Post CT Discography

[CATS22]

I have started doing lumbar discograms again (using ISIS guidelines). Did a bunch in fellowship but its been a few years.

My last 3 patient's have had positive concordant pain during provocation. On post CT they all had full thickness annular tears with contrast extravasation into the epidural space.

How common is it to have full thickness tear after a provocative discogram? Is there any data on this? I did find one older study but this was dated...
I am a little surprised about having 100% of my patients with full thickness tears and wanted to hear about others experiences. My samples size is small though.....

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[SSdoc33]

there is no utility in a post-disco CT. if the surgeon wants it, they dont know what they are doing. it can be argued that there is no utility in discography at all.

if you are getting annular tears with extravasation into every disc you inject, you are injecting multilevel degenerative discs that probably are all old and crappy to begin with. do you really need to disco to figure out whats going on? please tell me that these patients arent all getting fused from t-spine to their sacrum....

 

[CATS22]

there is no utility in a post-disco CT. if the surgeon wants it, they dont know what they are doing. it can be argued that there is no utility in discography at all.

if you are getting annular tears with extravasation into every disc you inject, you are injecting multilevel degenerative discs that probably are all old and crappy to begin with. do you really need to disco to figure out whats going on? please tell me that these patients arent all getting fused from t-spine to their sacrum....

No. The discograms are for research purposes. We need to know which disc is the culprit (there are many flaws with disco, but its the best we got...) Also, the discs have to hold at least a minimal volume without extravasation or else the treatment injection will not "stay" in the disc and the patient is eliminated from the study.
Purpose of the trial is better and effective treatment for DDD and to avoid fusion.......

 

[lobelsteve]

No. The discograms are for research purposes. We need to know which disc is the culprit (there are many flaws with disco, but its the best we got...) Also, the discs have to hold at least a minimal volume without extravasation or else the treatment injection will not "stay" in the disc and the patient is eliminated from the study.
Purpose of the trial is better and effective treatment for DDD and to avoid fusion.......

Sounds like you have some AEs to report. And possibly violating the protocol by posting here. Oops.

 

[ampaphb]

there is no utility in a post-disco CT.

I dont know about the rest of you, but I am not perfect. Post-disco CT confirms that te dye is in the nucleus, the grade and location of the anular tear, and the presence or or absence of contrast in the epidural space.

Grade 5 anular tears are frequently present in provocation positive discs.
http://www.ncbi.nlm.nih.gov/pubmed/21268300
http://www.ncbi.nlm.nih.gov/pubmed/23236303
http://www.ncbi.nlm.nih.gov/pubmed/19430778

I am assuming that an HIZ is indicative of a grade 5 anular tear

 

[Taus]

I get them for the same (and only) reason I do a disco: referring surgeon asked for it. I have no other indication to do the procedure and will occasionally try to talk patient out if it if they're not really interested in surgery or not tried reasonable conservative care. I let the patient then make decision to proceed or not.

 

[lobelsteve]

Disco is good for billing and assessing pain tolerance. Not much else. And im sure its great with secondary paingain states like wc and auto injury. I mean as far as the billing goes.

 

[Stim4me]

Reimbursement for discograms are poor... I see a fair amount ~30% grade 5 years usually when the patients pain is discordant with the MRI disc pathology. I still support PDD and idet technology and use discograms in the selection process. I barely perform 6 a year now...that's nothing

 

[pmrmd]

I still support PDD and idet technology...

I just LOL'd.

 

[ampaphb]

Disco is good for billing and assessing pain tolerance. Not much else. And im sure its great with secondary paingain states like wc and auto injury. I mean as far as the billing goes.

Given that the purpose of the procedure is to determine whether an individual disc is capable of generating pain, "assessing pain tolerance", although inartfully phrased, is exactly what the procedure is intend to do.

