Lumbar Discography Research Articles

Interventional Techniques in The Management of Chronic Spinal Pain: Evidence-Based Practice Guidelines

The lifetime prevalence of spinal pain has been reported as 54% to 80%, with as many as 60% of patients continuing to have chronic pain five years or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Available evidence documents a wide degree of variance in the definition and the practice of interventional pain management. To develop evidence-based clinical practice guidelines for interventional techniques in the management of chronic spinal pain, with utilization of all types of evidence, applying an evidence-based approach, with broad representation of specialists from academic and clinical practices. A systematic review of diagnostic and therapeutic interventions applied in managing chronic spinal pain by a policy committee. Design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions, and statements about relationships between clinical interventions and outcomes. The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, formal endorsement by the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), and blinded peer review. Methodologic quality evaluation criteria utilized included AHRQ criteria, QUADAS criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). The accuracy of facet joint nerve blocks was strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it was moderate in the diagnosis of thoracic facet joint pain. The evidence was strong for lumbar discography, whereas, the evidence was limited for cervical and thoracic discography. The evidence was moderate for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies. The evidence was moderate for sacroiliac joint injections in the diagnosis of sacroiliac joint pain. The evidence for therapeutic lumbar intraarticular facet injections of local anesthetics and steroids was moderate for short-term improvement and limited for long-term improvement, whereas, it was negative for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks was moderate. The evidence for medial branch neurotomy was moderate to strong for relief of chronic low back and neck pain. The evidence for caudal epidural steroid injections was strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections was strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence was moderate. The evidence for transforaminal epidural steroid injections was strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it was moderate for cervical nerve root pain and limited for lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis was strong. For spinal endoscopic adhesiolysis, the evidence was strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence was moderate for short-term relief and limited for long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain was indeterminate. The evidence for intradiscal electrothermal therapy was strong for short-term relief and moderate for long-term relief in managing chronic discogenic low back pain, whereas, for nucleoplasty, the evidence was limited. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome was strong for short-term relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems was moderate to strong. These guidelines included the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines do not represent "a standard of care".

Lumbar discography

Discography is utilized to evaluate internal disc anatomy and to identify clinically symptomatic disc disruption. While MRI imaging is useful in providing a general anatomic image of the disc, it is relatively insensitive in identifying annular disruption and its clinical relevance. Discography is the only diagnostic study that can determine whether the disc is the primary pain generator responsible for the patient’s symptoms. It additionally provides valuable information in surgical planning by identifying which discs are symptomatic and may therefore be appropriate for inclusion in potential disc surgery, as well as to exclude from surgery those discs that are asymptomatic. The technique of lumbar discography is described and the complications of the procedure are discussed.

Lumbar discography: should we use prophylactic antibiotics? A study of 435 consecutive discograms and a systematic review of the literature.

Lumbar discography can be used in the diagnostic work-up of degenerative spine disease. The most serious complication is discitis, believed to be due to penetration of the disc by a needle contaminated with skin flora. The use of prophylactic antibiotics has been advocated, although there is great concern regarding their efficacy and possible adverse effects on disc cells. In the current study, the incidence of postdiscography discitis without the use of prophylactic antibiotics was studied in a consecutive patient group. Additionally, a systematic literature review was performed using strict criteria: 1). Discography was performed by means of a two-needle technique, 2). complications such as discitis were specifically looked for at follow-up, and 3). the exact numbers of patients and those lost to follow-up were reported. The clinical results of 200 patients with 100% follow-up for a minimum period of 3 months showed no case of discitis. In the literature review, 10 studies were selected. Nine studies without prophylactic antibiotics reported an overall incidence of 12 cases in 4891 patients (0.25%) or 12770 discs (0.094%). The only study with prophylactic antibiotics (127 patients) showed no case of discitis. Regarding the small number of patients in the only study in which antibiotics were used and the overall low incidence of postdiscography discitis, not enough evidence was found that prophylactic antibiotics can prevent discitis. It was concluded that in lumbar discography by means of a two-needle technique without prophylactic antibiotics, the risk of postdiscography discitis is minimal and there is not enough support from the literature to justify the routine use of prophylactic antibiotics.

