诱发疼痛与椎间盘的病理变化：腰腿痛的CT椎间盘造影

作者对７３例腰腿痛患者进行了ＣＴＭ间盘造影检查，共１４６个间盘，其中突出５１个，退变９５个。根据造影中出现诱发疼痛与否，可分为无痛、非类似疼痛、类似疼痛和疼痛再现４类。椎间盘突出中６８． ９％有类似疼痛和疼痛再现。突出不合并或合并轻度退变时容易出现疼痛再现，合并严重退变则疼痛再现明显减少。无退变间盘常常是无痛的，退变间盘常有非类似疼痛。椎间盘造影诱发出的不同性质的疼痛有辅助诊断价值。疼痛的病理机制仍有待探讨。     

A comparison of CT/discography, pain response and radiographic disc height

CT/discograms of 107 low-back patients were classified by annular degeneration, annular disruption, and pain response. These parameters were compared with the heights of the corresponding discs. Disc height correlated significantly with degenerative annular changes. Comparison of the painless and exact reproduction groups at the L5-S1 level showed a significant increase in exact pain reproduction in narrow discs compared with normal discs. Discs demonstrating slight degenerative changes were often painful but narrowing was detected only when degeneration increased to moderate or severe levels. Some severely degenerated discs were painless and only part of the severe group was narrow. Measuring disc height is a poor method for detecting early, painful degeneration changes.     

Disc deterioration in low-back syndromes. A prospective, multi-center CT/discography study

Disc deterioration and pain provocation in different low-back pain syndromes was studied using computed tomography (CT) discography. Data were prospectively collected for 300 patients (816 discs). Patients were classified by their pre-discography diagnosis of disc herniation (DH), degenerated disc (DD), lumbar syndrome (LS), lumbar radicular syndrome (LRS), or other. The CT/discograms were classified by discographic pain response, the amount of degeneration and annular disruption. Eighty-two percent of DH patients, 80% of DD, 56% of LS, and 59% of LRS patients had both positive discographic pain provocation and moderate or severe disc deterioration. The study indicates that intradiscal pathology plays a major role in nonspecific low-back pain syndromes.     

Pain provocation and disc deterioration by age. A CT/discography study in a low-back pain population

The computed tomography (CT)/discograms and discographic pain provocation reports of 291 clinical patients, 790 discs (mean age, 38; range, 17-79) were collected. The CT/discograms were classified separating anular disruption and degeneration and recording the pain provoked during discography as no pain, dissimilar, similar, or exact reproduction of the patient's clinical pain. Nondegenerated discs usually were found to be painless, and deteriorated discs painful. The proportion of severely degenerated but painless discs increased with age, as did the discs producing dissimilar pain. This may help explain the poor correlation of low-back pain with radiographic degenerative changes reported in previous epidemiologic studies.     

椎间盘源性腰痛的分型

目的 介绍一种新的椎间盘源性腰痛的分型方法 ,以更好地指导临床诊断和治疗.方法通过回顾性分析386例慢性腰痛患者的椎间盘造影术中X线荧光影像和术后CT扫描片,结合术中患者有无一致性疼痛复制反应,将椎间盘源性腰痛进行分型.结果386例腰痛患者共行1056个椎间盘的腰椎间盘造影术,共有192例患者(49.7%)的226个椎间盘(21.4%)出现疼痛复制反应.192例出现疼痛复制反应的患者中,由于纤维环破裂(internal disc disruption,IDD)160例,由于终板破裂(internal end-plate disruption,IED)32例,分别占83.3%和16.7%.应用修正的Dallas CT椎间盘造影分级方法评估IDD患者纤维环放射状撕裂程度,应用术中荧光X线影像结合术后CT扫描评估IED患者终板放射状破裂程度.IDD患者纤维环破裂分级越高,椎间盘造影时一致性疼痛比例越大(r=-0.604,P=0.000).IED患者终板破裂程度越大,椎间盘造影时一致性疼痛比例越大(r=0.683,P=0.000).结论 根据临床研究结果,我们将椎间盘源性腰痛分为两种类型,由IDD引起的腰痛和由IED引起的腰痛.临床上这两种类型的椎间盘源性腰痛都要通过腰椎间盘造影术确诊,诊断过程、放射状撕裂方式和疼痛反应方式完全一致,表明其为一种科学、合理的分型方法.     

