Discogenic low back pain - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

Discogenic low back pain is a complex, multi-factorial, clinical condition. It is characterized by low back pain, with or without the concurrence of radicular lower limb symptoms, in the presence of radiologically-confirmed degenerative disc disease.
Magnetic resonance imaging is the imaging study of choice for degenerative disk disease due to its unique detail on the representation of the disk status. Other tests may include plain radiographs, computed tomography scanning, or provocative discography.
Nonsurgical treatments include lifestyle measures, followed by the judicious use of medications, physical therapy, and therapeutic needling procedures.
Surgical treatment includes decompression of neural structures and, in selected patients, a fusion of the motion segment.

Quick Reference

History & Exam
- Key Factors
- Other Factors
More information...
Diagnostics Tests
More information...
Treatment Options
More information...

Definition

Epidemiology

Etiology

Pathophysiology

Images

MRI spine: degenerate facet joints and a large facet cyst from the left L5S1 facet joint compressing the left S1 nerve root
MRI spine: degenerate L4-5 disk with a disk bulge and L5S1 disk with a high-intensity zone
T2-weighted MRI spine: sagittal view (left) demonstrates degenerate disks; axial view (right) demonstrates left-sided L5S1 foraminal narrowing
T2-weighted MRI spine: sagittal view (left) demonstrates 2 level disk dehydration at L4-5 and L5S1 with a moderate reduction in disk height; axial views (right) demonstrate constitutionally narrow canal at L4-5 with a moderate disk prolapse and a large disk prolapse at L5S1 level with left S1 root compression
Discography: a patient presents with back and right leg pain that did not respond to a trial of conservative management. MRI (left, sagittal T2-weighted image) demonstrates multiple degenerate disks with loss of normal hydration, reduced signal, and loss of the nuclear-annular transition, with a normal disk height. A 3-level discography at L3-4, L4-5, and L5S1 (middle, AP radiograph; right, lateral radiograph) reveals a low-pressure injection with degenerate annular tears at all 3 levels, with 5/5 pain concordance at L5S1; 3/5 at L4-5; and 0/5 at L3-4
Spondylolisthesis: flexion/extension views
Preoperative MRI sagittal T2 sequence
Intraoperative images showing a gradual reduction of the deformity: L4 to S1 instrumented fusion, transforaminal fusion at L5S1 and bilateral L5 decompression
Postoperative radiographs
Pre- and post-surgical views: a patient presents with back pain and neurogenic claudication with stenosis and degenerative slip at L4-5 and a degenerate disk at L5S1 (left, T2-weighted sagittal MRI); L4-S1 decompression and instrumented fusion and a 2-level transforaminal lumbar interbody fusion was performed (AP radiograph top; lateral, bottom)
Disk replacement: patient presents with severe back pain, having previously undergone right L5S1 discectomy for a right S1 radiculopathy. Though initially recovered, the right S1 pain recurred after 10 months, with back pain. An MRI scan shows a degenerate L5S1 disk (left, T2-weighted sagittal view). Patient subsequently had a disk replacement (AP radiograph top right, lateral bottom right). The pain in the back and the right leg resolved completely

Citations

Key Articles

Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014 Jan;14(1):180-91.[Abstract]
National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. Dec 2020 [internet publication].[Full Text]
Expert Panel on Neurological Imaging, Hutchins TA, Peckham M, et al. ACR Appropriateness Criteria® Low Back Pain: 2021 Update. J Am Coll Radiol. 2021 Nov;18(11s):S361-S379.[Abstract][Full Text]
Modic MT, Steinberg PM, Ross JS, et al. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology. 1988 Jan;166(1 Pt 1):193-9.[Abstract]
Pfirrmann CW, Metzdorf A, Zanetti M, et al. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976). 2001 Sep 1;26(17):1873-8.[Abstract]
Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop Relat Res. 1982 May;(165):110-23.[Abstract]

Referenced Articles

1. Olmarker K, Rydevik B. Disc herniation and sciatica; the basic science platform. In: Gunzburg R, Szpalski M, eds. Lumbar Disc Herniation. Philadelphia: Lippincott. Williams & Wilkins; 2002:31-7.
2. Postacchini F, Gumina S, Cinotti G, et al. Ligamenta flava in lumbar disc herniation and spinal stenosis. Light and electron microscopic morphology. Spine. 1994 Apr 15;19(8):917-22.[Abstract]
3. Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop Relat Res. 1982 May;(165):110-23.[Abstract]
4. Andersson GB. Epidemiological features of chronic low back pain. Lancet. 1999 Aug 14;354(9178):581-5.[Abstract]
5. Carragee EJ, Hannibal M. Diagnostic evaluation of back pain. Orthop Clin North Am. 2004 Jan;35(1):7-16.[Abstract]
6. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001 Feb 1;344(5):363-70.[Abstract]
