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Disc Space Response to Lidocaine during Lumbar Discography: Association with Radial Tear and Contras 2006

Interventional Spine

Walter S Bartynski, MD, ASSR Member
William E Rothfus, MD, ASSR Member

Scientific Paper

Purpose

Local anesthetic is commonly injected into a painful disc after it is studied by lumbar discography in order to reduce/eliminate the patient's pain during and after the procedure. Lidocaine administration into a painful disc has also been suggested as an additional test that helps identify painful discs that will respond well to surgical intervention.
We recently noted that some painful discs are responsive to lidocaine injection while others do not improve after lidocaine administration. This appeared to be related to the presence or absence of radial tear and extravasation of contrast into the spinal canal and epidural space.
The purpose of this study was to evaluate for the presence/absence of pain reduction after lumbar intradiscal lidocaine administration during discography and compare with the presence or absence of radial tear/contrast extravasation on the discogram images and post discogram CT.

Methods & Materials

The clinical records, discogram reports and discogram/post discogram CT imaging studies were retrospectively reviewed in 82 sequential patients who had lumbar discography. Intradiscal lidocaine was injected at 122 significantly painful disc levels in 79 of these patients. The clinical records and imaging studies were reviewed for documentation of response to the lidocaine injection and for the presence or absence of radial disc tear and contrast extravasation at the studied disc space.
Pain response was graded as: complete or substantial pain improvement, partial improvement or no significant improvement with/after lidocaine administration. Fluoroscopic imaging at discography and the post discogram CT studies were evaluated for the disc space characteristics in particular assessing for the presence or absence of radial tear and contrast extravasation. These results were tabulated and compared.

Results

Sixty two of the 122 painful disc spaces demonstrated radial tear/contrast extravasation into the spinal canal, neural foramen or both while 60 disc spaces contrast remained contained without extravasation.
In the 62 disc spaces with contrast extravasation, 45 (72%) demonstrated complete or substantial pain reduction after intradiscal lidocaine administration, 13 (21%) discs demonstrated partial pain improvement and 4 (6.5%) demonstrated no pain relief. In the 60 contained painful disc spaces, 48 (80%) demonstrated no improvement after lidocaine administration, 6 (10%) demonstrated partial improvement and 6 (10%) demonstrated complete relief.
Many patients demonstrated more than one painful disc with both types of disc space response to local anesthetic.
Available pre procedure MR imaging studies infrequently (<20%) demonstrated a 'High Intensity Zone' adjacent to the painful disc margin but when identified, this finding tended to correlate with the presence of radial tear.

Conclusion

Painful lumbar discs with radial tears and contrast extravasation tend to be highly responsive to intradiscal lidocoine administration while contained painful discs tend not to improve after lidocaine administration. In the responsive painful discs, local anesthetic must be reaching the location of pain provocation while in contained discs the anesthetic does not reach the injured painful tissue. This observation has implications with respect to targeting the origin of a patients back pain and may have specific implications with respect to choice of treatment. This might also help explain the response of low back pain to epidural steroid/anesthetic administration as well as the variable response to many disc treatment methods.