4. Disc Derangement

Question 1

What are the 3 main things that can happen to a disc?

Answer 1

Degeneration
Derangement
Herniation

Question 2

What are the 5 possible pathoanatomical diagnoses that can cause pain in the lumbar spine?

Answer 2

• disc
• facet
• sprain
• strain
• fracture

Question 3

Approximately what percentage of lumbar pain has a discogenic origin?

Answer 3

40%

Question 4

In a disc derangement, where do tears usually occur first?

Answer 4

Inner laminae, where there is no pain innervation, and usually in the posterior disc.

Question 5

Why are tears of the lamina more common in the posterior disc?

Answer 5

Due to flexion loads of everyday life

Question 6

Describe the innervation of a disc

Answer 6

• Only the outer third has pain receptors so tears in the inner 2/3 may not cause pain
• Previously injured discs can grow pain fibers into the inner rings and therefore start experiencing pain much after the initial injury
• this makes it difficult to predict which deranged disc are causing the pain

Question 7

What happens to the nucleus pulposis in disc derangements?

Answer 7

The tears in the annular fibers can have nucleus pulposis migrate into them. This usually occurs in the posterior direction which is why flexion aggravates a posterior disc derangement.

Question 8

The direction of herniation is _______ the direction of the load.

Answer 8

Opposite

Question 9

Describe the features of back pain associated with disc derangement

Answer 9

• Midline, deep, achy, poorly localized
• can be constant or intermittent and various degrees of severity
• can be stabbing and very severe in the acute phase

Question 10

What is the most common cause of lumbar disc derangement?

Answer 10

Repetitive microtrauma usually in flexion

Can also be caused by trauma such as heavy lifting

Question 11

Why are symptoms of disc derangement worse first thing in the morning?

Answer 11

Because the disc has swollen/taken on water over night and therefore is takes less movement to push the nucleus pulposis into the tears in the annular fibers

Question 12

Why does sitting and standing up from sitting aggravate pain of disc derangement?

Answer 12

Because most common disc derangement is posterior and when sitting or standing up from sitting, the lumbar spine goes into flexion and pushes nucleus pulposis into the posterior tears.

Question 13

What is often the primary complaint in the patient history that would indicate disc derangement?

Answer 13

Sitting intolerance that rapidly aggravates LBP and may be relieved by standing

Question 14

What is Dejerine’s triad?

Answer 14

Straining with:

• BM
• coughing
• sneezing

Question 15

Dejerine’s triad is indicative of what LBP cause?

Answer 15

Disc derangement

Question 16

Patients with disc derangement with have load sensitivity patterns. Describe them.

Answer 16

• Usually flexion aggravates pain but rotation and side bending can also aggravate
• extension can aggravate but only if the annular tears are anterior which is uncommon

Question 17

Describe the referred pain associated with disc derangement

Answer 17

• usually unilateral but can be bilateral
• to the buttock and lower extremity, usually no further than the knee
• referred pain is not as intense as back pain
• non-dermatomal and may be accompanied by paresthesia and vague weakness (normal neuro)
• occurs later in course of condition

Question 18

How do you distinguish between facet and disc referral pain based on their patterns?

Answer 18

You can’t because they overlap too much

Question 19

What is the key clinical predictor of discogenic pain?

Answer 19

Pain centralization of symptoms

• it is the only exam finding that is supported by clinical evidence

Question 20

What is pain centralization?

Answer 20

Territory of pain is reduced and moves away from the leg and towards the spine.

Question 21

How is pain centralized?

Answer 21

With repetitive (10x) or sustained (30 sec) end range loading of lumbar spine in directional preference with or without weight bearing

Question 22

What is the most common directional preference that induces pain centralization in disc derangement?

Answer 22

Extension (60-70% of the time), although multiple directions need to be explored

Question 23

If centralization of pain does not occur, what other information can be obtained from the process of trying to induce pain centralization?

Answer 23

Directional preference that decreases the intensity of the pain (not territory) or improve AROM

Question 24

What is the most important antalgic posture to indicate a deficiency derangement?

Answer 24

Lateral pelvic shift

• correction of this is an early treatment goal because it can cause compensatory injury to other tissues

Question 25

Describe the AROM found on physical exam with a disc derangement

Answer 25

Painful and reduced in flexion > extension (unless it is the uncommon anterior disc derangement)

Question 26

What is Minor’s sign and when would you likely see it?

Answer 26

Antalgic positioning when getting out of a chair or when moving into or out of flexion as seen in posterior disc derangements

Question 27

What would you expect to happen with a valsalva maneuver in patient with acute disc derangement?

Answer 27

It might induce back pain, but not always, because in increases intradiscal pressure which can push nucleus pulposis into the tears

Question 28

What would you expect with spinal compression tests in acute disc derangement?

Answer 28

May be painful Ex: active double leg raise, 4 quadrant test, hip flexor muscle testing

Question 29

What would the neurological exam look like with disc derangement?

Answer 29

Normal SMRs

Question 30

What would you expect with nerve tension tests in disc derangement?

Answer 30

Negative * tight hamstrings can cause posterior pelvic tilt -> flexion, which could aggravate back pain so SLR might cause pain but it is not neurogenic

Question 31

What findings are common with static palpation in a disc derangement?

Answer 31

- Interspinal/midline tenderness that can be provoked by tapping adjacent spinous processes - no step deformity - secondary MFTP’s in paraspinals may be present

Question 32

What should be the goal of motion palpation and manipulation in disc derangement?

Answer 32

Look for a level and vector that causes pain centralization and adjust there instead of the painful restricted joint

Question 33

Disc derangement diagnosis can be made with reasonable level of certainty if the patient presents with what 3 things?

Answer 33

- LBP with or without referred buttock, thigh or leg pain that worsens with flexion - LBP and referred lower extremity pain that can be centralized with sustained positioning, manual procedures or repetitive movements - lateral trunk shift, limited lumbar mobility and reduced lumbar lordosis

Question 34

What ancillary studies are indicated in disc derangement?

Answer 34

Usually none, unless surgery is being considered, because they usually are normal and do not change treatment procedures.

Question 35

What advanced imaging is capable to showing annular tears? The presence of what, makes the MRI positive for tears

Answer 35

MRI, by presence of high intensity zone (HIZ)

Question 36

What is considered the gold standard advanced imaging for imaging disc?

Answer 36

Discography, although its accuracy is controversial

Question 37

In order for a discography to be positive for a disc derangement, what two things must happen?

Answer 37

The test must reproduce the patients characteristic pain and the dye must demonstrate internal derangement by not remaining contained in the nucleus pulposis

Question 38

What role does CMT have in the management of disc derangements?

Answer 38

Manipulation should be done into pain centralizing direction, which is usually extension (because posterior derangement is most common) during acute phase. Flexion and distraction is also an option, with emphasis on distraction and limited flexion

Question 39

What role does STM have in the management of disc derangement?

Answer 39

Hamstrings may be tight and need stretching

Question 40

What role does home exercises have in the management of disc derangement?

Answer 40

- correct lateral pelvic shift if present - 10 repetitions every waking hour in directional preference can be prescribed for pain control due to its pain centralizing ability - core stabilization can be done but not in acute phase

Question 41

What role does behavior modification have in management of disc derangement?

Answer 41

- Limit flexion loads, especially in the morning when discs are fully hydrated and during acute phase - reduce time sitting due to flexion load, taking regular breaks every 20-30 minutes - use hip hinging, neutral pelvis and abdominal bracing especially when making transition movements

Question 42

If conservative treatment for disc derangement fails, what is then next treatment option? What is the length of time conservative treatment should be tried before making this referral?

Answer 42

After 3-6 months of conservative care, if patient is not improving, referral for epidural injections is the next step

Question 43

Other than conservative treatment and epidural injections, what are other treatment options for disc derangement?

Answer 43

- Spinal fusion, although effectiveness is controversial, it is a common surgery - intradiscal electrothermal therapy (IDET) - percutaneous intradiscal radiofrequency thermocoagulation (PIRFT)