#9: Intervertebral Discs and Discogenic Pain

In this episode, we discuss the anatomy and physiology of intervertebral discs which help support the spine and provide flexibility. We also discuss pain that can originate from the discs themselves as well as treatments for discogenic pain.

Transcript

SPEAKER_00 0:00

The reason we are doing this is because every day folks are dealing with new pain that doesn't go away.

SPEAKER_01 0:07

Pain's a difficult thing to understand to let people know what kind of options they have.

SPEAKER_00 0:12

Well, welcome back to uh the podcast that Dr. Powers and I, Scott Glazer, uh are producing to help patients and physicians understand the causes of pain and the treatments and the developments, not just the past couple of decades, but the past couple of years. Um and the uh call our podcast Maximize Life Advances in Pain Treatment.

SPEAKER_01 0:40

And if you want to Google it, what's the best way to Google it? Uh the best way to get to us is uh go to our website, painshicago.com. Um we're coming from Pain Specialists of Greater Chicago here in Burr Ridge, Illinois. Uh best way to get there is is is via that. Um we're on Spotify, uh, Apple Podcasts, um YouTube. YouTube. Yep, we're on YouTube. That's where you can see us. That's probably the best way to uh to listen to our podcast because we're able to interact, you see the things that we're doing. You see our nice podcast studio that that we've created.

SPEAKER_00 1:12

And you see the cartoon that you created of us, uh the mountain man and the and the and the baby.

SPEAKER_01 1:19

Oh, they get the cartoon no matter what. So that that comes in all.

SPEAKER_00 1:24

I don't know about that. But uh today uh we wanted to move on in our treatment in our discussion of some of the most common things we that patients suffer. Um and we've been talking about originally he's talking about some of the newer procedures, and we're gonna go back to one of those procedures, intracept today. Um then after we talked about some of the newer procedures to get everybody excited, we started talking about basic causes of pain and basic procedures that we perform, treating the facet joints, because that again is the most one of the most certainly the most common cause of pain and the easiest one for us to treat. Unfortunately, is patients who don't get relief when we treat the facet joints, and they are suffering discogenic pain. Pain from or discogenic pain or vertebragenic pain. They're pain suffering pain in the midline that's from the structures in front of the spinal canal. You want to go on from there?

SPEAKER_01 2:22

Yeah, yeah. So I, you know, a lot of people might just wonder, you know, what is a disc? I've been told I got a disc problem. Um so when someone's referring to a disc uh in the back, they're uh referring to the inter what's called an intervertebral disc, inter meaning between, so between the vertebra. You got you got a bunch of bones in your back uh and cushioning those bones, allowing for spinal flexibility uh are kind of a jelly-like disc that exists uh uh between uh between the spines of the bone. Um you have them between every single vertebra except for right at the tip top uh between your C1 and two. Otherwise, from C23 all the way down to your L5S1, you have discs. Uh in your sacrum, you don't have discs. Those are all those are all fused. Some people have discs. I shouldn't say no one no one does, but uh some some people have discs. So a disc uh consists of two parts. There's one part that's called the annulus, that's the outside of it. It has like concentric rings almost like a tree.

SPEAKER_00 3:23

It's it's cartilaginous.

SPEAKER_01 3:26

Yeah, it's yeah, it's primarily um cartilaginous, and and uh uh yeah, if you were to cut it uh and look at it, you'd see that it has alternating rings to it. So you got fibers that run one way, you got fibers that run the other way. And and why is that provides um stability and it uh it creates a stronger structure. And then inside of that you have something called the nucleus pulposis. Um that's jelly-like. That's in younger people that could be up to like 90% water. So it's a bunch of things. Prote proteoglycans. Right. Yeah, so it holds water. Holds water. And that's important because it can pressurize the joint. Uh cushions. Yeah, it cushions, yeah. So um uh, you know, just like uh I don't know, I guess I'm trying to think of uh an example right now, but you know, essentially distributes uh weight uh across the the end plate of the vertebra, uh of the vertebral body, so the the large part of the um of the spine. So the front part, large part of the phone. I think that's important.

