4. Disc Derangement Flashcards
What are the 3 main things that can happen to a disc?
Degeneration
Derangement
Herniation
What are the 5 possible pathoanatomical diagnoses that can cause pain in the lumbar spine?
- disc
- facet
- sprain
- strain
- fracture
Approximately what percentage of lumbar pain has a discogenic origin?
40%
In a disc derangement, where do tears usually occur first?
Inner laminae, where there is no pain innervation, and usually in the posterior disc.
Why are tears of the lamina more common in the posterior disc?
Due to flexion loads of everyday life
Describe the innervation of a disc
- 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
What happens to the nucleus pulposis in disc derangements?
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.
The direction of herniation is _______ the direction of the load.
Opposite
Describe the features of back pain associated with disc derangement
- 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
What is the most common cause of lumbar disc derangement?
Repetitive microtrauma usually in flexion
Can also be caused by trauma such as heavy lifting
Why are symptoms of disc derangement worse first thing in the morning?
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
Why does sitting and standing up from sitting aggravate pain of disc derangement?
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.
What is often the primary complaint in the patient history that would indicate disc derangement?
Sitting intolerance that rapidly aggravates LBP and may be relieved by standing
What is Dejerine’s triad?
Straining with:
- BM
- coughing
- sneezing
Dejerine’s triad is indicative of what LBP cause?
Disc derangement
Patients with disc derangement with have load sensitivity patterns. Describe them.
- 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
Describe the referred pain associated with disc derangement
- 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
How do you distinguish between facet and disc referral pain based on their patterns?
You can’t because they overlap too much
What is the key clinical predictor of discogenic pain?
Pain centralization of symptoms
- it is the only exam finding that is supported by clinical evidence
What is pain centralization?
Territory of pain is reduced and moves away from the leg and towards the spine.
How is pain centralized?
With repetitive (10x) or sustained (30 sec) end range loading of lumbar spine in directional preference with or without weight bearing
What is the most common directional preference that induces pain centralization in disc derangement?
Extension (60-70% of the time), although multiple directions need to be explored
If centralization of pain does not occur, what other information can be obtained from the process of trying to induce pain centralization?
Directional preference that decreases the intensity of the pain (not territory) or improve AROM
What is the most important antalgic posture to indicate a deficiency derangement?
Lateral pelvic shift
- correction of this is an early treatment goal because it can cause compensatory injury to other tissues
Describe the AROM found on physical exam with a disc derangement
Painful and reduced in flexion > extension (unless it is the uncommon anterior disc derangement)
What is Minor’s sign and when would you likely see it?
Antalgic positioning when getting out of a chair or when moving into or out of flexion as seen in posterior disc derangements
What would you expect to happen with a valsalva maneuver in patient with acute disc derangement?
It might induce back pain, but not always, because in increases intradiscal pressure which can push nucleus pulposis into the tears
What would you expect with spinal compression tests in acute disc derangement?
May be painful
Ex: active double leg raise, 4 quadrant test, hip flexor muscle testing
What would the neurological exam look like with disc derangement?
Normal SMRs
What would you expect with nerve tension tests in disc derangement?
Negative
- tight hamstrings can cause posterior pelvic tilt -> flexion, which could aggravate back pain so SLR might cause pain but it is not neurogenic
What findings are common with static palpation in a disc derangement?
- Interspinal/midline tenderness that can be provoked by tapping adjacent spinous processes
- no step deformity
- secondary MFTP’s in paraspinals may be present
What should be the goal of motion palpation and manipulation in disc derangement?
Look for a level and vector that causes pain centralization and adjust there instead of the painful restricted joint
Disc derangement diagnosis can be made with reasonable level of certainty if the patient presents with what 3 things?
- 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
What ancillary studies are indicated in disc derangement?
Usually none, unless surgery is being considered, because they usually are normal and do not change treatment procedures.
What advanced imaging is capable to showing annular tears? The presence of what, makes the MRI positive for tears
MRI, by presence of high intensity zone (HIZ)
What is considered the gold standard advanced imaging for imaging disc?
Discography, although its accuracy is controversial
In order for a discography to be positive for a disc derangement, what two things must happen?
The test must reproduce the patients characteristic pain and the dye must demonstrate internal derangement by not remaining contained in the nucleus pulposis
What role does CMT have in the management of disc derangements?
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
What role does STM have in the management of disc derangement?
Hamstrings may be tight and need stretching
What role does home exercises have in the management of disc derangement?
- 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
What role does behavior modification have in management of disc derangement?
- 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
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?
After 3-6 months of conservative care, if patient is not improving, referral for epidural injections is the next step
Other than conservative treatment and epidural injections, what are other treatment options for disc derangement?
- Spinal fusion, although effectiveness is controversial, it is a common surgery
- intradiscal electrothermal therapy (IDET)
- percutaneous intradiscal radiofrequency thermocoagulation (PIRFT)