Lumbar discogram resulting from lumbar interlaminar epidural injection

Lumbar discography is a diagnostic modality to determine whether the intervertebral disc is the cause of pain. The injection of radiopaque contrast into the nucleus pulposus of the disc can reveal the internal details of the disc. We describe a case of inadvertent lumbar discogram resulting from an attempted lumbar interlaminar epidural injection at L 5–S 1 under fluoroscopy. The patient did not have a postdural puncture headache or nerve root irritation. The potential triangle in the lateral aspect of spinal cord may be the explanation for this situation, because this triangle is composed of the exiting nerve root laterally, the lateral margin of the dura medially, and the pedicle as its base. The L 5–S 1 disc is located in the center of the triangle. In our case, the Tuohy needle was placed possibly in the center of the triangle, too laterally to puncture the dura. Hence, the patient did not suffer from postdural puncture headache. The needle was probably inferior to the nerve root, and no obvious nerve root trauma or irritation occurred. This potential triangle may provide alternative access for lumbar discography at the L 5–S 1 level.

Prospective Controlled Study of the Development of Lower Back Pain in Previously Asymptomatic Subjects Undergoing Experimental Discography

A prospective controlled longitudinal study. To determine whether subjects, asymptomatic for lower back problems, who undergo experimental discography, will develop lower back problems during the medium term to the full term. Previous work has shown significant pain on discographic injection in approximately 40% of asymptomatic subjects. It has been suggested that those subjects with painful injections would soon develop lower back pain (LBP) syndromes in the near future: that is, the experimental discography was detecting an imminent "pain generator" before clinically symptomatic. METHODS.: Fifty subjects without low back pain were recruited for clinical and psychometric testing, MRI scanning, and experimental lumbar discography to determine the rate of painful lumbar disc injections in select subjects without LBP history. After determining which subjects had painful injections, all subjects completing the discography protocol were prospectively followed at yearly intervals to determine the occurrence of LBP and LBP disability over time. Statistical methods were then used to determine the correlation, if any, between the asymptomatic subjects' clinical, MRI, and discography findings, and the subsequent LBP measures. Controls, not participating in the lumbar discography study, were also followed. Controls were matched for clinical features, sex, age, and occupational/recreational exposure. Follow-up examinations were performed at yearly intervals by blinded researchers using a scripted interview and completing standard questionnaires. A total of 46 of 50 completed the discogram, and all 46 subjects completed the final 4-year follow-up examination. There was a low incidence of LBP episodes in the experimental groups and control. A painful disc injection, independent of psychological profile, did not predict LBP or any other functional outcome measure at follow-up on multivariate analysis. The presence of an anular fissure seen on discography was weakly associated with the cumulative incidence of LBP episodes after discography (P = 0.08). The presence of high intensity zone on MRI in any disc was also weakly associated with the development of LBP episodes (P = 0.09). Psychometric profiles at the start of the study strongly and independently predicted future back pain (P = 0.01), medication usage (P = 0.002), and work loss (P = 0.01) over the 4-year study. Compared with controls not having undergone discography, there was no significant difference in back pain, function, work loss, doctors visits for back pain, or medication intake in any group. A subset in the injection group with somatization disorder had a higher LBP visual analog score compared with somatization disorder controls at 1 year,but this was not significant at 4 years after testing. Painful disc injections are poor independent predictors of subsequent LBP episodes in subjects initially without active lower back complaints. Anular disruption is a weak predictor of future LBP problems. Psychological distress and preexisting chronic pain processes are stronger predictors of LBP outcomes.

