Ideas and technical innovations E pean

nelournal
© Springer-Verlag t994

Eur Spine J (1994) 3 : 233-235

Bony vibration stimulation:

a new, non-invasive method for examining intradiscal pain
M. Yrjfimfi and H. V a n h a r a n t a
University of Oulu, Department of Physical Medicine and Rehabilitation, Oulu, Finland

Summary. Fifty-seven patients with low-back pain were clinical pain [6, 8, 10]. The purpose of the present study was
evaluated immediately prior to a discography examination to find a non-invasive, practical tool for examining the in-
by means o f an electrical tool which produced bony vibra- tradiscal source of pain in patients with low-back disorders.
tion to the lumbar spinal processes. The vibrator was com-
posed of a standard electric toothbrush shaft (Braun) with a
blunt head instead of the brush. The lumbar spinal pro-
Materials and methods
cesses were compressed one by one for a few seconds with
this blunt, vibrating tool. The patient's pain experience pro- Fifty-seven patients suffering from lower-back disorders were ex-
voked by vibration was compared with that from injections amined by means of bony vibration stimulation and discography.
during discography. A good correlation was found between Twenty-six (46%) of the patients were female, mean age 40.8
these two examinations when patients with previously op- years (range 30-54 years), and 31 (54%) were male, mean age
erated backs and painful, prolapsed discs were excluded: 39~7 years (range 21-55 years). An ordinary commercial electric
sensitivity was 0.96 and specificity 0.72. Prolapsed, but toothbrush (Braun 3-D) was used as the basic vibrator device. The
shaft of the brush was provided with a stable, blunt head 1 cm z in
discographically painful discs were always painless in the size (Fig. 1). The frequency of the vibrator device was 42-50 Hz.
vibration examination. The local, non-invasive bony vibra- Lumbar spinal processes were compressed with the blunt head one
tion stimulation test is an easy, quick, safe, inexpensive and by one at a right angle to the skin with a force of 1-3 kg/cm; (Fig.
reliable method for examining intradiscal pain. 2). The vibrating time for each spinal process was 2-5 s. The
whole vibration test for the lumbar spine takes 1-2 rain per patient.
Key words: L o w - b a c k pain - B o n y vibration - Discogra- The vibration test was evaluated in all patients just before the
discography examination. The patients had received premedication
phy
(mild tranquillizer and antibiotic) for discography, but no locai
anaesthesia was used before the vibration tests. The patients were
asked if the vibration was more painful than plain compression and
if it induced their clinical pain, i.e. whether the pain was similar or
The knowledge gained of disc innervation has changed ear- identical. The patients were lying on their more symptomatic side
lier concepts of the production of low-back pain [2, 3, 11 ]. during the examination as in the discography examination. In 12
patients, the levels vibrated were confirmed by fluoroscopy.
Today, nerve root compression is not regarded as the only
source of back pain; it may also be attributed to intradiscal
ruptures of the annulus fibrosus [1, 4, 8]. In fact, nerve root
compression is quite an unusual cause of back pain, and on
the other hand, intradiscal rupture of the annulus has been
found in many different lumbar syndromes [5, 7, 9, 11].
However, no simple tools are available for the identifica-
tion of these intradiscal ruptures in back patients. The only
possible method for examining intradiscal pain has been
discography, which has to be performed under fluoroscopy.
Discography is laborious and expensive and, in addition,
not feasible in everyday medical practice for most patients
suffering from low-back disorders. A normal disc is pain-
less during discography, but a close correlation has been
found between annular rupture and the reproduction o f

