Discography - Accelerated Degeneration Lumbar Disc: Spine 2009 Epub Sep 14

[Slackwater]

Pubmed ID: 19755936


Spine 2009;34:2338–2345
Spine 2009 Sep 14. [Epub ahead of print]
(C) 2009 Lippincott Williams & Wilkins, Inc.

Does Discography Cause Accelerated Progression of Degeneration
Changes in the Lumbar Disc:

A Ten-Year Matched Cohort Study


Carragee, Eugene J. MD; Don, Angus S. FRACS; Hurwitz, Eric L. DC, PhD; Cuellar, Jason M. MD, PhD; Carrino, John MD; Herzog, Richard MD

Division of Orthopaedic Surgery, Stanford University, CA

Published Ahead-of-Print

Abstract

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.

Key words: disc degeneration, discography, anular puncture, complications.
==============================

"The iatrogenic causes of progressive disc degeneration include direct surgical trauma, iatrogenic disc infection,
degeneration next to a long segment fusion, etc. For many years amodel of disc degeneration has been used in
animals studies, which included the anular puncture of the disc.1–4 In some large animal models, small needle
gauge puncture has not shown short-term changes,5 whereas other have.6 Nonetheless, small needle anular
punctures, such as those preformed in discography or intradiscal treatment procedures, are common and controversial procedures.

Whether these intradiscal diagnostic or treatment procedures cause any observable damage to the punctured
discs over time is currently unknown. Most practitioners of these techniques estimate the risk of secondary
degenerative change to be extremely remote.7–9

Patients exposed to discography have been followed with plain radiographs without apparent morphologic
changes,10 but no MR images of a similar cohort have been followed. Experimental discography, in
volunteer subjects without serious axial pain syndromes have been performed by Holt,11 Walsh et al,12 Wood et al,13 Carragee et al,14–17 and Derby et al,18 among others. Early analysis of some of these subjects has
detected increased back pain reported after discography, which attenuates to apparent background levels over
1 or 2 years.15,19 This effect was primarily seen in subjects with psychological distress at the time of the
injection. However, no long-term controlled, clinical, and imaging follow-up of discs exposed to
anular puncture and injection has been reported thus far.

The present matched cohort study was performed to provide a definitive evaluation of the risk of progressive
disc degeneration and associated findings in subjects exposed to a modern technique, 3-level discography procedure using limited pressurization. This discography group was tested at baseline and compared up to 10-
years later, using a standard lumbar MRI grading protocol and experienced readers."

==============================

Suggest there may or will be other imaging techniques to determine the state
of intervertebral disc degeneration beyond MRI, without discography, as mentioned
elsewhere on ADRSUPPORT.org ,


slackwater ( discography, two-levels )

[Harrison]

Modern discography techniques can lead to accelerated disc degeneration
By Lee Beadling

November 2009

SAN FRANCISCO—Discography, even with the use of smaller-gauge needles and limited pressurization, can result in accelerated disc degeneration, according to the results of a long-term cohort-controlled study.

“Modern discography techniques with smaller pressures and smaller gauge needles did appear to have an accelerated degeneration at 10 years,” Eugene Carragee, MD, said. “But this is not at all a homogenous effect; many of the discs appeared to not be effected at all whatsoever.”

Carragee presented the 10-year results of the prospective, controlled, match-cohort study comparing disc degeneration in patients who did or did not receive discography at the 24th Annual Meeting of the North American Spine Society, here.

The study included 75 patients who did not have serious back pain and received a protocol MRI and an L3/4, L4/5, and/or L5/S1 discography examination in 1997. These patients were compared to a 75-pateint control cohort. For the 10-year follow-up there were 50 discography patients and 52 controls available for study.

MRIs were taken at baseline, 1, 2, and 5 years.

“The MRI readers were blinded to the patients who had the MRI scans,” Carragee said. “We looked for the Pfirmann ratings, herniations, end plate changes and high intensity zone.”

Overall, in all graded or measured parameters the discs that had been exposed to puncture and injection had greater progression of new degenerative findings compared to the noninjected discs.

“The progression of one or more grades on the Pfirmann Grade was greater by a statistical test in the discography group than in the nondiscography group,” Carragee said. However, many of the discs did not progress at all, he noted. “The majority of the ones that were punctured had no progression of Pfirmann grade.”

New disc herniations were increased in the discography group as were Modic changes, he said.

“Careful consideration of risk and benefit should be used in recommending procedures involving disc injection,” Carragee said.

Reference:

Carragee E, Don A, Hurwitz EL, et al. Does discography cause accelerated progression of degeneration changes in the lumbar disc: A ten-year cohort-controlled study. Paper #7. Presented at the 24th Annual Meeting of the North American Spine Society. Nov. 10-14, 2009. San Francisco.

Source: http://www.orthosupersite.com/view.asp?rID=50644