Kurt P. Schellhas

Technological improvements in spinal imaging and interventional techniques have led to increased understanding of the origins of spinal pain. Magnetic resonance (MR) imaging provides us with variable sensitivity in detecting extramedullary spinal pathology, depending upon the anatomical region under study (cervical, thoracic, or lumbar).1-23 Degenerative changes involving multiple spinal structures (discs, facet joints, ligaments, vertebral bodies, and musculature) at multiple spinal segments (multisegmental disease) are commonly observed with high-quality MR imaging. The existence of visible (imaging studies) multistructural and/or multisegmental degeneration has led to increasing demand for more definitive spinal injections to elucidate the significance of imaging observations relative to clinical complaints and/or physical findings. Discography in particular has been the focus of increased clinical utilization and scientific investigation.1,3-5,7,9,11-21,25-31,32-42

The concept of spinal disc internal derangement9 with or without discogenic pain has gained widespread international recognition as a result of research that has correlated disc pathology observed on MR imaging with discography in both lifelong asymptomatic subjects and nonlitigious chronic pain sufferers.5,17,22,40 These investigations have revealed the limitations of MR imaging in the evaluation of spinal origin pain. Sensitivity to MR procedures has been proven to be low in the detection of symptomatic internal disc disruption and annular tears in the thoracic region22 and even worse in the cervical spine.18,19

When one is evaluating pain and/or disability of suspected spinal origin, it is of critical importance to accurately diagnose the precise ori-gin(s) of pain and structural derangement.43-45 It is equally important to evaluate the significance of pathological findings on imaging studies and whether they correlate with symptoms. Discography is used in the lumbar,1,5,9,16,30,35-37,40,41,43 thoracic,15,22,23 and cervical10,17,18,28 regions to assess pain that is suspected to be of discogenic origin. Formal investigations have shown that discography performed by skilled, knowledgeable, and experienced proceduralists can substantially im prove both surgical and nonsurgical treatment outcomes.26 Clinical questions to be answered by12,13 discography include the following.

1. Whether disc or vertebral body endplate pathology observed on imaging studies of clinical significance?

2. To determine if therapeutic intervention is indicated, and if so, what type of therapy (surgical or nonsurgical)?

3. If surgical intervention is a consideration, what spinal segments and structures may need to be dealt with? Also, the choice of operative procedure will be influenced by the results of discography. Is a satisfactory surgical outcome possible?

4. What is the ultimate prognosis?

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Natural Pain Management

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