Chronic Discogenic Low Back Pain and Non-Surgical Treatment Methods: An Update

Abstract

Low back pain originating from intervertebral disc is described by two separate but related etiologies: disc herniation and discogenic pain. When other causes are excluded, prevalence of discogenic pain was reported to be between 17-42%. Diagnostic modalities include clinical examination, imaging, and discography and provocative discography remains to be the golden standard for diagnosis. Treatment methods include noninvasive approaches such as drugs, physiotherapy modalities, and multidisciplinary biopsychosocial rehabilitation; invasive approaches such as intradiscal treatments and epidural injections; and lastly surgical approaches such as fusion and artificial joint replacement. Evidence for drug treatment in chronic discogenic low back pain is limited to nonsteroidal anti-inflammatory drugs and opioids which are associated with many adverse outcomes. It has been shown that when noninvasive methods are used together with other modalities patients may obtain additional benefits. Evidence base is limited for many other physical and behavioral treatment methods like low back school and specific exercise programs. There is moderate evidence for epidural injections and poor evidence for intradiscal treatments. Evidence for surgical fusions and disc replacements are similar and it is not superior to multidisciplinary biopsychosocial rehabilitation or well-designed physical treatment. Multiple authorities have emphasized potential complications and limited the indication of surgical approaches to patients who do not response conservative treatments. In future, the most promising treatments seem to be multidisciplinary and long-term exercise programs and/or epidural injections. High quality randomized controlled studies with adequate sample sizes and long term follow ups should be designed in order to determine optimal treatment modalities.