Provocative cervical discographic symptom mapping

Abstract

Purpose of study: This was a prospective visual and statistical descriptive study of pain provocation of a cohort of subjects undergoing cervical discography. In a prospective study assessing 10 subjects, Schellhas compared cervical discography with magnetic resonance imaging. Within that study he reported on the distribution of pain for the C3–4 to C6–7 levels. Four years later, Grubb reported on his 12-year experience using cervical discography. The results concerning the regions of provoked pain by specific disc levels raised many interesting questions. When there is chest pain, is the C6–7 disc the only level implicated? Does head or facial pain emanate only from the C2–3 or C3–4 discs? Does cervical discogenic pain equally refer pain unilaterally as it does bilaterally? The objective of this study was to answer the aforementioned questions by formally mapping concordant pain referral patterns provoked during cervical discography.Methods used: Prospective multicenter design in which pain referral maps were generated of each disc level from patients undergoing a minimum of two-level cervical discography. If concordant pain was reproduced in a morphologically abnormal disc, the subject immediately completed a pain diagram. An independent observer interviewed the subject and recorded the location of provoked symptoms. Visual data were compiled using a body sector bit map, which consisted of 48 clinically relevant bodies. Visual maps with graduated color codes and frequencies of symptom location at each cervical disk level were generated.of findings: A total of 101 symptom provocation maps were recorded during cervical discography on 41 subjects. There were 10 at C2–3, 19 at C3–4, 27 at C4–5, 27 at C5–6, 16 at C6–7 and 2 at C7–T1. Predominantly unilateral symptoms were provoked just as often as bilateral symptoms. C2–3 discography provoked pain in the posterior neck 90% and suboccipital area 60% of the time. C3–4 discography provoked posterior neck pain 90% of the time, posterior inferior neck pain 79% of the time and suboccipital pain 26% of the time. C4–5 discography provoked pain in the face, anterior neck and chest; pain was provoked in each location 15% of the time. C5–6 discography provoked pain in the posterior neck (74%) and chest (19%). C6–7 provocation never resulted in anterior chest wall pain.Relationship between findings and existing knowledge: Our findings corroborated those reported by Grubb. Cervical discography provokes pain unilaterally just as often as Grubb reported that only C2–3 or C3–4 refers pain to head whereas Schellhas found that the C3–4 through C5–6 discs levels can refer pain to the head. In contrast, we observed that the C2–3, C3–4 and C4–5 discs provoked pain in the head. Interestingly the results of chest pain symptom reproduction were quite different than reported by Grubb and more consistent with that of Schellhas. We found that mid-cervical levels (C4–5 and C5–6) provoked pain in the chest, whereas the C6–7 disc provoked pain only in the interscapular, periscapular and upper arm regions. Finally, when upper extremity symptoms are described, the potentially involved disc levels include C3–4 through C6–7, which does not correlate with the results obtained from either Grubb or Schellhas.Overall significance of findings: The results of this study allow the spine clinician to make accurate assumptions about probable disc level involvement by considering the location of symptom manifestation. For example, the patient who describes only upper neck and occipital pain requires at maximum a four-level discogram; C2–3, C3–4, C4–5 and control level.Disclosures: No disclosures.Conflict of interest: No conflicts.