Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. Cost-effectiveness of minimal interventional procedures for chronic mechanical low back pain: design of four randomised controlled trials with an economic evaluation Evaluation of the relative contributions of various structures in chronic low back pain. Correlation of clinical examination characteristics with three sources of chronic low back pain. Results of Sacroiliac Joint Double Block and Value of Sacroiliac Pain Provocation Tests in 54 Patients With Low Back Pain Medial branch neurotomy in management of chronic spinal pain: systematic review of the evidence. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Clinical effectiveness of botulinum toxin A compared to a mixture of steroid and local anesthetics as a treatment for sacroiliac joint pain. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Evidence-based medicine and the challenge of low back pain: where are we now? Fluoroscopic lumbar interlaminar epidural injections in managing chronic lumbar axial or discogenic pain Prevalence of lumbar facet joint pain in chronic low back pain. Capacity of the Clinical Picture to Characterize Low Back Pain Relieved by Facet Joint Anesthesia: Proposed Criteria to Identify Patients With Painful Facet Joints Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized, double-blind controlled trial: Clinical Trial NCT00355914. Evaluation of Lumbar Facet Joint Nerve Blocks in Managing Chronic Low Back Pain: A Randomized, Double-Blind, Controlled Trial with a 2-Year Follow-Up The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline From the American Pain Society Percutaneous Lumbar Zygapophysial (Facet) Joint Neurotomy Using Radiofrequency Current, in the Management of Chronic Low Back Pain: A Randomized Double-Blind Trial Evaluation of the effect of sedation as a confounding factor in the diagnostic validity of lumbar facet joint pain: a prospective, randomized, double-blind, placebo-controlled evaluation. Comparative effectiveness of a one-year follow-up of thoracic medial branch blocks in management of chronic thoracic pain: a randomized, double-blind active controlled trial. Fluoroscopic caudal epidural injections in managing chronic axial low back pain without disc herniation, radiculitis, or facet joint pain Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, double-blind controlled trial: clinical trial NCT00355914.
BACKGROUND Chronic refractory spinal pain poses a peculiar diagnostic challenge because of multiple putative pain sources , overlapping clinical features , and nonspecific radiologic findings . Diagnostic injection techniques are employed to isolate the source ( s ) of pain . Facet or zygapophysial joint pain is an example of spinal pain diagnosed by local anesthetic injections of the facet joint or its nerve supply . Diagnostic facet joint injections are expected to meet the cardinal features of a diagnostic test ( i.e. , accuracy , safety and reproducibility ) . Accuracy must be compared with a " gold " or criterion st and ard that can confirm presence or absence of a disease . There is , however , no available gold st and ard , such as biopsy , to measure presence or absence of pain . Hence , there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections . OBJECTIVES To evaluate accuracy , safety and reproducibility of facet or zygapophysial joint injections in diagnosing chronic spinal pain of facet joint origin . STUDY DESIGN A systematic review of the literature for clinical studies on efficacy and utility of facet joint/nerve injections in diagnosing spinal pain from facet joints . METHODS Relevant literature on diagnostic facet injections was identified through data base search es . Excluded were abstract s , review s , book chapters , case reports and studies based on single blocks or blocks without radiologic control . Prospect i ve studies with placebo control , or controlled comparative local anesthetic blocks , were given priority over retrospective studies . Each study was grade d using AHRQ and QUADAS criteria . The level of evidence was classified as conclusive , strong , moderate , limited , or inconclusive . RESULTS Available literature pointed to strong evidence for controlled comparative local anesthetic facet joint medial branch blocks in the diagnosis of neck and low back pain . There was moderate evidence in the diagnosis of pain arising from thoracic facet joints . CONCLUSION The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joint nerves ( medial branch or dorsal ramus ) are reproducible , reasonably accurate , and safe . The sensitivity , specificity , false-positive rates , and predictive values of these diagnostic tests for neck and low back pain have been vali date d and reproduced in multiple studies Background Minimal interventional procedures are frequently applied in patients with mechanical low back pain which is defined as pain presumably result ing from single sources : facet , disc , sacroiliac joint or a combination of these . Usually , these minimal interventional procedures are an integral part of a multidisciplinary pain programme . A recent systematic review issued by the Dutch Health Insurance Council showed that the effectiveness of these procedures for the total group of patients with chronic low back pain is yet unclear and cost-effectiveness unknown . The aim of the study is to evaluate whether a multidisciplinary pain programme with minimal interventional procedures is cost-effective compared to the multidisciplinary pain programme alone for patients with chronic mechanical low back pain who did not respond to conservative primary care and were referred to a pain clinic . Methods All patients with chronic low back pain who are referred to one of