Delayed pain response after lumbar discography

Summary The delayed onset of symptomatic pain following lumbar discography (with no immediate pain response) is described in six patients, five with a minimum 2-year follow-up. It is usually seen in patients with nearly normal disc morphology who have incomplete or discrete annular tears that are not filled at the time of injection. Later (2–12 h in this study), dye leakage occurs through these lesions, thereby precipitating the discogenic pain This phenomenon may be missed and is probably more common than previously believed due to early discharge from the hospital, the patient expecting discomfort after the invasive study (hence no complaint is made), and the clinician being unaware of this delayed symptom, thereby not asking about it in follow-up. Close patient questioning regarding a delayed onset of symptomatic pain after discography is, therefore, an essential element in diagnostic information following this study.     

经皮腰间盘切割术中髓核造影的X线分析

20例腰椎间盘脱出的患者在行经皮腰椎间盘切割术(PLD)前进行了髓核造影。28个髓核造影有三种表现:蕈伞征占28.6%,团块征占39.3%,纤维环破裂征占32.1％。髓核造影能直接显示髓核的变化,椎间盘脱出的方向和程度,以及纤维环破裂的直接征象.因此我们认为当X线检查与临床体征部位不一致时,行PLD前作髓核造影可起到进一步确诊的作用。     

The pathogenesis and clinical significance of a high-intensity zone (HIZ) of lumbar intervertebral disc on MR imaging in the patient with discogenic low back pain

Recently, the presence of a high-intensity zone (HIZ) within the posterior annulus seen on T2-weighted MRI has aroused great interest and even controversy among many investigators, particularly on whether the HIZ was closely associated with a concordant pain response on awake discography. The study attempted to interpret the correlation between the presence of the HIZ on MRI and awake discography, as well as its characteristic pathology. Fifty two patients with low back pain without disc herniation underwent MRI and discography successively. Each disc with HIZ was correlated for an association between the presence of a HIZ and the grading of annular disruption and a concordant pain response. Eleven specimens of lumbar intervertebral discs which contain HIZ in the posterior annulus from 11 patients with discogenic low back pain were harvested for histologic examination to interpret the histologic basis of a nociceptive response during posterior lumbar interbody fusion (PLIF). The study found that in all of 142 discograms in 52 patients, 17 presented HIZ. All 17 discs with HIZ showed painful reproduction and abnormal morphology with annular tears extending either well into or through the outer third of the annulus fibrosus. The consecutive sagittal slices through the HIZ lesion showed that a notable histologic feature of the formation of vascularized granulation tissue in the outer region of the annulus fibrosus. The current study suggests that the HIZ of the lumbar disc on MRI in the patient with low back pain could be considered as a reliable marker of painful outer anular disruption.     

腰椎间盘造影在椎间盘源性腰痛诊治中的应用

[目的]探讨椎间盘造影对椎间盘源性腰痛的诊断价值及椎间融合手术的疗效。[方法]2003年10月～2004年6月间对45例具有椎间盘源性腰痛症状的病人进行了椎间盘造影,共101个椎间盘,45例中依据椎间盘造影的结果行椎间360°融合手术18例,保守治疗27例。所有病例全部进行了MRI和CT检查。观察造影图像和MRI表现,记录诱发痛,随访手术组和保守组的疗效。[结果]45例中2l例出现了诱发痛(47%),101个造影椎间盘中有21个椎间盘出现诱发痛(21%);21例诱发痛阳性的病人中18例接受了360°融合手术,随访时间平均6个月(3～10个月),术后1l例病人腰痛完全消失(11/18,优:61%),4例疼痛基本消失(4/18,良:22%),3例腰痛无变化(3/18,差:17%);3例诱发痛阳性的病人和24例诱发痛阴性的病人行保守治疗,在同期随访中,1例腰痛完全消失(1/27,优:4%),10例疼痛基本消失(10/27,良:37%),16例疼痛没有变化甚至加重(16/27,差:59%)。[结论]腰椎间盘造影对椎间盘源性腰痛的诊断具有一定的敏感性,对确定为疼痛原因的椎间隙实施椎间360°融合手术可以消除病人的疼痛,近期效果比保守治疗好。     

椎间盘造影亚甲蓝盘内注射治疗椎间盘源性腰痛的疗效分析与探讨

目的:探讨椎间盘源性腰痛的特点以及造影亚甲兰盘内注射治疗椎间盘源性腰痛的效果,为其诊断治疗提供参考。方法:2006年～2007年我科对15例经保守治疗无效,考虑为椎间盘源性腰痛的患者进行椎间盘造影亚甲兰盘内注射,观察造影剂的形态和疼痛的复制性,并对术前、术后和术后三月患者疼痛的VAS评分进行疗效评估。结果:15例患者共行28个椎间盘穿刺,其中造影剂外漏16节段,诱发复制痛13个节段,13例患者术后疼痛即刻缓解,2例无效,vas评分由术前平均8.2分降至术后1.4分和术后三月的2.2分,改善率分别为83.5%和74%,有效率分别达到86.7%和73.3%。结论:椎间盘造影是诊断腰椎间盘源性腰痛的可靠方法,亚甲兰盘内注射可有效的缓解症状,为临床治疗该病提供了新的方法和思路。     

