Diskogenic Pain Research Articles

An Effectiveness Evaluation of Nucleo-Annuloplasty for Lumbar Discogenic Lesions Using Disc-FX: A Scoping Review.

Background and Objectives: Degenerative disk disease is a widespread chronic condition that causes diskogenic pain. Diskogenic pain can be treated with various therapy methods. Disc-FX is a revolutionary, minimally invasive, percutaneous nucleo-annuloplasty method that combines manual diskectomy with nuclear and annular remodeling using radiofrequency ablation to relieve diskogenic pain. In this study, the technical features, clinical outcomes, and complications of Disc-FX are summarized. Materials and Methods: A comprehensive literature review was performed. By exploring several databases, we collected studies on Disc-FX for treating diskogenic pain. The outcomes included perioperative data, clinical results, and complications. Results: In the 15 studies included, data from 570 patients were collected. L4-L5 was the most frequently operated level, and most cases underwent single-level procedures. The follow-up period for these patients ranged from 2 months to 24 months. One study reported a procedure time between 35 and 60 min, whereas the remaining studies reported a procedure time of less than 30 min. The mean visual analog scale score decreased from 7.22 preoperatively to 1.81 at the final follow-up. The mean numerical rating scale score decreased from 6.98 preoperatively to 3.9 at the final follow-up. The mean Japanese Orthopaedic Association score improved from 16.26 preoperatively to 25.88 in the final follow-up. The mean Oswestry Disability Index score decreased from 35.37 preoperatively to 14.66 at the final follow-up. The mean satisfaction rate (based on the Macnab criteria) was 87.6% (range, 78.4-95.2%). The total incidence of postoperative transient pain was 8.77% (50/570) after nucleo-annuloplasty using Disc-FX, and recurrence was 1.58% (9/570). Conclusions: According to our comprehensive evaluation, using percutaneous nucleo-annuloplasty for treating lumbar diskogenic diseases provided considerable pain alleviation and improved functional outcomes with fewer complications. Disc-FX is a safe and effective procedure that is a good treatment option for patients with diskogenic pain.

Patient with Lumbar Spondylosis and Diskogenic Pain

Diskogenic low back pain (LBP), defined as pain that originates from a damaged vertebral disk, is a common cause of LBP. It is characterized by a three-phase cascade of degeneration marked by dysfunction, instability, and stabilization. A distinct pathologic characteristic of the disks from patients with diskogenic LBP has been found to be the formation of the zones of vascularized granulation tissue, with extensive innervation extending from the outer layer of the annulus fibrosus into the nucleus pulposus along a torn fissure. In addition, there appears to be an association between microbial infection and symptomatic disk degeneration. Low-virulence microorganisms, in particular Propionibacterium acnes, might be causing a chronic low-grade infection in the lower intervertebral disks in some patients. The diagnosis of diskogenic pain is primarily based on clinical manifestations, physical examinations, imaging studies, and provocative diskography. Diskogenic pain should be differentiated from other axial back pain conditions, such as facet arthropathy, sacroiliac joint pain, myofascial strain and pain, vertebral compression fracture, and other, less common conditions. Treatment options should be tailored to individual needs. Early and gradual physical and behavioral therapies are encouraged. Pharmacologic therapy, composed primarily of analgesics, nonsteroidal antiinflammatory drugs, muscle relaxants, and antidepressants, may have modest positive effects. A subset of patients with Modic type I changes in magnetic resonance imaging may benefit antibiotic therapy directed at the infected disks by P. acnes and other low-virulence microorganisms. There is evidence that supports the use of epidural steroid injections and intradiskal injections (methylene blue, ozone, steroids) for diskogenic pain. Additional options include intradiskal biacuplasty, gray ramus communicans nerve blocks/radiofrequency ablation, and intradiskal stem cell injections for disk repair/regeneration, all of which have gained support in clinical trials. These treatment modalities have shown promise to provide equal or even better outcomes compared with surgical spinal fusion or total disk replacement with an artificial disk. This review contains 2 figures and 149 references. Keywords: collagen, diskogenic low back pain (LBP), herniation, intervertebral disk, spondylosis

