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Biomechanical studies have shown that lumbar and patient care and outcomes through systematic review of
cervical facet joint capsules can undergo high strains care against explicit criteria and the implementation
during spine-loading.41 Neuroanatomic studies have of the change.54 A recently published clinical audit of
demonstrated free and encapsulated nerve endings in results of radiofrequency neurotomy for chronic neck
facet joints, and also nerves containing substance P and pain provided evidence of ecacy and generalizability of
calcitonin gene-related peptide.41 Neurophysiologic the procedure in routine clinical practice.53
studies have shown that facet joint capsules contain In this study, we sought to evaluate the prevalence
low-threshold mechanoreceptors, mechanically sensitive of facet joint pain by spinal region in patients with
nociceptors, and silent nociceptors.41 chronic spinal pain presenting to an interventional pain
On the basis of controlled diagnostic blocks of facet management practice for diagnosis and treatment. We
joints, in accordance with the criteria established by the used the same protocol21 as was previously published to
International Association for the Study of Pain,42 facet determine the presence of facet joint pain using responses
joints have been implicated as responsible for spinal pain to controlled comparative local anesthetic facet joint
in 15% to 45% of the patients with chronic low back nerve blocks, performed in accordance with International
pain,21,25,4346 42% to 48% of patients with chronic Association for the Study of Pain criteria.42
thoracic pain,21,47 and 54% to 67% of patients with
chronic neck pain.21,4850
Multiple authors25,4350 in the past have studied MATERIALS AND METHODS
individual regions and presented the results in various In this retrospective evaluation, 500 consecutive
types of practices. Manchikanti et al21 evaluated 500 patients receiving controlled comparative local anesthetic
patients in an interventional pain management practice blocks were included. The patients presented with chronic
setting with comparative local anesthetic blocks in a neck, thoracic, or low back pain or a combination
prospective study and reported the prevalence of facet thereof. Patients were managed by one physician in a
joint pain in patients with chronic cervical spine pain as nonuniversity, private practice setting in the United
55%, chronic thoracic spine pain as 42%, and lumbar States. The procedures were performed in an interven-
spine as 31%. They also reported false-positive rates with tional pain management ambulatory surgery center. The
single blocks with lidocaine of 63% in the cervical spine, practice provides comprehensive, interventional pain
55% in the thoracic spine, and 27% in the lumbar spine. management services.
Systematic reviews51,52 also have established the preva- The chart review was performed by 3 investigators
lence, false-positive rates, and the value and validity of who were not involved in performing the procedures.
diagnostic facet or zygapophysial joint blocks. Even then, Inclusion criteria at the institution included: con-
all these studies were performed by 2 investigators of secutive patients undergoing controlled comparative local
heterogenous settings and populations. anesthetic blocks, of ages 18 to 90 years, who had pain for
Generalizability is a measure of the extent to which at least 6 months, which was nonspecic rather than
others can achieve the same outcomes as those of original radicular in nature. The treating physician excluded disc-
authors. Consequently, it is an important feature of any related pain with radicular symptoms in all patients based
intervention, either therapeutic or diagnostic. In practical on radiologic or neurologic testing, lack of a neurologic
terms, generalizability may be reected by the extent to decit, and radicular symptoms or pain that involved
which practitioners in a conventional practice can predominantly the upper or lower extremity or chest wall.
reproduce results obtained in academic research studies, All patients selected had failed conservative management
or reproduce the results in a large population base.53 including physical therapy, chiropractic manipulation,
Generalizability is also achieved by multiple prospective exercises, drug therapy, and bedrest.
or randomized trials. Consequently, in the case of Each of the patients had a work-up, which included
prevalence of spinal facet joint pain, all the prospective comprehensive history, physical examination, and evalua-
studies have been produced by only the 2 groups. Thus, tion of the results of prior procedures and investigations.
further trials by dierent groups are required. However, Of the 500 patients who had undergone controlled
another approach is to conduct a retrospective review in a comparative local anesthetic blocks, 438 patients were
substantial series of patients. Such an evaluation would eligible to be included in the retrospective review. The
demonstrate whether the same or similar outcomes can be study period lasted from January 2004 to March 2006.
achieved in practical settings as have been reported in Facet joint pain was investigated in all patients
research studies. starting with diagnostic blocks using 1% lidocaine.
