Lumbar discography

Analysis of the efficacy of retrodiscal approach percutaneous epidural adhesiolysis with WHIP catheter® in patients with lumbar radiculopathy: A retrospective study

Percutaneous epidural adhesiolysis (PEA) is an effective treatment for patients with lumbar radiculopathy unresponsive to single steroid injections. Various approaches and instruments have been developed to access these lesions. This study aimed to evaluate the utility of a retrodiscal approach for epidural adhesiolysis using a WHIP catheter®. This retrospective study was conducted at Bundang Seoul National University Hospital, reviewing cases from January to December 2022. Forty-seven patients diagnosed with lumbar radiculopathy, aged 20 to 80 years, who underwent PEA with the WHIP catheter® were included. Outcomes assessed Numeric Rating Scale (NRS) for pain, Patients' Global Impression of Change (PGIC) scores, and the incidence of procedure-related complications. Follow-up evaluations occurred at 1, 3, and 6 months post-procedure. Among 47 patients, 41 completed the study, showing significant pain reduction at all follow-up points: 1 month (N = 41, 1.32 ± 1.68, P < .001), 3 months (N = 31, 1.90 ± 2.14, P < .001), and 6 months (N = 30, 2.50 ± 2.30, P < .001). PGIC scores indicated that 40% of the patients reported substantial improvement at one-month post-procedure. The complications were minimal, with only one case of intradiscal injection and 2 cases of vascular uptake. The retrodiscal approach PEA using the WHIP catheter® demonstrated significant efficacy in pain reduction with minimal safety concerns for patients with lumbar radiculopathy. These findings suggest that this procedure is a viable option for patients who are unresponsive to conservative treatment. However, the retrospective nature of this study and its small sample size necessitate further prospective controlled studies to confirm our results and establish long-term outcomes.

Effect of DiscoGel treatment of the intervertebral disc at MRI

AIM

To determine the impact of ethanol gel chemonucleolysis (EGCh) on the radiological picture of the treated intervertebral disc, the relationship between the initial radiological status and the clinical status of the patient after EGCh treatment, and the optimal radiographic criteria for qualifying a patient for EGCh treatment.

MATERIALS AND METHODS

The study involved a group of 45 patients (25 men and 20 women) aged 23-68 years (46 ± 11) who underwent an EGCh procedure after qualification, radiography, and clinical questionnaire evaluation.

RESULTS

The results showed a decrease in the size of the protrusion and Gadolinium-Enhanced (GI) zone in the treated intervertebral disc. The presence of a high-intensity zone (HIZ) on baseline magnetic resonance imaging was found to be a good predictor of the timing and outcome of treatment, and an increase in disc height was observed in adjacent segments.

CONCLUSION

These findings suggest that EGCh is a promising treatment for spine diseases, and the HIZ on baseline magnetic resonance imaging can be used as a qualification criterion for this procedure.

Ultrasound-guided disc pain induction test for diagnosis of discogenic lumbar pain: a cross-sectional study

BACKGROUND

Several methods can be used to diagnose discogenic pain, but only discoblock can diagnose discogenic pain definitively. This study aimed to examine the usefulness of an ultrasound-guided disc pain induction test for a simple and accurate diagnosis of the culprit lesion.

METHODS

We included 41 patients with lumbar pain in whom pain was induced by an ultrasound-guided disc pain induction test. All patients had confirmed pain at L1/2 to L5/S1 based on an ultrasound-guided disc pain induction test and underwent X-ray photography and magnetic resonance imaging. Seventeen patients who required injection due to severe pain underwent discoblock procedures for discs with the most intense pain, and visual analogue scale (VAS) scores were obtained before and after the procedure for these patients. We analysed the association between painful discs and radiological findings.

RESULTS

Pain induction was noted in a total of 65 discs, and the pain was induced in 23 patients in only one disc. All patients had disc degeneration of Pfirrmann classification grade 1 or higher, with more significant disc degeneration in painful discs than in painless discs. There was no significant relationship between the presence or absence of pain and Modic type. The average VAS measurements improved significantly from 9.5 (pre-procedure) to 2.5 (post-procedure). These results suggest that the most painful discs were the causes of discogenic lumbar pain.

CONCLUSIONS

Our ultrasound-guided disc pain induction test may help diagnose disc degeneration and identify culprit lesions, even when multiple discs exhibit findings of degeneration.

Defining the Patient with Lumbar Discogenic Pain: Real-World Implications for Diagnosis and Effective Clinical Management

There is an enormous body of literature that has identified the intervertebral disc as a potent pain generator. However, with regard to lumbar degenerative disc disease, the specific diagnostic criteria lack clarity and fail to capture the primary components which include axial midline low back pain with or without non-radicular/non-sciatic referred leg pain in a sclerotomal distribution. In fact, there is no specific ICD-10-CM diagnostic code to classify and define discogenic pain as a unique source of pain distinct from other recognized sources of chronic low back pain including facetogenic, neurocompressive including herniation and/or stenosis, sacroiliac, vertebrogenic, and psychogenic. All of these other sources have well-defined ICD-10-CM codes. Corresponding codes for discogenic pain remain absent from the diagnostic coding vernacular. The International Society for the Advancement of Spine Surgery (ISASS) has proposed a modernization of ICD-10-CM codes to specifically define pain associated with lumbar and lumbosacral degenerative disc disease. The proposed codes would also allow the pain to be characterized by location: lumbar region only, leg only, or both. Successful implementation of these codes would benefit both physicians and payers in distinguishing, tracking, and improving algorithms and treatments for discogenic pain associated with intervertebral disc degeneration.

