| 제목 |
Discography negative discogenic pain confirmed by displacement and reposition of intradiscal device |
| 소속 |
Korea University Medical Center, Department of Physical Medicine and Rehabilitation1 |
| 저자 |
Soonwoo Kwon1*, Nackhwan Kim1†, Sang Heon Lee1† |
Low back pain is highly prevalent in general population of all ages and its etiology seems to be multifactorial. The diagnosis of discogenic back pain is based on the typical symptoms, physical examination, imaging study and discography. Discography is known as the main diagnostic tool and also a therapeutic tool. However, it is reported that there are some patients who present with symptoms of discogenic pain and also have the abnormal discs in MRI but showed negative discography.
We report a case of a 56-year-old, male with a history of axial low back pain and both inguinal pain which persisted and worsened for several years. The patient presented with probable symptoms of discogenic pain and had obvious pathological changes on MRI at L4/L5 and L5/S1 level disc. The electrodiagnostic studies showed no definite evidence of lumbosacral radiculopathy. Discography performed at L3/L4, L4/L5, L5/S1 level discs were negative. Conservative treatment including intradiscal steroid injection and percutaneous disc decompression and ablation with L’DISQ device was unsuccessful with re-occurrence of similar pain few days after the treatment. Consequently, he was transferred to neurosurgery department and discharged with a relief of the symptom after having ‘posterior screw fixation on L4/L5, L5/S1 disc level and oblique lumbar interbody fusion with cage inserted at L4/L5, L5/S1 disc’ done. However, although there was a pain relief for 6 weeks post-surgery, the disabling symptom re-ocurred and he was admitted for further evaluation. The groin pain worsened with Valsalva maneuver and coughing but pathologic lesions were not noted in evaluation by urology and colorectal specialists. Plain films of lumbar spine showed the cage of L5/S1 disc was displaced anteriorly over the anterior edge of the vertebral body. So the patient had revisional cage reposition operation. Postoperatively, the disabling pain relieved and was able to walk.
Diagnosis of discogenic pain is known to be difficult and the reliability of the diagnostic tools including discography has been controversial. This is a case of a patient with probable discogenic pain but was negative in discography. In consideration of patients’ typical symptom of discogenic low back pain and pathological findings on lumbar spine MRI, conservative treatment targeting discogenic origin was performed but wasn’t effective. The patient re-visited and re-admitted for the reoccurring disabling pain. So the patient willingly wanted to have the surgery as the last resort. Although the discography did not provoked the concordant pain, the displacement and and reposition of surgically inserted intradiscal device provoked and also relieved the symptom. This may explain the origin of this disabling but undiagnosed pain could be from intradiscal lesion. Therefore it is important not to exclude the diagnosis of discogenic pain even though the discography was negative. |
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Fig 1. T2-weighted magnetic resonance imaging (A, B) of lumbar spine. Mid-saggital view (A) and transverse view (B) of L5/S1. Disc bulging and degeneration with annular fissures at L4/5 and L5/S1 is noted.
Fig 2. Intra-discography images (A, B). Coronal (A) and saggital (B) intra-discography images. The L4/5 and L5/S1 disc had a damaged annulus that permitted contrast extravasation. The patient expressed pain among the exam but showed no concordant pain.
Fig 3. Plain radiographs of lumbar spine (A, B). Anterior displacement of the L5/S1 intradiscal device (A) and surgically repositioned intradiscal device (B).
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