Discogenic low back pain

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

neurological emergency (nerve root deficit or cauda equina syndrome)

1st line – neural decompression

Back

1st line –

neural decompression

Cauda equina syndrome (CES) is caused by compression of the lumbosacral nerve roots of the cauda equina.

CES is a neurosurgical emergency, and delays in diagnosis and treatment can lead to permanent disability.

Features of CES include: low back pain; bilateral or unilateral sciatica; progressive neurological deficits; difficulty starting or stopping urination or impaired sensation of urinary flow; urgency; urinary retention with overflow urinary incontinence; loss of sensation of rectal fullness; faecal incontinence; laxity of the anal sphincter; saddle anaesthesia or paraesthesia; and sexual dysfunction. Not all patients show all features, but bladder dysfunction is an essential component of CES.

Magnetic resonance imaging is carried out as soon as possible in patients with suspected CES. Patients with CES require urgent surgical decompression of the spinal canal. See Cauda equina syndrome (Management Approach)

A painful nerve root deficit (motor deficit with pain in the same dermatome) in the presence of identifiable disc compression is amenable to surgery. It should be differentiated from a painless nerve deficit (i.e., a painless foot drop) and from a peripheral nerve lesion.

ACUTE

acute back pain: <3 months duration from initial presentation or exacerbation of chronic pain

1st line – paracetamol and/or oral non-steroidal anti-inflammatory drug

Back

1st line –

paracetamol and/or oral non-steroidal anti-inflammatory drug

The majority of patients with acute exacerbations of discogenic back pain will improve by 4 weeks.

Paracetamol is often used in mild or moderate pain, as it may offer a more favourable safety profile than non-steroidal anti-inflammatory drugs (NSAIDs).[104] However, UK guidelines do not recommend paracetamol alone as a first line agent for managing low back pain.[65]

NSAIDs are also frequently used.[65] NSAIDs should only be used for a limited time (no longer than 3 months). No specific NSAID has been found to be more effective than any other.[106]

Consider using gastric protection, such as a proton-pump inhibitor, in patients who are on prolonged NSAID therapy, especially if they are at higher risk for having gastrointestinal bleeding.[65]

In the event of acute exacerbation of pre-existing chronic back pain, the clinician should seek out the cause of the acute symptoms. It is imperative to exclude other causes of acute symptoms such as discitis. Documentation of any changes in the neurological assessment should be made. Repeat imaging scans may help identify the problem. The possible events leading to the acute increase in the symptoms should be viewed in the light of possible changes in the pathology.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

-- AND / OR --

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

ibuprofen: 300-600 mg orally every 6-8 hours when required, maximum 2400 mg/day

diclofenac potassium: 50 mg orally (immediate-release) twice or three times daily when required

diclofenac sodium: 100 mg orally (extended-release) once daily when required

Consider – topical analgesia

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Consider –

topical analgesia

Additional treatment recommended for SOME patients in selected patient group

Acute symptoms can also be managed with topical analgesia.[101]

Capsaicin depletes the local resources of substance P, which is implicated in the mediation of noxious stimuli.[102]

Topical non-steroidal anti-inflammatory drugs (NSAIDs) are useful in pain that may be mediated through muscular causes. Limited local absorption help to treat symptoms arising from periarticular structures, and systemic absorption delivers the therapeutic agent to intracapsular structures.[103] Plasma NSAID concentration following topical administration is typically <5% of that following oral NSAID administration and is, therefore, less effective. However, use of topical NSAIDs can potentially limit systemic adverse events.[103]

Topical agents avoid gastric side effects and adverse drug interactions. Their use is beneficial in older patients and patients with comorbidities.

