Discography <ul><li>Indications </li></ul><ul><ul><li>Axial pain </li></ul></ul><ul><ul><li>Multilevel Disease </li></ul><...
Discography <ul><li>Is Discography a predictor of successful lumbar fusion? </li></ul><ul><li>(3 or more “+” levels on dis...
Discography <ul><li>Technique </li></ul><ul><ul><li>Sterile Technique (full gown/gloves/prep/drape) </li></ul></ul><ul><ul...
Intradiscal Procedure Approach
Intradiscal Procedure Approach
Discography
Discography
Discography
Discography
Discogram Interpretation <ul><li>Injected Volume </li></ul><ul><li>End Point (Subjective or measured) </li></ul><ul><li>El...
Discogram Interpretation <ul><li>Discometry </li></ul>Pressure @ 1 st  Reported Pain Classification <15 PSI <ul><ul><li>Ch...
Discography
Dallas Classification Grade Description 0 Contrast is within the nucleus 1 Extravasation in the inner 1/3 of the annulus 2...
Discography <ul><li>Risks/Complications </li></ul><ul><ul><li>Nerve Root Contact/Injury </li></ul></ul><ul><ul><li>Disciti...
Discography-Discitis <ul><li>Risk Factors </li></ul><ul><ul><li>Diabetes </li></ul></ul><ul><li>Prevention </li></ul><ul><...
Discography-Discitis <ul><li>Presentation </li></ul><ul><ul><li>severe back pain two to four weeks after the procedure </l...
Disc Decompression <ul><li>Coblation/Laser </li></ul><ul><li>Percutaneous Disc Decompression </li></ul>
Disc Decompression <ul><li>Indications </li></ul><ul><ul><li>Herniated Disc/Protrusion </li></ul></ul><ul><ul><li>Radicula...
Intra-Discal Electrothermal Therapy (IDET)
Intra-Discal Electrothermal Therapy (IDET) <ul><li>Indications </li></ul><ul><ul><li>Axial low back pain of at least 6 mon...
Intra-Discal Electrothermal Therapy (IDET) <ul><li>Contraindications </li></ul><ul><ul><li>Absolute </li></ul></ul><ul><ul...
DDD with Annular Tear
Intra-Discal Electrothermal Therapy (IDET) <ul><li>Efficacy </li></ul><ul><ul><li>Boswell MV, Trescot AM, Datta S,  Schult...
IDET-Mechanism of Action
 
IDET
IDET
Intradiscal Procedures (misc) <ul><li>Intradiscal Steroids </li></ul><ul><li>Chemonucleolysis </li></ul><ul><ul><li>Chymop...
Intradiscal References: <ul><li>Derby R, Howard M, Grant J, Lettice JJ,Van Peteghem PK, Ryan DP. The ability of pressure c...
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Intradiscal procedures

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Intradiscal procedures

  1. 2. Discography <ul><li>Indications </li></ul><ul><ul><li>Axial pain </li></ul></ul><ul><ul><li>Multilevel Disease </li></ul></ul><ul><ul><li>PLANNED INTERVENTION (if “+”) </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Local Neoplasm </li></ul></ul><ul><ul><li>Anti-coagulation/Coagulopathy </li></ul></ul><ul><ul><li>Iodine Allergy? (May use Gadolinium) </li></ul></ul>
  2. 3. Discography <ul><li>Is Discography a predictor of successful lumbar fusion? </li></ul><ul><li>(3 or more “+” levels on discography are contraindication to fusion) </li></ul>
  3. 4. Discography <ul><li>Technique </li></ul><ul><ul><li>Sterile Technique (full gown/gloves/prep/drape) </li></ul></ul><ul><ul><li>Extra Spinal vs. Trans-Dural </li></ul></ul><ul><ul><li>IV vs. Intradiscal Antibiotics </li></ul></ul><ul><ul><li>“ Double Needle” Technique </li></ul></ul><ul><ul><li>Pressure monitoring/recording </li></ul></ul><ul><ul><li>Post Discography CT </li></ul></ul>
  4. 5. Intradiscal Procedure Approach
  5. 6. Intradiscal Procedure Approach
  6. 7. Discography
  7. 8. Discography
  8. 9. Discography
  9. 10. Discography
  10. 11. Discogram Interpretation <ul><li>Injected Volume </li></ul><ul><li>End Point (Subjective or measured) </li></ul><ul><li>Elicited Pain Intensity/Quality/Location </li></ul><ul><li>Analgesia/response to intradiscal Local Anesthetic (after “+” response) </li></ul><ul><li>Nucleogram (Morphology) </li></ul>
  11. 12. Discogram Interpretation <ul><li>Discometry </li></ul>Pressure @ 1 st Reported Pain Classification <15 PSI <ul><ul><li>Chemically Sensitive </li></ul></ul>15-50 PSI <ul><ul><li>Mechanically Sensitive </li></ul></ul>>50 PSI <ul><ul><li>Indeterminate </li></ul></ul>
  12. 13. Discography
  13. 14. Dallas Classification Grade Description 0 Contrast is within the nucleus 1 Extravasation in the inner 1/3 of the annulus 2 Extravasation in the middle 1/3 of the annulus 3 Extravasation in the outer 1/3 of the annulus 4 More then 30 degrees of annular circumference 5 Extra-annular contrast
  14. 15. Discography <ul><li>Risks/Complications </li></ul><ul><ul><li>Nerve Root Contact/Injury </li></ul></ul><ul><ul><li>Discitis (0.1%) </li></ul></ul><ul><ul><li>Dural Puncture </li></ul></ul><ul><ul><li>Chemical/bacterial Meningitis </li></ul></ul><ul><ul><li>Epidural Abcess/Hematoma </li></ul></ul><ul><ul><li>Allergic Reaction (Contrast/Antibiotics) </li></ul></ul>
  15. 16. Discography-Discitis <ul><li>Risk Factors </li></ul><ul><ul><li>Diabetes </li></ul></ul><ul><li>Prevention </li></ul><ul><ul><li>IV Antibiotics </li></ul></ul><ul><ul><li>Intra-discal Antibiotics </li></ul></ul><ul><ul><li>Styletted Needles </li></ul></ul><ul><ul><li>Double Needle Technique </li></ul></ul>
  16. 17. Discography-Discitis <ul><li>Presentation </li></ul><ul><ul><li>severe back pain two to four weeks after the procedure </li></ul></ul><ul><ul><li>Pain is exacerbated by any motion and relieved by rest. </li></ul></ul><ul><li>Diagnosis </li></ul><ul><ul><li>MRI (“Gold Standard”) </li></ul></ul><ul><ul><li>ESR </li></ul></ul><ul><ul><li>Bone Scan </li></ul></ul><ul><ul><li>(Leukocytosis & fever are uncommon) </li></ul></ul><ul><ul><li>(In the first three weeks bone scan, MRI, and ESR can be normal) </li></ul></ul>
  17. 18. Disc Decompression <ul><li>Coblation/Laser </li></ul><ul><li>Percutaneous Disc Decompression </li></ul>
  18. 19. Disc Decompression <ul><li>Indications </li></ul><ul><ul><li>Herniated Disc/Protrusion </li></ul></ul><ul><ul><li>Radicular pain </li></ul></ul><ul><ul><li>“ +” Discography </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Instability </li></ul></ul><ul><ul><li>Loss of disc height (>30% loss) </li></ul></ul>
  19. 20. Intra-Discal Electrothermal Therapy (IDET)
  20. 21. Intra-Discal Electrothermal Therapy (IDET) <ul><li>Indications </li></ul><ul><ul><li>Axial low back pain of at least 6 months duration </li></ul></ul><ul><ul><li>Failure to respond to conservative treatment </li></ul></ul><ul><ul><li>>60% residual disc height </li></ul></ul><ul><ul><li>Positive concordant discogram at low pressure </li></ul></ul><ul><ul><li>Normal neurologic exam (or at least no new deficits attributable to level to be treated.) </li></ul></ul><ul><ul><li>Negative straight-leg raise </li></ul></ul><ul><ul><li>MRI with no evidence of root compression, tumor, or infection (if root compression is present, consider PMDD) </li></ul></ul><ul><li>Contraindications </li></ul>
