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Discogenic low back pain Treatment agrasen hospital gondia vidarbha dr sandeep c agrawal www.drsandeepagrawal.com www.agrasenortho.com

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Diagnosis of discogenic back pain can be difficult. There are characteristic findings on physical examination, but these same findings are seen in patients with other types of back pain as well. Imaging studies can be performed, such as MRI.
Discogenic pain is pain originating from a damaged vertebral disc, particularly due to denenegrative disc disease

. However, not all degenerated discs cause pain. Disc degeneration occurs naturally with age.

Once a fully degenerated disc no longer has any inflammatory proteins that can cause pain, the disc enters into a stable position. Hence, discogenic pain rarely occurs after 60 years of age.

Discogenic pain can usually be successfully treated with non-surgical treatments, such as pain medication and physical therapy and exercise, but chronic discogenic pain that is severe and limits the individual's ability to function may need to be treated with surgery.

Damage to the disc occurs naturally or through a twisting injury where the inner and/or outer portions of the disc may tear, exposing or irritating the nerves on the outer edge of the annulus.

The injury can also create excessive micro-motion instability at the adjacent vertebrae because the disc cannot hold the vertebral segment together as well as it used to.

The disc itself has very few nerve endings and no blood supply. Without a blood supply the disc does not have a way to repair itself, and pain created by the damaged disc can last for years, either as a chronic condition or with periodic painful flare ups. The symptoms are most common in individuals age 30 to 60 years old.

Published in: Health & Medicine

Discogenic low back pain Treatment agrasen hospital gondia vidarbha dr sandeep c agrawal www.drsandeepagrawal.com www.agrasenortho.com

