The Ability of Diagnostic Spinal Injections to Predict Surgical Outcomes : Anesthesia & Analgesia

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Analgesia: Pain Medicine: Research Report

The Ability of Diagnostic Spinal Injections to Predict Surgical Outcomes

Cohen, Steven P. MD*†; Hurley, Robert W. MD, PhD*

Editor(s): Liu, Spencer S.

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Anesthesia & Analgesia 105(6):p 1756-1775, December 2007. | DOI: 10.1213/01.ane.0000287637.30163.a2
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Since their first description more than 80 yr ago, the use of diagnostic spinal injections to predict surgical outcomes has been the subject of intense controversy. Because there are no standardized guidelines or substantive reviews on this topic, their use has remained inconsistent.


Diagnostic procedures included in this review were lumbar and cervical discography, lumbar facet blocks, lumbar and cervical selective nerve root blocks, and sacroiliac (SI) joint injections. We garnered materials via MEDLINE and OVID search engines, books and book chapters, bibliographic references, and conference proceedings.


The lack of randomized, comparative studies for all blocks limited the conclusions that could be drawn. For the data that do exist, there is limited evidence that lumbar discography improves fusion outcomes, and no evidence that it influences disk replacement results. Although limited in scope, the current literature supports the notion that cervical discography improves surgical outcomes. There is strong evidence that lumbar selective nerve root blocks improve the identification of a symptomatic nerve root(s), and moderate evidence that both lumbar and cervical nerve root blocks improve surgical outcomes. The data supporting surgery for facet arthropathy are weak, and the use of screening blocks does not appear to improve outcomes. The data supporting SI joint fusion for degenerative, nontraumatic injuries are similarly weak. Because the most reliable method to diagnose a painful SI joint is with low volume, diagnostic injections, one might reasonably conclude that screening blocks improve surgical outcomes. However, this conclusion is not supported by indirect evidence.


The ability to evaluate the effect of diagnostic blocks on surgical outcomes is limited by a lack of randomized studies, methodological flaws, and wide-ranging discrepancies with regard to injection variables, surgical technique, and outcome measures. More research is needed to optimize injection techniques and determine which, if any, diagnostic screening blocks can improve surgical outcomes.

Spinal injections are the most frequently performed interventions in pain clinics across the United States, accounting for upwards of 75% of all procedures (1). For patients and many physicians, the ostensible reason for performing these procedures is pain relief. However, the high failure rate for surgery and nonsurgical interventions (2,3), coupled with the burgeoning economic cost of low back pain (LBP) (4), have led many experts to question the “shot-gun approach” to LBP management.

The use of diagnostic injections to identify the source of LBP dates back to the 1920s when von Gaza (5) used nerve blocks to illuminate obscure pain pathways. Motivated by the futility of treating pain without a proper diagnosis, Steindler and Luck (6) used procaine injections in the 1930s to identify specific pain generators in patients with chronic LBP. In the intervening years, spinal injections have been periodically advocated as both diagnostic and prognostic screening tools before surgery (7–12), but their use in this capacity has been sporadic and inconsistent.

Spurred by a wave of highly publicized articles questioning the wisdom of unrestrained surgery for LBP (2,3,13,14), a new philosophy has emerged emphasizing precision diagnosis together with high-tech interventions (15). Termed “reductionism” by Bogduk and McGuirk (15), one aspect of this strategy stresses the diagnostic and prognostic utility of nerve blocks as a prerequisite for optimizing treatment outcomes. Yet, despite the push towards improved diagnosis and refined selection criteria, the routine use of spinal nerve blocks as a screening tool for surgical intervention remains unproven and unpracticed. The purpose of this review is to systematically explore whether diagnostic spinal injections improve outcomes for a wide range of surgical procedures. Articles selected for inclusion were obtained via MEDLINE and OVID search engines, books and book chapters, and bibliographic references dating to the early 1900s.


Provocative discography is one of the most controversial diagnostic tests in pain medicine. First developed in 1948 as a diagnostic tool for herniated nucleus pulposus (16), the use of discography to diagnose radicular pain has since been supplanted by safer and more accurate imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI). The rationale for performing discography is that it remains the only tool that purports to correlate symptoms with pathology. This reasoning seems justified considering that the estimated lifetime prevalence of LBP ranges from 60% to more than 80% (17,18), and that 60% of asymptomatic subjects display radiologic evidence of lumbar disk degeneration (19,20). Although the prevalence rates for neck pain are somewhat less than for LBP, the numbers are equally compelling. Whereas 16%–22% of adults suffer from chronic neck pain (21,22), over 70% of asymptomatic individuals have radiological evidence of cervical disk pathology.

The main criticism of discography is that disk stimulation may provoke pain in normal disks. The reported incidence of false-positive discography is contingent on multiple factors, including, but not limited to, investigator perspective (i.e., most studies that report high false-positive rates were done by spine surgeons), the use of manometry, criteria for positive discograms (e.g., the use of facial expressions or combined pain provocation and analgesic response to local anesthetic [LA] injection) and the patient population studied. For lumbar discography, published false-positive rates range from <10% (25,26) to upwards of 50% in susceptible individuals (27–30). The reported false-positive rate for cervical discography ranges from <5% to 27%, being higher in patients with chronic neck pain than in asymptomatic subjects (31,32). Previous studies conducted with lumbar disk provocation have found that patients with somatization disorder or hypochondriasis, depression, chronic pain complaints, and high psychometric scores are more likely to report concordant pain production in normal appearing disks (27–29). The main criticism regarding studies that have attempted to quantify false-positive discography rates is that disk stimulation in asymptomatic volunteers may not be an accurate indicator of pain provocation in nonpainful disks in subjects with LBP. One of the hallmarks of a positive discogram is concordant pain provocation, which is not possible in people without low back symptoms.

In addition to false-pain provocation, markedly degenerative disks may also fail to provoke pain during disk injection (33–36), especially in the elderly (34). In recent reviews by Cohen et al. (37,38), the authors estimated that 15%–25% of degenerative disks fail to elicit concordant pain during disk stimulation (Fig. 1).

Figure 1.:
Computed tomography discogram demonstrating a large right posterolateral annular tear. On this axial image, the spread of contrast appears to be mostly contained within the annulus.

Lumbar Discography and Fusion Outcomes

Despite the widespread use of lumbar discography as a presurgical screening tool, few studies have evaluated its effect on surgical outcomes. The relative lack of controlled studies is further compounded by the widespread variability in outcomes and the controversy surrounding spinal arthrodesis for discogenic LBP. The surgical outcomes for the treatment of internal disk disruption are widely acknowledged to be inferior than for radiculopathy, with the reported success rates ranging from <50% to >80% (3,39,40). Moreover, the few randomized studies that do compare arthrodesis to conservative treatment demonstrate mixed results (2,3,14). The presence of concomitant pain sources in most patients with discogenic pain, along with inconsistent clinical outcomes even with a technically successful arthrodesis, are factors that must be considered when evaluating the predictive value of discography for surgical outcomes.

In the largest and most methodologically sound study attempting to correlate discographic findings with arthrodesis results, Colhoun et al. (41) found a strong correlation between positive discography and surgical outcomes. The authors prospectively collected outcome data on 162 patients who underwent preoperative discography for axial LBP. In the 137 patients with concordant pain on discography, 89% had a favorable outcome at the mean follow-up period of 3.6 yr. In the 25 patients whose disks showed morphological abnormalities but elicited no provocation of symptoms, only 52% reported significant benefit. The surgical treatments evaluated were mainly spinal fusions.

Some retrospective observations have failed to duplicate these results. Esses et al. (42) examined the role of external spinal fixation in predicting the success of spinal fusion in 35 patients with refractory LBP. Thirty-two patients underwent provocative discography before fixator placement. To summarize these findings, neither concordant pain provocation nor discographic evidence of disk degeneration predicted pain relief with external fixator placement, or subsequent spinal fusion. The main flaw in this study is that it was not designed to evaluate the predictive value of discography for spinal fusion; hence, not all patients underwent preoperative disk stimulation.

Madan et al. (43) conducted a retrospective analysis designed to determine the effect provocative discography had on surgical outcomes in 73 patients with chronic LBP. The first 41 patients in this series underwent circumferential arthrodesis without preoperative discography, whereas the last 32 patients proceeded to surgery only if concordant pain was produced during disk stimulation. In the discography group, 75.6% of patients had satisfactory outcomes at the minimum 2-yr follow-up versus 81.2% in the group who did not undergo preoperative discography.

