Abstract
Provocative lumbar discography was investigated in a series of clinical studies at the Stanford University of Medicine, Stanford, CA. This work demonstrated that pain intensity during disc injection is strongly influenced by the subject’s emotional and psychological profiles, chronic pain behavior, and ongoing compensation claims whether the patient has any back pain illness or not. Pain reproduction was also primarily related to penetration of the dye through the outer annulus and could not reliably be used to confirm the location of the pain source.
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References and Recommended Reading
Allan DB, Waddell G: An historical perspective on low back pain and disability. Acta Orthop Scand Suppl 1989, 234:1–23.
Frymoyer J, ed: The magnitude of the problem. In The Lumbar Spine, vol 1, edn 2. Philadelphia: W.B. Saunders; 1996:8–15.
Bigos S, Battie M, Spengler D, et al.: A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine 1991, 16:1–6.
Bigos S, Battie M, Spengler D, et al.: A longitudinal, prospective study of industrial back injury reporting. Clin Orthop 1992, 279:21–34.
Burton A: Spine update: back injury and work loss: biomechanical and psychosocial influences. Spine 1997, 22:2575–2580.
Burton A, Tillotson K, Main C, et al.: Psychosocial predictors of outcome in acute and subacute low back trouble. Spine 1995, 20:722–728.
Klenerman L, Slade P, Stanley I, et al.: The prediction of chronicity in patients with acute attack of low back pain in a general practice setting. Spine 1995, 20:478–484.
Main C, Wood P, Hollis S, et al.: The distress and risk assessment method (DRAM): a simple patient classification to identify distress and evaluate the risk of a poor outcome. Spine 1992, 17:42–52.
Boden S, Davis D, Dina T, et al.: Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am 1990, 72A:403–408.
Jensen M, Brant-Zawadzki M, Obuchowski N, et al.: Magnetic resonance imaging of the lumbar spine in people without back pain. New Engl J Med 1994, 331:69–73.
Weisel S, Tsourmas N, Feffer H, et al.: A study of computerassisted tomography. I. The incidence of positive CAT scans in an symptomatic group of patients. Spine 1984, 9:549–551.
Carragee E: Prevalence and clinical features of internal disk disruption in patients with low back pain [letter]. Spine 1996, 21:776–777.
Aprill C, Bogduk N: High-intensity zone: a diagnostic sign of painful lumbar disc on magnetic resonance imaging. Br J Radiol 1992, 65:361–369.
Bogduk N: Point of view. Spine 1998, 23:1259–1260.
Schwarzer A, Aprill C, Bogduk N: The sacroiliac joint in chronic low back pain. Spine 1995, 20:31–37.
Schwarzer A, Aprill C, Derby R, et al.: The prevalence and clinical features of internal disc disruption in patients with chronic LBP. Spine 1995, 20:1878–1883.
Schwarzer A, Aprill C, Fortin J, et al.: The relative contribution of the zygapophyseal joint in chronic low back pain. Spine 1994, 19:801–806.
Schwarzer A, Aprill CN, Derby R, et al.: The prevalence and clinical features of internal disk disruption in patients with low back pain. Spine 1995, 20:1878–1883.
Vanharanta H, Sachs BL, Ohnmeiss DD, et al.: Pain provocation and disc deterioration by age. ACT/discography study in a low-back pain population. Spine 1989, 14:420–423.
Weinstein J, Claverie W, Gibson S: The pain of discography. Spine 1988, 13:1344–1348.
Yrjama M, Tervonen O, Kurunlahti M, et al.: Boney vibration simulation test combined with magnetic resonance imaging. Spine 1997, 22:808–813.
Zuckerman J, Derby R, Hsu K, et al.: Normal magnetic resonance imaging with abnormal discography. Spine 1988, 13:1355–1359.
Guyer R, Ohnmeiss D: Lumbar discography. Position statement from the North American Spine Society Diagnostic and Therapeutic Committee. Spine 1995, 20:2048–2059.
Sachs B, Vanharanta H, Spivey M, et al.: Dallas discogram description: a new classification of CT/discography in low-back disorders. Spine 1987, 12:287–284.
Moneta G, Videman T, Kaivanto K, et al.: Reported pain during lumbar discography as a function of anular ruptures and disc degeneration: a reanalysis of 833 discograms. Spine 1994, 19:1968–1974.
Walsh T, Weinstein J, Spratt K, et al.: Lumbar discography in normal subjects: a controlled prospective study. J Bone Joint Surg 1990, 72A:1081–1088.
