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Acta Ortopdica Brasileira verso impressa ISSN 1413-7852

Acta ortop. bras. v.10 .3 S!o "a#lo $#l.%set. 2002


doi& 10.15'0%S1413-78522002000300007

Lumbar discography

Discografia lombar

Sady RibeiroI; Magnolia Leo da Nobrega GaucheII


I

Pain Specialist, American Pain Board of Medicine, Department of Neurobiology, University of Te as, !ouston, USA II Doctor Anest"esiology, !ospital das #linicas, $MUSP, responsible for Pain %roup from N&cleo de ' tens(o, #asa de AIDS !#, $MUSP, S(o Paulo, SP Address for correspondence

SUMM R! Discograp"y, a controversial test t"at due to ne) image diagnosis tec"ni*ues )as left be"ind, is discussed+ A literature revie), regarding tec"ni*ue, indications, benefits and limitations of discograp"y is presented+ A ne) approac", focusing t"e results on presence of a familiar pain during t"e e am is presented+ "ey #ords$ Discograp"y, lo) bac- pain, disc "erniation

R%SUM& .s autores apresentam uma revis(o da discografia, e ame controvertido, *ue com a introdu/(o de novas t0cnicas , o diagn1stico por imagem, ficou relegado a um segundo plano+ Mostram uma revis(o da literatura, abordando a t0cnica, indica/2es, benef3cios, limita/2es e eventuais complica/2es deste e ame+ Uma nova abordagem para o e ame com foco na evoca/(o da dor usual, *uando a in4e/(o de contraste, 0 discutida+

Descri'ores$ Discografia, lombalgia, "0rnia discal+

Although controversial, discography has been used as diagnostic tool for a half century (22). When first introduced, the main indication of discography was the assessment of patients with back pain and sciatica, whose myelography, the only test available to study intraspinal pathology at that time, was either negative or indeterminate(5). he rate of false negatives for myelography, mainly at the level !5"#$, was high($%). &iscography proved to be useful for this diagnosis. echnology gave us the ' and later, the ()*. hese two tests significantly improved the diagnosis of back pain with sciatica and made discography a test of secondary value in this clinical circumstance($5). +owever, patients with back pain and radicular pain, whether or not accompanied by an abnormal neurological e,am, are a minority in the population with back pain. A,ial back pain with or without referred pain (that is different from radicular pain) is the most common presentation in patients suffering from chronic back pain, and to determine the source of pain in this population can be a challenge (%). -ur current understanding permits us to consider the disc, independent of any root compression, as the cause of pain in appro,imately ./0 of these patients (2%). he disc presents a neuro"anatomical substrate that gives it a condition of being a pain generator when pathologically altered (.). *t receives its innervation from branches of the sinuvertebral nerve and the gray rami communicantes. he first supplies mainly the outer annulus of the posterior and posterior lateral aspect of the disc, and the second supplies the lateral and anterior part of it (.). he concept of internal disc disruption introduced in the seventies improved our understanding of intradiscal pathology and how a disc can be a generator of pain. *n this condition, fissures occur in the substance of the inner annulus and e,tend into the outer annulus. A degenerated disc would produce several inflammatogenic substances that, together with mechanical stimuli, could activate the nerve endings of the outer annulus (1). ()* is able to show internal disc morphology. 2ood 3uality 2 weighted images provide a contrast between the nucleus pulposus and the outer annulus of a normal disc (4). *n disc disruptions, eventually, it can be seen in 2 weighted images at the posterior annulus. his finding has a positive predictive value for a disrupted symptomatic disc of 5%0 .

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+owever ()* can occasionally miss an abnormal disc, and not all altered discs have been shown to be symptomatic ($2). &iscography can then be used to determine if one or more discs are responsible for the patient6s back pain. Although disc morphology can sometimes be important, in

