Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation

STUDY DESIGN: The correlation between discogenic lumbar pain and disc morphology was investigated by using magnetic resonance imaging and discography. OBJECTIVES: To assess the various pathologic parameters seen on magnetic resonance imaging in patients with discogenic lumbar pain and to correlate them with observations on discography. SUMMARY OF BACKGROUND DATA: Although numerous previous studies on the subject have been performed, the correlations between various pathologic findings on magnetic resonance imaging and pain reproduction by provoked discography have not been explained fully. METHODS: One hundred and one lumbar discs in 39 patients were studied with magnetic resonance imaging and pain provocation discography. When pain reproduction under discography was concordant, various pathologic parameters on magnetic resonance imaging were analyzed by three statistical parameters to determine the associated magnetic resonance imaging findings. RESULTS: Radial tears commonly are demonstrated on magnetic resonance imaging in discs with concordant pain on discography. The presence of these tears is not a reliable predictor of a painful disc on discography. Although a high-intensity zone on T2-weighted images is a relatively reliable predictor of pain, the statistical values were lower than those in previous studies. Massive degeneration and severe disc height loss were rare in this population. These findings were good predictors of pain on disc injection. CONCLUSIONS: Although the lumbar intervertebral discs with posterior combined anular tears are likely to produce pain, the validity of these signs for predicting discogenic lumbar pain is limited.     

Consistency of lumbar discograms of the same disc obtained twice at a 2-week interval: influence of needle tip position

: Although numerous papers have emphasized the importance of accurate needle positioning in lumbar discography, no concrete evidence is available to support this contention, and no study has evaluated the image consistency of discography as influenced by this factor. By observing the consistency of two images in relation to needle tip position we aimed to clarify the importance of needle positioning in discography. One hundred and ninety-two patients (324 discs) receiving steroid intradiscal therapy in whom discography of the same disc was performed twice at a 2-week interval and in whom the needle tip position was within the acceptable range (as defined by us) were studied. The patients were divided into two groups: in group G, in whom the needle tip was within a limited range on both discograms, and group P, in whom the needle tip was in this range on only one discogram. Image consistency was compared roentgenographically in the two groups. The consistent image rate for the total number of discs was 48.5%, being significantly higher in group G (53.2%) than in group P (39.0%). The rates were lower in the nucleus pulposus and the posterior portion of the disc than in the other disc areas, but were significantly higher in group G (85. 4% and 75.0%, respectively, for these two areas). The necessity for accurate needle tip positioning was proved roentgenographically.     

Late results of cervical disc surgery

Late results of cervical disc surgery have been reported and statistically studied in 383 cases: 83% were lateral discs, 13% were central spondylosis discs, and 4% central soft discs. Central spondylosis occured at a higher spinal level, and caused cord compression with or without weakness of the hands, but no pain. A posterior approach was used in all lateral discs, and either an anterior or a posterior approach, with or without fusion, for central discs. Preoperative myelography was always done and is recommended postoperatively in central disc surgery to evaluate the results. Our results were good to excellent in 95% of lateral discs, in 64% of central spondylosis discs, and in an unexpected 91% of 11 cases of central soft discs. There were no recurrences and no serious complications, although 20% developed other cervical or lumbar disc herniations.     

Disc degeneration/back pain and calcification of the abdominal aorta. A 25-year follow-up study in Framingham