Perhaps rather than snark, you might first try and recall the purpose of the procedure. I completely understand you don't want to offend your referral sources by limiting their standard three-level fusions. However, those of us who instead have the patient's best interest at heart ought not to have to put up with your uninformed crap.

 

[Stim4me]

I just LOL'd.

Provide your irrefutable evidence for epidural procedures.... I assume you have reviewed the indeterminate epidural data and perform them regularly... Am I wrong to assume you have made an equally individual medical decision based on limited data.... not lol.

 

[lobelsteve]

Given that the purpose of the procedure is to determine whether an individual disc is capable of generating pain, "assessing pain tolerance", although inartfully phrased, is exactly what the procedure is intend to do.

Perhaps rather than snark, you might first try and recall the purpose of the procedure. I completely understand you don't want to offend your referral sources by limiting their standard three-level fusions. However, those of us who instead have the patient's best interest at heart ought not to have to put up with your uninformed crap.

Would love to see your disco results translate into functional improvement by limiting levels fused or making patients return to work....not so much?

 

[ampaphb]

Once again, we need to go back to basics. Discography is a DIAGNOSTIC procedure. As such, it would have no way of impacting functon one way or another.

As it is a pre-surgical staging procedure, it would also have no impact on patients returning to work.

My data re limiting surgical levels? Everytime a patient is sent with an MRI showing herniations at multiple levels. Every level I call asymptomatic, or discordant, is one less level the surgeon can justify operating on.

 

[ampaphb]

PDD and IDET data is non-existant. Epidurals have mixed data (generally dependent on whether the investigator is a nihilist, a medication management specialist, or an interventionist), but it clearly is more favorable than PDD and IDET.

 

[lobelsteve]

Clinical Utility
Clinical utility can be cast or measured in various ways.
One domain, often invoked for assessing the utility of disc
stimulation, is therapeutic utility. It asks if making the diag-
nosis of discogenic pain leads to improved outcome after
treatment; but this is only one domain of clinical utility; and
it can be cast as positive therapeutic utility. A converse
domain is negative therapeutic utility, which asks if making
the diagnosis prevents misadventure through inappropri-
ate treatment. An additional domain is diagnostic utility,
which asks if making the diagnosis serves a useful
purpose even if treatment is not available.
Positive Therapeutic Utility
The experiment to prove positive therapeutic utility for disc
stimulation is demanding and has not been conducted. It
would require patients to undergo disc stimulation, but the
results would be masked, yet the patients would then
nevertheless proceed to treatment. Thereafter, their
response to treatment would be correlated with their
response to disc stimulation (Table 13). Positive therapeu-
tic utility would arise if it emerged that success rates of
treatment were significantly higher in those patients in
whom the correct disc, according to disc stimulation, had
been treated.
Several difficulties apply to such a study. It would require
patients to agree to undergo disc stimulation. Those who
treat the patients must be prepared and able to do so
without the results of the diagnostic test. The treatment
must be target specific, i.e., designed to treat selectively
only a painful disc; treatments that do not target specific
discs do not require a specific, segmental diagnosis. The
treatment must have a reasonable chance of success, in
order to generate the required numbers in the first column
of the contingency table (Table 13); its success rate would
have to be substantially greater than that of a placebo.
Large numbers of patients would be required in order to
overcome the potential influence of chance. Given that
most symptomatic discs occur at L4-5 and L5-S1, there is
a 0.50 probability that treatment could be directed at the
correct disc by chance alone.



Disc stimulation has intrinsic diagnostic utility. It establishes
that the patient has a genuine, detectable reason for their
pain. This allays the distress of not knowing and protects
patients from false accusations and from the continued
pursuit of a diagnosis. It brings about closure.

That's the best Nik can do.

 

[Stim4me]

PDD and IDET data is non-existant. Epidurals have mixed data (generally dependent on whether the investigator is a nihilist, a medication management specialist, or an interventionist), but it clearly is more favorable than PDD and IDET.

