COMMENTARY

Does Diskography Cause Accelerated Progression of Degeneration Changes in the Lumbar Disk?

Joseph K. Lee, MD

Disclosures

December 18, 2009

Introduction

Low back pain attributed to spinal disk degeneration has been routinely diagnosed via diskography. Although its validity has been debated, diskography represents a diagnostic tool to help differentiate pain that is diskogenic in nature from other etiologies of low back pain.[1,2,3,4,5] The procedure carries short-term risks such as bleeding, infection (ie, diskitis), nerve injury, and increased pain.[5] However, long-term sequelae of this procedure have not been well delineated.

2009 ISSLS Prize Winner: Does Discography Cause Accelerated Progression of Degeneration Changes in the Lumbar Disc: A Ten-year Matched Cohort Study

Carragee EJ, Don AS, Hurwitz EL, Cuellar JM, Carrino J, Herzog R
Spine (Phila Pa 1976). 2009;34:2338-2345

Summary

Dr. Carragee and colleagues studied the progression of disk degeneration over a 10-year period using a prospective cohort study. Fifty-seven patients with low back pain underwent a 3-level lumbar diskography (L3-L4, L4-L5, L5-S1 levels) in 1997 as well as a baseline magnetic resonance imaging (MRI) study of the lumbar spine. Diskography was performed with a small-gauge needle, pressure controls, nonionic contrast, and prophylactic antibiotics. Fifty-four matched cohort patients also underwent baseline lumbar spine MRI.

At 7-10 years after baseline evaluation, both groups underwent repeat blinded, standardized MRI evaluation of all lumbar spine disks. MRI assessed the following areas: disk degeneration (Pfirrmann grade), disk herniation type, new disk herniations, Modic changes, disk hyperintensity zone, disk height, and disk signal loss.

Comparison of L1-L3 intervertebral disks between the diskography group and the control group showed no significant differences in disk degeneration progression. At the L3-S1 disk levels, 35% of disks in the diskography group showed increased progression of disk degeneration, in contrast to 14% in the control group. In addition, the diskography group had a 2.5-times greater incidence of new disk herniation than the control group (55 vs 22). The diskography group also had a statistically significant increased degree of Modic endplate signal changes and high-intensity zones as well as a greater loss of disk height and disk signal.

Viewpoint

Although diskography has been used on a routine basis, this study on diskography delineates for the first time the long-term consequences that this type of procedure may have, even with the use of modern techniques. The utility of such a diagnostic procedure should be weighed carefully against the potential short-term and long-term risks. The study authors also express concern regarding the continued use of current diagnostic and therapeutic intradiskal procedures because both approaches carry a non-zero risk for long-term adverse effects.

The investigators noted that the study had certain limitations, including recruiting study participants from a higher-risk population, most of whom had a history of disk herniation. In addition, there were only 2 timepoints of data (baseline and 10 year), and as such, the study does not show timely progression of any of these findings. There has been no commercial support or funding for this study.

Abstract

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