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. 2023 Feb 13;7(2):129–135. doi: 10.22603/ssrr.2022-0193

Progress in Discography

Yang Chen 1, Zhichao Gao 2
PMCID: PMC10083091  PMID: 37041872

Abstract

Discography is an important method for diagnosing discogenic low back pain (LBP) and replicating the effects of pain. However, its development is not smooth due to its safety and reliability, which have not been completely confirmed. Beginning with the clinicians using discography, there remains constant controversy. With the continuous progress of related research on discography, clinicians and scholars' understanding of discography is constantly improving. This article reviews the background, clinical application, and safety of discography.

Keywords: discography, discogenic low back pain, intervertebral disc puncture, intradiscal injection pressure

Background

Discography refers to injecting a certain dose of contrast agent into the nucleus pulposus cavity of the intervertebral disc with the assistance of X-ray, CT, or MRI and understanding the pathological characteristics of the intervertebral disc by observing the morphological changes of the nucleus pulposus and annulus fibrosus. As a diagnostic test, discs can be confirmed or ruled out as a source of back pain.

Discography is not a routine inspection item. Discography can be commonly performed in the following cases: when patients with chronic low back pain cannot identify the cause of low back pain through noninvasive imaging examinations and other testing items and when the pain cannot be effectively relieved or controlled after 6-12 weeks of conservative treatment. It can be said that it is used to confirm or exclude the target disc that is causing severe and persistent pain in the patient, but it is only performed under certain conditions. In addition to the above conditions, discography can also be used to determine the need for spinal invasive treatments such as thermal coagulation, discectomy, or spinal fusion surgery.

As early as 1948, Lindbloom, the first scholar to study intradiscal injection in vivo1), named the method “discography” after discovering the radial destruction of the annulus fibrosus. In the same year, this technology was promoted for clinical diagnosis of lumbar disc herniation, but due to its safety and reliability, it was gradually replaced by imaging technologies such as CT and MRI. With the improvement of today's medical level and the gradual deepening of the understanding of intervertebral discography, many scholars have carried out further research on intervertebral discography.

1. Anatomy and Pathophysiology of the Intervertebral Disc

1.1 Intervertebral disc

The intervertebral disc is located between the adjacent vertebral bodies and supports the spine to carry the gravity. It can change in relaxation and contraction with the magnitude of the spinal force and the direction of movement. It is composed of three parts: the cartilage endplate, the annulus fibrosus (AF), and the nucleus pulposus (NP). Among them, the cartilage endplate is located at the lower edge of the upper vertebral body and the upper edge of the lower vertebral body, and its thickness is usually less than 1 mm. Like other cartilage joints, the cartilage endplate can bear a certain pressure and reduce the pressure load on the vertebral body. The annulus fibrosus is located at the outer edge and consists of 15-25 concentric rings2,3), mainly composed of highly oriented collagen fibers (primarily type I collagen), and organized into alternately oriented lamellar fibrillar collagens4), where fibers parallel in each layer, which may help the intervertebral disc to restore its original arrangement after stretching or bending5) and maintain the stability of the spine; the nucleus pulposus is located in the center of the intervertebral disc and is a highly hydrated gel tissue, the main component of which is water, containing many dispersed population of negatively charged proteoglycans6), where these proteoglycans are important for attracting and retaining water in the disc core, i.e., hydration7,8).

