discogram on fusions

[jsaul]

---

Members do not see this ad.

I have a surgeon who insists me doing discograms on levels that are already fused. What do you guys think of this and how can it be technically done. I have told him I would typlically do it on the levels above and below the fused levels but he insists on trying to do at the fused levels as well

 

[101N]

I have a surgeon who insists me doing discograms on levels that are already fused. What do you guys think of this and how can it be technically done. I have told him I would typlically do it on the levels above and below the fused levels but he insists on trying to do at the fused levels as well

Unless the preceding surgery was an ALIF there is residual disc left and you can perform a discogram on it. Your surgeon is looking for a pseudarthrosis.

If the fusion was a PLIF or TLIF try to ascertain which side the cage was placed from. A more complete discectomy is performed on that side so enter on the contralateral side. Rt-handed surgeons often operate from the patient's left side and place their cages from the left. If that's the case then enter from the right.

 

[PinchandBurn]

Unless the preceding surgery was an ALIF there is residual disc left and you can perform a discogram on it. Your surgeon is looking for a pseudarthrosis.

If the fusion was a PLIF or TLIF try to ascertain which side the cage was placed from. A more complete discectomy is performed on that side so enter on the contralateral side. Rt-handed surgeons often operate from the patient's left side and place their cages from the left. If that's the case then enter from the right.

J saul brings a good question out.

What I have seen surgeons do, especially when doing a ALIF, is htat they place a 'cage' device or artificial disc in the interspace. I'm assuming this is made from metal,etc. So how am I to stick a needle into a metallic object? Additinally, when they place the disc in the interspace, dont they remove all the 'bad' disc and then place this new 'disc' in there. So I am having trouble visualizing why I would need to do a disco at that level.

 

[101N]

J saul brings a good question out.

What I have seen surgeons do, especially when doing a ALIF, is htat they place a 'cage' device or artificial disc in the interspace. I'm assuming this is made from metal,etc. So how am I to stick a needle into a metallic object? Additinally, when they place the disc in the interspace, dont they remove all the 'bad' disc and then place this new 'disc' in there. So I am having trouble visualizing why I would need to do a disco at that level.

The interbody device used in an ALIF is much larger than the interbody device used in a PLIF or TLIF because the exposure is better and the discectomy with an ALIF is more complete. Consequently, there is less residual disc with an ALIF. However, with PLIF or TLIF the surgeon is placing the interbody device through Kambin's triangle - our 'safe triangle' - and there is less room for either the spacer or the discectomy.

If you are dealing with a patient who has had a PLIF or TLIF there will be a significant amount of residual disc contralateral to the side of cage placement.

 

[knoxdoc]

I would think that the hardware and bone from a PLIF is going to make it real difficult to get around in order to even access the disc. Transforaminals can be a pain in those folks.

 

[bedrock]

I have a surgeon who insists me doing discograms on levels that are already fused. What do you guys think of this and how can it be technically done. I have told him I would typlically do it on the levels above and below the fused levels but he insists on trying to do at the fused levels as well

I think the real moral of the story whic the surgeon doesn't want to admit to himself is that---he should stop fusing so many people!

His technique may have been perfect but maybe fusin that 35 year old with fibromyalgia wasnt a good idea...

 

[Aether2000]

My thinking is that either the surgeon doubts the fusion and believes there is a pseudoarthrosis or is incompetent. There are absolutely zero studies or even an implication that pressurizing a fused segment has any validity. It is extrapolating well beyond the limits of diagnostic acuity of the technique.

 

[Tenesma]

a discogram at a fused level is stupid

a discogram at a level that was fused with an intervertebral cage even though there may be pseudoarthrosis is stupid

a discogram at a level that was fused purely with interspinous fixation or facet fusion where the disc was never touched..... arguable... but how will that improve decision making re: revision?

basically your surgeon is a dumb ass - and my answer would be: "I am sorry, this is not a procedure I provide"

 

[101N]

a discogram at a fused level is stupid

a discogram at a level that was fused with an intervertebral cage even though there may be pseudoarthrosis is stupid

a discogram at a level that was fused purely with interspinous fixation or facet fusion where the disc was never touched..... arguable... but how will that improve decision making re: revision?

basically your surgeon is a dumb ass - and my answer would be: "I am sorry, this is not a procedure I provide"

Maybe🙂

 

[clubdeac]

How would a discogram show a pseudoarthrosis? So you get a post disco CT, all you're gonna see is dye extravasation all throughout the disc, right? That's what CT w/multiplanar reconstruction is for I thought. I really don't get the concept of looking for pseudoarthrosis with a discogram...

