Low back pain is one of the most common medical problems encountered by healthcare providers. Accordingly, the lumbar spine is the most commonly requested site for discography. For patients whose symptomatology is predominately axial and nonmyelopathic and/or nonradicular, imaging may be insufficient or equivocal for determining the nature, location, and extent of symptomatic pathology. Conversely, imaging reveals asymptomatic abnormalities in a substantial proportion of patients (29).
A major controversial issue regarding discography is how effective spine arthrodesis is for alleviating primarily axial pain. Most of the recent literature supports the use of discography in select patients. In general, the role of surgery for axial pain is limited. At present, there is a paucity of prospective, randomized or controlled trials evaluating spinal fusion outcomes. However, one study supports that discogenic pain syndromes can be treated by arthrodesis, with a 46% satisfactory outcome (30).
Demand for discography is increasing, as a diagnostic tool to determine levels of pain generation for patients who are being considered for surgical management (e.g., interbody arthrodesis) or other minimally invasive disc procedures (see Chapter 13). Degenerated discs may be relatively motionless, and the source of pain may be at the relatively normal appearing (or at least less degenerated appearing) levels above or below owing to abnormal bio-mechanics at these levels. Surgeons concerned with limiting the extent of fusion are interested in obtaining more
Disc Classification Based on Pressure-Controlled Discography
Intradiscal pressure at pain provocation >90 psi
15-50 psi above opening pressure
Pain at <15 psi above opening pressure immediate onset of familiar pain occurring as < 1 cc of contrast is seen at the outer annulus
Further investigation warranted Positive
(but other pain generators may be present) Positive
Positive psi, Pounds per square inch.
Adapted from Derby R, Howard MW, Grant JM, Lettice JJ, Van Peteghem PK, Ryan DP. The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes. Spine 1999;24:364-371.
or evidence beyond MRI abnormalities to document what disc levels are contributing to the painful syndrome.
To summarize, patients who may benefit from discography include (31):
1. Patients with persistent back/neck and/or radicular pain when traditional diagnostic modalities have failed to identify the pain source precisely.
2. Patients in whom findings (bulging discs), identified on imaging studies, are equivocal (to determine if such abnormalities are the pain generator).
3. Patients who are to undergo fusion or other minimally invasive procedures (to determine which levels need treatment).
4. Patients who have previously undergone fusion of the spine (to help determine whether levels above or below are causing persistent symptoms).
5. Patients in whom imaging techniques cannot differentiate recurrent disc herniation from scar tissue.
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