Utility of Discography as a Preoperative Diagnostic Tool for Intradural Lumbar Disc Herniation

Preoperative definitive diagnosis of intradural lumbar disc herniation (ILDH) is difficult despite the availability of various neuroradiological investigative tools. We present a case of ILDH diagnosed preoperatively by discography and computed tomography-discography (disco-CT).The patient was a 63-year-old man with acute excruciating right leg pain. Discography and disco-CT demonstrated leakage of the contrast medium into the intradural space. Based on these findings, a right L5 nerve root disturbance caused by ILDH was diagnosed. A right L5 hemi-laminectomy and a dorsal durotomy were performed. The herniated disc was carefully dissected and then completely removed. Three months after surgery, the patient had fully recovered. This report highlights the importance of making a definitive diagnosis of ILDH preoperatively for better surgical planning and improved clinical outcomes. Furthermore, discography and disco-CT are both useful preoperative diagnostic tools for the diagnosis of ILDH.

The diagnosis and therapy of discogenic low back pain / 天津医药

Many reasons cause low back pain, such as muscles and ligaments injury, vertebral joints retrogression, spinal canal stenosis, lumbar disc herniation, lumbar spondylolisthesis, spondyloarthritis, infection, tumor and metabolic bone disease. It is in recent years that discogenic low back pain be recognised, especially after the MRI widely applied in clinics. This article makes a summary on discogenic low back pain of recent years from etiology, pathogenesis, diagnosis and therapy.

Comparative study of CT discography and MR discography in diagnosing chronic lumbago / 介入放射学杂志

Objective To explore the diagnostic consistency and correlation between MR discography (MRD) and CT discography (CTD) in diagnosing chronic low back pain. Methods Guided by C - arm fluoroscopy the mixed solution of gadoterate meglumine (GD-DOTA) and Iohexol (GD-DOTA at a dilution of 1 ∶ 400 with Iohexol) was injected into 96 lumbar intervertebral discs of the 36 patients. CT scanning was performed at 15 minutes after the injection of contrast, and axial together with sagittal SE T1WI MR scanning was carried out one hour after the injection. CTD and MRD images were randomly numbered and were independently evaluated by two experienced radiologists according to Dallas discogram scale in order to assess the diagnostic consistency and correlation between (MRD) and (CTD). In addition the diagnostic value of MRD was evaluated. Results The results revealed that in determining disc degeneration grade CTD and MRD were highly consistent with each other(Kappa = 0.836, P < 0.01), and the diagnostic results judged by the two reviewers were essentially in agreement (ICC = 1.00, P < 0.01; r = 0.997, P < 0.01). Higher consistency (Kappa = 0.836, P < 0.01) and correlation(ICC = 0.90, P < 0.01; r = 0.869, P < 0.01; Kappa =0.836, P < 0.01) in determining annulus rupture extent were also obtained. Conclusion MRD is an accurate diagnostic method for the determination of disc degeneration and the severity of annulus rupture, and this technique has greater consistency and correlation with CTD in diagnosing chronic low back pain.

Intraoperative Discography for Detecting Concealed Lumbar Discal Cysts

Lumbar discal cyst is a rare cause of radiculopathy. Their exact pathogenesis and the optimal treatment modality remain unidentified. Depending on their location, discal cysts cannot always be easily identified intraoperatively. We describe 2 patients with discal cysts and introduce an intraoperative discography technique for discal cyst location. Both patients were treated with surgical excision; with intraoperative discography, the cystic lesions could easily be detected and removed.

New Diagnostic Tool for Far Lateral Lumbar Disc Herniation : The Clinical Usefulness of 3-Tesla Magnetic Resonance Myelography Comparing with the Discography CT

OBJECTIVE: To prospectively assess the diagnostic and clinical value of a new technique (3-tesla magnetic resonance myelography, 3T MRM) as compared to computed tomographic discography (disco-CT) in patients with far lateral disc herniation. METHODS: We evaluated 3T MRM and disco-CT of 25 patients, whom we suspected of suffering from far lateral disc herniation. Using an assessment scale, 4 observers examined independently both 3T MRM and disco-CT images. We analyzed observer agreement and the accentuation of each image. RESULTS: We found complete matching, and observer agreement, between high resolution images of 3T MRM and disco-CT for diagnosing far lateral disc herniation. CONCLUSION: We think noninvasive 3T MRM is an appropriate diagnostic tool for far lateral disc herniation as compared to disco-CT.