I would say there is a fair amount of PDD data, a lot more from NZ and Europe where it is actually paid for...the data is mixed like any other Spinal intervention or surgery... Yet we make our own medical decisions and offer; tfesi, PDD, idet, multilevel lamis, multilevel fusions, so fusions, mild, kyphos, etc... Selection is key, PDD procedures equate to less than 1% of my procedural volume, that's selective....

 

[geauxg8rs]

I get them for the same (and only) reason I do a disco: referring surgeon asked for it. I have no other indication to do the procedure and will occasionally try to talk patient out if it if they're not really interested in surgery or not tried reasonable conservative care. I let the patient then make decision to proceed or not.

I don't have to talk the patient out of it. I just have a simple discussion.

Question #1 do you want to have surgery?

If yes then

Question#2 do you want a fusion?

If yes then offer the disco per surgeon request. But I have never gotten to this point.

The no s all get something else

Most people stop at question #1 and say "I thought the disco was going to reduce my pain!"

 

[ampaphb]

Prof. Bogduk is wrong on multiple points:

The only justifiable reason to perform a test is if the results will change your treatment. Giving the patient a diagnosis or an answer is not sufficient to put them at risk, however small, of discitis.

However, not all back pain had a disc eitiology. So in addition to L4/5 or L5/S1, it is also possible that all 3 levels hurt, and the study is indeterminate, or none of the discs hurt. In either case, the result adds to the diagnostic utility of discography.

Additionally, Prof. Bogduk's model assumes an honest, reasonable, intelligent surgeon. But this is not always the case. Frequently, a 3 level fusion has been prroposed. As stated earlier, it is in those instances where discography provides its greatest utility, limiting the surgeon to one, or at most two, levels.

 

[ampaphb]

I don't have to talk the patient out of it. I just have a simple discussion.

Question #1 do you want to have surgery?

If yes then

Question#2 do you want a fusion?

If yes then offer the disco per surgeon request. But I have never gotten to this point.

The no s all get something else

Most people stop at question #1 and say "I thought the disco was going to reduce my pain!"

That's because you don't go on to Question #3: OK, since no one is going to write you narcotics forever, are you willing to live with your current pain for the rest of your life?

 

[lobelsteve]

Prof. Bogduk is wrong on multiple points:

The only justifiable reason to perform a test is if the results will change your treatment. Giving the patient a diagnosis or an answer is not sufficient to put them at risk, however small, of discitis.

However, not all back pain had a disc eitiology. So in addition to L4/5 or L5/S1, it is also possible that all 3 levels hurt, and the study is indeterminate, or none of the discs hurt. In either case, the result adds to the diagnostic utility of discography.

Additionally, Prof. Bogduk's model assumes an honest, reasonable, intelligent surgeon. But this is not always the case. Frequently, a 3 level fusion has been prroposed. As stated earlier, it is in those instances where discography provides its greatest utility, limiting the surgeon to one, or at most two, levels.

An "honest, reasonable, intelligent surgeon does not offer a 3 level fusion. And most of the other guys do their own discos tonprove fusions need doing.

Lastly, Id like to see the case where a negative disco stopped a surgeon.

 

[ampaphb]

An "honest, reasonable, intelligent surgeon does not offer a 3 level fusion. And most of the other guys do their own discos tonprove fusions need doing.

Lastly, Id like to see the case where a negative disco stopped a surgeon.

Every case where the comp or insurance guidelines required one. Also, in my area, most attorneys require one prior to moving forward with surgery

 

[lobelsteve]

So the question is one of an honest, reasonable, and intelligent pain physician needing or not needing one to substantiate a legal claim. I guess of the doc was also a lawyer....

 

[SSdoc33]

you shouldnt be associating with surgeons who are doing fusions for back pain. you may justify it to yourself by saying that you are limiting the harm done, but you are legitimizing the fusion by doing so.

 

[ampaphb]

you shouldnt be associating with surgeons who are doing fusions for back pain. you may justify it to yourself by saying that you are limiting the harm done, but you are legitimizing the fusion by doing so.

