms
- Fracture: major/minor trauma, strenuous lifting, steroid use, osteoporosis
- Cancer: age >50 years or <20 years, fever, weight loss, severe nighttime pain
- Infection: fever, IV drug use, skin infection, UTI, immunosuppression
Yellow flags: indicate risk for development of prolonged pain
- Depression, impaired global function, job dissatisfaction, disputed compensation claims

PHYSICAL EXAM

Assess gait, posture, range of motion, reflexes, sensation (particularly femoral, peroneal, tibial, lateral femoral cutaneous nerves and L2 " L5, S1 dermatomes), and strength (assess muscles of hip girdle, knee, ankle, and foot).
Palpate/percuss spine and other bony landmarks
Paraspinal muscle spasm often present
For radiculopathy
- Straight-leg raise (SLR) test: nerve root irritation; Las ¨gue sign: sciatic nerve irritation
- Crossed SLR test: If positive, consider pathognomonic for disc herniation.
- Loss of Achilles reflex: S1 impingement
- Combined femoral stretch test, patellar reflex, medial ankle sensation, and crossed femoral stretch test: L4 impingement

DIFFERENTIAL DIAGNOSIS

Acute or chronic lumbosacral strain
Facet joint disease
Piriformis syndrome
Spondylosis/spondylolisthesis
Spinal arthritis
Spinal stenosis
Sciatica
Compression fracture
Metastatic and primary tumors
Vertebral infection
Vertebral vascular insufficiency
Cauda equina syndrome
Fibromyalgia
Referred pain from hip, pelvis, retroperitoneum, abdomen

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Labs are not routinely recommended.
Red flags are present or suspected organic causes (infection, autoimmune): CBC, ESR, or CRP
Suspected malignancy: also obtain Serum protein electrophoresis (SPEP), urine protein electrophoresis (UPEP)
Suspected urogenital etiology: urinalysis
Lumbosacral plain films not routinely indicated. Obtain if patient is >50 years of age, history of trauma, presence of neuromuscular deficits, unexplained weight loss, history of drug/alcohol abuse, history of cancer, fever, corticosteroid use, recurrent visits for same complaint, patient seeking compensation
MRI is the modality of choice for evaluation of disc and nerve root pathology, spinal stenosis, masses, and discitis. Consider if severe or progressive neurologic deficits present, patient adherent to therapy but failed conservative treatment after 6 weeks, or if clinical suspicion warrants further evaluation.
Noncontrast CT: useful if bony abnormality is suspected; limited evaluation of neural pathology without use of thecal contrast
CT myelogram: considered definitive for diagnosis of herniation, stenosis, or osteophytes but invasive and rarely used
Nerve conduction studies/EMG: helps localize spinal level; only positive after radiculopathy present for 4 or more weeks; does not exclude radiculopathy if negative
Discogram: gold standard for identifying specific disc pathology but invasive and rarely used (1)[A]

Test Interpretation

It is difficult to distinguish the imaging findings of normal aging process of disc degeneration from specific lesions causing LBP and sciatica; provider must correlate history, physical exam, and radiologic findings.
Degenerative findings on MRI in asymptomatic patients are not reliably predictive of development or duration of future symptomatology.

TREATMENT

GENERAL MEASURES

Conservative therapy is recommended for 6 weeks in absence of red flags.
Goals of treatment include decreasing pain, improving mobility, and preventing mental and physical disability (2)[A].
Multidisciplinary approach that includes psychologic interventions yields better outcomes (1)[A],(3)[B],(4)[C].
Relative rest for 1 to 3 days, lying in semi-Fowler position, and avoiding prolonged sitting may decrease symptoms (5)[A].
Aerobic exercise decreases pain and disability through improvement of physical and psychological functioning (2)[A].
Physical therapy to address isometric core strengthening (back/abdomen/legs) and postural retraining (5,6)[A]
Consider reevaluation and imaging studies if conservative management fails after 6 weeks.
Communicate treatment expectations, risks, and short- and long-term benefits.

MEDICATION

First Line

No consensus on effective first-line oral medication.
NSAIDs: COX-2 inhibitors are most commonly used due to lower side effect profile. In vitro studies show that COX-2 inhibitors may have short-term analgesic effect, but may upregulate nerve growth factor potentially resulting in chronic pain.
Acetaminophen has routinely been recommended as first-line therapy; however, clinical studies have shown no difference in pain intensity or disability compared to placebo.
Muscle relaxants for acute paraspinal muscle spasm only (5)[A]
If depression is present, it should be treated with first-line interventions for improved outcomes and decreased need for narcotic medications (5)[A].

Second Line

May consider short- or long-term use of tramadol; use lowest effective oral dose starting with 50 mg q6h as needed (5,6)[A].
Opioids may be considered for acute flares, but early and prolonged use is associated with more severe pain, increased disability, and decreased quality of life. Side effect profile of tolerance, dependence, abuse, accidental overdose, and increased fracture risk should warrant careful consideration when prescribing (7)[B].

