Lumbar Discography – Indications, Procedure and Inference

Last Updated on May 19, 2025

Lumbar discography is a diagnostic procedure that involves instilling iodinated contrast into the nucleus pulposus after inserting a needle under fluoroscopy.

The goal is to visualize internal disc morphology and to determine whether a specific disc is the source of a patient’s pain.

This technique is typically used in cases of chronic low back pain where standard imaging (such as MRI or CT) does not clearly identify the symptomatic disc.

By provoking pain and capturing detailed internal contrast patterns, discography can help distinguish between painful and non-painful discs.[1]

Although its role is controversial and not routinely indicated for all back pain cases, discography remains a valuable tool in select patients, particularly when surgical intervention is being considered and the pain source is unclear.

Thus, lumbar discography not only defines the anatomical architecture of the disc but also tells whether a particular disc is painful.

Relevant Anatomy and Pathophysiology

The lumbar spine consists of five vertebrae (L1–L5), each separated by an intervertebral disc that functions as a shock absorber and allows for flexibility. Each disc is composed of [2]

• Annulus fibrosus: A tough outer ring of concentric collagen fibers.
• Nucleus pulposus: A gelatinous core that distributes axial loads.
• Vertebral endplates: Cartilaginous structures that anchor the disc to the vertebral bodies and mediate nutrient exchange.

Disc innervation is primarily limited to the outer annulus, supplied by the sinuvertebral nerve and branches of the ventral rami. As a result, disc degeneration or internal disruption can cause pain when the inner disc becomes exposed to innervated regions.

[Read the detailed anatomy of the spine]

The posterior half of the vertebra consists of the spinous process, and the lamina and pedicles connect the posterior and anterior portions.

Thus vertebra is anteriorly connected to the adjacent vertebra via a disc whereas posteriorly, facet joints act as the connectors.

 The intervertebral discs are approximately 7–10 mm thick and 4 cm in diameter in the lumbar region.

Pathophysiology of Discogenic Pain

The degeneration process leads to disc dehydration and desiccation of the nucleus. Often, it is not symptomatic.

Weakening and tearing of the annulus occur due to repetitive loading and degeneration. This causes nuclear material to touch the passing nerve roots, causing pain. Disc herniation may occur, releasing inflammatory factors.

The stimulation of pain receptors in the posterolateral annulus, ligamentum flavum, and posterior longitudinal ligament may cause pain of discogenic origin.

Therefore, the pathophysiology of disc pain involves

• Degeneration of the nucleus pulposus and annular fissures
• Mechanical stress on pain-sensitive structures (e.g., posterior longitudinal ligament)
• Release of inflammatory mediators that stimulate nociceptors

In many cases, MRI may show disc desiccation or bulges, but these findings do not always correlate with pain. Lumbar discography combines anatomic visualization with provocation testing to identify symptomatic discs.

Basis of Lumbar Discography

Lumbar discography is a provocative diagnostic procedure used to identify discs that may be the source of chronic low back pain, especially when imaging findings (such as MRI) are inconclusive. [1]

Unlike MRI or CT, which provide anatomical imaging, discography directly tests whether a specific disc is pain-generating by applying pressure to it using contrast injection under fluoroscopic guidance.

Pain that matches the patient’s usual symptoms (concordant pain) strongly suggests that the injected disc is the primary pain generator.

Mechanisms Behind Pain Provocation are [1]

• Increased Intradiscal Pressure: When contrast is injected into the nucleus pulposus, pressure builds up inside the disc. If the disc is damaged or chemically inflamed, this pressure can provoke pain.
• Neurochemical Stimulation: Damaged discs may release inflammatory mediators. Pressurizing the disc can amplify this irritation, triggering pain via chemical pathways.
• Endplate Deflection and Annular Disruption: Degenerated or fissured annular fibers may respond to pressure by stimulating nociceptors (pain receptors) within the outer annulus or nearby ligaments.
• Reproduction of Concordant Pain: Pain that matches the patient’s usual symptoms (concordant pain) strongly suggests that the injected disc is the primary pain generator.

