Chronic back pain has nine common structural and functional causes: annular tears, degenerative disc disease, herniated discs, facet joint arthritis, sciatica, spinal stenosis, sacroiliac joint dysfunction, muscular imbalance, and failed back surgery syndrome. Identifying the correct cause is the first step toward a targeted, non-surgical treatment plan.
Back pain is the leading cause of disability worldwide, and roughly 30% of U.S. adults report recent low back pain. When pain persists beyond twelve weeks, it crosses into chronic territory — and the right treatment depends entirely on the right diagnosis. This guide covers the nine most common drivers of chronic back pain evaluated at Valor Spine and explains how each is typically addressed without surgery. For a complete map of conservative options, see our non-surgical spine treatment guide, or compare specific approaches in our non-surgical spine treatment comparison.
If you are weighing alternatives to fusion specifically, our spinal fusion alternatives hub covers the broader decision framework. The list below is ordered by how often each cause appears in chronic-pain consultations. For a deeper look at the anatomy involved, see What Is the Lumbar Spine? and What Is Chronic Low Back Pain?
Comparison: Chronic Back Pain Causes at a Glance
| Cause | Pain Pattern | Common Imaging Finding | First-Line Non-Surgical Approach |
|---|---|---|---|
| Annular tears | Deep, axial low back pain | HIZ on MRI, disc fissure | Intra-annular fibrin injection |
| Degenerative disc disease | Stiffness, activity-related ache | Disc height loss, dehydration | Biologic disc repair, physical therapy |
| Herniated disc | Radiating leg pain | Focal disc protrusion | Physical therapy, fibrin disc treatment |
| Facet arthritis | Pain with extension/rotation | Facet hypertrophy | Targeted injections, physical therapy |
| Sciatica | Buttock-to-leg radiation | Nerve root compression | Conservative care; fibrin procedure if disc-driven |
| Spinal stenosis | Pain with standing/walking | Central or foraminal narrowing | Decompression-based physical therapy |
| SI joint dysfunction | Unilateral low back/buttock pain | Often normal MRI | SI-targeted physical therapy, injections |
| Muscular imbalance | Diffuse, postural pain | None on imaging | Structured rehabilitation |
| Failed back surgery | Recurrent post-op pain | Hardware, adjacent segment changes | Biologic disc repair when indicated |
1. What Are Annular Tears and Why Do They Cause Chronic Pain?
Annular tears are fissures in the tough outer ring of the spinal disc, and they are one of the most under-diagnosed sources of chronic axial low back pain. Routine MRI reports often note them in passing without connecting them to a patient’s symptoms.
Tears allow inflammatory mediators from inside the disc to reach pain-sensitive nerve fibers in the outer annulus. Because the tear itself remains open, conservative treatments that reduce inflammation temporarily rarely produce lasting relief.
- Pain is typically deep, central, and worse with sitting or sustained bending
- High-intensity zones (HIZ) on T2-weighted MRI are a classic imaging sign
- Annular tears are the direct structural target of the intra-annular fibrin injection
- Conservative care alone often fails when the tear remains unsealed
Clinical bottom line: When imaging confirms an annular tear and conservative care has stalled, a clinical evaluation is the only way to know for certain whether biologic disc repair is an appropriate next step. For a deeper look at the anatomy involved, see What Is the L4-L5 Disc?
2. How Does Degenerative Disc Disease Become a Source of Chronic Pain?
Degenerative disc disease (DDD) describes the gradual dehydration, height loss, and structural wear of one or more spinal discs. It is not a disease in the traditional sense — it is a wear pattern that becomes painful when the disc loses its ability to absorb load and small tears develop in the annulus.
- Morning stiffness and achiness after prolonged sitting are common presentations
- Activity-related aching that eases with light movement is a hallmark pattern
- Imaging shows reduced disc height and dark, dehydrated discs
- DDD frequently coexists with annular tears, which drive the ongoing pain signal
Clinical bottom line: The structural changes of DDD are permanent, but the pain component is often addressable through biologic repair of the underlying tears combined with targeted rehabilitation.
3. When Does a Herniated or Bulging Disc Require More Than Conservative Care?
A herniated disc occurs when inner disc material pushes through a tear in the annulus and contacts a nerve root. The good news: roughly 80–90% of sciatica cases driven by disc herniation improve without surgery.
- Radiating pain, numbness, or weakness in the leg or arm follows a clear nerve root distribution
- Most herniations resolve with time; the underlying annular tear may not
- Sealing the annular tear through the fibrin procedure is designed to reduce the risk of recurrent herniation
- Surgical intervention is reserved for progressive neurologic deficits — not pain alone
Clinical bottom line: For patients who have tried conservative care for three or more months without lasting relief, biologic disc repair addresses the structural source rather than the symptom.
4. What Makes Facet Joint Arthritis a Driver of Chronic Low Back Pain?
The facet joints are paired joints at the back of each spinal segment. They develop arthritic changes from years of asymmetric load and movement. Facet pain is a frequent driver of chronic low back pain in older adults and in patients who have had prior spinal fusion.
- Pain worsens with extension, rotation, or prolonged standing
- Often localized to one or both sides of the spine, not into the leg
- Diagnostic medial branch blocks confirm the source
- Targeted injections and motion-control rehabilitation are the clinical mainstay
Clinical bottom line: Facet-driven pain rarely requires surgery. For more, see What Is Lumbar Facet Syndrome? and What Is Spinal Osteoarthritis?
5. What Is Sciatica and When Is It Disc-Related?
Sciatica is pain that radiates along the sciatic nerve path — typically from the lower back through the buttock and down one leg. Most cases trace back to disc pathology: a herniated disc or collapsed disc space compresses the nerve root.
- Pain, tingling, or numbness follows one leg, often below the knee
- Sitting, coughing, or sneezing can worsen symptoms
- 80–90% of disc-driven sciatica cases resolve without surgery (AAFP / Cochrane review)
- For patients whose sciatica is driven by an annular tear, the fibrin procedure targets the structural source
Clinical bottom line: Conservative care is the right first move. When sciatica persists and imaging points to disc pathology, a clinical evaluation is the only way to determine whether biologic disc repair is appropriate.
6. How Does Spinal Stenosis Contribute to Chronic Back and Leg Pain?
Spinal stenosis is a narrowing of the spinal canal or nerve root exits (foramina) that compresses the spinal cord or exiting nerves. It develops gradually from disc degeneration, bone spurs, and thickening of the ligamentum flavum.
- Classic symptom: neurogenic claudication — leg pain or heaviness that worsens with walking and eases when leaning forward or sitting
- Symptoms are bilateral in many cases
- Conservative care including decompression-based physical therapy is the first-line approach
- When stenosis is driven partly by disc collapse, addressing the disc may reduce pressure on the canal
Clinical bottom line: Stenosis severity and symptom pattern together determine the appropriate treatment path. See What Is Ligamentum Flavum Hypertrophy? for one of its most common structural contributors.
7. What Is Sacroiliac Joint Dysfunction and How Is It Different from Disc Pain?
Sacroiliac (SI) joint dysfunction occurs when the joint connecting the sacrum to the pelvis becomes inflamed, hypermobile, or hypomobile. It is often misattributed to disc pathology because MRI of the lumbar spine appears normal.
- Pain is typically unilateral — one-sided low back and buttock pain that does not follow a nerve root pattern
- Provocative physical exam tests (FABER, FADIR, thigh thrust) are diagnostically important
- SI-targeted injections and stabilization-focused physical therapy are the primary treatments
- SI pain is outside the scope of disc-repair procedures
Clinical bottom line: Accurate diagnosis is essential before any treatment decision. For a full overview, see What Is Sacroiliac Joint Dysfunction? and What Is the Sacroiliac Joint?
8. Can Muscular Imbalance Cause Chronic Back Pain Without a Disc Problem?
Yes. Muscular imbalance — patterns of overactive and underactive muscles around the lumbar spine — can produce persistent pain without any disc abnormality on imaging. It is a functional problem rather than a structural one.
- Pain is typically diffuse and postural, worsening with prolonged postures
- Imaging is normal or shows only age-related changes
- Physical therapy addressing core stability, hip strength, and movement mechanics is the definitive treatment
- This pattern does not involve disc pathology and is outside the scope of fibrin-based procedures
Clinical bottom line: Structured rehabilitation is effective when muscular imbalance is the primary driver. A clinical evaluation clarifies whether a disc component is also present. See What Is Lumbar Lordosis? for related postural anatomy.
