the stages of disc degeneration as revealed by discograms

THE
STAGES
OF
DISC
DEGENERATION
BY
A.
M.
One
hundred
radio-opaque
Examination
and
thirty-nine
fluid and dye.
of the sections
The
discs
REVEALED
DISCOGRAMS
ADAMS,
From
AS
P.
DOLAN,
Poh’technic
from
W.
C.
ofCentra!
cadaveric
HUTTON
London
lumbar
spines
were
injected
with
a mixture
of
Discograms
were taken and the discs were then sectioned
in the sagittal
plane.
revealed
that injected
fluid did not at first mix with the disc matrix
but pushed it
aside to form pools of injected
fluid. The location
of these pools, and hence the appearance
of a discogram,
depended
on the stage of degeneration
of the disc. It is concluded
that useful clinical
information
can be
obtained
from discograms.
The
usefulness
ofdiscography
established.
characteristic
1964;
has
Certain
types
of patients
Fraser
et a!. 1983)
and
asymptomatic
volunteers
Unfortunately,
the
not
been
of “abnormal”
with low back
are
satisfactorily
discogram
are
pain (Feinberg
relatively
uncommon
(Holt
1968).
fact that abnormal
in
between
8 and 60 years,
who had been fully mobile
prior
to death.
Three
of the spines
were tested
“fresh”.
The
others
were stored
at
20 C in sealed
plastic
bags for up
to four weeks,
until required
for testing.
They were then
-
thawed
Method.
discograms
in their bags at room
temperature
One hundred
and thirty-nine
for I 2 hours.
of the discs were
sometimes
occur
in asymptomatic
people
has led to
discography
being dismissed
as being an unreliable
diagnostic
test (Holt
1968).
However,
it is likely
that discograms
reveal a great deal about
the state of degeneration
injected
with a mixture
of dye and radio-opaque
fluid.
Seventeen
discs were not injected
and these were used as
controls.
For the injection.
a straight
21-gauge
needle
on a
ofan
intervertebral
disc; after all, they are patterns
which
represent
the distribution
of radio-opaque
fluid injected
into a disc,
and this distribution
must
depend
on the
physical
properties
of the nucleus
and on the presence
of
S ml syringe
was inserted
the disc; up to 2 ml of
blue dye, was injected.
inserted
between
thumb
fissures
in the
ing degenerative
graph
of applied
injection
pressure)
was the minimum
toms
ignoring
evidence
changes
if this evidence
can
reliable.
The present
investigation
demonstrate
what
happens
be shown
and
(and
does
annulus.
The difficulties
changes
in the disc
not justify
to determine
hence
the
degeneration.
rent vogue
papain.
about
whether
discogram)
This work
for injecting
often
whether
concerning
such
to be precise
and
was carried
out in order
to
injected
into a disc
or
not the fluid distribution
is a reliable
guide
to disc
first
the disc
in relatsymp-
to fluid
was partly
intervertebral
without
involved
to patients’
prompted
discs
obtaining
is degenerate
by the curwith chymo-
direct
evidence
Cadaveric
removed
at
material.
routine
AND
taken
plane
Sixty-two
necropsies
lumbar
from
M. A. Adams,
PhD,
Research
Fellow
P. Dolan,
PhD,
Research
Fellow
W. C. Hutton,
DSc, Professor
of Biomechanics
School
of Engineering
and Science,
Polytechnic
115 New Cavendish
Street,
London
WIM
8JS,
Requests
for reprints
1986 British
0301-620X/86/1035
36
shouldbesentto
Editorial
$2.00
Society
in the sagittal
plane
(and sometimes
in the frontal
also) and the spine was frozen
at - 20#{176}C.
While
still frozen,
the spines
were cut up to obtain
and
spines
subjects,
of Central
England.
W. C. Hutton.
Joint
Surgery
___________________________
London,
each
below
with
about
it. Thirty-two
5 mm
of the
of vertebral
injected
body
discs
above
along
with
the I 7 control
discs were then cut into 3-mm-thick
slices
in the sagittal
plane,
using a hacksaw
with a thin blade.
The slices were wiped
with damp
cotton-wool
to remove
cutting
examined
Professor
of Bone
and
were
aged
to
the
disc
slowly
and smoothly
until no more could
be injected
or
until dye was observed
to be leaking
from a fissure
in the
disc; this procedure
took up to 20 seconds.