Clinical Utility of Discography

Discography is not performed routinely. It is used selectively when surgery is being considered and when no clear cause of pain has been found through conservative means or imaging. [1]

Its value lies in confirming whether a specific disc is responsible for the patient’s symptoms.

Discography also enables evaluation of disc morphology, internal architecture (annular tears, radial fissures), and pressure tolerance, all of which influence the treatment plan.

Indications of Lumbar Discography

For the latest insurance and guideline-based criteria, see the update section at the end.

It should be noted, though, that in most cases, clinical examination and magnetic resonance imaging can identify the offending disc with sufficient certainty, and discography is not routinely needed.

Lumbar discography should be performed only if adequate attempts have failed to reveal the etiology of the back pain.

Thus, lumbar discography is a selective diagnostic tool, reserved for cases where conventional imaging and conservative treatments have failed to explain persistent back pain. Its main purpose is to determine whether a specific intervertebral disc is the source of pain.

General Criteria

Discography should only be considered when all of the following are met-

• Chronic low back pain lasting more than 3 months
• Failure to improve with adequate conservative treatment (e.g., physiotherapy, medications)
• No evidence of:
  • Spinal stenosis
  • Infection
  • Tumor
  • Clear disc herniation with radiculopathy
• Surgery is being contemplated (e.g., spinal fusion or disc replacement) [1]
• Other sources of pain (facet joints, sacroiliac joints) have been reasonably ruled out and pain is likely to be discogenic [2]

Specific Indications:

• Severe, persistent low back pain with no obvious cause on MRI, but clinically suspected to be discogenic
• Preoperative planning before lumbar fusion or disc arthroplasty to confirm the symptomatic disc(s)
• Postoperative failed back surgery syndrome, to assess the integrity and whether the pain source is in previously operated levels or adjacent segments
• Multilevel disc degeneration, where it is necessary to isolate the single pain-producing level
• Discrepancy between clinical symptoms and imaging — e.g., patient has intense pain but MRI appears normal or inconclusive

{Read – What is Failed Back Surgery]

Contraindications

Absolute Contraindications

• Infection: Active systemic infection or local infection at the needle insertion site (e.g., cellulitis, abscess)
• Allergy: Known allergy to contrast media
• Bleeding Disorders:
  • Bleeding disorders or coagulopathy (e.g., thrombocytopenia, hemophilia)
  • Patients on anticoagulation therapy without proper withdrawal (e.g., warfarin not stopped in time)
• Pregnancy: Due to radiation exposure during fluoroscopy
• Noncooperative Patient: Inability to cooperate during the procedure — For example, severe anxiety, pain intolerance, or physical disability preventing proper positioning
• Severe spinal canal compromise: Increases the risk of neurologic injury

Relative Contraindications:

• Severe psychiatric illness or somatization disorders — as pain perception and response during discography may be unreliable
• Immunosuppressed Patients: Uncontrolled diabetes or immunosuppression, which raises the risk of infection
• Poor candidate for surgery — if the outcome of discography is unlikely to alter clinical management, the procedure may be unnecessary

How is Lumbar Discography Done

Lumbar discography is a fluoroscopy-guided, contrast-enhanced diagnostic test.

Pre-procedural Steps

• Clinical preparation includes full history taking, pain diagram analysis, assessment of allergy status (especially to contrast media), and cessation of anticoagulants as per protocol (e.g., stop warfarin 5 days prior).
• Informed consent must be obtained, explaining potential risks such as infection, pain flare-up, or disc injury.
• Prophylactic antibiotics may be given depending on institutional practice.
• Sedation is avoided unless necessary — the patient must be awake to describe pain characteristics. Mild anxiolytics may be used in selected cases.

Patient Positioning

The posterolateral approach is most commonly used. Patient lies in a lateral decubitus position, slightly rotated forward (~45° to the bed).

Fluoroscopic guidance is used to visualize disc space alignment in both anteroposterior and lateral views.

