Does discography damage the discs?

[mmglobal]

A few days ago Crystal posted an abstract by Dr. Carragee (below) about the risk of damaging the disc with discography. Thank you Crystal! This is a great subject that deserves its own thread. I'm sure this will be a great discussion.

The question, “does discography damage a healthy disc” is something that’s been discussed on the forums for years. The abstract that Crystal posted below really piqued my interest. I’ve discussed this extensively with dozens of leading surgeons and pain management doctors over the years. Many will say that poking a small gauged needle through the “radial ply” fibers of the annulus is much like poking a knitting needle through a knit wool sweater. That would do no discernible damage, whereas, poking a pin through a silk blouse will ruin it. Some doctors are discography naysayers. I think that's more about the results controversy than the damage to the disc. Early discography techniques that were fraught with errors. I think much of the bad rap is dogma associated with the old horror stories.

Discography done on a degenerated disc may be another story. Some of the doctors will still say it’s harmless, while others will concede that in a severely degenerated disc discography may push it over the edge. This would not necessarily be from the damage to the annulus. IMHO, this is more likely from an existing protrusion that would be exacerbated by pressurizing the disc, lubricating and increasing the nucleus volume. My second discography was only at L5-S1 to rule it out. We were hoping that I was a single level candidate. I could have been one of the first US Charite’ patients. About three weeks after the discography my left foot went numb. Until that point, I had no radiculopathy associated with my L5-S1 disc. While there was a substantial bulge, there was no frank protrusion at the time of the discography. Remarkably, an MRI a few weeks later showed a new, large (15mm) protrusion at L5-S1. While nobody could say what happened, I do believe that the discography substantially increased the risk of, or may have actually caused the protrusion.

For years, when my clients had asked me about doing discography that was recommended by their surgeons, I have usually suggested that they should only do the discography if they are prepared to follow through with treatment if the discography is positive. With their risk of discography making a very bad disc and worse I believe that it's a mistake to have discography unless you have been through the decision making process and field that your situation justifies having surgery if the discography is positive. There is no such thing as risk free access anywhere in the spine. Control levels have been thought of as important, but the idea of poking and needle into a healthy disc makes me wonder.

I believe that discography is still an important and useful tool that increases the probability of a correct diagnosis. However, it is not the be all, end all definitive test. It’s just another useful tool. Technique is important. A poorly done discography can cloud the situation. Under the best of circumstances, there may still be a risk of false positive or false negative results. If I need to rule levels in or out, all still have discography. This is a very interesting study. I look forward to seeing where this goes as the science improves.

Let the discussion begin!

Mark

Originally Posted by Crystal33

2009: Carragee Eugene J; Don Angus S; Hurwitz Eric L; Cuellar Jason M; Carrino John; Herzog Richard

2009 ISSLS Prize Winner: Does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study.
Spine 2009;34(21):2338-45.

STUDY DESIGN: Prospective, match-cohort study of disc degeneration progression over 10 years with and without baseline discography. Objectives. To compare progression of common degenerative findings between lumbar discs injected 10 years earlier with those same disc levels in matched subjects not exposed to discography. Summary of Background Data. Experimental disc puncture in animal and in vivo studies have demonstrated accelerated disc degeneration. Whether intradiscal diagnostic or treatment procedures used in clinical practice causes any damage to the punctured discs over time is currently unknown.

METHODS: Seventy-five subjects without serious low back pain illness underwent a protocol MRI and an L3/4, L4/5, and L5/S1 discography examination in 1997. A matched group was enrolled at the same time and underwent the same protocol MRI examination. Subjects were followed for 10 years. At 7 to 10 years after baseline assessment, eligible discography and controlled subjects underwent another protocol MRI examination. MRI graders, blind to group designation, scored both groups for qualitative findings (Pfirrmann grade, herniations, endplate changes, and high intensity zone). Loss of disc height and loss of disc signal were measured by quantitative methods.

RESULTS: Well matched cohorts, including 50 discography subjects and 52 control subjects, were contacted and met eligibility criteria for follow-up evaluation. In all graded or measured parameters, discs that had been exposed to puncture and injection had greater progression of degenerative findings compared to control (noninjected) discs: progression of disc degeneration, 54 discs (35%) in the discography group compared to 21 (14%) in the control group (P = 0.03); 55 new disc herniations in the discography group compared to 22 in the control group (P = 0.0003). New disc herniations were disproportionately found on the side of the anular puncture (P = 0.0006). The quantitative measures of disc height and disc signal also showed significantly greater loss of disc height (P = 0.05) and signal intensity (P = 0.001) in the discography disc compared to the control disc.

