Discogenic Pain
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Male 47 years old, healthy, weight 80 kg, height 1,80 metres. He suffers from a pain on his back on the lumbar level in the middle of the spine with some lateralization to the left side. The pain has gradually evolved in the last six months into moderate intensity along the day, with increases with the action of bending in flexion and in sitting position. He drives long distances by car.
On physical examination, the palpation on his back -midline- is painful. There is not radiation to the buttock or leg (Lasegue -) and reflexes are normal.
MRI: L5-S1 disc shows posterolateral hernia to the left.Some degenerative changes on the other discs.
The patient was scheduled for diagnostic discography for the next day. He was admitted early in the morning because of severe pain; it was controlled with NSAIDS, Acetaminophen and morphine IV.
During the afternoon the discography was perform under radioscopic guidance on the L5-S1 and L4-L5. On the L5-S1 disc it was not possible to inject contrast dye because of high pressure. On L4-L5 disc we inject 0,5-1,0 cc medium, where we found concordant pain and a leak of contrast on the left side. We considered we have had done the diagnosis and proposed the patient to perform a thermal radiofrecuency 72 hours later.
The patient was free of pain the first 24 hours, but the pain begins to increase. We have had the doubt if it was correct to perform another punture to the disc at that time. The second questions is if all the clinical picture came from the L4-L5 disc.
Finally we perform a thermal radiofrequency 7 days after the discography. We access the L4-L5 disc by the left side with a radiofrequency needle 1,5 cm active tip; once in place, we delivered one pulse of thermal 80ª /2 minutes to nucleus and repeated 6 times. A final pulsed radiofrequency 42ª/6 minutes was done to the annulus. At the end of the procedure, the patient was free of pain -on standing and walking- and was discharged.
Two days later he sent us a message saying he had pain -4 NRS- that increases next days. Last Friday -10 days after the thermal radiofrequency-, he has moderate pain on the buttock and left leg. He was treated with Pregabalin and Steroids.
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Do you have an axial image from the MRI?
Have you looked at the SI joint?
It seems you likely were in the annulus for the L5/S1 discography. It’s tough to argue the L4/5 disc is the source of the pain given that MRI at L5/S1. What about ESI with catheter to the L5/S1 disc via the S1 foramen? We do S1 lysis technique this way. That would likely work wonders.
Dural tug maneuver?
Looking forward to hearing updates.
Matt
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According to the saggital MRI the main source of pain is hernia on L5-S1 level. Why don`t you try to repeat discography for the L5-S1? In case it positive, after RF patient get significant pain relief or make ESI.
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In our practice we always do two discs, one suspected and other one as control(sham). In this case as rightly said by experts above, the source could be
L5-S1 as seen on MRI. repeating a L5-S1discography could possibly help.
thanks.Sarfaraz Khan, MD, FIPP
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Discogenic pain is difficult to diagnose and even more difficult to treat – in my opinion. It is not 100% clear if the pain comes from the disc only, from the inflammation on PLL and anterior epidural space at the affected disc level or a combination.
1, There are some questions regarding pressure monitoring during your discography – have you done any?
2, As far as I understand you tried to inject even L5/S1 but it was impossible to inject anything because to high resistence. I guess in both discs you performed some disc decompression and this caused some temporary pain relief (if the discs were really pain generators)
3, RF protocol you used to treat the disc is a bit strange to me. Thermal for nucleus and pulsed for anulus? Might be better and more logical to do opposite way.
4, We perform disc fx procedure for confirmed disc/discs, it is a complex procedure ( manual disc decompression with grasper – disc tissue is often red/inflammated, nucleus modulation with RF and finally posterior annulus denervation). With a correct indication and a correct technique – reasonably good results.You can do more levels at one session.
5, Very often it is important to treat also anterior epidural space at the affected disc level – PRP or steroids.
6, If symptomps come back – back to the drawing table – you missed something or failed on the treatment technique?Keep well!
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Dr. Rapcan,
You mentioned PRP in your 5th possible treatment. Do you normally prefer PRP over mesenchymal stem cells? I know many physicians who only use MSC’s, as data shows them to be much more effective.
Thank you!
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