About
5 to 10
minutes
after
injection,
discograms
of the spine
were
or not.
METHODS
force (which
can easily be converted
to
against
time.
The pressure
recorded
required
to inject
any fluid into the
disc; it was zeroed
by measuring
the pressure
required
expel
the viscous
Conray
plus dye mixture
from
needle
into the air. The fluid was injected
into the
the discs,
MATERIAL
anteriorly
along
the midline
of
Conray
480, containing
aniline
A strain-gauged
load
cell was
and syringe
in order
to obtain
a
were
debris,
under
preserved
Several
then
thawed,
photographed
a binocular
microscope.
Some
in formalin
for histological
injection
tests were
performed
pieces
of nucleus
and annulus
so that the
methods
could
be observed
directly
under
and
slices
investigation.
on isolated
fluid
the
transport
binocular
microscope.
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
THE
STAGES
OF DISC
showed
that
DEGENERATION
RESULTS
Examination
of the
disc
slices
the
fluid did not at first mix with the disc matrix
it aside,
creating
pools
of fluid. After
this
bution,
the
fluid
slowly
mixed
with
bination
of fluid flow (caused
the hydrophilic
proteoglycans)
mixing
processes
were
too
5 to 10-minute
interval
discogram
being
taken.
mixing
took place during
and
this
was
revealed
rounding
discs.
slowness
characteristic
only on the
much
effect
slices
were
washed
gel ofthe
in
ofthe
slices
mixing
under
away,
in the
matrix.
from
This
meant
Types
was
non-
that
the discograms
of the injected
in the annulus.
In this way the
to the degree
ofdisc
degeneration.
a
but
sur-
young,
processes
shapes
seen on
initial
distribution
in the
the injection
and the
a certain
amount
of
and slicing
of the disc
the
depended
fluid into
The location
of these pools was determined
of fibrosis
of the nucleus
and the presence
fissures
related
by the
of any
discogram
was
of the
radio-opaque
of the discograms
and
five of these
discogram
stages
in disc
which
Table
I. The
they represent
Discogram
shadow.
degeneration.
types
Close
the disc slices showed
types
corresponded
In
is summarised
five
were distinguished
on the
features
in the shape
and
in Table
ofdiscogram
and
type
the
comparison
that only
to distinct
following
classifica-
I, the discogram
the stages
Stage
ofdisc
ofdisc
types
degeneration
degeneration
ofdiscogram.
or centrally
These
annulus
specimens
is followed
by a descripusually
associated
with
Then
the stage
ofdegeneration
located.
discs showed
no
signs
is
of degeneration.
was white
and unfissured
the nucleus
was a soft
and
white
The
in non-injected
amorphous
that
contained
no fissures
or fibrous
lumps
(Fig.
The injected
fluid was contained
within
the
forming
a continuous
system
of pools surrounding
blobs
matrix
of matrix
tended
to
gel
I b).
nucleus,
small
(Fig.
Ic). Mixing
of the fluid with the
occur
rather
quickly
in this type of
nucleus
washing.
so that
little of the
The fluid distribution
location
of the needle-tip
dye
within
could
be removed
by
was not affected
by the
the nucleus.
However,
if
the needle-tip
was placed
in the annulus,
the fluid could
only be injected
very slowly
and under
high pressure;
it
would
tend to flow around
between
the lamellae
and not
pass
of discogram
density
type
each definition
of degeneration
used
to explain
the distribution
of injected
fluid,
and
hence the appearance
of the discogram.
1. Cottonball.
The radio-opaque
shadow
appears
to be
contained
within
the nucleus
and is of uniform
density
(Fig.
Ia, level L3-4).
The shape
is not necessarily
round
nucleus
pressure
Various
types
of discogram
basis ofconsistently
identifiable
tion,
to have
pressure
of
Both these
pools
could
be washed
be seen as a slight
halo
noticeable
degenerated
The
pools.
degree
slow
proteoglycan-water
particularly
by a com-
by the swelling
and diffusion.
between
However,
freezing
if the
tap: the fluid in the
some
blue dye could
the matrix
that
pushed
distri-
37
BY DISCOGRAMS
are defined
and
tion of the stage
injected
but
initial
AS REVEALED
into
the
nucleus.
Injection
into
required
very little pressure,
associated
with these discs
be due
to the
deform
and
reluctance
make
of the
room
isolated
pieces
so the high
(see Table
annulus
and
of
injection
II) must
end-plate
to
for the fluid.
