Discogenic lumbar pain due to fibrous ring rupture

In most cases, pain in the lumbar spine is caused by damage to the intervertebral discs (IVD), facet joints and/or sacroiliac joints and in these cases is regarded as non-specific lumbar pain (NLP). The pathogenetic basis of axial discogenic pain (DP) is inflammation and ingrowth of nerve fibers into the structure of IVD. DP is confirmed by the positive effect of epidural administration of local anesthetics and glucocorticoids. One of the little-known DP variants is the rupture of a fibrous ring (RFR), which is detected by magnetic resonance imaging in the T2 weighted mode as a zone with high signal intensity in the posterior segments of a fibrous ring. The recommended first-line treatment for NLP is patient's education, tips for maintaining activity, physiotherapy exercises and manual therapy. For the drug therapy nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxers are used. We describe two clinical observations of patients with NLP with RFR. Educational program, Aertal as NSAID and Mydocalm Long as muscle relaxer were effective in terms of therapy. The issues of optimization of treatment of patients with NLP are discussed.

1. DePalma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med. 2011 Feb;12(2):224-33. doi: 10.1111/j.1526-4637.2010.01045.x. Epub 2011 Jan 25.

2. Kim HS, Wu PH, Jang IT. Lumbar Degenerative Disease Part 1: Anatomy and Pathophysiology of Intervertebral Discogenic Pain and Radiofrequency Ablation of Basivertebral and Sinuvertebral Nerve Treatment for Chronic Discogenic Back Pain: A Prospective Case Series and Review of Literature. Int J Mol Sci. 2020 Feb 21;21(4):1483. doi: 10.3390/ijms21041483

3. Adams MA, Dolan P. Intervertebral disc degeneration: evidence for two distinct phenotypes. J Anat. 2012 Dec;221(6):497-506. doi: 10.1111/j.1469-7580.2012.01551.x. Epub 2012 Aug 12.

4. Farley T, Stokke J, Goyal K. Chronic Low Back Pain: History, Symptoms, Pain Mechanisms, and Treatment. Life (Basel). 2024 Jun 27;14(7):812. doi: 10.3390/life14070812

5. Manchikanti L, Soin A, Benyamin RM. An Update of the Systematic Appraisal of the Accuracy and Utility of Discography in Chronic Spinal Pain. Pain Physician. 2018 Mar;21(2):91-110.

6. Isaykin AI, Ivanova MA, Kavelina AV, et al. Discogenic low back pains. RMJ. 2016;24:1599-605 (In Russ.).

7. Parfenov VA, Isaikin AI. Pain in the lumbar region. 2nd ed. Moscow: MEDpress-inform; 2019. 200 p. ISBN 978-5-00030-727-4. EDN PBHSUX (In Russ.).

8. Yakhno NN, Abuzarova GR, Alekseev VV, et al. Pain: A Practical Guide. Moscow: MEDpress-inform; 2022. 416 p. ISBN 978-5-907504-41-7. EDN AVPSUG (In Russ.).

9. Gushcha AO, Sharif S, Zileli M. Acute back pain: Clinical and radiologic diagnosis: WFNS spine committee recommendations. World Neurosurg X. 2024 Feb 9;22:100278. doi: 10.1016/j.wnsx.2024.100278

10. Peng BG. Fundamentals of intervertebral disc degeneration and related discogenic pain. World J Orthop. 2025 Jan 18;16(1):102119. doi: 10.5312/wjo.v16.i1.102119

11. Lorio MP, Beall DP, Calodney AK. Defining the Patient with Lumbar Discogenic Pain: RealWorld Implications for Diagnosis and Effective Clinical Management. J Pers Med. 2023 May 12;13(5):821. doi: 10.3390/jpm13050821

12. Dongfeng R, Hou S, Wu W, et al. The expression of tumor necrosis factor-α and CD68 in high-intensity zone of lumbar intervertebral disc on magnetic resonance image in the patients with low back pain. Spine. 2011;36(6):429-33. doi: 10.1097/BRS.0b013e3181dfce9e

13. Cohen SP, Larkin TM, Barna SA. Lumbar discography: a comprehensive review of outcome studies, diagnostic accuracy, and principles. Reg Anesth Pain Med. 2005 MarApr;30(2):163-83. doi: 10.1016/j.rapm.2004.10.006

14. Cuellar JM, Stauff MP, Herzog RJ. Does provocative discography cause clinically important injury to the lumbar intervertebral disc? A 10-year matched cohort study. Spine J. 2016 Mar;16(3):273-80. doi: 10.1016/j.spinee.2015.06.051. Epub 2015 Jun 29.

15. Engel AJ, Stojanovic MP, Vorobeychik Y, MacVicar J. High-pressure discography may injure discs. Spine J. 2017 Apr;17(4):612-3. doi: 10.1016/j.spinee.2016.06.024

16. Bartynski WS, Agarwal V, Trang H. Enhancing Annular Fissures and High-Intensity Zones: Pain, Internal Derangement, and Anesthetic Response at Provocation Lumbar Discography. AJNR Am J Neuroradiol. 2023 Jan;44(1):95-104. doi: 10.3174/ajnr.A7749. Epub 2022 Dec 22.