STUDY DESIGN: A 25-year follow-up study of 606 members of the population-based Framingham cohort, who had received lateral lumbar radiographs in 1967-1968 and 1992-1993, and completed an interview on back symptoms at the second examination. OBJECTIVES: To evaluate whether calcific lesions in the posterior wall of the abdominal aorta, the source of the feeding arteries of the lumbar spine, are associated with disc degeneration or back pain, which would suggest that ischemia of the lumbar spine leads to disc degeneration. METHODS: The presence of radiographic aortic calcification was ascertained in front of each lumbar segment from L1 through L4, and disc degeneration at intervertebral spaces from L1-L2 through L4-L5. The associations between aortic calcification, disc degeneration, and back pain were tested using logistic regression with adjustment for age and sex. RESULTS: At the baseline examination, aortic calcification was significantly associated with general disc degeneration, that is, disc space narrowing or endplate sclerosis at any lumbar level (odds ratio 1.6; 95% confidence interval 1.0-2.5; P = 0.034). In longitudinal, level-specific analyses, comparing local aortic calcifications with disc degeneration at the matching level, aortic calcifications predicted disc deterioration, that is, a decrease in disc space or appearance of endplate sclerosis, between the examinations (odds ratio 1.5; 95% confidence interval 1.3-1.8; P < 0.001). Furthermore, subjects in whom aortic calcifications developed between the examinations had disc deterioration twice as frequently as those in whom aortic calcifications did not develop (odds ratio 2.0; 96% confidence interval 1.2-3.5; P = 0.013). Also, individuals with severe (Grade 3) posterior aortic calcification in front of any lumbar segment were more likely than others to report back pain during adult life (odds ratio 1.6; 95% confidence interval 1.1-2.2; P = 0.014). CONCLUSIONS: Advanced aortic atherosclerosis, presenting as calcific deposits in the posterior wall of the aorta, increases a person's risk for development of disc degeneration and is associated with the occurrence of back pain.     

Posterior lumbar epidural fat as a functional structure? Histologic specificities

STUDY DESIGN: A topographic and histologic study was done to describe the location of the lumbar epidural fat and to find potential tissular specificities. OBJECTIVES: To search for possible histologic characteristics of posterior lumbar epidural fat, which so far has been described as semifluid tissue, and to determine whether posterior lumbar epidural fat is not a simple incidental tissue. SUMMARY OF BACKGROUND DATA: The lumbar epidural fat on two fetuses was studied. In adults, subcutaneous fat and posterior lumbar epidural fat were taken from seven corpses. The authors obtained 13 posterior lumbar epidural fat pads (two at L1-L2, three at L2-L3, six at L3-L4, and two at L4-L5) and four subcutaneous fat pads. METHODS: The authors studied abdominal axial histologic sections in two fetuses, histologic multiplanar sections in seven adults, and semithin sections in four adults of posterior lumbar epidural fat and subcutaneous fat. RESULTS: Fetal distribution of epidural fat was circumferential. Adult epidural fat distribution was limited to the posterior part of the vertebral canal and located at the disc level. Fascicles of connective tissue were less numerous and thinner in posterior lumbar epidural fat than in subcutaneous fat. Organized sliding spaces were found in the posterior epidural fat ped. CONCLUSIONS: Posterior lumbar epidural fat is not a simple incidental tissue and shows specific histologic features: sliding spaces and rarefaction of connective tissue that could explain semifluid features of the tissue. These characteristics suggest a functional role of posterior epidural fat in the lumbar spinal unit.     

Intradural lumbar disc herniations: report of three cases

Intradural lumbar disc herniation is a rare pathological entity. Three new cases among a series of 5000 lumbar spine operations are added to the about 60 previous case reports in the literature. None of our patients had undergone lumbar spine surgery before. In one patient the location of the free disc fragment was medial within the dural sac; in two patients the free disc fragment had penetrated the dural sac from the axilla of the nerve root. Pathogenesis is discussed (congenital adhesions of the dura mater to the posterior longitudinal ligament at the lower lumbar spine; weakness of the dura mater ventrally and at the axilla of the nerve root). By multiplanar MRI, the free disc hernia within the dural sac may be shown preoperatively.     