 

[jsaul]

a discogram at a fused level is stupid

a discogram at a level that was fused with an intervertebral cage even though there may be pseudoarthrosis is stupid

a discogram at a level that was fused purely with interspinous fixation or facet fusion where the disc was never touched..... arguable... but how will that improve decision making re: revision?

basically your surgeon is a dumb ass - and my answer would be: "I am sorry, this is not a procedure I provide"

this was what I told him but he states that especially those that are fused posteriorly where the disc was not touched- he may then fuse anteriorly if positive discs there.

he also states to try to get it in where there are cages...I told him that is near impossible.

 

[101N]

this was what I told him but he states that especially those that are fused posteriorly where the disc was not touched- he may then fuse anteriorly if positive discs there.

he also states to try to get it in where there are cages...I told him that is near impossible.

The surgeon here is correct.

 

[Aether2000]

I disagree. The surgeon is an incompetent fool fishing for more surgery. The approach to a posteriorly fused disc necessarily causes the needle tip to stray more laterally, far off the safety provided by the superior articular process border of Kambin's triangle. Instead, this foolish surgeon is encouraging an approach that may lead to pithing of the exiting nerve at the level of the disc at the point of most posterior entry into the disc.
A pseudoarthrosis is readily visualized on CT scan: it does not require a non-diagnostic experimental approach to confirm the pseudoarthrosis, nor to feed into the surgeons ego of ignorance

 

[101N]

Too strong an indictment with too little information about this patient, the surgeon asking the question, and the surgical approaches used for interbody fusion.

A true PLIF, TLIF, XLIF, or ALIF all include some type of interbody cage. A posterolateral fusion (PLF) does not. I agree that wiith a PLF there CAN be exhuberant callus formation that makes a safe-triangle approach difficult or impossible. But even with a PLF this is not always the case.

Some surgeons use an interspinous process fusion - Aspen - that is posterior, not lateral. Moreover, sometimes even an intertransverse process fusion does not encroach on the safe triangle. In most instances only ALIFs will have a big enough cage/s that CT would be the preferred route to document a pseudarthrosis because there is minimal residual disc.

You are all assuming a compete discectomy and large cage placement. But this isn't reality.

 

[Aether2000]

There is plenty of information to show the surgeon is a fool. There is no study on discography in fused disc. There are no studies demonstrating any predictive effect from pressuring a fused disc. There are no studies demonstrating any clinical rationale to do this procedure. Interpretation as to both stimulation and contrast pattern is completely speculative. The question of foolishness of the procedure is answered in my mind, and the lack of education of the surgeon. The only remaining question is which is more costly: settling the malpractice suit for nerve injury in a clearly experimental procedure or the fraud case Medicare or the insurer will build against you for human experimentation.

 

[101N]

There is plenty of information to show the surgeon is a fool. There is no study on discography in fused disc. There are no studies demonstrating any predictive effect from pressuring a fused disc. There are no studies demonstrating any clinical rationale to do this procedure. Interpretation as to both stimulation and contrast pattern is completely speculative. The question of foolishness of the procedure is answered in my mind, and the lack of education of the surgeon. The only remaining question is which is more costly: settling the malpractice suit for nerve injury in a clearly experimental procedure or the fraud case Medicare or the insurer will build against you for human experimentation.

"The lady doth protest too much, methinks."

 

[Aether2000]

You thinks wrong. While you may promote cowboy medicine without a shred of evidence in a public forum, I believe you do a great disservice to those that are fellows and students in this student forum. The promotion of cavalier human experimentation will lead to litigation and an indefensible complication set because of what- the surgeon told you to do it? Perhaps you should take your brand of practice to the CRNA forums where they will welcome with open arms the type of ineptitude you promote.

