management of lumbar zygapophysial (facet) joint pain

Laxmaiah Manchikanti, Joshua A Hirsch, Frank JE Falco, Mark V Boswell

Laxmaiah Manchikanti, Pain Management Center of Paducah, Paducah, KY 42003, United States

Laxmaiah Manchikanti, Mark V Boswell, Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY 40292, United States

Joshua A Hirsch, NeuroInterventional Services and Neuroendovascular Program, Massachusetts General Hospital, Boston, MA 02114, United States

Joshua A Hirsch, Harvard Medical School, Boston, MA 02115, United States

Frank JE Falco, Mid Atlantic Spine and Pain Physicians, Newark, DE 19702, United States

Frank JE Falco, Pain Medicine Fellowship Program, Temple University Hospital, Philadelphia, PA 19140, United States

Author contributions: Manchikanti L, Hirsch JA, Falco FJE and Boswell MV contributed to this work; Manchikanti L and Boswell MV designed the research; Manchikanti L and Falco FJE performed the research; Manchikanti L and Hirsch JA contributed new reagents/analytic tools, analyzed the data and wrote the paper; all authors reviewed all contents and approved for submission.

Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.

Data sharing statement: There is no such statement required. This manuscript has not described any basic research or clinical research.

Open-Access: This article is an openaccess article which was selected by an inhouse editor and fully peerreviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: http://creativecommons.org/licenses/bync/4.0/

Correspondence to: Laxmaiah Manchikanti, MD, Medical Director of the Pain Management Center of Paducah, Clinical

Professor, Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, KY 42003, United States. [email protected]: +12705548373101Fax: +12705548987

Received: June 9, 2015 Peer-review started: June 11, 2015 First decision: September 30, 2015Revised: January 14, 2016 Accepted: January 27, 2016Article in press: January 29, 2016Published online: May 18, 2016

AbstractAIM: To investigate the diagnostic validity and ther-apeutic value of lumbar facet joint interventions in managing chronic low back pain.

METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encom-passed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anes-thetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including PubMed from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources including

SYSTEMATIC REVIEWS

315 May 18, 2016|Volume 7|Issue 5|WJO|www.wjgnet.com

Management of lumbar zygapophysial (facet) joint pain

Submit a Manuscript: http://www.wjgnet.com/esps/Help Desk: http://www.wjgnet.com/esps/helpdesk.aspxDOI: 10.5312/wjo.v7.i5.315

World J Orthop 2016 May 18; 7(5): 315-337ISSN 2218-5836 (online)

© 2016 Baishideng Publishing Group Inc. All rights reserved.

previous systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level Ⅰ to level Ⅴ.

RESULTS: Across all databases, 16 high quality dia-gnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assess-ing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level Ⅰ, based on a range of level Ⅰ to Ⅴ derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level Ⅱ to Ⅲ, with level Ⅱ evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement (greater than 6 mo), and level Ⅲ evidence for lumbo-sacral zygapophysial joint injections for short-term improvement only.

CONCLUSION: This review provides significant evi-dence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofre-quency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.

Key words: Chronic low back pain; Lumbar facet joint pain; Lumbar discogenic pain; Intraarticular injections; Lumbar facet joint nerve blocks; Lumbar facet joint radiofrequency; Controlled diagnostic blocks; Lumbar facet joint

© The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.

Core tip: This review summarizes diagnostic and therapeutic aspects of chronic low back pain of facet joint origin. Even though multiple high quality diagno-stic accuracy studies are available, there is room for further studies to confirm accuracy. These studies are key for the universal acceptance of facet joint nerve blocks of the lumbosacral spine as the gold standard. Deficiencies continue with therapeutic interventions. Lumbar radiofrequency neurotomy studies have shown contradicting results with short-term follow-ups. There is limited high quality literature for lumbar facet joint

nerve blocks, and the available literature contains contradictory findings in multiple trials of intraarticular injections.

Manchikanti L, Hirsch JA, Falco FJE, Boswell MV. Management of lumbar zygapophysial (facet) joint pain. World J Orthop 2016; 7(5): 315337 Available from: URL: http://www.wjgnet.com/22185836/full/v7/i5/315.htm DOI: http://dx.doi.org/10.5312/wjo.v7.i5.315

INTRODUCTIONLow back pain is a common health problem with increasing prevalence, health challenges, and economic impact[120]. Studies indicate that low back pain is the number one cause contributing to most years lived with disability in 2010 in the United States and globally[1,2]. In addition, workrelated low back pain continues to be an important cause of disability[3]. The global burden of low back pain has a point prevalence of 9.4% of the population, with severe chronic low back pain but a lack of lower extremity pain accounting for 17% of cases, and of low back pain with leg pain 25.8%[2]. Low back pain increased 162% in North Carolina, from 3.9% in 1992 to 10.2% in 2006[4]. Treatment of chronic low back pain has yielded mixed results and the substantial economic and health impact has raised concerns among the publicatlarge, policymakers, and physicians[619]. The large increase in treatment types and rapid escalation in health care costs may be attributed to multiple factors, including the lack of an accurate diagnosis and various treatments that do not have appropriate evidence of effectiveness.

Numerous structures in the lower back may be responsible for low back and/or lower extremity pain, including lumbar intervertebral discs, facet joints, sacroiliac joints, and nerve root dura, and may be amenable to diagnostic measures such as imaging and controlled diagnostic blocks[10,2129]. Other structures also capable of transmitting pain, including ligaments, fascia, and muscles, may not be diagnosed with accuracy with any diagnostic techniques[29]. Discrelated pathology with disc herniation, spinal stenosis, and radiculitis are diagnosed with reasonable ease and accuracy leading to definitive treatments[30]. However, low back pain from discs (without disc herniation), lumbar facet joints, and sacroiliac joints is difficult to diagnose accurately by noninvasive measures including imaging[10,2135]. Consequently, no gold standard is generally acknowledged for diagnosing low back pain, irrespective of the source being facet joint(s), intervertebral disc(s), or sacroiliac joint(s), despite the fact that lumbar facet joints, the paired joints that stabilize and guide motion in the spine, have been frequently implicated.

Based on neuroanatomy, neurophysiologic, biomechanical studies, and controlled diagnostic facet joint nerve blocks, lumbar facet joints have been recognized

Manchikanti L et al . Lumbar facet joint pain


as a potential cause of low back pain as well as referred lower extremity pain in patients who have chronic low back pain[10,2235]. Lumbar facet joints are well innervated by the medial branches of the dorsal rami, with presence of free and encapsulated nerve endings as well as nerves containing substance P and calcitonin generelated peptide[10,3538]. While there are many causes for pain in the facet joints, mechanical injury and inflammation of the facet joints have produced persistent pain in experimental settings[3945]. Further, the high prevalence of facet joint osteoarthritis has been illustrated in numerous studies[4649]. Nonetheless, attempts to make the diagnosis of lumbar facet joint pain by history, identification of pain patterns, physical examination, and imaging techniques better have shown low accuracy and utility[10,2229,35]. It has been proposed that controlled diagnostic blocks may be the only means to diagnose lumbar facet joint pain with reasonable accuracy, although controversy continues regarding the diagnostic accuracy of controlled local anesthetic blocks[10,2129,31,32,35,5053].

With appropriate diagnosis, accurate and evidencebased treatments may be expected to achieve reasonable outcomes; however, the disadvantages of controlled local anesthetic blocks, apart from discussions on their accuracy, include invasiveness, expenses, and difficulty in interpretation, occasionally making them problematic in routine clinical practice as a primary diagnostic modality. Various systematic reviews have assessed the value and validity of various diagnostic maneuvers including diagnostic facet joint nerve blocks[10,28,29,32,35].

Therapeutic interventions include conservative modalities and interventional techniques and occasionally surgical interventions[10,33,5473]. Conservative management includes drug therapy, chiropractic manipulation, physical therapy, and biopsychosocial rehabilitation. However, there have not been any trials reported in the literature that studied conservative management[10,5467] in confirmed lumbar facet joint pain or discogenic pain[74,75]. The literature regarding pain of presumed facet joint origin has involved interventional techniques using intraarticular injections, facet joint nerve blocks, and various neurolytic techniques, including injection of neurolytic solutions, radiofrequency neurotomy, and cryoneurolysis. However, as with diagnostic accuracy studies of facet joint nerve blocks, therapeutic interventions have met with favor, skepticism, and critiques[10,15,5055,6974].

The aim of this systematic review is to assess the diagnostic accuracy of lumbar facet joint nerve blocks and the therapeutic effectiveness of multiple interventional techniques based on a best evidence synthesis.

MATERIALS AND METHODSA systematic review was conducted utilizing the review process derived from evidencebased systematic reviews

and metaanalysis of diagnostic accuracy studies and randomized controlled trials (RCTs)[7683].

Criteria for considering studies for this reviewDiagnostic accuracy studies and RCTs evaluating accuracy and efficacy managing lumbar facet joint pain were included. Patients above 18 years of age with chronic lumbar facet joint pain of at least 3 mo duration after failure of previous pharmacotherapy, physical therapy, and exercise therapy were included for interventional pain management. Types of included studies were all RCTs and diagnostic facet joint nerve blocks appropriately performed with proper technique under fluoroscopy or computed tomography guidance.

Outcome measures The outcome measures included pain relief as the primary criterion for diagnostic accuracy studies concordant with the local anesthetic used and the ability to perform previously painful movements. The primary outcome parameter for RCTs of efficacy was pain relief with shortterm defined up to 6 mo and longterm defined as longer than 6 mo with functional improvement as the secondary outcome measure.

Literature search Literature searches were performed utilizing PubMed from 1966, EMBASE from 1980, Cochrane library, United States National Guideline Clearinghouse, previous systematic reviews and cross references, and any other trials available from any source in all languages from all countries, through March 2015.

Search strategy The search strategy included a review of the literature through March 2015 and emphasized chronic low back pain, facet or zygapophysial joint pain, cryoneurolysis, neurolytic injections, chronic lumbar facet joint pain, and selected studies meeting inclusion criteria.

The search terminology was as follows: (((((((((((((((((chronic low back pain) OR chronic back pain) OR disc herniation) OR discogenic pain) OR facet joint pain) OR herniated lumbar discs) OR nerve root compression) OR lumbosciatic pain) OR postlaminectomy) OR lumbar surgery syndrome) OR radicular pain) OR radiculitis) OR sciatica) OR spinal fibrosis) OR spinal stenosis) OR zygapophysial)) AND (((((((facet joint[tw]) OR zygapophyseal[tw]) OR zygapophysial[tw]) OR medial branch block[tw]) OR diagnostic block[tw]) OR radiofrequency[tw]) OR intraarticular[tw]).

Data collection and analysis At least 2 of the review authors independently in an unblinded standardized manner performed each search and assessed outcome measures. The searches were combined to obtain a unified search strategy.

Methodological quality or validity assessment At least 2 of the review authors independently assessed



Summary measuresSummary measures for diagnostic accuracy studies included at least 50% pain relief with an ability to perform previously painful movements as the criterion standard, whereas for RCTs, summary measures included a 50% or more reduction of pain in at least 40% of the patients or at least a 3 point decrease in pain scores.

Outcomes and analysis of evidenceOutcomes of the studies of diagnostic accuracy were assessed for prevalence and falsepositive rates when available. For therapeutic efficacy, the short and longterm outcomes were assessed. For diagnostic accuracy and therapeutic efficacy studies, 5 levels of evidence were utilized as shown in Table 1, varying from level Ⅰ with the highest evidence with multiple relevant high quality RCTs, or multiple high quality diagnostic accuracy studies, to level Ⅴ with minimal evidence and results based on consensus. Any disagreement among authors was resolved by a third author or by consensus.

RESULTSFigure 1 lists the study selection flow diagram of diagnostic accuracy studies and therapeutic intervention trials.

Based on the search criteria, there were multiple diagnostic accuracy and therapeutic efficacy studies; however, utilizing inclusion criteria as described above,there were 16 diagnostic accuracy studies meeting inclusion criteria for methodological quality assessment[2225,8495], whereas there were 14 trials meeting inclusion criteria for therapeutic efficacy assessment[96109]. Among the multiple trials not meeting methodological quality assessment inclusion criteria, Leclaire et al[110] was of significant importance. This trial was randomized and placebo controlled. It assessed 70 patients with a 12wk followup. This was a relatively small study but

the criteria for inclusion for methodological quality assessment and then performed the methodological quality assessment. Authors with a perceived conflict of interest for any manuscript, either with authorship or any other aspect, were recused from reviewing those manuscripts.