Finally, Derby et al. (11) concluded preoperative discographic screening was valuable based on a retrospective study investigating the influence discography had on outcomes in surgical and nonsurgical LBP patients. Disks were classified as chemically sensitive, mechanically sensitized, or negative/indeterminate. Although no differences were found between outcomes and the type of fusion for the entire sample taken as a whole, subgroup analysis revealed that those patients with chemically sensitized disks had better results following interbody/combined fusion (89% success rate) than after intertransverse fusion (20%), or nonoperative treatment (12%).

With the exception of Derby et al. (11), no study used manometry as a determining factor in discographic interpretation. In addition to enhancing patient safety by preventing over-pressurization of degenerative disks, the use of manometry objectifies discography by providing a reference standard. In two reviews by Cohen et al. (37,38), the authors found no difference in fusion outcomes between studies that used discography and those that did not. In summary, the lack of strong evidence for the use of fusion to treat degenerative disk disease and methodological flaws in the studies make data interpretation exceptionally difficult. For the data that do exist, there is limited evidence that discography improves fusion outcomes in patients with discogenic LBP (Table 1) (44).

Table 1:
Studies Evaluating the Effect of Lumbar Discography on Fusion Outcomes

Lumbar Discography and Disk Replacement Outcomes

Since its introduction in 1966 by Fernstrom (45), lumbar disk replacement has been used to treat discogenic LBP in Europe since the 1980s, and in the United States since the early 2000s. There are currently more than two dozen published studies evaluating disk replacement outcomes, which contain wide variations in outcome criteria and follow-up periods. The success rates in these studies range from around 50% to upwards of 90% (37,38), with approximately half routinely using discography as a preoperative screening tool (Table 2) (46–70). Although the lack of any direct outcome comparison between patients who were selected based on discography results and those who underwent disk replacement based purely on clinical and radiological findings precludes any meaningful conclusions, an indirect comparison does not reveal any significant differences in outcomes between those studies that used preoperative discography and those that did not.

Table 2:
Summary of Outcome Data for Lumbar Disk Replacement Surgery Based on Preoperative Discography Screening

Cervical Discography and Spinal Fusion

The evidence supporting cervical fusion to treat cervical discogenic pain is weak and conflicting (3). In a Cochrane review, Jacobs et al. (71) concluded that discectomy alone provides comparable symptom relief to that of fusion, but that it is associated with shorter recuperation times and hospital stays. Discography has thus been advocated as a means to improve surgical outcomes; however, the ability to discern the effect of discography on cervical fusion outcomes is limited by several factors. Foremost, there are no prospective studies comparing outcomes between cohorts who were screened with preoperative discography and those who were not. Second, in those studies that have used discography as a surgical screening tool, publication bias, serious methodological flaws, and wide variability in outcome measures and follow-up periods undermine the conclusions that can be inferred.

Yet, when all the data are assembled, a pattern emerges whereby higher success rates tend to be reported when discography is used as a screening tool before cervical fusion. Perhaps the most relevant study is by Kikuchi et al. (12) who conducted a retrospective survey evaluating surgical outcomes in patients who underwent anterior discectomy and spinal fusion for axial and radicular neck pain. In the 138 patients who were operated based on presurgical discography screening, 80% were either pain-free or had mild discomfort that did not interfere with work 1-yr postprocedure. In a control cohort who underwent cervical fusion without the benefit of discography, only 60% had favorable outcomes. In a prospective study by Hubach (72), 193 consecutive patients with neck pain and neurological symptoms were treated with discectomy and anterior fusion, with the operative levels in most patients being determined by intraoperative discography. In the first 23 patients who were fused without discography, 35% developed pain at an adjacent spinal segment. In the 156 patients who underwent fusion based on discographic abnormalities, only 12% developed juxtafusional pain. These findings indicate that discography may be beneficial not only in determining whether or not to perform surgery, but also in deciding what levels to operate on.

Similar to lumbar discography (37), cervical discography may be more sensitive in detecting anatomical abnormalities than MRI (73), though the clinical relevance of this remains unclear. In an observational study by Zheng et al. (32) the authors found a 64% correlation between MRI results and cervical discograms by level and 24% by patient. Surgical findings were not used as the “gold standard,” but compared with CT-discography, MRI was associated with a 51% false-positive and 27% false-negative rate. Satisfactory results were obtained in 76% of patients. An earlier study by Schellhas et al. (31) also demonstrated that discography may be a more sensitive indicator of internal disk disruption than MRI. In 20 disks read as normal on MRI in 10 asymptomatic subjects, 17 were found to have annular tears discographically, although none was concordantly painful. Among 11 radiologically normal disks found in 10 patients with chronic cervical pain, 10 had annular tears during disk injection, with two being concordantly painful. In a study from the 1960s by Klafta and Collis (74), the authors found cervical discography to be less accurate than myelography in predicting surgical findings (72% vs 55%). The authors did not attempt to correlate pain provocation with either surgical findings or outcomes, but did note “pain on injection to be highly indicative of disk abnormalities.” These results are in contrast with those of Simmons et al. (9,75), who found discography superior to myelography in predicting surgical findings.

There are more than a dozen studies, all of which are retrospective or observational, that examined outcomes in patients who have undergone anterior cervical fusion based on positive discograms. Most of them have reported success rates of 75%–80% at intermediate to long-term follow-up (75–82). Reported success rates for fusion studies that were done without discography tend to be more variable than those that have used discography as a screening tool. Positive results have ranged from around 30% to upwards of 90%, with most reporting around 60% success rates (71,83–85). Although limited in scope, the current evidence supports using provocative discography as a screening tool before cervical fusion (Table 3) (86).

Table 3:
Studies Evaluating Surgical Outcomes Following Cervical Discography
Table 3:

Cervical Discography and Disk Replacement Outcomes

Inspired by favorable reports from lumbar disk replacement, spine surgeons began implanting cervical prosthetic disks in patients with severe cervical spondylosis (87). In the few clinical studies published on cervical disk arthroplasty, success rates have generally been more than 80% at intermediate-term follow-up (88–91). However, no conclusions regarding the potential value of preoperative discography can be drawn because all published studies have included patients with radiculopathy and/or myelopathy, and none has used provocative discography as a screening tool. Symptoms of myelopathy or spinal cord compression are absolute contraindications for cervical disk injection (92).


The prevalence of lumbar facet arthropathy varies widely, as reported in the literature, being functionally dependent on the diagnostic method and perspective of the investigator (i.e., higher prevalence rates are reported in pain literature than spine surgery literature). Further confounding estimates of prevalence rates are the high incidence of false-positive blocks, estimated at between 25% and 40% using comparative LA blocks or saline controls (93–96). Using single medial branch or intraarticular blocks, reported prevalence rates range from 8% to upwards of 90% (97,98). When placebo-controlled or comparative double blocks are used, false-positive rates decline significantly to between 9% and 40% (93,94,96,99,100). The frequent incidence of false-positive blocks has led some experts to advocate double-blocks as the only reliable method to diagnose the lumbar zygapophysial (l-z) joints as primary pain generators (94,101).

Multiple guidelines and review articles have promoted medial branch blocks (MBB) and intraarticular injections as having comparable diagnostic utility (101–103). However, a critical review of the evidence cited for these claims revealed only two randomized studies comparing MBB and intraarticular injections (Fig. 2) (104–106). Neither study used a crossover design or prescreened patients for l-z joint pain based on diagnostic injections, and both used excessive injectate volumes, which undermines specificity (106). Thus, although MBB and facet joint injections appear to provide similar relief to axial back pain sufferers, the question of which more accurately diagnoses a painful z-joint(s) remains unanswered. In a randomized comparative study comparing the prognostic value of MBB to pericapsular facet injections in patients undergoing radiofrequency denervation, Birkenmaier et al. (107) found better results lasting up to 6 mo postprocedure in the MBB group. But unlike intraarticular facet injections, pericapsular injections are not usually advocated as an accurate means to diagnose facet arthropathy. In general, higher success rates have been found for facet joint radiofrequency denervation in those studies using controlled or confirmatory blocks (108–110).

Figure 2.:
Anteroposterior fluoroscopic image showing bilateral diagnostic L3 and L4 medial branch blocks. These nerves provide innervation to the superior poles of the L5–S1 facet joints, the L4–5 facet joints, the inferior poles of the L3–4 facet joints, and the multifidus muscle.

