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BackTable / MSK / Article
Multi-Level Degenerative Disc Disease: Symptoms, Diagnosis & Treatment Planning
Lilyrose Bahrabadi • Updated Jul 2, 2025 • 39 hits
When managing a patient with broad, multi-level back pain, accurately identifying the source of the pain can be challenging, but is crucial for providing appropriate treatment. Managing multi-level degenerative disc disease requires a strategic blend of clinical examination, targeted imaging, and procedural insight to accurately identify symptomatic levels and guide effective treatment. While reliance on imaging alone can fall short, especially in patients with widespread disc degeneration, a simple physical exam, patient questionnaire and focused history taking technique can be powerful diagnostic tools in providing effective relief for complex disease presentations. Combining these simple tools with advanced imaging provides a holistic view of multi-level disc degeneration and can immensely improve diagnostic accuracy, helping pinpoint specific pain generators that might otherwise be overlooked.
In cases involving significant multi-level degeneration tools like diagnostic discograms remain essential for correlating patient reported symptoms to specific discs. More recently MR disc spectroscopy has begun reshaping diagnostic pathways by providing a more nuanced view of disc health. By helping detect markers, like elevated lactate levels and altered proteoglycan ratios, spectroscopy provides insight into early degenerative changes and helps determine candidacy for biological or regenerative treatments. As treatment plans become more complex, many clinicians are adopting these highly effective hybrid approaches, benefiting from both more traditional physical assessments and advanced imaging techniques to tailor their interventions and optimize outcomes for each patient effectively.
This article features excerpts from the BackTable MSK Podcast and features practical guidance from interventional pain specialist Dr. Olivier Clerk-Lamalice. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable MSK Brief
• A focused physical exam combined with patient history and questionnaires can effectively identify symptomatic discs, often before advanced imaging is necessary.
• Key clinical indicators like pain with forward bending, sitting, or axial loading are essential clues in diagnosing vertebrogenic pain.
• High intensity zones and annular fissures found under T2 weighted MRI should be interpreted alongside clinical exams to improve diagnostic confidence.
• In a multi-level disease, diagnostic discograms remain a valuable tool for confirming which levels reproduce concordant pain and should be targeted.
• Treatment planning must weigh the practicality of single versus multi-level intervention, especially in cases of contiguous or pan lumbar degeneration.
• MR disc spectroscopy is a promising, noninvasive technique that detects early metabolic changes, helping guide regenerative or biologic therapy decisions.
• A hybrid diagnostic approach, merging clinical insight, imaging and MR spectroscopy, typically offers the most effective path to personalized treatment.
Table of Contents
(1) Critical Criteria for Diagnosing Symptomatic Lumbar Degenerative Disc Disease
(2) Evaluating & Treating Multi-Level Disc Degeneration
(3) The Role of Spectroscopy in Identifying Target Discs in Multi-Level Degenerative Disc Disease
Critical Criteria for Diagnosing Symptomatic Lumbar Degenerative Disc Disease
Accurately diagnosing symptomatic lumbar degenerative disc disease requires attention to a few core clinical indicators that can often be identified through a straightforward physical exam, patient history, and patient questionnaire. The key symptoms include pain with axial loading, pain while sitting, and pain with forward bending. These can be evaluated effectively in the clinic through a brief patient questionnaire or simple physical maneuvers – asking the patient to bend forward, touch their toes, or describe their pain while seated. One particularly valuable maneuver is sustained hip flexion, where the patient brings their knees to their chest while lying supine. The reproduction of pain during this test is a strong indicator of anterior column pain and has become a favored tool among doctors.
Once these symptoms are identified, MRI evaluation should follow to confirm disc pathology. Key imaging features supporting the diagnosis would include signs of disc degeneration, T2-weighted high intensity zones and annular fissures. These results combined with clinical insight can improve a holistic diagnostic image and help guide effective treatment planning. By integrating a thorough physical exam with appropriate advanced imaging techniques, physicians can more confidently identify the primary pain generator in multilevel disc disease and provide clarity for patients who may have seen multiple specialists without a clear diagnosis.
[Dr. Jacob Fleming]
Excellent. Talking about the right patient, let's give just a bit of an overview of how to identify patients with symptomatic lumbar degenerative disc disease. What are the common signs that you see in imaging findings?
