Use Of Discography Research Articles

Quantitative MRI to Characterize the Nucleus Pulposus Morphological and Biomechanical Variation According to Sagittal Bending Load and Radial Fissure, an ex vivo Ovine Specimen Proof-of-Concept Study

Background and context: Low back pain is a dramatic burden worldwide. Discography studies have shown that 39% of chronic low back pain patients suffer from discogenic pain due to a radial fissure of intervertebral disc. This can have major implications in clinical therapeutic choices. The use of discography is restricted because of its invasiveness and interest in it remains low as it represents a static condition of the disc morphology. Magnetic Resonance Imaging (MRI) appears to be less invasive but does not describe the biomechanical dynamic behavior of the fissure.Purpose: We aimed to seek a quantitative MRI protocol combined with ex vivo sagittal loading to analyze the morphological and biomechanical changes of the intervertebral disc structure and stress distribution.Study design: Proof of concept.Methods: We designed a proof-of-concept ovine study including 3 different 3.0 T-MRI sequences (T2-weighted, T1 and T2 mapping). We analyzed 3 different mechanical states (neutral, flexion and extension) on a fresh ovine spine specimen to characterize an intervertebral disc before and after puncturing the anterior part of the annulus fibrosus. We used a mark tracking method to calculate the bending angles and the axial displacements of the discal structures. In parallel, we created a finite element model to calculate the variation of the axial stress and the maximal intensity shear stress, extrapolated from our experimental boundary conditions.Results: Thanks to an original combination of specific nuclear relaxation time quantifications (T1, T2) of the discal tissue, we characterized the nucleus movement/deformation into the fissure according to the synchronous mechanical load. This revealed a link between disc abnormality and spine segment range of motion capability. Our finite element model highlighted significant variations within the stress distribution between intact and damaged disc.Conclusion: Quantitative MRI appears to provide a new opportunity to characterize intra-discal structural morphology, lesions and stress changes under the influence of mechanical load. This preliminary work could have substantial implications for non-invasive disc exploration and could help to validate novel therapies for disc treatment.

Clinical decision making in spinal fusion for chronic low back pain. Results of a nationwide survey among spine surgeons

ObjectivesTo assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain.Design and settingNationwide survey among spine...

The Positive Predictive Value of Provocative Discography in Artificial Disc Replacement

Identifying the primary source of pain in patients with low back pain is challenging in many patients, despite advanced imaging techniques. Often, multiple levels will show some degree of degenerative disc disease (DDD) on imaging, and determining which level(s) should be treated is difficult. In these patients with questionable pathology, provocative discography is often performed. However, the use of discography to diagnose “discogenic pain” remains a highly controversial topic in spine surgery and radiology communities.

The use of discography in the diagnosis of lesions in the thoracic spine hernia

The use of discography in the diagnosis of lesions in the thoracic spine hernia

Will a New Study End the Use of Discography as a Diagnostic Test for Painful Disc Degeneration?

The Back Letter: July 2009 - Volume 24 - Issue 7 - p 73,79-81 doi: 10.1097/01.BACK.0000357539.86986.9e

Discography: Interpretation from a surgeon's perspective

The use of spinal discography has been controversial since its inception. Although its intended common uses and indications have changed over the decades, questions about its reliability and how to interpret results have persisted. As it has evolved from a primary diagnostic tool for spinal disc protrusions in the pre-computed tomography (CT) and pre-magnetic resonance imaging (MRI) eras to a more limited role in evaluating the nature of suspected painful discs, the controversies have continued. Here, the author reviews the historical evolution of spinal discography and recent literature focused on the role of provocative discography in evaluating patients with neck pain and/or lower back pain. Currently available literature pertinent to this issue is summarized for lumbar, cervical, and thoracic discography. Many worthwhile studies are omitted from this literature review only to focus on those that relate directly to evaluating discography's role in screening potential patients for surgical intervention. The use of discography to identify patients for interventional pain procedures is not evaluated. How recent technology in spine surgery has affected current usage of discography is then reviewed. The author concludes by summarizing his current practice and opinions regarding discography.

