Lumbar Discography

Dr. Craig Best

What is lumbar discography?

Provocative lumbar discography is the gold standard diagnostic test to precisely confirm or exclude the intervertebral disc as a cause of low back pain. Using fluoroscopic (x-ray) guidance, needles are placed within two or more discs and pressurized using contrast dye. Based on patient response and imaging findings such as fissures (tears) within the disc(s), a diagnosis of discogenic low back pain can be confirmed or ruled out as a source of low back pain.

Who is a candidate for lumbar discography?

Patients who have been experiencing low back pain for greater than 3 months, have tried and failed conservative management (medications, physical therapy, chiropractic), and for whom non-invasive diagnostic tests (x-ray, MRI) have failed to precisely diagnose the source of low back pain.

Why is lumbar discography performed?

Low back pain is a very common cause of musculoskeletal disability, but “low back pain” is not a diagnosis. There are distinct anatomic spinal structures that can potentially generate pain. Studies have shown that the intervertebral discs are the main pain generating structure in 40-70% of cases of low back pain. In patients younger than 60 years of age, the disc is the most common cause of low back pain, followed by the sacroiliac joint then the facet joint. In patients older than 60 years of age, the facet joint is the most cause of low back pain, followed by the disc then the sacroiliac joint. As such, provocative lumbar discography is an important tool to precisely diagnose pain emanating from the lumbar discs.

What are the common features of discogenic low back pain?

Patients with discogenic low back pain typically complain of deep and aching pain that can become sharp with movement, an inability to sit for prolonged periods of time, temporary relief with change of position, and low back more than leg pain. This type of low back pain commonly begins with a lifting and/or twisting injury.

Does lumbar discography contribute to disc degeneration?

Despite concerns raised by some physicians that lumbar discography contributes to higher rates of disc degeneration, a recent review of the safety and overall diagnostic value of provocative lumbar discography concluded that it is a safe and helpful diagnostic test when performed by properly trained physicians using strict procedural guidelines as outlined by the Spine Intervention Society.

What are the potential benefits of diagnosing discogenic low back pain using lumbar discography?

First, in patients who eventually go on to have fusion surgery for management of their discogenic low back pain, there is an 88% chance of success with a positive discogram compared to just a 50% chance of success with a negative discogram. Second, when lumbar discography identifies the source of a patient’s low back pain earlier in his or her course, it can save the patient from potentially excessive and unnecessary testing and treatment. Lastly, it can potentially provide peace of mind by having a concrete and precise diagnosis of one’s low back pain.

References

Schwarzer et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 1995; 20:1878–83.
DePalma et al. What is the source of chronic low back pain and does age play a role? Pain Med 2011;12:224–33.
Carragee et al. Does discography cause accelerated progression of degeneration changes in the lumbar disc: A ten-year matched cohort study. Spine 2009;34:2338–45.
Cuellar et al. Does provocative discography cause clinically important injury to the lumbar intervertebral disc? A 10-year matched cohort study. Spine J 2016;16: 273–80.
McCormick et al. Diagnostic value, prognostic value, and safety of provocation discography. Pain Medicine 2018;19:3-8.

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