SPINE Volume 34, Number 21, pp 2338 –2345
©2009, Lippincott Williams & Wilkins
2009 ISSLS Prize Winner: Does Discography Cause
Accelerated Progression of Degeneration Changes in the
Lumbar Disc
A Ten-Year Matched Cohort Study
Eugene J. Carragee, MD,* Angus S. Don, FRACS,* Eric L. Hurwitz, DC, PhD,†
Jason M. Cuellar, MD, PhD,‡ John Carrino, MD,§ and Richard Herzog, MD¶
Study Design. Prospective, match-cohort study of disc
degeneration progression over 10 years with and without
baseline discography.
Objectives. To compare progression of common de-
generative findings between lumbar discs injected 10
years earlier with those same disc levels in matched sub-
jects not exposed to discography.
Summary of Background Data. Experimental disc
puncture in animal and in vivo studies have demon-
strated accelerated disc degeneration. Whether intradis-
cal diagnostic or treatment procedures used in clinical
practice causes any damage to the punctured discs over
time is currently unknown.
Methods. Seventy-five subjects without serious low
back pain illness underwent a protocol MRI and an L3/4,
L4/5, and L5/S1 discography examination in 1997. A
matched group was enrolled at the same time and under-
went the same protocol MRI examination. Subjects were
followed for 10 years. At 7 to 10 years after baseline assess-
ment, eligible discography and controlled subjects under-
went another protocol MRI examination. MRI graders, blind
to group designation, scored both groups for qualitative
findings (Pfirrmann grade, herniations, endplate changes,
and high intensity zone). Loss of disc height and loss of disc
signal were measured by quantitative methods.
Results. Well matched cohorts, including 50 discogra-
phy subjects and 52 control subjects, were contacted and
met eligibility criteria for follow-up evaluation. In all
graded or measured parameters, discs that had been ex-
posed to puncture and injection had greater progression
of degenerative findings compared to control (nonin-
jected) discs: progression of disc degeneration, 54 discs
(35%) in the discography group compared to 21 (14%) in
the control group (P ⫽ 0.03); 55 new disc herniations in
the discography group compared to 22 in the control
group (P ⫽ 0.0003). New disc herniations were dispropor-
tionately found on the side of the anular puncture (P ⫽
0.0006). The quantitative measures of disc height and disc
From the *Stanford University School of Medicine, Stanford, CA; †De-
partment of Public Health Sciences, John A. Burns School of Medicine,
University of Hawaii at Ma៮ noa, Honolulu, HI; ‡NYU Hospital for
Joint Diseases, New York, NY; §Johns Hopkins University, Baltimore,
MD; ¶Hospital for Special Surgery, New York, NY.
Acknowledgment date: November 15, 2008. Acceptance date: January
15, 2009.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
Institutional funds were received in support of this work. No benefits in
any form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Eugene J. Carragee,
MD, Division of Orthopaedic Surgery, Stanford University, 300
Pasteur Drive, Room R171, Stanford, CA 94305; E-mail:
carragee@leland.stanford.edu
2338
signal also showed significantly greater loss of disc
height (P ⫽ 0.05) and signal intensity (P ⫽ 0.001) in the
discography disc compared to the control disc.
Conclusion. Modern discography techniques using
small gauge needle and limited pressurization resulted in
accelerated disc degeneration, disc herniation, loss of
disc height and signal and the development of reactive
endplate changes compared to match-controls. Careful
consideration of risk and benefit should be used in rec-
ommending procedures involving disc injection.
Key words: disc degeneration, discography, anular
puncture, complications. Spine 2009;34:2338 –2345
The iatrogenic causes of progressive disc degeneration in-
clude direct surgical trauma, iatrogenic disc infection, de-
generation next to a long segment fusion, etc. For many
years a model of disc degeneration has been used in animals
studies, which included the anular puncture of the disc.1– 4
In some large animal models, small needle gauge puncture
has not shown short-term changes,5 whereas other have.6
Nonetheless, small needle anular punctures, such as those
preformed in discography or intradiscal treatment proce-
dures, are common and controversial procedures.
