Lumbaler diskogener Schmerz - Bandscheibendegeneration und minimalinvasive Therapie

Lumbaler diskogener Schmerz ist verantwortlich für zahllose Arbeitsausfälle und verursacht Kosten in Millionenhöhe. In den letzten Jahren haben minimalinvasive Therapieverfahren deutlich an Akzeptanz gewonnen. Das jahrhundertealte Dilemma dieser Schmerzen ist dennoch bis heute nicht gelöst. Sicher ist nur: Diskogene Schmerzen haben viele Gründe. Aus dem Nucleus pulposus austretende biochemische Substanzen sind sicherlich für die Entstehung von Entzündungen und somit von Schmerz verantwortlich. Neuropeptide, freigesetzt von den peripheren Enden nozizeptiver afferenter Bahnen, sind Entzündungsmediatoren, also Schmerzerzeuger. Die den Diskus versorgenden Nerven sind mittlerweile bekannt und können mit guten Ergebnissen denerviert werden. Bei diesen Nerven von posterior nach anterior handelt es sich um die sinuvertebralen Nerven, die Rami communicantes und den Truncus sympathicus.

Discogenic pain has been responsible for a countless number of missed workdays and millions if not billions of dollars of lost revenue. Minimaly invasive interventional therapies of the discogenic back pain gained significant acceptance among the proceduralists. The centuries old dilemma of discogenic low back pain has by no means been answered. We know today that discogenic low back pain has a multitude of causes. The leaking „chemical soup” within the nucleus pulposus is certainly responsible for causing inflammation and thus pain. However, neuropeptides released from peripheral endings of nociceptive afferents are also inflammatory mediators and pain generators. The nerves innervating the discs have been identified and in many cases denervated with good results. These nerves from posterior to anterior include the sinuvertebral nerve, the rami communicantes, and the sympathetic trunk. Diagnosing discogenic low back pain is the key to successful treatment. Classically this should be a low back pain in a „band-like” distribution without radiculopathy that is worse in the morning, worse with Valsalva, and aggravated by standing in flexion. Provocative discography with manometric monitoring is essential in aiding the diagnosis. Once the diagnosis is confirmed, a multitude of invasive therapy may be offered including: L2 root sleeve blocks, intradiscal RFTC, RFTC of the rami communicantes, or Comparative data on the effectiveness of the above-mentioned procedures is lacking and may in fact be an excellent topic for future discussion.