7. Mooney V. Where is the lumbar pain coming from? Ann Med. 1989 Oct;21(5):373-9.[Abstract]
8. Nachemson AL. The lumbar spine an orthopedic challenge. Spine. 1976;1:59-71.
9. Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations in lumbar spine using local anaesthesia. Orthop Clin North Am. 1991 Apr;22(2):181-7.[Abstract]
10. Schwarzer AC, Aprill CN, Derby R, et al. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine (Phila Pa 1976). 1994 Apr 1;19(7):801-6.[Abstract]
11. Hassett G, Hart DJ, Manek NJ, et al. Risk factors for progression of lumbar spine disc degeneration: the Chingford study. Arthritis Rheum. 2003 Nov;48(11):3112-7.[Abstract][Full Text]
12. Hangai M, Kaneoka K, Kuno S, et al. Factors associated with lumbar intervertebral disc degeneration in the elderly. Spine J. 2008 Sep-Oct;8(5):732-40.[Abstract]
13. McNally DS, Shackleford IM, Goodship AE, et al. In vivo stress measurement can predict pain on discography. Spine. 1996 Nov 15;21(22):2580-7.[Abstract]
14. Sachs BL, Vanharanta H, Spivey MA, et al. Dallas discogram description. A new classification of CT/discography in low-back disorders. Spine. 1987 Apr;12(3):287-94.[Abstract]
15. Vanharanta H, Sachs BL, Spivey MA, et al. The relationship of pain provocation to lumbar disc deterioration as seen by CT/discography. Spine. 1987 Apr;12(3):295-8.[Abstract]
16. Freemont AJ, Peacock TE, Goupille P, et al. Nerve ingrowth into diseased intervertebral disc in chronic back pain. Lancet. 1997 Jul 19;350(9072):178-81.[Abstract]
17. Battie MC, Videman T, Kaprio J, et al. The twin spine study: contributions to a changing view of disc degeneration. Spine J. 2009 Jan-Feb;9(1):47-59.[Abstract]
18. Heliovaara M. Risk factors for low back pain and sciatica. Ann Med. 1989 Aug;21(4):257-64.[Abstract]
19. Adams MA, Dolan P, Hutton WC, et al. Diurnal changes in spinal mechanics and their clinical significance. J Bone Joint Surg Br. 1990 Mar;72(2):266-70.[Abstract][Full Text]
20. Lyons G, Eisenstein SM, Sweet MB. Biochemical changes in intervertebral disc degeneration. Biochim Biophys Acta. 1988 Feb;13(2):179-87.[Abstract]
21. Urban JP, McMullin JF. Swelling pressure of the lumbar intervertebral discs: influence of age, spinal level, composition and degeneration. Spine (Phila Pa 1976). 1988 Feb;13(2):179-87.[Abstract]
22. Frobin W, Brinckmann P, Kramer M, et al. Height of lumbar discs measured from radiographs compared with degeneration and height classified from MR images. Eur Radiol. 2001;11(2):263-9.[Abstract]
23. Adams MA, McNally DS, Dolan P. "Stress" distributions inside intervertebral discs. The effects of age and degeneration. J Bone Joint Surg Br. 1996 Nov;78(6):965-72.[Abstract][Full Text]
24. Kang JD, Georgescu HI, McIntyre-Larkin L, et al. Herniated lumbar intervertebral discs spontaneously produced matrix metalloproteinases, nitric oxide, interleukin-6, and prostaglandin E2. Spine. 1996 Feb 1;21(3):271-7.[Abstract]
25. Bogduk N, Tynan W, Wilson AS. The nerve supply to the human lumbar intervertebral discs. J Anat. 1981 Jan;132(Pt 1):39-56.[Abstract][Full Text]
26. Hirsch C, Ingelmark B, Miller M. The anatomical basis for low back pain: studies on the presence of sensory nerve endings in ligamentous, capsular, and intervertebral disc structures in the human lumbar spine. Acta Orthop Scand. 1963;33:1-17.[Abstract]
27. Jackson HC, Winkelmann RK, Bickel WH. Nerve endings in the human lumbar spinal column and related structures. J Bone Joint Surg Am. 1966 Oct;48(7):1272-81.[Abstract]
28. Ohtori S, Takahashi K, Chiba T, et al. Sensory innervation of the dorsal portion of the lumbar intervertebral discs in rats. Spine. 2001 Apr 15;26(8):946-50.[Abstract]
29. Ohtori S, Takahashi K, Chiba T, et al. Substance P and calcitonin gene- related peptide immunoreactive sensory DRG neurons innervating the lumbar intervertebral discs in rats. Ann Anat. 2002 May;184(3):235-40.[Abstract]
30. Ozawa T, Aoki Y, Ohtori S, et al. The dorsal portion of the lumbar inter-vertebral disc is innervated primarily by small peptide-containing dorsal root ganglion neurons in rats. Neurosci Lett. 2003 Jun 19;344(1):65-7.[Abstract]
31. Peng B, Hao J, Hou S, et al. Possible pathogenesis of painful intervertebral disc degeneration. Spine (Phila Pa 1976). 2006 Mar 1;31(5):560-6.[Abstract]
32. Peng B, Chen J, Kuang Z, et al. Expression and role of connective tissue growth factor in painful disc fibrosis and degeneration. Spine (Phila Pa 1976). 2009 Mar 1;34(5):E178-82.[Abstract]
33. Freemond AJ. The cellular pathobiology of the degenerate intervertebral disc and discogenic back pain. Rheumatology (Oxford). 2009;48:5-10.