1.2 Blood vessels and nerves of the intervertebral disc

Normally, the intervertebral discs of healthy adults are almost devoid of blood vessels9,10), and the segmental nutrient arteries at each spinal level give rise to the intervertebral arteries until capillaries form at the ends of the cartilaginous endplates5,11). The survival of inner cells mainly depends on the capillaries at the edge of the cartilage endplate to supply nutrients and exchange metabolites5,12,13). There are many micropores in the cartilage endplate, which are the pathways for the water and metabolites of the nucleus pulposus, and there is no nerve tissue in it. Therefore, when the cartilage endplate is damaged, it will neither cause pain nor repair itself12,14). The nerves of the intervertebral disc have been shown to usually accompany these vessels but can also arise alone. The sinus vertebral nerves that innervate the posterior disc are composed of mixed nerves from the ventral spinal and gray communicating branches, which converge to the dorsal root ganglion, enter the intervertebral foramen, and then divide into a major ascending branch and a smaller descending branch; the nerve fibers innervating the anterior disc come from the communicating branches of the sympathetic trunk close to it; lateral to the disc is innervated by the sinus vertebral nerve and the anterior sympathetic nerve14-16). In an animal study17), Nakamura et al. found that there is a deep dense neural network in the posterior part of the lumbar intervertebral disc and a superficial longitudinal neural network in the posterior longitudinal ligament by isolating the lumbar sympathetic nerve of mice. These results show that in rats, the posterior lumbar disc of the lumbar intervertebral disc and the posterior longitudinal ligament are innervated by sympathetic bilateral and multisegment nerves. It is also pointed out that disc-derived low back pain can be transmitted through sympathetic nerves. Brian Shayota et al.18) did similar animal experiments, and their study showed that in rats, the innervation of the posterior part of the lumbar disc is largely sympathetic, and the sinus vertebral nerves were found to terminate at the articular process. In addition, the facet joints of the vertebral bodies are also innervated by autonomic and somatic nerves19,20); that is, these tissues share common neural circuits and sensory feedback pathways, so that the brain may not be able to distinguish the exact source of sensory input reaching common neurons19-21). Therefore, pain of disc origin and facet joint origin are often indistinguishable from each other22).

1.3 Pathophysiology of the painful intervertebral discs

Intervertebral disc degeneration (IDD) occurs under the action of various initiating factors9), which is a physiological trend. Adams and Roughley23) believe that although intervertebral disc degeneration is related to age, intervertebral disc degeneration is not equal to intervertebral disc aging. In other words, although intervertebral disc aging is related to intervertebral disc degeneration, the two can be distinguished through basic scientific research, as shown in Table 1.

Table 1.

Factors to Distinguish Intervertebral Disc (IVD) Aging and IVD Degeneration.

IVD aging IVD degeneration
Loss of proteoglycans and water content
Increased collagen crosslinking and advanced glycation end-product accumulation

Endplate sclerosis hypo-osmolarity and reduced nutrition
Reduced cellularity and increased cellular senescence

Dysregulated nutrient sensing
Signaling of NF-κB, mitogen-activated protein kinases 		Proinflammatory cytokines, nociceptive stimuli (nitric oxide, leukotrienes, prostaglandin E, and lactic acid)

Injury and neurovascular ingrowth
Pathological structural defects
Biomechanical dysfunction
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Table 1 Factors to distinguish intervertebral disc (IVD) aging and IVD degeneration.

The above pathogenic factors have been confirmed by many scholars19,24-31). The intervertebral disc undergoes many biochemical and structural changes during various injuries (enzymatic chemical injury, autoimmune and inflammatory injury, etc.31)) or other abnormal degenerative processes, such as thinning and clearing of the cartilage endplate. The nucleus pulposus loses hydration, the intradiscal pressure decreases, the height of the intervertebral disc decreases, the stress distribution of the annulus fibrosus is unbalanced, and then radial tears occur. Granulation tissue rich in blood vessels and many pain receptors is formed around the intervertebral disc and between the fissures, which is invaded by mechanical or chemical stimulation, resulting in corresponding clinical symptoms, namely, low back pain.

2. Clinical Application of Discography

2.1 The main uses of discography

As a diagnostic technique, discography is mainly used for judging whether the patient's low back pain is of intervertebral disc origin and identifying the disc level causing the pain, evaluating the shape of the intervertebral disc, and showing the number, location, and depth of annulus fibrosus tears. Simulating pain, the pain-replicating effect, is also the most clinically valuable feature of discography, and according to the International Association for the Study Pain (IASP)/International Spine Intervention Society (ISIS) criteria32), the operational criteria for pathogenic pain during discography are defined as follows:

(1) The pain produced by stimulating the target intervertebral disc is consistent with the low back pain usually felt.

(2) The intensity of this pain has a numerical rating score of at least 7 on a scale of 0-10, or 70% of maximum spontaneous pain.

(3) Pain is produced at injection pressures not exceeding 50 psi, preferably below 15 psi.

(4) It is not painful to stimulate at least one adjacent disc.

In addition, pain arising during the disc examination should exceed baseline pain.

2.1.1 Indications for discography

The indications for discography are as follows33):

(1) Persistent severe low back pain (visual analog scale score ≥7), and after at least 3 months of conservative treatment, the pain has not been effectively relieved or controlled, and there is no obvious radiating pain in the leg.