Lumbar discography: Diagnostic role in discogenic pain

Although modern imaging techniques such as magnetic resonance imaging and computed tomography are useful in detecting anatomic abnormalities within the intervertebral disc, they cannot provide any information regarding the presence or absence of pain arising from anatomic abnormalities. Discography is currently the only diagnostic method that is available to determine whether an anatomically abnormal intervertebral disc is the cause of a given patient's ongoing pain. However, discography is a subjective test, relying entirely on the patient's pain experience during the conduct of this brief procedure, which is without effective controls. This article discusses the current scientific evidence regarding the use of discography at lumbar spinal levels, describes the technique and associated complications, and explores the controversies surrounding the usefulness of this diagnostic test.

Needle Puncture Injury Affects Intervertebral Disc Mechanics and Biology in an Organ Culture Model

A bovine intervertebral disc organ culture model was used to study the effect of needle puncture injury on short-term disc mechanics and biology. To test the hypothesis that significant changes in intervertebral disc structure, mechanics, and cellular response would be present within 1 week of needle puncture injury with a large-gauge needle but not with a small-gauge needle. Defects in anulus fibrosus induced by needle puncture injury can compromise mechanical integrity of the disc and lead to degeneration in animal models. The immediate and short-term mechanical and biologic response to anulus injury through needle puncture in a large animal model is not known. Bovine caudal intervertebral discs were harvested, punctured posterolaterally using 25G and 14G needles, and placed in organ culture for 6 days. Discs underwent a daily dynamic compression loading protocol for 5 days from 0.2 to 1 MPa at 1 Hz for 1 hour. Disc structure and function were assessed with measurements of dynamic modulus, creep, height loss, water content, proteoglycan loss to the culture medium, cell viability, and histology. Needle puncture injury caused a rapid decrease in dynamic modulus and increase in creep during 1-hour loading, although no changes were detected in water content, disc height, or proteoglycan lost to the media. Cell viability was maintained except for localized cell death at the needle insertion site. An increase in cell number and possible remodeling response was seen in the insertion site in the nucleus pulposus. Relatively minor disruption in the disc from needle puncture injury had immediate and progressive mechanical and biologic consequences with important implications for the use of discography, and repair-regeneration techniques. Results also suggest diagnostic techniques sensitive to mechanical changes in the disc may be important for early detection of degenerative changes in response to anulus injury.

Lumbar discography

Purpose of review: This article will review recent advances in our understanding of lumbar discography and how it relates to the evaluation of patients with suspected discogenic low back pain. Recent findings: Several recent studies have added to our knowledge of lumbar discography. One interesting area is the use of manometry or pressure monitoring to reduce the incidence of false positive results. The idea that there may be subsets of patients with positive discograms based on pressure measurements is gaining popularity. It also appears that sufficiently high pressures may induce a pain response in otherwise asymptomatic discs. Despite these advances in our understanding, it has been shown that psychosocial factors probably play a greater role in predicting disability. Finally, as we move further into the era of motion preservation and disc arthroplasty the use of discography in the classification of degenerative disc disease of the lumbar spine may prove to be very helpful. Summary: Lumbar discography remains a valuable tool in the evaluation of patients with suspected discogenic low back pain. Use of manometric or pressure monitoring techniques may help reduce the incidence of false positive results and improve patient outcomes. Careful patient selection and attention to psychosocial factors remain critical to successful management of these patients.

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.

Guidelines for the use of discography for the diagnosis of painful degenerative lumbar disc disease

Discography has been used as a diagnostic test in the evaluation of patients with recalcitrant low-back pain. Recently, its usefulness has been questioned because of the occurrence of false-positive results as well as the influence of psychological factors on test results. The purpose of this review is to establish the literature support for and against the use of discography. A search of the English-language literature published between 1966 and 2001 was performed. Papers were selected based on inclusion criteria described in the text, and the quality of information was graded using previously described methods. The authors propose a set of practice parameters based on the literature. Although the data were not judged adequate for the determination of a treatment standard, parameters for the use of discography are provided at a guideline and option level.