2. Lobular.
The radio-opaque
shadow
appears
to be contamed
within
the nucleus
and has a lobular
appearance,
being denser
near the end-plates
and less dense or absent
in the
centre
(Fig.
burger
or horseshoe.
superficial
appearance
lobular
nature
Occasionally
These
starting
2a).
Typical
shapes
The lobes can
of a cottonball
is revealed
by
the
resemble
overlap
(Fig.
a ham-
to give
2b) but
variation
in density.
only one lobe is filled on injection.
were
typical
mature
discs
with
the
to coalesce
into
fibrous
lumps
the
the
which
nucleus
were
separ-
I . Cottonball
No signs of degeneration.
Soft white amorphous
nucleus
ated
from
the annulus
and cartilage
end-plates
(and
occasionally
from
each
other)
by
softer
material.
Usually,
these areas of softer material
contained
clefts or
lines of fracture
(Fig.
2c). The lamellae
of the annulus
2. Lobular
Mature
starting
fibrous
were distinct,
and sometimes
bulged
into the nucleus,
but
they were not disrupted
by fissures.
The injected
fluid stayed
in the nucleus
and formed
3. Irregular
Degenerated
4.
Fissured
;iii::
-
-
5. Ruptured
disc with nucleus
to coalesce
into
lumps
disc
with
pools
lumps.
nucleus
and
inner
annulus
cartilage
fissures
and
clefts
in the
slowly
Degenerated
disc with
radial
fissure
leading
to the
outer edge of the annulus
fluid has
to escape.
Disc
a completeCan be
radialin
fissure
that allows
injected
any state
of degeneration
in the softer
material
surrounding
These
pools were particuarly
large
end-plates
with
68-B,
No.
I, JANUARY
1986
(Figs
matrix
2d
and
2e).
so a considerable
The
fibrous
to the
fluid
amount
mixed
of it
could
be removed
by washing.
could
depend
on
the
needle
nucleus:
fluid injected
very near
The
fluid distribution
placement
within
the
one end-plate
may not
reach
end-plate
the clefts
near
the opposite
and
the disco-
gram would
then show only half of the hamburger.
Very
little fluid could
be injected
into isolated
pieces
of annulus, but injection
into pieces
of nucleus
was easy, unless
the needle-tip
VOL.
the soft
the
adjacent
was in the centre
ofa
fibrous
lump.
M. A. ADAMS,
38
3.
Irregular.
shape
The
and
(Fig.
radio-opaque
appears
3a).
These
discs
to
shadow
penetrate
showed
distinct
with a fibrous
nucleus
and
nucleus
and inner
annulus.
has
into
the
signs
P. DOLAN,
an irregular
inner
annulus
There
was little
mixing
with
the matrix
(Fig.
jection
into isolated
pieces
of disc was generally
all locations
except
the outer annulus.
shadow
haps
trast
(Fig.
limit
The
pictures
tile
should
t;1()
read
he
pages.
.
.
‘
of degeneration.
between
nucleus
and annulus.
The injected
fluid formed
pools
around
the fibrous
lumps
of nucleus
and in the fissures
in the inner annulus.
Fissured.
The
acros.c
C. HUTTON
clefts and small fissures
in the
There
was poor
differentia-
tion
4.
W.
discogram
shows
the
3b). Ineasy in
radio-opaque
Figure
l-Cottonhabl
In a young
non-degenerated
disc the nucleus
consists
of soft
blobs
that can be easily
separated
(Fig.
lb).
When
dyed
radio-opaque
solution
is
injected
into this type of disc it
forms
a continuous
system
of
pools
in the nucleus
(Fig.
lc)
and yields
a cottonball
discogram (Fig.
la, level L3-4).
w
M-14
L3-S1
reaching
to the outer
edge of the annulus
(perbeyond
the edge of the vertebral
body),
but no conmaterial
escapes
from the disc through
the annulus
4a, at levels
L I 2 and L3- 4). There
is a definite
(usually
I to 3 ml) to the volume
offluid
that can be
Fig.
Ia
injected.
and
These
often
discs were
discoloured
usually
degenerated,
and narrowed.
