Skip to main content
SpringerLink
Log in

Diagnostic Discography: What is the Clinical Utility?

  • Anesthetic Techniques in Pain Management (GJ Brenner, Section Editor)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

The diagnosis and treatment of discogenic back pain is challenging. Provocation discography, an invasive spinal procedure, has been suggested as a diagnostic test for internal disc disruption to provide information on disc morphology and reproduction of symptoms. Current applications consist of the evaluation of persistent spinal pain in individuals, including postoperative patients, as well as providing a guide for patient selection for spinal fusion surgery and minimally invasive interventional pain procedures. While the validity of discography has been questioned by multiple scientific studies, technical refinements have addressed many of the initial limitations. An updated review on the safety and utility of discography will be provided, covering key areas of debate including false-positive rates, technical parameters, clinical utility, and risk of discography procedural-related intervertebral disc damage.

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

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Lindblom K. Technique and results of diagnostic disc puncture and injection (discography) in the lumbar region. Acta Orthop Scand. 1951;20:315–26.

    Article  PubMed  CAS  Google Scholar 

  2. Lindblom K. Technique and results in myelography and disc puncture. Acta Radiol. 1950;34:321–30.

    Article  PubMed  CAS  Google Scholar 

  3. Manchikanti L, Glaser SE, Wolfer L, et al. Systematic review of lumbar discography as a diagnostic test for chronic low back pain. Pain Physician. 2009;12:541–59.

    PubMed  Google Scholar 

  4. Chou R, Loeser JD, Owens DK, et al: American Pain Society Low Back Pain Guideline Panel: Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976) 2009;34:1066–77.

  5. •• American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine: Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010; 112: 810–33. These practice guidelines developed by the American Society of Anesthesiologists and the American Society of Regional Anesthesia and Pain Medicine provide an up-to-date analysis of the evidence, with recommendations for both invasive and noninvasive treatments for pain.

    Article  Google Scholar 

  6. Martin BI, Turner JA, Mirza SK, et al: Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997–2006. Spine (Phila Pa 1976) 2009; 34: 2077–84.

  7. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006;332:1430–4.

    Article  PubMed  CAS  Google Scholar 

  8. Cohen SP, Hurley RW: The ability of diagnostic spinal injections to predict surgical outcomes. Anesth Analg 2007; 105: 1756, 75, table of contents.

  9. Resnick DK, Choudhri TF, Dailey AT, et al. American Association of Neurological Surgeons/Congress of Neurological Surgeons: Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 6: magnetic resonance imaging and discography for patient selection for lumbar fusion. J Neurosurg Spine. 2005;2:662–9.

    Article  PubMed  Google Scholar 

  10. Boden SD, McCowin PR, Davis DO, et al. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72:1178–84.

    PubMed  CAS  Google Scholar 

  11. Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331:69–73.

    Article  PubMed  CAS  Google Scholar 

  12. Saifuddin A, Braithwaite I, White J, et al: The value of lumbar spine magnetic resonance imaging in the demonstration of annular tears. Spine (Phila Pa 1976) 1998;23:453–7.

    Google Scholar 

  13. Carragee EJ, Paragioudakis SJ, Khurana S: 2000 Volvo Award winner in clinical studies: Lumbar high-intensity zone and discography in subjects without low back problems. Spine (Phila Pa 1976) 2000;25:2987–92.

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

    Article  PubMed  CAS  Google Scholar 

  15. O’Neill C, Owens DK. Lumbar facet joint pain: time to hit the reset button. Spine J. 2009;9:619–22.

    Article  PubMed  Google Scholar 

  16. North RB, Kidd DH, Zahurak M, Piantadosi S. Specificity of diagnostic nerve blocks: a prospective, randomized study of sciatica due to lumbosacral spine disease. Pain. 1996;65:77–85.

    Article  PubMed  CAS  Google Scholar 

  17. Siddall PJ, Cousins MJ: Spinal pain mechanisms. Spine (Phila Pa 1976) 1997; 22: 98–104.

  18. Marks R. Distribution of pain provoked from lumbar facet joints and related structures during diagnostic spinal infiltration. Pain. 1989;39:37–40.