Needle Insertion

• After cleaning the area with povidone-iodine or chlorhexidine, local anesthesia (1% lidocaine) is infiltrated through the skin and soft tissue.
• A 3.5-inch 18G spinal needle is inserted through the anesthetized tract, directed toward the disc using fluoroscopy.
• A 22G spinal needle is passed through the outer needle into the nucleus pulposus. The final needle tip position must be:
  • Centered in the disc in AP view
  • Midline in the sagittal view
• Slight resistance is expected at the annulus. If the bone is struck, reposition gently.

Contrast Injection and Pain Assessment

• A non-ionic iodinated contrast medium (e.g., iopamidol or iodohexol) is injected slowly using a pressure syringe.
  • In patients with known contrast allergies, iso-osmolar agents like iodixanol may be considered.
  • Gadolinium-based contrast agents have also been explored for patients with iodinated contrast hypersensitivity.
• Parameters noted include
  • Opening pressure
  • Pressure at the onset of pain
  • Maximum pressure tolerated
• The patient is asked to report:
  • Pain presence
  • Pain intensity
  • Location and radiation
  • Whether the pain is concordant (matches usual pain) or discordant (unrelated)
• Pain scores are recorded using a verbal rating scale.

Pain Response Code	Description
P0	No pain
P1	Partial concordance
P2	Discordant pain
P3	Concordant pain

Videotaping during discography involves both disc injection phases, and the patient’s facial expression can help the surgeon determine the response and mannerisms. Exaggerated pain mannerisms may suggest poor surgery-related outcomes.

Attention should be paid to note whether the pain is similar to or exactly like the symptoms for which the patient seeks relief. The location of the pain and its intensity should be noted.

Inference

• Degenerated disc: Demonstrates annular tears or radial fissures. Extravasation of contrast beyond the nucleus pulposus indicates annular disruption.
• Normal disc: Shows central pooling of contrast without radial spread.

Volume and Resistance

• High-volume, low-resistance filling: Suggests internal derangement, annular tear, or advanced degeneration.
• Low-volume, high-resistance: Often associated with healthy or mildly degenerative discs.

Patient Feedback and Documentation

The patient’s facial expressions, verbal cues, and response timing are important. Some centers record the entire procedure for later review of patient reaction (especially useful when surgical decisions hinge on concordance).

Overall

Pain at low pressures is mostly due to chemical irritation. If low resistance is encountered, a tear through the annulus should be suspected. Pain at high pressures is generally due to mechanical irritation, end-plate deflection, or stimulation of pressure receptors.

If a large volume of contrast can be injected, the disc has degenerated or there is a fissure extending through the outer annular wall.

Complications of Lumbar Discography

Complications are relatively uncommon, but lumbar discography carries some notable risks.

Infectious Complications

• Discitis: It is the most serious complication. It may require IV antibiotics or surgical intervention.
• Neurological Risks: Nerve root irritation or injury, spinal cord damage (rare, usually due to technical error)
• Intradural injection: Accidental dural puncture may lead to headache or more serious complications due to CSF leak.
• Exacerbation of existing symptoms
• Contrast-Related Reactions: Urticaria or allergic response, nausea, vomiting, hypotension (rare, vasovagal)
• Disc herniation (rare)
• Retroperitoneal hemorrhage (especially in anticoagulated patients
• Post-procedural pain flare-ups

According to Carragee and colleagues, overuse of discography in poorly selected patients may lead to unnecessary surgeries or long-term complications, underscoring the importance of patient selection and interpretation [1].

Summary

Lumbar discography provides both anatomical and functional insight by assessing disc morphology and eliciting pain responses that may correlate with the patient’s symptoms.

The procedure is most valuable when other diagnostic modalities like MRI are inconclusive, especially in patients being considered for surgical intervention. Discography can distinguish symptomatic from asymptomatic discs through pressure-pain correlation and contrast patterns.

Discography is invasive and carries risks such as discitis, nerve injury, and exacerbation of symptoms. Therefore, it should be performed with strict sterile technique and interpreted in conjunction with clinical, imaging, and psychosocial evaluations.

In experienced hands and with judicious use, lumbar discography remains a useful adjunct in the comprehensive assessment of chronic low back pain.