Whether these intradiscal diagnostic or treatment
procedures cause any observable damage to the punc-
tured discs over time is currently unknown. Most prac-
titioners of these techniques estimate the risk of second-
ary degenerative change to be extremely remote.7–9
Patients exposed to discography have been followed
with plain radiographs without apparent morphologic
changes,10 but no MR images of a similar cohort have
been followed. Experimental discography, in volunteer
subjects without serious axial pain syndromes have been
performed by Holt,11 Walsh et al,12 Wood et al,13 Car-
ragee et al,14 –17 and Derby et al,18 among others. Early
analysis of some of these subjects has detected increased
back pain reported after discography, which attenuates
to apparent background levels over 1 or 2 years.15,19 This
effect was primarily seen in subjects with psychological dis-
tress at the time of the injection. However, no long-term
controlled, clinical, and imaging follow-up of discs exposed
to anular puncture and injection has been reported thus far.
The present matched cohort study was performed to
provide a definitive evaluation of the risk of progressive
disc degeneration and associated findings in subjects ex-
posed to a modern technique, 3-level discography proce-
dure using limited pressurization. This discography
 Discography and Lumbar Disc Degeneration • Carragee et al 2339
group was tested at baseline and compared up to 10-
years later, using a standard lumbar MRI grading proto-
col and experienced readers. By documenting MR
changes over time in this group compared to a closely-
matched control group exposed to the same baseline MR
and follow-up evaluations (excepting the discography in-
jections), the structural effects, if any, associated with the
injection could be investigated. We intended to analyze
these data to determine if there were clear differences in
progression of common degenerative findings between those
discs injected 10-years earlier compared to those same level
discs in matched subjects not exposed to discography.
Materials and Methods
Study Design
This is a prospective, matched cohort study to investigate the
morphologic effects of provocative lumbar discography on the
intervertebral disc. At 7 to 10 years after baseline MR imaging
of the lumbar spine, the progression of disc degeneration was
assessed in subjects undergoing provocative discography (L3–
S1) and compared to matched subjects having the same base-
line MRI evaluation.
Primary Hypothesis
Lumbar discography using modern techniques (small needle gauge,
pressure controls, antibiotics, and nonirritating contrast) will not be
associated with an observable increase in disc degeneration findings
on MRI 7 to 10 years after disc puncture and injection.
Subject Recruitment
Between 1997 and 1998, a cohort of 75 subjects were recruited
and enrolled in a study of discography (L3–S1) in persons
asymptomatic or minimally symptomatic for low back
pain.14,16,20 Subjects were recruited from 1 of 3 patient pools:
subjects having documented cervical disc disease (n ⫽ 40); sub-
jects having previous lumbar disc herniation with complete
symptom resolution (n ⫽ 25); and subjects with no history of
either cervical nor lumbar disc illness but who did have a his-
tory of serious psychological distress consistent with a somati-
zation disorder (n ⫽ 10). From the same 3 subject pools, 75
matched subjects who would not have discography performed,
were simultaneously recruited to act as control subjects: again
these were recruited in the same proportions from the previous
cervical disease (n ⫽ 40), previous symptomatic lumbar disc
herniation (n ⫽ 25), and somatization groups (n ⫽ 10). These
subjects were matched to age, sex, and previous cervical or
lumbar disc troubles, and psychometric profiles, and had the
same baseline evaluations (LBP questionnaires, psychometric
questionnaires, radiographs, and MRI scan) with the sole ex-
ception of the provocative discography (L3–S1).
After the baseline evaluations, 75 discography subjects were
scheduled to undergo lumbar discography (L3–S1). The results
of these studies have been previously reported.14,16,20 Discog-
raphy and control subjects were then followed at intervals for
clinical low back pain problems. Clinical low back pain prob-
lems up to 5 years after enrollment in these discography and
control subjects has previously been reported.19,21
At 10 years after the start of the study, discography subjects
and controls were contacted. If subjects had received a high-
quality lumbar MRI more than 7 years after the discogram,
these were obtained and compared to the baseline MRI. If no
MRI had been performed for clinical reasons, or if the MRI
obtained was not consistent with the protocol for MRI reading,
subjects were asked to undergo a new MRI at Stanford Univer-
sity School of Medicine. (See Follow-up MRI Collection).
