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Side-by-side comparison of a healthy (a) and degenerated (b) intervertebral disc [18]. J. Pers. Med. 2023, 13, x FOR PEER REVIEW 5 of 14
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There is an enormous body of literature that has identified the intervertebral disc as a potent pain generator. However, with regard to lumbar degenerative disc disease, the specific diagnostic criteria lack clarity and fail to capture the primary components which include axial midline low back pain with or without non-radicular/non-sciatic referre...
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Background Lumbar discal cysts are rare intraspinal extradural lesions presenting as lumbar radiculopathy. The rarity of the lesion is sufficient to evoke interest in its diagnosis. The hitherto unsolved etiopathogenesis prompted us to look into these areas in this study.
Objectives 1) To review the literature and summarize the clinicoradiological...
Citations
... Discogenic pain may occur due to loading in a fully flexed position combined with axial rotation . This position and load cause lesions within the fibrous ring (Lorio et al., 2023). This typically occurs in gymnastics during a backward full-twisting somersault landing (Sweeney et al., 2023). ...
Gymnastics encompasses various disciplines, including artistic gymnastics, rhythmic gymnastics, trampoline gymnastics, acrobatics, aerobic gymnastics, parkour, and gymnastics for all. While there are many differences in characteristics, movement execution, and equipment, all disciplines involve brief and high-intensity movements. Athletes achieve extreme ranges of motion and generate and absorb significant forces while performing gymnastic elements. Consequently, gymnasts are prone to numerous injuries, with frequencies ranging from 0.5 to 9.4 injuries per 1000 hours of athlete exposure. The most common types of gymnastics injuries are sprains and strains. In females, lower limb injuries prevail, whereas males predominantly experience upper limb injuries. Specifically, the ankle, knee, and foot are frequent sites of injury in the lower limb, while the shoulder joint, wrist, and elbow are commonly affected in the upper limb. Spinal and head injuries occur less frequently. Identifying factors associated with injuries is important for their prevention. They can be classified as non-modifiable, potentially modifiable, and modifiable. By addressing the latter two groups of factors, we can contribute to reducing the incidence of injuries. The main intrinsic factors linked to injury onset include age, a rapid growth period, previous injuries, joint laxity and instability, limb asymmetry, abnormal muscle stiffness, stress, fear, and lack of focus, while the main extrinsic factors are early specialization, training volume and duration. Most injuries occur during artistic gymnastics routines, especially during the floor exercise. Although more injuries happen during training sessions, the injury rate is higher during competitions. Furthermore, a higher number of injuries is associated with less experienced coaches and inadequate equipment. Preventive measures for gymnastics injuries revolve around training equipment, and healthcare modifications. Optimal landing technique, balanced workload, and comprehensive rehabilitation are crucial, alongside addressing mental and emotional strain.
... The term DDD is notably nonspecific, lacking clarity regarding the specific pain source, particularly in distinguishing between the presence or absence of radicular pain. Recent advocacy has emerged for the formal recognition of DBP as a unique pain source by formally recognizing discogenic back pain with its own ICD-10-CM code, akin to other sources of low back pain, including sacroiliac, facetogenic, lumbar stenosis with or without neurogenic claudication, radiculopathy, cluneal neuropathy, vertebrogenic or psychogenic pain [12]. Diagnosis of discogenic pain involves physical manipulation exam, MRI, and in some cases discography [5]. ...
Purpose of Review
The purpose of this review is to provide an update on recent developments in the field of regenerative medicine, specifically focusing on emerging data related to biologics, including platelet-rich plasma and mesenchymal cells, for the treatment of discogenic back pain.
Recent Findings
There has been a notable surge of interest in biologics, as evidenced by a wealth of recent reviews and studies. While serious adverse events are generally uncommon, considerable heterogeneity exists in study designs. More robust investigations are warranted to thoroughly evaluate the safety and efficacy of biologics in treating discogenic back pain.
