Article type
Year
Abstract
Background: Discography attempts to determine whether chronic back pain is caused by disc pathology. A needle is inserted into discs and an X-ray dye is injected with imaging. Positive test results involve reproduction and/or augmentation of the patient’s pain. However, as this procedure is fairly painful, sedation is required. Recommendations for the use of discography differ among various organizations.
Objectives: To use the American College of Occupational and Environmental Medicine (ACOEM) low back pain systematic reviews and practice guidelines to assess evidence. Guideline recommendations were compared with those of the American Society of Interventional Pain Physicians (ASIPP) and the North American Spine Society (NASS).
Methods: All three practice guidelines and systematic reviews were reviewed for recommendations about lumbar discography.
Results: ACOEM concluded that the evidence does not support discography, either as a solitary test or when paired with imaging (e.g. magnetic resonance imaging). These recommendations were based on two high-, and 23 moderate-quality studies. A recent systematic review did not find high-quality evidence to support cervical discography and did not find studies that showed discography could improve clinical outcomes in patients considering cervical surgery. Specificity for discography among high-quality trials ranges from 31% to 100%. The estimated positive predictive value (PPV) is at or below 50%. Contrary to ACOEM, ASIPP recommends use of discography with appropriate indications in patients with low back pain to prove a diagnostic hypothesis of discogenic pain specifically after exclusion of other sources of lumbar pain. NASS also recommends the selective use of lumbar discography for select clinical indications.
Conclusions: Guidelines differ. However, no high- or moderate-quality study or systematic review has documented sufficient PPV to warrant this procedure. Discrepancies in recommendations are a major concern with regard to subsequent discussions of using discography results in surgical and other interventional planning. Despite the sizable volume of literature, additional study appears warranted.
Objectives: To use the American College of Occupational and Environmental Medicine (ACOEM) low back pain systematic reviews and practice guidelines to assess evidence. Guideline recommendations were compared with those of the American Society of Interventional Pain Physicians (ASIPP) and the North American Spine Society (NASS).
Methods: All three practice guidelines and systematic reviews were reviewed for recommendations about lumbar discography.
Results: ACOEM concluded that the evidence does not support discography, either as a solitary test or when paired with imaging (e.g. magnetic resonance imaging). These recommendations were based on two high-, and 23 moderate-quality studies. A recent systematic review did not find high-quality evidence to support cervical discography and did not find studies that showed discography could improve clinical outcomes in patients considering cervical surgery. Specificity for discography among high-quality trials ranges from 31% to 100%. The estimated positive predictive value (PPV) is at or below 50%. Contrary to ACOEM, ASIPP recommends use of discography with appropriate indications in patients with low back pain to prove a diagnostic hypothesis of discogenic pain specifically after exclusion of other sources of lumbar pain. NASS also recommends the selective use of lumbar discography for select clinical indications.
Conclusions: Guidelines differ. However, no high- or moderate-quality study or systematic review has documented sufficient PPV to warrant this procedure. Discrepancies in recommendations are a major concern with regard to subsequent discussions of using discography results in surgical and other interventional planning. Despite the sizable volume of literature, additional study appears warranted.