(2) In clinical investigations and imaging examinations, there is no clear cause of low back pain other than disc degeneration, such as disc compression (not bulging or herniation), segmental instability, spondylolisthesis, compression fractures, cancer pain, or infectious disease.

(3) There are no surgical contraindications, such as a history of allergy to contrast agents, pregnancy, suspected infectious diseases, blood coagulation disorders, or renal failure. It is emphasized here that the use of discography should follow the indications; otherwise, it will result in an unacceptably high false-positive rate34).

In addition, some scholars have found that factors such as anatomy and social psychology may cause false positives in discography35).

2.1.2 Academic views on discography

There are different attitudes toward intervertebral discography in the academic community. A review of relevant literature found that some scholars do not advocate routine intervertebral discography. As an invasive examination item, the damage to the human body cannot be completely clear; some scholars believe that intervertebral discography should be performed. Afterward, the benefits for patients outweigh the risks, which can help patients improve their assessment of certain diseases. In response to the general controversy surrounding discography, the North American Spine Society (NASS) stated that discography should only be performed when noninvasive imaging tests fail to demonstrate a painful disc and surgery is required36), and NASS also believes that discography is the only way to diagnose discogenic low back pain37).

Different scholars express their opinions on whether discography is an effective method for diagnosing discogenic pain. Some scholars believe that the positive results of discography, that is, the induction of low back pain that is exactly the same as usual, can be used as the main basis for diagnosis38-40). Manchikant et al. systematically reviewed the relevant discography literature, conducted the Quality Assessment of Reliability Research (QAREL), and finally concluded that discography may be a useful tool for evaluating chronic lumbar discogenic pain41). However, Alamin et al. believed that discography was not the absolute gold standard for diagnosing discogenic low back pain42). They performed discography on subjects and screened positive patients for functional anesthesia discography, involving the injection of a low-dose local anesthetic into the painful disc level, which is used to assess the accuracy of discography. All in all, discography remains the gold standard tool for discogenic low back pain. When other imaging tests fail to find the disc that causes the pain, discography can accurately locate the target disc with a low false-positive rate and can help identify patients with pain43).

2.2 Supplement to the uses of discography

Junhui Liu et al. found that painful SN that is difficult to receive conservative treatment is an indication for discography, and their study demonstrated that discography and disco block therapy can provide rapid and durable relief of symptoms, thereby improving the quality of life of patients44). Discography has been proven to be a useful tool for surgical planning45), and the study by Xi M A et al. showed that discography can accurately locate and reduce the level of lumbar spinal fusion surgery46), thereby ensuring the quality of surgery. The study by Peng B et al. demonstrated that the use of cervical discography can ensure ideal surgical results before performing anterior cervical fusion surgery or artificial cervical disc replacement47). Takano et al. believed that the use of discography could be helpful for the final preoperative diagnosis of posterior epidural migration of lumbar disc fragments (PEMLD)48), thereby achieving the purpose of confirming the diagnosis. Matsumoto believes that discography is a useful preoperative diagnostic tool for intradural lumbar disc herniation (ILDH)49), which is absolutely critical for preventing postoperative neurological deficits and improving postoperative clinical outcomes. Kang et al. believed that discography can be performed in intervertebral disc degeneration patients to accurately locate the location of annular tears and improve the efficacy of annuloplasty using radiofrequency (RF) or laser in the treatment of discogenic LBP50). The study by Liliang et al. showed that the analgesic rate of annuloplasty for degenerative discogenic LBP was approximately 67.7%, and the best outcome predictor for annuloplasty was discography, which improved the success rate of annuloplasty in the treatment of degenerative discogenic LBP51). The study by Lee et al. was the first to report the predictive value of automatic pressure control intervertebral discography (APCD) in Anterior Lumbar Interbody Fusion (ALIF) surgery, and the results suggested that APCD was beneficial to the surgical outcome of ALIF in patients with suspected lumbar discogenic pain; therefore, APCD is recommended prior to ALIF to confirm lumbar discogenic pain52). In addition, many scholars currently use the discography results of the target intervertebral disc as a reference or comparison standard when studying intervertebral disc-related diseases53,54), so as to conduct and improve related research.

The discography is of great help to spinal surgeons and to guide spinal surgery.

