Enhancing Annular Fissures and High-Intensity Zones: Pain, Internal Derangement, and Anesthetic Response at Provocation Lumbar Discography

Receiver operating curves (ROCs) for predicting concordant pain (A) and significant pain (B) based on HIZ and EAF features. Sens indicates sensitivity; Spec, specificity.

A 49-year-old woman with long-standing LBP and some bilateral leg radiation (most severe VAS = 10/10; immediate preprocedural VAS = 5/10) with prior discectomy at L5–S1. Concordant pain was provoked at L2–3, L3–4, and L4–5, with all 3 levels demonstrating partial provoked pain improvement with intradiscal lidocaine, and all 3 levels appearing contained on postdiscogram CT. A, Sagittal postcontrast T1-weighted image demonstrates posterior EAFs at L2–3, L3–4 (thin arrows), and L4–5 (thick arrow). B, Sagittal T2-weighted image. The L2–3 HIZ, considered Grade 4, and L3–4 HIZ, considered Grade 2 by consensus group 1, were identified as HIZs by consensus group 2 (thin arrows). The EAF at L4–5 considered a Grade 1 HIZ by consensus group 1 was not identified as an HIZ by consensus group 2 (thick arrow). C, Sagittal reconstructed CT image demonstrates the posterior annular margin at L4–5, consistent with the EAF (thick arrow). D and E, Axial postdiscogram CT images through the L4–5 disc demonstrates severe annular degeneration (Dallas Grade 3) with the posterior annular margin noted, consistent with the EAF (thick arrow).