Provocative Discography

Recent reports of provocative discography not only instill confusion, but also create numerous questions about its value in evaluating low back pain. It was reported that provocative discography produced pain in patients who were not suffering with low back pain but suffering with somatization disorder and depression. This study was designed to evaluate 50 randomly assigned patients, with 25 patients in Group I without somatization disorder and 25 patients in Group II with diagnosis of somatization disorder. In addition, depression, generalized anxiety disorder and combinations thereof were also evaluated. All patients underwent discography, investigating two to three discs in each patient. All studies included a control level with a disc that did not produce the patient's pain upon injection of contrast medium. Provocation with exact pain reproduction concordant with the symptom complex upon injection of contrast into the disc was considered positive. Any other response, with or without pain, was considered negative. Results showed positive provocative discography in 46% of the patients in the somatization group compared to 54% in the non-somatization group; in 46% of patients with depression compared to 54% of patients without depression; in 15 of 30 patients with generalized anxiety disorder; in 11 of 20 patients without generalized anxiety disorder; and in 42% of patients with combined somatization and depression, with negative discography in 58% of the patients. It is concluded that provocative discography provides similar results in patients with or without somatization, with or without depression, with somatization but with or without depression or with other combinations of the psychological triad of somatization disorder, depression, and generalized anxiety disorder.

Background: Understanding the neurophysiological basis of chronic spinal pain and diagnostic interventional techniques is crucial in the proper diagnosis and management of chronic spinal pain.Central to the understanding of the structural basis of chronic spinal pain is the provision of physical diagnosis and validation of patient symptomatology. It has been shown that history, physical examination, imaging, and nerve conduction studies in non-radicular or discogenic pain are unable to diagnose the precise cause in 85% of the patients. In contrast, controlled diagnostic blocks have been shown to determine the cause of pain in as many as 85% of the patients. Objective: To provide evidence-based clinical practice guidelines for diagnostic interventional techniques. Design: Best evidence synthesis. Methods: Strength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II. Diagnostic Criteria: Diagnostic criteria established by systematic reviews were utilized with controlled diagnostic blocks. Diagnostic criteria included at least 80% pain relief with controlled local anesthetic blocks with the ability to perform multiple maneuvers which were painful prior to the diagnostic blocks for facet joint and sacroiliac joint blocks, whereas for provocation discography, the criteria included concordant pain upon stimulation of the target disc with 2 adjacent discs producing no pain at all. Results: The indicated level of evidence for diagnostic lumbar, cervical, and thoracic facet joint nerve blocks is Level I or II-1. The indicated evidence is Level II-2 for lumbar and cervical discography, whereas it is Level II-3 for thoracic provocation discography. The evidence for diagnostic sacroiliac joint nerve blocks is Level II-2. Level of evidence for selective nerve root blocks for diagnostic purposes is Level II-3. Limitations: Limitations of this guideline preparation include a continued paucity of literature and conflicts in preparation of systematic reviews and guidelines. Conclusion: These guidelines include the evaluation of evidence for diagnostic interventional procedures in managing chronic spinal pain and recommendations. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a “standard of care.” Key words: Diagnostic interventional techniques, chronic spinal pain, facet joint interventions, epidural procedures, provocation discography, sacroiliac joint blocks, post lumbar surgery syndrome, spinal stenosis, provocation discography

This is a prospective study of the validity of a positive test result in provocative lumbar discography for the diagnosis of "discogenic pain." To investigate the hypothesis that provocative discography by strict criteria accurately identifies a low back pain illness due to a primary disc lesion. According to the Sackett and Haynes criteria for establishing diagnostic test validity, no test without a gold standard external standard can be meaningfully applied. Provocative discography as a test for determining "discogenic pain" has, to date, not been compared against a gold standard. Absent a gold standard reference, there can be no validity assessment or systematic improvement of test accuracy. This is the first study to apply an external gold standard evaluation of the diagnostic validity of discography in any manner. Over a 5-year period using a strict enrollment protocol, 32 patients with low back pain and a positive single-level low-pressure provocative discogram, underwent spinal fusion. Subjects with known patient selection comorbidities were excluded. Generic surgical limitations/morbidity were controlled by comparison to the clinical outcomes of a strictly-matched cohort of 34 patients having a well-accepted single-level lumbar pathology (unstable spondylolisthesis). Treatment success was compared between groups. In the control-spondylolisthesis group, 23 of 32 patients (72%) met the highly effective success criteria compared with 8 of 30 in the presumed discogenic pain cohort (27%). The proportion of patients who met the "minimal acceptable outcome" was 29 of 32 (91%) in the spondylolisthesis group and 13 of 30 (43%) in the presumed discogenic pain group. Adjusting for surgical morbidity and dropout failure, by either criteria of success, the best-case positive predictive value of discography was calculated to be 50% to 60%. 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.