Correspondence to: M. Yrjfim~i, Rokuan Kuntokeskus, SF-91670 Fig. 1. The vibrator with its blunt head
Rokua, Finland Fig. 2. The vibration stimulation test
234
Table 1. The pain responses of all 57 patients with tow-back pain
studied by vibration and discography. Sensitivity of the vibration
test compared with discographic pain provocation was 0.71 and
specificity 0.63
Vibration Discography
Painful (n = 38) Painless (n = 19)
Painful (n = 34) 27 7
Painless (n = 23) t1 12
Table 2. The pain responses of 40 patients with low-back pain. Pa-
tients with total annular ruptures (n = 13) and previously operated
backs (n = 4) have been excluded. Sensitivity of the vibration test
compared with discographic pain provocation was 0.96 and speci-
ficity 0.72
Vibration Discography
Painful (n = 26) Painless (n = 14)
Painful (n = 29) 25 4 painless during the vibration provocation test but painful during
Painless (n = 11) 1 10
Table 3. With 12 patients the levels of the lumbar spinal processes
vibrated were confirmed by fluoroscopy, and 34 discs were exam-
ined. Sensitivity of the vibration test compared with discographic
pain provocation was 0.81 and specificity 0.85
Vibration Discography
Painful (n = 21) Painless (n = 13)
Painful (n = 19) 17 2 Painful (n = 19)
Painless (n = 15) 4 11
Discography was performed in most cases on the three lowest
lumbar discs posterolaterally under fluoroscopy with local anaes-
thesia. A non-ionized contrast agent (Omnipaque) was used 2.5 ml
per disc if the patient did not consider the injection painful or if
the resistance did not increase beforehand, The patients were re-
quested to report any pain during the injection procedure, The ex-
aminer did not know the results of the vibration tests when per-
forming the discography examination.
Results
Thirty-eight o f the 57 patients (67%) experienced pain
during discography, and 27 o f them also reported pain in
the vibration provocation tests. Nineteen patients reported
no pain in discography, and t 2 o f these also considered
the vibration examination painless. The sensitivity o f the
vibration test c o m p a r e d with discographic pain provoca-
tion was 0.71 and specificity 0.63 (Table 1).
W h e n patients with disc prolapses (n = 13) as observed
on the discographic image and those with previous spine
surgery (n = 4) were excluded, there were 40 patients re-
maining for analysis. Twenty-six (65%) o f these 40 pa-
tients experienced pain during discography, and 25 of
these 26 also felt pain when examined by vibration. Of the
14 patients with no pain during discography, 10 also re-
ported no pain during the vibration tests. On this occasion
Fig.3. CT/discogram of a typical disc with internal annular rapture
which is painful when examined both by vibration and discogra-
phy
Fig.4. CT/discogram of a disc with total annular rupture which is
discography
Table 4. Two prolapsed discs were excluded from those 34 discs
examined by discography. The levels vibrated were confirmed by
fluoroscopy in the 12 patients and 32 discs remaining. Sensitivity
of the vibration test compared with discographic pain provocation
was 0.89 and specificity 0.85
Vibration Discography
Painful (n = 19) Painless (n = 13)
17 2
Painless (n = 13) 2 11
the sensitivity of the vibration test was 0.96 and speci-
ficity 0.72 (Table 2).
With 12 patients the levels of the vertebrae vibrated
were confirmed by fluoroscopy, and 34 discs were exam-
ined by discography. With one patient the spinal pro-
cesses were vibrated while there were three discographic
needles in place in the lumbar discs. It was seen and felt
that the needle below the vibrated vertebra began to vi-
brate. The results o f vibration pain provocations were
c o m p a r e d level by level with the results o f discographic
pain provocation. Twenty-one (62%) o f these 34 discs
were painful during discography, and 17 o f these were
also painful upon vibration provocation. Thirteen discs
were painless on discography examination, and 11 o f these
were also painless when examined by vibration provoca-
tion. T h e sensitivity o f b o n y vibration c o m p a r e d with
discographic pain provocation was 0.81 and specificity
0.85 (Table 3). W h e n cases of disc prolapse (n = 2) were
excluded, the sensitivity was 0.89 and specificity 0.85
(Table 4).
Figure 3 shows a typical discogram of a painful disc,
as obtained by means o f both the vibration test and injec-
tion of the contrast agent. A typical disc that is painless
during the vibration test but painful during discography is
presented in Fig. 4. It can be seen that the annulus of the
disc is totally ruptured.

