A Tale of 50 years' Low Back Pain

A slender, well-educated 77 years old lady, in elegant dress and light make-up, walked gracefully into the clinic room. She said she already had chronic low back pain since 25 years old during pregnancy of her first baby until now. 

(Visual Analog Scale "VAS": 0 to10 points; 0= no pain, 10= extremely painful) 

  At her 30's (around 1960s), due to agonizing persistent backache (VAS: 8 to 10), that she had been bedridden for 4 years and was unable to do anything except lying in bed. After that episode, backache decreased to an extent of tolerable (VAS: 4 to 6) and she could resume normal daily activities, even found a job until retirement at her 60's; of course, she had sick leave once in a while due to backache.  
  Low back pain lingers for 52 years until today, and she is doing well (VAS: 2 to 5): shopping, touring, housekeeping, taking care grand children, and so on. . 

Q: "Did you ever consider surgery to alleviate backache at one time in all those painful years? 
A: "Never."  
Q: " Why?"
A: " I was afraid of surgery."
Q: "How do you feel now?" 
A: " I am doing well. Backache is already part of me, it bothers but I can cope." 

 Her lumbar anteroposterior radiography show degenerative scoliosis about 15 degrees.

Lumbar MRI sagittal T2 image shows significant disc degeneration from L1-2 to L5-S1 levels, and Modic changes.

 
 This case demonstrates that it is a very rare chance for any physician who may encounter a case of chronic low back pain for 50 years. 
  Although her clinical history may be anecdotal, but from the image findings, it suggests that it is definitely a case of discogenic low back pain.  Amazingly, the terminology of discogenic low back pain (LBP) is possibly derived only 25 years ago from the Henry Crock's hypothesis of Internal disc disruption (1986). In these 25 years, the surgical treatments for discogenic LBP are flourishing: intradiscal electrothermal therapy (IDET), Neulecoplasty (Bipolar RF/”Coblation”), artificial disc replacement (ADR), nucleus replacement, percutaneous laser discectomy, interbody fusion, facet replacement, and so on.    
  
   This web page is very well-balanced and must see, regarding the efficacy of above mentioned interventional treatments for LBP.


 What did we learn from this lady?
1. There is no long-term longitudinal study (more than 10 years) for discogenic LBP. A real regret;

2.  Long-term outcomes using conservative measures seem optimistic, at least for a certain portion of patients (read: time heals);

3. We knew too little about the nature of discogenic LBP but do too much;
4. therefore, various surgical modalities for discogenic LBP, whether the already phased-out ones, currently popular, or the new-comers, they all leave something to be desired;
5. The lady is wise.

  Is this: Injectable spinal fusion, one of the future options? We shall see.