3. The Safety of Discography

3.1 Puncture needle

It has been found that the use of puncture needles will affect not only the results of the discography itself but also the impact on the intervertebral disc. In this regard, many scholars have carried out research on the choice of discography puncture needles. McCormick et al.55) used a 22 G needle for disc puncture in all patients in their discography group, but they did not observe acceleration of disc degeneration. In the previous study, 86% of subjects performed a disc puncture with a 25 G needle instead of a 22 G needle. This finding suggests that the use of 22 G (vs. 25 G) needles may not alter the incidence of disc degeneration or new disc herniation. Wang et al.56) used both hypodermic and spinal needle for discography in their study. Results showed that the difference in needle type had no significant effect on the biomechanics of the intervertebral disc microstructure, which was only slightly affected by the size of the needle. In addition, collagen fibers of the intervertebral disc were torn to a greater extent by the large needle, which confirms that puncturing of the disc for diagnostic or therapeutic purposes should be avoided as much as possible, as needles of all types and sizes can cause similar injuries, and smaller needle sizes should be used when necessary. Huang et al.57) chose rats as experimental subjects to study the effect of intervertebral discography on IDD by selecting needle size and contrast dose. The study proved that 30 G needles will not cause severe IDD, although some scholars had a review of the literature58) showing that the effect of puncture on IVD was variable and insignificant when the needle diameter was less than 40% of the IVD height. However, this analysis was limited by in vitro tissue and only biomechanical testing. Huang et al. showed that the smaller the diameter of the needle, the more difficult it is to puncture the intervertebral disc, which increases the risk of needle breakage and other factors. Therefore, without increasing the difficulty and risk of discography, a puncture needle with a smaller diameter should be selected as much as possible. Van Heeswijk et al.59) concluded in their study that the risk of acute lumbar disc herniation at the puncture site of discography depends on the diameter of the needle used. Through experiments, it was found that the 18 G puncture needle caused more damage to the disc tissue than 25 G, while the 25 G needle resulted in relatively few broken fibers around it.

3.2 Intradiscal injection pressure

While focusing on the influence of different punctures on the intervertebral disc, some scholars have also explored the pressure during intradiscal injection and its influence. A study by Kallewaard et al.60) found that intradiscal pressure at adjacent levels does not increase during provocative lumbar discography in humans using the pressure-controlled low-velocity technique. Therefore, it is believed that false-positive pain responses caused by potentially painful adjacent discs are unlikely to occur during pressure-controlled discography. APCD was used in the study by Lee52), where the injection rate was set at 0.5 ml/min for all patients, and a total of 3 ml was injected at the time of disc injection with a pressure level of 50 psi or below; their findings suggested that the APCD system can improve accuracy and objectivity in identifying discogenic LBP by automatically recording intradiscal pressure, injection volume, and pain response.

Through experimental studies, Cuellar et al.35) proposed three plausible mechanisms by which the intervertebral disc may be injured during discography, including intradiscal pressure, and concluded that disc puncture and pressurized injections during provocative discography may increase the risk of clinical disc problems in exposed patients. However, Cuellar's conclusion is not completely convincing. Engel et al.61) pointed out that the intradiscal injection was not performed according to the IASP/ISIS standard in Cuellar et al.'s study, and they set the maximum injection pressure at 100 psi. Engal et al. reviewed the original report of Cuellar et al. and found that among subjects who underwent discography, 68 of 71 (96%) subjects recorded at least one disc of at least 80 psi of pressure, and 40 of 71 (56%) subjects recorded a pressure of 100 psi in at least one disc. McCormick, Z. L55) et al. performed discography using the IASP/ISIS criteria, the intradiscal contrast volume was limited to 3 ml, and the maximum intradiscal pressure did not exceed 50 psi of opening pressure. Results showed that patients with overt symptomatic LBP who underwent low-pressure PD but did not subsequently undergo spinal fusion surgery developed disc degeneration and new disc herniation at similar rates to the corresponding discs of matched control patients.

3.3 The complications of discography

A review of the relevant literature on discography found that acute complications following discography have been uncommon since routinely implemented perspective guidance during spinal invasive procedures and improved the modern technique and safety measures during discography, which included but not limited to disc infection, vascular injury, nerve root injury, hemorrhage, acute disc herniation, etc.9,37,62-64). Among them, due to the avascular nature of intervertebral discs, once a disc infection occurs, it will be difficult to treat with antibiotics, which makes disc infection the most dreaded complication of discography65). Preoperative use of intravenous antibiotics, coaxial rather than single needle techniques, and maintenance of strict aseptic technique have been shown to reduce the risk of infection during surgery66). According to statistics, the overall incidence rate calculated by adding all incidences together is less than 0.25% by patient and less than 0.14% by disc64).