Patient with Lumbar Spondylosis and Diskogenic Pain

Patient with Lumbar Spondylosis and Diskogenic Pain

Bertolotti Syndrome

Bertolotti syndrome is caused by a lumbosacral transitional vertebra, a congenital variation of the most caudal lumbar vertebra, characterized by an enlarged transverse process that articulates or fuses with the sacrum, ilium, or both. This syndrome accounts for 4.6 to 7% of cases of low back pain in adults and for more than 11% of patients with low back pain who are under 30 years old. The primary effect of lumbosacral transitional vertebra is reduced and asymmetrical motion between the transitional vertebra and the sacrum, resulting in early arthritic changes at pseudoarticulation; the secondary effect is the progressively compensatory modifications in the biomechanics of the mobile vertebral segments superior to the transitional vertebra related to restriction in rotation and bending motion at the lumbosacral articulation. Bertolotti syndrome should be considered in the differential diagnosis of low back pain. Clinical findings include low back pain in the midline or paramedian area that is reproduced with palpation along the base of the lumbosacral spine and near the posterosuperior iliac spine and aggravated by forward flexion, excessive extension, or lateralization of the back to the same side of the mega-apophysis. A plain x-ray is diagnostic; the extension-flexion lumbosacral radiographs in anteroposterior, lateral, and oblique views demonstrate lumbosacral transitional vertebra, with an enlarged unilateral or bilateral transverse process of the most distal lumbar vertebra, abnormally articulating with the ala of the sacrum and degenerative changes of the pseudarthrosis. Other imaging studies, such as computed tomography and magnetic resonance imaging of the lumbosacral spine and selective radiculography of the spinal nerve, could provide additional detailed anatomic information. Major differential diagnoses of Bertolotti syndrome include sacroiliac joint pain, myofascial pain, lumbar facet pain, lumbar disk herniation, compression fracture, and Baastrup disease/interspinous bursitis. These conditions are not mutually exclusive and, in fact, often coexist. A course of conservative management, including activity modification, medication management with nonsteroidal antiinflammatory drugs, muscle relaxants, and rehabilitative physical therapy, should be offered initially. Due to the multifactorial etiology of low back pain in patients with Bertolotti syndrome, procedures such as diagnostic intrapseudoarticular block for arthritis, medial branch block for facet arthropathy, diskography for diskogenic pain, and selective nerve roots block for radiculopathy can potentially help identify the primary and secondary origins of the pain. Surgical treatment of Bertolotti syndrome was only slightly better than conservative treatment and should only be used in very selective patients with disk pathology. To achieve long-term improvement by any of these therapeutic options, a continuing physical rehabilitation program is often needed. Key words: Bertolotti syndrome, intrapseudoarticular block, transitional lumbosacral vertebra, transverse process

Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study

ObjectiveTo determine whether single injections of autologous platelet-rich plasma (PRP) into symptomatic degenerative intervertebral disks will improve participant-reported pain and function. DesignProspective, double-blind, randomized controlled study. SettingOutpatient physiatric spine practice. ParticipantsAdults with chronic (≥6 months), moderate-to-severe lumbar diskogenic pain that was unresponsive to conservative treatment. MethodsParticipants were randomized to receive intradiskal PRP or contrast agent after provocative diskography. Data on pain, physical function, and participant satisfaction were collected at 1 week, 4 weeks, 8 weeks, 6 months, and 1 year. Participants in the control group who did not improve at 8 weeks were offered the option to receive PRP and subsequently followed. Main Outcome MeasuresFunctional Rating Index (FRI), Numeric Rating Scale (NRS) for pain, the pain and physical function domains of the 36-item Short Form Health Survey, and the modified North American Spine Society (NASS) Outcome Questionnaire were used. ResultsForty-seven participants (29 in the treatment group, 18 in the control group) were analyzed by an independent observer with a 92% follow-up rate. Over 8 weeks of follow-up, there were statistically significant improvements in participants who received intradiskal PRP with regards to pain (NRS Best Pain) (P = .02), function (FRI) (P = .03), and patient satisfaction (NASS Outcome Questionnaire) (P = .01) compared with controls. No adverse events of disk space infection, neurologic injury, or progressive herniation were reported following the injection of PRP. ConclusionParticipants who received intradiskal PRP showed significant improvements in FRI, NRS Best Pain, and NASS patient satisfaction scores over 8 weeks compared with controls. Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up. Although these results are promising, further studies are needed to define the subset of participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP injectate.

