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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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intraoperative electromyographic and somatosensory evoked potential recordings in
spinal surgery: Correlation of clinical and electrophysiologic findings in a prospective,
consecutive series of 213 cases. Spine (Phila Pa 1976) 2004;29(6):677-684.
transpedicular lumbosacral spine instrumentation: Initial clinical results. Spine (Phila
Pa 1976) 1994;19(24):2780-2786.
safe thoracic pedicle screw placement? Spine (Phila Pa 1976) 2002;27(18):2030-2035.
prospective analysis of intraoperative electromyographic monitoring of pedicle screw
placement with computed tomographic scan confirmation. Spine (Phila Pa 1976)
1995;20(12):1375-1379.
analysis of intraoperative electromyographic monitoring of posterior cervical screw
fixation. J Spinal Disord Tech 2005;18(6):515-518.
in spine deformity surgery: Development of an intraoperative checklist to optimize
response. Spine Deform 2014;2(5):333-339.
This study used the Delphi method to establish best practices concerning IONM in
patients with stable spines undergoing deformity correction surgery. A checklist was
developed to assist surgical and IONM team members during stressful situations.
and Peripheral Nerves of the American Association of Neurological Surgeons and
Congress of Neurological Surgeons: Electrophysiological monitoring during surgery for
cervical degenerative myelopathy and radiculopathy. J Neurosurg Spine
2009;11(2):245-252.
Surgeons/Congress of Neurological Surgeons: Guidelines for the performance of fusion
procedures for degenerative disease of the lumbar spine: Part 15. Electrophysiological
monitoring and lumbar fusion. J Neurosurg Spine 2005;2(6):725-732.
procedures for degenerative disease of the lumbar spine: Part 15. Electrophysiological
monitoring and lumbar fusion. J Neurosurg Spine 2014;21(1):102-105.
This guideline, based on expert opinion, specifically focuses on the use of IONM during
surgery for lumbar degenerative disease.
Monitoring, 2014. Available at:
http://www.spinesection.org/files/pdfs/IOMPositionStatement04.24.2014.pdf. Accessed
March 30, 2017.
This position statement identifies specific issues found in the IONM literature and
quotes the original articles. It makes no attempt to present either a literature
consolidation or systematic review.
Statement, 2009. Available at: http://www.srs.org/about-srs/quality-and-safety/position-
statements/neuromonitoring-information-statement. Accessed March 30, 2017.
Chapter 8
Diagnostic Procedures in Spine
Care
D. Scott Kreiner, MD Timothy Sanford, MD
Abstract
Proper diagnosis regarding the etiology of low back pain is important to
guide appropriate management, improve outcomes, optimize resources, and
reduce medical costs. Several diagnostic procedures are associated with
each source of low back pain. These include diskography for intervertebral
disk pain, medial branch blocks for zygapophyseal joint–mediated pain,
intra-articular sacroiliac joint blocks for sacroiliac joint pain, and selective
nerve root blocks for radiculopathy and/or radicular pain.
Keywords: diagnostic; diskography; medial branch blocks;
sacroiliac joint; selective nerve root blocks, SI joint
Dr. Kreiner or an immediate family member serves as a board member, owner,
officer, or committee member of the North American Spine Society. Neither Dr.
Sanford nor any immediate family member has received anything of value from or
has stock or stock options held in a commercial company or institution related
directly or indirectly to the subject of this chapter.
Introduction
Back pain and its subsequent management is often generalized. To properly
manage back pain, accurate assessment and diagnosis are crucial. Accurate
diagnosis of back pain will help guide management, improve outcomes,
optimize resources, and reduce medical costs. Several structures, including
muscles, tendons, ligaments, bones, nerves, joints (zygapophyseal and
sacroiliac), and intervertebral disks, can cause back pain. To define a
structural basis for the pain, back pain is commonly categorized as axial or
radicular. Chronic axial pain most commonly occurs in three main structures,
which forms a basis for categorical division: disk-mediated, zygapophyseal
joint (Z joint)–mediated, and sacroiliac (SI) joint–mediated pain. Several
diagnostic procedures can be used to help determine the etiology of low back
pain.
Axial Back Pain
Pain located in the intervertebral disk, Z joint, and SI joint comprises 90% of
chronic axial back pain. Pain resulting from vertebral fractures, pelvic
fractures, Baastrup syndrome, and fusion hardware accounts for the
remaining 10%. In a study of 170 patients, intervertebral disk–mediated pain
accounted for 41.8% of low back pain, Z joint–mediated pain for 30.6% of
low back pain, and SI joint–mediated pain for 18.2% of low back pain
1
(Table 1).
Discogenic Back Pain
Disk-mediated pain is the most common etiology of back pain.1 Imaging can
depict disk abnormalities at multiple levels, and determining the concordant
pain level can be challenging. One study reported that MRI findings of a disk
protrusion with a high-intensity zone (HIZ) correlated with pain provocation;
however, a bulging disk with an HIZ, disk degeneration without HIZ, and
disk protrusion without HIZ did not correlate with pain provocation.
