Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain


Clinical practice guidelines state that the tissue source of low back pain cannot be specified in the majority of patients. However, there has been no systematic review of the accuracy of diagnostic tests used to identify the source of low back pain. The aim of this systematic review was therefore to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint or sacroiliac joint (SIJ) as the source of low back pain. MEDLINE, EMBASE and CINAHL were searched up to February 2006 with citation tracking of eligible studies. Eligible studies compared index tests with an appropriate reference test (discography, facet joint or SIJ blocks or medial branch blocks) in patients with low back pain. Positive likelihood ratios (+LR) > 2 or negative likelihood ratios (-LR) < 0.5 were considered informative. Forty-one studies of moderate quality were included; 28 investigated the disc, 8 the facet joint and 7 the SIJ. Various features observed on MRI (high intensity zone, endplate changes and disc degeneration) produced informative +LR (> 2) in the majority of studies increasing the probability of the disc being the low back pain source. However, heterogeneity of the data prevented pooling. +LR ranged from 1.5 to 5.9, 1.6 to 4.0, and 0.6 to 5.9 for high intensity zone, disc degeneration and endplate changes, respectively. Centralisation was the only clinical feature found to increase the likelihood of the disc as the source of pain: +LR = 2.8 (95%CI 1.4–5.3). Absence of degeneration on MRI was the only test found to reduce the likelihood of the disc as the source of pain: −LR = 0.21 (95%CI 0.12–0.35). While single manual tests of the SIJ were uninformative, their use in combination was informative with +LR of 3.2 (95%CI 2.3–4.4) and −LR of 0.29 (95%CI 0.12–0.35). None of the tests for facet joint pain were found to be informative. The results of this review demonstrate that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain. However, the changes in probability are usually small and at best moderate. The usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2


  1. 1.

    Airaksinen O, Brox JI, Cedraschi C et al. (2006) Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 15(Suppl 2):S192–S300

  2. 2.

    Aprill C, Bogduk N (1992) High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging. Br J Radiol 65:361–369

  3. 3.

    Bogduk N (1995) The anatomical basis for spinal pain syndromes. J Manipulative Physiol Ther 18:603–605

  4. 4.

    Bogduk N (2005) Low Back Pain. In: Clinical anatomy of the lumbar spine and sacrum. 4th edn. Elsevier, Sydney pp 183–216

  5. 5.

    Braithwaite I, White J, Saifuddin A et al. (1998) Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography. Eur J Radiol 7:363–368

  6. 6.

    Carragee EJ, Alamin TF, Miller J et al. (2002) Provocative discography in volunteer subjects with mild persistent low back pain. Spine J 2:25–34

  7. 7.

    Carragee EJ, Alamin TF, Carragee JM (2006) Low-pressure positive Discography in subjects asymptomatic of significant low back pain illness. Spine 31:505–509

  8. 8.

    Carragee EJ, Lincoln T, Parmar VS et al. (2006) A gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine 31:2115–2123

  9. 9.

    Carrera GF (1980) Lumbar facet joint injection in low back pain and sciatica: preliminary results. Radiology 137:665–667

  10. 10.

    Derby R, Kim B-J, Lee S-H et al. (2005) Comparison of discographic findings in asymptomatic subject discs and the negative discs of chronic LBP patients: can discography distinguish asymptomatic discs among morphologically abnormal discs? Spine J 5:389–394

  11. 11.

    Deville WL, Buntinx F, Bouter LM et al. (2002) Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Med Res Methodol 2:9

  12. 12.

    Donelson R, Aprill C, Medcalf R et al. (1997) A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine 22:1115–1122

  13. 13.

    Dreyfuss P, Michaelsen M, Pauza K et al. (1996) The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 21:2594–2602

  14. 14.

    Dreyfuss PH, Dreyer SJ, Nass (2003) Lumbar zygapophysial (facet) joint injections. Spine J 3:50S–59S

  15. 15.

    Fritz JM, George S (2000) The use of a classification approach to identify subgroups of patients with acute low back pain. Interrater reliability and short-term treatment outcomes. Spine 25:106–114

  16. 16.

    Holt EP Jr. (1968) The question of lumbar discography. J Bone Joint Surg Am 50:720–726

  17. 17.

    Horton WC, Daftari TK (1992) Which disc as visualized by magnetic resonance imaging is actually a source of pain? A correlation between magnetic resonance imaging and discography. Spine 17:S164–S171

  18. 18.

