Anterior annular disruption presenting as hip pain: A case report of iliopsoas contrast extravasation during lumbar discography

Abstract

Background

Discogenic pain may present with atypical referral patterns that mimic primary hip pathology, creating diagnostic challenges when conventional imaging findings are inconclusive. Provocative discography remains one of the few diagnostic procedures capable of correlating structural disc abnormalities with concordant pain symptom reproduction.

Case presentation

A 79-year-old woman with chronic low back pain, severe left anterior hip and groin pain, and lumbar degenerative disc disease without Modic endplate changes underwent lumbar discography after failure of conservative and interventional treatments. Discography demonstrated a grade V (Dallas Modified Discogram Scale) annular tear at L4–5 with contrast extravasation anteriorly into the iliopsoas compartment, reproducing the patient's characteristic hip pain. Following intradiscal steroid administration, the patient reported approximately 50% overall pain reduction. Serial follow-up fluoroscopic imaging obtained at repeat therapeutic intradiscal steroid administration (6 months, 9 months, and approximately 3 years) demonstrated progressive reduction in anterior contrast propagation, resolution of the iliopsoas communication, and improved pain as well as eventual resolution of the grade V annular tear and intradiscal contrast containment.

Conclusion

This case illustrates an unusual presentation of discogenic pain in which anterior annular disruption with extension into the iliopsoas compartment reproduced concordant hip pain and mimicked primary hip pathology. Long-term imaging demonstrated interval stabilization of the annular defect following serial intradiscal steroid therapy, providing a unique radiographic correlation between symptomatic annular disruption, referred hip pain, and clinical response.

1. Introduction

Discogenic pain is a known cause of low back pain and is believed to arise from structural disruption of the intervertebral disc and associated inflammatory processes. Annular fissuring, internal disc disruption, and the release of inflammatory mediators may stimulate nociceptive fibers within the outer annulus and adjacent structures, resulting in both axial and referred pain symptoms. Despite advances in spinal imaging, identifying the symptomatic disc remains challenging because degenerative changes frequently occur in asymptomatic individuals [1], [2].

Provocative discography remains one of the few diagnostic procedures capable of correlating structural disc abnormalities with concordant symptom reproduction. Discography provides both anatomical and functional information regarding potential pain generators and may demonstrate annular fissures, internal disc disruption, and contrast extravasation through annular defects [3]. Systematic reviews support its selective use in carefully evaluated patients with suspected discogenic pain when clinical findings and conventional imaging are inconclusive [4].

Despite perceived controversies regarding the safety and utility of lumbar discography, when procedural parameters are utilized that strictly adhere to the IPSIS/IASP guidelines to prevent over-pressurization, the procedure can be performed safely [5].

Lumbar disc pathology may present with pain patterns extending beyond the low back. Referred pain involving the buttock, groin, hip, pelvis, and proximal lower extremity has been described and may mimic primary hip pathology [6]. Similar patterns have been reported in spinally mediated referred pain syndromes, including Maigne syndrome, in which pain is perceived distant from the primary spinal pain generator [7].

Current technical recommendations for lumbar discography emphasize meticulous fluoroscopic guidance, controlled contrast injection, and continuous monitoring of intradiscal pressure and symptom reproduction to optimize diagnostic accuracy and procedural safety [8]. Although intradiscal steroid therapy has historically demonstrated variable outcomes, both earlier and contemporary studies suggest that selected patients with inflammatory discogenic pain may derive meaningful benefit from targeted intradiscal anti-inflammatory treatment strategies [9], [10].

We present the case of an elderly woman with chronic low back and hip pain in whom lumbar discography demonstrated anterior annular disruption with contrast extravasation into the iliopsoas compartment, reproducing her characteristic hip pain. Serial follow-up imaging over approximately three years demonstrated interval reduction in extravasation following intradiscal steroid therapy, providing a unique radiographic correlation between annular disruption, referred hip pain, and clinically positive and presumed therapeutic response.

2. Case presentation

A 79-year-old woman with a history of chronic low back pain, lumbar degenerative disc disease, osteoporosis, osteoarthritis, and chronic left hip pain presented with persistent axial low back pain associated with severe left anterior hip, groin, and proximal thigh pain. The patient had undergone extensive conservative and interventional treatment, including opioid analgesics, gabapentin, muscle relaxants, physical therapy, and three prior L5 transforaminal epidural steroid injections over four months without durable relief. Her symptoms were exacerbated by activity and lumbar flexion and had progressively impaired ambulation and activities of daily living. Physical examination demonstrated lumbar paraspinal tenderness at L4–5/L5–S1, pain with lumbar flexion, diminished sensation in the left L5 distribution, and an antalgic gait. Examination of the left hip revealed findings attributed to osteoarthritis and iliopsoas tendonitis. Lumbar magnetic resonance imaging demonstrated degenerative disc disease at L4–5 without Modic endplate changes or other imaging findings sufficient to explain the severity and distribution of her symptoms.

