Discogen
Diagnosis an
James P. Rath
Professor of A
University of
Burlington, V
nic Pain:
nd Treatment
hmell, M.D.
Anesthesiology
f Vermont College of Medicine
Vermont, USA
Cottage Sunrise
Westford, Vermont•2005
Learning O
• Discuss the degenerat
to discogenic pain
• Explain discography,
surrounding this test,
its use in evaluating l
• Apply an evidence-ba
new treatments for di
Objectives
tive cascade that leads
, the controversy
and opinion regarding
low back pain
ased approach to use of
iscogenic pain
Discoge
• Anatomy and path
• Patient evaluation
• Treatment
– Functional restora
– Intradiscal Electro
– Lumbar fusion
enic Pain
hophysiology
n
ation
othermal Therapy (IDET)
Lumbar Spine
• Very common in act
• Mechanism of injury
–Acute, dynamic ove
–Chronic, repetitive e
• Natural history
–First time episode u
–High recurrence rat
Pain: General
tive population
y
erload
exertion
sually self-limited
te, 70-90%
Lumbar
Degenerativ
Segmental dysfunction
Segmental instability
Segmental stabilization
r Spine:
ve Cascade
Segmental D
• Disc pathology
–Circumferential annular te
–Radial annular tears
• Z-joint pathology
–Synovitis
–Hypomobility
• Clinical correlates
–Axial pain
–“Lumbar sprain/strain”
syndrome
Dysfunction
ears
Segmental
• Disc pathology
–Internal
derangement/degeneration
–Herniation
• Z-joint pathology
–Degeneration
–Capsular laxity
• Clinical correlates
–Axial pain ± radicular pain
–HNP, instability, stenosis
Instability
Segmental S
• Disc
–Progressive degeneration
–Osteophytes
• Z-joint
–Progressive degeneration
–Osteophytes
• Clinical correlates
–Axial pain/stiffness
–Radicular pain
–Osteoarthritis, spinal steno
Stabilization
osis
Lumbar Disc: A
• Mostly H2O (60-70%)
• Type I collagen
(thickness)
• Proteoglycans – binds
H2O
• Layers (lamellae)
arranged in opposite
directions
Annulus Fibrosis
Lumbar Disc: N
• Mostly H2O (70-90%)
• Type II collagen
(viscosity)
• Proteoglycans
• Posterior location
Nucleus Pulposus
Lumbar Disc: Sta
Weight bearing:
nucleus pulposus
transmits force to
annulus fibrosis
and endplate
Rotation: Lamellae of
annulus in concentric
layers oriented in
opposite direction
to resist torsion
abilizing Functions
Disc Degener
Internal disc disruption
– Chemical phenomenon
of nucleus or annulus
– Trauma = end-plate
fracture
– Heal or radial fissure
– Diagnosis
• Discography
• High-intensity zone
on MRI
ration (Early)
Disc Degene
• Radial fissure
• Disc bulge
• Disc protrusion
• Disc extrusion
• Disc sequestration
eration (Late)
Discoge
• Anatomy and path
• Patient evaluation
• Treatment
– Functional restora
– Intradiscal Electro
– Lumbar fusion
enic Pain
hophysiology
n
ation
othermal Therapy (IDET)
Degenerative
• Axial back pain
• Pain worsened with
prolonged sitting or
standing
• Radiographic changes
are variable
• Pain reproduction with
provocative
discography
Schwarzer A, Aprill C, Derby R et al. The
disc disruption in patients with chronic lo
Disc Disease
e prevalence and clinical features of internal
ow back pain. Spine 1995; 20: 1878 – 1883.
Lumbar
Discogenic
Symptoms and signs
– Onset
• Sudden: annulus fibro
• Insidious: internal disc
– Truncal shift or forwa
– Painful motion: usual
– Midline and paraverte
– Usually normal neuro
r Spine:
Pain-Axial
osis tear
c disruption
ard list
lly flexion
ebral tenderness/spasm
ologic exam
Lumba
Discogenic
Imaging: plain radiographs
– Acute
• Limited sensitivity and
specificity
– Chronic
• Evaluate for multilevel
degenerative changes
• Evaluate for instability
with flexion-extension
lateral images
ar Spine:
Pain – Axial
Lumbar Spine: D
Imaging: advanced: MRI
test of choice, to assess
for:
• high intensity zone,
correlates with annular tear
• internal architecture of disc
• disruption of endplates
• central disc herniation
Discogenic Pain
Discog
• Discography consists
of 4 components:
– Volumetric
– Manometric
– Radiographic
– Pain provocation
• Concordant versus
discordant
• Controversy: can
discography determine
pain generators?
graphy
Rathmell J. Atlas of Image-Guided
Intervention in Regional Anesthesia and
Pain Medicine. Lippincott Williams &
Wilkins, Philadelphia, 2005.
What is the role
Lumbar Dis
The debate continues
Pro: “…disc stimulation
is a highly specific
diagnostic test…if a disc
hurts in a patient there
must be something
wrong with that disc…”
-Nikolai Bogduk
Bogduk N, Modic MT. Spine
1996;21:402-404
of discography?
scography
What is the role
Lumbar Dis
The debate continues
Con: “Until submitted to
strict scientific evaluation,
there is no basis for the
performance of
discography in clinical
medicine.”
-Michael Modic
Bogduk N, Modic MT. Spine
1996;21:402-404
of discography?
scography
Discography
To
Lumbar Computed Tom
• The f
demo
• Prese
symp
been
• The a
patie
• The a
• The a
surgi
Guyer RD, Ohnmeiss DD. Contemporary
Position statement from the Nort
Therapeu
y: Indications
o determine if a given disc is
mogrsaypmhpyt-oDmisactiocginra…phy
further evaluation of
onstrably abnormal discs
ence of persistent, severe
ptoms where other tests have
n unrevealing
assessment of failed surgery
ents
assessment of discs before fusion
assessment of minimally invasive
ical candidates
concepts in spine care: lumbar discography.
th American Spine Society Diagnostic and
utic Committee. Spine 1995;20:2048-2059.
Rathmell J. Atlas of Image-Guided Interv
Medicine. Lippincott Williams & Wilkins
vention in Regional Anesthesia and Pain
s, Philadelphia, 2005.