For diagnostic accuracy studies, all articles were assessed based on the quality appraisal of reliability studies checklist, which has been validated[80]. All randomized trials were assessed for methodological quality utilizing Cochrane review criteria[78] and Interventional Pain Management Techniques Quality Appraisal of Reliability and Risk of Bias Assessment (IPMQRB) criteria[79].


Table 1 Modified grading of qualitative evidence with best evidence synthesis for diagnostic accuracy and therapeutic interventions

Level Ⅰ Evidence obtained from multiple relevant high quality randomized controlled trials orEvidence obtained from multiple high quality diagnostic accuracy studies

Level Ⅱ Evidence obtained from at least one relevant high quality randomized controlled trial or multiple relevant moderate or low quality randomized controlled trials orEvidence obtained from at least one high quality diagnostic accuracy study or multiple moderate or low quality diagnostic accuracy studies

Level Ⅲ Evidence obtained from at least one relevant moderate or low quality randomized controlled trial study orEvidence obtained from at least one relevant high quality non-randomized trial or observational study with multiple moderate or low quality observational studies orEvidence obtained from at least one moderate quality diagnostic accuracy study in addition to low quality studies

Level Ⅳ Evidence obtained from multiple moderate or low quality relevant observational studies orEvidence obtained from multiple relevant low quality diagnostic accuracy studies

Level Ⅴ Opinion or consensus of large group of clinicians and/or scientists.

Source: Manchikanti et al[82].

Computerized and manual search of literature n = 1820

Articles excluded by titlen = 1482

Abstracts reviewedn = 338

Potential articlesn = 338

Abstracts excludedn = 210

Manuscripts considered for inclusion: Diagnostic accuracy studies = 16 Therapeutic interventions = 14

Full manuscripts reviewedn = 128

Figure 1 Flow diagram illustrating literature evaluating diagnostic accuracy and therapeutic effectiveness of lumbar facet joint interventions.


more importantly, the technique used was inappropriate as was using intraarticular injections for diagnostic evaluation. Subsequently, the authors have agreed that the results may not be applied in clinical practice[111]. Multiple studies assessing the influence of factors of prevalence and accuracy of facet joint pain were also considered[112123].

Methodological quality assessmentMethodological quality assessment of diagnostic accuracy studies is shown in Table 2 and methodological quality assessment of therapeutic interventions by Cochrane review criteria is shown in Table 3, whereas methodological quality assessment utilizing IPMQRB criteria is shown in Table 4.

Study characteristics Diagnostic accuracy study characteristics are shown in Table 5, and therapeutic efficacy trial characteristics are shown in Table 6.

Among the diagnostic accuracy studies, 6 studies were performed utilizing ≥ 75% pain relief as the criterion standard[24,8587,93,94]. All told there were 856 patients, a heterogenous population with prevalence ranging from 30% to 45%, including a falsepositive rate of 25% to 44%. These results are also similar to 80% pain relief as the criterion standard studied in 5 studies[23,8991,95] in 1431 patients. The prevalence in a heterogenous population ranged between 27% and 41%. However, utilizing controlled diagnostic blocks, the prevalence was shown somewhat differently in specific populations with 30% in patients younger than 65 years and 52% in patients older than 65[93], 36% in nonobese patients and 40% in obese patients[94], 16% in post surgery patients[92], and 21% with involvement of a single region[88].

Among the therapeutic interventions, a total of 14 trials met inclusion criteria with 9 trials evaluating lumbar radiofrequency neurotomy[96101,105,108,109], 2 trials evaluating lumbar facet joint nerve blocks[102,108], and 5 trials evaluating the role of intraarticular facet joint injections[101,103,104,106,107]. Among the radiofrequency neurotomy trials, of the 9 trials included, 7 moderate to high quality trials showed longterm effectiveness[96,98101,105,108], whereas one moderate to high quality trial showed a lack of effectiveness[97] with one trial showing shortterm effectiveness[109]. Among the longterm trials with effectiveness assessed at least for one year, Civelek et al[108] included 50 patients, Tekin et al[96] included 20 patients in the conventional radiofrequency neurotomy groups, and van Kleef et al[99] included only 15 patients in the radiofrequency neurotomy group showing positive results with a total number of 85 patients included among the 3 trials. van Wijk et al[97], showing a lack of effectiveness, included 40 patients undergoing radiofrequency neurotomy. Among the other studies, Cohen et al[109] included 14 patients with controlled diagnostic blocks, Nath et al[105] included 20 patients with triple diagnostic blocks, Dobrogowski et

al[98] included 45 patients with controlled diagnostic blocks, Moon et al[100] included 82 patients utilizing 2 different types of techniques with controlled diagnostic blocks, and Lakemeier et al[101] included 27 patients with an intraarticular injection of local anesthetic with a single block.

The evidence for therapeutic lumbar facet joint nerve blocks was assessed in 2 RCTs[102,108]. In these trials, Manchikanti et al[102] studied 120 patients with chronic lumbar facet joint pain with a confirmed diagnosis with a criterion standard of 80% pain relief using controlled diagnostic blocks after failure of conservative management. At the end of a 2year study period, significant pain relief was seen in 85% of the patients who received a local anesthetic and 90% of the patients who received a local anesthetic with steroids. The patients received an average of 5 to 6 total treatments. In the second study, Civelek et al[108] assessed 100 patients suffering from chronic low back pain. These patients had failed conservative therapy utilizing noninvasive diagnostic criteria; however, without diagnostic blocks. They compared lumbar facet joint nerve blocks with conventional radiofrequency neurotomy. Effectiveness was seen in 69% of the patients who received facet joint nerve blocks. In the radiofrequency neurotomy group, 90% effectiveness was seen. Civelek et al[108] showed significant improvement in 90% of the patients at one year followup, Cohen et al[109] showed 64% of the patients responding at 3 mo selected with controlled diagnostic blocks, Nath et al[105] showed at 6 mo followup significant reduction in the majority of patients, Tekin et al[96] reported a significant percentage of patients with appropriate relief at one year in the conventional radiofrequency neurotomy group, van Wijk et al[97] showed a lack of response at 3 mo followup, Dobrogowski et al[98] showed effectiveness of radiofrequency neurotomy in 66% of the patients at one year followup, van Kleef et al[99] showed effectiveness of radiofrequency neurotomy at one year in 47% of the patients, Moon et al[100] showed significant reduction in pain and disability index scores at the end of one year, and finally Lakemeier et al[101] showed significant improvement with conventional radiofrequency neurotomy at the end of 6 mo.

Intraarticular injections were studied in 5 trials[101,103,

104,106,107]. Of these, 3 high quality RCTs showed effectiveness with shortterm followup of less than 6 mo[101,106,107]. However, 2 moderate to high quality RCTs showed opposing results with a lack of effectiveness[103,104]. Ribeiro et al[107] showed effectiveness of intraarticular injections at the end of 6 mo with selection criteria not including diagnostic blocks. Lakemeier et al[101] showed significant improvement with selection of patients with a single intraarticular injection at 6 mo. Yun et al[106] showed positive results at the end of 3 mo with selection of patients without diagnostic blocks. In contrast, Carette et al[103] in a large controlled trial showed a lack of effectiveness of intraarticular steroid injections with selection of the patients with a single




Tabl

e 2 Q

ualit

y ap

prai

sal o

f th

e di

agno

stic

acc

urac

y of

lum

bar

face

t jo

int

nerv

e bl

ock

diag

nost

ic s

tudi

es

Man

chik

anti

et a

l[23]

Pang

et

al[2

5]

Schw

arze

r et

al[2

2]

Schw

arze

r et

al[8

4]

Man

chik

anti

et a

l[86]

Man

chik

anti

et a

l[79]

Man

chik

anti

et a

l[85]

Man

chik

anti

et a

l[93]

Man

chik

anti

et a

l[94]

Man

chik

anti

et a

l[88]

Man

chik

anti

et a

l[82]

Man

chik

anti

et a

l[90]

Man

chuk

onda

et

al[9

1]

Man

chik

anti

et a

l[92]

Man

chik

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l[95]

DeP

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4]

(1) W

as th

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a

spec

trum

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ld

norm

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the

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YY

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(2) W

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d?

NN

NN

NN

NN

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(4) W

ere

rate

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e fin

ding

s of

oth

er

rate

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YY

YY

YY

YY

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(5) W

ere

rate

rs

blin

ded

to th

eir

own

prio

r out

com

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of th

e te

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nder

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alua

tion?

NN

NN

NN

NN

NN

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NN

NN

(6) W

ere

rate

rs

blin

ded

to c

linic

al

info

rmat

ion

that

may

hav

e in

fluen

ced

the

test

ou

tcom

e?

NN

NN

NN

NN

NN

NN

NN

NN

(7) W

ere

rate

rs

blin

ded

to

addi

tiona

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s,

not i

nten

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to

form

par

t of t

he

diag

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st

proc

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YN

YY

YY

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bloc

k an

d Fu

chs

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l[104

] pro

vide

d un

dete

rmin

ed res

ults

with

a la

rge

num

ber of

inje

ctio

ns o

ver a

perio

d of

6 m

o w

hich

is n

ot a

pplic

able

clin

ical

ly.

Analy

sis o

f evid

ence

Lum

bar

face

t jo

int ne

rve

bloc

ks in

the

dia

gnos

is o

f chr

onic lu

mba

r fa

cet jo

int pa

in h

ave

an e

vide

nce

leve

l of Ⅰ

base

d on

7 c

ontr

olle

d di

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stic s

tudi

es w

ith 8

0% o

r m

ore

pain

rel

ief[2

3,88

92,

95] a

nd 6

stu

dies

with

a c

riter

ion

stan

dard

of a

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st 7

5% p

ain

relie

f[24,

858

7,93

,94].

For th

erap

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inte

rven

tions

, the

re is

leve

l Ⅱ e

vide

nce

for th

e lo

ngt

erm

effe

ctiv

enes

s of

using

lum

bar fa

cet j

oint

ner

ve b

lock

s an

d ra

diof

requ

ency

neu

roto

my.

For

sho

rt

term

impr

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f 6 m

o or

less

, lum

bosa

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iden

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leve

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DIS

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w a

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the

dia

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and

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f lu

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t in

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diag

nost

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acet

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nt n

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blo

cks

and

ther

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traa

rticul

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ions

, fa

cet

join

t ne

rve

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and

radi

ofre

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here

is le

vel Ⅰ

evid

ence

for

the

dia

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of lu

mba

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join

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nd le

vel Ⅱ

evi

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r ra

diof

requ

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neu

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my,

leve

l Ⅱ e

vide

nce

for

lum

bar

face

t jo

int ne

rve

bloc

ks, a

nd le

vel Ⅲ

evi

denc

e fo

r lu

mbo

sacr

al in

traa

rticul

ar

inje

ctio

ns fo

r lon

gte

rm im

prov

emen

t of >

6 m

o.

Leve

l Ⅰ ev

iden

ce is

est

ablis

hed

for

diag

nost

ic a

ccur

acy

stud

ies

base

d on

mul

tiple

hig

h qu

ality

dia

gnos

tic a

ccur

acy

stud

ies

that

hav

e pa

in r

elie

f of

at

leas

t 75

% a

s th

e cr

iterio

n st

anda

rd u

tilizin

g du

al b

lock

s w

ith m

ild v

aria

bilit

y in

the

prev

alen

ce a

nd fa

lse-

positiv

e ra

tes.

The

ther

apeu

tic e

ffica

cy o

f rad

iofre

quen

cy n

euro

tom

y, b

ased

on

mul

tiple


(8) W

as th

e or

der

in w

hich

rate

rs

exam

ined

sub

ject

s va

ried

?

YY

YY

YY

YY

YY

YY

YY

YY

(9) W

ere

appr

opri

ate

stat

istic

al m

easu

res

of a

gree

men

t use

d?

YY

YY

YY

YY

YY

YY

YY

YY

(10)

Was

the

appl

icat

ion

and

inte

rpre

tatio

n of

the

test

app

ropr

iate

?

YY

YY

YY

YY

YY

YY

YY

YY

(11)

Was

the

time

inte

rval

bet

wee

n m

easu

rem

ents

su

itabl

e in

rela

tion

to th

e st

abili

ty o

f th

e va

riab

le b

eing

m

easu

red?

YY

YY

YY

YY

YY

YY

YY

YY

(12)

If th

ere

wer

e dr

opou

ts fr

om th

e st

udy,

was

this

less

th

an 2

0% o

f the

sa

mpl

e

YY

YY

YY

YY

YY

YY

YY

YY

Tota

l9/

128/

129/

129/

129/

129/

129/

129/

129/

129/

129/

129/

129/

129/

129/

129/

12

Y: Y

es; N

: No.

