Lumbar Discography: Diagnosis Tool for Spinal Pain Analysis

1. LUMBAR DISCOGRAPHY 放射診斷科 施博文

2. Introduce • What and who • Why • Anatomy • Prepare • Procedure • Complication • Image • Conclution

3. Introduce • Discs degenerate in all adults as we grow older. Degeneration is associated with the loss of water in the disc and decreased disc height. These changes may be painful. Typical symptoms related to disc degeneration are neck or back pain and sometimes pain in the lower limbs. Severe degeneration may cause pain when the spine presses on nerve roots or forces more load onto the facet joints in the back of the spine. Disc degeneration is a common process, however, and is not always painful.

4. What is discography • Similar myelogram、vertebralplasty • Evaluatin pain and/or disability of suspected spinal origin • Critical importance to acdcurately diagnose the precise origin of pain and structural derangement • Used in the lumbar,thoracic,and cervical

5. Who performed • It is performed by skilled,knowledgeable,and experienced proceduralists • Knowledgeable in spinal anatomy and pathology,fluoroscopic imagery,radiological equipment,and radiological projection • Most interventionists and procedurally oriented neuroradiologists adapt of this procedure

6. Equipment • High resolution • Multidirectional • Fluoroscopic device with magnification • Tilting fluoroscopic table

7. Why discography • Why not MRI • Disc or vertebral body endplate pathology observed on imaging studies of clinical significance • To determine what type of therapy • If surgical,what spinal segments and structures need to be dealt with • What is the ultimate prognosis

8. Anatomy

9. Anatomy

10. Anatomy

11. Prepare • Should not eat any solid foods after midnight • Any history of allergy reaction • Female patient will be asked if they are or may be pregnant • Sedation only used for selected patients who are agitated,have physical limitations,and/or who are in such extreme pain

12. Procedure • Prone position • Reduce lumbar lordosis and to elevate the side of the patient into which we will be introducing the needle. • Identify the route of optimal access for needle placement into each disc • Leave a small,lasting skin imprint on the patient’s skin • Cleanse a wide area of the patient’s skin with iodine solution

13. Procedure • Contrast and other injectable media are drawn up • The skin cleansing solution is rinsed from the patient’s skin with alcohol,a sterile,fenestrated drape is placed over the prepared site

14. Procedure-techniques • Single-needle and coaxial(3.5 to 8 in.,22-gauge,26-gauge,25-gauge spinal needle) • Coaxial technique to be unnecessary.Needle inserted for only 1 to 3 minutes.slower procedure may increase the risk of infection. • Two-needle technique

15. Procedure-techniques • Skin puncture • Needle is incrementally to the inferior margin of the disc • When the needle tip raches the disc annulus,it is firmly advanced 1.5 to 2 cm into the center of the disc nucleus • Tube rotate to either a lateral or AP projection to confirm the depth and location

16. Procedure-techniques • If a nerve is inadvertently hit or irritated,the needle shouldbe withdrawn slightly and repositioned,if possible,in an attempt to avoid the nerve

17. Procedure-contrast agent inject • A typical intact lumbar disc will accept approximately 1.5 to 3.5 mL,4 to 5 atm of pressure(120-150 mmHg) • An end point is reached,preventing further injection • Pain manifestations are observed • At least 4 mL of saline has been injected ,indicating leakage

19. Procedure-after filming • Patient is questioned about the experience during injection(pain ,pressure or no sensation at all) • Concordant versus nonconcordant relative to their clinical complaints • Rate the maximum intensity of the experience on a scale of 0 to 10(positive：≧7/10)

20. Procedure-after injection • Injection was painful,exhibited annular pathology,high intensity rating,inject local anesthetic(2-4% lidocainf or 0.5%bupivacaine,1 to 3 mL in total volume) • Relieves pain,decreases the likelihood of producing false positive results later in studies of adjacent discs

21. Classification of lumbar disc annular lesion • Grade0-normal,intact annulus • Grade1-fissure/tear involving inner one third of annulus • Grade2-fissure/tear involving inner two thirds of annulus • Grade3-tear extending from the nuclear space either into or through the outer one third of the disc annulus,involving up to 30 degree of the disc circumference • Grade 4-tear extending from the nuclear space either into or through the outer one third of the annulus,involving greaterr than 30 degree of the disc circumference

22. Complication • Infections • Neural • Vascular • Other

29. Conclution • Discography is a very specific tool that may help your health care provider determine if the abnormal disc is causing your pain. Due to conflicting data on the benefits of discography, the use of discography is controversial among spine care physicians. However, many health care providers do find it is helpful in identifying the source of pain.

30. Thank you for your attention