Myofascial and discogenic origins of lumbar pain: A critical review

Abstract

The purpose of this three-part narrative review is to examine the anatomy of, and the research which supports, either the lumbar myofascia or intervertebral disc (IVD) as principal sources of our patient's low back pain. A comprehensive understanding of anatomical lumbar pain generators in combination with the current treatment-based classification system will further improve and enhance clinical decision-making skills. Section I reviews the anatomy of the spinal myofascia, myofascial sources of lumbar pain, and imaging of myofascial tissues. Part II reviews the anatomy of the IVD, examines the IVD as a potential lumbar pain generator, and includes detailed discussion on Nerve Growth Factor, Inflammatory Cytokines, Vertebral End Plates and Modic change, Annular tears, and Discogenic instability. Part III looks at the history of myofascial pain, lab-based research and myofascial pain, and various levels of discogenic pain provocation research including animal, laboratory and human subjects. Our review concludes with author recommendations on developing a comprehensive understanding of altered stress concentrations affecting the posterior annulus fibrosis, neo-innervation of the IVD, inflammatory cytokines, discogenic instability, and how this knowledge can complement use of the Treatment-Based Classification System.

Keywords: Myofascial back pain; discogenic lumbar pain; low back pain; lumbar disc degeneration; manual therapy.

Figure 1.

The Three Layers of the Thoracolumbar Fascia. With permission by: Muscolino, J. (2017, August 30). Ligaments of the lumbar spine and pelvis. Learn Muscles. Retrieved March 11, 2023, from https://learnmuscles.com/blog/2017/08/30/ligaments-of-the-lumbar-spine-and-pelvis/.

Figure 2.

Basic Components of the Intervertebral Disc. With permission by: Smith, L. J., Nerurkar, N. L., Choi, K. S., Harfe, B. D., & Elliott, D. M. (2011). Degeneration and regeneration of the intervertebral disc: lessons from development. Disease models & mechanisms, 4(1), 31–41.

Figure 3.

The Ingrowth of Nociceptors: With permission by: García-Cosamalón, J., Del Valle, M. E., Calavia, M. G., García-Suárez, O., López-Muñiz, A., Otero, J., & Vega, J. A. (2010). Intervertebral disc, sensory nerves and Neurotrophins: Who is who in discogenic pain? Journal of Anatomy, 217(1), 1–15. https://doi.org/10.1111/j.1469–7580.2010.01227.x.

Figure 4.

Type I Modic Change (left) and Type II Modic Change (right). With permission by: Chen, Y., Bao, J., Yan, Q., Wu, C., Yang, H., & Zou, J. (2019). Distribution of Modic changes in patients with low back pain and its related factors. European Journal of Medical Research, 24(1). https://doi.Org/10.1186/s40001-019-0393-6.

Figure 5.

Progressive Nuclear Dehydration as shown in Pfirrmann’s five grades of disc degeneration. With permission by: Chen, Y., Bao, J., Yan, Q., Wu, C., Yang, H., & Zou, J. (2019). Distribution of Modic changes in patients with low back pain and its related factors. European Journal of Medical Research, 24(1). https://doi.org/10.1186/s40001-019-0393-6.