CONCLUSION: Modern discography techniques using small gauge needle and limited pressurization resulted in accelerated disc degeneration, disc herniation, loss of disc height and signal and the development of reactive endplate changes compared to match-controls. Careful consideration of risk and benefit should be used in recommending procedures involving disc injection.

[mmglobal]

The first surgeons' conference I attended was the annual meeting of The American Academy of Minimally Invasive Spinal Medicine and Surgery (AAMISMS) in 2002, hosted by Tony Yeung. I was taken by the deference that was paid Dr. Richard Derby. He was obviously a heavy hitter. It was a pleasure to meet him and to thank him for his work that had helped me so much. I don't know the true history of discography, but in my experience he is referred to as the father of modern discography. He's been a wonderful resource for me through the years. I've had many clients travel across the country to do diagnostics with him.

I'll be soliciting input from several doctors that I know who do discography ( I have a few clients who are pain management doctors!) My first contact about this subject was with Dr. Derby. He graciously sent me an article that he's written that is essentially a rebuttal to the Carragee study. This is hot off the presses. I don't believe it's been published yet.

I'll write more about both of these articles later, but I don't want to introduce their arguments before introducing their papers.

Here is Dr. Derby's article. I look forward to the discussion that follows!

Mark

[fuzzy]

I cancelled my disco with dr. Derby. His office communication was terrible. I had no way to discuss with him pre disco. Overall I was not impressed at all.

They do discos once a month with a 2 month wait.

Even though disco is to be seen as just another tool it is getting way overrated in my personal opinion. Controversy is deserved.

I had one, it made me feel terrible and did not contribute to my final outcome other then cost me money. I knew this before hand.

[mmglobal]

Fuzzy, thanks for posting. I'm suprised to hear that that was your experience. I've had > a dozen clients go to him and have not heard any negative feedback. It's funny how experiences can be so varied.

I've had 4 discographies myself and if I was considering lumbar surgery again, unless the case is very clear cut, I'd still do it. I've been in the procedure room for > 50 discographies now and have seen a wide variety of results. I have seen may cases where the disc that looked worst was not a pain generator at all, when a disc that didn't look nearly as bad and was going to be left out of the surgery was VERY CLEARLY the main pain generator. In cases like these, discography makes all the difference in the world. (See annC's story on the GPN story pages.) I have had many experiences like that.

Discography is a double subjective test. The outcome depends upon the doctor's subjective assessment of the patient's subjective assessment of their pain. Under the best of circumstances, the usefulness of the test will vary a great deal and there are many variables. Technique is VERY importatant. The patient's anatomy and pathology is very important. Appropriate anesthesia (or lack thereof) is very important. Also, most important is the communication between the doctor and patient. Several time's I've been present when the doctor asks the patient a question, then the patient answers a different question. Neither one knew that there was a disconnect. I've seen this happen many time and it's not necessarily a language problem.

More later,

Mark

[fuzzy]

Mark you are hitting the nail right on the head.

Doctor patient communication. !...could rule out unnecessary discography procedures.

This was my issue my dr. Derby but also other dr.s. A lot of mistakes can be made when you only spend 10 minutes with the patient after looking for 5 minutes at the file that stuck to outside of the door. Worse yet, having to deal with an assistant. Maybe if *you* are part of a patient case its a little different but many are by themselves and are not necessarily qualified to know what is appropriate during times of pain. I have run into several surgeons who simply use this test as standard precedure to pre qualify for surgery without properly looking at the case to determine whether a disco is actually warranted.

I don't doubt at all that this procedure has diagnostic value but I feel it is over used after insufficently studying a patients case, i.e. proper patient selection. Too often it simply feels like it is used simply as a safe guard against possible malpractice legal problems after a poor outcome. Fact is that this procedure does have risks, especially in cervical cases.

[Maria]

So far so good w/o further incidence to report and glad of it. Always thought it is probably a combination of factors that might push the disc prob to a new level like just time for it to blow out anyway, over pressurization, mistakes, technique, luck of the draw ...

[dshobbies]

My first discogram was here in the state, under anesthesia. Four levels were tested, all with positive results. However, upon awakening, I was screaming out in pain, so much so that I was again put under. Knowing what I know now, this should have nullified the results but no, but Dr. Del.. and Dr. R considered this as gospel.

Dr. B insisted on doing his own test without anesthesia, much to my dislike, which very positively identified the fourth level as a non pain generator.

I don't even know the name of the doctor who performed the first test but based on the second one, his skill is/was wanting.

When I first heard about new technology, I also saw Dr. Dillan from the Kerlan-Jobe clinic. He saw me for all of 2 minutes, if that long, (after a 3+ hour wait because he had a migrain) before ordering a discogram and nerve test. We hadn't discussed surgery or any other treatment. His migrain gave me other aches and I never went back but should he have known that a discogram could have caused further harm? Could he have caused an emergency situation?