Baseline Entry Criteria
The detailed entry criteria were described in each previous
study.14,16,20 All subjects were screened for current low back
problems using a screening questionnaire and the Oswestry
Disability Index. Where subjects were involved as patients or
subjects of concurrent studies, the original medical charts, di-
agnosis criteria, or study questionnaires were examined to con-
firm the absence of significant LBP symptoms. Inclusion criteria
required that subjects were not receiving or seeking medical
treatment for LBP, be taking no medications for backache, and
have no activity restrictions because of LBP. Of the subjects
with minimal back pain and those recruited after lumbar disc-
ectomy, there was a further criterion that subjects have normal
psychometric scores. Approval was obtained from the institu-
tional review board and the Administrative Panel of Human Sub-
jects in Medical Research according to US Department of Health
and Human Services regulations at Stanford University School of
Medicine. Informed consent according to University and US De-
partment of Health and Human Services guidelines was obtained
from all prospective participants at the original studies.
Psychometric Studies
A Modified Zung Depression Test, Modified Somatic Pain
Questionnaire (full score) (MSPQ), and Medication Scales
were administered to each patient as a routine intake step. Both
the Zung Depression Test and the MSPQ are validated tests.22
Discography
The discography protocol that was used in these studies was uni-
form across all study groups. The discographer with more than
10-years experience and an average of 50 to 100 discography
examinations per year performed all the injections. The discogra-
pher and his assistant/observer were blinded to the group assign-
ments and performed all discography on a mix of asymptomatic
volunteers and active clinical patients with serious low back pain.
Similarly, the assistants/observers who graded the response to in-
jections were also blinded to whether the injection was performed
on an active clinical patient or an asymptomatic volunteer. The
side of needle entry (right or left) was determined by the predom-
inant site of pain in the active clinical LBP patients; whereas in the
asymptomatic volunteers, research assistants randomly assigned
the side by random number sequence, immediately before the
discography. Pressure measurements were made during the injec-
tion indicating continuous recordings in pounds per square inch
on a manometer, with each 0.5 mL of the injection (Hewlett-
Packard, Palo Alto, CA). A pressure relief valve set at 100 psi
limited the maximum possible injection pressure to this level. The
lowest static pressure (relative to the opening pressure) associated
with a pain response was noted. In those subjects without pain on
injection, the highest static pressure was recorded. The criteria for
pain response, pain behavior, and determining a “positive” injec-
tion was the same as used in the original work of Walsh et al12 A
“low pressure” positive injection met these criteria with a static
pressure of less than 22 psi when pain was provoked.23 In all
subjects, a negative “control” disc was required to determine a
“positive” finding.
Follow-up MRI Collection
Discography and control group subjects were contacted at 10-
years after the baseline testing. An independent research assis-
2340 Spine • Volume 34 • Number 21 • 2009
tant (EvdH) who was blinded to patient baseline data conducted
scripted telephone interviews, This examiner had no knowledge
of control or discogram status and was not involved in the study
design. The interview was conducted by telephone, including an
interval medical history, interval lumbar imaging studies history,
occupational history, medication usage, serious injury history and
spinal procedure history since the last (5-year) follow-up record.
Subjects were enrolled for 10-year follow-up MRI evaluation un-
less they were noted to have one or more of the following exclu-
sion criteria: subjects were excluded if since the baseline evalua-
tion they had a history of new lumbar spine fracture or
dislocation; interval lumbar spine surgery or intradiscal therapy of
any type; another lumbar discogram; lumbar infection or tumor;
new rheumatic disease diagnosis which required treatment; or was
unable to have a new MRI due to imaging contraindications (e.g.,
cardiac pacemaker, ocular injury, etc.). If subjects had received an
MRI of the lumbar spine during the last 3 years, and that MRI met
the analysis protocol, that scan was used in lieu of another MRI at
the 10-year point.
