1. 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

2. No conflicts of interests to disclose
Disclosure
No conflicts of interests to disclose

3. 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

4. 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.

5. 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.

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

7. 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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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.

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

18. 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.

19. 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.

20. 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):

21. 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

22. 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.

23. 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.

24. 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.

25. 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

26. 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.

27. 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

28. 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.

29. 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.

30. 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.

31. 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.

32. 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: E 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: Moon K et al. Reliability of MRI findings for symptomatic extraforaminal disc herniation in lumbar spine. Asian Spine Journal 2009; 3(1): Negron E et al. Appropriateness criteria in the evaluation of back pain. Univ of Puerto Rico School of Medicine