Clinical relevance of discography combined with CT scanning. A study of 100 patients

Two different classifications of discograms have been used in a prospective study of 279 injected discs in 100 patients. The five-stage classification of Adams, Dolan and Hutton (1986) showed increased degeneration in the lower lumbar discs and more degenerative changes in men than in women. Exact reproduction of the patient's pain on injection was more common in fissured or ruptured discs than in less degenerate discs, with 81% sensitivity and 64% specificity of the discogram for pain. The additional information obtained by comparing computerised tomography (CT) with discograms was minimal. Discography was found to be useful in the evaluation of chronic low back pain in patients whose ordinary CT scans, myelograms and flexion-extension radiographs were normal. In spondylolysis and spondylolisthesis, discography can disclose whether fusion needs to be extended above the lytic level, and it may show if the pain in patients who have had posterolateral fusion is discogenic. Thus, discography gives information which is useful in deciding whether to operate on patients with chronic low back pain.     

腰椎间盘造影一致性疼痛反应和纤维环破裂程度的相关性研究

目的: 研究椎间盘源性下腰痛病人纤维环破裂程度和腰椎间盘造影一致性疼痛之间的关系。方法: 105例慢性下腰痛且无椎间盘突出的病人, 行腰椎间盘造影术。询问造影时病人疼痛反应, 分析造影后的X线片和造影后的CT片, 比较纤维环破裂程度与腰椎间盘造影一致性疼痛之间的相关性。结果: 105例病人中的 285个造影的腰椎间盘中, 67个腰椎间盘诱发一致性疼痛反应, 且全部呈现 2级以上的纤维环破裂。纤维环破裂分级越高, 椎间盘造影时一致性疼痛比例越大, 两者之间有显著的正相关性。结论: 椎间盘造影诱发的一致性疼痛反应比例和纤维环外层破裂程度呈正相关, 研究结果表明纤维环外层撕裂是疼痛复制的起源部位。     

An analysis of radiating pain at lumbar discography

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. Received: 29 November 1997 Revised: 20 March 1998 Accepted: 6 April 1998     

CT引导下腰椎间盘造影的临床应用

目的探讨CT引导下椎间盘造影的临床应用价值。方法回顾性分析55例慢性腰痛或腰腿痛患者的CT引导下椎间盘造影表现及临床资料,依据对比剂在椎间盘内、外的弥散范围,对椎间盘破裂、椎间盘退行性变及椎间盘退行性变合并椎间盘破裂进行分级。结果 55例中,2例穿刺失败,53例造影成功。造影椎间盘132个;根据达拉斯CT椎间盘造影评价法,51个椎间盘形态正常,81个椎间盘形态异常。阳性椎间盘73个,其中椎间盘纤维环撕裂30个,包括Ⅰ级3个、Ⅱ级15个、Ⅲ级12个,椎间盘纤维环退行性变24个,包括Ⅰ级2个、Ⅱ级12个、Ⅲ级10个,椎间盘退行性变并合椎间盘破裂19个。CT引导下椎间盘造影同时可激发再现原有腰痛或腰腿痛,证实腰痛或腰腿痛的病因。结论依据CT引导下椎间盘造影表现可准确对椎间盘退行性变和破裂程度及椎间盘退行性变合并破裂进行分级,有助于临床诊断和治疗。     

Anterior and combined anteroposterior fusion for lumbar disc pain. A preliminary study.

This article reports on a study of 51 consecutive patients (83 lumbar discs) with back pain who underwent anterior interbody lumbar fusion or combined anterior and posterior fusion at the same operation during a 2-year period. All patients met the criteria for diagnosis of a painful internal disc disruption and/or failed back syndrome and have had a lengthy trial of conservative treatment consisting of rest, physical therapy, back support, nonsteroidal anti-inflammatory drug therapy, and guarded activity; this treatment was often supplemented by epidural cortisone injections, pain management, and functional rehabilitation. Patients with prolonged back pain who failed with conservative care after a minimum of 12 months of severely disabling symptoms were selected for surgery on the basis of a positive dynamic discogram reproducing their exact pain and demonstrating a morphologically degenerative disc (internal disc disruption). For the purpose of this study, patients were categorized into three groups and followed up for 15-36 months after the operation. There were no deaths or major complications, and the overall success in achieving measurable diminution of preoperative pain was 80%. This article discusses preliminary conclusions on the efficacy and safety on anterior and anteroposterior fusion for lumbar disc pain.     

