Table 61 Classification of lumbar disc annular lesions

Grade 0 Normal, intact annulus

Grade I Fissure/tear involving inner one third of annulus

Grade II Fissure/tear involving inner two thirds of annulus

Grade III Tear extending from the nuclear space either into or through the outer one third of the disc annulus, involving up to 30° of the disc circumference

Grade IV Tear extending from the nuclear space either into or through the outer one third of the annulus, involving greater than 30° _of the disc circumference_

rienced discographers to routinely monitor injection pressures with manometry. It is, however, important to carefully monitor, record, and report when the pain response occurs; if it occurs immediately with injections of low pressure and volume, one can then confidently make the diagnosis of a chemically sensitized disc without having to use special manometric devices.

We have treated and observed patients who received substantial therapeutic benefit of varying duration (weeks to years, including no relapse) from the intradiscal injection of steroid and local anesthetic into painfully deranged lumbar discs.12 Our experience has been that nonprotruding, chemically sensitive HIZ lesions associated with clinical pain and no neurological deficit are most likely to benefit from this therapeutic intervention (Figure 6.6). When this procedure is performed, we frequently combine it with a diagnostic discogram and initially inject a small amount of contrast medium for provocation, to assure intranuclear needle placement, and to rule out major venous communication with the nuclear space. If the discogram is positive, after filming we inject 1 to 4 mL of a mixture of equal parts betamethasone and lidocaine (2-4%) and/or bupivacaine (0.5%) through the same needle placed for the provocative test. We have performed this procedure in up to three discs at one setting. Our best results, however, have been in individually deranged discs, showing either normal external contour or minimal protrusion and the HIZ lesion. Non-HIZ discs also may respond, as long as a tear either into or completely through the outer annulus exists, permitting the therapeutic substances to directly contact the sensitive nerve endings and/or chemoreceptors, both within and/or immediately adjacent to the painful tear.46,47

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