Thoracic discograms

[Yo GabbaPentin]

Anyone doing thoracic discograms per surgeon request? Is the increased pneumo risk worth it?

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[clubdeac]

Sounds like a really stupid idea...

 

[Taus]

Wow... Must be a hungry surgeon to operate in the t spine without fracture or cord involvement.

 

[101N]

Fun to do & zero utility. If you know a surgeon who is performing thoracic fusions, run.

 

[Yo GabbaPentin]

Ok that all pretty much confirms what I thought.

 

[bedrock]

Fun to do & zero utility. If you know a surgeon who is performing thoracic fusions, run.

+1

 

[stim4u]

left field request...

 

[emd123]

Wow... Must be a hungry surgeon to operate in the t spine without fracture or cord involvement.

History of "thoracic" fusion?

Was going to say, I don't think I've even ever seen this unless it was some unstable T spine fracture, burst, etc or something just plain weird going on.

 

[SSdoc33]

History of "thoracic" fusion?

Was going to say, I don't think I've even ever seen this unless it was some unstable T spine fracture, burst, etc or something just plain weird going on.

ive seen some thoracic disc herniations cause myelopathy, and the patients end up with fusions. but a thoracic discogram implies that someone thinks that there is thoracic discogenic pain that can be fixed with an operation. goo!!!!

 

[clubdeac]

Although I think there's really no use for it, I have seen a handful of patients with thoracic back pain who failed ESIs, mbbs, RFA, tpi's, topicals, SNRIs, TCAs, NSAIDs, and on and on and I couldn't help but wonder if they had true discogenic mid back pain. Even if I diagnosed it with disco, what am I gonna do? Send them for fusion? I think not

 

[jsaul]

I have probably done over 30 thoracic discograms in the past 2 years. Ordered by a huge spine surgery practice where people are getting fused up to the Tspine.

 

[lobelsteve]

I have probably done over 30 thoracic discograms in the past 2 years. Ordered by a huge spine surgery practice where people are getting fused up to the Tspine.

It is spelled N O. Do you think you may be part of the problem and not the cure? That is just not good care. And it certainly does not appear to be based in science.

Pain Physician. 2008 Sep-Oct;11(5):631-42.
Systematic review of thoracic discography as a diagnostic test for chronic spinal pain.
Singh V, Manchikanti L, Shah RV, Dunbar EE, Glaser SE.
Author information

Abstract
BACKGROUND:
Even though the prevalence of thoracic pain has been reported to be 15% of the general population and up to 22% of the population in interventional pain management settings, the role of thoracic discs as a cause of chronic thoracic and extrathoracic pain has not been well researched. The intervertebral discs, zygapophysial or facet joints, and other structures including the costovertebral and costotransverse joints have been identified as a source of thoracic pain.

OBJECTIVE:
To systematically assess the quality of clinical studies evaluating the diagnostic accuracy of provocation thoracic discography.

STUDY DESIGN:
A systematic review of provocation thoracic discography.

METHODS:
A systematic review of the literature was performed to assess the diagnostic accuracy of thoracic discography with respect to chronic, function limiting, thoracic or extrathoracic pain. Studies meeting the Agency for Healthcare Research and Quality (AHRQ) methodologic quality criteria with scores of 50 or higher were included for the assessment of the level of evidence. Level of evidence was based on the United States Preventive Services Task Force (USPSTF) criteria for the assessment of accuracy of diagnostic studies. Based on the level of evidence, recommendations were made according to Guyatt et al's criteria.

RESULTS:
The clinical value of thoracic provocation discography is limited (Level II-3) with 2C/weak recommendation derived from low quality or very low quality evidence indicating that other alternatives may be equally reasonable.

CONCLUSION:
Based on the available evidence for this systematic review, thoracic provocation discography is provided with a weak recommendation for the diagnosis of discogenic pain in the thoracic spine, if conservative management has failed. This is qualified by the need to appropriately evaluate and diagnose other causes of chronic thoracic pain including pain originating from thoracic facet joints.

