The Functional Anaesthetic Discogram: Description of a Novel Diagnostic Technique and Report of 3 Cases

Alamin, Todd F.; Malek, Fatemeh; Carragee, Eugene J.; Kim, Mi‐Jung

doi:10.1016/sasj-2007-0123-nt

Cited by 3 publications

(2 citation statements)

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“…A previous retrospective study had demonstrated the presence of the artery of Adamkiewicz traversing within this triangle, although most occurred above the level of L3 (92%) [ 7 ]. This site of intervertebral disc access has been used for radiographic purposes in discograms [ 8 ], pain management purposes for steroid injections [ 4 - 5 ], and more recently, for percutaneous minimally invasive surgical approaches to intervertebral disc for discectomies and spinal fusions [ 6 , 9 ]. This retroperitoneal, posterolateral approach to the lumbar spine has been considered a safe area of access to the disc space and, thus, an effective approach in reducing complications, such as violation of the thecal sac, injuries to the nerve root, or destabilization of the bony elements of the spine.…”

Section: Introductionmentioning

confidence: 99%

Cadaveric Analysis of the Kambin's Triangle

Hoshide¹,

Feldman²,

Taylor³

2016

Cureus

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IntroductionKambin’s Triangle is a right triangle over the dorsolateral disc. The area of this right triangle currently serves as a strategic site of posterolateral, minimally invasive access to the nerve root for delivery of epidural steroid injections. This posterolateral approach has also been considered a safe area of access to the intervertebral disc space and, thus, an effective approach in reducing complications, such as violation of the thecal sac, the nerve root, or the bony elements of the spine during minimally invasive spinal surgery. No published studies have been performed to characterize the dimensions of the Kambin's Triangle. Our aim is to characterize its dimensions at the lumbar levels and determine its efficacy and safety as a site of access for minimally invasive spinal surgery.MethodsTwo randomly chosen adult male cadavers were used for this study. The measurements were made bilaterally at their lumbar levels (L1–L5), which equates to 16 total measurements (eight bilateral disc spaces on two cadavers). The disc space was first accessed using a Kirschner wire in a standard oblique approach. With the assistance of fluoroscopy, a Kirschner wire was passed into the disc through the Kambin’s Triangle. The procedure was performed on the cadavers bilaterally at four levels, followed by open dissection. The calculations of the area were made by measuring the exiting nerve root, the superior border of the caudal vertebra, and the superior articulating facet—the borders of the Kambin's Triangle.ResultsThe Kambin’s Triangle height and width respectively averaged at 12 mm and 10 mm (L1–L2), 13 mm and 11 mm (L2–L3), 17 mm and 11 mm (L3–L4), and 18 mm and 12 mm (L4–L5). Thus, the area at each level was 60 mm2 (L1–L2), 71.5 mm2 (L2–L3), 93.5 mm2 (L3–L4), and 108 mm2 (L4–L5). All dissected levels demonstrated adequate anchoring of the Kirschner wire into the disc space with no evidence of nerve injury. Following this, a retractor was placed and complete discectomies were performed. All exiting nerves were protected in this safe zone and the thecal sac remained inviolate.ConclusionUnderstanding the Kambin’s Triangle will assist surgeons in the minimally invasive approach to spinal surgeries, with potentially safe placement of interbody cages through this strategic space.

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Section: Introductionmentioning

confidence: 99%

Cadaveric Analysis of the Kambin's Triangle

Hoshide¹,

Feldman²,

Taylor³

2016

Cureus

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“…In addition, multiple reports by Carragee et al (131)(132)(133)(134)(135)(136)(137)(138)(139)(140) and several guidelines based on the available literature (217)(218)(219)(220)(221)(222)(223) have suggested that discography may in fact result in unnecessary surgery and accelerated disc degeneration in addition to misdiagnosis (210)(211)(212)(213)(214)(215). Much of the literature related to negative aspects of discography, as described earlier, is from Carragee et al (131)(132)(133)(134)(135)(136)(137)(138)(139)(140)(212)(213)(214)(215)(216). In a recent assessment of provocation discography causing clinically important injury to lumbar intervertebral disc (210), the authors concluded that the disc puncture and pressurized injection performed during provocative discography can increase the risk of clinical disc problems in exposed patients.…”

Section: Bogduk and Aprill 1993 (59)mentioning

confidence: 97%

An Update of the Systematic Appraisal of the Accuracy and Utility of Discography in Chronic Spinal Pain

Manchikanti

Soin²,

et al. 2018

Pain Phys

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Background: The intervertebral disc has been implicated as a major cause of chronic spinal pain based on clinical, basic science, and epidemiological research. There is, however, a lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, lumbar intervertebral discs have been shown to be the source of chronic back pain without disc herniation in 26% to 39% of patients, and in 16% to 53% of patients with pain in the cervical spine. Lumbar, cervical, and thoracic provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature on point, intense debate continues about lumbar discography as a diagnostic tool. Study Design: A systematic review of the diagnostic accuracy of lumbar, cervical, and thoracic provocation and analgesic discography literature. Objective: To systematically assess and re-evaluate the diagnostic accuracy of lumbar, cervical, and thoracic discography. Methods: The available literature on discography was reviewed. A methodological quality assessment of included studies was performed using the Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were included in the analysis. To assess the level of evidence, a modified grading of qualitative evidence criteria was utilized, with grading of evidence into 5 categories from Level I to Level V incorporating evidence obtained from multiple high quality diagnostic accuracy studies for Level I and opinion or consensus of a large group of clinicians and/or scientists for Level V. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2017, and manual searches of the bibliographies of known primary and review articles. Results: Over 100 manuscripts were considered for inclusion. Of these, 8 studies met inclusion criteria for diagnostic accuracy and prevalence with 5 studies assessing lumbar provocation discography and 3 studies assessing cervical discography. The results showed variable prevalence from 16.9% to 26% for discogenic pain and 16.9% to 42% for internal disc disruption. The cervical discogenic pain prevalence ranged from 16% to 53%. Based on methodological quality assessment criteria the strength of evidence for lumbar provocation discography is Level III and for cervical discogenic pain is Level IV. Limitations: Despite multiple publications in the lumbar spine, value and validity of discography continues to be debated. In reference to cervical and thoracic discography, the available literature and value and validity continues to be low. Conclusion: This systematic review illustrates that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain. The evidence is weaker for cervical and nonexistent for thoracic discography. Key words: Lumbar intervertebral disc, cervical intervertebral disc, thoracic intervertebral disc, discography, provocation discography, analgesic discography, diagnostic accuracy, prevalence

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