Sou

rce:

Luc

as et

al[8

0].


mod

erat

e to

hig

h qu

ality

ran

dom

ized

tria

ls is

leve

l Ⅱ w

ith 7

tria

ls[9

6,98

101

,105

,108

] sho

win

g ef

ficac

y fo

r at

leas

t 6 m

o fo

llow

-up,

with

disco

rdan

t evi

denc

e de

mon

stra

ting

a la

ck o

f ef

fect

iven

ess

in o

ne m

oder

ate

to h

igh

qual

ity R

CT[9

7]. T

here

is le

vel Ⅱ

evi

denc

e fo

r lu

mba

r fa

cet j

oint

ner

ve b

lock

s ba

sed

on 2

mod

erat

e to

hig

h qu

ality

RCT

s[102

,108

] for

long

te

rm im

prov

emen

t. Fo

r lu

mbo

sacr

al in

traa

rticul

ar in

ject

ions

, the

evi

denc

e is le

vel Ⅲ

bas

ed o

n 3

RCTs

[101

,106

,107

] sho

win

g ef

fect

iven

ess

with

2 ran

dom

ized

tria

ls s

how

ing

a la

ck

of e

ffect

iven

ess[1

03,1

04] .

In r

ecen

t ye

ars,

und

erst

andi

ng lu

mba

r fa

cet

join

t pa

in,

not

only

with

pat

hoph

ysio

logy

, bu

t w

ith d

iagn

ostic

and

tre

atm

ent

stra

tegi

es,

has

expa

nded

with

num

erou

s pu

blicat

ions

[10,

15,2

225

,34

49,5

355

,84

123]. H

anco

ck e

t al

[53] s

yste

mat

ical

ly a

sses

sed

test

s to

iden

tify

the

stru

ctur

es in

the

low

bac

k re

spon

sibl

e fo

r ch

roni

c pa

in, i

nclu

ding

face

t jo

ints

. Th

eir re

sults

dem

onst

rate

d th

e la

ck o

f dia

gnos

tic a

ccur

acy

for va

rious

test

s. T

hus,

con

trol

led

diag

nost

ic b

lock

s se

em to

be

the

only

via

ble

and

appr

opria

te d

iagn

ostic

met

hod,

de

spite

discu

ssio

ns a

bout

the

prec

isio

n an

d ac

cura

cy o

f the

se te

chni

ques

[10,

34] . A

lthou

gh th

e m

ajor

ity o

f sys

tem

atic rev

iew

s de

mon

stra

te th

e ac

cura

cy o

f con

trol

led

diag

nost

ic

bloc

ks w

hen

perfo

rmed

by

inte

rven

tiona

l pai

n ph

ysicia

ns[1

0,28

,34], o

ther

s fa

iled

to d

emon

stra

te a

ccur

acy[5

052

] thou

gh d

ebat

e co

ntin

ues[1

0,28

,34].

Rubi

nste

in e

t al

[32] o

f the

Coc

hran

e Re

view

Mus

culo

skel

etal

Gro

up c

ondu

cted

a b

est

evid

ence

rev

iew

of n

eck

and

low

bac

k pa

in d

iagn

ostic

pro

cedu

res.

The

y co

nclu

ded

that

sur

prisin

gly,

man

y of

the

ort

hope

dic

test

s fo

r th

e lo

w b

ack

had

very

little

evi

denc

e to

sup

port

the

ir di

agno

stic a

ccur

acy

in c

linical

pra

ctice.

The

y al

so c

onclud

ed t

hat

lum

bar

face

t jo

int

nerv

e bl

ocks

per

form

ed f

or d

iagn

ostic

pur

pose

s ha

d m

oder

ate

evid

ence

for

the

ir us

e. T

his

was

bas

ed o

n sy

stem

atic r

evie

ws

and

diag

nost

ic a

ccur

acy

stud

ies

perfo

rmed

by

inte

rven

tiona

l pai

n ph

ysicia

ns p

rior

to 2

008.

Sin

ce th

en, t

he li

tera

ture

has

exp

ande

d co

nsid

erab

ly. A

s su

ch, d

espi

te th

e fa

ct th

at a

true

pla

cebo

con

trol

te

chni

que

may

be

the

gold

sta

ndar

d, d

ue t

o pr

actic

al d

ifficu

lties

, su

ch a

s lim

ited

clin

ical

util

ity a

nd c

ost

impl

icat

ions

, as

wel

l as

the

ethi

cal a

nd lo

gist

ic is

sues

ass

ocia

ted

with

using

a tru

e pl

aceb

o[124

126

] , con

trol

led

com

para

tive

loca

l ane

sthe

tic b

lock

s w

ith lo

cal a

nest

hetic

s, b

oth

shor

tac

ting

and

long

act

ing,

hav

e be

com

e a

reco

gnized

way

for


Man

chik

anti

et a

l[102]

Car

ette

et

al[1

03]

Fuch

s et

al[1

04]

Nat

h et

al

[105]

van

Wijk

et

al[9

7]

van

Kle

ef e

t al

[99]

Teki

n et

al

[96]

Civ

elek

et

al[1

08]

Dob

rogo

wsk

i et

al[9

8]

Coh

en e

t al

[109]

Rib

eiro

et

al[1

07]

Moo

n et

al

[100]

Lake

mei

er e

t al

[101]

Yun

et

al[1

06]

Rand

omiz

atio

n ad

equa

teY

YY

YY

YY

YY

YY

YY

YC

once

aled

trea

tmen

t allo

catio

nY

YN

YY

YY

YU

NY

YY

YPa

tient

blin

ded

YY

YY

YY

YN

YN

YY

YN

Car

e pr

ovid

er b

linde

dY

YN

YY

YY

NY

UN

YN

NO

utco

me

asse

ssor

blin

ded

NY

YY

YY

YU

UU

NY

NN

Dro

p-ou

t rat

e de

scri

bed

YY

NY

YY

YY

YY

YY

YY

All

rand

omiz

ed p

artic

ipan

ts

anal

yzed

in th

e gr

oup

YY

YY

YY

YY

YY

YN

YY

Repo

rts

of th

e st

udy

free

of

sugg

estio

n of

sel

ectiv

e ou

tcom

e re

port

ing

YY

YY

YY

YY

YY

YY

YY

Gro

ups

sim

ilar a

t bas

elin

e re

gard

ing

mos

t im

port

ant

prog

nost

ic in

dica

tors

YY

YY

YY

YY

YY

YY

YY

Co-

inte

rven

tion

avoi

ded

or

sim

ilar i

n al

l gro

ups

YN

NY

YY

YY

YY

YY

YY

Com

plia

nce

acce

ptab

le in

all

grou

psY

YY

YY

YY

YY

YY

NN

Y

Tim

e of

out

com

e as

sess

men

t in

all g

roup

s si

mila

rY

YY

YY

YY

YY

YY

NY

Y

Scor

e11

/12

11/1

28/

1212

/12

12/1

212

/12

12/1

29/

1210

/12

8/12

10/1

29/

129/

129/

12

Tabl

e 3 M

etho

dolo

gica

l qua

lity

asse

ssm

ent

of r

ando

miz

ed t

rial

s of

lum

bar

face

t jo

int

inte

rven

tion

s ut

ilizi

ng C

ochr

ane

revi

ew c

rite

ria

Y: Y

es; N

: No;

U: U

ncle

ar. S

ourc

e: F

urla

n et

al[7

8].


diag

nosing

chr

onic lu

mba

r fa

cet jo

int pa

in, w

ithou

t di

sc h

erni

atio

n or

rad

icul

ar p

ain,

afte

r fa

iling

cons

erva

tive

man

agem

ent.

Onc

e th

e di

agno

sis

is e

stab

lishe

d, p

atie

nts

may

be

offe

red

trea

tmen

t with

lum

bar f

acet

join

t ner

ve b

lock

s or

radi

ofre

quen

cy n

euro

tom

y, a

nd p

erha

ps in

traa

rticul

ar fa

cet i

njec

tions

. Si

gnifi

cant

pro

gres

s al

so h

as b

een

mad

e w

ith t

hera

peut

ic in

terv

entio

ns, ac

cord

ing

to R

CTs

and

syst

emat

ic r

evie

ws

publ

ishe

d ov

er t

he p

ast

5 ye

ars.

Con

sequ

ently

, th

e qu

ality

and

leve

l of e

vide

nce

for

ther

apeu

tic in

terv

entio

ns h

as b

een

impr

ovin

g, w

ith le

vel Ⅱ

evi

denc

e fo

r lo

ngt

erm

rel

ief (

long

er tha

n 6

mo)

for

radi

ofre

quen

cy n

euro

tom

y an

d th

erap

eutic

lum

bar

face

t jo

int ne

rve

bloc

ks, e

ven

thou

gh the

evi

denc

e fo

r lu

mbo

sacr

al in

traa

rticul

ar in

ject

ions

con

tinue

s to

lack

for

long

ter

m im

prov

emen

t an

d is le

vel

Ⅲ fo

r sho

rtt

erm

impr

ovem

ent.

Ther

e ha

s be

en s

ubst

antia

l con

trov

ersy

in r

efer

ence

to

tech

niqu

e. B

ogdu

k et

al[7

1] h

ave

reco

mm

ende

d pa

ralle

l pla

cem

ent

of t

he n

eedl

e to

ach

ieve

app

ropr

iate

res

ults


Man

chik

anti

et a

l[102]

Car

ette

et

al[1

03]

Fuch

s et

al[1

04]

Nat

h et

al

[105]

van

Wijk

et

al[9

7]

van

Kle

ef

et a

l[99]

Teki

n et

al

[96]

Civ

elek

et

al[1

08]

Dob

rogo

wsk

i et

al[9

8]

Coh

en e

t al

[109]

Rib

eiro

et

al[1

07]

Moo

n et

al[1

00]

Lake

mei

er

et a

l[101]

Yun

et

al[1

06]

Ⅰ T

rial

des

ign

and

guid

ance

repo

rtin

g

(1) C

onso

rt o

r spi

rit

33

33

22

22

23

22

22

Ⅱ D

esig

n fa

ctor

s

(2) T

ype

and

desi

gn o

f tri

al2

32

33

33

22

22

22

2

(3) S

ettin

g/ph

ysic

ian

21

13

33

22

22

22

11

(4

) Im

agin

g3

32

33

33

32

33

33

3

(5) S

ampl

e si

ze3

22

11

11

11

32

22

2

(6) S

tatis

tical

met

hodo

logy

11

11

11

11

11

11

11

Ⅲ P

atie

nt fa

ctor

s

(7) I

nclu

sive

ness

of P

opul

atio

nFo

r fac

et jo

int i

nter

vent

ions

:2

10

21

11

01

10

21

0

(8) D

urat

ion

of p

ain

22

12

23

20

20

02

20

(9

) Pre

viou

s tr

eatm

ents

2

00

00

01

20

00

22

1

(10)

Dur

atio

n of

follo

w-u

p w

ith a

ppro

pria

te in

terv

entio

ns3

21

22

22

21

01

12

1Ⅳ

Out

com

es

(11)

Out

com

es a

sses

smen

t cri

teri

a fo

r sig

nific

ant i

mpr

ovem

ent

44

24

42

22

20

22

21

(1

2) A

naly

sis

of a

ll ra

ndom

ized

par

ticip

ants

in th

e gr

oups

22

22

22

22

22

20

22

(1

3) D

escr

iptio

n of

dro

p ou

t rat

e 2

12

22

22

22

22

22

2

(14)

Sim

ilari

ty o

f gro

ups

at b

asel

ine

for i

mpo

rtan

t pro

gnos

tic in

dica

tors

22

22

22

22

22

22

22

(1

5) R

ole

of c

o-in

terv

entio

ns1

00

11

11

11

11

11

1Ⅴ

Ran

dom

izat

ion

(1

6) M

etho

d of

Ran

dom

izat

ion

22

22

22

22

22

22

22

Ⅵ A

lloca

tion

conc

ealm

ent

(1

7) C

once

aled

trea

tmen

t allo

catio

n2

21

22

22

22

02

22

2Ⅶ

Blin

ding

(1

8) P

atie

nt b

lindi

ng

11

01

11

10

10

11

10

(1

9) C

are

prov

ider

blin

ding

11

01

11

10

10

01

00

(2

0) O

utco

me

asse

ssor

blin

ding

01

00

10

00

00

01

00

Ⅷ C

onfli

cts

of in

tere

st

(2

1) F

undi

ng a

nd s

pons

orsh

ip2

31

20

32

00

22

22

1

(22)

Con

flict

s of

inte

rest

3

31

30

32

00

23

33

0To

tal

45

4

0

26

4

2

36

40

37

2

8

29

2

8

32

3

2

3

8

37

Tabl

e 4 M

etho

dolo

gica

l qua

lity

asse

ssm

ent

of r

ando

miz

ed t

rial

s ut

ilizi

ng I

nter

vent

iona

l Pai

n M

anag

emen

t te

chni

ques

- Q

ualit

y A

ppra

isal

of

Rel

iabi

lity

and

Risk

of B

ias

Ass

essm

ent

criter

ia

Sour

ce: M

anch

ikan

ti et

al[7

9].


