Vertebral Disc Pain

Common ICD-9 codes: 722.0, 722.11, 722.10, 724.2, 724.3, 724.4, ect

Disc Anatomy

intervetebraldisc

The disc itself is comprised of a central nucleus pulposus surrounded peripherally by the annulus fibrosis. The principal functions of the disc are to allow movement between vertebral bodies and to transmit loads from one vertebral body to the next. When axial loads are transmitted to the spine, the annulus and nucleus display a complex intertwined role allowing for pressure dispersal. The intervertebral disc is the largest avascular structure in the body and it is dependent on diffusion across the endplate for nutrition and waste removal. Mechanical activity has a great deal to do with the exchange of water and oxygen concentration in the disc. The pumping action maintains the nutrition and biomechanical function of the intervertebral disc. Unchanged posture, as a result of constant pressure such as standing, sitting, or lying, leads to an interruption of pressure-dependent transfer of liquid, which doesn’t allow functionality. It can be said the human intervertebral disc lives because of mechanical movement.

The recurrent sinuvertebral nerve, innervates the area around the disc space. This nerve exits from the dorsal root ganglion and enters the foramen, where it then divides into a major ascending and lesser descending branch. In human studies, the outer annular regions are innervated, but the inner regions and nucleus pulposus are not innervated[1]. In addition studies have demonstrated that the ALL also receives afferent innervation from branches that originate in the dorsal root ganglion. The PLL is richly innervated by nociceptive fibers from the major ascending branch of the sinuvertebral nerve. These nerves also innervate the adjacent outer layers of the anulus fibrosis[1,2].

  • 1. Palmgren T, Gronblad M, Virri J, et al: An immunohistochemical study of nerve structures in the anulus fibrosus of human normal lumbar intervertebral discs. Spine 24:2075-2079, 1999
  • 2. Coppes MH, Marani E, Thomeer RT, et al: Innervation of "painful" lumbar discs. Spine 22:2342-2350, 1997
  • Neurophysiology of Disc Pain

    The actual discogenic pain that a patient feels may result from a combination of two things: (1) biochemicals called cytokines, which are spawned from the disc itself (especially the nucleus pulposus) because of the passageway created by the annular tear, come in contact with the nociceptive (pain producing) nerve endings in the outer annulus and initiate a painful inflammatory process; and (2) biomechanical changes which have resulted secondary to the new passageway communicating the nucleus with the outer annulus (i.e., the annular tear) which causes a loss of hydraulic pressure within the nucleus and redistributes loadbearing from the center of the nucleus on to the posterior annulus (which is exactly where we don't want the axial load to be, because this is where all the pain fiber is). Now, mechanical compression of the already inflamed sinuvertebral nerves may cause severe discogenic pain. In other words, the pain is because the sinuvertebral nerves within the posterior annulus have become "activated" with inflammation (which may cause pain in and of itself) and compressed by the weight of the body because the biomechanics of the disc have been changed by the annular tear from the center of the disc to the posterior periphery.

    Treatment options

    -Short Term Goals-

  • Nsaids and ice- to control pain and reduce inflammation
  • Manual traction/distraction- Creating negative pressure allows more room for nerve root.
  • Joint manipulation- see below
  • Massage/soft tissue work- Decreases muscle spasm and increases local cirrculation to surrounding soft tissue.

    -Long Term Goals-

  • Trunk/Core stabilty- Sterngthening trunk stabilizers when pain has been reduced and range of motion has been improved.
  • Activity modifaction- Patients that return to the same habitual motor patterns are more likey to exberience excerbations and pain. Posture and avoidance are a necessary part of treatment.

    How does joint manipulation reduce chronic back pain arising from the intervertebral disc?

    Spinal manipulation primarily mechanically affects the facet articulations increasing joint proprioception. Such facet motion would necessarily cause motion in the intervertebral disc. This would improve fluid mechanics of the disc(imbibition), disperse the accumulation of inflammatory exudates, and initiate a neurological sequence of events that would decrease nociception.

    Absolute Contraindications to Spinal Manipulative Therapy

  • Active inflammatory arthropathy
  • Tumor/metastasis
  • Acute fracture/dislocation
  • Cauda equina syndrome
  • Referral

    It is often times necessary to be more aggresive with discogenic pain. I believe that an integrative co-management with the referring physician is important to meet the goals and pain needs of the patient.

    We will take great care when treating your patient. There are a variety of technical procedures for adjusting the lumbar spine, of which, we choose the best technique that fits the case presentation. If any lumbar pain patients do not respond to the first few treatments, I will let you know. Six to eight treatments in the first two weeks would not be unusual. Disc problems can be a long chronic problem, we believe manipulation is one important supplement in pain management solution for your patient.

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