[Dr. Olivier Clerk-Lamalice]
Yes. That can be very easy once you know how to do it. It is virtually three things. Pain with axial loading, pain with sitting, pain with forward bending. You can ask the patient to do it in front of you. You can ask the patient if they have pain while sitting for extended period of time, if they always switch from one buttocks to the other, if they have difficulty bending forward, touching their boots and putting your socks on. Those three questions normally will really orient you in the right direction.
After that, you take a look at the MRI. If you see sign of disc degeneration or T2 high intensity zone or annular fissures, bingo, that will likely be the diagnosis. It's a fairly easy physical examination or a questionnaire that really will change your practice in a certain way.
The other thing also is that when you start to look into that, you see that some professions or some individuals will really tell you exactly what their issue is. We see, for instance, a lot of surgeons or a lot of individuals that tend to bend forward about 15 degrees. This is one of the angulations that will really stress more your posterior annulus and create pain on your disc. Once you understand the pathophysiology and how to stress the disc, it is a fairly straightforward physical examination or questionnaire to ask the patient.
[Dr. Jacob Fleming]
I agree. It's one of those things that once you start recognizing it, you realize just how common it is. Of course, there are cases where, like you said, you may have a combined discogenic and facetogenic picture. Those are a little bit odd because, yes, I have pain when I'm sitting, but other times I'll have pain if I'm extending and things like that. That's when you do have to recognize that there can often be multiple pain generators.
I would say far more cases where disc or the anterior column is the pain generator without the posterior column involved. Like you said, it's an easy questionnaire. I have to give shout out to probably my favorite, the greatest of all time, the goat of physical exam maneuvers, which is sustained hip flexion, is my favorite maneuver. All it is to have the patient lie on the exam table, help them bring their legs up to 90 degrees, and then ask them to slowly lower while you keep your hands there so they don't just completely fall over.
Basically, reproducing any sense of that pain while they're doing that with this slow, sustained hip flexion is a very good sign of anterior column pain. That's one that I love to incorporate into my perfunctory interventional radiologist physical exam. It's just one of those things, it's like, it's so simple, it does give you a fair bit of information.
[Dr. Olivier Clerk-Lamalice]
It's so simple. This test is fantastic. It is, even for us interventional radiologists, we're able to do it. Often you hear that radiologists are not doing physical examination, well, there you go, like every Tuesday, I'm evaluating about 45 patients for mixed axial low back pain to compression fracture, so we're doing it. I think once you start doing it, you become really good at it and you recognize pattern. We're good for pattern recognition in radiology. That's what we're doing here with physical examination.
I really enjoy it because I'm able to correlate, often we put in our reports or we used to, but try not to, to say correlated with clinical presentation. You can do it yourself. You can take a look, you can assess the patient and you take a look at the MRI. It's very valorizing and sometimes you're wrong and you learn from it. More frequently than not, you're right. Especially if you know how to read spinal imaging, you're going to be really good at determining what the issue is and orienting the patient in the right direction.
Those patients will be forever grateful because often they come to you and they've seen a bunch of other specialists. They don't really understand what's going on. Then you can find a solution for it.
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Evaluating & Treating Multi-Level Disc Degeneration
In the evaluation of multi-level disc degeneration accurately identifying the symptomatic level, (or levels) is critical to developing an effective, targeted care plan. This process begins with a detailed physical exam to help distinguish whether pain is localized to a single segment or distributed across multiple discs. Subtle findings during the exam, such as vertebrogenic pain on physical challenge or restriction in forward flexion, can help guide the clinician towards the likely pain generator.
Imaging also plays an important role in these diagnoses, particularly when evaluating diffuse disc degeneration and identifying specific locations for intervention. Imaging alone is often insufficient for diagnosis, especially in patients with widespread degenerative changes, but in cases like these diagnostic discography can help clarify the clinical picture. These discograms can be provocative or passive, but both can help elucidate symptom progression by disc level.