Stud

y/m

etho

dsPa

rtic

ipan

tsIn

terv

ention

(s)

Out

com

e m

easu

res

Com

men

tsR

esul

tsM

etho

dolo

gica

l qua

lity

scor

ing

Prev

alen

ce w

ith

95%

CI

and

criter

ion

stan

dard

False-

positive

rat

e w

ith

95%

CI

Pang

et a

l[25], 1

998

100

cons

ecut

ive

adul

t pat

ient

s w

ith c

hron

ic lo

w b

ack

pain

with

un

dete

rmin

ed e

tiolo

gy w

ere

eval

uate

d w

ith s

pina

l map

ping

Sing

le b

lock

was

per

form

ed b

y in

ject

ing

2% li

doca

ine

into

face

t jo

ints

Ver

bal a

nalo

g sc

ale

This

is th

e fir

st s

tudy

eva

luat

ing

appl

icat

ion

of d

iagn

ostic

blo

cks

in th

e di

agno

sis

of in

trac

tabl

e lo

w b

ack

pain

of

unde

term

ined

etio

logy

with

face

t joi

nt

dise

ase

in p

oten

tially

48%

of p

atie

nts

with

a s

ingl

e bl

ock

Sing

le b

lock

90%

pai

n re

lief

NA

Pros

pect

ive,

sin

gle

bloc

kPa

in m

appi

ng

Onl

y fa

cet j

oint

pai

n =

24%

8/12

90%

pai

n re

lief

Lum

bar n

erve

root

and

face

t di

seas

e =

24%

Tota

l = 4

8%

Schw

arze

r et a

l[22], 1

994

176

cons

ecut

ive

patie

nts

with

ch

roni

c lo

w b

ack

pain

afte

r so

me

type

of i

njur

y

Zyga

poph

ysia

l joi

nt n

erve

blo

cks

or in

traa

rtic

ular

inje

ctio

ns w

ere

perf

orm

ed w

ith e

ither

2%

lign

ocai

ne

or 0

.5%

bup

ivac

aine

At l

east

50%

pai

n re

lief

conc

orda

nt w

ith th

e du

ratio

n of

loca

l ane

sthe

tic in

ject

ed

Firs

t stu

dy o

f eva

luat

ion

of c

ontr

olle

d pr

eval

ence

and

fals

e-po

sitiv

e ra

tes

50%

pai

n re

lief

38%

(95%

CI:

30%

-46%

)Pr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

15%

(95%

CI:

10%

-20%

)

9/12

Schw

arze

r et a

l[84], 1

995

63 p

atie

nts

with

low

bac

k pa

in la

stin

g fo

r lon

ger t

han

3 m

o un

derw

ent c

ompu

ted

tom

ogra

phy

and

bloc

ks o

f the

zy

gapo

phys

ial j

oint

s

Patie

nts

unde

rwen

t a p

lace

bo

inje

ctio

n fo

llow

ed b

y in

traa

rtic

ular

zy

gapo

phys

ial j

oint

inje

ctio

ns w

ith

1.5

mL

of 0

.5%

bup

ivac

aine

At l

east

50%

redu

ctio

n in

pai

n m

aint

aine

d fo

r m

inim

um o

f 3 h

This

stu

dy s

how

s th

at c

ompu

ted

tom

ogra

phy

has

no p

lace

in th

e di

agno

sis

of lu

mba

r zyg

apop

hysi

al jo

int p

ain,

with

an

impu

re p

lace

bo d

esig

n

50%

pai

n re

lief

NA

Rand

omiz

ed, i

mpu

re

plac

ebo,

con

trol

led

diag

nost

ic b

lock

s

40%

(95%

CI:

27%

-53%

)

9/12

Man

chik

anti

[95], 2

010

491

patie

nts

with

chr

onic

lo

w b

ack

pain

und

ergo

ing

eval

uatio

n fo

r fac

et jo

int p

ain

with

80%

pai

n re

lief a

nd 1

81

patie

nts

with

50%

pai

n re

lief

Con

trol

led

diag

nost

ic b

lock

s of

lu

mba

r fac

et jo

int n

erve

s w

ith 1

%

pres

erva

tive-

free

lido

cain

e an

d 0.

25%

pr

eser

vativ

e-fr

ee b

upiv

acai

ne 1

mL

At l

east

80%

pai

n re

lief

with

the

abili

ty to

per

form

pr

evio

usly

pai

nful

m

ovem

ents

Hig

her p

reva

lenc

e th

an w

ith 5

0% p

ain

relie

f, bu

t stil

l hig

her t

han

doub

le b

lock

al

gori

thm

ic a

ppro

ach

50%

pai

n re

lief

50%

pai

n re

lief

Retr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

61%

(95%

CI:

53%

-81%

)17

% (9

5%C

I: 10

%-2

4%)

9/12

80%

pai

n re

lief

80%

pai

n re

lief

31%

(95%

CI:

26%

-35%

)42

% (9

5%C

I: 35

%-5

0%)

Man

chik

anti

et a

l[85], 2

000

200

cons

ecut

ive

patie

nts

with

ch

roni

c lo

w b

ack

pain

wer

e ev

alua

ted

Con

trol

led

diag

nost

ic b

lock

s w

ith

1% li

doca

ine

and

0.25

% b

upiv

acai

ne

wer

e in

ject

ed o

ver f

acet

join

t ner

ves

with

0.4

to 0

.6 m

L

75%

pai

n re

lief w

ith a

bilit

y to

per

form

pre

viou

sly

pain

ful m

ovem

ents

The

stud

y sh

owed

that

the

clin

ical

pic

ture

fa

iled

to d

iagn

ose

face

t joi

nt p

ain

75%

pai

n re

lief

37%

(95%

CI:

32%

-42%

)Pr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

42%

(95%

CI:

35%

-42%

)

9/12

DeP

alm

a et

al[2

4], 2

011

A to

tal o

f 156

pat

ient

s w

ith

chro

nic

low

bac

k pa

in w

ere

asse

ssed

for t

he s

ourc

e of

ch

roni

c lo

w b

ack

pain

incl

udin

g di

scog

enic

pai

n, fa

cet j

oint

pai

n,

and

sacr

oilia

c jo

int p

ain

Dua

l con

trol

led

diag

nost

ic b

lock

s w

ith 1

% li

doca

ine

for t

he fi

rst b

lock

w

ith 0

.5%

bup

ivac

aine

for t

he se

cond

Con

cord

ant r

elie

f with

2

h fo

r lid

ocai

ne a

nd 8

h

for b

upiv

acai

ne w

ith 7

5%

pain

relie

f as

the

crite

rion

st

anda

rd

This

is th

e th

ird

stud

y ev

alua

ting

vari

ous

stru

ctur

es im

plic

ated

in th

e ca

use

of lo

w

back

pai

n w

ith c

ontr

olle

d di

agno

stic

bl

ocks

[23,

25]

75%

pai

n re

lief

NA

Retr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

31%

(24%

-38%

)

9/12

Man

chik

anti

et a

l[93], 2

001

Prev

alen

ce s

tudy

in 1

00 p

atie

nts

with

50

patie

nts

belo

w a

ge o

f 65

and

50 p

atie

nts

aged

65

or o

ver

was

ass

esse

d

Con

trol

led

diag

nost

ic b

lock

s75

% p

ain

relie

f with

abi

lity

to p

erfo

rm p

revi

ousl

y pa

infu

l mov

emen

ts w

as

utili

zed

as th

e cr

iteri

on

stan

dard

This

stu

dy s

how

ed h

ighe

r pre

vale

nce

of

face

t joi

nt p

ain

in th

e el

derl

y co

mpa

red

to

the

youn

ger a

ge g

roup

in c

ontr

ast t

o th

e la

test

stud

y by

Man

chik

anti

et a

l[117

] whi

ch

show

ed n

o di

ffere

nces

75%

pai

n re

lief

< 65

yr =

26%

(95%

CI:

11%

-40%

)Pr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

< 65

yr =

30%

(95%

CI:

17%

-43%

)>

65 y

r = 3

3% (9

5%C

I: 14

%-3

5%)

> 65

yr =

52%

(95%

CI:

38%

-66%

)9/

12M

anch

ikan

ti et

al[9

4], 2

001

100

patie

nts

with

low

bac

k pa

in

wer

e ev

alua

ted.

Pat

ient

s w

ere

divi

ded

into

2 g

roup

s, g

roup

Ⅰ

was

nor

mal

wei

ght a

nd g

roup

Ⅱ

was

obe

se

Face

t joi

nts

wer

e in

vest

igat

ed w

ith

diag

nost

ic b

lock

s us

ing

lidoc

aine

1%

initi

ally

follo

wed

by

bupi

vaca

ine

0.25

%, a

t lea

st 2

wk

apar

t

A d

efini

te re

spon

se w

as

defin

ed a

s re

lief o

f at l

east

75

% in

the

sym

ptom

atic

are

a

This

stu

dy s

how

ed n

o si

gnifi

cant

di

ffere

nce

betw

een

obes

e an

d no

n-ob

ese

indi

vidu

als

eith

er w

ith p

reva

lenc

e or

fa

lse-

posi

tive

rate

of d

iagn

ostic

blo

cks

in

chro

nic

face

t joi

nt p

ain

75%

pai

n re

lief

Non

-obe

se in

divi

dual

s =

44%

(95%

CI:

26%

-61%

)Pr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

9/12

Prev

alen

ce:

Obe

se in

divi

dual

s =

33%

(95%

CI:

16%

-51%

)N

on-o

bese

indi

vidu

als

= 36

%

(95%

CI:

22%

-50%

)O

bese

indi

vidu

als

= 40

%

(95%

CI:

26%

-54%

)

Tabl

e 5 C

hara

cter

istics

of

stud

ies

asse

ssin

g th

e ac

cura

cy o

f di

agno

stic

fac

et jo

int

inje

ctio

ns a

nd n

erve

blo

cks

in t

he lu

mba

r sp

ine




Man

chik

anti

et a

l[23], 2

001

120

patie

nts

wer

e ev

alua

ted

with

chi

ef c

ompl

aint

of c

hron

ic

low

bac

k pa

in to

eva

luat

e re

lativ

e co

ntri

butio

ns o

f var

ious

st

ruct

ures

in c

hron

ic lo

w b

ack

pain

. All

120

patie

nts u

nder

wen

t fa

cet j

oint

ner

ve b

lock

s

Con

trol

led

diag

nost

ic b

lock

s w

ith

1% li

doca

ine

follo

wed

by

0.25

%

bupi

vaca

ine

80%

pai

n re

lief w

ith a

bilit

y to

per

form

pre

viou

sly

pain

ful m

ovem

ents

This

stu

dy e

valu

ated

all

the

patie

nts

with

low

bac

k pa

in, e

ven

with

sus

pect

ed

disc

ogen

ic p

ain

80%

pai

n re

lief

47%

(95%

CI:

35%

-59%

)Pr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

40%

(95%

CI:

31%

-49%

)

9/12

Man

chik

anti

et a

l[86], 1

999

120

patie

nts

with

chr

onic

lo

w b

ack

pain

afte

r fai

lure

of

cons

erva

tive

man

agem

ent w

ere

eval

uate

d

Con

trol

led

diag

nost

ic b

lock

s w

ith

1% li

doca

ine

follo

wed

by

0.25

%

bupi

vaca

ine

Con

cord

ant p

ain

relie

f with

75

% o

r gre

ater

cri

teri

on

stan

dard

with

abi

lity

to

perf

orm

pre

viou

sly

pain

ful

mov

emen

ts

This

was

the

first

stu

dy p

erfo

rmed

in

the

Uni

ted

Stat

es in

the

hete

roge

nous

po

pula

tion

as p

revi

ous

stud

ies

wer

e pe

rfor

med

in o

nly

post

-inju

ry p

atie

nts

75%

pai

n re

lief

41%

(95%

CI:

29%

-53%

)Pr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

45%

(95%

CI:

36%

-54%

)

