Discography
What is discography?
Discography involves the injection of contrast dye into the center of a disc under x-ray control. It is strictly a diagnostic procedure. Local anesthesia and sedation is used during the procedure.
What is the purpose of discography?
Discography is used to determine whether or not pain is coming from a disc as well as identifying abnormalities in the disc. Abnormalities can include disc herniations, tears, fissures. These abnormalities are clinically significant when they reproduce a patient’s pain.
Which patients are candidates for discography?
Patients that have significant pain and have undergone conservative management are candidates for discography. Conservative management for the lower back usually includes medication, physical therapy, epidural steroid injections. Patients should also have had an MRI scan to identify disc abnormalities. Typically, patients with lower back discogenic pain experience pain with sitting and forward bending. However, it should be kept in mind that the symptoms are not specific. Patients may have other symptoms such as pain with extension or rotation of the back.
Are discograms painful?
Discography is usually not very painful. Local anesthetics and sedation are used. However, because of the very nature of discography, patients with positive discograms will have pain during disc injection. This will usually subside after a few minutes. Narcotic medications can be given after discography has been completed.
Why can’t an MRI scan or x-ray show where my pain is coming from?
In some cases, abnormalities on imaging studies are very profound and correlate very well with the patients pain. However, most abnormalities on imaging studies are nonspecific and do not identify the pain generator. In fact, there was a New England Journal of Medicine study that showed that a significant number of patients without lower back pain had disc bulges.
Are there any risks or side effects associated discography?
There are few risks associated with discography. Because the procedure is performed under strict sterile conditions, the risk of infection is minimal. In addition, patients are given antibiotics for the procedure. Patients usually have some injection site tenderness that lasts up to one week and are given narcotic medications for this time.
What if the discography does not reproduce my pain or does not elicit any pain during injection of the disk? This indicates that it is not likely that pain is coming from the disk. This can even be true if the disk is herniated or has a fissure. The reproduction of pain is the single most important factor in determining whether a subsequent intervention (such as the IDET procedure, surgery) on a disk will be successful in reducing the patients pain. In the event that the discogram does not reproduce pain, consideration should be made for other diagnostic interventions.
What if the discogram is positive?
The options for patients with discogenic pain currently include intra-discal electrothermal therapy (IDET), and surgery.
Which studies support the use of discography?
There are numerous studies supporting the use of discography in the diagnosis of spinal pain. Discography is considered a standard accepted procedure in the fields of pain medicine, radiology, orthopedic spine surgery, and neurosurgery. The following is a list of studies supporting discography.
1. Manchikanti et al. Provocative Discography in Low Back Pain Patients With or Without Somatization Disorde: A Randomized Prospective Evaluation. Pain Physician, Volume 4, No. 3, 2001, pp. 227 -- 239.
This study evaluated 50 randomly assigned patients with 25 patients without somatization disorder and 25 patients with somatization disorder. All patients underwent lumbar discography. Results showed positive provocative discography in 46% of the patient in the somatic sensation group compared to 54% in the non somatic station group. It is concluded that provocative discography provides similar results in patients with or without somatization disorder.
2. Southern EP. Disc degeneration: A Human Cadaveric Study Correlating Magnetic Resonance Imaging And Quantitative Discomanometry. Spine 2000 September 1; 25 (17): 2171 -- 2175.
This was a human catheter study evaluating disc degeneration of the lumbar spine using MRI and discography with manometry. Based on results from 19 discs, an overall good correlation between MRI scores and 6 discomanometric parameters were demonstrated. Quantitative discography with manometry may be an important technique for evaluating early disc degeneration especially tears of annular fibers which may be missed on MRI.
3. Ohnmeiss et al. Relation Between Pain Location and Disc Pathology: A Study of Pain Drawings and CT/Discography. The Clinical Journal Pain, volume 15, 1999, pp. 210 -- 217.
This is a study of 187 patients with lower back pain and lower leg pain that underwent CT/discography at the lower three lumbar levels. Results showed a statistically significant relationship (p < 0.05, chi-square) between pain location in the drawing and lumbar disc levels identified as clinically painful and disrupted by CT/Discography. The results of this study indicate that pain drawings may be helpful in identifying specific discs associated with pain complaints.
4. Min, K. et al. Discography with Manometry and Discographic CT: Their Value in Patient Selection for Percutaneous Lumbar Nucleotomy. Bulletin of Hospital Jt Dis. 1996; 54 (3): 153 -- 157.
This was a study that analyzed the findings of 360 lumbar discs from 1988 -- 1994. The diagnostic accuracy of determining the exact anatomic location of the herniation with discography alone was 75%. This increased to 99.55% with the use of CT discography. The conclusion is that CT discography is an accurate and useful diagnostic aid.
5. Derby et al. The Ability of Pressure Controlled Discography to Predict Surgical and Nonsurgical Outcomes. Spine 1999 February 15; 24 (4): 364 -- 71.
This was a multicenter retrospective study of long-term surgical and nonsurgical patient outcomes after lumbar discography. Patients with highly sensitive or chemically sensitive discs appear to achieve better long-term outcomes with interbody/combined fusion than with intertransverse fusion. Precise prospective categorization of positive discographic diagnoses may predict outcomes for treatment.
6. Walsh et al. Lumbar Discography in Normal Subjects. A Controlled, Prospective Study. Journal of Bone & Joint Surgery American. 1990 August; 72 (7):1081 --1088.
This was a study of 7 patients with lower back pain and 10 normal volunteer patients. There were 5 raters blinded to the condition of the participant that graded the disc as normal or abnormal on the basis of magnetic resonance images made before the injection and CT/discography. Each participant's pain related response was evaluated independently by two raters who viewed the videotapes of the discography. Inter-rater reliability for pain was 0.99. In asymptomatic individuals, the discogram was interpreted as abnormal for 17% of the 35 discs.
7. Schwarzer et al. The Prevalence and Clinical Features of Internal Disc Disruption in Patients with Chronic Low Back Pain. Spine 1995 volume 20, No. 17 pp. 1878 -- 1883.
This was a cross-sectional analytic study of patients with chronic lower back pain. There were 92 consecutive patients with chronic low back pain and no history of previous lumbar spine surgery. The diagnostic criteria for internal disc disruption were fully satisfied in 39% of the patients most commonly at L5 S1 and L4 5.
8. Botsford et al. Radiological Considerations: Patient Selection for Percutaneous Laserdisc Decompression. Journal of Clinical Laser Medicine Surgery 1994 October; 12 (5): 255 -- 9.
This was a retrospective study of 90 patients treated with percutaneous lumbar disc decompression. There was overall improvement in 73.3% of treated patients. An abnormal CT discogram correlated with success in 100% of the treated patients whereas abnormal MRI, CT scan alone, myelogram correlated with 75% success. Therefore this study suggests that discography can greater predict surgical success.
Is this procedure covered by insurance?
The overwhelming majority of insurance companies currently cover this procedure including Medicare and other government insurance plans. However, your coverage may vary depending on your specific plan and policy.
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Injectable fat soluble preparations of corticosteroids have much fewer side effects than oral or intravenously administered corticosteroids the effects are usually dose related and will occur most frequently in patients who use these medications systemically over long period of time. Excessive corticosteroids can result and salt and water imbalances, gastrointestinal disturbances, weakness, decreased stress response, osteoporosis, depression.
What sort of conditions are epidural steroid injections used to treat pain?
