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Annular tear
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Annular tear


  ALAS!!!
  After a few weeks of research I think I have come upon something and
  I have a few questions.
  I have posted here before and have got wonderful suggestions.  I have been
  seeing a Physiatrist for about 5 months for a horrible lower right back pain,
  with referred pain into the groin and leg.  The back pain is the primary pain.
  They have treated me right by the book but all tests are negative.
  (MRI, bone scan, CT abdomen, EMG) I found the following information
  on the internet:
  Annular Tear;

  - Discussion:
   - lesion labeled annuular tear or internal disruption is based on
        concept of leaking disc, one which permits the irritating liquid
        material normally restricted to the center of the disc to come into
        contact with the innervated tissue;
   - annular tissue that permits egress of this liquid has a poor capacity
        for healing;
   - at most, a thin layer of scar tissue at the periphery of the tear may
        seal the leak but leave the disc highly susceptible to retearing;
   - where as herniated disc has a significant capacity to be resolved w/
        time, annular tear continues to produce symptoms indefinitely;
   - clinical picture is based on pain related to increased intradiscal
        pressure and irritability of neural structures;
   - annular tear is usually produced by injury that increases intradiscal
        pressure significantly;
   - predominant element in the history is back pain, either alone or in
        exess of leg pain;
   - leg pain may be either unilateral or bilateral;
   - increases in intradiscal pressure exacerbate the pain;
   - pain is often worse when sitting than when standing;
   - coughing & sneezing worsen the pain as do forward bending and lifting;
   - on PE no nerve compression is evident;
   - key finding is positive sciatic stretch test that produces back pain
        or back pain greater than leg pain;
   - positive test is presummably produced by tension on irritated dural
        tissue or possibly by increased intradiscal pressure;
   - myelogram, MRI, & CT, tests show no compression of neural structures;
   - key test is discography with CT discography;
   - positive examination will show dye extending into the epidural space
        or extending to the periphery of the disc where it can contact
        innervated portion of the annulus fibrosus;
   - posiitve test also requires a reproduction of pain accompanying
        injection of dye;
   - back pain alone or back pain greater than leg pain;
   - increased back pain with increased intradiscal pressure;
   - reproduction of back pain to greater degree than leg pain by sciatic
        stretch test;
   - no neurologic deficit;
   - reproduction of pain by discography and discographic dye extending to
        or beyond the periphery of the annulus fibrosis;
  I FIT THIS PROFILE ALMOST 100%- I just found this yesterday and have not
  mentioned it to my Doctor.  I have not had a Discogram but my questions
  are as follows:
  1.  Is it necessary to have a Discogram to find this,  because if the
  treatment does not change,  why go thru the pain?
  2.  What is the treatment for an annular tear if indeed this is what I have?
  Is is always non-surgical,  surgical?
  3.  Can a person recover fully from an annular tear,  or will I have to
  rely on pain management the rest of my life??
  4.  Are there any publications which may discuss annular tears in greater
  detail.  I live in a small Indiana city where there is no major
  medical school,  so I have limited access to a medical library.
  My mother lives in Cleveland,  if indeed this is what I have does
  it make sense to visit you folks at the Cleveland clinic?
  Thank you so much,
  Ron  
===========================================================================
Dear Ron:
Your questions address very contoversial areas in the managemant of back and leg pain, and answers will differ depending upon speciality, region of the world, experience and expertise, etc.
The very existence of "discogenic" pain and pain from annular tears, while plausible, is controversial. The "test" is the reproduction of pain with injection into one particulat disc (and not others) during discography. This is obviously a rather subjective test open to inerpretation.
The prognosis following anterior interbody fusion (frequently offered operative treatment for this situation) may be no better that the prognosis with just conservative treatment. No randomised controlled trial to address this has been done, however.
Modern day MRI (with/without contrast) is probably almost as sensitive for annular tears as a discogram is. The problem lies not in finding abnormalities on spine imaging studies (they are abundant even in asymptomatic individuals); the problem lies in knowing what to do with these abnormalities. Regrettably there is little scientific evidence to support several common surgical practices.
The following are some publications that may be of interest.
Magnetic resonance imaging of the lumbar spine in people without back pain N Engl J Med  (United States), Jul 14 1994, 331(2) p69-73
AUTHOR(S):  Jensen MC; Brant-Zawadzki MN; Obuchowski N; Modic MT; Malkasian D; Ross JS
Lumbar discography.
Spine  (United States), Feb 1 1996, 21(3) p402-4
AUTHOR(S):  Bogduk N; Modic MT
Contrast-enhanced MR imaging in acute lumbar radiculopathy: a pilot study of the natural history
Radiology  (United States), May 1995, 195(2) p429-35
AUTHOR(S):  Modic MT; Ross JS; Obuchowski NA; Browning KH; Cianflocco AJ; Mazanec DJ
N.B. Dr Modic is the chairman of the department of radiology at the Cleveland Clinic, and an internationally renowned expert on spine imaging.
It does make sense to see us at the Cleveland Clinic! Please call (216(444-5559, or (800)223-2273 for appointments. You may benefit the most by seeing a neuromuscular specialist first (any of Drs. Mitsumoto, Shields, Levin, or Pioro).




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