L5 nerve root duplication in the setting of MRI-depicted L5-S1 disk herniation

Abstract Lumbosacral nerve root anomalies are rare anatomic variations with a predilection for the lumbosacral spine. Among these, conjoined nerve roots are the most common with other rare variants such as nerve root duplication occurring far less frequently. While these anatomic variations are exceedingly rare, their presence has significant clinical ramifications. Undiagnosed lumbosacral nerve root anomalies are at risk for iatrogenic injury, may contribute to wrong-site surgery and contribute to continued postoperative symptoms. Herein, we present a case of a 74 year-old female with diskogenic back pain and L5 radiculopathy found to have a duplicated L5 nerve root intraoperatively. Interestingly, the L5-S1 disk was found to be normal and unlikely to contribute to her presentation. She underwent L5-S1 laminectomy and L5 foraminotomy with resolution of her L5 radicular symptoms postoperatively.

Diagnostic and therapeutic spinal interventions: Diskography.

Diskography (provocation diskography, disk stimulation) is an invasive diagnostic test performed to confirm or exclude internal disk disruption as the cause of axial spine pain. Diskography involves injecting fluid into the nucleus of the disk under manometric control; a positive response is reproduction of typical pain. Extensive but indirect literature validates diskography in the lumbar spine; it is less well-supported in the cervical or thoracic spine. Risks include rare instances of infection and neural injury; lumbar diskography may be associated with accelerated disk degeneration. Diskography has utility in establishing a diagnosis of diskogenic pain. When negative, it prevents inappropriate interventions directed at the disk; when positive, it prevents interventions directed at other axial pain generators. Its role in selecting patients for therapies directed at diskogenic pain is limited by the lack of available validated treatments.

Intradiskal Methylene Blue Treatment for Diskogenic Low Back Pain

Low back pain is a leading cause of pain and disability. The intervertebral disk has been identified as the most common source of chronic low back pain. Although prior treatments directed at intervertebral disks have been disappointing, recent studies show promising improvement of pain and function after a single intradiskal injection of methylene blue. To assess changes in pain and function in patients with diskogenic low back pain, diagnosed by diskography, after an intradiskal injection of methylene blue. Prospective trial. Patients diagnosed with diskogenic pain by diskography underwent a single treatment of intradiskal injection of methylene blue, determined by prior provocation diskography. Pain and function measurements were completed at baseline and 1, 2, and 6 months after treatment. Treatment was considered a categorical success based on a 30% improvement in pain according to a visual analog scale (VAS) and function on the Oswestry Disability Index (ODI). Treatment was considered a categorical failure if less than 30% improvement in pain and function was achieved or if the patient pursued other invasive treatment options during the trial period. Sixteen patients received the intradiskal methylene blue injection. Eleven patients received a single-level injection, 4 patients received a 2-level injection, and one patient received injections at 3 levels. For the VAS, at 1, 2, and 6 months after the injection, the categorical success rates were 25%, 21%, and 25%, respectively. For the ODI, at 1, 2 and 6 months after the injection, the categorical success rates were 25%, 21%, and 33%, respectively. The overall categorical success rates at 1, 2, and 6 months after the injection were 19%, 21%, and 25%, respectively. This small trial did not demonstrate overall clinical success of intradiskal methylene blue injection for patients diagnosed with diskogenic pain by diskography.