Primary options

capsaicin topical: (0.025%, 0.075%) apply to the affected area(s) three to four times daily when required

diclofenac topical: consult product literature for guidance on dose

Consider – opioid analgesia

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Consider –

opioid analgesia

Additional treatment recommended for SOME patients in selected patient group

Opioid analgesics may be used judiciously in patients with acute severe, disabling pain that is not controlled (or is unlikely to be controlled) with paracetamol and/or non-steroidal anti-inflammatory drugs (NSAIDs).[65] A weak opioid can be considered (with or without paracetamol) for acute low back pain if NSAIDs are contraindicated, or not tolerated.[65]

Opioid medication should not be used to treat chronic low back pain.[107][65]

Primary options

codeine phosphate: 15-60 mg orally every 4-6 hours when required, maximum 240 mg/day

Secondary options

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

Consider – muscle relaxant

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Consider –

muscle relaxant

Additional treatment recommended for SOME patients in selected patient group

Muscle relaxants, such as diazepam, are an option for short-term relief of acute low back pain; however, these need to be used with caution because of a risk of adverse effects (primarily sedation) and dependency.[108]

Primary options

diazepam: 5-10 mg orally three times daily

Consider – alternative therapies

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Consider –

alternative therapies

Additional treatment recommended for SOME patients in selected patient group

Several therapies may be used within the remits on conventional health care systems as alternative therapies. Clinicians should consider the addition of non-pharmacological therapies, such as acupuncture, acupressure, and yoga.[122][127]

with axial back pain predominant

Plus – physiotherapy

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Plus –

physiotherapy

Treatment recommended for ALL patients in selected patient group

Remaining active is recommended for the treatment of acute low back pain (LBP), rather than bed rest.[113][114] Education of patients as employed in back schools, regarding positions of ease, exercise, and correct lifting techniques, has shown improved patient outcomes in both the short and intermediate term.[115][116]

Physiotherapy with strengthening exercises (both for abdominal wall and for lumbar musculature) has demonstrated positive effects in patients with axial pain.[117] However, timing of use of exercise is controversial, with use of exercise programmes being shown to be effective in subacute and chronic disease.

A number of exercise regimens have been used to treat LBP. The McKenzie method of evaluating and categorising patients has been shown to be highly successful.[118] The McKenzie method produced better short-term results than non-specific guidelines and was equal to the results of the strengthening and stabilisation protocols.[119]

Spinal manipulation has been shown to be equivalent to physiotherapy in the treatment of acute LBP.[120][121]

Use of a variety of interferential systems and stimulators may provide benefit for acute and chronic symptoms; however, their use is controversial.[122][123]

Consider – facet joint blocks

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Consider –

facet joint blocks

Additional treatment recommended for SOME patients in selected patient group

Facetogenic pain is a well defined clinical entity. The symptoms include axial back pain and posterior thigh pain (typically to the knee). The infiltration of a long-acting local anaesthetic agent, with or without a local-acting corticosteroid, can provide an assessment of the origin of the pain from the facet joints.

The infiltration can either be around the medial branch as it crosses over the superomedial aspect of the transverse process, or it could be intra-articular. The former is a more accurate intervention. The facet joints have a dual-level innervation; hence, the level above should be injected as well.

Spinal injections are not recommended for the management of low back pain in the UK or the US.[65][139] The Getting it Right First Time (GIRFT) spinal services report recommend that short-term pain relief injections should be replaced with long-term physical and psychological rehabilitation programmes to help patients cope with back pain.[140]

with radicular pain predominant

Consider – selective nerve root block or epidural injection

Back

Consider –

selective nerve root block or epidural injection

Additional treatment recommended for SOME patients in selected patient group

Radicular leg pain associated with degenerative disc disease can result from nerve root compression due to hypertrophied facet joints, disc prolapse, or foraminal narrowing due to loss of disc height or due to instability at that motion segment.

Inflammation as a cause of radicular symptoms with a mild or moderate compression can be treated by a selective nerve root block.

This is performed with radiological guidance for the placement of a spinal needle in close proximity to the nerve root. A long-acting local anaesthetic, with or without a local-acting corticosteroid, is then infiltrated.

Epidural injections are used for radicular pain due to multilevel, bilateral pathology.[130]

A long-acting local anaesthetic, with or without a local-acting corticosteroid, can be injected either in the foramen or in the spinal canal.[131][168] Infiltration in the spinal canal can be achieved by the lumbar route (through the posterior ligaments), the transforaminal route (through the epidural space targeting a specific nerve root)or the caudal route (through the sacral hiatus).[64][128][129] The volume of the injectate required increases with each of these routes.