Bupivacaine—the deadly friend of intervertebral disc cells?

The development of diagnostic criteria and the use of provocative discography allow identifying the degenerative disc as causative structure for chronic low-back pain. Unfortunately, none of the available interventional treatment options have been demonstrated to be effective over a prolonged period of time for a considerable number of patients. Pathophysiological studies indicate sprouting of sensory nerves and inflammatory processes as underlying pain mechanisms. Pulsed radiofrequency (PRF) treatment in small and larger joints was described to reduce pain and improve healing by stimulating the immunology. Earlier findings of PRF applied in the disc annulus were promising. It is assumed that PRF applied in the nucleus would change the conductivity of nerve endings and provide a clinically relevant pain reduction. The application of the electric field of PRF in the disc may also activate the immune system, thus reducing the inflammation process of chronic pain. Pulsed radiofrequency in the nucleus was studied in 76 patients with discogenic pain confirmed by magnetic resonance imaging and provocative discography. At 3-month follow-up, 38% of the patients had > 50% pain reduction, at 12 month the effect is maintained in 29%. In patients with unsatisfactory pain relief 3 months after the intervention, secondary pain sources may have been revealed. The latter were treated accordingly. Of all patients, 56% had > 50% pain reduction 1 year after first treatment. Our findings suggest that PRF in the nucleus may be considered for patients with proven discogenic pain. A randomized controlled trial to confirm our findings is justified.▪

To assess whether unilateral L2 infiltration with local anesthetic can be used to identify patients who will have negative discograms and thus eliminate the need for the discogram. Discogenic low-back pain is considered to have afferent pathways in the sinuvertebral nerves, mainly originating from the ventral rami of the spinal nerves. There is evidence that pain arising from the lower lumbar intervertebral discs may be transmitted through the sympathetic afferent fibers contained in the L2 spinal nerve root. Provocative discography, within the context of other clinical data, is the current "gold standard" by which to diagnose discogenic low-back pain, but a far more invasive procedure than L2 infiltration. To evaluate the correlation between unilateral second lumbar (L2) spinal nerve root infiltration with local anesthetic and provocative discography in patients with chronic low back pain. A prospective, observational study. All patients scheduled for discography were asked to participate in having local anesthetic infiltration of the L2 spinal nerve root at least two weeks prior to discography, until forty subjects were enrolled. Discography was performed after the patient's pain level returned to baseline. Local anesthetic infiltration of the L2 spinal nerve root was predictive of provocative discography results in only 46.5% of the subjects (26% true positives, and 20.5% true negatives). In 53.5% of the subjects, L2 infiltration was not predictive of discography results (20.5% false positives, and 33% false negatives). The results showed that unilateral L2 infiltration is not predictive of discogenic low-back pain when compared to discography, the current "gold-standard" for diagnosis.

Determine the effectiveness of intradiscal corticosteroid injection (IDCI) for the treatment of discovertebral low back pain. Systematic review. Adults with chronic low back pain attributed to disc or vertebral end plate pain, as evidenced by positive provocation discography or Modic 1 or 2 changes on magnetic resonance imaging. Fluoroscopically guided or computed tomography-guided IDCI. Sham/placebo procedure including intradiscal saline, anesthetic, discography alone, or other active treatment. Reduction in chronic low back pain reported on a visual analog scale or numeric rating scale and reduction in disability reported by a validated scale such as the Oswestry Disability Index. Four reviewers independently assessed articles published before January 31, 2023, in Medline, Embase, CENTRAL, and CINAHL. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The risk of bias in randomized trials was evaluated with the Cochrane Risk of Bias tool (version 2). Of the 7806 unique records screened, 6 randomized controlled trials featuring 603 total participants ultimately met the inclusion criteria. In multiple randomized controlled trials, IDCI was found to reduce pain and disability for 1-6 months in those with Modic 1 and 2 changes but not in those selected by provocation discography. According to GRADE, there is low-quality evidence that IDCI reduces pain and disability for up to 6 months in individuals with chronic discovertebral low back pain as evidenced by Modic 1 and 2 changes but not in individuals selected by provocation discography. PROSPERO (CRD42021287421).