SPEAKER_00 4:33

We talk about the spine. When we talk about end plate, again, we talked about during the in talking about the intercept procedure, but the end plates are the top and the bottom of the vertebra, and they're not just bone. Uh the the nutrients to the disc go through the end plate. The end plate's very much more complex than we used to think. We used to think it was like bone, like like a humerus, but it's much more than that. We'll talk more about that. But the important thing is, if I don't I'm gonna interrupt a little bit and add on to it. So when you're born, you have this all this fluid in the center of your disc in the nucleus pulposus. And that's when you jump, stand, walk, just forces of gravity, that fluid in that in that nucleus pulposis, that's where that that's where the the vertebra bounce up and down on, and and all the forces sustained by that nucleus pulposis. But as one of the the first sign of degeneration is losing the fluid content, and that can occur young if you have bad genetic makeup, or it can occur later in life. It also is affected by how active you are, what your job is, you know, what your activities are. But that's the first degeneration is you lose the fluid content, and so then because it's not the center of the disc is not cushioning the vertebra, all the way to the vertebrae, your body, all the weight goes onto the annulus, and then the annulus stuff starts to wear down and take it from there, please.

SPEAKER_01 6:04

Yeah, and the annulus is actually it's the the inner part of the disc, um, like you were saying, uh gets its nutrients by basically diffusing uh into the disc. So the the discs don't really have a good blood supply to them at all, um, which is why they tend to degenerate over time. Um and the outside of the disc it has has nerves in it, um, something things called the cyanovertebral nerves. Yeah, yeah, the the the annulus. And actually, as you lose that nucleus palposis, you end up getting uh more innervation to the disc. So um that's where people can start to feel more discogenic pain. It's kind of a um you know catch-22 or or whatever you want to however you want to call that.

SPEAKER_00 6:50

It's uh it's it's just like a a joint in your body. Once other joints in your body, you know, is that they get degenerated, you have no pain. But then if there's an injury in addition to the degeneration, and the pain nerves are activated by that injury because that's what that's a warning sign, you know. We we were talking about that pain is a protective maneuver. You you want to kind of hold your back still for a minute after you injure your back. But that pain, because it's cartilaginous, again, as we discussed, uh not enough stem cells come there to repair sometimes. Sometimes they do, sometimes you have pain that goes away. But if you develop a chronic pain in the middle of your back from a disc injury to you know to the annulus, so the pain nerves are activated, sometimes they never get better. And that's patients we end up seeing who have discogenic pain. You want to talk about the difference between discogenic pain and uh and uh vertebragenic pain?

SPEAKER_01 7:49

Yeah, so uh they you know both of these uh both of these types of pains are kind of happening in a similar area. Um you know, vertebragenic pain is is us really identifying that uh a large portion of pain that's coming from uh degenerative discs uh are carried through pain fibers that are actually in in the bone of the of the spine, the large bone, the vertebral body, uh, and specifically carried by something called the basivertebral nerve. And that really starts to get affected when you get uh changes to the end plates of the uh of the vertebral body, so the tops and the bottoms. And how does that occur? I mean, you can get herniation of disc material through the end plate of the vertebral body, irritating the basivertebral nerve. The the disc con disc contents are are very pro-inflammatory. Um so they're gonna they're gonna tell the body that there's a problem when disc contents leak out. So that can happen with uh disc herniations or also called like annular tears uh in some cases. Um but it's very irritating to the body. So when it gets into the bone, you end up with something called this vertebragenic uh pain.

SPEAKER_00 9:02

Um when you get inflammation, disruption or inflammation of the sometimes it's just inflammation of the end plates. Yeah. You see it on MRI where the thing called uh mob modic changes, which is evidence of wear and tear of the actual end plate. But go ahead.

SPEAKER_01 9:18

Yeah. And in discogenic pain, you can have pain from the disc without having swelling in the vertebral body because the discs themselves are also innervated, innervated by something called the sine vertebral nerve, which is basically a bunch of nerve endings that come off of um like the first nerves that come off of your spinal cord. Uh uh, some of them are redirected towards the disc. Um, so if you have changes to the to the annulus or the outside of the disc, um you can end up with uh with kind of more discogenic pain. And typically uh when you have uh damage to the annulus that's gonna happen in the back of the disc or the posterior part of the disc, that's the thinnest part of the annulus. If you if you think about how your body is positioned, it makes a little bit of sense. Most of your weight is in front of your spine. The majority of weight is in front of the spine. So your annulus in the front, the thick cartilaginous part that holds the jelly-like interior in, is thicker at the front. And it's thinner at the back. Well, if it's thinner at the back and you have a lot of pressure inside of that disc for whatever reason, um, could be an injury, um, could be, you know, uh just a lifetime of uh of living. Uh and uh you you can get tears in that annulus, and they're typically going to happen at the back.