Derby R, Howard MW, Grant JM, et al.: The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes. Spine 1999, 24:364–671. Some patients with low back pain syndromes appeared to respond to discographic injection with pain at very low injection pressures. The authors suggest this is due to a chemical irritation of neurologic structures by material expressed from the disc during injection rather than mechanical distension of the disc. The “chemically” sensitive disc patients responded best to anterior rather than posterior spinal fusion.
Heggeness MH, Watters WC, III, Gray PM Jr: Discography of lumbar discs after surgical treatment for disc herniation. Spine 1997, 22:1606–1609.
Carragee EJ: Single-level posterolateral arthrodesis, with or without posterior decompression, for the treatment of isthmic spondylolisthesis in adults. A prospective, randomized study. J Bone Joint Surg Am 1997, 79:1175–1180.
Holt E: The question of discography. J Bone Joint Surg 1967, 50A:720–726.
Nachemson A: Lumbar discography—where are we today? Spine 1989, 14:555–557.
Massie W, Stevens D: A critical evaluation of discography. J Bone Joint Surg 1967, 49A:1243–1244.
Carragee E, Tanner C, Vittum D, et al.: Positive provocative discography as a misleading finding in the evaluation of low back pain [abstract]. In Proceedings of the North American Spine Society. Chicago, IL: 1997:388.
Block A, Vanharanta H, Ohnmeiss D, et al.: Discographic pain report: influence of psychological factors. Spine 1996, 1:334–338.
Ohnmeiss DD, Vanharanta H, Guyer RD: The association between pain drawings and computed tomographic/ discographic pain responses. Spine 1995, 20:729–733.
Carragee E, Tanner C, Khurana S, et al.: False positive lumbar discography in select patients without low back complaints. Spine 2000, in press. Subjects with no history of low back pain underwent experimental discography. Three groups were examined including normal, chronic pain, and somatization disorder subjects. Magnitude of pain on disc injection varied with disc disruption, psychological distress, and history of active compensation claims. Overall, 10 of 26 subjects had significantly painful injections.
Carragee E, Chen Y, Tanner C, et al.: Provocative discography in patients after limited lumbar discectomy. A controlled, randomized study of pain response in symptomatic and asymptomatic subjects. In Proceedings of the North American Spine Society. Chicago, IL: 1999:95–96. This paper examined the pain response to provocative discography in subjects with and without back complaints at levels of previous discectomy. The pain on injection was high in both groups in those previously operated discs compared with nonoperated discs. The magnitude of pain corresponded with psychometric measures of depression and somatic awareness.
Siddle P, Cousins M: Spinal pain mechanisms. Spine 1997, 22:98–104.
Lenz F, Gracely R, Romanoski A, et al.: Simulation in the somatosensory thalamus can reproduce both the affective and sensory dimensions of previously experienced pain. Nat Med 1995, 1:910–913.
Lenz FA, Gracely RH, Hope EJ, et al.: The sensation of angina can be evoked by stimulation of the human thalamus. Pain 1994, 59:119–125.
Carragee E, Tanner C, Yang B, et al.: False positive findings on lumbar discography: reliability of subjective concordance assessment during provocative disc injection. Spine 1999, 24:2542–2547. In an experimental model of nondiscogenic low back pain, subjects with no history of low back pain but a recent posterior iliac crest bone graft harvesting could not discriminate the pain sensation on disc stimulation from the pain from the recent iliac crest bone graft surgery. The study calls into question the reliability of pain reproduction as used in provocative discography.
Ito M, Incorvaia KM, Yu SF, et al.: Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. Spine 1998, 23:1252–1258.
Schellhas KP, Pollei SR: The role of discography in the evaluation of patients with spinal deformity. Orthop Clin North Am 1994, 25:265–273.
Schellhas KP, Pollei SR, Dorwart RH: Thoracic discography. A safe and reliable technique. Spine 1994, 19:2103–2109.
Schellhas KP, Pollei SR, Gundry CR, et al.: Lumbar disc highintensity zone. Correlation of magnetic resonance imaging and discography. Spine 1996, 21:79–86.
Schellhas KP, Smith MD, Gundry CR, et al.: Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine 1996, 21:300–311.
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Carragee, E.J. Is lumbar discography a determinate of discogenic low back pain: Provocative discography reconsidered. Current Review of Pain 4, 301–308 (2000). https://doi.org/10.1007/s11916-000-0107-2
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DOI: https://doi.org/10.1007/s11916-000-0107-2