Cervical Discograms

What is the Cervical Disc?

The cervical disc is a contained structure. On the outside, the walls of the annulus are the outer boarders of the disc. These walls are made out of collagen, the strong but flexible material that is somewhat like the burlap or nylon of a coat. The inside of the disc is made up of the nucleus, a jelly like substance that is under pressure.

The entire disc can be thought of as a car tire filled with jelly. Normally the disc wall is quite strong but pliant enough to absorb shock and allow some motion including rotation, lateral bending and even some shifting called translation or shear.

Torn Disc in Neck

The disc can unfortunately degenerate enough to produce neck pain. This pain is generated by the tears in the disc wall (the annulus). Disc pain can also be generated by the bony endplate if the disc becomes degenerative enough to allow impact forces to overstress this area, isolated disc resorption or IDR will occur.

Diagnosing the origin of this pain is sometimes very easy if the patient has typical neck pain and that pain is associated with only one degenerative disc found in the neck. However, with multiple degenerative cervical discs present, the diagnosis becomes more difficult. If the neck pain is significant and the patient has failed other conservative treatments, surgery may need to be contemplated.

What is a Cervical Discogram?

This is where the discogram is useful. The discogram can identify the pain generator or generators. It must be noted that this is a pre-surgical test and should not be utilized unless a surgical plan can be contemplated.

The test is quite simple. A needle is introduced into the middle of the disc at the center of the nucleus. X-ray dye is then injected into the disc center to increase the interior pressure.

The skill of the discographer is paramount to the accuracy of the test and the comfort of the patient. Before the first needle is placed, a fast acting pharmacological agent should be employed to significantly sedate the patient. A fully sedated patient will not feel the needles being introduced.

This is similar to the insertion of an intravenous line (IV). The discomfort occurs with initial “poke” through the skin but once the line has been placed, there is no discomfort at the site of insertion.

Once the needles are placed, the patient then needs to be awakened, conscious and capable of answering questions rationally. The discographer needs to be patient to await the subject recovering from this fast acting anesthetic agent to be rational enough to critically answer questions.

How a Discogram is Performed

Three sets of data are generated.

First data points are the opening and maximum pressures of the disc. Opening pressure is the initial pressure that the dye flows into the disc. The maximum pressure is endpoint of the dye flow. These pressures tell us about the integrity of the disc. A disc that has a large tear might be so incompetent that it cannot hold any pressure and maximum pressure generated is low.

The second set of data points are the volume of dye and dye pattern that is generated within the disc. A normal disc is similar to a stiff water balloon. It will admit only a small amount of dye and the dye will stay within the center of this disc. If there is a tear in the disc, this dye will leak out along the tear. If the tear goes through and through the wall of the disc, the dye will exit out along the tear into the adjacent structures.

The most important data point is pain generation. The patient may still be slightly sedated but needs to be awake and able to report the quality and intensity of pain. As the disc is pressurized, a positive test will reproduce the typical pain this patient experiences on a day-to-day basis. This is called “concordant pain”.

Pain is graded on a one to ten visual analog scale. Pain can also be patient-rated as non-concordant. This is pain that occurs with pressurization but is not identifiable as the typical day-to-day pain.

A normal disc should cause no pain but possibly the patient will note a slight “pressure” sensation.

Some discographers always want a “normal” (non-painful) disc to be included to make sure the patient has no pain processing problems. There are circumstances that would make a tested normal disc valuable but many circumstances this is not required (in my opinion).

It bears repeating that this test depends upon the skill of the individual who is performing the test. Various factors can lead to false information. The needle placed into the annulus and not into the center of the nucleus will always cause pain, even in a normal disc. The patient needs to be awake and capable of answering questions. A patient that is not fully awake cannot give appropriate answers. Also, rushing patient answers and not repeating pressurization multiple times to confirm answers can lead to false information.

Related Links

(Click to Enlarge Image) Front to back discogram. Large arrow points to degenerative disc with irregular boarders. Smaller arrow points to normal disc.

(Click to Enlarge Image) Side view discogram. Large arrow points to degerative disc and small arrow points to normal disc.

(Click to Enlarge Image) Normal top-down cervical discogram. Black arrow demonstrates the dye pattern staying within the normal boarders of the disc wall (annulus).

(Click to Enlarge Image) Abnormal top-down cervical discogram. Black arrow demonstrates the dye pattern expanding beyound the normal boarders of the disc wall (annulus) and extending into the spinal canal.

Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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What is the Cervical Disc?

Torn Disc in Neck

What is a Cervical Discogram?

How a Discogram is Performed

Related Links

About the Author: Donald Corenman, MD, DC