No, I recognize that if I dont do them, some feral injectionist will, and give the surgeon license to do the 3 level fusion he wants to do.

 

[ampaphb]

So the question is one of an honest, reasonable, and intelligent pain physician needing or not needing one to substantiate a legal claim. I guess of the doc was also a lawyer....

Wait, so

1) No legal claim is ever legitimate?
2) It is impossible to render a reasonable opinion?
3) Discography is never done for the patient benefit, and is only done to bolster a legal claim?

Clearly I disagree with all of the above, and believe that objective testing (reports of concordant pain at the appropriate time in the discography, consistent with the pathologic morphology of the disc, within valid pressure parameters) like that offered through discography, yields improved outcomes.

 

[Hoya11]

Wait, so

1) No legal claim is ever legitimate?
2) It is impossible to render a reasonable opinion?
3) Discography is never done for the patient benefit, and is only done to bolster a legal claim?

Clearly I disagree with all of the above, and believe that objective testing (reports of concordant pain at the appropriate time in the discography, consistent with the pathologic morphology of the disc, within valid pressure parameters) like that offered through discography, yields improved outcomes.

if you think that discos are helpful in identifying problem discs vs non-problem discs, i would simply say maybe you are not good at analysis/reasoning. plenty of booksmart people can quote this or that, but most reasonable people, when they have decent experience with discos, pain patients, and mixing them, realize that the study has too many variables to produce useable information.

and you seem to be arguing that your discos are saving people from unnecessary surgery, when, IME, they are used to do exactly the opposite. hmmm, this persons got back pain, a few different discs are abnormal on MRI, no relief from epidurals or facet blocks, lets do a disco, oh shocker its abnormal? lets operate with this ammunniton. discos are so 20 years ago. what do you think would happen if i put a needle into your disc and injected pressurized contrast? it would ****ing hurt, more than the level above? you just cant reliably ascertain that information, and if you think you are doing so, you are simply wrong.

 

[SSdoc33]

No, I recognize that if I dont do them, some feral injectionist will, and give the surgeon license to do the 3 level disco he wants to do

dont be that feral injectionist, then.

2 wrongs dont make a right.

 

[emd123]

"Feral injection"

I like that. Lol

 

[Papa Lou]

Hoya made some great points. In the end if you're doing WC/PI work this is going to come your way, and if you turn it down they will move on down the street to the next guy who will do it. The motivating force$ seem clear. Don't deny it, embrace what you're doing.

..actually if there's ever been a study that compared frequency of fusions after disco being lower than without disco ampaphb has a solid argument. If that study does not exist, he has to accept defeat because logically plausible deniability is not currently on his side as Hoya stated.

Regardless of all of that, just b/c you do discos doesn't mean you're an overutilizer who doesn't prioritize ethics and helping his community/patients above income.

 

[101N]

J Pain Res. 2014; 7: 699–705.
Published online 2014 Dec 2. doi: 10.2147/JPR.S45615
PMCID: PMC4259559
Provocative diskography: safety and predictive value in the outcome of spinal fusion or pain intervention for chronic low-back pain

Abstract
There is still no clear definition of diskogenic low-back pain and no consensus on a generally agreed test, such as provocative diskography (PD), to diagnose painful disk degeneration, and probably more importantly, to predict the outcome of therapy intended to reduce pain that is presumed to be diskogenic in nature. Nevertheless, PD is the most specific procedure to diagnose diskogenic low-back pain. Its accuracy, however, is rather low or at best unknown. Although rare, the most prevalent complication, postdiskography diskitis, can be devastating for the individual patient, so all measures, like strict sterile conditions and antibiotic prophylaxis, should be taken to avoid this complication. It is advised to perform the procedure in a pressure-controlled way with a constant low flow, and optionally computed tomography imaging. PD should not be performed in morphologically normal disks. A standardized execution of the test should be established in order to perform high-quality studies to determine its accuracy to lead to meaningful interventions, and find best practices for diagnosis and treatment of diskogenic back pain. Possibly, PD may have detrimental effects on the disk, causing early degeneration, although it is unknown whether this will be related to clinical symptoms. Especially with these possible adverse side effects in mind, the risk–benefit ratio with the lack of clear benefits from treatments provided, and possible complications of disk puncture, the rationale for PD is questionable, which should be stressed to patients in the process of shared decision making. Diskography as a stand-alone test is not recommended in clinical decision making for patients with chronic low-back pain.