The Effect of Creep on Human Lumbar Intervertebral Disk Impact Mechanics

The intervertebral disk (IVD) is a highly hydrated tissue, with interstitial fluid making up 80% of the wet weight of the nucleus pulposus (NP), and 70% of the annulus fibrosus (AF). It has often been modeled as a biphasic material, consisting of both a solid and fluid phase. The inherent porosity and osmotic potential of the disk causes an efflux of fluid while under constant load, which leads to a continuous displacement phenomenon known as creep. IVD compressive stiffness increases and NP pressure decreases as a result of creep displacement. Though the effects of creep on disk mechanics have been studied extensively, it has been limited to nonimpact loading conditions. The goal of this study is to better understand the influence of creep and fluid loss on IVD impact mechanics. Twenty-four human lumbar disk samples were divided into six groups according to the length of time they underwent creep (tcreep = 0, 3, 6, 9, 12, 15 h) under a constant compressive load of 400 N. At the end of tcreep, each disk was subjected to a sequence of impact loads of varying durations (timp = 80, 160, 320, 400, 600, 800, 1000 ms). Energy dissipation (ΔE), stiffness in the toe (ktoe) and linear (klin) regions, and neutral zone (NZ) were measured. Analyzing correlations with tcreep, there was a positive correlation with ΔE and NZ, along with a negative correlation with ktoe. There was no strong correlation between tcreep and klin. The data suggest that the IVD mechanical response to impact loading conditions is altered by fluid content and may result in a disk that exhibits less clinical stability and transfers more load to the AF. This could have implications for risk of diskogenic pain as a function of time of day or tissue hydration.

Annular tears, fissures or HIZ?

Low back pain (LBP) is an acute or chronic pain in the lumbar or sacral regions [1], is highly prevalent and has substantial socioeconomic implications [2]. Jensen et al noted that low back pain is the second most common reason that patients seek medical care in the United States and that the estimated annual cost of related medical care is more than $8 billion [3]. Robertson noted also that the rate of low back–related disability has grown at a rate 14 times that of the population during the last 30 years [3]. MRI is established as the investigation of choice for assessing patients presenting with low back pain (LBP) and sciatica; recognised causes of nerve root compression include disc herniation and spinal stenosis, however many patients presenting with LBP and pain referred to the lower limb(s) show no evidence on imaging studies of nerve root compression, suggesting that there are other factors involved in the production of pain [4]. One of the prominent somatic sources of low back pain is the internal disc disruption of the lumbar spine, the socalled discogenic lumbar pain, which is the condition causing back pain without radiculopathy [5]. The annulus fibrosus is innervated by the recurrent meningeal nerve and by the small branches from the ventral ramus of the somatic spinal nerve; a proposed mechanism for such pain is inflammation of nerve roots (chemical radiculopathy) from leak of degenerative nuclear material through full-thickness annular tears [4, 5]. Compared with asymptomatic disks, painful disrupted lumbar intervertebral disks have higher concentrations of sensory fibers in their endplates and nucleus; this high concentration of sensory fibers, combined with increased levels of proinflammatory mediators such as IL-8 and PGE2, provides a substrate for hyperalgesia and presumably pain [6]. In this hyperalgesic state, even normal mechanical loading will be painful [6]. The concept of diskogenic pain caused by nocioceptive ingrowth into annular fissures has been supported only indirectly by observing a strong correlation between pain provocation and the presence of annular fissure during provocation diskography and subsequent CT imaging; annular fissures reaching the outer annular fibers are in fact the source of symptoms in patients suffering from chronic diskogenic LBP [6]. Discogenic lumbar pain is characterized by nonradicular pain, has a somatotropic rather than dermatomal pattern of pain projection; therefore, the use of symptoms and clinical findings to localize the level of abnormality is difficult; the source of discogenic pain is still unknown [7]. Ideally, a history and physical examination would consistently diagnose the source of a patient’s low back pain, and, if one diagnosed pain secondary to the intervertebral disc, one would be able to identify the exact level or levels involved; in reality, however, the exact source of low back pain is often illusive, because discogenic pain projects in a somatotropic rather than a dermatomal pattern, confirming and localizing a discogenic source, much less the exact level, using clinical findings alone remains unproven [8]. MR imaging provides an unique means to evaluate the morphologic status of intervertebral disks and their relationship to neural structures in patients with low back pain; moreover, the technique allows assessment of the biochemical status of the disk on T2-weighted spin-echo and fast spin-echo MR images [7]. One of the first structural abnormalities that predicted concordant pain provocation during disc stimulation was high-signal-intensity zones (HIZ) at first described by Aprill and Bogduk in 1992 [8]. HIZ are defined as small foci of high signal intensity at:

Radiofrequency Ablation Within the First Intercoccygeal Disk for Coccygodynia: A Case Report