SPEAKER_00 10:37

Um and just to again, just I don't want people to be confused. Herniated discs, disc issues can cause sciatica, can cause ridicular pain. We're not talking about that. We're talking about dicks, you know, that's a separate issue, which we'll talk about. Yeah. We're talking about lower back pain, pain that's confined to your lower back, where you've had you have problems with your annulus, you may have a bulging disc, you may have a herniated disc, but you're not suffering sciatica, you're suffering back pain from that. Yeah, because the annulus, you know, the disc can't come back unless there's a disruption on the annulus, and that's what annular tears are. Uh we just you can sometimes you can see it on a on an MRI, sometimes you can't. If you see one, it's just more positive that that that the that's the cause of the pain. Um let's talk about treatments of disc pain or the lack thereof. Yeah.

SPEAKER_01 11:34

So do you want to talk about the history of treating disc disc pain? Why don't you? Well, because I I don't I don't do as much of the because I've lived longer than you. Well, well, yeah. A lot of the the previous treatments that we were doing for discs, like intradiscal injections and things like that, we just don't do as much of, I guess, um anymore.

SPEAKER_00 11:53

Unfortunately, the only way the only treatments for pain that we can get approved these days are treatments that have a robust scientific evidence. Facet joint injections, nerve blocks, radiofrequency ablation, epidurals. There, unfortunately, there have been many treatments for discogenic pain. People who we do facet joint injections, facet joint treatments for, and they don't get relief. It's midline, we do an epidural, they don't get relief. We used to have treatments for that, but in we they the science is not as robust. There's not as many studies. People could still get better for them if we were allowed to do them to patients. We're just not allowed to do them anymore. One of the first was called intradiscal electrothermal annuloplasty, IDET, which involved uh putting a needle in the disc in the back on one side, and then putting a device in uh that was uh a steerable uh tubing that you it would circle all the way around to the back of the disc. You'd position it against the back, the posterior annulus, and then you'd heat up the posterior annulus. So it's a basically it's a heat treatment, just like and you're heating up the you're heating up the gnosisptors, i.e. the pain nerves, in the posterior annulus. Just it's the same way we treat facet drain pain. You're treating nerves that are carrying the pain. I helped a lot of patients with that procedure over the years. It used to be approved by Medicare. Oh, it hasn't been approved. I mean again, because so many patients because of relief instead of 70% of patients, it was 50% of patients, insurance companies won't pay for it. And um the there's another procedure called biocuplasty, which I've been doing on for patients up until a month ago when the company stopped uh making the device anymore because so few people are doing it anymore. Because biocuplasty, which is another radio frequency treatment for the back of the disc, where you put in two probes on either side of the disc and you create a radio frequency current between them heating up the back of the disc. Biacuplasty is not approved by Medica or Bucus Persia. I only could do it on patients who had personal injury cases, um, and where we're not having the insurance government telling us what to do. I explained to the patient this could help you. Your only other option at this point is back surgery. And I've had wonderful results with uh bioculoplasty, not in every patient, but the majority of patients. But I can't do it except on those patients. And now I can't do it at all because they don't have that device anymore. We've done we used to do steroid injections into the disc. What's the uh we can't get we really don't get that approved anymore either.

SPEAKER_01 14:51

What is the um there there are other like nucleus pulposis like replacement products out there? Uh there's a few of them and I'm blanking on them, right? They're not approved.

SPEAKER_00 15:02

I mean they're self-paying and they don't they don't have robust science behind them. So basically what we're telling you audience is that it's hard to treat disc pain. Um there aren't a lot of procedures. The ones that we do have aren't approved anymore. Um and that's why we hope everybody has facet mostly facet joint pain. Um any other comments about that? Uh I feel like I'm missing something here.

SPEAKER_01 15:29

Yeah, yeah. I mean, we we talked about intercept for you know for patients that do have end plate involvement, um, which a lot a lot of people do.

SPEAKER_00 15:38

Well, and that's that the the the this is true. I mean, unfortunately, when you are younger, you're not gonna have the end plate as a cause of pain, most likely. But someday they might show that not only does the sino vertebral nerve carrying the pain from the disc, but maybe somehow it's connected to the BVN. Maybe we'll start doing radiofrequency, the intercept procedure inside the vertebra to treat disc pain, but I don't know when that'll be. And and I'm probably wrong. It's there's probably not a connection. Um what else? You know, I will say, this is in interesting. A lot of our patients who have discogenic pain who don't want to have a fusion surgery because so many people that are harmed by fusion fusion surgery and made worse. There is one other option. And the big news is that Humana just approved this option. Uh we can now do spinal cord stimulators for patients with Humana to control their lower back pain, even though they haven't had back surgery. This is huge, huge for discogenic pain because you don't want to have surgery. That's crossing a bridge that you can't ever uncross. And what you want is pain relief. So you put a stimulator in a patient, keep their pain under control at the stimulator until something better is invented. Because you can see just by our conversations, things get invented. It's not uncommon. They'll hopefully invent a procedure or uh injectate for disc pain in the near future. And so those patients who we put in stimulators, we can do that injection, their pain goes away, we take out the stimulator. At least that's the grand plan, right? Yeah, yeah, that would be. I think we've covered everything else, except we didn't really talk about disc pain in anywhere besides the lumbar spine. You can have disc pain in your neck, you can have pain in your thoracic spine. Even harder to treat. Yeah. Even harder to treat because when we do uh transfermal epidurals now in the lower back for discogenic pain, we're if we do the approach, the Cammon trials approach, we're putting the needle right behind the disc. I mean, you're putting steroid right behind the disc. We can't do that approach in the cervical or thoracic spine. Those patients are probably going to end up with uh spinal cord stimulators or peripheral nerve stimulators, don't you think?

