Provocation Lumbar Diskography at Previously Fused Levels

Recurrent or persistent low back pain (LBP) after lumbar fusion can be related to many factors. We reviewed the provocation lumbar diskogram (PLD) features and redo-fusion outcome in our patients evaluated for recurrent/persistent LBP after technically successful fusion. LD was performed in 27 patients with recurrent/persistent LBP after prior successful lumbar surgical fusion (31 fused levels: single-level fusion-23; two-level fusion-4). PLD response and imaging characteristics at fused and non-fused levels were assessed including: intra-diskal lidocaine response, diskogram-image/post-diskogram CT appearance, presence/absence of diskographic contrast leakage, and evidence of fusion integrity or hardware failure. Outcomes in patients having redo-fusion were assessed.

Concordant pain was encountered at 15 out of 23 (65%) single-level fusions, non-concordant pain in one fusion with non-painful response in seven. Adjacent-level concordant pain was identified in seven out of 23 (30%) patients (three of 15 with painful fused levels; four of seven with non-painful fusions). In two-level fusions, concordant pain was encountered at one fused level in each patient. In painful fused levels, leaking and contained disks were encountered with partial or complete pain elimination after intra-diskal lidocaine injection. In anterior fusions, space or contrast surrounding the cage was noted at five of 11 levels. Pseudoarthrosis was noted only with trans-sacral screw fusions. Redo-fusion in 13 patients resulted in significant improvement in nine and moderate improvement in one.

Patients with recurrent/persistent LBP after technically successful fusion may have a diskogenic pain source at the surgically fused or adjacent level confirmed by lidocaine-assisted PLD.