MRI Protocols
All baseline images were obtained from one center. All 10-year
follow-up studies by protocol were obtained from the same
center and used the same protocol as the baseline examina-
tions.24,25 MR images performed for clinical indications (back
or leg pain) were acquired from several clinical practices when
done before the 10-year protocol examination; as a result, vari-
able MR imaging techniques were performed in a minority of
studies. However, all MR imaging protocols had the following
pulse sequences in common: T1-weighted sagittal conventional
spin echo, T2-weighted sagittal fast spin echo (FSE) or turbo
spin echo without or with fat suppression, and T2-weighted
axial fast spin echo/turbo spin echo parallel to the interverte-
bral disc. All baseline and follow-up images were collected
electronically and stored directly as DICOM files. All images
were deidentified for patient confidentiality and readers were
blind to discography versus control status of the subjects.
All lumbar levels (i.e., 5 discs, L1–S1) were scored for qual-
itative and quantitative findings of disc degeneration, disc con-
tour changes, anular disruption, and endplate changes by the
protocol below.
Comparisons
The primary comparison was between the progression of de-
generative findings in the injected discs (L3–S1) of the discog-
raphy group compared to the progression in same levels in the
matched control group.
Secondary comparison between groups was made for the
noninjected levels (L1–L3) to determine whether the rate of
degeneration in the noninjected discs was otherwise similar
between groups independent of the discography intervention at
lower levels.
Within the discography group, progression of disc findings
was analyzed for correlation with (1): with the size of the nee-
dle puncture (22 vs. 25 gauge) (2); whether the disc injection
had been painful; and (3) whether degeneration changes (e.g.,
disc protrusion) appeared to be greater on the side ipsilateral to
the needle puncture.
Quantitative Image Evaluation. Quantitative measurements of
disc height and disc signal intensity was performed using the
method described by Videman et al.26 Disc signal intensity was
determined relative to the adjacent CSF signal. Interval signal
change is expressed as the percentage signal change com-
pared to the baseline images (i.e., signal loss is recorded as a
negative percentage, brighter signal at follow-up is recorded
as a positive percentage).
Qualitative Image Evaluation. The observers for the qualita-
tive and semiquantitative evaluation were four physicians ex-
perienced in spine MRI interpretation (2 radiologists and 2
orthopedic spine surgeons). Similar training on this grading
system was provided to all examiners. A handbook containing
standardized definitions of imaging characteristics with picto-
rial and diagrammatic examples was provided to each reader.
Definitions were derived from the literature or by consensus
when no relevant publication was available. This MR reading
protocol has been previously described and has acceptable inter
and intrarater reliability.24,25 Before study initiation, readers
evaluated a sample set of images and met to review images and
refine the standardized definitions.
All MR images were graded by 2 examiners for findings at the
lowest 5 disc segments. If there was disagreement in grading, the
images were independently regraded by 2 additional “tie-
breaker” examiners. If these were both consistent with one of the
original grades, this grade was accepted. If disagreement still
existed between the 2 “tie-breaker” examiners, a consensus read-
ing would be obtained with at least 3 examiners reviewing the films
together.
The spine MR imaging findings assessed were the following:
disc degeneration, disc herniation, marrow endplate abnormal-
ity (Modic changes), intervertebral disc posterior, posterior-
lateral or foramenal anular hyperintense zone, disc height, and
relative signal intensity compared to the adjacent CSF.
Image interpretation was recorded using a standardized
data collection form prompting the reader to select from mul-
tiple choice lists of findings for imaging characteristics at each
intervertebral disc level. This method of qualitative grading of
common degenerative findings has previously been evaluated
for inter-rater and intrarater reliability.24,25 Classification of
disc morphology by this method showed substantial intra- and
inter-reader agreement (kappa 0.81). 3 of the readers (EC, JC,
RH) in the current study participated as readers in the Lurie et
al study, and have had extensive experience with this method.
The other reader was trained in the same fashion as the readers
in the Lurie et al study.
