The patient’s history, as always, is extremely important in my effort to pin down the pain generator. Multiple key questions help me diagnose the disc or facets as the source of pain. With pressures within the disc increasing significantly with forward flexion at the waist, patients will typically report exacerbation of pain with prolonged sitting, driving, rising from a seated position, first thing in the morning, bending over to pick something up, tie their shoes, doing dishes, bending over to shave, etc. However, the discs bear some amount of pressure in all positions, so there is some variability.
Often there is a specific trauma: I’ve heard coughing, sneezing, vomiting, picking up a table, picking up something as light as a pen. However, just as often, there is no inciting event and patients will “wake up with it.” Relieving positions often include lying flat or on side with legs bent up, sort of in the fetal position. Staying active and moving around is often reported to ease discomfort. Often patients will point to the lumbar spine and report pain in a band-like pattern around the waist line and radiating into hips. Of course, if there is nerve root (sciatica) involvement, there can be a history of pain radiating into buttocks and down the leg. A surgical history in that area of the spine can change biomechanics and increase susceptibility to discogenic pain as well.
by Nathan S. Walters, MD
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