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The discography controversy, especially concerning the specificity of symptom response, continued after the 1994 AHCPR Guide #14 until subsequent data was far less supportive. The award winning work of Dr. Eugene Carragee, et al, in articles 12/99-12/00 further precluded justification for the invasive nature of the technique, studying concordance, HIZ, safety and false positive risk as well as a `02 paper of not distinguishing severity of symptoms or being predictive for a reasonable surgical outcome.

Carragee et al, from 1999-2002 reconsidered the Walsh et al, with a more appropriate control group addressing: False-positive findings on lumbar discography was too high to be clinically relevant. Reliability of subjective concordance assessment during provocative disc injection was low. The rates of false-positive lumbar discography in select patients without prior low back symptoms was too high to be clinically relevant. Discography caused long-term back symptoms in previously asymptomatic subjects. Lumbar high-intensity zone and discography in subjects without low back problems was not predictive. Provocative discography in volunteer subjects with mild persistent low back pain could not differentiate their findings from those disabled. Prospective study predicting development of LBP in previously asymptomatic subjects undergoing experimental discography found it not to be predictive. Carragee EJ; Tanner CM; Yang B; Brito JL; Truong T, False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection. Spine 1999 Dec 1;24(23):2542-7. Carragee EJ; Tanner CM; Khurana S; Hayward C; Welsh J; Date E; Truong T; Rossi M; Hagle C, The rates of false-positive lumbar discography in select patients without low back symptoms. Spine 2000 June 1;25(11):1373-80. Carragee EJ; Chen Y; Tanner CM; Hayward C; Rossi M; Hagle C, Can discography cause long-term back symptoms in previously asymptomatic subjects? Spine 2000 Jul 15;25(14):1803-8. Carragee EJ, Paragioudakis SJ, Khurana S. 2000 Volvo Award winner in clinical studies: Lumbar high-intensity zone and discography in subjects without low back problems. Spine 2000 Dec 1;25(23):2987-92. Carragee EJ, Alamin TF, Miller J, Grafe M. Provocative discography in volunteer subjects with mild persistent low back pain. Spine J. 2002 Jan-Feb;2(1):25-34

Since discograms are commonly anatomically positive at young age groups, the poor specificity of symptom reproduction makes it difficult anymore to categorize discography as experimental let alone consider it a scientifically reliable technique. Thus, it bodes poorly for the procedures for which they are supposedly diagnostic - (IDET and lumbar fusion for internal disk derangement where outcomes are quite paltry).

Considering the lack of discrimination available with discography it is no wonder that now 3 controlled trial attempts providing no evidence of clinical efficacy for the IDET theory despite what once seemed as overwhelming retrospective results published before the prospective trials (Pauza et al., 2004, Lau et al.,2004, Freeman et al. 2005). Despite how the Pauza abstract reads, there was a lack of any clinical significance in his study for IDET as was evinced further double blinded efforts by Freeman and the stopped Lau study for lack of trend). Pauza et al`04 without blinding the provider, found statistical significance is only based upon a 1.5/10 difference compared to the controls noted on a Visual Analog Scale using high mean of about 6/10 rather than 10/10 as the range, but this provides no clinical significant difference. Pauza KJ, Howell S, Dreyfuss P, Peloza JH, Dawson K, Bogduk N. A randomized placebo-controlled trial of IDET for the treatment of discogenic LBP. The Spine J 2004;4:27-35. Lau, Bogduk. A controlled trial of IDET. ISIS Annual Meeting, 2004. Freeman BJ, Fraser RD, Cain CM, Hall DJ, Chapple DC.. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine. 2005 Nov 1;30(21):2369-77)

The most reliable literature (trials and prospective cohort studies) condemn invasive treatment predicated upon discography.