9/12

Man

chik

anti

et a

l[79], 2

014

180

cons

ecut

ive

patie

nts

with

ch

roni

c lo

w b

ack

pain

wer

e ev

alua

ted

afte

r hav

ing

faile

d co

nser

vativ

e m

anag

emen

t

Con

trol

led

diag

nost

ic b

lock

s w

ith

1% li

doca

ine

and

0.25

% b

upiv

acai

ne

with

or w

ithou

t Sar

apin

and

/or

ster

oids

75%

pai

n re

lief w

ith a

bilit

y to

per

form

pre

viou

sly

pain

ful m

ovem

ents

This

stu

dy s

how

ed n

o si

gnifi

cant

di

ffere

nce

if th

e st

eroi

ds w

ere

used

or n

ot75

% p

ain

relie

f25

% (9

5%C

I: 21

%-3

9%)

Pros

pect

ive,

con

trol

led

diag

nost

ic b

lock

s36

% (9

5%C

I: 29

%-4

3%)

9/12

Man

chik

anti

et a

l[88], 2

003

At t

otal

of 3

00 p

atie

nts

with

ch

roni

c lo

w b

ack

pain

wer

e ev

alua

ted

to a

sses

s th

e di

ffere

nce

base

d on

invo

lvem

ent

of s

ingl

e or

mul

tiple

spi

nal

regi

ons

Con

trol

led

diag

nost

ic b

lock

s w

ith

1% li

doca

ine

follo

wed

by

0.25

%

bupi

vaca

ine

80%

pai

n re

lief w

ith a

bilit

y to

per

form

pre

viou

sly

pain

ful m

ovem

ents

This

stu

dy s

how

s a

high

er p

reva

lenc

e w

hen

mul

tiple

regi

ons

are

invo

lved

80%

pai

n re

lief

Sing

le re

gion

:Pr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

Sing

le re

gion

:17

% (9

5%C

I: 10

%-2

4%)

21%

(95%

CI:

14%

-27%

)M

ultip

le re

gion

s:9/

12M

ultip

le re

gion

s:27

% (9

5%C

I: 18

%-3

6%)

41%

(95%

CI:

33%

-49%

)

Man

chik

anti

et a

l[82], 2

014

120

cons

ecut

ive

patie

nts

with

ch

roni

c lo

w b

ack

pain

and

nec

k pa

in w

ere

eval

uate

d to

ass

ess

invo

lvem

ent o

f fac

et jo

ints

as

caus

ativ

e fa

ctor

s

Con

trol

led

diag

nost

ic b

lock

s w

ith

1% li

doca

ine

follo

wed

by

0.25

%

bupi

vaca

ine

80%

pai

n re

lief w

ith a

bilit

y to

per

form

pre

viou

sly

pain

ful m

ovem

ents

The

resu

lts a

re s

imila

r to

invo

lvem

ent

of m

ultip

le re

gion

s w

ith a

pre

vale

nce

of

40%

as

illus

trat

ed in

ano

ther

stu

dy

80%

pai

n re

lief

30%

(95%

CI:

20%

-40%

)Pr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

40%

(95%

CI:

31%

-49%

)

9/12

Man

chik

anti

et a

l[90], 2

004

500

cons

ecut

ive

patie

nts

with

ch

roni

c, n

on-s

peci

fic s

pina

l pai

n w

ere

eval

uate

d of

whi

ch 3

97

patie

nts

suffe

red

with

chr

onic

lo

w b

ack

pain

Con

trol

led

diag

nost

ic b

lock

s w

ith

1% li

doca

ine

follo

wed

by

0.25

%

bupi

vaca

ine

80%

pai

n re

lief w

ith a

bilit

y to

per

form

pre

viou

sly

pain

ful m

ovem

ents

Larg

est s

tudy

per

form

ed in

volv

ing

all

regi

ons

of th

e sp

ine

80%

pai

n re

lief

27%

(95%

CI:

22%

-32%

)Pr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

31%

(95%

CI:

27%

-36%

)

9/12

Man

chuk

onda

et a

l[91],

2007

500

cons

ecut

ive

patie

nts

with

ch

roni

c sp

inal

pai

n w

ere

eval

uate

d of

whi

ch 3

03 p

atie

nts

wer

e ev

alua

ted

for c

hron

ic lo

w

back

pai

n

Con

trol

led

diag

nost

ic b

lock

s w

ith

1% li

doca

ine

follo

wed

by

0.25

%

bupi

vaca

ine

80%

pai

n re

lief w

ith a

bilit

y to

per

form

pre

viou

sly

pain

ful m

ovem

ents

Seco

nd la

rges

t stu

dy p

erfo

rmed

invo

lvin

g al

l reg

ions

of t

he s

pine

80%

pai

n re

lief

45%

(95%

CI:

36%

-53%

)

Retr

ospe

ctiv

e, c

ontr

olle

d di

agno

stic

blo

cks

27%

(95%

CI:

22%

-33%

)

9/12

Man

chik

anti

et a

l[92], 2

007

A to

tal o

f 117

con

secu

tive

patie

nts

with

chr

onic

non

-sp

ecifi

c lo

w b

ack

pain

wer

e ev

alua

ted,

afte

r lum

bar s

urgi

cal

inte

rven

tions

, with

pos

tsur

gery

sy

ndro

me

and

cont

inue

d ax

ial

low

bac

k pa

in

Con

trol

led,

com

para

tive,

loca

l an

esth

etic

blo

cks

with

1%

lido

cain

e an

d 0.

25%

bup

ivac

aine

80%

relie

f as

the

crite

rion

st

anda

rd w

ith a

bilit

y to

pe

rfor

m p

revi

ousl

y pa

infu

l m

ovem

ents

Low

er p

reva

lenc

e in

pos

tsur

gery

pat

ient

s80

% p

ain

relie

f49

% (9

5%C

I: 39

%-5

9%)

Pros

pect

ive,

con

trol

led

diag

nost

ic b

lock

s 16

% (9

5%C

I: 9%

-23%

)

9/12


NA

: Not

app

licab

le.


Stud

y/st

udy

char

acte

rist

ic/

met

hodo

logi

cal q

ualit

y Sc

orin

gN

o. o

f pa

tien

ts a

nd

sele

ctio

n cr

iter

iaC

ontr

olIn

terv

ention

sO

utco

me

mea

sure

sTi

me

of

mea

sure

men

tR

epor

ted

resu

lts

Stre

ngth

sW

eakn

esse

sC

oncl

usio

n/co

mm

ents

Radi

ofre

quen

cy n

euro

tom

y

Civ

elek

et a

l[108

] , 201

210

0 pa

tient

s w

ith

chro

nic

low

bac

k pa

in w

ith fa

iled

cons

erva

tive

ther

apy

and

stri

ct s

elec

tion

crite

ria;

how

ever

, w

ithou

t dia

gnos

tic

bloc

ks

Face

t joi

nt n

erve

bl

ock

with

loca

l an

esth

etic

and

st

eroi

ds in

50

patie

nts

Con

vent

iona

l ra

diof

requ

ency

ne

urot

omy

at 8

0 ℃

for

120

s in

com

bina

tion

with

hig

h do

se lo

cal

anes

thet

ic a

nd s

tero

ids,

in

50

patie

nts

Vis

ual N

umer

ic

Pain

Sca

le, N

orth

A

mer

ican

Spi

ne

Soci

ety

patie

nt

satis

fact

ion

ques

tionn

aire

, Eu

ro-Q

ol in

5

dim

ensi

ons

and ≥

50

% re

lief

1, 6

and

12

mo

At o

ne y

ear,

90%

of

pat

ient

s in

the

radi

ofre

quen

cy g

roup

an

d 69

% o

f the

pat

ient

s in

the

face

t joi

nt n

erve

bl

ock

grou

p sh

owed

si

gnifi

cant

impr

ovem

ent

com

pare

d to

92%

and

75

% a

t 6-m

o fo

llow

-up

Rand

omiz

ed

rela

tivel

y la

rge

num

ber o

f pat

ient

s w

ith 5

0 in

eac

h gr

oup

No

diag

nost

ic b

lock

s w

ere

perf

orm

ed.

Hig

h do

se s

tero

ids

and

loca

l ane

sthe

tics

wer

e ut

ilize

d in

bot

h gr

oups

Effic

acy

was

sho

wn

even

with

out

diag

nost

ic b

lock

s,

both

for f

acet

join

t ne

rve

bloc

ks a

nd

radi

ofre

quen

cy

neur

otom

y

Ra

ndom

ized

, act

ive-

cont

rol

tr

ial

Q

ualit

y sc

ores

:

Coc

hran

e =

9/12

IP

M-Q

RB =

28/

48

C

ohen

et a

l[109

] , 201

015

1 ch

roni

c lo

w b

ack

pain

, 51

patie

nts

with

no

diag

nost

ic

bloc

k, 5

0 pa

tient

s a

sing

le d

iagn

ostic

bl

ock,

50

patie

nts

in

doub

le d

iagn

ostic

bl

ock

Radi

ofre

quen

cy

neur

otom

y in

pa

tient

s w

ithou

t di

agno

stic

bl

ocks

Con

vent

iona

l ra

diof

requ

ency

ne

urot

omy

at 8

0 ℃

fo

r 90

s in

all

patie

nts;

ho

wev

er, i

n 2

grou

ps

with

eith

er

a si

ngle

blo

ck p

arad

igm

or

a d

oubl

e bl

ock

para

digm

test

ing

for

posi

tive

resu

lts

Gre

ater

than

50%

pa

in re

lief c

oupl

ed

with

a p

ositi

ve

glob

al p

erce

ived

ef

fect

per

sist

ing

for 3

mo

3 m

o D

ener

vatio

n su

cces

s ra

tes

in g

roup

s 0,

1 a

nd

2 w

ere

33%

, 39%

and

64

%, r

espe

ctiv

ely

Mul

ticen

ter,

rand

omiz

ed

cont

rolle

d tr

ial w

ith

or w

ithou

t dia

gnos

tic

bloc

ks

Aut

hors

m

isin

terp

rete

d co

st-

effe

ctiv

enes

s with

out

cons

ider

atio

n of

man

y fa

ctor

s re

port

ed

Resu

lts s

how

ed

effic

acy

whe

n do

uble

di

agno

stic

blo

cks

wer

e ut

ilize

d

Ra

ndom

ized

, dou

ble-

blin

d,

co

ntro

l tri

al

Qua

lity

scor

es:

C

ochr

ane

= 8/

12

IPM

-QRB

= 2

8/48

N

ath

et a

l[105

] , 200

8 40

pat

ient

s w

ith

chro

nic

low

bac

k pa

in fo

r at l

east

2 y

r w

ith 8

0% re

lief o

f lo

w b

ack

pain

afte

r co

ntro

lled

med

ial

bran

ch b

lock

s.

The

patie

nts

wer

e ra

ndom

ized

into

an

activ

e an

d a

cont

rol

grou

p

Con

trol

led

sham

le

sion

in 2

0 pa

tient

s in

the

cont

rol g

roup

The

20 p

atie

nts

in

the

activ

e gr

oup

rece

ived

con

vent

iona

l lu

mba

r fac

et jo

int

radi

ofre

quen

cy

neur

olys

is a

t 85 ℃

for 6

0 s.

The

20

patie

nts

in th

e co

ntro

l gro

up re

ceiv

ed

sham

tr

eatm

ent w

ithou

t ra

diof

requ

ency

ne

urol

ysis

of t

he lu

mba

r fa

cet j

oint

s

Num

eric

Rat

ing

Scal

e, g

loba

l fu

nctio

nal

impr

ovem

ent,

redu

ced

opio

id in

take

, em

ploy

men

t st

atus

6 m

oSi

gnifi

cant

redu

ctio

n no

t onl

y in

bac

k an

d le

g pa

in; f

unct

iona

l im

prov

emen

t; op

ioid

re

duct

ion;

and

em

ploy

men

t sta

tus

in th

e ac

tive

grou

p co

mpa

red

to th

e co

ntro

l gr

oup

Rand

omiz

ed, d

oubl

e-bl

ind

tria

l afte

r the

di

agno

sis

of fa

cet

join

t pai

n w

ith tr

iple

di

agno

stic

blo

cks

Shor

t-ter

m fo

llow

-up

with

sm

all n

umbe

r of

pat

ient

s

Effic

acy

of

radi

ofre

qenc

y ne

urot

omy

was

sh

own

com

pare

d to

loca

l ane

sthe

tic

inje

ctio

n an

d sh

am

lesi

onin

g

Ra

ndom

ized

, dou

ble-

blin

d,

sh

am c

ontr

ol tr

ial

Q

ualit

y sc

ores

:

Coc

hran

e =

12/1

2

IPM

-QRB

= 4

2/48

Te

kin

et a

l[96], 2

007

60 p

atie

nts

with

ch

roni

c lo

w b

ack

pain

rand

omiz

ed

into

3 g

roup

s w

ith

20 p

atie

nts

in e

ach

grou

p. S

ingl

e di

agno

stic

blo

ck o

f fa

cet j

oint

ner

ves

with

0.3

mL

of

lidoc

aine

2%

with

Sham

con

trol

w

ith lo

cal

anes

thet

ic

inje

ctio

n

Eith

er p

ulse

d ra

diof

requ

ency

(42 ℃

for

4 m

in) o

r con

vent

iona

l ra

diof

requ

ency

ne

urot

omy

(80 ℃

for 9

0 s)

in 2

0 pa

tient

s in

eac

h gr

oup

Vis

ual a

nalo

g sc

ale

and

Osw

estr

y D

isab

ility

Inde

x

3, 6

and

12

mo

Vis

ual a

nalo

g sc

ale

and

Osw

estr

y D

isab

ility

In

dex

scor

es d

ecre

ased

in

all

grou

ps fr

om

3 pr

oced

ural

leve

ls.

