Lumbosacral Discogenic Pain Syndrome (LSPS)

Lumbosacral discogenic pain syndrome (LSPS) is a frequent cause of low back pain and originates from various lumbar structures, particularly facet joints, spinal muscles, and ligaments. Low back pain represents a major clinical and socioeconomic challenge in healthcare worldwide.

Anatomy

The intervertebral disc is located between two vertebrae and consists of a semifluid nucleus pulposus surrounded by a fibrous annulus fibrosus. The nucleus contains 70–80% water, but this decreases with age². The annulus is made up of 10–20 concentric fibrous lamellae with alternating fiber orientation.

The main function of the disc is to allow motion between vertebrae and to distribute load from one vertebra to the next².

Etiology

Several factors predispose individuals to LSPS:

• Familial predisposition

• Degenerative disc changes, often related to older age, male sex, and smoking

• Occupational exposure (especially prolonged sitting and vibration, e.g., professional drivers)

• Repetitive strain and physically demanding work, which can accelerate degeneration and increase risk of annular tears³

Epidemiology

Lumbar disc disease is highly prevalent and often asymptomatic. Disc changes are found in 25% of individuals under 60 years of age and in more than 50% of those over 60. A disc change in a patient with nonspecific low back pain does not necessarily indicate causality. Correlation with symptoms such as myotomal weakness or dermatomal sensory deficits, and with outcomes from interventions such as epidural injections or facet joint blocks, is crucial to determine clinical relevance⁴.

Clinical Assessment

History

Discogenic pain is typically aggravated by sitting, forward flexion, coughing, or sneezing, due to increased intradiscal pressure².

Clinical examination

There is no single test that reliably identifies discogenic pain. However, some findings may provide indications, for example:

• Biphasic return from flexion, suggestive of disc involvement⁵

• Palpation over the spinous processes reproducing pain⁵

• Overpressure test: The therapist applies downward pressure on the patient’s shoulders while seated; reproduction of pain may suggest discogenic involvement. Flexion may provoke anterior disc pain, while extension may reproduce posterior disc pain.

These tests are not validated, and imaging (MRI/CT) is required to confirm the diagnosis²⁵⁶.

Differential Diagnoses²

• Lumbosacral facet joint syndrome

• Lumbosacral radiculopathy

• Lumbosacral spondylolisthesis

• Lumbosacral spondylolysis

• Lumbar muscle strain or ligament injury¹

A thorough medical history, clinical examination, and relevant imaging are required for an accurate diagnosis.

Physiotherapy Management

For acute or subacute disc injuries, conservative treatment is the first-line recommendation. The primary goals are to reduce muscle tension, improve segmental mobility, and correct mechanical dysfunction, while also teaching the patient appropriate home exercises². Later, a lumbar stabilization program can be introduced².

Kallewaard et al. found no clear evidence that active exercise is superior to other conservative interventions such as rest, traction, heat therapy, or bracing⁵. Ohtori et al. reported that surgical treatment provided significantly better long-term pain outcomes compared to conservative therapy at two-year follow-up⁶. Bronfort et al. demonstrated moderate evidence that spinal manipulation is more effective than mobilization in acute low back pain, while in chronic cases both techniques showed only short-term effects similar to NSAIDs⁷.

Clinical Considerations in Treatment Selection

Given the mixed evidence, there is no definitive standard of care for LSPS. The therapist should therefore remain flexible and tailor treatment based on the patient’s individual response.

Sources:

1. Pathak S, Conermann T. Lumbosacral discogenic syndrome. 2020 :https://www.ncbi.nlm.nih.gov/books/NBK560537/

2. Windsor R. Lumbosacral Discogenic Pain Syndrome. 2010 http://emedicine.medscape.com/article/94673-overview#a0106 Level of evidence: D

3. Singh AD, Pechman K, Zar S. Discogenic Lumbar Pain. : https://now.aapmr.org/discogenic-lumbar-pain/

4. Radiopedia Lumbar disc disease :https://radiopaedia.org/articles/lumbar-disc-disease

5. Kallewaard JW, et al. 15. Discogenic low back pain. Pain Practice, Volume 10, Issue 6, 2010 560–579.

6. Ohtori S, et al. Surgical Versus Nonsurgical Treatment of Selected Patients With Discogenic Low Back Pain. SPINE Volume 36, Number 5, pp 347–354

7. Bronfort G, et al. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. The Spine Journal 4 (2004) 335–356