    Ito M, Incorvaia KM, Yu SF et al. (1998) Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. Spine 23:1252–1258

  19. 19.

    Kent P, Keating J (2004) Do primary-care clinicians think that nonspecific low back pain is one condition? Spine 29:1022–1031

  20. 20.

    Kokkonen S-M, Kurunlahti M, Tervonen O et al. (2002) Endplate degeneration observed on magnetic resonance imaging of the lumbar spine: correlation with pain provocation and disc changes observed on computed tomography diskography. Spine 27:2274–8

  21. 21.

    Lam KS, Carlin D, Mulholland RC (2000) Lumbar disc high-intensity zone: the value and significance of provocative discography in the determination of the discogenic pain source. Eur Spine J 9:36–41

  22. 22.

    Laslett M, Young SB, Aprill CN et al. (2003) Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother 49:89–97

  23. 23.

    Laslett M, Oberg B, Aprill CN et al. (2004) Zygapophysial joint blocks in chronic low back pain: a test of Revel’s model as a screening test. BMC Musculoskeletal Disorders 5:43

  24. 24.

    Laslett M, Aprill CN, McDonald B et al. (2005) Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 10:207–218

  25. 25.

    Laslett M, Oberg B, Aprill CN et al. (2005) Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J 5:370–380

  26. 26.

    Laslett M, Oberg B, Aprill CN et al. (2006) A study of clincal predictors of lumbar discogenic pain as determined by provocation discography. Eur Spine J 15:1473–1484

  27. 27.

    Laslett M, McDonald B, Aprill CN et al. (2006) Clinical predictors of screening lumbar zygapophysial joint blocks: Development of clinical prediction rules. Spine J 6:370–379

  28. 28.

    Lim C-H, Jee W-H, Son BC et al. (2005) Discogenic lumbar pain: association with MR imaging and CT discography. Eur J Radiol 54:431–437

  29. 29.

    Maigne JY, Boulahdour H, Chatellier G (1998) Value of quantitative radionuclide bone scanning in the diagnosis of sacroiliac joint syndrome in 32 patients with low back pain. Eur Spine J 7:328–331

  30. 30.

    Manchikanti L, Pampati V, Fellows B et al. (1999) Prevalence of lumbar facet joint pain in chronic low back pain. Pain Physician 2:59–64

  31. 31.

    Manchikanti L, Pampati V, Fellows B et al. (2000) The inability of the clinical picture to characterize pain from facet joints. Pain Physician 3:158–166

  32. 32.

    McKenzie RA, May S (2003) The lumbar spine: mechanical diagnosis and therapy. 2nd edn. Spinal Publications New Zealand Ltd, Waikanae

  33. 33.

    Merskey H, Bogduk N (1994) Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. IASP Press, Seattle

  34. 34.

    Milette PC, Raymond J, Fontaine S (1990) Comparison of high-resolution computed tomography with discography in the evaluation of lumbar disc herniations. Spine 15:525–33

  35. 35.

    Ohnmeiss DD, Vanharanta H, Ekholm J (1999) Relationship of pain drawings to invasive tests assessing intervertebral disc pathology. Eur Spine J 8:126–131

  36. 36.

    Osti OL, Fraser RD (1992) MRI and discography of annular tears and intervertebral disc degeneration: A prospective clinical comparison. J Bone Joint Surg Ser B 74:431–435

  37. 37.

    Parker LM, Murrell SE, Boden SD et al. (1996) The outcome of posterolateral fusion in highly selected patients with discogenic low back pain. Spine 21:1909–1916

  38. 38.

    Revel M, Poiraudeau S, Auleley GR et al. (1998) Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine 23:1972–1976

  39. 39.

    Revel ME, Listrat VM, Chevalier XJ et al. (1992) Facet joint block for low back pain: identifying predictors of a good response. Arch Phys Med Rehabil 73:824–8

  40. 40.

    Ricketson R, Simmons JW, Hauser BO (1996) The prolapsed intervertebral disc. The high-intensity zone with discography correlation. (see comment). Spine 21:2758–2562

  41. 41.

    Saal JS (2002) General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques... including commentary by Prager J, Saal J, Slosar P, Straus B, Turk D, Wetzel FT et al. Spine 27:2538–2546

  42. 42.

    Saifuddin A, Braithwaite I, White J et al. (1998) The value of lumbar spine magnetic resonance imaging in the demonstration of anular tears. Spine 23:453–457

  43. 43.