the 13 participating pain clinics will be asked to participate in an observational study . Patients with a suspected diagnosis of facet , disc or sacroiliac joint problems will receive a diagnostic block to confirm this diagnosis . If confirmed , they will be asked to participate in a R and omized Controlled Trial ( RCT ) . For each single source a separate RCT will be conducted . Patients with a combination of facet , disc or sacroiliac joint problems will be invited for participation in a RCT as well . An economic evaluation from a societal perspective will be performed alongside these four RCTs . Patients will complete question naires at baseline , 3 and 6 weeks , 3 , 6 , 9 and 12 months after start of the treatment . Costs will be collected using self-completed cost question naires . Discussion No trials are yet available which have evaluated the cost-effectiveness of minimal interventional procedures  in patients with chronic mechanical low back pain , which emphasizes the importance of this study .Trial registration numberNational Trial Register : An attempt was made to determine the relative contribution of various structures to chronic low back pain , including facet joint(s ) , disc(s ) , and sacroiliac joint(s ) in a prospect i ve evaluation . Precision diagnostic blocks , including disc injections , facet joint blocks , and sacroiliac joint injections , are frequently used . In contrast , selective nerve root blocks or transforaminal epidural injections are used occasionally to evaluate persistent or recurrent low back pain in patients without appropriate radiologic or neurophysiologic diagnosis . One hundred and twenty patients with a chief complaint of low back pain were evaluated with precision diagnostic injections , which included medial branch blocks , provocative discography and sacroiliac joint injections . In 40 % ( 95 % CL , 31 % , 49 % ) , of the patients , facet joint pain was diagnosed ; and in 26 % ( 95 % CL , 18 % , 34 % ) of the patients discogenic pain was diagnosed ; and 2 % of the patients were diagnosed with sacroiliac joint pain BACKGROUND CONTEXT Research has demonstrated some progress in using a clinical examination to predict discogenic or sacroiliac ( SI ) joint sources of pain . No clear predictors of symptomatic lumbar zygapophysial joints have yet been demonstrated . PURPOSE To identify significant components of a clinical examination that are associated with symptomatic lumbar discs , zygapophysial joints and SI joints . STUDY DESIGN A prospect i ve , criterion-related concurrent validity study performed at a private radiology practice specializing in spinal diagnostics . PATIENT SAMPLE The sample consisted of 81 patients with chronic lumbopelvic pain referred for diagnostic injections .  OUTCOME MEASURES Contingency tables were constructed for nine features of the clinical evaluation compared with the results of diagnostic injections . Statistical analysis included chi-squared test for independence , phi and odds ratios with confidence intervals . METHOD Patients received blinded clinical examinations by physical therapists , and diagnostic injections were used as the criterion st and ard . RESULTS Significant relationships were found between discogenic pain and central ization of pain during repeated movement testing , and pain when rising from sitting . Lumbar zygapophysial joint pain was associated with absence of pain when rising from sitting . Sacroiliac joint pain was related to three or more positive pain provocation tests , pain when rising from sitting , unilateral pain and absence of lumbar pain . CONCLUSIONS Significant correlations exist between clinical examination findings and symptomatic lumbar discs , zygapophysial and SI joints . The strongest relationships were seen between SI joint pain and three or more positive pain provocation tests , central ization of pain for symptomatic discs and absence of pain when rising from sitting for symptomatic lumbar zygapophysial joints Study Design This prospect i ve study consisted of the evaluation of a double sacroiliac block in patients with low back pain . Objectives To determine the prevalence of sacroiliac pain in a selected population of patients suffering from low back pain , and to assess certain pain provocation tests . Summary of Background Data Previous studies have implicated the sacroiliac joint as a potential etiology of back and leg pain , but none has tested double anesthetic blocks in a prospect i ve fashion . Methods Fifty‐four patients with unilateral low back pain , pain mapping compatible with a sacroiliac origin , tenderness over the sacroiliac joint , and no obvious source of pain in the lumbar spine were selected for a double anesthetic block . The procedure consisted of a thorough clinical examination with a visual analog scale , testing of sacroiliac pain provocation tests followed by a first screening block with a short‐acting anesthetic . A second examination consisting of the same tests assessed the efficacy of the first block . If results were positive , a confirmatory block was performed . All blocks were performed under fluoroscopic guidance . Results Nineteen patients had a  positive response to the first block . Among them , 10 ( 18.5 % ) were temporarily relieved by the confirmatory block . No pain provocation test reached statistical significance . Conclusion The present study suggests the sacroiliac joint is an uncommon but real source of low back pain . The accuracy of some of the presumed “ sacroiliac pain provocation tests ” is question ed Zygapophysial or facet joints have been implicated as cause of low back , mid back , upper back and neck pain with referred pain . Cervical , thoracic and lumbar facet joints are innervated by the medial