Because the patient's symptoms were disproportionate to the degree of hip pathology and remained refractory to conservative management, including both intra-articular and greater trochanteric injections discogenic pain was suspected. The patient underwent lumbar discography with therapeutic intradiscal injection at the L4–5 level. Using a standard fluoroscopically guided extrapedicular discography technique, a 25-gauge 5-inch spinal needle was advanced into the L4–5 intervertebral disc. Discography was performed using 2 cc of iohexol contrast media containing cefazolin 1 mg/mL for antibiotic prophylaxis (8). Concordant pain was identified upon opening pressure of less than 5 psi, and a free extradiscal flow was noted. Therapeutic intradiscal injection was then administered, consisting of 80 mg of Depo-Medrol mixed with 1 cc of 4% lidocaine. Volume, intradiscal pressure, and patient response were continuously monitored throughout the procedure.

Fluoroscopic imaging demonstrated anterior annular disruption at L4–5 with contrast extension beyond the confines of the intervertebral disc (Fig. 1). Progressive contrast propagation resulted in the formation of a well-defined extra-discal collection within the expected anatomical region of the iliopsoas compartment, confirmed on oblique and lateral projections (Fig. 2, Fig. 3). These findings correlated directly with reproduction of the patient's characteristic left anterior hip pain during injection, supporting the iliopsoas communication as the anatomical source of her atypical hip-predominant pain presentation.

Fig. 1.

Initial procedure, AP fluoroscopic image demonstrating annular disruption at L4–5 with progressive anterior contrast extension beyond the disc margin, consistent with anterior annular breach. Continued contrast propagation resulted in formation of a well-defined extra-discal collection extending anteriorly into the expected anatomical region of the iliopsoas compartment.

Fig. 2.

Initial procedure, Oblique view demonstrating a well-defined extra-discal contrast collection within the iliopsoas compartment.

Fig. 3.

Initial procedure Lateral view confirming anterior localization of the extravasated contrast.

Rather than representing a procedural complication, the observed extravasation was interpreted as a clinically meaningful diagnostic finding demonstrating symptomatic anterior annular disruption with communication into the iliopsoas compartment. The concordant pain provocation at the time of contrast extension suggested that irritation of the iliopsoas muscle and adjacent lumbar plexus structures contributed to the patient's atypical hip-predominant pain presentation. A total of 4 cc of injectant was administered (2 cc contrast, 1 cc Depomedrol, 1 cc 4% Lidocaine).

At follow-up approximately one month later, the patient reported approximately 50% overall axial pain reduction following the intradiscal therapeutic injection, with improvement in both low back and hip pain symptoms. Because of the favorable initial response, the patient subsequently underwent serial intradiscal steroid injections as part of ongoing therapeutic management. Follow-up fluoroscopic imaging obtained approximately 6 months after the initial diagnostic discography demonstrated interval reduction in anterior contrast propagation and decreased iliopsoas extravasation compared to the initial study (Fig. 4). Subsequent lateral and AP fluoroscopic projections obtained approximately 9 months after the initial diagnostic discography demonstrated progressive improvement in intradiscal contrast containment with minimal residual anterior propagation (Fig. 5). Long-term follow-up lateral fluoroscopic imaging obtained approximately 3 years after the initial diagnostic discography demonstrated continued intradiscal contrast containment without recurrence of the previously observed iliopsoas contrast collection, suggesting interval stabilization of the anterior annular disruption (Fig. 6). These interval imaging findings paralleled the patient's favorable clinical response (resolution of hip complaints) and supported functional stabilization of the symptomatic anterior annular disruption following serial intradiscal steroid therapy.

Fig. 4.

Fluoroscopic projection obtained approximately 6 months after the initial diagnostic discography demonstrating decreased anterior contrast propagation and reduced iliopsoas extravasation following serial intradiscal steroid therapy.

Fig. 5.

Sequential Lateral and AP fluoroscopic projections obtained during follow-up intradiscal evaluation nine months from initial discography, demonstrating improved intradiscal contrast containment with reduced anterior propagation compared to the initial study.

Fig. 6.

Long-term follow-up lateral fluoroscopic image obtained approximately 3 years after the initial diagnostic discography demonstrating contrast largely confined to the L4–5 disc space without recurrence of the previously observed anterior iliopsoas contrast collection. Compared with the initial study, there is marked reduction in anterior contrast propagation, consistent with interval stabilization and resolution of the symptomatic anterior annular disruption following serial intradiscal steroid therapy.