Summary
Continued research and funding are needed to better understand the underlying mechanisms of disc degeneration and to develop targeted therapies that can alleviate and reduce the burden of this debilitating condition. Biologics may offer effective treatments for discogenic pain; however, more multi-center, prospective, double-blinded, randomized placebo-controlled trials are essential to further establish their effectiveness.
... Pain Physician: November 2024 27:E865-E871 E866 www.painphysicianjournal.com A A n enormous amount of theoretical and experimental research has definitively identified the intervertebral disc as a distinct, potent, and relatively common pain generator (1)(2)(3)(4). Lumbar discogenic pain results from spinal degeneration originating initially in the lumbar intervertebral disc as early as the second decade of life (5)(6)(7)(8). The nucleus pulposus (NP) is normally highly hydrated, but degeneration substantially reduces its ability to cushion physiological loads due to the loss of its capacity to bind water under compression (9). ...
Background:
Preventing disc degeneration remains a clinical challenge; patients experiencing chronic lumbar discogenic pain have limited treatment options. Minimally invasive intradiscal procedures such as allogeneic nucleus pulposus (NP) injection have the potential to fill the treatment gap between failed conservative care and spine surgery.
Objectives:
Our study sought to evaluate the magnitude and durability of improvement in back function in patients with chronic lumbar discogenic pain followed for 6 months after a single intradiscal injection of minimally manipulated, off-the-shelf processed NP allograft (VIA Disc NP®, VIVEX Biologics, Inc.) at up to 2 vertebral levels.
Study design:
Single-arm, prospective, multicenter, pilot study.
Setting:
Academic and private practice outpatient clinics.
Methods:
A total of 29 patients with symptomatic lumbar discogenic pain refractory to conservative care who had a back function score of 40-80 points on the Oswestry Disability Index (ODI), ≥ 6 on an 11-point back pain Numeric Rating Scale (NRS-11) and corresponding imaging evidence of disc degeneration were enrolled. A single dose, intradiscal injection of approximately 100 mg of NP allograft mixed with sterile saline was administered to the affected level or levels.
Results:
The average ODI and NRS-11 improvements between baseline and 6-months postprocedure were 54.8% (95% CI, 41.3-68.3) and 52.9% (95% CI, 34.7-71.1) respectively (P < 0.001). A minimal clinically important difference of ≥ 30% improvement over baseline was achieved in 79% (22 of 28) and 68% (19 of 28) of patients for ODI and NRS-11, respectively. At 6-months postprocedure, 64% (18 of 28) of patients had an NRS-11 score ≥ 3.
Limitations:
This pilot study did not employ a concurrent control group and the clinical follow-up was limited to 6 months.
Conclusions:
These pilot findings demonstrate the feasibility of treating patients with symptomatic lumbar disc degeneration with a single intradiscal injection of allogeneic NP to provide significant and durable improvements in back function and pain.
... ISASS has been at the forefront in identifying the importance of discogenic pain and advocating for specific diagnostic coding. 2 Indeed, the intervertebral disc has been the most intensively studied and characterized structure in the human spine. While countless research groups have contributed to our rich knowledge about degeneration of the intervertebral disc, several key individuals and an event were instrumental in our current perception of lumbar discogenic pain. ...
... 6,7 Discogenic back pain can occur with or without nonradicular/nonsciatic referred leg pain in a sclerotomal distribution. 2 We believe these codes will provide several advantages: z Precision in diagnosis: Health care providers will have clearer criteria for diagnosing discogenic low back pain (LBP), allowing for more precise identification of the underlying pathology. This can guide treatment decisions and improve patient outcomes by ensuring that interventions are targeted to the specific cause of the pain. ...
... Various factors contribute to low back pain, including segmental spinal instability, facet joint degeneration, spinal canal stenosis, nerve root pain, and lumbar disc herniation. IVDD is closely linked to the development of these conditions [3]. ...