A new approach in the treatment of hypotension in human septic shock by NG-monomethyl-L-arginine, an inhibitor of the nitric oxide synthetase

Between 1987 and 1991, 33 patients with spinal stenosis of the lumbar spine were treated by decompression (33 patients) and posterior fusion (30 patients). Indication for decompression was based on case history and lumbar myelography with flexion/extension views. At follow-up 1-5.5 years later, 28 patients were happy with the results of the treatment and would be willing to be operated on again in a similar situation. Two other patients also presented objectively good results, but were dissatisfied for reasons not related to the operation. Our study shows that myelography and case history are adequate investigations for determination of the level of pathology and for making a decision about operative decompression in spinal stenosis of the lumbar spine. CT or MRI are only needed if the symptoms of the patient are not explained by the myelogram. Although MRI is advocated as the investigation of first choice for lumbar spinal stenosis, we still prefer the myelography, which is easier to interpret during the operation. Our study also shows that operative treatment of spinal stenosis is very rewarding, since 9 out of 10 patients will have good results. We usually combine decompression and fusion. Decompression alone is only performed in patients without any back pain and with stable motion segments after adequate decompression.     

Technique and value of discography for the cervical syndrome (author's transl)

Discography produces relatively many false pasitive findings. Their number, about 28% in our material, may be reduced decisively to below 10% when clinical, electro-physiologic and myelographic findings are considered together. It can be further reduced when results are judged in groups of varying value. Findings of high value are: 1) entry of the contrast fluid from the disc behind the posterior longitudinal ligament. 2) Exact reproduction of spontaneous pain during injection 3) The extension of a contrast band along the roots on the side and level of clinical findings. With such strict evaluation discographic findings are correct in 88%. In additon discography may be in certain cases the only method to elucidate a syndrome which clinically and in the myelogram permits various interpretations. Discography should always preceded operation. On the basis of 368 discographies with control of the diagnosis at operation its value is explained.     

Study on the etiology of cholesterin granuloma of the middle ear (author''s transl)

The radiological features of 20 surgically proven thoracic disc protrusions are reviewed. In 15 (75%), characteristic plain film changes were found to be very helpful in making the correct diagnosis. Calcified disc material in the spinal canal was clearly demonstrated in 11 (55%) cases, and this, in association with linear calcification in the adjacent disc space, has been shown to be diagnostic of the condition. At myelography, central protrusions (55%) were found to be predominant, while lateral protrusions were uncommon. The differential diagnosis of a calcified lesion in the spinal canal includes thoracic disc protrusion, osteochondroma and meningioma.     

Spinal imaging and intervention: 1998

Imaging of the lumbar spine is the most common application of magnetic resonance (MR) imaging in many radiologic practices. MR imaging has replaced computed tomography (CT) and CT myelography as the primary mode of spinal imaging and has relegated myelography to a secondary role in the evaluation of lumbar spinal disorders. At the same time, however, it has become evident that the correlation between gross anatomic findings as depicted on MR images and the clinical signs and symptoms detected by the clinician may be lacking. Defining the precise anatomic source of patients' complaints on the basis of imaging studies must be approached judiciously because a significant proportion of the population has disc disease as depicted on imaging studies, yet many have no clinical findings.     

Intraradicular and intradural lumbar disc herniation: experiences with nine cases

BACKGROUND: Intraradicular or intradural disc herniation is a very rare complication of spinal degenerative processes. The aim of our study is to analyze the clinical spectrum, the mechanism, and the treatment of this acute spinal pathology. METHODS: Retrospective clinical examination was performed in nine personal cases of intradural disc herniation: among these, six were associated with lateral perforation, the remaining three with intradural herniation and ventral perforation. A review of the literature concerning mainly the frequency pathogenesis and diagnosis of intradural disc herniation has also been done. RESULTS: Nine cases of intradural herniations comprise 1.51% of the 593 cases of ruptured lumbar disc that underwent surgery from 1980 to 1992. The site most frequently involved is at level L4-L5, and 30% of patients have previously undergone surgery for lumbar disc herniation. Most patients reported in literature and in our present series have been complaining of a chronic history of sciatica, complicated later by bilateral neurologic signs. In the present series, diagnosis was obtained by means of myelography and computerized tomography; magnetic resonance imaging was performed in one case. All patients underwent surgery, reporting excellent results in five cases and good results in the other four. Surgery was performed either with an interlaminar approach or with a bilateral laminectomy in cases of ventral perforation. CONCLUSIONS: There is no typical neuroradiologic picture of intraradicular herniation, while a total or subtotal block is frequently observed in intradural ventral perforations. Dural perforation is often an unexpected intraoperative finding. Surgical treatment is always necessary. Favorable results are obtained if surgical treatment is carried out before the neurologic deficit becomes too pronounced.     

