DIAGNOSING DISCOGENIC LBP
Magnetic Resonance Imaging (MRI) is the primary diagnostic standard of care for spine, including for discogenic pain, and is done over 10,000,000 times/year for spinal disorders including discogenic pain (#1 MRI category at 26%). MRI is generally limited to showing structural and tissue hydration changes in the spine, but not other tissue chemistry changes. This often provides useful diagnoses for identifying disc bulges or bone spurs as sources of radicular pain (e.g. sciatica) arising from disc bulges or herniations and structural nerve root impingement. However the primary structural and hydration indications of DDD are not diagnostically useful for distinguishing painful from non-painful discs causing axial discogenic pain. As a result, despite its prevalent use in these patients, MRI exams are not always reliable as useful for diagnosing the painful discs sufficient to appropriately direct therapy.
An invasive needle-based "provocative discography" procedure often follows MRI today, about 400,000 times/year, as a "second line" standard to diagnose discs causing discogenic pain. A patient's spine surgeon considering possible surgical intervention will typically prescribe the discography exam by referral to a specialist who conducts the procedure. During the procedure, one or more discs of an awake & only lightly sedated patient are punctured in serial progression with a needle and injected with pressurized contrast media in order to intentionally "provoke" pain. Upon each injection, the patient is asked to score the severity of the provoked pain and its similarity to the usual pain symptoms (on 0-10 scales). A disc level is typically considered "positive" (or “painful”) if these scores exceed minimum thresholds, and conversely “negative” under these thresholds, while other criteria are also often applied. At least one recent study suggested relatively high diagnostic accuracy, with relatively low false positive rates, may be achieved using one specific technique incorporating various contemporary refinements and believed to represent the modern standard of care. Namely, this involves determining a disc as positive only via pain scores provoked at only relatively lower provocation pressures, presence of annular disc tear, and another disc level testing "negative" or “non-painful” (e.g. failing to meet these criteria) during the procedure. However, discography is highly controversial for various reasons, including the invasive and deliberately painful nature of the exam. One recently published study suggested that the needle punctures in discs from provocative discography significantly increase disc degeneration and herniation rates.
Another new diagnostic approach known as "anaesthetic" or "functional anaesthetic" discography has more recently been developed for the purpose of improving accuracy vs. "provocative" discogram. This attempts to diagnose a disc as painful by temporarily "relieving" pain with a local needle injection of anaesthetic into that disc level, thus the opposite objective of provocative discography. Nonetheless, the similarities between the two invasive needle punctures, in addition to other shortcomings, have prevailed to prevent this newer approach from being widely adopted or accepted.
To appropriately treat chronic, severe axial discogenic pain with directed surgical therapies, e.g. spinal fusion or disc replacement, the surgery must be directed to only disc level(s) properly diagnosed to be the pain generator(s). However, without accurate diagnosis and specificity in terms of the origin of pain, there is a risk such aggressive surgical procedures could be performed at improper locations, either missing the appropriate level or over-treating to additional levels that are not pain generators. This could result in more extensive intervention than required, sub-optimal treatment outcomes, and/or unnecessary costs (which can be significant).
A clear and urgent need exists to augment the diagnostic regimen available for localizing discogenic back pain to source painful discs via a non-invasive, non-painful, objective test to effectively guide the subsequent course of treatment.
Any patient suffering from LBP should consult their own doctor, including possible specialists when indicated, to determine the recommended course of diagnostic or therapeutic options available to that patient for their particular condition, and should not direct any decision with respect to their medical care in any way based upon this summary or information provided on this site - which is intended for general background purposes of our company's direction and mission only.
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