Professional Statements and Societal Positions Guidelines
American Society of Interventional Pain Physicians (ASIPP): 2013
The ASIPP issued an update of its evidence-based guidelines for interventional techniques in chronic spinal pain. In regards to the clinical utility of discography, the ASIPP issued the following recommendations:
- Provocation discography continues to be controversial with respect to diagnostic accuracy and its impact on surgical volume.
- Proponents of discography claim that the rationale is well established, and discography is helpful in individuals with low back pain (LBP) to acquire information about the structure and sensitivity of their lumbar discs and to make informed decisions about treatment and modifications of activity.
- Opponents of discography contend that escalating numbers of unnecessary fusions have been performed in the United States each year for indications of discogenic pain.
- Discography is an invasive diagnostic test that should only be applied to individuals with chronic LBP in whom one suspects a discogenic etiology and an appropriate treatment is available.
- To be valid, provocation discography must be performed utilizing strict criteria of having concordant pain in one (1) disc with at least two (2) negative control discs.
- In the ASIPP management algorithm for chronic LBP, discography is suggested following clinical evaluation indicating that facet joint blocks or sacroiliac joint blocks were negative.
American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS): 2014
A joint committee of the AANS/CNS issued an update to their guidelines regarding the use of discography in evaluating LBP prior to surgical intervention. The following recommendations regarding discography were made:
- Based primarily on retrospective studies, discography as a stand-alone test is not recommended to formulate treatment strategies for individuals with LBP with abnormal imaging findings.
- A single randomized cohort study demonstrated an improved potential of discoblock over discography as a predictor of success following lumbar fusion. Therefore, discoblock should be considered as a diagnostic option during the evaluation of an individual presenting with chronic LBP.
- There is a possibility that an association exists between progression of degenerative disc disease and the performance of a provocative discogram. It is therefore recommended that individuals be counseled regarding this potential development prior to undergoing discography.
American College of Radiology (ACR): 2015
In a guideline on appropriateness criteria for individuals with LBP updated in 2015, the ACR states that the use of provocative discography to identify a discogenic source of lumbar spinal pain is controversial. The test is subjective and depends entirely upon the individual’s description of pain during the procedure.
The ACR deemed that x-ray discography is usually not appropriate for use in individuals with acute, subacute, or chronic uncomplicated LBP or radiculopathy associated with 1 or more of the following: low velocity trauma, osteoporosis, elderly individual, or chronic steroid use (rating of 1) or for surgery or intervention candidates with persistent or progressive symptoms during or following 6 weeks of conservative management (rating of 3). For the latter group, the ACR states that, although controversial, discography may be useful for individuals with chronic LBP (lasting > 3 months).
The ACR concluded that discography may be appropriate for individuals with LBP or radiculopathy with new or progressing symptoms or clinical findings with a history of prior lumbar surgery (rating of 5).