Lumbar disc degeneration (LDD) represents a cause of the low back pain (LBP) [1]. A strong correlation between the severity of degeneration and LBP has not been established. Some studies have found a relationship between the radiological findings of LDD and LBP [2], while others indicate a high prevalence of abnormal radiological changes in asymptomatic individuals [3, 4]. A substantial inter-individual variation among LDD patients with regard to the pain sensitivity and the requirement of post-operative analgesia has been recognized. Thirty five to 68 percent of the LBP susceptibility has been reported to be accounted for by the genetic factors [5].

Variation in certain genes encoding proteins involved in pain modulation, transduction, transmission, and conduction pathways (pain-genes), could be helpful in classifying the LDD patients experiencing varying degrees of pain. With regard to the variation in human pain phenotypes, associations have been reported with single nucleotide polymorphisms (SNPs) in genes coding for catechol-O-methyltransferase (COMT), opioid receptors (OPRM1, OPRD1), transient receptor potential (TRPV1, TRPA1), fatty acid amide hydrolase (FAAH) and α-subunit of voltage gated sodium channel (SCN9A)[6–11]. Among these, COMT gene variations (more than 30 SNPs) are the most studied in both human and experimental models.

COMT is an enzyme that mediates the O-methylation of certain catecholic pain pathway neurotransmitters including catecholamines (adrenaline and noradrenaline), dopamine, catecholestrogens and their hydroxylated metabolites [12–14], thereby eliminating their biological activity and toxicity. COMT is highly expressed in liver, kidney, brain, adrenal and lungs [15]. Although the exact mechanism is unclear, it has been proposed that it acts by effecting the adrenergic, noradrenergic and dopaminergic pain modulating and processing mechanisms [16, 17].

The COMT gene is located on chromosome 22q11.2 [18]; with a 1.3 kb transcript producing the low affinity soluble S-COMT and a 1.5 kb transcript producing both soluble and high affinity membrane bound MB-COMT[15]. Polymorphisms of the COMT gene have been shown to contribute to the inter-individual variations in sensitivity, severity and chronicity of pain as well as its response to analgesics [8, 19]. Pain intensity is also influenced by psychological factors and use of pain medication. Anxiety and depression are often associated with chronic pain [20].

The most studied COMT SNP (rs4680. Val 158Met) is located in the coding region, where a non-synonymous A to G single nucleotide change causes replacement of valine (Val) to methionine (Met) at codon 158 in MB-COMT and 108 in S-COMT[21]. Met158 has lower thermo-stability and hence a decreased enzyme activity at normal body temperature as compared to the Val 158 [22]. With regard to the genotypes, it has been shown that Val 158 homozygous individuals have three-fourfold increased activity of COMT compared to the Met 158 homozygotes, and an intermediate COMT activity with heterozygotes [23]. The COMT activity showed an inverse correlation with pain sensitivity. It has also been reported that in response to muscular pain, individuals homozygous for the 158Met allele possessed decreased activation and higher density of μ-opioid receptors in brain compared to 158Val homozygotes [24]. In another study involving cancer pain patients, it was reported that 158Val homozygotes required a 50% higher morphine dose than the 158Met homozygotes in [25].

An allele at another coding COMT polymorphism rs6267, also encodes a substantially less active enzyme but its prevalence is much lower [26]. In the non-coding region of the COMT gene, rs2075507 has been shown to impart a minor effect on the enzyme activity through altering mRNA expression [27].

A recent study found an association of a COMT SNP rs4633, as well as of a haplotype containing rs4633, rs4680, rs6269 and rs4818 with greater improvement in 1 year post-operative Oswestry Disability Index (ODI) score in patients who had fusion for persistent LBP [28].

On the basis of variation in experimental pain sensitivity; a study has identified a high pain sensitivity (HPS) or low COMT activity haplotype, a low pain sensitivity (LPS) or higher COMT activity haplotype, both including the similar amino acid sequence of Val 158Met polymorphisms and differing in a synonymous SNP [8]. The APS/HPS diplotype causing the low COMT activity was also found to be associated with higher pre-operative pain scores and increased risk for post-operative pain [29].

In light of the broad spectrum of pain ratings in patients with LDD treated for LBP, we aimed to investigate the effect of the genetic variation in COMT gene on the pain and disability scores among patients treated with lumbar instrumental fusion or cognitive intervention and exercises.

In the present study we found significant associations between the COMT polymorphisms rs4633 and rs4680 (Val 158Met) and pain reduction at long term follow-up among fused and non-fused patients with chronic LBP. The polymorphism rs4633 was in complete linkage disequilibrium (LD) with rs4680 and hence showed similar results.

Dai et al were the first to test the association between COMT variants and surgical outcome with regard to pain and disability in 69 patients with lumbar fusion. They reported an association between improvement in ODI score and both a single marker (rs4633) and a COMT haplotype [28]. Our results are in line with Dai et al. with regard to the associations observed between success of treatment and rs4633 but do not replicate their findings, as our associations were with pain reduction and not with ODI. In addition we reported association for rs4680 as well, which was not found in the study by Dai et al.