Lumbar Disc Disease

Neurosurgeons should strive to undertake treatment of their patients and to make more accurate diagnoses of their diseases. The spectrum of lumbar disc disease ranges from disc herniation with radiculopathy to simple degeneration of the disc causing intermittent low-back pain. In this issue of Neurosurgical Focus we examine the anatomical and pathophysiological features of the lumbar disc; consider controversial topics such as discography, annuloplasty, and nucleoplasty; learn newer techniques of lumbar discectomy; benefit from expert how-to reports; look at a literature-based guideline on the use of discography; see how outcomes research can be applied to diseases of the lumbar spine; and receive an update on artificial disc technology. It is hoped that this issue will inspire further thought about lumbar disc disease so that we can diagnose earlier, intervene less invasively, and create better long-term outcomes for our patients.

Lumbar Discography

A comprehensive review of the literature dealing with lumbar discography was conducted. The purpose of the review was to generate a position statement addressing criticisms of lumbar discography, identify indications for its use, and describe a technique for its performance. Lumbar discography remains a controversial diagnostic procedure. There are concerns about its safety and clinical value, although others support its use in specific applications. Articles dealing with lumbar discography were reviewed and summarized in this report. Most of the recent literature supports the use of discography in select patients. Although not to be taken lightly, many of the serious and high complication rates were reported before 1970 and have decreased since because of improvement in injection technique, imaging, and contrast materials. Most of the current literature supports the use of discography in select situations. Particular applications include patients with persistent pain in whom disc abnormality is suspect, but noninvasive tests have not provided sufficient diagnostic information or the images need to be correlated with clinical symptoms. Another application is assessment of discs in patients in whom fusion is being considered. Discography's role in such cases is to determine if discs within the proposed fusion segment are symptomatic and if the adjacent discs are normal. Discography appears to be helpful in patients who have previously undergone surgery but continue to experience significant pain. In such cases, it can be used to differentiate between postoperative scar and recurrent disc herniation and to investigate the condition of a disc within, or adjacent to, a fused spinal segment to better delineate the source of symptoms. When minimally invasive discectomy is being considered, discography can be used to confirm a contained disc herniation, which is generally an indication for such surgical procedures. Lumbar discography should be performed by those well experienced with the procedure and in sterile conditions with a double needle technique and fluoroscopic imaging for proper needle placement. Information assessed and recorded should include the volume of contrast injected, pain response with particular emphasis on its location and similarity to clinical symptoms, and the pattern of dye distribution. Frequently, discography is followed by axial computed tomography scanning to obtain more information about the condition of the disc.

A Reassessment of Holt??s Data on

This paper is a detailed critique of Holt's study entitled "The Question of Lumbar Discography." His finding of a 37% false positive rate in asymptomatic volunteers has been used to discredit lumbar discography as a valid diagnostic study in the investigation of low back pain patients with nonprolapsing disc disease of the lumbar spine. The authors show why Holt's paper should no longer be used as scientific and authoritative evidence against the use of discography by today's standards.

Treatment of Scoliosis in the Adult Thoracolumbar Spine with Special Reference to Fusion to the Sacrum

The major indication for operative intervention in adults with lumbar and thoracolumbar curves is pain. A careful analysis of the pain, including a careful history and the use of discography and facet blocks, has greatly enhanced the success rate both in terms of correction and relief of symptoms postoperatively. Zielke instrumentation is the preferred surgical technique for thoracolumbar curves that do not require extension of the fusion to the sacrum. Cotrel-Dubousset fixation is particularly advocated in those cases that show evidence of spinal stenosis and require posterior decompression or in cases of rigid kyphoscoliosis following an anterior release. Fusions of the sacrum require a combined anterior and posterior approach. Iatrogenic loss of lumbar lordosis can be prevented by careful attention to detail and posterior instrumentation with preservation of lumbar lordosis, contouring of rods, and hyperextension of spine and hips at the time of surgery. Loss of lumbar lordosis, which may result in marked fatigue and pain as well as a deformity often worse than the initial one, can be corrected, preferably by a combined anterior and posterior approach (Fig. 5).