34. Kuisma M, Karppinen J, Haapen M, et al. Are the determinants of vertebral endplate changes and severe disc degeneration in the lumbar spine the same? BMC Musculoskeletal Disord. 2008 Apr 16;9:51.[Abstract][Full Text]
35. Butler D, Trafimow JH, Andersson GB, et al. Discs degenerate before facets. Spine (Phila Pa 1976). 1990 Feb;15(2):111-3.[Abstract]
36. Adams MA, Hutton WC. The relevance of torsion to the mechanical derangement of the lumbar spine. Spine. 1981 May-Jun;6(3):241-8.[Abstract]
37. Livshits G, Popham M, Malkin I, et al. Lumbar disc degeneration and genetic factors are the main risk factors for back pain in women: the Twin Spine Study. Ann Rheum Dis. 2011 Oct;70(10):1740-5.[Abstract][Full Text]
38. Kalichman L, Hunter DJ. The genetics of intervertebral disc degeneration. Associated genes. Joint Bone Spine. 2008 Jul;75(4):388-96.[Abstract]
39. Kalichman L, Hunter DJ. The genetics of intervertebral disc degeneration. Familial disposition and heritability estimation. Joint Bone Spine. 2008 Jul;75(4):383-7.[Abstract]
40. Cheung KM. The relationship between disc degeneration, low back pain and human pain genetics. Spine J. 2010 Nov;10(11):958-60.[Abstract]
41. Luoma K, Riihimaki H, Raininko R, et al. Lumbar disc degeneration in relation to occupation. Scan J Work Environ Health. 1998 Oct;24(5):358-66.[Abstract][Full Text]
42. Riihimaki H, Mattsen T, Zitling A, et al. Radiologically detectable degenerative changes of the lumbar spine among concrete reinforcement workers and house painters. Spine (Phila Pa 1976). 1990 Feb;15(2):114-9.[Abstract]
43. Vo N, Wang D, Sowa G, et al. Differential effects of nicotine and tobacco smoke condensate on human annulus fibrosus cell metabolism. J Orthop Res. 2011 Oct;29(10):1585-91.[Abstract]
44. Akmal M, Kesani A, Anand B, et al. Effect of nicotine on spinal disc cells: a cellular mechanism for disc degeneration. Spine (Phila Pa 1976). 2004 Mar 1;29(5):568-75.[Abstract]
45. Fogelholm RR, Alho AV. Smoking and intervertebral disc degeneration. Med Hypotheses. 2001 Apr;56(4):537-9.[Abstract]
46. Uei H, Matsuzaki H, Oda H, et al. Gene expression changes in an early stage of intervertebral disc degeneration induced by passive cigarette smoking. Spine (Phila Pa 1976). 2006 Mar 1;31(5):510-4.[Abstract]
47. Sandén B, Försth P, Michaëlsson K. Smokers show less improvement than non-smokers two years after surgery for lumbar spinal stenosis: a study of 4555 patients from the Swedish Spine Registry. Spine (Phila Pa 1976). 2011 Jun;36(13):1059-64.[Abstract]
48. Wang J, Yang X. Age-related changes in the orientation of lumbar facet joints. Spine. 2009 Aug 1;34(17):E596-8.[Abstract]
49. Kalichman L, Li L, Kim DH, et al. Facet joint osteoarthritis and low back pain in the community-based population. Spine (Phila Pa 1976). 2008 Nov 1;33(23):2560-5.[Abstract][Full Text]
50. Cyron BM, Hutton WC. Articular tropism and stability of the lumbar spine. Spine. 1980 Mar-Apr;5(2):168-72.[Abstract]
51. Park JB, Chen H, Kim KW, et al. Facet tropism: a comparison between far lateral and posterolateral lumbar disc herniation. Spine. 2001 Mar 15;26(6):677-9.[Abstract]
52. Schwab F, Patel A, Ungar B, et al. Adult spinal deformity-postoperative standing balance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976). 2010 Dec 1;35(25):2224-31.[Abstract]
53. Glassman SD, Bridewell K, Dimar JR, et al. The impact of positive sagittal balance in adult spinal deformity. Spine. 2005 Sep 15;30(18):2024-9.[Abstract]
54. Linke M, Solovieva S, Lamminen A, et al. Disc degeneration of the lumbar spine in relation of overweight. Int J Obest. 2005 Aug;29(8):903-8.[Abstract][Full Text]
55. Won HY, Park JB, Riew KD. Effect of hyperglycemia on apoptosis of notochordal cells and intervertebral disc degeneration in diabetic rats. J Neurosurg Spine. 2009 Dec;11(6):741-8.[Abstract]
56. Anekstein Y, Smorgick Y, Lotan R, et al. Diabetes mellitus as a risk factor for the development of lumbar spinal stenosis. Isr Med Assoc J. 2010 Jan;12(1):16-20.[Abstract][Full Text]
57. Videman T, Battie MC, Gibbons LE, et al. Disc degeneration and bone density in monozygotic twins discordant for insulin dependent diabetes mellitus. J Orthop Res. 2000 Sep;18(5):768-72.[Abstract]
58. Leino-Arjas P, Kaila-Kangas L, Solvieva S, et al. Serum lipids and low back pain: an association? A follow-up study of working population sample. Atherosclerosis. 2006 Apr 20;31(9):1032-7.[Abstract]
59. Kurunlahti M, Tervonen O, Vanharanta H, et al. Association of atherosclerosis with low back pain and the degree of disc degeneration. Spine (Phila Pa 1976). 1999 Oct 15;24(20):2080-4.[Abstract]