Although the pain genes could only explain 3.0% of the variance in pain change, association remained significant after adjustment for covariates. The most important covariates were the reported use of pain medication and anxiety and depression at follow-up, as the explained variance increased from about 11% for the pain gene with age, gender and treatment to about 31% with addition of pain medication and anxiety and depression. Twice as many fused patients (51%) used analgesics daily at follow up, compared with the cognitive intervention and exercises (24%) and although the co linearity and correlation statistics was acceptable for performing multiple regression analysis, fusion was both negatively (with pain medication) and positively associated with change in pain (Table 3). The observed associations suggest that it seems unlikely that treatment responses can be predicted solely by the analysis of COMT gene polymorphisms and it may be recommended to assess the influence of candidate genes for both disc degeneration and pain in a larger cohort.

In the present study the largest improvement was observed for A/G heterozygous patients using the recessive genetic model. These results are contrary to the dose effect of the SNP and along with lack of association observed in the additive model, suggest that the effect is not increasing. Studies have shown that the three genotypes of the rs4680 influence the human experience of pain differently, with Met/Met homozygous patients being more pain sensitive compared to the Val/Val and those heterozygous possessed an intermediate pain sensitivity [24]. Increased enzyme activity is inversely related with the pain sensitivity and it has been reported that Val/Val homozygotes produce an effective enzyme and vice versa, while the heterozygotes express an intermediate COMT activity [14]. Lotsch et al. reported that carriers of Val/Val alleles were more sensitive to pain compared to the non carriers [43]. The present findings of a larger pain reduction in heterozygous individuals after stratification according to genotypes, does not fit with the already reported results. Frequency of Val/Met heterozygotes was much higher in our sample compared to Val/Val and Met/Met homozygotes. Due to a small sample size the findings could be false and by chance as we have not observed pain improvement in homozygous individuals which should have been in line with assumed functional effect of the enzyme. A case control study involving 61 Turkish fibromyalgia patients has previously reported a higher frequency of Val/Met heterozygotes [44] and also an association between individuals heterozygous for COMT gene polymorphisms rs464312 and rs6269 and pain sensitivity has previously been reported [10].

The association observed in the present study was with change in pain scores at long term follow-up, while Dai et al. have assessed the change at 1 year and in contrast to our findings Dai et al. reported a greater improvement with rs4633 homozygotes and an intermediate improvement with heterozygotes. In the present study change in ODI and VAS LBP were moderately correlated (r ² = 0.6) and therefore it is not unlikely to detect an association with one variable and not with the other. Contrary to Dai et al. who reported a significant association between a haplotype involving rs4633, rs4680, rs6269 and rs4818 and greater improvement in ODI score, our associations for similar haplotypes did not reach statistical significance neither for ODI nor for pain change. This is despite the fact that we have found association for two individual SNPs i.e. rs4680 and rs4633, which were also a part of this haplotype. Diatchenko L et al have also reported that as a single SNP, rs4680 was not associated with pain sensitivity despite possessing the same amino acid sequence as part of different haplotypes possessing different COMT activity and pain sensitivities [8]. These minor discrepancies could be due to population differences in LD and haplotype structures. The contrasting results make it difficult to establish the true genotypic effect. Nevertheless both these studies support the polymorphism as being associated. Genetic studies ideally require a large patient number that can tolerate the correction for multiple testing in order to avoid false positive results. Patient sample of the present study is larger as compared to Dai et al. and included fused and non-fused patients.

The mechanism of pain modulation is complex and many studies have either failed to show any associations between COMT variation and pain sensitivity [45, 46], while other studies have found an association with pain sensitivity and variation in dosage requirement of morphine in cancer pain patients [25].

Inclusion of covariates in the analysis and homogeneity with regard to genetic make up and ethnicity are the strengths of this study. The distribution of different genotypes of rs4680 (A/A, A/G and G/G) was homogenous among both surgical and cognitive-exercise group (p = 0.6), and hence there was no evidence for selection bias on the basis of genetic make up among patients treated by the two different modules.

The conservative estimate for smallest difference for VAS LBP change was set at 17.4 in this study. Despite having limitations of sample size and being underpowered, this study gives suggestion towards the direction in which future research should head in examining the different clinical phenotypes related to patients with lumbar disc degeneration.

LBP is a major cause of disability among the population of the industrialized world, in turn leading to a socio-economic deterioration [47]. The pathogenesis and etiology of lumbar disc degeneration is complex regarding both degenerative process and patient’s symptomatology with regard to pain and disability. Radiologically assessed changes in the discs may or may not cause pain [48] and there is a visible variation in the patient outcomes after treatment. Thus, there is an indication and need for spine researchers to expand their knowledge at the molecular level, with regard to genetics of the degeneration of the lumbar discs and an inter-individual difference in pain sensitivity following the treatments.

Co-morbidity in patients with LBP has also been reported. Hagen et al, reported that pain was more often located to the whole spine (not just the lower back), legs and head, in patients with LBP as compared to the normal healthy controls [49]. Another study reported an increased prevalence of subjective health complaints in patients suffering from sciatica due to a herniated disc, compared to the normal healthy population [50]. These findings suggest a role of underlying genetic factors related to the pain sensitivity and perception that can predispose the patient to chronic pain, not just in the lower back but in other parts of the body as well. Previous studies have focussed on disc degeneration and genetics to reveal spine specific risk factors, while the focus on the role of pain genetics in the clinical outcome of LBP patients has been lacking.

This study reports an association between variation in the pain gene COMT and reduction in pain in patients with LBP and lumbar disc degeneration at long term follow-up. Our findings suggest that genetic variants of COMT gene may contribute to describe the success of treatment, but that psychosocial factors might be more important. These results warrant replication in large samples with testing for other pain related genes, which in turn may help explain the inter-individual variation and contribute to more predictable treatment outcome.