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2 Table 1. Comparison of Signal Intensity on T2-weighted Image and Provocative Pain to Discography Signal Intensity on T2WI Grade 0 Grade 1 Grade 2 Normal Decrease Table 2. Comparison of Disc Height on MR and Provocative Pain to Discography Disc Height on MR Grade 0 Grade 1Grade 2 Normal Decrease

43예의 추간판에 대한 MRI에서의 이상 소견 유병률과 CTD 소견간의 통계 분 석 결과는 Table 6과 같다. Table 3.

Grade 2 14 9 3 5 3 9 0.040 Fig. 1. A 53-year-old woman showing correlation of decreased signal intensity of disc on T2-weighted image and disc degeneration and radial tear on CT discography. A. Sagittal T2-weighted image demonstrates decreased signal intensity of L4-5 disc (arrow).

CT discogram at L4-5 level shows multiple irregular annular tears (short arrows) and a radial tear (long arrow) of the disc. Discography provocated concordant pain at this level. B A B C Fig. 2.

3 대한영상의학회지 2004;51: 팽대, HIZ의 존재 소견들이 추간판성 통증과 유의한 상관관 계를 보였다. 반면에 추간판 높이의 감소, 추간판 탈출의 소 견들은 통증 등급과 연관성이 없었다. 43예의 추간판에 대한 MRI에서의 이상 소견 유병률과 유발 통증 반응간의 통계 분 석 결과는 Table 1-5와 같다. CTD 소견에서 추간판의 퇴행성 변화와 방사상 파열은 자 기공명영상 T2-강조영상에서 신호강도의 감소와 상관관계를 보였으며(Fig. 1), 조영제 누출의 소견은 자기공명 영상에서 섬유륜 팽대, 추간판 탈출의 소견과 유의한 상관관계를 보였 다. CTD 소견에서의 방사상 파열은 자기공명 영상에서 HIZ A 소견과 유의한 상관관계를 보였다(Fig. 2). 43예의 추간판에 대한 MRI에서의 이상 소견 유병률과 CTD 소견간의 통계 분 석 결과는 Table 6과 같다. Table 3. Comparison of Annular Bulging on MR and Provocative Pain to Discography Annular Bulging on MR Presence Absence Grade 0 Grade 1 Grade Fig. 1. A 53-year-old woman showing correlation of decreased signal intensity of disc on T2-weighted image and disc degeneration and radial tear on CT discography. A. Sagittal T2-weighted image demonstrates decreased signal intensity of L4-5 disc (arrow). Decreased height and high-intensity zone (curved arrow) of this disc are associated. B. CT discogram at L4-5 level shows multiple irregular annular tears (short arrows) and a radial tear (long arrow) of the disc. Discography provocated concordant pain at this level. B A B C Fig. 2. A 26-year-old woman showing good correlation of HIZ on MR with provocative pain and radial tear on discography. A. Sagittal T2-weighted image reveals high-intensity zone at L5-S1 disc (curved arrow). The signal intensity and height of this disc are decreased. L4-5 disc shows normal morphology. B, C. Discography provocated definite pain at L5-S1 disc level. L4-5 disc is also normal without provocated pain. Conventional (B) and computed tomographic discograms (C) at L5-S1 level show a radial tear (arrows) combined with a concentric tear (curved arrow) at the posterior part of disc. 543

Table 4. Comparison of High Intensity Zone (HIZ) on MR and Provocative Pain to Discography HIZ on MR Grade 0 Grade 1 Grade 2 Presence 03 4 7 Absence 20 4 5 0.005 Table 5.