Automated Pressure-Controlled Discography with Constant Injection Speed and Real-Time Pressure Measurement

OBJECTIVE: This study was designed to investigate automated pressure-controlled discography (APCD) findings, to calculate the elastance of intervertebral discs, and to assess the relationship between the calculated elastance and disc degeneration. METHODS: APCD was performed in 19 patients. There were a total of 49 intervertebral discs treated. Following intradiscal puncture, a dye was constantly injected and the intradiscal pressure was continuously measured. The elastance of the intervertebral disc was defined as unit change in intradiscal pressure per fractional change in injected dye volume. Disc degeneration was graded using a modified Dallas discogram scale. RESULTS: The mean elastance was 43.0 +/- 9.6 psi/mL in Grade 0, 39.5 +/- 8.3 psi/mL in Grade 1, 30.5 +/- 22.3 psi/mL in Grade 2, 30.5 +/- 22.3 psi/mL in Grade 3, 13.2 +/- 8.3 psi/mL in Grade 4 and 6.9 +/- 3.8 psi/mL in Grade 5. The elastance showed significant negative correlation with the degree of degeneration (R2 = 0.529, p = 0.000). CONCLUSION: APCD liberates the examiner from the data acquisition process during discography. This will likely improve the quality of data and the reliability of discography. Elastance could be used as an indicator of disc degeneration.

Clinical and Radiological Findings of Discogenic Low Back Pain Confirmed by Automated Pressure-Controlled Discography

OBJECTIVE: Few studies on the clinical spectrum of automated pressure-controlled discography (APCD)-defined positive discs have been reported to date. Thus, the present study was undertaken to analyze clinical parameters critical for diagnosis of discogenic pain and to correlate imaging findings with intradiscal pressures and pain responses in patients with APCD-positive discs. METHODS: Twenty-three patients who showed APCD-positive discs were selected for analysis. CT discogram findings and the degrees of nuclear degeneration seen on MRI were analyzed in comparison to changes of intradiscal pressure that provoked pain responses; and clinical pain patterns and dynamic factors were evaluated in relation to pain provocation. RESULTS: Low back pain (LBP), usually centralized, with diffuse leg pain was the most frequently reported pattern of pain in these patients. Overall, LBP was most commonly induced by sitting posture, however, standing was highly correlated with L5/S1 disc lesions (p < 0.01). MRI abnormalities were statistically correlated with grading of CT discogram results (p < 0.05); with most pain response observed in CT discogram Grades 3 and 4. Pain-provoking pressure was not statistically correlated with MRI grading. However, it was higher in Grade 3 than Grade 4. CONCLUSION: APCD-positive discs were demonstrated in patients reporting centralized low back pain with diffuse leg pain, aggravated by sitting and standing. MRI was helpful to assess the degree of nuclear degeneration, yet it could not guarantee exact localization of the painful discs. APCD was considered to be more useful than conventional discography for diagnosis of discogenic pain.

Causes and Diagnostic Strategies for Chronic Low Back Pain

Chronic low back pain (CLBP) has become more prominent with globally increasing life expectancy. Its cause is more attributable to degenerative changes than to traumatic lesions. Although the diagnosis of CLBP is recently on higher demand, lack of clinical features and non-informative imaging findings in patients with CLBP are challenging to clinicians to establish the diagnosis. Therefore, understanding of the new concept of pathogenesis, elimination of prejudice, and evidence-based diagnostic steps are required to resolve the question of pain source. Analysis of pain distribution patterns and careful history taking can be utilized as an initial guide to divide CLBP into somatic and radicular pain. Zygapophyseal joint pain and sacroiliac joint pain representing somatic pain can be further investigated using medial branch and sacroiliac joint blocks. However, comparative blocks are essential to decreased false positive rate. Infiltration of a small volume of local anesthetics can increase the specificity of the procedures. Discogenic pain stemming from internal disk derangement can be confirmed by pressure-controlled discography. Automated discography is recommended to provide the constant rate of dye injection with obviating the fluctuation of intradiscal pressure. Evidencebased concept and diagnostic procedures can provide more accurate and efficient methods to establish the diagnosis of CLBP.