Disc degeneration grade was ranked on a 5-level ordinal
scale as described by Pfirrman et al in 2001.27 The type of
endplate marrow abnormality was designated using the Modic
classification for simplicity of reference.28 Each vertebral level
was scored by the dominant Modic change. Semiquantitative
assessment of extent of endplate marrow signal alteration was
performed for each endplate involved above (inferior) and be-
low (superior) a specified intervertebral disc level. The observer
assessed the amount of signal alteration from anterior-
posterior (AP): less than or equal to 50%, or greater than 50%;
and cranial-caudal (CC): less than 25%, 25%–50%, or greater
than 50%). A hyperintense zone (HIZ) was defined based on
the original description as an area of bright signal intensity in
the posterior anulus that is brighter than nucleus on T2-
weighted images.29 The location of the HIZ was designated as
central, posterolateral, or foraminal (as well as right and left if
not central). Presence of an anterior HIZ was not assessed. Disc
herniation was graded as focal protrusion, broad protrusion,
extrusion and sequestration. Herniations were also graded for
location (central, paracentral, foraminal, and far-lateral), right
and left sided, and root displacement or compression.24
 Discography and Lumbar Disc Degeneration • Carragee et al 2341

Figure 1. Subject flow chart.

Statistical Methods is, all 52 discography subjects and 50 control subjects

Descriptive statistics were used to summarize patient socio- had MRI available for comparison (100% enrollment of
demographic and MRI characteristics measured at baseline, remaining eligible subjects) (Figure 1).
and at follow up. Means, standard deviations, and medians
were calculated for continuous variables; frequency distribu- Baseline Clinical and Demographic Characteristics of
tions were generated for categorical variables. Comparative the Study Population
between group analysis of categorical MRI findings (disc grade, The baseline demographic as well as clinical characteris-
HIZ, herniation, and Modic changes) used a ␹2 test. Compar- tics of the discography and controls subjects are given in
ative between group analysis of continuous, normal distribu- Table 1. These are well matched without important dif-
tion data (disc signal intensity and disc height) was performed ferences between groups. The subjects lost to follow-up
using a student t test. StatView statistical program (SAS Insti- did not appear to differ in baseline characteristics from
tute, Cary, NC) was used for all analyses.
the subjects completing the study.
Results Reader Agreement
Of 75 discography subjects, 71 completed the baseline There was agreement in qualitative findings scores be-
evaluation: 4 subjects in the somatization group refused tween the initial 2 reviewers in 95 of 102 subjects. These
the disc injection and 1 also could not complete the MRI. remaining seven scans were then evaluated by 2 addi-
Of the 75 control subjects, 73 completed the entire base- tional readers and reviewed for analysis of 18 discrepant
line evaluation; 2 subjects in the somatization group findings in these seven scans. In all but 3 findings, these 2
could not tolerate the MRI scanner. At 10 years after the
baseline assessment, 57 of 71 discography subjects
(80.3%) and 54 of 73 control subjects (74.0%) were Table 1. Demographic and Clinical Data of Control,
Discography, and Excluded/Lost Study Subjects
successfully contacted. After the scripted medical inter-
view, 5 discography subjects were excluded (all had un- Discography Control
dergone new lumbar surgery before 7 years follow-up) Group Group Exclusion/Lost
and 4 control subjects were excluded (1 had died, 1 had
n 52 50 48
new lumbar surgery before 7 years follow-up, 1 had sus- Age 40.2 41.1 39.9
tained a high-energy L2 burst fracture, and 1 had new Sex (male) 74% 75% 75%
onset psoriatic spondyloarthropathy), leaving 52 discog- Weight 77.1 76.4 77.4
Height 173 175 172