Cytokine evaluation in individuals with low back pain using discographic lavage

Background contextThe pathophysiology underlying degenerative disc disease and its implication in painful syndromes remain unclear. However, spine magnetic resonance imaging (MRI) can demonstrate changes in disc water content and the annulus; provocative discography purportedly identifies degenerate discs causing serious low back pain; and biochemical assays have identified local inflammatory markers. No study to date has correlated pain on disc injection during discography evaluation with relevant MRI findings and biochemical markers.PurposeThe purpose of this study was to correlate concordant pain on during discography to biochemical markers obtained by disc lavage and MRI findings.Study designThis is a Phase 1 Diagnostic Test Assessment Cohort Study (Sackett and Haynes).Patient sampleThe patient sample included 21 symptomatic patients with suspected discogenic pain and three Phase 1 control subjects.Outcome measuresThe outcome measures included discography pain scores, MRI degenerative grades, and immunoreactivity to various inflammatory cytokine concentrations present in disc lavage samples.MethodsTwenty-one symptomatic patients with lumbar degenerative disc disease and three control subjects underwent discography, MRI, and biochemical analysis of disc lavage fluid. Lumbar MRI was scored for Pfirrmann grading of the lumbar discs, and annular disruption was identified by nuclear disc lavage. Disc lavage samples were analyzed for biochemical markers by high-sensitivity immunoassay.ResultsEighty-three discs from 24 patients were studied: 67 discs from 21 patients with axial back pain (suspected discogenic pain group) and 16 discs from 3 scoliosis patients without back pain (Phase 1 control subjects). Among the biochemical markers surveyed, interferon gamma (IFN-γ) immunoreactivity was most consistently identified in patients with axial back pain. Discs with annular disruption and concordant pain reproduction at a visual analog scale of 7 to 10/10 had greater IFN-γ immunoreactivity than those without this finding (p=.003); however, at least some IFN-γ immunoreactivity was found in all but one disc in the symptomatic group.ConclusionsAmong the potential inflammatory markers tested in this Phase 1 study, IFN-γ immunoreactivity was most commonly elevated in discogram “positive” discs but absent in asymptomatic controls. However, this marker was also frequently elevated in degenerative but “negative” discography discs. From these findings, Phase 2 and Phase 3 validity studies are reasonable to pursue. Phase 4 utility studies may be performed concurrently to assess this method's predictive value in outcome studies.     

The stress lumbar discogram

Stress discography is that done during the time in which the subject's pain is present at a significant level of intensity. This prospective study examines the findings in 200 patients who were evaluated for low-back pain. A standardized injection technique was used and the contrast pattern within the disc was studied radiographically and with CT scanning. Pain response was recorded. Familiar low-back pain was reproduced in all cases, and familiar leg pain in 46% of cases. Of 549 discs studied, 319 reproduced familiar pain, an average of 1.6 discs per patient. Pain reproduction occurred in 69% of the L5 discs, 62% of the L4 discs, and 25% of the L3 discs. Internal disc disruption was present in 302 discs, but extruded annular material was found in only 19. Stress discography is a useful diagnostic study in evaluating patients with low-back pain.     

False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection

STUDY DESIGN: Experimental disc injections in subjects with no history of low back symptoms. OBJECTIVE: To determine in an experimental model the reliability of patients' subjective interpretation of pain concordancy during provocative disc injection. BACKGROUND: Discography in the evaluation of low back pain relies on a patient's subjective assessment of pain magnitude and quality during disc injection. Reproduction of significant pain on disc injection, which is similar to patients' usual pain, is believed to prove that the disc injected is the source of the patient's low back pain. In the current study, this hypothesis was tested in a controlled setting on patients with known nonspinal pain in a common referral area of discogenic pain. METHODS: Patients with no history of low back pain were recruited to participate in a study of discography. Patients scheduled to undergo posterior iliac crest bone graft harvesting for nonthoracolumbar procedures were evaluated with lumbar radiography, magnetic resonance imaging, and psychometric testing. Two to 4 months after bone graft harvesting, patients underwent lumbar discography by strict blinded protocol. Patients were asked to compare the sensations elicited at discography to their usual back/buttock pain since bone graft harvesting. Pain was rated as 0-5 on a pain thermometer and concordancy was rated as none, dissimilar, similar, or exact. RESULTS: Eight subjects completed the study, and 24 discs were injected. Of the 14 disc injections causing some pain response, 5 were believed to be "different" (nonconcordant) pains (35.7%); 7 were "similar" (50.0%), and 2 were "exact" pain reproductions (14.3%). The presence of anular disruption predicted concordant pain reproduction (P < 0.05). Of 10 discs with anular tears, injection of 5 elicited pain that was similar to or an exact reproduction of pain at the iliac crest bone graft harvest sites. By the usual criteria for positive discography, 4 of the 8 patients (50%) would have been classified as positive. In these patients, the pain on a single disc injection was very painful, and the pain quality was noted to be exact or similar to the usual discomfort. All subjects had a negative control disc. CONCLUSIONS: The findings of this study demonstrate that patients with no history of low back pain who had undergone posterior iliac bone graft harvesting for nonlumbar procedures often experienced a concordant painful sensation on lumbar discography with their usual gluteal area pain. Thus, the ability of a patient to separate spinal from nonspinal sources of pain on discography is questioned, and a response of concordant pain on discography may be less meaningful than often assumed.     