Novel Ultrasound-Guided Cervical Intervertebral Disc Injection of Platelet-Rich Plasma for Cervicodiscogenic Pain: A Case Report and Technical Note

Ultrasound-guided needle placement into the cervical intervertebral discs using a lateral-to-medial approach is reportedly possible. Clinically, however, patients commonly present with very high uncovertebral joints or narrowed intervertebral spaces, making the method difficult or impossible. This report presents a novel ultrasound-guided needle placement technique to the cervical intervertebral discs using a more medial approach between the trachea/thyroid gland and the carotid sheath. A patient presented with neck pain radiating to the right shoulder and right-sided interscapular regions that affected his sleep and daily functioning. Physiotherapy, selective nerve root block, and percutaneous endoscopic right C7 laminotomy did not sufficiently improve his condition, which progressed to bilateral interscapular and bilateral shoulder pain. Provocative discography was performed with injection of leukocyte-poor and red blood cell-poor platelet-rich plasma to provoke the discogenic pain, which was treated with platelet-rich plasma mixed with lidocaine. The patient recovered well. A month later, there was a significant decrease in the neck disability index score from the initial 28/50 to 14, and there was a further decrease to 5 after 2 months. In conclusion, this medial approach of ultrasound-guided cervical disc needle placement is feasible, even in patients where disc access by previously described approaches is impossible.

Two Cases of Iatrogenic Lumbar Foraminal Disc Herniations

Objective

We report two cases of iatrogenic deterioration of lumbar foraminal disc herniations following lumbar disc injections. Summary of Background Data. Complications associated with discography were reported. However, only a few reports have thus far referred to the iatrogenic deterioration of lumbar foraminal disc herniations.

Cases

60-year-old and 74-year-old men were treated with MR images of L4-5 foraminal disc herniations without fragment in the spinal canal. The patients underwent discography and disc block for its diagnosis and treatment. After disc injections, both patients complained of deterioration of L4 radiculopathy.

Results

On disco-CT or reexamined MR images after disc injections, herniated fragment was migrated from neural foramen to cranial central spinal canal with was not shown in previous MR images. The herniated fragments were extirpated by means of osteoplastic laminoplasty or transforaminal lumbar interbody fusion with facetectomy. The herniated fragments were migrated from neural foramen to cranial central spinal canal.

Conclusions

The injection of liquid medicine into the nucleus led the intradiscal pressure increased, and the disc fragment might prolapsed through the raptured region of annulus fibrosus and migrated to cranial central spinal canal by anatomical reason. The disc injection may have a risk for deterioration of foraminal disc herniation. Our report is instructive for the management of discography for the diagnosis of foraminal disc herniations.

Micro-mechanical damage of needle puncture on bovine annulus fibrosus fibrils studied using polarization-resolved Second Harmonic Generation(P-SHG) microscopy

Needle injection has been widely used in spinal therapeutic or diagnostic processes, such as discography. The use of needles has been suspected in causing mild disc degeneration which can lead to long-term back pain. However, the localised microscopic damage caused by needles has not been well studied. The local progressive damage on a microscopic level caused by needle punctures on the surface of bovine annulus fibrosus was investigated. Four different sizes of needle were used for the puncture and twenty-nine bovine intervertebral discs were studied. Polarization-resolved second harmonic generation and fluorescent microscopy were used to study the local microscopic structural changes in collagen and cell nuclei due to needle damage. Repeated 70 cyclic loadings at ±5% of axial strain were applied after the needle puncture in order to assess progressive damage caused by the needle. Puncture damage on annulus fibrosus were observed either collagen fibre bundles being pushed aside, being cut through or combination of both with part being lift or pushed in. The progressive damage was found less relevant to the needle size and more progressive damage was only observed using the larger needle. Two distinct populations of collagen, in which one was relatively more organised than the other population, were observed especially after the puncture from skewed distribution of polarization-SHG analysis. Cell shape was found rounder near the puncture site where collagen fibres were damaged.

Disc height discrepancy between supine and standing positions as a screening metric for discogenic back pain in patients with disc degeneration

BACKGROUND CONTEXT

The diagnosis of discogenic low back pain (LBP) from disc degeneration of the lumbar spine is often evaluated with discography. Noninvasive, simple screening methods other than invasive discography are useful, as evidence supporting clinical findings and magnetic resonance imaging (MRI) have come to the forefront.

PURPOSE

To investigate disc height (DH) discrepancy between supine and standing positions on simple radiography to clarify its clinical screening value in individuals with discogenic LBP.

STUDY DESIGN/SETTINGS

Retrospective matched cohort design.

PATIENT SAMPLE

Ninety-two patients with early to middle stage disc degeneration (Pfirrmann grade II, III, or IV).

OUTCOME MEASURES

Each subject underwent simple radiographs and MRI. Baseline characteristics, including demographic data and MRI findings, and radiological findings, including DH discrepancy, segmental angle, and sagittal balance, were analyzed. DH discrepancy ratio was calculated as (1 - [calibrated DH on standing radiography/calibrated DH on supine radiography]) × 100%.

METHODS

We matched LBP group of 46 patients with intractable discogenic pain (≥7 of visual analog scale scores) confirmed by discography with control group of 46 patients with similar stage disc degeneration with mild LBP (≤4 of visual analog scale scores). Binary regression analysis, receiver operating characteristic curve analysis, and cut-off value for diagnosis were used to evaluate and clarify diagnostic value of various factors.

RESULTS

There was no significant difference between the two groups in terms of baseline characteristics, including age, sex, body mass index, pathological level, and magnetic resonance findings such as disc degeneration, high intensity zone, and para-spinal muscle volume. Among the various radiological findings, the calibrated mean DH in the standing position (20.87±5.65 [LBP group] vs. 26.95±3.02 [control group], p<.001) and the DH discrepancy ratio (14.55±6.13% [LBP group] vs. 1.47±0.75% [control group], p=.007) were significantly different between the two groups. The cut-off value for DH discrepancy ratio to screen discogenic LBP was ≥6.04%. Additionally, as a compensation for pain, sagittal vertical axis (3.43±2.03 cm [LBP group] vs. -0.54±3.05 cm [control group], p=.002) and pelvic incidence (54.74±6.76° [LBP group] vs. 43.98±8.67° [control group]; p=.006) were different between the two groups.

CONCLUSIONS

The results suggest that DH discrepancy between the supine and standing positions could be a screening metric for discogenic LBP in early to middle stage disc degeneration of the lumbar spine.

