1. 2013;16;SE55-SE95An Update of the Systematic Appraisal of the Accuracy and Utility of Lumbar Discography in Chronic Low Back Pain
   Systematic Review
   Steven P. Cohen, MD, Joshua A. Hirsch, MD, David L. Caraway, MD, Lee T Snook, MD, Sukdeb Datta, MD, Aaron K. Calodney, MD, Frank J.E. Falco, MD, Haroon Hameed, MD, Richard Derby, MD, Lee R. Wolfer, MD, Standiford Helm II, MD, Vijay Singh, MD, Ramsin M. Benyamin, MD, and Laxmaiah Manchikanti, MD.

BACKGROUND: The intervertebral disc has been implicated as a major cause of chronic lumbar spinal pain based on clinical, basic science, and epidemiological research. There is, however, a lack of consensus regarding the diagnosis and treatment of intervertebral disc disorders. Based on controlled evaluations, lumbar intervertebral discs have been shown to be the source of chronic back pain without disc herniation in 26% to 39% of patients. Lumbar provocation discography, which includes disc stimulation and morphological evaluation, is often used to distinguish a painful disc from

other potential sources of pain. Despite the extensive literature, intense debate continues about lumbar discography as a diagnostic tool.

STUDY DESIGN: A systematic review of the diagnostic accuracy of lumbar provocation and analgesic discography literature.

OBJECTIVE: To systematically assess and re-evaluate the diagnostic accuracy of lumbar discography.

METHODS: The available literature on lumbar discography was reviewed. A methodological quality assessment of included studies was performed using the Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were included in the analysis. However, studies scoring less than 50% are presented descriptively and critically analyzed.
The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF).
Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2012, and manual searches of the bibliographies of known primary and review articles.

RESULTS: Over 160 studies were considered for inclusion. Of these, 33 studies compared discography with other diagnostic tests, 30 studies assessed the diagnostic accuracy of discography, 22 studies assessed surgical outcomes for discogenic pain, and 3 studies assessed the prevalence of lumbar discogenic pain. The quality of the overall evidence supporting provocation discography based on the above studies appears to be fair. The prevalence of internal disc disruption is estimated to be 39% to 42%, whereas the prevalence of discogenic pain without assessing internal disc disruption is 26%.

CONCLUSION: This systematic review illustrates that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain.