Below is an interview with Dr. Christian Balkovec regarding low back pain and disc degeneration. The below interview discusses the recent research study on Hydrogel injections, read the abstract here. For the more research studies by Christian Balkovec, please see the complete research list.

As our loyal readers know, low back pain and low back disc degeneration are common within the developed countries. Luckily, low back pain and disc degeneration don’t mean you have to live with low back pain! If you have low back pain or have been diagnosed with low back disc degeneration, consider conservative treatments first before surgery, like physical therapy. Though physical therapy can’t help all cases of low back pain, it is an effective treatment when addressing biomechanics, physiology, and pain reduction (as discussed below).

1. What are the main risk factors for low back pain and disc degeneration?

Low back pain can arise from a variety of sources. Back pain that has been caused through mechanical means typically arises from when a motion, posture, load, or combination of these three damages a tissue. The spine needs to move and needs to be put under load, but what’s important to remember is the Goldilocks principle: too much load, and the stresses on the tissues can be too great for them to bear; too little load, and there is not enough of a stimulus for structures to adapt and remodel. Every tissue in our bodies can fail at some point. Luckily, there are ways for our bodies to adapt and heal. Failure happens when our bodies can’t keep up; tissues can either fail through being overwhelmed all at once, or through being fatigued over time.

Our spine is made up of a highly complex linkage of bony vertebrae and discs sandwiched in between. It needs to perform the double-duty of allowing us to move in all directions, but also hold up our torsos and provide stability. The discs of our spine are soft tissues that allow for movement. They consist of layer-upon-layer of collagen rings, and in the center is a fluid-like nucleus. To simplify things, imagine the disc as a jelly-filled donuts. If we flex our spines (bend forward) and at the same time apply enough compression, the jelly comes out of the donut; this is a disc herniation. Similarly, if too much compression is applied, even if our spine isn’t flexed, the vertebrae sandwiching the discs can fracture.

Here’s the problem: the nucleus (our jelly from the donut) is seen as a foreign material by our bodies, and if it escapes from the disc, our bodies attack it. This can cause inflammation, and if this happens around nerves, pain can occur. In order to stop this from occurring, it’s important to avoid motions, postures, and loads that put us at an increased risk for tissue damage. These include:

-Spine flexion (bending forward) combined with compression

-Twisting combined with flexion/compression

-Putting too much load on our spines

-Staying in the same posture for too long

When performing activities that place high load on the spine, the posture with the lowest risk for injury is one where the spine is neutral.

2. How can someone determine what is the cause of their low back pain?

First and foremost, seeking out the expertise of your primary care physician is an integral step in this process to create a personalized plan and identifying or ruling out more serious and threatening causes of your pain. Recovery, however, is not a passive process, and understanding the clues your body is telling you and taking action is key. It’s important to be aware of the mechanisms that can cause injury in the spine. Armed with this knowledge, one can begin to ask themselves what the culprit could be for their specific pain. Go through your daily activities, identify motions, postures, and loads that make you feel worse and those that make you feel better. Examine each component of your morning routine, work habits, gym workouts, etc. and cross-reference them with your new-found knowledge of injury mechanics. You are both a detective and scientist on a fact-finding mission to isolate specific pain triggers that punish you either immediately or over the next few days. Each and every strategy to alleviating pain should be personalized and tailored to the individual. In general, avoidance of the activities that are causing pain can be effective as can altering the movement strategy used. Ultimately, the successful method will vary with the individual and with the type of injury that is causing the pain. A fantastic resource that elaborates further on helping to guide individuals through a self-assessment of their pain triggers is the book ‘Back Mechanic’ by Dr. Stuart McGill. This book can help to empower individuals to remove the cause of their pain through movement change and build the foundation for pain-free movement.

3. What percentage of low back pain is due to decreased disc space (disc degeneration)?

Finding reliable statistics on low back pain can be a challenge. Many cases of back pain are reported as non-specific; however, this may just mean that the specific cause could not be identified. Compressive fractures and disc herniations can both create disc height loss and lead to pain. Progressive degeneration of the discs is also associated with height loss, and these rates have been shown to range between 15-49% from ages 30-70. Degeneration, however, does not necessarily equate to pain.