branches of the dorsal rami . Zygapophysial ( facet ) joints have been implicated as the source of chronic pain in 15 % to 45 % of the patients with chronic low back pain , 54 % to 60 % of the patients with chronic neck pain and 48 % of the patients with thoracic pain . A systematic review of the evidence of effectiveness of radiofrequency denervation in the management of chronic spinal pain was undertaken . This review included r and omized clinical trials , as well as non-r and omized or observational studies in the analysis . Literature search included MEDLINE , EMBASE , systematic review s , narrative review s , cross-references to the review s and various published trials ; and peer review ed abstract s from scientific meetings during the past two years . An algorithmic approach was followed in study evaluation with a description of inclusion and exclusion criteria . A set of high-performing scales or checklists pertaining to r and omized clinical trials and observational trials derived from the Agency for Healthcare Research and Quality ( AHRQ ) was utilized ; Systems to Rate the Strength of Scientific Evidence . Qualitative analysis was conducted , using five levels of evidence for effectiveness of medial branch neurotomy . Our search strategy identified over 1,000 citations as the result of electronic and manual screening . A total of 7 r and omized trials of radiofrequency neurotomy for spinal pain were identified . However , only 4 related to medial branch neurotomy . Two of the four met the inclusion criteria . Among the multiple observational studies considered for inclusion , 4 prospect i ve evaluations were included in the systematic review . In addition , 3 retrospective evaluations were also included . Two r and omized trials comprised of 27 patients receiving active treatment . The first study consisted of cervical facet joint pain and the second consisted of lumbar facet joint pain . Both studies showed positive results . Similar to r and omized trials , prospect i ve , as well as retrospective evaluations showed positive evidence , both in short-term and long-term . The results of this systematic review of 2 well- design ed r and omized trials , 4 prospect i ve well- design ed trials without r and omization and 3 retrospective evaluations provided strong evidence that radiofrequency denervation offers short-term relief and moderate evidence of long-term pain relief of facet joint origin OBJECTIVE To compare the diagnostic accuracy of a multitest regimen of 5 sacroiliac joint ( SIJ ) pain provocation tests with fluoroscopically controlled double SIJ blocks using a short- and long-acting local anesthetic in order to reduce the exposure of patients to unnecessary invasive SIJ procedures . DESIGN Prospect i ve , observational study . SETTING Hospital setting . PARTICIPANTS Sixty patients with chronic low back pain . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Visual analog scale score and receiver operating characteristic ( ROC ) curve . RESULTS Twenty-seven patients responded positively to the blocks , of whom 23 were found positive after the multitest regimen and 4 were negative . For the nonresponders ( n=33 ) , these figures were 7 positive and 26 negative . The calculated sensitivity and specificity were .85 ( 95 % confidence interval [ CI ] , .72-.99 ) and .79 ( 95 % CI , .65-.93 ) , respectively . Positive and negative predictive values were .77 ( 95 % CI , .62-.92 ) and .87 ( 95 % CI , .74-.99 ) , respectively . The positive likelihood ratio was 4.02 ( 95 % CI , 2.04 - 7.89 ) ; the negative likelihood ratio was .19 ( 95 % CI , .07-.47 ) . The area under the ROC curve was .799 . CONCLUSIONS The test regimen with 3 or more positive tests is indicative of SIJ pain . It can be used in early clinical decision making to reduce the number of unnecessary minimally invasive diagnostic SIJ procedures OBJECTIVE The sacroiliac joint ( SIJ ) is one of the sources of low back pain and referred pain to the lower limb . Steroid injections have been used to treat SIJ pain , but this frequently necessitates repeated injections . Botulinum toxin ( BT ) type A has been shown to provide significant reduction of joint pain , and functional improvements . This study investigated the efficacy of BT for reducing SIJ pain and maintaining a clinical effect , compared with steroid injections . DESIGN Prospect i ve case control study . SETTING Spine hospital . PATIENTS Patients who were diagnosed with SIJ syndrome based on physical examination and diagnostic SIJ injection were selected . INTERVENTIONS Either Dysport ( BT group ) or a mixture of triamcinolone and lidocaine ( triamcinolone and local anesthetics [ TA ] group ) was injected into the posterior sacroiliac ligaments under C-arm fluoroscopy . OUTCOME MEASURES Numeric Rating Scale ( NRS ) and Oswestry Disability Index ( ODI ) were used for evaluation at pretreatment , 1 month , 2 months , and 3 months after treatment . RESULTS At 1 month , the BT and TA group showed no significant differences in NRS or ODI . However , at 2 and 3 months , the BT group had significantly lower scores in NRS and ODI than did the TA group . CONCLUSION BT shows clinical usefulness in pain reduction and for functional improvement in patients with SIJ pain . This effect was maintained for 3 months following the injection , by which time the effects of TA had diminished Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain Recommendation 1 : Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy or spinal stenosis , or back pain potentially associated with another specific spinal cause . The history should include assessment of psychosocial risk factors , which predict risk for chronic disabling back pain ( strong recommendation , moderate- quality evidence ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied Low  back pain  has long been described as a challenge for both primary care physicians and specialists . Management of  low back pain  has also been criticized as frequently arbitrary , inappropriate , or ineffective . Contributing factors have been an inadequate evidence base and a need for more rigorous appraisal s of the available literature . Evidence -based medicine , an approach to clinical problem solving , is predicated on the premise that high- quality health care will result from practice s consistent with the best evidence . In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion , authority , and un systematic clinical observations , evidence -based medicine emphasizes the need for rigorous critical appraisal s of the scientific literature to inform medical decision making . Evidence -based medicine places strong weight on the requirement for valid studies , particularly r and omized controlled trials , to appropriately evaluate the effectiveness of health care interventions . Because of the rapidly increasing volume of medical literature , however , most clinicians are unable to keep up-to- date with all the new data . Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic review s and evidence -based clinical practice guidelines . Like primary studies , systematic review s and clinical practice guidelines must adhere to high method ologic st and ards to reduce error and bias . As in other areas of medicine , the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings . In addition to more rigorous primary studies , an increasing number of high- quality systematic review s and evidence -based clinical practice guidelines for low back pain are also available . Although some research gaps and method ologic shortcomings persist , the richer evidence base has greatly improved our underst and ing of what does and does not work for low back pain . Despite these advances , the best available evidence often does not inform everyday clinical decisions for low back pain . Nonetheless , there is widespread agreement that adherence to evidence -based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care . This article review s basic principles of evidence -based medicine , discusses evidence -based medicine in the context of low back pain management , and summarizes some useful evidence -based medicine re sources Among the multiple causes of chronic low back pain , axial and discogenic pain are common . Various modalities of treatments are utilized in managing discogenic and axial low back pain including epidural injections . However , there is a paucity of evidence regarding the effectiveness , indications , and medical necessity of any treatment modality utilized for managing axial or discogenic pain , including epidural injections . In an interventional pain management practice in the US , a r and omized , double-blind , active control trial was conducted . The objective was to assess the effectiveness of lumbar interlaminar epidural injections of local anesthetic with or without steroids for managing chronic low back pain of discogenic origin . However , disc herniation , radiculitis , facet joint pain , or sacroiliac joint pain were excluded . Two groups of patients were studied , with 60 patients in each group receiving either local anesthetic only or local anesthetic mixed with non-particulate betamethasone . Primary outcome measures included the pain relief-assessed by numeric rating scale of pain and functional status assessed by the , Oswestry Disability Index , Secondary outcome measurements included employment status , and opioid intake . Significant improvement or success was defined as at least a 50 % decrease in pain and disability . Significant improvement was seen in 77 % of the patients in Group I and 67 % of the patients in Group II . In the successful groups ( those with at least 3 weeks of relief with the first two procedures ) , the improvement was 84 % in Group I and 71 % in Group II . For those with chronic function-limiting low back pain refractory to conservative management , it is concluded that lumbar interlaminar epidural injections of local anesthetic with or without steroids may be an effective modality for managing chronic axial or discogenic pain . This treatment appears to be effective for those who have had facet joints as well as sacroiliac joints eliminated as the pain source This prospect i ve study was design ed to determine the prevalence of lumbar facet joint pain in a consecutive series of patients with chronic low back pain treated at an interventional , multidisciplinary private pain management practice utilizing double diagnostic blocks , to determine the prevalence of false positive rate of uncontrolled facet joint blocks , and to determine the relationship of clinical features of responders and non-responders to double diagnostic blocks . One hundred and twenty patients with low back pain with or without lower extremity pain were selected . The procedure consisted of diagnostic blocks using lidocaine and bupivacaine on separate occasions , usually two weeks apart . Each facet joint nerve was infiltrated with either 0.4 to 0.6 ml of 1 % lidocaine ( Xylocaine(R ) ) or 1 % lidocaine ( Xylocaine(R ) ) and 0.25 % bupivacaine ( Marcaine(R ) ) . A definite response was defined as substantial with at least 75 % relief of pain in the symptomatic area following local anesthetic block . Confirmatory blocks using bupivacaine 0.25 % were performed at the same levels as the first injection if definite relief was obtained . The response to bupivacaine blocks which lasted longer than the lidocaine blocks was accepted as a positive response . All blocks were