Provocative discography: current status
Senior Consultant Radiologist, Programme Office (Graduate Medical School), Singapore Health Services
Low back pain is a common clinical problem that may be due to a variety of causes, including disc disease. Provocative discography is an imaging-guided procedure in which a contrast agent is injected into the nucleus pulposus of the disc. Despite its controversial history, it remains the only imaging technique that provides both anatomical and functional information about a diseased disc. Disc morphology is usually assessed on either radiographs or computed tomography (CT), or both. Functional evaluation of the disc consists of pain provocation and careful assessment of the patient's response to pain. As provocative discography is an invasive procedure, it should not be used as a screening study in patients with back pain. It should instead be reserved for carefully- selected patients whose painful symptoms cannot be explained by findings on non-invasive imaging modalities such as magnetic resonance imaging or CT, and who are not responsive to conservative measures. Discography is helpful in selection of patients and disc levels to be operated upon. Careful application of indications and meticulous technique are however required if a successful outcome is to be expected.
Keywords: Discography, Low back pain, Intervention
discography is an imaging-guided procedure in which a contrast
agent is injected into the nucleus pulposus of the intervertebral
disc. It provides both anatomical and functional information
about a disc suspected to be diseased. Following intradiscal
contrast injection, disc morphology is usually assessed on
radiographs or computed tomography (CT), or both. The functional
evaluation consists of pain provocation and careful assessment
of the patient's response to pain. The discography results
influence the surgical decision-making process and selection
of disc levels to be operated on.
Low back pain is a very common clinical problem. It may
result from a variety of causes, including intervertebral
disc disease. Currently, magnetic resonance (MR) imaging is
widely regarded as the imaging modality of choice for investigating
patients with suspected disc lesions. However, it is well
known that many asymptomatic discs appear abnormal on MR imaging
Discs that appear normal on MR imaging have also been shown
to be abnormal on discography [8,9].
Ever since its first description in 1948, provocative discography
has been regarded as a controversial procedure. To date, provocative
discography remains the only imaging technique that directly
relates the patient’s pain response to the morphological
appearance of the disc [10,11,12,13,14,15].
Despite an incomplete understanding of the pathophysiology
of discogenic pain and the variable pain response of individual
patients , many studies have supported provocative discography
as a valuable diagnostic test in the investigation of discogenic
However, being an invasive procedure, provocative discography
should not be used as a screening study in patients with back
pain but should instead be reserved for carefully selected
In general, provocative discography should be performed only
if the patient has failed adequate attempts at conservative
management of persistent severe back or neck pain and if non-invasive
tests, such as MR imaging, do not provided sufficient information
for a definitive diagnosis. To keep things in perspective,
only a minority of patients presenting with low back pain
require imaging. Pain due to facetogenic, neoplastic, inflammatory
and traumatic causes should be excluded first, initially using
radiographs and if required, supplementation by CT. The persistent
back pain should be at least four months in duration and non-responding,
before provocative discography is considered [20,21].
Discography should only be performed on a patient under consideration
for operation to assist in identifying the appropriate level
for surgery .
Specific indications for provocative discography are [11,12,14,15,19,22]:
- Further evaluation of a radiologically-abnormal disc for
the full extent of abnormality or correlation of the abnormality
with the clinical symptoms.
- Investigation of persistent, severe symptoms that do not
correlate with equivocal or inconsistent MR imaging or CT
- Determination of symptomatic disc levels in cases where
MR imaging or CT shows disc disease at multiple levels.
- Assessment of disc prior to fusion to determine if a disc
within proposed fusion segment is symptomatic, and whether
the adjacent discs are normal.
- Assessment of disc prior to percutaneously-directed therapies
such as intradiscal electrothermal therapy [23,24,25,26].
- Assessment of patients prior to minimally-invasive surgery
in order to confirm that disc herniation is contained, or
to investigate contrast distribution before chemonucleolysis.
