Why do I hurt? And...

[ans]

At a disc that was positive for a discogram years ago. There was a Grade V annular tear and it couldn't retain fluid then.

What are the pain generators that make this pain worse and worse over the years?

Is it the nerve fibers in the annulus? How do tears cause pain? Am I missing anything else?

And a giant "duh" but in a fusion or ADR, is the annulus completely removed?

Thanks. I know these are elementary questions but I can't seem to "get it".

My best, ans

[Harrison]

Alan, my 2 cents as a layman, patient and editor who has tracked this phenomenon…

What are the pain generators that make this pain worse and worse over the years?

Well, who knows?! It depends on the patient's condition; e.g. the number of years they’ve been afflicted with the spinal disease(s), the cause of the inflammation, the degree of involvement (soft tissue, bone, more), degree and cause of nerve compression, compensation by muscles causing more ischemic compression (splinting)…

Is it the nerve fibers in the annulus? How do tears cause pain? Am I missing anything else?

It could be. Some people assert that the annulus itself has specific nerve receptors that are actuated by the ooze; but I am really not sure myself. On a related note, look at the article I just posted in the library on MM-28, which may be a new biomarker for assessing or tracking DDD.

And a giant "duh" but in a fusion or ADR, is the annulus completely removed?

That's not a “duh” question by any means! We kicked this question around a few times during the years, because there is some variability in the surgical procedure. In my case, the degree of DDD was very bad at L5-S1, and spurs were forming between the two vertebral bodies; so Dr. Banco spent considerable time cleaning the plates, readying them for the Charite.’ If I had waited another month or two, it would have been too late!

But there were so much “cleaning” that was required, all of my annulus was removed. My understanding is that generally, the posterior of the annulus is left in to provide a little bit of extra stability. A speculation here: my recovery went well, and had little to no back pain in my recovery. The complete removal of all the inflamed/diseases tissue could be the reason why I did so well.

So, I don't know if this helped much, but I hope it does. As I recall from one of your posts, you were thinking seriously about fusion because of possible contraindications...

[Slackwater]

Originally Posted by ans

What are the pain generators that make this pain worse and worse over the years?

Is it the nerve fibers in the annulus? How do tears cause pain? Am I missing anything else?

You asked what are the pain generators. I think this is a multifactorial answer. Orthopaedic researchers suggest certain factors in the course of intervertebral disc aging and damage, including but not limited to the below:

ref: 2009 Annual Meeting of the Orthopaedic Research Society
Paper No. 78 (2.5MB?)

Multipotency of Annulus Fibrosus Cells: A Possible Role in the Pathogenesis of Intervertebral Disc Degeneration

INTRODUCTION:

Human intervertebral disc (IVD) consists of three distinct regions, the annulus fibrosus (AF), the nucleus pulposus (NP) and the endplates.

While the NP is considered to be the ruminant of the notochord, AF is thought to be derived from mesoderm. The intact disc is the largest avascular organ and is generally aneural except in the outermost part of the AF; however, during the moderate and end stages of disc degeneration, fibrocartilage-like tissue, bone formation, nerve and blood vessel growth are found in the IVD.

We hypothesize that the normal AF tissue contains mutipotent adult progenitor cells (MAPCs), which are able to differentiate into cartilage/fibrocartilage cells, osteoblasts, neurons and blood vessel cells. There may be nerve ingrowth to the IVD and homeostasis is interrupted as we age.

PMID: 18303465

Spine 2008 Feb 1;33(3):312-7.

Lactic acid and proteoglycans as metabolic markers for discogenic back pain.

Keshari, Lotz, Link, Hu S, Majumdar, Kurhanewicz UCSF

STUDY DESIGN: Disc tissue was removed at surgery from 9 patients with discogenic pain and 9 deformity patients with scoliosis undergoing anterior and posterior spinal fusion. These samples were then analyzed using ex vivo proton high resolution magic angle spinning (HR-MAS) NMR spectroscopy to produce metabolic profiles for comparison between the 2 patient groups.

OBJECTIVE: The goal of this study was to use quantitative ex vivo HR-MAS NMR spectroscopy to identify biochemical markers associated with discogenic back pain.

SUMMARY OF BACKGROUND DATA: Biomarkers of disc degeneration have been previously described using NMR spectroscopy, but the link between discogenic back pain and biomarkers has not been completely understood.

METHODS: HR-MAS NMR spectroscopy was performed on snap frozen samples taken from 9 patients who underwent discectomies for painful disc degeneration. The resulting proton NMR spectrums were compared with those from discs harvested from a reference population consisting of 9 scoliosis patients.

RESULTS: Spectral analyses demonstrated significantly lower proteoglycan (PG)/collagen (0.31 +/- 0.22 vs. 0.77 +/- 0.48) and PG/lactate (0.46 +/- 0.24 vs. 2.24 +/- 1.11) ratios, and a higher lactate/collagen (0.77 +/- 0.49 vs. 0.40 +/- 0.21) ratio in specimens obtained from discogenic pain patients when compared with scoliosis patients.

CONCLUSION: Our results suggest that spectroscopic markers of proteoglycan, collagen, and lactate may serve as metabolic markers of discogenic back pain. These results provide a further basis of the potential to develop in vivo MR spectroscopy for the investigation of discogenic back pain.

-------------------------------

slackwater_sf

mva - reading about alternatives to stop or minimize symptoms

[annapurna]

As you've figured out by now, the consensus is that it is impossible to say what the pain generators are in the absence of a very detailed medical history and testing. I'll go a step further and point out due to gating theory, your pain generators are necessarily what you think they are. Essentially a really intense pain in a location "takes up" all of the available pain sensations from the area and "gates out" all of the lesser pains. In order to figure out all of the things that are causing your pain, you'd have to block the pain signals from all of the other things. Effectively, you'd start with your disk and block the signals from it. Then you'd check your facets maybe and if they turned out to hurt, you'd block the signals from them. You'd continue this until all of the pain generators were blocked and you didn't hurt. This would be an incredibly lengthy set of injections and tests and you'd likely never find anyone to do it, even if your body was capable of handling all of the work necessary.

[ans]

I mean, big-time thank you for your helpful and provocative answer this this question that has a childish credulity but is enormously complex! Like dudes/dudettes: wow.

The Burton Report I think mentioned a while back that nerve fibers grown downward into a disc but an ADR or fusion should take care of this.

I will read all of your responses closely (just got home) and most much of this stuff up to some docs for consults.

A huge wet sloppy kiss to you all.

There, that did it, future responses by very bright folks craftily nipped in the bud.