Discograms Inaccurate?

[Judi]

Does it matter who does the discogram? Is it more important to get it done by the surgeon doing the ADR? Can there be false positives with one disc inflaming the adjacent one? Maybe some people are straightforward and 'no-brainers'. One disc hurts and the other doesn't. But what if all the discs produce pain, then what?

[wbaker68]

Topic of discussion this weekend, where Dr. Yeung was pretty strong with his feelings that the surgeon should be the one doing the discogram or at least someone that he is very familiar with and is confident in their testing. He was a little upset when one of the doctors mentioned that he didn't do the discograms himself.

All disc may produce pain, the main question is whether the pain produced is replicating the pain you are having. At least that is what I understand to be essential to a good discogram reading.

Bill

We really have no data on how sensitive discgrams are to discogenic pain. If a disk is painful in a discogram, it is likely a pain generator. However, if a discogram does NOT produce pain, it does not rule the disk out. I say this because we have NO DATA on the false negative rate of discography. No on operated on disks with negative discograms unless this disk is so bad it cant pressurize.

Put another way, if your disogram is negative, there is no data anywhere in the scientific literature that can tell you how accurate that is.

Some will disagree, but any diagnostic test must meet minimal requirements for sensitivity (ability to detect underlying pathology with regularity...as in few false negatives) and specificity (a low false positive rate).

If you compare the sensitivity and specificity of the ELISA-Western Blot combination for diagnosing the presence of HIV in the blood, then one can see how weak disography is by comparison.

Some may say its unrelealistic to expect great reliability and accuracy in tests that involve pain. My response is that other fields of medicine also hav had difficult problems to solve, but have developed diagnostic tools far superior to discography.

I think spinal surgery is in the dark ages compared to other areas of medicine, and I dont believe it is because the subject matter is more difficult.

[decker]

One way a degenerated disc is supposed to cause pain is that it no longer holds the space between vertibrae and nerves get pinched. If this is the source of the pain, how could injecting the disc possibly reproduce this?
dave

Dave,

I dont think it would. Here's another scenario: what happens if a person's nerve roots are inflammed because there is slow leakage of cytokines and other irritating chemicals though the annulus? Sudden onset acute pressure will do nothing because the pain is do to ongoing inflammation.

Here'sa another one: suppose the nerve pain in the legs takes a few minutes of sitting before it really starts to kick in. This may be due to the fact that it takes a while for a compressed nerve to become hypoxic in response to continued compression. How would a sudden, 5-second pressure test from a discogram elicit this?

In other words, if one had chemically-mediated, "discogenic leg pain," how would discography be remotely useful?

[Justin]

Paul,

You're analysis regarding discography is right on and I couldn't have said it better.

I think spinal surgery is in the dark ages compared to other areas of medicine, and I dont believe it is because the subject matter is more difficult.

Justin

[JL]

Paul, When you were asking the discogram questions at the end, my pain and brain were in and out. I know you covered it well with false and postive and I did manage to hang on and write down the Dr.s responses. They spoke of pain as it's own disease that it is a multi-piece puzzle, many things can cause pain. How long. Can become it's own disease.

Clinical evaluation, Neurological Eval. Discogram. Doctor doesn't trust Radiologists report. Has retested and came to different conclusions on occasions. What about discograms when Pt given 10 mg. of Valium or pain killer?

These were Dr.s responses to your questions.

Go back to disc. Selective nerve block. Paralyze Pt. with Saline Solution. (I think that is what he said, I was getting grogy and a little paralyzed myself)

See an x-ray, correlate to Pt. Discogram comes from somewhere else, very hard to make a decesion.

Requires concordinate pain.

Question to audience posed. How many had exact pain at the level ? 50% response. How many has so much pain they just said yes? 50% response.

Still an art. What about positive but the needle caused the pain?

Wasn't Asymetrical.

Do your own Control. "Know the person doing the discogram or do it yourself."

I have to agree with you assesment about the exact science involved in this. We have a casio in our state.

[Ksrowd]

I was told the exact same thing as Bill by my surgeon and the pain managment doctor that did my discogram. They told me they were going to try to recreate the same shooting paralyzing pain that I have on a daily basis, and they succeed quite well. My doctor actually did a post procedural interview with me after I had calmed down and had taken some pain medication. We dicussed if the pain was the same type and in the same locations as my daily pain. It was only after this that my doctor wrote his report and sent it to my doctor. I also think who ever reads the discogram pictures makes some evaluations about the problems and structure of th disk because mind contained a second report from a third independent doctor I did not know.
Kevin

[Mariaa]

I've had a disc with annular tear that was concordant for pain the first time, and not the 2nd discogram. This leaves me wondering whether this disc should be removed or not...
I know L4 and L5S1 must go..tho L3, I am wondering what to believe even tho I was told by 2 surgeons involved in trials that got the discogram report of 12/04 that I was a candidate for a 2 level ADR.
This one thing plus wondering if I'll have a similar arachnoiditis like response for 5 plus years in buttocks and lower extrems bilat keep me asking questions.. tho possibility is I've waited too long and let other things take abuse such as facets..
1rst discogram done by surgeon that was going to do 3 level global fusion
2nd discogram outsourced to doc in SF specializing in doing these other than surgeon to do ADR
next discogram...?? I'm only going for one more~

[Still Standing]

Paul,
You raise some interesting questions. It does seem like discography would not be helpful in cases of chemically-mediated discogenic leg pain, since it would not be able to recreate the cause of the pain. I wonder how they could go about recreating pain due to this cause. I know that chirogeek has written some about this, but there doesn't seem to be that much info on this condition. I'm also wondering if the outcomes after ADR would be different for this type of problem as compared to plain old discogenic LBP or nerve compression? Would there be different effects from the distraction process?