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Review
. 2025 Sep;25(7):e70062.
doi: 10.1111/papr.70062.

14. Discogenic Low Back Pain

Wouter K M van Os  1 , Ricardo Alvarez-Jimenez  1 , Steven P Cohen  2   3 , Milan P Stojanovic  4   5   6 , Ricardo Ruiz-Lopez  7 , Jan Van Zundert  8   9 , Jan Willem Kallewaard  1   10
Affiliations
Review

14. Discogenic Low Back Pain

Wouter K M van Os et al. Pain Pract. 2025 Sep.

Abstract

Introduction: Discogenic low back pain can be severely disabling, clinically challenging to diagnose, and expensive to treat. Disc degeneration is characterized by disc dehydration, which diminishes the ability of the disc to distribute pressure, making it more susceptible to damage, and leading to annular tears, fissures, and a higher incidence of herniation. Furthermore, the abnormal annular in-growth of nerves and inflammation of the disc increase the number and sensitivity of nociceptors, leading to chronic discogenic low back pain (CDLBP). The purpose of this article was to review the current literature.

Methods: In this narrative review, the literature on the diagnosis and treatment of discogenic low back pain was summarized.

Results: Symptoms and findings during physical examination may guide the diagnostic process but are not specific or sensitive regarding CDLBP. Magnetic resonance imaging (MRI) can rule out other pathology and provides a basis for the decision about whether to perform pressure-controlled provocative discography, the current diagnostic standard. Conservative care includes pain education programs, structured exercise therapies, psychological interventions, and pharmacological treatment. Various minimally invasive interventional treatment strategies for refractory CDLBP exist, of which biacuplasty or cooled radiofrequency can be used as therapeutic options. Promising new treatments include intradiscal injection of mesenchymal stem cells and platelet-rich plasma, radiofrequency ablation of the sinuvertebral and basivertebral nerves, dorsal root ganglion stimulation, and spinal cord stimulation. Future research regarding the safety and efficacy of these treatments should include large randomized controlled trials with strict inclusion criteria and longer follow-up periods. A primary focus should be on increasing the evidence base for diagnosing discogenic low back pain.

Keywords: chronic discogenic low back pain; discography; evidence‐based medicine; interventional therapy; intradiscal therapy.

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Conflict of interest statement

Dr. Jan Van Zundert and dr. Ricardo Ruiz‐Lopez are Editorial Board member of Pain Practice and a co‐author of this article. To minimize bias, they were excluded from all editorial decision‐making related to the acceptance of this article for publication.

Figures

FIGURE 1
FIGURE 1
Schematic drawing of the lumbosacral innervation. Connections to the dural nerve plexus. Illustration Rogier Trompert Medical Art. http://www.medical‐art.eu.
FIGURE 2
FIGURE 2
Sagittal magnetic resonance images showing types I, II, and III Modic changes. Type I: Low intensity on T1‐weighted images (T1WI), high on T2‐weighted images (T2WI). Type II: High intensity on both T1WI and T2WI. Type III: Low intensity on both T1WI and T2WI. Retrieved from Manabe et al. [48].
FIGURE 3
FIGURE 3
Discography at three levels: L3–4 and L4/5 normal discs and L5‐S1 with tear.
FIGURE 4
FIGURE 4
Gradation of the radial fissures visible on CT discography. Illustration: Rogier Trompert Medical Art. http://www.medical‐art.eu.
FIGURE 5
FIGURE 5
Intradiscal electrothermal therapy at level L5‐S1 in anterior–posterior view.
FIGURE 6
FIGURE 6
Biacuplasty at level L4‐L5 in anterior–posterior and lateral view.
FIGURE 7
FIGURE 7
Radiofrequency ablation of the rami communicantes at levels L3–L4 and L4–L5 in lateral view.
FIGURE 8
FIGURE 8
Algorithmic approach for the treatment of chronic discogenic low back pain. BVN, basivertebral nerve; CT, computed tomography; MRI, magnetic resonance imaging; RFA, radiofrequency ablation; SI, sacroiliac; SVN, sinuvertebral nerve.
See this image and copyright information in PMC

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