If a patient has a normal MRI of the lower back and x-rays with normal flexion/extension views but a positive subjective response to a discogram at L3-4 and L4-5, can an invasive spinal fusion, anterior and posterior, with instrumentation at L3-4 and L4-5 be recommended or performed?

The procedure was done by an experienced discographer and the patient has chronic back pain and bilateral leg pain (left leg more than right leg). Thank you!

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Doctor's response:

It can be done but it is a highly unreliable procedure. It has been well documented that spine fusion surgery in the face of a normal MRI scan is probably only helpful in 50% of patients.

The other problem with a two level fusion in this area is that this pretty much removes all the motion in the spine, and so if the fusion does not work, you now have back pain and a stiff spine.

Discograms, even when done by an experienced discographer, are a very subjective study, and their results are still very controversial among spine surgeons. Although some surgeons place a lot of emphasis on a positive discogram, many do not feel that they are significant if there is no corresponding pathology on the MRI scan.

Not all pain is from an anatomic reason. Trying to fix back pain when a lesion is not readily identifiable is probably the most common cause of failed back surgery. Keep in mind that if the spine fusion does not help the pain, it cannot be undone and again you will have a stiffer back. Some patients’ pain is actually worse after a surgery where the pathology is not identifiable.

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In Spine-health’s Doctor Advice section, physicians respond to frequently asked questions about back pain issues. These responses represent the opinion of one physician, and do not necessarily reflect the views of the broader medical community. The advice presented has not been peer reviewed by Spine-health’s medical advisory board.