Conclusions
Spine pain is one of the most common reasons for a physician visit in the United
States. Numerous spine surgeries are performed each day for treatment, and in
many cases, post-operative success has been shown to improve with the use of
pre-operative discography as an aid to surgical planning. It has been felt by
some that a positive pain response by discography is necessary for diagnosis
and surgical planning because there is an equal chance that these disc levels
may or may not be responsible for the production of a patient's symptoms. Furthermore,
MRI does not reliably predict or replace discography.
Psychological factors have been implicated in the development of new onset
spine pain following discography. This is not surprising, and is a concept that
is likely applicable to any pain generating procedure. The pain threshold differs
on an individual basis, and those with psychological factors such as depression
have been known to have a lower pain threshold.
Spine surgery is associated with a significant morbidity and mortality. It
does not seem prudent to perform a high-risk operation without a definitive
diagnosis. Due to the multitude of presentations of spinal pain, in many cases,
without discography, a definitive diagnosis is not made. This alone would be
justification for discography in the majority of situations. Discography may
prevent patients from undergoing unnecessary surgery in many cases, and this
is a very important consideration. Grubb's article found that discography was
essential to adequately identify abnormal levels in patients being considered
for spinal fusion surgery, and that roentgenograms and myelograms alone were
inadequate (35). Discography may prevent patients from undergoing surgery unnecessarily,
and this is an important consideration.
A patient with coronary artery stenosis would not be subjected to the risks
of coronary artery bypass grafting surgery unless a definitive diagnosis was
made by cardiac catheterization first, if time allowed. Cardiac catheterization
is an invasive procedure involving contrast, with significant risks of it's
own. It assists with the pre-operative planning to allow execution of a strategic
plan in the operating room. Similarly, when appropriate, discography should
be performed to assist with a proper treatment plan in the evaluation of a patient
with cervical or lumbar discogenic pain.
Cardiac catheterization is a skill that requires fellowship training of at
least two years after one has completed residency. At the present time, there
is no such requirement with regards to discography and many other interventional
procedures. People are attempting various interventional techniques after a
weekend or weeklong course at times. Perhaps there should be a fellowship-training
requirement to regulate interventional spine procedure performance, as there
is a fellowship-training requirement for cardiac catheterization?
With all of these things being said, why does the controversy over the validity
of discography continue? This question was best answered by Nikolai Bogduk,
from Australia, in 1996 when he said the following:
"The tragedy of discography is that instead of being evaluated and proven
under strict scientific guidelines such as those that apply to new drugs,
discography was popularized and adopted before it's validity and utility were
determined. On the one hand, this has resulted in improper use of discography
in some quarters. On the other hand, motivated investigators have had to catch
up, trying to justify its use retrospectively. The controversies that have
arisen pertain not so much to the biological basis of discography but stem
rather from how discography has been misunderstood and misrepresented by it's
opponents or how it has been misused by unscrupulous operators."(27)
Techniques and technology have changed significantly, decreasing the complication
rate associated with discography. Fellowships, although not required, are offered
in which the proper skills can be taught to minimize the potential complications
associated with the procedure. Discography can be performed safely and provide
valuable diagnostic information when it is undertaken in sterile conditions
by those well experienced with the procedure (19), and when those with a genuine
enthusiasm for learning these techniques and using them in the proper indications
are given the opportunity to do so.
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