Madan et al., 2002 study found no difference in outcome from spinal fusion with or without pre- operative discography. The issue of discography as a diagnostic tool to identify correctable lesions in the disk has since been put to bed by Carragee et al.,`06. This prospective comparison of fusion outcomes based on "idea discography" patients vs. spondylolisthesis meeting "Posner criteria" for instability. Excellent surgical fusion results (no daily analgesia and return to usual work) using "ideal instability" indications was 72% compared to 26.6% for "ideal discography" where Minimally acceptable results (no narcotics and return to some work) were 43% and 57% poor results (requiring narcotics and unable to work) from fusion seems unacceptable relative to the surgical complication risks. Excellent surgical fusion results (no daily analgesia and return to usual work) using "ideal instability" indications was 72% compared to 26.6% for "ideal discography" indications. Minimally acceptable results (no narcotics and return to some work) or better were 91% and 43% respectively. A 57% poor results (requiring narcotics and unable to work) from fusion based upon ideal discography seems unacceptable relative to the surgical complication risks compared to 9% fused for Posner criteria of instability. Might the criteria seem to strict consider Carragee et al.`03 assessment of the minimally acceptable expectations of patients awaiting spinal fusion for presumed diskogenic pain. Greater than 90% of the patients wanted at least, 1. return to some gainful employment, 2. narcotic discontinuation, and 3. high physical functioning level. According to the available literature, such good results are uncommon after disk surgery based upon discography in patients with persistent disabling back pain (Fritzell`01, Brox`03, Fairbank`05, Pauza`04, Freeman`05, Carragee`06). Fritzell P, Olle Hägg, Wessberg P, Nordwall A, Lumbar Fusion Versus Non-surgical Treatment for Chronic Low Back Pain, A Multi-center Randomized Controlled Trial From the Swedish Lumbar Spine Study Group, Spine 2001;26:2521-2532. Brox JI, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A, Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, Riise R, Reikeras O. Randomized Clinical Trial of Lumbar Instrumented Fusion and Cognitive Intervention and Exercises in Patients with Chronic Low Back Pain and Disk Degeneration.Spine. 2003 Sep 1;28(17):1913-1921. Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K, Collins R; Spine. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial.BMJ. 2005 May 28;330(7502):1233. Epub 2005 May 23. Erratum in: BMJ. 2005 Jun 25;330(7506):1485. Pauza KJ, Howell S, Dreyfuss P, Peloza JH, Dawson K, Bogduk N. A randomized placebo-controlled trial of IDET for the treatment of discogenic LBP. The Spine J 2004;4:27-35. Freeman BJ, Fraser RD, Cain CM, Hall DJ, Chapple DC.. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine. 2005 Nov 1;30(21):2369-77). Carragee EJ, Lincoln T, Parmar VS, Alamin T. A gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine 2006; 31:2115-2123.

At present there is even less support for discography in the cervical spine where aging changes (DDD) and symptoms parallel the frequency in the lumbar spine. Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 1990 Sep;72(8):1178-84. Matsumoto M, Fujimura Y, Suzuki N, Nishi Y, Nakamura M, Yabe Y, Shiga H. MRI of cervical intervertebral discs in asymptomatic subjects. J Bone Joint Surg Br 1998 Jan;80(1):19-24. Cote P, Cassidy JD, Carroll L.The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine. 1998 Aug 1;23(15):1689-98

After Harry Crock’s corollary to Kirkaldy-Willis staging of Disk degeneration resurrected discography, Walsh et al., `90 was first real support for discography came in 1990 using 10 healthy 20 year olds for controls.

Walsh TR, Weinstein JN, Spratt KF, Lehmann TR, Aprill C, Sayre H. Lumbar discography in normal subjects. A controlled, prospective study. J Bone Joint Surg [Am] 1990 Aug;72(7):1081-8.

Then Carragee’s group used larger numbers and more relative controls to evaluate the Walsh hypothesis.

Carragee EJ; Tanner CM; Yang B; Brito JL; Truong T, False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection. Spine 1999 Dec 1;24(23):2542-7

Carragee EJ; Tanner CM; Khurana S; Hayward C; Welsh J; Date E; Truong T; Rossi M; Hagle C, The rates of false-positive lumbar discography in select patients without low back symptoms. Spine 2000 June 1;25(11):1373-80.

Carragee EJ; Chen Y; Tanner CM; Hayward C; Rossi M; Hagle C, Can discography cause long-term back symptoms in previously asymptomatic subjects? Spine 2000 Jul 15;25(14):1803-8,

Carragee EJ, Paragioudakis SJ, Khurana S. 2000 Volvo Award winner in clinical studies: Lumbar high-intensity zone and discography in subjects without low back problems. Spine 2000 Dec 1;25(23):2987-92,

Carragee EJ, Alamin TF, Miller J, Grafe M. Provocative discography in volunteer subjects with mild persistent low back pain. Spine J. 2002 Jan-Feb;2(1):25-34

Last Paragraph of recent Discussion: by Buenaventura et al.,2007 as follows:

“In the interim (until future research is available), questioning the validity of discography warrants questioning the role of the intervertebral disc as a discrete pain generator (strongly questioned by trials by Madan`02, Pauza`04, Freeman`05 for IDET and Fritzell`01, Brox`03, Fairbank`05, Carragee`06 for fusion for disc disease), or more specifically, challenges the concept of symptomatic internal disc disruption. If one considers discography to be a useless test, then one may have to abandon the concept of the IVD as a discrete pain generator and abandon the pursuit of intradiscal therapies, whether surgical or non-surgical.”

