'Progressive-onset' versus injury-associated discogenic low back pain: features of disc internal derangement in patients studied with provocation lumbar discography

Abstract

Chronic low back pain (LBP) can be 'progressive onset' or injury-related. This study compares the patient-reported cause of chronic LBP to features of disc internal derangement at painful concordant discs evaluated by provocation lumbar discography. Concordant LBP was identified in 114 patients with chronic LBP studied by provocation discography. LBP cause, discogram pain response and discogram/post-discogram CT features of internal derangement were retrospectively reviewed. 'Progressive-onset' LBP was reported in 32 (28%) patients, injury-related LBP in 75 (66%) with LBP equated to non-specific causes in seven. Injury-related LBP was more commonly identified in men (52 of 63 [83%]) with women reporting near-equal frequency of 'progressive-onset' (23 of 44 [52%]) and injury-related (21 of 44 [48%]) LBP (p=0.002). In 172 concordant painful discs, near-equal frequency of severely degenerative (Dallas grade-3: 82 of 172 [47.3%]) and full-thickness radial fissure discs (Dallas grade-3: 90 of 172 [52.7%]) were identified. Women with 'progressive-onset' LBP demonstrated more frequent severely degenerative discs (24 of 37 [65%]); women with injury-related LBP demonstrated more frequent radial-defect discs (21 of 31 [68%]; p=0.01). In men with injury-related LBP, severe degeneration-only (44 of 89 [49%]) and radial defect discs (45 of 89 [51%] were seen with equal frequency. In men with 'progressive-onset' LBP, radial defects are more common (11 of 15 [73%]). 'Progressive-onset' and injury-related chronic LBP subgroups are definable. Gender-related differences in incidence and internal derangement features at concordant discs are identified at discogram/post-discogram CT. These differences may have implications related to LBP origin/treatment-response.

Figure 1

Two women with LBP and single-level concordance at provocation discography. A,B) Patient is a 52-year-old woman with a 6 year history of progressive LBP. Concordant pain was encountered at L3-L4 with a VAS pain level of 8-9/10. Lateral discogram image (A) demonstrates internal disc derangement at L3-L4 (arrow). Post-discogram CT (B) demonstrates severe Dallas Grade 3 annular degeneration (arrows). C,D) Patient is a 53-year-old woman with severe LBP since a fall on the ice 4 years ago. Concordant LBP was encountered at L5-S1 with a VAS pain level of 8/10. Lateral discogram image (C) demonstrates internal disc derangement at L5-S1 (arrow). Post-discogram CT (D) demonstrates a right sided lateral radial tear (arrow) projecting into a peripheral annular tear (arrowheads).

Figure 2

A,B) Patient is a 33-year-old woman with a long-standing history of progressive LBP without specific inciting event. Concordant LBP was encountered at L4-L5 (A) and L5-S1 (B) with VAS pain levels of 7/10. A) Lateral discogram image demonstrates disc internal derangement at L4-L5 (short arrow) and L5-S1 (long arrow). B) Post-discogram CT at L4-L5 demonstrates severe annular degeneration/fragmentation (arrows). C) Post-discogram CT at L5-S1 demonstrates severe annular degeneration/fragmentation (arrows).

Figure 3

Patient is a 33-year-old gymnast with long-standing LBP since her athletic activities. Concordant LBP was encountered at L3-L4 (VAS 10/10), L4-L5 (VAS 8/10) and L5-S1 (VAS 10/10). Post-discogram CT demonstrated radial tears/fissures at all three levels. A) AP discogram image demonstrates disc internal derangement at L3-L4, L4-L5 and L5-S1. B) Post-discogram CT at L3-L4 demonstrates a left-sided Dallas Grade 3 radial tear (arrow) projecting into a peripheral annular tear (arrowhead). C) Post-discogram CT at L4-L5 demonstrates a Dallas Grade 3 left-sided radial tear (arrow) projecting into a focal peripheral annular tear (arrowhead). D) Post-discogram CT at L5-S1 demonstrates bilateral Dallas Grade 3 lateral radial tear (white arrow) with fragmentation of the residual intervening posterior annulus (black arrows) with peripheral annular tears and residual peripheral annular margin (white arrowheads).

Figure 4

Patient is a 33-year-old man with a 3 year history of progressive LBP. Concordant LBP was encountered at L4-L5 (VAS 10/10). A,B) AP and lateral discogram images demonstrate disc internal derangement at L4-L5 (arrows) with radial tear and contrast leak into the canal. C) Post-discogram CT demonstrates a Dallas Grade 3 central radial tear/fissure (large black arrow) projecting into a peripheral annular tear (white arrowhead) with some degeneration of the adjacent attached residual annular components (small white arrows).

Figure 5

Patient is a 52-year-old man with a 20 year history of LBP following a lifting/twisting injury with heavy weight. He had severe concordant LBP encountered at L3-L4 and non-concordant pain at L4-L5 and L5-S1. A,B) AP and lateral discogram images demonstrate significant internal disc derangement at L3-L4 (short arrows) and L4-L5 (long arrows). C) Post-discogram CT at L3-L4 demonstrates bilateral Dallas Grade 3 radial tears (white arrows) with fragmentation and lamellar separation of the residual intermediate annulus (black arrows). D) Post-discogram CT at the non-concordant L4-L5 level demonstrates severe Dallas Grade 3 annular degeneration (arrows).

Figure 6

Patient is a 53-year-old man with severe LBP since a fall 3 years ago. Concordant LBP was encountered at L4-L5 and L5-S1. A,B) AP and lateral discogram images demonstrate severe disc internal derangement at L4-L5 (long arrows) and L5-S1 (short arrows). C) Post-discogram CT at L4-L5 demonstrates severe Dallas Grade 3 annular degeneration (arrows). D) Post-discogram CT at L5-S1 demonstrates severe Dallas Grade 3 annular degeneration (arrows).

Figure 7

Patient is a 49-year-old man with severe LBP since a lifting injury 5 years ago. Concordant pain was encountered at L4-L5 with mild concordant pain provoked at L5-S1. A,B) AP and lateral discogram images demonstrate internal derangement at L4-L5 (long arrows) and L5-S1 (short arrows). C) Post-discogram CT at L4-L5 demonstrates a lateral tear (white arrow) projecting into a focal protruding peripheral annular tear (black arrowheads). D) Post-discogram CT at L5-S1 demonstrates severe Dallas Grade 3 annular degeneration and fragmentation (arrows).