W. James Gardner: pioneer neurosurgeon and inventor.

W. James Gardner, a skillful neurosurgeon and inventor, is best remembered for his cervical tongs and hydrodynamic theory of syringomyelia. A pioneer of modern neurosurgery, Gardner trained under Charles Frazier in Philadelphia, and in 1929 he moved to Ohio where he became chief of neurosurgery at the Cleveland Clinic, a position he was to hold for the next 33 years. A large surgical practice made it imperative for Gardner to develop surgical methods that were quick, effective, and advantageous for patient and surgeon. He was an early proponent of the sitting position for patients undergoing cranial surgery, which led to the development of a neurosurgical chair with a head fixation device. To reduce the risks of hypotension and air embolism when the patient is in the sitting position, Gardner invented the clinical G suit. He was the first to advocate and use induced arterial hypotension for intracranial surgery and the first neurosurgeon in the US to publish his experiences performing lumbar discography. He converted an operating table so that he could induce hypothermia during aneurysm surgery and then applied pneumatic cuffs to occlude the major arterial supply to the brain. His pioneering work has been documented in many other areas such as hemifacial spasm and trigeminal neuralgia, for which he performed the first vascular decompression, in cervical sympathectomy for treatment of various ailments, and in the use of intrathecally delivered steroid drugs for sciatica. During his career, he authored 256 publications and one book on the dysraphic states. Many of his contributions to the discipline of neurosurgery are now taken for granted.

Internal Disc Derangement in Patients with Low Back Pain: Correlation of MR Imaging and Provocative Discography and CT Discography

Purpose: The aim of this study was to correlate the MR imaging abnormalities of the lumbar intervertebral discs, with emphasis being placed on the high intensity zone (HIZ) with the use of discography for pain provocation and disc morphologic evaluation of the disc. Materials and Methods: Consecutive patients with low back pain unresponsive to conservative treatment, and who were being considered for spinal fusion had MRI performed, and this was followed by lumbar discography. The MR imaging, discography and CT discography (CTD) were evaluated for all of the 19 patients. Fortythree lumbar discs in 19 patients were included in this study. The findings of MR and CTD images were evaluated retrospectively with the professional opinion and agreement of two radiologists. MR images were assessed for the presence or absence of decreased T2-wighted signal intensity, decreased disc height, annular bulging, HIZ on T2-weighted images and disc herniation. The results of pain provocation were graded as 0, nonconcordant pain; 1, definite pain, but only as part of the symptom complex; 2, concordant pain. The morphology of CTD was analyzed for presence or absence of disc degeneration, radial tearing and extravasation of the contrast agent. The presence of radial tearing was defined as contrast extension to the outer third of the annulus. The prevalence of all MR abnormalities was calculated, and the data were compared with disc morphologic characteristics and the pain response on provocative discography. We used the chi-square test to analyze the results. Results: Grade 1 and 2 discogenic pain was observed in 8 (19%) and 12 disc levels (28%), respectively. All of the seven non-degenerated discs on MR had no pain response. The decreased SI on T2-weighted image, annular bulging and HIZ were significantly correlated with discogenic pain. Extravasation of contrast media had good correlation with annular bulging and disc herniation on MRI. Radial tearing on CT discography correlated significantly with HIZ. The HIZ was detected in 14 levels (32.6%). The HIZ on MRI correlated significantly with the pain provocation and radial tearing noted on the discograms. Conclusion: Several MR imaging findings correlated significantly with the severity of pain provocation to discography. For patients with symptomatic low back pain, the HIZ observed on MR may represent a painful outer annular disruption.