Lumbar intervertebral disc herniation in children less than 16 years of age. Long-term follow-up study of surgically managed cases

STUDY DESIGN: In this retrospective study, the long-term clinical results of lumbar intervertebral disc herniation in children less than 16 years of age were reviewed. OBJECTIVES: To evaluate the effectiveness of surgical treatment including posterior discectomy, extraperitoneal anterolateral discectomy, and anterior interbody fusion for lumbar intervertebral disc herniation in children less than 16 years of age. SUMMARY OF BACKGROUND DATA: Although previous follow-up studies on surgically managed lumbar intervertebral disc herniation in children and adolescents generally reveal good outcomes, few reports have focused on the time course of clinical findings and the long-term results. METHODS: The outcome of subjective symptoms, clinical signs, and time-related change of the intervertebral disc space in 11 patients were evaluated with an average follow-up period of 9 years (range, 5-12 years). RESULTS: The posterior discectomy procedure relieved clinical symptoms quickly. In the case of central herniation with or without intervertebral instability, extraperitoneal anterolateral discectomy or anterior interbody fusion led to favorable long-term results. Clinical symptoms (lower back pain, leg pain) and neurologic disturbance disappeared within 3 months after surgery. Recovery of normal straight leg raising test results (tight hamstrings), however, required much more time than recovery of other symptoms. Narrowing of the intervertebral disc space progressed up to 3-6 months after discectomy, but then disc space widening occurred. CONCLUSIONS: Satisfactory long-term clinical results and early return to school life were obtained with each surgical procedure. It is important to aim toward an early return to school via surgical treatment.     

Macrophage tissue infiltration, clinical symptoms, and signs in patients with lumbar disc herniation. A clinicopathological study on 179 patients

It is postulated that in addition to nerve-root compression, an inflammatory stimulus of the herniated lumbar disc is responsible for sciatic pain and radiculopathy. The clinical relevance of the histologically described inflammatory infiltrates is, however, not clearly defined [8, 22]. It was the aim of this study to assess the clinical relevance of inflammatory cells in herniated lumbar disc specimens. The presence of inflammatory cells was examined immunohistochemically in routinely processed resection specimens of the lumbar disc. The histological results were compared to prospectively obtained clinical data. Disc specimens of 179 patients who underwent surgery for lumbar disc herniation were studied immunohistologically. Preoperatively each patient received a visual analogue scale for classification of the pain level and general clinical data were recorded prospectively. Varying amounts of inflammatory cells could be demonstrated in the resected disc tissue. In the statistical workup no statistically significant correlation between the histological evidence of macrophage infiltrates and the pain grading scale or the clinical data could be found. In our study there is no statistically significant correlation between macrophage infiltrates in herniated lumbar disc specimen and the obtained clinical data.     

