Peer-Review ReportOperative and Nonoperative Treatment Approaches for Lumbar Degenerative Disc Disease Have Similar Long-Term Clinical Outcomes Among Patients with Positive Discography
Introduction
Chronic back pain, with an annual prevalence of 15%–45%, results in enormous health-related expenditure without a consistent improvement in physical, mental, and functional health-related outcomes (32). Chronic low back pain has been attributed to degenerative disc disease (DDD) in a subset of patients, and provocative discography has been proposed as a decision-making guide to better select patients who could potentially benefit from interventional/surgical procedures for relief of back pain thought to be secondary to DDD (31). Discography involves injection of a “contrast” material into the disc space to provide information on disk morphology and to assess whether the injection elicits a “provoked” pain response. Although morphologic alterations may be readily appreciated on discography, their presence alone does not necessarily implicate the disc as a pain generator 1, 31, 33. As a result, considerable importance is given to the provoked pain response, which, when reported by the patient to be similar to their symptomatic pain, is considered as evidence of a symptomatic disk. There is extensive debate in the spine literature with regard to discography, with one of the major concerns being a high false-positive rate of the provoked pain response in asymptomatic and symptomatic individuals 5, 7, 8, 24, 40, 52. However, a recent meta-analysis of false-positive studies using the International Spine Intervention Society standard suggested that discography has a specificity of 0.94, after setting certain patient selection criteria (52).
Multiple studies have tried to determine the correlation between discography results and treatment outcomes 9, 10, 20, 26, 30, 37, 46, 51. The results have been inconsistent, with variable outcomes regarding pain, functionality, and quality of life. The question whether surgery should be performed for back pain relief for those with a positive discogram still remains without a clear answer. Some investigators recommend surgical intervention after a positive discogram only for patients who also have associated abnormal magnetic resonance imaging (MRI) findings 37, 38, 39. The controversy is further compounded by recent translational and clinical evidence documenting damage and progression of disc degeneration as a result of dye injection as part of the discography procedure 6, 21, 22, 25. Interpretation of evidence regarding efficacy of presurgical discography becomes difficult with divergent views among various investigators.
Our objective in the present study was to assess the long-term clinical outcomes of patients with a positive, concordant lumbar discogram who were offered spinal fusion and either accepted or declined this surgical treatment. Our hypothesis was that, compared with the patients electing for nonoperative treatment, the patients treated with lumbar fusion would have better health-related quality of life (HRQOL) and satisfaction scores at long-term follow-up.
Section snippets
Methods
This study was a retrospective review of consecutive patients who were referred for a diagnostic lumbar discography procedure between 2003 and 2009 at a single institution (Thomas Jefferson University, Philadelphia, Pennsylvania, USA). Inclusion criteria for the present study were symptoms of axial low back pain, attempted conservative therapy for a minimum of 6 weeks, and a one level or a two adjacent level positive discogram that was concordant with lumbar DDD based on MRI. All patients
Baseline Comparisons Between the Patient Groups with and without Follow-Up
A total of 200 patients were identified who met baseline inclusion criteria and were offered surgical treatment (lumbar fusion). Of these 200 patients, follow-up was obtained for 96 (48%), including 53 (55%) of the 96 total patients treated with lumbar fusion and 43 (41%) of the total 104 patients in the nonoperative group (based on initial management plan). Compared with patients for whom follow-up could not be obtained, those with follow-up were slightly older (mean age, 47.1 years vs. 43.9
Discussion
Discography was first introduced by Lindblom (28) as an imaging procedure to visualize the herniated nucleus pulposus in the 1940s. At present, discography is used by some physicians as a diagnostic test to help determine whether a patient with back pain with degenerative disk disease may be a candidate for surgical intervention. According to Derby et al. (12), a positive discogram is determined by the following criteria: a pain severity more than 6/10, which is concordant with the patient's
Conclusions
The present study provides comparison of long-term outcomes for patients with low back pain and a positive concordant discography and who either elected for or against lumbar fusion. The results of our study demonstrate significantly improved pain scores at follow-up for the operative and nonoperative treatment groups and do not demonstrate a significant difference for standardized outcome measures of pain, generalized health status, satisfaction, or disability. Collectively, these findings do
References (53)
- et al.
Lumbar discography: a comprehensive review of outcome studies, diagnostic accuracy, and principles
Reg Anesth Pain Med
(2005) - et al.
Comparison of discographic findings in asymptomatic subject discs and the negative discs of chronic LBP patients: can discography distinguish asymptomatic discs among morphologically abnormal discs?
Spine J
(2005) - et al.
Deleterious effects of discography radiocontrast solution on human annulus cell in vitro: changes in cell viability, proliferation, and apoptosis in exposed cells
Spine J
(2012) - et al.
Predictors of long-term opioid use among patients with painful lumbar spine conditions
J Pain
(2010) - et al.
The Adams classification for cadaveric discograms: inter- and intra-observer error in the clinical setting
Eur Spine J
(2002) - et al.
Lumbar spine surgery in the obese patient
J Spinal Disord
(1997) - et al.
Changes in radiographic and clinical outcomes with primary treatment adult spinal deformity surgeries from two years to three to five years of follow-up
Spine (Phila Pa 1976)
(2010) - et al.
Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study
Spine (Phila Pa 1976)
(2009) - et al.