There are several studies assessing the ability of intraarticular facet injections to predict spinal fusion outcomes and surgical findings, all of which are limited by methodological flaws, high volumes in those studies in which injectate composition was listed, and the absence of controlled or comparative blocks. In general, the results of these studies have been disappointing. Bough et al. (111) conducted a retrospective review to determine whether pain provocation during facet arthrography could predict histological findings in 84 patients who underwent facetectomy. Whereas the specificity for provocative l-z joint injection was 75%, the low sensitivity (59%) and negative predictive value (43%) led the authors to conclude facet arthrography was of little value as a surgical screening tool. A flaw in this study was the use of pain provocation to diagnose facet joint pain. Previous studies have found pain provocation to be a less reliable indicator of painful zygapophysial joint than analgesic response to LA infiltration (112). In a small observational study by Esses et al. (42), the authors found a nonsignificant negative association between the response to diagnostic facet blocks and short-term outcomes from external spinal fixation. In a later retrospective study, Esses and Moro (113) found no correlation between the response to facet blocks and success for either operative or nonoperative treatment in 296 patients with axial LBP. These findings are consistent with those of Jackson (114), who found no difference in arthrodesis outcomes between those patients who experienced significant pain relief after l-z injections and those who did not.

In an observational study, Lovely and Rastogi (7) reported excellent or good results with spinal fusion in 23 of 28 patients who obtained >70% pain relief after three facet blocks. However, the findings in this study are undermined by widespread methodological flaws, including the large volumes used during blocks (3–5 mL) and the lack of an adequate comparison group (results were available on only one “negative” facet block that failed to fuse). In summary, the evidence does not support using diagnostic lumbar facet blocks as a predictive tool before spinal fusion. There are currently no studies evaluating the predictive value of either thoracic or cervical facet blocks as screening tools before surgical intervention (Table 4) (115).

Table 4:
Studies Evaluating the Ability of Lumbar Facet Blocks to Predict Operative Results


Selective nerve root blocks (SNRB) have been used for almost 40 yr to provide diagnostic and prognostic information in patients with radicular pain. Although the terms “SNRB” and “transforaminal epidural injection” are sometimes used interchangeably, the two are different procedures with distinctly separate indications. Transforaminal epidural steroid injections are specifically used to treat radicular pain. Because the injectate is purposefully administered into the epidural space where it ostensibly spreads to adjacent spinal levels, the diagnostic information that a transforaminal epidural injection provides is limited by the lack of specificity. On the other hand, because SNRBs purportedly anesthetize only one spinal nerve, they are often touted as accurate diagnostic and predictive tools for planned decompression procedures (Table 5). In addition to their diagnostic utility, nerve root injections done with steroids and LA have been shown in some studies to provide intermediate-term pain relief and reduce the need for operative intervention (116–121). However, the potential beneficial effects of these procedures, especially transforaminal injections performed with particulate steroids, have been tempered by multiple reports of spinal cord injury, paraplegia and even death (122–125), prompting some clinicians to propose alternative methods of selectively anesthetizing nerve roots (126).

Table 5:
Indications for Selective Nerve Root Blocks

Despite the theoretical appeal of SNRB, their diagnostic utility is limited by several factors including a narrow therapeutic window whereby the analgesic effects can be realized and epidural or plexus spread avoided, dermatomal overlap, lack of uniform effects on sensory function, individual variations in dermatomal maps, inability of patients to discern pain provocation and/or pain relief after anesthetic injection, use of excessive injectate volumes, superficial anesthesia and sedation, and inconsistency between nerve root stimulation patterns and dermatomal pain patterns.

One caveat that should be heeded when performing SNRB and other analgesic diagnostic procedures is the need to limit injectate volumes to optimize specificity. In a landmark prospective study by North et al. (127) conducted in 33 patients with clinical and radiological evidence of lumbosacral radiculopathy, the authors performed a battery of LA nerve blocks that included SNRB, sciatic nerve block, MBB, and subcutaneous control injections. Approximately 90% of patients obtained near-complete pain relief after SNRB, 70% obtained almost complete relief after the sciatic block, and a majority received more than 50% pain relief after the MBB. In contrast, the median degree of pain relief after the subcutaneous injection was around 30%. These findings led the authors to conclude that the specificity of diagnostic nerve blocks for the evaluation of spinal pain is low. However, the volumes used during these blocks (3 mL for each procedure) far exceeded that used in current standard practice.

Low-volume SNRB will produce predictable dermatomal sensory changes for between 75% and 85% of patients in the cervical and lumbar spine, being somewhat less valid and reliable in patients with long-standing or multisegmental neurological deficits. One of the first studies to evaluate the validity of SNRB was conducted by Castro et al. (128), who randomized 94 patients to receive CT-guided L4 nerve root injections using 0.5, 1, or 2 mL of contrast. Epidural spread was noted to occur in 48%, 67%, and 75% of subjects in each of these groups, respectively. More significantly, definitive spread to an adjacent nerve root, which may undermine the specificity of a nerve block by causing anesthesia outside the intended dermatome, was found in 24% of the 0.5 mL group, 27% of the 1 mL group, and 33% of injections done with 2 mL of contrast. Spread into the psoas muscle, where the nerve roots converge to become a plexus, was noted in 12% of patients who received 0.5 mL contrast, 33% of subjects who received 1 mL injections, and 68% of people who were injected with 2 mL contrast. These results raise further questions regarding the validity and specificity of SNRB, even when low volumes are used.

Wolff et al. (129–131) performed a series of studies designed to evaluate the sensory and motor effects of segmental nerve root blocks in patients with chronic radicular LBP. In the first study, the authors performed 42 low-volume (0.5 mL) SNRB in 29 patients (129). Using standard dermatomal maps (132), hypesthesia and paresthesias were noted in 80% of patients. However, significant pain reduction was only achieved in 43% of patients. In the second study, 38 low-volume (0.7 mL) SNRB were performed in 20 patients with lumbosacral radiculopathy (130). In all but two patients, hypesthesia to pinprick was noted in the corresponding dermatome level. Although the median decrease in pain score was 4 points on a 0–10 scale, some patients reported no reduction in symptoms. In the third study, the authors performed 20 L4 SNRB in 10 patients with either ropivacaine or lidocaine in a double-blind, crossover fashion (131). In the seven patients with baseline sensory deficits, SNRB produced variable, but nonsignificant, changes in the extent and distribution of preexisting hypesthesia. Clinically significant (≥2 points) postblock pain reductions occurred in only eight of the 20 block sessions. These findings indicate that SNRB may be less valid in patients with long-standing, nondermatomal sensory changes.

Several investigations have demonstrated that properly performed cervical SNRB can successfully identify a painful nerve root(s). Anderberg et al. (133) performed cervical SNRB with 1 mL of LA in 20 patients with cervical radiculopathy correlating with single-level MRI pathology. In the 10 patients whose pain was provoked with active neck motion, 9 (90%) reported significant reduction in arm pain (mean 85%). In the 10 patients whose arm pain was not provoked with neck movement, all experienced significant pain reduction (mean 88%). In a similar study conducted in 30 patients with two-level MRI pathology, the same group of authors found a 60% correlation between SNRB results and the most severely degenerated spinal level based on MRI, a 27% correlation between SNRB and neurological examination, and a 23% correlation between nerve root blocks and classical dermatome maps (134). Among the 11 patients with a positive SNRB at two-levels, 6 (55%) had consonant disk pathology on MRI. In only 20% of patients did neurological deficits, MRI and SNRB results correlate.

Following up on the Castro et al. (128) study, Anderberg et al. (135) used multislice CT to evaluate the contrast dispersal patterns of transforaminal nerve root blocks in nine patients with cervical radiculopathy using volumes of 0.6, 1.1, or 1.7 mL. In the two lowest volume groups, a small amount of contrast spread was noted at the adjacent nerve root in two of the three injections; however, because the contrast encompassed less than one-quarter diameter of the nerve root, all blocks were considered valid. In the three 1.7 mL injections, none was selective enough to be valid. Similar to lumbar SNRB, these findings underscore the need to use low volumes to enhance the specificity of cervical SNRB. Finally, Slipman et al. (136) performed a prospective study comparing the pain referral patterns for 134 cases of cervical nerve root stimulation and documented sensory dermatomal maps. The authors found that although the distribution of symptom provocation resembled classic dermatomal patterns, pain and paresthesias were often provoked outside these maps.

SNRB and Lumbosacral Decompression

Several authors have attempted to correlate the results of SNRB with surgical findings and outcomes. Haueisen et al. (8) reported good operative results in a retrospective study conducted in 55 patients with lumbosacral radiculopathy who underwent surgical exploration based on SNRB. In the 46 patients with a “definitive” or highly suggestive nerve root injection, corresponding surgical pathology was found in 93% of patients. In contrast, myelography and electromyography correctly identified the site of pathology in only 24% and 38% of patients, respectively. At follow-up periods ranging from 1 to 5 yr, 49% of patients had minimal or no pain versus 16% of patients who were treated nonoperatively. In an effort to determine the predictive value of SNRB, Stanley et al. (137) performed a prospective study in 50 patients with lumbosacral radicular pain. In the 19 surgically treated patients in whom typical pain was reproduced during injection and relieved after LA infiltration, SNRB correctly identified the level of surgical pathology in 18 patients, which favorably compared with the predictive value of CT (14 patients) and radiculography (12 patients).