performed under fluoroscopic guidance . Eighty-one patients ( 67.5 % ) reported a definite response to lidocaine blocks . Confirmatory blocks with bupivacaine were performed in all 81 patients with 54 patients , i.e. 45 % of total sample or 66.6 % of lidocaine positive group reporting definite response with a false positive rate of 41 % . Prevalence and relationship of pain referral pattern in patients with and without facet joint pain confirmed by double blocks showed no significant correlation . We found no relationship between the history , physical findings , age , gender , trauma , duration of pain , and diagnostic blocks . However , history of previous surgery showed a negative correlation as only 29 % of the patients after previous surgery were positive in contrast to 51 % of the nonsurgical population . The results of this study echo previous concerns of reliability of uncontrolled single blocks , history , and clinical features . This study demonstrated that the facet joint is a source of pain in 45 % of the patients suffering with chronic low back pain in an interventional pain management setting in a private practice Study Design . Prospect i ve r and omized study to compare the efficacy of facet joint injection with lidocaine and facet joint injection with saline in two groups of patients with low back pain , with and without clinical criteria that were determined in a previous study to implicate the facet joint as the primary source of the pain . Objectives . To assess the efficacy of single facet joint anesthesia versus placebo ( saline injections ) and to determine clinical criteria that are predictive of significant relief of LBP after injection . Summary of Background Data . There is no syndrome that discriminates between lower back pain caused by facet joint and that caused by other structures . Single or double facet joint anesthesia , and single photon emission computed tomography are expensive and time‐consuming procedures for selecting patients in controlled clinical trials with large population s. Methods . Results of a previous study showed that seven clinical characteristics were more frequent in patients who responded to facet joint anesthesia than in those who did not . In the current study , a group of 43 patients with lower back pain who met at least five criteria were compared with 37 patients who met fewer criteria . Patients r and omly received injection of either lidocaine or saline into the lower facet joints . The result was considered positive if more than 75 % pain relief was determined by visual analog scale . The patient , the radiologist , and the investigator were blinded . An analysis of variance was used to seek an interaction between clinical group effect and injection effect , and logistic regression analysis to select the best set of variables that would be predictive of minimum pain relief of 75 % after the injection . Results . There was a significant interaction between clinical group and injection effect ( P= 0.003 ) . In patients with back pain , lidocaine  provided greater lower‐back pain relief than saline ( P = 0.01 ) . Lidocaine also‐provided greater pain relief in the back pain group than in the the nonpain group ( P = 0.02 ) . The presence of five among seven variables ( age greater than 65 years and pain that was not exacerbated by coughing , not worsened by hyperextension , not worsened by forward flexion , not worsened when rising from flexion , not worsened by extension‐rotation , and well‐relieved by recumbency ) , always including the last item , distinquished 92 % of patients responding to lidocaine injection and 80 % of those not responding in the lidocaine group . Conclusions . A set of five clinical characteristics can be used in r and omized studies to select lower back pain that will be well relieved by facet joint anesthesia . These characteristics should not , however , be considered as definite diagnostic criteria of lower back pain originating from facet joints BACKGROUND Lumbar facet joints have been implicated as the source of chronic pain in 15 % to 45 % of patients with chronic low back pain . Various therapeutic techniques including intraarticular injections , medial branch blocks , and radiofrequency neurotomy of lumbar facet joint nerves have been described in the alleviation of chronic low back pain of facet joint origin . OBJECTIVE The study was conducted to determine the clinical effectiveness of therapeutic local anesthetic lumbar facet joint nerve blocks with or without steroid in managing chronic function-limiting low back pain of facet joint origin . DESIGN A r and omized , double-blind , controlled trial . SETTING An interventional pain management setting in the United States . METHODS This study included 60 patients in Group I with local anesthetic and 60 patients in Group II with local anesthetic and steroid .  The inclusion criteria was based on the positive response to the diagnostic controlled comparative local anesthetic lumbar facet joint blocks . OUTCOME MEASURES Numeric pain scores , Oswestry Disability Index , opioid intake , and work status . All outcome assessment s were performed at baseline , 3 months , 6 months , and 12 months . RESULTS Significant improvement with significant pain relief ( > 50 % ) and functional improvement ( > 40 % ) were observed in 82 % and 85 % in Group I , with significant pain relief in over 82 % of the patients and improvement in functional status in 78 % of the patients . Based on the results of the present study , it appears that patients may experience significant pain relief 44 to 45 weeks of 1 year , requiring approximately 3 to 4 treatments with an average relief of 15 weeks per episode of treatment . CONCLUSION Therapeutic lumbar facet joint