 

[Ducttape]

wow, algos...

maybe you should sit down, take a deep breath, close your eyes, focus on the rhythm of your breathing, slowly in... then out...

cause i can almost see those blood vessels straining...

 

[101N]

You thinks wrong. While you may promote cowboy medicine without a shred of evidence in a public forum, I believe you do a great disservice to those that are fellows and students in this student forum. The promotion of cavalier human experimentation will lead to litigation and an indefensible complication set because of what- the surgeon told you to do it? Perhaps you should take your brand of practice to the CRNA forums where they will welcome with open arms the type of ineptitude you promote.

Rough day at work?

For the fellows...

The issue here is how much residual disc was left with the initial surgery. Did the surgeon perform a sub-total discectomy and place a small, single, cage? Obviously the patient is having back pain post fusion and someone suspects a failed fusion or pseudarthrosis.

If you are asked to do this and you are not comfortable then simply pass on it. I work closely with surgeons and I'm asked to do it on occasion. If you work closely with spine surgeons you will be asked to do it at some point. It typically comes up when; the initial approach was posterior, performed by different surgeon with whom the patient is now dissatisfied, and the new surgeon is considering a revision to an ALIF.

When I'm asked to do this I will look at the imaging prior to the case to assess the size of the cage/s and read the op note to understand what the approach was. If the initial surgery was an ALIF, or a PLIF/TLIF with two cages then it probably can't be performed. Constructs like that leave only an annulus with no residual disc. When you try to cannulate those you will simply bounce off, or worse perform an annulogram. If you don't know what an annulogram looks like don't attempt this. Annulograms are always painful and will produce a false positive.

But at other times the initial surgery was a TLIF or PLIF, sometimes with a unilateral approach that places a single cage at a diagonal through the disc, and often from the patient's left side. In those circumstances there is a lot of residual disc left and that disc can be cannulated from the Rt. If that disc reproduces the patient's pain at < 90 psi, and the surrounding discs are painless, then I am suspicious about the construct.

 

[Aether2000]

For the fellows: the above is total bull**** and constitutes an example of exactly why pain medicine is under attack, especially fraudulant use of discography.

 

[SSdoc33]

excellent comments and discussion.

i agree with algos. i can barely accept provocation discography as a legitimate tool on a "virgin" back. you throw a fusion in there and there are WAY too many variables.

also, 101, with your example of a PLIF and the possible need for an ALIF, one needs to accept the possibility that anterior-based disc herniations cause pain. we see these all the time on MRIs and generally don't believe they are painful.

so, anecdotally, on those patients who have had a fusion and have residual pain that you have "positive" discogram on, do they do well with their new fusion?

this just seems like a great way to justify a revision fusion, even though we all know that if you stick a needle into an area that has been operated on and fill it up with a bunch of fluid, its gonna hurt.....

 

[101N]

