Pain Physician 2012; 15:E869-E907 • ISSN 2150-1149

Systematic Review

An Update of the Systematic Assessment of
the Diagnostic Accuracy of Lumbar Facet Joint
Nerve Blocks
Frank J.E. Falco, MD1, Laxmaiah Manchikanti, MD2, Sukdeb Datta, MD3, Nalini Sehgal, MD4,
Stephanie Geffert, MLIS5, Obi Onyewu, MD6, Vijay Singh, MD7, David A. Bryce, MD8,
Ramsin M. Benyamin, MD9,10, Thomas T. Simopoulos, MD11, Ricardo Vallejo, MD, PhD9,12,
Sanjeeva Gupta, MD13, Stephen P. Ward, MD, FRCA, FFPMRCA14, and Joshua A. Hirsch, MD15
From: 1,5,6 Mid Atlantic Spine& Pain Physicians, Newark,
DE, and Temple University
Hospital, Philadelphia, PA; 2Pain
Management Center of Paducah,
Paducah, KY, and University ofLouisville,Louisville, KY; 3Laser
Spine & Pain Institute, New York,NY; 4University of Wisconsin
School of Medicine and Public
Health Madison, WI; 7Spine Pain
Diagnostics Associates, Niagara,
WI; 8Advanced Pain Management,
Madison, WI; 9,11Millennium
Pain Center, Bloomington,
IL; and 10University of Illinois,
Urbana-Champaign, IL; 11BethIsrael Deaconess Medical Center
Harvard Medical School, Boston,MA; 12Illinois State University,
Normal, IL; 13Bradford Teaching
Hospitals NHS Foundation Trust,
Bradford, United Kingdom;
14
Brighton and Sussex University
Hospitals, Nhs Trust, United
Kingdom; and 15Massachusetts
General Hospital, and Harvard
Medical School, Boston, MA.
Additional Author Affiliation
information and Conflicts ofInterest listed on pages E895-E896.
Address Correspondence:Frank J.E. Falco, MD
139 East Chestnut Hill Road
Newark, DE 19713
E-mail: cssm01@aol.com;
jcolonna@midatlanticspine.com
Manuscript received: 10/10/2012
Accepted for publication:
10/24/2012
Free full manuscript:
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Background: Lumbar facet joints are a well recognized source of low back pain and referredpain in the lower extremity in patients with chronic low back pain. Conventional clinical featuresand other non-invasive diagnostic modalities are unreliable in diagnosing lumbar zygapophysial
joint pain. Controlled diagnostic studies with at least 80% pain relief as the criterion standard
have shown the prevalence of lumbar facet joint pain to be 16% to 41% of patients with chronic
low back pain without disc displacement or radiculitis, with a false-positive rate of 17% to 49%
with a single diagnostic block.
Study Design: A systematic review of the diagnostic accuracy of lumbar facet joint nerve
blocks.
Objective: To determine and update the diagnostic accuracy of lumbar facet joint nerve blocks
in the assessment of chronic low back pain.
Methods: A methodological quality assessment of included studies was performed using
Quality Appraisal of Reliability Studies (QAREL). Only diagnostic accuracy studies meeting atleast 50% of the designated inclusion criteria were utilized for analysis. Studies scoring less than
50% are presented descriptively and analyzed critically.
The level of evidence was classified as good, fair, and limited or poor based on the quality ofevidence developed by the United States Preventive Services Task Force (USPSTF).
Data sources included relevant literature identified through searches of PubMed and EMBASE
from 1966 to June 2012, and manual searches of the bibliographies of known primary andreview articles.
Outcome Measures: Studies must have been performed utilizing controlled local anesthetic
blocks. Pain relief was categorized as at least 50% pain relief from baseline pain and the ability
to perform previously painful movements.
Results: A total of 25 diagnostic accuracy studies were included. Of these, one study evaluated
50% to 74% relief as criterion standard with a single block with prevalence of 48%, 4 studies
evaluated 75% to 100% relief as the criterion standard with a single block with a prevalence of
31% to 61%, 5 studies evaluated 50% to 74% relief as the criterion standard with controlled
blocks with a prevalence of 15% to 61%, and 13 studies evaluated 75% to 100% relief as thecriterion standard with controlled blocks with a prevalence of 25% to 45% in heterogenous
populations. False-positive rates ranged from 17% to 66% in the 50% to 74% pain relief groupand 27% to 49% with at least 75% relief as the criterion standard. Based on this evaluation, theevidence showed that there is good evidence for diagnostic facet joint nerve blocks with 75% to100% pain relief as the criterion standard with dual blocks and fair evidence with 50% to 74%
pain relief as the criterion standard with controlled diagnostic blocks; however, the evidence ispoor with single diagnostic blocks of 50% to 74%, and limited for 75% or more pain relief as
the criterion standard.

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Pain Physician: November/December 2012; 15:E869-E907

Limitations: The shortcomings of this systematic review of the accuracy of diagnostic lumbar facet joint nerve blocks include a
paucity of literature and continued debate on an appropriate gold standard.
Conclusion: There is good evidence for diagnostic facet joint nerve blocks with 75% to 100% pain relief as the criterion standard
with dual blocks, with fair evidence with 50% to 74% pain relief.
Key words: Chronic low back pain, lumbar facet or zygapophysial joint pain, facet joint nerve blocks, medial branch blocks,
controlled comparative local anesthetic blocks

Chronic low back pain, with or without lower
extremity pain of spinal origin constitutes amajor portion of chronic pain (1-11). Thus,
the numerous modalities of treatments for managing
chronic low back pain and the growing social andeconomic costs continue to influence medical decisionmaking (1,2,5,12-37). Even though low back pain is acommon complaint in primary care and tertiary care,
it is often difficult to reach a definitive diagnosis(2,27,38-41). Controlled studies have establishedintervertebral discs, facet joints, and sacroiliac joints
as potential sources of low back and lower extremity
pain (2,27,38-47). Thus, lumbar facet joints are a wellrecognized source of low back and referred pain in thelower extremity in patients with chronic low back pain
(2,41-54). Facet joints are well innervated by the medial
branches of the dorsal rami (55-62). Neuroanatomic,
neurophysiologic, and biomechanical studies havedemonstrated free and encapsulated nerve endings
in lumbar facet joints, as well as nerves containing
substance P and calcitonin gene-related peptide (6373).
The exponential growth in treatment modalities
and subsequent rise in health care costs are the resultof multiple factors, including the inherent difficulty inobtaining an accurate diagnosis (1-5,14-37,74-84). An
inaccurate or incorrect diagnosis may lead not only totreatment failure, but also results in wasted health caredollars, diverting essential health care resources. Fundamental to an accurate diagnosis is the reliability of thetest used to make the diagnosis (2,38,41,46,47,85-90).
Attempts have been made to improve the accuracy of
diagnostic lumbar facet joint pain by multiple means, including physical examination, imaging techniques, andcontrolled local anesthetic blocks (2,38,41-47,91-149).
There is, however, no universally accepted gold
standard for the diagnosis of low back pain, regardlessof whether the suspected source is the facet joint(s),intervertebral disc(s), or sacroiliac joint(s). The recom-

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mended reference standards typically involve anesthetic or provocative injections. Multiple arguments havebeen made in favor of and against the diagnostic accuracy of controlled local anesthetic blocks, but controlled
local anesthetic blocks continue to be the best available
tool to identify intervertebral disc(s), facet joint(s), or
sacroiliac joint(s) as the source of low back pain. Yet,these reference standards are invasive, expensive, andoften difficult to interpret, and therefore may not besuitable for routine clinical use as a primary diagnostic
modality.
The published radiological investigations reportno correlation between the clinical symptoms of low
back pain and degenerative spinal changes observedon radiologic imaging studies, including radiographs,
magnetic resonance imaging (MRI), computed tomography (CT) scanning, single photon emission computed
tomography (SPECT), and radionuclide bone scanning(2,41,106-135). Specifically, the association between
degenerative changes in the lumbar facet joints andsymptomatic low back pain remains unclear and is asubject of ongoing debate.
Conventional clinical features are unreliable in diagnosing lumbar zygapophysial (facet) joint pain. Hancock et al (47) performed a systematic review of tests to
identify the disc, sacroiliac joint, and facet joint as thesource of low back pain. They found that none of thetests for facet joint pain were found to be informative.
Consequently, controlled local anesthetic blocks of the
facet joint or its nerve supply are routinely employed todiagnose facet joint pain. The rationale for controlled
diagnostic blocks is that an anesthetic blockade of apainful joint will abolish pain arising from that joint
for the duration of the anesthetic effect, while an anesthetic blockade of a non-painful joint will not alter thepain report. The probability that the blocked joint is theactual source of pain is increased if repeating the blockwith an anesthetic agent that has a different durationof action reproduces the analgesic response (33). To

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Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

ensure accuracy and validity, these blocks must be controlled and verified for the delivery of a local anesthetic
agent and placebo response. Fluoroscopic guidance andcontrolled dual blocks eliminate or greatly reduce placebo responses. Single facet joint injections are not recommended, as they do not control for a false-positive
response (42,43,75,96,98,136-149). Rubinstein and van
Tulder (46) also provided a best-evidence review of diagnostic procedures for neck and low back pain. They
commented that it is quite remarkable that while many
named orthopedic tests of the neck and low back areoften illustrated in orthopedic textbooks, there is little
evidence to support their diagnostic accuracy, and therefore their use in clinical practice. Consistent with clinicalexperience, many studies have demonstrated that thephysical examination serves primarily to confirm suspicions that arise during the history. The placebo-controlled technique is considered the gold standard, but
has limited clinical utility due to cost implications andto the ethical and logistical issues of designing a trueplacebo. Controlled comparative blocks with short- andlong-acting local anesthetics are an acceptable alternative strategy (38,39,41,150-153).
The accuracy and validity of controlled comparative
blocks have been criticized, and the precision of these
diagnostic techniques questioned (2,22,27,154-166).
Although these tests control and verify the location of
local anesthetic delivery, they are faulted for assumingthat reports and documentation of the magnitude andquality of pain relief are accurate. Because these tests
employ subjective criteria, i.e., rely on a patient’s reportof the presence or absence of pain following a blockand their ability to isolate different painful areas or differentiate between significant and insignificant pain
relief (when pain relief is incomplete), they promote
doubt about the accuracy of these procedures.
Multiple systematic reviews have concluded that evidence for the diagnostic accuracy of lumbar facet joint
nerve blocks is strong (27,41,46,47,160). Rubinstein andvan Tulder (46), who have performed multiple Cochranereviews, also concluded that there was strong evidence
for the diagnostic accuracy of facet joint blocks in evaluating spinal pain.
Kalichman et al (126) evaluated facet joint osteoarthritis and low back pain in the community-based
Framingham Heart Study. They concluded that there
is a high prevalence of facet joint osteoarthritis in
the community-based population with a prevalenceof 59.6% in males and 66.7% in females. The prevalence of facet joint osteoarthritis increased with age

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and reached 89.2% in individuals 60 to 69 years old
with the highest prevalence of facet joint osteoarthritis found at the L4/5 spinal level. Furthermore, they
showed that individuals with facet joint osteoarthritis
identified by a CT scan at any spinal level showed noassociation with low back pain. Eubanks et al (167) in astudy of 647 cadaveric lumbar spines found that facet
joint osteoarthritis is a universal finding. Characteristicfeatures of osteoarthritis emerge early on in the life
cycle, with more than half of adults younger than 30
years demonstrating arthritic changes in the facets,with the most common arthritic level being L4/5. The
relationship between lumbar facet joint osteoarthritis
and back pain is not clear. Gong et al (168) exploreda rat model of lumbar facet joint osteoarthritis associated with facet-mediated mechanical hyperalgesia
induced by an intraarticular injection of monosodium
iodoacetate (MIA). The results showed that progressive
cartilage degeneration and changes in subchondralbone were observed after injection. A biphasic pattern of mechanical hyperalgesia was noted in the hindpaw. They concluded that with the establishment of anexperimental lumbar facet joint osteoarthritis model
associated with facet-mediated mechanical hyperalgesia with an intraarticular injection of MIA, this model
might provide a useful tool for further study to ascertain the complex mechanism of facet joint pain.
Henry et al (64) with the objective of developing a novel animal model of persisting lumbar facet
joint pain showed that in a rat model, lumbar facet
joint compressive injury induces lasting changes in local structure, nociceptive scores, and inflammatory
mediators. They concluded that the compression ofa facet joint induces a novel model of local cartilage
loss accompanied by increased sensitivity to mechanical stimuli and increases in inflammatory mediators.
The results of this study showed a site-specific loss of
cartilage, tactile hypersensitivity, and increases in proinflammatory cytokines.
The latest review of the diagnostic accuracy oflumbar facet joint nerve blocks was published in August 2009 (41). However, the value of systematic reviews continues to deteriorate with time (169,170).
Thus, frequent updates of systematic reviews havebeen recommended for evolving subjects. This systematic review has been undertaken in order to assess
the current evidence and also to update the previous
systematic review (41) on the accuracy of lumbar facet
joint nerve blocks in the diagnosis of chronic low back
pain.