- Assessment of post-surgical failed back syndrome of patients
in whom MR imaging is non-diagnostic, including differentiating
recurrent disc herniation from a painful pseudoarthrosis
or identifying a symptomatic disc within a posteriorly-fused
Contraindications to provocative discography are [12,15,22]:
- Patients with a known bleeding disorder and those on anticoagulation
- Systemic infection or skin infection over the puncture
- Severe allergy to injectate, especially the contrast agent.
- Previously-operated disc.
- Solid bone fusion that does not allow access to the disc.
- Severe spinal cord compromise at disc level to be investigated.
TECHNIQUE AND EQUIPMENT
Before the start of the procedure, the patient should be
interviewed about the type, location and nature of the pain,
and any history of prior surgery. Pain drawings may be helpful
in identifying the specific discs that are associated with
the patient’s painful complaints .
The patient’s medical and imaging records should be
carefully reviewed, and the MR images compared with radiographs
to evaluate for possible level ambiguity due to a transitional
lumbosacral segment. MR imaging should be assessed for overall
disc morphology and to identify a normal disc that can be
used as a control.
In obtaining informed consent, the patient needs to understand
the purpose of the pain provocation test and its risks. The
patient should fast for six to eight hours prior to the procedure.
Giving an intravenous dose of prophylactic antibiotics is
recommended. In some centres, a mild sedative is administered
prior to the procedure, while others do not recommend sedation
as the patient’s response to pain reproduction may be
affected. The patient should ideally be monitored by nursing
staff during the procedure. Strict asepsis is mandatory, with
the radiologist being fully scrubbed up and gowned.
Provocative discography is best performed in an interventional
suite within the diagnostic radiology department. Biplane
fluoroscopy is preferred but if this is not available, then
high-quality C-arm fluoroscopy is an acceptable alternative.
In some centres, CT is used to guide needle placement. For
patients who are allergic to iodinated contrast agents, MR
discography using intradiscal gadolinium-chelate has recently
been found to be a viable alternative [28,29,30,31,32].
There are variations in the size and type of needles used
by different centres and practitioners. Some practitioners
advocate the single needle approach using a styleted needle
that ranges in size from 18- to 22-gauge .
Many practitioners adopt the double-needle approach for the
following reasons: lower rate of discitis ,
use of the thinner 26-gauge inner needle to decrease the size
of puncture hole in the annulus fibrosis, and having a pre-shaped
curve at the distal end of the inner needle to facilitate
entry into centre of the L5-S1 nucleus. In the double-needle
technique, the inner needle that enters the nucleus pulposus
does not come in contact with the skin, contributing to a
reduction in the infection rate.
The discography set that I use consists of a 21-gauge 12.5
cm long stainless steel spinal needle with stylet and a 26-gauge
16.0 cm long stainless steel spinal needle with stylet for
thoracic and lumbar discography. A 20-gauge 6.35 cm long stainless
steel spinal needle with stylet and a 26-gauge 8.9cm long
stainless steel spinal needle with stylet are used for cervical
and thoracic discography. A curved needle set consisting of
a 21-gauge 10.0 cm long stainless steel straight needle with
stylet, and a 26-gauge 15.0 cm long nitinol curved needle
is preferred for the L5/S1 disc.
CERVICAL AND THORACIC DISCOGRAPHY
Cervical discography (Figure 1) remains a controversial procedure
with some investigators recommending that this procedure should
not be performed as the information obtained from cervical
discography does not outweigh the increased risks of complications,
reported to occur in up to 13% of cases .
These complications include discitis, epidural abscess, haematoma,
myelopathy and quadriplegia . Other
practitioners have found cervical discography to be a safe
and useful procedure in selected patients with chronic intractable
neck pain with negative or indeterminate imaging findings,
and are being considered for surgery [18,36,37].
[View this figure]
|Figure 1 Cervical discography
in a 49-year-old woman with neck pain. Lateral radiographic
projection shows a normal C4/5 disc, and degenerate
C5/6 and C6/7 discs with posterior protrusions.
Note anterior approach used for needle placement.
The needles for the upper 2 discs have been removed.
There are very few indications for thoracic discography and
it is rarely performed. Severe and disabling thoracic pain
secondary to disc degeneration that requires discography has
not been well studied [12,22].