Value of Preoperative Cervical Discography

PURPOSE: The aim of this study was to describe the method and the value of cervical discography as correlated with the MR findings. MATERIALS AND METHODS: Twenty-one discs in 11 consecutive patients who underwent cervical discography were analyzed. MR and CT discography (CTD) were performed in all patients. Discography was performed after swallowing barium for visualizing the pharynx and the esophagus to prevent penetration. We also analyzed the preceding causes of the subjects' cervical pain. The results of the pain provocation test were classified into concordant pain, discordant pain and a negative test. MRI was analyzed according to the T2-signal intensity (SI) of the disc, disc height, annular bulging and disc herniation. The CTD was analyzed for degeneration or radial tear of the disc, epidural leakage of the contrast agent and pooling of the contrast agent at the periphery of the disc. The pain provocation tests were correlated with the MR and CTD findings. We used the chi-square test to analyze the results. RESULTS: Concordant pain was observed in 14 cases, discordant pain in 3 cases and there were negative tests in 4 cases. There were no complications related to the procedure. Four patients had undergone anterior cervical fusion and four patients had pain that developed after traffic injuries. The decreased T2-SI and annular bulging on MRI, disc degeneration and peripheral pooling of the contrast agent on CT were significantly correlated with pain provocation. CONCLUSION: When the diagnosis of disc disease is difficult with performing MRI, cervical discography with using swallowed barium solution to reduce the penetration of the esophagus or hypopharynx may play be helpful. The decreased T2-SI and annular bulging on MRI correlated significantly with a positive result on the pain provocation test.

Diagnosis and treatment of discogenic pain / 中国矫形外科杂志

The discogenic back pain has been paid more and more attention to.It is lumbar intervertebral disc degenerative disease without performance of pressure to nerve tissue(that is,except for lumbar disc herniation,lumbar spinal stenosis,etc.).The pathogenesis and diagnostic method was investigated in a large number of studies.A number of attempts have also been carried out in the treatment.Minimally invasive treatment,integration and non-fusion surgery have achieved good efficacy.This article summarizes the diagnosis and new progress in treatment of this disease,at the same time looks to the future development.

Clinical value of discography followed by computed tomography for the treatment of multi-level lumbar disc degeneration / 中国矫形外科杂志

[Objective]To explore the clinical value of discography followed by computed tomography for the treatment of multi-level lumbar disc degeneration. [Methods]Twenty-eight cases were enrolled from January 2005 to January 2008.There were 12 males and 16 females with average age of 38.2 years,ranging from 30 to 56 years.The level of degenerated disc included L3、4 and L4、5(9 cases),L4、5 and L5S1(15 cases),L3、4,L4、5 and L5S1(4 cases).The level of discography included L2、3(10 cases),L3、4(28 cases),L4、5(28 cases),and L5S1(26 cases) with a total of 92 discs.The painful discs(or responsible discs) were screened according to diagnostic criteria of provocative discography and treated with interbody fusion.[Results]Thirty-two responsible discs were screened in total of 92 discs.ODI scores between pre and post operation were significantly different(P

The diagnosis of internal disc disruption with CT discography / 介入放射学杂志

Objective To study the value of diagnosis for internal disc disruption(IDD)with CT discography(CTD).Methods 42 discs of 32 patients showing no disc herniation on CT or MRI,but suffering from chronic low back pain,were undertaken CTD to work out the types of CTD with correlation between contrast medium dosages and the induction of pain.Results CTD demonstrated 4 types of IDD which was individually correlated with the contrast dosages and induced pain.furthermore the dosages for positive and negative disc cases showed significant differece(P

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. Forty-three 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.

Pain Provocation and Disc Degeneration in Lumbar Discography

OBJECTIVE: To determine the relationship between pain provocation and level and disc degeneration in lumbar discography. METHOD: Seventy-one patients with lumbar discogenic pain and total 109 discography were studied. During contrast mediun injection, the patient's pain response was reported. The patients were invited to choose among the following options: 'no pain or only pressure feeling', 'dissimilar', 'similar', and 'exact'. And pain location was chosen among the followings: 'low back', 'buttock', 'anterior thigh', 'posterior thigh', and 'lateral thigh'. Correlation between degeneration and provocation response was analyzed. And discography level and provocation area were evaluated. RESULTS: Low back and buttock area was the most common provocation pain site, but it was not specific by disc level. And provocation pain frequently appeared in irregular and fissured types, but the existence of provocation pain was significantly low in ruptured type. CONCLUSION: There was no correlation between provocation pain area and discography level. And existence rate of provocation pain in ruptured disc was very low. It might be due to low mechanical compression with little stimulation of nociceptor. We suggested that if patients have a ruptured disc with chemical irritation, provocation pain was not a good indicator of diagnosis of discogenic back pain.

