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Discography (Discogram)

If you suffer from neck pain, mid-back pain, or low back pain that has failed to respond to conventional treatment, you may need a diagnostic discogram to see if you suffer from discogenic pain.

What is a Discogram?

A discogram is a test used to ascertain which spinal discs are the source of a given patient’s neck or back pain. In the most basic sense, the procedure allows a physician to see directly into the internal structure of a vertebral disc and tell whether it is damaged or abnormal…and causing pain. With discography, one can find out if a tear is present, the degree of the disruption, and the portion of the disc involved.  

A discogram is not a routine test. It may be performed prior to spinal disc surgery to determine which disc levels will be treated. Nearly 80% of the general population is affected by low back pain at least once in their lifetime.[1] Even more staggering is the fact that low back pain is the fifth leading cause of physician visits, as well as the leading cause of work-related disability.

Discography is a proven method for diagnosing discogenic pain (DP) – pain caused by damaged, herniated, bulging or torn discs.  Even the most sophisticated MRI’s cannot diagnose this type of pain as effectively as a discogram.

Indications

DiscogramDiscography is useful for patients who have disabling low back pain, neck pain, and arm or leg radiation pain when other conservative diagnostic methods and treatments have failed. When conventional, non-invasive imaging, such as magnetic resonance imaging (MRI) is unable to discover the cause of one’s neck or low back pain, or reveal any abnormalities consistent with the pain symptoms, discography can be used to diagnose the cause.[2] More the point, when the cause of the pain is the disc itself (discogenic).

DP is one of the most common causes of chronic back pain and accounts for approximately 10% of all low back pain complaints. Discs themselves can be the source of pain in anywhere from 39% – 65% of patients with non-radiating low back pain.[3],[4]  In these cases, conventional treatment will almost inevitably fail and most MRI’s will be unable to detect these abnormal discs. Discography is the lone option.

What are the Benefits?

The rationale for discography is based on three factors

  1. The high prevalence of spine pain.
  2. The high prevalence of abnormal MRI findings at asymptomatic levels.
  3. The low success rate for surgical interventions for degenerative spondylosis.
Annular Tear as seen on an MRI

Annular Tear as seen on an MRI

While MRI is considered by most to be the gold standard for imaging the spine and the intervertebral discs, it lacks any means to correlate abnormal findings with potential causes for pain. In essence, MRI does not show what is causing your pain, only how your spine looks different to a “normal” spine. Confounding matters is that MRI studies conducted in patients with no pain to speak of have consistently demonstrated that a majority of people have abnormalities in the cervical, thoracic, and lumbar spine regions, with the proportion increasing with age.[5-7] In other words, a person with no pain whatsoever can have an abnormal MRI, and vice versa – someone with back pain can have a normal MRI or have positive findings that are not causing any pain whatsoever.[8] When used alongside MRI, discography allows physicians to sort out these confusing issues. Others have even suggested that discography, by itself, is superior to MRI for detecting disc ruptures.[9]

Discography is considered a minimally invasive procedure and it is performed when:

  • Your physician has a high suspicion you are suffering from DP.
  • A spine surgeon would like to pre-operatively evaluate your spine to see what levels should be focused on and ascertain if other parts can handle the increased stress of surgery post-operatively

Procedure - Patient Details

Discography is typically performed as an outpatient with mild sedation. You will be awake during the procedure as it will be necessary to communicate with the physician. Before the procedure starts, the staff will give you some antibiotics to minimize any risk of infection. Your physician will sterilize your back then numb the skin with local anesthetic to make you as comfortable as possible. A thin needle is then inserted using Fluoroscopy – a real time X-ray device that will allow your physician to visualize the needle the entire way and make sure it is properly placed inside the disc. The tip of the needle is positioned just beyond the outer layer of the disc (annulus fibrosis) and placed into the center portion (the nucleus pulposis).