    Article  PubMed  CAS  Google Scholar 

  19. Slipman CW, Plastaras CT, Palmitier RA, et al: Symptom provocation of fluoroscopically guided cervical nerve root stimulation. Are dynatomal maps identical to dermatomal maps? Spine (Phila Pa 1976) 1998; 23: 2235–42.

  20. Agorastides ID, Lam KS, Freeman BJ, Mulholland RC. The Adams classification for cadaveric discograms: inter- and intra-observer error in the clinical setting. Eur Spine J. 2002;11:76–9.

    Article  PubMed  Google Scholar 

  21. Milette PC, Fontaine S, Lepanto L, et al: Differentiating lumbar disc protrusions, disc bulges, and discs with normal contour but abnormal signal intensity. Magnetic resonance imaging with discographic correlations. Spine (Phila Pa 1976) 1999; 24: 44–53.

    Google Scholar 

  22. Adams MA, Dolan P, Hutton WC. The stages of disc degeneration as revealed by discograms. J Bone Joint Surg Br. 1986;68:36–41.

    PubMed  CAS  Google Scholar 

  23. Holt Jr EP. The question of lumbar discography. J Bone Joint Surg Am. 1968;50:720–6.

    PubMed  Google Scholar 

  24. Simmons JW, Aprill CN, Dwyer AP, Brodsky AE. A reassessment of Holt’s data on: “The question of lumbar discography”. Clin Orthop Relat Res. 1988;237:120–4.

    PubMed  Google Scholar 

  25. •• Wolfer LR, Derby R, Lee JE, Lee SH: Systematic review of lumbar provocation discography in asymptomatic subjects with a meta-analysis of false-positive rates. Pain Physician 2008; 11: 513–38. This is an extensive review and meta-analysis on the published false-positive rates for discography.

    PubMed  Google Scholar 

  26. Walsh TR, Weinstein JN, Spratt KF, et al. Lumbar discography in normal subjects. A controlled, prospective study. J Bone Joint Surg Am. 1990;72:1081–8.

    PubMed  CAS  Google Scholar 

  27. Carragee EJ, Tanner CM, Yang B, et al: False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection. Spine (Phila Pa 1976) 1999;24:2542–7.

    Google Scholar 

  28. Carragee EJ, Tanner CM, Khurana S, et al: The rates of false-positive lumbar discography in select patients without low back symptoms. Spine (Phila Pa 1976) 2000;25:1373, 80; discussion 1381.

  29. Carragee EJ, Chen Y, Tanner CM, et al: Provocative discography in patients after limited lumbar discectomy: A controlled, randomized study of pain response in symptomatic and asymptomatic subjects. Spine (Phila Pa 1976) 2000;25:3065–71.

    Google Scholar 

  30. Block AR, Vanharanta H, Ohnmeiss DD, Guyer RD: Discographic pain report. Influence of psychological factors. Spine (Phila Pa 1976) 1996;21:334–8.

    Google Scholar 

  31. Ohnmeiss DD, Vanharanta H, Ekholm J. Relationship of pain drawings to invasive tests assessing intervertebral disc pathology. Eur Spine J. 1999;8:126–31.

    Article  PubMed  CAS  Google Scholar 

  32. • Daubs MD, Patel AA, Willick SE, et al: Clinical impression versus standardized questionnaire: the spinal surgeon’s ability to assess psychological distress. J Bone Joint Surg Am 2010;92:2878–83. This study demonstrates the difficulties in assessing patients’ psychological distress levels.

    Article  PubMed  Google Scholar 

  33. Bogduk N. Practice Guidelines for Spinal Diagnostic and Treatment Procedures. 1st ed. San Francisco, California: International Spine Intervention Society; 2004.

    Google Scholar 

  34. Carragee EJ, Alamin TF, Carragee JM: Low-pressure positive Discography in subjects asymptomatic of significant low back pain illness. Spine (Phila Pa 1976) 2006;31:505–9.

    Google Scholar 

  35. O’Neill C, Kurgansky M: Subgroups of positive discs on discography. Spine (Phila Pa 1976) 2004;29:2134–9.

  36. Kim D, Wadley R. Variability in techniques and patient safety protocols in discography: a national multispecialty survey of International Spine Intervention Society members. J Spinal Disord Tech. 2010;23:431–8.