Lumbar discography: an update

Discogenic pain most commonly affects the low back, buttocks, and hips and is thought to be a byproduct of internal disk degeneration. It is postulated that progressive annular breakdown and tearing results in biomechanical and/or biochemical stimulation of the pain fibers that reside in the outer one third of the annulus. Although multiple imaging modalities, most notably MRI, can show morphologic abnormalities of the spine, discography remains the only test that provides physiologic information regarding what role a given intervertebral disk plays in a patient's symptom complex. The controversy surrounding discography is here to stay until more definitive, well-designed studies are performed. In the meantime, there are certain things that can help the discographer maximize the accuracy of the test: 1. Always try to inject one "normal" disk as a "control level." 2. Be alert for factors that are associated with an increased false-positive rate (abnormal non-anatomic pain maps, a history of chronic pain of spinal or nonspinal origin, abnormal psychometric testing, and prior surgery at the injected disk level). In these cases, special attention should be directed to both the patient's verbal and nonverbal cues during disk injection. 3. Do not give any audible clues as to what level is being injected or when the injection is starting or finishing. In this regard, we find it very helpful to have one of our personnel talk with the patient during this portion of the procedure while closely observing the patient for any nonverbal cues regarding their pain response. This distraction is preferable to a silent room where the patient is intensely focused on what is going on with the injections. We also find that music playing during the procedure helps to relax and often distract the patient as well. 4. If the results are equivocal at a level (i.e., you are unable to determine whether or not the patient's pain response was truly concordant), go on to inject another disk level and then come back to reinject more contrast into the disk in question. As radiologists, we tend to focus on the technical aspects of a procedure and the anatomic/morphologic information it provides. However, it cannot be emphasized enough that when performing lumbar discography, the assessment of the patient's pain response during the injection is the most important component of the procedure, and requires not only technical skills, but an understanding of how best to avoid some of the pitfalls that can lead to inaccurate results.

8. A prospective analysis of lumbar discography findings in select participants without low back symptoms

8. A prospective analysis of lumbar discography findings in select participants without low back symptoms

5. Low pressure positive discography in subjects without significant LBP illness

HYPOTHESIS: If the criteria for a “positive” disc injection during provocative lumbar discography included only discs sensitive at low pressures, then the risk of false positive injections would effectively be eliminated. To test this hypothesis the injection pressure during experimental discography in subjects without chronic LBP illness was analyzed and compared to disc sensitivity at low pressures in chronic LBP patients undergoing discography.

Radiation Exposure to the Spinal Interventionalist Performing Lumbar Discography

To evaluate radiation exposure to the spinal interventionalist performing lumbar discography. A prospective study on four spinal interventionalists who performed 106 consecutive lumbar discograms (levels) on 37 patients with low back pain. Radiation exposure was monitored with the assistance of a radiological technologist (RT) who allocated four (4) dosimetry badges to all spinal interventionalists performing Discograms on consecutive patients being referred for evaluation of possible discogenic pain. The badges were placed on the ring finger, glasses and both the inside and outside of the lead apron worn by the interventionalist. The mean fluoroscopy time per procedure was 57.24 seconds. The mean/cumulative exposure per procedure was 3.66(-/+0.915)/390(-/+9.750) mREM at the "ring" badge, 2.35(-/+0.635)/251(-/+6.275) mREM at the "outside apron" badge, 1.49(-/+0.373)/159(-/+3.975) mREM at the "glasses" badge. A statistically significant higher radiation exposure was found on discograms at the L5/S1 level compared to the L4/5 and L3/4 levels. Our study illustrates that radiation exposure to the spinal interventionalist performing lumbar discography is well within safety limits.

