title: An update of the systematic appraisal of the accuracy and utility of lumbar discography in chronic low back pain.
abstract: BACKGROUND
  The intervertebral disc has been implicated as a major cause of chronic lumbar spinal pain based on clinical, basic science, and epidemiological research. There is, however, a lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, lumbar intervertebral discs have been shown to be the source of chronic back pain without disc herniation in 26% to 39% of patients. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from other potential sources of pain. Despite the extensive literature, intense debate continues about lumbar discography as a diagnostic tool.
  
  
  METHODS
  A systematic review of the diagnostic accuracy of lumbar provocation and analgesic discography literature.
  
  
  OBJECTIVE
  To systematically assess and re-evaluate the diagnostic accuracy of lumbar discography.
  
  
  METHODS
  The available literature on lumbar discography was reviewed. A methodological quality assessment of included studies was performed using the Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were included in the analysis. However, studies scoring less than 50% are presented descriptively and critically analyzed. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2012, and manual searches of the bibliographies of known primary and review articles.
  
  
  RESULTS
  Over 160 studies were considered for inclusion. Of these, 33 studies compared discography with other diagnostic tests, 30 studies assessed the diagnostic accuracy of discography, 22 studies assessed surgical outcomes for discogenic pain, and 3 studies assessed the prevalence of lumbar discogenic pain. The quality of the overall evidence supporting provocation discography based on the above studies appears to be fair. The prevalence of internal disc disruption is estimated to be 39% to 42%, whereas the prevalence of discogenic pain without assessing internal disc disruption is 26%.
  
  
  CONCLUSIONS
  This systematic review illustrates that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain.
authors.affiliation: Pain Management Center of Paducah, Paducah, KY, USA. drlm@thepainmd.com
authors.forename: Laxmaiah
authors.initials: L
authors.lastname: Manchikanti
authors.forename: Ramsin M
authors.initials: RM
authors.lastname: Benyamin
authors.forename: Vijay
authors.initials: V
authors.lastname: Singh
authors.forename: Frank J E
authors.initials: FJ
authors.lastname: Falco
authors.forename: Haroon
authors.initials: H
authors.lastname: Hameed
authors.forename: Richard
authors.initials: R
authors.lastname: Derby
authors.forename: Lee R
authors.initials: LR
authors.lastname: Wolfer
authors.forename: Standiford
authors.initials: S
authors.lastname: Helm
authors.forename: Aaron K
authors.initials: AK
authors.lastname: Calodney
authors.forename: Sukdeb
authors.initials: S
authors.lastname: Datta
authors.forename: Lee T
authors.initials: LT
authors.lastname: Snook
authors.forename: David L
authors.initials: DL
authors.lastname: Caraway
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Hirsch
authors.forename: Steven P
authors.initials: SP
authors.lastname: Cohen
mesh_terms: D059350:Chronic Pain / Q000175:diagnosis*; D019937:Diagnostic Techniques and Procedures; D006801:Humans; D017116:Low Back Pain / Q000175:diagnosis*; D008161:Lumbosacral Region; D010147:Pain Measurement