Provocative Discography in Patients After Limited Lumbar Discectomy: A Controlled, Randomized Study of Pain Response in Symptomatic and Asymptomatic Subjects Psychological aspects of chronic low back pain. Evaluation of the relative contributions of various structures in chronic low back pain. Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks. Reliability of psychological evaluation in chronic pain in an interventional pain management setting. The Relative Contributions of the Disc and Zygapophyseal Joint in Chronic Low Back Pain Evaluation of the effect of sedation as a confounding factor in the diagnostic validity of lumbar facet joint pain: a prospective, randomized, double-blind, placebo-controlled evaluation. Clinical Features of Patients with Pain Stemming from the Lumbar Zygapophysial Joints: Is the Lumbar Facet Syndrome a Clinical Entity? Is Sedation Indicated Before Spinal Injections? Characteristics of chronic low back pain in patients in an interventional pain management setting: a prospective evaluation. The effect of sedation on diagnostic validity of facet joint nerve blocks: an evaluation to assess similarities in population with involvement in cervical and lumbar regions (ISRCTNo: 76376497). Results of Sacroiliac Joint Double Block and Value of Sacroiliac Pain Provocation Tests in 54 Patients With Low Back Pain Prevalence of lumbar facet joint pain in chronic low back pain. The role of placebo and nocebo effects of perioperative administration of sedatives and opioids in interventional pain management. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents Chronic Cervical Zygapophysial Joint Pain After Whiplash: A Placebo‐Controlled Prevalence Study A randomized, prospective, double-blind, placebo-controlled evaluation of the effect of sedation on diagnostic validity of cervical facet joint pain. The Prevalence of Chronic Cervical Zygapophysial Joint Pain After Whiplash Provocative discography in low back pain patients with or without somatization disorder: a randomized prospective evaluation.
Study Design . This was a prospect i ve observational study of patients with low back pain and those without after laminotomy and discectomy .  Objectives . To determine , using a strict experimental design , the relative pain intensity response to provocative discography in symptomatic and asymptomatic subjects after lumbar discectomy for intervertebral disc herniation . Background . Provocative discography frequently is used to evaluate persistent or recurrent low back pain syndromes in patients who have undergone posterior discectomy . The validity of interpreting painful injections during this procedure has not been critically assessed . The prevalence of significantly painful disc injections in a group with good outcomes after surgery is not known . Knowing the rates of significantly painful injections in asymptomatic patients after lumbar discectomy may clarify the meaning of painful injections in symptomatic patients . Methods . From a cohort of 240 patients who had undergone single-level limited discectomy for sciatica , 20 asymptomatic volunteers were recruited for experimental three-level lumbar discography . Inclusion criteria required nearly perfect scores on st and ardized back pain rating instruments , no other spinal pathology , and normal psychometric screening . A control group of 27 symptomatic patients , after single-level discectomy with intractable low back pain syndrome , and without other spinal pathology , underwent discography . Seven patients in the control group had normal psychometric tests . Experienced raters who were blinded to control versus experimental status of the subjects scored the magnetic resonance imaging , discogram , psychometric tests , and discography videotapes of the subjects ’ pain behavior . Results . There were 8 of 20 ( 40 % ) positive injections of discs that had previous surgery in the asymptomatic group and 17 of 27 ( 63 % ) positive injections in the symptomatic group . Specifically with regard to the symptomatic group , there were 3 of 7 ( 43 % ) positive injections ( all concordant ) in patients with normal psychometric scores , as compared with 14 of 20 ( 70 % ) positive injections ( 12 concordant ) in patients with abnormal psychometric scores . Injections of discs that had previous surgery result ed in a mean pain score of 2.1 of 5 in the asymptomatic group , 2.1 in the symptomatic group with normal psychometric scores , and 3.4 in the symptomatic group with abnormal psychometric scores . Of the discs not treated with surgery , 2 were positive in the asymptomatic group ( 10 % ) , 3 in 2 symptomatic subjects with normal psychological testing ( 29 ) , and 18 in 13 symptomatic subjects with abnormal psychometric testing ( 76 % ) . Conclusions . A high percentage of asymptomatic patients with normal psychometric testing who previously have undergone lumbar discectomy will have significant pain on injection of their discs that had previous surgery ( 40 % ) . This is not significantly different from the experience of symptomatic patients with normal psychometric testing