Discography

DISC LEVEL

STOPPING POINT (pain vs. firm resistance)

# CC's INJECTED

PAIN SCALE (0 to 10)

PAIN CHARACTERISTICS (concordant vs. partially-concordant vs. non-concordant)

RADICULAR PAIN (no vs. R leg vs. L leg)

DISC MORPHOLOGY (normal nucleogram vs.annular tear vs. DDD)

2. Information regarding whether or not a post-procedure CT-scan is requested by the referring physician - otherwise, no CT-scan will follow after the procedure

3. Recent (within the last two months) MR examination of the spine with report.

This information will be reviewed by the radiologist before scheduling the procedure.

In addition, the scheduler will ask the patient the following questions:

1. Has your physician explained to you what a discogram is, and why it is necessary?

2. Are you contemplating surgery to treat your pain? Are you being sent to have a discogram performed to make a decision regarding surgery?

The patient should have an understanding of the procedure extensive enough to include:

- The fact that discography is a diagnostic test, rather than a therapeutic test. I.e. it may exacerbate their pain, and it is not meant to make them feel better.

- It is an interventional procedure that last approximately 1 hour, and requires placement of several needles in the spine.

- It can potentially be painful, and requires sedation.

- Why the referring physician is requesting it in the patient's particular situation: i.e. possible surgery (discectomy vs. fusion; prior failed surgery - considering revision).

In the event that the patient does not have this minimum amount of information, he or she will directed to call his or her physician before the procedure is scheduled. It is the responsibility of the referring physician to explain this basic information.

Discography requires cooperation from the patient in communicating his or her pain response while under the stress of the procedure; therefore, it is imperative that the patient has a realistic understanding of what is expected of him or her.

SCHEDULING TELEPHONE NUMBERS:

rosemarie 215-612-4697
jen 215-612-4696
interventional scheduling 215-612-4013

PRE-PROCEDURE ORDERS: INTRAVENOUS & INTRADISCAL ANTIBIOTIC (prepared by Karen Green, RN)

Each time a patient is scheduled to undergo a Discogram, the Radiology Nurse needs to clarify with Dr. Parellada or Dr. Glickman which scenario of medications he will be ordered. The Radiology Nurse will clarify patient allergies prior to order writing.

Preferably, Dr. Parellada or Dr. Glickman will write the medication orders; however the Interventional Radiologist on-site may write the order once he has conferred with Dr. Parellada.

Pre-procedure medications: written orders need to be sent to Observation Unit, or Nursing Unit where patient is admitted.

Options:

Cefazolin (Ancef)

Cefazolin (Ancef), 1 gram IVPB within 1 hour before procedure to be administered in the Observation Unit
Cefazolin (Ancef) 10 mg / 5 mL normal saline (yields 2 mg / mL) - will be utilized during the procedure for disc injection in the Interventional Radiology Suite. This syringe will be delivered to the IR Suite or a member of the IR team will need to pick it up from Pharmacy

NOTE: The radiologist will mix 0.5cc. of diluted Cefazolin with 2.5cc. of contrast (non-ionic myelographic contrast - Omnipaque) in a 3cc. syringe for injection.

Clindamycin (Cleocin) - If patient has cephalosporin or penicillin allergy

Clindamycin 600 mg IVPB administered within 1 hour before procedure to be administered in the Observation Unit
Clindamycin 6 mg / 5 mL normal saline (yields 1.2 mg / mL; 0.6 mg / 0.5 mL) - will be utilized during the procedure for disc injection in the Interventional Radiology Suite. This syringe will be delivered to the IR Suite or a member of the IR team will need to pick it up from Pharmacy.

NOTE: The radiologist will mix 0.5cc. of diluted Clindamycin with 2.5cc. of contrast in a 3cc. syringe for injection.