Image Study of the Lumbar Spine / 대한척추외과학회지

Low back pain is one of the most common disorders during the lives in general population. When it is persistent for a long time without relief or aggravated, or accompanied with neurological signs such as weakness or radiculopathy, the imaging studies are required. Discogenic disease and facet joint disease are the common causes developing back pain. Other diseases should be included in the differential diagonsis, for example, spondylolysis, spondylolisthesis, congenital lesions, infection and trauma. As a imaging method, radiography, computed tomography, Magnetic resonance imaging, myelography and discography combined with or without ccmputed tomography are currently used. In this review, I like to describe about principles, advantages, and limitations of the imaging methods as well as finding of the common spinal disorders briefly.

Intradiscal Electrothermotherapy(IDET) in Patients with Chronic Discogenic Low Back Pain; Preliminary Report

OBJECTIVE: The IDET(Intradiscal electrothermal therapy) appears as a new therapeutic modality for intractable discogenic back pain. We carried out a prospective study to analyze and evaluate the therapeutic effects of IDET. METHODS AND RESULTS: During a six month period, we performed IDET in 39 patients with chronic low back pain using RITA Model 30 Electrosurgical device. The patients included 21 men and 18 women. The mean patient age was 50.2 years(range 21-73 years). All patients underwent preoperative plain radiography and MRI for excluding non-discogenic back pain. We conducted discography-CT to reveal painful discs in all patients. During the study, we measured intradiscal pressure subjectively. The area of annular tear, which identified with post-discography CT scan, was coagulated in 90degreesC of temperature for 15 minutes. Of the 17 patients who were followed up more than three months after surgery, the 10 patients(58.8%) experienced clinical improvement. Three patients had high intradiscal pressure on discography, other three patients had loss of disc height more than 30% of normal on plain radiography, and one patient suffered from postoperative epidural abscess. All of these patients were included in the remaining no improvement group(41.2%). CONCLUSION: The IDET procedure could be an alternative modality for discogenic back pain. It appears that a patient who has low intradiscal pressure on discography and intact disc height on plain radiography is considered a good candidate for IDET.

Discogenic Lumbar Pain: Correlation between Magnetic Resonance Imaging and Discography / 대한마취과학회지

BACKGROUND: Although numerous previous studies on the subject have been performed, the correlations between various pathologic findings on magnetic resonance imaging and pain reproduction by provoked discography have not been fully explained. A higher sensitivity and positive predictive value (PPV) of the high intensity zone (HIZ) for predicting concordant pain was reported. Moreover, although the apparent validity of this sign has been corroborated by some investigators, it has been questioned by others. The validity of this sign awaits confirmation. The various pathologic parameters seen on magnetic resonance imaging (MRI) in patients with discogenic lumbar pain was assessed and correlated with observations on discography. METHODS: There were 18 patients enrolled, ranging in age from 28 to 64 years with an average age of 48.8 +/- 10.2 (mean +/- SD) years. Five men (28%) and thirteen women (72%) participated in the study. All patients underwent provocation discography by a standard technique, as mentioned previously. The lumbar discs examined were L3-L4;(2), L4-L5;(14) and L5-S1;(10). The relationship between discogenic lumbar pain and disc morphology was investigated by using MRI and provocation discography. RESULTS: Of the 26 discs being studied, 16 proved to be concordantly painful at discography relative to clinical back, buttock, hip, groin, and proximal leg pain complaints. Fourteen of the 16 painful and concordant pain discs exhibit grade 2, 3 with annular tears, and four with free leakage of contrast into the epidural space. Using chi-square analysis, we observed a significant correlation (P 0.05) between a concordant pain response and the presence of an HIZ regardless of the level and grade of disc disruption. CONCLUSIONS: The presence or lack of the HIZ does not exclude the disc as a source of pain and should not replace provocation discography as a means of evaluating low back pain with or without sciatica.

The correlation between the lumbar endplate Modic degeneration and degeneration of lumbar intervertebral disc or pain provocation observed on CT discography / 中华骨科杂志

Objective To determine the correlation between the Modic degeneration of lumbar endplate on MRI and the pain provocation or degeneration of lumbar intervertebral discs observed on CT discography. Methods One hundred and twenty lumbar intervertebral discs (40 L3-4, 40 L4-5, 40 L5S1 intervertebral discs) of 40 patients among 45 patients were examined. 120 intervertebral discs underwent discography guided by CT scan, according to Dallas Discography Description system, degeneration of lumbar intervertebral disc were divided into 0-3 grade, and pain provocation were graded into negative, indifferent and positive. On the basis of Modic classification system of the lumbar endplate changes and Pearce classification system of the degeneration of lumbar intervertebral disc, the lumbar endplate changes were divided into 0-3 grade, the degeneration of lumbar intervertebral disc were graded into Ⅰ-Ⅴ. All the results were analysed by Chi-Square test for the correlations. Results There was positive correlation between pain provocation test and the lumbar endplate Modic degeneration; There was a positive correlation between the Modic degeneration of lumbar endplate and the degeneration of lumbar intervertebral disc and so is the relation between the CT discography and MRI on discs. Conclusion There is positive correlation between pain provocation test and the Modic degeneration of lumbar endplate, it suggest the endplate might be one of the sources of low back pain. There is a positive correlation between the Modic degeneration of lumbar endplate and the degeneration of lumbar intervertebral disc.

Visualization of Disc Degeneration: Comparison between Magnetic Resonance Imaging and Discography

OBJECTIVE: To determine the relationship between magnetic resonance imaging (MRI) and discography in visualization of disc degeneration. METHOD: Forty-eight patients with suspected discogenic pain in lumbar spines and degenerative changes of the lumbar intervertebral discs in T2-weighted magnetic resonance imaging were studied. Five types of discogram (cottonball, lobular, irregular, fissured, and ruptured) were classified by identifiable features in shape and density of radio-opaque shadow. Three types of MRI (bulging, protrusion, and extrusion) were classified by degrees of disc herniation. The correlation between two imaging techniques of lumbar intervertebral discs were analyzed using Spearman's correlation coefficient. RESULTS: Of sixty-three discs, MRI finding of the disc herniation revealed as follows: bulging, 17 discs; protrusion, 20 discs; extrusion, 26 discs. Discography revealed as follows: cottonball, 15 discs; lobular, 2 discs; irregular, 11 discs; fissured, 10 discs; ruptured, 25 discs. 46 discs of 63 discs showed internal structural abnormalities (irregular, fissured, or ruptured). There was no statistically significant correlation between MRI and discography in visualization of the disc degeneration (r=0.081). CONCLUSION: Severity of the lumbar intervertebral disc degeneration in MRI was not correlated with degenerative severity of discographic imaging. Supplementary discography may be useful in evaluation of patients with discogenic pain since discographic imaging when compared to MRI visualizes disc degeneration more accurately.

Comparison of Magnetic Resonance Imaging and Discography in the Diagnosis of Internal Disc Derangement / 대한정형외과학회잡지

PURPOSE: To compare the effectiveness of Magnetic Resonance Imaging and discography in the diagnosis of internal disc derangement (IDD) . MATERIALS AND METHODS: This study was confined to 90 discs of 30 patients diagnosed as IDD by MRI & disco-CT. We compared the pain nature of discogram, degree of annular tear in the disco-CT and degree of disc degeneration in MRI. The presence of HIZ (High Intensity Zone) in MRI was also compared with the pain of discogram. RESULTS: Those discs with more severe annular tears in the disco-CT showed more definite pain pattern in the discogram. More degeneration in the MRI was also correlated with more anatomical deterioration in disco-CT. Of the 27 discs with normal MRI, 6 (22%) showed severe pain provocation in discography. Of the 63 discs with degeneration in MRI, 14 (22%) showed no pain provocation in discography. Of all discs, HIZ was present in 16% (15/90) . When HIZ was present in a disc of a symptomatic patient, the possibility of it being a painful disc was 93%. CONCLUSION: In the diagnosis of IDD, MRI was helpful is seeing the degree of disc degeneration to rule out disc herniation or spinal stenosis. But the discogram is considered the only way for definite diagnosis of painful discs.