Pain Improvement after Intradiskal Lidocaine Administration in Provocation Lumbar Diskography: Association with Diskographic Contrast Leakage
W.S. Bartynskia and
W.E. Rothfusa
a From the Department of Radiology, Division of Neuroradiology, Presbyterian University Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pa
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Fig 1. Patient is a 39-year-old man with an injury 20 years ago related to an overturned military vehicle. He has long-standing lower back pain that has recently worsened (VAS score, 8/10). Significant degenerative disk changes are present at L4-5 and L5-S1 on MR imaging, and surgery is now being considered. After 3-mL contrast injection at L5-S1, severe concordant lower back pain was provoked (VAS score, 8/10), with no improvement after 1 mL of intradiskal lidocaine administration.
A, Frontal diskographic fluoroscopic image obtained after contrast injection at L5-S1 demonstrates degenerative changes with nuclear and annular fragmentation (arrow) but no contrast leakage.
B. Axial postdiskographic CT image obtained at L5-S1 demonstrates significant degenerative disk changes with central and peripheral annular tears (arrows) without leakage.
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Fig 2. Patient is a 36-year-old man with long-standing back pain and left leg pain (VAS score, 8/10), who had prior diskectomy at L4-5, with only limited improvement. Diskography was requested for follow-up assessment. After 2-mL contrast injection at L5-S1, severe nonconcordant pain was provoked (VAS score, 8/10) with no improvement after 1 mL of intradiskal lidocaine administration. His pain did reproduce concordantly at the diskectomy level.
A, Outside MR sagittal T2-weighted image demonstrates significant degenerative disk changes at L4-5 and L5-S1 (arrowheads) with a high-intensity zone noted along the posterior L5-S1 disk margin (arrow).
B, Lateral diskographic fluoroscopic image obtained after contrast injection at L5-S1 demonstrates degenerative changes (arrow), without evidence of contrast leakage. Contrast dilution was noted throughout the disk after lidocaine administration (not shown), but provoked pain did not improve.
C, Axial postdiskographic CT image obtained at L5-S1 demonstrates a contained radial tear with focal disk protrusion and focal contrast accumulation without epidural leakage (arrow).
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Fig 3. Patient is a 50-year-old woman with long-standing lower back pain, not associated with injury (VAS score, 10/10), with an outside MR imaging study demonstrating mild degenerative disk changes at L4-5 and significant degenerative disk changes at L5-S1 but no evidence of disk protrusion. The patient is currently being evaluated further by provocation diskography for potential surgical treatment. After 2.5-mL contrast injection at L5-S1, her severe and concordant lower back pain reproduced (VAS score, 9–9.5/10). Partial improvement in her concordant pain occurred after intradiskal administration of 1-mL lidocaine.
A, Frontal diskographic fluoroscopic image obtained after contrast injection at L5-S1 demonstrates fragmentation and degenerative changes of both nuclear and annular components (arrow), without evidence of contrast leakage.
B, Axial postdiskographic CT image at L5-S1 demonstrates degenerative disk changes with fragmentation and tears of the annulus (arrows) but without any epidural contrast leakage.
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Fig 4. Patient is a 40-year-old man with long-standing severe lower back pain (VAS score, 10/10) and some leg diskomfort, without specific injury or trauma, with an outside MR imaging study that demonstrated degenerative disk changes at L4-5 and L5-S1. He was being considered for surgical intervention, and diskography was requested. After 3-mL contrast injection at L4-5, the patient developed severe and concordant pain (VAS score, 10/10). Injection of 1.5-mL lidocaine into this painful disk resulted in complete or near-complete elimination of the provoked pain.
A, Lateral diskographic fluoroscopic image at L4-5 demonstrates degenerative disk changes (arrow) with clear contrast leakage extending into the epidural space (arrowheads).
B, Axial postdiskographic CT image at L4-5 demonstrates complex degenerative changes with both nuclear fragmentation and annular tears (arrow) and a small disk protrusion and focal leakage of contrast into the adjacent epidural space on the left (arrowhead).
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Fig 5. Patient is a 35-year-old man with long-standing lower back pain along with minor leg diskomfort, experiencing increasing pain during the past year. Outside MR imaging demonstrated significant degenerative changes at L4-5 and L5-S1, with possible spondylolysis of L5. Currently, he claimed the back pain would "bring him to his knees" (VAS score, 10/10), and diskography was requested in consideration of surgical intervention. After 3-mL contrast was injected at L5-S1, severe and concordant LBP was provoked without leg pain (VAS score, 10/10). Injection of 1-mL lidocaine resulted in complete elimination of his provoked back pain.
A, Frontal diskographic image at L5-S1 demonstrates degenerative disk changes with annular tears and fragmentation (arrow), along with a peripheral annular tear projecting over the left foraminal disk margin (arrowhead) and focal leakage into the foramen and far lateral region (short arrow).
B, Axial postdiskographic CT image demonstrates internal annular tears and fragmentation (arrow) and a peripheral annular tear on the left (short arrow), with leakage into the epidural space, L5-S1 foramen, and far lateral region (arrowheads).
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