There
one or more
radial
fissures
usually
led to the posterior
the disc. The fissure
occurred
being
were
fibrous
always
in the annulus
and
these
or posterolateral
border
of
either
in the mid-plane
of
.
the
often
disc
or
near
one
end-plate.
bulged
beyond
the edge
The injected
fluid usually
The
posterior
of the vertebral
formed
large
annulus
bodies.
pools
in the
Fig.
F-37
L4-5
2b
annulus
and nucleus.
It flowed
down
the radial
fissure,
but was prevented
from escaping
by either
the outermost
lamellae
of the annulus
or the posterior
longitudinal
ligament (Fig. 4b). Injection
into isolated
pieces
ofdisc
was
generally
easy
5. Ruptured.
in all locations.
The
discogram
extending
to the outer
from the disc entirely.
contrast
material
Fig, I a; and levels
escape
on
the volume
edge
There
shows
of the
might
material
annulus
and escaping
be a large quantity
of
within
the disc space
(see level L5-Sl,
L2- 3 and L5-Sl
, Fig.
4a) or most may
injection
offluid
(L4 5, Fig. 4a). There
that can be injected.
These
discs come
in all stages
there
is always
a complete
radial
posterior
annulus.
The injected
fluid sometimes
the fissure.
and annulus
contrast
In other
cases
as well (Figs
from
the disc could
posterior
longitudinal
is no limit
Fig.
3a
to
of degeneration,
fissure,
usually
but
in the
flowed
down
straight
Figure
3-Irregular
When
dyed
radio-opaque
solution
is
injected
into a mildly
degenerated
disc it
forms
pools
in the nucleus
and tills clefts
in the inner annulus
(Fig. 3b). The resulting discogram
has an irregular
appearance (Fig. 3a).
it formed
poois
in the nucleus
5a and Sb). The escape
route
be obstructed
ligament.
and
diverted
by
the
Occasionally,
dye was observed
in the vertebral
bodies
on the discogram.
revealing
a fracture
of the
vertebral
end-plate.
This
happened
in five discs,
all of
which
were in the upper
three
lumbar
levels.
Two were
Type 2 discs, while three were Type 5, but none of these
are included
in Table
II. We could
have classified
these as
a sixth type but we decided
against
it since this classification is based on the disc rather
than the end-plate.
The
histological
sections
showed
that
the clefts
Fig.
THE
4a
JOURNAL
OF BONE
AND
JOINT
SURGERY
THE
STAGES
OF DISC
DEGENERATION
AS REVEALED
39
BY DISCOGRAMS
A
Figure
2-Lobular
In a mature
disc, the nucleus
consists
of
fibrous
lumps
separated
by softer
material,
often
containing
clefts
(Fig.
2c).
When
dyed radio-opaque
solution
is injected
into
this type ofdisc
it forms
pools in the softer
material
and
these
can
be particularly
large near the end-plates
(Figs 2d, 2e). The
resulting
discogram
has a lobular
appearance
(Fig.
2a) though
lobes
may overlap
(Fig. 2b).
Fig.
Fig.
4b
Figure
4-Fissured
When
dyed
radio-opaque
solution
is
injected
into a fissured
disc, it flows down
the fissure
but is prevented
from escaping
by the outermost
annulus
or the posterior
longitudinal
ligament
(Fig. 4b). The resulting
discogram
shows
a radio-opaque
shadow
up to or beyond
the edge of the
vertebral
body as shown
at levels L I -2 and
L3 -4 (Fig. 4a).
VOL.
68-B,
No.
I, JANUARY
986
Sb
Figure
5-Ruptured
Figure
5a-When
dyed radio-opaque
solution
was
injected
into this disc,
it flowed
down
the fissure,
but was diverted
by the posterior
longitudinal
ligament
and
escaped
from
a posterolateral
corner.
The discogram
is shown
in Figure
4a, level L2-3.
Figure
Sb-In
this young
disc, the injected
solution
formed
a large pool in the nucleus
before
escaping
down
the fissure.
As in Figure
5a, the escaping
solution was diverted
by the posterior
longitudinal
ligament.
The discogram
is shown
in Figure
Ia, level
L5-Sl.
40
M. A. ADAMS,
P. DOLAN,
observed
in and around
the nucleus
(Figs 2c, 2d and 3b)
were not artefacts
caused
by injection
on cutting;
their
smooth
edges indicated
a natural
origin.
W.
C. HUTTON
ing of the
vertebral
end-plates
disc height
on injection
(Brinckmann
therefore
At the end of the experiment,
each discognam
was
assessed
by the authors
(acting
together)
and assigned
to
one of the five types.