Once the symptomatic levels are identified, treatment planning begins by determining whether single level or multi-level treatment provides the most practical outcome for the patient. While theoretically it may be ideal to isolate a single pain generator, in practice, diffuse disease will often necessitate multi-level interventions, particularly when degeneration spans contiguous discs. When it comes to facet joint intervention, if multiple adjacent levels show degeneration and the patient describes broad, overlapping symptoms, it can be more effective to address all affected levels rather than focusing on just one. Having this ability to assess a combination of clinical pattern recognition, imaging interpretation and patient feedback during procedures is what ultimately can guide physicians to the most appropriate and effective treatment approach tailored to each individual patient.
[Dr. Jacob Fleming]
Completely agree. On that segue, talking about the actual imaging studies, one thing that comes up very frequently is figuring out what is the symptomatic level. Often we have patients, into their 70s or 80s who have, I call it pan lumbar disc degeneration, just all five lumbar discs are just gone basically. That's very difficult, especially if you're looking for a single level to treat, it probably is a multi-level type of thing.
There are cases where there are two or more symptomatic discs. There are some times when it's a slam dunk to say this is the symptomatic level, especially based on imaging findings like a high intensity zone, annular fissure, like you mentioned, or just out of proportion degeneration compared to the other discs. I would say you see this very frequently, especially in the 35 to 55-year-old crowd, on a four or five and or five, one disc that's a little bit or significantly out of proportion to the degeneration in the other discs.
That one or two has a very good chance versus there's basically a 0% chance that it's coming from the other discs. Could you tell us just a little bit about your approach to navigating the single level versus multi-level phenomenon?
[Dr. Olivier Clerk-Lamalice]
Again, it starts with physical examination. If it seems to arise from the anterior colon and you have one disc that is degenerated or you have a T2 high intensity zone, more likely than not, this is where it's going to be coming. If you have multiple discs that are degenerated, agreed, it can be challenging to determine which one is the source of pain. Again, you have subtle sign that can orient you in the right direction.
Often you will have to do discogram on all those levels or many of those levels. Although I don't really do the classic provocative discogram, I ask the patient while I inject a dye, if this correlates with where he has pain, he or she has pain. That's the a part. Then as the discs are degenerated at multiple levels, well, often I'll just treat all levels depending on the type of treatments that you're aiming for.
More forgotten than not, there's a little bit of a theoretical aspect of it to try to find where the pain generator is. If you have, just like when you're assessing facets joints, it's interesting to know if there's one facet joint that is more painful than the other. In reality, if you see osteoarthritis from L3 to S1 on the left side, well, more likely than not you will treat just all three levels rather than spending a lot of time trying to assess if there's one joint that is more painful than-- Tend to have a little bit the same approach with a disc, often I will first do that provocative aspect of it while I inject, and the other thing is recognizing, basically, there's some that have T2 high-intensity zone.
Other techniques also in imaging can be useful, but again, at this point, in my opinion, often you have a little bit of pain that will be coming, let's say, from the L3, L4, a little bit more at the L4, L5, and some, but almost none at L5, S1. What do you do in those cases? Do you just treat the more painful one, but you're still going to have 30% to 40% pain? More frequently than not, I take care of all levels there.
If you wanted to assess that further, well, first, an important point to make is that even in those Modified Pfirrmann grade five, without the high-intensity zone, when you do discogram. Without them, you will see tears. Even if you don't see the high-intensity zone, some of those discs can be highly painful. You cannot just rely on the T2 high-intensity zone to target discs. That's another reason why I tend to do more discogram based on the FIC presence of degeneration.
The Role of Spectroscopy in Identifying Target Discs in Multi-Level Degenerative Disc Disease
As clinicians navigate the complexities of multi-level degenerative disc disease, the need for precision in diagnosis and treatment planning has become increasingly important. MR disc spectroscopy represents a promising advancement for that space, offering insights into disc health on a molecular level. By identifying markers such as elevated lactate levels and altered proteoglycan to lactate ratios, spectroscopy can help reveal early degenerative changes that are often invisible on standard MR imaging. These biochemical signals can reflect reduced vascularity, metabolic stress, and progressive tissue breakdown, particularly in the nucleus pulposus.
Although MR disc spectroscopy has not yet been widely adopted, it has shown significant benefits in diagnostic strength when strategically applied. The diagnostic benefits are particularly notable when differentiating between multiple levels of degeneration or determining candidacy for regenerative or biological disc therapies. The noninvasive nature and metabolic specificity of MR spectroscopy make it especially useful in patients being considered for targeted interventions where precision matters most.