60. Schwarzer AC, Aprill CN, Derby R, et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine. 1995;20:1878-83.
61. Vanharanta H. The intervertebral disc: a biologically active tissue challenging therapy. Ann Med. 1994 Dec;26(6):395-9.[Abstract]
62. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014 Jan;14(1):180-91.[Abstract]
63. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. Dec 2020 [internet publication].[Full Text]
64. Expert Panel on Neurological Imaging, Hutchins TA, Peckham M, et al. ACR Appropriateness Criteria® Low Back Pain: 2021 Update. J Am Coll Radiol. 2021 Nov;18(11s):S361-S379.[Abstract][Full Text]
65. Braithwaite I, White J, Saifuddin A, et al. Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography. Eur Spine J. 1998;7(5):363-8.[Abstract]
66. Modic MT, Masaryk TJ, Ross JS, et al. Imaging of degenerative disk disease. Radiology. 1988 Jul;168(1):177-86.[Abstract]
67. Boden SD, Davis DO, Dina TS, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8.[Abstract]
68. Borenstein DG, O'Mara JW Jr, Boden SD, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study. J Bone Joint Surg Am. 2001 Sep;83-A(9):1306-11.[Abstract]
69. Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14;331(2):69-73.[Abstract][Full Text]
70. Jarvik JJ, Hollingworth W, Heagerty P, et al. The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data. Spine. 2001 May 15;26(10):1158-66.[Abstract]
71. Jarvik JG, Hollingworth W, Heagerty PJ, et al. Three-year incidence of low back pain in an initially asymptomatic cohort: Clinical and imaging risk factors. Spine. 2005 Jul 1;30(13):1541-8; discussion 1549.[Abstract]
72. Nachemson A. The load on lumbar disks in different positions of the body. Clin Orthop Relat Res. 1966 Mar-Apr;45:107-22.[Abstract]
73. Modic MT, Steinberg PM, Ross JS, et al. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology. 1988 Jan;166(1 Pt 1):193-9.[Abstract]
74. Kuisma M, Karppinen J, Niinimaki J, et al. A three-year follow-up of lumbar spine endplate (Modic) changes. Spine (Phila Pa 1976). 2006 Jul 1;31(15):1714-8.[Abstract]
75. Kjaer P, Korsholm L, Bendix T, et al. Modic changes and their associations with clinical findings. Eur Spine J. 2006 Sep;15(9):1312-9.[Abstract][Full Text]
76. Kjaer P, Leboeuf-Yde C, Sorensen JS, et al. An epidemiologic study of MRI and low back pain in 13-year-old children. Spine (Phila Pa 1976). 2005 Apr 1;30(7):798-806.[Abstract]
77. Fayad F, Lefevre-Colau MM, Rannou F, et al. Relation of inflammatory modic changes to intradiscal steroid injection outcome in chronic low back pain. Eur Spine J. 2007 Jul;16(7):925-31.[Abstract][Full Text]
78. Vital JM, Gille O, Pointillart V, et al. Course of Modic 1 six months after lumbar posterior osteosynthesis. Spine (Phila Pa 1976). 2003 Apr 1;28(7):715-20; discussion 721.[Abstract]
79. Arana E, Kovacs FM, Royuela A, et al. Modic changes and associated features in southern European chronic back pain patients. Spine J. 2011 May;11(5):402-11.[Abstract]
80. Aprill C, Bogduk N. High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging. Br J Radiol. 1992 May;65(773):361-9.[Abstract]
81. Wolfer LR, Derby R, Lee JE, et al. Systematic review of lumbar provocation discography in asymptomatic subjects with a meta analysis of false-positive rates. Pain Physician. 2008 Jul-Aug;11(4):513-38.[Abstract]
82. Ricketson R, Simmons JW, Hauser BO. The prolapsed intervertebral disc: The high- intensity zone with discography correlation. Spine (Phila Pa 1976). 1996 Dec 1;21(23):2758-62.[Abstract]
83. Schellhas KP, Pollei SR, Gundry CR, et al. Lumbar disc high-intensity zone. Correlation of magnetic resonance imaging and discography. Spine (Phila Pa 1976). 1996 Jan 1;21(1):79-86.[Abstract]
84. Yu SW, Haughton VM, Sether LA, et al. Comparison of MR and diskography in detecting radial tears of the anulus: a postmortem study. AJNR Am J Neuroradiol. 1989 Sep-Oct;10(5):1077-81.[Abstract]
85. Pfirrmann CW, Metzdorf A, Zanetti M, et al. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976). 2001 Sep 1;26(17):1873-8.[Abstract]
86. Weishaupt D, Zanetti M, Hodler J, et al. Painful lumbar disk derangement: relevance of endplate abnormalities at MR imaging. Radiology. 2001 Feb;218(2):420-7.[Abstract]
87. Bogduk N. Provocation discography: Lumbar disc stimulation. In: ISIS, ed. Practice guidelines for spinal diagnostic and treatment procedures. Seattle, WA: International Spine Intervention Society;2004:20-46.