Key words

discogenic back pain - discogram - annuloplasty

Literatur

• 1 Linblom K.. Diagnostic puncture of interveterbral disks in sciatica.  Acta Orthop Scand. 1984;  17 231
• 2 Hirsch C.. An attempt to diagnose the level of a disc lesion clinically by disc puncture.  Acta Ortho Scand. 1948;  18 132
• 3 Bogduk N.. Klinische Anatomie von Lendenwirbelsäule und Sakrum. Berlin, Heidelberg, New York: Springer 2000
• 4 Faustmann PM, Dermietzel R.. Funktionelle Anatomie und Biomechanik - Halswirbelsäule, Lendenwirbelsäule. In: Wirth CJ, Zichner L (eds). Orthopädie und Orthopädische Chirurgie. Krämer J (ed). Wirbelsäule, Thorax. Stuttgart: Thieme 3-27
• 5 Malinsky J.. The ontogenetic development of nerve terminations in the intervertebral discs of man.  Acta Anat. 1959;  38 96-113
• 6 Ashton IK, Roberts S, Jaffray DC. et al. . Neuropeptides in the human intervertebral disc.  J Orthop Res. 1994;  12 186-192
• 7 Bucknill AT, Coward K, Plumpton C. et al. . Nerve fibres in lumbar spine structures and injured spinal roots express the sensory neuron-specific sodium channels SNS/PN3 and NaN/SNS2.  Spine. 2002;  27 135-140
• 8 Oegema TR, Johnson SL, Aguiar DJ, Ogilvie JW.. Fibronectin and its fragments increase with degeneration in the human intervertebral disc.  Spine. 2000;  25 2742-2747
• 9 Groen GJ, Baljet B, Drukker J.. Nerves and nerve plexuses of the human vertebral column.  Am J Anat. 1990;  188 282-296
• 10 Higuchi K, Sato T.. Anatomical study of lumbar spine innervation.  Folia Morphol. 2002;  61 71-79
• 11 Ohtori S, Takahashi K, Chiba T. et al. . Sensory innervation of the dorsal portion of the lumbar intervertebral discs in rats.  Spine. 2001;  26 946-950
• 12 Nakamura S, Takahashi K, Takahashi Y. et al. . Origin of nerves supplying the posterior portion of lumbar intervertebral discs in rats.  Spine. 1996;  8 917-924
• 13 Sato K, Kikuchi S, Yonezawa T.. In Vivo Intradiscal Pressure Measurement in Healthy Individuals and in Patients with Ongoing Back Problems.  Spine. 1997;  4 39-52
• 14 Weißkopf M, Herlein S, Birnbaum K. et al. . Vergleichende Evaluation der lumbalen Degeneration nach Röntgenuntersuchung und Großschnittkryomikrotomie.  Z Orthop. 2003;  141 86-91
• 15 Aprill C, Bogduk N.. High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging.  Br J Radiol. 1992;  65 361-369
• 16 Derby R.. A second proposal for discography standards. ISIS Newsletter Nr 2.  International Spinal Injection Society, Daly City California. 1994;  2 108-122
• 17 Merskey H, Bogduk N.. Classification of Chronic Pain. Discription of Chronic Pain Syndromes and Definition of Pain Terms. 2. ed. IASP Press, Seattle, WA 1994: 180-181
• 18 Endres S, Bogduk N.. Practice guidelines and protocols. Lumbar disc stimulation. ISIS 9th Annual Scientific Meeting. International Spinal Injection Society, San Francisco, CA 2001: 1456-1474
• 19 Bogduk N, McGuirk B.. Causes and sources of low back pain. In: Bogduk N, McGuirk B (eds). Medical Management of Acute and Chronic Low Back Pain. An Evidence-Based Approach. Amsterdam: Elsevier 2002: 115-125
• 20 Sachs BL, Vanharanta H, Spivey MA. et al. . Dallas discogram description: a new classification of CT/discography in low back disorders.  Spine. 1987;  12 287-294
• 21 Vanharanta H, Sachs BL, Spivey MA. et al. . The relationship of pain provocation to lumbar disc deterioration as seen by CT/discography.  Spine. 1987;  12 295-298
• 22 Moneta GB, Videmann T, Kaivanto K. et al. . Reported pain during lumbar discography as a function of anular ruptures and disc degeneration. A re-analysis of 833 discograms.  Spine. 1994;  17 1968-1974
• 23 Kniesel B.. Lumbar Discogenic Pain Pathomechanism, Diagnosis, Clinical Picture.  Z Orthop Ihre Grenzgeb. 2004;  142 709-715
• 24 Moneta GB, Videmann T, Kaivanto K. et al. . Reported pain during lumbar discography as a function of anular ruptures and disc degeneration. A re-analysis of 833 discograms.  Spine. 1994;  17 1968-1974
• 25 Walsh TR, Weinstein JN, Spratt KF. et al. . Lumbar discography in normal subjects.  J Bone Joint Surg (Am). 1990;  72 1081-1088
• 26 Rauschmann MA, Warzecha J, Arabmotlagh M. et al. . IDET Diagnostics and minimally invasive therapy for chronic low back pain) Schmerz.  Review. German. 2004;  6 463-74
• 27 Hildebrandt J.. Relevanz von Nervenblockaden bei der Diagnose und Therapie von Rückenschmerzen.  Der Schmerz. 2001;  15 474-483

Korrespondenz