Dec

reas

e in

pai

n sc

ores

was

mai

ntai

ned

in th

e co

nven

tiona

l ra

diof

requ

ency

gro

up a

t 6

mo

and

one

year

.

Rand

omiz

ed, d

oubl

e-bl

ind,

con

trol

led

tria

l com

pari

ng

cont

rol,

puls

ed

radi

ofre

quen

cy,

and

conv

entio

nal

radi

ofre

qenc

y ne

urot

omy.

Aut

hors

al

so u

tiliz

ed a

par

alle

l ne

edle

pla

cem

ent

Smal

l sam

ple

size

with

a s

ingl

e bl

ock

and

50%

re

lief a

s in

clus

ion

crite

ria.

Aut

hors

ha

ve n

ot d

escr

ibed

th

e si

gnifi

cant

im

prov

emen

t pe

rcen

tage

s

Effic

acy

with

co

nven

tiona

l ra

diof

reqe

ncy

neur

otom

y up

to

one

year

, whe

reas

ef

ficac

y w

ith lo

cal

anes

thet

ic b

lock

w

ith s

ham

con

trol

ra

diof

requ

ency

ne

urot

omy

and

Ra

ndom

ized

, act

ive

and

sh

am, d

oubl

e-bl

ind

co

ntro

lled

tria

l

Qua

lity

scor

es:

C

ochr

ane

= 12

/12

IP

M-Q

RB =

37/

48

Tabl

e 6 St

udy

char

acte

rist

ics

of r

ando

miz

ed c

ontr

olle

d tr

ials o

f lu

mba

r ra

diof

requ

ency

neu

roto

my,

fac

et jo

int

nerv

e bl

ocks

, an

d in

traa

rtic

ular

inje

ctio

nsManchikanti L et al . Lumbar facet joint pain


50%

or g

reat

er re

lief

How

ever

, in

puls

ed

radi

ofre

quen

cy g

roup

, th

e im

prov

emen

t was

si

gnifi

cant

onl

y at

6 m

o,

but n

ot 1

yr

appr

oach

puls

ed

radi

ofre

quen

cy

neur

otom

y at

6 m

o on

ly

va

n W

ijk et

al[9

7], 2

005

81 p

atie

nts

with

ch

roni

c lo

w b

ack

pain

wer

e ev

alua

ted

with

radi

ofre

qenc

y ne

urot

omy

with

41

pat

ient

s in

the

cont

rol g

roup

w

ith a

t lea

st 5

0%

relie

f for

30

min

w

ith a

sin

gle

bloc

k w

ith in

traa

rtic

ular

in

ject

ion

of 0

.5 m

L lid

ocai

ne 2

%

Sham

lesi

on

proc

edur

e af

ter

loca

l ane

sthe

tic

inje

ctio

n

40 p

atie

nts

rece

ived

co

nven

tiona

l ra

diof

requ

ency

lesi

onin

g at

80 ℃

for 6

0 s

and

41

patie

nts

rece

ived

sha

m

lesi

onin

g

Pain

relie

f, ph

ysic

al a

ctiv

ities

, an

alge

sic

inta

ke,

glob

al p

erce

ived

ef

fect

, sho

rt-

form

-36,

qua

lity

of

life

mea

sure

s

3 m

oG

loba

l per

ceiv

ed

effe

ct im

prov

ed a

fter

radi

ofre

quen

cy fa

cet

join

t den

erva

tion.

The

vi

sual

ana

log

scal

e in

bo

th g

roup

s im

prov

ed.

The

com

bine

d ou

tcom

e m

easu

res

show

ed n

o di

ffere

nce

betw

een

radi

ofre

qenc

y fa

cet j

oint

de

nerv

atio

n (2

7.5%

vs

29.3

% s

ucce

ss ra

te)

Dou

ble-

blin

d, s

ham

co

ntro

l, ra

ndom

ized

tr

ial

Poor

sel

ectio

n w

ith

a si

ngle

dia

gnos

tic

bloc

k of

50%

pai

n re

duct

ion

even

th

ough

17.

5% o

f th

e pa

tient

s te

sted

po

sitiv

e. F

urth

er,

auth

ors

desc

ribe

d th

at th

e ne

edle

was

po

sitio

ned

para

llel;

how

ever

, the

ra

diog

raph

ic fi

gure

s ill

ustr

ate

the

need

le

was

bei

ng p

ositi

oned

pe

rpen

dicu

larl

y ra

ther

than

par

alle

l to

the

nerv

e

Lack

of e

ffica

cy w

ith

met

hodo

logi

cal

defic

ienc

ies

and

a sh

ort-t

erm

follo

w-u

p

Ra

ndom

ized

, dou

ble-

blin

d,

sh

am c

ontr

ol tr

ial

Q

ualit

y sc

ores

:

Coc

hran

e =

12/1

2

IPM

-QRB

= 3

6/48

D

obro

gow

ski e

t al[9

8], 2

005

45 c

onse

cutiv

e pa

tient

s w

ith c

hron

ic

low

bac

k pa

in ju

dged

to

be

posi

tive

with

co

ntro

lled

diag

nost

ic

bloc

ks

Inje

ctio

n of

sal

ine

in

patie

nts

afte

r co

nven

tiona

l ra

diof

requ

ency

(8

5 ℃

for 6

0 s)

neu

roto

my

to e

valu

ate

post

oper

ativ

e pa

in

Con

vent

iona

l ra

diof

requ

ency

ne

urot

omy

at 8

5 ℃

fo

r 60

s, fo

llow

ed b

y in

ject

ion

of e

ither

m

ethy

lpre

dnis

olon

e or

pe

ntox

ifylli

ne

Vis

ual a

nalo

g sc

ale,

min

imum

of

50%

redu

ctio

n of

pai

n in

tens

ity,

patie

nt s

atis

fact

ion

scor

e

1, 3

, 6 a

nd 1

2 m

o G

reat

er th

an 5

0%

of re

duct

ion

of p

ain

inte

nsity

was

obs

erve

d in

66%

of t

he p

atie

nts

12

mo

late

r. Th

ere

was

no

diffe

renc

e in

the

long

-te

rm o

utco

mes

Rand

omiz

ed, a

ctiv

e co

ntro

l tri

al

Ver

y sm

all

stud

y ev

alua

ting

effe

ctiv

enes

s of

ra

diof

requ

ency

ne

urot

omy

and

post

oper

ativ

e pa

in

Radi

ofre

quen

cy

neur

otom

y ef

fect

ive

with

or w

ithou

t st

eroi

d in

ject

ion

afte

r ne

urol

ysis

Ra

ndom

ized

, act

ive

cont

rol

tr

ial

Q

ualit

y sc

ores

:

Coc

hran

e =

10/1

2

IPM

-QRB

= 2

9/48

va

n K

leef

et a

l[99], 1

999

31 p

atie

nts

with

a

hist

ory

of a

t lea

st o

ne

year

of c

hron

ic lo

w

back

pai

n ra

ndom

ly

assi

gned

to o

ne o

f 2

trea

tmen

t gro

ups.

Si

ngle

dia

gnos

tic

bloc

k w

ith 5

0% re

lief

Sham

con

trol

of

radi

ofre

quen

cy

afte

r loc

al

anes

thet

ic

inje

ctio

n in

16

patie

nts

The

15 p

atie

nts

in

the

conv

entio

nal

radi

ofre

quen

cy

trea

tmen

t gro

up

rece

ived

an

80 ℃

ra

diof

requ

ency

lesi

on

for 6

0 s

Vis

ual a

nalo

g sc

ale,

pai

n sc

ores

, gl

obal

per

ceiv

ed

effe

ct, O

swes

try

Dis

abili

ty In

dex

3, 6

and

12

mo

Afte

r 3, 6

and

12

mo,

th

e nu

mbe

r of s

ucce

sses

in

the

lesi

on a

nd s

ham

gr

oups

was

9 o

f 15

(60%

) an

d 4

of 1

6 (2

5%),

7 of

15

(47%

) and

3 o

f 16

(19%

), an

d 7

of 1

5 (4

7%) a

nd 2

of

16

(13%

) res

pect

ivel

y.

Ther

e w

as a

sta

tistic

ally

si

gnifi

cant

diff

eren

ce

Dou

ble-

blin

d,

rand

omiz

ed, s

ham

co

ntro

lled

tria

l

A s

ingl

e bl

ock

with

a

smal

l sam

ple

with

in

clus

ion

crite

ria

of 5

0% p

ain

relie

f to

ent

er th

e st

udy.

Th

e st

udy

has

been

crit

iciz

ed th

at

elec

trod

es w

ere

plac

ed a

t an

angl

e to

the

targ

et n

erve

, in

stea

d of

par

alle

l (5

1A)

Effic

acy

show

n in

a

smal

l sam

ple

with

a

sing

le d

iagn

ostic

bl

ock

Ra

ndom

ized

, dou

ble-

blin

d,

sh

am c

ontr

ol tr

ial

Q

ualit

y sc

ores

:

Coc

hran

e =

12/1

2

IPM

-QRB

= 4

0/48



M

oon

et a

l[100

] , 201

382

pat

ient

s w

ere

incl

uded

with

low

ba

ck p

ain

with

41

patie

nts

in e

ach

grou

p ei

ther

with

a

para

llel p

lace

men

t of

the

need

le o

r pe

rpen

dicu

lar

plac

emen

t of t

he

need

le

An

activ

e co

ntro

l tr

ial w

ith n

eedl

e pl

acem

ent w

ith

perp

endi

cula

r ap

proa

ch

41 p

atie

nts

in e

ach

grou

p w

ere

trea

ted

with

radi

ofre

quen

cy

(80 ℃

for 9

0 s)

afte

r ap

prop

riat

e di

agno

sis

of fa

cet j

oint

pai

n w

ith

dual

dia

gnos

tic b

lock

s w

ith 5

0% re

lief a

s th

e cr

iteri

on s

tand

ard.

The

ne

edle

was

pos

ition

ed

eith

er u

tiliz

ing

a di

scal

app

roac

h or

pe

rpen

dicu

lar o

r ut

ilizi

ng tu

nnel

vis

ion

appr

oach

with

par

alle

l pl

acem

ent o

f the

nee

dle

NRS

, OD

I1

and

6 m

oPa

tient

s in

bot

h gr

oups

sh

owed

a s

tatis

tical

ly

sign

ifica

nt re

duct

ion

in N

RS a

nd O

swes

try

disa

bilit

y in

dex

scor

es

from

bas

elin

e to

that

of

the

scor

es a

t 1 a

nd

6 m

o (a

ll P

< 0.

0001

, Bo

nfer

roni

cor

rect

ed)

Rand

omiz

ed, d

oubl

e-bl

ind,

con

trol

led

tria

l. Th

e m

ajor

str

engt

h is

that

aut

hors

hav

e pr

oven

that

par

alle

l ap

proa

ch m

ay n

ot b

e th

e be

st a

s ha

s be

en

desc

ribe

d. D

iagn

osis

of

face

t joi

nt p

ain

by

dual

blo

cks

Act

ive

cont

rolle

d tr

ial w

ithou

t pla

cebo

gr

oup.