Biochemical injection treatment for discogenic low back pain: a pilot study

Background context: Biochemical treatment options including attempts at intervertebral disc restoration are desirable for the physiologic treatment of degenerative disc disease. Purpose: This was a pilot study to test the potential effectiveness of intradiscal injection therapy using agents known to induce proteoglycan synthesis in the treatment of intervertebral disc disease. Study design: Prospective, within subject, experimental design was applied in the study. Patient sample: Thirty patients, average age 46.5 years, with chronic intractable low back pain of 8.5 years average duration, took part in the study. All patients had lumbar discography with reproduction of pain. Outcome measures: Pretreatment Roland-Morris disability scores and visual analogue scores were compared with 1-year follow-up posttest values of these scores. Methods: Lumbar intervertebral discs were injected with a solution of glucosamine and chondroitin sulfate combined with hypertonic dextrose and dimethlysulfoxide (DMSO). Assessment of pain and disability was completed before treatment and an average of 12 months after the last treatment. Results: Posttreatment Roland-Morris scores for the entire group of 30 patients of 6.4±.994 were significantly (p<.001) lower than pretreatment scores of 12.0±.92 (mean±SE). The posttreatment visual analogue scores of 3.00±.44 were also significantly less than the pretreatment of 6.11±.33 (mean±SE). Although the results were statistically significant for the 30 patients as a whole, 17 of the 30 patients (57%) improved markedly with an average of 72% improvement in disability scores and 76% in visual analogue scores. The other 13 patients (43%) had little or no improvement. Patients who did poorly included those with failed spinal surgery, spinal stenosis and long-term disability. There were no complications or serious side effects, although postinjection pain was moderate to severe for 48 to 72 hours and required epidural steroids in five cases. Conclusions: The results of this pilot study suggest that intradiscal injection therapy with glucosamine, chondroitin sulfate, hypertonic dextrose and DMSO warrants further evaluation with randomized controlled trials.

Spinal injection procedures: volume, provider distribution, and reimbursement in the U.S. medicare population from 1993 to 1999.

To evaluate spinal injection procedures for trends in volume, reimbursement, and physician specialty participation. By using the 1993, 1996, 1998, and 1999 Medicare Part B claims database, we studied Current Procedural Terminology revision 4 codes used for percutaneous spinal injection procedures, including cervical and lumbar discography, disk aspiration and/or injection, facet and/or perifacet joint injection, and epidural steroid injection. For each of these procedures, volume, reimbursement, and physician specialty participation (categorized as radiology, anesthesiology, surgery, physiatry, and other specialties) for each year were recorded. Despite an overall increase in spinal injection procedure volume and reimbursement from 1993 to 1999, nonradiologists performed most of these procedures. Epidural steroid and facet joint injections had the highest volume and reimbursement during this time period and were performed almost exclusively by nonradiologists (predominantly anesthesiologists). Radiologists performed more discography procedures than did other specialists in 1993, but participation decreased each year, while anesthesiologist participation increased; as of 1999, anesthesiologists performed more discography procedures than did radiologists. Although radiologists performed more disk aspiration procedures than did other specialists, procedure volume remained low during the period studied. Spinal injection volume and reimbursement have increased substantially in the Medicare population from 1993 to 1999. During this interval, radiologist participation has decreased. Nonradiologists perform most spinal injection procedures.

General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques.

The literature on diagnostic tests available to the spine clinician for the evaluation of chronic low back pain was reviewed. To review critically the available information and data on invasive diagnostic tests used for evaluation of chronic low back pain. Numerous published studies have described the technique and clinical results of diagnostic blocks for chronic low back pain. There are various methodologies, but most lack of an adequate "gold standard" with which to compare the results of the diagnostic test. The available published studies of diagnostic tests commonly used in the evaluation of chronic low back pain were reviewed, with a focus on invasive techniques. The techniques were evaluated on the basis of the data available to support the conclusions that could be drawn for each of these techniques. The principles of diagnostic testing, including specificity and sensitivity, were reviewed and applied in the context of the data available for each of these invasive tests. The essential features the clinician seeks in a diagnostic test are accuracy, safety, and reproducibility. It is essential to have a gold standard with which to compare the accuracy of a given diagnostic test. There is no completely reliable gold standard with which to compare a diagnostic test (or injection) when the absence of pain is the end point. The clinical setting in which the test is used directly affects the test results. The prevalence of the disease therefore affects the meaningfulness of the test results. Imaging studies have their greatest value in the exclusion of other conditions. These studies alone were not adequate for predicting the patients who would respond to controlled diagnostic blocks of the facet joint. Facet joint diagnostic blockade probably is most accurately performed by median nerve branch block. The greatest specificity for a positive response to a facet denervation procedure is achieved when the diagnosis is established via highly controlled anesthetic blocks. Over the past few decades, the sacroiliac joint has received varying degrees of interest as an important pain generator of low back pain. Despite testimonials to the contrary, no diagnostic physical examination has correlated with sufficient specificity to diagnose this condition reliably from a clinical standpoint. Lumbar discography has been one of the single most controversial subjects in the management of degenerative, painful lumbar spine conditions. The specificity and sensitivity are high for the diagnosis of disc degeneration. The question that revolves around discography concerns the accuracy of this test for the diagnosis of discogenic pain. An integral part of the problem is the lack of an adequate gold standard. In a comparison of nerve root blockade, sciatic nerve block, posterior ramus block, and subcutaneous injection in a cohort of patients with sciatica, the sensitivity of nerve root block was very high, with only a moderate level of specificity. In the case of diagnostic selective nerve blocks used for evaluation of complex or protean nerve compression, surgical confirmation and clinical results should be a reliable gold standard. Conflicting results have been presented depending on the target lesion and method of study. There are inherent limitations in the accuracy of all diagnostic tests. The tests used to diagnose the source of a patient's chronic low back pain require accurate determination of the abolition or reproduction of the patient's painful symptoms.

