Introduction Historically, lumbar discography has been one of the most controversial subjects in the management of discogenic low back pain. The diagnostic value of normal psychometric specific pain provocation by disc pressurization has emerged. The sensitivity, specificity and accuracy of discography as a diagnostic test are not in doubt. In clinical discography pain reproduction and location are essential elements. There is an accepted rate of 0–10% false positives. This rate is influenced by occupational disability and abnormal psychometric profiles. By contrast, little attention has been given to false negative results and their outcomes if surgically treated. Traditionally, whether or not the test is considered to be positive or negative is determined immediately after completion of the diagnostic procedure. This study shows that patient’s pain reproduction may occur up to 24 hours after the discogram which often initially interpreted as a true negative when it is actually a false negative result. This study verifies the existence and significance of a false negative through the patients’ treatment and outcomes. Methods In this study, 150 patients underwent discography for investigation of chronic persistent low back pain (CPLBP). All patients had a control (morphologically normal) discogram at the level above the degenerative segment. No patients with abnormal psychometric profiles or compensation were included. All patients were followed up 24 hours post discogram by the radiologist to further assess their clinical status. Ten of the patients (7.5%) were considered to have a false negative discogram, as per the Dallas Discogram Scale. The surgeon correlated the delayed response on the subsequent follow-up. These ten patients were diagnosed as having a positive response and were treated surgically for their discogenic pain. VAS-B, VAS-L, ODI, RMD were collected prospectively. Preoperative and 6 month results were reviewed. Results Seven of the 10 patients (70%) reported severe increase CPLBP and reproduction of pain within 8 hours of the discogram, while 3 patients (30%) did so in the ensuing 24 hours after the discogram. Surgical treatment was either by total disc replacement or anterior lumbar interbody fusion. All patients reported greater than 50% reduction in VAS-B and VAS-L and with improvements of greater than 50% in their ODI and RMD scores. Discussion The clinical reliability of discography hinges on the subjective assessment of pain concordance as the discriminating factor in determining false positives from false negatives. Given the limitations of discography, all information about the patient should be considered prior to diagnosis, including clinical, radiological, historical, and psychometric factors. The delayed positive discography response is an important consideration for the patient, the radiologist, and the treating surgeon to be aware of. The results of this study verify the existence of this subgroup and justify their surgical treatment

Aims. The presence of facet tropism has been correlated with an elevated susceptibility to lumbar disc pathology. Our objective was to evaluate the impact of facet tropism on chronic lumbosacral discogenic pain through the analysis of clinical data and finite element modelling (FEM). Methods. Retrospective analysis was conducted on clinical data, with a specific focus on the spinal units displaying facet tropism, utilizing FEM analysis for motion simulation. We studied 318 intervertebral levels in 156 patients who had undergone provocation discography. Significant predictors of clinical findings were identified by univariate and multivariate analyses. Loading conditions were applied in FEM simulations to mimic biomechanical effects on intervertebral discs, focusing on maximal displacement and intradiscal pressures, gauged through alterations in disc morphology and physical stress. Results. A total of 144 discs were categorized as ‘positive’ and 174 discs as ‘negative’ by the results of provocation discography. The presence of defined facet tropism (OR 3.451, 95% CI 1.944 to 6.126) and higher Adams classification (OR 2.172, 95% CI 1.523 to 3.097) were important predictive parameters for discography-‘positive’ discs. FEM simulations showcased uneven stress distribution and significant disc displacement in tropism-affected discs, where loading exacerbated stress on facets with greater angles. During varied positions, notably increased stress and displacement were observed in discs with tropism compared to those with normal facet structure. Conclusion. Our findings indicate that facet tropism can contribute to disc herniation and changes in intradiscal pressure, potentially exacerbating disc degeneration due to altered force distribution and increased mechanical stress. Cite this article: Bone Joint Res 2024;13(9):452–461

