Management of lumbar zygapophysial (facet) joint pain

Table 5 Characteristics of studies assessing the accuracy of diagnostic facet joint injections and nerve blocks in the lumbar spine

Study/methods	Participants	Intervention(s)	Outcome measures	Comments	Results
Methodological quality scoring					Prevalence with 95%CI and criterion standard	False-positive rate with 95%CI
Pang et al[25], 1998	100 consecutive adult patients with chronic low back pain with undetermined etiology were evaluated with spinal mapping	Single block was performed by injecting 2% lidocaine into facet joints	Verbal analog scale	This is the first study evaluating application of diagnostic blocks in the diagnosis of intractable low back pain of undetermined etiology with facet joint disease in potentially 48% of patients with a single block	Single block 90% pain relief	NA
Prospective, single block			Pain mapping		Only facet joint pain = 24%
8/12			90% pain relief		Lumbar nerve root and facet disease = 24%
					Total = 48%
Schwarzer et al[22], 1994	176 consecutive patients with chronic low back pain after some type of injury	Zygapophysial joint nerve blocks or intraarticular injections were performed with either 2% lignocaine or 0.5% bupivacaine	At least 50% pain relief concordant with the duration of local anesthetic injected	First study of evaluation of controlled prevalence and false-positive rates	50% pain relief	38% (95%CI: 30%-46%)
Prospective, controlled diagnostic blocks					15% (95%CI: 10%-20%)
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Schwarzer et al[84], 1995	63 patients with low back pain lasting for longer than 3 mo underwent computed tomography and blocks of the zygapophysial joints	Patients underwent a placebo injection followed by intraarticular zygapophysial joint injections with 1.5 mL of 0.5% bupivacaine	At least 50% reduction in pain maintained for minimum of 3 h	This study shows that computed tomography has no place in the diagnosis of lumbar zygapophysial joint pain, with an impure placebo design	50% pain relief	NA
Randomized, impure placebo, controlled diagnostic blocks					40% (95%CI: 27%-53%)
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Manchikanti [95], 2010	491 patients with chronic low back pain undergoing evaluation for facet joint pain with 80% pain relief and 181 patients with 50% pain relief	Controlled diagnostic blocks of lumbar facet joint nerves with 1% preservative-free lidocaine and 0.25% preservative-free bupivacaine 1 mL	At least 80% pain relief with the ability to perform previously painful movements	Higher prevalence than with 50% pain relief, but still higher than double block algorithmic approach	50% pain relief	50% pain relief
Retrospective, controlled diagnostic blocks					61% (95%CI: 53%-81%)	17% (95%CI: 10%-24%)
9/12					80% pain relief	80% pain relief
					31% (95%CI: 26%-35%)	42% (95%CI: 35%-50%)
Manchikanti et al[85], 2000	200 consecutive patients with chronic low back pain were evaluated	Controlled diagnostic blocks with 1% lidocaine and 0.25% bupivacaine were injected over facet joint nerves with 0.4 to 0.6 mL	75% pain relief with ability to perform previously painful movements	The study showed that the clinical picture failed to diagnose facet joint pain	75% pain relief	37% (95%CI: 32%-42%)
Prospective, controlled diagnostic blocks					42% (95%CI: 35%-42%)
9/12
DePalma et al[24], 2011	A total of 156 patients with chronic low back pain were assessed for the source of chronic low back pain including discogenic pain, facet joint pain, and sacroiliac joint pain	Dual controlled diagnostic blocks with 1% lidocaine for the first block with 0.5% bupivacaine for the second	Concordant relief with 2 h for lidocaine and 8 h for bupivacaine with 75% pain relief as the criterion standard	This is the third study evaluating various structures implicated in the cause of low back pain with controlled diagnostic blocks[23,25]	75% pain relief	NA
Retrospective, controlled diagnostic blocks					31% (24%-38%)
9/12
Manchikanti et al[93], 2001	Prevalence study in 100 patients with 50 patients below age of 65 and 50 patients aged 65 or over was assessed	Controlled diagnostic blocks	75% pain relief with ability to perform previously painful movements was utilized as the criterion standard	This study showed higher prevalence of facet joint pain in the elderly compared to the younger age group in contrast to the latest study by Manchikanti et al[117] which showed no differences	75% pain relief	< 65 yr = 26% (95%CI: 11%-40%)
Prospective, controlled diagnostic blocks					< 65 yr = 30% (95%CI: 17%-43%)	> 65 yr = 33% (95%CI: 14%-35%)
					> 65 yr = 52% (95%CI: 38%-66%)
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Manchikanti et al[94], 2001	100 patients with low back pain were evaluated. Patients were divided into 2 groups, group I was normal weight and group II was obese	Facet joints were investigated with diagnostic blocks using lidocaine 1% initially followed by bupivacaine 0.25%, at least 2 wk apart	A definite response was defined as relief of at least 75% in the symptomatic area	This study showed no significant difference between obese and non-obese individuals either with prevalence or false-positive rate of diagnostic blocks in chronic facet joint pain	75% pain relief	Non-obese individuals = 44% (95%CI: 26%-61%)
Prospective, controlled diagnostic blocks
9/12					Prevalence:	Obese individuals = 33% (95%CI: 16%-51%)
					Non-obese individuals = 36% (95%CI: 22%-50%)
					Obese individuals = 40% (95%CI: 26%-54%)
Manchikanti et al[23], 2001	120 patients were evaluated with chief complaint of chronic low back pain to evaluate relative contributions of various structures in chronic low back pain. All 120 patients underwent facet joint nerve blocks	Controlled diagnostic blocks with 1% lidocaine followed by 0.25% bupivacaine	80% pain relief with ability to perform previously painful movements	This study evaluated all the patients with low back pain, even with suspected discogenic pain	80% pain relief	47% (95%CI: 35%-59%)
Prospective, controlled diagnostic blocks					40% (95%CI: 31%-49%)
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Manchikanti et al[86], 1999	120 patients with chronic low back pain after failure of conservative management were evaluated	Controlled diagnostic blocks with 1% lidocaine followed by 0.25% bupivacaine	Concordant pain relief with 75% or greater criterion standard with ability to perform previously painful movements	This was the first study performed in the United States in the heterogenous population as previous studies were performed in only post-injury patients	75% pain relief	41% (95%CI: 29%-53%)
Prospective, controlled diagnostic blocks					45% (95%CI: 36%-54%)
9/12
Manchikanti et al[79], 2014	180 consecutive patients with chronic low back pain were evaluated after having failed conservative management	Controlled diagnostic blocks with 1% lidocaine and 0.25% bupivacaine with or without Sarapin and/or steroids	75% pain relief with ability to perform previously painful movements	This study showed no significant difference if the steroids were used or not	75% pain relief	25% (95%CI: 21%-39%)
Prospective, controlled diagnostic blocks					36% (95%CI: 29%-43%)
9/12
Manchikanti et al[88], 2003	At total of 300 patients with chronic low back pain were evaluated to assess the difference based on involvement of single or multiple spinal regions	Controlled diagnostic blocks with 1% lidocaine followed by 0.25% bupivacaine	80% pain relief with ability to perform previously painful movements	This study shows a higher prevalence when multiple regions are involved	80% pain relief	Single region:
Prospective, controlled diagnostic blocks					Single region:	17% (95%CI: 10%-24%)
					21% (95%CI: 14%-27%)	Multiple regions:
9/12					Multiple regions:	27% (95%CI: 18%-36%)
					41% (95%CI: 33%-49%)
Manchikanti et al[82], 2014	120 consecutive patients with chronic low back pain and neck pain were evaluated to assess involvement of facet joints as causative factors	Controlled diagnostic blocks with 1% lidocaine followed by 0.25% bupivacaine	80% pain relief with ability to perform previously painful movements	The results are similar to involvement of multiple regions with a prevalence of 40% as illustrated in another study	80% pain relief	30% (95%CI: 20%-40%)
Prospective, controlled diagnostic blocks					40% (95%CI: 31%-49%)
9/12
Manchikanti et al[90], 2004	500 consecutive patients with chronic, non-specific spinal pain were evaluated of which 397 patients suffered with chronic low back pain	Controlled diagnostic blocks with 1% lidocaine followed by 0.25% bupivacaine	80% pain relief with ability to perform previously painful movements	Largest study performed involving all regions of the spine	80% pain relief	27% (95%CI: 22%-32%)
Prospective, controlled diagnostic blocks					31% (95%CI: 27%-36%)
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Manchukonda et al[91], 2007	500 consecutive patients with chronic spinal pain were evaluated of which 303 patients were evaluated for chronic low back pain	Controlled diagnostic blocks with 1% lidocaine followed by 0.25% bupivacaine	80% pain relief with ability to perform previously painful movements	Second largest study performed involving all regions of the spine	80% pain relief	45% (95%CI: 36%-53%)
Retrospective, controlled diagnostic blocks					27% (95%CI: 22%-33%)
9/12
Manchikanti et al[92], 2007	A total of 117 consecutive patients with chronic non-specific low back pain were evaluated, after lumbar surgical interventions, with postsurgery syndrome and continued axial low back pain	Controlled, comparative, local anesthetic blocks with 1% lidocaine and 0.25% bupivacaine	80% relief as the criterion standard with ability to perform previously painful movements	Lower prevalence in postsurgery patients	80% pain relief	49% (95%CI: 39%-59%)
Prospective, controlled diagnostic blocks					16% (95%CI: 9%-23%)
9/12

NA: Not applicable.