At the time of assessment,
the age
deformation
tance
rises
of the end-plate
until eventually
and sex of each spine was known,
and it was also known
if any dye had been observed
to leak from the disc during
injection.
The object
of this exercise
was to indicate
the
age range,
spinal
level,
injection
pressure
and injection
(Galante
volume
normally
associated
with each type of discogram.
This
could
possibly
aid the interpretation
of difficult
discograms
in life. Table
II shows
the frequency
of each
type of discogram.
Fissured.
and ruptured
discs are most
common
in old spines
but also occur in some young
ones.
Older
require
discs accept
a greater
volume
a lower injection
pressure.
Table
II must
be viewed
tion as it was compiled
even, we repeated
our
of injected
with
by only
classification
some
fluid
and
statistical
three
observers.
after a period
cauHowof six
months
had elapsed
in order
to see how reproducible
it
was. One hundred
and seventeen
(87%)
of the discograms
were assigned
to the same type, and of the 1 7 that
were
not. 9 involved
the distinction
between
Types
2
and
3.
young
discs
fluid
high
The
results
has shown
it is injected
are
consistent
happens
to an aqueous
an intervertebral
disc.
with
the
observations
of
Erlacher
(1952)
who
described
similar
patterns
of
injected
fluid distribution
in cadaveric
discs, but did not
relate the patterns
to stages
in disc degeneration.
Let us now consider
how the disc makes
space
for
the injected
solution.
This is achieved
by outward
bulgTable
II. Details
of the discs
to discogram
type
and
the injection
--
---
type
2
3
Discogram
I-Number
ofdiscs
each age range:
Number
at each
Injection
(kgcm
Injected
(ml)
in
of discs
level:
pressuret
2)
volumet
* 5 discs
had
are not given
t Measurements
discs
fractures
data
------
tabulated
according
5
Total
number
ofdiscs
4
increase
is stiffer
this
is probably
injection
were
in
The pressure
resistance
to
and this resisis accepted.
In
and
less
why
they
pressure.
recorded
extensible
accept
less
Occasionally
in older
discs
although
these may be due to injection
into a fibrous
part
of the nucleus.
If more
and more
fluid is forced
into a
disc under
ever-increasing
pressure,
the result
is a fractured
end-plate
Herbert
and
and
Barks
not a ruptured
annulus
(Jayson,
1973).
The relative
weakness
and
deformability
of the end-plate
compared
explains
why the largest
poo1s are located
neath
the end-plates
and
not
between
to the annulus
directly
undernucleus
and
annulus.
ent
Our
from
position
pressures
tone,
large
ferent
injection
pressures
those
measured
(Quinnell,
should
be
were not significantly
differin living
people
in the prone
Stockdale
slightly
and
higher,
Willis
1983).
In vivo
because
of muscle
but this effect has apparently
variation
in injection
pressure
ages and stages of degeneration.
Discograms
what
into
an overall
and annulus,
no more
fluid
annulus
and
and require
greater
injection
pressures
DISCUSSION
This experiment
solution
when
the
1967),
and
and Horst
1985).
depends
upon
the
are
determined
been masked
between
discs
by the
fluid pools,
and hence
by the
The first four types of discogram
initial
by the
of dif-
pattern
degeneration
of the
that we have called
of
disc.
cot-
tonball,
lobular,
irregular
and fissured
represent
successive stages
in disc degeneration.
The fifth type denotes
a
rupture,
and this can occur
in a disc at any stage
of
degeneration.
Viewing
a good indication
tion.
The
soft
the four
stages
ofthe
natural
history
amorphous
nucleus
in succession
gives
ofdisc
degeneraof a young
disc
becomes
less homogeneous
with age. At an early age it
has regions
of greater
and lesser cohesion
(Fig.
lb) that
gradually
become
more
exaggerated
and coalesce
(Fig.
2e). By about
several
discrete
material
which
the
fifth decade
the nucleus
fibrous
bodies
surrounded
may contain
large fissures
6
3
3
3
33
the nucleus
0
14
6
12
15
47
cated,
fissures
and clefts appear
in the inner annulus
(Fig.