Prospective match cohort study of disc degeneration progression over ten years with and without baseline discography. To compare progression of common degenerative findings between lumbar discs injected ten years earlier with those same disc levels in matched subjects not exposed to discography. Seventy-five subjects without serious low back pain illness underwent a protocol MRI and a L3/4, L4/5 and L5 S1 discography in 1997. A match group was enrolled at the same time and underwent the same protocol MRI examination. Subjects were followed for ten years. At 7 to 10 years after baseline assessment, eligible discography in controlled subjects underwent another protocol MRI. MRI graders, blind to group designation, scored both groups for qualitative findings. Well matched cohorts, including 50 discography subjects and 52 control subjects 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 (non-injected) 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 annular 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. This study demonstrates that the dimensions of the LSP change with age. Increases in LSP height occur with age. More impressive increases in LSP width occur with advancing age. This study suggests that loss of lumbar lordosis is correlated with changing LSP morphology. The increased width of the LSP with age influences access to the spinal canal, particularly if midline-preserving approaches are attempted in the ageing population. There is increased bone volume for bone grafting procedures with increasing age. The reduced distance between LSPs with age may influence design of implants that stabilize this region of the spine, and occur not only as a result of disk space narrowing, but also as a consequence of increased LSP dimensions

Introduction: The role of discography before lumbar fusion had been discussed in the literature. No study discussed its role before total lumbar disc replacement (TDR). Degenerate discs are not necessarily painful, even if they show Modic changes or HIZ. Moreover, discogenic pain might not be the predominant element in the patient’s symptoms and most of the back pain could be originating form other spinal structures. The aim of our prospective cohort study is to show whether or not provocative discography plays any significant role before TDR and to define that role. Methods: Twenty patients (11 females and 9 males) had “Prodisc” TDR. Mean age = 38.5 years (range: 20–56). All patients had mechanical low back pain with degenerative disc disease diagnosed by MRI scan. 65% (N=13) had radicular pain as well. The mean duration of back pain = 66.9 months (range: 16–240). Pre-operative provocative discography was performed in all cases. The clinical outcome was assessed by comparing the preoperative SF36-v2, ODI and VAS scores’ means to the 3, 6, 12 and 24 months post-operative ones and also comparing the last follow up SF36-v2 scores with the, age and sex adjusted, normative data for the general UK population obtained from the Oxford Healthy Lifestyle Survey III. All patients were followed up for a minimum of 2 years. Results: 90% (N=18) experienced a clinically significant improvement of their back pain (MCID for SF36-v2 scales=1SD, ODI=10 points and VAS=2 points). There has been a statistically significant improvement in the follow up outcome measures (P< 0.05) at 3, 6, 12 and 24 mths. SF 36-v2 scores of 15% of patients (N=3) reached or exceeded the normative values for the UK general population. Conclusion: Provocative discography is an important diagnostic tool before TDR. It is the only dynamic method to diagnose discogenic pain and is indispensable to exclude the painless levels in cases of multilevel disc degeneration

This prospective study was carried out to correlate findings of magnetic resonance imaging (MRI) and discography. Fifty-five consecutive patients with degenerative disc disease not responding to non-operative treatment were included in the study. There were 19 men and 36 women and the mean age was 45 years. Discography was carried out on 131 disc levels. The discograms were classified using modified Adams’s classification and pain recorded into three grades. MRI scans were graded using a new classification system based on parasagittal and axial images by two independent observers blinded to discography findings. There was good intraobserver (kappa 0. 74) and interobserver (kappa 0. 70) agreement for the classification system. There was a significant correlation in the morphology of discs as determined by discograms and MRI classification (p< 0. 001). Each disc was graded on MRI scan as painful or painless on basis of defined criteria. Concordant discography pain was considered as the gold standard. The sensitivity and specificity of MRI in predicting symptomatic disc using defined criteria was 94% and 77%. The sensitivities and specificity of high intensity zones was 27% and 87% and for end plate changes was 32% and 98% respectively. In 14 patients (25%) the findings of MRI and discography did not correlate. In conclusion though MRI is an excellent investigation for assessing disc morphology it should be interpreted along with discography findings before planning fusion surgery. The proposed MRI classification is a useful aid in predicting painful degenerative disc. The utility of high intensity zones and end plate changes is limited due to low sensitivity

We analysed the functional outcome (Oswestry Disability Index) after technically and radiologically successful lumbar fusion in 39 non-compensation seeking patients with chronic low back pain, who had a High Intensity Zone (HIZ) – positive MRI and subsequently underwent discography. The average follow-up was 33 months. The HIZ-positive, discogrampositive group was the only one with statistically significant improvement. The HIZ-positive, discogram-negative group had the worst outcome. Relying only on the HIZ fails to identify the group of patients who would have had negative discography at the same levels. Therefore the presence of HIZ alone should not dictate treatment plan without discography confirmation