    Schellhas KP, Pollei SR, Gundry CR et al. (1996) Lumbar disc high-intensity zone. Correlation of magnetic resonance imaging and discography. Spine 21:79–86

  44. 44.

    Schwarzer AC, Aprill CN, Derby R et al. (1994) Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 19:1132–1137

  45. 45.

    Schwarzer AC, Aprill CN, Derby R et al. (1994) The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 58:195–200

  46. 46.

    Schwarzer AC, Aprill CN, Bogduk N (1995) The sacroiliac joint in chronic low back pain. Spine 20:31–37

  47. 47.

    Schwarzer AC, Aprill CN, Derby R et al. (1995) The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 20:1878–1883

  48. 48.

    Simmons JW, Emery SF, McMillin JN et al. (1991) Awake discography. A comparison study with magnetic resonance imaging. Spine 16:S216–S221

  49. 49.

    Slipman CW, Sterenfeld EB, Chou LH et al. (1996) The value of radionuclide imaging in the diagnosis of sacroiliac joint syndrome. Spine 21:2251–2254

  50. 50.

    Smith BM, Hurwitz EL, Solsberg D et al. (1998) Interobserver reliability of detecting lumbar intervertebral disc high-intensity zone on magnetic resonance imaging and association of high-intensity zone with pain and anular disruption. Spine 23:2074–2080

  51. 51.

    Spitzer WO (1987) Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the quebec task force on spinal disorders. Spine 12:S16–S19

  52. 52.

    Van Der Wurff P, Buijs EJ, Groen GJ (2006) A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil 87:10–14

  53. 53.

    Vanharanta H, Sachs BL, Spivey M et al. (1988) A comparison of CT/discography, pain response and radiographic disc height. Spine 13:321–324

  54. 54.

    Vanharanta H, Ohnmeiss DD, Aprill CN (1998) Vibration pain provocation can improve the specificity of MRI in the diagnosis of symptomatic lumbar disc rupture. Clin J Pain 14:239–247

  55. 55.

    Walsh TR, Weinstein JN, Spratt KF et al. (1990) Lumbar discography in normal subjects. A controlled, prospective study. J Bone Joint Surg Am 72:1081–1088

  56. 56.

    Weishaupt D, Zanetti M, Hodler J et al. (2001) Painful lumbar disk derangement: relevance of endplate abnormalities at MR imaging. Radiology 218:420–427

  57. 57.

    Whiting P, Rutjes AWS, Reitsma JB et al. (2003) The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 3:25

  58. 58.

    Wilczynski NL, Haynes RB, Hedges T (2005) EMBASE search strategies for identifying methodologically sound diagnostic studies for use by clinicians and researchers. BMC Med 3:7

  59. 59.

    Yoshida H, Fujiwara A, Tamai K et al. (2002) Diagnosis of symptomatic disc by magnetic resonance imaging: T2-weighted and gadolinium-DTPA-enhanced T1-weighted magnetic resonance imaging. J Spinal Disord Tech 15:193–198

  60. 60.

    Young S, Aprill C, Laslett M (2003) Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J 3:460–465

  61. 61.

    Yrjama M, Vanharanta H (1994) Bony vibration stimulation: a new, non-invasive method for examining intradiscal pain. Eur Spine J 3:233–235

  62. 62.

    Yrjama M, Tervonen O, Vanharanta H (1996) Ultrasonic imaging of lumbar discs combined with vibration pain provocation compared with discography in the diagnosis of internal anular fissures of the lumbar spine. Spine 21:571–575

  63. 63.

    Yrjama M, Tervonen O, Kurunlahti M et al. (1997) Bony vibration stimulation test combined with magnetic resonance imaging. Can discography be replaced? Spine 22:808–813

  64. 64.

    Zamora J, Abraira V, Muriel A et al. (2006) Meta-DiSc: a software for meta-analysis of test accuracy data. BMC Med Res Methodol 6

Download references


Chris Maher’s research fellowship and Mark Hancock’s PhD scholarship are funded by Australia’s National Health and Medical Research Council (NHMRC). An NHMRC project grant funds the salaries of James McAuley and Megan Spindler.

Author information

Correspondence to M. J. Hancock.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Hancock, M., Maher, C., Latimer, J. et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 16, 1539–1550 (2007).

Download citation


  • Systematic review
  • Low back pain
  • Diagnosis