    Article  PubMed  Google Scholar 

  37. Derby R, Howard MW, Grant JM, et al: The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes. Spine (Phila Pa 1976) 1999;24:364, 71; discussion 371–2.

    Google Scholar 

  38. Derby R, Lee SH, Kim BJ, et al: Pressure-controlled lumbar discography in volunteers without low back symptoms. Pain Med 2005;6:213, 21; discussion 222–4.

    Google Scholar 

  39. Shin DA, Kim HI, Jung JH, et al. Diagnostic relevance of pressure-controlled discography. J Korean Med Sci. 2006;21:911–6.

    Article  PubMed  Google Scholar 

  40. Shin DA, Kim SH, Han IB, et al: Factors influencing manometric pressure during pressure-controlled discography. Spine (Phila Pa 1976) 2009;34:E790–3.

    Google Scholar 

  41. •• Choi WS, Shin DA, Kim HI, et al: Toward more useful pressure-controlled discography: in vitro evaluation of injection speed, sensor location, and tube length. Pain Med 2011; 12: 36–44. This study highlights the importance of standardizing equipment utilized for the measurements of intradiscal pressures.

    Article  PubMed  Google Scholar 

  42. Derby R, Lee SH, Lee JE, Lee SH. Comparison of pressure-controlled provocation discography using automated versus manual syringe pump manometry in patients with chronic low back pain. Pain Med. 2011;12:18–26.

    Article  PubMed  Google Scholar 

  43. • Hebelka H, Gaulitz A, Nilsson A, et al: The transfer of disc pressure to adjacent discs in discography: a specificity problem? Spine (Phila Pa 1976) 2010; 35: E1025–9. This study demonstrates how false-positive results may be a consequence of the stimulation of adjacent discs.

  44. Derincek A, Mehbod A, Schellhas K, et al. Discography: can pain in a morphologically normal disc be due to an adjacent abnormal disc? Arch Orthop Trauma Surg. 2007;127:699–703.

    Article  PubMed  Google Scholar 

  45. Heggeness MH, Doherty BJ: Discography causes end plate deflection. Spine (Phila Pa 1976) 1993;18:1050–3.

    Google Scholar 

  46. Freeman BJ, Mehdian R. Intradiscal electrothermal therapy, percutaneous discectomy, and nucleoplasty: what is the current evidence? Curr Pain Headache Rep. 2008;12:14–21.

    Article  PubMed  Google Scholar 

  47. Freeman BJ. IDET: a critical appraisal of the evidence. Eur Spine J. 2006;15 Suppl 3:S448–57.

    Article  PubMed  Google Scholar 

  48. Freeman BJ, Fraser RD, Cain CM, et al: A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine 2005;30:2369, 77; discussion 2378.

    Google Scholar 

  49. Appleby D, Andersson G, Totta M. Meta-analysis of the efficacy and safety of intradiscal electrothermal therapy (IDET). Pain Med. 2006;7:308–16.

    Article  PubMed  Google Scholar 

  50. Pauza KJ, Howell S, Dreyfuss P, et al. A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J. 2004;4:27–35.

    Article  PubMed  Google Scholar 

  51. Kapural L, Ng A, Dalton J, et al. Intervertebral disc biacuplasty for the treatment of lumbar discogenic pain: results of a six-month follow-up. Pain Med. 2008;9:60–7.

    Article  PubMed  Google Scholar 

  52. Arnold PM, Robbins S, Paullus W, et al. Clinical outcomes of lumbar degenerative disc disease treated with posterior lumbar interbody fusion allograft spacer: a prospective, multicenter trial with 2-year follow-up. Am J Orthop (Belle Mead NJ). 2009;38:E115–22.

    Google Scholar 

  53. Madigan L, Vaccaro AR, Spector LR, Milam RA. Management of symptomatic lumbar degenerative disk disease. J Am Acad Orthop Surg. 2009;17:102–11.