[Katie]

So how much anesthetic should be used? I blew through everything that was used on me last August on a three level discogram. Plus he did an extra three when trying a new procedure, using Methylene Blue dye in the same discs to try and eliminate the pain. It was a procedure he learned about at a conference in London, UK this spring.

I just about passed out from the pain. None of the doctors involved had this happen before. They said they had used a cocktail of drugs to sedate me, I assume enough to try to keep me comfortable, but able to speak. It failed miserably. But I definitely had three positive discs.

Apparently he has used it successfully in numerous other patients...I was just a loser all the way round.

[fuzzy]

No anethesia for me. Yes, of cause it hurt. Duh! What da ja expect when shovin that thing all the way through my neck?

[ans]

What about the notion of applying marcane (sic) to the disc vs. conventional discography. Does the first method involve pumping the disc pressure, etc.?

If this is a safer method, I wonder who does it.

I shall find out.

[nomorepain]

my 1st spine surgery was with the help of a discography gone bad!
true, it was back in a day when the tests and surgery itself archaeic-i think i spelled that right
anyhow, mine was at the L4-L5 level and blew up my disc-i was in surgery as soon as i could tolerate the anestetic that was in 1979. so when my surgeon said in 2002 i must do a discography before surgery i was sweating bullets,scared to death more of that than the surgery. Was my disc diseased, thats the real question they were trying to figure out. i wish i had my medical records from 30+years ago.

[annapurna]

Hello everyone - great discussion! Over the past two months, I've had discograms at a couple of cervical levels and one lumbar level.

The cervical discograms were intended to figure out which disc (or discs) were responsible for progressive myleopathy. Since all my cervical discs were "tall" on MRI with no significant bulges or herniations, were didn't think that myleography was going to tell us much. The discography showed a HUGE posterior tear in c6/c7 which leaked dye right onto the myleon sheath and every nerve root in the near viscinity - plus concordant pain. Other levels were normal or close to normal. Since the myleopathy was due to irritation rather than outright compression of the myleon, discography was able to identify it very well.

My lumbar discogram was intended to check the disc annulus for tears and leaks prior to chondrocyte transplantation. The disc in question is dark on MRI, but still tall. In order to prolong it's life, I decided to try nucleus chondrocyte transplantation. This is a fairly successful technique that can prolong the life of the disc by adding the living cells that produce the proteoglycan molecules in the nucleus. You need to do discography before the transplantation, though, to make sure the disc doesn't have any huge leaks that would prevent it from containing the new cells in the nucleus where they do their job.

I definitely agree with Mark, though about being prepared for action. If you stick a needle into a disc and do discography, you'd better be prepared to take whatever action is indicated: replace, repair, or watch-and-wait.

[Maria]

I'm so glad to see you posting again and very interested in what you are going to proceed with in terms of preservation of the involved disc.

Would you feel comfortable sharing more information with regard to where you'll be having this done and more about the procedure, expected downtime, recovery time and so forth?

I'm sure there is more information here about this perhaps in a different part of the forum such as articles however I'm sort of out of the loop re spine surgeries as I've continued to be avoidant successfully I think tho perhaps not if one considers returning to work and a very active life. I am happy with pretty good pain control for now and being more active and some other things as well.

How are your activity levels currently?? As I recall you worked quite a bit and were very physically active tho this is from a few years back.

Again, glad to see you post and thank you for the information that you've already given here.

[annapurna]

Thanks for the interest Maria!

I'm still fighting both knee and spine problems, but am doing okay with pain control. Physical activity is limited to swimming, yoga, and stationary cycling, however, I continue to hope for improvement in the future.

Chondrocyte transplantation is a fairly old technique and has been used to repair large, chondral lesion in the knee for the past 15 years or so. Chondrocytes are the living cells that produce both collagen and proteoglycan in cartilage and other connective tissue. Cartilage is mostly "dead" tissue (matrix) with only a few chondrocytes per unit volume producing more tissue. Some of us (luck ) folks don't seem to have very many chondrocytes in our cartilage and discs, so, we experience premature degeneration .

Lucky for us, chondrocytes are very portable. You can harvest them from someplace you don't need them, expand them in a lab (at great expense), then re-implant them somewhere you do need them. Like I mentioned before, this technique has been in use for repairing knee chondral lesions for at least a decade. For spinal discs, you can use add chondrocytes to the nucleus of a dehydrated disc to rehydrate it. The transplanted chondrocytes produce proteoglycans, which hold lots of water, and keep the nucleus from shrinking.