SPEAKER_01 18:00

Yeah, yeah, I think so. Yeah, probably spinal cord stimulators. Yep.

SPEAKER_00 18:04

Well, you're recently trained. Am I missing anything, you know, about disc pain that you learned that I haven't mentioned?

SPEAKER_01 18:10

Unfortunately, I think we've talked about pretty much everything. So but but it is a it is a huge focus um, I think nowadays to to find new treatments for for it. So there's I I think there's a lot on the horizon for and I remembered what uh what I what we forgot to talk about.

SPEAKER_00 18:28

So how do you diagnose disc pain? No matter how much time we've spent telling you guys that uh MRIs don't give us the answer because people can have five degenerated discs and no pain, or they can have no degenerated disc and severe pain because they have an annual terror that you can't see on the MRI. So there is a gold standard for disc pain, uh, and that's called uh discogram. Uh discography is um what we're doing is we're actually stimulating the disc to see which one is causing pain because normal disks don't cause pain when you stimulate it. And I like to explain to patients before we do a discogram, let's say that you had knuckle pain and I couldn't see very well, so I just started feeling your knuckles. I'd put some pressure on this knuckle. Is that the one that causes pain? No, it's pressure, but it doesn't cause pain. Put pressure on this one, it's the one that's got arthritis in it and pain and inflammation. Oh yeah, that makes it worse when you press on it. Pressure makes pain worse. That's what we're doing with a discogram. We're pressurizing the discs to find out which discs are painful and which ones are not. Now it's a very controversial uh procedure. Uh you have to be well trained in it, and I hope to train you in it eventually. Um to do it right. It's it's part science, part art, because you've got to converse with the patient. You've got to set their expectations so they understand what's going on, because it's not fun to have needles stuck in your disc to do this procedure, because we do have to put a needle on the disc. I can't reach in your body and squeeze the disc. And uh, and of course there's some risk with there's always the risk of diskitis infection of the disc. We've discussed this. Our procedures are very safe, but there's this one in a hundred thousand or so risk of infection anytime you break the skin uh with a needle. But it does give us good information. I've been doing disc I still do discograms uh on personal injury patients. Again, it's not approved by the insurance companies. Uh discograms aren't anymore. They used to be. Um, and uh it gives us valuable information for patients. It's those are the pay, those are the pay, you know, once we figure out which discs are causing the pain, those are the patients I can offer a biochioplasty for. But I have surgeons sending me patients also for discograms to help them plan their surgery, which is what they uh when we didn't have biochyoplasty and IDA, that's the only use of discograms is to plan the surgery. You wouldn't do a discogram unless you had something you could do to to help the disc that you found was causing the pain. So I think that covers it, dude. Yeah, yeah. Um thank you again for setting up the studio and doing everything you did to make this podcast a reality, including the crazy uh mountain man and baby. Um yeah, I I really appreciate it.

SPEAKER_01 21:27

Yeah, yeah, definitely. Well, thanks everyone for uh joining us to talk about discogenic pain, uh intervertebral discs of the spine. Um again, we're coming in from Pain Specialists in Greater Chicago. Thanks everyone for joining us. Uh we're gonna be back. Hopefully, we'll be doing this uh on a more of a weekly basis, yeah. So we'll see everyone in the next episode.

SPEAKER_00 21:50

Thanks. And yeah, as far as next episodes, how about we talk uh a little bit more about ridicular pain and ridicular symptoms like neurogenic claudication. And just go over that whole all about epidurals and the different areas of the spine.

SPEAKER_01 22:05

Yeah, we can uh kind of piggyback off of this and and talk about the differences between disc bulges and protrusions and and you know the difference between all those and prognosis for those as well. All right.

SPEAKER_00 22:17

Thanks so much. All right.

SPEAKER_01 22:18

Appreciate it.