Provocative Annulography for the Diagnosis of Outer Annular Lesions

Conor O'Neill, MD
Conor W O'Neill, MD
Richard Derby, MD
Bjorn C Eek, MDPA
Laura Kenderes, BS

Purpose:

Determine a method for diagnosing painful non–communicating outer annular lesions.

Methods:

Data was collected prospectively from 39 patients (13 controls and 26 cases) undergoing provocative discography. All of the controls had at least one clearly positive disc on discography and therefore a low clinical index of suspicion for primary annular pathology. All of the cases had a high clinical index of suspicion for primary annular pathology.

Results:

Discography was performed on 110 discs in 39 patients. 28% had abnormal nucleograms, and 22% had a positive discogram (abnormal nucleogram, pain > 6/10). 72% had normal nucleograms, of these, 72% had no pain provocation and 28% did have pain provocation. A total of 47 annulograms were performed. The 13 control discs were all normal on discography, and all of the annulograms were normal without pain provocation. Of the 34 case discs, 24 were classified as positive, defined as a disrupted annulogram with pain provocation (6 of these had a normal nucleogram and no pain with discography). The other 10 annulograms were negative, 6 of these had normal morphology and no pain provocation and 4 discs had abnormal morphology and no pain provocation.

Conclusions:

In a group of patients with negative or indeterminate findings on discography, but with a high index of suspicion for a torsional injury to the outer annulus, injection of the annulus will demonstrate painful annular tears, despite a normal nucleogram. Discussion: These findings suggest that in patients with negative discography but a strong clinical suspicion for discogenic pain annulography should be considered.