The question of lumbar discography.

Carl Hirsch of Sw-eden noted that symptoms from ruptured discs could be exacerbated by injection of normal saline directly into the affected disc, atsd he reported sixteen such cases in 1948. At his suggestion, Knut Lindblom, long iu search of a w-ay of studying lumbar discs by contrast roentgenography, injected diodrast directly into fifteets discs in thirteen patietsts and described the typical appeararsce of a normal disc and a ruptured one. In 1950, he reported on thirty-eight patients who had fifty-two lumbar discs similarly injected. He noted that fifty discs were more or less ruptured. In 1951, his series had extended to 150 cases, but no metstion was made of the ratio of normal to pathological discs. By 1962, Collis and Gardner claimed superiority for the method over lunsbar myelography in detection of lumbar-disc disease, and they published findings in 1,014 cases. The bibliographies of Fernstr#{246}m and Collis cover virtually all the pertinent material published prior to 1963. Fernstr#{246}m’s article tentatively and soberly coissidered discography from all angles. He was aware of certain weaktsesses in the method ; Collis was more enthusiastic about the procedure. Approximately six additional articles on lumbar discography have appeared in the English literature between 1960 and 1967 1,2,10,13,19,20 Most authors display enthusiasm for the method, not as a successor to myelography but as an adjunct in detection of discogenic disease. Some 6,18 claim that careful physical examination usually suffices for accurate diagnosis. But lumbar myelography as an adjunct is certainly useful at-sd reliable . Everyone realizes that myelography cannot reveal lesions of the nucleus pulposus where the prolapse is directed neither posteriorly nor posterolaterally; however, the need for surgical intervention for prolapse of a disc where neither the spinal cord nor any nerve root is compressed is not established. Such prolapses, whether through vertebral plates (Schmorl’s nodes) or in any other direction, may not produce more than temporary pain. It also has not been established whether internal derangement of the lumbar disc is sufficiently symptom-producing to be a therapeutic objective, especially a surgical one, or whether it represetits anything more than an aging process. Thus, the patterns of degeneration seen in 628 of 2,187 discs injected by the Cleveland group and 773 of 6,784 discs injected by Feinberg or 322 of 870 discs injected by Massie and Stevens may represent nothing more than normal patterns for the age groups studied. Massie and Stevens found by discography that 34 per cent of the fifty-two asymptomatic volunteers had pathological changes at the interspace betw-een the fifth lumbar and first sacral vertebrae and also noted 16 per cent pathological changes in a total of 137 lumbar discs in this volunteer group. Discography enthusiasts seem to believe that no disc which show-s an irregularity or leakage of dye can be normal. The question arises from whence came the concept that the human disc, cervical or lumbar, is competent to and w’ill retain injected material of any sort. Certainly, this is not true in the cervical area where discography in fifty asymptomatic volunteers, ages twenty-one to fifty, gave patterns of leakage in 93 per cent of 148 discs injected 12#{149}A similar study of lumbar discography is reported in this paper. * Department of Orthopaedic Surgery, Washington Utsiversity School of Mediciuse, 660 South Euclid Avenue, St. Louis, Missouri 63110.