Lumbar Discograms

What is a Lumbar Discogram?

The discogram is a unique spinal test. It is the only test to indicate if the disc is the source of lower back or neck pain. The discogram test actually stresses the disc to determine if it is reproducing pain. This test also has a visual component to it. You can observe what the architecture of the disc is like by the discogram to corroborate the stress results.

Most spinal injection tests are analgesic. These tests “numb” a structure and the pain level in the patient will be temporarily reduced for 2-3 hours. The discogram is the only spinal test that is provocative. It is designed to reproduce pain in an awake patient to prove the source of pain or the “pain generator”. The pain is replicated only for an instant and if pain is reproduced, the patient can identify if the pain is the typical pain that occurs from day to day.

How Does a Discogram Work?

The concept of the discogram is easy to understand. Back pain from the disc is caused by aggravation of pain receptors in the torn annulus (plies of the tire) or the compression of a degenerative bony vertebral endplate (see degenerative disc disease of cervical or degenerative disc disease lumbar spine in separate section). This test is designed to stress these structures and reproduce the normal day to day pain only for a moment. It is essentially a pressure test of the disc designed to reproduce typical pain.

The test also has value in looking at the morphology of the disc (what the inside of the disc looks like). The fluid injected is X-ray contrast dye (mixed with some antibiotic). If tears are present, this dye will demonstrate the tears in the disc walls. The walls will be either intact (the dye looking somewhat like a cotton ball in the center of the disc) or there will be a disruption of the disc wall. A through and through tear will leak the dye into the surrounding tissues.

How is a Discogram Performed?

The test is actually very simple. A needle is placed into each disc in question in a sedated patient. Only after needle placement, the patient is awakened. If you have ever had an IV placed, you will know that the only discomfort occurs when the IV is initially placed. After the IV is in, there is no lingering pain. Just like getting an IV placed, the discomfort of needle placement only occurs with the initial needle positioning and that discomfort is never noted with proper initial sedation.

It is a very investigator sensitive test. That is, the physician who leads the examination (normally an anestheologist, an interventional radiologist or a PM & R physician) has to be meticulous where he or she places the needles. The location of the end of the needle is paramount. The needle tip has to be placed into the center of the disc directly in the nucleus (jelly of the donut). If the needle is positioned in the layers of the annulus, the test will cause pain, even in a normally non-painful disc. Also, the patient has to be reasonably awake and alert during the provocation while still under minimal sedation. A patient who is too sedated will not be able to confer accurate information.

The test should be “blinded” to the patient. For more accuracy, the discographer should test the discs in non-sequential order that is not communicated to the patient and hide the fluoroscopy screen from the patient’s view. If L3-S1 were being tested, the order should be “mixed up”. For example, test L3-L4 first, L5-S1 second and L4-L5 third. This assures the patient cannot know which segment is being tested and give what he or she thinks is the “appropriate” results. If there is any doubt about the patient’s genuineness regarding the origin of his or her back pain, this takes some of the question of origin of pain out of the picture.

There are rare cases of patients that are allergic to X-ray contrast dye and if necessary, these patients will then get a saline discogram. There is no imaging dye that is injected into the disc, so the pain response can be assessed but the integrity of the interior of the disc will not be known. The discographer has to be a master of his craft to be able to do this procedure.

What Do Discogram Results Mean?

The discogram has to generally test more than one disc level. There has to be a “control” or normal disc included in the testing. The levels determined to be tested progress from the MRI and x-ray findings as well as the history and physical examination (See how to read an MRI or Xray). There are three possible results with a discogram. All the tested discs are painful, none of the discs are painful or only some of the discs are painful.

If all the discs including a normal disc are painful, the patient is most likely not a good surgical candidate. This is because the thalamus, an organelle in the lower portion of the brain and the “switchbox” for pain signals cannot distinguish between a normal and abnormal disc. A normal disc may cause some “pressure” discomfort under high pressure but will not be significantly painful. If the discogram has been performed well and normal discs are painful, any surgery has less likelihood of being successful.

If none of the discs are painful, then the spine pain problem probably rests with some other pain generator. Investigation of facet pain, nerve pain or other painful stimuli needs to be completed. There are rare occasions that the disc suspected of generating pain is so torn and disrupted that there is no possibility of generating enough pressure in the disc using the discogram technique. This would be similar to having a massively torn sidewall on a tire where any air pressure put into the valve stem would immediately leak out of the tire and pressure could not be built up. Surgical decision making is more difficult in this case.

Over 90% of the time, the presentation of discogram results would indicate a non-painful normal disc and a painful torn disc or discs. This would point toward the painful disc or discs being the source of lower back or neck pain and the control or normal level indicate that there is no pain processing problem with the brain. Depending on the circumstances, this patient would probably make a good surgical candidate.

There are rare times that there is no normal disc in the area to be tested. All the discs of the area to be tested are degenerative but some more so than others. If there is no disc that is normal on MRI and all develop some discomfort, titration of the amount of pain generated is important. Some discs can cause only minimal pain. Is the pain the same as the patient has day to day? There are some discs that are pain discordant. They create pain but the pain is not recognizable as typical day to day pain.

The decision as to if you are a good surgical candidate will depend upon the discogram results as well as many other variables. The discussion with your surgeon is very important.

For more information on spinal discograms, or for additional resources on orthopedic spine conditions, exams or surgeries, please contact Dr. Donald Corenman, Colorado spine surgeon at 888-888-5310.

(Click to Enlarge Image) This is a front to back view (AP) of the discogram at L3-4, L4-5 and L5-S1. Again, the black arrows point to the top two normal discs (L3-5) and the bottom white arrow points to the disrupted L5-S1 disc. You can see a tear in the side wall of the lowest disc (L5-S1).

(Click to Enlarge Image) This is a lateral CT scan of a discogram of L3-4, L4-5 and L5-S1. The black arrows point to the top two normal discs (L3-5) and the bottom white arrow points to the disrupted L5-S1 disc. You will notice that the normal discs (L3-5) are thick and hold the dye within the disc with a typical “cotton ball” type pattern. You could see with your minds eye (deduction) that the annular walls are intact and the dye is held within the central jelly. The lowest disc at L5-S1 (white arrow) has a tear in it and the dye is leaking out the back 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.

What is a Lumbar Discogram?

How Does a Discogram Work?

How is a Discogram Performed?

What Do Discogram Results Mean?

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About the Author: Donald Corenman, MD, DC

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