Although epidural steroid injections might provide greater benefit than gabapentin for some outcome measures, the differences are modest and are transient in most cases.[137]

The American Academy of Neurology assessed the use of epidural corticosteroid injections to treat patients with radicular lumbosacral pain, they suggest that pain may be improved in the short term (2-6 weeks post injection), but no impact on average impairment of function, on need for surgery, or on long-term pain relief beyond 3 months was demonstrated. Routine use is not recommended for patients with radicular lumbosacral pain.[136]

In 2012, an outbreak of fungal infections of the central nervous system was reported in the US in patients who received epidural or paraspinal glucocorticoid injections of preservative-free methylprednisolone acetate prepared by a single compounding pharmacy.[138] Although such cases are extremely rare, it highlights the need for the highest standards in drug preparation and injection if these routes of administration are used.

Consider – neural decompression

Back

Consider –

neural decompression

Additional treatment recommended for SOME patients in selected patient group

Decompression of the nerve roots and neural structures relieves radicular symptoms. Removal of degenerate facet joints allows for a better subarticular decompression and removes one of the potential pain sources. An indirect decompression can be achieved by placement of interbody grafts to increase the disc height and open up the foramen.

ONGOING

chronic back pain: ≥3 months duration from initial presentation

1st line – continued pain management

Back

1st line –

continued pain management

Patients with chronic low back pain should use paracetamol regularly.

If the patient has found some relief with non-steroidal anti-inflammatory drugs (NSAIDs) in the past, but has not been taking them regularly, then NSAIDs could be added; however, they should only be used for up to 3 months.

Opioids such as codeine or tramadol may be required for more severe pain, but they should not be used chronically.

If pain is still not relieved, patients should be referred to a pain specialist for further advice. Buprenorphine (transdermal) may be prescribed and its use closely monitored by the specialist.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

-- AND / OR --

ibuprofen: 300-600 mg orally every 6-8 hours when required, maximum 2400 mg/day

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

diclofenac potassium: 50 mg orally (immediate-release) twice or three times daily when required

diclofenac sodium: 100 mg orally (extended-release) once daily when required

Secondary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

-- AND --

codeine phosphate: 15-60 mg orally every 4-6 hours when required, maximum 240 mg/day

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

Tertiary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

and

buprenorphine transdermal: consult specialist for guidance on dose

Consider – pain clinic referral

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Consider –

pain clinic referral

Additional treatment recommended for SOME patients in selected patient group

A multidisciplinary clinic comprising a pain specialist (typically an anaesthetist with a special interest in pain management) with additional input from specialist nurse practitioners, physiotherapists, psychologists, and pharmacists.

Goal is to streamline medications, provide input on ergonomic issues, and deal with psychological issues, if any. In addition, the pain physician can undertake procedures such as nerve root and epidural infiltrations and facet rhizolysis.

Consider – functional/vocational rehabilitation

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Consider –

functional/vocational rehabilitation

Additional treatment recommended for SOME patients in selected patient group

The treatment of low back pain often necessitates a multidisciplinary approach.[164][165] The disciplines usually contain a physical element and also a combination of social, occupational, and psychological components. Multidisciplinary rehabilitation was found to be more effective than simple rehabilitation programmes.[164]

Functional/vocational rehabilitation is defined as whatever helps someone with a health problem to stay at, return to, and remain in work. It is an approach, intervention, and service with a focus towards work-focused health care and accommodating work places to working-age adults. Several return to work programmes have been trialled with due attention to manual material handling (MMH) advice and assistive devices, although one Cochrane review found moderate quality evidence that such interventions do not reduce back pain, back pain-related disability, or absence from work when compared with no, or alternative, interventions.[166][167] There was also no evidence from randomised controlled trials to support the effectiveness of MMH advice and training, or MMH assistive devices for the treatment of back pain.