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Pain Physician: November/December 2012; 15:E869-E907

1.0 Methods
The methodology utilized in this systematic review
followed the review process derived from evidencebased systematic reviews and meta-analysis of diagnostic accuracy studies (22,46,47,85-90,171,172).

1.1 Criteria for Considering Studies for This
Review
1.1.1 Types of Studies
Diagnostic accuracy studies evaluating lumbar facet joint pain.

1.1.2 Types of ParticipantsParticipants of interest were adults aged at least 18
years with chronic low back pain of at least 3 months
duration.
Participants must have failed previous pharmacotherapy, exercise therapy, etc., prior to starting diagnostic interventional pain management techniques.

1.1.3 Types of Interventions
The interventions were lumbar facet joint nerve
blocks appropriately performed with proper techniqueunder fluoroscopic or CT guidance.

1.1.4 Types of Outcome Measures♦♦♦

The primary outcome parameter was pain relief
concordant with the type of controlled diagnostic
blocks performed.
The secondary outcome measure was the ability
to perform previously painful movements without
significant pain or complications.
At least 2 of the review authors independently, in
an unblinded standardized manner, assessed theoutcomes measures. Any disagreements between
reviewers were resolved by a third author andconsensus.

1.2 Literature Search
Searches were performed from the following
sources without language restrictions:
1. PubMed from 1966
www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed
2. EMBASE from 1980
www.embase.com
3. Cochrane Library
www.thecochranelibrary.com/view/0/index.html
4. U.S. National Guideline Clearinghouse (NGC)www.guideline.gov

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5.
6.

Previous systematic reviews and cross references
Clinical Trials
clinicaltrials.gov

The search period was from 1966 through June2012.

1.3 Search Strategy
The search strategy emphasized chronic low backpain, facet or zygapophysial joint pain, lumbar facet injections, and lumbar facet joint nerve blocks.
This systematic review focused only on diagnostic
studies, including invasive and noninvasive techniques
and reports of complications. Only lumbar facet joint
nerve blocks performed under fluoroscopy or CT imaging techniques were evaluated. Interventional techniques performed blindly or using other identification
modalities were excluded. All studies describing appropriate outcome evaluations with proper statistical evaluations were reviewed. Reports without appropriate
diagnosis, nonsystematic reviews, book chapters, andcase reports were excluded.
At least 2 of the review authors independently, in
an unblinded standardized manner, performed eachsearch. A statistician confirmed accuracy. All searches
were combined to obtain a unified search strategy. Any
disagreements between reviewers were resolved by athird author and consensus.

1.4 Data Collection and Analysis
The quality of each individual article used in thisassessment was based on the Quality Appraisal of Reliability Studies (QAREL) checklist (Table 1) (85). This
checklist has been validated and utilized in multiple
systematic reviews (86). Each study in the final sampleof eligible manuscripts was assessed using a 12-item
appraisal checklist designed to assess the quality andapplicability of studies. The face validity of these checklists was established by consultation with methodology experts (85) and comparison with quality appraisal
checklists used in other systematic reviews examining
diagnostic reliability (173-177). This checklist was also
developed in accordance to the Standards for Reporting Studies of Diagnostic Accuracy (STARD) (89), andthe Quality Assessment of Diagnostic Accuracy Studies(QUADAS) (90) appraisal tool. Studies were not given
an overall numeric quality score; instead, each item wasconsidered separately and graded as “yes,” “no,” “unclear,” or “not applicable.”www.painphysicianjournal.com

Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

Table 1. Quality Appraisal of Diagnostic Reliability (QAREL) checklist.

Item

Yes

No

Unclear

N/A

1. Was the test evaluated in a spectrum of subjects representative of patients who would
normally receive the test in clinical practice?
2. Was the test performed by examiners representative of those who would normally performthe test in practice?
3. Were raters blinded to the reference standard for the target disorder being evaluated?
4. Were raters blinded to the findings of other raters during the study?
5. Were raters blinded to their own prior outcomes of the test under evaluation?
6. Were raters blinded to clinical information that may have influenced the test outcome?
7. Were raters blinded to additional cues, not intended to form part of the diagnostic test
procedure?
8. Was the order in which raters examined subjects varied?
9. Were appropriate statistical measures of agreement used?
10. Was the application and interpretation of the test appropriate?
11. Was the time interval between measurements suitable in relation to the stability of thevariable being measured?
12. If there were dropouts from the study, was this less than 20% of the sample.
TOTAL
Lucas N, et al. Reliability of physical examination for diagnosis of myofascial trigger points. Clin J Pain 2009; 25:80-89 (85).

1.4.1 Selection of Studies♦♦

In an unblinded standardized manner, 2 review authors screened the abstracts of all identified studies
against the inclusion criteria.
All articles with possible relevance were then retrieved in full text for a comprehensive assessmentof internal validity, quality, and adherence to inclusion criteria.

1.4.2 Inclusion and Exclusion Criteria
The following are the inclusion and exclusion
criteria.
1. Are the patients described in sufficient detail to allow one to decide whether they are comparable tothose who are treated in interventional pain management clinical practices?
A. Setting – office, hospital, outpatient, inpatient
B.	Physician – interventional pain physician, general physician, anesthesiologist, physiatrist,
neurologist, rheumatologist, orthopedic surgeon, neurosurgeon, etc.
C. Patient characteristics - duration of pain
D.	Noninterventional techniques or surgical intervention in the past
2. Is the intervention described in sufficient detail toenable one to apply its use to patients in interventional pain management settings?

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3.

A. Nature of intervention
B. Frequency of intervention
C. Duration of intervention
Were clinically relevant outcomes measured?
A. Proportion of pain relief
B. Disorder/specific disability
C. Functional improvement
D.	Allocation of eligible and noneligible patientsto return to work
E. Ability to work

1.4.3 Clinical RelevanceThe clinical relevance of the included studies wasevaluated according to 5 questions recommended by
the Cochrane Back Review Group (Table 2) (178,179).
Each question was scored as positive (+) if the clinicalrelevance item was met, negative (–) if the item was
not met, and unclear (?) if data were not available toanswer the question.

1.4.4 Methodological Quality or Validity
Assessment
Each study was evaluated by at least 2 authors forstated criteria and any disagreements were discussedwith a third reviewer. Authors with a perceived conflictof interest for any manuscript were recused from reviewing the manuscript.

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Pain Physician: November/December 2012; 15:E869-E907
Table 2. Clinical relevance questions.

P (+)

N (-)

U (unclear)A) Are the patients described in detail so that one can decide whether they are comparable to those
who are treated in practice?
B) Are the interventions and treatment settings described in sufficient detail to apply its use in clinicalpractice?
C) Were clinically relevant outcomes measured and reported?
D) Is the size of the effect clinically meaningful?
E) Do the likely treatment benefits outweigh the potential harms?
Scoring adapted and modified from Staal JB, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev 2008;
3:CD001824 (179).

Table 3. Method for grading the overall strength of the evidence for an intervention.

Grade

Definition

Good

Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly
assess effects on health outcomes (at least 2 consistent, higher-quality RCTs or studies of diagnostic test accuracy).

Fair

Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number,quality, size, or consistency of included studies; generalizability to routine practice; or indirect nature of the evidence on
health outcomes (at least one higher-quality trial or study of diagnostic test accuracy of sufficient sample size; 2 or morehigher-quality trials or studies of diagnostic test accuracy with some inconsistency; at least 2 consistent, lower-quality trials
or studies of diagnostic test accuracy, or multiple consistent observational studies with no significant methodological flaws).

Limited or Poor

Evidence is insufficient to assess effects on health outcomes because of limited number or power of studies, large andunexplained inconsistency between higher-quality trials, important flaws in trial design or conduct, gaps in the chain ofevidence, or lack of information on important health outcomes.

Adapted and modified from methods developed by U.S. Preventive Services Task Force (22,23,181-183).

Only diagnostic accuracy studies meeting at least
50% of applicable inclusion criteria were included foranalysis. Studies scoring less than 50% are reported descriptively with critical analysis.

standard for diagnosis was between 75% to 100% pain
relief with dual blocks, to reduce clinical heterogeneity.

1.4.5 Data Extraction and Management

Data was separately summarized using meta-analysis when at least 5 studies per type of diagnostic criteria were available that met the inclusion criteria (e.g.,single block, double blocks, and 50% to 74% relief).
The minimum acceptable relief was considered to
be 50%; however, data were sub-analyzed for ≥ 80%
and 50% to 74% relief as the cutoff threshold for apositive block during the performance of previously
painful movements. Four separate diagnostic categories were evaluated (i.e., 50% to 74% relief as the cutoff threshold with single and dual blocks; and 75% to100% relief as the cutoff threshold with single or dual
blocks). For dual blocks, there had to have been a concordant response with short-acting and long-acting local anesthetics, or placebo.

Two review authors independently, in an unblinded
standardized manner, extracted the data from the included studies. Disagreements were resolved by discussion between the 2 reviewers; if no consensus could be reached,a third author was called in to break the impasse.

1.4.6 Assessment of Heterogeneity
Whenever meta-analyses were conducted, the Isquared (I2) index was used to identify heterogeneity(180). Combined results with I2 > 50% were considered
substantially heterogenous.
Analysis of the evidence was based on diagnostic
criteria as follows: 1) blocks in which the reference standard for diagnosis was between 50% to 74% pain relief
with a single block; 2) blocks in which the reference standard for diagnosis was between 50% to 74% pain relief
with dual blocks; 3) blocks in which the reference standard for diagnosis was between 75% to 100% pain relief
with a single block; and 4) blocks in which the reference

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1.4.7 Measurement of Treatment Effect in Data
Synthesis (Meta-Analysis)

1.4.8 Integration of Heterogeneity
A meta-analysis was performed only if there wereat least 5 studies meeting inclusion criteria for eachvariable.

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Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

Computerized and manual search ofliterature
2,105

Potential articles
325

Articles excluded by title
1,780

Abstracts reviewed
325

Abstracts excluded
230

Full manuscripts reviewed
170

Manuscripts considered for inclusion = 74
Diagnostic accuracy studies = 25
Studies evaluating influence of various factors= 23

Fig. 1. Flow diagram illustrating published literature evaluating the accuracy of lumbar facet joint nerve blocks in the diagnosis of lumbar facet joint pain.

Statistical heterogeneity was explored using univariate meta-regression (180).

1.5 Summary Measures
Summary measures included 50% to 74% or 75%
to 100% pain relief with the ability to perform previously painful movements concordant with the durationof local anesthetic.

1.6 Analysis of Evidence
The analysis of the evidence was performed basedon United States Preventive Services Task Force (USPSTF) criteria (181) as illustrated in Table 3, which has
been utilized by multiple authors (22,23,27,28,182,183).
The analysis was conducted using 3 levels of evidence: good, fair, and limited or poor (22,23,181-183).

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At least 2 of the review authors independently, in
an unblinded standardized manner, analyzed the evidence. Any disagreements between reviewers were resolved by a third author and consensus. If there were
any conflicts of interest (e.g., authorship), those reviewers were recused from assessment and analysis.

1.7 Outcome of the Studies
Outcomes included the prevalence of lumbar facet
joint pain and false-positive rate. Based on the above
parameters, the reliability of the data derived fromeach study was assessed.

2.0 Results
Figure 1 shows a flow diagram of study selection. There were 74 studies considered for inclusion

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Pain Physician: November/December 2012; 15:E869-E907(43,44,49-54,95-102,136-149,157,163-166,184-222)
Among these, 25 evaluated diagnostic facet joint
injections of accuracy and outcomes (43,44,95,98102,136-140,142-146,149,166,184,192,200,205,217),
with 3 duplicate publications (95,137,217). In addition, 21 studies evaluated various factors influencing
the diagnostic accuracy (141,147-149,163-166,187189,194,195,200-203,205,206,212,218). Tables 4 and5 show diagnostic accuracy studies evaluating prevalence and false-positive rates, and studies assessing
various factors. Multiple studies evaluating the roleof ultrasound guidance, reviews, therapeutic evaluations, studies focusing on radiographic evaluation,
non-invasive studies, and studies focusing on otheraspects of facet joint pain were excluded from assessment in this evaluation. Table 6 shows reasons for exclusion of select studies.

ies scoring less than 50% were considered to be of poor
quality and excluded.
There were 22 studies evaluating diagnostic
accuracy(43,44,98-102,136,138-140,142146,149,166,184,192,200,205), after the exclusion of 3
duplicate publications (95,137,217). All were considered to be high quality.

2.1 Diagnostic Accuracy Studies

2.5 Meta-Analysis

Table 4 shows the characteristics of studies considered for inclusion. There was one study utilizing
single blocks with 50% to 74% relief (44), and 4 studies utilizing single blocks with 75% to 100% relief(99,100,102,166). There were 5 studies utilizing 50% to
74% relief with controlled blocks (98,136,140,166,192)
and one publication with false-positive rates (146),
with one duplicate publication (137), and 13 studies
utilizing 75% to 100% relief with controlled blocks(43,101,138,139,142-145,149,166,184,200,205) with one
duplicate publication (95).