Yet another method of conrming the results of a Patients with lidocaine-positive results were further
previous study and solving the problem of reproducibility studied using 0.25% bupivacaine on a separate occasion,
is to conduct a clinical audit on the basis of available data usually 3 to 4 weeks after the rst injection. The blocks
to ensure this knowledge is being used to the best eect. were performed on the ipsilateral side in patients with
Outcomes for a large series of patients, formerly unilateral pain or bilaterally in patients with bilateral or
initiated in 1993 at the United Kingdoms National axial pain. Blocks were performed at a minimum of 2
Health Service (NHS), clinical audit was dened as, a levels to block a single joint. Target joints were identied
quality improvement process that seeks to improve by the pain pattern, local or paramedian tenderness over
the area of the facet joints, and reproduction of pain with additional variable in the demographic characteristics was
deep pressure. Blocks were performed with intermittent height, which was greater in patients with involvement of
uoroscopic visualization using a 22-gauge, 2-inch spinal 1 region compared with 2 regions or 2 to 3 regions.
needle at each of the indicated medial branches in the Salient features based on regional involvement of
cervical and thoracic spine, and with a 22-gauge, 3.5-inch the spine are illustrated in Table 2. There were no
spinal needle at each of the indicated medial branches at signicant dierences noted in any of the variables.
the L1-L4 levels and the L5 dorsal ramus at the L5 level
of the lumbar spine. Results of Comparative Local Anesthetic Blocks
Intravenous access was established and light seda- Table 3 illustrates the results of diagnostic blocks
tion with midazolam was oered to all patients. Each evaluating facet joint pain in all 3 regions. In the cervical
facet nerve was inltrated with 0.5 mL of 1% lidocaine or spine, lidocaine blocks were performed in 251 patients, in
0.25% bupivacaine. Following each block, the patient 65 patients in the thoracic spine, and 303 patients in the
was examined and asked to perform previously painful lumbar spine. Of these, 175 of 251 patients in the cervical
movements. A positive response was dened as at least an spine reported a denite response with a positive result to
80% reduction of pain with ability to perform previously initial lidocaine blocks, whereas 38 of the 65 patients in
painful movements, as assessed using a verbal numeric the thoracic spine reported a positive result, and 150 of
pain rating scale. To be considered positive, pain relief 303 patients with lumbar spinal pain reported positive
from a block had to last at least 2 hours when lidocaine results with a single lidocaine block.
was used, and at least 3 hours, or longer than the duration Of the 175 patients positive for single blocks with
of relief with lidocaine, when bupivacaine was used. Any lidocaine, 97 patients reported positive response to
other response was considered as a negative outcome. bupivacaine blocks in the cervical spine, whereas 22 of
All patients judged to have a positive response with 38 patients in the thoracic spine positive for single
lidocaine blocks underwent subsequent bupivacaine lidocaine blocks were also positive with bupivacaine
blocks. Patients who were determined not to have facet blocks. Eighty-three patients in the lumbar spine showed
joint pain were oered other diagnostic or therapeutic positive results with bupivacaine from 150 of the
interventions, including discography, epidural injections, lidocaine positive patients.
or sacroiliac joint injections. The controlled comparative local anesthetic blocks
Data were recorded on a Microsoft Access 97 with positive results using double local anesthetic blocks
database. The SPSS version 9.0 Statistical Package was provided a prevalence rate of facet joint pain in patients
used to generate frequency tables. The prevalence and with chronic neck pain of 39% (95% CI, 32%-45%); 34%
95% condence intervals (CI) were calculated. Dier- (95% CI, 22%-47%) in patients with chronic thoracic
ences in proportions were tested using the w2 test. Fischer pain; and 27% (95% CI, 22%-33%) in patients with
exact test was used whenever the expected value was less chronic low back pain.
than 5. Results were considered statistically signicant if Table 3 also illustrates false-positive rates. False-
the P value was <0.05. positive rates were calculated by assuming all patients
with no response to lidocaine to be true negative, and all
RESULTS patients with a positive response to lidocaine and a
Five hundred consecutive patients undergoing con- negative response to bupivacaine or positive response to
trolled comparative local anesthetic blocks for the both lidocaine and bupivacaine as false-positives. The
evaluation of facet joint pain were reviewed. Of these, false-positive rates for cervical facet joints with a single
438 patients met the inclusion criteria. Sixty-two patients block were 45% (95% CI, 37%-52%), for thoracic facet
were excluded from the review. Patient ow is illustrated joints with a single lidocaine block were 42% (95% CI,
in Figure 1. 26%-59%), and for lumbar spine 45% (95% CI,
36%-53%).
Patient Evaluation Flow Pattern
All the patients were included in the analysis. As
Characteristics of Regional Involvement
shown in Figure 1, follow-up was not available after the Table 4 illustrates facet joint involvement by region
rst block in 4 patients in lumbar, 8 patients in cervical, on the basis of controlled comparative local anesthetic
and 3 patients in thoracic regions, whereas follow-ups blocks. Overall, at least one region was judged to be
were not available after the second block in 10 patients in positive in 156 patients or 36% of the 438 patients.
lumbar, 12 patients in cervical, and 2 patients in thoracic However, in 25% of the 181 patients were positive among
groups. The results were considered negative or false- patients with involvement of 2 and 3 regions.
positive for all the patients with lack of follow-up. Adverse Effects
Demographic Characteristics No major adverse eects were noted in this study.
