Korean J Pain.  2021 Oct;34(4):447-453. 10.3344/kjp.2021.34.4.447.

Predictors of discogenic pain in magnetic resonance imaging: a retrospective study of provocative discography performed by posterolateral approach

• Jain A
• Jain S
• Barasker SK
• Agrawal A

• KMID: 2520752
• DOI: http://doi.org/10.3344/kjp.2021.34.4.447

Abstract

Background
Provocative discography (PD) is a test that is useful in diagnosing discogenic pain (DP). In this study, to diagnose DP, we used a posterolateral approach of needle placement and followed pressure criteria laid down by the Spine Intervention Society. The aim was to identify the correlation between magnetic resonance imaging (MRI) findings (desiccation, high intensity zone and change in shape and size of the disc) and the results of PD.
Methods
Records of 50 patients who underwent PD for DP were analyzed. A total of 109 PDs were performed, with 54 suspect and 55 control discs. Alternate pain generators were ruled out.
Results
A total of 35 suspect discs were positive on PD. The mean disc pressure in the suspect disc was 31.9 ± 7.9 psi (range, 15-44). Of the 50 patients who underwent PD, 35 had positive MRI findings. A significant positive correlation was found only between disc desiccation and discography result (r = 0.6, P < 0.001). Logistic regression analysis revealed that only desiccation successfully predicted the result of discography (OR = 26.5, P < 0.001); a high intensity zone and a disc protrusion/extrusion had an OR 2.3 and 1.24, respectively. Disc desiccation of Pfirmann grade 3 or more had a sensitivity and specificity of 0.93 and 0.64 respectively in identifying painful discs; the positive likelihood ratio was 2.58 while the negative likelihood ratio was 0.11.
Conclusions
In patients with DP, disc desiccation is the most useful MRI feature that predicts a painful disc on PD.

Keyword

Desiccation; Diagnosis; Discography; Intervertebral Disc; Intervertebral Disc Degeneration; Low Back Pain; Magnetic Resonance Imaging; Pain Management; Sensitivity and Specificity; Spinal Diseases

Figure

• 

  Fig. 1 Lumbar spine magnetic resonance imaging (MRI) images showing desiccation, high intensity zone (HIZ), and protrusion/extrusion. (A) Sagittal T2-weighted MRI image showing a HIZ and Pfirrmann grade IV. ‘*’ denotes the HIZ. (B) Axial T2-weighted MRI image showing a left paracentral disc protrusion (arrow). (C) Sagittal T2- weighted MRI image showing HIZ and Pfirrmann grade IV disc (arrow). (D) Axial T2- weighted MRI image showing a HIZ without protrusion/extrusion (arrowhead).

• 

  Fig. 2 Diagrammatic explanation of the surface marking used for identifying the site of needle insertion; also depicted is the needle trajectory. 1: line in the midline along the spinous processes, 2: line along the intervertebral disc with C-arm in anteroposterior view, 3: line along the intervertebral disc with the C-arm in the lateral view, 4: line denoting center of the disc with C-arm in the lateral view, 5: a perpendicular from line 2 onto line 3 at a distance ‘d’ from the midline, 6: point of needle insertion for posterolateral approach of provocative discography, d: distance from skin surface to line ‘4’ as measure in lateral view of C-arm.

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  Fig. 3 Fluroscopic images of provocative discography. (A) Lateral view with needle in disc space. (B) Disc with injected dilute radiocontrast (Omnipaque, 1:1 in normal saline) in lateral view. (C) Disc with injected dilute radiocontrast (Omnipaque, 1:1 in normal saline) in antero-posterior view.

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  Fig. 4 Study summary. LBP: low back pain, PD: provocative discography, NRS: numerical rating scale, psi: per square inch, HIZ: high intensity zone.

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  Fig. 5 Receiver operating characteristic curve for disc desiccation and painful disc.

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