Spine (Phila Pa 1976). 2000 Apr 1;25(7):853-7.
Anterior lumbar fusion improves discogenic pain at levels of prior posterolateral fusion.
Barrick WT, Schofferman JA, Reynolds JB, Goldthwaite ND, McKeehen M, Keaney D, White AH.
Source
Spine Care Medical Group, San Francisco Spine Institute, Daly City, CA 94015, USA.
Abstract
STUDY DESIGN:
A descriptive case review.
OBJECTIVES:
To assess the outcomes of anterior lumbar interbody fusion for painful discs within a solid posterolateral spinal fusion.
SUMMARY OF BACKGROUND DATA:
Some patients continue to have pain after posterolateral spinal fusion despite apparently solid arthrodesis. One potential etiology is pain that arises from a disc within the fused levels.
METHOD:
Retrospective review of 176 patients with anterior interbody fusion, which located 20 who had anterior interbody fusion levels of prior posterolateral spinal fusion. All had low back pain, solid posterolateral spinal fusion, and painful disc(s) at the posterolateral spinal fusion level(s) but not elsewhere. Pain was measured by the Numerical Rating Scale, function by Oswestry Disability Questionnaire, and patient satisfaction by the North American Spine Society Outcome Questionnaire.
RESULTS:
Follow-up data were available for 18 patients (90%). Mean follow-up was 58 months (25 to 102). There were 10 men and 8 women. Mean age was 45 years (26 to 72). Diagnoses were degenerative discs, herniated nucleus pulposus, spondylolisthesis, and spinal stenosis. Eight patients had injuries after the previous posterolateral spinal fusion that precipitated new symptoms. Two patients had one level fusion, 14 had two levels, and 1 each had three and four levels. Four patients had one prior surgery, 5 had two, and 9 had three or more. All patients had solid anterior interbody fusion by radiograph. Mean Numerical Rating Scale improved from 7.9 before surgery to 4.7 after (P< 0.001). Mean Oswestry Disability Questionnaire improved from 56.3 before surgery to 47.9 after (P = 0.04). Of 15 patients unable to work before anterior interbody fusion, 5 returned to work. Sixteen patients (89%) were satisfied with their results.
CONCLUSION:
Low back pain that continues or recurs after apparently solid posterolateral spinal fusion may be caused by painful disc(s) at motion segment(s) within the fusion. A solid posterolateral spinal fusion may not protect the residual disc(s) from injury. Anterior interbody fusion can provide significant improvements in pain and function and a high degree of patient satisfaction in this clinical setting.

 

[jsaul]

are you jerome schofferman?

 

[Aether2000]

Ok, so in this retrospective series of 20 patients that had subsequent anterior fusions based on discography, 1/3 of those working returned to work, and 3 of the 18 were not apparently working in the first place and presumably did not help them engage in gainful employment. There were no controls so we really don't know if the 5 would have started working again despite the pain, nor whether multiple painful segments fused or with discography has any meaning at all. Certainly once you get to two or three or four positive discs, then the validity of discography wanes rapidly. It appears that the motion segment was an assumed diagnosis without proof, and discography was part of the sham in a sham surgery. What happened to the people that had subsequent fusion without discography- without a comparative group, this series makes assumptions that discography would be useful in patient selection but does not validate that with a control group or historical control. At most, this is level IV or level V NASS EBM and does not rise to the level of inclusion in most scientific or medical guidelines or recommendations.
It is actually a fascinating study but not terribly relevant.

 

[101N]

Ok, so in this retrospective series of 20 patients that had subsequent anterior fusions based on discography, 1/3 of those working returned to work, and 3 of the 18 were not apparently working in the first place and presumably did not help them engage in gainful employment. There were no controls so we really don't know if the 5 would have started working again despite the pain, nor whether multiple painful segments fused or with discography has any meaning at all. Certainly once you get to two or three or four positive discs, then the validity of discography wanes rapidly. It appears that the motion segment was an assumed diagnosis without proof, and discography was part of the sham in a sham surgery. What happened to the people that had subsequent fusion without discography- without a comparative group, this series makes assumptions that discography would be useful in patient selection but does not validate that with a control group or historical control. At most, this is level IV or level V NASS EBM and does not rise to the level of inclusion in most scientific or medical guidelines or recommendations.
It is actually a fascinating study but not terribly relevant.

It's very relevant to this discussion. This is precisely what the surgeon referred to by the OP was thinking of.

Your antipathy toward spine suregons and spine surgery is, IMO, unprofessional and very, very biased. Not all spine surgeons are Shylocks.

 

[Mister Mxyzptlk]

If the surgery left the disk preserved then I see no reason why the disk can't be a pain generator e.g. develop annular tears, herniate, etc.

If the disk was fiddled with (ALIF, cage, etc) then I don't see how you could interpret the results no matter what they were.

Having said all that, I don't know how one can be expected to actually perform the procedure with lateral bony masses at the target level.