As shown in Table 4, all of the diagnostic accuracy
studies were evaluated for homogeneity for inclusionin the meta-analysis.
There were 4 studies utilizing placebo control(99,100,140,192). There was one study utilizing single blocks with 50% to 74% relief (44). In the groupwith single blocks where there was greater than 75%
pain relief, there were 4 studies (99,100,102,166). In
the group with 50% to 74% relief with controlled
blocks, there were 5 studies (98,136,140,146,166,192),
without homogeneity among 5 studies. Two of thestudies were published by Schwarzer et al (136,140),
2 were published by Manchikanti et al (98,166), andone was published by Schütz et al (192), all with varying methodology and heterogenous patient populations. Among the studies utilizing 75% or higher
relief with controlled blocks, there were 13 studies
after the exclusion of duplicates (43,101,138,139,142145,149,166,184,200,205). However, 11 of thesewere published by a single group, Manchikanti et al(43,138,139,142-145,149,166,200,205), in different
populations with assessment of various factors. There
were only 2 homogenous studies (144,145). Metaanalysis was not feasible in any of the categories.

2.2 Studies of Factors Influencing Diagnosis
Table 5 shows the characteristics of relevant studies. There were 3 studies assessing the influence of age(147,189,200), 2 studies assessing psychological variables (148,194), 2 studies assessing the influence ofbody mass index (189,205), 5 studies assessing the influence of surgery (149,187,188,206,218), 2 studies assessing gender/smoking related factors (189,201), 3 studies
assessing the influence of sedation (163,202,203), and 5
studies assessing the influence of diagnostic blocks ontherapeutic outcomes (164-166,195,212).

2.4 Clinical RelevanceAn assessment of clinical relevance of included
studies of diagnostic accuracy with lumbar facet joint
nerve blocks was included. Among the 22 studies assessed for clinical relevance (43,44,98-102,136,138140,142-146,149,166,184,192,200,205), and after theelimination of 3 duplicate publications (95,137,217), allstudies met the criteria with a score of 3 of 5 or greater.
Table 8 illustrates the assessment of clinical relevance.

2.3 Methodological Quality Assessment
A methodological quality assessment of diagnostic
accuracy studies meeting inclusion criteria was carriedout utilizing QAREL criteria as shown in Table 7. Studies
achieving 50% or higher scores were included. Scoresof 67% or higher were considered to be high quality,
50% were considered to be moderate quality, and stud-E876

2.6 Analysis of Evidence
The evidence was synthesized based on the relief
criteria when lumbar facet joint nerve blocks were performed. Tables 4 and 5 describe the study characteristics. Table 9 illustrates data of the prevalence of lumbar
facet joint pain by diagnostic blocks.

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Participants

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In a prospective evaluation,
100 consecutive adult patientswith chronic low back pain with
undetermined etiology were
evaluated with spinal mapping.

80 patients underwent diagnostic
facet joint injections meeting thecriterial to identify patients withpainful facet joints with chronic low
back pain.

102 patients with chronic low
back pain were evaluated with
21 exclusions to correlate clinicalexamination characteristics with 3
sources of chronic low back pain.

Revel et al, 1998
(100)

Young et al, 2003
(102)

63 patients with low back pain lasting
for longer than 3 months underwent
computed tomography and blocks ofthe zygapophysial joints

Schwarzer et al,
1995 (137,140)

Manchikanti et al, 200 consecutive patients with
2000 (98)chronic low back pain were
evaluated.

176 consecutive patients withchronic low back pain after some
type of injury.

Schwarzer
et al, 1994
(136,146,217)

Controlled Blocks With 50%-74% Relief

Manchikanti et al, 491 patients with chronic low back2010 (166)pain undergoing evaluation for facet
joint pain.

51 patients with chronic low backpain were evaluated to identify
predictors of good response in apreliminary evaluation.

Revel et al, 1992
(99)

Single Blocks With ≥75%-100% Relief

Pang et al, 1998
(44)

Single Blocks With 50%-74% Relief

Study/Methods

At least 50% pain
relief concordant withthe duration of local
anesthetic injected.

At least 80% pain
relief with the ability
to perform previously
painful movements.

Controlled diagnostic blocks with
1% lidocaine and 0.25% bupivacaine
were injected over facet joint nerveswith 0.4 to 0.6 mL.

75% pain relief withability to perform
previously painful
movements.

Patients underwent a placebo
At least 50% reduction
injection followed by intraarticular in pain maintained forzygapophysial joint injections with minimum of 3 hours.
1.5 mL of 0.5% bupivacaine.

Zygapophysial joint nerve blocks
or intraarticular injections
were performed with either 2%
lignocaine or 0.5% bupivacaine.

Controlled diagnostic blocks oflumbar facet joint nerves with 1%
preservative-free lidocaine and 0.25%
preservative-free bupivacaine 1 mL.

80% or greater pain
relief for 30 to 60
minutes after the
injection.

75% pain relief

Intraarticular injection of 1 mL of
2% lidocaine or 1 mL of sodium
chloride solution was injected in arandomized fashion.
Single diagnostic block with 2%
lidocaine with less than 1.5 mL

90% pain relief

Visual analog scale

Outcome Measures

Intraarticular injection of 1 mL of
2% lidocaine or 1 mL of sodium
chloride solution was injected in arandomized fashion.

Single block was performed byinjecting 2% lidocaine into facet
jointsIntervention(s)Table 4. Studies assessing the accuracy of diagnostic blocks.

False-positive rate
= 37%

Prevalence = 42%

Prevalence = 40%

False-positive rate
= 38%

Prevalence = 15%

Prevalence = 53%

Prevalence = 61%

Prevalence = 31%

Prevalence = 33%

Prevalence
Only facet joint pain
= 24%
Lumbar nerve root
and facet disease =24%
Total = 48%

Results

The study showed that the clinical picture
failed to diagnose facet joint pain.

This study shows that computed
tomography has no place in the diagnosisof lumbar zygapophysial joint pain.

First study of evaluation of controlled
prevalence and false-positive rates.

Higher prevalence than with 50% pain
relief, but still higher than double block
algorithmic approach.

High proportion of patients showing
positive results in a non-prevalence study
conducted to correlate clinical examination
characteristics with 3 sources of chronic
low back pain in highly select population.

This was not a prevalence study andauthors evaluated capacity of the clinicalpicture to characterize low back pain
relieved by facet joint anesthesia to identify
the proposed criteria.

This is a preliminary study and was also
was not a prevalence study.

This is the first study evaluating applicationof diagnostic blocks in the diagnosis of
intractable low back pain of undetermined
etiology with facet joint disease in potentially
48% of patients with a single block.

Conclusion(s)Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

E877

E878
There were 6 parallel groups
with Group 1 receiving a sham+ placebo + local anesthetic
injection, Group 2 receiving sham
+ local anesthetic + placebo,Group 3 receiving placebo +sham + local anesthetic, Group
4 receiving placebo + local
anesthetic + sham, Group 5
receiving local anesthetic +placebo + sham, and Group 6
receiving local anesthetic + sham+ placebo.

Either intraarticular or facet joint
nerve block with 0.5 mL of 2%
lidocaine or 0.5% bupivacaine if
the response was positive with thefirst block

Laslett et al 2004,
2006 (95,101)

151 patients with chronic low backpain were assessed for clinicalpredicators with screening by
lumbar zygapophysial joint blocks.
120 patients were included in the
study.

Controlled diagnostic blocks withlidocaine and 1% lidocaine and0.25% bupivacaine with or without
Sarapin and/or steroids

Controlled diagnostic blocks with
1% lidocaine followed by 0.25%
bupivacaine.

Manchikanti et al, 120 patients with chronic low back1999 (138)pain after radiographic conservative
management were evaluated.

Manchikanti et al, 180 consecutive patients with
2000 (139)chronic low back pain were
evaluated after having failed
conservative management

Controlled diagnostic blocks with
1% lidocaine followed by 0.25%
bupivacaine.

Manchikanti et al, 120 patients were evaluated with
2001 (43)chief complaint of chronic low
back pain to evaluate relative
contributions of various structuresin chronic low back pain. All 120
patients underwent facet joint nerve
blocks.

Controlled Blocks With ≥75%-100% Relief

60 consecutive patients with chronic
low back pain were identified
in a complicated prospective,
randomized, single blinded, simple
cross-over study with 6 parallelgroups.

Schütz et al, 2011
(192)

Intervention(s)Controlled diagnostic blocks oflumbar facet joint nerves with
1% preservative-free lidocaine
and 0.25% preservative-freebupivacaine 1 mL.

Participants

Manchikanti et al, 181 patients with at least 50% pain2010 (166)
relief with concordant pain relief
were evaluated with dual blocks.

Study/Methods

Table 4 (cont). Studies assessing the accuracy of diagnostic blocks.

75% through 95% ormore pain reduction

75% pain relief withability to perform
previously painful
movements

Concordant pain relief
with 75% or greater
criterion standard
with ability to perform
previously painful
movements.

80% pain relief withability to perform
previously painful
movements

At least 50% pain relief

At least 50% pain relief
and ability to perform
previously painful
movements.

Outcome Measures

Prevalence = 24.2%

False-positive rate
= 25%

Prevalence = 36%

False-positive rate
= 41%

Prevalence = 45%

False-positive rate
= 47%

Prevalence = 40%

False-positive rate
= 66%

False-positive rate
= 17%

Prevalence = 61%

Results

The prevalence reduced from 24.2% at
75% relief to 20.8% at 80% relief, 18.3% at
85%, 14.2% at 90%, and 10.8% and 95%;
however, this was not a prevalence study.

This study showed no significant difference
if the steroids were used or not

This was the first study performed in
the United States in the heterogenous
population as previous studies were
performed in only post-injury patients.

This study evaluated all the patientswith low back pain, even with suspecteddiscogenic pain.

Authors recommended abandoning
single diagnostic blocks prior to invasive
therapies, comparative facet joint blocks
with local anesthetics and placebo controls
also have to be interpreted carefully.

An unusually high proportion of positive
rate for facet joint prevalence.

Conclusion(s)Pain Physician: November/December 2012; 15:E869-E907

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Controlled diagnostic blocks with
1% lidocaine followed by 0.25%
bupivacaine.

Manchukonda etal, 2007 (145)

Controlled diagnostic blocks oflumbar facet joint nerves with
1% preservative-free lidocaine
and 0.25% preservative-freebupivacaine 1 mL.
Dual controlled diagnostic blocks
with 1% lidocaine for the first
block with 0.5% bupivacaine forthe second.

Manchikanti et al, 491 patients with chronic low back2010 (166)pain undergoing evaluation for facet
joint pain.

DePalma et al,2011 (184)

In a retrospective evaluation, a
total of 156 patients with chronic
low back pain were assessed for thesource of chronic low back pain
including discogenic pain, facet joint
pain, and sacroiliac joint pain.

Controlled, comparative, local
anesthetic blocks with 1%
lidocaine and 0.25% bupivacaine.

Manchikanti et al, A total of 117 consecutive patients2007 (149)with chronic non-specific low
back pain were evaluated, after
lumbar surgical interventions,with postsurgery syndrome andcontinued axial low back painwith controlled, comparative local
anesthetic blocks.

False-positive rate
= 42%

Prevalence = 31%

False-positive rate
= 49%

Prevalence = 16%

False-positive rate
= 45%

Prevalence = 27%

False-positive rate
= 27%

Prevalence = 31%

False-positive = 30%

Prevalence = 40%

Multiple Regions:
Prevalence = 41%
False-positive rate =27%

Single Region:
Prevalence = 21%
False-positive rate
= 17%

Results

Concordant relief with 2 Prevalence = 31%
hours for lidocaine and8 hours for bupivacaine
with 75% pain relief as
the criterion standard.

At least 80% pain relief
with ability to perform
previously painful
movements.

80% relief as thecriterion standard

80% pain relief withability to perform
previously painful
movements.

80% pain relief withability to perform
previously painful
movements.

Controlled diagnostic blocks with
1% lidocaine followed by 0.25%
bupivacaine.

Manchikanti et al, 500 consecutive patients with
2004 (144)chronic, non-specific spinal pain
were evaluated of which 397 patients
suffered with chronic low back pain.

500 consecutive patients withchronic spinal pain were evaluatedof which 303 patients were evaluatedfor chronic low back pain.

80% pain relief withability to perform
previously painful
movements.

Controlled diagnostic blocks with
Manchikanti et al, 120 consecutive patients with
2002, (143)chronic low back pain and neck pain 1% lidocaine followed by 0.25%
were evaluated to assess involvement bupivacaine.
of facet joints as causative factors.

Outcome Measures
80% pain relief withability to perform
previously painful
movements.

Intervention(s)Controlled diagnostic blocks with
1% lidocaine followed by 0.25%
bupivacaine.

Participants

Manchikanti et al, At total of 300 patients with chronic
2003 (142)low back pain were evaluated toassess the difference based on
involvement of single or multiple
spinal regions.

Study/Methods

Table 4 (cont). Studies assessing the accuracy of diagnostic blocks.

This is the third study evaluating various
structures implicated in the cause of low
back pain with controlled diagnostic blocks(43,44).

Much lower prevalence with stricter criteria
compared to 50% pain relief.

Lower prevalence

Second largest study performed involving
all regions of the spine by the same groupof authors (144).

Largest study performed involving all
regions of the spine.

The results are similar to involvement ofmultiple regions with a prevalence of 40%
as illustrated in another study.

This study shows a higher prevalence when
multiple regions are involved.