This procedure has been used to evaluate symptomatic Scheuermann’s
disease . Thoracic discs with prominent
Schmorl’s nodes may be intensely painful, even in asymptomatic
subjects, and thoracic discography may demonstrate disc pathology
that is not seen on MR imaging .
The vast majority of discograms performed in clinical practice
are for evaluating the lower three lumbar discs. For lumbar
discography, the patient may be placed in a prone or left
lateral decubitus position, depending on operator preference.
Some advocate the prone position state in which the patient
is more stable and immobile [12,22].
This author prefers the left lateral decubitus position. The
patient flexes his or her knees to about 60º to 90º,
with a pillow placed underneath his or her waist to keep the
spine straight. The skin puncture point is approximately eight
to 10 cm to the right of the midline. After the patient is
cleaned and draped, and local anaesthesia is given, the outer
discography needle is inserted (Figure 2).
[View this figure]
|Figure 2 Patient positioning
and skin puncture for lumbar discography. Photograph
shows the patient lying in a left lateral decubitus
position. The skin puncture point is approximately
8cm to the right of the midline. The shorter outer
needle has been inserted with an obliquity of approximately
45 degrees to the sagittal plane. Its stylet is
being removed in preparation for insertion of the
longer inner needle.
The posterolateral extradural approach is preferred as it
avoids puncturing the thecal sac [12,15,22].
The outer needle is inserted with an obliquity of about 45º
to 60º to the sagittal plane. For the L5-S1 disc, due
to the overlying iliac crest, an additional caudal angulation
of up to 40º is usually necessary. After repeated fluoroscopic
imaging in the AP and lateral directions, the outer needle
is positioned such that its tip is placed at the right posterolateral
corner of the annulus fibrosis of the target disc. Imaging
landmarks are: needle tip is located in line with the posterior
cortex of the adjacent vertebral bodies on the lateral projection
and in line with the ipsilateral pedicles of the adjacent
vertebral bodies on the anteroposterior projection. Mild rubbery
but firm resistance is felt when the needle tip comes into
contact with the annulus fibrosis. The stylet of the outer
needle is then removed, and the longer inner needle is inserted
inside the outer needle. Under fluoroscopic guidance in the
two orthogonal directions, the tip of the inner needle is
directed to the centre of the nucleus pulposus (Figure 3).
[View this figure]
|Figure 3 Needle placement for
lumbar discography. (a) Anteroposterior and (b)
lateral radiographic projections show the tip of
the thicker, shorter outer needle at the posterolateral
corner of the annulus fibrosis of the intervertebral
disc. The tip of the thinner, longer inner needle
is located in the centre of the intervertebral disc.
Test injection of contrast agent confirms that the
inner needle tip lies in the nucleus pulposus.
When the position of the inner needle is satisfactory, its
stylet is removed and the needle is attached to a 1 ml tuberculin
syringe with 0.1 ml markings. A test injection of 0.1 ml of
non-ionic contrast agent is then made to confirm the needle
position (Figure 3b). The injected contrast agent should form
a rounded or curvilinear blob near the centre of the disc
space. In a normal disc, there is moderate resistance during
contrast injection while in a degenerate disc, there is mild
or no resistance to contrast injection. If there is marked
resistance to contrast instillation at the beginning of the
injection with the contrast agent staying immediately at the
needle tip, then the needle tip may be located within the
annulus fibrosis. If the position of the needle tip is suboptimal,
adjustment of needle position and repeat fluoroscopic screening
After the needles are removed, the patient’s back
or neck is cleaned, and small adhesive bandages are used to
cover the puncture sites. Following completion of post-discography
imaging, the patient should be observed for up to two hours
in either a reclining or recumbent position. The patient’s
vital signs should be monitored. Upon discharge, most practitioners
will give their patients a prescription of a non-narcotic
painkiller, with an option of prescribing a short prophylactic
course of oral broad-spectrum antibiotics .