MRI and discography in traumatic intervertebral disc lesions

In this study we evaluated magnetic resonance imaging (MRI) in trauma patients for assessing traumatised adjacent discs of fractured vertebrae before dorsoventral stabilisation. In a prospective study, MRI of 54 discs was performed with a 1.5-T MRI unit. The preoperative MRI with sagittal T1-W-SE and T2-W-TSE was compared to intraoperative discography, which was carried out on both intervertebral discs adjacent to the fractured vertebrae. Signal alterations, morphological changes in the adjacent discs, fractured vertebrae and associated ligament injuries were evaluated. In 47/54 (87%) of the intervertebral discs, the results of both imaging findings were concordant. The discs adjoining vertebral fractures were normal in 18 cases. Regarding the positive concordant imaging findings, MRI and discography revealed traumatised adjacent cranial and caudal discs in 22 discs. In 7 cases, only the cranial adjacent disc was affected. Moreover, 17 cases of intradiscal bleeding, 13 intraosseous herniations into the fractured vertebrae and 20 anuluar tears were visualised in MRI. Associated ligament injuries were detected in 18 cases. Findings were discordant in eight discs. In six discs, MRI was abnormal, demonstrating signal alterations suggestive of positive imaging findings, whereas discography demonstrated no disc injury. MRI failed to detect disc injury in two discs, whereas discography was positive, showing an irregular intradiscal contrast media distribution. MRI, as a non-invasive method for assessing fractures of the thoraco-lumbar spine, may detect traumatised adjacent intervertebral discs. MRI is superior to intraoperative discography. The performance of MRI of the thoraco-lumbar spine is recommended before dorsoventral stabilisation in trauma patients, as it can reveal additional preoperative information such as fractures, disc and associated ligament injuries.     

椎间盘造影在决定腰椎融合节段中的作用

目的 评估椎间盘造影术在决定选择腰椎间融合节段中的应用价值.方法 对17例下腰痛(共56个椎间盘)进行椎间盘造影.根据临床症状、辅助检查、椎间盘造影结果制定手术计划,采用椎间盘切除,腰椎间融合术.术前、术后给予VAS、ODI评分以及影像学评估.结果 本组均成功进行了椎间盘造影.椎间盘造影阳性20个,其中MRI显示只有17个为异常椎间盘.在椎间盘造影阴性的36个椎间盘中,18个MRI显示正常.MRI检测症状椎间盘的假阴性率为15%,假阳性率为50%.17例均接受了腰椎间融合术.ODI评分,术前平均51%,术后1周,1、3、6、12个月结果平均为15%,融合率100%,无一例发生并发症.VAS术前平均7分(6～9分),术后平均2分(0～4分),临床效果良好.结论 椎间盘造影术可避免不必要的腰椎融合,临床症状、辅助检查结合椎间盘造影可以提供更多的信息以更准确地选择融合节段.     

腰椎间盘磁共振正常的椎间盘源性腰痛

目的 研究MRI显示椎间盘正常信号强度但椎间盘造影显示纤维环破裂和存在疼痛复制反应的椎间盘源性腰痛特殊病例,并对其产生的原因和意义进行探讨.方法 2003年8月至2008年11月,慢性下腰痛且行腰椎间盘造影术病人288例.其中腰椎MRIT2加权显示正常信号强度,但椎间盘造影术显示纤维环撕裂和腰痛复制的病人12例.男7例、女5例.年龄20～44岁,平均29.6岁.病程8个月～3年,平均1.8年.应用Dallas CT椎间盘造影分级方法评估纤维环撕裂程度.结果 12例慢性腰痛但MRI显示正常信号强度的病人中,共行腰椎间盘造影33个椎间盘.12个病人12个椎间盘显示疼痛复制和纤维环撕裂,其中显示2级撕裂者3个,3级撕裂者9个.结论 对一些顽同性腰痛病人,保守治疗无效,提示是椎间盘源性的,但MRI检查正常需要行进一步治疗时,如行腰椎微创手术或腰椎融合术时,仍需考虑行腰椎间盘造影术,以确定疼痛的椎间盘.     

Usefulness of discography,discoblock and a new mechanical method for identifying a painful segment/disc

BackgroundWe previously described a procedure for eliciting deep spatial discrimination of individual segments in the healthy lumbar spine of normal subjects: the percutaneous mechanical provocation (PMP) test. Our goal was to devise a method for accurate identification of the spinal level of pathology in chronic low back pain (CLBP). In the present study, we validated the PMP test, using a subgroup of CLBP patients with isthmic spondylolisthesis (IS). Because there is clinical consensus that IS back pain originates in the slipped segment/disc, the level of pathology can be directly compared to the result of the PMP test. The test is agnostic with respect to the underlying pathological mechanism, and therefore might be useful in identifying the involved segment(s) irrespective of the painful structure.MethodsIn 37 patients with confirmed IS (slippage 3–15 mm), we compared sensitivity between the PMP test, the widely used provocative discography test and the discoblock test.ResultsThe PMP test reliably identified the slip level in patients with IS, with sensitivity of 92%. Accepting the slipped disc as the origin of pain in IS, the sensitivity of the provocative discography and discoblock tests were 49% and 35%, respectively: i.e., too low to be contributive in clinical practice.ConclusionsThe PMP test reliably identified the origin of localized pain in IS as the slip level, but should be used with care in CLBP patients in selecting discogenic pain patients for fusion surgery, since the specificity of the test is not known and it may be positive for any origin of localized pain.