| Back Pain - Disc Pain
Background:
A 36 year old man presented with a 12 year history of back pain that developed during a game of beach rugby when he picked up an opponent, twisted and turned in a tackle. He felt his back go. The pain had been worse in the previous five years. The pattern during this time was of flare ups every 3 months lasting for 1 month. Triggering events included bending down to lift his daughter or prolonged sitting on the floor. The pain was worse as the day progressed, but during the periods of lesser pain he could sit for an hour at work. He had mild morning stiffness.
The background pain was about 5/10. He had stopped competitive sport although he still tries to run.
The pain is predominantly across the low lumbar region and then referred into the buttocks and posterior thigh.
Previous treatment includes an interlaminar epidural which did not help. There is no significant previous history or current medications.
On examination there was a reasonably good range of movement. No abnormal peripheral neurological findings. Tenderness was present bilaterally over the L4/5 articular pillars more so than L5/S1 or the sacroiliac joint.
The provisional diagnosis was lumbar zygapophysial (facet) joint pain. The diagnostic blocks proved negative. He then underwent MRI and discography.
The MRI was as follows: At L5/S1 there was a left contained paracentral disc protrusion that abutted and mildly displaced the left S1 nerve root. At L4/5 there was a small central contained disc bulge with associated annular tear but no apparent nerve root compromise. There was a congenitally small central spinal canal particularly at the L4/5 level. At the L3/4 level there was a far left lateral disc protrusion that displaced the exited L3 nerve root. Disc height was retained at all levels and there were no end-plate changes.
He then underwent discography.
OPERATION REPORT: Lumbar discography
Details:
Following explanation and discussion the patient was taken to the operating room and placed prone on the operating room table. An intravenous line was inserted and then the lower back extensively prepped with Betadine. Sterile drapes were applied. Under C arm fluoroscopic control the ideal entry points to the lower lumbar discs were identified. Skin anaesthesia was performed with 2% Xylocaine. A 16 gauge intravenous cannula was inserted through the skin in a modified double needle technique. Through this 6 inch pre-curved Ciba needles were placed into the L3/4, L4/5 & L5/S1 discs. Luer lock syringes (3 ml) were primed using Isovue 360 in combination with Cephazolin. Then, 200mg. of Cephazolin was added in a routine way to the 10ml. of Isovue mixture. He tolerated the procedure well.
Discogram Results:
|
L3/4 |
L4/5 |
L5/S1 |
Opening pressure |
10 |
5 |
8 |
Maximum pressure |
85 |
80 |
70 |
Volume |
1.2 |
1.6 |
1.7 |
Morphology |
Normal |
Posterior fissure |
Right Posterolateral fissure/ |
Pain production
- at opening + psi |
nil |
Minor -general |
9/10
+ 32 psi |
- retest |
Confirmatory |
Confirmatory |
Confirmatory |
- nature (comparison to patient’s usual pain) |
|
not typical |
Similar -concordant |
- distribution |
|
|
Similar |
 
 
Conclusion:
This was a positive discogram at L5/S1. He was scheduled for L5/S1 nucleoplasty.
Alternative treatments for this pain are as follows:
- No treatment: this is always an option. The unknown is for how long a particular disc problem will last. There is no data on this.
- IDET: another option for discogenic pain. Pain that is predominantly in the back and has associated referred but not true radicular leg pain with a positive discogram might also be helped by IDET. These treatments aim to denervate the painful tissue as well as to scar up the degenerate and inflamed tissue. The limiting features on this therapy include the inability to definitely achieve this aim. The needle is thin and the area of pain producing tissue probably widespread. It may be that the heat lesions are not comprehensive enough at this stage of development.
- Operation: various operations can also be performed. These include simple discectomy, which is the least invasive but may not help if any pain is from inside the disc; discectomy and fusion; and discectomy and disc replacement.
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Percutaneous Disc Decompression - DISC Nucleoplasty
Level : L5/S1
Indication – Positive Discogram
Procedure:
Routine sterile draping & gowning. 1 gram cephazolin given intravenously pre-op. Right sided access under fluoroscopic imaging. A crisp vertebral body endplate and oblique alignment to achieve disc pucture. 1% Xylocaine to the skin, then a 14 G jelco placed in direct line of sight to disc. A 17G Crawford need le was then directed through the jelco to the disc. AP & Lateral imaging confirmed good intra-discal placement.
6 passes around the ‘clock’ from 12, 2, 4, 6, 8, 10 rotations –positions. Coblation on forward passing and coagulation on withdrawal. A small amount of cephazolin laced intra-discally at conclusion.
A exit foramen epidural with 2ml Xylocaine 2% and 1ml Celestone to assist post operative pain management. Discharged at 90 minutes.
 
 
The images show PA and lateral views of the nucleoplasty wand in the L5/S1 disc
Results:
The patient reported at 4 months that the results had been "sensational". Before the procedure pain had been at 9/10, and the typical pain in between attacks was 5/10. Pain had remained at 0-1/10 since the nucleoplasty. He said it was the first time that he had been pain free in “I don’t know how long”. He could tell there was something different within one week of the treatment.
The literature suggests that if the pain is under control at this point after the nucleoplasty then it will remain good.
June 2006
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