This case illustrates an unusual but clinically important presentation of discogenic pain in which anterior annular disruption with extension into the iliopsoas compartment reproduced concordant hip pain, thereby identifying the anatomical origin of symptoms that had previously mimicked primary hip pathology. Similar to referred pain patterns observed in Maigne syndrome, this case highlights how spinal pathology may present predominantly as hip or groin pain, potentially leading to diagnostic confusion when the true pain generator is extra-articular.

3. Discussion

This case demonstrates an uncommon presentation of discogenic pain in which anterior annular disruption at L4–5 produced concordant anterior hip pain through communication with the iliopsoas compartment. While discogenic pain most commonly presents as axial low back pain, structural disruption of the annulus may produce atypical referral patterns through inflammatory and mechanical irritation of adjacent tissues [1], [6]. The patient's predominant hip and groin symptoms initially suggested primary hip pathology; however, provocative discography directly reproduced her characteristic pain while simultaneously demonstrating contrast extension beyond the anterior annulus into the iliopsoas region.

The diagnostic significance of the observed extravasation extends beyond identification of a structural annular defect. Discography remains one of the few procedures capable of linking imaging findings with symptom reproduction in real time [3], [4]. In the present case, fluoroscopic visualization of anterior contrast propagation into the iliopsoas compartment occurred concurrently with reproduction of the patient's typical anterior hip pain, providing direct anatomical correlation between lumbar disc pathology and her concordant pain symptoms.

This referral pattern shares similarities with spinally mediated referred pain syndromes such as Maigne syndrome, in which spinal pathology produces pain perceived within the hip, groin, pelvic, or iliac regions despite minimal pathology at the site of symptoms [7]. Although our patient did not meet classic criteria for thoracolumbar junction syndrome, the case highlights how spinal pathology may masquerade as primary hip disease and emphasizes the importance of considering spinal pain generators in patients with persistent extra-articular hip pain.

The procedure was performed using a standard fluoroscopically guided extrapedicular discography technique consistent with contemporary recommendations of the International Pain & Spine Intervention Society (IPSIS) [5], [8]. Notably, the observed contrast extension into the iliopsoas compartment was not considered a procedural complication but rather a clinically meaningful diagnostic finding that helped localize the symptomatic annular disruption. Multi-planar fluoroscopic imaging confirmed the anterior and lateral location of the extravasated contrast, supporting communication between the disrupted disc and the iliopsoas region.

An additional unique aspect of this case was the availability of serial follow-up imaging after intradiscal steroid therapy. Historically, evidence supporting intradiscal steroid injections has been mixed, with some studies demonstrating short-term benefit in carefully selected patients [9]. More recent treatment paradigms suggest that patients with inflammatory discogenic pain may respond favorably to targeted anti-inflammatory intradiscal therapies [10], [11]. Notably, our patient demonstrated sustained clinical and radiographic improvement despite the absence of Modic endplate changes on MRI, suggesting that symptomatic annular disruption rather than vertebral endplate inflammation represented the primary pain generator. In this patient, serial fluoroscopic studies obtained at 6 months, 9 months, and approximately 3 years demonstrated progressive reduction in anterior contrast propagation, resolution of the iliopsoas communication, and improved intradiscal contrast containment. Although causality cannot be established from a single case, the radiographic evolution paralleled the patient's clinical response and suggests functional stabilization of the symptomatic annular disruption.

This case highlights several important clinical considerations. First, lumbar disc pathology may present predominantly as hip or groin pain and should remain within the differential diagnosis of persistent extra-articular hip symptoms. Second, provocative discography may provide unique diagnostic information when conventional imaging fails to identify the primary pain generator. Finally, serial imaging demonstrated a temporal association between intradiscal steroid therapy, reduced contrast extravasation, and sustained symptomatic improvement. These findings contribute to the evolving understanding of discogenic pain and support further investigation into imaging correlates of therapeutic response in patients with symptomatic annular disruption [12].

4. Conclusion

This case demonstrates an unusual presentation of discogenic pain in which anterior annular disruption at L4–5 with extension into the iliopsoas compartment reproduced concordant hip and groin pain, thereby identifying the anatomical source of symptoms that had previously mimicked primary hip pathology. The observed iliopsoas communication was not a procedural complication but rather a clinically meaningful diagnostic finding that correlated structural pathology with symptom reproduction during discography. Serial follow-up intradiscal procedures (performed with steroid based on patient's reported pain relief) with fluoroscopic imaging over approximately three years demonstrated progressive reduction in anterior contrast propagation and resolution of the iliopsoas communication, paralleling sustained clinical improvement following intradiscal steroid therapy. This case highlights the importance of considering discogenic pain in the differential diagnosis of persistent extra-articular hip pain and suggests that serial fluoroscopic imaging may provide valuable insight into the evolution and stabilization of symptomatic annular disruption.

Patient consent

Written informed consent was obtained from the patient for publication of this case report and the accompanying clinical information and images. All identifying information has been removed to protect patient privacy.