Lumbar discography

Discography, a controversial test that due to new image diagnosis techniques was left behind, is discussed. A literature review, regarding technique, indications, benefits and limitations of discography is presented. A new approach, focusing the results on presence of a familiar pain during the exam is presented.

New Advances in Lumbar Discography

LEARNING OBJECTIVES:After reading this article, the participant should be able to:Describe the appropriate role of discography in the management of chronic low back pain.Describe the technique used to perform discography.List the complications associated with discography.

MR lumbar discography with intradiscal gadolinium in patients with severe anaphylactoid reaction to iodinated contrast material.

Describe our experience using discography with intradiscal gadolinium and MR lumbar discography in patients with a history of severe anaphylactoid reaction to iodinated radiocontrast agents. Observational study of 14 patients. From 1997 to 1999, 14 patients were referred for lumbar discography with intradiscal gadolinium followed by MRI. Patients with a history of a severe anaphylactoid reaction to iodinated radiocontrast media or those who refused the use of iodinated contrast material were included in the study. In fourteen patients, 58 discs were studied. The post discography MRIs identified seven annular tears and seven annular fissures. None of the fourteen patients reported symptoms suggestive of allergic reaction either during or after discography. Discography using intradiscal administration of gadolinium followed by MRI provides a method of obtaining a clinically pertinent study in a subset of patients who likely would not be offered the procedure, secondary to severe anaphylactoid reactions to iodinated contrast materials.

New Advances in Lumbar Discography

LEARNING OBJECTIVES:After reading this article, the participant should be able to:Describe the appropriate role of discography in the management of chronic low back pain.Describe the technique used to perform discography.List the complications associated with discography.

Lumbar discography

Lumbar discography

Side of symptomatic annular tear and site of low back pain: is there a correlation?

A retrospective chart review. To report the correlation between the side of a concordantly painful, post-discography computer tomography (CT) visualized, annular tear, and the side of a patients' low back pain. An annular fissure extending from the nucleus to the outer one-third of the annulus is thought to be the nociceptive source stimulated during provocative lumbar discography. To our knowledge, there are no studies that have attempted to delineate whether the side of the annular tear correlates with the side of the patient pain. One hundred and one post-discography CT scans, performed on patients with single level, concordantly painful, and fissured discs identified during lumbar discography, were randomly obtained from the archived and current files of the Penn Spine Center's film library. These were reviewed by both the lead author and a spine radiologist, both of who were blinded to the side of the patients pain, to determine which scans demonstrated clearly definable tears extending to the outer one-third of the annulus. Statistical analysis via the exact method was used to determine the correlation between the side of the patients tear and the side of the patients pain. Forty post-discography CT scans met the inclusion criteria. There was a random correlation between the side of the patients concordantly painful annular tear and the side of the patients pain. The results of this study raise several questions regarding the embryologic development of the intervertebral disc and its somite, neurologic transmission of discogenic pain, distribution of chemical inflammagens, validity of discography, technique of ESI, and technique and validity of IDET.