Consider – alternative therapies

Back

Consider –

alternative therapies

Additional treatment recommended for SOME patients in selected patient group

Several therapies may be used within the remits on conventional healthcare systems and as alternative therapies. Clinicians should consider the addition of non-pharmacological therapies, such as acupuncture, acupressure, and yoga.[122][127]

Consider – amitriptyline

Back

Consider –

amitriptyline

Additional treatment recommended for SOME patients in selected patient group

Antidepressants are used for the treatment of chronic low back pain. Studies have shown that tricyclic antidepressants (e.g., amitriptyline) produced symptom reduction, whereas selective serotonin-reuptake inhibitors did not.[109] Amitriptyline is useful for improving sleep quality and dealing with neuropathic pain.

SSRIs, serotonin-noradrenaline reuptake inhibitors, or tricyclic antidepressants are not recommended for management of low back pain in the UK.[65]

Due to a lack of evidence, US guidance does not make a recommendation for the use of amitriptyline for the treatment of lumbar disc herniation with radiculopathy.[64]

Primary options

amitriptyline: 10 mg orally once daily at night initially, increase gradually according to response, maximum 50 mg/day

with axial back pain predominant

Plus – physiotherapy

Back

Plus –

physiotherapy

Treatment recommended for ALL patients in selected patient group

Physiotherapy with strengthening exercises (both for abdominal wall and for lumbar musculature) has demonstrated positive effects in patients with discogenic pain.[117] However, timing of use of exercise in controversial, with use of exercise programmes being shown to be effective in subacute and chronic disease.

A number of exercise regimens have been used to treat low back pain. The McKenzie method of evaluating and categorising patients has been shown to be highly successful.[119]

Use of a variety of interferential systems and stimulators may provide benefit for acute and chronic symptoms; however, their use is controversial.[122][123]

Consider – facet joint blocks or facet rhizolysis

Back

Consider –

facet joint blocks or facet rhizolysis

Additional treatment recommended for SOME patients in selected patient group

Facetogenic pain is a well defined clinical entity. The symptoms include back pain and posterior thigh pain (typically to the knee).

Infiltration of long-acting local anaesthetic agent ± locally acting corticosteroids can provide an assessment of the origin of the pain from the facet joints.

The infiltration can either be around the medial branch as it crosses over the superomedial aspect of the transverse process, or it could be intra-articular. The former is a more accurate intervention. The facet joints have a dual level innervation; hence, the level above should be injected as well.[169]

Facet rhizolysis by radiofrequency ablation may provide a longer-term effect on facetogenic pain, especially with a positive response to the facet block, although its efficacy is unclear.[141][142]

Consider – spinal fusion

Back

Consider –

spinal fusion

Additional treatment recommended for SOME patients in selected patient group

Spinal fusion is most appropriate for patients with evidence of spinal instability (trauma, tumour, infection, deformity, and intravertebral disc disease). In the presence of degenerative disc disease without significant instability, the application of spinal fusion is based on the perception that preventing any motion across a painful disc or removing the disc altogether and fusing the motion segment will stop the progression of the disease and relieve the pain.[151][152][170]

Currently, clinical indications for spinal fusion include: failure of aggressive conservative treatment, prolonged chronic pain, disability for over 1 year, and advanced disc degeneration as identified on magnetic resonance imaging limited to 1 or 2 disc levels.[143][144] In the presence of a clear pathology with evident instability (spondylolysis, isthmic spondylolisthesis with instability, facetal arthropathy with a degenerative spondylolisthesis), the response to physiotherapy may be noted for a shorter period of time (6 months) before consideration given to surgery.

Several techniques that have been developed and advocated for achieving fusion in the lumbar spine, including: the posterolateral fusion (with pedicle screws or not), the posterior lumbar interbody fusion, the transforaminal lumbar interbody fusion, and the anterior lumbar interbody fusion. Generally, the use of instrumentation has been shown to increase the fusion rates but at the cost of increased complication rates, blood loss, and surgical time.[145][153] All fusion techniques reduce pain and disability, with no disadvantage identified to using the less demanding of the surgical techniques.[153][154][155]

with radicular pain predominant

Consider – interferentials including stimulators

Back

Consider –

interferentials including stimulators

Additional treatment recommended for SOME patients in selected patient group

Use of a variety of interferential systems and stimulators may provide benefit for acute and chronic symptoms; however, their use is controversial.[122][123]

Consider – gabapentin or pregabalin

Back

Consider –

gabapentin or pregabalin

Additional treatment recommended for SOME patients in selected patient group

Gabapentin and pregabalin may alleviate pain and improve quality of life in patients with chronic neuropathic pain, although this is controversial and caution is needed.[110][111][112] Pregabalin appears to have better adherence and better bioavailability than gabapentin and is, therefore, usually preferred over gabapentin.

