What is the treatment for annular tearing?

Treatment of Annular Tearing (Intervertebral Disc)

Initial Management Approach

Conservative management with physical therapy and pain control should be the first-line treatment for annular tears, as most lumbar disc herniations and annular tears improve over time with or without medical intervention. 1

• The majority of annular tears are asymptomatic and can be found in patients without any symptoms, making aggressive early intervention unnecessary 1
• Conservative therapy should be attempted for at least 6 months before considering more invasive options 2
• Physical therapy combined with at least 4 invasive treatments (such as epidural corticosteroid injections or radiofrequency neurotomies) should be exhausted before proceeding to advanced interventional treatments 2

When Conservative Treatment Fails

For patients with chronic discogenic low back pain (lasting >6 months) who have failed conservative management, the following interventional options can be considered:

Regenerative Medicine Approaches

Intra-annular fibrin bio-adhesive sealant has demonstrated significant long-term efficacy for treating symptomatic annular tears, with sustained improvement in pain and function for up to 3 years. 2

• Fibrin sealant works by immediately integrating into disc defects as a bio-adhesive, sealing annular tears and facilitating new disc tissue growth 2
• At 12-month follow-up, 50% of patients achieved minimal clinically important differences in disability scores 2
• This treatment showed effectiveness even in patients who had failed multiple prior treatments including discectomy, fusion, platelet-rich plasma (PRP), or bone marrow aspirate 2
• Significant improvements were demonstrated in Oswestry Disability Index, visual analog scale pain scores, and PROMIS mental and physical scores at 1,2, and 3-year follow-ups 2

Alternative Regenerative Options

• Platelet-rich plasma (PRP) and bone marrow aspirate (BMC) injections can be considered, though they lack fibrin's bio-adhesive properties and may have lower success rates 2
• These treatments should be attempted before considering surgical intervention 2

Important Clinical Considerations

Prognostic Factors

The presence of an annular tear alone does not predict accelerated disc degeneration, which should inform treatment decisions and patient counseling. 3

• In discs with Pfirrmann grade >2, only 25% of discs with annular tears showed progression of degeneration over 4-5 years, similar to the 22% progression rate in matched control discs without tears 3
• Age-related disc degeneration begins early in adulthood and progresses regardless of annular tear presence 4

Workplace and Mechanical Factors

• Common workplace stresses contribute to annular tears: compression, torsion, combined compression with flexion, and vibration 4
• Acute trauma may produce disc herniation with or without predisposing degenerative factors 4

Treatment Algorithm

1. First 6 months: Conservative management with physical therapy and pain medications 1, 2

2. 6 months to 1 year: If symptoms persist, proceed with minimally invasive interventions:

   • Epidural corticosteroid injections
   • Radiofrequency neurotomies
   • Consider PRP or BMC injections 2

3. After failed conservative and minimally invasive treatments: Consider intra-annular fibrin sealant for patients with:

   • Chronic low back pain >6 months
   • Failed at least 4 prior invasive treatments
   • MRI-confirmed annular tears corresponding to symptom location
   • No contraindications (carcinoma, fracture, instability, severe stenosis) 2

4. Surgical consideration: Reserved only for patients with severe symptoms who have failed all conservative and regenerative approaches, though surgery (discectomy/fusion) may accelerate adjacent disc degeneration 2

Common Pitfalls to Avoid

• Do not pursue aggressive treatment for asymptomatic annular tears found incidentally on MRI, as these are common in pain-free individuals 1
• Avoid premature surgical intervention, as discectomies weaken discs and fusions cause damage to adjacent discs, both accelerating degeneration 2
• Do not assume annular tears will inevitably progress to severe degeneration, as evidence shows similar progression rates compared to discs without tears 3