Published ahead of print on July 3, 2008
doi: 10.3174/ajnr.A1151
Postdiskogram CT Features of Lidocaine-Sensitive and Lidocaine-Insensitive Severely Painful Disks at Provocation Lumbar Diskography
W.S. Bartynskia,
W.E. Rothfusa and
M. Kurs-Laskyb
a Department of Radiology, Division of Neuroradiology, Presbyterian University Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pa
b Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh Pa
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Fig 1. Postdiskogram CT features commonly identified in painful degenerative lumbar disks studied at diskography. A, Simple radial annular tear (column 1); radial annular tear with a peripheral annular pocket (column 2); annular gap or wide radial annular tear (column 3). B, Central radial tear into a peripheral annular tear (column 1); combined central and lateral radial tears into peripheral annular tear (column 2); lateral radial tear into a peripheral annular tear (column 3). C, Central radial tear with lamellar annular tears (column 1); combined central and lateral radial tears with lamellar annular tears (column 2); lateral radial tear with lamellar annular tears (column 3). D, Central lamellar annular tears (column 1); combined central and lateral lamellar annular tears (column 2); lateral lamellar annular tears (column 3). E, Central peripheral annular tear (column 1); combined central and lateral peripheral annular tear (column 2); lateral peripheral annular tear (column 3). F, Extensive circumferential lamellar annular tears (column 1); attached annular fragments, loose annular fragments, and bucket-handle annular tear (column 2); extensive free annular fragments with severe macerative annular tears and debris (column 3).
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Fig 2. Development of annular gaps. Complex radial annular tears extending into peripheral circumferential annular tears may (A–C) lead to detachment of fragments of the annulus that become free within the central nuclear region (G). Alternatively, peripheral circumferential annular tear (D and E) may become sufficiently detached from the outer annulus with development of a "bucket-handle tear" (F) that subsequently fragments and detaches, coming to lie free within the central nuclear region.
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Fig 3. A and B, Patient is a 30-year-old man with a 4-year history of increasing severe LBP with some left leg numbness, which he relates to heavy labor at work but without clear injury incident. MR imaging demonstrated degenerative changes with asymmetric disk bulge at L4–5. Diskographic contrast injection at L4–5 (3 mL) provoked severe and concordant back pain (VAS 7/10). Lidocaine injection into this disk (1.5 mL) resulted in near-complete elimination of the provoked pain. Axial postdiskogram CT demonstrates a wide annular gap (curved arrows) along with a peripheral annular tear (arrows). Also noted are free annular fragments present in the annular gap (arrowheads). Diskographic contrast leakage was noted at the margin of the annular gap (not shown).
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Fig 4. Patient is a 33-year-old man with a long-standing history of severe LBP that has worsened over the past 3 years. Outside MR imaging demonstrates disk degenerative changes, in particular at L5–S1. Diskographic contrast injection at L5–S1 (2.5 mL) provoked severe and concordant LBP (VAS 10/10). Intradiskal lidocaine injection (1.5 mL) resulted in no improvement in the provoked pain. Axial postdiskogram CT imaging demonstrates circumferential lamellar annular tears (arrows), multiple free annular fragments (arrowheads), and a peripheral annular tear (curved arrow) without diskographic contrast leakage.
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Fig 5. A and B, Patient is a 38-year-old man who sustained a service-related injury 16 years ago with progressively increasing severe LBP with some left leg radiation. Outside MR imaging demonstrated significant degenerative disk changes at L3–4. Diskographic contrast injection (3 mL) provoked severe concordant pain (VAS 9/10) at L3–4. Lidocaine injection into the disk (1.5 mL) resulted in no improvement in the provoked pain. Postdiskogram CT imaging demonstrates a central radial tear (curved arrows) and a peripheral annular pocket (arrow), along with loose annular fragments (arrowheads) without diskographic contrast leakage.
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