Conclusion(s)Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

E879

This study showed no significant difference
between obese and non-obese individuals
either with prevalence or false-positive rateof diagnostic blocks in chronic facet joint
pain.

There was one study (44) evaluating the prevalenceof facet joint pain utilizing the single block paradigm
with 50% to 74% relief, yielding a prevalence of 48%
with poor evidence.

2.6.2 Single Block with 75% to 100% Relief

False-positive rate:
Non-obese individuals= 44%
Obese individuals =33%

Prevalence:
Non-obese individuals= 36%
Obese individuals =40%

Controlled diagnostic blocks

Facet joints were investigatedwith diagnostic blocks using
lidocaine 1% initially followed bybupivacaine 0.25%, at least 2 weeks
apart.

Manchikanti et al, Controlled comparative prevalence
2001 (200)study in 100 patients with 50
patients below age of 65 and50 patients aged 65 or over wasassessed.

Manchikanti et al, Authors evaluated 100 patients with
2001 (205)
low back pain. Patients were divided
into 2 groups, Group I was normal
weight and Group II was obese.

75% pain relief withability to perform
previously painful
movements was
utilized as the criterion
standard.

2.6.1 Single Block with 50% to 74% Pain Relief

There were a total of 4 studies meeting the inclusion criteria evaluating facet joint pain using a cutoff
threshold between 75% and 100% relief following asingle block (99,100,102,166). Two of the 4 studies
showed a prevalence of 31% and 33% (99,100) whereas
the other 2 studies showed 53% and 61% prevalence(102,166). It appears that a high proportion of patients
will yield positive evidence and undergo unnecessary
therapeutic facet joint modalities. Consequently, theevidence is limited.

2.6.3 Dual Blocks with 50% to 74% Pain Relief
A definite response
was defined as reliefof at least 75% in thesymptomatic area.

This study showed higher prevalence of
facet joint pain in the elderly compared to
the younger age group in contrast to thelatest study by Manchikanti et al whichshowed no differences (147).
Prevalence:< 65 years = 30%> 65 years = 52%

E880

False-positive rate:< 65 years = 26%> 65 years = 33%

Conclusion(s)Intervention(s)Participants
Study/Methods

Table 4 (cont). Studies assessing the accuracy of diagnostic blocks.

Outcome Measures

Results

Pain Physician: November/December 2012; 15:E869-E907

There were 5 studies after the exclusion of duplicate
publications evaluating the role of 50% to 74% relief
with controlled diagnostic blocks in assessing the prevalence and false-positive rates (98,136,140,166,192).
Of these, 2 studies evaluated false-positive rates
only (146,192). Among the 3 remaining studies, themost widely quoted studies by Schwarzer et al (136,140)
yielded a prevalence of 15% and 40%, whereas the 2studies by Manchikanti et al (98,166) yielded 42% and
61% prevalence. The 2 studies evaluating false-positive
rates yielded a false-positive rate of 38% by Schwarzer
et al (146), whereas Schütz et al (192) yielded a falsepositive rate of 66%. Manchikanti et al (98,166) showeda false-positive rate variable of either 17% or 37%.
Thus, the prevalence has been shown to be variable from 15% to 61% with a false-positive rate of 17%
to 66%, with the evidence, which is fair, utilizing 50%
to 74% relief as the criterion standard.

2.6.4 Dual Blocks with 75% to 100% Relief
This is the category most widely studied. Afterthe exclusion of duplicate publications, there were 13
studies (43,101,138,139,142-145,149,166,184,200,205)
utilizing greater than 75% relief as the criterion standard with controlled diagnostic blocks. The prevalencein these studies ranged from 25% to 45% with falsepositive rates demonstrated from 25% to 49% in heterogenous populations. However, in post-laminectomy
syndrome, the prevalence was less with 16%. In the elderly, prevalence rates were higher, whereas with obesity, there was no significant difference.

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A total of 303 patients were evaluated with chronic
low back pain. Patients were allocated into no
psychopathology group, major depression, generalized
anxiety disorder, and somatization disorder. Controlled
comparative local anesthetic blocks with 80% pain
relief and the ability to perform previously painful
movements was utilized as the criterion standard.

86 patients for chronic axial low back or cervical pain
in a prospective cohort study were classified into low
psychopathology group, moderate psychopathology
group, or high psychopathology group. Diagnostic
blocks were performed utilizing facet joint nerve
blocks with methylprednisolone 20 to 30 mg and0.25% bupivacaine with a total volume of 1 to 1.25
mL injection per level.

Manchikanti et al, 2008
(148)
Assessment of influenceof psychological variableson the diagnosis of facet
joint involvement inchronic low back pain.

Wasan et al, 2009 (194)
Evaluation of influenceof psychopathology to
predict the outcome of
medial branch blocks withcorticosteroid injection
for chronic axial low backpain in

Influence Of Psychological Factors

The low psychopathology group reported a mealof 23% improvement in pain at one month while
the high psychopathology group reported a mean
worsening of 0.58% in pain. 45% of low group had aleast 30% improvement in pain versus 10% in the highgroup.

The prevalence of lumbar facet joint pain was 28%
in no psychopathology group compared to 43% inpatients with major depression, 42% in patients withgeneralized anxiety disorder, and 38% in patients withsomatization disorder with false-positive rates of 58%,
39%, 40%, and 42%, respectively.

This is poorly performed flawed evaluation withinappropriate methodology.

The study illustrates no significant difference inpatients with or without psychopathology.

This study showed higher prevalence of facet
joint pain in the elderly compared to the younger
age group in contrast to the latest study byManchikanti et al which showed no differences(147).

Controlled comparative prevalence study in 100
patients, in which 50 patients below age of 65 and 50
patients aged 65 or over were assessed. Controlled
diagnostic blocks were performed with 75% pain
relief with ability to perform previously painful
movements utilized as the criterion standard.

Manchikanti et al, 2001
(200)
Assessment of the role offacet joints in chronic low
back pain in the elderly

The prevalence of facet joint pain was determined as
30% in the adults below the age of 65 and 52% in theelderly above the age of 65 with false-positive rates of
26% and 33%, respectively.

Based on this study it appears that female, elderly,
obese patients may have higher prevalence of facet
joint pain.

Body mass index was associated with significant
increases in the prevalence of facet joint pain. Facet
joint pain was the most likely source of chronic low
back pain for male patients who were approximately
54 years of age (30%-54%), regardless of body massindex, whereas, for female patients who were 65 years
facet joint pain was most likely (46%-57%).

153 patients with chronic low back pain were
evaluated in a retrospective evaluation with dual
diagnostic blocks with 1% lidocaine and 0.5%
bupivacaine with concordant relief of 75% of thecriterion standard.

Age related prevalence of
facet joint involvement
and chronic low backpain was evaluated in a
retrospective assessment.

Manchikanti et al, 2008
(147)

DePalma et al, 2012 (189)
Assessment ofrelationships between
age, gender, and bodymass index and source ofchronic low back pain

Comments
Age-related prevalence ranged from a low of 18% to ahigh of 44% with overall prevalence of 27%. Similarly,
false-positive rates also changed. Overall it appears
that there is not a substantial difference based on theage, especially the elderly, even though Group V withage of 61 to 70 years showed 21% prevalence whichis less than Group VI of over 70 years with 26%
prevalence and significantly different from Group IV,
51 to 60 year group of 44%.

Results
The prevalence was 28% in Group I, 18% in Group II,
28% in Group II, 44% in Group IV, 21% in Group V,
and 26% in Group VI with overall prevalence of 27%.
The false-positive rates were 40%, 50%, 45%, 30%,
64%, and 43% respectively, with overall false-positive
rate of 45%.

Methods And Assessment Criteria

A total of 303 patients were assessed divided into
6 groups with Group I aged 18-30 years, Group II
aged 31-40 years, Group III aged 41-50 years, GroupIV aged 51-60 years, Group V aged 61-70 years,
Group VI over 70 years. Controlled comparative
local anesthetic blocks with 80% pain relief and theability to perform previously painful movements was
utilized as the criterion standard.

Influence of Age

Study

Table 5. Assessment of factors influencing prevalence and false-positive rates of facet joint pain.

Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

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E882

158 patients underwent dual diagnostic blocks with
1% lidocaine and 0.5% bupivacaine with concordantrelief of 75% of the criterion standard. A total of 158
patients were evaluated.

DePalma et al, 2012 (188)
Evaluation of the sourceof chronic low back pain
based on the history ofsurgical discectomy.

This prospective, randomized, controlled comparativeevaluation was performed to determine theprevalence of facet joint pain in persistent low backpain in postlumbar laminectomy patients with acomparative non-surgical group. 100 patients with
50 patients in each group were randomly assignedwith group I consisting of 50 patients without historyof previous surgery and group II consisting of 50
patients with history of previous surgery.

A total of 28 fusion cases identified from 170 low
back pain patients undergoing diagnostic procedures
were assessed. Controlled diagnostic blocks were
performed.

DePalma et al, 2011 (187)
Evaluation of etiology
of chronic low backpain in patients having
undergone lumbar fusion

Manchikanti et al, 2001
(218)
Assessment of the role offacet joint pain in postsurgery syndrome

A total of 117 consecutive patients with chronic,
nonspecific low back pain, after lumbar surgicalintervention(s) were evaluated with controlled,
comparative local anesthetic blocks.

Manchikanti et al, 2007
(149)
Assessment of facet joint
pain in post-surgery
syndrome

Results showed that the prevalence of facet joint
There was a lower prevalence of facet joint pain inmediated pain in non-surgical patients was 44%
patients after surgical interventions.
compared to 32% in post surgical patients determined bycomparative controlled local anesthetic blocks utilizing
lidocaine and bupivacaine. This study also showed afalse positive rate of 36% in the non-surgical groupand 24% in the post-surgical group. In conclusion, thisstudy shows that facet joint mediated symptomatology
in chronic low back pain is prevalent, both in nonsurgical as well as post-surgical patients even though theprevalence was somewhat higher in the non-surgicalgroup compared to post-surgical group.

Results show lower prevalence in patients withsurgical discectomy; however, the sample size wasextremely small.

The results showed that patients even after lumbar
fusion have persistent low back pain secondary to
facet joint involvement in approximately 18% of
the patients. This is similar to other reports (149).

After 28 fusion cases, 5 patients were identified withzygapophysial pain with a prevalence of facet joint
pain of approximately 18%.

The study showed facet joint pain in 18.2% of thepatients whereas it was 32.6% of the patients inpatients without surgical intervention. However, there
were only 2 patients positive in patients with surgicaldiscectomy.

This study showed prevalence of lumbar facet
joint pain in patients after surgical interventions of
16% with a false-positive rate of 49% with a single
block.

The prevalence of lumbar facet joint pain inpatients with recurrent pain after various surgicalintervention(s) was 16% (95% confidence interval,
9%-23%). The false-positive rate with a single blockwith lidocaine was 49%.

Based on this study it appears that female, elderly,
obese patients may have higher prevalence of facet
joint pain.

Body mass index was associated with significant increases
in the prevalence of facet joint pain. Facet joint pain was
the most likely source of chronic low back pain for malepatients who were approximately 54 years of age (30%54%), regardless of BMI, whereas, for female patients who
were 65 years facet joint pain was most likely 46%-57%.

153 patients with chronic low back pain were
evaluated in a retrospective evaluation with dual
diagnostic blocks with 1% lidocaine and 0.5%
bupivacaine with concordant relief of 75% of thecriterion standard.

DePalma et al, 2012 (189)
Assessment ofrelationships between
age, gender, and bodymass index and source ofchronic low back pain

Influence of Surgery

This study showed the prevalence of lumbar facet
joint pain of 40% in obese patients and 36% in
patients of normal weight with a false-positive
rate of 33% in obese patients and 44% in nonobese patients is similar to the results of multiple
previous studies concluding that facet joint pain is acommon occurrence in obese patients; however, theincidence of facet joint mediated pain is similar inobese patients and non-obese patients.

Comments

The results showed that the prevalence rate of facet
joint pain in chronic low back pain in Group I or nonobese patients was 36%, in contrast to 40% in GroupII, or the obese patient group, with no significant
differences among the 2 groups. The study also
showed a false-positive rate of 39% in the total sample,
or 44% in Group I non-obese patients and 33% inGroup II, or obese patients.

Results

Authors evaluated 100 patients with low back pain.
Patients were divided into 2 groups, Group I was
normal weight and Group II was obese. Facet joints
were investigated with diagnostic blocks using
lidocaine 1% initially followed by bupivacaine 0.25%,
at least 2 weeks apart. A definite response was defined
as relief of at least 75% in the symptomatic area.

Methods And Assessment Criteria

Manchikanti et al, 2001
(205)
Assessment of the roleof obesity in chronic low
back pain.

Influence 0f Body Mass Index

Study

Table 5 (cont). Assessment of factors influencing prevalence and false-positive rates of facet joint pain.

Pain Physician: November/December 2012; 15:E869-E907

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320 patients were evaluated with controlled
diagnostic blocks performed with 75% pain relief
with the ability to perform previously painful
movements utilized as the criterion standard.