4 Table 4. Comparison of High Intensity Zone (HIZ) on MR and Provocative Pain to Discography HIZ on MR Grade 0 Grade 1 Grade 2 Presence Absence Table 5. Comparison of Disc Herniation on MR and Provocative Pain to Discography Disc Herniation on MR Grade 0 Grade 1 Grade 2 Presence Absence Table 6. Comparison of MR Imaging Findings and Disc Morphology on CT Discography CT Discography MR Imaging Findings Degeneration Radial tear Extravasation SI on + (n=36) T2WI (n=07) Disc + (n=28) Height (n=15) Annular + (n=23) Bulging (n=20) HIZ + (n=14) (n=29) Disc + (n=08) Herniation (n=35) Fig. 3. A 38-year-old man showing two levels of HIZ on MR and radial tear on discogram not associated with provocative discogenic pain. A. Sagittal T2-weighted image demonstrates high-intensity zones at the L2-3, L34 and L5S1 levels (curved arrows). L45 disc underwent discectomy 3 years ago. B. Discography shows radial tear extending to the outer annulus at all of the discs of L23, L34 and L5-S1 levels (arrows). Provocative pain was only positive at L2-3 level and the pain was negative at the L34 and L5S1 levels. A B 544

5 1. Aprill C, Bogduk N. High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging. Br J Radiol 1992;65: Ross JS, Modic MT, Masaryk TJ. Tear of the annulus fibrosus: assessment with Gd-DTPA-enhanced MR imaging. AJR Am J Roentgenol 1990;154: Zucherman J, Derby R, Hsu K, Picetti G, Koiser J, Schofferman J, et al. Normal magnetic resonance imaging with abnormal discography. Spine 1988;13: Walsh TR, Weinstein JN, Spratt KF, Lehmann TR, Aprill C, Sayre H. Lumbar discography in normal subjects. J Bone Joint Surg Am 1990;72: Buirski G, Silberstein M. The symptomatic lumbar disc in patients with low-back pain. Magnetic resonance imaging appearances in both a symptomatic and control population. Spine 1993;18: Schellhas KP, Pollei SR, Gundry CR, Heithoff KB. Lumbar disc high-intensity zone. Correlation of magnetic resonance imaging and discography. Spine 1996;21: Yoshida H, Fujiwara A, Tamai K, Kobayashi N, Saiki K, Saotome K. Diagnosis of symptomatic disc by magnetic resonance imaging: T2-weighted and gadolinium-dtpa-enhanced T1-weighted magnetic resonance imaging. J Spinal Disord Tech 2002;15: Schmidt TA, An HS, Lim TH, Nowicki BH, Haughton VM. The stiffness of lumbar spinal motion segments with a high-intensity zone in the anulus fibrosus. Spine 1998;23: Lam KS, Carlin D, Mulholland RC. Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the discogenic pain source. Eur Spine J 2000;9:36-545

6 Smith BM, Hurwitz EL, Solsberg D, Rubinstein D, Corenman DS, Dwyer AP, et al. Interobserver reliability of detecting lumbar intervertebral disc high-intensity zone on magnetic resonance imaging and association of high-intensity zone with pain and anular disruption. Spine 1998;23: Tehranzadeh J. Discography Radiol Clin North Am 1998; 36: Ito M, Incorvaia KM, Yu SF, Fredrickson BE, Yuan HA, Rosenbaum AE. Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. Spine 1998;23: Pearce RH, Thomson JP, Berbault GM, Flak B. Magnetic resonance imaging reflects the chemical changes of aging degeneration in human intervertebral disk. J Rheumatol Suppl 1991;27: Weishaupt D, Zanetti M, Hodler J, Min K, Fuchs B, Pfirrmann CW, et al. Painful lumbar disk derangement: relevance of endplate abnormalities at MR imaging. Radiology 2001;218: Guyer RD, Ohnmeiss DD. Lumbar discography. Position statement from the North American Spine Society Diagnostic and Theurapeutic Committee. Spine 1995;20: Weinstein J, Claverie W, Gibson S. The pain of discography. Spine 1988;13: Saal JS, Franson RC, Dobrow R, Saal JA, White AH, Goldthwaite N. High levels of inflammatory phospholipase A2 activity in lumbar disc herniations. Spine 1990;15: Horton WC, Daftari TK. Which disc as visualized by magnetic resonance imaging is actually a sourse of pain? A correlation between magnetic resonance imaging and discography. Spine 1992;17:S164- S Milette PC, Fontaine S, Lepanto L, Cardinal E, Breton G. Differentiating lumbar disc protrusions, disc bulges, and discs with normal contour but abnormal signal intensity. Magnetic resonance imaging with discographic correlations. Spine 1999;24: Ricketson R, Simmons JW, Hauser BO. The prolapsed intervertebral disc: the high-intensity zone with discography correlation. Spine 1996;21: Braithwaite I, White J, Saifuddin A, Renton P, Taylor BA. Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography. Eur Spine J 1998;7: Sandhu HS, Sanchez-Caso LP, Parvataneni HK, Cammisa FP Jr, Girardi FP, Ghelman B. Association between findings of provocative discography and vertebral endplate signal changes as seen on MRI. J Spinal Disord 2000;13:

