日期：114年7月18日(星期五)12：30 主題：椎間盤源性疼痛—病理機轉、診斷與治療 講師：張詠斌主治醫師-高醫大附設醫院神經外科

1. 椎間盤源性疼痛—病理機轉、診斷與治療
DISCOGENIC PAIN:
FROM DIAGNOSIS TO TREATMENT
高雄醫學大學附設醫院
神經外科
張詠斌

2. OUTLINE
• What is Discogenic Pain?
• Pathophysiology of Discogenic pain
• Clinical Features of Discogenic pain
• How to diagnose Discogenic pain
• Treatment of Discogenic pain
• Case sharing

3. WHAT IS DISCOGENIC PAIN?
• Inman and Saunders in 1947:
• Pain originating from the intervertebral
disc itself
• Crock in 1970 :
• Internal disc disruption to describe
unremitting lumbar spinal pain that lasted
longer than 4 months, was unresponsive
to conservative care, and could be
reproduced with discography
Calodney, A., & Buchalter, J. (2011). 1 Epidemiology and Etiology of Discogenic Pain: How Big Is the Problem?. Diagnosis, Management,
and Treatment of Discogenic Pain E-Book: Volume 3: A Volume in the Interventional and Neuromodulatory Techniques for Pain
Management Series; Expert Consult Premium Edition--Enhanced Online Features, 1.
Lorio MP, Beall DP, Calodney AK, Lewandrowski KU, Block JE, Mekhail N. Defining the patient with lumbar discogenic pain: real-world
implications for diagnosis and effective clinical management. JPM. 2023;13(5):821.

4. PATHOPHYSIOLOGY OF DISCOGENIC
PAIN

5. LOW BACK PAIN (LBP)
• The prevalence of LBP : 31%
• Lifetime prevalence : 60% - 80%
Ohtori S, Inoue G, Miyagi M, Takahashi K. Pathomechanisms of discogenic low back pain in humans and animal models. Spine J.
2015;15(6):1347–55.
Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012; 64 (6): 2028–37.
Fujii K, Yamazaki M, Kang JD, et al. Discogenic back pain: literature review of definition, diagnosis, and treatment. JBMR Plus. 2019;3(5):e10180.
What causes hip arthritis? Orthopaedics Toronto - OrthoTO.

6. Fujii K, Yamazaki M, Kang JD, et al. Discogenic back pain: literature review of definition, diagnosis, and treatment. JBMR Plus. 2019;3(5):e10180.

7. THE PROCESS OF AGING

8. YOUNG MAN
OpenAI. (2025). Portrait of a smiling young man with wavy hair in a blue shirt [AI-generated image].
on:Bickle I, Normal lateral lumbar spine radiograph. Case study, Radiopaedia.org (Accessed on 03 Jul 2025) https://doi.org/10.53347/rID-46575

9. ADULTS
Yonso M, Spondylolisthesis (grade II). Case study, Radiopaedia.org (Accessed on 03 Jul 2025) https://doi.org/10.53347/rID-
22450
OpenAI. (2025). Portrait of an adult male smiling in a gray T-shirt [AI-generated image]. ChatGPT. https://chat.openai.com/

10. OLD MAN
Imaging of musculoskeletal disorders. https://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/imaging-joints-bones/degenerative-disc-
disease#top_2nd_img

11. THE CHRONOLOGY OF DISC DEGENERATION
What are the stages of degenerative disc disease – and which ‘stage’ are you in? | stöckli medical ag.

12. Galbusera F, van Rijsbergen M, Ito K, Huyghe JM, Brayda-Bruno M, Wilke HJ. Ageing and degenerative changes of the intervertebral disc and
their impact on spinal flexibility. Eur Spine J. Published online January 31, 2014.

13. Galbusera F, van Rijsbergen M, Ito K, Huyghe JM, Brayda-Bruno M, Wilke HJ. Ageing and degenerative changes of the intervertebral disc and
their impact on spinal flexibility. Eur Spine J. Published online January 31, 2014.
Oichi T, Taniguchi Y, Oshima Y, Tanaka S, Saito T. Pathomechanism of intervertebral disc degeneration. JOR Spine. 2020;3(1):e1076.

14. https://www.youtube.com/watch?v=-y_DWul5rQI&t=60s

15. BIOMECHANICS OF DISC
Kirnaz S, Capadona C, Lintz M, et al. Pathomechanism and biomechanics of degenerative disc disease: features of healthy and degenerated
discs. International Journal of Spine Surgery. 2021;15(s1):10-25.

16. DISC METABOLISM
Huang, YC., Urban, J. & Luk, K. Intervertebral disc regeneration: do nutrients lead the way?. Nat Rev Rheumatol 10, 561–566 (2014).
https://doi.org/10.1038/nrrheum.2014.91

17. H2O IN DDD
PFIRRMANN STAGING
Farshad-Amacker NA, Farshad M, Winklehner A, Andreisek G. MR imaging of degenerative disc disease. Eur J Radiol. 2015;84(9):1768-1776.

18. Kirnaz S, Capadona C, Lintz M, et al. Pathomechanism and biomechanics of degenerative disc disease: features of healthy and degenerated
discs. International Journal of Spine Surgery. 2021;15(s1):10-25.

19. https://www.youtube.com/watch?v=-y_DWul5rQI&t=60s

20. DEGENERATIVE
VS
PAIN

21. PAIN? NO PAIN?

22. DISCOGENIC PAIN
• BIOMECHANICAL FAILURE
• CHEMICAL INFLAMMATION
• NERVE SENSITISATION
Samanta A, Lufkin T, Kraus P. Intervertebral disc degeneration—Current therapeutic options and challenges. Front Public Health.
2023;11:1156749.

23. https://www.completepaincare.com/patient-education/conditions-treated/discogenic-pain

24. JBMR Plus, Volume: 3, Issue: 5, First published: 05 February 2019, DOI: (10.1002/jbm4.10180)

25. CLINICAL FEATURES OF DISCOGENIC
PAIN

26. MAIN CLINICAL FEATURES OF DISCOGENIC PAIN
• Midline Pain or the immediate paraspinal region with occasional
radiation to the flanks or buttocks
• Worse with sitting for too long
Tonosu J, Inanami H, Oka H, et al. Diagnosing discogenic low back pain associated with degenerative disc disease using a medical interview.
PLOS ONE. 2016;11(11):e0166031.

27. https://www.totalpainspecialist.com/condition/persistent-spinal-pain-syndrome-discogenic-pain/

28. HIGH SENSITIVITY CLINICAL FEATURES OF
DISCOGENIC PAIN
• LBP from sitting too long
• LBP while standing after sitting too long
• Squirmed in a chair after sitting too long
• LBP while washing their face
• LBP in standing position with flexion
Tonosu J, Inanami H, Oka H, et al. Diagnosing discogenic low back pain associated with degenerative disc disease using a medical interview.
PLOS ONE. 2016;11(11):e0166031.

29. HOW TO DIAGNOSE DISCOGENIC PAIN

30. PROVOCATIVE DISCOGRAPHY
• The only confirmative test of
discogenic pain
• Lindgren from Scandinavia :1st
puncture of normal intervertebral
disc for diagnostic purposes in 1941
• Positive pain when PSI<50
Tomecek, FJ; Anthony, CS; Boxell, C; Warren, J. "Discography Interpretation and Techniques in the Lumbar Spine". Medscape. Archived from
the original on 3 April 2017. Retrieved 30 May 2022.
By BruceBlaus - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=44899518
Jain A, Jain S, Barasker SK, Agrawal A. Predictors of discogenic pain in magnetic resonance imaging: a retrospective study of provocative

31. RESULTS OF DISCOGRAPHY
Jain A, Jain S, Barasker SK, Agrawal A. Predictors of discogenic pain in magnetic resonance imaging: a retrospective study of provocative
discography performed by posterolateral approach. The Korean Journal of Pain. 2021;34(4):447-453.

32. Korn, M., Khan, D. (2022). NoncancerPain: Discogenic Low Back Pain. In: Banik, R.K. (eds) Anesthesiology In-Training
Exam Review. Springer, Cham. https://doi.org/10.1007/978-3-030-87266-3_46
PAIN

33. MORPHOLOGY OF DISCOGRAPHY
MODIFIED DALLAS CLASSIFICATION
Hacking C, Sharma R, Modified Dallas discographic classification of intervertebral disc radial tears. Reference article,
Radiopaedia.org (Accessed on 08 Jul 2025) https://doi.org/10.53347/rID-191354

34. BUT !!!

35. DISCOGRAPHY IN SPINE SURGERY DECISION
• Failed Back Surgery Syndrome (FBSS)
/Persistent Spinal Pain Syndrome (PSPS)
• Discography to guide op decision
• Carragee et al :
• Positive pain response in discography:
• Pain-free group : 10%
• Chronic cervical pain : 40%
• Somatization disorder : 83%
https://drjimmyw.com/%E8%85%B0%E6%A4%8E%E8%A1%93%E5%BE%8C%E7%96%BC%E7%97%9B%E7%97%87%E5%80%99%E7%BE%A4-fbss/
Carragee EJ, Tanner CM, Khurana S, et al. The rates of false-positive lumbar discography in select patients without low back symptoms: Spine.
2000;25(11):1373-1381.

36. FALSE POSITIVE IN DISCOGRAPHY
• Neuropathic pain : Hyperalgesia
• IASP (2009) :
• Increased pain greater than 7/10 recognized by the patient as
exactly reproduced or at least similar to the site of usual pain
and the injection pressure low or not more than moderate.
• Grade III annual tear with contrast reaching the disc surface.
• Control disc with not more than mild pain provocation with
moderate injection pressure.
• Positive outcome was also considered : 1.Almost complete
relief or better pain at rest and motion-associated pain when
compared with before discography.
• Pressure<15psi , contrast volume <3cc
• Discoblock & sinuvertebral nerve block
PAIN
Manchikanti, L., Boswell, M. V., Singh, V., Derby, R., Fellows, B., Falco, F., ... & Hirsch, J. A. (2009). Comprehensive review of
neurophysiologic basis and diagnostic interventions in managing chronic spinal pain. Pain Physician, 12(4), E71.

37. MRI IN DISCOGENIC PAIN
• AnnularTear
• High Intensity
Zone
Ajayi O, Annular fissure. Case study, Radiopaedia.org (Accessed on 09 Jul 2025) https://doi.org/10.53347/rID-82892

38. MODIC CHANGE
Teixeira A, Modic type I changes. Case study, Radiopaedia.org (Accessed on 09 Jul 2025) https://doi.org/10.53347/rID-23403

39. TREATMENT OF DISCOGENIC PAIN

40. TREATMENT OF DISCOGENIC PAIN
W.carter. English: Red and Blue Pill as in the Matrix. The Original Photo Is of Two Yellow Omega-3 Capsules, Placed on a Grainy Paper on a
Windowsill. Light All Natural from the Window. Processed in Photoshop for Color. Photographed in Visby, Gotland, Sweden.; 2014.
Find pain relief that lasts | pain management in florida.
Nonoperative Management Interventional Pain Management Surgery

41. NONOPERATIVE MANAGEMENT
Sveinsdottir V, Eriksen HR, Reme SE. Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain. J
Pain Res. 2012;5:371-380.
De Simone M, Choucha A, Ciaglia E, et al. Discogenic low back pain: anatomic and pathophysiologic characterization, clinical evaluation,
biomarkers, ai, and treatment options. JCM. 2024;13(19):5915.
Understanding different types of pills: a quick guide. https://sedpharma.com/.
BDS DAS. Why is physiotherapy used? News-Medical.
https://www.woninstitute.edu/acupuncture-points/
Physio B. Spinal traction - tatjana marx mcsp bschons physiotherapy. Bradley Physio.
Communication M and. Method bulks up muscle during bed rest | university of utah health | university of utah health.
The benefits of having an active lifestyle.
Oral analgesics Physiotherapy Psychotherapy (Cognitive Behavior Therapy)
Acupuncture/dry needling Back traction Bed Rest
STAY ACTIVE!!!

