Journal of Orthopaedic Surgery 2009;17(2):190-3

Correlation of low back pain to a high-

intensity zone of the lumbar disc in Indian
patients
Ketan C Pande,1 Ketan Khurjekar,1 Vilas Kanikdaley2
Sushrut Hospital, Research Centre & PGI Orthopaedics, Ramdaspeth, Nagpur, India
1

Medico Research India, Shankar Nagar, Nagpur, India

2

were 11%, 82%, and 62%, respectively.

ABSTRACT
Purpose. To assess the correlation between low back
pain and a high-intensity zone (HIZ) of the lumbar
disc in Indian patients.
Methods. 200 patients with low back and/or leg
pain underwent magnetic resonance imaging of the
lumbosacral spine. The location and severity of pain
and disability were assessed using the pain drawing,
visual analogue scale, and Oswestry Disability
Index, respectively. The inter-observer reliability was
assessed using the kappa statistic.
Results. The prevalence of an HIZ was 13% and 17%
according to observers A and B, respectively. The inter-
observer reliability was fair (=0.64, p<0.005). The
presence of an HIZ did not correlate with low back
pain according to the pain drawing, visual analogue
scale, and Oswestry Disability Index. According to
the pain drawing data, the sensitivity, specificity, and
positive predictive values of an HIZ to low back pain
Conclusion. The presence of an HIZ is not diagnostic
of a disrupted and painful disc, and should be
interpreted together with other prevailing symptoms
and clinical findings.
Key words: low back pain; magnetic resonance imaging;
pain measurement
INTRODUCTION
The pathophysiology of low back pain is complicated.
The clinical presentation may not correlate with
structural abnormalities identified by magnetic
resonance imaging (MRI).1,2 On lumbar spine MRI, a
high-intensity zone (HIZ) within the annulus of a disc
(separate from the nucleus pulposus) has a positive
predictive value of 86% for a severely disrupted,
painful disc.3 It is claimed that the presence of an
HIZ is diagnostic of painful disc disruption,47 but
others found no such correlation.810 We studied the

Address correspondence and reprint requests to: Dr Ketan C Pande, RIPAS Hospital, Bandar Seri Begawan, Negara Brunei
Darussalam. E-mail: ketanpande@yahoo.com
Vol. 17 No. 2, August 2009 Correlation of low back pain to a high-intensity zone of the lumbar disc 191
prevalence of an HIZ and its correlation with low
back pain in a cohort of Indian patients.
MATERIALS AND METHODS
Between February 2003 and September 2003, 200
patients with low back and/or leg pain underwent MRI
of the lumbo-sacral spine using a 0.5 T system with a
quadrature spine coil and completed a questionnaire
involving a pain drawing (Fig. 1),1113 visual analogue
scale (VAS),14,15 and Oswestry Disability Index (ODI)16,17
to assess pain location, pain severity, and disability,
respectively.
Two independent observers assessed the
presence of an HIZ from L1/2 to L5/S1 on mid-
sagittal T2-weighted MRIs (Fig. 2). Observer A was
an experienced spinal surgeon and observer B a
radiologist. Patients with and without an HIZ were
compared using standard non-parametric tests.
Correlation between different variables was tested
using Pearsons correlation coefficient (r). A p<0.05
was considered statistically significant. Inter-observer
reliability was assessed using the kappa statistic.18,19
Back
Left Right
Figure 1 An outline
drawing of the human
body for patients
to map the nature
and location of their
pain. An area of 1
cm high overlying the
lumbo-sacral spine is
marked; pain within
this area is recorded
as low back pain.
Figure 2 M i d -
sagittal T2-weighted
magnetic resonance
image showing a
high-intensity zone at
the L4/5 disc.
RESULTS
25 patients were excluded from analysis because of
infection or deformity. Of the remaining 175 patients,
22 (13%) and 30 (17%) were identified with an HIZ by
observers A and B, respectively (17 of them by both).
One patient was identified as having an HIZ in 2
discs by observer B only but not A. The inter-observer
reliability was fair (=0.64, p<0.005).
Of 172 patients who completed the pain drawing,
77% located the pain within the lumbo-sacral region
and 23% located it outside or indicated a radicular
pain only. Patients with no HIZ had higher mean VAS
scores but not statistically significant (observer A: 50
vs. 46, p=0.7; observer B: 51 vs. 40, p=0.9, independent
sample t test). Patients with and without an HIZ had
similar ODI (observer A: 46% vs. 43%, p=0.9; observer
B: 44% vs. 44%, p=0.5, independent sample t test).
The presence of an HIZ did not correlate with low
back pain according to the pain drawing, VAS, and
ODI (Table). According to the pain drawing data, the
sensitivity, specificity, and positive predictive values
of an HIZ for low back pain were 11%, 82%, and 62%,
respectively.
Table
Correlation between presence of a high-intensity zone
(HIZ) and clinical parameters
Clinical parameters Presence of an HIZ
Observer A Observer B
Pain drawing r=0.1, p=0.7 r=0.05, p=0.9
Visual analogue scale r=0.08, p=0.5 r=0.12, p=0.3
Oswestry Disability Index r=0.04, p=0.1 r=0.01, p=0.5
192 KC Pande et al. Journal of Orthopaedic Surgery

DISCUSSION treatment of low back pain.28

The prevalence of an HIZ has been reported to be 28
to 59% in patients with low back pain.3,10,2022 It was
much lower in our Indian patients (13% and 17%).
The inter-observer reliability of detecting an HIZ in
the lumbar disc is fair to good,9 and may be increased
by training in interpretation.23 No such training was
provided for our observers; only a description and a
picture of the appearance of an HIZ were provided.
There was no interaction between the observers to
reach consensus. An HIZ is considered a reliable
indicator of a painful outer annular disruption, as
vascularised granulation tissue is formed in the outer
region of annulus fibrosus.7
Discography has been used for morphologic
assessment of lumbar discs in patients with discogenic
pain,3,24,25 but some consider it has limited or no value
in modern practice.26,27 There is no clear evidence-
based indication for discography in the diagnosis and
Psychological and chronic pain issues appear to
predict pain response in discography. The injection
of a disc having an HIZ can itself be painful in
asymptomatic patients.27,29 There is no change or
spontaneous improvement of symptoms with time,
and evolution of an HIZ does not correlate with
change in symptoms.30 The presence of an HIZ is not
correlated with the duration of symptoms, disability
scores, or clinical features.10
The sensitivity, specificity, and positive predictive
values of an HIZ in detecting a disrupted and painful
disc varies from 27 to 81%, 81 to 95%, and 40 to 88%,
respectively.3,5,6,9 The low sensitivity indicates that an
HIZ does not correlate with low back pain. The high
specificity indicates fewer false positive results (an
HIZ is rarely seen in patients without low back pain).
The presence of an HIZ is not diagnostic of a disrupted
and painful disc, and should be interpreted together
with other prevailing symptoms and clinical findings.

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