Groin pain associated with lower lumbar disc herniation

STUDY DESIGN: Retrospective clinical and magnetic resonance imaging study of patients with groin pain associated with lower lumbar disc herniation. OBJECTIVES: To demonstrate the clinical features and magnetic resonance imaging findings of these patients. SUMMARY OF BACKGROUND DATA: Patients with lumbar disc herniation sometimes report groin pain. Little mention has been made, however, regarding the clinical features of groin pain stemmed from lower lumbar disc herniation until now, with only Murphey referring to groin pain in disc disease. METHODS: A total of 512 patients were diagnosed with singular lower lumbar disc herniation (L4-L5 and L5-S1) at Kakegawa City General Hospital between July 1990 and December 1993. Of these patients, 21 (4.1%) reported groin pain. The characteristic clinical features and magnetic resonance imaging findings of the 21 patients were investigated and compared with the features and findings of patients with no groin pain. RESULTS: Patients with groin pain had a higher mean age and lower rate of low back pain, and L4-L5 discs were more likely to be involved than L5-S1 discs. In their magnetic resonance images, herniation tended to be more central than in patients with no groin pain. CONCLUSIONS: Elderly patients with L4-L5 protruding herniation of the anulus fibrosus were most likely to experience groin pain. The sinuvertebral nerve that innervates the posterior anulus fibrosus, the posterior longitudinal ligament, and the dura was indicated as the afferent nerve of groin pain.     

Long-term administration of large doses of oral morphine for chronic pain

We here report a patient with chronic pain who was treated with large doses of oral morphine. A 37-year-old female was diagnosed as Lyme disease and lumbar disc hernia. When she received lumbar puncture for myelography, she fainted due to severe pain in the legs. After this incident, her pain increased markedly, and she visited our outpatient clinic in 1996. After confirming the temporary pain relieving effect of caudal block, we prescribed oral morphine tablets 60 mg daily. The dose of morphine necessary to relieve her pain increased gradually to 220 mg. But she did not develop dependence or side effects. However, when the daily dose of 300 mg was administered, she felt dizzy. We therefore performed lumbar sympathetic block with phenol. After the block, her conditions improved markedly at a dosage of 300 mg. In conclusion, our experience in this case has shown the effectiveness of long-term morphine use with non-cancer patients and the efficacy of nerve block to avoid increasing the morphine dosage.     

Dynamic effects on the lumbar spinal canal: axially loaded CT-myelography and MRI in patients with sciatica and/or neurogenic claudication

STUDY DESIGN: In patients with sciatica or neurogenic claudication, the structures in and adjacent to the lumbar spinal canal were observed by computed tomographic myelography or magnetic resonance imaging in psoas-relaxed position and during axial compression in slight extension of the lumbar spine. OBJECTIVES: To determine the mechanical effects on the lumbar spinal canal in a simulated upright position. SUMMARY OF BACKGROUND DATA: For years, functional myelographic investigation techniques were shown to be of value in the evaluation of suspected encroachment of the spinal canal. Since the advent of computed tomography and magnetic resonance imaging, there have been few clinical and experimental attempts that have imitated these techniques. The data indicate that the space within the canal is posture dependent. METHODS: Portable devices for axial loading of the lumbar spine in computed tomographic and magnetic resonance examinations were developed. Fifty patients (94 sites) were studied with computed tomographic myelography, and 34 patients (80 sites) with magnetic resonance in psoas-relaxed position followed by axial compression in slight extension. The dural sac cross-sectional area at L2 to S1, the deformation of the dural sac and the nerve roots, and the changes of the tissues surrounding the canal were observed. RESULTS: In 66 of the investigated 84 patients, there was a statistically significant reduction of the dural sac cross-sectional area in at least one site during axial compression in slight extension. Of the investigated patients, 29 passed the borderlines for relative (100 mm2) or absolute stenosis (75 mm2) in 40 sites. In 30 patients, there was deformation of the dural sac in 46 sites. In 11 of the patients investigated with magnetic resonance imaging, there was a narrowing of the lateral recess in 13 sites, during axial compression in slight extension. CONCLUSIONS: Axial loading of the lumbar spine in computed tomographic scanning and magnetic resonance imaging is recommended in patients with sciatica or neurogenic claudication when the dural sac cross-sectional area at any disc location is below 130 mm2 in conventional psoas-relaxed position and when there is a suspected narrowing of the dural sac or the nerve roots, especially in the ventrolateral part of the spinal canal in psoas-relaxed position. The diagnostic specificity of the spinal stenosis will increase considerably when the patient is subjected to an axial load.     

