Provocative discography with manometry is a test used to determine whether pain originates from one or more intervertebral discs.
It is not a treatment but rather a diagnostic test in which a substance is injected into the intervertebral disc to confirm the origin of the pain.
This test is performed when the physician suspects the pain is originating from a disc. The objective is to confirm whether the pain indeed originates from one or two discs due to annular tearing or a herniated disc. The test is performed when percutaneous intradiscal treatments or surgery are considered potential treatment options.
Diagnostic criteria from the International Association for the Study of Pain (IASP) and the International Spinal Intervention Society (ISIS) are used to confirm or exclude the presence of intradiscal pain. The patient may be told the provocative discography results at the end of the procedure. A report is sent to the referring physician. If axial tomography is performed after the test, the disc’s condition is noted in the report using the Dallas discogram description.
With the patient lying on the stomach, the skin is disinfected and a local anesthetic is applied on the required areas. With few exceptions, the same procedure is performed on a minimum of two, more often three, intervertebral discs. A trocar is then inserted into each disc under fluoroscopic guidance. After ensuring proper positioning, a contrast agent combined with an antibiotic is injected into the nucleus pulposus under direct fluoroscopic guidance to assess the intradiscal distribution of the contrast agent. The patient usually feels no pain if the disc is normal.
However, in cases involving tearing or herniation, the procedure can reproduce pain familiar to the patient. Sedation may be provided, although it must be light because patient cooperation is needed to indicate the topography, intensity and correspondence of the induced pain with their normal level of pain.
Injections and disc stimulation are performed with a manometer to evaluate the pressure corresponding to the level of pain induced in the patient. A local anesthetic can then be injected into the intervertebral disc that was symptomatic during disc stimulation in order to decrease the pain and to make the procedure more comfortable.
After the disc stimulation and the pressure of the two or three intervertebral lumbar discs is taken, the needles are removed and the patient is kept under observation for 20 to 30 minutes. If necessary, an axial tomography scan of the tested discs may be performed in the three hours following the disc provocation.
Complications are essentially related to the injection, the anatomy involved and the substances injected. The risk of hemorrhaging is rare. An allergic reaction to contrast agents is extremely rare and can be treated rapidly if it occurs. Intradiscal antibiotics significantly lower the risk of intradiscal infection.
Complications are essentially related to the injection, the anatomy involved and the substances injected. Complications are very rare. Using radiography to confirm the injection’s pathway enhances the safety of the procedure. The risks of complications, such as infection or hemorrhaging, are the same as for any other type of injection, and are quite exceptional.
Sometimes the use of anticoagulants and Plavix must be stopped before the procedure. If this is necessary, the patient’s prescribing physician must authorize a temporary pause of these medications. Pregnancy is contraindicated for provocative discography with manometry. Report all allergies to medications or contrast agents to the physician.