Provocative discography in patients after limited lumbar discectomy: a controlled, randomized study of pain response in symptomatic and asymptomatic subjects
Spine (Phila Pa 1976)
(2000) - et al.
2009 ISSLS Prize Winner. Does discography cause accelerated progression of degeneration changes in the lumbar disc?: a ten-year matched cohort study
Spine (Phila Pa 1976)
(2009)
The rates of false-positive lumbar discography in select patients without low back symptoms
Spine (Phila Pa 1976)
False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection
Spine (Phila Pa 1976)
Cassar Pullicino VN: Provocation discography as a guide to planning operations on the spine
J Bone Joint Surg Br
Anterior-only stabilization using plating with bone structural autograft versus titanium mesh cages for two- or three-column thoracolumbar burst fractures: a prospective randomized study
Spine (Phila Pa 1976)
The outcomes of lumbar microdiscectomy in a young, active population: correlation by herniation type and level
Spine (Phila Pa 1976)
Patient satisfaction with medical care for low-back pain
Spine (Phila Pa 1976)
Revision surgery following operations for lumbar stenosis
J Bone Joint Surg Am
The effect of obesity on clinical outcomes after lumbar fusion
Spine (Phila Pa 1976)
A prospective randomised study on the long-term effect of lumbar fusion on adjacent disc degeneration
Eur Spine J
The Oswestry Disability Index
Spine (Phila Pa 1976)
Does obesity affect the results of lumbar decompressive spinal surgery in the elderly?
Clin Orthop Relat Res
Functional results after anterior lumbar fusion at L5-S1 in patients with normal and abnormal MRI scans
Spine (Phila Pa 1976)
Invertebral disc changes after discography
Acta Chir Scand
Changes observed in the intervertebral disc after discography
Acta Pathol Microbiol Scand
The question of lumbar discography
J Bone Joint Surg Am
Does discography injure normal discs? An analysis of repeat discograms
Spine (Phila Pa 1976)
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Conflict of interest statement: Approval for the present study was obtained through the institutional review board of Thomas Jefferson University. Justin S. Smith is a consultant for Medtronic, Biomet, Globus; received honoraria for teaching: Medtronic, Depuy, Biomet; Research study group support: Depuy. Christopher Shaffrey is a consultant, patent for Biomet; received royalties, patent from Medtronic; is a consultant for Depuy; got grant funding from NIH and DOD. Alexander Vaccaro received Health Care Entity Relationships and Investments from the following companies: Replication Medica / Stock/ Stock Option Ownership Interests; DePuy / Receipt of Royalty Payments; Medtronics / Receipt of Royalty Payments; Stryker Spine / Receipt of Royalty Payments, Institutional/ Educational Grant; Biomet Spine / Receipt of Royalty Payments; Globus / Receipt of Royalty Payments, Stock/ Stock Option Ownership Interests; K-2 Medical / Stock/ Stock Option Ownership Interests; Paradigm Spine / Stock/ Stock Option Ownership Interests; Stout Medical / Consulting/Independent Contractor, Stock/ Stock Option Ownership Interests; Aesculap / Receipt of Royalty Payments; Spine Medica / Stock/ Stock Option Ownership Interests; Computational Biodynamics / Stock/ Stock Option Ownership Interests; Progressive Spinal Technologies / Stock/ Stock Option Ownership Interests; Spinology / Stock/ Stock Option Ownership Interests; Small Bone Innovations / Stock/ Stock Option Ownership Interests; NeuCore / Stock/ Stock Option Ownership Interests; Cross Current / Stock/ Stock Option Ownership Interests; Syndicom / Stock/ Stock Option Ownership Interests; In Vivo / Stock/ Stock Option Ownership Interests; Flagship Surgical / Stock/ Stock Option Ownership Interests; Advanced Spinal Intellectual Properties / Stock/ Stock Option Ownership Interests; Cytonics / Stock/ Stock Option Ownership Interests; Bonovo Orthopaedics / Stock/ Stock Option Ownership Interests; Electrocore Stock/ Stock Option Ownership Interests; Nuvasive / Receipt of Royalty Payments, Institutional/ Educational Grant; Gamma Spine / Stock/ Stock Option Ownership Interests; Location Based Intelligence / Stock/ Stock Option Ownership Interests; FlowPharma / Stock/ Stock Option Ownership Interests; R.S.I. /Stock/ Stock Option Ownership Interests; Gerson Lehrman Group / Consulting/Independent Contractor; Guidepoint Global / Consulting/Independent Contractor; Medacorp / Consulting/Independent Contractor; Cerapedics / Institutional/ Educational Grant; Rothman Institute and Related Properties / Stock/ Stock Option Ownership Interests; AO Spine / Service on Scientific Advisory Board/Board of Directors/Service on Committees; Innovative Surgical Design / Consulting/Independent Contractor, Service on Scientific Advisory Board/Board of Directors/Service on Committees, Stock/ Stock Option Ownership Interests; Association of Collaborative Spine Research / Service on Scientific Advisory Board/Board of Directors/Service on Committees; Spinicity / Service on Scientific Advisory Board/Board of Directors/Service on Committees, Stock/ Stock Option Ownership Interests. Gursukhman Sidhu, Ken Bode, David Gendelberg, Mitchell Maltenfort, David Ibrahimi have nothing to disclose.