High- and low-bar squatting techniques during weight-training

STUDY DESIGN: Tissues in the area of herniated lumbar discs were examined for inflammatory cytokines to elucidate the causes of sciatic pain in lumbar disc herniation. OBJECTIVES: To determine the role of inflammatory cytokines in the stimulation of sciatic pain in lumbar disc herniation. SUMMARY OF BACKGROUND DATA: It is postulated that in addition to mechanical compression of lumbar nerve roots and sensory root ganglia by herniated discs, there is a chemical stimulus to the production of sciatic leg pain. The exact mechanisms of chemical stimulation are not clearly defined. METHODS: During surgery, cases of lumbar disc herniation in 77 patients were classified macroscopically into protrusion, extrusion, and sequestration types. Tissues adjacent to nerve roots at the herniation were excised and analyzed biochemically and immunohistochemically for the presence of inflammatory cytokines and for the production of these cytokines and prostaglandin E2 in vitro. RESULTS: The homogenates of samples were analyzed for interleukin-1 alpha, interleukin-1 beta, interleukin-6, tumor necrosis factor-alpha, and granulocyte-macrophage colony stimulating factor, which were detectable. Most of the cytokine-producing cells were histiocytes, fibroblasts, or endothelial cells in extrusion and sequestration types, and chondrocytes in protrusion type. The secretion of these cytokines and prostaglandin E2 was decreased by the addition of betamethasone. The prostaglandin E2 production was dramatically enhanced by additional interleukin-1 alpha, but decreased by the addition of tumor necrosis factor-alpha. CONCLUSION: The results demonstrate that at the site of lumbar disc herniation, inflammatory cytokines such as interleukin-1 alpha are produced, which increases prostaglandin E2 production. Further studies are required to elucidate the role of inflammatory cytokines in causing sciatic pain.     

The surgical treatment of low back pain

If nonoperative management fails to relieve a clearly identifiable and surgically treatable cause of lumbar pain, then surgery may be beneficial. Certain "red flags" indicate the need for urgent or emergent surgical intervention. Low back pain is associated with several degenerative conditions in the lumbar spine, including degenerative disc disease, spinal stenosis, spondylolisthesis, degenerative scoliosis, facet joint syndrome, and disc herniation.     

Acute spinal subdural hematoma following lumbar puncture

A case of acute spinal subdural hematoma following lumbar puncture in a patient with a normal coagulation profile is reported. Lumbar myelography may be unsuccessful. Other methods of myelography (via cisternal or lateral cervical puncture) to corroborate a block may be made or a laminectomy at the proper clinical level without further studies may be indicated.     

Thoracic discography. A safe and reliable technique

OBJECTIVES: To evaluate the safety and reliability of discography used to investigate thoracic disc degeneration observed on magnetic resonance (MR) imaging studies in patients with clinical pain, we analyzed retrospectively the results of thoracic discograms performed on 100 outpatients. METHODS: After MR imaging, clinically suspect, morphologically abnormal thoracic discs and at least one, nearby, control level were injected with either nonionic contrast or saline, filmed, and individually described by the patient as concordant versus nonconcordant relative to clinical pain and rated in intensity on a scale of 0-10. RESULTS: There were no serious complications in the series, and the authors resolved whether the injected discs related to pain in each case. They found discs with anular tears, intrinsic degeneration, and/or associated vertebral body endplate infractions to be painful approximately 75% of the time. Clinical concordance was approximately 50%. Control levels were usually painless. CONCLUSIONS: They conclude that thoracic discography can be performed safely by experienced individuals as a reliable tertiary diagnostic procedure to determine if degenerated discs on MR studies are related to clinical complaints.