Background: Over several decades, investigators have been trying to identify the painful degenerate disc. Their work included two main methods. The first was to set criteria on the radiological investigations, mainly the MRI scan, to describe the severity of the degenerative disc disease (DDD); and the second was to perform discographies. Neither of these two methods precluded the need for the other. Purpose: Using Pfirrmann’s classification, we correlated static MRI images, for the severity of segmental disc degeneration, with dynamic lumbar discography, with the aim to improve the identification of painful ‘disco-genic’ intervertebral segments. Study design: Prospective cohort study. Inclusion criteria included patients with mechanical low back pain who exhausted the conservative measures and required surgical treatment. Patient Sample and Methods: We investigated 69 patients (45 females, 24 males). The average age was 38.9 years (range 20–56). All patients had degenerative disc disease (DDD) on lumbar MRI scans. Provocative discographies were performed in all cases as a routine investigation to identify painful levels prior to fusion or disc replacement surgery. The severity of DDD was graded using Pfirrmann’s classification. A total of 162 discographies were performed using the ‘miss the facet joint, double needle technique’. Outcome measures: During discography typical or concordant pain only was regarded as positive. Among each of the five Pfirrmann grades, the percentage of positive discographies was calculated. Significance and correlation then were investigated using the Chi-squared and Spearman’s correlation tests. Results: 24 discs were classified as Pfirrmann grade I, 33 grade II, 63 grade III, 27 grade IV and 15 grade V. The percentages of positive provocative discography for concordant pain among these groups were 0%, 9.1%, 71.4%, 100% and 100% respectively. Statistical analysis showed a high correlation between the severity of DDD on MRI scan and the result of the provocative discography (Chi2 = 32.96, P < 0.001 and correlation coefficient = 0.756). Conclusion: The higher the grade of segmental DDD, the more likely it will be painful on discography. All discs showing Pfirmann grade IV and V disease were painful on discography. We strongly recommend the Pfirrmann classification for use in grading the severity of lumbar DDD especially when assessing for its association with discogenic pain as determined by provocative discography

Introduction: Recent cadaveric studies have identified neovascularisation and neoneuralisation as probable mechanisms in the causation of discogenic pain. Calcium pyrophosphate deposits have been observed in discs in several studies. Their significance in the causation of discogenic pain is unclear. Direct correlation between the pain site and histological features can be verified by aware state endoscopic visualisation. Aim and Objectives: The study aims to examine and correlate the presence of neovascularisation, crystalline pyrophosphate deposits in the disc, and discogenic pain by spinal probing and discography under endoscopic visualisation. Material and Methods: Tissue removed from intervertebral discs of 224 patients during surgery was examined directly, and polarised microscopy was used to identify the presence of calcium pyrophosphate and neovascularisation. Their presence was correlated to diagnostic provocative findings of spinal probing and discography and intradiscal distortion during aware state endoscopy. Results: Calcium Pyrophosphate: Twenty out of 224 patients (9%) demonstrated calcium pyrophosphate in the discs. Fourteen had pain reproduced on probing or discography. Thirteen out of 20 patients (65%) had either an annular collection or leak at the index level. 6 had an extradiscal cause of pain. One hundred percent of the patients with annular collections or leaks had pain on spinal probing or discography. Sixteen patients with pyrophosphate deposits did not have neovascularisation. Neovascularisation: Thirty seven out of 224 patients (16.5%) showed neovascularisation in the disc. Four discs had crystalline pyrophosphate deposits. Thirty three out of 37 (90%) had pain on probing and/or discography. Out of four patients who had no pain on probing or discography, two had demonstrated tears during previous discographic procedures which were treated with laser annealing. These patients had disc bulges and compressive radiculopathy. Conclusion: The presence of pyrophosphate in the disc without a tear or leak does not directly render them tender to provocation. The presence of pyrophosphate is not correlated to neovascularisation. Annular tears or leaks are not directly correlated to the presence of pyrophosphates. There is a high correlation between pain provocation and neovascularisation