Percutaneous navigable intradiscal decompression in treatment of lumbar disc herniation: a single-center experience

Background/aim

Minimally invasive procedures have been increasingly used for the treatment of herniated discs. Nonsurgical interventions minimize the secondary damage to other tissues and shorten the length of hospital stay by avoiding general anesthesia. Possible complications are thermal injuries, root injury, discitis, endplate damage, dural injury, meningitis, infection, increase in pain, and muscle spasm. We aimed to evaluate the efficacy of percutaneous decompression therapy by using intradiscal navigable electrodes on pain and functional movement index in patients with herniated nucleus pulposus (HNP).

Materials and methods

A total of 209 patients with protrusive lumbar disc herniation underwent percutaneous ablation decompression treatment using an intradiscal routable electrode (L-Disq) in our pain clinic. Visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were recorded at the beginning and at the 1st, 3rd, 6th, and 12th months after treatment. Patient satisfaction was evaluated at the 12th month by a patient satisfaction scale (PSS).

Results

When compared to initial values, VAS and ODI scores showed statistically significant improvement at the 1st, 3rd, 6th, and 12th months (P < 0.001). Mean VAS scores were 7.28 and 3.03 points (P < 0.001) while mean ODI scores were 32.46 and 20.48 points (P < 0.001) at the beginning and at the 12th month, respectively. Satisfaction rate of all patients was 81%. We also attempted to treat the existing annular fissure using an ablation method and we believe that treating the herniated disc together with the fissure in the same session increased our success rate.

Conclusion

With clinical evidence, we suggest that L-Disq may be considered as an appropriate option with a low risk of complications in pain management in cases of lumbar disc herniation that are resistant to conservative methods.

Discogenic Back Pain: Literature Review of Definition, Diagnosis, and Treatment

Discogenic back pain is multifactorial; hence, physicians often struggle to identify the underlying source of the pain. As a result, discogenic back pain is often hard to treat—even more so when clinical treatment strategies are of questionable efficacy. Based on a broad literature review, our aim was to define discogenic back pain into a series of more specific and interacting pathologies, and to highlight the need to develop novel approaches and treatment strategies for this challenging and unmet clinical need. Discogenic pain involves degenerative changes of the intervertebral disc, including structural defects that result in biomechanical instability and inflammation. These degenerative changes in intervertebral discs closely intersect with the peripheral and central nervous systems to cause nerve sensitization and ingrowth; eventually central sensitization results in a chronic pain condition. Existing imaging modalities are nonspecific to pain symptoms, whereas discography methods that are more specific have known comorbidities based on intervertebral disc puncture and injection. As a result, alternative noninvasive and specific diagnostic methods are needed to better diagnose and identify specific conditions and sources of pain that can be more directly treated. Currently, there are many treatments/interventions for discogenic back pain. Nevertheless, many surgical approaches for discogenic pain have limited efficacy, thus accentuating the need for the development of novel treatments. Regenerative therapies, such as biologics, cell‐based therapy, intervertebral disc repair, and gene‐based therapy, offer the most promise and have many advantages over current therapies. © 2019 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research

The Impact of Chronic Discogenic Low Back Pain: Costs and Patients' Burden

Introduction

Chronic discogenic low back pain (CDP) is frequently diagnosed in patients referred to specialized pain clinics for their back pain. The aim of this study is to assess the impact of CDP both on the individual patient and on society.

Materials and Methods

Using the baseline records of 80 patients in a randomized trial assessing the effectiveness of a new intervention for CDP, healthcare and societal costs related to back pain are calculated. Furthermore, the impact of the condition on perceived pain, disability, health-related quality of life, Quality of life Adjusted Life Years (QALY), and QALY loss is assessed.

Results

Using the friction costs approach, we found that the annual costs for society are €7,911.95 per CDP patient, 51% healthcare and 49% societal costs. When using the human capital approach, total costs were €18,940.58, 22% healthcare and 78% societal costs. Healthcare costs were mainly related to pain treatment. Mean pain severity was 6.5 (0-10), and 46% suffered from severe pain (≥7/10). Mean physical limitations rate was 43.7; 13.5% of the patients were very limited to disabled. QALY loss compared to a healthy population was 64%.

Discussion

This study shows that in patients with CDP referred to a pain clinic, costs for society are high and the most used healthcare resources are pain therapies. Patients suffer severe pain, are physically limited, and experience a serious loss in quality of life.

No Transfer of Pressure to Adjacent Discs During Human Low-Pressure Controlled Discography: A Prospective Clinical Study

Background

A substantial part of low back pain (LBP) originates from degeneration of the intervertebral disc. To confirm the diagnosis of discogenic pain, provocation discography seems the best available tool. However, provocation discography is also considered to be a controversial and subjective test because the patient's personal pain response is the most crucial for the result of the test. Recently, an in vivo porcine study and a study in nine human subjects showed passing of pressure to the adjacent discs during discography. This could mean that the concordant pain the patient describes originates from an adjacent disc. The object of this study is to assess if during human lumbar pressure-controlled provocation discography there is pressure transmission to adjacent discs.

Methods

Consecutive patients between age 18 and 65 years with intractable low back pain and at least 50% preserved height of the suspected painful disc were included. Exclusion criteria were prior lumbar surgery of the suspected level, use of anticoagulants, pregnancy, local infection, and iodine allergy. An arterial blood pressure monitoring system simultaneously assessed the pressure in the adjacent discs while low-speed flow, pressure-controlled discography was performed.

Results

In 50 patients with a positive discography, the average intradiscal peak pressure was 15.1 psi (SD = 11.1). In 48 procedures, no pressure rise in the adjacent discs was found. A small pressure rise (1.1 psi) in the adjacent disc during discography was recorded in two patients.

Conclusions

Pressure rise in adjacent discs does not seem to occur during low-speed flow pressure-controlled lumbar provocation discography. False-positive pain reactions caused by potentially painful adjacent discs are therefore unlikely during pressure-controlled discography.

Biomechanical Effects of Human Lumbar Discography: In Vitro Experiments and Their Finite Element Validation

STUDY DESIGN

An experimental and computational finite element analysis of human lumbar spine discography and its resulting effects on disk biomechanics.