3.4 The prognosis of discography

How will life change for patients who undergo discography? Carragee et al.67) conducted a 10-year matched cohort study that found that participants who underwent discography had a greater probability and degree of disc degeneration than those who did not in the control group and also showed that the site of long-term complications of the intervertebral disc after undergoing discography was associated with the puncture site. Hur68) followed up 38 patients with intervertebral discography for 5 years and analyzed the related results of follow-up before and after discography. It was founded that intervertebral disc discography would accelerate the degeneration of the intervertebral disc and the degree of degeneration progression was related to the degree of intervertebral disc descent and IDD before discography. Therefore, it is recommended that procedures such as disc injections be involved and risks and benefits be carefully considered. Lipscomb et al.69) used experimental model for finite element analysis and tried to find the influencing factors of intervertebral disc biomechanics. The result of the study shows that IVD will undergo major changes after intervertebral disc puncture. Along with intervertebral disc puncture, the stress in the intervertebral disc will greatly change, which is most obvious in the interior of NP and the outer edge of AF. Over time, these physiological changes may lead to rupture of AF fibers, leading to disc bulge, disc herniation, and further IVD degeneration, and these changes are independent of needle size. However, intradiscal injection was not performed according to IASP/ISIS criteria in this study, and set the maximum injection pressure at 100 psi.

4. Conclusion

Discography remains the gold standard for diagnosing discogenic pain, and it provides great help to spine surgeons. Following the relevant standards and indications of IASP/ISIS, discography can be performed under relatively safe conditions.

Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.

Sources of Funding: None.

Author Contributions: Zhichao Gao searched the literature.

Yang Chen searched the literature and wrote the manuscript.

Ethical Approval: The systematic review did not require approval from the relevant institutional ethical review board.

Informed Consent: Consent was not required because this study involved no human subject.