Spine (Phila Pa 1976). 1999 Aug 1;24(15):1548-55.
Thoracic discography in healthy individuals. A controlled prospective study of magnetic resonance imaging and discography in asymptomatic and symptomatic individuals.
Wood KB, Schellhas KP, Garvey TA, Aeppli D.
Author information

Abstract
STUDY DESIGN:
A prospective case-control investigation.

OBJECTIVES:
To determine the responses to thoracic discography of asymptomatic individuals.

SUMMARY OF BACKGROUND DATA:
Literature regarding lumbar and cervical discography reveals that even morphologically abnormal discs often are not painful, whereas painful discs typically exhibit anular or endplate disruption.

METHODS:
Ten adult lifelong asymptomatic volunteers, ages 23 to 45 years, underwent magnetic resonance imaging of the thoracic spine, followed by four-level discography. Provocative responses were graded on a scale of 0 (no sensation) to 10 (extreme pain or pressure), and filmed discs were graded using a modified Dallas scheme. Concomitantly, 10 nonlitigious adults (6 men and 4 women, ages 31 to 55 years) experiencing chronic thoracic pain were similarly studied as a control group.

RESULTS:
The mean pain response in the asymptomatic volunteers was 2.4/10. Three discs were intensely painful (scores of 7/10, 8/10, 10/10), with all three exhibiting prominent endplate irregularities and anular tears typical of thoracolumbar Scheuermann's disease. On discography, 27 of 40 discs were abnormal, with endplate irregularities, anular tears, and/or herniations. Ten discs read as normal on magnetic resonance imaging showed anular pathology on discography. In the group with chronic thoracic pain, the average pain response was 6.3/10 (P < 0.05). Of the 48 discs studied, 24 were concordantly painful, with a pain response of 8.5/10 (P < 0.05); 17 had nonconcordant pain/pressure, with an average pain of 4.8/10 (P < 0.05); and 5 had no response. On magnetic resonance imaging 21 of the 48 discs appeared normal. However, on discography, only 10 were judged as normal.

CONCLUSIONS:
On discography, thoracic discs with prominent Schmorl's nodes may be intensely painful, even in lifelong asymptomatic individuals, but the pain is unfamiliar or nonconcordant. Thoracic discography may-demonstrate disc pathology not seen on magnetic resonance imaging.

http://emedicine.medscape.com/article/96284-workup#a0721 Whoever wrote this crap for Medscape took Wood's article and tried to spin it positive as useful. (It was Malanga)

An update of the appraisal of the accuracy of thoracic discography as a diagnostic test for chronic spinal pain.
Vijay Singh, Laxmaiah Manchikanti, Obi Onyewu, Ramsin M Benyamin,Sukdeb Datta, Stephanie Geffert, Allan T Parr, Frank J E Falco

Spine Pain Diagnostics Associates, Niagara, WI; Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY; Mid Atlantic Spine & Pain Physicians of Newark, Newark, DE, and Temple University Hospital, Philadelphia, PA;
Pain physician (Impact Factor: 10.72). 11/2012; 15(6):E757-76.
Source: PubMed
ABSTRACT Even though the prevalence of thoracic pain has been reported to be 13% of the general population and up to 22% of the population in interventional pain management settings, the role of thoracic discs as a cause of chronic thoracic and extrathoracic pain has not been well studied. The intervertebral discs, zygapophysial or facet joints, and other structures including the costovertebral and costotransverse joints have been identified as a source of thoracic pain.
A systematic review of provocation thoracic discography.
To systematically assess and update the quality of clinical studies evaluating the diagnostic accuracy of provocation thoracic discography.
A systematic review of the literature was performed to assess the diagnostic accuracy of thoracic discography with respect to chronic, function limiting, thoracic or extrathoracic pain. The available literature on thoracic discography was reviewed. A methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL). The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles.
The evidence and clinical value of thoracic provocation discography is limited (poor) with a paucity of evidence, with only 2 studies meeting inclusion criteria.
The limitation of this study continues to be the paucity of literature.
Based on the available evidence for this systematic review, due to limited evidence, thoracic provocation discography is rarely recommended for the diagnosis of discogenic pain in the thoracic spine, if conservative management has failed and facet joint pain has been excluded.



