Cervical Discogenic Pain Syndrome Workup
- Author: Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM; Chief Editor: Craig C Young, MD more...
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- Laboratory studies typically are not indicated in the diagnosis of cervical discogenic pain syndrome.
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- Radiographs of the cervical spine primarily are indicated in cases in which significant trauma is involved (eg, motor vehicle accident, sport injuries) and in cases in which the history and physical examination suggest the possibility of a fracture or instability. See the images below.
- An oblique view is necessary to evaluate for fracture of the pars interarticularis and facet joint arthropathy. If spondylolisthesis is found and is believed to be symptomatic, flexion/extension lateral views are helpful to evaluate for instability.
- In cervical discogenic pain syndrome (CDPS), radiographic findings can be normal or can show decreased intervertebral space and associated facet joint and/or vertebral body degenerative changes. Radiographic findings commonly show degenerative changes in persons older than 55 years. Little correlation exists between symptomatic and asymptomatic individuals and structural changes on roentgenographic examinations.[2, 17, 36]
- In 1987, Deyo recommended radiographic studies be obtained in the following circumstances :
- Patients older than 50 years
- History of significant trauma (fracture risk)
- Neuromotor deficits (to rule out spondylolisthesis or tumor)
- Unexplained weight loss (to rule out malignancy)
- Drug or alcohol abuse (risk factors for osteomyelitis, osteoporosis, and trauma)
- History of cancer (to rule out metastasis)
- Use of corticosteroids (increased risk of infections and osteoporosis)
- Fever (potential sign of osteomyelitis or epidural abscess)
- Failure to improve with conservative therapy
- Medicolegal cases involved in litigation
- CT scanning provides high-quality osseous detail and spatial resolution.
- CT scanning is a valuable adjunct in evaluating patients with extensive bony degenerative changes and suspected stenosis or bony pathology not identified by plain radiographic films.
- CT scan also is an alternative to evaluate for disc herniations in patients in which MRI is contraindicated. See the image below.
- When combined with discography, axial CT scanning surpasses MRI in detecting annular fissures.
- CT scanning with myelography is helpful in evaluating patients with extradural compression of the neural elements from bone or disc material.[39, 40]
- MRI is the study of choice in patients with suspected degenerative discogenic disease. See the images below.
- MRI is a sensitive diagnostic modality that offers multiplanar imaging capability and excellent soft-tissue and spatial resolution without ionic radiation. MRI also provides physiologic information regarding the water content of the disc.
- Schellhas et al studied subjects who were asymptomatic and those who experienced pain. The investigators concluded that significant disc annular tears often escape MRI detection and that MRI cannot reliably identify the source or sources of cervical discogenic pain syndrome (CDPS).
- MRI abnormalities are common in patients who are asymptomatic and must therefore be corroborated with physical examination findings in making the diagnosis of cervical discogenic pain syndrome (CDPS).
- Matsumoto et al completed a study of 497 patients who were asymptomatic. In this study, cervical MRI revealed that the frequency of degenerative changes increases as age increases. Disc degeneration was the most common observation. In men and women in their 20s, 17% of men and 12% of women showed disc degeneration; in individuals than 60 years, 86% of men and 89% of women showed disc degeneration. Posterior disc protrusion with demonstrable compression of the spinal cord was found in 7.6% of subjects, mostly those older than 50 years.
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- Cervical discography
- Cervical discography is an important adjunct in the evaluation of the patient with cervical discogenic pain syndrome (CDPS), particularly when other diagnostic studies fail to detect any abnormalities in a patient with subjective symptoms of cervical discogenic pain.[42, 44]
- Manchikanti et al performed a systematic review of the cervical discography literature. The investigators found that cervical discography plays a significant role in selecting surgical candidates and improving outcomes, despite concerns regarding the false-positive rate, lack of standardization, and assorted potential confounding factors. Manchikanti et al concluded that cervical discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic cervical pain, without disc herniation or radiculitis. "Based on a modified Agency for Healthcare Research and Quality (AHRQ) accuracy evaluation and US Preventive Services Task Force (USPSTF) level of evidence criteria, this systematic review indicates the strength of evidence as level II-2 for diagnostic accuracy of cervical discography."
- Cervical discography is also useful in the evaluation of patients with multiple degenerative disc findings or various levels of disc herniations in which surgery is contemplated.
- The most important part of the cervical discography evaluation is the provocation/analgesia response, because it will differentiate symptomatic from nonsymptomatic discs. In a study published by Osler, a series of patients with positive cervical analgesic discography followed by anterior cervical fusion with or without discectomy resulted in 81% excellent or good results. Osler concluded that analgesic discography is the most effective test for location of the lesion in the painful disc syndrome.[47, 48]
- Electromyography (EMG)
- EMG is performed primarily by specialists in neurology or physical medicine and rehabilitation as an extension of the history and physical examination of patients with suspected cervical radiculopathy.
- Prevalence studies of cervical radiculopathies demonstrate that 2 age peaks exist, one in the 60s and 70s and one in the 20s. Cervical radiculopathy in the older age group almost always is caused by a combination of osteophytic spurs and disc protrusion compressing an exiting nerve root, and cervical radiculopathy in the younger age group tends to be caused by a typical type of disc herniation.
- EMG is a physiologic test not necessary in the initial evaluation of patients with new symptoms unless it is being utilized as a baseline for worker's compensation or to assess personal injuries to rule out a preexisting injury.
- Wait approximately 3 weeks after the onset of symptoms to perform an EMG. Delaying the study for 3 weeks ensures accurate detection of positive waves and fibrillation potentials.[17, 49]
- EMG can also be useful by assisting in the determination of the approach to epidural injections, selective nerve root blocks, and/or surgery. EMG is valuable in identifying other possible concomitant neurologic conditions, such as entrapment neuropathies, peripheral neuropathies, brachial plexopathies, myopathies, and motor neuron diseases.
- Sensory-evoked potentials are useful in evaluating patients with cervical myelopathy.
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