Demographic characteristics are illustrated in Table 1.
Signicant dierences were identied in patients with DISCUSSION
involvement of 1 region and 2 regions with a greater This retrospective evaluation of patients with
proportion of female patients compared with male. An chronic nonspecic spinal pain involving the cervical,
Involvement of
Involvement of Involvement of
three regions = 15
one region = 272 two regions = 151
Thoracic pain = 65
Lumbar pain = 303
Cervical pain = 251
TABLE 3. Results of Single and Double Facet Joint Nerve Blocks (Single Blocks With Lidocaine and Double Blocks With Lidocaine
and Bupivacaine)
Cervical (251) Thoracic (65) Lumbar (303)
Double Blocks* Double Blocks* Double Blocks*
Single Blocksw Positive Negative Positive Negative Positive Negative
Positive 97 78 22 16 83 67
Negative 76 27 153
Prevalence 39% (95% CI, 32%-45%) 34% (95% CI, 22%-47%) 27% (95% CI, 22%-33%)
False-positive rate 45% (95% CI, 37%-52%) 42% (95% CI, 26%-59%) 45% (95% CI, 36%-53%)
*With double blocks, 97 patients with neck pain, 22 with thoracic pain, and 83 with lumbar pain had positive responses.
wWith single blocks in the cervical spine, 175 patients (ie, 97+78) had positive responses with lidocaine blocks, 38 (22+16) patients with thoracic pain had positive
responses, and 150 (83+67) patients with lumbar pain had positive responses.
12. Croft PR, Lewis M, Papageorgiou AC, et al. Risk factors for neck pain:
TABLE 4. Facet Joint Involvement by Region on the Basis a longitudinal study in the general population. Pain. 2001;93:317325.
of Double Facet Joint Blocks 13. Cote P, Cassidy JD, Carroll LJ, et al. The annual incidence and
Double Blocks Number % of Positive course of neck pain in the general population: a population-based
cohort study. Pain. 2004;112:267273.
At least 1 region positive 438 36% (156) 14. Enthoven P, Skargren E, Oberg B. Clinical course in patients
At least 2 regions positive 166 26% (43) seeking primary care for back or neck pain: a prospective 5-year
All 3 regions positive 15 20% (3) follow-up of outcome and health care consumption with subgroup
analysis. Spine. 2004;29:24582465.
15. Elders LA, Burdorf A. Prevalence, incidence, and recurrence of low
back pain in scaolders during a 3-year follow-up study. Spine.
CONCLUSIONS 2004;29:E101E106.
This evaluation showed that patients with chronic, 16. Croft PR, Papageorgiou AC, Thomas E, et al. Short-term physical
risk factors for new episodes of low back pain. Prospective evidence
nonspecic spinal pain involving cervical, thoracic, from the South Manchester Back Pain Study. Spine. 1999;24:
and lumbar spine may be evaluated for the prevalence 15561561.
of facet joint pain. However, this should be performed 17. Miedema HS, Chorus AMJ, Wevers CWJ, et al. Chronicity of back
with controlled, comparative local anesthetic blocks problems during working life. Spine. 1998;23:20212028.
owing to the signicant rate of false-positive response. 18. Thomas E, Silman AJ, Croft PR, et al. Predicting who develops
chronic low back pain in primary care. A prospective study. Brit
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patients in the cervical spine, 34% of the patients in the 19. Yeung SS, Genaidy A, Deddens J, et al. Prevalence of musculoske-
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20. Manchikanti L, Pampati V. Research designs in interventional pain
ACKNOWLEDGMENTS management: is randomization superior, desirable or essential? Pain
The authors thank Tonie Hatton and Diane Neiho, Physician. 2002;5:275284.
21. Manchikanti L, Boswell MV, Singh V, et al. Prevalence of facet joint
transcriptionists; Kim S. Damron, RN and Carla D. pain in chronic spinal pain of cervical, thoracic, and lumbar regions.
McManus, RN, BSN, clinical coordinators; and Doris E. BMC Musculoskelet Disord. 2004;5:15.
Brandon, CST; for their assistance in preparation of this 22. Jacob T, Zeev A. Are localized low back pain and generalized back
manuscript. pain similar entities? Results of a longitudinal community based
study. Disabil Rehabil. 2006;28:369377.
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