raphy subjects and 50 control subjects eligible for the Prior microdiscectomy 8 7 5
follow-up MRI study. Occupational lifting
During the 3 years before final follow-up, acceptable Light 22 19 18
Medium 16 18 16
new lumbar MR images had been performed and were Heavy 14 13 14
available for 13 discography subjects and 8 control sub- Start smoker 21 24 25
jects. New MR imaging was performed on the remaining Final smoker 18 17 Not applicable
Time to MRI 8.7 8.9 Not applicable
subjects who had not received a recent clinical scan; that
2342 Spine • Volume 34 • Number 21 • 2009

Table 2. Baseline and Follow-up MR Findings for L3/4, Table 3. Baseline and Follow-up MR Findings for
L4/5, and L5–S1 Discs in Discography and Control Discs Noninjected L1/2 and L2/3 Discs in Discography and
Control Subjects
Baseline* Follow-Up
Baseline* Follow-Up*
Discography Control Discography Control P†
Discography Control Discography Control
n 155 150 155 150
Degeneration n 100 100 100 100
grade Degeneration grade
DDD grade 91 85 50 68 0.03 DDD grade I–II 44 41 37 36
I–II DDD grade III–IV 39 40 41 39
DDD grade 48 53 76 66 DDD grade V 17 19 22 25
III–IV Herniation
DDD grade 16 12 29 16 Broad based 6 4 9 8
V Focal (C, PC) 9 7 11 10
Herniation Focal (F, FL) 7 8 9 11
Broad based 15 16 33 21 0.1 Extrusion 1 1 1 1
Focal (C, PC) 17 15 26 21 0.5 New herniation — — 7 6
Focal (F, FL) 12 13 30 18 0.07 High intensity Zone 2 0 2 (1 new) 1 new
Extrusion 3 2 13 8 0.29 Modic changes 3 4 5 6
New herniation — — 55 22 0.00003 Disc height (SD) 8.54 (0.9) 8.29 (1.1) 8.17 (.8) 8.01 (1.7)
High intensity 13 14 17 (10 new) 13 (4 new) 0.1 Disc signal loss (%) — — ⫺7.71% ⫺7.52%
zone
Modic changes 10 12 29 16 0.04 *No statistical difference found for baseline values between Discography and
Disc height 10.47 (1.3) 10.56 (1.1) 8.93 (1.7) 9.90 (1.3) 0.05 Control groups.
DDD indicates degenerative disc disease Pfirrmann Grade; C, central protru-
(SD)
sion; PC, paracentral; F, foramenal; FL, far lateral.
Disc signal — — ⫺13.28% ⫺8.46% 0.001
loss (%)
*No statistical difference found for baseline values between discography and
control groups. Progression of Disc Degeneration at L1–L3
†P value comparing follow-up findings discography group compared with
control group. (Noninjected Levels) in Discography and
DDD indicates degenerative disc disease Pfirrmann Grade; C, central protru- Control Subjects
sion; PC, paracentral; F, foramenal; FL, far lateral.
Comparing the upper lumbar discs (L1/2 and L2/3) in
both groups (none of which had discography punctures
or injection), there was no apparent difference in quali-
additional reviewers agreed with one of the original read- tative progression of disc degeneration grades, the inci-
ers. The remaining 3 items were scored by a consensus dence of new disc herniation, endplate changes or anular
reading involving 3 graders (EJC, JC, RH) by conference. fissures. The loss of disc height and disc signal appeared
similar in both groups at these noninjected levels (Table 3).
Progression of Disc Degeneration at L3–S1 in the Impact of Needle Size
Discography and Control Subjects There were 134 needle injections with a 25-gauge needle
Table 2 shows the interval findings in the discography and 21 injections with a 22-gauge needle. No statistical
group compared to the control group for the L3–S1 differences were found in the progression of degenera-
discs. In all graded or measured parameters, discs which tion findings between these 2 groups, although there was
had been exposed to puncture and injection had greater a trend to greater degeneration in the discs punctured
progression of new degenerative findings. with a 22-gauge needle. This analysis is limited by small
There was progression of disc degeneration from nor- numbers of injections using the larger bore needle.
mal (Grade 1 and 2) or from moderate (Grade 3 and 4)
Side of Injections
degeneration in 54 discs (35%) in the discography group
There were 34 new disc herniation on the ipsilateral side
compared to 21 (14%) in the control group (P ⫽ 0.03).