  1. 1. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Discogenic Low Back Pain Dr.Sandeep Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India drsandeep123@gmail.com Visit us at: www.drsandeepagrawal.com www,agrasenortho.com
  2. 2. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com InterVertebral Disc
  3. 3. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Causes of Back Pain 25-40% Back Pain (Discogenic Back Pain) Muscles,Tendons,Ligamaents
  4. 4. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com RED FLAGS Discogenic Back Pain
  5. 5. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Degenerated Disc Annuloplasty Disc Decompression Chemonucleolysis
  6. 6. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Ventral ramus, sympathetic chain, dorsal root ganglion
  7. 7. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Discogenic low back pain • Diagnosis ..primarily with “provocative discography” ! • Type I collagen in Nucleus pulposus and annulus fibrosus is increasingly replaced by type II collagen • Chondroitin sulfate is replaced by keratan sulfate • Disc is innervated by the sinuvertebral nerve, which is formed by branches from the ventral nerve root and parasympathetic plexus • Sinuvertebral nerve innervate anterior aspect of disc and anterior longitudinal ligment • Free nerve endings of sinuvertebral nerve can penetrate into the deep annulus fibrosus and nucleus pulposus and are immunoreactive for several pain-related neuropepitides
  8. 8. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Biochemical Change After Stress • Matrix protein loss • Loss of hydrostatic pressure • Bulking of annular lamellae • Annulus wall shear stress ↑, Tear • Axial back pain & dysfunction
  9. 9. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com • Chemical factors such as phospholipae A2, IL-1 and matrix metalloproteinase may play roles in discogenic pain • Discogenic pain is nothing to do with mechanoreceptors and nociceptors in the facet joint capsules and synovium • In DDD, density of sensory nerve will decrease in vertebral end plates and underlying cancellous bone • Clinically, discogenic pain is characterized by axial low back pain with associated radicular pain, nerve tension sign • Discogenic pain is deep, aching, and exacerbated by sitting, bending and axial loading • Refer pain may radiate in a sclerotomal fashion to the S-I joints, buttocks, or posterior thigh and occasionally into the inguinal area with involvement of the L5-S1 disc
  10. 10. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com • Patient has mechanical back pain related to posture or motion and has radiographic instability • Micromotion at the intervertebral segment :role in the pathogenesis of discogenic pain • Normal MRI highly correlate with negative lumbar discogram and should be presumed to have a nondiscogenic cause of low back pain • MRI in patient without loss of disc high shows low signal on T1- weighted imaging or annular tear • Provocative discogram : to confirm diagnosis of discogenic pain when surgery is being considered • What is the “positive provocative discogram” ? • Some studies : high-pressure pain response suggests chemical pathway for pain generation and will have better outcome following fusion
  11. 11. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  12. 12. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Discogenic Low Back Pain • Axial low back pain • No instability • Diagnosis – MRI (dark disc, hyperintensity zone) – Provocative discogram • Concordant pain • Abnormal disk morphology • Negative control
  13. 13. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Provocative Discogram
  14. 14. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com • Provocative discography (+) is the definite diagnosis of DDD • 90% patients will go on to complete pain relief within 2 to 6 weeks • NSAID and antispasmolytic medicine are effective in the management of acute back pain, but is unclear in chronic pain • Intradiskal electrothermotherapy (IDET) has been proposed as an option of the treatment • Lumbar fusion surgical procedure of choice for the treatment of discogenic back pain with poor response to conservative treatment • Disc excision or decompression procedure are another recommended procedures in treating DDD • Successful fusion is obtained in 60% to 90% of patients who undergo posterior procedure, but clinical outcomes are satisfactory in only 40% to 70%.
  15. 15. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Surgery for back pain;
 MRI… • Clinical correlation is must • Discography is very helpful Remember: FBSS 30% Re-surgery; failure & risk
  16. 16. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Discogenic Low Back Pain
 Pathoanatomy and Pathophysiology • Type II collage -> Type I collagen • Chondrotin sulfate -> Keratan sulfate • Dehydration in nucleus pulposus • Radial tear within the annulus fibrosus • Disk height loss • Laxity in the peripheral attachment • Free nerve ending (sinuvertebral nerve)
  17. 17. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Discogenic Low Back Pain
 Clinical Features • Deep, aching, exacerbated by sitting, bending and axial loading • Referred pain : sacroiliac joints, buttocks, posterior thighs, inguinal area (L5-S1 occasionally)
  18. 18. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Patients with Loss of Disc Height • End plate sclerosis, mild facet joint arthrosis • Disc bulging, ligamentum flavum infolding, mild canal and foraminal stenosis • Positive discograms in 25% patients with mild symptoms
  19. 19. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Patients Without Loss of Disc Height • No facet joint or end plate changes • Dark disc, annular tear
  20. 20. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Discogenic Low Back Pain
 Prognosis • Acute back pain – 90% complete relief within 2 to 6 weeks • Chronic back pain – 40% as discogenic pain • 5-year follow-up – 68% improve – 24% worsen – 8% remained unchanged
  21. 21. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Discogenic Low Back Pain
 Management • Conservative – Medication, physical therapy, exercise • Intradiscal electrothermal therapy(IDET) • Lumbar fusion – Mechanoreceptos and nociceptors in the facet joint decrease after interbody fusion – Posterior • Successful fusion 60% to 90% • Satisfactory outcome 40% to 70% – Anterior • Successful fusion 80% to 96% • Artificial disc
  22. 22. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com • Posterior procedures – PLIF – TLIF • ALIF can remove pain fibers and receptors from the annulus fibrosus and nucleus pulposus, eliminate motion across disc, restore disc height and indirectly decompress neuroforamen, avoid posterior muscle disruption – Open – Laparoscopic ALIF
  23. 23. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com IDET 
 Intradiscal Electrothermal Annuloplasty• Local anesthesia • 90 degrees Celsius for 15-17 minutes • Contract and thicken the collagen fibers • Cauterize nerve endings IntraDiscal ElectroThermotherapy ( IDET )
 For discogenic pain (axial pain)
  24. 24. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Thermal energy: 65ºC for 17 minutes •Collagen shrinkage •Destruction of nociceptive fibers
  25. 25. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Indications (Saal & Saal) • Axial pain > 6 months • Non-operative care at least 3 months • No psychosocial problems • SLRT (-) • Disc height: > 50% preserved • MRI: no compressive lession • Provocative discogram (+)
  26. 26. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  27. 27. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Results of IDET! highly varied • 70% satisfied result Saal JA. Spine. 2000 • 50% were dissatisfied Davis TT. Spine. 2004 • Not effective Spruit M. Eur Spine J. 2002 • Potentially beneficial in carefully selected patients Biyani A. Spine. 2003 • Worthwhile in a small proportion of strictly defined patients Pauza KJ. Spine J. 2004
  28. 28. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Complications • Discitis • Nerve root injury • Catheter breakage • Cauda equina syndrome
  29. 29. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com General Concept of IDET • IDET should be considered as “Experimental Procedure” • Maybe useful in highly selected patient
  30. 30. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Biaculoplasty (Cooled RF)
  31. 31. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Disc Herniation; Discectomy
  32. 32. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Hydrodiscectomy (Spine jet®)
  33. 33. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Laser and RF Plasma
  34. 34. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Percutaneous Nucleotomy
  35. 35. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Dekompressor
  36. 36. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Ozone Neucleolysis
  37. 37. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Intervertebral Disc Surgery • Three classical surgical steps conservative! treatment percutaneous! surgeries open! surgeries fusion! surgeries I II III
  38. 38. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Brothers • Lumbar spinal stenosis • Lumbar disc Herniation • Discogenic Low Back Pain
  39. 39. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Future of Non surgical Treatment
  40. 40. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  41. 41. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Take Home Message • Disc contributes 25-40% back pain • Only 10% patients require Intervention • MRI alone does not guarantee the diagnosis of discogenic pain • Until supported by clinical judgment and discography • Surgery is indicated in selected cases specially sequestrated disc and emergent situation • Non-surgical management is very safe & successful in most of the patients.
  42. 42. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com This presentation is for doctors in general.! . Some graphics and jpeg files are taken from Google Image  to heighten the specific points in this presentation. ! • If there is any objection/or copyright violation, please inform drsandeep123@gmail.com for prompt deletion. ! • It is intended for use only by the doctors of orthopaedic surgery.! . Views expressed in this presentation are personal. • .For any confusion please contact the sole author for clarification. ! • Every body is allowed to copy or download and use the material best suited to him. !
  43. 43. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Requirements towards the development 
 of a fine personality 1. Clarity of goals and purpose in life 2. Doing beyond expectation 3. Learning from failures 4. Initiatives 5. Enthusiasm 6. Character and personality 7. Self discipline 8. Positive mental attitude 9. Managing 10. Sound physical and mental health 11. Team work 12. Hard work 13. Growing in one’s knowledge and skills 14. Desiring pleasure and excitement
  44. 44. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com THE CAN DO ATTITUDE • You CAN DO everything, but not all at once. • You CAN DO everything, if it’s important enough for you to do. • You CAN DO everything, but you may not be the best at everything. • You CAN DO everything, but there will be limitations. • You CAN DO everything, but you’ll need help.

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