nerve blocks , with or without steroid , may provide a management option for chronic function-limiting low back pain of facet joint origin Study Design : A r and omized , double-blind , controlled trial . Objective : To determine the clinical effectiveness of therapeutic lumbar facet joint nerve blocks with or without steroids in managing chronic low back pain of facet joint origin . Summary of Background Data : Lumbar facet joints have been shown as the source of chronic pain in 21 % to 41 % of low back patients with an average prevalence of 31 % utilizing controlled comparative local anesthetic blocks . Intraarticular injections , medial branch blocks , and radiofrequency neurotomy of lumbar facet joint nerves have been described in the alleviation of chronic low back pain of facet joint origin . Methods : The study included 120 patients with 60 patients in each group with local anesthetic alone or local anesthetic and steroids .  The inclusion criteria was based upon a positive response to diagnostic controlled , comparative local anesthetic lumbar facet joint blocks . Outcome measures included the numeric rating scale ( NRS ) , Oswestry Disability Index ( ODI ) , opioid intake , and work status , at baseline , 3 , 6 , 12 , 18 , and 24 months . Results : Significant improvement with significant pain relief of ≥ 50 % and functional improvement of ≥ 40 % were observed in 85 % in Group 1 , and 90 % in Group II , at 2-year follow-up . The patients in the study experienced significant pain relief for 82 to 84 weeks of 104 weeks , requiring approximately 5 to 6 treatments with an average relief of 19 weeks per episode of treatment . Conclusions : Therapeutic lumbar facet joint nerve blocks , with or without steroids , may provide a management option for chronic function-limiting low back pain of facet joint origin Facet joints have been described as an important source of low back pain . The value of medial branch blocks in the diagnosis of facet joint mediated pain is considered important . However , the therapeutic value of medial branch blocks has not been determined . This study was design ed to evaluate the duration of relief obtained and therapeutic value following controlled medial branch blocks with or without adjuvant agents Sarapin ( High Chemical Company , Levittown , PA ) and Depo-medrol ( Pharmacia and Upjohn Company , Kalamazoo , MI ) . The study population consisted of 180 consecutive patients seen in a single pain management practice , divided into three groups with 60 patients in each group . Group I was treated with local anesthetic only , Group II with the addition of Sarapin , and Group III with the addition of Depo-medrol along with Sarapin . The prevalence of facet joint pain in chronic low back pain was determined as 36 % , with a false-positive rate of 25 % . Comparison of duration of relief in days with each block in the three groups showed that the relief was significantly superior in Group III compared with Group I and Group II , whereas Group II was superior to Group Previous research indicates that physical examination can not diagnose sacroiliac joint ( SIJ ) pathology . Earlier studies have not reported sensitivities and specificities of composites of provocation tests known to have acceptable inter-examiner reliability . This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations , in relation to an accepted criterion st and ard . In a blinded criterion-related validity design , 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ .  The tests were evaluated singly and in various combinations ( composites ) for diagnostic power . All patients with a positive response to diagnostic injection reported pain with at least one SIJ test . Sensitivity and specificity for three or more of six positive SIJ tests were 94 % and 78 % , respectively . Receiver operator characteristic curves and areas under the curve were constructed for various composites . The greatest area under the curve for any two of the best four tests was 0.842 . In conclusion , composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ . Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections . When all six provocation tests do not provoke familiar pain , the SIJ can be ruled out as a source of current LBP Study Design . Clinical practice guideline . Objective . To develop evidence -based recommendations on use of interventional diagnostic tests and therapies , surgeries , and interdisciplinary rehabilitation for low back pain of any duration , with or without leg pain . Summary of Background Data . Management of patients with persistent and disabling low back pain remains a clinical challenge . A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing , but in some cases their utility remains uncertain or controversial . Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain . Methods . A multidisciplinary panel was convened by the American Pain Society . Its recommendations were based on a systematic review that focused on evidence from r and omized controlled trials . Recommendations were grade d using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations , Assessment , Development , and Evaluation Working Group . Results . Investigators review ed 3348 abstract s. A total of 161 r and omized trials were deemed relevant to the recommendations in this guideline . The panel developed a total of 8 recommendations . Conclusion . Recommendations on use of interventional diagnostic tests and therapies , surgery , and interdisciplinary rehabilitation are presented . Due to important trade-offs between potential benefits , harms , costs , and burdens of alternative therapies , shared decision-making is an important component of a number of the recommendations Study Design . A r and omized controlled study of percutaneous radiofrequency neurotomy was conducted in 40 patients with chronic low back pain ( 20 active and 20 controls ) . Objective . The aim of the study was to evaluate the possible beneficial effect of percutaneous radiofrequency zygapophysial joint neurotomy in reducing pain and physical impairment in patients with pain from the lumbar zygapophysial joints , selected after repeated diagnostic blocks . Summary of Background Data . Facet or zygapophysial joint pain may be one of the causes of chronic low back pain and may be treated by a percutaneous radiofrequency denervation . Patients may possibly be identified by a positive diagnostic block . These blocks need to be repeated as false positive responses to single blocks occur . In all previous studies patients treated with radiofrequency denervation have been selected after single diagnostic blocks result ing in a varying degree of relief . Methods . All patients were examined by an orthopedic surgeon before and 6 months after the treatment ( sham or active ) . Inclusion criteria were 3 separate positive facet blocks . Denervation was achieved by multiple lesions at each level in an effort to provide effective denervation . Results . The active treatment group showed statistically significant improvement not only in back and leg pain but also back and hip movement as well as the sacro-iliac joint test . Pre operative sensory deficit and weak or absent ankle reflex normalized ( P < 0.01 ) and ( P < 0.05 ) , respectively . There was significant improvement in quality of life variables , global perception of improvement , and generalized pain . The improvement seen in the active group was significantly greater then that seen in the placebo group with regard to all the above-mentioned variables . None of our patients had any complication other than transient postoperative pain that was easily managed . Conclusion . Our study indicates that radiofrequency facet denervation is not a placebo and could be used in the treatment of carefully selected patients with chronic low back pain BACKGROUND Lumbar facet ( zygapophysial ) joints have been implicated as the source of chronic pain in 15 % to 45 % of patients with chronic low back pain . Diagnosis may be confounded by false-positive results with a single diagnostic block and administration of anxiolytics and narcotics prior to or during the diagnostic facet joint blocks . OBJECTIVE To evaluate the effect of midazolam and fentanyl on the diagnostic validity of of lumbar facet joint pain . STUDY DESIGN R and omized , prospect i ve , double-blind , placebo-controlled evaluation . METHODS The design consisted of a placebo group receiving sodium chloride solution and two experimental groups receiving either midazolam or fentanyl . The patients included in the study were diagnosed with facet joint pain with controlled comparative local anesthetic blocks of medial branches or L5 dorsal rami . They had been treated with lumbar facet joint nerve blocks with good pain relief , and were presenting for repeat treatment after a period of symptom relief . The study was undertaken in an interventional pain management practice . OUTCOME MEASURES Outcomes were assessed at baseline and after the administration of 1 of the 3 solutions ( Group I , sodium chloride solution ; Group II , midazolam ; or Group III , fentanyl ) . Outcome measures included numeric pain scale , proportion of pain relief , and ability to perform prior painful movements . RESULTS Pain relief of > or = 80 % was noted in 2 % of the patients in Group I , 5 % of the patients in Group II , and 7 % in Group III . Pain relief of > or = 50 % was noted in 7 % of the patients in Group I , 5 % of the patients in Group II , and 13 % of the patients in Group III . There were no significant differences among the groups . CONCLUSION The administration of sedation with midazolam or fentanyl is a confounding factor in the diagnosis of lumbar facet joint pain in patients with chronic low back pain . However , this study suggests that if strict criteria including pain relief and ability to perform prior painful movements is used as the st and ard for evaluating the effect of controlled local anesthetic blocks , the diagnostic validity of lumbar facet joint nerve blocks may be preserved BACKGROUND Thoracic facet joints have been implicated as the source of chronic pain in the mid back or upper back in 34 % to 42 % of patients when the modified criteria of the International Association for the Study of Pain ( IASP ) is utilized . Various therapeutic techniques utilized in managing chronic thoracic pain of facet joint origin include intraarticular injections , medial branch blocks , and radiofrequency neurotomy of thoracic medial branch nerves . STUDY DESIGN A r and omized , double-blind , active controlled trial . SETTING A private practice , interventional pain management setting , and a specialty referral center setting in the United States . OBJECTIVE To determine the clinical effectiveness of therapeutic local anesthetic medial branch blocks with or without steroid in managing chronic function-limiting mid back or upper back pain of facet joint origin . METHODS The study was performed in an interventional pain management private practice , a tertiary referral center , in the United States . A total of 100 participants were included , with 50 participants in each of the local anesthetic and steroid groups . All of the participants met the diagnostic criteria of thoracic facet joint pain by means of comparative , controlled diagnostic blocks and the inclusion criteria . Group I participants received thoracic medial branch blocks with bupivacaine , whereas Group II participants received thoracic medial