Introduction. Degenerative disc disease results from mechanical alteration of the intervertebral disc. Biochemical modifications of the nucleus matrix are also incriminated. Furthermore, genetic predispositions as well as vascular factors have been advocated in the process of disc degeneration. A relationship between sciatica and Propionibacterium acnes has been described. However, it remains unclear if the hypothesis of a subclinical spondylodiscitis might play a role in the pathophysiology of degenerative disc disease. The purpose of this study was to analyze the possible presence of bacteria in lumbar discs of patients with degenerative disc disease. Methods. We prospectively analyzed the presence of bacteria in 83 patients (34 males and 49 females, average age 41 years) treated by lumbar disc replacement at L3-L4, L4-L5 or L5-S1. An intraoperative biopsy and microbiological culture were performed for each disc to determine if intradiscal bacteria were present. Great care was taken to avoid any source of contamination during the conditioning process of the biopsy. Microbiological results were compared to the magnetic resonance stages of disc degeneration according to the Pfirrmann and Modic classifications. Possible sources of previous iatrogenic disc contamination after discography or nucleotomy were analyzed. Results. The magnetic resonance stages were Pfirrmann IV or V, with Modic I signs in 32 and Modic II in 25 cases. A preoperative discography was performed in 49 patients, and 24 had previous nucleotomy. Germs were found in 40 discs, 43 cultures were steriles. The following bacteria were evidenced: Propionibacterium acnes 18, Staphylococcus coagulase negative 16, Staphylococcus aureus 3, Gram negative bacilli 3, Micrococcus 3, Corynebacterium 3, others 5. Ten biopsies presented several different germs. Bacteria were predominantly found in males (p=0.012). The mostly positive level was L4-L5 (p=0.075). Histological examination of 31 discs found inflammatory cells in 33 % of the biopsies with positive bacterial culture, versus 5 % of the sterile biopsies (p=0.038). There was no significant relationship between bacterial evidence and Modic sign. A preoperative discography or previous nucleotomies did not represent significant contamination sources. None of the patients presented clinical signs of infection. Conclusions. The finding of bacteria in 48 % of disc biopsies, presence of inflammatory cells at histological examination, the absence of responsibility of the discography as a factor of contamination, and the absence of clinical post-operative infection, defend the hypothesis of a low-grade spondylodiscitis which might play a role in the pathophysiology of degenerative disc disease. On the other hand, the presence of skin commensal bacteria, of ¼ of polymicrobial biopsies, and the fact that previous nucleotomy doesn't seem to be involved in inoculation, cannot allow to eliminate a contamination of the samples. Further studies are necessary to elucidate the responsability of intradiscal bacteria in degenerative disc disease. This could influence our treatment strategy of back pain, which could be based in the future on antibiotics

Objectives: To examine and correlate the presence of neovascularisation, crystalline pyrophosphate deposits and other hisotological features in the disc and discogenic pain established by spinal probing and discography under aware state endoscopic visualisation. Design: Tissue removed from intervertebral discs of 224 patients during surgery were examined by direct and polarised microscopy to identify the presence of calcium pyrophosphate and neovascularisation. Material and Methods: Histology was correlated to the diagnostic provocative findings of spinal probing and discography, discal palpation during aware state endoscopy. Results:Calcium Pyrophosphate: 20/224 (9%) patients demonstrated calcium pyrophosphate in the discs. Fourteen had pain reproduced on probing or discography; 13/20 (65%) of patients had either an annular collection or leak at the index level; 6/20 had an extradiscal cause of pain. Neovascularisation: Thirty-seven out of 224 (16.5%) patients showed neovascularisation in the disc; four discs had crystalline pyrophosphate deposits; 33/37 (90%) had pain on probing and/or discography. Conclusion: The presence of pyrophosphate in a disc without a tear or leak is not associated with annular tenderness. The presence of pyrophosphates in radial tears or leaks is associated with annular tenderness. Annular tears or leaks are not directly correlated to the presence of pyrophosphates. There is a high correlation between pain provocation and neovascularisation