 

[Aether2000]

My antipathy towards spine surgeons is based on facts. The fact is, spine fusion surgery results in an average 31% reduction in pain 2 years after surgery and 25% increase in function. Not exactly stellar numbers for an $80,000 surgery, and in your case, followed by another $80,000 surgery based on some whacked idea about pain generators being contained within the anterior part of the disc. For those of us who have actually DONE the fusion procedure, the endplates (and contained innervation), nucleus pulposis (with ingrowth of neural structures), and part of the annulus fibrosis are destroyed in the process. The facet joints and capsules are distended beyond the point they have settled and the bone remodeling that has occurred to accommodate the disc narrowing is disrupted. The posterior annulus fibrosis with the inflammatory membrane that is evident during endoscopy, is further distended but not removed by fusion surgery. So it is a flight of fancy (or $$$) to compare a discogram in this situation with an intact disc and controls. In the study presented, there were up to 4 level disc fusions being performed. Sounds like discography is really helping distinguish "pain generators"! But furthermore it sounds like a monetary symbiosis between surgeon and injection technician to use an unproven uncontrolled crappy technique to justify an even crappier treatment. Excuse me for not buying into the NASS nonsense about how great fusions are. For most patients, they aren't great....and in many they result in unnecessary surgery that turn out to be disastrous.

 

[101N]

For those of us who have actually DONE the fusion procedure, the endplates (and contained innervation), nucleus pulposis (with ingrowth of neural structures), and part of the annulus fibrosis are destroyed in the process.

This part, in particular, interests me. Please elaborate on the fusions you have done.

 

[Aether2000]

During my years as a surgery resident.

 

[101N]

During my years as a surgery resident.

So tell me more about your surgery residency where YOU performed lumbar fusions? When was this, specifically what year did you perform your surgical residency? Who were your proctors and what approach did you perform?

 

[Aether2000]

None of your god damned business.

 

[bedrock]

okay now, let's just take things down a notch and keep it friendly.

 

[Aether2000]

That was being friendly. 🙂

 

[101N]

There is plenty of information to show the surgeon is a fool. There is no study on discography in fused disc.

Hmm...

Spine (Phila Pa 1976). 2000 Apr 1;25(7):853-7. Anterior lumbar fusion improves discogenic pain at levels of prior posterolateral fusion. Barrick WT, Schofferman JA, Reynolds JB, Goldthwaite ND, McKeehen M, Keaney D, White AH. Source Spine Care Medical Group, San Francisco Spine Institute, Daly City, CA 94015, USA.

An experienced anesthesiologist specializing in spinal injections
performed discography at all levels within and at least one
level above the prior PLF. The discographer determined
whether pain was provoked during injection and whether pain
was concordant or discordant. Pain was graded using a 0- to
10-point numerical rating scale (NRS): 0 to 1 (absent), 2 to 4
(mild), 5 to 7 (moderate), and 8 to 10 (severe). Only moderate
or severe concordant pain was considered positive. Any patient
with painful disc(s) at levels above or below the previous PLF
or other potential structural causes for the pain were excluded.

 

[lobelsteve]

Agree with the Algos. And Ssdoc.

Surgically altered discs cannot be reliably used in discography and have not been studied with any rigor to allow 101's theory to carry weight. Anatomical constraints fail to demonstrate why attempting to pressurize a surgically altered disc would make scientific sense. Now im just a former academic guy and not the educational chair of ISIS.

 

[PinchandBurn]

I dont know why this reminds me of an xray I saw on teh screen of a neurosurgeon last week when I walked into his office.

In the cervical neck, the patient had anterior AND posterior fusion of 5 out of the 7 cervical vertebrae.

Yes, you did read that correctly. And I thought I had seen everything................🙄🙄

 

[Jcm800]

I want in on this....

No I don't. I think that doing discography on even a virgin back is probably worthless in most cases,even by the worlds bestests discographers, but in a fused level, it is beyond crazy talk.

This is crazy talk. I would like to see an actual fist fight come out this.
The first rule of pain rounds fight club is...

 

[Aether2000]

Studies started in 1995 before pain docs had discovered the words "randomized" or "controlled" or "statistically significant" are of interesting historical value but are certainly not valid for making medical decisions based on current EBM constructs. This is especially true when you have an uncontrolled non-randomized diagnostic test being used to direct an uncontrolled non-randomized therapeutic intervention in a statistically invalid small sample size, then try to draw meaningful conclusions about the utility of the diagnostic test. Doesn't hold water.

 

[stim4u]

the discord amoung the forum members regarding the relevency of discograms is understandable.
But pain physicians that work closely with good/reasonable spinal surgeons, and routinely perform discograms for them, actually prevent unecessary spinal fusion surgeries. Personally, I have a high threshold to call a discogram concordant. and typically my regional surgeons never request discograms on fused segments, no matter what the prior surgical approach was.

 

[Aether2000]

Agree. With properly psych screened patients using rigid criteria for discography it is a useful procedure.

 

[Tenesma]

i agree w/ algos... 101N - you are not standing on a firm leg...

what is the point of discography --- if it is purely to stick a needle into the intervertebral space and make a pretty picture - then yes, with good skill and an entry point, it is doable by most well trained practitioners...

the issue is that we use "provocative" discography as a diagnostic tool to diagnose internal disc disruption and see if it correlates as a pain generator...

1) a previously surgically manipulated disc (ie: discectomy followed by cage) is already disrupted by definition...
2) the reason that disc was fused was based on the assumption that it is a pain generator...

so please explain the diagnostic utility of a discography in a fused segment?

maybe you live in a world where the disc can still hurt until you have cut out every piece of the disc and done a 360 fusion --- but guess what? people can still have axial discogenic type pain after a 360 fusion....

boy, I wish you could have brought up your "thesis" at Q&A w/ Bogduk at ISIS this year - it would have been fun...

 

[PinchandBurn]

i agree w/ algos... 101N - you are not standing on a firm leg...

what is the point of discography --- if it is purely to stick a needle into the intervertebral space and make a pretty picture - then yes, with good skill and an entry point, it is doable by most well trained practitioners...

the issue is that we use "provocative" discography as a diagnostic tool to diagnose internal disc disruption and see if it correlates as a pain generator...

1) a previously surgically manipulated disc (ie: discectomy followed by cage) is already disrupted by definition...
2) the reason that disc was fused was based on the assumption that it is a pain generator...

so please explain the diagnostic utility of a discography in a fused segment?

maybe you live in a world where the disc can still hurt until you have cut out every piece of the disc and done a 360 fusion --- but guess what? people can still have axial discogenic type pain after a 360 fusion....

boy, I wish you could have brought up your "thesis" at Q&A w/ Bogduk at ISIS this year - it would have been fun...

I work wit a few surgeons, somewhat 'closely'. One guy is a little more aggressive than the other, for lack of a better word.

I asked h im about this debate. He thinks you can still have discogenic pain anteriorly if the approach was posterior. Obviously, he's somewhat biased. But he is one of the more 'conservative' guys.

Personally, I wouldnt do a discogram on a fused level because I dontthink I could get the needle into the right spot.

This would be a great Q and A sort of debate at a conference. It would be nice to have a premier pain guy vs a spine surgeon debate this.

In terms of EBM for this. I'm not sure if EBM is all that great for a lot of things in medicine, in fact a lot of it has been debunked. As a relatively young attending, I can tell youthat there are many 'non' EBM things that happen to work without good science and is safe. For example, why is it that after ONE diagnostic MBB with just bupivicaine, a patient's pain is gone for 1 year or so? I've seen this now atleast 6 times in the last 1 year....

 

[Aether2000]

Unfortunately CMS and most insurers require ebm before paindocs get paid for what they do. Once these entities turn their guns on fusion it will fundamentally affect spine surgery in the us. Thatis one reason spine surgeons are flocking to nass injection conferences so they can partially preserve their incomes after the great fall. I agree some ebm is taken to ridiculous extremes such as acoem and aps guidelines. I believe discogenic pain can occur in the anterior annulus but considering the lamella are 20 thick compared to the 11 layers posteriorly that it is rare. However I did convince a surgeon to fuse for abdominal pain associated with a grade v anterior rent and this did relieve most of the abdominal pain.

