An analysis of radiating pain at lumbar discography

Abstract

IntroductionLow back pain with radiation into the lower limb is a common clinical complaint. Imaging studies frequently show absence of nerve root compression [9] and it has been suggested that the origin of such referred pain lies within the intervertebral disc itself. Crock introduced the concept of 'internal disc disruption', suggesting that chemical alterations within the nucleus pulposus of a degenerative disc could result in both back pain and lower limb pain [2,3]. The aim of the present study was to identify pathological features of the intervertebral disc, as demonstrated by discography, that were associated with concordant pain radiation. Materials and methodsThe study consisted of a retrospective review of lumbar discography reports of 99 consecutive patients. All patients were referred for discography by a single spinal surgeon over a period of 30 months for the investigation of chronic low back pain, with or without radiating pain, as a precursor to spinal fusion. The study group comprised 52 males and 47 females with a mean age of 43.3 years (range 22-69 years). MRI prior to discography excluded the presence of nerve root compression. All discograms were performed by a single radiologist using a posterolateral injection technique. Non-ionic contrast medium was injected through a single 18-G needle until there was either a firm end-point to the injection, or until pain was provoked, or to a maximum of 5-6 ml. For each disc injected, the following features were recorded: (1) nuclear morphology, (2) presence and site of annular tears and (3) patient response (no pain, concordant back pain, concordant radiating pain into the buttock, hip, groin or lower limb, or non-conAbstract This study aimed to identify the morphological abnormalities of the intervertebral disc, as demonstrated by lumbar discography, that are associated with pain radiation to the hip, groin, buttock or lower limb. We carried out a retrospective review of 99 consecutive lumbar discogram reports. The association of disc degeneration, annular tears (partial or full thickness) and the level of disc injected was determined with respect to the presence and pattern of radiating pain. A total of 260 discs were injected, of which 179 were considered abnormal. Posterior annular tears were demonstrated in 84 discs, anterior annular tears in 15 discs and 45 discs had both anterior and posterior tears. A significant association was identified between isolated posterior tears and the production of concordant radiating pain (P = 0.0041). No difference was identified between partial thickness posterior tears and full thickness posterior tears associated with leak of contrast medium, with regard to radiating pain. Similarly, there was no significant association between disc level injected and the pattern of pain radiation. The results indicate that pain experienced in the buttock, hip, groin or lower limb can arise from the posterior annulus of the intervertebral disc without direct involvement of the nerve root.

Surgical Outcome and Postoperative Work Status of Lumbar Discogenic Pain Following Transforaminal Interbody Fusion

“…5) With no other gold standard, induced concordant pain and radiological abnormal distribution by provocative discography are the most trusted findings for diagnosis of this disorder to date. 22) Related imaging studies also support the diagnosis of this disease. Several current studies suggest that MR imaging may have some predictive value for screening of discogenic pain.…”

Diagnosis of the Vertebral Level from Which Low Back or Leg Pain Originates. A Comparison of Clinical Evaluation, MRI and Epiduroscopy

“…The problems of identifying the segment(s) of significant pathology by clinical evaluation are familiar to the pain physician. Pure segmental distribution of pain is frequently not found 1–7 . To explain the inconsistent results from clinical evaluation, MRI findings, and epiduroscopy, 3 possible pathophysiological mechanisms should be considered.…”

“…The diagnosis of the correct vertebral level through clinical evaluation often depends on dermatomal, myotomal, and sclerotomal distributions of the nervous system. Identification of these patterns in clinical practice is often ambiguous 1–4 . MRI is considered by many to be the gold standard for localization of common spinal pathology, but the accuracy of MRI has been questioned 5–11 .…”

“…This permits evaluation of the patient’s response to manipulation of epidural structures in distinct regions of the epidural cavity. If pain produced by contact with epidural structures is similar in nature and distribution to the pain for which the patient is seeking treatment (concordant pain), it can be assumed that this region of the spinal canal is directly or indirectly related to spinal pathology of interest 2,4 . The aim of the study reported here was to compare the clinically significant vertebral level identified through endoscopic evaluation with the level determined through clinical evaluation (history and physical examination) and the level determined with MRI and to obtain the frequency distribution of the vertebral levels at which a concordant pain response could be evoked through epiduroscopy.…”

Management of Isthmic Spondylolisthesis with Posterolateral Endoscopic Foraminal Decompression

“…2,3,4,5,37 Endoscopy revealed impaction on the exiting nerve by the displaced bony and fibrous elements of the pars defect. Neural displacement and compression were accentuated by the deformed disc and necessitated discectomy and annuloplasty in addition to foraminal widening with clearance.…”