Markus Kornberg, MD KEY POINTS FROM DAN MURPHY: 1) The most useful modality for assessing symptomatic degeneration of thelumbar intervertebral disc is discography. 2) With aging, intervertebral discs lose water. Determination of discdegeneration with magnetic resonance imaging (MRI) depends on the loss of watercontent in the disc. 3) Four trauma case histories are presented of patients with negative MRIstudies but with abnormal discography: #1: 35-year-old man fell while roller-skating, developed low back and right legpain. MRI and Discogram performed at 2 years: MRI normalDiscogram L5-S1 annular disruption, injection reproduced pain #2: 27-year-old man fell a short distance off scaffolding, developed low back andbilateral leg pain. MRI and Discogram performed at 4 months:MRI normalDiscogram L5-S1 disc degeneration, injection reproduced pain #3: 41-year-old woman tripped and fell to pavement, injuring spine.Myelogram normal CT normalAfter 2.5 years of continuous symptoms, MRI and Discogram:MRI normalDiscogram L5-S1 annular disruption, injection reproduced pain #4: 37-year-old man thrown against wall by a pressure hose, developed LBP andleft leg pain. MRI and Discogram performed at 2 years:MRI normalDiscogram L5-S1 disc degeneration, injection reproduced pain 4) Normal lumbar disc MRI does not necessarily rule out [symptomatic] discdegeneration. 5) A normal MRI does not rule out early disc degeneration.2 6) There is an interval of time between the development of traumaticdisruption of the annulus and loss of sufficient water content to be reflected on MRIas decreased signal intensity. 7) If MRI fails to demonstrate evidence of disc degeneration, then discographyis indicated to determine the status of the annulus and for pain provocation. COMMENTS FROM DAN MURPHY I found this study doing a search for a PI attorney (plaintiff) from Salt Lake City. Itwas important in his case. The primary perspective is: It is often (essentially always) claimed by insurance defense attorneys andtheir experts that if the MRI is normal that there is no injury. This studyclearly shows that is not the case. A discogram is clearly more accurate than MRI is documenting symptomatic discinjury and degeneration. A plaintiff attorney might use such a study to ask adefense expert something like: Doctor… * Can a discogram prove post-traumatic symptomatic disc degeneration incases where the MRI appears to be normal? * To give a more complete opinion in this case, would you have liked to haveseen the results of a discogram? * In order for an expert to give his/her best opinion, should one not first haveobtained the best possible evidence? * Because you did not have the results of a discogram in this case, you reallydo not have the best evidence as to whether the disc is injured or not, do youdoctor? Although I believe these concepts are important, I am not in favor of routinediscograms as there is evidence that disrupting the integrity of the annular ring ofthe disc with a needle, either for diagnostics or for treatment, tends to acceleratedisc degenerative disease. [Article Review 11-11: Does Discography Cause Accelerated Progression of Degeneration Changes in the Lumbar Disc: A Ten-YearMatched Cohort Study; Spine; October 1, 2009, Volume 34, Number 21, pp. 23382345:2009 ISSLS Prize Winner (International Society for the Study of the LumbarSpine).]