Manchikanti et al, 2002
(201)
Evaluation of theinfluence of gender,
occupational injury, andsmoking on prevalence of
facet joint pain

180 patients with confirmed diagnosis of facet
joint pain following controlled comparative local
anesthetic blocks were injected intravenously withsodium chloride solution, midazolam, or fentanyl.

Evaluation of 60 patients with 20 patients in eachgroup with chronic low back pain. Diagnosis wasestablished with controlled comparative local
anesthetic blocks. Patients received either sodium
chloride solution, midazolam, or fentanyl.

Manchikanti et al, 2004
(202)
Assessment of theeffect of sedation as aconfounding factor in
the diagnostic validity oflumbar facet joint pain

Manchikanti et al, 2006
(203)
Evaluation of the effectof sedation on diagnostic
validity of facet joint
nerve blocks

INFLUENCE OF
SEDATION

153 patients with chronic low back pain were
evaluated in a retrospective evaluation with dual
diagnostic blocks with 1% lidocaine and 0.5%
bupivacaine with concordant relief of 75% of thecriterion standard.

DePalma et al, 2012 (189)
Assessment ofrelationships between
age, gender, and bodymass index and source ofchronic low back pain

INFLUENCE OF
GENDER/SMOKING

Methods And Assessment Criteria

138 consecutive patients with radicular pain syndromesin Group I underwent microdiscectomy with pathology
being disc extrusion or sequestration, Group II underwent
nucleoplasty for nerve root compression caused bycontained disc herniation – disc protrusion, and Group III
with a nerve root compression caused by uncontained discherniation/disc extrusion treated by nucleoplasty.

Study

Bokov et al, 2011 (206)
Assessment of facet joint
pain in patients after
nerve root decompression

As many as 10% of the patients reported significant
relief (≥80%) with the ability to perform prior painful
movements. Pain relief of 50% or greater was illustrated
in 5% of the patients in sodium chloride group, 5%
in patients receiving midazolam, and 10% in patients
receiving fentanyl. However 80% or greater relief wasobserved in 5% of patients in sodium chloride group
and also midazolam group, and 0% in fentanyl group.

Pain relief of 80% was noted in 2% of the patientsin sodium chloride group, 5% of the patients inmidazolam group, and 7% of the patients receiving
fentanyl. However, pain relief of 50% or greater wasnoted in 7% of the patients in sodium chloride group,
5% of the patients in midazolam group, and 13% of
the patients receiving fentanyl.

Facet joint pain was present in 38% of men compared
to 43% of women. Smokers had prevalence of 43%
compared to nonsmokers of 41% in heavy smokers.
Patients with occupational injury reported 28% ofprevalence of facet joint pain compared to 44% withpatients with gradual onset without injury. Falsepositive rates varied from 28% to 46%.

Body mass index was associated with significant
increases in the prevalence of facet joint pain. Facet
joint pain was the most likely source of chronic low
back pain for male patients who were approximately
54 years of age (30%-54%), regardless of BMI,
whereas, for female patients who were 65 years facet
joint pain was most likely 46%-57%.

The failure rate of surgery with continued pain
problems were present in 44.7% in Group I, 47.8%
in Group II, and 85.2% in Group III. Facet joint pain
was identified in 23.1% in Group I (15 of 65 patients),
16.9% in Group II (11 of 46 patients), and 22.2% inGroup III (6 of 27 patients).

Results

Table 5 (cont). Assessment of factors influencing prevalence and false-positive rates of facet joint pain.

Comments

This study also demonstrates, similar to previous
studies, that there is no significant difference when
sedation was used with potential false-positive
rates.

Overall there was no significant difference withplacebo response with either sodium chloride
solution, midazolam, or fentanyl intravenous
injections. The administration of sedation withmidazolam or fentanyl may be a confounding
factor, specifically if 50% relief is used as acriterion standard.

The study showed the prevalence of facet joint
pain to be less in male patients and occupational
injury patients. , There were no differences basedon smoking.

Based on this study it appears that female, elderly,
obese patients may have higher prevalence of facet
joint pain.

Authors once again show that facet joint painis present in patients who have undergone discdecompression either by microdecompression or
nucleoplasty.

Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

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E884

This study evaluated the role of placebo and nocebo
effects of perioperative administration of sedatives
and opioids in interventional pain management in
360 patients, 180 patients with chronic low back pain,
in a placebo controlled randomized, double-blindevaluation.

Methods And Assessment Criteria

At the end of one year, the diagnosis was confirmed
in 75% of the group with 50% relief, whereas it was
93% in the group with 80% relief. At the end of 2-year
follow-up, the diagnosis of lumbar facet joint pain
was sustained in 51% of the patients in the group with50% relief, whereas it was sustained in 89.5% of thepatients with 80% relief.

85% of the patients available for follow-up withstoodthe diagnosis of facet joint pain at the end of 2 years,
whereas this proportion decreased to 75% if all thepatients in the study were included in the intent-totreat analysis.
In the greater than or equal to 50% group, successrates were 52% and 67% based on pain relief andglobal perceived effect respectively. Among patients
who experienced greater than 80% relief fromdiagnostic blocks, 56% obtained greater than or equal
to 50% relief from radiofrequency denervation and
66% had a positive global perceived effect.

Authors evaluated 151 patients with suspected lumbar
facet joint pain for radiofrequency neurotomy. GroupI was treated with radiofrequency denervation without
diagnostic blocks, Group II with a positive response fora single diagnostic block with 50% relief, and GroupIII underwent radiofrequency neurotomy in patients
who were positive with controlled comparative local
anesthetic blocks with a 50% relief of criterion standard.

Controlled comparative local anesthetic blocks were
performed WITH lidocaine, bupivacaine, with either
50% to 79% relief or over 80% relief as the criterion
standard with ability to perform previously painful
movements.

Cohen et al, 2010 (164)
Evaluation of the role ofdiagnostic blocks without
any diagnostic blocks,
with a single diagnostic
block, or dual diagnostic
block

Manchikanti et al, 2010
(166)
Assessment of the accuracyof diagnostic lumbar facet
joint nerve blocks with either
50% relief or 80% relief as
the criterion standard with
controlled comparative local
anesthetic blocks

Manchikanti et al, 2003
The diagnosis was established with dual blocks with
(195)
80% pain relief with ability to perform previously
Evaluation of the accuracy painful movements.
of diagnostic facet joint
nerve blocks with a longterm follow-up

Cohen et al, 2008 (212)
Assessment of the factors
contributing to successof radiofrequency
denervation based on
diagnostic medial branch
blocks

In “0”group, 17 patients (33%) obtained a successful
outcome at 3 months versus eight patients (16%)
in “1” and “2” group (22%) patients in group “2”.
Denervation success rates in groups 0, 1, and 2 were33, 39, and 64%, respectively.

Authors evaluated 152 patients diagnosed with lumbar
facet joint pain utilizing controlled comparative local
anesthetic blocks, with lidocaine 1% or bupivacaine
0.25% with concordant relief with criterion standard of
80%, the accuracy of diagnostic lumbar facet joint nerve
blocks. Assessment was carried out at a 2 year follow-up.

Authors evaluated, in a multicenter analysis, thefactors contributing to success of radiofrequency
denervation based on diagnostic medial branch
blocks and their relief in 262 patients from 3 centers.
The relief criteria used was with a single block withbupivacaine of medial branches with either 50% to
79% pain relief or 80% or greater.

This study shows it is not only placebo effectthat influences the patients experience, butalso the nocebo effect even when opioid andbenzodiazepine are used.

Comments

Based on a single diagnostic block there wasno difference in improvement related toradiofrequency neurotomy, either with a criterion
standard of 50% or 80% with a single block.

The study shows that diagnostic lumbar medial
branch blocks are valid and the diagnosis of facet
joint pain is sustainable after 2 years.

Application of 80% relief with controlled
comparative local anesthetic blocks provides arobust diagnostic criteria.

This study showed clearly that dual diagnostic
blocks were superior to either no diagnostic block
or a single diagnostic block, despite miscalculationof cost effectiveness.

At the end one year, 93% of the patients and at the end Controlled comparative local anesthetic blocksof 2 years 89.5% of the patients were considered towith 80% pain relief showed validity.
have lumbar facet joint pain.

Between 13% and 30% of all patients across all 3groups of the study, rated their pain relief following
injection as better than their previous experience. A
small proportion, 3% to 8% of patients in all 3 groups
rated their experience following injection as worse
than their previous experience.

Results

Pampati et al, 2009 (165)
Diagnostic validity

Influence of Diagnostic Blocks on Therapeutic Outcomes

Effect of placebo andnoceboManchikanti et al, 2005
(163)

Study

Table 5 (cont). Assessment of factors influencing prevalence and false-positive rates of facet joint pain.

Pain Physician: November/December 2012; 15:E869-E907

www.painphysicianjournal.com

Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

Table 6. List of excluded studies.

Manuscript
Author(s)Reason for Exclusion

Pneumaticos et al, 2006
(97)

This was a prospective evaluation of use of bone scintigraphy with single photon emission computed tomography(SPECT) for identification of patients with low back pain who would benefit from facet joint injections, rather than
diagnostic accuracy study.

Ackerman & Ahmad,
2008 (127)Authors evaluated therapeutic effect of intraarticular or medial branch nerve blocks without diagnostic blocks andwithout evaluation of prevalence and false-positive rates.

Ackerman et al, 2004
(157)

Authors evaluated if diagnostic lumbar facet joint injections are influenced by pain of muscular origin rather thanaccuracy, prevalence, or false-positive rates.

Chua et al 2011, (186)This study describes if diagnostic blocks have any beneficial effects on pain processing. It is not a prevalence,
diagnostic accuracy, or false-positive rate study.

Holm et al 2000, (193)This study evaluated influence of facet joint anesthesia on isokinetic muscle performance in patients with chronic
degenerative low back disorders rather than diagnostic accuracy, prevalence, or false-positive rates.

Mayer et al 2004, (196)Authors evaluated corticosteroid joint injections in 70 patients with segmental rigidity. They concluded that 17% of
the patients with lumbar segmental rigidity met criteria for the facet syndrome.

Birkenmaier et al, 2007
(197)

This study used uncontrolled blocks comparing pericapsular blocks in evaluating cryo-denervation. The injection
was also of high volumes with 0.5% bupivacaine.

Marks et al, 1992 (198)

Authors compared facet joint nerve blocks and intraarticular injections with high volume injections with very shortterm follow-up in a randomized trial. No prevalence or false-positive rate data were available.

Nash, 1990 (199)

Authors compared the effectiveness of intraarticular injections with medial branch blocks on a short-term basis withno controlled local anesthetic blocks or false-positive rate evaluation.

Bokov et al, 2010 (207)

Authors evaluated difference in treatment of nerve root compression pain caused by lumbar disc herniation applying
nucleoplasty.

Steib et al, 2012 (208)Authors evaluated predictors of facet joint syndrome after lumbar disc surgery.

Senoglu et al, 2010 (209)Authors described morphological evaluation of cervical and lumbar facet joints with consideration of intraarticular
facet joint injections.

Miyakoshi et al, 2007
(211)

In this manuscript total dorsal ramus block for the treatment of chronic low back pain was described as a preliminary
study.

Schwarzer et al, 1994
(217)

Authors evaluated combination of discogenic and facet joint pain in the same patients utilized in other studies.

Jackson et al, 1988 (219)This study with intraarticular injections showed mean relief of 29%. Authors evaluated multiple factors. Authors
concluded that facet joint was not commonly the single or primary cause of pain in the great majority of low backpain patients.

Selby & Paris, 1981
(220)

Anatomic correlation of the facet joints was evaluated.

Raymond & Dumas, 1989
(221)

Twenty-five patients were evaluated with intraarticular facet blocks with discussions about if intraarticular injection isdiagnostic or therapeutic procedure.

Schwarzer et al, 1994
(222)

Authors evaluated the value of provocation response in lumbar zygapophysial joint injections showing that the
study called into the question the validity of pain provocation alone as a criterion standard in patients undergoing
diagnostic lumbar zygapophysial joint blocks.

The level of evidence is good for dual blocks with
75% to 100% relief.

2.7 Analysis of Confounding Factors
Prevalence and false-positive rates were evaluatedfor age, psychological factors, weight/obesity, surgery,
gender/smoking, sedation, and other confounding
factors.

www.painphysicianjournal.com

2.7.1 Influence of Age
There were 3 studies evaluating the influenceof age on the prevalence and false-positive rate offacet joint injections (147,189,200). Manchikanti et al(147,200) evaluated the influence of age. In the firstevaluation (200), they showed a significant differencewith a prevalence of 30% in those who were aged lessthan 65 years old, and 52% in those aged 65 or older,

E885

E886
–
+
+

+

+
+
+
+

+

+

3. Were raters blinded to the reference
standard for the target disorder being
evaluated?

4. Were raters blinded to the findings ofother raters during the study?

5. Were raters blinded to their own
prior outcomes of the test underevaluation?

6. Were raters blinded to clinicalinformation that may have influenced
the test outcome?

7. Were raters blinded to additionalcues, not intended to form part of thediagnostic test procedure?

8. Was the order in which raters
examined subjects varied?

9. Were appropriate statistical measuresof agreement used?

10. Was the application andinterpretation of the test appropriate?

11. Was the time interval between
measurements suitable in relation
to the stability of the variable being
measured?

12. If there were dropouts from thestudy, was this less than 20% of thesample.
9/12

+

+

+

+

+

–

–

+

+

–

+

+

11/12

+

+

+

+

+

+

+

+

+

–

+

+

12/12

+

+

+

+

+

+

+

+

+

+

+

+

Schwarzer Schwarzer
et al
et al
(136,146,217) (137,140)

11/12

+

+

+

+

+

+

+

+

+

–

+

+

Manchikanti
et al (138)

12/12

+

+

+

+

+

+

+

+

+

+

+

+

Manchikanti
et al (139)

Y=yes; N=no; U=unclear; N/A=not applicable
Lucas N, et al. Reliability of physical examination for diagnosis of myofascial trigger points. Clin J Pain 2009; 25:80-89 (85).