Facet joint orientation, facet and costovertebral joint osteoarthrosis, disc degeneration, vertebral body osteophytosis, and Schmorl's nodes in the thoracolumbar junctional region of cadaveric spines.

The disc degeneration in the thoracolumbar junctional region (T10-L1) of 37 male cadaveric spines was recorded with the use of discography. From 24 of these spines the facet joint orientation and degenerative findings of the facet and costovertebral joints, vertebral bodies (osteophytosis) and discs, and Schmorl's nodes were recorded directly from bones. At T11-12, the most common site for the transitional zone between thoracic and lumbar facet type, there was a marked variation in the orientation of facets. The occurrence of degenerative findings and Schmorl's nodes at the three levels in the region differed. At T10-11, disc degeneration, vertebral body osteophytosis, and Schmorl's nodes were most common (anterior degeneration). At T12-L1, facet and costovertebral joint degeneration were dominant (posterior degeneration). At T11-12, disc degeneration, vertebral body osteophytosis, Schmorl's nodes, and facet and costovertebral joint degeneration all occurred (anterior and posterior degeneration). The results point to a pathoanatomic association between degenerative changes and facet orientation.

The effect of discography on the canine intervertebral disc.

With increasing use of chemonucleolysis, interest and use of discography is at an all-time high. Various reports in past years have disagreed on the safety and efficacy of intradiscal injections of contrast mediums. This experimental study was devised to determine the effects of discography on the gross and histologic appearance of the lumbar intervertebral disc. Through a laparotomy approach, five lumbar discs in ten dogs were exposed. In each dog, one disc served as a control, another punctured with a needle, and the others injected with metrizamide, hypaque, or saline, At 2, 4, 6, 8, and 10 weeks postoperative, two dogs were killed at each time interval. Examination of the discs revealed no gross differences between any of the groups. The normal gross architecture of the concentric annulus and gelatinous nucleus was maintained in all specimens. This study found no evidence that discography results in gross or histologic damage to the intervertebral disc. It does not appear that discography will predispose a normal intervertebral disc to herniate. Discography alone appears to be a safe diagnostic procedure with no experimental evidence of any untoward gross or histologic effects.

Localization of Symptomatic Lumbar Pseudarthroses by Use of Discography

Twenty-four patients with lumbar pseudarthroses following attempted fusion were investigated by preoperative discography. The pseudarthroses were confirmed at surgical exploration. In 19 patients, discography at the level of a pseudarthrosis reproduced typical back pain, and in two patients the level above the fusion reproduced typical pain. Discography is not indicated when the major symptoms are leg or buttock pain. Technical errors included injection into the annulus fibrosis and impingement of the needle into the vertebral endplate. The latter may produce a false-positive result. Previous posterior fusions and very narrow disc spaces prevented insertion of the needle in some patients. Not all lumbar pseudarthroses were symptomatic, and two frequently occurred in the same patient. Discography is a useful adjunct to the traditional investigation of lumbar pseudarthroses.

Late results of treatment of intervertebral disc disease with chymopapain.

The authors report a 12-year follow-up review of 33 patients treated with chymopapain (Discase) injection for intervertebral disc disease. This carefully controlled series of patients was treated under local anesthesia in the prone position. Only the single offending disc that correlated with the myelographic and clinical pathology (without the use of discography) was injected with Discase. Anaphylaxis is treated instantly at the first sign of disturbance, and no patients suffered shock. The percentage of patients who were completely cured or improved continues at about 70%. Aside from sensitivity, complications attributable to proper use of the enzyme remain at zero. Follow-up review of those patients over 10 years would indicate that there is no risk of delayed organ toxicity, no risk of carcinogenesis, and no apparent risk of first-generation teratogenesis.