Lumbar discography (L3/L4) surgical technique
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The lumbar intervertebral disc has been viewed as a potential source for pain for many years. In 1934 Mixtel and Barr published their article on the intervertebral disc and its role in sciatica and since then the disc has been put forward as playing a role in discogenic back pain. The postulated mechanisms of action include stretching the fibres of the annulus fibrosus, extravasation of noxious chemicals from the disc around the nerve and dura, pressure on the nerves, granulation tissue within the annulus, and abnormal loading on the annulus or nucleus.
Lumbar discography is aimed at assessing the state of the disc and its part in the causation of a patient’s pain. X-rays, CT scans, and MRI scan are all imaging modalities that tell us about the anatomy of the disc but don’t directly indicate whether the disc is causing a patient’s pain.
Lumbar discography is not universally accepted as being an effective management due to the risk of false positives and complications such as discitis. Its use is therefore controversial.
The aim is to place the needle tip into the nucleus pulposus and then inject dye to assess the disc morphology, provoke pain by increasing the intradiscal pressure, and try to reduce the pain over time using local anaesthetic directly into the disc space. The provocative element of this test can be controlled using an adjacent disc space for comparison but I prefer to only inject into the disc space of interest due to the potentially devastating consequences of discitis in an otherwise normal disc space.
Fluoroscopy is required in multiple planes to navigate the needle tip safely into position within the disc space. A good working understanding of the local anatomy is essential especially with regard to Kambins Triangle. This is covered in the Nerve root block technique on OrthOracle at https://www.orthoracle.com/library/lumbar-nerve-root-block/. This is the posterolateral extradural approach which avoids the thecal sac. At the L3/4 level described here the needle trajectory enters the disc space low in Kambins triangle which is delineated medially by the dural edge, inferiorly by the superior endplate of the L4 vertebra below, and superolaterally by the L3 exiting nerve root.
I utilise a ‘needle inside needle’ technique which stops the inner needle (which will enter the intervertebral disc) from coming into contact with the skin. This is aimed at reducing the chance of discitis as a potentially devastating complication.
This technique describes lumbar discography, though the technique is also described in the thoracic and cervical spine. The complications in the cervical spine include epidural abscess, discitis, haematoma, and paralysis and given these has understandably limited indications.
The technique here deals with the L4/5 level. The L5/S1 level is possible but access is more difficult due to the narrow corridor of approach imposed by the iliac crest obstructing the trajectory.
Author: Mr Andrew Young,FRCS (Tr & Orth)
Institution: The RoyalOrthopaedic Hospital, Birmingham, UK.
- Each operation and the questions associated become a named course in the CPD section
- The operative technique itself is read as a lesson as is any company implant information if this is being assessed.
- You’ll need to tick the box to confirm this has been done and can do this immediately if you have already read the op tech.
- The vast majority of operations have a 10-15 MCQ quiz covering all aspects of the decision making and the technique
- There are four possible answers of which one is correct (or on occasion more correct) than the others.
- There are additional quiz modules on the surgical steps, the implants and problem cases being added continually
- The course is completed once all the lessons are read and quizzes submitted and passed.
- On successful completion of each quiz you will receive validated CPD points that add to the certificate in your CPD folder.
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- When you restart you will resume at the same point in the module.
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The pass mark is 75%.
- If you fall below this level you will be directed back to re-read the slides where you’ve tripped up.
- Once these have been read you can re-do just the questions you failed on.
- Once you have passed the quiz you can return at a future stage & resit .
- Operation Quiz – 1 CPD point
- Surgical steps Quiz – 1/4 CPD point
- Implants Quiz – 1/4 CPD point
- Problem case Quiz – 1/2 CPD point
One CPD point equates to one hour of academic activity
Welcome to the Professional Development question section. The objective of taking these tests is to demonstrate that you have understood all aspects of the assessment and management of patients requiring surgical intevention. On successful completion you will receive a certificate accredited by both the Royal College of Surgeons of both England and Edinburgh as well as the British Orthopaedic Association.
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