    PubMed  Google Scholar 

  54. Fritzell P, Hagg O, Wessberg P, Nordwall A: Swedish Lumbar Spine Study Group: 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976) 2001;26:2521, 32; discussion 2532–4.

  55. Fritzell P, Hagg O, Nordwall A. Swedish Lumbar Spine Study Group: Complications in lumbar fusion surgery for chronic low back pain: comparison of three surgical techniques used in a prospective randomized study. A report from the Swedish Lumbar Spine Study Group. Eur Spine J. 2003;12:178–89.

    PubMed  Google Scholar 

  56. • Chou R, Baisden J, Carragee EJ, et al: Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976) 2009;34:1094–109. This review provides a detailed overview of the current level of evidence for surgical intervention for low back pain.

  57. Mirza SK, Deyo RA: Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine (Phila Pa 1976) 2007;32:816–23.

    Google Scholar 

  58. Ekman P, Moller H, Shalabi A, et al. A prospective randomised study on the long-term effect of lumbar fusion on adjacent disc degeneration. Eur Spine J. 2009;18:1175–86.

    Article  PubMed  Google Scholar 

  59. Martin BI, Mirza SK, Comstock BA, et al: Are lumbar spine reoperation rates falling with greater use of fusion surgery and new surgical technology? Spine (Phila Pa 1976) 2007;32:2119–26.

  60. Gibson JN, Waddell G: Surgery for degenerative lumbar spondylosis. Cochrane Database Syst Rev 2005; (2): CD001352.

  61. Maghout Juratli S, Franklin GM, Mirza SK, et al: Lumbar fusion outcomes in Washington State workers’ compensation. Spine (Phila Pa 1976) 2006;31:2715–23.

    Google Scholar 

  62. Cohen SP, Larkin TM, Barna SA, et al. Lumbar discography: a comprehensive review of outcome studies, diagnostic accuracy, and principles. Reg Anesth Pain Med. 2005;30:163–83.

    PubMed  Google Scholar 

  63. Colhoun E, McCall IW, Williams L. Cassar Pullicino VN: Provocation discography as a guide to planning operations on the spine. J Bone Joint Surg Br. 1988;70:267–71.

    PubMed  CAS  Google Scholar 

  64. Knox BD, Chapman TM. Anterior lumbar interbody fusion for discogram concordant pain. J Spinal Disord. 1993;6:242–4.

    Article  PubMed  CAS  Google Scholar 

  65. Wetzel FT, LaRocca SH, Lowery GL, Aprill CN: The treatment of lumbar spinal pain syndromes diagnosed by discography. Lumbar arthrodesis. Spine (Phila Pa 1976) 1994;19:792–800.

  66. Madan S, Gundanna M, Harley JM, et al. Does provocative discography screening of discogenic back pain improve surgical outcome? J Spinal Disord Tech. 2002;15:245–51.

    Article  PubMed  Google Scholar 

  67. Gill K, Blumenthal SL: Functional results after anterior lumbar fusion at L5–S1 in patients with normal and abnormal MRI scans. Spine (Phila Pa 1976) 1992;17:940–2.

    Google Scholar 

  68. Resnick DK. Evidence-based guidelines for the performance of lumbar fusion. Clin Neurosurg. 2006;53:279–84.

    PubMed  Google Scholar 

  69. Resnick DK, Malone DG, Ryken TC. Guidelines for the use of discography for the diagnosis of painful degenerative lumbar disc disease. Neurosurg Focus. 2002;13:E12.

    Article  PubMed  Google Scholar 

  70. Smith SE, Darden BV, Rhyne AL, Wood KE: Outcome of unoperated discogram-positive low back pain. Spine (Phila Pa 1976) 1995;20:1997, 2000; discussion 2000–1

  71. Neal JM, Rathmell JP. Complications in Regional Anesthesia & Pain Medicine. Philadelphia: PA, Saunders Elsevier; 2007. p. 386.

    Google Scholar 

  72. •• Carragee EJ, Don AS, Hurwitz EL, et al: 2009 ISSLS Prize Winner: Does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study. Spine (Phila Pa 1976) 2009;34:2338–45. This study suggests that modern discography techniques using small needles and low pressures may result in accelerated disc degeneration.