88. Saboeiro GR. Lumbar discography. Radiol Clin North Am. 2009 May;47(3):421-33.[Abstract]
89. Moore RJ, Crotti TN, Osti OL, et al. Osteoarthrosis of the facet joints resulting from anular rim lesions. Spine (Phila Pa 1976). 1999 Mar 15;24(6):519-25.[Abstract]
90. Jaikumar S, Kim DH, Kam AC. History of minimally invasive spine surgery. Neurosurgery. 2002 Nov;51(5 Suppl):S1-14.[Abstract]
91. Carragee EJ, Lincoln T, Parmar VS, et al. A gold standard evaluation of the "discogenic pain" diagnosis as determined by provocative discography. Spine. 2006 Aug 15;31(18):2115-23.[Abstract]
92. Modic MT, Steinberg PM, Ross JS, et al. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology. 1988 Jan;166(1 Pt 1):193-9.[Abstract]
93. Pfirrmann CW, Metzdorf A, Zanetti M, et al. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976). 2001 Sep 1;26(17):1873-8.[Abstract]
94. Pathria M, Sartoris DJ, Resnick D. Osteoarthritis of the facet joints: accuracy of oblique radiographic assessment. Radiology. 1987 Jul;164(1):227-30.[Abstract]
95. Rajasekharan S, Venkatadass K, Naresh Babu J, et al. Pharmacological enhancement of disc diffusion and differentiation of healthy, ageing and degenerate discs. Eur Spine J. 2008 May;17(5):626-43.[Abstract][Full Text]
96. Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop Relat Res. 1982 May;(165):110-23.[Abstract]
97. Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009 May 1;34(10):1066-77.[Abstract]
98. Vroomen PC, de Krom MC, Knottnerus JA. Predicting the outcome of sciatica at short-term follow-up. Br J Gen Pract. 2002 Feb;52(475):119-23.[Abstract][Full Text]
99. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006 Jun 17;332(7555):1430-4.[Abstract][Full Text]
100. Jorge LL, Feres CC, Teles VE. Topical preparations for pain relief: efficacy and patient adherence. J Pain Res. 2010 Dec 20;4:11-24.[Abstract][Full Text]
101. Anand P, Bley K. Topical capsaicin for pain management: therapeutic potential and mechanisms of action of the new high-concentration capsaicin 8% patch. Br J Anaesth. 2011 Oct;107(4):490-502.[Abstract][Full Text]
102. Derry S, Moore RA, Gaskell H, et al. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database Syst Rev. 2015;(6):CD007402.[Abstract][Full Text]
103. Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):505-14.[Abstract][Full Text]
104. van der Gaag WH, Roelofs PD, Enthoven WT, et al. Non-steroidal anti-inflammatory drugs for acute low back pain. Cochrane Database Syst Rev. 2020 Apr 16;4:CD013581.[Abstract][Full Text]
105. Roelofs PD, Deyo RA, Koes BW, et al. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD000396.[Abstract][Full Text]
106. Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018 Mar 6;319(9):872-82.[Abstract][Full Text]
107. van Tulder MW, Touray T, Fulan AD, et al. Muscle relaxants for nonspecific low back pain. Cochrane Database Syst Rev. 2003;(2):CD004252.[Abstract][Full Text]
108. Staiger TO, Gaster B, Sullivan MD, et al. Systematic review of antidepressants in the treatment of chronic low back pain. Spine (Phila Pa 1976). 2003 Nov 15;28(22):2540-5.[Abstract]
109. Yildirim K, Deniz O, Gureser G, et al. Gabapentin monotherapy in patients with chronic radiculopathy: the efficacy and impact on life quality. J Back Musculoskelet Rehabil. 2009;22(1):17-20.[Abstract]
110. Gilron I. Gabapentin and pregabalin for chronic neuropathic and early postsurgical pain: current evidence and future directions. Curr Opin Anaesthesiol. 2007 Oct;20(5):456-72.[Abstract]
111. Enke O, New HA, New CH, et al. Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis. CMAJ. 2018 Jul 3;190(26):E786-93. [Abstract][Full Text]
112. Hagen KB, Jamtvedt G, Hilde G, et al. The updated Cochrane review of bed rest for low back pain and sciatica. Spine (Phila Pa 1976). 2005 Mar 1;30(5):542-6.[Abstract]
113. Hayden JA, van Tulder MW, Malmivaara A, et al. Exercise therapy for the treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD000335.[Abstract][Full Text]
114. Heymans MW, van Tulder MW, Esmail R, et al. Back schools for nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine (Phila Pa 1976). 2005 Oct 1;30(19):2153-63.[Abstract]
115. Heymans MW, de Vet HC, Bongers PM, et al. The effectiveness of high-intensity versus low-intensity back schools in an occupational setting: a pragmatic randomized controlled trial. Spine (Phila Pa 1976). 2006 May 1;31(10):1075-82.[Abstract]
116. Dickerman RD, Zigler JE. Disocgenic back pain. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine. 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:319-30.