OBJECTIVE

To characterize the changes in stress and displacement of the human lumbar spine disks after puncture due to discography.

SUMMARY OF BACKGROUND DATA

Discography of the intervertebral disk (IVD) may be used to diagnose pathology of the disk and determine whether it may be a source for chronic back pain. It has recently been suggested that discography may lead to IVD degeneration, and has been a cause of controversy among spine care physicians.

MATERIALS AND METHODS

Both in vivo experiment using cadaveric specimens and a finite element model of the same L3-L5 lumbar spine was developed using computed tomography scans. Discography was simulated in the model as an area in the disk affected by needle puncture. The material properties in the nucleus pulposus were adjusted to match experimental data both before and after puncture.

RESULTS

Puncture of the IVD leads to increased deformation and increased stresses in the annulus fibrosis region of the disk. Pressure in the nucleus pulposus was found to decrease after puncture. Experimental and computational results correlated well.

CONCLUSIONS

Puncturing the IVD changes disk biomechanics and hence may lead to progressive spine degenerations in particular in the punctured disks.

Posterior Dynamic Stabilization With Direct Pars Repair via Wiltse Approach for the Treatment of Lumbar Spondylolysis: The Application of a Novel Surgery

STUDY DESIGN

A retrospective study to evaluate the clinical outcomes of a novel surgical method for treating patients with lumbar spondylolysis.

OBJECTIVE

The aim of this study was to investigate the effectiveness of posterior ISOBAR TTL stabilization of the lumbar spine with direct pars repair using Wiltse approach for the treatment of lumbar spondylolysis with or without slight spondylolisthesis and discuss the indications of this surgery.

SUMMARY OF BACKGROUND DATA

Surgical treatment of lumbar spondylolysis has yielded relatively good results. However, there are still many limitations of the current surgical methods, including, adjacent level degeneration, restricted indications, and soft tissue damage.

METHODS

Between August 2010 and January 2013, 13 (9 males and 4 females; mean age: 28.2 yrs), patients with lumbar spondylolysis with or without slight spondylolisthesis underwent posterior ISOBAR TTL stabilization of the lumbar spine, with direct pars repair via Wiltse approach. All patients were followed up for at least 24 months at outpatient visits or telephonically. Pre-operative and postoperative radiological assessments included anteroposterior, lateral and flexion extension radiographs, 3-dimensional reconstruction computed tomography (CT), and magnetic resonance imaging (MRI). Data pertaining to intraoperative blood loss, duration of operation, visual analog score (VAS), Oswestry disability index (ODI) scores, and other assessments were collected.

RESULTS

The median follow-up duration was 36 months (range, 24-53 months). Surgery was successful in all patients with no complications; bony fusion of pars was confirmed on CT scan at postoperative 2 years. Significant pain relief was achieved in all patients including those with discogenic pain, those >30 years of age, and those with severe disc degeneration (P < 0.01).

CONCLUSION

We evaluated a new surgical technique for the treatment of patients with spondylolysis with or without slight spondylolisthesis. Besides the good clinical results, the indications for this new surgery are much wider and can potentially overcome the limitations of earlier techniques.

LEVEL OF EVIDENCE

4.

Three-dimensional intraoperative imaging with O-arm to establish a working trajectory in percutaneous endoscopic lumbar discectomy

Introduction

Successful percutaneous endoscopic lumbar discectomy (PELD) requires an appropriate working trajectory. Due to the complexity of spinal anatomy, this is difficult to verify with conventional 2-dimensional fluoroscopy.

Aim

Here we assessed the feasibility and utility of the O-arm for establishing the working trajectory for PELD.

Material and methods

We retrospectively reviewed the records of 89 patients with lumbar disc herniation who underwent PELD using the O-arm. The working trajectory was evaluated with standard fluoroscopic images or 3-dimensional, volumetric computed tomography scan. Based on the detail provided by the multiplanar view, we confirmed the ideal working trajectory and adjusted the surgical approach accordingly.

Results

At the 12-month follow-up, based on MacNab's criteria, 85.9% of patients showed an excellent or good outcome. There were no major complications.

Conclusions

The O-arm provides detailed multiplanar intraoperative high-quality imaging for PELD, and enables the surgeon to ascertain the surgical anatomy, determine the optimal working trajectory, and improve the accuracy of surgery.

Efficacy and cost-effectiveness of intradiscal methylene blue injection for chronic discogenic low back pain: study protocol for a randomized controlled trial

BACKGROUND

Low back pain (LBP) is a common health problem and a substantial part of LBP is presumed to be attributable to degeneration of the intervertebral disc. For patients suffering from intractable discogenic LBP, there are few evidence-based effective interventional treatment options available. In 2010, the results of a randomized controlled trial (RCT) were published concerning "intradiscal methylene blue injection" (IMBI), in which this intervention appeared to be very successful in relieving discogenic pain. Therefore, we decided to repeat this study to investigate whether we could replicate the published results. The results of our preliminary feasibility study gave reason to set up an RCT. The aim of this RCT is to evaluate if IMBI is a more effective treatment of discogenic low back pain as an intradiscal placebo intervention, and furthermore, to assess the cost-effectiveness of this intervention.

METHODS/DESIGN

Consecutive discogenic low back pain patients referred to four specialized pain treatment facilities are being screened for eligibility. After a positive standardized provocation discography and informed consent, patients are randomized into two groups. The treatment group receives an intradiscal injection with methylene blue, lidocaine, and contrast, and the control group receives intradiscal isotonic saline with lidocaine and contrast. Main outcome measures are pain at the 6-month follow-up, patient's global impression of change, cost-effectiveness, quality of life, disability, and analgesic intake.

DISCUSSION

The importance of this study is emphasized by the fact that for intractable discogenic low back pain patients, evidence-based effective pain treatments are rare. If this study establishes clinical success and cost-effectiveness, IMBI could become the "pain treatment of choice" for a selected group of patients with chronic discogenic low back pain for whom noninvasive treatment options have failed.

