Cervical Discography Research Articles

Provocative cervical discographic symptom mapping

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.

Cervical discography: clinical implications from 12 years of experience.

Positive pain responses provoked in an inclusive series of cervical discograms performed over a 12-year period were categorized by level and reviewed. To report the prevalence of cervical pathology over an entire series of patients, to determine whether a reproducible pattern of concordant pain could be associated with each symptomatic level identified, and to calculate the rate of complications. Cloward wrote the first articles explaining the technique of cervical discography and reported on the pain responses induced. Currently, the technique is viewed as an invaluable diagnostic tool, but it also is criticized for failing to contribute unique information beyond that available from imaging studies despite the inherent risks. A series of 173 cervical discograms performed over 12 years was examined. Pain responses provoked and recorded during discography were grouped by disc level and examined for recurring patterns. The prevalence of disc pathology was calculated. In all, 807 discs were injected, and 404 concordant pain responses (50%) were elicited. Three or more abnormal disc levels were identified in more than half of the patients. Complications developed in four patients (2.3%). No further complications were reported. Surgical treatment was indicated as viable in only 35 studies. Discography is a safe and valuable diagnostic procedure showing characteristic pain patterns that may have clinical significance. In more than half of the studies, three or more levels were identified as pain generators, suggesting that treatment decisions based on information from fewer discs injected during discography may be tenuous.

The relation between cervical discographic pain responses and radiographic images.

The purpose of this study was to investigate the relation between cervical discographic pain responses and radiographic images. Records were reviewed for a series of patients who had undergone cervical discography. All patients were being treated at a spine specialty clinic. A total of 269 discs were studied in 161 discographic procedures in patients with neck, shoulder, or arm pain. All patients underwent other diagnostic procedures before discography, including magnetic resonance imaging, computed tomography (CT), and CT/myelography. During the injection of contrast in each disc evaluated, the patient was asked if any pain was felt, and if so, was it similar or dissimilar to the pain typically experienced. Results were determined by analyzing the pain responses during disc injection with respect to imaged pathology seen on the axial CT discographic image of the disc. Results were further analyzed based on patient age. There was a significant relation between the radiographic image of the disc and the results of clinical pain provocation (p < 0.01; chi2). Among the 35 discs appearing as normal, clinical pain was provoked in only 14.3%. Among the 234 discs appearing as abnormal, clinical pain was provoked in 77.8%. The mean age of the patients with painless radiographically abnormal discs was significantly greater than that of the patients in the other subgroups of the study population. There was good agreement between the radiographic appearance of the disc and the pain provocation results. Discs that were painless but disrupted were found among older patients. Among such patients, discography may be particularly helpful in differentiating clinically significant abnormalities from those associated with aging.

Thoracic discography in healthy individuals. A controlled prospective study of magnetic resonance imaging and discography in asymptomatic and symptomatic individuals.

A prospective case-control investigation. To determine the responses to thoracic discography of asymptomatic individuals. Literature regarding lumbar and cervical discography reveals that even morphologically abnormal discs often are not painful, whereas painful discs typically exhibit anular or endplate disruption. Ten adult lifelong asymptomatic volunteers, ages 23 to 45 years, underwent magnetic resonance imaging of the thoracic spine, followed by four-level discography. Provocative responses were graded on a scale of 0 (no sensation) to 10 (extreme pain or pressure), and filmed discs were graded using a modified Dallas scheme. Concomitantly, 10 nonlitigious adults (6 men and 4 women, ages 31 to 55 years) experiencing chronic thoracic pain were similarly studied as a control group. The mean pain response in the asymptomatic volunteers was 2.4/10. Three discs were intensely painful (scores of 7/10, 8/10, 10/10), with all three exhibiting prominent endplate irregularities and anular tears typical of thoracolumbar Scheuermann's disease. On discography, 27 of 40 discs were abnormal, with endplate irregularities, anular tears, and/or herniations. Ten discs read as normal on magnetic resonance imaging showed anular pathology on discography. In the group with chronic thoracic pain, the average pain response was 6.3/10 (P < 0.05). Of the 48 discs studied, 24 were concordantly painful, with a pain response of 8.5/10 (P < 0.05); 17 had nonconcordant pain/pressure, with an average pain of 4.8/10 (P < 0.05); and 5 had no response. On magnetic resonance imaging 21 of the 48 discs appeared normal. However, on discography, only 10 were judged as normal. On discography, thoracic discs with prominent Schmorl's nodes may be intensely painful, even in lifelong asymptomatic individuals, but the pain is unfamiliar or nonconcordant. Thoracic discography may-demonstrate disc pathology not seen on magnetic resonance imaging.

Complications of Cervical Discography

The use of cervical discography remains controversial. Recently in a small patient group, a high complication rate was reported. The purpose of this study was to determine the incidence of complications associated with cervical discography. Data from 161 cervical discography procedures, involving 269 disc injections, were recorded. There were four complications; thus the complication rate was 2.48% based on the number of procedures and 1.49% based on the number of disc injections. The complications were two cases of discitis, one postinjection hematoma, and one patient developed significant headache pain after the disc injection. Reports of high complication rates associated with cervical discography and serious outcomes from them should serve as a warning that the procedure does have associated risks, and great care is warranted. However, based on the results of our study, discography is not an inherently unsafe procedure. It can be accomplished with few complications when performed in sterile conditions by those well experienced with cervical disc injections.

Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers.

Asymptomatic subjects and chronic head/neck pain sufferers were studied with high-field magnetic resonance imaging and cervical discography to compare and correlate both tests. To assess the accuracy of magnetic resonance imaging and discography in identifying the source(s) of cervical discogenic pain. Previous retrospective studies describe a generally poor correlation between magnetic resonance imaging and provocative discography in the cervical spine. Ten lifelong asymptomatic subjects and 10 nonlitigious chronic neck/head pain patients underwent discography at C3-C4 through C6-C7 after magnetic resonance imaging. Disc morphology and provoked responses were recorded at each level studied. Of 20 normal discs by magnetic resonance from the asymptomatic volunteers, 17 proved to have painless anular tears discographically. The average response per disc (N = 40) for this group was 2.42, compared to 5.2 (N = 40) for the neck pain group. In the pain patients, 11 discs appeared normal at magnetic resonance imaging, whereas 10 of these proved to have anular tears discographically. Two of these 10 proved concordantly painful with intensity ratings of at least 7/10. Discographically normal discs (N = 8) were never painful (both groups), whereas intensely painful discs all exhibited tears of both the inner and outer aspects of the anulus. Significant cervical disc anular tears often escape magnetic resonance imaging detection, and magnetic resonance imaging cannot reliably identify the source(s) of cervical discogenic pain.

Complications of Cervical Discography

Complications of Cervical Discography

Complications of cervical discography: analysis of 4400 diagnostic disc injections.

Despite extensive experience with diagnostic cervical disc injection, the role of this procedure in the evaluation of patients with degenerative disc disease and severe neck pain remains controversial. Beyond the debate regarding its efficacy in identifying the site of cervical symptomatology and directing appropriate intervention are the potential morbidity and mortality associated with this diagnostic procedure. Discitis, subdural empyema, spinal cord injury, vascular injury, and prevertebral abscess have all been reported as complications of diagnostic cervical disc injection. Any meaningful assessment of the role of cervical discography in the evaluation of degenerative disc disease must include a determination of the risks inherent in the procedure. We retrospectively analyzed 4400 cervical disc injections in 1357 patients performed by an experienced radiologist between 1988 and 1993 to define the morbidity and mortality associated with discography. In addition, we reviewed the extant medical literature on the complications of this controversial procedure. This study demonstrates significant complications from diagnostic discography procedures occurring in less than 0.6% of the patients and 0.16% of the cervical disc injections.

A correlation of cervical magnetic resonance imaging and discography/computed tomographic discograms.

The morphology of sagittal T2-weighted magnetic resonance imaging (MRI) of the cervical spine was correlated with provocative discography and subsequent computed tomography (CT) discograms in 52 patients with discogenic pain. The authors determined if the morphology of cervical spine discs, as seen on MRI, correlates with discography/CT discograms in patients with discogenic pathology. Several studies have demonstrated a correlation between MRI and discography in the lumbar spine. No studies have attempted to show if this relationship exists in the cervical spine region. The morphology of cervical T2-weighted MRI was characterized with regard to the disc nuclear signal and posterior anulus status. Provocative discography was evaluated with regard to positive or negative responses. Computed tomography was performed after discography on each patient. There was no correlation between pain response or morphology as seen on either discography or CT discography. A significant correlation was found between abnormality as seen on MRI and pain response on discography but the false-positive and false-negative rates were high. Our results suggest that several MRI patterns correlate well with positive or negative cervical discography responses while several other patterns are equivocal. Magnetic resonance imaging is a useful adjunct to cervical discography but there are some MRI patterns that cannot be considered pathologic, and discography is required to diagnose discogenic pain syndrome.

Cervical discography in discogenic pain syndrome and its predictive value for cervical fusion.

We have reviewed 27 patients who underwent fusion of a total of 39 cervical levels for discogenic pain syndrome. All patients were diagnosed by positive discography defined as provocation of their characteristic pain on a Adams type 3-5 contrast distribution pattern. The mean age of the patients was 46.4 years and the follow-up averaged 16.2 months (range 9-42 months). Fusion was performed through a ventral approach with the use of an iliac bone graft in all patients. There were 22 one-level, 7 two-level and 1 three-level fusions. Overall 19 patients (73%) had good to excellent results according to the criteria of Simmons and Segil. Six patients (23%) had a fair outcome and one (3.8%) a poor result. More good to excellent results (85.7%) were seen after two-level fusions than after one-level fusions (61.9%). Patients presenting with pain radiation to the upper limbs had a more favorable outcome. Better results also were found in patients with pain onset after cervical spine trauma than those without. However, due to the limited number of patients in this group, differences did not reach statistically significant levels. Reported postoperative results in the literature in similar patient groups without preoperative evaluation of the symptomatic level by discography show a good to excellent outcome in a less favorable range of 35%-46%.