branch blocks with bupivacaine and non-particulate betamethasone . OUTCOMES ASSESSMENT Outcomes measures included numeric rating scores ( NRS ) , Oswestry Disability Index ( ODI ) , opioid intake , and return to work status at baseline , 3 months , 6 months , and 12 months . Significant pain relief was defined as > /= 50 % pain relief and /or a positive change in ODI scores . RESULTS In Group I and Group II 90 % of participants showed significant pain relief and functional improvement at 12 months . The majority of the participants experienced significant pain relief of 47.2 ± 10.1 weeks in Group I and 46.3 ± 8.4 weeks in Group II , requiring approximately 3.5 treatments per year with an average relief of 15.8 ± 10.5 in Group I and 13.6 ± 3.6 weeks in Group II per episode of treatment . LIMITATIONS Study limitations include the lack of a placebo group . CONCLUSIONS Therapeutic thoracic medial branch blocks , with or without steroid , may provide a management option for chronic function-limiting mid back or upper back pain of facet joint origin . CLINICAL TRIAL NCT00355706 Background Chronic low back pain without disc herniation is common . Various modalities of treatments are utilized in managing this condition , including epidural injections . However , there is continued debate on the effectiveness , indications , and medical necessity of any treatment modality utilized for managing axial or discogenic pain , including epidural injections . Methods A r and omized , double-blind , actively controlled trial was conducted . The objective was to evaluate the ability to assess the effectiveness of caudal epidural injections of local anesthetic with or without steroids for managing chronic low back pain not caused by disc herniation , radiculitis , facet joints , or sacroiliac joints . A total of 120 patients were r and omized to two groups ; one group did not receive steroids ( group 1 ) and the other group did ( group 2 ) . There were 60 patients in each group . The primary outcome measure was at least 50 % improvement in Numeric Rating Scale and Oswestry Disability Index . Secondary outcome measures were employment status and opioid intake . These measures were assessed at 3 , 6 , 12 , 18 , and 24 months after treatment . Results Significant pain relief and functional status improvement ( primary outcome ) defined as a 50 % or more reduction in scores from baseline , were observed in 54 % of patients in group 1 and 60 % of patients in group 2 at 24 months . In contrast , 84 % of patients in group 1 and 73 % in group 2 saw significant pain relief and functional status improvement in the successful groups at 24 months . Conclusion Caudal epidural injections of local anesthetic with or without steroids are effective in patients with chronic axial low back pain of discogenic origin without facet joint pain , disc herniation , and /or radiculitis BACKGROUND The prevalence of persistent low back pain with the involvement of lumbar facet or zygapophysial joints has been described in controlled studies as varying from 15 % to 45 % based on the criteria of the International Association for the Study of Pain . Therapeutic interventions utilized in managing chronic low back pain of facet joint origin include intraarticular injections , medial branch nerve blocks , and neurolysis of medial branch nerves . OBJECTIVE To determine the clinical effectiveness of therapeutic lumbar facet joint nerve blocks in managing chronic low back pain of facet joint origin . DESIGN A prospect i ve , r and omized , double-blind trial . SETTING An interventional pain management setting in the United States . METHODS In this preliminary analysis , data from a total of 60 patients were included , with 15 patients in each of 4 groups . Thirty patients were in a  non-steroid group  consisting of Groups I ( control , with lumbar facet joint nerve blocks using bupivacaine ) and II ( with lumbar facet joint nerve blocks using bupivacaine and Sarapin ) ; another 30 patients were in a steroid group  consisting of Groups III ( with lumbar facet joint nerve blocks using bupivacaine and steroids ) and IV ( with lumbar facet joint nerve blocks using bupivacaine , Sarapin , and steroids ) . All patients met the diagnostic criteria of lumbar facet joint pain by means of comparative , controlled diagnostic blocks . OUTCOME MEASURES Numeric Rating Scale ( NRS ) pain scale , the Oswestry Disability Index 2.0 ( ODI ) , employment status , and opioid intake . RESULTS Significant improvement in pain and functional status were observed at 3 months , 6 months , and 12 months , compared to baseline measurements . The average number of treatments for 1 year was 3.7 with no significant differences among the groups . Duration of average pain relief with each procedure was 14.8 + /- 7.9 weeks in the non-steroid group , and 12.5 + /- 3.3 weeks in the steroid group , with no significant differences among the groups . CONCLUSION Therapeutic lumbar facet joint nerve blocks with local anesthetic , with or without Sarapin or steroids , may be effective in the treatment of chronic low back pain of facet joint origin
The results of this review demonstrate that tests do exist that change the probability of the disc or SIJ ( but not the facet joint ) as the source of low back pain .
Clinical practice guidelines state that the tissue source of low back pain can not be specified in the majority of patients .
However , there has been no systematic review of the accuracy of diagnostic tests used to identify the source of low back pain .
The aim of this systematic review was therefore to determine the diagnostic accuracy of tests available to clinicians to identify the disc , facet joint or sacroiliac joint ( SIJ ) as the source of low back pain .