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or a discogram, is an invasive diagnostic tool used to characterize the anatomical
structure of the intervertebral disc and determine if a specific disc is causing back pain.




Dr.  !" reportedly was the first to demonstrate discography by injecting lead into
cadaveric discs.

In #$%&, he published the first description stating-͞Diagnostic disc puncture with injection of radio-
opaque medium demonstrates disc ruptures and protrusions and tells if the patient symptoms originate
from the punctured disc.͟

c"'''(2003)

 


(i) Assess the '(')!"* '+


(ii) Evaluation of patients-''','' ""*diagnostic tests have failed).


(iii) Evaluation of patients-)'  ','


(iv) Evaluation of patients !')' )


(v) Evaluation of candidates for "",,' ','-

(vi) Investigate ' !'before chemonucleolysis or percutenous procedures.

According to guidelines from the c"'c)''.'

)''*/001+, lumbar provocative discography is not recommended as a stand-alone
test for treatment decisions in persons with LBP.

It should not be attempted in individuals with ""!2 -





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, *+ :"If a particular disc is painful, then stressing it should reproduce the
patient's usual pain. If the disc is not the source of a patient's pain, then stressing it either should not be
painful or should produce pain that is not the patient's familiar or accustomed pain" ('
'',''[ISIS] Guidelines).

c' 4 Whereas PD attempts to confirm the disc as a pain source, AD attempts to
relieve those symptoms, by injection of local anaesthesia.

PROCEDURE
Identify exact  of his/her pain

' is determined prior to discography for comparison with pain after injection

Intravenous line-normal saline-containing fluids is started

Prophylactic antibiotic is given i.v and also included in the contrast.

- patient's body is slightly oblique at a 45° angle to the bed and rotated forward

Positioning at %15 -Allows better visualization of the lumbosacral junction

-Easy needle placement,

-Reduces the chance of striking the iliac crest on needle insertion

Blood pressure and pulse oximetry are monitored.

Local anesthetic is infiltrated to the skin and musculature

"'  approach

Under fluoroscopy, this needle should strike the 'c'

Needle is walked slightly lateral and at a midpoint between the endplates

Needle must pass lateral to the Superior Articular Process and medial to nerve root
 Resistance and back pain will be noted on passing it through the annulus

Lancinating pain into the extremity likely suggests contact with the nerve root

The use of a 67'' ''8' reduces the risk of disc infection.

Water-based iodine contrast (Isovue 300 or Omnipaque) is used

'''is noted when dye is appreciated within the disc space

Correlation of opening pressure and pressure at pain onset

Integrity of the disc can be determined by assessing the amount of pressure it can hold.

Incompetent disc will "bleed off" pressure quite rapidly because of leakage of contrast.

Disc "characteristics, complete or partial ', and any ' ' of contrast should
be noted.

Patient should quantify his pain on a scale of 0 to 10.

Pain classified as  ,

 , or

 

Suspected painful disc(s) should be injected last

A local anesthetic should not be injected into a painful disc after the contrast injection before
proceeding to an adjacent disc.

Extravasation of local anesthetic to adjacent discs--false-negative result

  c

When familiar pain is produced at pressures with use of manometer

9#1psi above opening pressure chemically sensitive disc (c)

#:710psi above opening pressure mechanically sensitive disc (m)

107$0psi above opening pressure indeterminately sensitive (i)

'$0psi above opening pressure Normal Disc. (n)

2
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1. Abnormal disk

Stretching of the annular fibers

Stimulate nerve endings.

2. Biochemical reaction neurochemical stimulation

Pain

3. Increase pressure at the end plates

Pressure transferred to the vertebral body

Increase in intravertebral pressure

Pain

4. Normal disc

Transfer of pressure

Abnormal disc
 Positive pain response

COMPLICATIONS:

nausea seizures headache increased pain

Spinal headache, Meningitis,

Intrathecal hemorrhage,

Arachnoiditis,

Severe reaction to accidental intradural injection,

Damage to the disk, urticaria,

Retroperitoneal hemorrhage,

Rarely disk herniations

The incidence of diskitis is /7;< when a single-needle technique is used and 0-=<when a double-needle
technique is used.

à


  à

  
: Manometrically

Volumetrically normal + no pain on injection.

Radiographically
: Type 1 + pain on injection

: Annular tears lead to a radial fissure.

3a (posterior radial fissure),

3b (fissure radiates posterolateral),

3c (fissure extends lateral to a line drawn from the center of the disk tangential to the lateral
border of the superior articulating process).

: Radial fissure reaches the periphery of the annulus fibrosus,

Nuclear material may protrude,

Bulge of annulus fibrosus

: Outer annular fibers rupture,

Nuclear materials extrude beneath the posterior longitudinal ligament and come in direct
contact with either the Dura or a nerve root.

: Extruded fragment is no longer in continuity with the interspaces (sequestrated).

Manometrically,

Volumetrically, abnormal

Radiographically,

Familiar pain reproduced if enough pressure is generated against the free fragment to cause
stimulation of the pain-sensitive structures.

: Internal disk disruption, characterized by multiple annular tears

Manometrically abnormal

Volumetrically abnormal

Familiar pain may or may not be reproduced.

Radiographically- contrast fills the interspace in a chaotic fashion.

Contrast extravasations throughout multiple annular tears.