Interventional procedures for coccydynia (coccygodynia) are limited. This is a case report of long-term improvement following radiofrequency ablation (RFA) within the 1st intercoccygeal disk. A 44-year-old female presented with a 1 year history of coccydynia following a fall. Examination under fluoroscopy localized her pain at the disk between the 1st and 2nd coccygeal vertebrae. Provocation with needle entry reproduced the patient's pain, and the 1st intercoccygeal disk was injected with 40 mg of methylprednisolone. This gave the patient excellent relief for about 3 weeks. The procedure was repeated at 4 weeks, providing with the same response. Decision was then made to proceed with RFA. Her symptoms were reproduced in response to stimulation at 50 Hz with 0.9 V, and stimulation at 2 Hz at 2 V did not result in any motor stimulation. RFA was then carried out at 70°C for 80 seconds, followed by injection of 20 mg of methylprednisolone. The patient's Numeric Rating Scale pain score decreased from 9/10 to 3/10 after the RFA. She had about 70% relief for about 6 months. There is evidence that intercoccygeal disks can be a source of coccydynia. Immunohistochemistry has shown mechanoreceptors in intercoccygeal disks, and coccygeal discography has been shown to reproduce coccygeal pain. Intercoccygeal disk injection is described as a therapeutic option in the literature. Because various RFA techniques have been successfully used for intervertebral diskogenic pain, the decision was made to attempt RFA at the 1st intercoccygeal disk with resultant significant long-term improvement.

Provocation Lumbar Diskography at Previously Fused Levels

Recurrent or persistent low back pain (LBP) after lumbar fusion can be related to many factors. We reviewed the provocation lumbar diskogram (PLD) features and redo-fusion outcome in our patients evaluated for recurrent/persistent LBP after technically successful fusion. LD was performed in 27 patients with recurrent/persistent LBP after prior successful lumbar surgical fusion (31 fused levels: single-level fusion-23; two-level fusion-4). PLD response and imaging characteristics at fused and non-fused levels were assessed including: intra-diskal lidocaine response, diskogram-image/post-diskogram CT appearance, presence/absence of diskographic contrast leakage, and evidence of fusion integrity or hardware failure. Outcomes in patients having redo-fusion were assessed. Concordant pain was encountered at 15 out of 23 (65%) single-level fusions, non-concordant pain in one fusion with non-painful response in seven. Adjacent-level concordant pain was identified in seven out of 23 (30%) patients (three of 15 with painful fused levels; four of seven with non-painful fusions). In two-level fusions, concordant pain was encountered at one fused level in each patient. In painful fused levels, leaking and contained disks were encountered with partial or complete pain elimination after intra-diskal lidocaine injection. In anterior fusions, space or contrast surrounding the cage was noted at five of 11 levels. Pseudoarthrosis was noted only with trans-sacral screw fusions. Redo-fusion in 13 patients resulted in significant improvement in nine and moderate improvement in one. Patients with recurrent/persistent LBP after technically successful fusion may have a diskogenic pain source at the surgically fused or adjacent level confirmed by lidocaine-assisted PLD.

Blockade of the Sinuvertebral Nerve for the Diagnosis of Lumbar Diskogenic Pain

In this exploratory study we evaluated sensitivity and target specificity of sinuvertebral nerve block (SVNB) for the diagnosis of lumbar diskogenic pain. Diskography has been the diagnostic gold standard. Fifteen patients with positive diskography underwent SVNB via interlaminar approach to the posterior aspect of the disk. Success was defined as > or = 80% pain reduction or excellent relief of physical restrictions after the block. The sensitivity was 73.3% (95% CI: 50.9%-95.7%). The target specificity was 40% (15.2%-64.8%). The results indicate that SVNB cannot yet replace diskography but encourage future studies to improve its target specificity.

Poster 210: Functional Anesthetic Diskography to Confirm Diskogenic Back Pain in a Patient with Equivocal Results on Provocation Diskography Testing: A Case Report

Poster 210: Functional Anesthetic Diskography to Confirm Diskogenic Back Pain in a Patient with Equivocal Results on Provocation Diskography Testing: A Case Report

Postdiskogram CT Features of Lidocaine-Sensitive and Lidocaine-Insensitive Severely Painful Disks at Provocation Lumbar Diskography

At lumbar diskography, intradiskal lidocaine can eliminate or reduce provoked diskogenic pain. The purpose of this study was to evaluate the postdiskogram CT features of lidocaine-sensitive and lidocaine-insensitive severely painful disks. Intradiskal lidocaine was injected at 182 severely painful levels in 111 patients. Clinical records/imaging studies were reviewed for response to intradiskal lidocaine (complete/substantial, partial, and no pain improvement), evidence of diskographic contrast leakage (fluoroscopic/CT images), and the overall postdiskogram CT appearance in these severely painful disks. The assessed traditional Dallas grade (degeneration/radial tear [RT]) was supplemented by identified postdiskogram CT features of annular derangement (annular gap [AG], RT into peripheral annular tear [PAT], isolated PAT, lamellar annular tear, free/attached annular fragments, bucket-handle tear, and peripheral annular pocket). Isolated degenerative changes (40%) and radial defects with or without degeneration (60%) subsets were noted. Dallas grade 3 degeneration was most commonly observed (69%) with increased features of annular derangement in disks with a worsening Dallas grade. Complete/substantial versus no pain improvement was significantly associated with disk state (diskographic leakage, contained), radial defect (none, RT, or AG), and "RT-into-PAT" and were statistically significant in univariate models (P < .001). The associations remained significant in multivariate models. Higher Dallas degenerative grade and presence of free annular fragments were associated with a greater chance of no pain relief. Severely painful disks demonstrated complex annular derangement with both radial defects (RTs and AGs) or degenerative changes present, alone or in combination. Complete/substantial pain improvement after lidocaine administration is associated with disk state, radial defect (RT and AG), and RT-into-PAT.

Intervertebral Disk Cooled Bipolar Radiofrequency (Intradiskal Biacuplasty) for the Treatment of Lumbar Diskogenic Pain: A 12-Month Follow-Up of the Pilot Study

Dear Editor, In your respected Journal, we reported earlier on favorable 6-month follow-up results of the first prospective pilot study on intradiskal biacuplasty (IDB), cooled bipolar radiofrequency system for the treatment of diskogenic pain [1]. Many pain physicians across the country inquired about the 1-year outcomes of this procedure. As we reported earlier [1], 15 patients, 22–55 years old, underwent a one- or two-level IDB treatment of their painful lumbar intervertebral disks. We used strict selection criteria with history of chronic low back pain of >6 months and intolerance to sitting, back pain exceeding leg pain, concordant pain …

Contribution of centralization phenomenon to the diagnosis, prognosis, and treatment of diskogenic low back pain

The centralization phenomenon is the migration of low back and/or radiating pain to the spinal midline in response to specific positions or movements, for instance during a McKenzie mechanical assessment. However, differences in the definition of the centralization phenomenon occur across studies, most notably regarding the smallest required change in pain location and the time to centralization. Standardized criteria would be useful. Available data fail to establish that centralization is sufficiently specific of diskogenic pain as to obviate the need for investigations, particularly in patients considered for surgical treatment (e.g., fusion or implant). Although centralization correlates strongly with a positive diskography, the value of this last finding as a sign of diskogenic pain or an indicator that surgery is needed remains highly controversial. Nevertheless, centralization may indicate a high likelihood of diskogenic pain and may provide therapeutic guidance. Because centralization is associated with better outcomes after nonsurgical treatment, even in patients with nerve root pain, its presence may constitute an argument against surgical treatment. Finally, the McKenzie assessment may induce pain relief, albeit to a modest extent and for no longer than 3 months.

PR_208: Intravascular Injection of Contrast During Lumbar Diskography: A Previously Unreported Complication

