Bad Backs and Bad Medicine: Discography Linked to Development of Back Pain

Any person who spends time in claims has run into files in which a patient with back pain has undergone “provocative discography.”  The procedure involves injecting intervertebral discs suspected of causing the claimant’s pain with fluid along with “healthy control” discs.  Purportedly, if the claimant feels an increase of pain in the suspected disc compared to the “control” discs, then the suspected disc is confirmed as being the cause of the claimant’s back pain.  The problem is threefold.  First, studies have determined that provocative discography cannot do what it is supposed to do.  It cannot identify “discogenic pain.”  Second, studies have definitively concluded that not only is provocative discography an ineffective diagnostic tool but also that it causes the degeneration of injected intervertebral discs to accelerate.  Third, a recent study published in The Spine Journal (subscription required) found in a 10 year study that provocative discography performed on persons without back complaints actually led to back pain and surgical intervention.  Healthnewsreviews.org has an outstanding piece about the study and the lack of coverage in the health news media.  This is important because even today, with knowledge that provocative discography is an ineffective diagnostic tool, 70,000 procedures are performed annually in the United States.  Anyone involved in medico-legal claims should read the Healthnewsreviews.org piece.  Here are some of the highlights:

Experts say that provocative discography has no proven benefit for identifying symptomatic discs and has previously been shown on magnetic resonance imaging to be associated with faster degeneration of injected discs. The new study followed 75 patients who received the injections and compared them to 75 matched controls. The point of the new study was to see whether the disc degeneration seen on MRI would translate into clinically important back pain symptoms.

There was no significant history of back pain in either group when the study began. But the new 10-year data showed that there were more back pain surgeries (16 vs. 4); more frequent sciatica and back pain syndromes, and greater work loss and doctor visits for low back pain in the punctured discs compared to controls.

Such is the import of this study that an orthopedic surgeon interviewed as part of the article flat out stated:

“But readers should be aware that a trial of this sort with 10 years of follow up is very compelling evidence of discography’s potential problems,” Rickert says. “Such long term studies are rare,” he adds, and this one should tell readers: “Do not go undergo provocative discography.”

Perhaps the best summary was provided by another doctor consulted for the article.  Steven Atlas, MD, MPH, told Healthnewsreviews.org:

So, not surprisingly, results are not very reliable. We also know that patients who have fusion based upon findings of provocative discography don’t do any better than individuals who have surgery but don’t undergo this test. We also know that patients can report more pain after the procedure, including pain they didn’t have before the procedure. And now we know that there are long-term risks associated with discography.

The article is worth reading in its entirety.  One hopes that discography and its costs, both direct and indirect, will soon disappear from the health care landscape.  In the meantime, claims professionals should expect their IME doctors on back pain cases to be familiar with the study and use it in their reports when treating physicians recommend or actually perform provocative discography and use it to diagnose the cause of back pain and the need for surgery.

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