The Role of Discography in the Evaluation of Patients with Spinal Deformity

The indications, applications, and technique of lumbar, thoracic, and cervical discography in patients with spine deformity are presented. Details of technique for each anatomic region are provided, along with representative case presentations. The role of discography in the assessment of juvenile discogenic disease in association with spinal deformity (Scheuermann's disease) in the thoracic and lumbar regions also is discussed.

Cervical discography complications and clinical efficacy.

To determine the incidence and magnitude of complications of cervical discography as well as to assess the clinical results of operative treatment based on discographic findings, a series of 31 patients who underwent cervical discography was reviewed. Twenty-six patients (84%) experienced provocative concordant symptomatology and were considered positive. The overall complication rate was 13% (4/31), including the development of an acute epidural abscess that led to myelopathy and eventual quadriplegia. Of the twenty-two patients who underwent anterior cervical discectomy and fusion on the basis of cervical discography, one patient had an excellent result (5%), nine patients had good results (41%), and six patients each had fair and poor results (54%). Diagnostic cervical discography was found not to provide the degree of clinical predictive value necessary to substantiate its potential risks and complications.

Digital subtraction discography

Conventional cervical discography was carried out in 25 patients during the period of one year. At the same time, we employed the well known principle of digital subtraction. The results of DSD have been compared with conventional discography. In every case more informative images were obtained despite the use of lower amounts of contrast. The distribution pattern of the reduced amounts of contrast in the disc provides valuable information. In the shoulder region, great improvement in picture quality is possible. For these reasons, the use of digital subtraction for discography is justified.

Cervical Discogenic Syndrome

In order to determine the validity of cervical discography in the diagnosis and treatment of patients presenting with cervical discogenic syndrome, a retrospective analysis of 34 patients who underwent cervical arthrodesis on the basis of positive cervical discography was performed. The symptomatic cervical levels were selected by reproduction of the patient's symptoms at the time of injection. No patient had radicular symptoms, and other diagnostic modalities such as computed tomography (CT) scanning or myelography had been within normal limits. Seventy percent of patients who underwent surgical intervention had good or excellent results. With proper utilization, cervical discography is a valid diagnostic study.

CANINE CERVICAL DISCOGRAPHY

A technique was developed to perform cervical discography in dogs. The radiographic appearance of 70 normal canine cervical discograms was established. No clinical effects were detected when the contrast medium was injected into the discs. No abnormalities were found in subsequent pathologic examinations. In four dogs with cervical disc disease, dorsal and lateral ruptures of the annulus fibrosus were detected by discography. When combined with myelography, discography allowed differentiation between various causes of spinal compression at intervertebral spaces.

Localisation of the level of symptomatic cervical disc degeneration

There are many difficulties associated with the localisation of the symptomatic segment in patients presenting with cervicobrachial pain with no evidence of impaired conduction in the nerve root. Ancillary radiological investigations such as myelography, epidural phlebography, and epidural myelograms are of unreliable diagnostic value. However, discography can be of value if the technique described here is used. Infiltration of the cervical nerve root with local anaesthetic has also proved useful in the localisation of the symptomatic segment. The techniques used in cervical discography and infiltration of the nerve root are described and their reliability is assessed.

Cervical Discography in Traumatic Myelopthy

Cervical Discography has been performed on 5 cases of traumatic myelopathy. These cases have no fracture, dislocation and disc degeneration in X-P. All of them have negative myelogram.In discography contrast medium leaked into the spinal canal and all patients complained of nape pain, arm pain, when disc was injected.In two patients the pain spread downward into abdomen and extremities.All of them were performed anterior body fusion of cervical spine, neurological recovery were excellent.

Cervical Discography: Is Surgery Necessary?-Reply

To the Editor.— The follow-up evaluation was very inadequate. Increased symptoms above or below the operated space will develop two to ten years after the fusion. Most followups reported in the literature have been made in less than two years, even those reported by Robinson et al ( J Bone Joint Surg 44A:1569, 1962). It is true that cervical syndromes are quite common and that symptoms can probably be well relieved by intradisk injection of lidocaine. However, it is also true that very few patients in this group will require surgery if they follow conservative principles already well established by Ruth Jackson. 1

Letter: Cervical discography: is surgery necessary?

Letter: Cervical discography: is surgery necessary?

Cervical Discography: Is Surgery Necessary?

To the Editor.— Some skepticism should be directed towards Dr Roth's article, Cervical Analgesic Discography: A New Test for the Definitive Diagnosis of the Painful-Disk Syndrome (235:1713, 1976), on both anatomical and clinical grounds. First, Dr Roth has not proved that cervical disk can be a source of chronic pain without protrusion, nerve root compression, or neurologic deficit. When a lumbar disk is removed under local anesthesia, pain may result from manipulation of the nerve root or incision of the posterior longitudinal ligament, but not from removal of the disk material itself. 1 I am unaware of any study that demonstrates pain fibers within lumbar or cervical disks, and particularly in the nuclear center where the spinal needle is placed for analgesic discography. The injection of 1 ml of a 2% solution of lidocaine (Xylocaine) into a cervical disk is a relatively large volume compared with the total volume