Think of disc height loss as more of an indicator or clue of dysfunction rather than the principle cause of pain. Disc height loss can cause the structures in our spine to be loaded differently which could potentially lead to injury or aggravation of tissues, it’s this chain-reaction that could lead to a host of different causes of pain.

4. What “successful” treatments exist for those with decreased disc space (discdisc degeneration degeneration) low back pain?

“Success” is a difficult metric to define and will vary from person-to-person. Rather, here is an overview of treatments that exist at the moment. Current treatments can be divided into those that are surgical and non-surgical. Non-surgical methods for the alleviation of pain may be attempted first, but it is important to note that avoiding motions, postures, and loads that elevate spine injury risk is a key component of this process. This will help to avoid exacerbating pain and physical injuries and allow the body’s pain response to decrease in sensitivity. How we move is important and will influence the road to recovery; be diligent in moving in a spine-sparing manner, and you will help your body and shield yourself against future injury risk. Continue to load your spine in a risky manner and you may find yourself frustrated and in chronic pain.

Surgical methods at the moment include fusion, total disc replacement, discectomy, and intradiscal electrothermal therapy. As always, the answer to which treatment is appropriate is “it depends”, and is something that should always be discussed with your primary healthcare practitioner.

5. What is a hydrogel injection and how can it help?

A hydrogel (in this context) is a material that is a liquid at room temperature, and forms a soft gel at body temperature. That means it has the potential to replace lost nucleus in the disc and restore disc height (referred to as disc degeneration). Because it doesn’t become a gel until it reaches body temperature, it customizes its shape to the individual all through a simple needle delivery rather than a larger incision.

The spine is a linkage. What happens at one point can affect what happens at another point. Injury at one disc can compromise how another disc is loaded and the stresses placed on it, potentially creating a higher risk for injury and failure in the future. Hydrogel injections offer the potential to restore mechanical integrity to an injured disc and help to alleviate some of the risk for further injury. The desire would be to stop the chain-reaction from occurring – restore the environment, and we reduce the risk for further tissue injury that could lead to painful symptoms. At the moment, our testing is still in the experimental stages and focuses only on the mechanical aspects of this potential therapy.  

6. Can patients with low back pain get hydrogel injections?

Current techniques use pre-formed implants that require a larger incision to place into the disc. At the moment, injectable solutions are still in mechanical and experimental testing phases.

7. What else needs research in regards to hydrogel injections?

Further testing needs to be done in spines that show more advanced disc degeneration. These discs are typically stiffer, may respond differently and not be as easily plumped up as one that is freshly injured. This will help to develop realistic guidelines or boundaries for conditions that hydrogels can be useful under and for when alternative techniques need to be considered.

The viability of this technique also needs to be assessed using live models in order to characterize how it performs under daily loading conditions. It’s important to note that all materials can degrade once placed in the hostile conditions of the body. Any intervention needs to be carefully managed and continually monitored; if the mechanism of injury is repeated, re-injury can occur.

8. If someone has a loss of disc height (disc degeneration) and it is causing pain, what do you recommend for them?

This would depend on the type of injury that has caused the disc height loss. Again, loss of disc height is an indicator of potential mechanical dysfunction rather than cause of pain. With a disc bulge or herniation, the most likely culprit is spinal flexion. Motions that involve spine flexion need to be avoided and retraining to use the hips while maintaining a neutral spine during stooped postures would be highly beneficial. Compression fractures will typically generate pain sensitivity during dynamic loading such as running or walking down stairs. Further, activities such as carrying heavy objects, holding objects in front of you, or operating heavy machinery may also generate pain. Lying on your stomach may help provide some relief in this case, as there is less compression on the spine in this posture. Additionally, practicing with activating your core muscles while in a neutral spine posture will help you to identify the range that you can tolerate pain-free (ie. too much activation or not enough).