Results of the ESRA-Grunenthal Survey on Degenerative Disc Disease

Low back pain (LBP) is the leading cause of disability worldwide [1]. In 2015, the global point prevalence of activity-limiting low back pain was 7.3%, responsible for around 60.1 million years lived with disability in 2015 – an increase of 54% since 1990 [1]. In 80–90% of cases, LBP is self-limited (lasting <6 weeks with a favourable prognosis), but approximately 5–10% of patients with LBP develop chronic LBP (symptoms lasting >3 months) [2]. Degenerative disc disease (DDD) is the most common etiology of cLBP in adults [3-5]. The current treatment options for cLBP associated with DDD include conservative nonpharmacological and pharmacological treatments as well as interventional and surgical treatments [2, 6]. General practitioners, physiotherapists, neurosurgeons and orthopaedic surgeons play a role in the diagnosis and management of these patients, but little is known about the role of the anaesthesiologists and pain specialists.

ESRA and Grunenthal developed an online survey in order to:

• better understand the role of anaesthesiologists / pain specialists in diagnosis and treatment of cLBP associated with DDD
• gain insights into the disease and its associated signs and symptoms
• understand the tools health care professionals utilise for differential diagnosis, and
• understand DDD patient journey.

The survey was launched on the 19^th of September 2020 during the ESRA & ASRA International e-Congress. Data collection concluded on the 6^th November with the participation of 363 respondents across Europe, 96% of which were anaesthesiologists and/or pain specialists.

Over 74% of the respondents are actively involved in the diagnosis and/or management of cLBP associated with DDD, which highlight the substantial role anaesthesiologists and pain specialists undertake.

Anaesthesiologists/Pain Specialists refer their DDD patients most often to spine surgeons, neurosurgeons and orthopaedic surgeons.

According to the respondents, most bothersome signs/symptoms which drive patients to seek medical advice are worsening back pain and the impact back pain has on their daily functioning, 57% and 63% respectively.

Signs and symptoms particularly associated with DDD are the location and quality of back pain as well as its functional impact, with 53%, 43% and 44% respectively.

Magnetic resonance imaging is the preferred imaging modality used for the differential diagnosis (90%), followed by plain x-ray (27%) and CT (21%). Discography is needed / employed in up to 19% of cases. According to respondents, approximately 1/3 of the patients have a single level of symptomatic degeneration, 1/3 of the patients have two, and the others have multiple levels.

Anaesthesiologists and/or pain specialists play the most significant role in the management of patients with DDD, followed by spine surgeons, orthopaedic surgeons and neurosurgeons.

Treatment goals of the respondents for their patients with cLBP associated with DDD are to provide substantial pain relief at rest and on exertion, as well as to provide functional improvement.

Epidural and/or intradiscal injections are commonly administered in patients with cLBP associated with DDD. Steroids and local anaesthetics are the most commonly employed as first or second line treatment.

The majority of the respondents have no experience with cell therapies in the treatment of DDD (86%), but expect that such therapies may provide long lasting, clinically meaningful reduction in pain intensity and improvements in functional outcomes.

In summary:

• Anaesthesiologists and/or pain specialists seem to play an important role in the management of patients with DDD
• Limited resources/guidelines force clinical decision making based on personal experiences rather than evidence based medicine
• There is a need for continued medical education also including cell therapies
• DDD patients are difficult to diagnose, difficult to manage and difficult to treat
• Limited treatment options
• 30% surgical candidates
• 40% of those decline surgery

References

1. Hartvigsen, J., et al., What low back pain is and why we need to pay attention. Lancet, 2018. 391(10137): p. 2356-2367.
2. Urits, I., et al., Stem Cell Therapies for Treatment of Discogenic Low Back Pain: a Comprehensive Review. Curr Pain Headache Rep, 2019. 23(9): p. 65.
3. DePalma, M.J., J.M. Ketchum, and T. Saullo, What is the source of chronic low back pain and does age play a role? Pain Med, 2011. 12(2): p. 224-33.
4. Peng, B.G., Pathophysiology, diagnosis, and treatment of discogenic low back pain. World J Orthop, 2013. 4(2): p. 42-52.
5. Zhang, Y.G., et al., Clinical diagnosis for discogenic low back pain. Int J Biol Sci, 2009. 5(7): p. 647-58.
6. Zigler, J., et al., Comparison of Lumbar Total Disc Replacement With Surgical Spinal Fusion for the Treatment of Single-Level Degenerative Disc Disease: A Meta-Analysis of 5-Year Outcomes From Randomized Controlled Trials. Global Spine J, 2018. 8(4): p. 413-423.