I m a g i n g o f Di s c o g e n i c an d

Ver t e b rog e n i c P a i n
Frederik Abel, MDa, Franziska C.S. Altorfer, MDb,c, Varun Rohatgi, BSd,
Wende Gibbs, MD, MAe, Joseph Levi Chazen, MDa,*

KEYWORDS
 Vertebrogenic pain  Discogenic pain  MRI  CT  Discography  UTE  Quantitative MRI

KEY POINTS
 Discogenic and vertebrogenic pain are 2 major entities causing chronic lower back pain, involving
painful intervertebral disc degeneration and vertebral endplate deterioration.
 Conventional imaging faces challenges in identifying specific findings indicative of both pain forms,
with MRI offering the highest diagnostic value.
 Advanced techniques like single photon emission computed tomography (SPECT)/CT, ultra-short
echo time, and quantitative MRI aim to enhance precision and accuracy in detecting early disco-
genic and vertebrogenic changes.

INTRODUCTION CT, and mainly MRI are common in clinical practice.

Advanced techniques (eg, SPECT/CT or quantita-
Lower back pain (LBP) is a burdensome medical tive MRI) can be appropriate depending on the
condition that affects a substantial portion of the patient history, clinical suspicion, or in research set-
global population, with a life-time prevalence re- tings. Provocative discography is considered the
ported to be 60% to 80%.1 Remaining a primary gold standard for discogenic pain, but due to its
contributor to disability, global LBP patient count invasiveness and potential acceleration of IVD
is projected to rise from 619 to 843 million by degeneration, it is generally not a first-line study
2050, mainly attributed to global population and only applied to selected patients. Basivertebral
growth and aging.2 nerve blocks, while theoretically useful for vertebro-
Two major sources of chronic, axial LBP are dis- genic pain, are similarly invasive and not ideal for an
cogenic and vertebrogenic pain. Discogenic pain early detection method.4
is associated with abnormal intervertebral disc This review aims to 1) cover the current under-
(IVD) degeneration, while vertebrogenic pain, a standing of the pathophysiology of discogenic
more recently described entity, relates to deterio- and vertebrogenic pain, 2) explore the value of
ration of vertebral endplates.3,4 diagnostic imaging modalities in discriminating
In diagnosing LBP, imaging is becoming more both entities, and 3) briefly outline treatment trends
crucial to pinpoint the potential cause of chronic for these pain sources.
LBP, although many imaging findings lack
specificity. PATHOPHYSIOLOGY
Various imaging modalities are available to aid in
diagnosis and management of LBP. Radiographs, Vertebrogenic pain results from structural alter-
ations of the highly innervated endplates of a
radiologic.theclinics.com

a
Department of Radiology and Imaging, Hospital for Special Surgery, 535 East 70th Street, NY 10021, USA;
b
Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th Street, NY 10021, USA;
c
Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich
8008, Switzerland; d Department of Radiology, Weill Cornell Medicine, 525 East 68th Street, NY 10065, USA;
e
Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 West Thomas Road, Phoenix,
AZ 85013, USA
* Corresponding author.
E-mail address: [email protected]

Radiol Clin N Am - (2023) -–-

https://doi.org/10.1016/j.rcl.2023.10.003
0033-8389/23/Ó 2023 Elsevier Inc. All rights reserved.
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2 Abel et al