7 Internal Disc Derangement in Patients with Low Back Pain: Correlation of MR Imaging and Provocative Discography and CT Discography 1 Hye Won Chung, M.D. 1, 2, Jung-Eun Cheon, M.D., Sung Hwan Hong, M.D., Heung Sik Kang, M.D., Ji-Ho Lee, M.D. 3, Joo Han Oh, M.D. 3, Pyoung Jeon, M.D. 4 1 Department of Radiology, Seoul National University College of Medicine 2 Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine 3 Department of Orthopaedic Surgery, Seoul Municipal Boramae Hospital, Seoul National University College of Medicine 4 Department of Diagnostic Radiology, National Health Insurance Corporation Ilsan Hospital Purpose: The aim of this study was to correlate the MR imaging abnormalities of the lumbar intervertebral discs, with emphasis being placed on the high intensity zone (HIZ) with the use of discography for pain provocation and disc morphologic evaluation of the disc. Materials and Methods: Consecutive patients with low back pain unresponsive to conservative treatment, and who were being considered for spinal fusion had MRI performed, and this was followed by lumbar discography. The MR imaging, discography and CT discography (CTD) were evaluated for all of the 19 patients. Fortythree lumbar discs in 19 patients were included in this study. The findings of MR and CTD images were evaluated retrospectively with the professional opinion and agreement of two radiologists. MR images were assessed for the presence or absence of decreased T2-wighted signal intensity, decreased disc height, annular bulging, HIZ on T2-weighted images and disc herniation. The results of pain provocation were graded as 0, nonconcordant pain; 1, definite pain, but only as part of the symptom complex; 2, concordant pain. The morphology of CTD was analyzed for presence or absence of disc degeneration, radial tearing and extravasation of the contrast agent. The presence of radial tearing was defined as contrast extension to the outer third of the annulus. The prevalence of all MR abnormalities was calculated, and the data were compared with disc morphologic characteristics and the pain response on provocative discography. We used the chi-square test to analyze the results. Results: Grade 1 and 2 discogenic pain was observed in 8 (19%) and 12 disc levels (28%), respectively. All of the seven non-degenerated discs on MR had no pain response. The decreased SI on T2-weighted image, annular bulging and HIZ were significantly correlated with discogenic pain. Extravasation of contrast media had good correlation with annular bulging and disc herniation on MRI. Radial tearing on CT discography correlated significantly with HIZ. The HIZ was detected in 14 levels (32.6%). The HIZ on MRI correlated significantly with the pain provocation and radial tearing noted on the discograms. Conclusion: Several MR imaging findings correlated significantly with the severity of pain provocation to discography. For patients with symptomatic low back pain, the HIZ observed on MR may represent a painful outer annular disruption. Index words : Spine, intervertebral disks Spine, MR Discography Computed tomography (CT) Magnetic resonance (MR), comparative studies Address reprint requests to : Hye Won Chung, M.D., Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-gu, Seoul , Korea. Tel Fax hwchung@smc.samsung.co.kr 547

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical