Does discography damage the discs?

[mmglobal]

A few days ago Crystal posted an abstract by Dr. Carragee (below) about the risk of damaging the disc with discography. Thank you Crystal! This is a great subject that deserves its own thread. I'm sure this will be a great discussion.

The question, “does discography damage a healthy disc” is something that’s been discussed on the forums for years. The abstract that Crystal posted below really piqued my interest. I’ve discussed this extensively with dozens of leading surgeons and pain management doctors over the years. Many will say that poking a small gauged needle through the “radial ply” fibers of the annulus is much like poking a knitting needle through a knit wool sweater. That would do no discernible damage, whereas, poking a pin through a silk blouse will ruin it. Some doctors are discography naysayers. I think that's more about the results controversy than the damage to the disc. Early discography techniques that were fraught with errors. I think much of the bad rap is dogma associated with the old horror stories.

Discography done on a degenerated disc may be another story. Some of the doctors will still say it’s harmless, while others will concede that in a severely degenerated disc discography may push it over the edge. This would not necessarily be from the damage to the annulus. IMHO, this is more likely from an existing protrusion that would be exacerbated by pressurizing the disc, lubricating and increasing the nucleus volume. My second discography was only at L5-S1 to rule it out. We were hoping that I was a single level candidate. I could have been one of the first US Charite’ patients. About three weeks after the discography my left foot went numb. Until that point, I had no radiculopathy associated with my L5-S1 disc. While there was a substantial bulge, there was no frank protrusion at the time of the discography. Remarkably, an MRI a few weeks later showed a new, large (15mm) protrusion at L5-S1. While nobody could say what happened, I do believe that the discography substantially increased the risk of, or may have actually caused the protrusion.

For years, when my clients had asked me about doing discography that was recommended by their surgeons, I have usually suggested that they should only do the discography if they are prepared to follow through with treatment if the discography is positive. With their risk of discography making a very bad disc and worse I believe that it's a mistake to have discography unless you have been through the decision making process and field that your situation justifies having surgery if the discography is positive. There is no such thing as risk free access anywhere in the spine. Control levels have been thought of as important, but the idea of poking and needle into a healthy disc makes me wonder.

I believe that discography is still an important and useful tool that increases the probability of a correct diagnosis. However, it is not the be all, end all definitive test. It’s just another useful tool. Technique is important. A poorly done discography can cloud the situation. Under the best of circumstances, there may still be a risk of false positive or false negative results. If I need to rule levels in or out, all still have discography. This is a very interesting study. I look forward to seeing where this goes as the science improves.

Let the discussion begin!

Mark

Originally Posted by Crystal33

2009: Carragee Eugene J; Don Angus S; Hurwitz Eric L; Cuellar Jason M; Carrino John; Herzog Richard

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(21):2338-45.

STUDY DESIGN: Prospective, match-cohort study of disc degeneration progression over 10 years with and without baseline discography. Objectives. To compare progression of common degenerative findings between lumbar discs injected 10 years earlier with those same disc levels in matched subjects not exposed to discography. Summary of Background Data. Experimental disc puncture in animal and in vivo studies have demonstrated accelerated disc degeneration. Whether intradiscal diagnostic or treatment procedures used in clinical practice causes any damage to the punctured discs over time is currently unknown.

METHODS: Seventy-five subjects without serious low back pain illness underwent a protocol MRI and an L3/4, L4/5, and L5/S1 discography examination in 1997. A matched group was enrolled at the same time and underwent the same protocol MRI examination. Subjects were followed for 10 years. At 7 to 10 years after baseline assessment, eligible discography and controlled subjects underwent another protocol MRI examination. MRI graders, blind to group designation, scored both groups for qualitative findings (Pfirrmann grade, herniations, endplate changes, and high intensity zone). Loss of disc height and loss of disc signal were measured by quantitative methods.

RESULTS: Well matched cohorts, including 50 discography subjects and 52 control subjects, were contacted and met eligibility criteria for follow-up evaluation. In all graded or measured parameters, discs that had been exposed to puncture and injection had greater progression of degenerative findings compared to control (noninjected) discs: progression of disc degeneration, 54 discs (35%) in the discography group compared to 21 (14%) in the control group (P = 0.03); 55 new disc herniations in the discography group compared to 22 in the control group (P = 0.0003). New disc herniations were disproportionately found on the side of the anular puncture (P = 0.0006). The quantitative measures of disc height and disc signal also showed significantly greater loss of disc height (P = 0.05) and signal intensity (P = 0.001) in the discography disc compared to the control disc.