In a retrospective evaluation performed in 62 patients with sciatica, Dooley et al. (138) found the combination of concordant pain provocation and analgesic response to LA infiltration during SNRB to have both strong positive and negative predictive value for determining nerve root pathology and predicting surgical outcomes. In the 46 patients whose typical pain was reproduced during needle placement and relieved by low-volume SNRB (Group I), all but one had surgical confirmation of nerve root pathology. In the 32 patients found to have a herniated disk (n = 8), bony entrapment (n = 17) or intraneural adhesions (n = 7) as the primary cause of radicular symptoms, 100%, 82%, and 71% experienced significant relief of radicular pain after decompression, respectively. In the four patients in whom pain was produced by needle placement but not relieved by LA injection (Group II), surgical exploration tended to show multiple root involvement.

Sasso et al. (10) demonstrated that preoperative SNRB can improve both lumbar and cervical surgical outcomes. In a retrospective analysis performed in 101 patients who underwent lumbar (n = 83) or cervical (n = 18) decompression, 90% of the 91 patients with a positive block experienced a good outcome at the mean 16-mo follow-up versus 60% in the 10 patients with negative blocks. The predictive value of these blocks compared favorably with MRI. In summary, there is strong evidence that SNRB can improve accurate identification of a symptomatic lumbar spinal level, and moderate evidence that SNRB improves operative outcomes. Nerve root blocks are most advantageous when low volumes are used, both pain provocation and analgesia are used as criteria for success, and possibly when adjacent/control levels are blocked in addition to the suspected spinal level.

SNRB and Cervical Decompression

Although still promising, the direct evidence supporting SNRB as a predictive tool for cervical decompression outcomes is less robust than for lumbar decompression, owing to a smaller body of literature on the subject. Anderberg et al. (133) conducted a prospective study comparing SNRB results to clinical symptoms and MRI findings in 20 patients with single-level cervical disk disease. In the 18 patients who underwent cervical decompression based on postblock pain relief and radiological findings, all experienced eradication of their radicular symptoms after operative intervention, although five continued to have shoulder pain. The follow-up period in this study was not noted. In a later study performed on 30 patients with multilevel cervical disk pathology, the same group reported good or excellent surgical outcomes in 9 of the 11 patients after low volume, dual-level cervical nerve root block (mean follow-up 31 mo) (134). This compared favorably to patients treated with transforaminal epidural steroid injections (69% success rate in 13 patients) or conservative therapy (50% success rate in eight patients). In the Sasso et al. (10) study reporting better surgical outcomes in patients with positive SNRB (91% good outcomes) than in those with negative SNRB (60% good outcomes), results were not tabulated based on site of pathology. However, 18% of patients presented with cervical radiculopathy. The positive predictive values of SNRB and MRI were similar (91% vs 88%), whereas the negative predictive value for SNRB was significantly higher than that for MRI (40% vs 15%). In conjunction with indirect evidence from data extrapolated from lumbar SNRB studies, there is moderate evidence supporting improved surgical outcomes when cervical SNRB are used before decompression procedures (Fig. 3; Table 6) (139–143).

Figure 3.:
Oblique fluoroscopic view demonstrating a two-level cervical nerve root block.
Table 6:
Studies Assessing Surgical Decompression Outcomes Based on Selective Nerve Root Blocks
Table 6:


Sacroiliac (SI) joint pain is a challenging condition affecting between 15% and 25% of patients with axial low back and buttock pain (144,145). Dozens of provocative maneuvers and alignment/mobility tests have been advocated as diagnostic aids in patients with suspected SI joint pain. However, numerous studies and reviews have found no single historical or physical examination feature to be a reliable indicator of a painful SI joint (144,146,147). Similar diagnostic shortcomings have been found for radiological studies, including radionuclide bone scanning, CT, and radiographic stereophotogrammetry (148–151). The lack of reliable alternative diagnostic modalities has led numerous experts to recommend diagnostic SI joint blocks as the most reliable means for diagnosing an SI joint as the primary pain generator (Fig. 4) (144,145,152). To maximize accuracy, these injections should always be performed using radiological guidance. In a prospective, double-blind study by Rosenberg et al. (153), the authors found intraarticular placement in only 22% of SI joint injections guided by anatomical landmarks. But even accurate needle placement using a low injectate volume does not guarantee validity or specificity. A prevalence study by Maigne et al. (154) conducted in 54 patients found that although 19 had a positive response to a screening SI joint block done with lidocaine, only 10 experienced >2 h of pain relief after a confirmatory bupivacaine block. Other studies have found similar false-positive rates for uncontrolled SI joint injections (155).

Figure 4.:
Anteroposterior image of a right-sided sacroiliac joint injection.

Whereas controlled studies have shown that peri-articular SI joint injections may provide comparable relief to intra-articular injections, the latter are generally regarded as the gold standard for identifying an SI joint(s) as the likely pain generator. Although speculative, the impetus to use intra- rather than peri-articular injections as a prognostic tool before SI joint fusion may be even more compelling, since the ostensible goal of arthrodesis in many cases is to provide stabilization for a painful, mal-aligned or overly mobile joint.

There are several indications for SI joint arthrodesis, including fractures, dislocation/instability, and arthritis. Of these, SI joint pain secondary to degenerative joint disease is the most controversial. Many factors undermine the conclusions that can be drawn regarding the ability of SI joint blocks to improve surgical outcomes, including differences in operative techniques, outcome measures and indications; disparities in the way diagnostic injections were performed; publication bias in the mostly retrospective published reports (i.e., case series and retrospective reports are more likely to be published when positive than negative); failure to properly report outcomes and injection variables; widespread methodological flaws; and lack of any direct comparison between patients who underwent preoperative screening blocks and those who did not. Particularly noteworthy is that all of the studies that used presurgical SI joint screening blocks either used excessive volumes or failed to mention the amount of LA injected. In two retrospective studies from the 1920s and 1930s whereby SI fusion was performed without diagnostic blocks, the earlier study reported excellent results in 85% of patients (22 of 26 patients returned to baseline), whereas the other reported excellent results in 52% of subjects (158,159). In the earlier study, both trauma and nontraumatic patients were included, although results were not separated based on etiology (158). In the later study (159), the primary indication in more than three-quarters of the patients was infection. Neither study used objective outcome measures or specified the follow-up period. In a more recent study by Dabezies et al. (160), compression rods were used to treat 11 cases of mostly trauma-related SI dislocation without the benefit of screening blocks. Although technical success was quantified, no mention was made of patient outcomes except for a brief notation that two patients continued to have mild residual back pain and one experienced worsening of a nerve injury. The average follow-up in this study was 26 mo.

Among the three largest studies evaluating SI fusion contingent on a positive response to fluoroscopically-guided intraarticular SI joint injections, two reported benefit. In a retrospective study assessing the results of 22 operations performed in 21 patients with SI joint osteoarthritis, Waisbrod et al. (161) found that half their patients obtained >50% pain relief at a mean follow-up of 2.5 yr. In the Discussion, the authors estimated that if patients with “psychosomatic disease” are excluded, about a 70% success rate can be expected for SI joint arthrodesis. In another retrospective study, conducted in 20 nontrauma patients with SI joint pain, Buchowski et al. (162) reported significant improvement in all SF-36 categories except for general health in the 15 patients who completed pre- and postoperative outcome assessments, with 60% of patients claiming they would repeat the procedure. Schutz and Grob (163) reported less auspicious results in a recent study evaluating bilateral fusion for SI joint arthropathy. Among their 17 study patients, three reported moderate or complete pain relief at the mean 39-mo follow-up period, with only 18% being satisfied with their results. Flaws in this study include the high volumes (5 mL) used in the 14 patients who underwent preoperative SI joint blocks and the fact that all fusions were bilateral. In most patients with injection-confirmed SI joint pain, the predominant symptoms tend to be unilateral (Table 7) (164–167).

Table 7:
Results of Sacroiliac Joint Arthrodesis Based on Response to SI joint Blocks

In summary, the evidence does not appear to show any advantage in performing preoperative SI joint blocks when the primary surgical indication is trauma-related fracture(s) and/or dislocation. The conclusions regarding the use of SI joint blocks before surgery for arthritis are more complex, partly because the evidence supporting SI joint arthrodesis for degenerative joint disease is weak and inconsistent. Because the evidence is strong that low volume diagnostic blocks are the gold standard for classifying a degenerative joint as painful, one might conclude, a priori, that screening blocks should be done before surgical intervention. However, a review of the disparate outcomes of the literature does not support the conclusion that patient selection based on SI joint blocks will improve the results of SI joint fusion.


