Internal disc disruption

Question 1

Definition/Description

Answer 1

Internal disc disruption, first proposed by Crock (1970), has been defined as lumbar spinal pain, with or without referred pain, stemming from an intervertebral disc, caused by internal disruption of the normal structural and biochemical integrity of the symptomatic disk

Crock (1970) postulated that traumatic damage to the vertebral end plate could cause an irritant substance to drain into the spinal canal and/or vertebral body. This could initiate an autoimmune response, causing an internal process of disc degradation, which would lead to annular tearing and irritation of the free nerve endings in the outer third of the annulus fibrosis

Question 2

Epidemiology /Etiology

Answer 2

Internal disc disruption is a subgroup of discogenic pain. The epidemiology/etiology of discogenic pain can be found here andhere.

The prevalence of IDD has been estimated to be 39% (95% CI: 29% to 49%) in ninety-two patients with chronic LBP. In a more recent study, it has been estimated at 42% (95% confidence interval [CI] = 35% to 49%).

Question 3

Characteristics/Clinical Presentation

Answer 3

rock’s (1986) description of IDD included the following features:

Intractable back pain with aggravation of pain and low of spinal motion with any physical exercises

Leg pain

Loss of energy

Marked weight loss
Profound depression

In the IASP’s Classification of Chronic Pain, IDD has the features of:

lumbar spinal pain, with or without referred pain in the lower limb girdle or lower limb;
aggravated by movements that stress the symptomatic disk[1]
According to Sehgal (2000), most of the patient’s experience:

diffuse, dull ache

a deep-seated, burning, lancinating pain in the back

a sensation of a weak, unstable back

referral of pain into the hips and lower limbs is not uncommon.

a varying degree of sitting intolerance
lumbar spine movements are slow, guarded and restricted

a history of lifting trauma precedes the back pain in acute cases

pain and muscle spasm are less dramatic and more nondescript in persistent cases

Question 4

Differential Diagnosis

Answer 4

• Disc herniation:
  In which the herniated nucleus pulposus is capable of generating back/leg pain when it causes a mechanical compression of the nerve-root.
• Ruptured disc:
  Fernston observed that a simple, ruptured disc without herniation can have a clinical presentation similar to herniated nucleus pulposus.
• Degenerative disc disease:
  The intervertebral disc transitions from being asymptomatic to pain generating as a result of degenerative changes. Although altered disc morphology may be asymptomatic, various mechanisms that may give rise to a symptomatic degenerate disc exist

Question 5

Diagnostic Procedures

Answer 5

he criteria for diagnosing IDD from the International Association for the Study of Pain’s Taxonomy Working Group is:

1. Lumbar spinal pain, with or without referred pain in the lower limb girdle or lower limb
2. Aggravated by movements that stress the symptomatic disc
3. Diagnostic criteria for lumbar discogenic pain must be satisfied including either:
   a) Selective anesthetization of the putatively symptomatic intervertebral disc completely relieves accustomed pain, or save that whatever pain persists can be ascribed to some other coexisting source or cause
   b) Provocative discography of the putatively symptomatic disc reproduces the patient’s accustomed pain, but not at least two adjacent discs, and the pain cannot be ascribed to some other source innervated by the same segments as the symptomatic disc
4. CT-discography must demonstrate a grade 3 or greater grade of annular disruption