Cervical Discography

Studies have proven that MR imaging is insensitive in the detection of painful cervical disc annular lesions and internal disc derange-ments.17,18,28 Positive (intense, concordant pain) cervical discography in symptomatic patients with either normal or mildly abnormal MR stud ies is common. Discography often reveals cervical disc annular lesions that are simply not visible on the highest resolution MR imaging studies. Prior research has demonstrated that discographically normal cervical discs should not be painful but are relatively uncommon in clinical practice, since coincidental (painless) annular lesions are the rule in the cervical spine. The presence or absence of annular disruption has little relevance in the cervical spine, although all intensely painful discs manifest tears either into or through the outer annulus (Figures 6.11 and 6.12). At C2-318 there is no demonstrable correlation between MR, discographic morphology, and provoked response (Figure 6.11C, D).

Cervical discography requires a high-resolution, multidirectional C-arm device with magnification and filming capability, as well as a sophisticated table. Although variable techniques have been described, we have used exclusively single 25-gauge needles in over 2900 patients, most of whom have undergone multilevel studies, and have had no serious complications. As in the lumbar and thoracic region, intra-discal Cefazolin is employed unless there is allergy to either cephalo-sporins or penicillins. It is crucial to review prior imaging studies (ideally MR) of the cervical spine before performing the discography. Discography should not be performed at any level where frank spinal cord compression exists, with or without myelopathy. Any disc level manifesting spinal cord deformity should be either avoided or studied with extreme care, depending upon individual circumstances.12,17,18

In preparation for cervical discography, the patient is placed on the fluoroscopic table, supine, with the shoulders slightly elevated and head extended and rotated away from the discographer. For a right-handed discographer, the needle is introduced from the right side, from approximately 30 to 45° oblique to and slightly below the target disc. A single 25-gauge needle is carefully advanced toward (ideally into) the disc, while the left index and middle fingers are used to palpate the cervical spine. The needle is directed between these fingers and passes directly through the skin and ideally into the disc, or as close to the disc as is possible. Neck palpation with the index and third fingers from the nondominant hand allows the proceduralist to push the carotid artery either laterally (most often) or medially and the esophagus (almost always medially) away from the intended needle tract. A 25-gauge needle, held in the right hand between the index finger and thumb, is carefully advanced through the skin and either into the disc or against the spine immediately adjacent to the disc. We perform the skin puncture and needle placement without live fluoroscopy. After needle insertion, we remove our hands from the field and perform flu-oroscopy for a few milliseconds to assess needle position. After needle position has been determined, fluoroscopy is used to assist with fine adjustments until optimal needle position within the intended disc has been achieved. In most cases, if the needle tip is within millimeters of the inferior disc margin, it can be manipulated upward and into the disc without difficulty. If, however, the needle is noted to be above the desired disc, we recommend needle removal and reintroduction. The performance of lateral fluoroscopy during needle placement helps one eliminate the risk of unintended needle advancement through the disc

Cervical Spine Anatomy Fluoroscopy

Figure 6.11. Painfully deranged cervical discs in patient with old, solid cervical fusion. (A) AP and (B) lateral films of the C3-4 disc obtained during injection reveal circumferential annular disruption and contrast leakage (arrows) (leakage best seen on lateral view, B). Note needle placement into center of nuclear space (A and B). 10/10 concordant bilateral upper and mid neck pain.

Figure 6.11. Painfully deranged cervical discs in patient with old, solid cervical fusion. (A) AP and (B) lateral films of the C3-4 disc obtained during injection reveal circumferential annular disruption and contrast leakage (arrows) (leakage best seen on lateral view, B). Note needle placement into center of nuclear space (A and B). 10/10 concordant bilateral upper and mid neck pain.

Neck Pain From

Figure 6.11. Continued. (C) AP and (D) lateral images obtained during injection of C2-3 disc reveal full-thickness tear posteriorly, with contrast leakage into both foramina and epidural space (arrow). Patient reported 9/10 concordant occipital head pain and upper neck pain.

Occipital Cervical Fusion
d

Figure 6.11. Continued. (C) AP and (D) lateral images obtained during injection of C2-3 disc reveal full-thickness tear posteriorly, with contrast leakage into both foramina and epidural space (arrow). Patient reported 9/10 concordant occipital head pain and upper neck pain.

Cervical Discogram
Bilateral Trapezius
Figure 6.12. Painfully deranged C4-5 disc. Lateral view obtained during injection reveals full-thickness posterior tear (curved arrow), with epidural leakage of contrast (straight arrow). Patient reported 9/10 concordant diffuse neck and bilateral trapezius muscle pain.

and into the spinal cord, which otherwise can easily occur (and has) in inexperienced hands.

Following successful needle placement into the disc, fluoroscopy is performed during the injection of either contrast or saline. Injection volume, end-point characteristics, patient response, concordance/non-concordance and intensity rating are recorded after the disc has been filmed. It is recommended17,18,28 that one study as many cervical discs as are accessible (C3-4 through C6-7 in most individuals), since pure imaging studies have been proven to be inaccurate in detecting painful annular lesions in the cervical spine. In special cases, especially when headache of suspected cervical origin is a prominent clinical complaint, discography at C2-3 may be indicated.18,28 In our experience, post-discography CT in the cervical region is generally noncontributory, although it has been studied, and is used by many.10 Whenever saline and Gadolinium are injected, postdiscography MR is performed.

Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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Responses

  • rasmus
    How painful is a posterior cervical discography?
    7 years ago
  • quintina
    Are cervical vetrebal bodies curved?
    6 years ago

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