Sho

rt-te

rm

follo

w-u

p

Posi

tive

resu

lts in

an

activ

e co

ntro

lled

tria

l, in

a re

lativ

ely

shor

t-te

rm fo

llow

-up

of 6

m

o, w

ith p

ositi

onin

g of

the

need

le e

ither

w

ith d

ista

l app

roac

h (p

erpe

ndic

ular

pl

acem

ent o

r tun

nel

visi

on) w

ith p

aral

lel

plac

emen

t of t

he

need

le w

ith so

me

supe

rior

ity w

ith

perp

endi

cula

r ap

proa

ch. T

his t

rial

ab

ates

any

cri

ticis

m

of n

eedl

e po

sitio

ning

on

e w

ay o

r the

oth

er

and

the

trad

ition

al

need

le p

ositi

onin

g ap

pear

s to

be

supe

rior

to p

aral

lel

need

le p

lace

men

t

Pr

ospe

ctiv

e, ra

ndom

ized

,

com

para

tive

stud

y

Qua

lity

scor

es:

C

ochr

ane

= 9/

12

IP

M-Q

RB =

38/

48

La

kem

eier

et a

l[101

] , 201

356

pat

ient

s w

ere

rand

omiz

ed in

to

2 gr

oups

with

29

patie

nts

rece

ivin

g in

traa

rtic

ular

ste

roid

in

ject

ions

and

27

patie

nts

rece

ivin

g ra

diof

requ

ency

de

nerv

atio

n af

ter t

he

diag

nosi

s w

as m

ade

with

intr

aart

icul

ar

inje

ctio

n of

loca

l an

esth

etic

with

a

sing

le b

lock

Intr

aart

icul

ar

inje

ctio

n of

loca

l an

esth

etic

and

st

eroi

d

Radi

ofre

quen

cy

neur

otom

y fo

r 90

s at

80

℃

Rola

nd-M

orri

s qu

estio

nnai

re,

VA

S, O

DI,

anal

gesi

c in

take

6 m

oPa

in re

lief a

nd

func

tiona

l im

prov

emen

t w

ere

obse

rved

in

both

gro

ups.

The

re

wer

e no

sig

nific

ant

diffe

renc

es b

etw

een

the

2 gr

oups

for p

ain

relie

f an

d fu

nctio

nal s

tatu

s im

prov

emen

t

Lack

of p

lace

bo

grou

p. R

elat

ivel

y sh

ort-t

erm

follo

w-u

p

Rand

omiz

ed,

doub

le-b

lind

tria

l with

sin

gle

diag

nost

ic b

lock

w

ith in

traa

rtic

ular

in

ject

ion

Both

gro

ups

show

ed

impr

ovem

ent.

Effe

ctiv

enes

s at

6

mo

in b

oth

grou

ps

with

intr

aart

icul

ar

inje

ctio

n or

ra

diof

requ

ency

ne

urot

omy

Ra

ndom

ized

, dou

ble-

blin

d,

ac

tive

cont

rolle

d tr

ial

Q

ualit

y sc

ores

:

Coc

hran

e =

9/12

IP

M-Q

RB =

37/

48

Lum

bar f

acet

join

t ner

ve b

lock

s

Civ

elek

et a

l[108

] , 201

210

0 pa

tient

s w

ith c

hron

ic lo

w

back

with

faile

d co

nser

vativ

e th

erap

y an

d st

rict

sel

ectio

n cr

iteri

a; h

owev

er,

with

out d

iagn

ostic

bl

ocks

Bloc

ks o

f fac

et

join

t ner

ves

with

lo

cal a

nest

hetic

an

d st

eroi

ds

Con

vent

iona

l ra

diof

requ

ency

ne

urot

omy

at 8

0 ℃

for

120

s in

com

bina

tion

with

hig

h do

se lo

cal

anes

thet

ic a

nd s

tero

ids

Vis

ual N

umer

ic

Pain

Sca

le, N

orth

A

mer

ican

Spi

ne

Soci

ety

patie

nt

satis

fact

ion

ques

tionn

aire

, Eu

ro-Q

ol in

5

dim

ensi

ons a

nd ≥

50

% re

lief

1, 6

and

12

mo

At t

he e

nd o

f one

yea

r, 90

% o

f pat

ient

s in

the

radi

ofre

quen

cy g

roup

an

d 69

% o

f the

pat

ient

s in

the

face

t joi

nt n

erve

bl

ock

grou

p sh

owed

si

gnifi

cant

impr

ovem

ent

vs 9

2% a

nd 7

5% a

t 6-m

o fo

llow

-up

Rand

omiz

ed a

ctiv

e-co

ntro

l tri

al w

ith

rela

tivel

y la

rge

num

ber o

f pat

ient

s w

ith 5

0 in

eac

h gr

oup

No

diag

nost

ic b

lock

s w

ere

perf

orm

ed.

Hig

h do

se s

tero

ids

and

loca

l ane

sthe

tics

wer

e pr

ovid

ed in

bo

th g

roup

s

Resu

lts s

how

ed

effic

acy

even

with

out

diag

nost

ic b

lock

s,

both

for f

acet

join

t ne

rve

bloc

ks a

nd

radi

ofre

quen

cy

neur

otom

y

Ra

ndom

ized

, act

ive-

cont

rol

tr

ial

Q

ualit

y sc

ores

:

Coc

hran

e =

9/12

IP

M-Q

RB =

28/

48



M

anch

ikan

ti et

al[1

02] , 2

010

120

patie

nts

with

ch

roni

c lo

w b

ack

pain

of f

acet

join

t or

igin

trea

ted

with

th

erap

eutic

lum

bar

face

t joi

nt n

erve

bl

ocks

Dou

ble

diag

nost

ic

bloc

ks w

ith 8

0%

relie

f

Loca

l ane

sthe

tic

only

Tota

l of 1

20 p

atie

nts

with

60

patie

nts

in

each

gro

up w

ith lo

cal

anes

thet

ic a

lone

or l

ocal

an

esth

etic

and

ste

roid

s.

Both

gro

ups

wer

e al

so

divi

ded

into

2 c

ateg

orie

s ea

ch w

ith th

e ad

ditio

n of

Sar

apin

Num

eric

Rat

ing

Scal

e, O

swes

try

Dis

abili

ty In

dex,

em

ploy

men

t st

atus

, and

opi

oid

inta

ke

3, 6

, 12,

18

and

24 m

oSi

gnifi

cant

pai

n re

lief

was

sho

wn

in 8

5%

in lo

cal a

nest

hetic

gr

oup

and

90%

in lo

cal

anes

thet

ic w

ith s

tero

ids

grou

p at

the

end

of th

e 2

yr s

tudy

per

iod

in b

oth

grou

ps, w

ith a

n av

erag

e of

5-6

tota

l tre

atm

ents

Rand

omiz

ed tr

ial

with

rela

tivel

y la

rge

prop

ortio

n of

pat

ient

s w

ith 2

-yr f

ollo

w-

up, w

ith in

clus

ion

of

patie

nts

diag

nose

d w

ith c

ontr

olle

d di

agno

stic

blo

cks

Lack

of p

lace

bo

grou

pEf

fect

iven

ess

dem

onst

rate

d w

ith

face

t joi

nt n

erve

bl

ocks

with

loca

l an

esth

etic

with

or

with

out s

tero

ids

Ra

ndom

ized

, dou

ble

blin

d,

ac

tive

cont

rol t

rial

Q

ualit

y sc

ores

:

Coc

hran

e =

11/1

2

IPM

-QRB

= 4

5/48

Lum

bar i

ntra

artic

ular

inje

ctio

ns

Car

ette

et a

l[103

] , 199

1Pa

tient

s w

ith c

hron

ic

low

bac

k pa

in w

ho

repo

rted

imm

edia

te

relie

f of t

heir

pai

n af

ter i

njec

tion

of lo

cal

anes

thet

ic in

to th

e fa

cet j

oint

s. S

ingl

e di

agno

stic

blo

cks

with

50%

relie

f wer

e ra

ndom

ly a

ssig

ned

to re

ceiv

e in

ject

ions

un

der fl

uoro

scop

ic

guid

ance

Intr

aart

icul

ar

inje

ctio

n of

is

oton

ic s

alin

e

Inje

ctio

n of

eith

er

sodi

um c

hlor

ide

or

met

hylp

redn

isol

one

into

the

face

t joi

nts

(49

for i

soto

nic

salin

e an

d 48

for s

odiu

m c

hlor

ide)

. O

nly

one

inje

ctio

n w

as

prov

ided

Vis

ual A

nalo

g Sc

ale,

McG

ill P

ain

Que

stio

nnai

re,

mea

n si

ckne

ss

impa

ct p

rofil

e

1, 3

and

6 m

oA

fter 1

mo,

42%

of

the

patie

nts

in th

e m

ethy

lpre

dnis

olon

e gr

oup

and

33%

in

the

sodi

um c

hlor

ide

grou

p re

port

ed m

arke

d or

ver

y m

arke

d im

prov

emen

t. A

t the

6

mo

eval

uatio

n, 4

6% in

th

e m

ethy

lpre

dnis

olon

e gr

oup

and

15%

in th

e pl

aceb

o gr

oup

show

ed

sust

aine

d re

lief.

Revi

sed

stat

istic

s sh

owed

22%

im

prov

emen

t in

activ

e gr

oup

and

10%

in

cont

rol g

roup

Wel

l-per

form

ed

rand

omiz

ed, d

oubl

e-bl

ind

cont

rolle

d tr

ial

Onl

y si

ngle

blo

ck

was

app

lied

and

patie

nts

wer

e tr

eate

d w

ith s

tero

ids

with

out l

ocal

an

esth

etic

with

onl

y on

e tr

eatm

ent a

nd

expe

cted

6 m

o of

re

lief

The

auth

ors

conc

lude

d th

at

resu

lts w

ere

nega

tive

in a

n ac

tive-

cont

rol

tria

l with

inje

ctio

n of

eith

er s

odiu

m

chlo

ride

sol

utio

n or

st

eroi

d in

to th

e fa

cet

join

ts a

fter d

iagn

osis

w

ith a

sin

gle

bloc

k

Ra

ndom

ized

, dou

ble

blin

d,

im

pure

pla

cebo

or a

ctiv

e-

cont

rol t

rial

Q

ualit

y sc

ores

:

Coc

hran

e =

11/1

2

IPM

-QRB

= 4

0/48

Fu

chs

et a

l[104

] , 200

560

pat

ient

s w

ith

chro

nic

low

bac

k pa

in w

ere

incl

uded

w

ith p

atie

nts

rand

omly

ass

igne

d in

to 2

gro

ups.

No

diag

nost

ic b

lock

s

Act

ive-

cont

rol

stud

y w

ith n

o co

ntro

l gro

up

Intr

aart

icul

ar in

ject

ion

of h

yalu

roni

c ac

id v

s gl

ucoc

ortic

oid

inje

ctio

n

VA

S, R

owla

nd-

Mor

ris

Que

stio

nnai

re,

OD

I, lo

w b

ack

outc

omes

sco

re,

shor

t for

m-3

6

3 an

d 6

mo

Patie

nts

repo

rted

la

stin

g pa

in re

lief,

bette

r fu

nctio

n, a

nd im

prov

ed

qual

ity o

f life

with

bot

h tr

eatm

ents

Rand

omiz

ed, a

ctiv

e-co

ntro

l, do

uble

-blin

d st

udy

Rela

tivel

y sm

all

sam

ple

of p

atie

nts

with

6 m

o fo

llow

-up

with

out a

pla

cebo

gr

oup,

with

out

diag

nost

ic b

lock

s

Und

eter

min

ed

(clin

ical

ly

inap

plic

able

) res

ults

w

ith h

igh

num

ber o

f in

ject

ions

dur

ing

a 6-

mo

peri

od

Ra

ndom

ized

, dou

ble-

blin

d,

ac

tive-

cont

rol t

rial

Q

ualit

y sc

ores

:

Coc

hran

e =

8/12

IP

M-Q

RB =

26/

48

Ri

beir

o et

al[1

07] , 2

013

60 p

atie

nts

with

a

diag

nosi

s of

face

t jo

int s

yndr

ome

rand

omiz

ed in

to

expe

rim

enta

l and

co

ntro

l gro

ups

Tria

mci

nolo

ne

acet

onid

e in

tram

uscu

lar

inje

ctio

n of

6

lum

bar

para

vert

ebra

l po

ints

Intr

aart

icul

ar in

ject

ion

of 6

lum

bar f

acet

join

ts

with

tria

mci

nolo

ne

hexa

ceto

nide

Pain

vis

ual

anal

ogue

sca

le,

pain

vis

ual

anal

ogue

sca

le

duri

ng e

xten

sion

of

the

spin

e,

Like

rt s

cale

, im

prov

emen

t pe

rcen

tage

sca

le,

Rola

nd-M

orri

s,

36-It

em S

hort

Fo

rm H

ealth

Su

rvey

, and

1, 4

, 12

and

24

wk

Both

gro

ups

show

ed

impr

ovem

ent w

ith n

o st

atis

tical

diff

eren

ce

betw

een

the

grou

ps.