ADDITIONAL THERAPIES

Procedural injections, epidural, or intradiscal: injection of lidocaine and/or steroids is commonly the next step when oral medication and therapy fail. Mixed data on clinical effectiveness (1)[A]
Methylene blue intradiscal injections: significant potential for future use given clinical improvement, but more research needed to validate (1)[A]
Ablative therapy (Intradiscal electrothermic therapy): likely ineffective for discogenic pain (1)[A]
Traction: theoretical benefit of unloading discs but no clinically significant benefit in RCT (1)[A]

SURGERY/OTHER PROCEDURES

Absolute indications: cauda equina syndrome, multiple episodes of radiculopathy, progressive severe neurologic deficit
May consider surgical procedures for persistent dysfunctional pain after failed trial of conservative management (1,6)[A]
Spinal fusion: indicated for unstable vertebral segments caused by severe degenerative changes. Relatively common surgical procedure for intractable LBP (6)[A]
Disc arthroplasty (disc prosthesis): appropriate for patients with degenerative changes confined to one localized lesion. Contraindications include vertebral abnormalities, nerve root compression, and spinal stenosis. Studies show no significant improvement over spinal fusion and greater potential for long-term complications (1)[A].
Decompressive surgery (open discectomy, microdiscectomy, hemilaminectomy): for patients with neurologic impingement such as spinal stenosis or disc herniation. Most evidence supports minimally invasive approach.

COMPLEMENTARY & ALTERNATIVE MEDICINE

Acupuncture, yoga, Pilates, and spinal manipulation are beneficial as adjunct therapies.

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization
Inpatient admission is uncommon; for protracted cases, infection in disc space or unstable spine consider pain management, infectious disease, or neurosurgery consults as appropriate.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Follow-up immediately if pain or neurologic deficit is increasing.
Return visit 10 days to 2 weeks following initial visit.
Monitor every 2 to 4 weeks until fully functional.
Follow-up visits should focus on pain level, neurologic status, psychosocial factors, and preventive care.

PATIENT EDUCATION

Validate pain and establish realistic goals and expectations for disease course. Encourage exercise, proper posture and body mechanics, and avoidance of risk factors.

PROGNOSIS

Most episodes of acute LBP (90%) or radiculopathy (75 " 90%) recover spontaneously within 6 weeks using conservative care.
63% of patients who require surgery have improvement in symptoms.
Risk factors for recurrence of back pain include return to work before full postop recovery, occupation requiring manual labor, and low education level.
4 " 20% of patients require reoperation.
Most helpful predictors of persistent disabling LBP are maladaptive pain coping skills, nonorganic signs, functional impairment, general health status, social isolation, and psychiatric comorbidities.

COMPLICATIONS

Foot drop with weakness of anterior tibial, posterior tibial, and peroneal muscles
Bladder and rectal sphincter weakness, with retention or incontinence
Limitation of movement, restricted activity, long-term disability, decreased quality of life

REFERENCES

11 Lu Y, Guzman JZ, Purmessur D, et al. Nonoperative management of discogenic back pain: a systematic review. Spine. 2014;39(16):1314 " 1324.22 Meng XG, Yue SW. Efficacy of aerobic exercise for treatment of chronic low back pain: a meta-analysis. Am J Phys Med Rehabil. 2015;94(5):358 " 365.33 Bunzli S, Watkins R, Smith A, et al. Lives on hold: a qualitative synthesis exploring the experience of chronic low-back pain. Clin J Pain. 2013;29(10):907 " 916.44 Sadosky AB, Taylor-Stokes G, Lobosco S, et al. Relationship between self-reported low-back pain severity and other patient-reported outcomes: results from an observational study. J Spinal Disord Tech. 2013;26(1);8 " 14.55 Morlion B. Chronic low back pain: pharmacological intervention and surgical strategies. Nat Rev Neurol. 2013;9(8):462 " 473.66 Bydon M, De la Garza-Ramos R, Macki M, et al. Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta-analysis of randomized controlled trials. J Spinal Disord Tech. 2014;27(5):297 " 304.77 Ashworth J, Green DJ, Dunn KM, et al. Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up? Pain. 2013;154(7):1038 " 1044.

CODES

ICD10

M51.36 Other intervertebral disc degeneration, lumbar region
M51.26 Other intervertebral disc displacement, lumbar region
M51.06 Intervertebral disc disorders with myelopathy, lumbar region
M48.06 Spinal stenosis, lumbar region
M51.35 Other intervertebral disc degeneration, thoracolumbar region
M51.27 Other intervertebral disc displacement, lumbosacral region
M51.25 Other intervertebral disc displacement, thoracolumbar region
G83.4 Cauda equina syndrome
M51.37 Other intervertebral disc degeneration, lumbosacral region

ICD9

722.52 Degeneration of lumbar or lumbosacral intervertebral disc
722.10 Displacement of lumbar intervertebral disc without myelopathy
722.73 Intervertebral disc disorder with myelopathy, lumbar region
724.02 Spinal stenosis, lumbar region, without neurogenic claudication
344.60 Cauda equina syndrome without mention of neurogenic bladder
722.51 Degeneration of thoracic or thoracolumbar intervertebral disc

SNOMED

Degeneration of lumbar intervertebral disc
Prolapsed lumbar intervertebral disc (disorder)
Lumbar disc prolapse with myelopathy (disorder)
Spinal stenosis of lumbar region
Degeneration of lumbosacral intervertebral disc (disorder)
Cauda equina syndrome (disorder)

CLINICAL PEARLS

In the absence of red flags, patients with LBP can be managed conservatively with pain management and self-care for 6 weeks. Most will recover spontaneously.
Routine imaging is rarely indicated. Indications include red flag symptoms, progressive neurologic deficits, or failure of conservative management at 6 weeks.
Addressing the psychological component of discogenic back pain improves patient outcomes.
Consider a surgical referral for patients with persistent and disabling pain who fail to improve after appropriate conservative management.

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