117. Clare HA, Adams R, Maher CG. A systematic review of efficacy of McKenzie therapy for spinal pain. Aust J Physiother. 2004;50(4):209-16.[Abstract][Full Text]
118. May S, Donelson R. Evidence-informed management of chronic low back pain with the McKenzie method. Spine J. 2008 Jan-Feb;8(1):134-41.[Abstract]
119. Cherkin DC, Deyo RA, Battié M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998 Oct 8;339(15):1021-9.[Abstract][Full Text]
120. Rubinstein SM, Terwee CB, Assendelft WJ, et al. Spinal manipulative therapy for acute low-back pain. Cochrane Database Syst Rev. 2012 Sep 12;(9):CD008880.[Abstract][Full Text]
121. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):492-504.[Abstract][Full Text]
122. Hurley DA, McDonough SM, Dempster M, et al. A randomized clinical trial of manipulative therapy and interferential therapy for acute low back pain. Spine (Phila Pa 1976). 2004 Oct 15;29(20):2207-16.[Abstract]
123. Jellema P, van Tulder MW, van Poppel MN, et al. Lumbar supports for prevention and treatment of low back pain: a systematic review within the framework of the Cochrane Back Review Group. Spine. 2001 Feb 15;26(4):377-86.[Abstract]
124. Luijsterburg PA, Verhagen AP, Ostelo RW, et al. Physical therapy plus general practitioners' care versus general practitioners' care alone for sciatica: a randomised clinical trial with a 12-month follow-up. Eur Spine J. 2008 Apr;17(4):509-17.[Abstract][Full Text]
125. Luijsterburg PA, Verhagen AP, Ostelo RW, et al. Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Eur Spin J. 2007 Jul;16(7):881-99.[Abstract][Full Text]
126. Saper RB, Lemaster C, Delitto A, et al. Yoga, physical therapy, or education for chronic low back pain: a randomized noninferiority trial. Ann Intern Med. 2017 Jul 18;167(2):85-94.[Abstract]
127. Parr AT, Manchikanti L, Hameed H, et al. Caudal epidural injections in the management of chronic low back pain: a systematic appraisal of the literature. Pain Physician. 2012 May-Jun;15(3):E159-98.[Abstract]
128. Benyamin RM, Manchikanti L, Parr AT, et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician. 2012 Jul-Aug;15(4):E363-404.[Abstract]
129. Benoist M, Boulu P, Hayem G. Epidural steroid injections in the management of low-back pain with radiculopathy: an update of their efficacy and safety. Eur Spine J. 2012 Feb;21(2):204-13.[Abstract]
130. Bicket MC, Horowitz JM, Benzon HT, et al. Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials. Spine J. 2015 Feb 1;15(2):348-62.[Abstract]
131. Chou R, Hashimoto R, Friedly J, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med. 2015 Sep 1;163(5):373-81.[Abstract]
132. Manchikanti L, Benyamin RM, Falco FJ, et al. Do epidural injections provide short- and long-term relief for lumbar disc herniation? a systematic review. Clin Orthop Relat Res. 2015 Jun;473(6):1940-56.[Abstract][Full Text]
133. Spijker-Huiges A, Vermeulen K, Winters JC, et al. Costs and cost-effectiveness of epidural steroids for acute lumbosacral radicular syndrome in general practice: an economic evaluation alongside a pragmatic randomized control trial. Spine (Phila Pa 1976). 2014 Nov 15;39(24):2007-12.[Abstract]
134. Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2020 Apr 9;4:CD013577.[Abstract][Full Text]
135. Armon C, Argoff CE, Samuels J, et al. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007 Mar 6;68(10):723-9.[Abstract][Full Text]
136. Cohen SP, Hanling S, Bicket MC, et al. Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. BMJ. 2015 Apr 16;350:h1748.[Abstract][Full Text]
137. Kainer MA, Reagan DR, Nguyen DB, et al; Tennessee Fungal Meningitis Investigation Team. Fungal infections associated with contaminated methylprednisolone in Tennessee. N Engl J Med. 2012 Dec 6;367(23):2194-203.[Abstract][Full Text]
138. Getting It Right First Time. Spinal surgery report may bring benefits for tens of thousands of back pain patients. Jan 2019 [internet publication].[Full Text]
139. Leggett LE, Soril LJ, Lorenzetti DL, et al. Radiofrequency ablation for chronic low back pain: a systematic review of randomized controlled trials. Pain Res Manag. 2014 Sep-Oct;19(5):e146-53. [Abstract][Full Text]
140. Juch JNS, Maas ET, Ostelo RWJG, et al. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the Mint randomized clinical trials. JAMA. 2017 Jul 4;318(1):68-81.[Abstract][Full Text]
141. Andersson GB, Shen FH. Operative management of the degenerative disc: posterior and posterolateral procedures. In: Herkowitz HN, Dvorak J, Bell G, et al, eds. The Lumbar Spine. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2004;317-23.
