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. 2025 Jul 1:18:3331-3343.
doi: 10.2147/JPR.S522750. eCollection 2025.

A Proposed Diagnostic and Treatment Algorithm for the Management of Lumbar Discogenic Pain

Morgan P Lorio  1 , Douglas P Beall  2 , Thomas J Myers  3 , Ramana K Naidu  4 , W Porter McRoberts  5 , Timothy T Davis  6 , Emmanuel G Gage  7 , Aaron K Calodney  8 , Paul Verrills  9 , Michael J De Palma  10 , Kasra Amirdelfan  11 , Jon E Block  12
Affiliations

A Proposed Diagnostic and Treatment Algorithm for the Management of Lumbar Discogenic Pain

Morgan P Lorio et al. J Pain Res. .

Abstract

Background: There is renewed interest in the intervertebral disc as a target for treatments aimed at ameliorating lumbar discogenic pain by restoring and preserving the natural structure and function of this component of the vertebral motion segment.

Methods: Using a modified Delphi methodology involving a panel of 11 experts, we developed a simple, understandable clinical algorithm to serve as a foundation for objective decision making regarding the diagnosis and treatment of lumbar discogenic pain throughout the entire continuum of care. A decision tree approach was utilized with "either/or" choices at each branch or node in the algorithm. Clinical activities in this algorithm were divided into examination procedures and corresponding treatment interventions. Corresponding treatment options were designated based on published degenerative disc disease (DDD)-specific clinical practice guidelines and/or meta-analyses.

Results: This algorithm recommends a systematic rule set for discogenic pain diagnostic and treatment options. Initially, the presence of lumbar discogenic pain is confirmed via assessment of a series of clinical signs including axial midline back pain (≥ 4 of 10), pain with flexion, sitting intolerance, positive pain provocation with sustained hip flexion, and absence of motor/sensory/reflex changes. Radiographic severity of DDD is graded by modified Pfirrmann grade (1 to 8). Treatment options are stratified by DDD severity to include conservative management (grades 1 and 2), minimally-invasive intradiscal therapies (grades 3 to 7), and more invasive surgical procedures (grade 8). Recognizing that the management program for patients with lumbar discogenic pain can be highly personalized, the treatment options recommended by this algorithm should be considered general guidance.

Conclusion: The proposed algorithm offers an easy-to-use clinical tool for identifying, evaluating and treating patients with lumbar discogenic pain. The successful implementation of this algorithm involves an important interplay between advanced practice providers, interventional pain physicians and spine surgeons.

Keywords: algorithm; disc degeneration; discogenic pain; intradiscal; minimally-invasive.

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Conflict of interest statement

DPB is a scientific advisor to Vivex Biologics; received grants or contracts from Medtronic, Medical Metrics, Avanos, Relievant, Boston Scientific, Stryker, Sollis Pharmaceuticals, Simplify Medical, Lenoss Medical, Spine BioPharma, Eliem Therapeutics, Smart Soft, Tissue Tech, Vivex, Stratus Medical, Restorative Therapies, Kolon, TissueGene, Companion Spine, DiscGenics; royalties from VIVEX and IZI; consulting fees from Medtronic, Spineology, Merit Medical, Johnson & Johnson, IZI, Techlamed, Peterson Enterprises, Medical Metrics, Avanos, Boston Scientific, Sollis Pharmaceuticals, Simplify Medical, Stryker, Lenoss Medical, Spine BioPharma, Piramal, ReGelTec, Nanofuse, Spinal Simplicity, Pain Theory, Spark Biomedical, Micron Medical Corp, Bronx Medical, Smart Soft, Tissue Tech, RayShield, Stayble, Thermaquil, Vivex, Stratus Medical, Genesys, Abbott, Eliquence, SetBone Medical, Amber Implants, Cerapedics, Neurovasis, Varian Medical Systems, Companion Spine, DiscGenics, Discure, SpinaFX, PainTEQ; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Artio, Sophiris, Eleven Biotherapeutics, Flow Forward, Lenoss Medical, ReGelTech, Spark Biomedical; and support for attending meetings and/or travel from Medtronic, ReGelTec, Nanofuse, Talosix, Spinal Simplicity, Pain Theory, Spark Biomedical, Smart Soft, Tissue Tech, Bronx Medical, Thermaquil, Vivex, Genesys, SetBone Medical, Amber Implants, Cerapedics, SpinaFX. RKN received consulting fees from Vivex, Boston Scientific, Ferring Pharmaceuticals. TTD received consulting fees from Abbott, Boston Scientific, Biotronik; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbott, Boston Scientific, Biotronik. AKC received consulting fees from Vivex Biologics. PV received a grant from Vivex Biologics; received consulting fees from Vivex Biologics and Saluda. MJD is a scientific advisor to Vivex Biologics; received grants or contracts from Spine BioPharma, Restorative, Novartis, SPR, Saol, Paradigm; royalties from Springer; patents from iSpine Ingenuity. JEB received support for medical writing from Vivex Biologics; consulting fees from Vivex. TM reports personal fees from Medtronic, personal fees from Boston Scientific, personal fees from SPR Therapeutics, personal fees from Vivex Biologics, outside the submitted work. The authors report no other conflicts of interest in this work.

Figures

Figure 1
Figure 1
Diagnostic and Treatment Algorithm for Lumbar Discogenic Pain.
See this image and copyright information in PMC

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