this new use of discography the goal is to reproduce the patient6s pain through the in7ection of contrast or normal saline in the nucleus pulposus (21). 8atients should be interviewed and e,amined before the procedure. 8hysicians must e,plain the nature of the procedure, its goal, and its possible complications. 8atients have to clearly understand that the procedure is to search for 9every day9 pain and not an atypical pain that may appear during the in7ection ($.). 8atients should also be instructed about the pain scale (/"$/) that will be used to measure the pain. 'oagulation function should be tested and corrected when needed. &uring the procedure the patient is placed either in the lateral position or prone decubitus position, and connected to an :;2 monitor and a pulse o,imeter($.). <euroleptic analgesia is generally administered in order to allow the patient to respond to painful stimuli. he lumbo"sacral area is prepared and draped accordingly. After the skin and subcutaneous tissue had been anestheti=ed with lidocaine $0, a 22"gauge needle is introduced, with the help of fluoroscopy, through an e,tradural approach in the postero lateral aspect of the disc and placed in the nucleus (25). he position of the needle is assessed by postero anterior and lateral views. he correct positioning of the needle is necessary for the validity of the interpretation of the test (24). #ome authors defend the use of a double needle techni3ue, believing that this will decrease the incidence of discitis (25). *n this case, an $5"gauge needle is used, and placed 7ust lateral to the annulus> the 22"gauge needle is then passed through it and penetrates into the disc. he placement of the needle at the level !5"#$ can be very difficult due the presence of a high iliac crest, reduction of the height of disc space, an osteophyte or a large transverse process. A needle with a curved tip can sometimes be helpful at this level. #ince the most commonly abnormal levels are the !."!5 and !5"#$, and since it is important to have a normal level as control in order to substantiate the test validity, discography is usually performed in the three lowest levels (5). When the !?"!. level is also abnormal, the level above should be tested. he criteria used to interpret discography include reproduction of familiar pain, volume acceptance, resistance, and morphology of the in7ected disc ($.). @efore the in7ection the patient is asked to grade his or her pain in a scale of / to $/. 'ontrast is then in7ected with a three cc syringe. A normal disc has a volume acceptance between /.5 and $.5 cc with a firm end point during in7ection. he in7ection is not painful and the contrast stays in the nucleus. An abnormal disc is painful> it has a low resistance to the in7ection, and a volume acceptance that varies with the degree of the degeneration. *n an abnormal disc, the contrast spreads to the annulus and can leak into the epidural space. *n the presence of pain, the patient is asked again to score it in the /"$/ scale. Although reproduction of familiar pain is the most important parameter, it is common to re3uest a ' after discography for a better documentation of the morphologic changes of the abnormal disc (2$), mainly when one is considering an intradiscal therapy (laser, chemonucleolysis or automated percutaneous discectomy) ($$). *t seems that these three procedures present better results with a contained disc. 8ain in discography is e,plained by the presence of a chemical and Aor mechanical sensiti=ed nociceptor in the outer annulus. #tatistical studies have shown that there is a strong correlation between positive pain response at discography and the presence of a fissure of the outer disc annulus, independently of the degree of disc degeneration (4). +yper fle,ion of the facet 7oints and pressure against the vertebral end plate during the contrast in7ection could also contribute to the pain ($5,21). )ecently, the use of pressure"controlled discography has been introduced in the practice of this procedure. Bsing a syringe with a manometer that registers the

intadiscal pressure during the in7ections, we can divide the discs with a positive pain response into two groups. 'hemically sensitive discs would present pain with pressure lower than the mechanical sensitive ones . he first group seems to achieve significantly better long"term outcomes with interbody and combined fusion than with intertransverse fusion($/). &iscography has been critici=ed in the past as a test with high false positive results($4), but studies utili=ing a better methodology have demonstrated the validity and reliability of this test(24). A false positive may result from misplacement of the needle either touching the end plate or inserted into the annulus instead of the nucleus(21). 8atients with a very low pain threshold or psychological problems are perhaps not able to distinguish between pressure due the in7ection and real pain (?). 'linical correlation and morphologic findings can help us with this scenario. Calse negatives are very rare and could be caused by an annular tear that does not communicate with the nucleus. -ver sedation will also prevent patient from informing the physician about pain. &iscography does not in7ure the disc when properly performed ($1). 'omplications such as retroperitoneal hemorrhage, intradural in7ection, and nerve lesion can happen, but are rare in the hands of an e,perienced physician. With regard to infection, discitis ($?), although rare, can occur. :pidural abscess has also been described(2/). <eedles should be used with the stiletto and some authors recommend double needle techni3ue to avoid discitis. Antibiotics, given *D and mi,ed with the contrast, have been used by almost everybody. *n e,perimental models *D cefa=olin protected the disk against discitis. When mi,ed with the contrast, cefa=olin is used in a concentration of $mgAcc. #taphylococcus is the most common bacteria, but when bowel perforation occurs during discography, a gram" negative bacteria can be the aggressor agent. 8atients with discitis generally present with a high sedimentation rate and severe back pain. An ()* and bone scan can take from two to four weeks to become positive. &iscography should only be used when is important to define if a disc is symptomatic and there is a specific therapy to be offered. he most common indication is to plan the level of spinal fusion that will include all of the symptomatic discs (2/). 8atients with abnormal morphologic disc and positive pain seem to present a better outcome to spinal fusion than patients with disrupted morphology, but a negative pain response during disc in7ection (2?). *n patients with back pain sciatica, ' or ()* must be the first choice, but when these test are inconclusive or intra discal therapy is being considered, discography can be very useful (2.). 8seudarthrosis is an important cause of failed spinal fusion, and discography helps in differential diagnosis between a symptomatic pseudarthrosis and a painful disc (2,$.). Although ()* with contrast usually can differentiate between scar tissue and recurrent hernia, discography with ' has proved to be able to detect recurrent herniation not identified by gadolinium enhanced ()* (2$). Cinally new therapies have appeared for treatment of discogenic pain (*&: , )C ') and discography is a must in the selection of patients and disc levels that can benefit form these procedures (2$).

CONCLUSION
&iscography certainly is not a perfect test, apart from being an invasive procedure. +owever when proper used, it can be very helpful in assessing patients with back pain. 'orrect selection of patients and correlation with patient symptoms and other

tests certainly helps us to validate discography results. As the test relies on patient information, those with important psychological problems should not undergo this e,am (?). &iscography should not be only an intellectual e,ercise and its overuse will lead to a low acceptance, poor credibility and enraged criticisms.

R%(%R)N*I S +I+LI&GR,(I* S
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ddress for correspondence Sady :ibeiro '6mail8 sadyN)t+net Magnolia @e(o da Nobrega %auc"0e '6mail8 magflo)erN"otmail+com Trabal"o recebido em 5DO5<O<AA5+ Aprovado em <<OA>O<AA<

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