Purpose of Review
Intervertebral disc degeneration (IVDD) is a common orthopaedic disease and an important cause of lower back pain, which seriously affects the work and life of patients and causes a large economic burden to society. The traditional treatment of IVDD mainly involves early pain relief and late surgical intervention, but it cannot reverse the pathological course of IVDD. Current studies suggest that IVDD is related to the imbalance between the anabolic and catabolic functions of the extracellular matrix (ECM). Anti-inflammatory drugs, bioactive substances, and stem cells have all been shown to improve ECM, but traditional injection methods face short half-life and leakage problems.
Recent Findings
The good biocompatibility and slow-release function of polymer hydrogels are being noticed and explored to combine with drugs or bioactive substances to treat IVDD.
Summary
This paper introduces the pathophysiological mechanism of IVDD, and discusses the advantages, disadvantages and development prospects of hydrogels for the treatment of IVDD, so as to provide guidance for future breakthroughs in the treatment of IVDD.
... Of high importance with regard to selecting appropriate candidates for this intervention, knowledge of the pathological processes of symptomatic internal disc disruption and the capability to identify patients with earlier-stage lumbar discogenic pain [64] have advanced considerably during the course of the investigations summarized here. These existing and emerging assessments, outside of the scope of this present review, involve functional MRI, MR spectroscopy and other advanced imaging techniques [64][65][66], the radiographic assessment of sagittal translation, rotations, and instability and associated clinical tests [67][68][69], and provocation or anesthetic discography combined with computed tomography (CT discogram) [64,66]. ...
... Of high importance with regard to selecting appropriate candidates for this intervention, knowledge of the pathological processes of symptomatic internal disc disruption and the capability to identify patients with earlier-stage lumbar discogenic pain [64] have advanced considerably during the course of the investigations summarized here. These existing and emerging assessments, outside of the scope of this present review, involve functional MRI, MR spectroscopy and other advanced imaging techniques [64][65][66], the radiographic assessment of sagittal translation, rotations, and instability and associated clinical tests [67][68][69], and provocation or anesthetic discography combined with computed tomography (CT discogram) [64,66]. ...
... Of high importance with regard to selecting appropriate candidates for this intervention, knowledge of the pathological processes of symptomatic internal disc disruption and the capability to identify patients with earlier-stage lumbar discogenic pain [64] have advanced considerably during the course of the investigations summarized here. These existing and emerging assessments, outside of the scope of this present review, involve functional MRI, MR spectroscopy and other advanced imaging techniques [64][65][66], the radiographic assessment of sagittal translation, rotations, and instability and associated clinical tests [67][68][69], and provocation or anesthetic discography combined with computed tomography (CT discogram) [64,66]. ...
Genipin polymers are self-forming tensile-load-carrying oligomers, derived from the gardenia fruit, that covalently bond to amines on collagen. The potential therapeutic mechanical benefits of a non-discrete in situ forming mesh of genipin oligomers for degraded spinal discs were first conceived in 1998. Over more than two decades, numerous studies have demonstrated the immediate mechanical effects of this injectable, intra-annular polymeric mesh including an early demonstration of an effect on clinical outcomes for chronic or recurrent discogenic low back pain. This literature review focused on articles investigating mechanical effects in cadaveric animal and human spinal discs, biochemical mechanism of action studies, articles describing the role of mechanical degradation in the pathogenesis of degenerative disc disease, initial clinical outcomes and articles describing current discogenic low back pain treatment algorithms. On the basis of these results, clinical indications that align with the capabilities of this novel injectable polymer-based treatment strategy are discussed. It is intended that this review of a novel nano-scale material-based solution for mechanical deficiencies in biologically limited tissues may provide a helpful example for other innovations in spinal diseases and similarly challenging musculoskeletal disorders.
... Despite the long history in research and practice, DLBP is not well-represented in this discourse (Han et al., 2023). Across the published evidence we find little consensus on the definition of DLBP or its diagnostic criteria (Fujii et al., 2019;Lorio et al., 2023). ...
