A Proposed Diagnostic and Treatment Algorithm for the Management of Lumbar Discogenic Pain [Letter]

Dear editor

We read with interest the recent article by Lorio et al, “A Proposed Diagnostic and Treatment Algorithm for the Management of Lumbar Discogenic Pain”.¹ The authors are to be commended for synthesizing a substantial body of evidence and presenting a clear, structured approach to this complex condition.

While we agree with the overall conclusions, we suggest that the proposed algorithm could be further strengthened by explicitly incorporating multifidus dysfunction, which frequently accompanies lumbar degenerative disc disease. A growing body of evidence demonstrates that chronic inhibition and degeneration of key spinal stabilizers—particularly the multifidus muscle—are highly prevalent in patients with discogenic pain and may contribute to persistent pain and disability even after structural nociceptive sources have been addressed.^2,3

Substantial clinical and preclinical evidence supports a close pathophysiological relationship between disc degeneration and multifidus dysfunction. Imaging studies consistently demonstrate strong associations between disc degeneration severity and multifidus atrophy and fatty infiltration, with Pfirrmann grade showing one of the strongest correlations.^2,3 Preclinical models support a causal link, demonstrating rapid, segment-specific multifidus degeneration following experimental disc injury, mediated by reflex inhibition, inflammatory signaling, and biomechanical alterations.⁴

The original ReActiv8-B pivotal trial and its ongoing five-year outcomes, combined with the RESTORE RCT, now represent one of the most robust bodies of prospective, controlled evidence for any non-structural intervention in chronic mechanical low back pain. Notably, grade 3 or higher degenerative disc disease was present in approximately 70% of patients enrolled in ReActiv8-B, underscoring the substantial overlap between disc degeneration and lumbar motor control dysfunction and highlighting the importance of evaluating both entities during diagnostic assessment.^5,6 Further Level I evidence is provided by the recently published RESTORE randomized controlled trial, a multicenter, blinded, sham-controlled study comparing restorative neurostimulation with optimized conventional medical management in patients with chronic, intractable discogenic low back pain and confirmed multifidus dysfunction. At the primary endpoint of 120 days, ≥50% pain reduction was achieved in 63% of patients in the treatment group compared with 4% in the control arm (p < 0.0001), with concomitant improvements in disability and quality of life that were sustained through the most recent follow-up.⁷

Integrating multifidus dysfunction into discogenic pain algorithms therefore represents an important opportunity. Given the current evidence, contemporary pain algorithms should incorporate both structural and neuromuscular contributors to achieve comprehensive care. We respectfully suggest that future iterations explicitly include an evidence-based pathway for multifidus dysfunction diagnosis and treatment in appropriately selected patients with predominant axially dominant chronic low back pain. Explicit consideration of multifidus dysfunction within diagnostic and treatment algorithms may enhance clinical decision-making and improve patient outcomes.

We appreciate the authors’ contribution and the opportunity to further advance this important discussion.