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%) | |||||
| 9/12 | ||||||
| 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%) | |||||
| 9/12 | ||||||
| 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%) | ||||||
| 9/12 | ||||||
| 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%) | |||||
| 9/12 | ||||||
| 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%) | |||||
| 9/12 | ||||||
| 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.