The amount of contrast agent injected into the nucleus pulposus
and resistance encountered during injection should be carefully
recorded. The normal lumbar disc usually takes up to 1.5 ml
of contrast agent. A degenerated lumbar disc will typically
have a volume of more than 2 ml. Most practitioners would
not inject more than 3 ml of contrast agent into a single
lumbar disc. The volume of contrast agent injected should
not exceed 0.5 ml per disc for cervical discography, while
0.5 ml to 1.0 ml is the usual volume for a normal disc in
thoracic discography . The injection
is usually terminated when very firm resistance is felt or
if severe pain is produced . Discography
interpretation may be supplemented by performing post-procedure
imaging using CT (CT discography). The two major aspects to
consider in the interpretation of discography are disc morphology
and pain provocation.
Disc morphology is usually determined on evaluation of anteroposterior
and lateral radiographs obtained after intradiscal contrast
injection (Figure 4). A normal disc maintains a normal height
on both AP and lateral radiographs. Injected contrast agent
remains in the nucleus pulposus, and may be unilocular (“cottonball”
or rectangular) or bilocular (“hamburger bun”)
in shape. Sometimes, a Schmorl’s node is seen as focal
protrusion of injected contrast agent into the adjacent vertebral
[View this figure]
|Figure 4 Discographic patterns
in a 43-year-old woman who had low back pain with
radiation to the left calf. (a) Anteroposterior
and (b) lateral radiographic projections show a
normal bilocular L2/3 disc. There is small posteroinferior
tear of the L3/4 disc that was asymptomatic. The
L4/5 disc is decreased in height, and had extensive
annular disruption and posterior protrusion. The
L4/5 disc was also symptomatic.
In degenerated discs, discography shows a reduced disc height,
and complex or multiple irregular fissures in the annulus
fibrosis, with or without contrast leakage through annular
tears. A bulging disc is often associated with degeneration,
and is characterized by circumferential, diffuse and symmetrical
annular bulging. Discography may show annular fissures with
an intact peripheral annulus. Disc protrusion refers to focal,
often asymmetrical, central or posterolateral protrusion of
disc material within an intact posterior longitudinal ligament.
On discography, a single annular fissure is often seen. The
nuclear material may migrate superiorly or inferiorly (giving
a “candle drip” appearance). A disc extrusion
is a large disc protrusion that involves the posterior longitudinal
ligament. On discography, an annular fissure with epidural
space contrast extravasation is seen. A sequestrated disc
is seen when extruded disc material is separated from the
parent disc, with the detached disc being located in the extradural
CT discograms are CT images obtained following discography
(Figure 5). It provides excellent anatomical details in the
axial plane. The Dallas discogram description (DDD) is based
on CT appearances and was originally classified into grades
0 to 3 , later modified to four grades
- Grade 0: Contrast agent is confined entirely
within the normal nucleus pulposus (Figure 5a).
- Grade 1: Contrast agent extends radially
along fissure involving the inner one-third of the annulus
- Grade 2: Contrast agent extends into
the middle one-third of the annulus fibrosis.
- Grade 3: Contrast agent extends into
the outer one-third of the annulus fibrosis, either focally
or radially, to an extent not greater than 30º of the
disc circumference (Figure 5b).
- Grade 4: Contrast agent extends into
the outer one-third of the annulus fibrosis, dissecting
radially to involve more than 30º of the disc circumference
Further modifications of the DDD are: Grade 5
- representing a full-thickness tear, either focal or circumferential,
with extra-annular contrast leakage ;
Grade 6 - representing disc sequestration;
and Grade 7 - representing a diffuse annular
tear in disc degeneration . Using a
spiral or multislice scanner to perform the CT discogram produces
good quality sagittal and coronal recontructed images that
may be useful in providing additional information 
[View this figure]
|Figure 5 CT discographic patterns
in a 36-year-old man who had low back pain with
right buttock pain and right leg radiation. (a)
Axial CT image shows a normal L3/4 disc (DDD grade
0). (b) Axial CT image shows a small L4/5 posterior
annular tear (DDD grade 3). (c) Axial CT image shows
extensive L5/S1 posterior annular disruption (DDD
grade 4). (d) Sagittal recontructed CT image provides
a good overview of a normal L3/4 disc, and posterior
tears of protruding L4/5 and L5/S1 discs. Both lower
discs were symptomatic.
