Zeegers change on discography / sedation?

[mmglobal]

In July, I was with a client in Munich for his ADR surgery. He's a young man of 32 with 2 discograms that were BOTH positive at 3 levels. His imaging looked as you'd expect for a man of 32... not too bad... still good disc height. However, he was SEVERELY disabled, on high doses of medications, and was completely at the end of his rope. Both discography reports were well written. (You must understand that some of the reports we see clearly tell us that the test results must be taken with a boulder of salt. A well written report about a well-done test yields much more confidence in the result.)

The case was confounding. The severity of the disability didn't seem to match the imaging. Doing a 3-level is reasonable in the presence of a very clear diagnosis, but this case had us scratching our heads. We went to see Dr. Baumbach, the neurologist for his evaluation. Unfortunately, this patient was so pain sensitive and was having anxiety attacks, so a meaningful neuro exam was impossible. A full-spine MRI was ordered to rule out cervical and thoracic issues that may be responsible for the patient's extreme symptoms. Interestingly enough, he had a substantial thoracic disc herniation, so it was back to Dr. Baumbach to evaluate whether or not that issue could be responsible for his symptoms. Dr. Baumbach did not believe that the thoracic issue was responsible for the symptoms.

What to do? There was some discussion of going straight to a 3-level because the discography seemed to be so well done. I was VERY uncomfortable with that. The most recent discography had been performed by a doctor I know, so we called him on his cell phone and fortunately we caught him at a time when he could talk. We discussed the test for about 20 minutes... he remembered the patient and the testing very well... clear positive at 3 levels. Zeegers was not comfortable going to a 3-level procedure on such a young man with tall discs without doing the discography himself. I was very concerned that we would not be able to get reliable discography. If the patient's pain sensitivity was such that we could not get through a basic neuro exam, how could we get reliable discography?

For years I have discussed discography techniques with the surgeons and every one I know who performs his own discography (which I believe is superior) - does so without sedation. Zeegers had always been adamant about the need for clear pain responses, not clouded by sedation. I suggested that in this case, the patient was too pain sensitive and he should consider using sedation. Dr. Zeegers said that he'd consider it, but wasn't sure. I was very worried about a potential 3-level in a 32 year-old man with confounding symptoms.

I insisted that we have a plan-B. What if we could not perform reliable discography. This was discussed at length with the patient and his wife, me and Dr. Zeegers. The patient decided that he trusted the 2 doctors who performed the prior discograms and had nothing to lose in trying the 3-level... he had no life and was unable to get help any way he turned. He'd do the 3-level. I was so, so uncomfortable with this decision, but after the discussion I kept quiet about it. He understood the issues. It was his decision to make.

The next morning when I got to the OR, Dr. Zeegers told me that he'd studied techniques the night before and had already discussed it with the anesthesiologist. The test would be performed with sedation. I'm not sure about the compounds used, but it was much like the tests we see in the US with Versed. The anesthesiologist could bring the patient in and out as needed. Under more for needle placement... almost fully awake for testing. Here is how the test went:

L2-3 - zero pain at high pressure and volume
L3-4 - zero pain at high pressure and volume
L5-S1 - low level of non-concordant pain at high pressure and volume
L4-5 - extreme concordant pain at low pressure and volume
L2-3 - did not retest because this level was NEVER suspect
L3-4 - zero pain at high pressure and volume
L5-S1 - zero pain at high pressure and volume
L4-5 - extreme concordant pain at low pressure and volume

I was so happy for my client! Immediately following the discogram, he was prepped for surgery and Zeegers performed a 1-level Activ-L. After the surgery, I went to Dr. Zeegers and asked him what he would have done if we could not have gotten through the test.

"I can always get it done", he replied.

"I want to know... what would you have done if we could not get through the test?", I insisted.

"I would not have done the surgery. There are more tests we could have performed. I would not do a 3-level unless we have done everything we could have!"

I have to tell you... I feel so proud and honored know Dr. Zeegers and to be able to participate in this process. This is the way medicine should be practiced. He cares deeply about his patients and does for them what he would do for his brother.