Problem Chronic disabling pain in the sacrococcygeal region is regarded by clinicians with great dismay because of unpredictability of the treatment outcome. The subject is under- represented in the literature. Method Thirty eight patients with intractable coccydynia had imaging investigations for the spine other than X-rays. Six of these patients were also investigated by means of sacrococcygeal and intercoccygeal discography. The excised specimen with intact sacrococcygeral joint was sent for histological examination in 22 patients. Patients’ assessment of the benefit of coccygectomy was conducted by telephonic interview. Results After a mean post surgical follow up of 6.75 years (range 2–16 yrs), results were available for 31 out of 38 patients. 16 patients benefited greatly from the surgery and 6 benefited to some extent, giving an overall good result of 71%. 7 patients had no or little relief from surgery (29%). Moderate to severe degenerate changes in SC and IC joints on histology were found in 59% of patients. 91.6 % of these patients did well with surgery. Only 60 % of those with mild changes did well. Discography was possible in five out of six attempted cases. Two were positive and both did well from surgery. Three patients had negative discographies and two of them had a poor result and one had only some relief. Conclusions Degenerate changes in sacrococcygeal discs give rise to pain. Surgical results are better in those with a severe degree of degenerative change. It is possible to identify these with discography, though a larger study needs to be carried out

Purpose. By systematic literature review, to quantify the association between vertebral endplate signal changes (VESC) and non-specific low back pain (NSLBP). Materials and methods. MEDLINE, EMBASE, and SveMED databases were searched for the period 1984 to June 2009. Articles were included which investigated the association between VESC and NSLBP and reported sufficient data to construct two-by-two tables. Articles on specific low back pain conditions were excluded. A standardised data collection and quality assessment were performed. To estimate the association between VESC and NSLBP, two-by-two tables were created and exact odds ratios were calculated with 95% confidence intervals (CI). Meta-analysis was performed on homogeneous studies. Results. Fourteen articles met the inclusion criteria. A statistically significant positive association between VESC and NSLBP was found in 10 of 14 studies from the general, working, and clinical populations with odds ratios ranging from 2.0 to 27.9. Two of the other four studies showed positive associations, one study a neutral association and the other a negative association but all these results were not statistically significant. Meta-analysis of the eight discography studies included in the review showed a pooled odds ratio between VESC and pain on discography of 4.50 (CI 1.96-10.32). The median prevalence of pain on discography was 88.8% in people with VESC and 41.6% in those without VESC (46.8% overall). Conclusions. The results from this systematic review show that VESC in the lumbar spine is associated with pain and therefore should be noted routinely in MRI reports

Aim: To assess the outcome of patients with chronic discogenic lumbar back pain who underwent intradiscal electro thermal therapy (IDET). Design: A prospective longitudinal study. Subjects: Patients undergoing IDET in our unit between April 2000 and October 2007 were included in the study after assessment with discography and diagnostic imaging. Discographic concordant symptoms with subsequent abolition with local anaesthetic led to inclusion in the study regardless of discogram volume. Outcome Measures: Subjects were assessed preoperatively with VAS pain scores, SF36, demographic data and pain diagrams. Then were then reassessed postoperatively with the, VAS pain scores SF36, employment status and subjective outcome at 6, and 12 months. Results: 83 patients were treated with IDET. We had a follow up rate of 75% leaving a cohort of 65 patients. Mean follow up 7.6 months. Overall there was a mean improvement in pain VAS scores of 1.9 (p=0.0875). SF36 scores showed minimal improvement in both physical and mental parameters and there was minimal improvement in subjective outcome in 55% of patients. However it was observed that a small subgroup of patients (30%) aged less than 40 with low volume positive discography and single level disease mean pain VAS scores improved by 3.78 from 7.52 to 3.74. 72% of these patients reported a subjective improvement in symptoms and SF36 scores improved significantly compared to the overall group. Further analysis also revealed that the use of pain diagrams when interpreted according to the principles of Mann et al was the predictive value. Conclusions: Patient selection seems to be crucial in determining a successful outcome using IDET. We still perform this procedure on those patients aged less than 40 with single level disease, positive low volume discography, no facet joint arthritis and an organic pre procedure pain diagram