Discogenic pain is likely to be due to a combination of different
mechanisms, all causing stimulation of nerve fibres located
in the outer annulus fibrosis. The postulated mechanisms for
discogenic pain provocation include stretching of fibres of
the abnormal annulus fibrosis, extravasation of irritating
chemical substances, pressure on nerves, vascularized granulation
tissue in the annulus fibrosis, posterior joint hyperflexion
during injection, and changes in the pattern of loading of
the posterolateral annulus fibrosis or nucleus pulposus [43,44,45,46].
Where possible, injecting an adjacent normal disc as a control
is recommended as it gives an indication of the patient’s
level of pain tolerance as well as the reliability of the
patient’s responses at other levels.
Pain provocation is the most useful and important aspect
of discography. However, as the individual patient’s
response is subjective, it is important to avoid introducing
bias during the procedure. Patients should instead be told
before the start of the procedure and intermittently reminded
to immediately inform the practitioner when they experience
any new or increasing pain. Leading questions should be avoided.
During injection, the location and character of the pain should
be noted and recorded. It is useful to observe the patient’s
facial expression or body movement for signs of pain response.
The pain response can be classified into the following categories:
- No or insignificant pain reproduction.
- Pain different from the usual painful symptoms (discordant).
- Pain similar to some of the usual painful symptoms (partially
- Pain identical to the usual painful symptoms (concordant).
When taking the disc morphology and pain provocation aspects
together, the categories of a discography study are:
- Normal study.
- Abnormal but asymptomatic disc(s)
- Abnormal disc(s) with discordant symptoms.
- Abnormal disc(s) with concordant (partially or fully) symptoms.
The finding of pain provocation during discography has been
found to have a direct impact on the surgical outcome. Eighty
nine percent of 137 patients with positive discograms had
clinical benefit from subsequent operation .
There is a 75% surgical success rate in patients with both
positive discograms and MR imaging at L5-S1 level, compared
to only 50% success rate in patients with a combination of
positive discograms and normal MR imaging .
The complication rate of discography is low, and is accepted
to be less than 1%. In a retrospective analysis of 10 discography
studies in which prophylactic antibiotics were not given,
an infection rate of 0.25% in 4891 patients and 0.094% in
12,770 discs was found, with the conclusion that the risk
of post-discography discitis was minimal .
The most serious and frequently encountered complication is
discitis. The incidence of infection can be decreased with
the use of double needles, prophylactic antibiotics and styleted
needles [11,33,49]. Many practitioners prophylactically administer
broad-spectrum antibiotics as a precaution against possible
Nerve damage may also occur but usually causes only transient
symptoms. Transthecal puncture route may result in post-procedural
headache. Other possible complications are needle breakage,
accidental intradural injection, intrathecal haemorrhage,
meningitis, arachnoiditis, osteomyelitis, and epidural abscess.
It has been shown that discography does not cause injury to
the disc itself [50,51].
Provocative discography remains the only diagnostic test
that provides both anatomical and functional information about
a suspected abnormal disc. It is a complementary test in patients
whose painful symptoms are not explained by findings on non-invasive
imaging modalities such as MR imaging or CT. Provocative discography
is a helpful tool in the management of patients with low back
pain, particularly for those who are not responsive to conservative
measures. Careful patient selection and meticulous technique
are paramount factors for a successful outcome.
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|Received 1 June 2005; accepted
for publication 5 July 2005
Correspondence: Programme Office (Graduate Medical School), Singapore Health Services, 7 Hospital Drive, #02-09, Singapore 169611, Republic of Singapore. Tel.: +65-63275843; Fax: +65- 63278803; E-mail: email@example.com (Wilfred C. G. Peh).
Please cite as: Peh WCG,
Provocative discography: current status, Biomed Imaging Interv J 2005; 1(1):e2