Discography Article - does this change how to deal with control levels?

[ampaphb]

Arch Orthop Trauma Surg. 2007 Jun 19; [Epub ahead of print]Related Articles
[SIZE=+1]Discography: can pain in a morphologically normal disc be due to an adjacent abnormal disc?[/SIZE]

Derincek A, Mehbod A, Schellhas K, Pinto M, Transfeldt E.

Twin Cities Spine Center, Minneapolis, MN, USA, [email protected].

Symptomatic patients who had Magnetic Resonance Imaging findings of degenerative disc disease and who failed conservative treatment were identified. As a preoperative test, these patients underwent discography. The patients, who experienced pain with injection into a morphologically normal disc adjacent to a morphologically abnormal disc, were included in the study. These patients subsequently had repeat discograms, during which the adjacent abnormal disc was first anesthetized with 2% lidocaine and the discogram was repeated at the adjacent normal level. All patients were blinded as to the nature of the procedure. Nine patients were identified (7 males and 2 females). The average age was 46.5 years (32-68). Two patients had a previous L4-Sacrum anterior and posterior fusion while 2 patients had L5-Sacrum anterior and posterior fusions. These four patients had solid fusions on Computerized Tomography scan and had developed adjacent segment degeneration according to MRI. Overall, each patient underwent an average of four discograms, at the lowest mobile disc segments. All of the patients were found to have a painful but morphologically normal disc adjacent to a painful and morphologically abnormal disc. The morphologically abnormal disc was anesthetized and the discography repeated on the normal disc. Upon this repeat discography, none of the patients experience any pain. The authors recommend anesthetizing painful abnormal discs prior to discography of the adjacent discs. This technique may avoid unnecessary dismissal of patients from treatment because of an appropriate response to discography. The normal disc may be due to referred pain from an adjacent abnormal disc.

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[lobelsteve]

Nice article. Scary.

How about a larger study with exclusion for prior back surgery.
Must have had MBB blocks with no response, SIJ injection with no response.
N=30
Two discograms on seprate dates with similar protocol.

Interesting.

 

[nvrsumr]

Interesting article. Maybe spread of anesthetic from incompetent annulus of abnormal discs to SvN, posterior plexus, etc.. innervating the normal disc.

 

[Mister Mxyzptlk]

I had the same thought. How do you anesthetize a disk from the inside? There was a discussion on the ISIS board a few months ago about this concept because there is a company that is coming out with a discography system that relies on anesthetizing disks. IIRC, it involves placing catheters into the disks and doing postop LA injections.

I have a lot of trouble with this statement: "The authors recommend anesthetizing painful abnormal discs prior to discography of the adjacent discs."

How do you know which disks are the painful abnormal ones before you do the injections? I thought that's why you did the procedure. If you knew that information in advance you wouldn't have to do the procedure in the first place.

 

[ampaphb]

I had the same thought. How do you anesthetize a disk from the inside? There was a discussion on the ISIS board a few months ago about this concept because there is a company that is coming out with a discography system that relies on anesthetizing disks. IIRC, it involves placing catheters into the disks and doing postop LA injections.

I have a lot of trouble with this statement: "The authors recommend anesthetizing painful abnormal discs prior to discography of the adjacent discs."

How do you know which disks are the painful abnormal ones before you do the injections? I thought that's why you did the procedure. If you knew that information in advance you wouldn't have to do the procedure in the first place.

You know which ones are morphologically normal and abnormal, don't you? And we all go into discography with expectations as to which are most likely to be painful.

The point here is, if you have a painful, morphologically abnormal 4/5 disc, and 3/4 is painful as well, even if it is morphologically normal, rather than having to go to 2/3 to get your control level, you might first want to inject some lidocaine into the 4/5 disc, and then repressurize at 3/4 first, to be certain your morphologically normal level is truly a pain generator.

 

[Aether2000]

MRI morphologies do not necessarily correlate to pathology: HIZ have high sensitivity but very low specificity to discography. Regarding discography morphology, once I pressurize a disc, frequently there is little room left for additional lidocaine, so forced overpressurization with lidocaine may not be in the patients best interest. Also, since discs are all relatively painful to one another, I begin injecting the least suspected disc to be abnormal, then go to those with higher index of suspicion of positivity. Frequently, the first disc will elicit pain that may be significant and the patient claims is concordant even though it is virtually normal on contrast morphology. When the more painful disc is injected, the response is much more significant and the patient then is permitted to reset their relative pain scale. Ultimately I retest in order of least painful to most painful disc to be sure. On second time injection, the normal disc may not produce significant pain.
It would seem to me that two separate discogram sessions would be required: the typical discogram, then retest with lidocaine in the adjacent disc.
It does not appear that all pain in the disc is caused by annular tears or nociceptive ingrowth. Touching the endplates in the center with a needle can be quite painful and distraction of the PLL (have done this with a nerve hook) can also create a very unpleasant situation.
Finally notice the very unusual journal in which this fascinating paper was published....

 

[ampaphb]

MRI morphologies do not necessarily correlate to pathology: HIZ have high sensitivity but very low specificity to discography. Regarding discography morphology, once I pressurize a disc, frequently there is little room left for additional lidocaine, so forced overpressurization with lidocaine may not be in the patients best interest. Also, since discs are all relatively painful to one another, I begin injecting the least suspected disc to be abnormal, then go to those with higher index of suspicion of positivity. Frequently, the first disc will elicit pain that may be significant and the patient claims is concordant even though it is virtually normal on contrast morphology. When the more painful disc is injected, the response is much more significant and the patient then is permitted to reset their relative pain scale. Ultimately I retest in order of least painful to most painful disc to be sure. On second time injection, the normal disc may not produce significant pain.
It would seem to me that two separate discogram sessions would be required: the typical discogram, then retest with lidocaine in the adjacent disc.
It does not appear that all pain in the disc is caused by annular tears or nociceptive ingrowth. Touching the endplates in the center with a needle can be quite painful and distraction of the PLL (have done this with a nerve hook) can also create a very unpleasant situation.
Finally notice the very unusual journal in which this fascinating paper was published....

Why a second session? We always turn off painful discs with lidocaine, so that the patient doesnt walk out more miserable than they came in.

In this case, turn off morphologically abnormal and painful disc with lidocaine, then rechallenge morphologically normal and painful disc, and see if it still hurts. All it takes is leaving your needles in a tad longer to enable the rechallenge.

 

[Mister Mxyzptlk]

The goal for which we strive in discography is to minimize the subjectivity of both the doctor and the patient. This procedure, on the other hand, requires preoperative assumptions regarding which disk will be deemed the bad one, and which one will be the good one. That is an inescapable paradox. You're biased before you even make a skin wheal.

 

[lobelsteve]

The goal for which we strive in discography is to minimize the subjectivity of both the doctor and the patient. This procedure, on the other hand, requires preoperative assumptions regarding which disk will be deemed the bad one, and which one will be the good one. That is an inescapable paradox. You're biased before you even make a skin wheal.

He was biased before he became a pain doc (amph)

 

[ampaphb]

The goal for which we strive in discography is to minimize the subjectivity of both the doctor and the patient. This procedure, on the other hand, requires preoperative assumptions regarding which disk will be deemed the bad one, and which one will be the good one. That is an inescapable paradox. You're biased before you even make a skin wheal.

The only way you could do these in an unbiased fashion would be to do all five levels every time, and not look at the MRI before proceeding. But we are clinicians, not mere technicians, and so thinking about the procedure is part of the art of what we do, so of course you start with a bias.

The point is, if the patient says my pain is familiar , and it is less than 50psi over opening, that is not subjective, that is objective.

I plan the procedure to wind up my patient as little as possible by investigating the least likely level first. Of course, if they scream the moment I raise the skin wheal, I may address the most likely disk first, in the hopes of gaining at least some clinically useful information before the patient elects to abort the procedure altogether.

To me, that doesn't make the procedure any more or less objective - it is just practicing both the art and science of medicine.

 

[drrinoo]

great study...confirms findings in the entire history of discography:
a morphologically normal disc (Adams or Sach's (Dallas))) will never produce pain and should never undergo treatment.

Even in Carragee's papers, psychometrically abnormal or chronic pain patients had control, i.e., non painful discs.

This is one of the most useful aspects of discography:
if a morphologically normal disc provokes pain...it should not be treated.

 

[Spine Specialist]

Anyone performing functional discography?

 

[Ligament]

I've assisted with a couple cases. The useful information gained from this procedure is still up in the air. Also it is more time intensive post op. We'll see how it pans out....

The procedure itself not bad if you are comfortable with regular discography.

Anyone performing functional discography?