We report a series of 98 patients with back pain and sciatica in whom the MRI scan was reported as normal. The patients were referred by their General Practitioners and the MRI was the first and only investigation. The patients were subsequently subjected to plain radiographs including weight-bearing spot laterals of the lumbo-sacral spine, and discography in which pain provocation and reversal were judged as indicative of a pain source. Significant degenerative change was noted in plain radiographs in 27 cases, and weight-bearing views revealed a spondylolisthesis in eight cases where the supine view and MR had appeared normal. Discography had revealed intradiscal fissuring correlating with pain reproduction and reversal in 36 cases. MRI is a scarce resource with very long waiting lists in many parts of the country and the value of the investigation may have been exaggerated both in terms of false positive and false negative results. On the basis of our study we recommend a review of radiological policy

Objective: To report a randomised controlled trial (RCT) of the therapeutic efficacy of intradiscal steroid injection for the treatment of discogenic back pain after two years. Introduction: Discography remains the main method to assess whether a degenerate disc is the source of back pain. The treatment of such discogenic pain is difficult. There is only one previous RCT of the use intradiscal steroids, but with a short follow-up. Patients and Methods: 120 consecutive patients with positive discography were randomised intra-operatively to receive an intradiscal injection of saline or 40mgs Depomedrone. Outcome was assessed using a back pain questionnaire at six weeks, three and six months, and at two years. Pain (using a visual analogue score), disability (the Oswestry Disability Index), and psychological status (DRAM score) were measured. The results were correlated with Modic changes and high intensity zones on MRI scan. Results: An initial improvement of back pain in the steroid group is not maintained at two years, with no statistical difference between the two groups. Correlation of the results with the MRI findings will be presented. Conclusion: This study demonstrates the need for long-term follow-up of such intradiscal therapeutic methods of treating discogenic pain

Aims: MRI changes to the symptomatic intervertebral disc following Intradiscal Electrothermal Therapy (IDET), in particular those relating to the Ç High Intensity Zone È (HIZ) in the posterior annulus, were determined in this prospective study. Methods: MRI images before the IDET procedure were compared to those taken at six months post procedure in 10 patients. The presence and absence of an HIZ, the disc height and hydration, and Modic changes, were determined from the images. Two of the patients also had discography performed post-IDET to supplement the MRI. Results: In 6 out of the 10 patients, an HIZ was present on the MRI images of the disc before the IDET procedure. In all 6 patients, a HIZ was still present six months after the procedure. In all 10 patients, there were no changes to disc height and hydration signal on T2 weighted images. Modic changes were not present in any of the patients on pre or post IDET images. Two patients had signiþ-cant changes to the shape of the posterior annulus compared to the pre-treatment MRI scans. The two patients who had discography after IDET had persistent annular tears. Conclusion: Our þndings question the clinical relevance of the Ç High Intensity Zone È. They also suggest that the main mechanism of action of IDET, may be other than that of sealing the annular tear

Introduction: We report a series of 10 cases from a cohort of 421 Dynesys procedures in which evidence of Accelerated Adjacent Disc Disease (AASDD). Spinal fusion for degenerative disc disease is known to have inconsistent outcomes. One concern is the possibility of AASDD as a result of the altered kinematics. The Dynamic Neutralisation System (Dynesys) appears to offer an advantage in that it restricts, rather than abolishes movement at the treated segment, and should thereby reduce the problem of AASDD, In the event of failure, it can in addition be removed, returning the spine to the former status quo. Various biomechanical studies confirmed flexibility of Dynesys. Method: Ten patients developed new and symptomatic disc disease within segments adjacent to Dynesys. The average age of patients was 49 year with range between 36–70 years. Average post Dynesys to secondary surgery for ASD was 24.7 months. Previous discography and MRI in all cases had shown no evidence of disc disease within these adjacent segements prior to Dynesys. All patients were evaluated preoperatively using Oswestry Disability Index, SF 36 and Visual Analogue Scores together with plain x ray imaging, MRI scanning and discography. Of this cohort Dynesys was indicated to treat single disc level in 7 and two levels in 3. Results: Incidence of AASDD associated with Dynesys was 2.1%. Further surgical intervention included:. Extension of Dynesys10. Dynesys combined with MIF2. Dynesys combined with PLIF2. There was no caudal ASD in our cohort. Discussion & Conclusions: Dyensys did not prevent the development of accelerated ASD. Evidence from Aylott cadaver studies suggests that Dynesys instrumentation alters the Kinematics of the adjacent segment and increases the excursion. It is unclear whether the small number of AASDD reported here is other than the natural progression of degenerative change. 95.7 cases did not progress

