S Boateng1, M Morris1, R Whiting2, S Rothenberg1, B Saboury1, R Tu2,3 Interactive Case-Based Review of the Recent Updates to Lumbar Disc Disease Nomenclature eEdE-219  S Boateng1, M Morris1, R Whiting2, S Rothenberg1, B Saboury1, R Tu2,3 1. University of Maryland Medical Center, Baltimore, MD 2. George Washington University, Washington, DC 3. Progressive Radiology, Falls Church, VA

No conflicts of interests to disclose Disclosure No conflicts of interests to disclose

Purpose Provided updated, detailed nomenclature to accurately describe lumbar disc pathology Provide reporting terms that can be interpreted accurately, consistently and precisely Provide common terms used inappropriately based on NASS guiding principles

Purpose Use of imprecise language is commonplace in our vernacular language. For example, here is a color graphic of the variation of words used to describe the same carbonated beverage. http://www.huffingtonpost.com/2012/11/12/soda-vs-pop_n_2103764.html

Purpose The use of standard language reduces the likelihood of misinterpretation as radiology reports are read by patients, referring care providers and non health professionals who serve as third party payers, disability actuaries and attorneys.

Purpose Examples of standardized medical language include BI-RADS: Breast Imaging LI-RADS: Liver Imaging Lung-RADS: Pulmonary Imaging CPT: Current Procedural Terminology

Guiding Principles for Diagnostic Terms Definition of diagnosis should Be based on anatomy and pathology Not be dependent or imply specific tests Not define or imply external etiologic events Not define or imply relationship to symptoms Not define or imply treatment

Degenerative Terminology Updates Annular fissure versus Annular tear Term is intended to describe separation of annular fibers from their vertebral body insertions Separation of fibers can extend radially, transversely or concentrically The terms “fissure” and “tear” are not synonymous “Tear” violates guiding principle which states diagnostic term should not imply external etiologic events by suggesting trauma as etiologic event

Axial Depiction of Annular Fissure Fardon et al. Lumbar disc nomenclature: version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Pathology and the American Society of Neuroradiology. The Spine Journal 2014;14:2525–2545.

T2-Weighted MRI Sagittal View of Annular Fissure Negron E et al. Appropriateness criteria in the evaluation of back pain. Univ of Puerto Rico School of Medicine. 2010.

Degenerative Terminology Updates Other nonstandard term used synonymously with annular fissure is annular gap Describes widening of radially directed annular fissure Bilateral annular fissure with an avulsion of the intermediate annular fragment or avulsion of a focal zone of the macerated annulus Annular gap is an imprecise term that prevents accurate, consistent and precise interpretation

Degenerative Terminology Updates Herniated disc is a term intended to describe focal extension (<25% of disc circumference) of disc material beyond the intervertebral space Nonstandard terminology such as herniated nucleus pulposus, prolapsed disc, protruded disc and bulging disc are often used nonspecifically to describe disc herniation These are unclear terms that are imprecise and prevent accurate, consistent and precise interpretation

Nonstandard Terminology Herniated nucleus pulposus: inaccurate and imprecise term as other materials other than nucleus pulposus are often components of displaced disc material Prolapsed disc: nonspecific, imprecise term used to describe protruded and extruded disc Disc rupture: carries implication of traumatic etiology Protruded disc: imprecise and nonspecific term used to denote herniated disc

Disc Herniation This diagnostic term does not imply etiology, symptoms, treatment or prognosis Describes displacement of disc material from normal location in intervertebral space Often associated with annular fiber disruptions or defect in vertebral body endplates Subsets of disc herniation include disc protrusion and disc extrusion

Disc Protrusion Subset of disc herniation where the greatest dimension between the edges of the displaced disc is less than the distance between the edges of the base from where it extends, when measured in the same plane.

Axial and Sagittal Depictions of Disc Protrusion Fardon et al. Lumbar disc nomenclature: version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Pathology and the American Society of Neuroradiology. The Spine Journal 2014;14:2525–2545.

T2-Weighted MRI Axial View of Disc Protrusion Watkins Spine. Microscopic Discectomy. 2013.

