Do all doctors use the same terms when describing spine
disc findings on MRIs? Many of you have had MRI studies of your spine, and
had discussion with your doctors about the findings.
Oftentimes, it seems that doctors are using the terms
this bulge or disc herniation interchangeably.
It can get confusing both for the patient, and unfortunately
also the medical doctors who need to discuss the findings.
So, in order to come up to some agreement on these terms doctors representing
spinal specialists and radiologists formed a group to
define these terms. The last recognized effort resulted in the
publication of an article called the Lumbar Disc Nomenclature, version
number two, published in the spine journal in 2014.
Very few people know that this often referenced article about standards of
reading spine MRIs was led by an orthopedic spinal specialist Dr.
David Fardon. As a spinal specialist, a doctor who actually examines and
determines treatments based on these tests not just
interpret the findings, Dr. Fardon championed the effort
in the publication. This 2014 paper established a common naming protocol
about disc findings. The authors took great pains to state
that MRI findings by themselves cannot offer any information on whether
the findings are caused by trauma or natural occurrence. To directly
quote the paper "the definitions of diagnoses
are not intended to imply external ideological events
such as trauma, they do not imply relationship to symptoms,
and they do not define or imply the need for specific treatment"
To summarize the paper, disc findings can be broken down into
two main types: the first is a disc bulge which is a
uniform presence of disc material outside the walls of the spine bone. The
paper actually uses the term ring apophyses, but for the public, it's
the margin of the spine bones. If you've seen our prior videos about
disc bulges versus herniations, it is the bulging of
the entire wall concept. In certain deformities such as scoliosis,
there can be some asymmetry of the bulge, but it's still a bulge. The second
is the herniated disc, where a focal or local displacement of disc material
occurs. My prior video explained this as the
jelly donut model.
Focal or localized is defined by displacement
that is less than 25% of the circumference of the whole disc.
I've had many spirited debates on whether I should call
a herniation, or a protrusion, or a bulge, or vice versa. Here's the
direct quote on page 2,533
from this often referenced study: "by exclusion of other terms, and by
reasons of simplicity and common usage, 'herniated disc' is the best term to
denote displacement of this material." Disc herniations then can be broken down
into three different types. Number one is a contained protrusion,
which are herniations that are still connected by an intact
outer fiber of the annulus. Number two is an extrusion which means that disc
herniation is no longer contained by the last fibers of the annulus. And
number three, sequestrations which means the disc
herniation is no longer in contact with the rest of the disc, and is its own
island of disc material. In addition to the
discussion about disc herniation and bulges,
this paper establishes that the breaks in the outside part of the disc
called the annulus should be called "fissures" instead of tears.
The term tear suggests a traumatic event, and it is well known that these annular
disruptions can be a natural process not associated with any
specific trauma. Since 1993, it's been established that having these
disc annular fissures, herniations, and degeneration is an
expected part of life, and oftentimes these findings are not
causing any pain to the person with these findings.
The paper also mentions various research studies that show
almost every disc that degenerates or ages
will also have an annular fissure. It's a normal part of life
like having wrinkles and thinning hair. The final point of the paper is to
discuss the so-called high intensity zone. In the early 1990's,
these findings of an area of brightness of the annulus
was thought to be a sign of an acute problem, an indication
of the cause of pain. In the early 1990's, many spinal fusions were performed
because of these findings on the MRI, but with unpredictable clinical results.
It turns out these high intensity zones represented fluid
or granulation tissue in the annulus. The presence of the high-intensity zone
is not specific to a traumatic event, and is not always associated with any
pain complaints. It may not even correspond to a true
annular fissure. Even today, its significance is not
established, and remains hotly debated. To me,
many parts of the disc nomenclature study are consistent with what I
already use in my practice. I define the problem
either a bulge or a herniation. If asked to further clarify the
herniation, then it's either contained, extruded, or sequestered. To me,
the MRI by itself cannot be used to age when the disc finding was created.
To me, the presence or absence of a high intensity zone
has very little benefit in determining the treatment option for the patients.
I learned from the 1990's experience. I've had the honor of listening to Dr.
Fardon speak in past meetings. While he retired from practice a few
years ago, he has left an impact on physician education,
and will always be honored as one of the greatest teachers
and proponents of rational, compassionate, and competent orthopedic and spine care. I
hope you found this discussion interesting. Thanks for watching. If you'd
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