segment leading to chronic LBP. Discogenic pain stress. Inflammation and degeneration unlock
involves IVD degeneration, including structural de- proinflammatory cytokines, promoting vascular
fects resulting in biomechanical instability and growth and sensory fiber ingrowth. The nervous
inflammation. These changes closely intersect ingrowth into the previously aneural degenerative
with the peripheral and central nervous systems disc precipitated by inflammatory insults induces
to cause nerve sensitization and ingrowth.3 To nociception, and contributes to discogenic pain.13
comprehend the pathophysiology of vertebro- Clinically differentiating between discogenic
genic and discogenic pain, a thorough under- and vertebrogenic pain can be challenging and
standing of the histologic and biomechanical often remains inconclusive. Both are associated
properties as well as the innervation of the IVD is with degenerative changes of the IVD. Imaging
essential. can assist in detecting endplate changes linked
The IVD comprises a central nucleus pulposus to vertebrogenic pain and advanced IVD degener-
(NP) surrounded by the annular fibrosus (AF), ation in cases of discogenic pain.
bordered by cartilage endplates (CEP) of the adja-
cent segments. The CEP are thin layers of hyaline RADIOGRAPHS
cartilage weakly binding the disc to the vertebrae.
The NP primarily consists of 70% to 90% water, Radiographs are often the initial diagnostic modal-
proteoglycans, and Type II collagen fibers, main- ity to evaluate the lumbar spine in patients pre-
taining its high-water content via proteoglycans senting with LBP. Radiographs provide a
and distributing the hydraulic pressure.5 The AF comprehensive overview of the spinal anatomy
exhibits a laminar structure with crisscross layers, and alignment, and can identify major pathology
including the inner (primarily type II collagen) and causing LBP, including compression fractures
outer AF (primarily type I collagen). Biomechani- and alignment and curvature abnormalities
cally, the central NP resists axial compression up- including spondylolisthesis or scoliosis.
right, while the AF withstands circumferential The utility of radiographs in diagnosing both verte-
loads and allows limited rotation and bending.6 brogenic and discogenic pain is limited to evaluating
Together, these components contribute to spinal degenerative osseous changes. Radiographs can
stability and flexibility. Nerves only exist in the identify IVD degeneration through disc space height
outer third of the AF.7 The CEP are densely inner- loss, vacuum phenomenon, calcified discs, and
vated by the basivertebral nerves (BVN), a branch bone spurs. These stigmata can be associated
of the sinuvertebral nerve entering the vertebral with discogenic pain, although not all degenerated
body via the posterior foramen. In degenerative discs are painful.3 However, since IVD is common
disc disease, CEP develop fissures and tears lead- in older individuals, these are nonspecific imaging
ing to depletion of proteoglycan in the cartilage, findings, and inadequate for distinguishing symp-
microfractures, and bony sclerosis of the vertebra tomatic from pain-free patients. Radiographs also
resulting in the release of inflammatory mediators.8 fall short in visualizing disc herniations and annular
These changes manifest as abnormal signals on fissures, potentially linked to painful discs.
MRI as Modic changes (MC)9 and are strongly Endplate-driven vertebrogenic pain can appear
linked to chronic LBP.10 Vertebrogenic pain arises as sclerotic endplate changes (Fig. 1) and/or end-
from damaged, chronically inflamed CEP. In this plate defects, often accompanied by manifesta-
state, the BVN carries painful sensations due to tions of IVD degeneration. Given the high
higher nociceptor density tracing back to the resolution of radiographs for osseous structures,
BVN compared to normal endplates.11 endplate changes are often evident at lower lum-
The pathophysiology for discogenic pain follows bar spine levels, revealing painful motion seg-
a different pattern. Compromised vertebral end- ments. However, for most of these findings, CT
plates impact the disc, leading to acidic conditions or MRI has higher sensitivity. Particularly MC
and degeneration.12 Consequently, the NP un- have been associated with vertebrogenic pain
dergoes dehydration with disc height loss and and are best assessed on MRI.14
eventual fibrosis.
Biomechanically, NP dehydration reduces elas- DISCOGRAPHY
ticity, diminishing its ability to withstand axial
forces. This hinders effective force absorption Historically, provocation discography has been
and distribution. The resulting NP displacement frequently used to assess discogenic pain, yet
leads to inner layer-focused outward lamella ongoing challenges arise from methodological het-
bowing, affecting primarily the inner layers. Stress erogeneity in the literature and accuracy debates.15
may lead to AF tears, gradual loss of disc height, Provocation discography entails fluoroscopic-
biomechanical shifts, and increased facet joint guided disc puncture using a spinal needle,

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 Imaging of Discogenic and Vertebrogenic Pain 3