142. Sidhu KS, Herkowitz HN. Spinal instrumentation in the management of degenerative disorders of the lumbar spine. Clin Orthop Rel Res. 1997 Feb;(335):39-53.[Abstract]
143. Fritzell P, Hagg O, Wessberg P, et al. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976). 2001 Dec 1;26(23):2521-32; discussion 2532-4.[Abstract]
144. Rihn JA, Hilibrand AS, Radcliff K, et al. Duration of symptoms resulting from lumbar disc herniation: effect on treatment outcomes: analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am. 2011 Oct 19;93(20):1906-14.[Abstract]
145. Radcliff KE, Rihn J, Hilibrand A, et al. Does the duration of symptoms in patients with spinal stenosis and degenerative spondylolisthesis affect outcomes?: analysis of the Spine Outcomes Research Trial. Spine (Phila Pa 1976). 2011 Dec 1;36(25):2197-210.[Abstract]
146. Drazin D, Shirzadi A, Jeswani S, et al. Direct surgical repair of spondylolysis in athletes: indications, techniques, and outcomes. Neurosurg Focus. 2011;31:E9.[Abstract][Full Text]
147. Waddell G, McCulloch JA, Kummel E, et al. Nonorganic physical signs in low-back pain. Spine (Phila Pa 1976). 1980 Mar-Apr;5(2):117-25.[Abstract]
148. Main CJ, Waddell G. Behavioral responses to examination. A reappraisal of the interpretation of "nonorganic signs". Spine (Phila Pa 1976). 1998 Nov 1;23(21):2367-71.[Abstract]
149. Hanley EN Jr, David SM. Lumbar arthrodesis for the treatment of back pain. J Bone Joint Surg Am. 1999 May;81(5):716-30.[Abstract]
150. Kishen TJ, Diwan AD. Fusion versus disk replacement for degenerative conditions of the lumbar and cervical spine: quid est testimonium? Orthop Clin North Am. 2010 Apr;41(2):167-81.[Abstract]
151. Fritzell P, Hägg O, Wessberg P, et al. Chronic low back pain and fusion: a comparison of three surgical techniques: a prospective randomized study from the Swedish lumbar spine study group. Spine (Phila Pa 1976). 2002 Jun 1;27(11):1131-41.[Abstract]
152. Lee GW, Lee SM, Ahn MW, et al. Comparison of posterolateral lumbar fusion and posterior lumbar interbody fusion for patients younger than 60 years with isthmic spondylolisthesis. Spine (Phila Pa 1976). 2014 Nov 15;39(24):E1475-80.[Abstract]
153. Liu XY, Qiu GX, Weng XS, et al. What is the optimum fusion technique for adult spondylolisthesis-PLIF or PLF or PLIF plus PLF? A meta-analysis from 17 comparative studies. Spine (Phila Pa 1976). 2014 Oct 15;39(22):1887-98.[Abstract]
154. Fekete TF, Porchet F. Overview of disc arthroplasty-past, present and future. Acta Neurochir (Wien). 2010 Mar;152(3):393-404.[Abstract]
155. Lin EL, Wang JC. Total disk arthroplasty. J Am Acad Orthop Surg. 2006 Dec;14(13):705-14.[Abstract]
156. Zigler JE. Clinical results with ProDisc: European experience and U.S. investigation device exemption study. Spine. 2003 Oct 15;28(20):S163-6.[Abstract]
157. Delamarter RB, Fribourg DM, Kanim LE, et al. ProDisc artificial total lumbar disc replacement: introduction and early results from the United States clinical trial. Spine. 2003 Oct 15;28(20):S167-75.[Abstract]
158. Putzier M, Funk JF, Schneider SV, et al. Charité total disc replacement -clinical and radiographical results after an average follow-up of 17 years. Eur Spine J. 2006 Feb;15(2):183-95.[Abstract]
159. Resnick DK, Watters WC. Lumbar disc arthroplasty: a critical review. Clin Neurosurg. 2007;54:83-7.[Abstract]
160. Jacobs WC, van der Gaag NA, Kruyt MC, et al. Total disc replacement for chronic discogenic low back pain: a Cochrane review. Spine (Phila Pa 1976). 2013 Jan 1;38(1):24-36.[Abstract]
161. Jacobs W, Van der Gaag NA, Tuschel A, et al. Total disc replacement for chronic back pain in the presence of disc degeneration. Cochrane Database Syst Rev. 2012 Sep 12;(9):CD008326.[Abstract][Full Text]