TRIAL REGISTRATION

National Trial register NTR2547 Registered at 29 September 2010 and 31 March 2014.

Discoscopic findings of high signal intensity zones on magnetic resonance imaging of lumbar intervertebral discs

A 32-year-old man underwent radiofrequency thermal annuloplasty (TA) with percutaneous endoscopic discectomy (PED) under local anesthesia for chronic low back pain. His diagnosis was discogenic pain with a high signal intensity zone (HIZ) in the posterior corner of the L4-5 disc. Flexion pain was sporadic, and steroid injection was given twice for severe pain. After the third episode of strong pain, PED and TA were conducted. The discoscope was inserted into the posterior annulus and revealed a migrated white nucleus pulposus which was stained blue. Then, after moving the discoscope to the site of the HIZ, a migrated slightly red nucleus pulposus was found, suggesting inflammation and/or new vessels penetrating the mass. After removing the fragment, the HIZ site was ablated by TA. To our knowledge, this is the first report of the discoscopic findings of HIZ of the lumbar intervertebral disc.

Long-term Outcomes of 2-Level Total Disc Replacement Using ProDisc-L: Nine- to 10-Year Follow-up

STUDY DESIGN

A prospective clinical data analysis.

OBJECTIVE

To determine the long-term clinical success of 2-level total disc replacement (TDR) in patients with degenerative disc disease.

SUMMARY OF BACKGROUND DATA

Early successful clinical results of 2-level TDR have been reported. Few studies exist that have described this procedure's durability in the long term.

METHODS

Fifteen patients underwent 2-level lumbar TDR with the ProDisc-L as part of a randomized trial, 13 of whom were available for follow-up. The patients were assessed preoperatively and at 2 years, 5 years, and more than 9 years postoperatively using visual Oswestry Disability Index. At the last follow-up visit, 2 additional questions were asked: satisfaction with surgery and willingness to undergo the same treatment. Finally, clinical success was assessed using a previously described definition.

RESULTS

Mean follow-up time was 9.6 years (range, 9.2-10.3 yr). Postoperatively there was a significant improvement in Oswestry Disability Index score from baseline (70.0 vs. 15.7 at 2 yr, P = 0.002) that remained unchanged during the period of follow-up (19.8 at 5 yr, P = 0.003 and 12.9 at 9-10 yr, P = 0.002). Ninety-two percent of patients were "satisfied" or "somewhat satisfied" with treatment and the same number would undergo treatment again. Eighty-five percent of patients achieved clinical success.

CONCLUSION

This prospective study demonstrates the durable clinical success of 2-level lumbar TDR as assessed at more than 9 years postoperatively.

LEVEL OF EVIDENCE

4.

Diagnostic criteria and treatment of discogenic pain: a systematic review of recent clinical literature

BACKGROUND CONTEXT

Pain innate to intervertebral disc, often referred to as discogenic pain, is suspected by some authors to be the major source of chronic low back and neck pain. Current management of suspected discogenic pain lacks standardized diagnosis, treatment, and terminology.

PURPOSE

In an attempt to determine whether patterns existed that may facilitate standardization of care, we sought to analyze the terminologies used and the various modes of diagnosis and treatment of suspected discogenic pain.

STUDY DESIGN

A systematic review of the recent literature.

METHODS

A Medline search was performed using the terms degenerative disc disease, discogenic pain, internal disc disruption while using the limits of human studies, English language, and clinical trials, for the last 10 years. The search led to a total of 149 distinct citations, of which 53 articles, where the intervertebral disc itself was considered the principal source of patient's pain and was the main target of the treatment, were retained for further analysis.

RESULTS

The results of this review confirm and help quantify the significant differences that existed in the terminology and all the areas of diagnosis and treatment of presumed discogenic pain.

CONCLUSIONS

Our findings show that suspected discogenic pain, despite its extensive affirmation in the literature and enormous resources regularly devoted to it, currently lacks clear diagnostic criteria and uniform treatment or terminology.

The dose response relationship between intervertebral disc flexion-extension neutral zone metrics and injected genipin concentration

PURPOSE

Quantify changes in the flexion--extension neutral zone of the intervertebral disc with injections of increasing genipin concentration.

METHODS

Bovine motion segments were treated with varying concentrations of genipin using bilateral injections of constant volume. After overnight static compression loading of the treated segments, anterior-posterior offset loading was used to simulate flexion-extension motion. Range of motion, neutral zone length, neutral zone stiffness, and an instability score were measured.

RESULTS

Injection of the disc annulus with increasing concentrations of genipin resulted in corresponding changes in flexion-extension neutral zone. A minimum concentration of 40 mM was needed to observe a significant change. The largest changes were observed with the 400 mM injection. Netural zone stability was the most sensitive of the metrics with a percent change of 48% at 40 mM and over 200% at 400 mM.

CONCLUSION

This study establishes the efficacy of using injection delivery to affect disc joint mechanics and quantifies the dose response between injected genipin and the flexion-extension stability of the disc.

Candida lusitaniae discitis after discogram in an immunocompetent patient

BACKGROUND CONTEXT

Discitis or epidural abscess after discogram is a rare but known complication. It is more commonly bacterial; however, fungal discitis has been previously reported in immunocompromised patients. The management of fungal discitis in immunocompetent patients is rarely presented or addressed in the literature.

PURPOSE

To present a rare atypical fungal discitis after routine discogram with a typical presentation in an immunocompetent host, review diagnostic and management guidelines for discitis, and provide recommendations for management of atypical discitis in immunocompetent patients.

STUDY DESIGN

Case report and review of the literature.

METHODS

A 40-year-old woman presented with a 3-week history of progressively worsening low back pain after a lumbar discogram. Magnetic resonance imaging revealed L3-L4 discitis without an epidural abscess. Left L3 and L4 hemilaminectomies with L3-L4 discectomy were performed. An inflammatory mass was seen in the L3-L4 disc space region extending to the left L3 foramen.

RESULTS

Culture specimens obtained during surgery from both the disc and epidural space speciated to Candida lusitaniae. The patient completed a 6-month course of fluconazole therapy. At 2-year follow-up, she continued to be asymptomatic, without any recurrence of infection or neurologic sequelae.