Fig. 1. Radiographs and MR images in a 44-year-old male experiencing axial low back pain for 6 months. Coronal
(A) and sagittal (B) plain radiographs of the lumbar spine demonstrate endplate sclerosis and marked reduced
disc height (arrows) at L3/4 with corresponding endplate edema signal (arrows) on the sagittal short-tau inversion
recovery (C) and T2-weighted (D) MR images, reflecting Modic changes Type 1.

followed by contrast media injection to pressurize Intervention Society (SIS)/ (International Associa-
the disc. Pressurization may provoke pain, and tion for the Study of Pain (IASP) technical guide-
post-interventional CT can reveal disc morphology, lines (Box 1). These guidelines lower false
radial fissures, or contrast extravasation into the positives compared to earlier, high-pressure tech-
ventral epidural space (Fig. 2). Such findings in niques.20 Notably, pain likelihood rises signifi-
the presence of a concordant pain response can cantly in patients with endplate damage.19
facilitate the diagnosis of a painful disc.16 Discogra- Hence, discography’s efficacy in distinguishing
phy is not routinely performed in many orthopedic pain originating from the disc AF versus the verte-
centers, as considerable drawbacks lie in its inva- bral endplate remains unclear, as pressurization
siveness, and potentially higher risk of accelerated might trigger nociception from both the annulus
disc degeneration, disc herniations, and discitis- (sinuvertebral nerve) and endplate (basivertebral
osteomyelitis.17,18 Moreover, there is controversy nerve).21
surrounding its ability to elicit a concordant painful
response in asymptomatic patients, although 1
CT AND CT-MYELOGRAPHY
meta-analysis suggests a low false-positive rate
of approximately 6% per disc.19 CT is a valuable imaging modality in the diagnosis
For standardization of provocation discography, and management of LBP, facilitated by its three-
it is recommended to adhere to the Spine dimensional (3D) multiplanar reformation (MPR)

Fig. 2. Discography and CT in a 54-year-old female experiencing axial low back pain for 3 years. Discography (A)
demonstrates needles within the L3/4–L5/S1 discs with injected contrast extending into the posterior annulus at
L4/5 (arrow). Sagittal post-discography CT (B) shows moderate disc degeneration with associated disc protrusions
(arrowheads) and an annular fissure at L4/5 (arrow), which is seen to better advantage on the corresponding axial
section (C) at L4/5 (dashed line, b).

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4 Abel et al

Box 1 capabilities, excellent bone visualization, and

The Spine Intervention Society (SIS)/ ultra-high spatial resolution (approaching terri-
International Association for the Study of Pain tories of 0.2 mm isotropic) that is driven by ad-
(IASP) consensus guidelines for provocation vances in photon-counting CT.22 These attributes
discography. permit thorough spinal anatomy analysis and
detection of many disorders such as spinal steno-
Provocation Discography sis, spondylolisthesis, fractures, and bone tumors.
1. Concordant pain response of 6/10 In patients with suspected discogenic pain,
2. Volume limit of 3 mL post-discography CT offers more detailed imaging
of damaged IVD than discograms (two-dimen-
3. Pressurization of the disc to no greater than
sional fluoroscopy). Common findings include
50 psi or 15 psi above opening pressure
fissured/ruptured discs and contrast agent
4. Adjacent disc(s) provide controls. extending into or beyond the outer annulus, that
a. For 1 control disc: have been shown to be positive in 94% and 97%
of concordant painful discs at discography,
i. Painless response
respectively (see Fig. 2).23
OR CT also facilitates detection of degenerative
ii. Non-concordant pain that occurs at a endplate defects owing to its superior spatial res-
pressure greater than 15 psi over open- olution and osseous detail. Endplate defects are
ing pressure closely linked to MC,24 which are primary indica-
b. For 2 adjacent control discs: tors (particularly MC Type 1) for vertebrogenic
pain, reflecting subchondral inflammation and
i. Painless response at both levels
bone marrow alterations. MC are often associ-
OR ated with endplate sclerosis and can help identify
ii. One painless disc AND 1 disc with non- a painful vertebrogenic motion segment on CT.
concordant pain that occurs at a pres- Endplate sclerosis can exist in all MC types (1–
sure greater than 15 psi over opening 3) and is not a characteristic feature of MC Type
pressure 3 (Fig. 3).25

Fig. 3. CT and MR images in a 65-year-old male with chronic low back pain for 2 years. Sagittal CT (A) demon-
strates sclerotic endplate changes (arrows) at L1/2 and L3/4 with collapsed discs. Corresponding T1-weighted
(B) and T2-weighted (C) MR images show hypointense endplate changes, indicative of sclerosis (Modic changes
Type 3).