162. Guzmán J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ. 2001 Jun 23;322(7301):1511-6.[Abstract][Full Text]
163. Brox JL, Sorensen R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ. 2001;26:377-86.
164. Waddell G, Burton AK, Kendall NAS. Vocational rehabilitation: what works, for whom, and when? [internet publication].[Full Text]
165. Verbeek J, Martimo KP, Karppinen J, et al. Manual material handling advice and assistive devices for preventing and treating back pain in workers: a Cochrane Systematic Review. Occup Environ Med. 2012 Jan;69(1):79-80.[Abstract]
166. MacVicar J, King W, Landers MH, et al. The effectiveness of lumbar transforaminal injection of steroids: a comprehensive review with systematic analysis of the published data. Pain Med. 2013 Jan;14(1):14-28.[Abstract][Full Text]
167. Falco FJ, Manchikanti L, Datta S, et al. An update of the systematic assessment of the diagnostic accuracy of lumbar facet joint nerve blocks. Pain Physician. 2012 Nov-Dec;15(6):E869-907.[Abstract]
168. Phillips FM, Slosar PJ, Youssef JA, et al. Lumbar spine fusion for chronic low back pain due to degenerative disc disease: a systematic review. Spine (Phila Pa 1976). 2013 Apr 1;38(7):E409-22.[Abstract]
169. Markman JD, Bolash RB, McAlindon TE, et al. Tanezumab for chronic low back pain: a randomized, double-blind, placebo- and active-controlled, phase 3 study of efficacy and safety. Pain. 2020 Sep 1;161(9):2068-2078.[Abstract][Full Text]
170. Kivitz AJ, Gimbel JS, Bramson C, et al. Efficacy and safety of tanezumab versus naproxen in the treatment of chronic low back pain. Pain. 2013 Jul;154(7):1009-21.[Abstract]
171. Dowell D, Ragan KR, Jones CM, et al. Prescribing Opioids for Pain - The New CDC Clinical Practice Guideline. N Engl J Med. 2022 Dec 1;387(22):2011-2013.[Abstract][Full Text]
172. Pengel LH, Herbert RD, Maher CG, et al. Acute low back pain: systematic review of its prognosis. BMJ. 2003 Aug 9;327(7410):323.[Abstract][Full Text]
173. DeBerard MS, Masters KS, Colledge AL, et al. Outcomes of posterolateral lumbar fusion in Utah patients receiving workers' compensation: A retrospective cohort study. Spine (Phila Pa 1976). 2001 Apr 1;26(7):738-46; discussion 747. [Abstract]
174. Franklin GM, Haug J, Heyer NJ, et al. Outcome of lumbar fusion in Washington State workers' compensation. Spine (Phila Pa 1976). 1994 Sep 1;19(17):1897-903; discussion 1904.[Abstract]
175. LaCaille RA, DeBerard MS, Masters KS, et al. Presurgical biopsychosocial factors predict multidimensional patient: outcomes of interbody cage lumbar fusion. Spine J. 2005 Jan-Feb;5(1):71-8.[Abstract]
176. Gibson JN, Grant IC, Waddell G. The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis. Spine (Phila Pa 1976). 1999 Sep 1;24(17):1820-32.[Abstract]
177. Mirza SK, Deyo RA. Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine. 2007 Apr 1;32(7):816-23.[Abstract]
178. Iwamoto J, Sato Y, Takeda T, et al. The return to sports activity after conservative or surgical treatment in athletes with lumbar disc herniation. Am J Phys Med Rehabil. 2010 Dec;89(12):1030-5.[Abstract]
179. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006 Nov 22;296(20):2441-50.[Abstract][Full Text]
180. Gillet P. The fate of the adjacent motion segments after lumbar fusion. J Spinal Disord Tech. 2003 Aug;16(4):338-45.[Abstract]
181. Okuda S, Iwasaki M, Miyauchi A, et al. Risk factors for adjacent segment degeneration after PLIF. Spine. 2004 Jul 15;29(14):1535-40.[Abstract]
182. Park P, Garton HJ, Gala VC, et al. Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine. 2004 Sep 1;29(17):1938-44.[Abstract]
183. Levin DA, Hale JJ, Bendo JA. Adjacent segment degeneration following spinal fusion for degenerative disc disease. Bull NYU Hosp Jt Dis. 2007;65(1):29-36.[Abstract]
184. Harrop JS, Youssef JA, Maltenfort M, et al. Lumbar adjacent segment degeneration and disease after arthrodesis and total disc arthroplasty. Spine. 2008 Jul 1;33(15):1701-7.[Abstract]
185. Ghiselli G, Wang JC, Bhatia NN, et al. Adjacent segment degeneration in the lumbar spine. J Bone Joint Surg Am. 2004 Jul;86-A(7):1497-503.[Abstract]
186. Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006 Mar;15(suppl 2):S192-300.[Abstract]
187. Burton AK, Balagué F, Cardon G, et al. Chapter 2. European guidelines for prevention in low back pain: November 2004. Eur Spine J. 2006 Mar;15 Suppl 2:S136-68.[Abstract]