discoblock better than discography

[nvrsumr]

Interesting article. Anyone going to try this?

Results of Surgery for Discogenic Low Back Pain
A Randomized Study Using Discography Versus Discoblock
for Diagnosis
Seiji Ohtori, MD, PhD

Study Design. Randomized, controlled study.

Objective. To evaluate the diagnosis of discogenic low
back pain (LBP) with discography and discoblock.

Summary of Background Data. Discogenic LBP is usually
diagnosed by magnetic resonance imaging and discography.
However, the reliability of discography is controversial.
Previously, we reported the usefulness of
discoblock with bupivacaine for diagnosis, and discoblock
improved the results of anterior interbody fusion
surgery. However, that study was not a randomized, controlled
study. Therefore, the purpose of the current study
was to compare the results of surgery after diagnosis of
LBP by discography and discoblock.

Methods. Patients (n
42) with severe LBP showing
L4–L5 or L5–S1 disc degeneration on magnetic resonance
imaging were evaluated by discography (1.5 mL of contrast
medium) or discoblock (intradisc injection of 0.75 mL
of 0.5% bupivacaine). We randomized the patients in turn.
Anterior discectomy and interbody fusion were performed
in patients who responded to the diagnostic procedures.
The visual analogue scale score (0, no pain; 100,
worst pain), Japanese Orthopedic Association Score (0,
worst pain; 3, no pain), Oswestry Disability Index, and
patient satisfaction before and 3 years after surgery were
recorded and compared between groups.

Results. Twelve patients did not show pain provocation
by discography or pain relief by discoblock and were
excluded. Fifteen patients who showed pain provocation
by discography and 15 patients who experienced pain
relief with discoblock were evaluated. Rates of improvement
in the visual analogue scale score, Japanese Orthopedic
Association Score, and Oswestry Disability Index
score in the discoblock group were significantly higher
than those in the discography group (P  0.05) from
baseline to 3 years after surgery. Three patients were
dissatisfied with surgery after discography compared
with one patient after discoblock.

Conclusion. Pain relief after injection of a small
amount of bupivacaine into the painful disc was a
useful tool for the diagnosis of discogenic LBP compared
with discography.

Key words: lumbar intervertebral disc, discography,
discoblock, low back pain. Spine 2009;34:1345–1348

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[PMR 4 MSK]

Intriguing concept. Basically like blocking a joint to see if it is causing the pain by anesthetising the joint.

My question would be could you get an effective block of the annulus via this method, which many people believe is where the pain generator is in DDD. Don't the nerves go from outside to in, and the nucleus being relatively free of innervation?

 

[Jcm800]

when i have a patient i do a discogram on and they are in a great deal of pain from provokation, i have put marcaine into the disc, and i gotta say, its results are spotty. Sometimes they feel better, sometime they dont.

the thing is, after you get a positive results, half of the time the pain "eases up" in a few minutes with just waiting...

so do you wait like 5 minutes, and if it doesnt let up, put marcaine in and see if it helps? i have tried that also. half of the time they are in pain AGAIN from more volume into the disc...

now they may be saying inject marcaine INSTEAD of dye, but that seem rather unreliable. you just put a needle into their back, and waht if they are not having pain at that moment when you inject the marcaine... this is response after only quickly reading it...

 

[nvrsumr]

the paper had some significant draw backs but so does provocative discography...... There were no criteria noted for pressures, concordant pain or control discs. Also the end point is fusion which implies that fusion success is gold standard for dx of discogenic pain?? Finally, only 4/24 fusion patients had a poor outcome? Other studies mentioned in the discussion of the paper indicate an almost 75% failure rate of fusion for discogenic pain.

The above being said-its easy and simple and takes operator error out of the equation which is a big problem with provocative discorgraphy in general.

 

[Tenesma]

while it is a better approach in my opinion it misses out on the issue of unclear discogenic pain...

There is a HUGE difference between a clearly bad disk at L3/L4 on MRI with all the other discs looking good, doing a discoblock at that level, then fusing that level VERSUS

a patient with axial low back pain with multiple horrible looking discs on MRI --- are you going to do a discoblock at one level, have them get up and walk around, and then re-drape for the next level?? why not just do a FAD?

 

[Jcm800]

while it is a better approach in my opinion it misses out on the issue of unclear discogenic pain...