... (Balagué et al., 2012;Ferreira et al., 2023;Han et al., 2023;Videman & Battié, 2012). Intervertebral disc derangement (IDD) has been reported as a significant structural source of symptoms in NSLBP patients and is frequently referred to as, discogenic low back pain (DLBP) (Fujii et al., 2019;Lorio et al., 2023;Peng, 2013). It is common, however, to find only minimal internal disc changes in patients diagnosed with DLBP (Kim et al., 2009;Ract et al., 2015;Zhou & Abdi, 2006). ...
... The results of the Laslett study More recent studies have not added additional information on diagnostic criteria other than to affirm DLBP is characterized by axial midline low back pain, sitting intolerance, pain with flexion, positive provocation with sustained hip flexion, absence of motor/sensor/reflex change, and positive discography although not all degenerated discs exhibit DLBP (Fujii et al., 2019;Lorio et al., 2023). There remains conflicting evidence for the usefulness of most clinical findings assisting with diagnoses, with the exception of centralization and non-organic signs (May et al., 2018). ...
The signs and symptoms of low back pain (LBP) associated with disc herniation (DLBP) and its underlying mechanism(s) are not well supported. One theory proposes that some low back pain (LBP) is the result of a disc herniation compressing adjacent tissues innervated with nociceptors.
The theory proposes that spinal manipulation (SM) and/or mobilizations (SMOB) can reduce the size and position of the herniation, and relieve pain and improve range of motion. There is no research to support or negate the theory even though clinical evidence supports its plausibility.
In this three-part study we examined clinical practices that have an anecdotal history of success. Part one consisted of surveying international clinicians in order to determine their perspectives on the signs and symptoms of DLBP. We then compared those views against published literature through a systematic review. The third part of the study used magnetic resonance imaging (MRI) technology to examine for evidence of change in order to test the hypothesis that disc morphology (i.e., the size and position) can be altered through a specific spinal movement or position.
Our findings showed that clinicians who screen for DLBP appear to follow what little guidance is available however most rely instead on theory, experience, and intuition. Despite the large numbers of proposed features of DLBP, this study shows that there is a need to develop valid and reliable criteria for its diagnosis. With the exception of the centralization phenomenon, there remains no consensus on reference-based index tests that would help clinicians to identify DLBP.
There remains a gap between clinical practice and evidence on the use of spinal manipulative therapy (SMT) for LBP. Currently there is no clear evidence to assist clinicians to determine the subgroup of LBP patients that respond best to SMT.
This study demonstrated a reliable method for measuring changes in disc shape. Future studies should focus on understanding these responses in larger and more diverse samples, as well as their clinical relevance in patients with existing discogenic low back pain.
... Significant advancements in the pathoanatomical characterization of the degenerative processes of the intervertebral disc have been instrumental in establishing and refining clinical diagnostic criteria specific to patients with lumbar discogenic pain. [1][2][3] Although diagnosis can be difficult, salient features of physical examination have been defined to include axial midline low back pain, sitting intolerance, pain with flexion, positive provocation with sustained hip flexion, absence of motor/sensor/reflex change, and positive discography with or without non-radicular/non-sciatic referred leg pain in a sclerotomal distribution. 2,4 In a recently published quantitative evaluation of the global burden of disease, the Institute for Health Metrics and Evaluation (IHME) reported that out of 395 diseases, injuries, and impairments, low back pain was the leading cause of years lived with disability (YLD), responsible for approximately 64 million YLDs or 7.4% of total global YLDs in 2019. 1 Estimates suggest that as many as 40% of patients exhibiting persistently severe low back pain have diagnostic signs and symptoms of discogenic origin including imaging evidence of internal disc disruption and other findings associated with annular tearing. ...