3b) and develop
into radial
fissures
(Fig. 4b). A complete
19
48
15
22
30
134*
LI -2
L2-3
L3-4
L4-5
L5-Sl
2
3
6
5
3
10
15
12
7
4
3
1
3
5
3
0
2
3
6
11
2
4
3
9
12
17
25
27
32
33
Mean
SD
n
2.41
1.16
15
1.96
1.02
39
1.84
0.54
7
1.20
0.63
16
1.36
0.73
25
Mean
SD
n
0.62
0.40
17
0.71
0.32
42
1.20
0.56
9
1.54
0.36
5
>2.0
<30
31-40
4 1-50
51-60
18
Total
in the
of pressure
?
vertebral
and
volume
end-plates,
were
more
fibrous
and
dessi-
radial fissure
(rupture)
can be the final stage of degeneration
(Fig.
5a). However,
ruptures
can also appear
in
young
non-degenerated
discs
(Fig.
Sb) where
they are
probably
related
to disc injury
(Adams
and Hutton
1982)
or fatigue
damage
(Adams
account
of disc degeneration
tural features
in the nucleus
vious
work
(for
example,
We
28
made
to become
and
Hutton
1985).
This
naturally
focuses
on strucbut it is consistent
with preVernon-Roberts
and
Pine
1977).
so discogram
only
continues
consists
of
by softer
(Fig.
2c). As
on
results
the
later
material
the same
tnibution
this
have
shown
that
discognams
on
reveal
the state ofdegenenation
be said ofdiscograms
on living
of injected
experiment
fluid
because
THE
must
exactly
JOURNAL
be the
same
the same
OF BONE
cadavenic
ofthe
discs. Can
people?
The dis-
AND
in vivo
patterns
JOINT
as in
of dis-
SURGERY
THE
cograms
on living
1969).
preting
image
have been described
people
(for example,
However,
discograms
is reduced;
in numerous
investigations
by Gnesham
and Miller
approach
could lead
and the needle
track;
discograms
in life than
the majority
of patients’
in
to confusion
and Types
4
us now
consider
the
usefulness
of this
so give
of the
Types
1 , 2 and 3 discs are not prolapsed,
degenerate
and it is difficult
to see how
others.
severely
could
be responsible
for
symptoms.
Type
4 may
or
they
well
be
symptomatic
since an incomplete
radial fissure can represent an intermediate
stage in the gradual
prolapse
of the
disc (Adams
and Hutton
1985).
When
this is the case,
there will probably
be nuclear
pulp in the fissure
causing
the outermost
annulus
and adhering
posterior
longitudinal
ligament
to bulge
outwards.
This
is often
injection
(Fraser
et a!. 1983). Type
5 discs may also be
symptomatic
since a disc rupture
could
indicate
a recent
no
extrusion
of nuclear
the rupture
may have
and
may
after
fifth
the nucleus
has
and sixth decades
probably
symptoms
longer
why disc
in people
people
(Gresham
the Type
5 discs
a!.
1983).
that disc
probably
leak;
In
and
give
certainly
coalesced
(Adams
ruptures
aged
pulp
(Fernstrom
occurred
long ago
it is unlikely
into fibrous
and Hutton
are
under
to do so
lumps
1985).
in the
This is
often
associated
with
35, but not in older
Miller
1969) and why only 21%
rise to pain on injection
(Fraser
summary,
the
available
Types
I , 2 and 3 are
is, and Type
5 may
evidence
not symptomatic,
be, especially
of
et
suggests
Type 4
in a young
the five types
ofdiscogram
may
be useful
in
predicting
the likely
effect
of chemonucleolysis
on that
disc. Chymopapain
seemingly
binds
rapidly
to the disc
matrix
and breaks
down
proteoglycans.
Its action
should
VOL.
68-B.
No.
I, JANUARY
1986
the potential
5 disc with
symptomatic)
to be both effective
a soft pulpy
nucleus
rupture
(Fig.
5b and
and
and a
Ia).
How-
ever,
the whole
question
of the usefulness
of chymopapain
in relieving
symptoms
at all is in some dispute.
Conclusions.
When an aqueous
solution
is injected
into a
initial
distribution
the matrix
Useful
discograms.
and hence
the
we
fissured
with
the
of injected
in pools,
the
fluid
of
degeneration
have
called
represent
disc matrix,
fluid. After
slowly
by the processes
ofdiffusion
clinical
information
can
The location
the appearance
stage
types
but
this
mixes
with
and fluid flow.
be obtained
from
of the pools
of injected
fluid,
of a discogram,
depends
on
of
the
disc.
cottonball,
successive
The
lobular,
stages
discogram
irregular
in disc
and
degeneration.