42. INTERVENTIONAL PAIN MANAGEMENT
• Epidural steroid injections
• Intradiscal electrothermal
therapy (IDET)
• Radiofrequency
annuloplasty
• Biacuplasty
• Methylene blue injection
Intradiscal electrothermal therapy (IDET)
Radiofrequency annuloplasty Biacuplasty
By Lucdesaulniers - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=2936888
Yoo Y, Bae J, Kim H, Lee H, Moon JY, Kim YC. Percutaneous nucleoplasty and intradiscal electrothermal therapy in the management of lumbar discogenic pain: A retrospective comparative study.
Medicine. 2024;103(32):e39230.
De Simone M, Choucha A, Ciaglia E, et al. Discogenic low back pain: anatomic and pathophysiologic characterization, clinical evaluation, biomarkers, ai, and treatment options. JCM.
2024;13(19):5915.
Epidural steroid injections

43. SURGERY
https://www.jamesstephensdo.com/service/spinal-cord-stimulation
Mathur S, Jenis LG, An HS: Surgical Management of Chronic Low Back Pain: Arthrodesis, in Jenis LG, ed: Low Back Pain: Monograph Series.
(Left) From Jenis LG: Surgical Management of Chronic Low Back Pain: Alternatives to Arthrodesis, in Jenis LG, ed: Low Back Pain:
Monograph Series. Rosemont, IL, Amer Acad of Orthop Surg, 2005.
Spinal cord stimulation (SCS) Surgery Lumbar Interbody Fusion
Prosthesis Disc Replacement
artificial disc replacement (ADR)
Dynamic Fixation System
Sacks G, DeStefano V, Parker C, Lebens R, Mushlin H. The artificial disc nucleus and other strategies for replacement of the nucleus
pulposus: past, present and future designs for an emerging surgical solution. Engineered Regeneration. 2024;5(2):269-281.
https://www.surgeryplanet.com/orthopaedics/dynesys-surgery.html

44. CASE SHARING

45. CASE 1
• 66 y/o female
• Back pain for 3 month
• VAS 6-7 with radiation to
right leg
• Severe at morning & lunch
nap and long standing
• Better after lying
• Phx: L45 TPS screw 10
years ago

46. L23
L34
L5S1
L23L34L5S1 DDD
L23 modic type 1
L5S1 modic type 2

47. right L23 discography

48. left L34 discography and left L34 transforaminal epidural injection

49. right L5S1 discography with epidural spreading

50. PAIN SCORE
• Pre interventionVAS 6-7
• 1 week VAS 2-3
• 1 monthVAS 3
• 3 monthsVAS 3
http://12345678910.com/

51. CASE 2
• 65 y/o male
• back pain for 3 months with both leg
numbness w/ right predominant
• VAS 3
• Unable to walk for 20 min
• claudication +
• PH:
• post Lumbar surgery L3-4-5 laminectomy,L4-
5 diskectomy 2022

52. L34
L45
L34 discogenic pain
L45 modic type 1 with spondylolisthesis

53. right L34 discography

54. right L45 discography with epidural spreading

55. PAIN SCORE
• Pre interventionVAS 3
• back pain improved toVAS 2 after 1
week
• Able to walk for 1 hour after 1week
http://12345678910.com/

56. CASE 3
• Low back pain for 1 months
• VAS 10
• Radiation to right leg
• More painful when flexed
• Claudication +
• Medication at clinic and
rehab but in vain

57. L34
L45
L34 rupture disc w/ modic type 1
L45 discogenic pain

58. Left L34 discography with epidural spreading

59. Left L45 discography

60. PAIN SCORE
• Pre interventionVAS 10
• Back pain improved toVAS 1 after 1
week
• Right leg soreness at night
http://12345678910.com/

61. THANKS!
高雄醫學大學附設醫院
神經外科
張詠斌