腰椎间盘MRI高信号区在诊断椎间盘源性下腰痛中的意义

目的:探讨腰椎间盘MRI高信号区(HIZ)在诊断椎间盘源性下腰痛中的作用。方法:对52例经保守治疗无效、CT影像上无腰椎间盘突出的下腰痛患者行腰椎MRI检查和腰椎间盘造影术,分析腰椎间盘MRI高信号区与腰椎间盘造影诱发的下腰痛之间的关系。结果:在行腰椎间盘造影的142个椎间盘中,共有38个椎间盘呈现疼痛复制反应,其中17个椎间盘显示高信号区。这17个有高信号区的椎间盘在椎间盘造影过程中全部呈现2～3级的纤维环破裂和疼痛复制反应。结论:无椎间盘突出的下腰痛患者在腰椎MRI上存在椎间盘内高信号区,可表明该椎间盘是产生腰痛的破裂椎间盘。     

Comparison between pain at discography and morphological disc changes at axial loaded MRI in patients with low back pain

Purpose

Discogenic pain is induced by axial load, but there are no studies evaluating the influence of dynamic MRI in relation to provoked pain at discography. The aim of this study was to investigate the relationship between discography-induced pain and morphological disc changes, occurring during axial loaded MRI (alMRI). A secondary aim was to compare and register the frequency of provoked concordant pain at alMRI and discography.

Methods

41 patients with assumed discogenic pain were investigated with MRI, alMRI and pressure-controlled discography (PCD) (119 discs). Provoked pain at both discography and alMRI was classified as concordant or discordant with daily pain as reference. A concordant discogram required pain intensity ≥5/10 (numerical rating scale) at ≤50 psi and one negative control disc. A concordant provocation at alMRI required pain intensity ≥5/10. The relationship between concordant pain at discography and morphological disc measures (degeneration, height, bulge, angle, area, and circumference) at MRI/alMRI was investigated.

Results

Changes in the morphological appearance occurred in at least one disc level in all patients when loaded and unloaded MRI were compared. However, no significant differences between concordant and discordant discograms in terms of morphological disc features at conventional MRI or alMRI were found. 78 % of the patients reported concordant provoked pain during the alMRI.

Conclusions

In the majority of patients with low back pain, discography as well as alMRI provoked concordant pain. Loading of the spine, alMRI, revealed however no clinically useful morphological characteristics in the discs with concordant discograms. Alternative or more sensitive diagnostic methods are needed to understand load-induced discogenic pain.     

What is intervertebral disc degeneration, and what causes it?

STUDY DESIGN: Review and reinterpretation of existing literature. OBJECTIVE: To suggest how intervertebral disc degeneration might be distinguished from the physiologic processes of growth, aging, healing, and adaptive remodeling. SUMMARY OF BACKGROUND DATA: The research literature concerning disc degeneration is particularly diverse, and there are no accepted definitions to guide biomedical research, or medicolegal practice. DEFINITIONS: The process of disc degeneration is an aberrant, cell-mediated response to progressive structural failure. A degenerate disc is one with structural failure combined with accelerated or advanced signs of aging. Early degenerative changes should refer to accelerated age-related changes in a structurally intact disc. Degenerative disc disease should be applied to a degenerate disc that is also painful. JUSTIFICATION: Structural defects such as endplate fracture, radial fissures, and herniation are easily detected, unambiguous markers of impaired disc function. They are not inevitable with age and are more closely related to pain than any other feature of aging discs. Structural failure is irreversible because adult discs have limited healing potential. It also progresses by physical and biologic mechanisms, and, therefore, is a suitable marker for a degenerative process. Biologic progression occurs because structural failure uncouples the local mechanical environment of disc cells from the overall loading of the disc, so that disc cell responses can be inappropriate or "aberrant." Animal models confirm that cell-mediated changes always follow structural failure caused by trauma. This definition of disc degeneration simplifies the issue of causality: excessive mechanical loading disrupts a disc's structure and precipitates a cascade of cell-mediated responses, leading to further disruption. Underlying causes of disc degeneration include genetic inheritance, age, inadequate metabolite transport, and loading history, all of which can weaken discs to such an extent that structural failure occurs during the activities of daily living. The other closely related definitions help to distinguish between degenerate and injured discs, and between discs that are and are not painful.     