Diagnostic Discogram

Diagnostic Discogram

Once the needle’s correct position is verified, a contrast solution is injected into the disc and your response to the injection is observed and recorded by the physician. Also, the shape taken by the contrast is important as certain shapes indicate a healthy disc whereas others mean an unhealthy or degenerative one. As each disc is injected, the patient is asked about symptoms. If this test can reproduce the same symptoms of back pain, it is called a positive discogram.  If symptoms are not replicated, it is a negative discogram.  If pain is experienced that is similar to your chronic pain condition (positive discogram), then it is highly possible the doctor has located the source of your pain. Depending on the patient, this is typically repeated in 2 additional discs. Your physician may also instruct you to go for a computed tomography (CT) scan directly after the discogram to better visualize the spread of the contrast within the scan and evaluate for the presence of an annular tear – these can be very painful and typically require treatment to heal.

Your doctor may put restrictions on food and medicine intake the day before and the day of the test. Although this is usually done as an outpatient procedure, another person should accompany the patient home. The procedure usually takes under an hour, although this may vary depending on how many discs are examined.

Risk Factors

As with any interventional procedure, there is always a risk of potential complication. Typically discography is considered low risk with minimal likelihood of complications. One potential complication is discitis – a painful infection inside the disc. This is uncommon but can be severe. Other potential complications include bleeding/hematoma, headache, numbness or increased pain.

Evidence of Performance

Based on current published research, it is clear that surgery performed for axial spine pain is associated with a high failure and significant complication rate.[10] Moreover, when one considers the high prevalence rates for spine pain and “coincidental” abnormalities found on imaging, an accurate means to correlate symptoms with imaging results is of the utmost importance. MRI and CT scans show anatomical abnormalities, whereas discography is able to pinpoint which discs are producing the pain. Small changes, like annular tears, can go undetected with imaging alone and still go untreated causing severe pain. Discography is the only test that purports to correlate symptoms with pathology.[11]

Most patients who undergo discography typically have not found satisfactory pain relief from other conservative measures like medication, physical therapy or modified activities. They are in some cases being considered for surgery. Several studies have shown that having discography performed pre-operatively correlated with improved outcomes. Colhoun et al reported in 137 patients with non-radiating low back pain in whom positive findings on discography, 89% had a favorable outcome at the mean follow-up period of 3.6 years.[12]

The Ainsworth Institute is Here to Help

If you are suffering from chronic neck or back pain that has been refractory to other treatments, and you are at a point where you might be considering surgery, contact the Ainsworth Institute of Pain Management today and schedule an appointment with one of our Board Certified Physicians to see if you could benefit from a Discogram.

References

[1] Cohen SP, Argoff CE, Carragee EJ: Management of low back pain. BMJ. 337:a2718 2008

[2] Wichman HJ. Discography: over 50 years of controversy. WMJ. 2007;106(1):27-9.

[3] Cohen SP, Larkin T, Fant GV, et al.: Does needle insertion site affect diskography results? A retrospective analysis. Spine. 27:2279-2283, 2002.

[4] Collins CD, Stack JP, O’Connell DJ, et al.: The role of discography in lumbar disc disease. a comparative study of magnetic resonance imaging and discography Clin Radiol. 42:252-257 1990

[5] Jarvik JG, Deyo RA: Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 137:586-597 2002

[6] Wood KB, Schellhas KP, Garvey TA, et al.: Thoracic discography in healthy individuals. A controlled prospective study of magnetic resonance imaging and discography in asymptomatic and symptomatic individuals. Spine. 24:1548-1555 1999

[7] Schellhas KP, Smith MD, Gundry CR, et al.: Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine. 21:300-311 1996

[8] Zucherman J, Derby R, Hsu K, et al.: Normal magnetic resonance imaging with abnormal discography. Spine. 13:1355-1359 1988

[9] Montes García C, Nava Granados LF. Evocative lumbar discography Acta Ortop Mex. 2007 Mar-Apr;21(2):85

[10] Deyo RA, Nachemson A, Mirza SK: Spinal-fusion surgery—the case for restraint. N Engl J Med.

[11] Benzon H, Raja S, Liu S. Essentials of Medicine. 3rd Edition. Elsevier Saunders. Philadelphia, 2011.

[12] Colhoun E, McCall IW, Williams L, et al.: Provocation discography as a guide to planning operations on the spine. J Bone Joint Surg (Br). 70:267-271 1988

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