Buenaventura RM, Shah RV, Patel V, Benyamin R, Singh V. Systematic Review of Discography as a Diagnostic Test for Spinal Pain: An Update. Pain Physician 2007; 10:147-164 • ISSN 1533-3159

Recent Lumbar discography literature has not been very supportive since Carragee's series 1999-2002 repeating Walsh et al.`90, with better controls:

O’Neill C, Kurgansky M. Subgroups of positive discs on discography. Spine 2004; 29:2134-2139.

Madan S, Gundanna M, Harley JM, Boeree NR, Sampson M. Does provocative discography screening of discogenic back pain improve surgical outcome? J Spinal Disord Tech 2002; 15:245-251.

Shin DA, Kim HI, Jung JH, Shin DG, Lee JO. Diagnostic relevance of pressure controlled discography. J Korean Med Sci 2006; 21:911-916.

Peng B, Hou S, Wu W, Zhang C, Yang Y. The pathogenesis and clinical significance of a high-intensity zone (HIZ) of lumbar intervertebral disc on MR imaging in the patient with discogenic low back pain. Eur Spine J 2006; 15:583-587.

Blankenbaker DG, Haughton VM, Rogers BP, Meyerand ME, Fine JP. Axial rotation of the lumbar spinal motion segments correlated with concordant pain on discography. A preliminary study. AJR 2006; 186:795-799.

Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI, and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J 2005; 5:24-35.

Carragee EJ, Alamin TF, Carragee JM. Low-pressure positive discography in subjects asymptomatic of significant low back pain illness. Spine 2006;31:505-509.

Carragee EJ, Lincoln T, Parmar VS, Alamin T. A gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine 2006; 31:2115-2123.

Derby R, Lee SH, Kim BJ, Chen Y, Aprill C, Bogduk N. Pressure-controlled lumbar discography in volunteers with low back pain symptoms. Pain Med 2005;6:213-221.

Derby R, Kim BJ, Lee SH, Chen Y, Seo KS, Aprill C. Comparison of discographic findings in asymptomatic subject discs and negative discs of chronic LBP patients: Can discography distinguish asymptomatic discs among morphologically abnormal discs? Spine J 2005;5:389-394.

Derby R, Kim BJ, Chen Y, Seo KS, Lee SH. The relation between annular disruption on computed tomography scan and pressure-controlled diskography. Arch Phys Med Rehabil 2005; 86:1534-1538.

Lim CH, Jee WH, Son BC, Kim DH, Ha KY, Park CK. Discogenic lumbar pain: association with MR imaging and CT discography. Eur J Radiol 2005; 54:431-437.

Shin DA, Kim HI, Jung JH, Shin DG, Lee JO. Diagnostic relevance of pressure controlled discography. J Korean Med Sci 2006; 21:911-916.

Supporting discography literature is especially limited in the cervical spine. Thus, the data is even weaker to support cervical discography or its interpretation.

Total search for Cervical Spine Discography though weak consists of:

Bogduk N, Aprill C. On the nature of neck pain, discography and cervical zygapophysial joint blocks. Pain 1993;54:213-217.

Connor PM, Darden BV II. Cervical discography complications and clinical efficacy. Spine 1993; 18:2035-2038.

Siebenrock KA, Aebi M. Cervical discography in discogenic pain syndrome and its predictive value for cervical fusion. Arch Orthop Trauma Surg 1994;113:199-203.

Parfenchuck TA, Janssen ME. A correlation of cervical magnetic resonance imaging and discography/computed tomographic discograms. Spine 1994; 19:2819-2825.

Schellhas KP, Smith MD, Gundry CR, Pollei SR. Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine 1996; 21:300-311.

Schellhas KP, Garvey TA, Johnson BA, Rothbart PJ, Pollei SR. Cervical diskography:analysis of provoked responses at C2-C3, C3-C4, and C4-C5. AJNR Am J Neuroradiol 2000; 21:269-275.

Motimaya A, Arici M, George D, Ramsby G. Diagnostic value of cervical discography in the management of cervical discogenic pain. Conn Med 2000;64:395-398.

Ohnmeiss DD, Guyer RD, Mason SL. The relation between cervical discographic pain responses and radiographic images. Clin J Pain 2000; 16:1-5.

Grubb SA, Kelly CK. Cervical discography: clinical implications from 12 years of experience. Spine 2000; 25:1382-1389.

Zheng Y, Liew SM, Simmons ED. Value of magnetic resonance imaging and discography in determining the level of cervical discectomy and fusion. Spine 2004; 29: 2140-2145.

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