SEDATION:

Mild sedation during the procedure:

Midazolam, 1-2 mg
Fentanyl 100-150 microgr. (only if strictly necessary) - avoid blunting the patient's response to the challenge

DISCHARGE INSTRUCTIONS:

PROCEDURE:

The name of the procedure you just had is .............................. discography. This procedure was prescribed by your physician to collect valuable information as to the source of your pain. In some patients this procedure may be painful, because the goal of the procedure is to reproduce the pain you regularly experience. This is done by injecting radiographic contrast material or dye into the discs (shock absorbers between vertebral bodies ) in your back.

WHAT TO EXPECT:

If you experienced pain during the procedure, it may take several hours for the pain to subside or return to your baseline level. Some patients experience pain or soreness in the back or at the puncture sites that last up to a week.

However, if you think that the type of pain you are experiencing is out of proportion to the soreness or dull pain to be expected from the procedure, do not hesitate to contact us.

POST-PROCEDURE MEDICATIONS:

You may resume your regular medications after the procedure is over. If dose adjustments are needed to cope with the expected post-operative pain or soreness, please contact your referring physician.

If you were not taking any medications regularly for pain control, the pain from the procedure itself can usually be controlled with over-the-counter pain relievers. Sometimes, a cold compress applied to the area of pain may help.

ACTIVITIES:

1. Do not drive for the remainder of the day. Also, avoid tasks that require concentration or quick reaction. Likewise, delay any important business or personal decisions for 24 hours.

2. Avoid strenuous activities, and try to rest the affected area for 3 or 4 days.

3. Keep the area of the procedure dry for 24 hours.

4. You can resume a normal diet as tolerated.

5. Do not drink alcoholic beverages for 24 hours.

WHAT TO LOOK FOR:

As the radiologist discussed with you at the time of obtaining consent, the main concern with discography is the possibility of a spine infection or discitis / osteomyelitis. It is important that you detect any early symptoms that may indicate an infection in the disc. If you notice any of the following:

1. Fever

2. Chills

3. Swelling or drainage from puncture site

4. Unusual severe pain, changing in quality from the time immediately after the procedure,

call the Interventional Radiology division at the Department of Radiology (215) 612-4021, and ask for the Radiology Nurse. After 5 p.m., call (215) 612-4021 and ask to speak with the Interventional Radiologist on call or with the Musucoloskeletal Radiologist who performed the procedure on you.

RESULTS:

The results of the test will be sent to your physician in the next few days. Please make an appointment with your physician to discuss the results and possible therapeutic options.

NEEDLES:

18g x 3.5" & 6" Spinal Needle

20g x 3.5" & 6" Spinal Needle

22g x 3.5" & 6" Spinal Needle

25g x 20cm & 25cm Chiba Biopsy Needle

REPORTING SYSTEM:

The nurse administering conscious sedation will collect the following tabulated information as each one of the different disc levels are injected consecutively:

This information will be typed on the lateral view of the lumbar spine obtained after the completion of the procedure as follows:

MODIFIED DALLAS DISCOGRAM SCALE:

Posterior radial annular tears or fissure should be reported using the MDDS, as follows:

Grade 0: Normal nucleogram - contrast medium confined to the nucleus pulposus with transverse lucent cleft:

Grade 1: Radial tear confined to the inner third of the annulus:

Note the small leakage of contrast into the annulus at 4:00

Grade 2: Radial tear extending to the middle third of the annulus

Grade 3: Radial tear extending to the outer third of the annulus

Grade 4: Radial tear dissecting the outer third of the annulus over more than 1/3 of its circumference:

Grade 5: Full-thickness radial tear with extra-annular leakage:


grade 4 tear with...	extra-annular leakage

SPECIAL SITUATIONS:

1. Diffuse Degenerative Disc Disease:

2. Iatrogenic Annular Injection:

CPT CODES:

These can be used for EACH level of discography for the lumbar spine:

62290, 72295

These are the codes for EACH level of discography for both the thoracic and cervical spine:

62291, 72285