... [1][2][3] Although diagnosis can be difficult, salient features of physical examination have been defined to include axial midline low back pain, sitting intolerance, pain with flexion, positive provocation with sustained hip flexion, absence of motor/sensor/reflex change, and positive discography with or without non-radicular/non-sciatic referred leg pain in a sclerotomal distribution. 2,4 In a recently published quantitative evaluation of the global burden of disease, the Institute for Health Metrics and Evaluation (IHME) reported that out of 395 diseases, injuries, and impairments, low back pain was the leading cause of years lived with disability (YLD), responsible for approximately 64 million YLDs or 7.4% of total global YLDs in 2019. 1 Estimates suggest that as many as 40% of patients exhibiting persistently severe low back pain have diagnostic signs and symptoms of discogenic origin including imaging evidence of internal disc disruption and other findings associated with annular tearing. 5,6 If discogenic low back pain becomes chronic and refractory to conservative medical management, there are few therapeutic options short of surgical discectomy often coupled with total disc arthroplasty or instrumented interbody spine fusion. ...
... [16][17][18] Consequently, for an injectable cell product to provide tangible and durable clinical benefit, it will need to embody some or preferably all of a variety of pro-regenerative characteristics to maximize the likelihood of efficacy. 19 These characteristics include, but are not limited to, (1) engrafting with a capacity to survive for an adequate period of time to directly contribute to matrix production, (2) having the potential to generate robust paracrine signaling to induce an anabolic switch in native cells to alter their behavior from degeneration to regeneration, (3) support the recruitment of regenerative cell types or otherwise limit the migration of fibrotic/catabolic cells into the disc, and (4) provide intradiscal structural and mechanical support that supplements volume loss and facilitates rehydration. 20 This commentary provides a perspective on the state of the science of intradiscal therapies aimed at ameliorating discogenic low back pain. ...
Specific clinical diagnostic criteria have established a consensus for defining patients with lumbar discogenic pain. However, if conservative medical management fails, these patients have few treatment options short of surgery involving discectomy often coupled with fusion or arthroplasty. There is a rapidly-emerging research effort to fill this treatment gap with intradiscal therapies that can be delivered minimally-invasively via fluoroscopically guided injection without altering the normal anatomy of the affected vertebral motion segment. Viable candidate products to date have included mesenchymal stromal cells, platelet-rich plasma, nucleus pulposus structural allograft, and other cell-based compositions. The objective of these products is to repair, supplement, and restore the damaged intervertebral disc as well as retard further degeneration. In doing so, the intervention is meant to eliminate the source of discogenic pain and avoid surgery. Methodologically rigorous studies are rare, however, and based on the best clinical evidence, the safety as well as the magnitude and duration of clinical efficacy remain difficult to estimate. Further, we summarize the US Food and Drug Administration’s (FDA) guidance regarding the interpretation of the minimal manipulation and homologous use criteria, which is central to designating these products as a tissue or as a drug/device/biologic. We also provide perspectives on the core evidence and knowledge gaps associated with intradiscal therapies, propose imperatives for evaluating effectiveness of these treatments and highlight several new technologies on the horizon.
... Therefore, in this study, the representative factors IL-10, TNF-α, MIF, the Notch pathway protein Notch1, and the extracellular matrix component collagen II, which are closely related to inflammation, were selected as the study focuses. It is extremely important to study the treatment or mitigation of IDD [9][10][11]. However, limitations still exist in the treatment of IDD. ...
Objective
To explore the potential mechanism of Yougui Wan on deformed lumbar intervertebral disk structure in rats.
Methods
Thirty male Sprague–Dawley rats were randomly divided into 3 groups, with 10 rats in each group. The animals in the blank control group were healthy rats without specific treatment, and those in the model group and traditional Chinese medicine (TCM) group were used to establish the intervertebral disk degeneration (IDD) model by puncturing the annulus. Four weeks after modeling, rats in the TCM group were administered Yougui Wan by gavage for 2 consecutive weeks. Serum interleukin-6 (IL-10), macrophage migration inhibitory factor (MIF) and tumor necrosis factor alpha (TNF-α) levels were measured by ELISA, and the protein expression levels of collagen II and Notch1 in intervertebral disk tissues were examined by Western blotting. Apoptosis was detected by the TUNEL method.