Discussion
The present study indicates that this non-invasive, inex-
pensive and quick vibration stimulation provokes clinical
pain very much like discography, in cases of intradiscal
pain. It is evident that by combining the information from
the vibration test with different imaging modalities [plain
radiographs, computed tomography (CT), magnetic reso-
nance imaging (MRI) or ultrasound], much more relevant
information can be obtained about the origin of the back
pain than by only examining the images. Bulges of the
disc do exist without pain, and the experience of pain is
also influenced by other factors than those seen in the
tests. These factors, such as the patient's emotional state,
are included in the pain provocation test.
The only patients, practically, in whom clinical pain
could be reproduced by discography but not by the vibra-
tion test were those with total annular rupture and disc
prolapse. It is evident that the various pain mechanisms
differ in cases of painful intradiscal ruptures or disc
bulges with nerve root irritation. It seems that some of the
annular fibres must be intact throughout the annular ring
when the patient's clinical pain can be provoked by bony
vibration. Thus, the vibration test is an aid in the most
problematic area of the diagnosis of back patients, i.e.
back pain without neurological signs. Patients who have
previously undergone back surgery almost always feel the
vibration provocation as painful, though it is not a ques-
tion of intradiscal pain. In these cases there may be vibra-
tion-sensitive nerve endings in places where they do not
exist before an operation.
The vibration instrument costs about 40 dollars. The
vibration test itself can be performed in 1-2 min at all
lumbar levels by any doctor in any type of examination
room. Patients can easily be re-tested in order to confirm
the findings or analyse the results of non-operative treat-
ment later. For the patient, the vibration test is not as
painful as discography, but the patients can easily report
whether or not the pain produced is similar to their ' o w n '
pain. The difference between the two procedures is large.
Discography requires, premedication and X-ray control
with needle injections and carries the possibility of com-
plications such as discitis. The vibration test is like a
deep palpation of discs. The examiner does not need any
special skills in doing the vibration test. However, it must
be emphasized that the test result can be negative both
when the disc is normal and when the annulus is totally
broken. These cases can be detected by other non-inva-
sive clinical and imaging methods such as ultrasound,
CT or MRI.
We have not yet noted any major side-effects with the
vibration procedure, but some patients have reported in-
creased pain after the examination, even on the following
day. The power of the vibrator is sufficient for the test in
most cases, but with some obese patients there may be
difficulties due to the limited power of the device. How-
235
ever, it is evident that the side-effects might increase if the
vibrating force was greater. We have used the test in
everyday practice with several hundred patients.
When one patient's spinal processes were vibrated
while there were three discographic needles in the lumbar
discs, it was seen and felt that vibrating a spinal process
made the disc needle below the provocated vertebra vi-
brate. This finding also confirms the fluoroscopic part of
the study: the painful discs were found to be the ones be-
low the vertebrae vibrated. The compression of the
processus spinosus will compress the disc below the ver-
tebrae and probably transmit the vibration to this disc.
Anatomically, the compression and vibration of the
processus spinosus may also irritate the disc above and
the posterior joints, and it is possible that the instances of
a painful vibration test without discographic pain are due
to facet joint irritation. A poor bony connection between
the processus spinosus and the disc may interfere with vi-
bration stimulation - currently we do not have sufficient
experience of how the vibration provocation works with
patients who have spondylolysis.
We believe that this vibration stimulator is a very use-
ful tool in detecting the origin of back pain. Bony vibra-
tion is a non-invasive, quick, safe, inexpensive and easy
means of examining patients to determine the source of
back pain, even in everyday practice.
References
1. Aprill C, Bogduk N (t992) High-intensity zone: a diagnostic
sign of painful lumbar disc on magnetic resonance imaging. Br
J Radiol 65: 361-369
2. Bogduk N, Tyrian W, Wilson AS (198I) The nerve supply to
the human lumbar intervertebral discs. J Anat 132:39-56
3. Coppes MA, Marani E, Thomeer RTWM, Oudega M (1990)
Innervation of annulus fibrosus in low back pain. Lancet 336:
189.-190
4. Crock HV (1970) A reappraisal of inte~ertebral disc lesions.
Med J Aust 16: 983-989
5. Friberg S (1954) Lumbar disc herniation in the problem of
lumbago sciatica. Bull Hosp J Dis 15 : 1-20
6. Lindblom K (1948) Diagnostic puncture of intervertebral discs
in sciatica. Acta Orthop Scand 17:231-239
7. Mooney V (1987) Where is the pain coming from? Spine 8 :
754-759
8. Vanharanta H, Sachs BL, Spivey MA, Guyer RD, Hochschnler
SH, Rashbaum RF, Johnson RG, Ohnmeiss D, Mooney V
(1987) The relationship of pain provocation to lumbar disc de-
terioration as seen by CT/discography. Spine 12:295-298
9. Vanharanta H, Guyer RD, Ohnmeiss DD, Stith WJ, Sachs BL,
Aprill C, Spivey M, Rashbaum RF, Hochschuler SH, Videman
T, Selby DK, Terry A, Mooney V (1988) Disc deterioration in
low-back syndromes. Spine 13 : 1349-1351
10. Walsh TR, Weinstein JN, Spratt KF, Lehmann TR, Aprill C,
Sayre H (1990) Lumbar discography in normal subjects. J
Bone Joint Surg [Am] 72:1081-1088
11. Yoshizawa H, O'Brien JP, Smith WT, Trumper M (1980) The
neuropathology of intervertebral discs removed for low-back
pain. J Pathol 132:95-I04