Setting: Case report from an academic university spine center. Patient: A 40-year-old woman with L5-S1 degenerative disk disease and persistent low back pain. Case Description: The patient failed to respond to multiple conservative treatments. Magnetic resonance imaging of the lumbosacral spine demonstrated disk desiccation with a paracentral bulge at L4-5. In consideration of surgical treatment, diskography was requested. Assessment/Results: A 22-gauge, 15.2-cm (6-in) needle was inserted to the central nucleus by a left posterolateral approach. Diskography was performed at L4-5 and L5-S1. Testing was performed with pressure manometry, beginning with the L4-5 disk as a control. The pressure increased with contrast injection, which is indicative of a normal disk. At 45psi, there was a drop to 20psi. Lateral views obtained during contrast injection demonstrated cephalad flow from a central nucleogram through the posterior annulus into the anterior epidural space. Images obtained with live fluoroscopy demonstrated a vascular flow pattern, confirmed with lateral and anteroposterior views. The needle tip was repositioned anterior-superiorly. Repeat injection resulted in an identical vascular pattern. From the time the pressure dropped, contrast flowed in the vascular pattern without propagation of the nucelogram or increase in intradiskal pressure. The patient was asymptomatic throughout the injection at L4-5. Injection at L5-S1 demonstrated a severely degenerative nucleogram and reproduced the patient’s usual low back pain. Discussion: Lumbar diskography is often used to direct surgical intervention for refractory diskogenic pain. Complications of diskography include diskitis, nerve injury, and dural puncture. However, hematoma formation following cervical diskography has been reported. The lumbar disk is an avascular structure, so vascular complications are rare. While superficial lamellae of the annulus fibrosis contain capillaries, blood vessels are not normally found within healthy lumbar disks. Conclusions: Vascular uptake of contrast can occur during lumbar diskography, even when the needle tip is ideally located.

Magnetic resonance imaging-guided diskography and diagnostic lumbar 0.23t MRI: an assessment study

To describe the in vivo appearance of magnetic resonance imaging (MRI) diskograms of normal and degenerated lumbar intervertebral disks, and to evaluate the differences in imaging findings between sequential diagnostic MRI and MRI diskography. Nine consecutive patients underwent MRI-guided diskography in order to determine possible pain provocation during puncture and contrast medium injection. All patients had preceding clinical suspicion of lumbar diskogenic pain and findings of lumbar disk degeneration in diagnostic (MRI, computed tomography (CT), plain radiography). A 0.23T open MRI scanner with interventional tools was used for imaging and instrument guidance. On all patients, a complementary diagnostic MRI study of the lumbar spine before and after the MRI-guided disk injection was performed, and subsequent axial MRI diskograms were obtained. A total of 25 disk punctures were initialized, and 25 MRI diskograms were obtained and their expression described. There was a correlation between the degenerative disk findings visualized by diagnostic MRI and MRI diskograms. The use of gadolinium contrast media in MRI-guided diskography enables the evaluation of MRI diskograms. Our results suggest that MRI-guided diskography can be used to substitute conventional diskography or CT-diskography and as an augmenting method to assess diagnostic information upon degenerative processes of the lumbar spine.

Histological and Molecular Structure Characterization of Annular Collagen after Intradiskal Electrothermal Annuloplasty

The mechanism of pain relief of intradiskal electrothermal annuloplasty (IDET) in the treatment of lumbar diskogenic pain is uncertain. Theories include sealing of annular fissures via collagen denaturation and contraction. Prior studies offer conflicting qualitative data on the ability of IDET to denature collagen. The objective of the present study is to evaluate IDET treatment effect on annular collagen using quantitative data supplied by Fourier-transform infrared imaging spectroscopy. The posterior annulus of disks (n = 3) from an intact human cadaveric spine at room temperature were treated with two different radiothermal catheters using standard intradiskal electrothermal annuloplasty (IDET) heating protocols. Disks were dissected free with catheters in place and fixed in formalin. Channels created by the catheters were marked and catheters were removed. Tissue samples of treated areas adjacent to the channels and internal control areas from the same disk were stained for light microscopy and placed on barium sulfate windows for Fourier transform infrared imaging spectroscopy (FT-IRIS) analysis. Treated areas showed evidence of disruption in the fibrillar organization of annular collagen by light microscopy compared to intact stroma from control areas. Quantitative FT-IRIS analysis compared ratios of wavenumber regions known to be sensitive to collagen denaturation. Mean values for the ratios amide II/1,338 cm(-1) (137.21 +/- 25.84 treated, 76.94 +/- 16.77 control) and 1,640/1,660 cm(-1) (0.98 +/- 0.03 treated, 0.89 +/- 0.03 control) were significantly different between treated and control samples (p < 0.001), indicating a breakdown in collagen integrity. Separate analysis by catheter type suggests that catheter design may impact treatment effect.