Results
Compared with those in the blank group, IL-10, MIF and TNF-α levels in the model group and TCM group were increased (P < 0.05), the protein expression levels of collagen II were decreased, and the protein expression levels of Notch1 were increased. Compared with those in the model group, the levels of IL-10 in the TCM group were increased (P < 0.05), the levels of MIF and TNF-α were decreased (P < 0.05), the protein expression levels of collagen II were increased, and the protein expression levels of Notch1 were decreased.
Conclusion
Yougui Wan can inhibit the inflammatory response in IDD rats, reduce the degradation of extracellular matrix, reduce apoptosis in nucleus pulposus cells, and alleviate intervertebral disk degeneration. The mechanism may be related to the regulation of the Notch signaling pathway.
... The problem of degenerative lumbar spine disease (DLSD) and intervertebral disc degeneration disease (IDDD) has been considered from the point of view of several disciplines, from orthopedics and surgery through to histology and molecular biology [1]. Arguably, this is where the varying lack of consensus on a clear definition of IDDD may stem from [2]. The main clinical symptom of both DLSD and IDDD is low back pain (LBP), but not all IDD patients present with clinical symptoms [3]. ...
... The following data, acquired prospectively, underwent evaluation: (1) selected demographic data, (2) presence of pain and other discomforts before, immediately after and one year after surgery according to the VAS scale, (3) degree of disability using the ODI questionnaire before, immediately after and one year after surgery, (4) duration of surgery measured from skin incision to suture, (5) occurrence of other discomforts and ailments after surgery. The patients independently completed the VAS scale assessment and ODI questionnaire: before the surgery and immediately after the surgery while in the hospital and one year after the surgery, receiving it by mail. ...
Low back pain (LBP) is a leading cause of disability and work absenteeism. The cause of LBP may be degeneration of the intervertebral disc. LBP is characterized by considerable variability and tends to develop into chronic pain. Treatment of LBP includes conservative and rehabilitative treatments, surgery, and so-called minimally invasive treatment. One of the most commonly performed procedures is interspinous stabilization using a dynamic interspinous DIAM (device for intervertebral assisted motion) stabilizer. There is still no clear, strong evidence for the effectiveness and superiority of surgical treatment over conservative treatment. This study aimed to compare the early and long-term outcomes of patients with LBP using the DIAM interspinous stabilizer in relation to patients treated conservatively. A group of 86 patients was prospectively randomized into two comparison groups: A (n = 43), treated with the DIAM dynamic stabilizer for degenerative lumbar spine disease (mean age = 43.4 years ± SD = 10.8 years), and B (n = 43), treated conservatively. Pain severity was assessed using the visual analog scale (VAS), whereas disability was assessed using the Oswestry disability index (ODI). The difference in preoperative and postoperative ODI scores ≥ 15 points was used as a criterion for treatment effectiveness, and the difference in VAS scores ≥ 1 point was used as a criterion for pain reduction. In patients under general anesthesia, the procedure only included implantation of the DIAM system. Patients in the control group underwent conservative treatment, which included rehabilitation, a bed regimen, analgesic drug treatment and periarticular spinal injections of anti-inflammatory drugs. It was found that all patients (n = 43) continued to experience LBP after DIAM implantation (mean VAS score of 4.2). Of the 36 patients who experienced LBP with sciatica before the procedure, 80.5% (n = 29) experienced a reduction in pain. As for the level of fitness, the average ODI score was 19.3 ± 10.3 points. As for the difference in ODI scores in the pre-treatment results vs. after treatment, the average score was 9.1 ± 10.6. None of the patients required reoperation at 12 months after surgery. There were no statistically significant differences between the two groups in either early (p = 0.45) or long-term outcomes (p = 0.37). In conclusion, neurosurgical treatment with the DIAM interspinous stabilizer was as effective as conservative treatment and rehabilitation during the one-year follow-up period.