CONCLUSIONS

We report a case of C. lusitaniae spondylodiscitis after discography in an immunocompetent patient with long-term follow-up. Clinicians must maintain a high index of suspicion for discitis in patients who undergo this procedure. If discitis is suspected, culture specimens must be evaluated for fungal and mycobacterial organisms, even in the immunocompetent host. With proper surveillance, surgical intervention, and appropriate postoperative follow-up, this complication can be effectively managed with excellent long-term outcome.

Provocative lumbar discography versus functional anesthetic discography: a comparison of the results of two different diagnostic techniques in 52 patients with chronic low back pain

BACKGROUND CONTEXT

There is mounting evidence that the currently available techniques for the diagnosis of discogenic low back pain are insufficiently accurate-this may explain some of the variability in outcomes of surgery for this important clinical problem. New diagnostic methods are needed to address this diagnostic issue; improvements here may do as much to improve overall patient outcomes as improvements in surgical treatment methods.

PURPOSE

To compare the results of standard pressure-controlled provocative discography (PD) to those of the functional anesthetic discogram (FAD) in a series of patients presenting with chronic low back pain and considering surgical treatment.

STUDY DESIGN

Prospective clinical series in an academic spinal surgical practice.

PATIENT SAMPLE

Fifty-two patients presenting with chronic low back pain; mean age 45 years (range, 24-70 years); 28 women, 24 men; and 25% in workman's compensation program.

OUTCOME MEASURES

Oswestry, visual analog scale for back pain, distress and risk assessment method psychometric analysis, demographic data, magnetic resonance imaging scan of lumbar spine. During provocative discogram: pressurization at pain, pain level, and concordancy. During FAD: position or activity used to elicit typical pain, baseline pain level before injection, during injection, at 5, 10, and 20 minutes after the injection, and substance injected.

METHODS

Standard pressure-controlled PD was performed, followed by (in positive cases or in patients with clinical features and imaging studies felt to be highly suggestive of symptomatic disc degeneration) the FAD test-an assessment of the response to injection of a low dose of local anesthetic into the disc during a position productive of the patient's typical pain.

RESULTS

Discordant results of the two tests were noted in 46% of the patients in the series. Of them, 26% of patients with positive PD had negative findings on the FAD test; 16% had positive findings at a single level only, whereas the provocative discogram had been positive at two or more levels; 4% had new positive findings on the FAD test.

CONCLUSIONS

We have presented the results of a new diagnostic technique in 52 patients with chronic low back pain presumed discogenic in origin that was designed to help differentiate between symptomatic and asymptomatic disc degeneration. The findings of the test differed from those of standard pressure-controlled PD in 46% of the cases reported on here. Further studies are needed to demonstrate the clinical utility of the test.

The effects of needle puncture injury on microscale shear strain in the intervertebral disc annulus fibrosus

BACKGROUND CONTEXT

Needle puncture of the intervertebral disc (IVD) is required for delivery of therapeutic agents to the nucleus pulposus and for some diagnostic procedures. Needle puncture has also been implicated as an initiator of disc degeneration. It is hypothesized that needle puncture may initiate IVD degeneration by altering microscale mechanical behavior in the annulus fibrosus (AF).

PURPOSE

Quantify the changes in AF microscale strain behavior resulting from puncture with a hypodermic needle.

STUDY DESIGN

Cadaveric IVD tissue explant study.

METHODS

Annulus fibrosus explants from bovine caudal IVDs that had been punctured radially with hypodermic needles were loaded in dynamic sinusoidal shear while being imaged with a confocal microscope. Digital image analysis was used to quantify local tissue strain and damage propagation with repeated shearing.

RESULTS

Needle puncture changed the distribution of microscale shear strains in the AF under load from homogenous (equal to far field) to a distinct pattern of high (4× far field) and low (0.25× far field) strain areas. Repeated loading did not cause further growth of the disruption beyond the second cycle.

CONCLUSIONS

Needle puncture results in a drastic alteration of microscale strain behavior in the AF under load. This alteration may directly initiate disc degeneration by being detrimental to tissue-cell mechanotransduction.

Percutaneous laser disc decompression for thoracic disc disease: report of 10 cases

BACKGROUND

Discogenic pain or herniation causing neural impingement of the thoracic vertebrae is less common than that in the cervical or lumbar regions. Treatment of thoracic discogenic pain usually involves conservative measures. If this fails, conventional fusion or discectomy can be considered, but these procedures carry significant risk.

OBJECTIVES

To assess the efficacy and safety of percutaneous laser disc decompression (PLDD) for the treatment of thoracic disc disease.

METHODS

Ten patients with thoracic discogenic pain who were unresponsive to conservative intervention underwent the PLDD procedure. Thoracic pain was assessed using the Visual Analog Scale (VAS) scores preoperatively and at 6-month intervals with a minimum of 18-months follow-up. Patients were diagnosed and chosen for enrollment based on abnormal MRI findings and positive provocative discograms. Patients with gross herniations were not included.

RESULTS

Length of follow-up ranged from 18 to 31 months (mean: 24.2 mo). Median pretreatment thoracic VAS score was 8.5 (range: 5-10) and median VAS score at final follow-up was 3.8 (range: 0-9). Postoperative improvement was significant with a 99% confidence interval. Of interest, patients generally fell into two groups, those with significant pain reduction and those with little to no improvement. Although complications such as pneumothorax, discitis, or nerve damage were possible, no adverse events occurred during the procedures.

LIMITATIONS

The study is limited by its small size and lack of a sham group. Larger controlled studies are warranted.

CONCLUSIONS

With further clinical evidence, PLDD could be considered a viable option with a low risk of complication for the treatment of thoracic discogenic pain that does not resolve with conservative treatment.

