Provocative discography in patients after limited lumbar discectomy: A controlled, randomized study of pain response in symptomatic and asymptomatic subjects

STUDY DESIGN: This was a prospective observational study of patients with low back pain and those without after laminotomy and discectomy. OBJECTIVES: To determine, using a strict experimental design, the relative pain intensity response to provocative discography in symptomatic and asymptomatic subjects after lumbar discectomy for intervertebral disc herniation. BACKGROUND: Provocative discography frequently is used to evaluate persistent or recurrent low back pain syndromes in patients who have undergone posterior discectomy. The validity of interpreting painful injections during this procedure has not been critically assessed. The prevalence of significantly painful disc injections in a group with good outcomes after surgery is not known. Knowing the rates of significantly painful injections in asymptomatic patients after lumbar discectomy may clarify the meaning of painful injections in symptomatic patients. METHODS: From a cohort of 240 patients who had undergone single-level limited discectomy for sciatica, 20 asymptomatic volunteers were recruited for experimental three-level lumbar discography. Inclusion criteria required nearly perfect scores on standardized back pain rating instruments, no other spinal pathology, and normal psychometric screening. A control group of 27 symptomatic patients, after single-level discectomy with intractable low back pain syndrome, and without other spinal pathology, underwent discography. Seven patients in the control group had normal psychometric tests. Experienced raters who were blinded to control versus experimental status of the subjects scored the magnetic resonance imaging, discogram, psychometric tests, and discography videotapes of the subjects' pain behavior. RESULTS: There were 8 of 20 (40%) positive injections of discs that had previous surgery in the asymptomatic group and 17 of 27 (63%) positive injections in the symptomatic group. Specifically with regard to the symptomatic group, there were 3 of 7 (43%) positive injections (all concordant) in patients with normal psychometric scores, as compared with 14 of 20 (70%) positive injections (12 concordant) in patients with abnormal psychometric scores. Injections of discs that had previous surgery resulted in a mean pain score of 2.1 of 5 in the asymptomatic group, 2.1 in the symptomatic group with normal psychometric scores, and 3.4 in the symptomatic group with abnormal psychometric scores. Of the discs not treated with surgery, 2 were positive in the asymptomatic group (10%), 3 in 2 symptomatic subjects with normal psychological testing (29), and 18 in 13 symptomatic subjects with abnormal psychometric testing (76%). CONCLUSIONS: A high percentage of asymptomatic patients with normal psychometric testing who previously have undergone lumbar discectomy will have significant pain on injection of their discs that had previous surgery (40%). This is not significantly different from the experience of symptomatic patients with normal psychometric testing undergoing discography on discs that had previous surgery. Patients with abnormal psychological profiles have significantly higher rates of positive disc injections than either asymptomatic volunteers or symptomatic subjects with normal psychological screening.