9. What Are the Options After Failed Back Surgery?
Failed back surgery syndrome (FBSS) describes persistent or recurrent pain after spinal surgery — most often fusion or discectomy. It is more common than patients are told: back surgery carries roughly a 40% failure rate by some estimates in the peer-reviewed FBSS literature.
- Pain may arise from adjacent segment degeneration, scar tissue, or untreated annular tears at non-fused levels
- Patients are often told that more surgery is the only remaining option
- Among outcome data for fibrin procedures, 80% of patients who had failed prior back surgery reported positive outcomes — individual outcomes vary
- A comprehensive evaluation after failed surgery looks at which discs remain untreated and whether annular repair is feasible
Clinical bottom line: Failed surgery does not mean no options remain. For patients who have had prior spine surgery without resolution, a clinical evaluation is the only way to know whether biologic disc repair addresses the remaining structural source. See What Is Lumbar Instability? for a related structural concern common in post-surgical patients.
Clinical Note
One pattern the Valor team sees regularly: a patient arrives with imaging that lists four or five findings — disc degeneration, a small herniation, mild stenosis, facet changes — and has been told by multiple providers that the source is unclear. The evaluation challenge is not cataloging what MRI shows; it is identifying which finding is actually generating the pain signal. In many of these cases, an unsealed annular tear is the driver that has been noted but not targeted. The clinical conversation we have with these patients is the same one we’d have in our office: what has been tried, what has worked partially, and what the imaging actually shows about disc integrity.
Frequently Asked Questions
What is the most common cause of chronic low back pain?
Annular tears in the disc wall are among the most frequent drivers of chronic axial low back pain, particularly in patients who have not found lasting relief from physical therapy or injections. They are often visible on MRI but not identified as the primary pain source without a targeted evaluation.
How do doctors diagnose the cause of chronic back pain?
Diagnosis combines a detailed clinical history, physical examination findings, and imaging — typically MRI. In cases where disc pathology is suspected but the MRI report is inconclusive, a diagnostic annulogram (an imaging-guided dye injection into the disc) can identify every tear and leak before treatment decisions are made.
Can chronic back pain from disc problems be treated without surgery?
For many patients, yes. Physical therapy, targeted injections, and — for disc-driven pain — the intra-annular fibrin injection are all non-surgical options. The fibrin procedure uses an FDA-approved fibrin sealant delivered under imaging guidance to seal annular tears. Whether a given patient is a candidate depends on clinical evaluation; individual outcomes vary.
What is Failed Back Surgery Syndrome?
Failed Back Surgery Syndrome (FBSS) refers to persistent or recurrent spinal pain after one or more surgeries. It occurs in a meaningful proportion of surgical patients and may result from adjacent segment degeneration, scar tissue, or untreated disc tears at non-fused levels. Non-surgical options, including biologic disc repair, exist for select patients with FBSS.
Is sciatica always caused by a disc problem?
Not always, but disc pathology — herniation or annular tear with nerve root involvement — is the most common structural cause of true sciatica. Other causes include spinal stenosis, piriformis syndrome, and SI joint dysfunction. A clinical evaluation distinguishes the source and guides the appropriate treatment path.
How long does back pain need to last before it is considered chronic?
Pain lasting beyond twelve consecutive weeks is the standard clinical threshold for chronic back pain. At that point, spontaneous resolution becomes less likely, and a more thorough diagnostic evaluation to identify the structural source is appropriate.
Are veterans with chronic back pain eligible for the fibrin procedure through the VA?
Under the Mission Act, the procedure may be a covered VA benefit when the VA cannot provide timely or appropriate care. VA coverage is determined case-by-case by the VA, not by Valor Spine. The Valor team works directly with VA referral coordinators to handle the paperwork so veterans do not have to navigate the process alone.
This content is for general informational purposes only and does not constitute medical advice, diagnosis, or treatment. It is not a substitute for evaluation by a qualified physician. Treatment decisions depend on your individual medical history and clinical findings. Schedule a consultation to discuss whether the procedure is right for you.
The fibrin sealant used in the procedure is FDA-approved as a sealant. Specific clinical applications, candidacy, and outcomes vary by patient.
VA coverage is determined case-by-case under Mission Act criteria by the VA, not by Valor Spine. Valor coordinates the referral process; the VA makes coverage decisions.
