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INVITED REVIEW ARTICLE

Medial Branch Blocks of the Cervical and Lumbar Spine
Stephan Klessinger, MD

Summary: Medial branch blocks are used to test if the pain stems from a zygapophysial joint because the medial branch innervates the joint. If the pain is not relieved after a medial branch block, the target nerve cannot be regarded as mediating the pain; this means the zygapophysial joint is not the pain source. If the answer is positive, the pain source is identified and a good chance of obtaining pain relief after radiofrequency neurotomy is predicted. The fundamental indication for medial branch blocks is the desire to know if the zygapophysial joints are the pain source. No clinical test exists to identify a zygapophysial joint as pain source. Because the singular reason for performing diagnostic medial branch blocks is to obtain information, the evaluation of the patient’s response is essential. A strong accuracy of facet joint nerve blocks in the diagnosis of lumbar and cervical facet joint pain can be achieved. Diagnostic lumbar facet joint nerve blocks are recommended in patients with suspected facet joint pain. Conflicting results of different treatment modalities are discussed: the degree of relief that should occur after medial branch blocks remains contentious. Medial branch blocks are a diagnostic tool. However, there are studies giving a strong recommendation for the use of therapeutic cervical and lumbar facet joint nerve blocks for the treatment of chronic facet joint pain. The evidence for intra-articular injections seems to be poor. Computed tomography (CT) guidance is not supported by guidelines. Key Words: medial branch blocks—zygapophysial pain—facet joint pain—facet joint nerve blocks—pain therapy. (Tech Orthop 2013;28: 18–22)

the article “Denervation of the zygapophysial joints of the cervical and lumbar spine” in this issue.

INDICATION
The fundamental indication for medial branch blocks is the desire to know if the zygapophysial joints are the pain source. Of course the response must affect the management. The only validated treatment for pain mediated by the medial branches is radiofrequency neurotomy.1,2 For patient selection first serious diseases like tumors, infection, or metabolic diseases must be excluded. Usually patients present with chronic back pain of unknown origin in which a zygapophysial pain seems likely. No clinical test exists to identify a zygapophysial joint as pain source.4,5 X-rays may or may not show sclerosis of the joint, also, often in magnetic resonance imaging degenerative changes can be found without any relevance. Target joints might be identified by the pain pattern, local tenderness over the area and provocation of pain with deep pressure. In the cervical spine pain maps of the zygapophysial joints can be very helpful for identifying the level to treat.6–9

Contraindications
Absolute contraindications for medial branch blocks exist in patients unwilling or unable to consent to procedure, patients with systemic infection, bleeding, diasthesis, or anticoagulants with high risk of bleeding and pregnancy. Relative contraindications are an allergy to contrast medium or local anesthetics.1,2

PRINCIPLES
Medial branch blocks are a diagnostic tool designed to test if a patient’s pain is mediated by one or more of the medial branches of the dorsal rami. The target nerve is anesthetized with a small volume of local anesthetic. By convention,1–3 medial branch blocks are used to test if the pain stems from a zygapophysial joint because the medial branch innervates the joint. For this reason medial branch blocks are also referred to as zygapophysial joint blocks or facet joint blocks. If the pain is not relieved after a medial branch block, the target nerve cannot be regarded as mediating the pain, this means the zygapophysial joint is not the pain source. A new hypothesis about the source of pain is required. If the answer is positive, the pain source is identified and a good chance of obtaining pain relief after radiofrequency neurotomy is predicted.1,2

TECHNIQUE
The detailed description of the implementation of medial branch blocks will follow the guidelines of the International Spine Intervention Society.1,2

Lumbar
Lumbar medial branch blocks are performed as an outpatient procedure. A procedure room suitable for aseptic procedures is needed. It is advisable that the procedure be performed in a room equipped with proper resuscitation facilities to deal with possible allergic reactions. Fluoroscopy is mandatory. The patient is placed prone on a radiolucent fluoroscopy table. The width of the operating table should ensure a free rotation of the C-arm. The patients back is prepared and draped in a sterile fashion. All personal must wear appropriate lead aprons and should be supplied with a personalized dosimeter. There should be at least 1 assistant available in the room for documentation, operating the C-arm, and looking after the patient. Generally, no sedation, systemic analgesia, or premedication is required. For the L1-L4 medial branches the target point is the junction of the superior articular process and the transverse process. The medial branch crosses midway between the superior border of the transverse process and the location of the
Techniques in Orthopaedics$ 