References

  • 1.Collis JS, Jr, Gardner WJ. Lumbar discography. Analysis of 600 degenerated disks and diagnosis of degenerative disk disease. JAMA. 1961;178(1):67-70. [DOI] [PubMed] [Google Scholar]
  • 2.Maroudas A, Stockwell RA, Nachemson A, et al. Factors involved in the nutrition of the human lumbar intervertebral disc: cellularity and diffusion of glucose in vitro. J Anat. 1975;120(1):113-30. [PMC free article] [PubMed] [Google Scholar]
  • 3.Cohen SP, Larkin TM, Barna SA. Lumbar discography: a comprehensive review of outcome studies, diagnostic accuracy, and principles. Reg Anesth Pain Med. 2005;30(2):163-83. [DOI] [PubMed] [Google Scholar]
  • 4.Nerurkar NL, Elliott DM, Mauck RL. Mechanical design criteria for intervertebral disc tissue engineering. J Biomech. 2010;43(6):1017-30. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Raj PP. Intervertebral disc: anatomy-physiology-pathophysiology-treatment. Pain Pract. 2008;8(1):18-44. [DOI] [PubMed] [Google Scholar]
  • 6.Roughley PJ. Biology of intervertebral disc aging and degeneration: involvement of the extracellular matrix. Spine. 2004;29(23):2691-9. [DOI] [PubMed] [Google Scholar]
  • 7.Lawson LY, Harfe BD. Developmental mechanisms of intervertebral disc and vertebral column formation. Wiley Interdiscip Rev Dev Biol. 2017;6(6)e283. [DOI] [PubMed] [Google Scholar]
  • 8.Sivan SS, Wachtel E, Roughley P. Structure, function, aging and turnover of aggrecan in the intervertebral disc. Biochim Biophys Acta. 2014;1840(10):3181-9. [DOI] [PubMed] [Google Scholar]
  • 9.Stretanski MF, Vu L. Fluoroscopy discography assessment, protocols, and interpretation. StatPearls. Treasure Island (FL); StatPearls PublishingCopyright 2022, StatPearls. Stat. Pearls Publishing LLC 2022. [PubMed] [Google Scholar]
  • 10.Li F, Zhu J, Sun K, et al. Progress on change of disc cell types and pathophysiology during intervertebral disc degeneration process. J Spinal Surg. 2021;19(5):347-52. [Google Scholar]
  • 11.Ji R, Chenf L, Tang J, et al. Study of applied anatomy of segmental nutrient arteries in vertebral canal. Acad J Second Mil Med Univ. 1997;18(5):14-5. [Google Scholar]
  • 12.Fagan AB, Sarvestani G, Moore RJ, et al. Innervation of anulus tears: an experimental animal study. Spine. 2010;35(12):1200-5. [DOI] [PubMed] [Google Scholar]
  • 13.Ito K, Creemers L. Mechanisms of intervertebral disk degeneration/injury and pain: a review. Glob Spine J. 2013;3(3):145-52. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Guo L, Cai Y. Clinical value of lumbar discography. Int J Med Rad. 2008;31(3):188-91. [Google Scholar]
  • 15.Pedersen HE, Blunck CFJ, Gardner E. The anatomy of lumbosacral posterior rami and meningeal branches of spinal nerves (sinu-vertebral nerves): with an experimental study of their functions. J Bone Joint Surg Am. 1956;38-A(2):377-91. [PubMed] [Google Scholar]
  • 16.Cohen SP, Larkin TM, Barna SA, et al. Lumbar discography: a comprehensive review of outcome studies, diagnostic accuracy, and principles. Reg Anesth Pain Med. 2005;30(2):163-83. [DOI] [PubMed] [Google Scholar]
  • 17.Nakamura S, Takahashi K, Takahashi Y, et al. Origin of nerves supplying the posterior portion of lumbar intervertebral discs in rats. Spine. 1996;21(8):917-24. [DOI] [PubMed] [Google Scholar]
  • 18.Shayota B, Wong TL, Fru D, et al. A comprehensive review of the sinuvertebral nerve with clinical applications. Anat Cell Biol. 2019;52(2):128-33. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Izzo R, Popolizio T, D'Aprile P, et al. Spinal pain. Eur J Radiol. 2015;84(5):746-56. [DOI] [PubMed] [Google Scholar]
  • 20.An G, Guan Y, Wan R, et al. Pathomechanism of lower-level discogenic groin pain and clinical outcomes of percutaneous endoscopic discectomy for the treatment of discogenic groin pain. Pain Phys. 2021;24(3):E289-97. [PubMed] [Google Scholar]
  • 21.Jinkins JR, Whittemore AR, Bradley WG. The anatomic basis of vertebrogenic pain and the autonomic syndrome associated with lumbar disk extrusion. AJR Am J Roentgenol. 1989;152(6):1277-89. [DOI] [PubMed] [Google Scholar]
  • 22.Gonzalez JCA. Validation of a new clinical sign of lumbar facet syndrome. Coluna Columna. 2018;17(4):303-7. [Google Scholar]
  • 23.Adams MA, Roughley PJ. What is intervertebral disc degeneration, and what causes it? Spine. 2006;31(18):2151-61. [DOI] [PubMed] [Google Scholar]
  • 24.Fujii K, Yamazaki M, Kang JD, et al. Discogenic back pain: literature review of definition, diagnosis, and treatment. JBMR Plus. 2019;3(5):e10180. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Rutges JPHJ, van der Jagt OP, Oner FC, et al. Micro-CT quantification of subchondral endplate changes in intervertebral disc degeneration. Osteoarthr Cartil. 2011;19(1):89-95. [DOI] [PubMed] [Google Scholar]
