Cervical Discogenic Pain
Patient Selection: Before being considered as possibly having cervical disc pain (also known as cervical discogenic pain), patients require a full history and examination including MRI scanning of their cervical spine. It is important for the treating clinician to ensure that there is not any major narrowing of the vertebral canal. Further, other, simpler causes of neck pain should be initially ruled out. These include pain related to the cervical muscles and the cervical zygapophysial (facet) joints.  In pain arising from the cervical structures such as the joints or discs, the pain patterns from each segmental level are in general reproducible and level specific. That means that both the joint at that level and the disc from that level have a similar pain pattern reported by the patient. If the pain is widespread it of course does not imply any particular segment.
Diagnosis: History: The first use of cervical discography (also known as discogram) occurred in the 1950s. The purpose of the discogram is to reproduce the patient’s pain that they regularly experience. This is known as pain provocation. Early discography was confounded by the abnormal patterns of dye flow within the disc. This could be attributed to the fact that fissures or tears in the disc increase with age but are not necessarily related in any way to pain generation. The dilemma when using pain provocation to make a diagnosis is that the competing hypothesis is that everything in this person’s neck hurts. It is therefore imperative that a pain-free control disc be present during the test. The diagnosis of discogenic pain can then be made when the target discs reproduce pain but adjacent discs are pain free. Patients who have discogenic pain will regularly report their provoked pain as greater than a pain score of 6/10 during the actual disc injection. A significant issue has been highlighted in the recent scientific literature which has shown that single level positive responses are uncommon. Further, it is more common to have three or even more levels that evoke pain on injection. The major side-effect risk with cervical discography is discitis. The early literature demonstrated that the risk was around 6 per 1000 cases. However, this was before the use of routine antibiotic cover during the procedure whereby antibiotics are routinely injected into the disc at the time of discography. Further, the use of stiletted needles has greatly reduced the risk of carrying any infection into the disc. We therefore conclude that the overall risk of discitis is much less than 6 per 1000 cases when cervical discography is performed in a manner according the International Spine Intervention Society (ISIS) standards. Contraindications: These include: - untreated local infection
- a tendency to bleed which may or may not be hereditary or induced by medications such as Warfarin
- evidence that the central vertebral canal in the cervical spine is very narrowed (stenotic) and in particular if the canal diameter is less than 10mms.
There are of course other relative contraindications that will need to be discussed with the treating clinician Technique: The cervical discography procedure is performed under careful aseptic – sterile conditions.  Cervical discography showing one disc level  Lateral view showing needle placement  Discography needles in position showing three levels Live fluoroscopic (x-ray) imaging is required for needle placement into the disc. The patient lays facing up and with their head slightly turned to the left. By convention all needles will enter from the front right side of the neck. Once the proceduralist has needles in each of the discs to be tested, a small amount of contrast dye will be injected and the relative pressures monitored. At all times it is important for the patient to report any distressing symptoms. The patient needs to be aware that this is, however, a physiological test and the goal of the test is to see if their normal, 'regular' pain can be reproduced. Therefore, when pain is felt on injection this needs to be immediately told to the proceduralist who will then clarify questions such as the severity of the pain, how closely it matches their normal pain for the area, intensity and character of their normal pain. Treatment: A major issue with arriving at the diagnosis of cervical discogenic pain is that at this time there are no validated treatment options. However, the treatment options include: - cervical nucleoplasty - percutaneous disc decompression,
- artificial disc replacement and
- anterior cervical discectomy and fusion.
Most of the scientific literature pertaining to these operations or surgical procedures are for patients who are suffering from disc prolapse and acute radicular pain in their arms. (That is, an acute sciatica type pain that goes down the arm or into the shoulder blade, whereas at this time the predicted outcomes for patients who purely have neck pain is unclear.) For related information on this topic visit the section on: |