PurposeThe goal of this study was to refine clinical MRS to optimize performance and then determine whether MRS-derived biomarkers reliably identify painful discs, quantify degeneration severity, and forecast surgical outcomes for chronic low back pain (CLBP) patients.MethodsWe performed an observational diagnostic development and accuracy study. Six hundred and twenty-three (623) discs in 139 patients were scanned using MRS, with 275 discs also receiving provocative discography (PD). MRS data were used to quantify spectral features related to disc structure (collagen and proteoglycan) and acidity (lactate, alanine, propionate). Ratios of acidity to structure were used to calculate pain potential. MRS-SCOREs were compared to PD and Pfirrmann grade. Clinical utility was judged by evaluating surgical success for 75 of the subjects who underwent lumbar surgery.ResultsTwo hundred and six (206) discs had both a successful MRS and independent pain diagnosis. When comparing to PD, MRS had a total accuracy of 85%, sensitivity of 82%, and specificity of 88%. These increased to 93%, 91%, and 93% respectively, in non-herniated discs. The MRS structure measures differed significantly between Pfirrmann grades, except grade I versus grade II. When all MRS positive discs were treated, surgical success was 97% versus 57% when the treated level was MRS negative, or 54% when the non-treated adjacent level was MRS positive.ConclusionMRS correlates with PD and may support improved surgical outcomes for CLBP patients. Noninvasive MRS is a potentially valuable approach to clarifying pain mechanisms and designing CLBP therapies that are customized to the patient.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

To explore the long-term outcome of lumbar disc herniation (LDH) after the treatment with modified mini-invasive Love operation. From January 1995 to December 2000, 373 patients suffered from LDH underwent the modified mini-invasive Love operation. There were 250 male and 123 female patients aged from 11 to 77-years-old (with a mean of 45.0-years-old). Most patients complained of sciatica accompanying back pain. The lesion level included L3,4 in 11 patients, L4,5 in 159 patients, L5-S1 in 195 patients and L4,5 combined with L5-S1 in 8 patients. The average operative duration was 65 min. The average blood lose was 22 ml. The average incision length was 3.2 cm. Till September 2005, 317 patients were available at the final follow-up during the period from 5 years and a half to 10 years and 5 months. The average duration of follow-up was 7 years and 8 months. A total of 135 patients underwent the CT discogram. According to the modified Roland-Morris Dysfunction Questionnaire, 198 patients were rated as excellent, 68 as good, and 51 as fair. The excellent rate was 84.0%. The scores for young patients were higher than senile patients. Herniation recurrence occurred in 10 patients (3.2%), in which 7 patients underwent the operation of internal fixation and 1 patient preferred the conservative treatment. One patient got the spondylolisthesis. The long-term outcome of the modified mini-invasive Love operation is effective. It is a good choice for the LDH patients.

One possible source of chronic low back pain is a degenerated intervertebral disc. In this review, various diagnostic methods for the assessment of the presence of degenerative changes are described. These include clinical MRI, a number of novel MRI techniques and nuclear magnetic resonance spectroscopy. Non-systematic literature review. Clinical MRI is the most commonly employed technique to determine the general "health status" of the intervertebral disc. Novel MRI techniques, such as quantitative MRI, T1ρ MRI, sodium MRI and nuclear magnetic resonance spectroscopy, are more sensitive in quantifying the biochemical changes of disc degeneration, as measured by alteration in collagen structure, as well as water and proteoglycan loss. As potential future diagnostic alternatives, miniature sensors are currently being developed to measure parameters associated with the disc degeneration cascade, such as intradiscal pressure and PG concentration. However, none of the methods listed above show sufficient specificity to identify a degenerated disc as the actual source of the pain. Provocative discography is the only test aimed at a direct diagnosis of discogenic pain, but it has a high false positive rate and there is some evidence of long-term adverse effects. Imaging techniques have also been tested for this purpose, but their validity has not been confirmed and they do appear to be problematic. A reliable diagnostic tool that could help a clinician to determine if a disc is the source of the pain in patients with chronic LBP is still not available. New MRI techniques are under investigation that could result in a significant improvement over current methods, particularly as they can allow monitoring, not only of morphological but also of biochemical changes.