In vitro assessment of the antibiotic efficacy of contrast media and antibiotics and their combinations at various dilutions

Discography is a controversial diagnostic procedure involving the injection of radiographic contrast medium (RCM) into the intervertebral disc. Iatrogenic bacterial discitis is a rare but serious complication. The intervention has been increasingly performed in our patients here in the United Arab Emirates. Prophylactic intravenous antibiotic administration can reduce post-interventional discitis; however, this may favour the development of bacterial resistance. Direct intradiscal injection of an antibiotic together with the RCM is a potential alternative. To date, there has been only one study on the efficacy of antibiotics added to an RCM. Equally, there are only limited data regarding the potential direct effect of RCM on bacterial growth. The purpose of this study was to determine whether the efficacy of antibiotics is affected when RCM are added. In an in vitro study, the effect of non-ionic RCM on the growth of five laboratory bacterial strains, alone and in combination with three broad-spectrum antimicrobials, was tested. Bacterial growth was assessed in the absence and the presence of RCM, antibiotics and their combinations. All three RCM alone demonstrated some inhibition of bacterial growth at high concentrations. In the presence of the RCM, all three antibiotics retained their inhibitory effect on bacterial growth. In conclusion, our in vitro experiments did not reveal any changes in the antimicrobial efficacy of the three antibiotics in the presence of the three tested RCM. Subsequent clinical trials will need to assess whether intradiscal antibiotic administration may be a suitable substitute for, or a supplement to, prophylactic systemic antibiotics before discography.

Inadvertent discogram during transforaminal epidural injection in patients with lumbar disc herniation -A report of 2 cases-

The transforaminal epidural injection (TFEI) has been preferred in many cases because it can deliver the injected dose of medication closer to the nerve root and better facilitate ventral epidural flow compared to other methods. However, in patients with deformities not demonstrated on fluoroscopic imaging, the needle may enter unwanted locations. We treated two cases of intradiscal injection of contrast dye, during the TFEI, in patients with lumbar disc herniation.

Cross-sectional magnetic resonance imaging study of lumbar disc degeneration in 200 healthy individuals

OBJECT

The current cross-sectional observational MR imaging study aimed to investigate the prevalence and risk factors of lumbar disc degeneration in a healthy population and to establish the baseline data for a prospective longitudinal study.

METHODS

Two hundred healthy volunteers participated in this study after providing informed consent. The status of lumbar disc degeneration was assessed by 3 independent observers, who used sagittal T2-weighted MR imaging. Demographic data collected included age, sex, body mass index, episode(s) of low-back pain, smoking status, hours of standing and sitting, and Roland-Morris Disability Questionnaire scores. There were 68 men and 132 women whose mean age was 39.7 years (range 30-55 years). Eighty-two individuals (41%) were smokers, and the Roland-Morris Disability Questionnaire scores were averaged to 0.6/24.

RESULTS

The prevalence of disc degeneration was 7.0% in L1-2, 12.0% in L2-3, 15.5% in L3-4, 49.5% in L4-5, and 53.0% in L5-S1. A herniated disc was observed at the corresponding levels in 0.5, 3.5, 6.5, 25.0, and 35.0% of cases respectively. Spondylolisthesis was observed in < 3% of this population. Multiple logistic regression analysis demonstrated that age and hours sitting were significantly related to L4-5 disc herniation. Episode of low-back pain, smoking status, body mass index, and hours standing did not affect the prevalence of disc degeneration.

CONCLUSIONS

The current study established the baseline data of lumbar disc degeneration in a 30- to 55-year-old healthy population for a prospective longitudinal study. Hours spent sitting significantly increased the prevalence of disc herniation, but episode of low-back pain, smoking status, obesity, and standing hours were not significant risk factors.

The prevention of discitis during discography

BACKGROUND CONTEXT

Because of the severe complications, discitis represents the most feared complication stemming from discography. Varying needle techniques have been used to prevent discitis, and evidence for the use of intravenous (IV) and/or intradiscal antibiotics is conflicting and often lacking. Consequently, no consensus has been formed for disc infection prevention during discography.

PURPOSE

The objectives of this review are to summarize and integrate all the available basic science, animal, and clinical evidence regarding prevention of infection from discography and to develop areas of future research.

STUDY DESIGN

A comprehensive review of the literature dealing with discitis stemming from discography was conducted.

METHODS

The MEDLINE and SCOPUS databases were searched focusing on prospective and retrospective studies and published case reports on the prevention of discitis. A meta-analysis could not be completed because of the scarcity of data and published randomized controlled trials.

RESULTS

Of the seven articles that specifically focused on the prevention of discitis, no randomized or controlled trials were located. Two prospective, nonrandomized trials, three retrospective case series, and two literature reviews have been published, but no consensus has been formed for the prevention of discitis during discography. Fifteen articles focused on penetration, efficacy, and dosage of antibiotics into intervertebral discs for the prevention of discitis. There are 14 additional articles that report incidences of discitis.

CONCLUSIONS

Based on the available clinical evidence, IV or intradiscal antibiotics during discography have not been conclusively shown to decrease the rate of discitis over sterile technique alone. Animal model research supports prophylactic antibiotic use when used before iatrogenic inoculation of intervertebral discs. Both single- and double-needle techniques when used with stylettes are superior to nonstyletted techniques.

2009 ISSLS Prize Winner: Does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study

STUDY DESIGN

Prospective, match-cohort study of disc degeneration progression over 10 years with and without baseline discography. Objectives. To compare progression of common degenerative findings between lumbar discs injected 10 years earlier with those same disc levels in matched subjects not exposed to discography. Summary of Background Data. Experimental disc puncture in animal and in vivo studies have demonstrated accelerated disc degeneration. Whether intradiscal diagnostic or treatment procedures used in clinical practice causes any damage to the punctured discs over time is currently unknown.

METHODS

Seventy-five subjects without serious low back pain illness underwent a protocol MRI and an L3/4, L4/5, and L5/S1 discography examination in 1997. A matched group was enrolled at the same time and underwent the same protocol MRI examination. Subjects were followed for 10 years. At 7 to 10 years after baseline assessment, eligible discography and controlled subjects underwent another protocol MRI examination. MRI graders, blind to group designation, scored both groups for qualitative findings (Pfirrmann grade, herniations, endplate changes, and high intensity zone). Loss of disc height and loss of disc signal were measured by quantitative methods.

RESULTS

Well matched cohorts, including 50 discography subjects and 52 control subjects, were contacted and met eligibility criteria for follow-up evaluation. In all graded or measured parameters, discs that had been exposed to puncture and injection had greater progression of degenerative findings compared to control (noninjected) discs: progression of disc degeneration, 54 discs (35%) in the discography group compared to 21 (14%) in the control group (P = 0.03); 55 new disc herniations in the discography group compared to 22 in the control group (P = 0.0003). New disc herniations were disproportionately found on the side of the anular puncture (P = 0.0006). The quantitative measures of disc height and disc signal also showed significantly greater loss of disc height (P = 0.05) and signal intensity (P = 0.001) in the discography disc compared to the control disc.

CONCLUSION

Modern discography techniques using small gauge needle and limited pressurization resulted in accelerated disc degeneration, disc herniation, loss of disc height and signal and the development of reactive endplate changes compared to match-controls. Careful consideration of risk and benefit should be used in recommending procedures involving disc injection.

[Non-specific lower back pain: In search of the origin of pain]

Lower back pain is a condition considered benign and with a specific cause determined only in 15% of patients. In the past years this concept has varied, because many papers have described no benign condition leading to back pain, citing their capacity to cause disability. Through many different diagnostic techniques it is possible to identify the structures capable of producing back pain. This identification, and the level of evidence of the interventional techniques, is the aim of this paper.

Lumbar discography

Lumbar discography has generally proven to be a safe diagnostic tool for the evaluation and potential treatment planning of presumed discogenic pain, but it has not been wholeheartedly embraced by the radiologic and surgical community because of doubts as to its safety, accuracy, and relevance to patient outcome. There have been some conflicting reports on the relative merits and limitations of the procedure in the diagnosis and treatment planning of low back pain and radiculopathy; further studies are needed to determine with certainty whether discography is in fact able to localize the precise discs of clinical significance and accurately predict those patients who will respond well to surgery and those who will not.

How often is low back pain not coming from the back?

STUDY DESIGN

Consecutive case series cohort.

OBJECTIVE

To determine the relative frequencies of the spine, the sacroiliac (SI) joint, and the hip joint being the primary pain generator among patients presenting at a spine surgery clinic for low back pain (LBP).

SUMMARY OF BACKGROUND DATA

Identification of the primary pain generator in a patient with LBP is difficult. Possible pain sources include the lumbar spine, the SI joint, and the hip joint. Their relative frequencies among patients presenting at a spine surgeon's clinic have not been well established.

METHODS

Three hundred sixty-eight new patients were seen at a single spine surgeon's clinic during a 10-month period. Of these, 289 (78.5%) complained primarily of LBP with or without leg pain. Seventy-seven had previous surgery. The remaining 200 cases were reviewed for all diagnostic tests performed, as well as the final diagnosis.

RESULTS

One hundred sixty-four (82%) had spine pathology, but only 130 (65%) had spine-only pathology, whereas 35 (17.5%) had a combination of spine plus hip and/or SI joint pathology. An additional 16 (8%) had hip and/or SI joint pathology without spine pathology. Twenty (10%) had an undefined pain source. Overall, 25 (12.5%) had hip pathology, and 29 (14.5%) had SI joint pathology.

CONCLUSION

For patients presenting to a spine surgeon's clinic for LBP, up to 25% of patients may have significant pain contribution from the hip or SI joints, and an additional 10% will still have an undefined pain source even after diagnostic workup. This underscores the need for clinicians to be aware of nonspinal pain generators and to appropriately pursue alternative diagnoses.

The accuracy of MRI in the detection of lumbar disc containment

BACKGROUND

MRI has proven to be an extremely valuable tool in the assessment of normal and pathological spinal anatomy. Accordingly, it is commonly used to assess containment of discal material by the outer fibers of the anulus fibrosus and posterior longitudinal ligaments. Determination of such containment is important to determine candidacy for intradiscal techniques and has prognostic significance. The accuracy of MRI in detecting containment has been insufficiently documented.

METHODS

The MRI's of fifty consecutive patients undergoing open lumbar microdiscectomy were prospectively evaluated for disc containment by a neuroradiologist and senior spinal surgeon using criteria available in the literature and the classification of Macnab/McCulloch. An independent surgeon then performed the surgery and documented the actual containment status using the same methods. Statistical evaluation of accuracy was undertaken.

RESULTS

MRI was found to be 72% sensitive, 68% specific, and 70% accurate in detecting containment status of lumbar herniated discs.

CONCLUSION

MRI may be inaccurate in assessing containment status of lumbar disc herniations in 30% of cases. Given the importance of containment for patient selection for indirect discectomy techniques and intradiscal therapies, coupled with prognostic significance; other methods to assess containment should be employed to assess containment when such alternative interventions are being considered.

The functional anaesthetic discogram: description of a novel diagnostic technique and report of 3 cases

BACKGROUND

The diagnostic evaluation of patients with presumed discogenic low back pain is controversial; recent studies have brought the specificity of the traditional technique, provocative lumbar discography, into question. One of the explanations for the relative lack of predictability in treatment outcomes for patients with discogenic low back pain may be a corresponding lack of certainty in the diagnosis.

PURPOSE

A new diagnostic technique is described for the evaluation of patients with presumptive discogenic low back pain; the cases of 3 patients in whom the technique was used are presented.

STUDY DESIGN/SETTING

Case report; university practice.

METHODS

A technique is described in which an anaesthetic catheter is placed into putative symptomatic lumbar discs, the patient elicits his or her typical pain via a position or activity, and anaesthetic or placebo is delivered to the disc. The effect of the injected substance on the patient's pain is then noted.

RESULTS

In one patient, the new test was confirmatory of the results of the provocative discogram; in two patients, the test results were divergent.

CONCLUSIONS

These case studies and technical description are presented as a first step in examining this method of preoperative assessment. Further study of the technique will allow us to make more definitive recommendations with regards to its validity and utility.

LEVEL OF EVIDENCE

Level 4 - Case Series.