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 Imaging of Discogenic and Vertebrogenic Pain 5

Nonetheless, CT is less effective for soft tissue SPECT/CT

discrimination (including spinal cord and nerve
roots) and IVD imaging compared to MRI. CT- Single photon emission computed tomography
Myelography, combining CT with contrast injec- (SPECT/CT), a hybrid technique merging bone
tion into the subarachnoid space, enhances soft scintigraphy with radiotracer uptake (often Tc-
tissue details and enables assessment of spinal 99m methylene diphosphonate) and anatomic ac-
cord, nerve roots, and disc contours. It is valuable curacy of CT, has shown promise in detecting
for diagnosing disc herniations and ruling out metabolically active vertebral endplates.
nerve root(let) or spinal cord compression causing Increased tracer uptake in bone scintigraphy
radicular pain.26 CT-Myelography is sometimes strongly correlates with MC Type 1,27 showing
obtained to evaluate the thecal sac in instances high agreement between MCs and metabolic ac-
of severe susceptibility from implants/instrumen- tivity on bone SPECT/CT imaging (Fig. 4).28 In
tation, but MRI in most cases remains the primary particular, MC Type 1, along with severe disc
imaging modality for discogenic and vertebro- degeneration, may predict positivity on SPECT/
genic pain evaluation. CT scans,29 and increased tracer uptake occurs

Fig. 4. Correlation between Modic

changes on MRI and osteoblastic activ-
ity on hybrid single photon emission
computed tomography (SPECT/CT) im-
aging. Modic change type I (A), type
II (B), and type III (C). (Adapted from
Reference 28 with permission.)

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6 Abel et al

more frequently in patients with LBP compared to disc degeneration in clinical practice and research
those without.30 Thus, SPECT/CT holds potential settings.
in the diagnostic workup of patients with LBP to HIZ describe T2 prolongation in the posterior
unmask painful endplate changes and/or severely AF, separated from the signal of the NP and are
degenerated discs or facet joints with greater often best visible on sagittal slices (Fig. 5). HIZ
specificity than conventional methods like qualita- may represent annular fissures and are strongly
tive MRI. Since SPECT/CT detects increased associated with painful discs during discogra-
metabolic activity in both severe IVD degeneration phy.33 While HIZ pose a risk factor for discogenic
and MC, it might prove clinically useful in manag- LBP, they are also frequently found (prevalence:
ing vertebrogenic and discogenic pain, though its w25%) in asymptomatic patients with degenera-
discriminative role requires further clarification. tive disc disease.34
The Pfirrmann score (Table 1) grades disc
QUALITATIVE MRI degeneration severity from I to V (none to severe)
on routine T2-weighted sequences based on
MRI provides both osseous and excellent soft tis- signal characteristics, height, and distinction
sue detail without using ionizing radiation, posi- between NP and AF (Fig. 6). Although higher Pfirr-
tioning it as the favored imaging modality for mann grades reportedly correlate with discogenic
working up LBP. Three-dimensional (3-D) se- pain,35 they have a similar specificity challenge as
quences enable MPR capabilities, bolstered by HIZ in that they are often seen in asymptomatic
spatial resolution improvements via deep learning patients.
reconstruction.31 T2-weighted signal changes can
assess IVD and endplate degeneration, and more
recently, ultra-short echo time (UTE) sequences Modic Changes
are emerging to characterize discogenic and/or
Advanced disc degeneration and herniations are
vertebrogenic pain sources.
associated with vertebral bone marrow changes,
termed “Modic changes (MC),” visible adjacent
T2-weighted Changes
to discs on MRI and are specific to painful re-
Multifactorial changes leading to discogenic pain sponses during provocation discography.36
can yield nonspecific late IVD degeneration find- Therefore, MC traditionally were established as
ings. IVD degeneration reduces signal on T2- possible discogenic pain triggers. However,
weighted sequences, blurred AF-NP boundary, recent findings of nerve ingrowth into damaged
irregular cartilage layers, and sparse horizontal endplates, sensitizing endplate nociceptors
trabeculae. High-intensity zones (HIZ) and Pfirr- through chemical and mechanical stimuli, support
mann scores32 are widely accepted to assess their role as vertebrogenic pain triggers.4