In the days that followed, I was expecting to have a very difficult time. Usually, the clients I go with for surgery who are on high doses of pain meds have a difficult time post-op. This guy absolutely kicked ass. His post-op days were a pleasure... just watching him come back to life. I had to leave Germany while he was still tender and moving slowly, but in the week that followed, his wife kept saying, "I can't keep up with him... he's walking everywhere... I can't believe how well he's doing."

The following week, another client was at the AlphaKlinik and benefited from Dr. Zeegers changed views on discography and sedation. In previous a previous discography, she had a vasovagal reaction to the pain which halted the test without meaningful results. She feared not being able to complete discography with Dr. Zeegers for the same reason. Armed with his experience from the prior week, Dr. Zeegers again did discography with sedation.

I think that the jury is still out on this. I believe that well performed test will be successful and reliable in most (but not all) cases with or without sedation. Poorly performed tests will be unreliable no matter which technique is used. I still believe that less sedation is preferable to more sedation. However, in some cases, particularly when the patient is pain sensitive, having anxiety attacks or has a history of bad reactions as Fiddle had... for these cases, sedation will allow the doctor to get good results more reliably than if the tests are performed without sedation.

Mark

PS.... On my recent trip to NY, I had a layover in the first client's city. He and his wife met me for breakfast. He's over 2 months out and is still coming down on the meds. He has nothing but positive things to say as he continues to do extremely well. In so many cases, I never get to meet my clients. Although I did go to Germany with him, it was still a great treat to see him post-op... especially doing so well.

[Maria]

Mark,
I'm glad to read your post re Zeeger's use of sedation w/discogram.
To date I've undergone 3 discograms here in California.

My first discogram was performed by my treating OSS done with the least amount of sedation or so it felt. I was concordant for pain at L3,L4,L5S1 so a 3 level global fusion was planned. That didn't sit well w/me so I waited it out a few more years. To be truthful, I'm sure I had enough sedation while at a minimum, and I'm not sure I didn't just squiggle at the thought when the surgeon told me he was at the L3 level.. I mean, I hope that I didn't give an unreliable response, but of course I've always wondered after what you'll read about the next two discograms...

The second time I had a discogram it was with a very reputable anesthesiologist that the Chief of Orthopedics at UCSF sent me to on one day's notice. Anyone who has Worker's Comp insurance and has been thru the maze of authorizations and time factors knows that this was an amazing feat in itself!

This discogram yielded results of concordant pain at L4 and L5 but NOT L3! I was leary... I wondered which exam was right but I felt that the 2nd exam was more reliable and I must say, I also felt more comfort and sedation was provided.

The anesthesiologist had gone so far as to sit me down for a good 10 minutes before the procedure to talk to me about it and also told me that sometimes persons on Medications such as mine may have a decreased threashhold for pain because of the pain medication and my response may be affected by this. I'd never heard that before.
A 2 level ADR (prodisc) surgery was planned but canceled before I could have the surgery as trial had closed.

Now this past year, a good 3 years later from last discogram, I had another one with my current PM doctor. An ESI was given afterwards.

With this discogram I had the most sedation it seemed as the procedure rendered me nearly unconscious or so it felt until my response to the painful discs at L4 and even greater at L5S1~

Mark, you have seen my reports, you've seen how they were written. In my opinion the 3rd discogram report was written extremely well as a good procedure report should be (esp. for WC).

Personally, I cannot imagine a discogram with no sedation...I am sure that I would squiggling and screaming at anything that was done~

Tell Dr.Zeegers there's one more American who is thankful that he's decided to use sedation during discogram! My feelings are that if the person who is doing the procedure is extremely skillful, the results yielded will be on the mark... I think it's all in the hands of the person performing the procedure, sedation or no sedation... that is my personal and humble opinion which of course can be debated or challenged by anyone if so desired~

thanks again for this post and that was a fortunate patient in terms of outcome of procedure and surgery!!!