11/12

+

2. Was the test performed by examiners
representative of those who would
normally perform the test in practice?

TOTAL

+

1. Was the test evaluated in a spectrumof subjects representative of patients
who would normally receive the test in
clinical practice?

Manchikanti Pang et
et al (43)al (44)

Table 7. Quality appraisal of the diagnostic reliability of lumbar facet joint diagnostic studies.

12/12

+

+

+

+

+

+

+

+

+

+

+

+

12/12

+

+

+

+

+

+

+

+

+

+

+

+

8/10

+

–

+

+

+

+

+

NA

NA

–

+

+

8/10

+

-

+

+

+

+

+

NA

NA

–

+

+

11/12

+

+

+

+

+

+

+

+

+

–

+

+

Laslett
Revel Revel Young
Manchikanti
et al
et al et al
et al
et al (98)(95,101)(99) (100) (102)Pain Physician: November/December 2012; 15:E869-E907

www.painphysicianjournal.com

www.painphysicianjournal.com
–

+

+

+

+
+
+
+

+

+

3. Were raters blinded to thereference standard for the target
disorder being evaluated?

4. Were raters blinded to thefindings of other raters during
the study?

5. Were raters blinded to theirown prior outcomes of the test
under evaluation?

6. Were raters blinded to clinicalinformation that may haveinfluenced the test outcome?

7. Were raters blinded to additionalcues, not intended to form part ofthe diagnostic test procedure?

8. Was the order in which raters
examined subjects varied?

9. Were appropriate statisticalmeasures of agreement used?

10. Was the application andinterpretation of the test
appropriate?

11. Was the time interval
between measurements suitablein relation to the stability of thevariable being measured?

12. If there were dropouts fromthe study, was this less than 20%of the sample.
11/12

+

+

+

+

+

+

+

+

+

–

+

+

11/12

+

+

+

+

+

+

+

+

+

–

+

+

11/12

+

+

+

+

+

+

+

+

+

–

+

+

Manchikanti Manchikanti Manchukonda
et al (143)et al (144)et al (145)

11/12

+

+

+

+

+

+

+

+

+

–

+

+

11/12

+

+

+

+

+

+

+

+

+

–

+

+

11/12

+

+

+

+

+

+

+

+

+

–

+

+

DePalmaManchikanti Manchikanti
et al 2011
et al (149)et al (166)(184)

Y=yes; N=no; U=unclear; N/A=not applicable
Lucas N, et al. Reliability of physical examination for diagnosis of myofascial trigger points. Clin J Pain 2009; 25:80-89 (85).

11/12

+

2. Was the test performed byexaminers representative of
those who would normally
perform the test in practice?

TOTAL

+

1. Was the test evaluated in a
spectrum of subjects representativeof patients who would normallyreceive the test in clinical practice?

Manchikanti
et al (142)

Table 7(cont.). Quality appraisal of diagnostic reliability of lumbar facet joint diagnostic studies.

11/12

+

+

+

+

+

+

+

+

+

–

+

+

11/12

+

+

+

+

+

+

+

+

+

–

+

+

11/12

+

+

+

+

+

+

+

+

+

–

+

+

Schütz et Manchikanti Manchikanti
al (192) et al (200)et al (205)

Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

E887

Pain Physician: November/December 2012; 15:E869-E907
Table 8. Clinical relevance of included studies.

Manuscript Author(s)A) Patient
descriptionB) Descriptionof interventions
and treatment
settings

C) Clinically
relevant
outcomes

D) ClinicalimportanceE) Benefits
versuspotential
harms

Total
Criteria
Met

Manchikanti et al 2001 (43)

+

+

+

+

+

5/5

Pang et al, 1998 (44)

+

+

–

+

+

4/5

Schwarzer et al, 1994 (136,146,217)

+

+

+

+

+

5/5

Schwarzer et al, 1995 (137,140)

+

+

+

+

+

5/5

+

+

+

+

+

5/5

Manchikanti et al, 1999 (138)
Manchikanti et al, 2000 (139)

+

+

+

+

+

5/5

Laslett et al, 2004, 2006 (95,101)

+

+

+

+

+

5/5

Manchikanti et al, 2000 (98)

+

+

+

+

+

5/5

Revel et al, 1992 (99)

+

+

–

+

+

4/5

Revel et al, 1998 (100)

+

+

–

+

+

4/5

Young et al, 2003 (102)

+

+

–

+

+

4/5

Manchikanti et al, 2003 (142)

+

+

–

+

+

4/5

Manchikanti et al, 2002, (143)

+

+

+

+

+

5/5

Manchikanti et al, 2004 (144)

+

+

+

+

+

5/5

Manchukonda et al, 2007 (145)

+

+

+

+

+

5/5

Manchikanti et al, 2007 (149)

+

+

+

+

+

5/5

Manchikanti et al, 2010 (166)

+

+

+

+

+

5/5

DePalma et al, 2011 (184)

+

+

+

+

+

5/5

Schütz et al, 2011 (192)

+

+

+

+

+

5/5

Manchikanti et al, 2001 (200)

+

+

+

+

+

5/5

Manchikanti et al, 2001 (205)

+

+

+

+

+

5/5

+ = positive; - = negative
Scoring adapted from Staal JB, et al. Injection therapy for subacute and chronic low back pain. Cochrane Database Syst Rev 2008; 3:CD001824(179).

with a false-positive rate of 26% and 33%, respectively.
In the second study (147), they categorized the patients
into various groups and found that age-related prevalence ranged from a low of 18% to a high of 44% withan overall prevalence of 27%. False-positive rates werealso variable from 30% to 64%. In fact, in elderly patients 61 to 70 years of age, the prevalence was 21%,
which was less than patients older than 70 years with26%. In contrast, DePalma et al (189) in their assessment found that chronic low back pain of facet joint
origin was most commonly seen in male patients of 54
years of age regardless of body mass index, whereas forfemale patients who were 65 years facet joint pain was
most likely.

E888

2.7.2 Influence of Psychological Factors
Psychological factors were studied by 2 groupsof authors, Manchikanti et al (148) and Wasan et al(194). The study by Wasan et al (194) was very poorly
performed with multiple evaluations and flaws withinappropriate methodology. The study by Manchikanti
et al (148) showed overall prevalence of facet joint
pain in 28% in patients without any psychopathology
compared to 43% in patients with major depression.
Overall the study illustrated no significant differencein patients with or without psychopathology including
depression, generalized anxiety disorder, and somatization disorder.

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Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

Table 9. Data of prevalence of lumbar facet joint pain by diagnostic blocks.

Methodological
Criteria Score

Number of
Subjects

Prevalence Estimateswith 95% ConfidenceIntervals

False-Positive Ratewith 95% ConfidenceIntervals

9/12

100

Prevalence 48%

NA

Revel et al, 1992 (99)

8/10

51

33%

NA

Revel et al, 1998 (100)

8/10

80

31%

NA

Young et al, 2003 (102)

11/12

102

61%

NA

Manchikanti et al, 2010 (166)

11/12

491

53% (67%-80%)

NA

Schwarzer et al, 1994
(136,146,217)

11/12

176

15%

38% (30% - 46%)

Schwarzer et al, 1995 (137,140)

12/12

57 of 6340% (27% - 53%)

NA

Manchikanti et al, 2000 (98)

12/12

200

42% (35% - 42%)37% (32% - 42%)

Manchikanti et al, 2010 (166)

11/12

181

61% (53% - 81%)17% (10%- 24%)

Schütz et al, 2011 (192)

11/12

60

NA

66%

Study
Single Blocks With 50%-74% Relief
Pang et al, 1998 (44)Single Blocks With ≥75%-100% Relief

Controlled Blocks With 50%-74% Relief

Controlled Blocks With ≥75%-100% Relief
Manchikanti et al, 2001 (43)

11/12

120

40% (31%–49%)

47% (35% - 59%)

Manchikanti et al, 1999 (138)

11/12

120

45% (36% - 54%)

41% (29% - 53%)

Manchikanti et al, 2000 (139)

12/12

180

36% (29% - 43%)

25% (21% - 39%)

Laslett et al 2004, 2006 (95,101)

12/12

151

24.2%

NA

Manchikanti et al, 2003 (142)

11/12

300
I: Single region
II: Multiple regions

I: 21% (14%-27%)
II: 41% (33%-49%)

I: 17% (10% - 24%)
II: 27% (18% - 36%)

Manchikanti et al, 2002, (143)

11/12

120

40% (31% - 49%)30% (20% - 40%)

Manchikanti et al, 2004 (144)

11/12

397

31% (27% - 36%)

27% (22% - 32%)

Manchukonda et al, 2007 (145)

11/12

303

27% (22% - 33%)

45% (36% - 53%)

Manchikanti et al, 2007 (149)

11/12

117

16% (9% – 23%)49% (39% – 59%)

Manchikanti et al, 2010 (166)

11/12

491

31% (26% - 35%)

42% (35% - 50%)

DePalma et al, 2011 (184)

11/12

156

31% (24% - 38%)NA

Manchikanti et al, 2001 (200)

11/12

100
I: (<65 years) = 50
II:(>65 years) = 50

I: 30% (17% - 43%)
II: 52% (38% - 66%)

I: 26% (11%-40%)
II: 33% (14%-35%)

Manchikanti et al, 2001 (205)

11/12

100
I: (BMI<30) = 50
II: (BMI >30) = 50

I: 36% (22%, 50%)
II: 40% (26%, 54%)

I: 44% (26%, 61%)
II: 33% (16%, 51%)

NA = Not available

2.7.3 Influence of Body Mass Index
Two studies evaluated the influence of body massindex on prevalence of facet joint pain and chronic low
back pain (189,205). DePalma et al (189) showed thatfemale patients with obesity were most likely to havefacet joint pain. In contrast, Manchikanti et al (205)showed no significant difference between obese andwww.painphysicianjournal.com

non-obese patients with a prevalence of 36% versus
40% with a false-positive rate of 44% versus 33%.

2.7.4 Influence of Surgery
The influence of post-laminectomy syndrome,
post-surgery syndrome or post-fusion was evaluatedin 5 studies (149,187,188,206,218). Manchikanti et al(149,218) evaluated post-surgery in 2 separate studies.

E889

Pain Physician: November/December 2012; 15:E869-E907

The recent study (149) showed a prevalence of 16%
with a false-positive rate of 49%. In this evaluation,
there was no comparison group. In the first study from2001 (218), evaluating obese and non-obese individuals, the authors showed both post-surgery patients andthose patients who had not undergone surgical interventions. The authors showed a prevalence of 44% in
nonsurgical patients and 32% in post-surgical patientswith a false-positive rate of 36% and 24%. Overall bothstudies showed a lower prevalence of facet joint pain
after surgery even though the rates were significantly
different. DePalma et al (187,188) assessed the etiology
of chronic low back pain in those who had a surgicaldiscectomy and those who had undergone lumbar fusion; however, there were very few patients included inthis assessment. In patients who had a previous surgical discectomy (188), the prevalence was 18.2%, compared to those without surgical intervention of 32.6%
in patients with post fusion (187) prevalence was 18%.
Another study by Bokov et al (206) showed the prevalence of facet joint pain of 16.9% to 23.1% based on
the type of intervention they underwent for nerve root
decompression.

2.7.5 Influence of Gender/Smoking
Two studied evaluated the influence of gender andsmoking (189,201). DePalma et al (189) showed thatelderly females with obesity might have higher prevalence of facet joint pain. Manchikanti et al (201) in a
2002 evaluation showed a lesser prevalence of facet
joint pain in male patients and occupational injury patients, although they were unable to detect any difference based on smoking.

2.7.6 Influence of Sedation
Manchikanti et al assessed the influence of sedation in 3 different studies (163,202,203). In the first 2
studies, evaluating the influence of sedation on the
diagnostic validity of facet joint blocks (202,203), theauthors showed that the influence was minimal eitherwith midazolam or fentanyl when 80% relief was usedas the criterion standard; however, there was a significant difference in pain relief in patients when 50% relief
was used as the criterion standard indicating that a criterion standard of 80% pain relief seems to have higher
accuracy compared to 50% pain relief. Manchikanti etal (163) also evaluated the effect of placebo and nocebo showing that approximately 13% to 30% of all
patients across all 3 groups of the study rated their pain
relief following injection as better than their previous

E890

experience with sodium chloride solution, midazolam,or fentanyl. However, a small proportion, 3% to 8% of
patients in all 3 groups rated their experience following
injection as worse than their previous experience. This
study essentially shows that even though midazolam
and fentanyl were administered, patients felt worse.