  • 26.Cox LGE, Van Donkelaar CC, Van Rietbergen B, et al. Decreased bone tissue mineralization can partly explain subchondral sclerosis observed in osteoarthritis. Bone. 2012;50(5):1152-61. [DOI] [PubMed] [Google Scholar]
  • 27.Risbud MV, Shapiro IM. Role of cytokines in intervertebral disc degeneration: pain and disc content. Nat Rev Rheumatol. 2014;10(1):44-56. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Depalma MJ, Gasper JJ. Cellular supplementation technologies for painful spine disorders. PM＆R. 2015;7(4):S19-25. [DOI] [PubMed] [Google Scholar]
  • 29.Navone SE, Marfia G, Giannoni A, et al. Inflammatory mediators and signalling pathways controlling intervertebral disc degeneration. Histol Histopathol. 2017;32(6):523-42. [DOI] [PubMed] [Google Scholar]
  • 30.Johnson ZI, Doolittle AC, Snuggs JW, et al. TNF-α promotes nuclear enrichment of the transcription factor TonEBP/NFAT5 to selectively control inflammatory but not osmoregulatory responses in nucleus pulposus cells. J Biol Chem. 2017;292(42):17561-75. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Shi X, Xu H, Liu X, et al. Research progress on the intervertebral disc degeneration model. Int J Pathol Clin Med. 2017;37(2):429-34. [Google Scholar]
  • 32.Practice guidelines for spinal diagnostic and treatment procedures. 2nd ed. San Francisco, CA: International Spine Intervention Society:420-33;2013. [Google Scholar]
  • 33.Son S, Lee SG, Kim WK, et al. Disc height discrepancy between supine and standing positions as a screening metric for discogenic back pain in patients with disc degeneration. Spine J. 2021;21(1):71-9. [DOI] [PubMed] [Google Scholar]
  • 34.Wolfer LR, Derby R, Lee JE, et al. Systematic review of lumbar provocation discography in asymptomatic subjects with a meta-analysis of false-positive rates. Pain Phys. 2008;11(4):513-38. [PubMed] [Google Scholar]
  • 35.Cuellar JM, Stauff MP, Herzog RJ, et al. Does provocative discography cause clinically important injury to the lumbar intervertebral disc? A 10-year matched cohort study. Spine J. 2016;16(3):273-80. [DOI] [PubMed] [Google Scholar]
  • 36.Mooney VHS, Nasca RJ. Position statement on discography, the Executive Committee of the North American Spine Society. Spine. 1988;13. [Google Scholar]
  • 37.Guyer RD, Ohnmeiss DD. Lumbar discography. Position statement from the North American Spine Society Diagnostic and Therapeutic Committee. Spine. 1995;20(18):2048-59. [PubMed] [Google Scholar]
  • 38.Vining RD, Shannon ZK, Minkalis AL, et al. Current evidence for diagnosis of common conditions causing low back pain: systematic review and standardized terminology recommendations. J Manipulative Physiol Ther. 2019;42(9):651-64. [DOI] [PubMed] [Google Scholar]
  • 39.Boswell MV, Trescot AM, Datta S, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Phys. 2007;10(1):7-111. [PubMed] [Google Scholar]
  • 40.Zheng YG, Liew SM, Simmons ED. Value of magnetic resonance imaging and discography in determining the level of cervical discectomy and fusion. Spine. 2004;29(19):2140-5. [DOI] [PubMed] [Google Scholar]
  • 41.Manchikanti L, Soin A, Benyamin RM, et al. An update of the systematic appraisal of the accuracy and utility of discography in chronic spinal pain. Pain Phys. 2018;21(2):91-110. [PubMed] [Google Scholar]
  • 42.Alamin TF, Kim MJ, Agarwal V. Provocative lumbar discography versus functional anesthetic discography: a comparison of the results of two different diagnostic techniques in 52 patients with chronic low back pain. Spine J. 2011;11(8):756-65. [DOI] [PubMed] [Google Scholar]
  • 43.Ross TD, Evans S, Ahern DP, et al. Discography or SPECT/CT: what is the best diagnostic tool for the surgical assessment of degenerative disk disease? Clin Spine Surg. 2021;34(10):355-8. [DOI] [PubMed] [Google Scholar]
  • 44.Liu J, Hao L, Zhang X, et al. Painful Schmorl's nodes treated by discography and discoblock. Eur Spine J. 2018;27(1):13-8. [DOI] [PubMed] [Google Scholar]