Disc Extrusion Subset of disc herniation where the greatest dimension between the edges of the displaced disc is greater than the distance between the edges of the base from where it extends, when measured in the same plane.

Axial and Sagittal Depictions of Disc Extrusion Fardon et al. Lumbar disc nomenclature: version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Pathology and the American Society of Neuroradiology. The Spine Journal 2014;14:2525–2545.

T2-Weighted MRI Axial View of Disc Extrusion Moon K et al. Reliability of MRI findings for symptomatic extraforaminal disc herniation in lumbar spine. Asian Spine Journal 2009; 3(1): 16-20.

Subsets of Disc Extrusion Sequestrated disc Extruded disc material has no continuity with disc of origin Migrated disc Extruded disc material displaced away from site of extrusion, regardless of continuity with disc

Axial and Sagittal Views of a Sequestrated Disc Fardon et al. Lumbar disc nomenclature: version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Pathology and the American Society of Neuroradiology. The Spine Journal 2014;14:2525–2545.

Axial and Coronal Depictions of Anatomic Zones Fardon et al. Lumbar disc nomenclature: version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Pathology and the American Society of Neuroradiology. The Spine Journal 2014;14:2525–2545.

Sagittal and Coronal Depictions of Anatomic Levels Fardon et al. Lumbar disc nomenclature: version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Pathology and the American Society of Neuroradiology. The Spine Journal 2014;14:2525–2545.

Disc Bulge Generalized extension of disc material beyond apophyseal edges that spans greater than 25% of disc circumference with < 3mm extension Can be symmetric or asymmetric Nonstandard use of the term includes use to describe focal disc extensions <25% disc circumference or diffuse, smooth disc displacement > 3mm

Axial Depictions of Disc Bulge Fardon et al. Lumbar disc nomenclature: version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Pathology and the American Society of Neuroradiology. The Spine Journal 2014;14:2525–2545.

Other Nonstandard Terminology Black disc Intra-annular displacement Communicating disc Intra-annular herniation Degenerative disc disease Perforated Labeling disc levels according to vertebral body above the disc Sequestrum Parent disc Displaced disc Parent nucleus Hard disc

Quiz What is the best term to describe the pathology shown? A) Annular tear B) Annular gap C) Annular fissure D) Degenerative disc disease Fardon et al. Lumbar disc nomenclature: version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Pathology and the American Society of Neuroradiology. The Spine Journal 2014;14:2525–2545.

Quiz Would you accept this sentence by your resident? At L4-L5, the disc protrusion extends 0.2cm diffusely beyond the end plate resulting in bilateral severe L4 exit neuroforaminal narrowing.

Quiz Would you accept this sentence by your resident? At L4-L5, the disc protrusion extends 0.2cm diffusely beyond the end plate resulting in bilateral severe L4 exit neuroforaminal narrowing. NO. What is described is a bulge extending beyond a 90 degree radian (25% of the diameter), not protrusion, a herniation subtype.

Quiz What is the best term to describe the pathology shown? A) Degenerative disc disease B) Disc protrusion C) Disc extrusion with sequestration D) Annular gap Fardon et al. Lumbar disc nomenclature: version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Pathology and the American Society of Neuroradiology. The Spine Journal 2014;14:2525–2545.

References Fardon et al. Lumbar disc nomenclature: version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Pathology and the American Society of Neuroradiology. The Spine Journal 2014;14:2525–2545. Fardon DF, Milette PC. Nomenclature and Classification of lumbar disc pathology: recommendations of the combined task forces of the North American Spine Society, American Society of Spine Pathology and the American Society of Neuroradiology. Spine 2001; 26: E93-113. Li Y, Fredrickson V, Resnick D. How Should We Grade Lumbar Disc Herniation and Nerve Root Compression? A Systemic Review. Clin Orthop and Relat Res (2015) 473:1896-1902 Moon K et al. Reliability of MRI findings for symptomatic extraforaminal disc herniation in lumbar spine. Asian Spine Journal 2009; 3(1): 16-20. Negron E et al. Appropriateness criteria in the evaluation of back pain. Univ of Puerto Rico School of Medicine. 2010.