Provocative discography in volunteer subjects with mild persistent low back pain.

BACKGROUND CONTEXT: Whether discographic injections would be positive in subjects with benign persistent "backache" who are not seeking treatment is unknown. This information is important, because benign backache undoubtedly co-exists in patients with chronic low back pain (CLBP) illness that is not discogenicin origin. If these subjects had a high rate of positive discography, the high background incidence of common backache would allow many positive tests in patients in whom discogenic processes were unrelated to their severe CLBP illness. Conversely, if subjects with benign low back pain rarely if ever had significant concordant pain reproduction on disc injections, the basic tenet of discographic diagnosis would be strengthened. PURPOSE: To compare, using a strict experimental design, the relative pain and concordancy response to provocative discography in subjects with clinically insignificant "backache" and clinical subjects with CLBP illness considering surgical treatment. STUDY DESIGN: Comparison of experimental disc injections in subjects with persistent mild backache and those with chronic low back pain (CLBP) illness. PATIENT SAMPLE: Twenty-five subjects with mild persistent low back pain (LBP) were recruited for an experimental discography study. Subjects were recruited from a clinical study of patients having had cervical spine surgery. Inclusion criteria required that subjects not be receiving or seeking medical treatment for LBP, be taking no medications for backache, have no activity restrictions because of LBP, and have normal psychometric scores. To more closely approximate the pain behavior in CLBP illness, 50% (12) of the "backache" group were recruited with a chronic painful condition (neck/shoulder) unrelated to the low back. CLBP subjects, patients coming to discography for consideration of surgical treatment, were used as control subjects. OUTCOME MEASURES: Results of discography were determined using the criteria of Walsh et al.: pain response of 3 or greater, two or more pain behaviors, a negative "control" discographic injection, and a similar or exact concordancy rating. METHODS: Discography was performed on experimental subjects and control patients. Experienced raters, who were blinded to control versus experimental status of the subjects, scored the magnetic resonance image, discogram, psychometric tests and discography videotapes of the subjects' pain behavior. RESULTS: Thirteen of 25 volunteer subjects had pain rated as "bad" or worse with disc injection. There were 12 painful and fully concordant disc injections in 9 of these 25 "backache" subjects (36%). These injections met all the Walsh et al. criteria for a positive diagnosis of discogenic pain. All positive discs had annular disruption to or through the outer annulus. Of the 9 subjects with positive discograms, 3 had no chronic pain states and 6 did. All subjects with positive injections had negative control discs. In comparison, in 52 subjects with CLBP illness 38 (73%) had at least one positive disc injection. CONCLUSIONS: In a group of volunteer subjects with persistent "backache," 36% were found to have significant pain on disc injection, which is reported to be concordant with their usual pain. The presence of positive concordant pain responses and negative control discs in 33% of subjects without CLBP illness seriously challenges the specificity of provocative discography in identifying a clinically relevant spinal pathology.     

Disc degeneration and angular movement of the lumbar spine: comparative study using plain and flexion-extension radiography and discography.

A study was made of the association between disc degeneration observed in plain radiographs, in discograms (Adams' classification), and instability expressed as abnormal angular movement of lumbar vertebrae. The series included 169 discs in 77 consecutive patients (42 men, 35 women) whose mean age was 34 (range 16-46) years. Discography was more sensitive than plain radiography in the diagnosis of disc degeneration was more common in men than in women (Chi square test, chi 2 = 9.88, p less than 0.05). An increase in disc degeneration was observed in lower lumbar segments (Chi square test, chi 2 = 48.63 p less than 0.001). However, no association between abnormal angular movement and discogram type was observed (Chi square test, chi 2 = 2.63, p less than 0.05). It seems that disc degeneration seldom results in abnormal angular movement and instability of the lumbar spine. Therefore, flexion-extension radiography may only have limited diagnostic value.