 

[Ducttape]

Hoya made some great points. In the end if you're doing WC/PI work this is going to come your way, and if you turn it down they will move on down the street to the next guy who will do it. The motivating force$ seem clear. Don't deny it, embrace what you're doing.

..actually if there's ever been a study that compared frequency of fusions after disco being lower than without disco ampaphb has a solid argument. If that study does not exist, he has to accept defeat because logically plausible deniability is not currently on his side as Hoya stated.

Regardless of all of that, just b/c you do discos doesn't mean you're an overutilizer who doesn't prioritize ethics and helping his community/patients above income.

this is not what i would consider ethical - because the other guy down the street would do it, then you should? what if he is only doing them because he is worried you will?

also, cant that logic be used to justify any crime?

perhaps the only situation i can see this being applicable is in war.

 

[lobelsteve]

this is not what i would consider ethical - because the other guy down the street would do it, then you should? what if he is only doing them because he is worried you will?

also, cant that logic be used to justify any crime?

perhaps the only situation i can see this being applicable is in war.

\Nik Cage stole the constitution so Ian could not.

 

[ampaphb]

1) Since I don't ever propose discograms de novo, all discos are referred to me on patients where their surgeon has proposed a discectomy/fusion/fusion with instrumentation.
2) Other guy down the street is typically a *****, with no fellowship training. Usually took a weekend course to learn how to do discography.
3) Discography is a very subjective evaluation. I'd like to think, after having worked with Drs Aprill and Derby, I have been well trained at both performing and interpreting these procedures.
4) If I chose not to do them, I can be reasonably certain the procedure will still be done, but done poorly
5) As a result, the patient will be better served if I perform the study, rather than allowing others to perform them and provide sub-optimal information.

To say my motivation is monetary is unfair. I am participating in the system, as it is currently composed. I would prefer that surgeons not perform 3 level fusions, but we all know they do. Rather than giving them carte blanche, my procedures help to limit the extent of their misadventure.

You may disagree with my decision points, but I don't think that, what I admit is a rationalization, is inherently unethical.

 

[lobelsteve]

1) Since I don't ever propose discograms de novo, all discos are referred to me on patients where their surgeon has proposed a discectomy/fusion/fusion with instrumentation.
2) Other guy down the street is typically a *****, with no fellowship training. Usually took a weekend course to learn how to do discography.
3) Discography is a very subjective evaluation. I'd like to think, after having worked with Drs Aprill and Derby, I have been well trained at both performing and interpreting these procedures.
4) If I chose not to do them, I can be reasonably certain the procedure will still be done, but done poorly
5) As a result, the patient will be better served if I perform the study, rather than allowing others to perform them and provide sub-optimal information.

To say my motivation is monetary is unfair. I am participating in the system, as it is currently composed. I would prefer that surgeons not perform 3 level fusions, but we all know they do. Rather than giving them carte blanche, my procedures help to limit the extent of their misadventure.

You may disagree with my decision points, but I don't think that, what I admit is a rationalization, is inherently unethical.

Because you get paid not to offend the surgeon, protect the patient from the other guy, and pass the patient off to the surgeon for fusion vs non-fusion. Lots of rationalization, little support for this ferret injectionist.

 

[Stim4me]

.dam phone

 

[Stim4me]

Amp has some fair points, and many are drawing a line and lambasting discograms excessively. There is a history and abundant literature on this diagnostic tool. It has limitations but also some benefits. My indeterminate WC discograms do not get fusion surgeries..... Negative discos do not get fusion surgeries either. It won't be approved with all the scrutiny involved with wc. Probably why I don't get many studies.

 

[Ducttape]

as a side note, how many of your procedures are negative altogether?

ampa, i cannot fault you for doing a procedure that you feel has clinical utility, and you have sufficient EBM to justify your hypothesis.

but i can disagree about doing a procedure just so it is done by you or just so you feel it is done right (because you are doing it). vox populi?

 

[ampaphb]

Systematic review of lumbar provocation discography in asymptomatic subjects with a meta-analysis of false-positive rates.
Wolfer LR, Derby R, Lee JE, Lee SH
Pain Physician. 2008 Jul-Aug; 11(4):513-38.

Results of surgery for discogenic low back pain: a randomized study using discography versus discoblock for diagnosis.
Ohtori S, Kino****a T, Yama****a M, Inoue G, Yamauchi K, Koshi T, Suzuki M, Orita S, Eguchi Y, Nakamura S, Yamagata M, Takaso M, Ochiai N, Kishida S, Aoki Y, Takahashi K
Spine (Phila Pa 1976). 2009 Jun 1; 34(13):1345-8.

The Positive Predictive Value of Provocative Discography in Artificial Disc Replacement
American Academy of Physical Medicine and Rehabilitation (AAPMR) September 2010 Volume 10, Issue 9, Supplement, Pages S68–S69
Emily M. Lindley, PhD1 , Blake Sherman, BS , Donna Ohnmeiss, PhD , Jack Zigler, MD , Douglas Kasow, DO , Michael Janssen, DO , Evalina L. Burger, MD , Vikas V. Patel, MA, MD

BACKGROUND CONTEXT: Identifying the primary source of pain in patients with low back pain is challenging in many patients, despite advanced imaging techniques. Often, multiple levels will show some degree of degenerative disc disease (DDD) on imaging, and determining which level(s) should be treated is difficult. In these patients with questionable pathology, provocative discography is often performed. However, the use of discography to diagnose ‘‘discogenic pain’’ remains a highly controversial topic in spine surgery and radiology communities.

PURPOSE: The purpose of this study was to investigate whether positive provocative discography is predictive of clinical outcomes in patients undergoing lumbar ADR.

STUDY DESIGN/SETTING: Retrospective analysis of data from a previous prospective, randomized clinical trial.

PATIENT SAMPLE: Patients with DDD enrolled in the ADR arm of a FDA-regulated clinical trial at a single institution.

OUTCOME MEASURES: Visual Analogue Scale (VAS); Oswestry Disability Index (ODI). METHODS: We retrospectively reviewed data from patients enrolled in the FDA ProDisc-L (Synthes Spine) IDE study that were randomized to the ADR arm of the clinical trial and underwent positive low pressure provocative discography. ADR was performed at L3-L4, L4-L5, or L5-S1. Clinical outcomes were assessed at 6 weeks and 3, 6, 12, and 24 months.

RESULTS: Of the patients that were treated with ADR at a single institution, 23 had a single-level positive low pressure discogram during their diagnostic workup. At 12 months postoperative, 16 out of 22 patients (73%) met both the high clinical success and the minimum clinically important change criteria. At 24 months postoperative, 18 out of 23 (78%) met the high clinical success criteria and 21 out of 23 (91%) patients met the minimum clinically important change criteria.

CONCLUSIONS: The positive predictive value of discography was high when using clinical outcomes after ADR to assess the diagnosis of discogenic pain. Discography was generally reserved for patients with unclear pathology or symptomology in this study; however, even in these difficult to diagnose patients, the predictive value of positive discography was 78% to 91%. These results suggest that future prospective studies may benefit from using clinical outcomes after ADR when investigating the predictive value of discography