2.7.7 Influence of Diagnostic Blocks on
Therapeutic Outcomes
Multiple evaluations were performed in this arena.
Pampati et al (165) showed controlled comparative local anesthetic blocks with 80% relief with high validity with 93% of patients with facet joint pain at theend of one year and approximately 90% of patientswith a sustained diagnosis of facet joint pain at 2 years.
Manchikanti et al (195) in a study in 2003 also showed
the sustainability of diagnosis at 85% at the end of 2
years when diagnostic blocks were performed with
80% pain relief with controlled diagnostic blocks. In another study, Manchikanti et al (166) assessed the accuracy of diagnostic lumbar facet joint nerve blocks witheither 50% relief or 80% relief as the criterion standard
with controlled comparative local anesthetic blocks. In
this study they showed that at the end of one year the
diagnosis was confirmed in 75% of the group with 50%
relief, whereas it was 93% in the group with 80% relief. At the end of the 2 year follow-up, the diagnosisof lumbar facet joint pain was sustained in 51% of patients in the group with 50% relief, whereas it was sustained in 90% of patients with 80% relief. Cohen et al(212) assessed, in a multicenter analysis, the factors contributing to the success of radiofrequency denervation.
Based on a single block they showed no significant difference with a criterion standard of either 50% or 80%.
Cohen et al (164) also evaluated the role of diagnostic blocks without any diagnostic blocks, with a single
diagnostic block, or dual diagnostic block. This study
clearly showed that dual diagnostic blocks were superior to either no diagnostic block or a single diagnostic
block, despite the miscalculation of cost effectiveness.

3.0 Complications
Complications from facet joint nerve blocks,
intraarticular injections, or radiofrequency neurolysis in
the lumbar spine are exceedingly rare (1,41,43,44,75,76,7983,98,106,127,130,136,140,142,144,164,189,191,195305). The most common complications of lumbar facet
joint interventions are twofold: Complications related tothe placement of the needle and those related to theadministration of various drugs. Most problems such as

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Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

local swelling, pain at the site of the needle insertion,and pain in the low back are short-lived and self-limited.
More serious complications may include dural
puncture, spinal cord trauma, subdural injection, neuraltrauma, injection into the intervertebral foramen, andhematoma formation; infectious complications including epidural abscess and bacterial meningitis; and side
effects related to the administration of steroids, local
anesthetics, and other drugs.
Other minor complications include lightheadedness, flushing, sweating, nausea, hypotension, syncope,pain at the injection site as described earlier, and nonpostural headaches.
Side effects related to the administration of steroids
are generally attributed to the chemistry or to the pharmacology of the steroids (282). The major theoreticalcomplications of corticosteroid administration include
suppression of pituitary-adrenal axis, hyperadrenocorticism, Cushing’s syndrome, osteoporosis, avascular necrosis of bone, steroid myopathy, epidural lipomatosis,
weight gain, fluid retention, and hyperglycemia.
The evaluation of the effect of neuraxial steroids
on weight and bone mass density showed no significant
differences in patients undergoing various types of interventional techniques with or without steroids (283),
multiple other studies have echoed the same (284-286).
Brill et al (285) also evaluated the effect of 3 consecutive epidural steroid injections with 40 mg methylprednisolone acetate once monthly for 3 months on weightgain and found no significant change in weight afteradministration. However, Lee et al (286) in a systematic
review of the effects of low-dose corticosteroids onbone mineral density of rheumatoid arthritis patients,
which included 7 studies on lumbar bone mineral density meta-analysis and 6 studies on femur bone mineraldensity meta-analysis, showed that corticosteroids resulted in a moderate worsening in lumbar bone mineraldensity compared with controls, whereas the femoral
bone mineral density differences were not significant.
They showed bone mineral density loss after low-dose
corticosteroid treatment in patients with rheumatoid
arthritis with practical implications for the long-term
management of patients with rheumatoid arthritis on
low-dose corticosteroids. Similarly, Korczowska et al(284), assessing low-dose and short-term glucocorticoid
treatment and the risk of osteoporosis in rheumatoid
arthritis in female patients, concluded that there wasanti-inflammatory effect of low-dose glucocorticoid
therapy in rheumatoid arthritis patients; however, inpatients who previously used glucocorticoids on a long-www.painphysicianjournal.com

term basis, the benefits are questionable. Multiple
other studies evaluating epidural injections showed nosignificant difference whether steroids were used or
not (291-298).
A study by Manchikanti et al (240) included over
7,500 episodes or 43,000 facet joint nerve blocks performed under fluoroscopic guidance in an ambulatory
surgery center by one of 3 physicians. The complications
encountered during the procedure and postoperatively
were prospectively evaluated. The results showed no
major complications. Multiple side effects and complications observed in lumbar facet joint nerve blocks included intravascular penetration in 4%, local bleedingin 73% of episodes, oozing in 10% of encounters, withlocal hematoma seen only in 0.1% of the encounterswith profuse bleeding, bruising, soreness, nerve root
irritation, and all other effects such as vasovagal reactions observed in 1% or less of the episodes.

4.0 Discussion
This systematic review of the diagnostic accuracy oflumbar facet joint nerve blocks in evaluation of chronic
low back pain without indications of disc herniation
or radiculitis after failure of conservative management shows varying results. The evidence is good for
utilization of 75% to 100% pain relief with controlled
diagnostic blocks as the criterion standard with a prevalence of 25% to 45% with false-positive rates of 25% to
49% in heterogenous population (43,101,138,139,142145,149,166,184,200,205). The evidence is fair for controlled diagnostic blocks utilizing 50% to 74% relief
as the criterion standard with a prevalence of 15% to
61% with a false-positive rate of 17% to 66% in heterogenous population (98,136,140,146,166,192). The
evidence is poor utilizing 50% to 74% or 75% andlimited for greater pain relief with a single diagnostic block with prevalence ranging from 33% to 61%(44,99,100,102,166).
Facet arthrosis has been suggested as a cause of
low back pain for decades (126,167). However, the exact source of pain in the facet joints is ambiguous. Theories on the generation of pain range from mechanicalalterations to vascular changes and molecular signaling. While disc degeneration can clearly cause low backpain, some patients may not experience pain until degenerative changes in the facet joints alter mechanicalalignment sufficiently to produce “articular” low backpain (306). Eubanks et al (167) and others (307,308) concluded that evidence of facet arthrosis appears earlyand can be linked to the amount of heavy work done

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Pain Physician: November/December 2012; 15:E869-E907

before age 20. Indeed, it appears that facet arthrosis
starts early, with nearly 60% of adults showing somesigns of degenerative changes by the time they reachage 30. After this early rise in arthritic changes, subsequent degeneration appears to steadily increase until
the seventh decade when the evidence of arthrosis becomes ubiquitous (167).
A systematic review is defined as, “the applicationof scientific strategies that limit bias by the systematic
assembly, critical appraisal, and synthesis of all relevant
studies on a specific topic” (309,310). Systematic reviews are labor intensive and require expertise in boththe subject matter and review methods. Thus, expertisein one or the other area is not enough and may lead toinaccurate conclusions in turn leading to inappropriate
application of the results (78,228-231). Thus, this systematic review has provided not only expertise in thesubject matter which is crucial, but also knowledge inreview methodology. A systematic review differs from anarrative review because a systematic review attempts
to minimize bias by the comprehensiveness and reproducibility of the search and selection of articles for review and provides assessment of the methodologicalquality of the studies (78,228-231). In this systematic
review, we attempted to answer specific narrow clinicalquestions in depth – the diagnostic accuracy and validity of facet joint blocks and the level of evidence withrecommendation for diagnostic facet joint injections. A
systematic searching, selecting, appraising, interpreting, and summarizing of data from original studies was
performed. The study summaries were qualitative andquantitative.
In this review we have also searched for othertypes of integrative evidence including other systematic reviews and cost effectiveness studies. Further,recent evaluations in reference to guideline warfare, evidence-based medicine, comparative effectiveness research, have been extensively discussed(27,28,36,37,161,162,311-313).
The IOM standards for systematic reviews (314)described 4 major standards: 1) standards for initiating
the systematic review, 2) standards for finding and assessing individual studies, 3) standards for synthesizing
the body of evidence, and 4) standards for reporting
systematic reviews. each one of the standards describe
in detail multiple aspects.
Further, the IOM also described multiple challenges
and guidance in developing guidelines (315). The IOM
states that the literature assessing the best methods for
guideline development have evolved dramatically in

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the 20 years since the IOM’s first report on the subject(316). The new definition from IOM for guidelines is asfollows (315):
Clinical practice guidelines are statements that include recommendations intended to optimize patientcare that are informed by a systematic review of evidence and an assessment of the benefits and harms ofalternative care options.
The outcomes of facet joint interventions to a great
extent may depend on the diagnosis. Multiple authors
have evaluated the factors related to accuracy of thediagnosis and its influence on the outcomes. It is wellknown that facet joint nerve blocks are inherently nonspecific, even when low volumes are injected underfluoroscopic guidance. Thus, a strong case can be madefor increasing the criteria to a more stringent 75% pain
relief. A study by Dreyfuss et al (317) found that using
0.5 mL low volume facet joint nerve block using conventional landmarks resulted in contrast spread into
the epidural space or intervertebral foramen in 16% ofcases, and between the cleavage plain of the multifidus
and longissimus muscles in all injections. Kaplan et al(318) also demonstrated the ability of lumbar medial
branch blocks to anesthetize the zygapophysial joint.
Consequently, 75% or higher relief with controlled
diagnostic blocks has been recommended. The rationale behind using 50% relief as criteria to proceed toa therapeutic radiofrequency neurotomy was outlined
by Schwarzer et al (136) who cite the high evidenceof concurrent spinal pathology occurring with lumbar
facet joint degeneration as the primary reason. Further,
Fujiwara et al (307) found that even though lumbar degenerative disc disease frequently occurs in absence of
lumbar facet joint degeneration, patients with severe
lumbar facet joint arthritis virtually always have radiologic evidence of degenerative disc disease and/or other spinal pathology. The role of 50% or 75% relief on
the diagnostic accuracy has been evaluated (165,166).
In these studies, it was illustrated that the prevalence
specifically with a and a single block with 50% criterion
standard is inordinately high (73%), along with proof
that diagnosis was sustained in 50% of patients at theend of 2 years when it was made by controlled diagnostic blocks with 50% minimum relief criteria. In contrast,
when the diagnosis was made by 80%, the diagnosis
of facet joint pain was sustained in 89.5% of patientsat the end of 2 years (166). In addition, 80% pain relief also has shown lack of confounding when sedation
was administered, either with midazolam or fentanyl(202,203). Even though, dual blocks with 80% relief as awww.painphysicianjournal.com

Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

criterion standard appears to be the best, some have argued that there is no difference between the outcome,specifically with radiofrequency neurotomy (319). In
fact, the results were also significant when patientswere selected without any diagnostic blocks, in a study
by Civelek et al (241), even though the study by Cohenet al (164) showed inferior results.
Cohen et al (212) emphasized that one reason that
double blocks were not used for their study on the success of lumbar zygapophysial joint radiofrequency denervation as a function of diagnostic block relief wasthat the use of controlled blocks was not cost-effective.
Manchikanti and Singh (320) commented that thewhole concept of single blocks resulting with 50% ormore relief followed by radiofrequency denervation
creates many questions regarding the reliability of diagnostic blockade, increased health care costs, and coverage for facet joint nerve blocks and radiofrequency
neurotomy. Schwarzer et al (136) using 50% relief ofpain as a standard showed the prevalence of lumbar
zygapophysial joint pain in 15% of patients. They (140)also showed a 40% prevalence in another study with
90% pain relief as the criterion standard with placebo
control. They also showed a false-positive response in
38% of the patients (146). Most publications agree that
2 diagnostic blocks must be performed before radiofrequency denervation and many payers are requiring
80% or more pain relief. Further, Cohen et al (164) in arandomized controlled trial investigated costs and outcomes of radiofrequency treatment using 3 different
medial branch blocks treatment paradigms including
radiofrequency without the use of a screening block,radiofrequency if the patient obtained significant relief after a single diagnostic block with 50% relief, andradiofrequency denervation only if a patient has an
appropriate response with a positive response of 50%
or more relief with 2 confirmatory blocks. By 3 months
after radiofrequency treatment, the proportion of successful outcomes of each individual cohort was highest
in the group where patients received radiofrequency
treatment after 2 diagnostic blocks with 64% of thepatients reporting relief. However, by utilizing the total number of patients, Cohen et al (164) confused theentire data and misinterpreted the results, concluding that it was more cost-effective to perform radiofrequency neurotomy without any type of diagnostic
blocks. This misinformation and inappropriate evaluation only lead to unnecessary radiofrequency neurotomy, increasing health care costs (39,162). Consequently,
a single block will definitely increase the costs of carewww.painphysicianjournal.com

as the single diagnostic block will lead to an increasein the number of radiofrequency denervations, which
are more expensive and time consuming. The cost effectiveness of controlled, comparative, local anesthetic
facet joint nerve blocks has been evaluated and foundto be superior to an algorithmic approach starting withdiscography in axial pain (43).
Manchikanti and coauthors in multiple publications(143-145) evaluated the prevalence and false-positive
rates of diagnostic blocks. In all included studies theyutilized a criterion standard of 80% pain relief withthe ability to perform previously painful movements
without pain utilizing 1% lidocaine. In a large studyof 500 patients in which prevalence of facet joint pain
in chronic spinal pain of cervical, thoracic, and lumbar
regions were evaluated (144), 397 patients were evaluated for low back pain showing a prevalence of 31%(95% CI, 27%, 36%) with a false-positive rate with single blocks with lidocaine of 27% (95% CI, 22%, 32%).
The second large study by Manchukonda et al (145)
evaluated 438 patients with 303 patients with lumbar
pain. The prevalence of lumbar facet joint pain wasdetermined as being 27% (95% CI, 22%, 33%), with afalse-positive rate of single blocks in the lumbar regionof 45% (95% CI, 36%, 53%).
Manchikanti et al (43) also have evaluated relative
contributions of various structures in chronic low backpain in 120 patients yielding similar results in terms ofprevalence and false-positive rates. They also evaluatedprevalence based on involvement of multiple regionswith a lower prevalence in patients with involvement of
only lumbar spine versus multiple regions (21% versus
41%) (142). They also have evaluated facet joint pain
in post-surgery syndrome yielding 16% prevalence andfalse-positive rate (149) with no significant difference
between age, gender, smoking, or obesity (201,205). In
their evaluation of confounding factors (202,203), they
showed significant accuracy in patients receiving sedation with midazolam or fentanyl, compared with sodium chloride solution when 80% relief was used as thecriterion standard instead of 50% which confounded
the results.
In recent years DePalma et al (184) have assessed
the prevalence of facet joint pain. They also publishedmultiple manuscripts with subgroup analysis (185,187190). Their study (184) with 156 subjects showed thatthe prevalence of internal disc disruption, facet joint
pain, and sacroiliac joint pain was 42%, 31%, and 18%,
respectively. Patients with internal disc disruption weresignificantly younger than those with facet joint pain