Dr. Bertagnoli has been using the technique for quite some time to restore nucleus material lost during discectomy. When someone has a disc herniation, the herniated fragment is used for cell culturing. In my case, I needed an ADR at c6/c7. This means I had an entire cervical nucleus available for culturing. That nucleus is now sitting, frozen at Codon in Berlin waiting for us to tell them to start the culturing process. If my cells grow (80% chance or so), then Dr. Bertagnoli can simply inject them into my dehydrated L4/L5. If they do their job, then I might buy years of extra life on L4/L5 before I would need ADR.

In my opinion, these celll transplant techniques fall under the "can't lose" category. Other than cost, they have very little risk and enormous potential for delaying the degenerative process.

Fun, eh?

Best to all!
Laura

[dshobbies]

Just curious, what is the 'great expense'. Is this legal in the US? What are the costs Germany vs. US?

Thanks, Dale

[annapurna]

I know that chondrocyte transplatation for disc nucleus restoration is not FDA-approved per se. On the other hand, chondrocyte transplantation for repair of chondral defects in the knee and other joints has been FDA approved since the early 1990's, so, it's possible that use of the same technique for spinal disc could be considered "off-label".

As far as great expense goes, I was whining. Codon, the German cell culturing company that ProSpine uses, charges about 7000 euros to do the culturing. That's actually a good price for cell culturing compared to the going rate for bone marrow or adipose mesenchymal cell expansion and similar. It's a FABULOUS price compared to the $70,000 that Carticel charges to do the same thing here in the states for autologous chondrocyte transplantation. Of course, Carticel has the US monopoly, so...

Like most folks, I'm trying to balance investing in my body vs. my bank account in the face of potential job losses in my family, etc. We're all there, I guess.

Best to all,
Laura

[Maria]

Laura,
this does sound very interesting and I'm wondering what the inclusion or exclusion criteria would be re the involved level/disc and if you know where to find that information.

It may be nothing that my long time disrupted disc levels are candidates for however perhaps adjacent levels that seem to be *ok*.. or at least so I'd like to think..

[Crystal33]

Regarding discography, when i read Carragee's paper I couldn't help but think of the many symptom free 'healthy' persons who have voluntarily undertaken the procedure in the past to help advance medical research and understanding. That a percentage of these persons will develop accelerated disc degeneration possibly leading to incapacity and/or spine surgery due to the procedure is tragic. Possibly they would have grounds for legal action, if they could afford it..

Carragee won an Award from eminent persons for the paper so I don’t think it can be discounted. Also he has no conflict of interest whereas Dr Derby benefits financially from discography. As there could possibly now be an increased risk of persons taking legal action if they have reasonable grounds to believe their spinal condition is result of a procedure which was described as safe or where risks were not disclosed providers of the service will naturally become defensive. Interesting how other posters here have mentioned actual personal adverse experiences.

One might wonder why Carragee would investigate the modern practice using fine needles, which is often described as safe. My guess is that with his vast research experience he suspected what the outcome would be from the outset. Us sufferers are indebted to people like him.

I wonder why Dr Derby, as a major provider, did not see or suspect any adverse consequences as identified by Carragee. Use of finer bullet tip needles sounds like a good idea and one could also wonder why this has not been the practice for some time. As larger needles have been previously established as a risk then surely use of the finest possible bullet tip needles would be a logical choice as providing the safest possible procedure for patients.

One would need to read Carragee’s full paper to see to what extent age, genetics, and any existing degeneration influenced the association between discography and accelerated disc damage/degeneration, assuming he addressed these factors.

I ’m surprised they don’t also closely consider post procedure activity (I assume they don’t). If two gymnasts underwent the procedure and one kept training each day but the other rested for a few weeks and avoided bending, twisting, lifting, I suspect the former would be at much greater risk of causing tiny tears at periphery of needle hole.

Personally I would avoid discography, unless absolutely no choice. Carragee has identified new unacceptable risks that add to existing risks regarding a procedure of questionable value.

The Discography Controversy: Discussion - Discussion Continued

FR Discography

[melodyl]

Prior to my cervical ADR surgery, a PM dr. I was seeing suggested I should have a discography. My surgeon (Dr. Chapman UWMC) was VERY opposed to the idea. When I told the PM dr. that my surgeon didn't want me to have a discography, the PM dr. told me that surgery was Chapman's specialty but discography (and other injections) were his specialty. He went on to say that he wouldn't tell Chapman how to perform surgery and Chapman shouldn't tell him.......

Anyway....my point is only that there is obvioulsy a lot of controversy about the procedure.

I went with the advice of my surgeon and everything turned out fine. However....lots of people have had the procedure and were happy they did. Everyone has to educate themselves as best they can...or find a professional they trust and listen to him/her.

melody