Lumbar Discography

Statement of purpose:

To provide guidelines to assist the Pain Physician with the performance of a discogram (discography). This is a diagnostic procedure used to determine the extent of involvement of a vertebral disc as a cause of the patient’s pain.

Policy:

The following are Guidelines. Exceptions to these guidelines are up to the discretion of each physician, and shall be based on that physician’s evaluation of the case in question.

Only the trained pain physician should do this and all pain blocks. The procedure will be done under fluoroscopy. May be done in same day surgery facilities, or in clinic facilities, if fluoroscopy and a sterile environment are available.

Equipment:

- “Crash cart” must be available in the facility.

- (2) two 10cc, luer-lock syringes

- (1) one 3cc, luer-lock syringe

- 25-G, 1.5-in, needle (1)

- 18-G needle (1)

- 18-G, 3-inch, Quincke spinal needle (one per level to be done) (usually 3-4)

- 22-G, 7-inch, Quincke spinal needle (one per level to be done) (usually 3-4)

- (1) one pressure manometer syringe (The kind used in angioplasties) “Basixä” 25 Inflation Syringe Catalog No. IN3125 (Merit Medical 1-801-253-1600 or 1-800-356-3748) or s similar pressure-gauged (manometer) 20-60 ml syringe (Merit Medical Digital Fluid Syringe KO5-L1-L5)

- (2) two 10cc bottles of contrast, water-soluble, non-ionic, hypoallergenic, myelogram-compatible dye/contrast. (20 ml) Either Isovue 200M or 300M, or Omnipaque 180. If patient is allergic to contrast, follow the “Protocol for patients with Allergies to Radiological Contrast”.

- Betadine prep or some other form of skin prep. (Alcohol or Hibiclens)

- Prep tray

- (4) four sterile towels

- (1) pack of sterile 4x4

- (1-4) one to four Band-Aids

- Prophylactic antibiotics (as ordered by physician): Gentamicin 120mg and Ancef 1gm IV, prior to procedure. Vancomycin 1gm IV, if allergic to penicillin.

- Fluoroscopy machine (C-Arm)

- Fluoroscopy table (Chic table)

- Sedation (as ordered by physician): Versed (Midazolam) 2-4mg, Fentanyl 2cc and/or propofol.

Medication:

- Ciproâ (ciprofloxacin) 500 mg PO BID 24 hr prior to procedure and 5 days after.

- Rocephinâ (ceftriaxone) 1-2gm. IV before the procedure

- Another alternative is Ancefâ or Kefzolâ (cefazolin) 1-2gm. IV, before procedure.

- Gentamicin (Garamycinâ) 100-200 mg IV

- (1) one 20-30cc bottle of 2% lidocaine

- If the patient is allergic to Penicillin, give Vancomycin 1gm. IV slowly before the procedure.

- Ancefâ or Kefzolâ (cefazolin) 5 mg/kg to mix with contrast, only if patient is not allergic to penicillin.

Procedure:

1. Schedule patient in Special Procedure area.

2. Ascertain and document that the patient has a driver, has not eaten 6 hours prior to procedure, and is not taking any blood thinners.

3. Confirm that the patient is not taking any blood thinners like Coumadin. If taking Coumadin, it most be stopped, with the consent of the prescribing physician, at least four (4) days prior to procedure. ASA and ASA-containing medications should be stopped eleven (11) days prior to the procedure.

4. Patient's Pain Clinic chart should be available at Special Procedures.

5. Ascertain and document that female patients are not pregnant. (Question patients about possibility)

6. The physician will review the procedure, including the risks and possible complications, and answer any questions that the patient or family may have, in the visit prior to the procedure day.

7. Have patient or guardian sign informed consent form.

8. Obtain baseline vital signs, which should include: BP, HR, RR, Temp, SaO₂, and NAS-11(VAS).

9. Start an IV.

10. Place patient in position. Position: prone for lumbar or thoracic disc and supine for cervical disc.

11. Prep: For lumbar disks, prep from the sacrum to the lower border of the scapula. For cervical, prep from the mandible to the collarbone (clavicle). Always prep wide.

12. The following laboratory should be ordered and drawn prior to the procedure, if requested by physician: CBC (WBC and platelet count), Sedimentation rate, bleeding time, PT/PTT, INR (as felt to be necessary by physician), and pregnancy test for females in childbearing years. The procedure should never be delayed waiting for these results, except for the pregnancy test. Ideally they should have been drawn days prior to procedure.

13. A C-Arm will be required for fluoroscopy.

14. Schedule for IV sedation using Versed and Fentanyl IV sedation.

15. Prophylactic antibiotics (as felt necessary by physician).
Gentamycin 120 mg IV before the procedure.

Ancef and Kefzol 1-2gm. IV, before procedure. (Except if allergic to penicillin)

16. If patient is not allergic to penicillin, mix 1gm of powdered cefazolin (Ancef) in 10 ml of Omnipaque 180. This will give you a concentration of 100mg/ml. Take 3 ml of this solution and mix it up to a total volume of 20 ml of Omnipaque 180, in the Merit Medical Digital Fluid Syringe. This will lead to a final concentration of 15 mg/ml.

17. If the patient is allergic to Penicillin, give Vancomycin 1gm. IV slowly before the procedure.

18. Sedate the patient (as ordered by physician). Maintain meaningful verbal contact at all times.

19. Assist physician as needed.

20. At completion of the procedure, have patient return to supine position.

21. Discard contaminated needles and equipment.

22. Document in procedure form:
a. Name of procedure, physician, indications, date, and place where performed (Hospital, Office)
b. Vitals signs every 15 minutes
c. Post-procedure NAS-11
d. Patient’s Status after procedure (Patient tolerance)
e. Any untoward effects or complications
f. Intradiscal pressures
g. Injected volume
h. Pain provocation and distribution pattern
i. End point
j. Morphologic distribution of radiological contrast

23. Observe patient for 10-15 minutes post procedure.

24. Arrange with Radiology to have the patient taken to the CT scanner immediately after the discogram injection, and then back to Special Procedures Recovery for discharge, once the patient has met discharge criteria.

25. Arrange for follow up appointment at the pain center in 1-2 weeks.

26. If the patient continues to have significant pain after the discogram, then schedule the patient for an evaluation and possible epidural steroid injection, upon return to the pain clinic.

If the patient develops pain and fever, then order a sed rate and CBC. If abnormal, consider ordering a Bone Scan to rule out discitis.

Appendix B – Pressure Manometry Syringe

25 ATM Inflation Devices

Disposable IntelliSystem® 25 Inflation Syringe with 14" (35.5cm) extension tubing. Medium pressure 3-way stopcock included separately. Packaged 5 units per box, 4 boxes per case.

UNITED STATES
Merit Medical Systems, Inc.
1600 West Merit Parkway
South Jordan, Utah 84095 USA
Telephone: 1-800-356-3748 (Toll Free)
Telephone: 1-801-253-1600 (Direct)
Fax: 1-801-253-1652