The words you are searching are inside this book. To get more targeted content, please make full-text search by clicking here.

Discogenic Pain: Diagnosis and Treatment James P. Rathmell, M.D. ... • 50% experienced no appreciable benefit Pauza KJ. The Spine Journal 2004; 4:27-35.

Discover the best professional documents and content resources in AnyFlip Document Base.
Search
Published by , 2017-01-27 03:50:04

Discogenic Pain: Diagnosis and Treatment

Discogenic Pain: Diagnosis and Treatment James P. Rathmell, M.D. ... • 50% experienced no appreciable benefit Pauza KJ. The Spine Journal 2004; 4:27-35.

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.


Click to View FlipBook Version