A Gold Standard Evaluation of the “Discogenic Pain” Diagnosis as Determined by Provocative Discography

Carragee, Eugene J.; Lincoln, Todd L.; Parmar, Vik Singh; Alamin, Todd F.

doi:10.1097/01.brs.0000231436.30262.dd

Cited by 224 publications

(147 citation statements)

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“…For example, discography, which requires injection of a radio opaque dye into the NP, has a best-case positive predictive value of 50% to 60%, and results in potential AF damage through needle puncture. 4 Intradiscal electrothermal treatment also requires puncture of the AF and additional anular disruption using a catheter. 5 Future treatments including growth factor therapy, 6 tissue engineering, 7 and gene and cell therapy 8,9 may also require puncture of the AF using a needle.…”

mentioning

confidence: 99%

Needle Puncture Injury Affects Intervertebral Disc Mechanics and Biology in an Organ Culture Model

Korecki¹,

Costi²,

Iatridis³

2008

Spine

133

114

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Study Design-A bovine intervertebral disc organ culture model was used to study the effect of needle puncture injury on short-term disc mechanics and biology.Objective-To test the hypothesis that significant changes in intervertebral disc structure, mechanics, and cellular response would be present within 1 week of needle puncture injury with a large-gauge needle but not with a small-gauge needle.Summary of Background Data-Defects in anulus fibrosus induced by needle puncture injury can compromise mechanical integrity of the disc and lead to degeneration in animal models. The immediate and short-term mechanical and biologic response to anulus injury through needle puncture in a large animal model is not known.Methods-Bovine caudal intervertebral discs were harvested, punctured posterolaterally using 25G and 14G needles, and placed in organ culture for 6 days. Discs underwent a daily dynamic compression loading protocol for 5 days from 0.2 to 1 MPa at 1 Hz for 1 hour. Disc structure and function were assessed with measurements of dynamic modulus, creep, height loss, water content, proteoglycan loss to the culture medium, cell viability, and histology.Results-Needle puncture injury caused a rapid decrease in dynamic modulus and increase in creep during 1-hour loading, although no changes were detected in water content, disc height, or proteoglycan lost to the media. Cell viability was maintained except for localized cell death at the needle insertion site. An increase in cell number and possible remodeling response was seen in the insertion site in the nucleus pulposus.Conclusion-Relatively minor disruption in the disc from needle puncture injury had immediate and progressive mechanical and biologic consequences with important implications for the use of discography, and repair-regeneration techniques. Results also suggest diagnostic techniques sensitive to mechanical changes in the disc may be important for early detection of degenerative changes in response to anulus injury. Keywordsspine; intervertebral disc; organ culture; needle puncture; bovine; discography; mechanics; dynamic compression loading ©2008, Lippincott Williams & WilkinsAddress correspondence and reprint requests to James C. Iatridis, PhD, 201 Votey Building, 33 Colchester Avenue, Burlington, VT, 05405; E-mail: E-mail: james.iatridis@uvm.edu. NIH Public AccessAuthor Manuscript Spine (Phila Pa 1976 Current and future procedures for intervertebral disc (IVD) diagnosis, repair, and regeneration often require needle injection to the nucleus pulposus (NP) through the anulus fibrosus (AF). For example, discography, which requires injection of a radio opaque dye into the NP, has a best-case positive predictive value of 50% to 60%, and results in potential AF damage through needle puncture. 4 Intradiscal electrothermal treatment also requires puncture of the AF and additional anular disruption using a catheter. 5 Future treatments including growth factor therapy, 6 tissue engineering, 7 and gene and cell therapy 8,9 may also require puncture of t...

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mentioning

confidence: 99%

Needle Puncture Injury Affects Intervertebral Disc Mechanics and Biology in an Organ Culture Model

Korecki¹,

Costi²,

Iatridis³

2008

Spine

133

114

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“…[2][3][4] However, critics question the reliability and specificity of discography since concordant pain has been suggested to originate from nonspine sources and can be reproduced in patients without any prior history of back pain. 5,8,11 A prospective study intended to evaluate the predictive value of provocative discography following lumbar fusion was performed by Carragee et al 7 Lumbar fusions were performed in 32 patients with presumed discogenic pain and a positive discogram (see Table 1). A circumferential fusion was performed in a single day and consisted of an anterior lumbar interbody fusion with femoral ring allograft, buttress screw, and local bone/ allograft inserted within and around the structural graft.…”

Section: Scientific Foundationmentioning

confidence: 99%

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 6: Discography for patient selection

Eck

Sharan

Resnick

et al. 2014

SPI

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Identifying the etiology of pain for patients suffering from chronic low-back pain remains problematic. Noninvasive imaging modalities, used in isolation, have not consistently provided sufficient evidence to support performance of a lumbar fusion. Provocative testing has been used as an adjunct in this assessment, either alone or in combination with other modalities, to enhance the diagnostic capabilities when evaluating patients with low-back pain. There have been a limited number of studies investigating this topic since the publication of the original guidelines. Based primarily on retrospective studies, discography, as a stand-alone test, is not recommended to formulate treatment strategies for patients with low-back pain. A single randomized cohort study demonstrated an improved potential of discoblock over discography as a predictor of success following lumbar fusion. It is therefore recommended that discoblock be considered as a diagnostic option. There is a possibility, based on a matched cohort study, that an association exists between progression of degenerative disc disease and the performance of a provocative discogram. It is therefore recommended that patients be counseled regarding this potential development prior to undergoing discography.

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“…Also lack of evidence is not the same as evidence that a diagnosis is not improving outcome. A recent Volvo award winning paper [10] concluded discography was not a valid test for identifying discogenic low back pain because patients with positive discography did not respond well to spinal fusion. In this study response to treatment was considered the ''gold standard'' for the validity of the diagnostic test.…”

Section: Misunderstanding 1: Until Diagnosis Is Shown To Improve Outcmentioning

confidence: 99%

Discussion paper: what happened to the ‘bio’ in the bio-psycho-social model of low back pain?

et al. 2011

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Purpose Over 20 years ago the term non-specific low back pain became popular to convey the limitations of our knowledge of the pathological source of most people's low back pain. Knowledge of underlying pathology has advanced little since then, despite limited improvements in outcomes for patients with low back pain. Methods This paper discusses potential misunderstandings related to diagnostic studies in the field of low back pain and argues that future diagnostic studies should include and investigate pathological sources of low back pain. Results Six potential misunderstandings are discussed.(1) Until diagnosis is shown to improve outcomes it is not worth investigating; (2) without a gold standard it is not possible to investigate diagnosis of low back pain; (3) the presence of pathology in some people without low back pain means it is not important; (4) dismissal of the ability to diagnose low back pain in clinical guidelines is supported by the same level of evidence as recommendations for therapy; (5) suggesting use of a diagnostic test in research is misinterpreted as endorsing its use in current clinical practice; (6) we seem to have forgotten the 'bio' in biopsychosocial low back pain. Conclusions We believe the misunderstandings presented in this paper partly explain the lack of investigation into pathology as an important component of the low back pain experience. A better understanding of the biological component of low back pain in relation, and in addition, to psychosocial factors is important for a more rational approach to management of low back pain.

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A Gold Standard Evaluation of the “Discogenic Pain” Diagnosis as Determined by Provocative Discography

Abstract: Positive discography was not highly predictive in identifying bona fide isolated intradiscal lesions primarily causing chronic serious LBP illness in this first study comparing discography results to a gold standard.

Cited by 224 publications

References 43 publications

Needle Puncture Injury Affects Intervertebral Disc Mechanics and Biology in an Organ Culture Model

Needle Puncture Injury Affects Intervertebral Disc Mechanics and Biology in an Organ Culture Model

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 6: Discography for patient selection

Discussion paper: what happened to the ‘bio’ in the bio-psycho-social model of low back pain?

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