Pregabalin appears to have better adherence and better bioavailability than gabapentin.

Gabapentinoids or anticonvulsants are not recommended for management of low back pain in the UK.[65]Guidance from the US does not make any recommendation for or against the use of gabapentin for the treatment of lumbar disc herniation with radiculopathy due to insufficient evidence.[64]

Primary options

pregabalin: consult specialist for guidance on dose

gabapentin: consult specialist for guidance on dose

Consider – selective nerve root block or epidural injection

Back

Consider –

selective nerve root block or epidural injection

Additional treatment recommended for SOME patients in selected patient group

Inflammation as a cause of radicular symptoms with a mild or moderate compression can be treated by a selective nerve root block.

This is performed with radiological guidance for the placement of a spinal needle in close proximity to the nerve root. A long-acting local anaesthetic with or without a local-acting corticosteroid is then infiltrated.

Epidural injections are used for radicular pain due to multilevel, bilateral pathology.[130]

A long-acting local anaesthetic, with or without a local-acting corticosteroid, can be injected either in the foramen or in the spinal canal.[131][168] Infiltration in the spinal canal can be achieved by the lumbar route (through the posterior ligaments), the transforaminal route (through the epidural space targeting a specific nerve root). or the caudal route (through the sacral hiatus).[64][128][129] The volume of the injectate required increases with each of these routes.

Although epidural steroid injections might provide greater benefit than gabapentin for some outcome measures, the differences are modest and are transient in most cases.[137]

Consider – neural decompression or spinal fusion

Back

Consider –

neural decompression or spinal fusion

Additional treatment recommended for SOME patients in selected patient group

Spinal fusion is most appropriate for patients with evidence of spinal instability (trauma, tumour, infection, deformity, and intervertebral disc disease). In the presence of degenerative disc disease without significant instability, the application of spinal fusion is based on the perception that preventing any motion across a painful disc or removing the disc altogether and fusing the motion segment will stop the progression of the disease and relieve the pain.[151][152]

Currently, clinical indications for spinal fusion include: failure of aggressive conservative treatment, prolonged chronic pain, disability for more than 1 year, and advanced disc degeneration as identified on magnetic resonance imaging limited to 1 or 2 disc levels.[143][144] In the presence of a clear pathology with evident instability (spondylolysis, isthmic spondylolisthesis with instability, facetal arthropathy with a degenerative spondylolisthesis), the response to physiotherapy may be noted for a shorter period of time (6 months) before consideration given to surgery.

In cases of radiculopathy, the presence of symptoms longer than 6 months has been associated with poorer clinical outcomes.[146] Similar findings were noted in patients treated for spinal stenosis, with treatment at earlier than 12 months of symptom duration correlating with better clinical outcomes.[147]

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Discogenic low back pain

Treatment algorithm

neurological emergency (nerve root deficit or cauda equina syndrome)

neural decompression

acute back pain: <3 months duration from initial presentation or exacerbation of chronic pain

paracetamol and/or oral non-steroidal anti-inflammatory drug

Primary options

topical analgesia

Primary options

opioid analgesia

Primary options

Secondary options

muscle relaxant

Primary options

alternative therapies

physiotherapy

facet joint blocks

selective nerve root block or epidural injection

neural decompression

chronic back pain: ≥3 months duration from initial presentation

continued pain management

Primary options

Secondary options

Tertiary options

pain clinic referral

functional/vocational rehabilitation

alternative therapies

amitriptyline

Primary options

physiotherapy

facet joint blocks or facet rhizolysis

spinal fusion

interferentials including stimulators

gabapentin or pregabalin

Primary options

selective nerve root block or epidural injection

neural decompression or spinal fusion