Vol. 20, No. 2 - Gray Matters - Case of "Discongenic" Low Back Pain

A 55-year-old man, a former college athlete, presents with progressive low back pain. He attributes the onset of his low back pain to a fall while shoveling snow two years earlier. His usual physical activities have been greatly curtailed as any degree of activity worsens the back pain, while rest improves it; the pain increases with axial loading and is partially relieved in recumbency. Over the past couple of years, the patient has had significant weight gain secondary due to his recent sedentary lifestyle and also describes some symptoms of depression. The patient denies radiation of pain into the legs. He denies leg weakness. There is no description of bowel or bladder dysfunction. Physical and occupational therapy prescribed by his primary-care physician have not been helpful. Pain medication, including narcotics, offer only temporary relief.

Neurological examination is nonfocal. There are no signs of myelopathy or radiculopathy. The patient has a limited range of motion of his low back.

MRI of the lumbosacral spine (FIGURE 1, shown in the attached image) shows spondylosis. There is spinal canal stenosis. There is no foraminal stenosis. While there is no disc herniation, there is the presence of a “black” disc at L4-5 with type I Modic changes of the adjacent endplates. Dynamic lumbosacral spine X-rays show no evidence of instability.

Based on the information presented in the feature, and the associated images, please answer the following questions.