  • 45.Kim BY, Concannon TA, Barboza LC, et al. The role of diagnostic injections in spinal disorders: a narrative review. Diagnostics. 2021;11(12):2311. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Xi MA, Tong HC, Fahim DK, et al. Using provocative discography and computed tomography to select patients with refractory discogenic low back pain for lumbar fusion surgery. Cureus. 2016;8(2):e514. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Peng B, Depalma MJ. Cervical disc degeneration and neck pain. J Pain Res. 2018;11:2853-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Takano M, Hikata T, Nishimura S, et al. Discography aids definitive diagnosis of posterior epidural migration of lumbar disc fragments: case report and literature review. BMC Musculoskelet Disord. 2017;18(1):151. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Matsumoto T, Toyoda H, Terai H, et al. Utility of discography as a preoperative diagnostic tool for intradural lumbar disc herniation. Asian Spine J. 2016;10(4):771-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Kang HY, Lee SH. Usefulness of post discogram computed tomography for the effective treatment of discogenic low back pain. Neuroradiology. 2018;60:S523-S4. [Google Scholar]
  • 51.Liliang PC, Lu K, Liang CL, et al. Nucleoplasty for treating lumbar disk degenerative low back pain: an outcome prediction analysis. J Pain Res. 2016;9:893-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Lee CK, Shin DA, Kim HI, et al. Automated pressure-controlled discography in patients undergoing anterior lumbar interbody fusion for discogenic back pain. World Neurosurg. 2017;97:8-15. [DOI] [PubMed] [Google Scholar]
  • 53.Kim SH, Lee SH, Jeong Y, et al. Evaluation of the prognostic factors affecting the clinical outcomes of intradiscal steroid injection therapy for discogenic low back pain: clinical and radiological prognostic factors. Spine J. 2016;16(10):S120. [Google Scholar]
  • 54.Schwan S, Ludtka C, Wiesner I, et al. Percutaneous posterolateral approach for the simulation of a far-lateral disc herniation in an ovine model. Eur Spine J. 2018;27(1):222-30. [DOI] [PubMed] [Google Scholar]
  • 55.Mccormick ZL, Lehman VT, Plastaras CT, et al. Low-pressure lumbar provocation discography according to spine intervention society/International Association for the Study of Pain standards does not cause acceleration of disc degeneration in patients with symptomatic low back pain: a 7-year matched cohort study. Spine. 2019;44(19):E1161-8. [DOI] [PubMed] [Google Scholar]
  • 56.Wang JY, Mansfield JC, Brasselet S, et al. Micro-mechanical damage of needle puncture on bovine annulus fibrosus fibrils studied using polarization-resolved Second Harmonic Generation(P-SHG) microscopy. J Mech Behav Biomed Mater. 2021;118:104458. [DOI] [PubMed] [Google Scholar]
  • 57.Huang XD, Wang WH, Meng QX, et al. Effect of needle diameter, type and volume of contrast agent on intervertebral disc degeneration in rats with discography. Eur Spine J. 2019;28(5):1014-22. [DOI] [PubMed] [Google Scholar]
  • 58.Elliott DM, Yerramalli CS, Beckstein JC, et al. The effect of relative needle diameter in puncture and sham injection animal models of degeneration. Spine. 2008;33(6):588-96. [DOI] [PubMed] [Google Scholar]
  • 59.Van Heeswijk VM, Thambyah A, Robertson PA, et al. Does an annular puncture influence the herniation path?: an in vitro mechanical and structural investigation. Spine. 2018;43(7):467-76. [DOI] [PubMed] [Google Scholar]
  • 60.Kallewaard JW, Geurts JW, Terheggen M, et al. No transfer of pressure to adjacent discs during human low-pressure controlled discography: a prospective clinical study. Pain Med. 2018;19(1):29-39. [DOI] [PubMed] [Google Scholar]
  • 61.Engel AJ, Stojanovic MP, Vorobeychik Y, et al. High-pressure discography may injure discs. Spine J. 2017;17(4):612-3. [DOI] [PubMed] [Google Scholar]
  • 62. Guyer RD, Collier R, Stith WJ, et al. Discitis after discography. Spine. 1988;13(12):1352-4. [DOI] [PubMed] [Google Scholar]
  • 63.Zarembinski C. Demonstrating C7-T1 discogram safety by avoiding lung apex with preprocedure cervical CT. Pain Med. 2019;20(12):2605-7. [DOI] [PubMed] [Google Scholar]
  • 64.Guyer RD, Ohnmeiss DD, Vaccaro A. Lumbar discography. Spine J. 2003;3(3):11-27. [DOI] [PubMed] [Google Scholar]
  • 65.Stout A. Discography. Phys Med Rehabil Clin N Am. 2010;21(4):859-67. [DOI] [PubMed] [Google Scholar]
  • 66.Saboeiro GR. Lumbar discography. Radiol Clin North Am. 2009;47(3):421-33. [DOI] [PubMed] [Google Scholar]
  • 67.Carragee EJ, Don AS, Hurwitz EL, 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. 2009;34(21):2338-45. [DOI] [PubMed] [Google Scholar]
  • 68.Hur J-W. Long-term follow-up of disc degeneration after discography. Spine J. 2017;S121(10). [Google Scholar]
  • 69.Lipscomb KE, Sarigul-Klijn N, Klineberg E, et al. Biomechanical effects of human lumbar discography: in vitro experiments and their finite element validation. Clin Spine Surg. 2017;30(3):E219-25. [DOI] [PubMed] [Google Scholar]

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