Dr. Jeff Buchalter Discusses Discogenic Pain
Hi my name is Dr. Jeff Buchalter, I am a board-certified anesthesiologist and board-certified pain medicine physician. I’m an associated clinical professor with the Florida State University, College of Medicine and the Chairman of The Gulf Coast Pain Institute. Today, we’re going to be talking about discogenic pain.
What is Discogenic Pain?
Discogenic Pain is pain that derives from inside the disc itself. As we know there are many sources of pain within the spine that can come from muscle-related injuries or joint-related injuries, but specific pain coming from the disc is due to internal injuries within the disc.
What we have found through literature and research is that inside the disc there are a number of nerve endings that can be injured, irritated resulting in swelling and chronic inflammation.
Treatment Methods for Discogenic Pain
Now there are a number of treatments that can be utilized to treat discogenic pain. We’re going to talk about a few of those treatments in specific and some in general terms. The treatments that we utilize in our practice include conservative based therapy, which includes medication base management and physical therapy base care. In the chiropractic division that we have, we have something called spinal decompression care. Spinal decompression is a computer assisted decompression mechanism for actually stretching the disc, thereby increasing blood flow into the disc allowing the healing process to occur.
In patients that don’t respond to the most conservative methods, we have a couple of innovational based techniques we can use as well one is called a retrodiscal transforaminal injection, which injects steroid behind the disc with the level of the tear. In other patients, we actually do a procedure called discography, which is a procedure where we place needles specifically into the disc where you’re concerned with and under pressure, we monitor a dye spread within the disc and at the same time discuss with the patient the type of sensations they’re feeling.
That combination along with what’s called a CT scan, we can identify where exactly the disc is torn, if that disc tear is symptomatic and that will lead us to other treatment remedies. The more aggressive or more invasive treatments that have been utilized in the past include intradiscal radiofrequency type procedures, in which we would place a catheter within the disc itself and heat up the tear hoping to seal that tear.
There are other treatments that can be done including intradiscal-based procedures and now with the intradiscal biologics coming along the course of treatment may include stem-cell related therapies within the disc itself to help the disc regenerate. Ultimately the course of treatment includes the most conservative to the most invasive treatments and if the patient does not respond, we have seen patients go on to require total disc replacement or spinal fusion type interventions.
When we talk about the injective therapy type regiments for discogenic pain one thing that is actually coming into the scope now is a procedure in which we can place a curve needle into the back of the actual disc itself. It’s a more specific radiofrequency procedure in which an 80-degree center grade lesion is placed at the level of the actual tear in a more specific fashion this will help in fact seal the tear as I stated and help decrease the ongoing inflammation that occurs when a disc is torn.
So with patients who present with back pain, which is a general symptom there are a whole host of sources that cause back pain. As I stated with patients who have muscular related pain the pain can be centralized, with Discogenic pain the pain does not generally radiant like a sciatic type pain within the back itself and it tends to be much worse with flexing forward rather than bending backward. In fact, the pain tends to be relieved by extension rather than made worse by extension.
The pain is generally diagnosed on physical examination because there is a normal neurological examination and there’s something called a positive dip test, which is a digital intraspinal pressure test in which you place your hand between the spinal processes, and as you have the patient bend forward you put digital pressure and that tends to transmit pressure to the disc itself. It can be an additional indication that the patient may have a discogenic pain generator. Otherwise as oppose to facet mediated pain, which is worse on extension and lateral rotation, as I stated this is worse when patients bend forward, when they’re sitting it is terrible, when they’re laying down supine it is better because you decrease the intradiscal pressure with the laying down position and you increase it with standing up or standing up and bending forward. Those are all indications that may help you delineate between a facet mediate pain issue or a discogenic pain issue.
So that’s generally what we do in our practice from a conservative to an interventional base approach for discogenic pain. If there is more interest in this particular topic a textbook that we rewrote called “Diagnosis, Management, Treatment of Discogenic Pain” which is available can be bought and read. It does have specific treatment base regiments for discogenic pain.