 

[101N]

In spite of the 'shock and awe' that this technique has inspired here it's not new, it's been published, and it's still used in spine circles. A lot of you guys have an overly simplistic conception of spine surgery: it's fused so it's done. That's not reality, technical failures occur. If you place a perc stim and initially the patient gets good coverage but then complains of a change in coverage and rib stim, is that a 'failed stim"? No it's a technical failure. In a similar vein, technical failures - pseudarthrosis, subsidence, hardware failures, adjacent segments, etc - also occur in spine surgery. Work with surgeons and you will see it. Revisions happen appropriately on occasion.

Summarizing your concerns:

1. It's dangerous: yes, everything we do is dangerous. But in the context of CTFESIs, C1/2 Arthrograms, Cervical Stim, etc. This just doesn't pan out. If you encounter a cage you can't get through. Your needle doesn't wedge in the cage and break and the patient doesnt exsanguinate or go into V-Fib. Same iatrogenic risks as discography.

2. It's too difficult. No to that as well. Try it on an ALIF and you will bounce off the cage or get only as far as the annulus. Try it on a PLF and it's pretty much just like a regular discogram. TLIFS & PLIFS lie somewhere in between depending upon the size, position, and # of cages. In my experience you don't need to consider this for an ALIF.

3. It's not reliable. Can't argue this as it's inherent in discography in general. You won't know what the patient will report until you start pressurizing. The biggest concern here is an unrecognized annulogram leading to a false positive. I've had an annulogram with an ALIF but I recognized it and reported it as such. The disc 2 levels up - L3/4 - produced concordant pain in that patient but we opted to try facets, stim, etc instead of a 'skip' fusion.

 

[PinchandBurn]

In spite of the 'shock and awe' that this technique has inspired here it's not new, it's been published, and it's still used in spine circles. A lot of you guys have an overly simplistic conception of spine surgery: it's fused so it's done. That's not reality, technical failures occur. If you place a perc stim and initially the patient gets good coverage but then complains of a change in coverage and rib stim, is that a 'failed stim"? No it's a technical failure. In a similar vein, technical failures - pseudarthrosis, subsidence, hardware failures, adjacent segments, etc - also occur in spine surgery. Work with surgeons and you will see it. Revisions happen appropriately on occasion.

Summarizing your concerns:

1. It's dangerous: yes, everything we do is dangerous. But in the context of CTFESIs, C1/2 Arthrograms, Cervical Stim, etc. This just doesn't pan out. If you encounter a cage you can't get through. Your needle doesn't wedge in the cage and break and the patient doesnt exsanguinate or go into V-Fib. Same iatrogenic risks as discography.

2. It's too difficult. No to that as well. Try it on an ALIF and you will bounce off the cage or get only as far as the annulus. Try it on a PLF and it's pretty much just like a regular discogram. TLIFS & PLIFS lie somewhere in between depending upon the size, position, and # of cages. In my experience you don't need to consider this for an ALIF.

3. It's not reliable. Can't argue this as it's inherent in discography in general. You won't know what the patient will report until you start pressurizing. The biggest concern here is an unrecognized annulogram leading to a false positive. I've had an annulogram with an ALIF but I recognized it and reported it as such. The disc 2 levels up - L3/4 - produced concordant pain in that patient but we opted to try facets, stim, etc instead of a 'skip' fusion.

I doubtyou have this on the go...but do you have a pic of the annulogram. I'm sure on the post disco CT it can easily be recognized, however when you are under live fluro I suspect it's somewhat difficult since you probably have only a small amount of nucleus pulposus in place with the cage taking most of the 'center part' of the disc.

 

[101N]

I doubtyou have this on the go...but do you have a pic of the annulogram. I'm sure on the post disco CT it can easily be recognized, however when you are under live fluro I suspect it's somewhat difficult since you probably have only a small amount of nucleus pulposus in place with the cage taking most of the 'center part' of the disc.

I do have a picture of it. However, with a big ALIF cage, even without the contrast, you should know that it's inadequate needle position even without the contrast. If you can't cannulate the outer third of the disc with your bevel - you can't with a typical ALIF cage - then you have to ask yourself if you should even attempt to inject contrast because your needle isn't in the center of the disc.

I use a 'poor man's axial' with 5/1.