of the disc injection, 14 on the contralateral side and 4
There were 55 new disc herniations of all types in the
central disc herniations, reflecting a strong statistical asso-
discography group compared to 22 in the control group
ciation of new pathology to the side of disc injection (␹2 P ⫽
(P ⫽ 0.0003). Notably, foramenal and far-lateral disc
0.0006). Furthermore, the new pathology seemed to be
herniations, at the site of anular puncture in the discog-
greatest in the foramen and far lateral regions, ipsilateral to
raphy group, appear to show the greatest difference be-
the injection (i.e., at the expected side of needle entry). In
tween groups.
the control group there did not appear to be any difference
Similarly there were more new endplate signal
(in right or left sided occurrence of disc herniation (10 on
changes (P ⫽ 0.04) and anular fissures with bright signal
the right and 11 on the left) (Table 4).
(P ⫽ 0.1) in the discography group compared to the
controls. The quantitative measures of disc height and Painful Disc Injection
disc signal also showed significantly greater loss of disc There were 32 painful disc injections and 273 negative
height (P ⫽ 0.05) and signal intensity (P ⫽ 0.001) in the disc injections during the baseline discography evalua-
discography disc compared to the control disc. tions. There did not appear to be a greater frequency of
 Discography and Lumbar Disc Degeneration • Carragee et al 2343

Table 4. New Disc Herniation Findings at Follow-up as period of time. For instance, of 91 grade I or II discs at
a Function of Right or Left Side (for Control Subjects) the time of injection, 50 remained at the Grade I or II
and Ipsilateral Side of Injection or Contralateral Side of level (normal) even 10 years after the disc puncture.
Injection (for Discography Subjects)* Nonetheless, the comparative results are striking. In
Control Discography every qualitative parameter measured (herniation, end-
plate changes, disc grade progression and anular fissures)
Right Left Ipsilateral Contralateral the discography group showed more frequent and
Herniation
greater degenerative findings compared to a well-
Broad based 2 2 9 4 matched control group. Quantitative measures of loss of
Focal (PC) 2 3 6 3 disc height and loss of disc signal were also clearly
Focal (F, FL) 2 4 9 4
Extrusion 1 1 7 3 greater after anular puncture and injection. The finding
All new herniation 9 12 36† 14† that new herniations were most frequently located on the
*Herniations graded as “central” are not included in this analysis (as these are side of disc puncture and that the greatest difference in
neither right or left sided). herniation between groups was foramenal and far-lateral
†␹2 P value comparing findings of ipsilateral to contralateral injection sites ⫽ 0.0006.
No control group comparisons are statistically significant at the 0.05 level. herniations suggest at least some specific local injury and
C indicates central protrusion; PC, paracentral; F, foramenal; FL, far lateral. sequelae.
These finding are of concern for several reasons. Dis-
cography as a diagnostic test is controversial and in view
disc degeneration progression, disc herniation, or new of these findings the utility of this test should be re-
anular fissure findings in injections that were painful viewed.30 Furthermore, discography in current practice
with injection when compared with those discs without will often include injecting discs with a low probability
significant pain on injection. (Table 5) In fact, there was of being symptomatic in an effort to validate other disc
a trend toward more frequent new foramenal or far- injections, a so-called “control disc.”8,9 Although this
lateral protrusions in the discs that were not significantly strategy has never been confirmed to increase test valid-
painful on the baseline injection. ity or utility, injecting normal discs even with small
Discussion gauge needles appears to increase the rate of degenera-
tion in these discs over time. The phenomenon of accel-
Disruption of the anulus using a needle puncture appears erated adjacent segment degeneration adjacent to fusion
to be a reliable method to induce experimental disc de- levels may be, in part, explained by previous disc punc-
generative findings in animals.2– 4 In general this has in- ture if discography was used in segments adjacent to the
volved a large bore needle puncture in a relatively small fusion. To our knowledge the potential contribution of
disc, resulting in rapid and near universal disc disrup- previous discography to adjacent segment disease has
tion. Recent experimental work suggests that even small not been well considered.