Objective: MRI changes to the symptomatic intervertebral disc following Intradiscal Electrothermal Therapy (IDET), in particular those relating to the “High Intensity Zone” (HIZ) in the posterior annulus, were determined in this prospective study. Material and Methods: MRI images before the IDET procedure were compared to those taken at six months post procedure in 10 patients. The presence and absence of an HIZ, the disc height and hydration, and Modic changes, were determined from the images. Two of the patients also had discography performed post-IDET to supplement the MRI. Results: In 6 out of the 10 patients, an HIZ was present on the MRI images of the disc before the IDET procedure. In all 6 patients, a HIZ was still present six months after the procedure. In all 10 patients, there were no changes to disc height and hydration signal on T. 2. weighted images. Modic changes were not present in any of the patients on pre or post IDET images. Two patients had significant changes to the shape of the posterior annulus compared to the pre-treatment MRI scans. The two patients who had discography after IDET had persistent annular tears. Conclusion: Our findings question the clinical relevance of the “High Intensity Zone”. They also suggest that the main mechanism of action of IDET, may be other than that of sealing the annular tear

Introduction The aim of the study was to determine the prevalence of different causes of neck pain in a private practice clinic by a retrospective audit of records. Methods The study included all consecutive patients attending a private spine pain clinic in the state of Washington, USA, seen between January 2003 and January 2005, in whom a diagnosis of neck pain was made. The records of all patients were examined to determine the prevalence of various diagnostic entities determined by history, examination, and invasive tests such as controlled diagnostic blocks and provocation discography. Using different denominators, the prevalence of various conditions was determined in all patients who presented with neck pain, in patients in whom investigations were undertaken, and in patients who completed investigations. Results A large proportion of patients (35%) did not pursue investigations, which diluted the crude prevalence of various conditions. A further 17% deferred completing investigations. Amongst the 48% of patients who completed investigations, the prevalence of zygapophysial joint pain was 55%, discogenic pain was 16%, and lateral atlanto-axial joint pain was 9%. A diagnosis remained elusive in only 17% of those patients who completed investigations. Discussion In a private practice setting, a patho-anatomic diagnosis for chronic neck pain can be established in over 80% of patients, provided that appropriate investigations are undertaken. The prevalence of cervical zygapophysial joint pain encountered in the present study corroborates the prevalence rates established in academic studies. The observed prevalence of discogenic pain is probably an underestimate because not all eligible patients underwent discography

Thirteen patients with symptomatic disc herniation in the cervical spine were treated with percutaneous laser disc decompression (PLDD). Patients included 10 males and 3 females with a mean age of 41.4 (range, 24–60) years old. Preoperative symptom was divided into 2 types; myelopathy in 8 and radiculopathy in 5 patients. The level of the treated disc, which was diagnosed from the provoked cervicobrachial neuralgia during discography, distributed to C4/5 in 1, C5/6 in 8, C6/7 in 4 patients. The Nd:YAG laser (1064 nm) was percutaneously irradiated to the involved disc through a needle of 1.5 mm with a mean energy of 600 joules. Clinical evaluations were assessed with modified Macnab`s criteria at a mean follow-up period of 3 years (range, 0.5–5.7 years) excluding one patient who received open surgery 3 weeks after PLDD. Six patients (46.2%) showed good to excellent results without any significant complications. Four patients of 7 with unsuccessful results received a subsequent open surgery. There was no significant difference between successful and unsuccessful group in gender, disc level, preoperative duration of symptoms, positive provocation during discography, and the total amount of irradiated energy. Patients with successful results tended to be younger with a mean age of 35.7 years compared to those with unsuccessful results with a mean of 46.3 (p=0.053). Clinical outcome in two patients with radiculopathy were judged as excellent. Although postoperative MRI revealed few morphological changes on the disc in 2–3 weeks after PLDD, MRI at the final follow-up showed remarkable decrease of signal intensity in the disc. On postoperative radiographs, the disc height and the range of motion during flexion to extension in the treated discs significantly decreased, indicating the acceleration of disc degeneration and the resultant stabilization of the segment