In an ideal setting, there would be no diagnostic nerve blocks. Noninvasive diagnostic modalities would be 100% accurate, and the evidence that they improved treatment outcomes would be incontrovertible. The only reason pain doctors would insert needles into patients would be to treat their underlying condition. But the world is not perfect, noninvasive modalities are not infallible, and diagnostic spinal injections will probably continue to be done as long as patients have back pain and surgeons are willing to operate on them (Table 8).

Table 8:
Summary of Diagnostic Spinal Injections as Predictors of Surgical Outcome

There are myriad causes for inaccurate diagnostic spinal injections which run the gamut from technical errors, lack of communication between provider(s) and patient, anatomical anomalies, poor patient understanding, expectation bias, placebo effect, overzealous use of superficial anesthesia, inappropriate administration of sedation and/or analgesics, excessive volumes of LA administered during blocks, systemic absorption of LA, and failure to adequately interpret the results of the procedure (106,144,167–170). Because similar shortcomings abound for imaging studies, there will never be a perfect correlation between nerve blocks and less invasive diagnostic tests. The same caveat holds true for nerve blocks and surgery. For these reasons, diagnostic nerve blocks rarely provide a definitive answer to the question of pain causation. Nerve blocks should therefore always be interpreted in context, as one piece of a complex puzzle, in conjunction with historical findings, physical examination, other diagnostic modalities and psychosocial issues. In light of the high failure rates for many surgical procedures and the high false-positive rates associated with most diagnostic spinal injections, negative blocks often provide more useful information than positive blocks (27–30,93–96,154,155).

Perhaps the most striking finding of this analysis is the absence of any methodologically sound, prospective, randomized study examining the impact of diagnostic blocks on surgical outcomes. Although this may render any conclusions we draw as purely speculative, it also underscores the need for better research studies.

For discography, there is weak evidence that preoperative disk provocation improves arthrodesis outcomes for lumbar and cervical fusion. The largest prospective study with the longest follow-up period found a substantial increase in success rates when concordant pain provocation, rather than morphological abnormalities, was used as the basis for surgical intervention (41), whereas smaller, retrospective studies failed to replicate these results (42,43). The evidence supporting cervical discography as a presurgical screening tool is one-sided in favor of outcome improvement, but mitigated by the anecdotal nature of the literature. The preponderance of data neither support surgery as a reliable treatment for facet arthropathy, nor the use of diagnostic facet blocks when surgery is attempted for this indication.

There is more outcome literature available for SNRB than any other diagnostic modality. Yet the evidence remains equivocal because there are no randomized studies comparing surgical outcomes between patients who underwent decompression surgery based on SNRB and those who received other screening procedures. The results of properly performed SNRB appear to correlate better with surgical pathology than imaging studies for lumbar disk surgery. Based on inductive reasoning, one might therefore assume that SNRB should improve surgical results. Although anecdotal, positive SNRB do seem to be associated with better intermediate-term surgical outcomes in both the lumbar and cervical regions. Thus, our conclusion is that there is moderate evidence to support using SNRB to improve surgical decompression outcomes.

Whether diagnostic blocks should be done before SI joint fusion is a complex question that must be asked in the framework of the more overriding question of whether SI joint fusion should even be done for degenerative joint disease. Taken as a whole, the retrospective studies that have examined SI joint arthrodesis outcomes do not show improved outcomes when SI joint blocks are routinely used as screening procedures. However, the wide variations in surgical technique and outcomes, and lack of standardization for the diagnostic injections do not permit definitive conclusions to be drawn as to the utility of SI joint screening blocks. If one operates under the unproven premise that SI joint fusion can be beneficial in a small subset of patients suffering with arthritis, then a priori one must conclude that diagnostic blocks can improve outcomes, because it is generally accepted that diagnostic blocks are the best way to diagnose a painful SI joint (144,147,171).

Driven by better-informed patients, ever-expanding treatment options, and increasing demand by third party payers for stronger evidence of good treatment outcomes, the selection criteria for spinal surgery will continue to evolve. As the frequency with which diagnostic injections are performed continues to increase, so will the need to optimize their validity. Presently, there are little data to support or refute the use of diagnostic injections as screening tools before spine surgery. More research is needed to determine what role, if any, diagnostic injections will play in the evaluation of spine surgical candidates.


1. Manchikanti L. The growth of interventional pain management in the new millennium: a critical analysis of utilization in the medicare population. Pain Physician 2004;7:465–82
2. Carragee EJ. Persistent low back pain. N Engl J Med 2005;352:891–8
3. Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery—the case for restraint. N Engl J Med 2004;350:722–6
4. Nachemson A. Newest knowledge of low back pain. Clin Orthop Relat Res 1992;279:8–20
5. von Gaza W. Die Resektion der paravertebralen Nerven und die isolierte Durchschneidung des Ramus communicans. Arch Klin Chir 1924;133:479
6. Steindler A, Luck JV. Differential diagnosis of pain in the low back: allocation of the source of the pain by the procaine hydrochloride method. JAMA 1938;110:106–13
7. Lovely TJ, Rastogi P. The value of provocative facet blocking as a predictor of success in lumbar spine fusion. J Spinal Disord 1997;10:512–7
8. Haueisen DC, Smith BS, Myers SR, Pryce ML. The diagnostic accuracy of spinal nerve injection studies. Their role in the evaluation of recurrent sciatica. Clin Orthop Relat Res 1985;198:179–83
9. Simmons EH, Segil CM. An evaluation of discography in the localization of symptomatic levels in discogenic disease of the spine. Clin Orthop Relat Res 1975;108:57–69
10. Sasso RC, Macadaeg K, Nordmann D, Smith M. Selective nerve root injections can predict surgical outcome for lumbar and cervical radiculopathy: comparison to magnetic resonance imaging. J Spinal Disord Tech 2005;18:471–8
11. Derby R, Howard MW, Grant JM, Lettice JJ, Van Peteghem PK, Ryan DP. The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes. Spine 1999; 24:364–72
12. Kikuchi S, Macnab I, Moreau P. Localisation of the level of symptomatic cervical disc degeneration. J Bone Joint Surg Br 1981;63:272–7
13. Abelson R, Petersen M. Operation to ease back pain bolsters the bottom line, too. NY Times (Print) 1999, December 31, 2003:A1
14. Gibson JN, Waddell G, Grant IC. Surgery for degenerative lumbar spondylosis. Cochrane Database Syst Rev 2000; 2:CD001352
15. Bogduk N, McGuirk B. Treatment strategies. In: Medical management of acute and chronic low back pain. An evidence based approach pain research and clinical management. Vol 13. Amsterdam: Elsevier Science, 2002:177–86
16. Lindblom K. Diagnostic puncture of intervertebral disks in sciatica. Acta Orthop Scand 1948;17:231–9
17. Walker BF. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord 2000;3:205–17
18. Manchikanti L. Epidemiology of low back pain. Pain Physician 2000;3:167–92
19. Weishaupt D, Zanetti M, Hodler J, Boos N. MR imaging of the lumbar spine: prevalence of intervertebral disk extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints in asymptomatic volunteers. Radiology 1998;209:661–6
20. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 1994;331:69–73
21. Guez M, Hildingsson C, Stegmayr B, Toolanen G. Chronic neck pain of traumatic and non-traumatic origin: a population-based study. Acta Orthop Scand 2003;74:576–9
22. Guez M, Hildingsson C, Nilsson M, Toolanen G. The prevalence of neck pain: a population-based study from northern Sweden. Acta Orthop Scand 2002;73:455–9
23. Ernst CW, Stadnik TW, Peeters E, Breucq C, Osteaux MJ. Prevalence of annular tears and disc herniations on MR images of the cervical spine in symptom free volunteers. Eur J Radiol 2005;55:409–14
24. Siivola SM, Levoska S, Tervonen O, Ilkko E, Vanharanta H, Keinanen-Kiukaanniemi S. MRI changes of cervical spine in asymptomatic and symptomatic young adults. Eur Spine J 2002;11:358–63
25. Walsh TR, Weinstein JN, Spratt KF, Lehmann TR, Aprill C, Sayre H. Lumbar discography in normal subjects. A controlled, prospective study. J Bone Joint Surg Am 1990;72:1081–8
26. Derby R, Lee SH, Kim BJ, Chen Y, Aprill C, Bogduk N. Pressure-controlled lumbar discography in volunteers without low back symptoms. Pain Med 2005;6:213–21
27. Block A, Vanharanta H, Ohnmeiss DD, Guyer RD. Discographic pain report: influence of psychological factors. Spine 1996;21: 334–8
28. Carragee EJ, Tanner CM, Yang B, Brito JL, Truong T. False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection. Spine 1999;24:2542–7
29. Carragee EJ, Tanner CM, Khurana S, Hayward C, Welsh J, Date E, Truong T, Rossi M, Hagle C. The rates of false-positive lumbar discography in select patients without low back symptoms. Spine 2000;25:1373–80
30. Carragee EJ, Chen Y, Tanner CM, Truong T, Lau E, Brito JL. Provocative discography in patients after limited lumbar discectomy. Spine 2000;25:3065–71
31. Schellhas KP, Smith MD, Gundry CR, Pollei SR. Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine 1996;21:300–11
32. Zheng Y, Liew SM, Simmons ED. Value of magnetic resonance imaging and discography in determining the level of cervical discectomy and fusion. Spine 2004;29:2140–5
33. Vanharanta H, Guyer RD, Ohnmeiss DD, Stith WJ, Sachs BL, Aprill C, Spivey M, Rashbaum RF, Hochschuler SH, Videman T, Selby DK, Terry A, Mooney V. Disc deterioration in low-back syndromes. A prospective, multi-center CT/discography study. Spine 1988;13:1349–51
34. Vanharanta H, Sachs BL, Ohnmeiss DD, Aprill C, Spivey M, Guyer RD, Rashbaum RF, Hochschuler SH, Stith WJ, Mooney V. Pain provocation and disc deterioration by age. A CT/discography study in a low-back pain population. Spine 1989;14:420–3
35. Moneta GB, Videman T, Kaivanto K, Aprill C, Spivey M, Vanharanta H, Sachs BL, Guyer RD, Hochschuler SH, Raschbaum RF, et al. Reported pain during lumbar discography as a function of anular ruptures and disc degeneration. Spine 1994;19:1968–74
36. Maezawa S, Muro T. Pain provocation at lumbar discography as analyzed by computed tomography/discography. Spine 1992;17: 1309–15
37. Cohen SP, Larkin TM, Barna SA, Palmer WE, Hecht AC, Stojanovic MP. Lumbar discography: a comprehensive review of outcome studies, diagnostic accuracy, and principles. Reg Anesth Pain Med 2005;30:163–83
38. Cohen SP, Larkin TM. Lumbar discography. In: Benzon H, Wu CL, Rathmell JP, eds. Raj’s practical management of pain. 4th ed. London: Elsevier Science, In press
39. Junge A, Frohlich M, Ahrens S, Hasenbring M, Sandler A, Grob D, Dvorak J. Predictors of bad and good outcome of lumbar spine surgery. A prospective clinical study with 2 years’ follow up. Spine 1996;21:1056–64
40. Zdeblick TA. The treatment of degenerative lumbar disorders. A critical review of the literature. Spine 1995;20(24 suppl):126S–137S
41. Colhoun E, McCall IW, Williams L, Cassar Pullicino VN. Provocation discography as a guide to planning operations on the spine. J Bone Joint Surg Br 1988;70:267–71
42. Esses SI, Botsford DJ, Kostuik JP. The role of external spinal skeletal fixation in the assessment of low-back disorders. Spine 1989;14:594–601
43. Madan S, Gundanna M, Harley JM, Boeree MR, Sampson M. Does provocative discography screening of discogenic back pain improve surgical outcomes? J Spinal Disord Tech 2002; 15:245–51
44. Carragee EJ, Lincoln T, Parmar VS, Alamin T. A gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine 2006;31:2115–23
45. Fernstrom U. Arthroplasty with intercorporeal endoprosthesis in herniated disc and in painful disc. Acta Chir Scand Suppl 1966;357:154S–159S
46. Enker P, Steffee A, McMillin C, Keppler L, Biscup R, Miller S. Artificial disc replacement: preliminary report with a 3-year minimum follow-up. Spine 1993;18:1061–70
47. Zeegers WS, Bohnen LM, Laaper M, Verhaegen MJ. Artificial disc replacement with the modular type SB Charite III: 2-year results in 50 prospectively studied patients. Eur Spine J 1999;8:210–7
48. Bertagnoli R, Kumar S. Indications for full prosthetic disc arthroplasty: a correlation of clinical outcome against a variety of indications. Eur Spine J 2002;11(suppl 2):S131–6
49. Hochschuler SH, Ohnmeiss DD, Guyer RD, Blumenthal SL. Artificial disc: preliminary results of a prospective study in the United States. Eur Spine J 2002;11(suppl 2):S106–10
50. Mayer HM, Wiechert K, Korge A, Qose I. Minimally invasive total disc replacement: surgical technique and preliminary clinical results. Eur Spine J 2002;(suppl 2):S124–30
51. Delmarter RB, Fribourg DM, Kanim LE, Bae H. ProDisc artificial total lumbar disc replacement: introduction and early results from the United States clinical trial. Spine 2003;28:S167–75
52. Blumenthal SL, Ohnmeiss DD, Guyer RD, Hochschuler SH. Prospective study evaluating total disc replacement: preliminary results. J Spinal Disord Tech 2003;16:450–4
53. Shim CS, Lee SH, Park CW, Choi WC, Choi G, Choi WG, Lim SR, Lee HY. Partial disc replacement with the PDN prosthetic disc nucleus device. J Spinal Disord Tech 2003;16:324–30
54. van Ooij A, Oner FC, Verbout AJ. Complications of artificial disc replacement: a report of 27 patients with the SB Charite disc. J Spinal Disord Tech 2003;16:369–83
55. Tropiano P, Huang RC, Girardi FP, Marnay T. Lumbar disc replacement: preliminary results with ProDisc II after a minimum follow-up period of 1 year. J Spinal Disord Tech 2003;16: 362–8
56. McAfee PC, Fedder IL, Saiedy S, Shucosky EM, Cunningham BW. SB Charite disc replacement: report of 60 prospective randomized cases in a U.S. center. J Spinal Disord Tech 2003;16:424–33
57. Kim WJ, Lee SH, Kim SS, Lee C. Treatment of juxtafusional degeneration with artificial disc replacement (ADR): preliminary results of an ongoing study. J Spinal Disord Tech 2003; 16:390–7
58. Jin D, Qu D, Zhao L, Chen J, Jiang J. Prosthetic disc nucleus (PDN) replacement for lumbar disc herniation. J Spinal Disord Tech 2003;16:331–7
59. Zigler JE, Burd TA, Vialle EN, Sachs BL, Rashbaum RF, Ohnmeiss DD. Lumbar spine arthroplasty: early results using ProDisc II: a prospective randomized trial of arthroplasty versus fusion. J Spinal Disord Tech 2003;16:352–61
60. Guyer RD, McAfee PC, Hochschuler SH, Blumenthal SL, Fedder IL, Ohnmeiss DD, Cunningham BW. Prospective randomized study of the Charite artificial disc: data from two investigational centers. Spine J 2004;4(6 suppl):252S–259S
61. Lemaire JP, Carrier H, Sariali el-H, Skalli W, Lavaste F. Clinical and radiological outcomes with the Charite artificial disc. A 10-year minimum follow-up. J Spinal Disord Tech 2005;18:353–9
62. Blumenthal S, McAfee PC, Guyer RD, Hochschuler SH, Geisler FH, Holt RT, Garcia R Jr, Regan JJ, Ohnmeiss DD. A prospective, randomized, multicenter Food and Drug Administration investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I: evaluation of clinical outcomes. Spine 2005;30:1565–75
63. Cakir B, Richter M, Kafer W, Puhl W, Schmidt R. The impact of total lumbar disc replacement on segmental and total lumbar lordosis. Clin Biomech 2005;20:357–64
64. Tropiano C, Huang RC, Girardi FP, Cammisa FP Jr, Marnay T. Lumbar total disc replacement. Seven to eleven-year follow-up. Bone Joint Surg Am 2005;87:490–6
65. Bertagnoli R, Yue JJ, Fenk-Mayer A, Eurulkar J, Emerson JW. Treatment of symptomatic adjacent-segment degeneration after lumbar fusion with total disc arthroplasty by using ProDisc prosthesis: a prospective study with 2-year minimum follow-up. J Neurosurg Spine 2006;4:91–7
66. Bertagnoli R, Yue JJ, Nanieva R, Fenk-Mayer A, Husted DS, Shah RV, Emerson JW. Lumbar total disc arthroplasty in patients older than 60 years of age: a prospective study of the ProDisc prosthesis with 2-year minimum follow-up period. J Neurosurg Spine 2006;4:85–90
67. Bertagnoli R, Yue JJ, Kershaw T, Shah RV, Pfeiffer F, Fenk-Mayer A, Nanieva R, Karg A, Husted DS, Emerson JW. Lumbar total disc arthroplasty utilizing the ProDisc prosthesis in smokers versus nonsmokers: a prospective study with 2-year minimum follow-up. Spine 2006;31:992–7
68. Chung SS, Lee CS, Kang CS. Lumbar total disc replacement using ProDisc II: a prospective study with a 2-year minimum follow-up. J Spinal Disord Tech 2006;19:411–5
69. Regan JJ, McAfee PC, Blumenthal SL, Guyer RD, Geisler FH, Garcia R Jr, Maxwell JH. Evaluation of surgical volume and the early experience with lumbar total disc replacement as part of the investigational device exemption study of the Charite Artificial Disc. Spine 2006;31:2270–6
70. Siepe CJ, Mayer HM, Wiechert K, Korge A. Clinical results of total lumbar disc replacement with ProDisc II: three-year results for different indications. Spine 2006;31:1923–32
71. Jacobs WC, Anderson PG, Limbeek J, Willems PC, Pavlov P. Single or double-level anterior interbody fusion techniques for cervical degenerative disc disease. Cochrane Database Syst Rev 2004;18:CD004958
72. Hubach PC. A prospective study of anterior cervical spondylodesis in intervertebral disc disorders. Eur Spine J. 1994;3: 209–13
73. Viikari-Juntura E, Raininko R, Videman T, Porkka L. Evaluation of cervical disc degeneration with ultralow field MRI and discography. An experimental study on cadavers. Spine 1989; 14:616–9
74. Klafta LA, Collis JS. An analysis of cervical discography with surgical verification. J Neurosurg 1969;30:38–41
75. Simmons EH, Bhalla SK. Anterior cervical discectomy and fusion. A clinical and biochemical study with eight-year follow-up. J Bone Joint Surg 1969;51:225–37
76. Riley LH, Robinson RA, Johnson KA, Walker AE. The results of anterior interbody fusion of the cervical spine. J Neurosurg 1969;30:127–33
77. Whitecloud TS, Seago RA. Cervical discogenic syndrome. Results of operative intervention in patients with positive discography. Spine 1987;12:313–6
78. Palit M, Schofferman J, Goldthwaite N, Reynolds J, Kerner M, Keaney D, Lawrence-Miyasaki L. Anterior discectomy and fusion for the management of neck pain. Spine 1999;24:2224–8
79. Siebenrock KA, Aebi M. Cervical discography in discogenic pain syndrome and its predictive value for cervical fusion. Arch Orthop Trauma Surg 1994;113:199–203
80. Motiyama A, Arici M, George D, Ramsby G. Diagnostic value of cervical discography in the management of cervical discogenic pain. Conn Med 2000;64:395–8
81. Roth DA. Cervical analgesic discography. A new test for the definitive diagnosis of the painful-disk syndrome. JAMA 1976;235:1713–4
82. Chirls M. Discography, myelography, and interbody fusions for cervical syndrome. J Med Soc N J 1970;67:530–2
83. Williams JL, Allen MB Jr, Harkess JW. Late results of cervical discectomy and interbody fusion: some factors influencing the results. J Bone Joint Surg Am 1968;50:277–86
84. Heiskari M. Comparative retrospective study of patients operated for cervical disc hernation and spondylosis. Ann Clin Res 1986;18(suppl):57–63
85. Martins AN. Anterior cervical discectomy with and without interbody bone graft. J Neurosurg 1976;44:290–5
86. Schaerer JP. Anterior cervical disc removal and fusion. Schweiz Arch Neurol Neurochir Psychiatr 1968;102:331–44
87. Goffin J, Casey A, Kehr P, Liebig K, Lind B, Logroscino C, Pointillart V, Van Calenbergh F, van Loon J. Preliminary clinical experience with the Bryan Cervical Disc Prosthesis. Neurosurgery 2002;51:840–5
88. Philips FM, Garfin SR. Cervical disc replacement. Spine 2005;30(17 suppl):S27–33
89. Anderson PA, Sasso RC, Rouleau JP, Carlson CS, Goffin J. The Bryan Cervical Disc: wear properties and early clinical results. Spine J 2004;4(6 suppl):303S–309S
90. Sekhon LH, Sears W, Duggal N. Cervical arthroplasty after previous surgery: results of treating 24 discs in 15 patients. J Neurosurg Spine 2005;3:335–41
91. Bertagnoli R, Yue JJ, Pfeiffer F, Fenk-Mayer A, Lawrence JP, Kershaw T, Husted DS. Early results after ProDisc-C cervical disc replacement. J Neurosurg Spine 2005;2:403–10
92. Zeidman SM, Thompson K, Ducker TB. Complications of cervical discography: analysis of 4400 diagnostic disc injections. Neurosurgery 1995;37:414–7
93. Manchikanti L, Pampati V, Fellows B, Bakhit CE. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents. Curr Rev Pain 2000;4:337–44
94. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 1994;58:195–200
95. Manchikanti L, Pampati V, Fellows B, Bakhit CE. Prevalence of lumbar facet joint pain in chronic low back pain. Pain Physician 1999;2:59–64
96. Schwarzer AC, Wang SC, Bogduk N, McNaught PJ, Laurent R. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis 1995;54:100–6
97. Murtagh FR. Computed tomography and fluoroscopy guided anesthesia and steroid injection in facet syndrome. Spine 1988;13:686–9
98. Jackson RP, Jacobs RR, Montesano PX. Facet joint injection in low-back pain. A prospective statistical study. Spine 1988; 13:966–71
99. Revel M, Poiraudeau S, Auleley GR, Payan C, Denke A, Nguyen M, Chevrot A, Fermanian J. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine 1998;23:1972–6
100. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine 1994;19:801–6
101. Bogduk N. International Spinal Injection Society guidelines for the performance of spinal injection procedures. Part I: zygapophysial joint blocks. Clin J Pain 1997;13:285–302
102. Dreyfuss PH, Dreyer SJ. Lumbar zygapophysial joint (facet) injections. Spine J 2003;3:50S–59S
103. Berven S, Tay BB, Colman W, Hu SS. The lumbar zygapophyseal (facet) joints: a role in the pathogenesis of spinal pain syndromes and degenerative spondylolisthesis. Semin Neurol 2002;22:187–95
104. Marks RC, Houston T, Thulbourne T. Facet joint injection and facet nerve block: a randomized comparison in 86 patients with chronic low back pain. Pain 1992;49:325–8
105. Nash TP. Facet joints. Intra-articular steroids or nerve block? Pain Clinic 1990;3:77–82
106. Cohen SP, Raja SN. Pathogenesis, diagnosis and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology 2007;106:591–614
107. Birkenmaier C, Veihelmann A, Trouillier HH, Hausdorf J, von Schulze Pellengahr C. Medial branch blocks versus pericapsular blocks in selecting patients for percutaneous cryodenervation of lumbar facet joints. Reg Anesth Pain Med 2007;32: 27–33
108. Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 2000;25: 1270–7
109. Lord SM, Barnsley L, Wallis BJ, McDonald GJ, Bogduk N. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med 1996;335:1721–6
110. Barnsley L. Percutaneous radiofrequency neurotomy for chronic neck pain: outcomes in a series of consecutive patients. Pain Med 2005;6:282–6
111. Bough B, Thakore J, Davies M, Dowling F. Degeneration of the lumbar facet joints. Arthography and pathology. J Bone Joint Surg Br 1990;72:275–6
112. Schwarzer AC, Derby R, Aprill CN, Fortin J, Kine G, Bogduk N. The value of the provocation response in lumbar zygapophyseal joint injections. Clin J Pain 1994;10:309–13
113. Esses SI, Moro JK. The value of facet joint blocks in patient selection for lumbar fusion. Spine 1993;18:185–90
114. Jackson RP. The facet syndrome. Myth or reality? Clin Orthop Relat Res 1992;279:110–21
115. Kim TK, Kim KH, Kim CH, Shin SW, Kwon JY, Kim HK, Baik SW. Percutaneous vertebroplasty and facet joint block. J Korean Med Sci 2005;20:1023–8
116. Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, Goette K. The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study. J Bone Joint Surg Am 2000;82:1589–93
117. Riew KD, Park JB, Cho YS, Gilula L, Patel A, Lenke LG, Bridwell KH. Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. J Bone Joint Surg Am 2006;88:1722–5
118. Narozny M, Zanetti M, Boos N. Therapeutic efficacy of selective nerve root blocks in the treatment of lumbar radicular pain. Swiss Med Wkly 2001;131:75–80
119. DePalma MJ, Bhargava A, Slipman CW. A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy. Arch Phys Med Rehabil 2005;86:1477–83
120. Windsor RE, Storm S, Sugar R, Nagula D. Cervical transforaminal injection: review of the literature, complications, and a suggested technique. Pain Physician 2003;6:457–65
121. Bush K, Hillier S. Outcome of cervical radiculopathy treated with periradicular/epidural corticosteroid injections: a prospective study with independent clinical review. Eur Spine J 1996;5:319–25
122. Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Pain 2003;103:211–5
123. Rozin L, Rozin R, Koehler SA, Shakir A, Ladham S, Barmada M, Dominick J, Wecht CH. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol 2003;24:351–5
124. Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: report of three cases. Spine J 2002;2:70–5
125. Glaser SE, Falco F. Paraplegia following a thoracolumbar transforaminal epidural steroid injection. Pain Physician 2005;8:309–14
126. Larkin TM, Carragee E, Cohen S. A novel technique for delivery of epidural steroids and diagnosing the level of nerve root pathology. J Spinal Disord Tech 2003;16:186–92
127. North RB, Kidd DH, Zahurak M, Piantadosi S. Specificity of diagnostic nerve blocks: a prospective, randomized study of sciatica due to lumbosacral spine disease. Pain 1996;65: 77–85
128. Castro WH, Gronemeyer D, Jerosch J, Seibel R, Lorenz G, Beutelstahl D, Ohlbrecht K, Gohlke KH. How reliable is lumbar nerve root sheath infiltration? Eur Spine J 1994;3: 255–7
129. Wolff AP, Groen GJ, Crul BJ. Diagnostic lumbosacral segmental nerve blocks with local anesthetics: a prospective double-blind study on the variability and interpretation of segmental effects. Reg Anesth Pain Med 2001;26:147–55
130. Wolff AP, Wilder Smith OH, Crul BJ, van de Heijden MP, Groen GJ. Lumbar segmental nerve blocks with local anesthetics, pain relief, and motor function: a prospective double-blind study between lidocaine and ropivacaine. Anesth Analg 2004;99:496–501
131. Wolff AP, Groen GJ, Wilder-Smith OH, Richardson J, van Egmond J, Crul BJ. Do diagnostic segmental nerve root blocks in chronic low back pain patients with radiation to the leg lack distinct sensory effects? A preliminary study. Br J Anaesth 2006;96:253–8
132. Foerster O. The dermatomes in man. Brain 1933;56:1–39
133. Anderberg L, Annertz M, Brandt L, Saveland H. Selective diagnostic cervical nerve root block—correlation with clinical symptoms and MRI-pathology. Acta Neurochir (Wien) 2004; 146:559–65
134. Anderberg L, Annertz M, Rydholm U, Brandt L, Saveland H. Selective diagnostic nerve root block for the evaluation of radicular pain in the multilevel degenerated cervical spine. Eur Spine J 2006;15:794–801
135. Anderberg L, Saveland H, Annertz M. Distribution patterns of transforaminal injections in the cervical spine evaluated by multi-slice computed tomography. Eur Spine J 2006;15:1465–71
136. Slipman CW, Plastaras CT, Ralmitier RA, Huston CW, Sterenfeld EB. Symptom provocation of fluoroscopically guided cervical nerve root stimulation. Are dynatomal maps identical to dermatomal maps? Spine 1998;23:2235–42
137. Stanley D, McLaren MI, Euinton HA, Getty CJ. A prospective study of nerve root infiltration in the diagnosis of sciatica. A comparison with radiculography, computed tomography, and operative findings. Spine 1990;15:540–3
138. Dooley JF, McBroom RJ, Taguchi T, Macnab I. Nerve root infiltration in the diagnosis of radicular pain. Spine 1988;13: 79–83
139. Krempen JF, Smith BS. Nerve-root injection: a method for evaluating the etiology of sciatica. J Bone Joint Surg Am 1974;56: 1435–44
140. Jonsson B, Stromqvist B, Annertz M, Holtas S, Sunden G. Diagnostic lumbar nerve root block. J Spinal Disord 1988;1: 232–5
141. Herron LD. Selective nerve root block in patient selection for lumbar surgery: surgical results. J Spinal Disord 1989;2:75–9
142. van Akkerveeken PF. The diagnostic value of nerve root sheath infiltration. Acta Orthop Scand 1993;64(suppl 251):61–3
143. Aspinall S, Mohammed S, Burke J, Sanderson PL. The value of nerve root injections in the evaluation of sciatica in patients with normal MRI scans. J Bone Joint Surg Br 2004;87(suppl 3):243
144. Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis and treatment. Anesth Analg 2005; 101:1440–53
145. Dreyfuss P, Dreyer SJ, Cole A, Mayo K. Sacroiliac joint pain. J Am Acad Orthop Surg 2004;12:255–65
146. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995;20:31–7
147. Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996;21:2594–602
148. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine 1989;14:162–5
149. Maigne JY, Boulahdour H, Chatellier G. Value of quantitative radionuclide bone scanning in the diagnosis of sacroiliac joint syndrome in 32 patients with low back pain. Eur Spine J 1998;7:328–31
150. Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E. The value of radionuclide imaging in the diagnosis of sacroiliac joint syndrome. Spine 1996;21:2251–4
151. Elgafy H, Semaan HB, Ebraheim NA, Coombs RJ. Computed tomography findings in patients with sacroiliac pain. Clin Orthop Relat Res 2001;382:112–8
152. Calvillo O, Skaribas I, Turnipseed J. Anatomy and pathophysiology of the sacroiliac joint. Curr Rev Pain 2000;4:356–61
153. Rosenberg JM, Quint DJ, de Rosayro AM. Computerized tomographic localization of clinically-guided sacroiliac joint injections. Clin J Pain 2000;16:18–21
154. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;21:1889–92
155. Manchikanti L, Singh V, Pampati V, Damron K, Barnhill R, Beyer C, Cash K. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician 2001;4:308–16
156. Luukkainen R, Nissila M, Asikainen E, Sanila M, Lehtinen K, Alanaatu A, Kautiainen H. Periarticular corticosteroid treatment of the sacroiliac joint in patients with seronegative spondyloarthropathy. Clin Exp Rheumatol 1999;17:88–90
157. Luukkainen R, Wennerstrand PV, Kautiainen HH, Sanila MT, Asikainen EL. Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in non-spondyloarthropathic patients with chronic low back pain in the region of the sacroiliac joint. Clin Exp Rheumatol 2002;20:52–4
158. Smith-Petersen MN, Rogers WA. End-result study of arthrodesis of sacroiliac joint for arthritis—traumatic and nontraumatic. J Bone Joint Surg 1926;8:118–31
159. Campbell WC. Operative measures in the treatment of affections of the lumbosacral and sacroiliac articulation. Surg Gynecol Obstet 1930;51:381–6
160. Dabezies EJ, Millet CW, Murphy CP, Acker JH, Robicheaux RE, D’Ambrosia RD. Stabilization of sacroiliac joint disruption with threaded compression rods. Clin Orthop Relat Res 1989;246:165–71
161. Waisbrod H, Krainick JU, Gerbershagen HU. Sacroiliac joint arthrodesis for chronic lower back pain. Arch Orthop Trauma Surg 1987;106:238–40
162. Buchowski JM, Kebaish KM, Sinkov V, Cohen DB, Sieber AN, Kostuik JP. Functional and radiographic outcome of sacroiliac arthrodesis for the disorders of the sacroiliac joint. Spine J 2005;5:520–8
163. Schutz U, Grob D. Poor outcome following bilateral sacroiliac joint fusion for degenerative sacroiliac joint syndrome. Acta Orthop Belg 2006;72:296–308
164. Berthelot JM, Gouin F, Glemarec J, Maugars Y, Prost A. Possible use of arthrodesis for intractable sacroiliitis in spondylarthropathy: report of two cases. Spine 2001;26:2297–9
165. Belanger RA, Dall BE. Sacroiliac arthrodesis using a posterior midline fascial splitting approach and pedicle screw instrumentation: a new technique. J Spinal Disord 2001; 14:118–24
166. Giannikas KA, Khan AM, Karski MT, Maxwell HA. Sacroiliac joint fusion for chronic pain: a simple technique avoiding the use of metalwork. Eur Spine J 2004;13:253–6
167. Hogan QH, Abram SE. Neural blockade for diagnosis and prognosis. A review. Anesthesiology 1997;86:216–41
168. Manchikanti L, Pampati V, Damron K. The role of placebo and nocebo effects of perioperative administration of sedatives and opioids in interventional pain management. Pain Physician 2005;8:349–55
169. Ackerman WE, Munir MA, Zhang JM, Ghaleb A. Are diagnostic lumbar facet injections influenced by pain of muscular origin? Pain Practice 2004;4:286–91
170. Woolf CJ, Wiesenfeld-Hallin Z. The systemic administration of local anaesthetics produces a selective depression of C-afferent fibre evoked activity in the spinal cord. Pain 1985;23:361–74
171. Hansen HC, McKenzie-Brown AM, Cohen SP, Spicegood JR, Colson JD, Manchikanti L. Sacroiliac joint interventions: a systematic review. Pain Physician 2007;10:165–84
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