Even through the growing popularity of spectroscopy, traditional discography still remains a staple in clinical workflows, particularly when real time, correspondent pain reproduction is needed to confirm diagnosis before more invasive interventions. In practice most clinicians have adopted a hybrid approach, finding benefit from using advanced imaging to narrow down disc level targets and discograms to confirm findings. As treatment options continue to evolve, incorporating metabolic assays like MR spectroscopy into diagnostic algorithms can offer a more nuanced and patient centered approach to care, bridging the gap between imaging, diagnosis, and intervention in modern management of multi-level disc degeneration.
[Dr. Olivier Clerk-Lamalice]
The other modality that can be useful is spectroscopy. Spectroscopy also that we do can be useful also to determine if there's presence mainly of some lactate markers. Normally you're going to see a reversal of the ratio between proteoglycans and lactate. That can be useful as well. It does take time. We don't do it on every patient, but we do it sometimes whenever there's a good reason to be extremely precise within the disc that we want to treat.
[Dr. Jacob Fleming]
Thanks for that excellent overview. Thank you for the allusion to MR spectroscopy of the disc. This is one of my nerdy radiology interests I get really interested about. I remember I told one of my, one of my co-residents, who's one of the smartest people I know, he is a neuroradiologist now, but I mentioned to this, I had learned about it at ASSR a few years ago. It necessitates a show of its own, but basically I was telling my friend about this.
I'm like, oh yes, some people are using MR spectroscopy on the disc to look at the different ratios of molecules and meteors and figure out what is the symptomatic level. He was like, "No, they're not."
[Dr. Olivier Clerk-Lamalice]
Yes, he can.
[Dr. Jacob Fleming]
From a neuroradiologist.
[Dr. Olivier Clerk-Lamalice]
He totally can.
[Dr. Jacob Fleming]
That's silly. That doesn't make any sense.
[Dr. Olivier Clerk-Lamalice]
He totally can.
[Dr. Jacob Fleming]
To you and me and anyone who treats patients with low back pain, it's like, yes, that has the potential to be a real game changer. Of course, I think there are some situations, I don't have that available currently. I definitely, in the patient who has a multi-level disease, I opt for starting off with what I refer to as a shotgun approach. Basically you have a shotgun approach to discography where you inject all the discs and we'll get into the actual technique momentarily, but inject each of those levels. You look for a pain response at each level as well. That gives you more information, even though you're injecting all of them.
For example, I did a three-level discogram on a gentleman a few weeks ago, bottom three levels and similar situation to what we were discussing. When I injected four, five, he almost jumped off the table, despite the fact he was sedated. I knew he was exceptionally tender there. That gives me some more insight into, okay, he may be symptomatic from all three levels to a degree, but that one seems to, by and large. Still, I didn't know that beforehand.
I started off with the shotgun approach. That's pretty much, I think, what you and I have both been taught to do. The practice that I keep. I contrast that with, of course, what Dr. Beal refers to as the hunt and peck approach. That's basically when you are maybe moving towards doing something like an implant or a therapeutic injection, and you may do literally one level at a time and allow the patient to go through the formal process, recover from sedation, see if they feel better, and you can go down the list.
Honestly, it's been relatively few times that I've ever had to do that, where you inject a patient more than once. Usually there's other things like that, like the concordant pain response being related more to one level. I find that those things give you so much additional information that even though you start off with this challenging diagnostic test of figuring out what is the symptomatic level among many levels, if you start off with the shotgun approach, it will almost invariably lead you towards the answer. That's just my opinion.
Podcast Contributors
Dr. Olivier Clerk-Lamalice
Dr. Olivier Clerk-Lamalice is an interventional radiologist that specializes in interventional pain management and diagnostic imaging in Calgary, Canada.
Dr. Jacob Fleming
Dr. Jacob Fleming is a diagnostic radiology resident and future MSK interventional radiologist in Dallas, Texas.
Cite This Podcast
BackTable, LLC (Producer). (2025, February 4). Ep. 67 – Introduction to Treatment of Discogenic Back Pain [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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