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Concurrent validity of the directional preference phenomenon compared to controlled lumbar discography: a supplementary analysis of a diagnostic accuracy study

Deneuville JP, Laslett M, Cervantes A, Peterlongo S, Ounajim A, Artico R

Musculoskeletal Science & Practice 2025 Nov;80:103413

primary study

BACKGROUND: Persistent low back pain (LBP) is a symptom with many potential causes. Centralisation phenomenon (CP) has emerged as promising diagnostic tools for identifying a subset of discogenic pain. CP represents a subgroup of patients demonstrating Directional Preference (DP) and to date the diagnosticaccuracy of DP has never been assessed. To bridge this gap, this study evaluates the diagnostic accuracy of DP for discogenic pain, compares its properties to CP, and explores the development of clinical diagnostic rules (CDRs) for patients with negative testing for DP, or inability to undergo repeated movement testing. METHODS: 103 persistent low back pain patients were assessed by a physiotherapist to collect clinical data and determine DP status. Subsequently, a radiologist performed controlled discography to determine the discogenic pain status. Both the physiotherapist and the radiologist were blinded to each other's findings. RESULTS: DP demonstrated high diagnostic accuracy (specificity 0.94; Positive Likelihood Ratio (LR+) 7.65) but low screening properties (sensitivity 0.48; Negative Likelihood Ratio (LR-) 0.56). CP showed similar diagnostic properties (specificity 0.94; LR+ 5.57). A CDR for untestable DP yielded low predictive power (Area Under the Curve (AUC) 0.57). Due to limited sample size and missing data, no valid CDR could be established to assist diagnostic decision when DP is negative. CONCLUSIONS: DP is a valid diagnostic tool for mechanical discogenic pain but has limited screening utility. Further studies are needed to refine diagnostic approaches and explore subgroups, such as those with Modic changes/inflammation-driven discogenic pain.

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