undergoing discography on discs that had previous surgery . Patients with abnormal psychological profiles have significantly higher rates of positive disc injections than either asymptomatic volunteers or symptomatic subjects with normal psychological screening BACKGROUND Patients with chronic low back pain present physicians with diagnostic and therapeutic problems . Physical treatments tend to have low success rates and it is postulated that this may be because low back pain can be a manifestation of abnormal illness behaviour . METHODS A structured prospect i ve study determined the prevalence of somatization in a sample of 131 adult patients with chronic low back pain using the Illness Behaviour Question naire ( IBQ ) and the Modified Somatic Perception Question naire ( MSPQ ) . The scores on these psychological question naires were compared with the blind interpretation of pain distribution drawings and with the results of a mechanical classification of the patient 's symptoms and signs . RESULTS Fifty-four per cent of patients had four or more ( out of five ) abnormal illness indicators . The MSPQ values for the group were significantly above the control values in the literature . Thirty-two per cent of pain diagrams were thought to be incompatible with an organic cause when assessed by an orthopaedic surgeon and sixty-two per cent when assessed by a psychiatrist . CONCLUSIONS Psychosocial factors are dominant in the presentation of chronic low back pain in adults and the disorder is not primarily a musculoskeletal one An attempt was made to determine the relative contribution of various structures to chronic low back pain , including facet joint(s ) , disc(s ) , and sacroiliac joint(s ) in a prospect i ve evaluation . Precision diagnostic blocks , including disc injections , facet joint blocks , and sacroiliac joint injections , are frequently used . In contrast , selective nerve root blocks or transforaminal epidural injections are used occasionally to evaluate persistent or recurrent low back pain in patients without appropriate radiologic or neurophysiologic diagnosis . One hundred and twenty patients with a chief complaint of low back pain were evaluated with precision diagnostic injections , which included medial branch blocks , provocative discography and sacroiliac joint injections . In 40 % ( 95 % CL , 31 % , 49 % ) , of the patients , facet joint pain was diagnosed ; and in 26 % ( 95 % CL , 18 % , 34 % ) of the patients discogenic pain was diagnosed ; and 2 % of the patients were diagnosed with sacroiliac joint pain OBJECTIVE To evaluate the prevalence of facet joint pain in patients with chronic low back pain ( CLBP ) after surgical intervention(s ) . DESIGN A prospect i ve , nonr and omized , consecutive study . SETTING An ambulatory interventional pain management setting . PARTICIPANTS The prevalence of facet joint pain was evaluated in patients with CLBP after various surgical intervention(s ) referred to an interventional pain management practice . The sample was derived from 282 patients with persistent CLBP after various surgical intervention(s ) . Of these , 242 patients consented to undergo interventional techniques .  A total of 117 consecutive patients with chronic , nonspecific low back pain , after lumbar surgical intervention(s ) were evaluated with controlled , comparative local anesthetic blocks . INTERVENTIONS Controlled , comparative local anesthetic blocks ( 1 % lidocaine or 1 % lidocaine followed by .25 % bupivacaine ) under fluoroscopic visualization using 0.5mL to block each facet joint nerve . MAIN OUTCOME MEASURES A positive response was defined as at least 80 % reduction of pain with ability to perform previously painful movements . A positive response was considered to be pain relief from the lidocaine block lasting at least 1 hour or at least 2 hours or greater than duration of relief with lidocaine when bupivacaine was used . Controlled , comparative local anesthetic blocks were used to eliminate false-positive results . Valid information is only obtained by performing controlled blocks in the form of comparative local anesthetic blocks , in which , on 2 separate occasions , the same joint is anesthetized by using local anesthetics with different duration s of action . If patients obtained appropriate response with both blocks , they were considered a positive . If they obtained appropriate response with lidocaine but not with bupivacaine , they were considered false-positive , whereas if the response was negative with lidocaine , they were considered negative . RESULTS The prevalence of lumbar facet joint pain in patients with recurrent pain after various surgical intervention(s ) was 16 % ( 95 % confidence interval , 9%-23 % ) . The false-positive rate with a single block with lidocaine was 49 % . CONCLUSIONS Facet joints are clinical ly important pain generators in a small but significant proportion of patients with recurrent CLBP after various surgical intervention(s ) BACKGROUND Psychological disorders may be associated with poor pain related treatment outcomes . However , there may be limitations