17. Jha SC, Higashino K, Sakai T, et al. Clinical significance of high-intensity zone for discogenic low back pain: a review. J Med Invest. 2016;63(1-2):1-7. doi: 10.2152/jmi.63.1

18. Yang L, Li W, Yang Y. The correlation between the lumbar disc MRI high-intensity zone and discogenic low back pain: a systematic review and meta-analysis. J Orthop Surg Res. 2023 Oct 7;18(1):758. doi: 10.1186/s13018-023-04187-5

19. Yang L, He L, Hu H, Li W. Does the highintensity zone of lumbar intervertebral disc at magnetic resonance imaging have diagnostic value for discogenic low back pain? A metaanalysis. BMC Musculoskelet Disord. 2024 Oct 30;25(1):869. doi: 10.1186/s12891-024-07981-2

20. Chen ZY, Ma L, Li T. Imaging of low back pain: comparative role of high intensity zone in diagnosing the discogenic low back pain with evidence-based radiology. Chin Med J. 2009;122(24):3062-5.

21. Carragee E, Paragioudakis SJ, Khurana S, et al. Lumbar high-intensity zone and discography in subjects without low back problems. Spine. 2000;25(23):2987-92. doi: 10.1097/00007632-200012010-00005

22. Mitra D, Cassar-Pullicino VN, Mccall IW. Longitudinal study of high intensity zone on MR of lumbar intervertehral discs. Clin Radiol. 2004;59(11):1002-8. doi: 10.1016/j.crad.2004.06.001

23. Golovacheva VA, Tabeeva GR, Golovacheva AA. Non-specific low back pain: principles and algorithms for successful management of patients in real clinical practice. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2023;15(3):85-94. doi:10.14412/2074-2711-2023-3-85-94 (In Russ.).

24. Golovacheva AA, Golovacheva VA, Parfenov VA. Kinesiotherapy and nonsteroidal anti-inflammatory drugs for nonspecific lumbago. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2022;14(1):89-96. doi: 10.14412/2074-2711-2022-1-89-96 (In Russ.).

25. Mukhametzyanova AK, Akhmedzhanova LT. Management of patients with chronic low back pain in outpatient practice: clinical observation. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2024;16(5):82-6. doi: 10.14412/2074-2711-2024-5-82-86 (In Russ.).

26. Golovacheva VA, Golovacheva AA, Tarshilova AR. Chronic musculoskeletal low back pain: mistakes in patient management and optimization issues. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2024;16(3):103-9. doi: 10.14412/2074-2711-2024-3-103-109 (In Russ.).

27. Dingle JT. The effects of NSAID on the matrix of human articular cartilages. Z Rheumatol. 1999 Jun;58(3):125-9. doi: 10.1007/s003930050161

28. Blot L, Marcelis A, Devogelaer JP, Manicourt DH. Effects of diclofenac, aceclofenac and meloxicam on the metabolism of proteoglycans and hyaluronan in osteoarthritic human cartilage. Br J Pharmacol. 2000 Dec;131(7):1413-21. doi: 10.1038/sj.bjp.0703710

29. Reginster JY, Paul I, Henrotin Y. Comment positionner l’aceclofenac au sein de l’arsenal therapeutique des pathologies osteo-articulaires chroniques? [What is the role of aceclofenac in the therapeutic arsenal against chronic osteoarthritis pathologies?]. Rev Med Liege. 2001 Jul;56(7):484-8 (In French).

30. Iolascon G, Gimenez S, Mogyorosi D. A Review of Aceclofenac: Analgesic and AntiInflammatory Effects on Musculoskeletal Disorders. J Pain Res. 2021 Nov 30;14:3651-63. doi: 10.2147/JPR.S326101

31. Patel PB, Patel TK. Efficacy and safety of aceclofenac in osteoarthritis: a meta-analysis of randomized controlled trials. Eur J Rheumatol. 2017;4(1):11-8. doi: 10.5152/eurjrheum.2017.160080

32. Lapeyre-Mestre M, Grolleau S, Montastruc JL; Association Francaise des Centres Regionaux de Pharmacovigilance (CRPV). Adverse drug reactions associated with the use of NSAIDs: a case/noncase analysis of spontaneous reports from the French pharmacovigilance database 2002–2006. Fundam Clin Pharmacol. 2013 Apr;27(2):223-30. doi: 10.1111/j.1472-8206.2011.00991.x. Epub 2011 Sep 20.

33. Isaikina MA, Isaikin AI, Akhmedzhanova LT. Efficacy and safety of aceclofenac in musculoskeletal diseases. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2023;15(2):114-9. doi: 10.14412/2074-2711-2023-2-114-119 (In Russ.).

34. Castellsague J, Riera-Guardia N, Calingaert B, et al. Individual NSAIDs and upper gastrointestinal complications: a systematic review and meta-analysis of observational studies (the SOS project). Drug Saf. 2012;35(12):1127-46. doi: 10.1007/BF03261999

35. Kukushkin ML, Brylev LV, Laskov VB, et al. Results of a randomized, double-blind, parallel study of the efficacy and safety of tolperisone in patients with acute nonspecific lower back pain. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova = S.S. Korsakov Journal of Neurology and Psychiatry. 2017;117(11):69-78. doi: 10.17116/jnevro201711711169-78 (In Russ.).

36. Zhao L, Manchikanti L, Kaye AD, Abd-Elsayed A. Treatment of Discogenic Low Back Pain: Current Treatment Strategies and Future Options-a Literature Review. Curr Pain Headache Rep. 2019 Nov 9;23(11):86. doi: 10.1007/s11916-019-0821-x

37. De Simone M, Choucha A, Ciaglia E. Discogenic Low Back Pain: Anatomic and Pathophysiologic Characterization, Clinical Evaluation, Biomarkers, AI, and Treatment Options. J Clin Med. 2024 Oct 3;13(19):5915. doi: 10.3390/jcm13195915

38. Ravikanth R. A review of discogenic pain management by interventional techniques. J Craniovertebr Junction Spine. 2020 JanMar;11(1):4-8. doi: 10.4103/jcvjs.JCVJS_19_20. Epub 2020 Apr 4.