Fig. 5. MR images in a 35-year-old male experiencing low back pain for 3 months. Sagittal (A) and axial (B) T2-
weighted MR images demonstrate a degenerated disc with prominent crescentic fissure (arrows) in the posterior
outer annulus at L1–2.

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 Imaging of Discogenic and Vertebrogenic Pain 7

Table 1
Pfirrmann grading system for lumbar disc degeneration

Distinction of
Nucleus
Grade Structure and Annulus Signal Intensity Disc Height
I Homogeneous, Clear Hyperintense, isointense Normal
bright white to cerebrospinal fluid
II Inhomogeneous with or Clear Hyperintense, isointense Normal
without horizontal to cerebrospinal fluid
bands
III Inhomogeneous, gray Unclear Intermediate Normal to slightly
decreased
IV Inhomogeneous, Lost Intermediate to Normal to
gray to black hypointense moderately
decreased
V Inhomogeneous, black Lost Hypointense Collapsed disc space

Three distinct types of MC are classified based higher in LBP patients (43% vs 6% in asymptomatic
on signal characteristics in T1-weighted and T2- patients),37 with MC Type 1 more often being asso-
weighted sequences (see Fig. 4). MC Type 1 are ciated with LBP compared to MC Type 2/3.38 On
hypointense on T1-weighted and hyperintense on MRI, MC are more common at lower lumbar levels
T2-weighted sequences, histologically represent- (L4–S1), typically symmetric, and frequently pro-
ing vascularized granulation tissue and endplate nounced at the anterior third of endplates. MC
edema as a sign of inflammation. MC Type 2 are Type 1 and Type 2 can transition over time, eventu-
hyperintense on both T1-weighted and T2- ally forming MC Type 3. The exact contribution of
weighted sequences, signifying fatty bone marrow MC, whether discogenic or vertebrogenic pain, re-
replacement. MC Type 3 are hypointense on both mains a dynamic research area, given evidence of
T1-weighted and T2-weighted sequences, indica- proinflammatory crosstalk between bone marrow
tive of stable sclerotic changes. MC prevalence is and adjacent disc in MC-associated back pain39

Fig. 6. MR images in a 56-year-old female presenting with acute on chronic low back pain. Sagittal short-tau
inversion recovery (A) and T2-weighted (B) MR images demonstrate different grades of disc degeneration (Pfirr-
mann I-V). Additionally, a caudally oriented disc extrusion is apparent (arrow) originating from the L4/5, seen to
better advantage on the axial T2-weighted section (C).