ANATOMY
For a medial branch block, exact anatomic knowledge is essential. The anatomy of the medial branches is described in
From the Nova Clinic, Department of Neurosurgery, Biberach, Germany. The author declares that he has nothing to disclose. Address correspondence and reprint requests to Stephan Klessinger, MD, Nova Clinic, Department of Neurosurgery, Eichendorffweg 5, 88400 Biberach, Germany. E-mail: klessinger@nova-clinic.de. Copyright r 2013 by Lippincott Williams & Wilkins ISSN: 0148-703/13/2801-0018

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Volume 28, Number 1, 2013

10 Multiple studies and systematic reviews have evaluated the reliability of diagnostic facet joint nerve blocks. There c 2013 Lippincott Williams & Wilkins 19 . The patient is discharged in the care of a responsible person.techortho. The target point for C7 medial branch block lies high on the apex of the superior articular process. Informed consent is obtained. the evaluation of the patient’s response is essential.10–13 In order to reduce the likelihood of responses being false positive. no sedation. Number 1. 2). The patient’s neck is prepared and draped in a sterile fashion. At the L5 level the target nerve is the dorsal ramus. for example a registered nurse. EVALUATION FIGURE 1. because they carry an unacceptable high false-positive rate. If there is no venous uptake.3 mL) of contrast medium can be injected. only a proportion of the pain will be relieved.com | Cervical Cervical medial branch blocks are performed as an outpatient procedure. Patients should have a driver with them after the procedure. 3 target points are used lying on a vertical line between the apex of the C3 superior articular process and the bottom of the C2-3 intervertebral foramen. False-positive rates of 17% to 49% were demonstrated. If more than one pain source is known.1 to 0. Examples of evaluation sheets can be found in the Practice Guidelines of the International Spine Intervention Society. 0. or premedication is required. 1). The use of contrast medium has not become a standard component for cervical medial branch blocks. For example the L5-S1 joint is innervated by the medial branch of the L4 dorsal ramus and the dorsal ramus L5. controlled blocks are mandatory. 2013 Medial Branch Blocks should be at least 1 assistant available in the room for documentation. patients should be reminded that they may experience unsteadiness. and looking after the patient. Fluoroscopy is mandatory. The needle is placed straight along the x-ray beam to the target point. and some time afterwards by an independent observer.Techniques in Orthopaedics$  Volume 28. The needle is placed straight along the x-ray beam in an oblique view to the target point. All personal must wear appropriate lead aprons and should be supplied with a personalized dosimeter. The www.1. A positive response to a block is complete relief of that part of the pain that the blocks are expected to relief for duration commensurate with the expected duration of action of the local anesthetic. The bevel should be directed caudally and a small amount (0. The patient is placed in lateral position with the target side uppermost on a radiolucent fluoroscopy table. Generally. Postprocedure Care Upon removal of the needles. The correct placement is confirmed by an anteroposterior view. For a given joint both of the 2 nerves that innervate the joint will need to be anesthetized. The width of the operating table should ensure a free rotation of the C-arm.3 mL of local anesthetic is injected (Fig. For medial branch blocks C3-C6 the target point is the centroid of the articular pillar with the same segmental number as the target nerve. Because the singular reason for performing diagnostic medial branch blocks is to obtain information. The patients should be observed after the procedure for a sufficient time with monitoring blood pressure and pulse-oximetry. provide strong evidence in the diagnosis of facet joint pain. Appropriate instruments for assessing the response are the Visual Analogue Scale and relief of disabilities. It is advisable that the procedure be performed in a room equipped with proper resuscitation facilities to deal with possible allergic reactions. Once the needle is in position. Before rising from the procedure table. 2 in “Denervation of the zygapophysial joints of the cervical and lumbar spine” in this issue).2 RESULTS Single diagnostic blocks are not valid.5 mL of local anesthetic is injected (Fig. A procedure room suitable for aseptic procedures is needed. systemic analgesia. utilizing at least 80% pain relief from baseline pain and the ability to perform previously painful movements. For the third occipital nerve. operating the C-arm. A lateral view of the spine must be obtained. Anteroposterior view of needles in position for an L4 medial branch block and L5 dorsal ramus block after application of contrast medium. On an oblique view the target point can be found near the “eye” of the “scotty dog” or in the middle of a line between the mamillo-accessory ligament and the mamillo-accessory notch.23 The review of Datta et al18 included 7 studies24–30 utilizing controlled local anesthetic blocks with evaluation of at least 80% pain relief. An ideal approach would be an evaluation of the results immediately after the block. Several potential sources of error exist.2 Uncontrolled blocks or intra-articular blocks lack validity.1. mamillo-accessory notch (see Fig. the skin is cleansed and an adhesive dressing is applied. 0.14–22 Datta et al18 and Falco et al19 recently performed a systematic assessment of the diagnostic accuracy of facet joint nerve blocks and concluded that controlled diagnostic blocks. Particularly false-positive answers can be produced for example because of the expectations of the patient or the doctor.

37. Target nerves can be anesthetized with different agents whose duration of effect is known. Similar results can be found in the review of Manchikanti et al22: for the lumbar and cervical spine evidence is level I or II-1. Diagnostic lumbar facet joint nerve blocks are recommended in patients with suspected facet joint pain. diagnostic blocks should produce complete relief of pain. Number 1. Ideally. Entering a narrow joint space can be difficult. Datta et al18 included 2 studies by Manchikanti et al. with between 85% and 93% significant improvement at 1 and 2 years in 2 groups with and without steroids. This criterion allows medial branch neurotomy to be used to provide substantial. have demonstrated the validity of 80% pain relief with controlled diagnostic blocks rather than Z 50% pain relief. If the response to medial blocks is positive radiofrequency neurotomy is a therapeutic utility with predictive validity. Several reviews exist about lumbar facet joint interventions including intra-articular injections.40 Significant improvement with pain relief and functional improvement was observed in 78% to 85%.49 FIGURE 2. The benchmark study on lumbar medial branch neurotomy used at least 80% relief following medial branch blocks as criterion for a positive response.34 A new study from New Zeeland uses 100% pain relief as criterion for cervical radiofrequency neurotomy.2: medial branch blocks are easier to perform.35 The distinction between 100% pain relief and being satisfied with less pain relief after a diagnostic medial branch block is relevant for daily work. No subsequent treatment after intra-articular blocks is known.22 Intra-articular Blocks Another treatment modality are intra-articular blocks. This would occur only when the patient’s sole or principal source of pain lies in the joints innervated by the nerves blocked.41–44 Thus.32 the evidence for short-term and long-term pain relief after therapeutic medial branch blocks is moderate. Lateral view with the needle in position for a C5 medial branch block. but not necessarily complete. level of evidence was level I or II-1 based on the 7 included studies. Datta et al.36 In patients with >1 pain source.techortho.38 Therapeutic Medial Branch Blocks Conflicting results have been reported for the different treatment modalities for lumbar zygapophysial joint pain in systematic reviews.18 found 5 randomized trials and 15 observational studies. for example after an operation or with spondylolisthesis. none c DISCUSSION In the literature and in every day practice differences of the above described proceeding can be found. relief of pain. the evidence is level I or II-1 based on the 9 included studies in the review of Falco et al. For the diagnosis of facet joint pain of the cervical spine.com 2013 Lippincott Williams & Wilkins . Boswell at al31. that has also been echoed in other reports. not for diagnostic reasons. however. such as >50% relief of pain. 2013 et al23 of the accuracy of diagnosis of lumbar facet joint pain by controlled comparative local anesthetic blocks utilizing either 50% or 80% pain relief as the criteria.Klessinger Techniques in Orthopaedics$  Volume 28. medial branch blocks may be utilized as an alternative to radiofrequency neurotomy. The indicated level of evidence is level II-1 or II-2 with a strong recommendation (1B or 1C) for the use of therapeutic joint blocks. Rubinstein and van Tulder33 in a best-evidence review of diagnostic procedures for low back pain concluded that there is strong evidence for the diagnostic accuracy of lumbar facet joint blocks in evaluating spinal pain. The intra-articular injections are always performed in a therapeutic intention. However. use a more liberal criterion. only a proportion of the pain will be relieved.22. Sometimes osteophytes degenerative changes may block the entry. or near complete relief. Four major aspects are worth being discussed. For therapeutic medial branch blocks several studies can be found.19 Also Boswell et al31.39.10 The results of a evaluation by Manchicanti 20 | www. In patients after ventral operations of the cervical spine the success rate is 53%. In the review of Boswell et al31. The Accuracy of Diagnostic Blocks The degree of relief that should occur after medial branch blocks remains contentious. Radiofrequency neurotomy is discussed in an extra chapter in this issue. Medial branches are safer because bone prevents over penetration of the needle and entering the spinal canal. several advantages of medial branch blocks exist1. Some investigators. which is nevertheless clinically worthwhile.32 gave a strong accuracy of facet joint nerve blocks in the diagnosis of lumbar and cervical facet joint pain. Manchikanti et al45 published an observational study and a randomized double-blind trial46–48 illustrating approximately 17 to 19 weeks of relief requiring approximately 6 episodes of cervical treatments over a period of 2 years.32 gave a moderate evidence for short-term and long-term improvement in low back pain. The review of Manchikanti et al22 gives a strong recommendation (1B or 1C) for the use of therapeutic cervical and lumbar facet joint nerve blocks to provide both short-term and long-term relief in the treatment of chronic facet joint pain. The evidence is limited in neck pain. some reviews are taken into account. For the cervical spine the systematic review by Falco et al19 showed moderate evidence for medial branch blocks and radiofrequency neurotomy.

ed. Pampati V. 12. No real time view of the track of the needle is available. Fellows B. Pain Physician. Bailey B. Manchikanti L. Part 1. Chronic low back pain of facet (zygapophysial) joint origin: is there a difference based on involvement of single or multiple spinal regions? Pain Physician. Pain Physician. 16. 2009. San Francisco. Datta S. Studies with a good recommendation to use therapeutic medial branch blocks with and without steroids exist. et al. Pain Physician. REFERENCES 1. Aprill C. Latimer J. Medial branch blocks are specific for the diagnosis of cervical zygapophyseal joint pain. van Kleef M. Pampati V.Techniques in Orthopaedics$  Volume 28. 1990. At least 80% pain relief should be the criteria. Comprehensive evidencebased guidelines for interventional techniques in the management of chronic spinal pain. et al.com | 21 .6:411–418. CT guidance is not supported by guidelines. Zygapophysial joint blocks. Practice Guidelines for Spinal Diagnostic and Treatment Procedures. Singh V. 2003.2 Using CT means a higher radiation exposition for the patient and the physician. a CT does not provide information on cephalocaudad spread of contrast medium. 80% relief. et al. 2010. San Francisco. Systematic review of tests to identify the disc. Govind J.54:100–106. 2013 Medial Branch Blocks met the inclusion criteria. Systematic review of diagnostic utility and therapeutic effectiveness of thoracic facet joint interventions. Manchikanti L. 2009. Clin J Pain. Pain Physician. 2.52 A CT demonstrates the anterior-posterior and medio-lateral location of the needle. Pain Pract. Pain Med. Number 1. or controlled diagnostic blocks. Manchikanti L. Boswell MV. 1996. Cash KA. Hirsch JA. Cervical medial branch blocks. Continuous fluoroscopy. 22. However.12:323–344. Pain Physician. Bogduk N. Storm SA. Falco FJE. c 2013 Lippincott Williams & Wilkins www. McKenzie-Brown A. it is much more time consuming.12:437–460. et al. Derby R. Schwarzer AC. Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions.68:79–83. 6. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents. et al.techortho.10:213–228. CT Guidance The International Spine Intervention Society does not mention CT-guided interventions in the guidelines. et al. Pain originating from the lumbar facet joints. et al. 5:365–371.51. 8. The false positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. 19.18:343–350.8:211–224. Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions. CA: International Spine Intervention Society. Electrical stimulation induced cervical medial branch referral patterns. 20. Manchikanti L. et al. Boswell MV.11:611–629. Atluri S. 18. 2003. during and throughout the injection of contrast medium is the only available means of demonstrating. 7.5:15. Singh V. 2007. 14. Prevalence of lumbar facet joint pain in chronic low back pain. et al. Pampati V.6:449–456. et al. International spinal injection society guidelines for the performance of spinal injection procedures. Bogduk N. Pampati S. 2009. Datta S. Manchikanti L. The evidence for intraarticular injections seems to be poor. Pain Physician. Wang S. 15. Fukui S.52 CT does not reveal arterial flow. and might seem to be more convenient because an additional view is not required to check depth of insertion.13:285–302. et al. 26. Shah RV.1. Aprill CN.2:59–64.10:459–469. Sehgal N. Windsor RE. Bogduk N. Pain Physician. Lumbar medial branch blocks. 2004.58:195–200. Maher CG. An accurate evaluation of the patient’s response is fundamental. Accuracy of precision diagnostic blocks in the diagnosis of chronic spinal pain of facet or zygapophysial joint origin: a systematic review.12:699–802. 2007. Fellows B. Falco FJE. et al. Lee M. 1993. 24. 3. Prevalence of facet joint pain in chronic spinal pain of cervical. Staats PS. Fluoroscopy is mandatory. Dwyer A. SIJ or facet joint as the source of low back pain. 2010.15:453–457. CA: International Spine Intervention Society. Nagula D. Cohen SP. There is no recommendation for therapeutic intra-articular facet joint injections in the review of Manchikanti et al22 The evidence for cervical intra-articular injections is lacking. 10. 21. Barnsley L. Ohseto K. 2007.13:133–143. intra-arterial flow away from the site of injection. Practice Guidelines for Spinal Diagnostic and Treatment Procedures. 13. Schwarzer AC. Pain Physician. Making sense of the accuracy of diagnostic lumbar facet joint nerve blocks: an assessment of the implications of 50% relief. Manchikanti L. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Pain Physician.12:E71–E120. Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami. Dunbar EE. Consequently. A narrative review of Bogduk50 suggested that intra-articular blocks were no better than placebo for chronic lumbar spine pain. thoracic. Singh V. Pain Med. et al. 5. 2009. Cervical zygapophysial joint pain maps.16:1539–1550. In case of a positive response the zygapophysial joints are identified as pain source and radiofrequency neurotomy is a therapeutic option. 12.51 CONCLUSIONS Medial branch blocks are a diagnostic tool designed to test if a patient’s pain is mediated by 1 or more of the medial branches of the dorsal rami. Reg Anesth. International Spine Intervention Society. Is there correlation of facet joint pain in lumbar and cervical spine? An evaluation of prevalence in combined chronic low back and neck pain. International Spine Intervention Society. Bogduk N. Erhart S. et al. 2004:47–65. 25. Cervical zygapophysial joint patterns I: a study in normal volunteers. Sehgal N. Pampati V. Shah RV. 1995. Comprehensive review of neurophysiologic basis and diagnostic interventions in managing chronic spinal pain. Vanelderen P. Boswell MV. et al. 2002. et al. Pain Physician. 9. 1997. Wargo BW. Pain. A narrative review of lumbar medial branch neurotomy for the treatment of back pain. Ann Rheum Dis. In: Bogduk N. Pain. 2003. BMC Musuloskelet Disord. Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. 1994.10:1035–1045. Shiotani M. 2004:112–137. injection into a vertebral artery or radicular artery will not be recognized (most important in transforaminal injections). et al.6:399–405. Singh V. Manchikanti L. Boswell MV. Bogduk N. Cooper G. and lumbar regions.8:344–353. Spine. Pain Physician. Manchikanti L. Dreyfuss P. The recommendation is very week or not to provide intra-articular injections. Eur Spine J. 23. et al.4:337–344. 4. Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update. ed. single block. 2005. Pain Physician. Falco FJE. Singh V. Curr Rev Pain. 2009. 2000. 27. In: Bogduk N. 1999. Bogduk N. Hancock MJ. Fluoroscopy is mandatory. 11. 2008. 17.

J Spinal Disord Tech. Gupta S. et al. Radiofrequency neurotomy for treatment of low back pain in patients with minor degenerative spondylolisthesis. Macvicar J. controlled trial with one-year follow-up. 2008. A critical review of the American pain society clinical practice guidelines for interventional techniques: part 2. Klessinger S. 45. Pain Med. controlled trial: clinical trial NCT0033272. Reassessment of evidence synthesis of occupational medicine practice guidelines for interventional pain management. 51. Borowczyk JM. Manchikanti L. et al. Pain Physician. 47. 52. Singh V. Boswell MV. 2007. Pain Med.13:621. 40. Spine (Phila Pa 1976). In response to Smuck M. Bogduk N. Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized. Diagnostic interventions. Anesthesiology. 2000. 2008.11:121–132. 42. Pain Med.112: 810–833. 48. Pain Physician. Singh V. Trescot AM. 2012. 2010.Klessinger Techniques in Orthopaedics$  Volume 28. Singh V. Pain Med.com c 2013 Lippincott Williams & Wilkins . et al. Therapeutic interventions. et al.13: E141–E174. Levin JH. et al. Cervical medial branch radiofrequency neurotomy in New Zealand. Bakhit C. Manchikanti L. 2010. Complications of spinal diagnostic and treatment procedures. American Society of Anesthesiologists. Bogduk N. Spine. A narrative review of intra-articular corticosteroid injections for low back pain.13:437–450. Manchikanti KN. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. van Tulder M. Pain Physician. 2007. Derby R.4:101–117.25:1270–1277. American Society of Regional Anesthesia and Pain Medicine.88:449–455. 2008. Klessinger S. Falco FJE. Singh V. Singh V. Baker R. Halbrook B.20:539–545. et al. Klessinger S. Effectiveness of cervical medial branch blocks in chronic neck pain: a prospective outcome study.11:393–482.11:1504–1510. 2008. 2010. Cervical medial branch radiofrequency neurotomy. et al. Aprill CN. Review.13:647–654. Task Force on Chronic Pain Management. double-blind controlled trial: clinical trial NCT00355914. Pampati V. 2010.22:471–482. 2012. The efficacy of medial branch blocks and radiofrequency neurotomy. 2007. Manchikanti L. Pain Med. 2004. 36. Comparative outcomes of a 2-year follow-up of cervical medial branch blocks in management of chronic neck pain: a randomized. 30. 2013 28. Evaluation of the relative contributions of various structures in chronic low back pain. 2006. Manchikanti L. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Zygapophysial joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. Pain Physician. Effectiveness of lumbar facet joint nerve blocks in chronic low back pain: a randomized clinical trial. Falco FJE. Pain Physician. Datta S. 2010. Falco FJ. Falco FJ. et al. Sehgal N. Cash KA. double-blind controlled trial.7:195–202. Pain Med. et al. Cervical medial branch blocks for chronic cervical facet joint pain: a randomized double-blind. Pauza K. Radiofrequency neurotomy for the treatment of therapyresistant neck pain after ventral cervical operations. et al. 32. 31. 2005. 38. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. [Epub ahead of print]. Derby R. Cash KA. 44. Manchikanti L. Best Pract Res Clin Rheumatol. 2007. Pain Physician. Manchukonda R. Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks. 33. Pain Physician.techortho.34:1116–1117. Pain Physician. Pain Physician. et al. Zygapophysial joint pain in post lumbar surgery syndrome. Datta S. Klessinger S. 37. Kennedy DJ. 2012. 43. 49. Manchikanti L. Dreyfuss P. 2012. doi: 10. Manchikanti L. 29. 2009. et al. Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized. Dreyfuss P.6:287–296. et al. Colson JD. 22 | www. Manchikanti L. Boswell MV. Manchikanti L. Pampati V. et al.15:E71–E78. Damron KS.13:E215–E264. Damron KS. 39. et al. 35. Pain Physician. Manchikanti L. A best-evidence review of diagnostic procedures for neck and low-back pain.10:1389–1394. Datta S. Pain Physician.4:308–316.10:7–111.9(S1):11–34.9:333–346. A critical review of the American pain society clinical practice guidelines for interventional techniques: part 1. et al. 46. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. et al.1111/pme. Number 1. 2001. Review. Singh V. 2001.12012. Pain Med. Paraplegia following imageguided transforaminal lumbar spine epidural steroid injection: two case reports. Pampati V.10:229–253. Dreyfuss P. Pain Physician. 41. 50. 2009. Manchikanti KN. 34. Arch Phys Med Rehabil. Manchikanti L. Manchukonda R. RE: Manchikanti L. et al. Macvicar AM. Rubinstein SM. double-blind.