There is a HUGE difference between a clearly bad disk at L3/L4 on MRI with all the other discs looking good, doing a discoblock at that level, then fusing that level VERSUS

a patient with axial low back pain with multiple horrible looking discs on MRI --- are you going to do a discoblock at one level, have them get up and walk around, and then re-drape for the next level?? why not just do a FAD?

my major issue with this is the name, Discoblock. Come on? Nothing better...

 

[ampaphb]

1) Why not just do FAD? $500 of unreimbursable costs you have to eat per level

2) Could you get an effective block of the annulus via this method? Morphologically normal discs don't hurt, so the only discs that can have concordant pain have anular disruptions. Infusing local into the nucleus extends into the anulus thorugh the anular fissures

3) The "easing up" phenomenon may well be a startle response when a fissure first opens. I typically do not call that positive unless I can reproduce their pain when I re-pressurize AFTER the initial response has dissipated.

4) This is not an either or - provoke their pain at <50psi under opening pressure, then inject marcaine. If you can't turn it off, it is more likely facet based. If you can, you can now be comfortable identifying that level as the pain generator.

 

[PMR 4 MSK]

2) Could you get an effective block of the annulus via this method? Morphologically normal discs don't hurt, so the only discs that can have concordant pain have anular disruptions. Infusing local into the nucleus extends into the anulus thorugh the anular fissures

So a simple degenerative disc without annular tear cannot cause pain?

 

[ampaphb]

So a simple degenerative disc without annular tear cannot cause pain?

A "simple degenerative disc" is not morphologically normal - typically, they have grossly disorganized nuclei, and shredded inner and outer anuli.

In my experience ALL degenerative discs have anular tears - whether they are discretely identifiable or not is the only issue

 

[nvrsumr]

if my memory serves me in the study not a single disc had a HIZ. They used modic changes to identify DDD.

 

[ampaphb]

if my memory serves me in the study not a single disc had a HIZ. They used modic changes to identify DDD.

In the Ohtori study, Modic changes were used to characterize endplate abnormalities. The text of the study made no mention of the presence or absence of HIZ's. The extent of DDD was characterized by the Thompson scheme for grading disc morpholgy (Spine 1990 May;15(5):411-5), which includes anular descriptions - Grade I: discrete fibrous lamellas; Grade II: mucinous material between lamellas; Grade III: extensive mucinous infiltration, loss of anular-nuclear demarcation, and Grade IV: focal disruptions.

Aprill and Bogduk's article (High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging, Br J Radiol 1992 May;65(773):361-9) correlated HIZ's with painful Dallas Grade IV anular disruptions. Several subsequent studies pointed out that, while a significant proportion discs with HIZ's have painful posterior radial fissures, not all discs with painful radial fissures have HIZ's. Thus the absence of an HIZ in no way precludes the level from being a painful when provoked during discography

 

[nvrsumr]

Please refer to table 1 of the Ohtori study. No HIZs were noted in either group so wonder if there were annular tears present?

 

[ampaphb]

.

 

[nvrsumr]

I think there is some confusion. The study specifically states no HIZs were noted in table 1. Im just pointing out limitations to the study. I assume most contributors to this post know what HIZ and modic changes represent.

 

[ampaphb]

I think there is some confusion. The study specifically states no HIZs were noted in table 1. Im just pointing out limitations to the study. I assume most contributors to this post know what HIZ and modic changes represent.

Perhaps.

you referenced that portion immediately after my post which stated that

"A "simple degenerative disc" is not morphologically normal - typically, they have grossly disorganized nuclei, and shredded inner and outer anuli.

In my experience ALL degenerative discs have anular tears - whether they are discretely identifiable or not is the only issue"
​

Perhaps I mistakenly assumed your post was responding to mine.

The table you made reference to also makes note that ALL of the discs studied had extensive anular fissuring based on their Thompson Grades, and thus none of them were morphologically normal.

 

[nvrsumr]

I was referring to your post but not to point out anything I didnt agree with just thought the lack of HIZ is interesting in light of the high grade tears you mention. I think the higher grade tears lead to incompetent discs which are hard to pressurize, plus I would wonder about extravastion of the LA in the other arm of the study thereby anethetising extra annular stuctures and putting into question what is being blocked.

From your other posts it sounds like you perform alot of discos so I am interested in your perspective.

Regards