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8 Abel et al

Ultra-short Echo Sequences QUANTITATIVE MRI

Ultra-short echo (UTE) sequences drastically Quantitative MRI (qMRI) techniques capture
reduce the effective echo time, permitting visual- biochemical information and are sensitive to path-
ization of highly organized structures with very ologic microstructural changes earlier than quali-
short T2 and T2* values (eg, cortical bone, carti- tative MRI. Particularly well-studied for cartilage,
lage) with rapid decay of transverse magnetiza- qMRI has been mainly applied to assess the pain-
tion. Lately, the UTE disc sign (hyper- or ful disc. Various qMRI techniques have been pro-
hypointense changes within the disc) emerged posed for evaluation of IVD degeneration, aiming
as a novel biomarker linked to IVD degeneration, to establish imaging biomarkers more specific to
disc bulges/extrusions, MC, spondylolisthesis, clinical symptoms to aid in diagnosis, treatment,
and reduced T1r (rho) values within the disc. and prognostication (Table 2).
The UTE disc sign correlates with chronic LBP T2 and T1r (rho) mapping are among the most
and disability,40 suggesting its potential in established and well-validated techniques,
assessing painful discs. Its morphologic counter- derived from quantifying T2 and T1 relaxation
part might reflect disc calcifications.41 Therefore, times. In IVD degeneration, water content and pro-
the UTE disc sign may serve as a sensitive teoglycan content decreases, resulting in
biomarker for early degeneration often unnoticed decrease of both T2 values and T1r,43 respec-
on conventional T2-weighted sequences. How- tively. Particularly T1r might excel in early changes
ever, additional validation is needed to determine detection due to its correlation with early proteo-
its correlation with discogenic pain. The glycan loss preceding water loss. T1r holds prom-
enhanced bone detail afforded by UTE se- ise in predicting discogenic pain, correlating with
quences might also aid in detecting CEP damage painful discs during discography44 and popular
responsible for vertebrogenic pain.42 Similar to clinical outcome measures like SF-36 or Oswestry
the UTE disc sign, the value of UTE for assess- Disability Index in chronic LBP patients.45
ment of vertebrogenic pain needs further confir- Another experimental method to assess painful
matory studies. IVD degeneration is glycosaminoglycan chemical

Table 2
Summary of popular quantitative MRI imaging techniques for painful disc evaluation

Technique Evaluated Structure Advantages Disadvantages

T2 mapping Water content and  Well-validated  Not sensitive to early
extracellular  Available on most systems disc degeneration
matrix structure and across different field
strengths
T1r PG/GAG content  Sensitive to early stages of  Susceptible to
disc degeneration quantification errors
 Lack of standardization
T2* mapping Water content and  High signal to noise ratio  Prone to field
extracellular (SNR) inhomogeneities
matrix structure  Short scan times
GagCEST PG/GAG content  Sensitive to early  Low SNR at 3T for
degeneration low GAG content
 Strong discrimination accu-  Less validated than
racy in severity of disc T1p/T2 mapping
degeneration
Sodium MRI PG/GAG content,  Sensitive to early stages of  Low SNR and spatial
pH changes disc degeneration resolution
 Strong correlation with PG  Requires specialized
content hardware
MRS Chemical composition  Can detect several metabo-  Low SNR
of metabolites lites that may function as  Limited availability
biomarkers

GAG, glycosaminoglycan, GagCEST, GAG chemical exchange saturation transfer, MRS, magnetic resonance spectroscopy,
PG, proteoglycan.

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 Imaging of Discogenic and Vertebrogenic Pain 9

