Discography

Overview

Lumbar discography is an injection technique used to evaluate patients with back pain who have not responded to extensive conservative (nonsurgical) care regimens. The most common use of discography is for surgical planning prior to a lumbar fusion.

This diagnostic procedure – also called a discogram – is a controversial one.

  • The protagonists of discography believe the information gleaned from this examination is unobtainable any other way.
  • The procedure’s antagonists feel the responses evoked from disc pressurization are not useful in evaluating back pain patients.

This article does not extol the use of discography; rather it addresses some aspects of the procedure that may make a patient more at ease with what is an uncomfortable exam.

Indications for a Discogram

Indications for a Discogram

The indications for getting a discogram prior to a lumbar fusion surgeryare extremely variable amongst spine surgeons. Ordering the procedure depends on access to a skilled discographer. A discogram is basically a very subjective test, and if there are no experienced discographers available, then the spine surgeon may forego the test since a poorly done discogram does not yield any useful information.

Lumbar discography is considered for patients who, despite extensive conservative treatment, have disabling lower back pain, groin pain, hip pain, and/or leg pain. When a variety of spinal diagnostic procedures have failed to elucidate the primary pain generator, these individuals may benefit from lumbar discography especially if spine surgery is contemplated.

Unique Aspects of Discography

Unique Aspects of Discography

It should be understood that the discogram is less about the anatomy of the disc (what the disc looks like) and more about its physiology (determining if the disc is painful). It is well known to discographers that a really abnormal looking disc may not be painful and a minimally disrupted disc may be associated with severe pain. It is impossible to definitively diagnose a painful disc without performing a discogram.

The Lumbar MRI and CT myelogram are very sensitive anatomic tests but are not very specific in defining actual pain generators. The lumbar discogram, if performed properly, is designed to induce pain in a sensitive disc. A spinal fusion procedure that is designed to obliterate an internally disrupted, painful disc (pain generator) would not be the procedure of choice if pressurization of the disc didn’t reproduce the patient’s clinical discomfort. The spine surgeon needs to be absolutely sure that the level or levels being fused are responsible for the patient’s pain.

If the fused levels were not initially painful, spine surgery will not help, and the patient will be left with a fused spine and probably still be in pain. Since a spine fusion procedure carries a significant level of risk and healing time, the more information that can be obtained prior to back surgery the better.

While different discographers may vary the procedure slightly, the following provides an overview of modern technique for a lumbar discogram diagnosing back pain.

History and Physical Exam

History and Physical Exam

A nurse or other healthcare professional conducts the initial interview. All of your questions and concerns should be addressed and answered. This is the time to relate any and all horror stories you may have heard from medical (and non-medical) experts. Despite what you’ve been told, the discogram is not designed to create agony.

Next, the discographer will talk with you to review the relevant anatomy and discuss the procedure in much greater detail. You now have a second chance to ask questions or decide whether or not to proceed.

Initial Preparation for the Discogram Procedure

Initial Preparation for the Discogram Procedure

If you agree to allow the discographer to perform this exam, an intravenous line is started just in case intra-procedural medications become necessary. Usually, sedation is avoided so as not to interfere with any reactions or sensations you may experience.

Next, you are placed on a specialized table around which a fluoroscopic (x-ray) unit is positioned. Your back is then marked with an ink pen over the disc spaces that will ultimately be examined. Then your back is thoroughly cleansed and sterile drapes are applied. The fluoroscope will also be sterilely draped and the discographer will be in a sterile surgical gown.

Administration of Local Anesthesia

Administration of Local Anesthesia

The goal is to anesthetize a core of tissue that extends from your skin to the disc surface. When these tissues are numbed a guide needle is directed towards the disc and will just touch the outer surface of the annulus (the outer margin of the disc).

Through this guide needle a much smaller disc needle is advanced towards and eventually into the center of the disc. This process should not be painful, but sometimes may be.

The discogram procedure usually takes less than an hour to perform. You’ll have soreness from the needle punctures that lasts several days. You may use acetaminophen, ibuprofen or apply an ice pack for a few minutes to ease the soreness. Some physicians prescribe short term narcotic pain medications for use after the procedure.

Pressurizing the Discs – the Diagnostic Portion of the Discogram Procedure

Pressurizing the Discs – the Diagnostic Portion of the Discogram Procedure

After all of the needles are placed, the discs are “pressurized” one at a time. Pressurization consists of injecting small amounts of a sterile liquid (usually contrast material (x-ray dye)) into the center of the disc.

This is the most important part of the study and you must concentrate on what you are feeling. There are essentially three choices:

  1. You feel nothing
  2. You feel pressure
  3. You feel pain

If you feel pain from the injection, the pain is either:

  • Familiar pain, which translates into “ouch, that’s my pain!”
  • Unfamiliar pain, which belongs to someone else or translates into “ouch, I’ve never felt that pain before.”

After each level is pressurized, pictures are taken with the fluoroscopic unit and the needles are removed. Usually, a post-discogram CT is obtained to document the internal architecture of the disc. And that’s it!

The procedure usually takes less than an hour to perform. You’ll have soreness from the needle punctures that lasts several days. You may use acetaminophen, ibuprofen or apply an ice pack for a few minutes to ease the soreness.

Possible Risks and Complications of a Discogram

Possible Risks and Complications of a Discogram

As with any other invasive test, there are associated risks and possible complications.

  • The most feared complication is a disc space infection, which can be very difficult to treat. Fortunately, by using very strict sterile techniques this is a very uncommon complication.
  • There are extremely remote possibilities of nerve root injury
  • Spinal headache is also a remote risk

With a skilled and experienced discographer who uses modern discography techniques, all of these risks are very rare.

In summary, a discogram is a preoperative study designed to determine if an intervertebral disc is a pain generator. The initial needle placement need not be painful. If pressurization of a disc causes a familiar pain, then surgical obliteration (fusion) of the pain generator(s) may afford significant back pain relief.

Philip R. Shalen, MD. “Philip R. Shalen, MD.” Spine-Health.com. (2000): n. page. Web.
http://www.spine-health.com/treatment/diagnostic-tests/lumbar-discography-back-pain-diagnosis.