BOTTOM LINE: If some surgeon wants to fuse the T-spine for disc pain, that is his problem and the patient's problem. Pretending we have any science to assist in that endeavor is pure crap. But if you had 30 negative discograms, I apologize straight away....

 

[Aether2000]

The microanatomy of the thoracic disc varies depending on which level. There is no magical dividing line between lumbar and thoracic discs with lumbar discography being valid and thoracic not. For levels T10, T11, T12, the disc microscopically is indistinguishable from the lumbar disc. However the T1-4 discs resemble the cervical discs, and discography at these levels encounters the same nonsensical results as is seen with cervical discography- extremely high "opening pressures", distraction capsular pain, and multiple adjacent levels usually positive. So is discography useful in the thoracic spine? Depends on the reason for doing the discography but most importantly the level in the thoracic spine.

 

[stim4u]

I have probably done over 30 thoracic discograms in the past 2 years. Ordered by a huge spine surgery practice where people are getting fused up to the Tspine.

you must me joshing us...
that is just nuts.
I have done hundreds of cervical/lumbar discograms over 10 years, but never thoracic. makes no sense.

 

[jsaul]

The microanatomy of the thoracic disc varies depending on which level. There is no magical dividing line between lumbar and thoracic discs with lumbar discography being valid and thoracic not. For levels T10, T11, T12, the disc microscopically is indistinguishable from the lumbar disc. However the T1-4 discs resemble the cervical discs, and discography at these levels encounters the same nonsensical results as is seen with cervical discography- extremely high "opening pressures", distraction capsular pain, and multiple adjacent levels usually positive. So is discography useful in the thoracic spine? Depends on the reason for doing the discography but most importantly the level in the thoracic spine.

I agree with this. The thoracic discograms I have done for these surgeons are in the lower Tspine.

many instances it has saved the patients from getting fusions in the tspine or extending their lumbar fusions into the tspine

 

[jsaul]

you must me joshing us...
that is just nuts.
I have done hundreds of cervical/lumbar discograms over 10 years, but never thoracic. makes no sense.

no joke. Where I live, the spine surgeons are cowboys and try to fuse everyone that walks in the door. It is the wild wild west

 

[stim4u]

no joke. Where I live, the spine surgeons are cowboys and try to fuse everyone that walks in the door. It is the wild wild west

where are you? I thought my region was a surgical war zone.
cant fight evil (thoracic fusions) with more evil (discos for more fusion).

 

[Ligament]

Here in Seattle, discography is dead. I do one patient a year on average. Nobody orders them.

 

[clubdeac]

I feel like Washington State must be like practicing in Europe where nothings covered

 

[Ducttape]

and you can get marijuana without a prescription...

 

[bedrock]

I feel like Washington State must be like practicing in Europe where nothings covered

Still amazing, that there is such a battle to cover interventional procedures in a state with so many of the masters of our field working in it.

Regarding Europe. Is it that nothing is covered or nobody bothers? I hear that european pain physicians make the same no matter what they do, and don't have easy access to fluoro, so most treatment is medication driven in europe? I have very little first-hand knowledge on pain treatment in europe, so someone feel free to educate us on it.

 

[stim4u]

I would keep your discogram skills up, future disc injectables (stem cells, recombinants, gels, etc) is the future... in my opinion.

 

[clubdeac]

I pray that it is the future...please!

 

[Jcm800]

History of "thoracic" fusion?

Was going to say, I don't think I've even ever seen this unless it was some unstable T spine fracture, burst, etc or something just plain weird going on.

guy in my area was doing LOTs of this, minimally invasive far lateral BS approach. hardware in place, nothing stabalized or fixated.