exchange saturation transfer (gagCEST). GagC- protocols and hardware setups, and the absence
EST exploits the exchange of protons between of direct histopathological correlates. Despite
bulk water protons and the hydroxyl and amine these limitations, non-invasive techniques remain
groups of glycosaminoglycans (GAGs), enabling valuable and have potential in identifying disco-
an indirect measurement of GAG content and its genic and painful by characterization of discs
loss within IVD. GagCEST shows a moderate and CEP, respectively.
negative correlation with IVD degeneration
severity and has been linked to LBP in patients46 TREATMENT
Sodium MRI is emerging for estimation of PG
content in degenerated discs, utilizing the attrac- Non-surgical interventions to target vertebrogenic
tion of cationic sodium to negatively charged or discogenic pain triggers most commonly
GAG. Sodium MRI correlates with a modified Pfirr- include epidural injections or radiofrequency abla-
mann score (Fig. 7), and its value may be tion. Epidural injections, including steroids and an-
increased be combination with T2 mapping47 to esthetics, are widely applied clinically to address
assess both water content and PG content. radicular pain, but are also used for LBP with
Although promising, sodium MRI’s impact in questionable efficacy.
detecting painful discs has yet to be evaluated. For vertebrogenic pain, a focused and enduring
UTE imaging affords evaluation of rapidly approach is achieved by intraosseous basiverte-
decaying T2* species and has been evaluated in bral nerve radiofrequency ablation (BVN RFA),
discs and their adjacent CEP. A study revealed which has recently demonstrated improvements
that compositional deficits of the cartilage end- in pain and functionality in patients with chronic
plate, reflected by low T2* values, were associated vertebrogenic LBP and MC Type 1 or 24. Typically,
with T1r changes of the NP and severity of disc BVN RFA utilizes a transpedicular access and bi-
degeneration in chronic LBP patients.48 Similar polar RFA to ablate the BVN at painful motion seg-
to other qMRI biomarkers, UTE-T2* significantly ments in the lower lumbar spine (Fig. 8). The
inversely correlates with Pfirrmann grades49 and reported benefits, including pain reduction and im-
is feasible for whole IVD characterization including provements in Oswestry Disability Index scores,
the CEP,50 highlighting its potential for quantita- lasting up to 5 years and longer,51 make BVN
tively assessing both discogenic and vertebro- RFA an attractive treatment choice for selected
genic painful motion segments. patient cohorts.
Until now, these findings are constrained by het- For non-surgical treatment of discogenic pain,
erogeneous and small cohorts, discrepancies in thermal (intradiscal) techniques in painful discs

Fig. 7. Sagittal T2-weighted fast spin

echo MR images of the lumbar spine,
representing different Pfirrmann
grades with corresponding 3-T quanti-
tative sodium concentration images.
Pfirrmann grade I (A), II (B), III (C),
and IV (D) demonstrate decrease in
the tissue sodium concentration with
increasing disc degeneration, which is
pronounced from grade III (C) to IV (D).

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10 Abel et al

Fig. 8. Basivertebral nerve radiofrequency ablation in a 51-year-old female with chronic vertebrogenic lower
back pain for 12 months. Anterior-posterior (A,B) and lateral (C,D) fluoroscopy show the radiofrequency tip
through a transpedicular approach on the right side (A, C) at L4 and on the left side (B,D) at L5.

have been largely abandoned due to their poor treatment for vertebrogenic pain. Implantable bio-
outcomes. Currently, promising approaches aim materials are a promising emerging treatment to
to implant biomaterials for annulus closures and/ address painful intervertebral discs, although
or NP replacements to repair the disc but are further studies are needed to assess safety and
controversial due to potential increased risk of efficacy.
re-herniation. Many AF repair and NP replacement
devices and biomaterials have been developed,3 CLINICS CARE POINTS
including whole IVD tissue-engineered structures,
that are currently being evaluated with regards to
their efficacy in IVD repair.52

SUMMARY  Radiographs can reveal disc degeneration

through disc space height loss, vacuum phe-
Discogenic and vertebrogenic pain are 2 major nomenon, calcified discs, and bone spurs.
pain triggers in the multifactorial pathophysiology These findings often lack specificity.
of chronic LBP. Distinguishing these etiologies re-  Computed tomography (CT) provides detailed
mains challenging, both clinically and through im- visualization of disc degeneration stigmata,
aging. While MRI is the primary imaging modality with post-discography CT enhancing accuracy
for detecting painful vertebrogenic or discogenic in detecting painful discogenic segments
segments, findings often lack specificity. such as the presence of high-grade radial
Advanced techniques like SPECT/CT, UTE, or fissures.
quantitative MRI could enhance sensitivity in iden-  CT can identify vertebrogenic painful end-
tifying painful endplate and disc deterioration. plate alterations by detecting endplate de-
Basivertebral nerve ablation is a promising fects and sclerotic changes.

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 Imaging of Discogenic and Vertebrogenic Pain 11

12. Bibby SRS, Urban JPG. Effect of nutrient deprivation

 Key findings for painful disc degeneration on
MRI include signal loss on T2-weighted se- on the viability of intervertebral disc cells. Eur Spine
quences, blurred boundaries, irregular carti- J 2004;13(8):695–701.
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