CONCLUSION: Modern discography techniques using small gauge needle and limited pressurization resulted in accelerated disc degeneration, disc herniation, loss of disc height and signal and the development of reactive endplate changes compared to match-controls. Careful consideration of risk and benefit should be used in recommending procedures involving disc injection.

[mmglobal]

The first surgeons' conference I attended was the annual meeting of The American Academy of Minimally Invasive Spinal Medicine and Surgery (AAMISMS) in 2002, hosted by Tony Yeung. I was taken by the deference that was paid Dr. Richard Derby. He was obviously a heavy hitter. It was a pleasure to meet him and to thank him for his work that had helped me so much. I don't know the true history of discography, but in my experience he is referred to as the father of modern discography. He's been a wonderful resource for me through the years. I've had many clients travel across the country to do diagnostics with him.

I'll be soliciting input from several doctors that I know who do discography ( I have a few clients who are pain management doctors!) My first contact about this subject was with Dr. Derby. He graciously sent me an article that he's written that is essentially a rebuttal to the Carragee study. This is hot off the presses. I don't believe it's been published yet.

I'll write more about both of these articles later, but I don't want to introduce their arguments before introducing their papers.

Here is Dr. Derby's article. I look forward to the discussion that follows!

Mark

[fuzzy]

I cancelled my disco with dr. Derby. His office communication was terrible. I had no way to discuss with him pre disco. Overall I was not impressed at all.

They do discos once a month with a 2 month wait.

Even though disco is to be seen as just another tool it is getting way overrated in my personal opinion. Controversy is deserved.

I had one, it made me feel terrible and did not contribute to my final outcome other then cost me money. I knew this before hand.

[mmglobal]

Fuzzy, thanks for posting. I'm suprised to hear that that was your experience. I've had > a dozen clients go to him and have not heard any negative feedback. It's funny how experiences can be so varied.

I've had 4 discographies myself and if I was considering lumbar surgery again, unless the case is very clear cut, I'd still do it. I've been in the procedure room for > 50 discographies now and have seen a wide variety of results. I have seen may cases where the disc that looked worst was not a pain generator at all, when a disc that didn't look nearly as bad and was going to be left out of the surgery was VERY CLEARLY the main pain generator. In cases like these, discography makes all the difference in the world. (See annC's story on the GPN story pages.) I have had many experiences like that.

Discography is a double subjective test. The outcome depends upon the doctor's subjective assessment of the patient's subjective assessment of their pain. Under the best of circumstances, the usefulness of the test will vary a great deal and there are many variables. Technique is VERY importatant. The patient's anatomy and pathology is very important. Appropriate anesthesia (or lack thereof) is very important. Also, most important is the communication between the doctor and patient. Several time's I've been present when the doctor asks the patient a question, then the patient answers a different question. Neither one knew that there was a disconnect. I've seen this happen many time and it's not necessarily a language problem.

More later,

Mark

[fuzzy]

Mark you are hitting the nail right on the head.

Doctor patient communication. !...could rule out unnecessary discography procedures.

This was my issue my dr. Derby but also other dr.s. A lot of mistakes can be made when you only spend 10 minutes with the patient after looking for 5 minutes at the file that stuck to outside of the door. Worse yet, having to deal with an assistant. Maybe if *you* are part of a patient case its a little different but many are by themselves and are not necessarily qualified to know what is appropriate during times of pain. I have run into several surgeons who simply use this test as standard precedure to pre qualify for surgery without properly looking at the case to determine whether a disco is actually warranted.

I don't doubt at all that this procedure has diagnostic value but I feel it is over used after insufficently studying a patients case, i.e. proper patient selection. Too often it simply feels like it is used simply as a safe guard against possible malpractice legal problems after a poor outcome. Fact is that this procedure does have risks, especially in cervical cases.

[Maria]

So far so good w/o further incidence to report and glad of it. Always thought it is probably a combination of factors that might push the disc prob to a new level like just time for it to blow out anyway, over pressurization, mistakes, technique, luck of the draw ...