2
Therefore, it is difficult to determine whether the disk is the pain generator
and at which level, especially if MRI findings demonstrate multilevel disk
abnormalities. Other studies have demonstrated abnormal disk findings in
asymptomatic patients,
3,4
including disk degeneration, herniation, or bulge
seen on MRI. One study found that 61% of study subjects (mean age, 42
years) had disk abnormalities.
4
An algorithmic approach should be followed in the diagnostic workup of
axial low back pain. In addition to a detailed history, examination, and
imaging studies, initial diagnostic procedures should include medial branch
blocks for Z joint–mediated pain and SI joint diagnostic injections followed
by diskography, a diagnostic procedure used to help determine whether the
intervertebral disk is the pain generator of axial low back pain. One of the
main reasons that initial diagnostic procedures should include the Z joint and
SI joint is that good evidence supports these procedures in the diagnosis of
their respective pain generator, and currently, the evidence to support
diskography is controversial.
Table 1
Figure 1
Lateral diskogram demonstrates an L3-L4 disk with a tear.
Figure 2
Lateral diskogram demonstrates an L5-S1 disk with a
fissure.
Diskography has been a topic of debate because the literature both
supports and questions its diagnostic and prognostic value, as well as its risk
profile. In addition, treatments of discogenic pain such as intradiscal
electrothermal therapy, lumbar disk arthroplasty, and spinal fusion have
become less common, questioning the need to perform diskography.
Diskography comprises two separate yet complementary procedures:
provocation lumbar diskography (PLD) and analgesic diskography.
Provocation Lumbar Diskography
PLD is used to determine the presence of an annular fissure and to confirm
the disk as a source of pain if the injection of contrast material into the disk
reproduces the patient’s pain. Image guidance (fluoroscopy or CT) is used to
direct a needle into the disk, and contrast material is injected to pressurize the
disk. In addition, the contrast media can confirm the presence of a fissure
(Figures 1, 2, and 3), which also can be confirmed using CT after
diskography. Optimal diagnostic results require adherence to strict criteria.
The 2013 International Spine Intervention Society’s (ISIS) guidelines for a
definitively positive diskogram result include concordant pain of 6 or greater
on a scale of 1 to 10, pain reproduced with pressure less than 50 psi greater
than opening pressure, and stimulation of two adjacent disks that reproduces
no pain.5 It is important that strict diagnostic criteria be followed. The
inconsistency in diagnostic criteria has resulted in the variable outcomes seen
in the literature, mainly with high rates of false-positive results. One review
concluded that if strict operational criteria are used during diskography, the
rate of false-positive results improves substantially.
6
Analgesic Diskography
Analgesic diskography is the process of injecting a local anesthetic into a
disk that has been confirmed to be the source of the patient’s pain using PLD.
One study demonstrated at least a 50% reduction in low back pain in 80% of
disks that were considered the source of pain by PLD after injection of 4%
lidocaine.7 Another study compared the outcomes of interbody fusion based
on positive results of analgesic diskography compared with PLD and
demonstrated significant improvement in low back pain and disability at 1-,
2-, and 3-year follow-up in the analgesic diskography group.8 Congruence
has been reported between the analgesic diskography and PLD.
7
Diagnostic Value of Diskography
Controversial discussions regarding the diagnostic and prognostic value and
the risk of diskography are referencing PLD and not analgesic diskography.
There was no consensus in the early literature as to whether diskography
provided high diagnostic value. However, a recent systematic review and
meta-analysis demonstrated that following ISIS guidelines strictly can result
in a clinically acceptable cumulative low false-positive rate of 9.3% per
patient.9 In previous studies in which the diagnostic criteria varied, higher
false-positive rates were demonstrated.
6,9-24
Prognostic Value of Diskography
In determining whether positive discographic results lead to better surgical
outcomes, a review of the literature suggests variable outcomes regarding the
prognostic outcomes of lumbar fusion in those in whom the diagnosis was
made via diskography versus clinical and imaging assessment alone.
25,26
However, the studies that demonstrated no improved outcomes after lumbar
fusion did not follow the strict ISIS guidelines. One prospective study
demonstrated that with adherence to the strict ISIS guidelines, those who
underwent lumbar fusion in the setting of positive PLD results experienced
improvement in function (specifically with daily activities) and were three
times more likely to have less back pain than those who had positive
discographic results but did not undergo surgery.
26
Figure 3
Lateral diskogram demonstrates healthy disks.
Complications Related to Diskography
Acute complications are rare and are mostly limited to case reports; they
include acute disk herniation, discitis, vascular insult, meningitis, abscess,
nerve/cord injury, and hemorrhage. Chronic complications can include future
disk degeneration; whether diskography predisposes to future disk
degeneration or injury is a current topic of debate. A recent 10-year matched
cohort study reported that diskography results in an increased risk of clinical
disk injury.21 In contrast, a 2013 study reported no acceleration of disk
degeneration at 5-year follow-up.27 Other human and animal studies have
also demonstrated mixed results and interpretation as to whether diskography
results in future disk injury.
20,28,29
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