Discography is a provocative test. It may worsen symptoms temporarily or cause disc injury in rare cases. Hence, it should only be performed when it will meaningfully impact decision-making.

Latest Updates in Lumbar Discography: Recommendations and Controversies

Recently, some authors have suggested revised guidelines for indications of lumbar discography,

According to Anthem clinical utilization medical guidelines, Jan 2025, discography can be considered medically necessary when all of the following are present [5]

• Unrelenting pain that has persisted for > 3 months
• Pain has not responded to conservative therapy (drugs, physical therapy)
• Noninvasive diagnostic studies have failed to provide sufficient diagnostic information regarding the origin of pain
• There is no evidence of contraindications such as severe spinal stenosis resulting in intraspinal obstruction, infection, or predominantly psychogenic pain.

In addition to those listed above, at least ONE of the following indications must be present-

• A high index of suspicion for discogenic pain, and the pain is severe enough to consider surgical intervention
• For failed back surgery individuals, to distinguish between painful pseudoarthrosis or a symptomatic disc in a posteriorly fused segment.

Otherwise, lumbar discography is considered not medically necessary.

According to Evicore spinal imaging guidelines (Feb 20250, the following uses of discography are considered controversial [6]

• To identify a symptomatic pseudoarthrosis in a failed spinal fusion
• To identify which of the two herniated discs seen on MRI is symptomatic when not determined clinically or otherwise
• To confirm the discogenic nature of pain when an abnormal disc is seen on MRI and to rule out pain from an adjacent disc level
• To confirm the presumptive diagnosis of “internal disc disruption”

Evocore considers the use of discography in the cervical and thoracic areas as controversial.

Frequently Asked Questions

Is lumbar discography painful?

Yes, it can be. The procedure involves intentionally pressurizing the disc to provoke pain. However, the goal is to replicate the patient’s typical pain, which helps identify the problematic disc. Local anesthesia is used to reduce discomfort during needle placement.

How long does the discography procedure take?

The entire procedure typically takes 30 to 60 minutes, depending on the number of discs tested and patient cooperation. Most of the time is spent on preparation, fluoroscopic positioning, and controlled contrast injection.

What happens if a disc shows pain during the test?

If the pain felt during the procedure matches the patient’s usual pain (“concordant pain”), it suggests that the disc is a likely pain source. This finding may influence surgical decisions or help guide targeted treatments.

Is discography still recommended over MRI?

MRI remains the first-line imaging modality. Discography is typically used only when MRI is inconclusive or when surgery is being planned, but pain localization is unclear. It offers both anatomical and pain-response information.

What are the long-term risks of lumbar discography?

While rare, potential risks include discitis, disc damage, worsening of pain, or nerve injury. Proper technique and sterile precautions minimize these complications.

References

1. Melnik, I., Derby, R., Baker, R.M. (2013). Provocative Discography. In: Deer, T., et al. Comprehensive Treatment of Chronic Pain by Medical, Interventional, and Integrative Approaches. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-1560-2_45
2. Gruver C, Guthmiller KB. Provocative Discography. [Updated 2023 May 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470389/
3. Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI, and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. 2005;5:24–35. [PubMed]
4. Wolfer LR, Derby R, Lee JE, Lee SH. Systematic review of lumbar provocation discography in asymptomatic subjects with a meta-analysis of false-positive rates. Pain Physician. 2008 Jul-Aug;11(4):513-38. [PubMed]
5. Guyer RD, Ohnmeiss DD. Lumbar discography. Spine J. 2003 May-Jun;3(3 Suppl):11S-27S. doi: 10.1016/s1529-9430(02)00563-6. PMID: 14589214.
6. Anthem Blue Cross. (2024). Lumbar Discography. Medical Policies – Clinical UM Guidelines. Retrieved May 19, 2025, from https://www.anthem.com/medpolicies/abc/active/gl_pw_c129886.html0.
7. eviCore Healthcare. (2025). Spine imaging guidelines (Version 1.1) [PDF]. Retrieved May 19, 2025, from https://www.evicore.com/..