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Pain Physician: November/December 2012; 15:E869-E907

or sacroiliac joint pain. Increased age was associatedwith a decreased probability of internal disc disruption
and increased probabilities of facet joint pain and sacroiliac joint pain as the source of low back pain until
approximately age 70. They concluded that their data
confirmed the intervertebral disc as the most common
etiology of chronic low back pain in adults, and the
younger the patient, the more likely low back pain is
discogenic in origin. Facetogenic or sacroiliac joint pain
is more likely in older patients.
No tissue diagnosis (biopsy or autopsy) techniques
are available to diagnose facet joint pain and confirm
specificity and sensitivity of facet joint nerve blocks.
However, pain relief and stability of the diagnosis withlong-term follow-up are employed as the criterion
standards and are accepted across different medical
disciplines (41,156,195). Thus, the validity of controlled
facet joint nerve blocks as a gold standard or reference
standard in the diagnosis of lumbar facet joint pain has
been established (165,166). Reference standards are
established in surgical situations via biopsy or autopsy.
However, these are difficult to apply in the diagnosis ofchronic spinal pain of facet joint origin. Thus, the longterm or dedicated clinical follow-up of the subjects appears to be the only solution in establishing a reference
standard with controlled facet joint nerve blocks (156).
Based on the criterion standard of long-term follow-up,
controlled diagnostic lumbar facet joint nerve blocks
have been shown to be valid utilizing the criteria of
80% pain relief and the ability to perform previously
painful movements, with a sustained diagnosis of lumbar facet joint pain in at least 89.5% of patients at theend of 2-year follow-up (165). However, the diagnosis
was sustained in only 51% of the patients with 50%
relief at the end of 2 years (165). Thus, the controlled
diagnostic blocks utilized in this study appear to bereliable.
Multiple evaluations have been performed assessing
the role of confounding factors in the diagnosis of facet
joint pain and its prevalence (147-149,163-166,185,187190,194,195,200-203,205,206,212,217,218). There were
3 studies evaluating the influence of age on prevalence and false-positive rates of facet joint injections(147,189,200), with only limited evidence showing thatthe prevalence of facet joint pain is higher in the elderly. Two studies assessing the influence of psychologicalfactors (148,194) showed no significant correlation withpsychopathology and prevalence of facet joint pain or
false-positive rate. Body mass index showed limited
evidence that obese patients may have a higher preva-

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lence of facet joint pain (189,205). In patients with postlaminectomy syndrome and fusion, the prevalence of
facet joint pain has been shown to be lower than in
non-surgical patients (149,187,188,206,218). In reference to smoking there has not been any significant difference noted, while in reference to gender it appears
that the prevalence of facet joint pain may be higher
in women (189,201). The influence of sedation was also
evaluated in 3 different studies (163,202,203) on the diagnostic accuracy, although these studies were by thesame group of authors.
The literature shows differing effects with injections of various solutions such as local anesthetic,
normal saline, or dextrose and also shows differing
effects by injection into the disc, facet joint, or multifidus muscle (321-327). It has been shown that a small
volume of local anesthetic or normal saline abolishes
muscle twitch induced by a low current (0.5 mA) during electrode location (321-324). Furthermore, there isdirect evidence for spinal cord involvement in placebo
analgesia (325). It also has been shown that epidurally
administered sodium chloride solution provides significant improvement in the pain and function (328-330).
Consequently, multiple misunderstandings aboundregarding the role of placebo control. Placebo control
in neural blockade is not only a difficult task, but also
adds ethical issues and difficulty with recruitment in the
United States. The majority of investigations performed
in interventional pain management with descriptionsof placebo control have been met with design flaws(27,28,36,37,161,162,331-333). In the interventional
pain management literature, the effect of any solution injected into a closed space, such as intraarticularspace or epidural space, or over a nerve continues tobe an enigma. Carrette et al (234,334) in their widely
acclaimed studies, showed that patients responded
similarly to an intraarticular injection or epidural injection, whether it contained a sodium chloride solution
or steroid with a low response in both groups, leading
to inappropriate conclusions, that the treatments do
not work. In fact, Birkenmaier et al (197) utilizing either pericapsular injections or medial branch blocks fordiagnostic purposes, went on to perform cryoneurolysis
and showed that results were superior in patients who
were diagnosed using medial branch blocks than inpatients diagnosed using a pericapsular injection of local anesthetic. These misconceptions have led to many
experts (22) to discard the value of diagnostic lumbar
facet joint nerve blocks. Even though the limitations oflack of placebo is most likely underestimated, it shouldwww.painphysicianjournal.com

Diagnostic Accuracy of Lumbar Facet Joint Nerve Blocks

also not be overestimated, specifically in diagnostic interventions. It is essential to design a proper placebo
prior to discarding their role.
In addition, multiple reviewers have considered a
local anesthetic injection also as a placebo leading toinaccurate conclusions. The mechanism of local anesthetics in providing longer than duration of its action
in chronic pain is a complex phenomenon, similar to theeffectiveness of steroids beyond the widely acclaimed
anti-inflammatory effect. In fact, it has been shown that
there is no additional effect with either local anesthetics alone or local anesthetics with steroids providing
similar effect. The literature is replete with descriptionsof epidural corticosteroids providing a certain level of
efficacy by their anti-inflammatory, immunosuppressive, anti-edema effects, and inhibition of neural transmission within C fibers, which is claimed to explain theeffectiveness of steroids for the proponents (78,291296,334-364), even though opponents of steroids continue to debate and deny such a role. Similarly, eventhough more debatable, local anesthetics also havebeen described to provide long-term symptomatic relief. It has been postulated that local anesthetics provide
relief by suppression of nociceptive discharge (352), theblockade of axonal transport (353,354), the blockadeof the sympathetic reflex arc, sensitization (355,356),
and anti-inflammatory effects (357). However, multiple
studies have shown the long-term effectiveness of local
anesthetics in a host of studies following local anesthetic nerve blocks or epidural injections in direct comparison with local anesthetics with steroids (234,334,345351). Thus, a large number of experimental and clinicalstudies have shown a lack of significant difference withlocal anesthetic alone, compared to combination of
local anesthetic with steroids (76,78,98,138,139,142145,147,148,149,163,165,166,195,200205,218,238,246,350-364).
In conclusion, there is good evidence for diagnostic
facet joint nerve blocks with 75% to 100% pain relief as
the criterion standard with dual blocks, whereas there
is fair evidence with 50% to 74% criterion standard
with controlled diagnostic blocks.

5.0 Conclusion
There is good evidence for diagnostic facet joint
nerve blocks with 75% to 100% pain relief as the criterion standard with dual blocks, whereas there is fairevidence with 50% to 74% criterion standard with controlled diagnostic blocks. However, the evidence is limited with single diagnostic blocks of either 50% to 74%

www.painphysicianjournal.com

or 75% to 100% pain relief as the criterion standard.

Acknowledgments
The authors wish to thank Pain Physician for permission to reproduce Datta et al’s (41) manuscript from2009 and the editorial board of Pain Physician for review and criticism in improving the manuscript. The
authors also wish to thank Vidyasagar Pampati, MSc,
for statistical assistance; Sekar Edem for assistance inthe search of the literature; Alvaro F. Gómez, MA, andLaurie Swick, BS, for manuscript review; and Tonie M.
Hatton and Diane E. Neihoff, transcriptionists, for theirassistance in preparation of this manuscript.

Conflict of Interest
Dr. Falco is a consultant for St. Jude Medical Inc.
and Joimax Inc.
Dr. Datta receives research support from Sucampo
Pharmaceuticals and an honorarium from Smith andNephew.
Dr. Benyamin is a consultant with Bioness and Nevro, serves on the advisory boards of Vertos Medical andNuvo Pharma, teaches/lectures for Vertos Medical, Boston Scientific, Neurotherm, and Bioness, and receives
research/grants from Alfred Mann Foundation, Teknon
Foundation, Spinal Restoration, Inc., Bioness, Boston
Scientific, Vertos Medical, Medtronic, Kimberly Clarke,
Epimed, BioDelivery Sciences International, Inc., Theravance, Mundipharma Research, Cephalon/Teva, AstraZeneca, and Purdue Pharma, LP.
Dr. Vallejo receives research support from Cephalon/Teva, BioDelivery Sciences International, Inc., Mundipharma Research GmbH & Co., AstraZeneca, Purdue
Pharma, LP, and Theravance.
Dr. Hirsch has received fees from CareFusion in thepast 12 months. He participated in an Aetrium focus
group and received compensation.

Author Affiliations
Dr. Falco is Medical Director of Mid Atlantic Spine& Pain Physicians, Newark, DE; Director, Pain Medicine
Fellowship Program, Temple University Hospital, Philadelphia, PA; and Associate Professor, Department of
PM&R, Temple University Medical School, Philadelphia,
PA.
Dr. Manchikanti is Medical Director of the PainManagement Center of Paducah, Paducah, KY, andClinical Professor, Anesthesiology and Perioperative
Medicine, University of Louisville, Louisville, KY.
Dr. Datta is Medical Director, Laser Spine & Pain In-

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Pain Physician: November/December 2012; 15:E869-E907

stitute, New York, NY.
Dr. Sehgal is Medical Director, Interventional Pain
Program, University of Wisconsin School of Medicine
and Public Health and Associate Professor, Departmentof Orthopedics and Rehabilitation Medicine, Madison,
WI.
Ms. Geffert is Director of Research and Education
and Administrative Assistant at Mid Atlantic Spine &Pain Physicians of Newark, DE, and Fellowship Coordinator at Temple University Hospital, Philadelphia, PA.
Dr. Onyewu is Attending Physician, Mid Atlantic
Spine & Pain Physicians, Newark, DE and Elkton, MD;
Faculty, Pain Medicine Fellowship Program, Temple University Hospital, Philadelphia, PA; and Adjunct AssistantProfessor, Temple University Medical School, Philadelphia, PA.
Dr. Singh is Medical Director, Spine Pain Diagnostics
Associates, Niagara, WI.
Dr. Bryce is a staff physician, Advanced Pain Management, Madison, WI.Dr. Benyamin is the Medical Director, Millennium Pain Center, Bloomington, IL, andClinical Assistant Professor of Surgery, College of Medicine, University of Illinois, Urbana-Champaign, IL.

Dr. Simopoulos is Assistant Professor, Departmentof Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School,
Boston, MA.
Dr. Vallejo is Director of Research, Millennium Pain
Center, Bloomington, IL, and Adjunct Professor of Biology, Illinois State University, Normal, IL.
Dr. Gupta is a Consultant in Pain Medicine andAnaesthesia, Bradford Teaching Hospital NHS Foundation Trust, Bradford Royal Infirmary, Bradford, United
Kingdom.
Dr. Ward is a Consultant in Pain Medicine, Brighton
and Sussex University Hospitals NHS Trust, Council Member of the British Pain Society, a Fellow of the Facultyof Pain Medicine of the Royal College of Anaesthetists,
and Secretary of the British Pain Society Interventional
Pain Medicine Special Interest Group, United Kingdom.
Dr. Hirsch is Chief of Minimally Invasive Spine Surgery, Depts. of Radiology and Neurosurgery, Massachusetts General Hospital, Boston, MA, and Associate Professor of Radiology, Harvard Medical School, Boston,MA.

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