 

[deleted79235]

I was able to find another article on this subject. Wasn't able to attach it but you can get it for free from pubmed.

Interv Neuroradiol. 2010 Sep;16(3):326-35. Epub 2010 Oct 25.
Provocation lumbar diskography at previously fused levels.
Dulai HS, Bartynski WS, Rothfus WS, Gerszten PC.
Source
Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA.
Abstract
Recurrent or persistent low back pain (LBP) after lumbar fusion can be related to many factors. We reviewed the provocation lumbar diskogram (PLD) features and redo-fusion outcome in our patients evaluated for recurrent/persistent LBP after technically successful fusion. LD was performed in 27 patients with recurrent/persistent LBP after prior successful lumbar surgical fusion (31 fused levels: single-level fusion-23; two-level fusion-4). PLD response and imaging characteristics at fused and non-fused levels were assessed including: intra-diskal lidocaine response, diskogram-image/post-diskogram CT appearance, presence/absence of diskographic contrast leakage, and evidence of fusion integrity or hardware failure. Outcomes in patients having redo-fusion were assessed. Concordant pain was encountered at 15 out of 23 (65%) single-level fusions, non-concordant pain in one fusion with non-painful response in seven. Adjacent-level concordant pain was identified in seven out of 23 (30%) patients (three of 15 with painful fused levels; four of seven with non-painful fusions). In two-level fusions, concordant pain was encountered at one fused level in each patient. In painful fused levels, leaking and contained disks were encountered with partial or complete pain elimination after intra-diskal lidocaine injection. In anterior fusions, space or contrast surrounding the cage was noted at five of 11 levels. Pseudoarthrosis was noted only with trans-sacral screw fusions. Redo-fusion in 13 patients resulted in significant improvement in nine and moderate improvement in one. Patients with recurrent/persistent LBP after technically successful fusion may have a diskogenic pain source at the surgically fused or adjacent level confirmed by lidocaine-assisted PLD.

 

[101N]

Thanks, I was not aware of that article. It's in pubmed central so you can read it for free.
Check out the medial broach of the screw in the photo below. It's a wonder he didn't have
leg pain when he woke up.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3277988/figure/F3/

 

[PinchandBurn]

Thanks, I was not aware of that article. It's in pubmed central so you can read it for free.
Check out the medial broach of the screw in the photo below. It's a wonder he didn't have
leg pain when he woke up.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3277988/figure/F3/

wow, i've never seen screws like that at L5/s1 (vertically placed through the disc space).

I can see why perhaps doing L4/5 and L3/4...but why L5/s1 in thta pic? It's fused posteriorly and sagittally. I would be darned if tht L5/s1 moved. Was this guys going to do an atnerior fusion at that level as well?.....

 

[lobelsteve]

Neat article. I like how 9/27 patients had reported successful outcomes.

33%. An amazing number in pain medicine.

More astounding is actually reading this GIGO article.

Disks were provoked by a moderate/rapid hand injection of 1-4.5 cc Iohexol 240 mgI/cc (GE Medical Products, Milwaukee WI, USA) under direct fluoroscopic guidance. Injection volume depended on 1) disk volume end-point, 2) post-operative disk volume end-point, 3) clearly established severe pain response or 4) exaggerated capacity in degenerative disks. Patients were kept unaware of whether a level was being provoked or which level was being studied. The initial injection response was observed by the operator and with a positive pain response, the features of the pain were clarified, VAS level of pain was established and these items recorded similar to Walsh et al. 19 "Concordant pain" was recorded if the provoked pain was the patient's typical/familiar pain and "non-concordant pain" was recorded if the provoked pain was not their typical pain. Fluoroscopic images were obtained for each disk level in anterior-posterior/lateral projections during and following the injections.

Over 4 years they did 390 dicsograms at their institute. Just like everybody else does?

Here is the full article:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3277988/

And those pics above are of a 32 y/o with chronic LBP who had the pole fusion 1 year prior for reported spondylolisthesis. Wonders never cease. Fusion for pain? Great. Maybe there was flexion/ext films or L5 radics, but it's not reported.