gauge needle punctures in large discs may trigger delete- Similarly, intradiscal therapeutic strategies (injecting
rious effects with time.6 steroids, sclerosing agents, growth factors, etc.) have
Our findings from this study appear to indicate that been proposed as a method to treat, arrest or prevent
small bore needle puncture and limited pressure injec- symptomatic disc disease. Our finding would suggest
tion, can clearly cause an increase in progression of de- that the injection procedure itself is not completely in-
generative findings. However, these findings are not al- nocuous and a recalculation of these demonstrated risks
ways seen and, when seen appear to develop over a long versus hypothetical benefits should be considered. Fi-
nally, alternative or novel strategies for the introduction
of intradiscal agents, as opposed to mechanical puncture
Table 5. Progression of Disc Degeneration or New MR
Findings in Discs in Which Injection Was Reported to be and injection, should be considered in developing future
Painful With the Baseline Discography Examination and strategies for early disc interventions.
Those With Little or No Pain With Injection The mechanism of action by which the baseline discog-
raphy may have caused the changes seen 10 years later is
Disc Injection unclear. Animal work has stressed both the mechanical in-
Disc Injection Not Painful
Painful (VAS 0, 1 or 2) jury to the anulus1,4,31,32 as well as secondary biochemical
and cellular processes.6,33 The activation of cytokine path-
N % N % ways and production of degeneration products as previ-
n (discs) 32 18.8% 273 17.9%
ously reported might all be at work.2,34,35 Andersson et al,
Progression DDD grade 6 3.1% 49 2.9% however, have stressed that disc puncture is a fundamen-
New focal protrusion (C, PC) 1 6.3% 8 5.9% tally artificial process and which likely differs from native
New focal protrusion (f, fl) 2 0.0% 16 6.6%
New broad based protrusion 0 3.1% 18 3.3% degeneration in some respects.36
New extrusion 1 6.3% 9 2.9% There are several limitations to this study. Subjects
HIZ 2 37.5% 8 39.6% were recruited predominantly from a pool of patients
Total 12 18.8% 108 17.9%
with a greater than average risk of disc degeneration (i.e.,
C indicates central protrusion; PC, paracentral; F, foramenal; FL, far lateral.
most had a history of previous cervical or lumbar disc
2344 Spine • Volume 34 • Number 21 • 2009
herniation). The results here may not be generalizable to
a population with high genetic resistance to the degener-
ation process or exceptionally low exposure to environ-
mental factors promoting degeneration. Nonetheless,
most patients in whom disc injections are contemplated
are necessarily in a high-risk group.
Another limitation may be the design with only a
baseline and 10 year MR evaluation. With only 2 data
points, the kinetics of disc degeneration cannot be es-
timated. We do note, however, that even by the 7 year
mark, the discography group already had more clinical
evaluations with MRI for lumbar problems and had
also had more lumbar surgery than the control group
(five vs. one). A comprehensive clinical evaluation of
these discography and control subjects is currently un-
derway, and will be the subject of a future publication.
Despite these limitations we feel our findings are
real and reproducible. Disc puncture with even a small
gauge needle and limited injection pressures appears
to be associated with accelerated disc degenerative
processes, disc herniation, loss of disc height and sig-
nal and the development of reactive endplate changes
compared to match-controls. We believe, careful con-
sideration of risk and benefit should be used in recom-
mending procedures involving disc puncture for diag-
nostic or therapeutic purposes unless clear and
demonstrable utility has been established.
Key Points
● Discography using modern small needle disc
puncture resulted in accelerated disc degen-
eration over 10-year follow-up compared to
matched controls.
● Qualitative MR findings of new disc herniation,
new endplate changes, and progression of disc de-
generation grade were all found more frequently in
discs exposed to disc injection.
● Quantitative MR findings of disc height loss and
nuclear signal loss were also greater in the discs
exposed to disc injection.
● New MR findings for disc herniation were dis-
proportionately found on the side of the disc injec-
tion compared to the contralateral side.
● Careful consideration of risk and benefit
should be used in recommending procedures in-
volving disc puncture for diagnostic or therapeu-
tic interventions.
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