Variability in techniques and patient safety protocols in discography: a national multispecialty survey of International Spine Intervention Society members

Abstract

Study design: National survey.

Objective: (1) Characterize the way discography is being carried out and by which specialties. (2) Quantify adherence to the International Spine Intervention Society (ISIS) guidelines. (3) To see if there is experience or specialty differences in technique.

Background: Discography is a controversial diagnostic tool that attempts to correlate disc morphology to concordant pain. It is increasingly performed by different specialties as a prelude to fusion, disc replacement, and percutaneous intradiscal procedures. A consensus committee of the ISIS has published guidelines for performing discography to increase diagnostic accuracy, standardize technique, and improve patient safety. This survey wishes to see how closely these guidelines are followed.

Methods: In all, 500 members of the ISIS were randomly selected to receive a 13-item questionnaire. The questions included the following demographic information: specialty, number of discograms in 1 year (<15, 15-50, >50). Patient safety questions included the following: use of preoperative antibiotics, intradiscal antibiotics, postoperative antibiotics, and use of double needle technique. Technical questions included the following: needle entry on the opposite site of symptoms, injecting the control disc first, using manometry to record opening pressure, using manometry to record pressure on pain reproduction, injecting discs adjacent to the painful disc, and using pain assessment forms. Comparison of responses was made between specialties. Responses to the questions were also compared based on the number of procedures performed per year.

Results: The response rate to the questionnaire was 34.6%. Of the 173 respondents, the following specialties were represented: 100 (57.8%) Anesthesiology, 53 (30.6%) Physical Medicine and Rehabilitation (PMR), 16 (9.2%) Radiology, 4 (2.3%) Other. Number of procedures carried out was as follows: <15 (22.54%), 15 to 50 (50.86%), >50 (26.58%). The adherence to patient safety guidelines were as follows: preoperative antibiotics (83.81%), intradiscal antibiotics (84.97%), postprocedure antibiotics (9.82%), use of double needle technique (64.16%). The adherence to technical guidelines were as follows: optional use of computed tomography scan (64.78%), pain assessment sheet (66.47%), entering on the side opposite symptoms (48.55%), manometry for opening pressure (65.31%), manometry of pain reproduction pressure (72.25%), injecting a control disc first (78.61%), injecting discs adjacent to the painful disc (56.64%). Significant differences across Anesthesiology, PMR, and Radiology were detected for computed tomography, intradiscal antibiotics, opening pressure, pain assessment form, and pain pressure measurement. There was no effect of volume of procedures done on overall adherence to guidelines. A significant interaction between specialty and number of procedures performed was detected for compliance with intradiscal antibiotics (P=0.092), opening pressure (P=0.027), and pain pressure (P=0.029) for respondents with >50 procedures. Respondents in Radiology were approximately 98% less likely to use intradiscal antibiotics compared with those in Anesthesiology (odds ratio, 0.019; 95% confidence interval, 0.001-0.264). PMR respondents were approximately 83% less likely than Anesthesiologists to use opening pressure (odds ratio, 0.168; 95% confidence interval, 0.035-0.82) when procedures were <15 per year.

Conclusions: Discography is being performed by multiple different specialties: Anesthesiology, PMR, Radiology (highest to lowest in number, respectively). Overall adherence to guidelines pertaining to infection control was fair except for double needle technique which was poor. Adherence to guidelines that affect the diagnostic value was poor. There is specialty variation in adherence to guidelines and to a lesser extent volume based effect on compliance.