Where is the pain coming from?
What to do about it.
In1934, William Jason Mixter, M.D. and Joseph S Barr, M.D., published a study in the New England Journal of Medicine (1) establishing the the rupture of the intervertebral disc could result in pressure on the related nerves, causing back and leg pain. In this study, it was also suggested that the lumbar disc could be the source of lower back pain without compressing a nerve root.
In
In 1947 Vern Inman, M.D. and JBM Saunders added to the concept of discogenic pain. Their study published in the Journal of Bone and Joint Surgery (2) suggested that discogenic lower back pain was a consequence of “sclerotogenous” referred pain. This term accounts for the diffuse non-specific nature of lower back pain that originates from the disc. Sclerotogenous pain is a referred pain that occurs when there is a sensory irritation to a structure that shares embryological nerve origins.
They further state:
“The annulus fibrosis (the outer portion of the disc) has been shown to possess a rich sensory nerve supply”
“There is now abundant experimental evidence to support the contention that distortion of the annulus fibrosis and related ligamentous structures of the neighboring joint, is in itself the source of pain of a characteristic type which, depending upon the level involved, may be referred to fairly specific areas of the body.”
One of the most prestigious journals concerning the spinal column is entitled Spine, appropriately. The inaugural issue was published in March of 1976 (3). An internationally recognized orthopedic surgeon named Alf Nachemson, M.D., published a detailed review of the literature citing 136 references pertaining to the state of knowledge on the topic of lower back pain. The time, Dr. Nachemson’s article was considered to be the most comprehensive and authoritative review available on the tope of low back pain, and it remains extensively cited in contemporary publications. His article is entitled, “The Lumbar Spine: An Orthopedic Challenge.” He basically concludes that, “The intervertebral disc is most likely the cause of pain.”
He presents 6 lines of reasoning and cites 17 references to support his contention that the disc is the most likely source of lower back pain. Interestingly, one of the studies he cites was completed by Smyth and Wright in 1958 (4). Regarding the work by Smyth and Wright, Dr. Nachemson notes:
“Investigations have been performed in which thin nylon threads were surgically fastened to various structures in and around the nerve root. Three to four weeks after the surgery these structures were irritated by pulling on the threads, but [lower back] pain resembling that which the patient had experienced previously could be registered only from the outer part of the annulus of the disc”
In 1987, the journal Spine published a presentation by Dr. Vert Mooney at the International Society for the Study of the Lumbar spine (5). The title of the address was: “Where is the Pain Coming From?”
In this article Dr. Mooney notes:
“Persistent pain in the back with referred pain to the leg is largely on the basis of abnormalities within the disc.”
“Chemistry of the disc is based on the relationship between mucopolysaccharide production and water content.”
“Mechanical events can be translated into chemical events related to pain.”
“An important aspect of disc nutrition and health is the mechanical aspects of the disc related to fluid mechanics.”
“Mechanical activity has a great deal to do with the exchange of water and oxygen concentration in the disc.”
“The pumping action maintains the nutrition and biomechanical function of the intervertebral disc. Thus, research substantiates the view that unchanging posture, as a result of constant pressure-dependent transfer of liquid. Actually the human intervertebral disc lives because of movement.”
“The fluid of the disc can be changed by mechanical activity, and the fluid content is largely bound to the proteoglycans, especially of the nucleus.”
Dr. Mooney summarizes: “In summary what is the answer to the question of where is the pain coming from in the chronic low-back pain patient? I believe its source, ultimately, is in the disc. Basic studies and clinical experience suggest that mechanical therapy is the most rational approach to relief of this painful condition.”
In 2006 physician researchers form Japan published in the journal Spine the results of a sophisticated immunochemistry study of the sensory innervation of the human lumbar intervertebral disc (6). The article is titled:
“The Degenerated Lumbar Intervertebral Disc is Innervated Primarily by Peptide-Containing Sensory Nerve Fibers in Humans.”
These authors note: “Both inner and outer layers of the degenerated lumbar intervertebral disc are innervated by pain sensory nerve fibers in humans.”
The nerve fibers in the disc, found in this study, “indicates that the disc can be a source of pain sensation.”
How do you treat herniated disc pain.
There is overwhelming evidence that chronic low back pain and pain arising from the nerve roots results from distorted and herniated lumbar discs. Discs are best treated through mechanical means. Passive therapies, medications, injections and even surgeries do not provide mechanisms to restore normal function of injured discs. Surgery is sometimes necessary when the disc disease has progressed past a certain point. Spinal Decompression Therapy along with restorative rehabilitation is the most aggressive mechanical therapy process in existence. This allows for the disc to heal as long as the disease process is not too far advanced. The patient example provided with before and after MRI studies experienced severe low back pain with left leg pain at the time of the October 2005 study. Surgery had been offered to correct the fragment compressing the left S1 nerve root. The patient decided to participate in spinal decompression therapy on the DRX 9000 with rehabilitation. Within 1 month of starting the program, the back and leg pain had reduced by 75%. This patient was treated less than 24 visits over a 2 month period of time. All normal activities were resumed including basketball and golf within six months. There have been no exacerbations of left leg pain in five years. This is confirmed with the repeat MRI showing complete absence of the original disc fragment and improved hydration of the L5/S1 disc.
Commentary:
Arrow A reveals a 10mm herniated disc at L5/S1. This herniation was accompanied with severe low back pain of 6 months duration with severe left leg pain. Arrow B reveals a 40-50% reduction of the size and volume of the disc herniation on this slice. More importantly, this patient has been completely free of the chronic back pain since April of 2006.