Impr

ovem

ent

"per

cent

age"

ana

lysi

s at

eac

h tim

e po

int

show

ed s

igni

fican

t di

ffere

nces

bet

wee

n th

e gr

oups

at w

eek

7 an

d w

eek

12. I

mpr

ovem

ent

perc

enta

ge w

as >

50%

at

all t

imes

in th

e

Rand

omiz

ed, d

oubl

e-bl

ind

cont

rolle

d tr

ial

Dia

gnos

tic b

lock

s w

ere

not e

mpl

oyed

, th

us, m

any

patie

nts

with

out f

acet

join

t pa

in m

ay h

ave

been

in

clud

ed in

this

tria

l

Ove

rall

intr

aart

icul

ar

ster

oids

sho

wed

po

sitiv

e ef

fect

iven

ess

for 2

4 w

k co

mpa

red

to in

tram

uscu

lar

ster

oids

pro

vide

d in

a

doub

le-b

lind

man

ner

Ra

ndom

ized

, dou

ble-

blin

d,

ac

tive

cont

rol

Q

ualit

y sc

ores

:

Coc

hran

e =

10/1

2

IPM

-QRB

= 3

2/48


with

con

vent

iona

l rad

iofreq

uenc

y ne

urot

omy.

How

ever

, an

ana

lysis

of r

esul

ts s

how

s no

sig

nific

ant

diffe

renc

e in

out

com

es w

ith p

lace

men

t of

the

nee

dle,

eith

er p

aral

lel

or p

erpe

ndicul

ar.

In f

act,

Moo

n et

al[1

00] ,

in a

pro

spec

tive

rand

omized

com

para

tive

tria

l of

82 p

atie

nts,

sho

wed

impr

ovem

ent

to b

e eq

ual i

n bo

th g

roup

s. T

he s

elec

tion

crite

ria w

ere

dual

dia

gnos

tic b

lock

s w

ith 5

0% r

elie

f. D

obro

gow

ski e

t al

[98] c

ompa

red

45 c

onse

cutiv

e pa

tient

s in

a r

ando

miz

ed a

ctiv

eco

ntro

l tria

l stu

dyin

g th

e ro

le o

f m

ethy

lpre

dnisol

one

or p

ento

xify

lline

afte

r pe

rfor

min

g co

nven

tiona

l rad

iofreq

uenc

y ne

urot

omy.

The

res

ults

wer

e sim

ilar

in b

oth

grou

ps w

ithou

t an

y sign

ifica

nt in

fluen

ce

of m

ethy

lpre

dnisol

one.

The

stu

dy e

ssen

tially

look

ed a

t po

stop

erat

ive

pain

rel

ief

with

ste

roid

s af

ter

conv

entio

nal r

adio

frequ

ency

neu

roto

my.

Coh

en e

t al

[109

] ass

esse

d th

e ef

ficac

y of

rad

iofre

quen

cy n

euro

tom

y w

ith a

3 m

o fo

llow

-up

with

eith

er n

o di

agno

stic b

lock

s, s

ingl

e di

agno

stic b

lock

, or

dua

l dia

gnos

tic b

lock

s. T

he r

esul

ts w

ere

supe

rior

in p

atie

nts

sele

cted

afte

r du

al d

iagn

ostic

blo

cks,

with

64%

res

pond

ing;

whe

reas

in p

atie

nts

with

out a

diag

nost

ic b

lock

, the

res

pons

e ra

te w

as 3

3% a

nd in

the

gro

up w

ith a

sing

le d

iagn

ostic

blo

ck, t

he res

pons

e ra

te w

as 3

9%. C

ivel

ek e

t al[1

08] p

erfo

rmed

con

vent

iona

l rad

iofre

quen

cy n

euro

tom

y in

50

patie

nts

with

out fi

rst p

erfo

rmin

g an

y di

agno

stic

bloc

ks w

ith s

igni

fican

t im

prov

emen

t in

90%

of p

atie

nts

at th

e en

d of

one

yea

r. Nat

h et

al[1

05] , i

n a

rand

omized

dou

ble

blin

d sh

am c

ontr

ol tr

ial w

ith a

6 m

o fo

llow

up,

sho

wed

ef

fect

iven

ess

of c

onve

ntio

nal r

adio

frequ

ency

neu

roto

my

com

pare

d to

sha

m le

sion

ing

and

loca

l ane

sthe

tic in

ject

ion.

The

2 R

CTs

asse

ssin

g fa

cet

join

t ne

rve

bloc

ks s

how

ed

posit

ive

resu

lts in

69%

of t

he p

atie

nts

by C

ivel

ek e

t al[1

08] a

nd 9

0% o

f the

pat

ient

s by

Man

chik

anti

et a

l[102

] with

loca

l ane

sthe

tic a

lone

or w

ith lo

cal a

nest

hetic

and

ste

roid

s (8

5%

in th

e lo

cal a

nest

hetic

gro

up a

nd 9

0% in

the

loca

l ane

sthe

tic w

ith s

tero

ids

grou

p) a

t the

end

of a

2y

ear p

erio

d. H

owev

er, l

umbo

sacr

al in

traa

rticul

ar in

ject

ions

did

not

pro

duce


acco

unta

bilit

y of

m

edic

atio

ns ta

ken

expe

rim

enta

l gro

up w

ith

intr

aart

icul

ar s

tero

ids;

ho

wev

er, s

igni

fican

t di

ffere

nce

was

not

ed a

t 24

wk

La

kem

eier

et a

l[101

] , 201

356

pat

ient

s w

ere

rand

omiz

ed in

to 2

gr

oups

rece

ivin

g in

traa

rtic

ular

st

eroi

d in

ject

ions

or

radi

ofre

quen

cy

dene

rvat

ion

afte

r the

di

agno

sis

was

mad

e w

ith in

traa

rtic

ular

in

ject

ion

of lo

cal

anes

thet

ic w

ith a

si

ngle

blo

ck

Intr

aart

icul

ar

inje

ctio

n of

loca

l an

esth

etic

and

st

eroi

d in

29

patie

nts

Radi

ofre

quen

cy

neur

otom

y fo

r 90

s at

80

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convincing positive results, with some benefit on a short-term basis in 3 cases[101,106,107] and 2 trials[103,104] showing no response.

Even now, there remains significant controversy regarding the diagnostic accuracy and therapeutic efficacy of facet procedures, particularly in reference to interventional techniques, including escalating utilization patterns and costs[6,10,13,14,68,127]. In fact, in the United States, the Office of Inspector General of the Department of Health and Human Services conducted an assessment of the appropriateness of facet joint injections, concluding that many of the procedures were inappropriate, without medical necessity and indications[117]. Further, in the current regulatory atmosphere, many local coverage determinations may paradoxically increase the utilization of facet joint interventions[68]. The present data show that facet joint interventions have increased 293% per 100000 feeforservice (FFS) Medicare population from 2000 to 2013, with an increase of 213% for lumbar facet joint interventions and a 522% for lumbosacral facet neurolysis. Likewise, there has been an increase in cervical and thoracic facet joint nerve blocks of 350%, and an increase in facet neurolysis of 845% from 2000 to 2013 in the FFS population[6,13,14,68]. However, the lumbar procedure increases appear to be smaller than cervical and thoracic facet joint interventions, even though the absolute procedure numbers are much higher for lumbar facet joint interventions. These data reflect only FFS Medicare patients in the United States, thus increases could be even higher.

There has been substantial discussion about various treatment strategies, control design of trials, placebo and nocebo effects, outcomes assessment between 2 active treatments rather than baseline to followup period, and everchanging methodological quality assessment[10,15,50,51,55,128,129]. For interventional techniques, complex mechanisms and variations in placebo and nocebo responses have been well described[123126,128133]. Thus far, appropriately designed placebo studies, i.e., injecting inactive solutions into inactive structures, have shown substantially accurate results without significant placebo effect[134,135]. Further, it is crucial to note that most investigators are missing the role of the nocebo effect[123126]. Thus, clinical trials must be designed appropriately with clinical relevance to avoid erroneous conclusions. Further, many studies have used subacute or acute patients without standard conservative management.

The results of this systematic review are similar to the results of numerous other systematic reviews[10,28,51,54,55,6973]; however, they do not agree with the systematic reviews of others[15,50]. Systematic reviews that showed a lack of effectiveness were often based on flawed methodology, also utilized in RCTs[136144]. Our results are similar to those of Falco et al[28,54] even though we used stricter criteria for the methodological quality assessment. In addition, in a systematic review of the comparative effectiveness of different solutions, including local anesthetics and steroids, Manchikanti et

al[136] showed equal efficacy of local anesthetic compared to steroids in longterm followup of lumbar facet joint nerve blocks; lumbar intraarticular facet injections were not found to be effective.

This evaluation included only RCTs for efficacy asse-ssment, thus it can be argued that we missed many high quality observational studies[71,144]. However, with adequate randomized trials available for radiofrequency neurotomy and intraarticular injections, inclusion of observational studies would not alter the findings.

The current study illustrates the diagnostic value and validity of nerve blocks and the therapeutic effectiveness of facet joint interventions, specifically radiofrequency neurotomy and facet joint nerve blocks for managing lumbar spine pain. Sixteen diagnostic accuracy studies and 14 RCTs of therapeutic interventions demonstrated level Ⅰ evidence for using lumbar facet joint nerve blocks as a diagnostic tool for chronic low back pain, level Ⅱ evidence for the therapeutic benefit of radiofrequency neurotomy and facet joint nerve blocks for longterm improvement (longer than 6 mo), and level Ⅲ evidence with lumbosacral intraarticular injections for shortterm improvement. Despite the debate regarding appropriate use of therapeutic modalities in managing lumbar facet joint pain, the accuracy of diagnostic facet joint nerve blocks and the efficacy of therapeutic facet joint interventions are supported by highquality evidence for appropriately selected patients after failure of conservative treatment.

ACKNOWLEDGMENTS Drs. Manchikanti, Hirsch, Falco, and Boswell contributed to this work. Drs. Manchikanti and Boswell designed the research; Drs. Manchikanti and Falco performed the research; Drs. Manchikanti and Hirsch contributed new reagents/analytic tools; Drs. Manchikanti and Hirsch analyzed the data; Drs. Manchikanti and Hirsch wrote the paper. All authors reviewed all contents and approved for submission.

COMMENTSBackgroundIn this systematic review, the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain were performed. Facet joint interventions are one of the multitude of modalities in managing chronic low back pain without disc herniation. There is a paucity of literature of not only systematic reviews, but also randomized controlled trials (RCTs) describing the efficacy of various modalities utilized and also diagnostic validity with controlled diagnostic blockade.

Research frontiersThere is a paucity of literature in assessing the diagnostic capability of various non-interventional and interventional modalities including radiologic investigations. Due to a lack of validity of various types of investigations, controlled diagnostic blocks have been considered as a reliable method in arriving at the diagnosis of facet joint pain. Similarly, there is also a paucity of literature in reference to therapeutic efficacy of various types of facet joint interventions utilized in managing chronic low back pain including intraarticular injections, facet joint nerve blocks, and radiofrequency neurotomy. By the same


COMMENTS


token, there is also a paucity of systematic reviews assessing the value and validity of diagnostic and therapeutic facet joint interventions in the lumbar spine.

Innovations and breakthroughsThe previous systematic reviews have limited their assessment to either diagnostic or therapeutic validity and value. Further, assessment has been carried utilizing variable methodologic quality assessments. In this systematic review, the authors have utilized the most recent methodologic quality assessment instruments to assess not only bias, but also the methodologic quality of the studies included. Further, this systematic review includes all the up-to-date RCTs which were not included in previous systematic reviews.

ApplicationsThe results of this systematic review are clinically oriented and applicable in daily practices. However, facet joint interventions must be performed only after the failure of all conservative modalities of treatments.

TerminologyFacet joint pain is described variously across the globe as facet joint pain, facet joint syndrome, and zygapophysial joint pain. Similarly, the structures are also described as either facet joints or zygapophysial joints. The innervation is described as medial branches from lumbar 1 (L1) through L4, whereas L5 innervation is described as the dorsal ramus.

Peer-reviewThis article is concerning management of lumbar zygapophysial (facet) joint pain. This thesis is an excellent review.

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P- Reviewer: Chen C, Guerado E, Korovessis P, Tokuhashi Y S- Editor: Ji FF L- Editor: A E- Editor: Liu SQ



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