Prospective case series. To determine the outcome of patients with chronic low back pain whose symptoms did not improve with aggressive nonoperative care and who chose (intradiscal electrothermal anuloplasty) IDET as an alternative to chronic pain management or interbody fusion surgery. Patients with unremitting chronic discogenic low back pain are faced with the choice of long-term pain management or fusion surgery. Intradiscal electrothermal anuloplasty (IDET) was developed as an alternative minimally invasive treatment. Sixty-two patients from the author's practice who had chronic low back pain unresponsive to nonoperative care, no evidence of compressive radiculopathy, and concordant pain reproduction at one or more disc levels on provocative discography were enrolled in the study. Visual analog scale (VAS) pain scores and Short Form (SF)-36 Health Status Questionnaire Physical Function subscale and SF-36 Bodily Pain subscale scores were assessed at baseline and at least 1 year later. Mean follow-up was 16 months, and mean preoperative duration of symptoms was 60 months. Baseline and follow-up outcome measures demonstrated a mean change in VAS score of 3.0 (P < 0.001), mean change in SF-36 physical function of 20 (P < 0.001), and mean change in SF-36 bodily pain of 17 (P < 0.001). Symptoms improved in 44 (71%) of 62 of the study group on the SF-36 physical function subscale, in 46 (74%) of 62 on the SF-36 Bodily Pain subscale, and in 44 (71%) of 62 on the VAS scores. Twelve (19%) of 62 of the patients did not show improvement on any scale. A cohort of patients with chronic unremitting low back pain of discogenic origin whose symptoms had failed to improve with aggressive nonoperative care demonstrated a statistically significant and clinically meaningful improvement on the SF-36 and the VAS scores at a minimum follow-up of 1 year after IDET. The positive results should be validated with placebo-controlled randomized trials and studies that compare IDET with alternative treatments.-

The effectiveness of intradiscal biologic treatments for discogenic low back pain: a systematic review

To investigate the prevalence of high-intensity zone (HIZ) and the correlation between HIZ and low back pain (LBP). The data of 1000 unselected cases, 566 males and 434 females, aged 49.49 (12 - 86), who underwent lumbar MRI were analyzed to examine the prevalence of HIZ. 200 of the 1000 cases with HIZ which had complete clinical history records, 112 males and 88 females, aged 52.29 (18 - 86), were divided into LBP (n = 115) and non-LBP series (n = 85). CT discography (CTD) was performed in 16 discs in 11 cases with HIZ and the correlation between the modified Dallas' discogram scale and pain reproduction in provocation discography was explored. HIZ located in posterior annulus fibrosus (AF) was shown in 378 discs in 317 cases, most located in L4/5 and L5/S1 (74.8%) and the location in left side (153 HIZs) was more common than that in right side (94 HIZs). HIZs were shown in superior region (15.4%), middle region (28.8%), as well as inferior region (55.8%) in sagittal plane. 115 of the 200 cases with HIZ who had complete clinical history records (57.5%) were symptomatic and 85 cases (42.5%) were asymptomatic. According to the modified Dallas' discogram scale, LBP could be provoked in 8 of the 9 patients with grade IV and could not be provoked in 6 of the 7 patients with the grade III. Whether HIZ is accompanied with LBP is related to the degree of disc degeneration. When CTD showed the degree of modified Dallas' grade IV and over most of the patients will show LBP. HIZ only indicates the possibility of discogenic LBP and can not replace provocation discography.

Background: Low back pain is a common worldwide health problem and has a significant socioeconomic impact on public health. Internal disc disruption has been considered as the most common cause of low back pain. Various therapies, including interbody fusion, disc replacement, injection therapies, and thermal annular procedures have been utilized for the treatment of discogenic low back pain. Recently, a new method of intradiscal methylene blue injection has been introduced to treat discogenic low back pain, but the clinical outcomes are controversial. Objectives: To investigate the clinical outcomes and magnetic resonance imaging changes of intradiscal methylene blue injection for the treatment of discogenic low back pain. Study Design: Observational study. Setting: An interventional low back pain management practice in a university hospital. Methods: A total of 33 patients were selected to be treated with intradiscal methylene blue injection. The clinical outcomes were evaluated by numeric rating scale and Oswestry Disability Index at pretreatment, one month, 3, 6, and 12 months after treatment. The magnetic resonance imaging changes of involved intervertebral discs were assessed by apparent diffusion coefficient and T2 values at pretreatment, 3, 6, and 12 months after treatment. Results: All of the patients got a follow-up period up to 12 months. The mean numeric rating scale scores at pretreatment, one month, 3, 6, and 12 months after treatment were 6.54, 2.98, 3.23, 3.66, and 4.72, respectively. There was a minimum of 2 points reduction at one month, 3, and 6 months after treatment, but less than 2 points reduction at 12 months. There was at least 50% improvement on the Oswestry Disability Index at one month, 3, and 6 months after treatment, but not at 12 months. The mean apparent diffusion coefficient and T2 value were significantly higher at 6 and12 months after treatment compared to pretreatment, but there was no significant difference between pretreatment and 3 months after treatment. Limitations: This is an observational study with a relatively small sample size and short-term follow-up. Conclusions: The intradiscal methylene blue injection might be an effective therapy for discogenic low back pain for the short-term and could improve disc degeneration condition to some extent. Key words: Low back pain, discogenic pain, internal disc disruption, provocation discography, methylene blue, intradiscal injection, disc degeneration, magnetic resonance, imaging

Lumbar interbody fusion comparing allograft bone dowels with threaded titanium cages: a prospective, randomized, multicenter study