  73. Nassr A, Lee JY, Bashir RS, et al: Does incorrect level needle localization during anterior cervical discectomy and fusion lead to accelerated disc degeneration? Spine (Phila Pa 1976) 2009; 34: 189–92.

  74. • Iatridis JC, Michalek AJ, Purmessur D, Korecki CL: Localized Intervertebral Disc Injury Leads to Organ Level Changes in Structure, Cellularity, and Biosynthesis. Cell Mol Bioeng 2009; 2: 437–47. This article provides an up-to-date review on the influence of intervertebral disc injury on biomechanics, cellularity, inflammation, and biosynthesis.

    Article  PubMed  Google Scholar 

  75. Goldie I. Changes observed in the intervertebral disc after discography. Acta Pathol Microbiol Scand. 1958;42:193–7.

    Article  PubMed  CAS  Google Scholar 

  76. Goldie I. Invertebral disc changes after discography. Acta Chir Scand. 1957;113:438–9.

    PubMed  CAS  Google Scholar 

  77. Johnson RG: Does discography injure normal discs? An analysis of repeat discograms. Spine (Phila Pa 1976) 1989;14:424–6.

    Google Scholar 

  78. Carragee EJ, Chen Y, Tanner CM, et al: Can discography cause long-term back symptoms in previously asymptomatic subjects? Spine (Phila Pa 1976) 2000;25:1803–8.

  79. Korecki CL, Costi JJ, Iatridis JC. Needle puncture injury affects intervertebral disc mechanics and biology in an organ culture model. Spine. 2008;33:235–41.

    Article  PubMed  Google Scholar 

  80. Elliott DM, Yerramalli CS, Beckstein JC, et al: The effect of relative needle diameter in puncture and sham injection animal models of degeneration. Spine (Phila Pa 1976) 2008;33:588–96.

    Google Scholar 

  81. Michalek AJ, Buckley MR, Bonassar LJ, et al. The effects of needle puncture injury on microscale shear strain in the intervertebral disc annulus fibrosus. Spine J. 2010;10:1098–105.

    Article  PubMed  Google Scholar 

  82. Hsieh AH, Hwang D, Ryan DA, et al: Degenerative anular changes induced by puncture are associated with insufficiency of disc biomechanical function. Spine (Phila Pa 1976) 2009;34:998–1005.

    Google Scholar 

  83. Keorochana G, Johnson JS, Taghavi CE, et al. The effect of needle size inducing degeneration in the rat caudal disc: evaluation using radiograph, magnetic resonance imaging, histology, and immunohistochemistry. Spine J. 2010;10:1014–23.

    Article  PubMed  Google Scholar 

  84. Ohtori S, Kinoshita T, Yamashita M, et al: Results of surgery for discogenic low back pain: a randomized study using discography versus discoblock for diagnosis. Spine (Phila Pa 1976) 2009;34:1345–8.

    Google Scholar 

  85. •• Lee H, Sowa G, Vo N, et al: Effect of bupivacaine on intervertebral disc cell viability. Spine J 2010;10:159–66. This is an in vitro study suggesting that injectates, such as bupivacaine, utilized during analgesic discography may pose a risk to the intervertebral disc health.

    Article  PubMed  Google Scholar 

  86. Hoelscher GL, Gruber HE, Coldham G, et al: Effects of very high antibiotic concentrations on human intervertebral disc cell proliferation, viability, and metabolism in vitro. Spine (Phila Pa 1976) 2000;25:1871–7.

    Google Scholar 

Download references

Disclosure

No potential conflicts of interest relevant to this article were reported.

Author information

Authors and Affiliations

  1. Institute for Pain Diagnostics and Care, Ohio Valley General Hospital, 500 Pine Hollow Road, McKees Rocks, PA, 15136, USA

    David A. Provenzano

Authors
  1. David A. Provenzano
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David A. Provenzano.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Provenzano, D.A. Diagnostic Discography: What is the Clinical Utility?. Curr Pain Headache Rep 16, 26–34 (2012). https://doi.org/10.1007/s11916-011-0239-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11916-011-0239-6

Keywords

Search

Navigation