title: Does provocative discography cause clinically important injury to the lumbar intervertebral disc? A 10-year matched cohort study.
abstract: BACKGROUND
  Provocative discography, an invasive diagnostic procedure involving disc puncture with pressurization, is a test for presumptive discogenic pain in the lumbar spine. The clinical validity of this test is unproven. Data from multiple animal studies confirm that disc puncture causes early disc degeneration. A recent study identified radiographic disc degeneration on magnetic resonance imaging (MRI) performed 10 years later in human subjects exposed to provocative discography. The clinical effect of this disc degeneration after provocative discography is unknown.
  
  
  OBJECTIVE
  The aim of this study was to investigate the clinical effects of lumbar provocative discography on patients subjected to this evaluation method.
  
  
  METHODS
  A prospective, 10-year matched cohort study.
  
  
  METHODS
  Subjects (n=75) without current low back pain (LBP) problems were recruited to participate in a study of provocative discography at the L3-S1 discs. A closely matched control cohort was simultaneously recruited to undergo a similar evaluation except for discography injections.
  
  
  METHODS
  The primary outcome variables were diagnostic imaging events and lumbar disc surgery events. The secondary outcome variables were serious LBP events, disability events, and medical visits.
  
  
  METHODS
  The discography subjects and control subjects were followed by serial protocol evaluations at 1, 2, 5, and 10 years after enrollment. The lumbar disc surgery events and diagnostic imaging (computed tomography (CT) or MRI) events were recorded. In addition, the interval and cumulative lumbar spine events were recorded.
  
  
  RESULTS
  Of the 150 subjects enrolled, 71 discography subjects and 72 control subjects completed the baseline evaluation. At 10-year follow-up, 57 discography and 53 control subjects completed all interval surveillance evaluations. There were 16 lumbar surgeries in the discography group, compared with four in the control group. Medical visits, CT/MRI examinations, work loss, and prolonged back pain episodes were all more frequent in the discography group compared with control subjects.
  
  
  CONCLUSIONS
  The disc puncture and pressurized injection performed during provocative discography can increase the risk of clinical disc problems in exposed patients.
authors.affiliation: Cedars-Sinai Medical Center, Spinal Surgery Fellowship, 444 S. San Vicente Blvd, Los Angeles, CA 90048, USA.
authors.forename: Jason M
authors.initials: JM
authors.lastname: Cuellar
authors.affiliation: Department of Orthopaedics and Physical Rehabilitation, University of Massachusetts Medical School, Spine Center, 119 Belmont St, Worcester, MA 01605, USA. Electronic address: michael.stauff@umassmemorial.org.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Stauff
authors.affiliation: Department of Radiology, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Herzog
authors.affiliation: Department of Radiology, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA.
authors.forename: John A
authors.initials: JA
authors.lastname: Carrino
authors.affiliation: Pacific Northwest University of Health Sciences, 111 University Parkway, Yakima, WA 98901, USA.
authors.forename: Geoffrey A
authors.initials: GA
authors.lastname: Baker
authors.affiliation: Department of Orthopedic Surgery, Stanford Medicine Outpatient Center, Stanford University School of Medicine, 450 Broadway St, Redwood City, CA 94063, USA.
authors.forename: Eugene J
authors.initials: EJ
authors.lastname: Carragee
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007267:Injections; D007403:Intervertebral Disc; D055959:Intervertebral Disc Degeneration / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery; D008137:Longitudinal Studies; D017116:Low Back Pain / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery; D008161:Lumbosacral Region; D008279:Magnetic Resonance Imaging; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D011446:Prospective Studies; D011677:Punctures; D014057:Tomography, X-Ray Computed
keywords: Degenerative disc disease; Disc degeneration; Low back pain; Lumbar discography; Lumbar surgery