This work
is supported
by a grant from the Arthritis
and Rheumatism
Council.
Our many
discograms
were taken
by Mrs A. Pettitt
and Mr D.
Horsfield
of the X-ray
Department
at the Royal
National
Orthopaedic
Hospital:
we are most grateful
to them.
We also thank
Michael
Sullivan,
FRCS,
who contributed
to our discussions
on the best classification
of
the different
types of discogram.
REFERENCES
Adams
MA, Hutton
WC. Prolapsed
injury. Spine l982;7: 184-91.
Adams
MA,
Hutton
WC.
Gradual
intervertebral
disc
disc:
prolapse.
Spine
a hyperfiexion
1985 ; in press.
Brinckmann
P, Horst
M. The
influence
of vertebral
body
fracture,
intradiscal
injection,
and partial
discectomy
on the radial
bulge
and height ofhuman
lumbar
discs.
Spine
1985; 10: 138-45.
Erlacher
PR.
Nucleography.
J Bone
Joint
Feinberg
SB. The place
of diskography
cases. AJR l964;92:127581.
Fernstrom
discs.
Fraser
U. A discographical
Acta Chir Scand
study
1960;Suppl
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[Br]
204-10.
as based
of ruptured
lumbar
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[Am]
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of lumbar
1968;5O-A
: 720-6.
MIV,
phology
Herbert
CM,
and bursting
Quinnell
RC,
Stockdale
within
normal
discs
HR,
Willis
in the lumbar
Vernon-Roberts
B, Pine
discs of the lumbar
1977:16: 13-21.
CJ. Degenerative
spine
and their
fibrosus.
spine by diskography
of the herniated
disk
J Bone
Dis
Joint
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discs: nuclear
1973:32:308-
mor15.
DS. Observations
spine.
Spine
1983:8:
changes
sequelae.
2320
in degener-
annulus
discography.
Barks JS. Intervertebral
pressures.
Ann Rheurn
on
intervertebral
J, McCall
1W, Park WM, O’Brien
JP. Discography
ating disc disease. Orthop
Trans l983:7(3):466.
Gresham
JL, Miller
R. Evaluation
of the lumbar
and its use in selection
of proper
treatment
syndrome.
C/in Orthop 1969:67:29-41.
Holt
1952;34-B:
in radiology
Galante
JO. Tensile
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of the human
Ada
Orthop
Scand
I967;Suppl
100.
Jayson
person.
Finally,
in the disc,
If this is the
suggested
by the appearance
of the discogram.
Type
4 discs are
common
in patients
with back pain and are the type most
often
associated
with symptomatic
pain reproduced
by
prolapse
with
1960). However,
chymopapain
has
useful
is the Type
disc it does
not at first mix
pushes
it aside to form pools
informa-
tion. Holt (1968)
showed
that asymptomatic
volunteers
can have
abnormal
discograms.
Evidently
there
is no
simple
correspondence
between
pathological
changes
in
the disc and patients’
symptoms.
Nevertheless,
certain
discogram
types are much more likely to be symptomatic
than
even
on its initial
distribution
of fibrosis
of the nucleus.
should
be the least efficiently
digested
(Fig. 4b). Unfortunately,
Type
4 discs are most
likely
to be symptomatic
and Type
I are least likely.
The category
of disc where
(possibly
disc.
Let
41
BY DISCOGRAMS
case then Type I discs should
be most effectively
digested
because
they have a non-fibrous
nucleus
that mixes
intimately
with any injected
fluid (Fig.
Ic) and Type 4 discs
this experiment.
discograms
clearly
types described
above
and
on the state of degeneration
AS REVEALED
therefore
depend
and on the degree
to distinguish
since
there
is no
when injected
fluid is escaping
reasons
it will be more difficult
to
show one of the five
accurate
information
injected
DEGENERATION
is more
scope
for error
in intertaken
in vivo:
the contrast
of the
the position
of the needle-tip
is less cer-
be difficult
confirmation
For these
categorise
Nevertheless,
OF DISC
there
tam; the posterolateral
between
disc fissures
and 5 may
direct
visual
from a disc.
STAGES
of pressures
166-9.
in the intervertebral
Rheumatol
Rehabil