[Diagnostic Testing] Lumbar Provocation Diskography: Helpful or Harmful?

[Justin]

Since the Forum's attachment function has been non-functional, I have not been able to post this. Now that the attachment function is working beautifully (finally!!!!!!! ), I can post this very thought-provoking publication.
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Attached is a great read regarding discography. It addresses a recent publication in Spine that demonstated discography and accelerated progression of degenerated changes in the lumbar disc -->

• 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 2009;34:2338- 2345

• The publication above posted on the Spine Patient Society website 9/21/09 --> Does Discography Cause Accelerated Progression of Degeneration Changes in Lumbar Disc: A 10-yr Matched Cohort Study

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PM&R. Vol. 2, 957-968, October 2010

Lumbar Provocation Diskography: Helpful or Harmful?
Wolfer et al. © 2010 by the American Academy of Physical Medicine and Rehabilitation

CASE SCENARIO

A 45-year-old woman with a history of fibromyalgia and well-controlled depression presents with a 1-year history of low back pain (LBP) after a work-related injury. She worked as a forklift operator at a local brewery and was required to load packages and pallets on and off her forklift. One year ago, she reported sharp central axial LBP after an attempt to move a 22.7 kg (50 lb) box. She has had continuous pain, at a level of 7/10, with flares weekly since that time. The pain does not refer into her buttock or leg. She denies neurologic symptoms such as weakness in her legs. Results of a physical examination revealed pain with lumbar flexion greater than extension, but she has preserved range of motion. Neurologic examination results were normal. She has tried medications, acupuncture, and multiple bouts of skilled physical therapy without success. She has not been able to return to her previous work. Magnetic resonance imaging (MRI) shows degenerative changes at L4-5 and L5-S1, with annular tear at L5-S1. Zygapophysial joint abnormalities are not evident on imaging. She recently consulted with a surgeon who thinks she is a viable candidate for lumbar disk replacement. Lumbar provocation diskography (PD) has been recommended. Is there a role for diskography for in this patient? If diskography were to be done, then what should be the proper protocol (eg, should there be psychological screening, pressure manometry, conscious sedation, control levels, or intradiskal anesthetic used)?

NOTE: the attached PDF is posted with copyright clearance directly from the publisher, Elsevier.
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Here are a couple excerpts from the full-text publication (my emphasis [underlining and bold type] below):

Note: PD = lumbar provocation diskography and CIs = confidence intervals

One recent concern raised in the literature [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 2009;34:2338- 2345.] is that current PD techniques with small-gauge needles and limited pressurization resulted in accelerated disk degeneration, disk herniation, loss of disk height, and reactive end plate versus controls. When the data are re-analyzed and 95% CIs are included, no significant change is seen in degeneration grade, type of herniation, or Modic changes when comparing cohorts (Table 1) [10].

CIs are overlapping, which indicates no significant differences between groups. Fifty-five new herniations were reported in the diskography group versus 22 in the control group; however, this result is only obtained by combining all the types of herniations. Examination of individual types of herniations does not reveal any significant difference. The quantitative definitions of a herniation are not included in the article; furthermore, specific measurements of disk-size changes are reported in actual millimeter values. When Modic changes are analyzed, CIs are also overlapping. In summary, PD does not accelerate progression of degenerative changes in the lumbar disk. Diskographers do not need to be reticent about performing diskography for fear of injuring the disk. MRIs checked after 10 years in patients with chronic LBP are likely to show progression of degenerative changes as a result of normal aging as well as their underlying disease process, not likely as a result from undergoing PD.