[fiddle]

Hello Mark and all new readers/contributors!

Thank you Mark, for starting up a website to support and inform the spine community! We can all use as much support and information as possible, and it is a wonderful way for each of us to participate with and contribute to the community.

I wanted to tell the spine community a bit about my discogram experiences. I have been through 11 years of testing and treatments for chronic back pain. My first discogram back in the late 90's was by far the most painful experience in my life. Keep in mind that I have breezed through MRIs, MRIs with contrast, myelograms, nerve root blocks, steroid injections and trigger point injections. I was told it would "hurt" and did it ever. This is my experience on doctor/nurse speak: "It won't hurt"= there will be a little discomfort; "There will be some discomfort"= it will hurt; "It will hurt"= you will be out of your mind with pain!

Anyway, I went to a highly regarded hospital in Boston. The needle placement went OK, but I did notice that my positioning, with me on my side/stomach and my arm up seemed to restrict the blood vessel in my neck. When he injected the dye into L5-S1 (the first level he chose), I felt the most excruciating unrelenting pain of my life. It felt like a huge pain wave that was only getting bigger. I immediately got all sweaty, nauseous, and cold at the same time, and within seconds I felt like I was very close to passing out. They said I had a vaso-vagal reaction, where your blood pressure drops and therefore your brain isn't getting enough oxygen. I have only fainted one other time in my life so this was very unusual. I had to stop the test. I felt so physically traumatized that I just hid under the covers for several hours afterwards in a recovery area.

My next discogram (a few years later) I agreed to because I negotiated with the doctor that he would NOT test L5-S1 -- I/we already knew that one was bad. There was some pain but not bad. One disc showed it was not a pain generator, and the other was questionable but the conclusion was that it was not a pain generator. No wonder it didn't hurt so much.

The third discogram was with Dr. Zeegers prior to my ADR surgery in July 2006. He wanted to do the dreaded L5-S1, and well as L3-L4 and L4-L5. Since he knew of my experience, he gratefully offered the test under sedation (but i would still be aware). I agreed. I have the feeling I was the second patient he tested under sedation.

I remember the test, but not in a traumatized way. I remember clearly feeling pain, and "telling" him i.e. AAOOWWHH!!!, but I remember it in an intellectual way, not in a fearful stomach-tightening way. Dr. Zeegers was able to get the information he needed, and then could make a decision about whether to proceed with the ADR surgery. And I also liked the idea that my surgeon would do the test, so that he could see firsthand what was going on.

I am so appreciative of Mark for spearheading this idea of discogram under sedation for those patients who need this. And I commend Dr. Zeegers for being willing to adopt a new strategy for helping patients with this test. Between the both of you, you are changing the experience of spine patients for the better. Thank you both for starting a new approach that will hopefully catch on in the U.S. and around the globe!

[ans]

Very interesting - thanks.

I had a discogram by Roy Simon in Westwood/LA. I was sedated but for the instant the discogram went in, the anesthesiologist lowered the dose. I hit the roof and nearly clawed the table end off. Strangely, in his subjective evaluation, I was only 7/10 in pain concordance. Odd world.

[Maria]

I think my first discogram was the least sedated one and I may have reacted re L3 in retrospect out of fear when advised OSS was testing L3. I just don't know anymore. But I'm afraid I'd have to be hog tied in 4 point restraints not to move re no sedation discogram~ then again, maybe it depends on the technique and who is performing testing as to how torturous it might be (spinal/disc condition considering).

[mmglobal]

The doctors I've spoken to about taking your own meds prior to discography (including Dr. Bertagnoli) have said to take your normal dose... don't overmedicate... don't undermedicate. Your normal dose will not keep you from feeling the discogram.

[martyusa]

Originally Posted by mmglobal

The doctors I've spoken to about taking your own meds prior to discography (including Dr. Bertagnoli) have said to take your normal dose... don't overmedicate... don't undermedicate. Your normal dose will not keep you from feeling the discogram.

Now he tells me.......