  21. 22. Intra-Discal Electrothermal Therapy (IDET) <ul><li>Contraindications </li></ul><ul><ul><li>Absolute </li></ul></ul><ul><ul><ul><li><50% disc height </li></ul></ul></ul><ul><ul><ul><li>Active infection </li></ul></ul></ul><ul><ul><ul><li>Coagulopathy </li></ul></ul></ul><ul><ul><ul><li>Lumbar instability/spondylolisthesis </li></ul></ul></ul><ul><ul><ul><li>Sequestered/extruded disc herniation </li></ul></ul></ul><ul><ul><ul><li>Severe compressive disc herniation </li></ul></ul></ul><ul><ul><ul><li>Moderately severe or severe spinal stenosis </li></ul></ul></ul><ul><ul><ul><li>Previous fusion at same level </li></ul></ul></ul><ul><ul><ul><li>Pregnancy </li></ul></ul></ul><ul><ul><li>Relative </li></ul></ul><ul><ul><ul><li>Herniated nucleus pulposis </li></ul></ul></ul><ul><ul><ul><li>>3 level positive discogram </li></ul></ul></ul><ul><ul><ul><li>Significant endplate sclerosis/modic changes </li></ul></ul></ul><ul><ul><ul><li>Previous surgery at same level </li></ul></ul></ul><ul><ul><ul><li>Inflammatory arthritides </li></ul></ul></ul>
  22. 23. DDD with Annular Tear
  23. 24. Intra-Discal Electrothermal Therapy (IDET) <ul><li>Efficacy </li></ul><ul><ul><li>Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Hansen HC, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L. Interventional techniques:evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007; 10:7-111. </li></ul></ul>
  24. 25. IDET-Mechanism of Action
  25. 27. IDET
  26. 28. IDET
  27. 29. Intradiscal Procedures (misc) <ul><li>Intradiscal Steroids </li></ul><ul><li>Chemonucleolysis </li></ul><ul><ul><li>Chymopapain </li></ul></ul>
  28. 30. Intradiscal References: <ul><li>Derby R, Howard M, Grant J, Lettice JJ,Van Peteghem PK, Ryan DP. The ability of pressure controlled discography to predict surgical and non-surgical outcome. Spine 1999; 24:364-371. </li></ul><ul><li>Shah RV, Everett CR, McKenzie-Brown AM, Sehgal N. Discography as a diagnostic test for spinal pain: a systematic and narrative review. Pain Physician 2005; 8:187-209. </li></ul><ul><li>Buenaventura RM, Shah RV, Patel V, Benyamin R, Singh V. Systematic review of discography as a diagnostic test for spinal pain: an update. Pain Physician 2007; 10: 147-164. </li></ul><ul><li>Hirsch C. Attempt to diagnose the level of disc lesion clinically by disc puncture. Acta Orthop Scand 1948; 18:131-140 </li></ul><ul><li>Vanharanta H, Sachs BL, Spivey MA, Guyer RD, Hochschuler SH, Rashbaum RF, Johnson RG, Ohnmeiss D, Mooney V. The relationship of pain provocation to lumbar disc deterioration as seen by CT/discography. Spine 1987; 12:295-298 </li></ul><ul><li>Zucherman J, Derby R, Hsu K, Picetti G, Kaiser J, Schofferman J, Goldthwaite N, White A. Normal magnetic resonance imaging with abnormal discography. Spine 1988; 13:1322-1359. </li></ul><ul><li>Lam KS, Carlin D, Mulholland RC. Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the discogenic pain source. Euro Spine J 2000; 9:36-41 </li></ul><ul><li>Fraser HF, Osti OL, Vernon-Roberts B. Discitis after discography. J Bone Joint Surg Br 1987; 69:26-35. 31. </li></ul><ul><li>Osti OL, Fraser HF, Vernon-Roberts B. Discitis after discography. The role of prophylactic antibiotics. J Bone Joint Surg Br 1990; 72:271-274 </li></ul><ul><li>Derby R, Eek B, Lee SH, Seo S, Kim BJ. Comparison of intradiscal restorative injections and intradiscal electrothermal treatment (IDET) in the treatment of low back pain. Pain Physician 2004; 7:63-66. </li></ul><ul><ul><li>Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Hansen HC, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L. Interventional techniques:evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007; 10:7-111. </li></ul></ul>

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