with studies evaluating the relationship between pain and psychopathology . OBJECTIVE To assess the reliability of  psychological evaluations  in interventional pain management by MCMI-III(R ) and P-3(R ) . STUDY DESIGN Prospect i ve evaluation of consecutive patients in an interventional pain management center . METHODS Patients were evaluated using a DSM-IV-TR(R ) question naire with a physician interview as an integral part of their comprehensive evaluation . In addition , all the patients participating in this study also underwent psychological evaluation with MCMI-III and P-3 . A positive diagnosis of major depression or generalized anxiety disorder based on DSM-IV-TR criteria was considered as the criterion st and ard . All of the patients presented for treatment of chronic pain . The data based on the criterion st and ard were compared with results of the diagnostic impression from the MCMI-III and the P-3 evaluation utilizing criteria for average , and above average , patient pain scores . RESULTS Major depression was diagnosed in a total of 59 of 100 patients using DSM-IV-TR criteria , in 32 patients based on MCMI-III criteria , and in 55 patients based on P-3 evaluations utilizing average pain patient criteria . Generalized anxiety disorder was diagnosed in 55 patients by means of DSM-IV-TR , 45 patients by MCMI-III , and 55 patients by P-3 Profile utilizing average pain patient scores . The specificity of MCMI-III was 100 % with a sensitivity of 54 % for diagnosis of depression ; whereas it was 78 % specificity and sensitivity for P-3 , with average pain patient scores . For generalized anxiety disorder , specificity of MCMI-III was 89 % with a sensitivity of 73 % compared to specificity of 80 % and sensitivity of 84 % for average pain patient scores for P-3 . CONCLUSION MCMI-III and P-3 are highly specific in diagnosing depression and generalized anxiety disorder , with variable sensitivity . A DSM-IV-TR question naire evaluation incorporated into the pain management question naire , along with a short clinical interview , is a reliable means of assessing depression and anxiety in patients suffering with chronic pain Study Design . A prospect i ve cross-sectional analytic approach was taken . Objectives . This study sought to determine the relative contribution of the disc and the zygapophyseal Joint as a pain source in patients with chronic low back pain . Summary of Background Data . Previous studies have employed either zygapophyseal joint blocks or discography , but in no studies have both procedures been performed . Methods . Ninety-two consecutive patients with chronic low back pain were studied using both discography and blocks of the zygapophyseal joints . Results . Thirty-six patients ( 39 % ) had at least one positive discogram as defined by exact pain reproduction , an abnormal image , and a negative control . Eight patients responded to both a screening zygapophyseal joint block using lignocaine and confimatory block using bupivacaine . Only three patients had both a positive discogram and a symptomatic zygapophyseal joint . Conclusions . In patients with chronic low back pain , the combination of discogenic pain and zygapophyseal joint pain is uncommon BACKGROUND Lumbar facet ( zygapophysial ) joints have been implicated as the source of chronic pain in 15 % to 45 % of patients with chronic low back pain . Diagnosis may be confounded by false-positive results with a single diagnostic block and administration of anxiolytics and narcotics prior to or during the diagnostic facet joint blocks . OBJECTIVE To evaluate the effect of midazolam and fentanyl on the diagnostic validity of of lumbar facet joint pain . STUDY DESIGN R and omized , prospect i ve , double-blind , placebo-controlled evaluation . METHODS The design consisted of a placebo group receiving sodium chloride solution and two experimental groups receiving either midazolam or fentanyl . The patients included in the study were diagnosed with facet joint pain with controlled comparative local anesthetic blocks of medial branches or L5 dorsal rami . They had been treated with lumbar facet joint nerve blocks with good pain relief , and were presenting for repeat treatment after a period of symptom relief . The study was undertaken in an interventional pain management practice . OUTCOME MEASURES Outcomes were assessed at baseline and after the administration of 1 of the 3 solutions ( Group I , sodium chloride solution ; Group II , midazolam ; or Group III , fentanyl ) . Outcome measures included numeric pain scale , proportion of pain relief , and ability to perform prior painful movements . RESULTS Pain relief of > or = 80 % was noted in 2 % of the patients in Group I , 5 % of the patients in Group II , and 7 % in Group III . Pain relief of > or = 50 % was noted in 7 % of the patients in Group I , 5 % of the patients in Group II , and 13 % of the patients in Group III . There were no significant differences among the groups . CONCLUSION The administration of sedation with midazolam or fentanyl is a confounding factor in the diagnosis of lumbar facet joint pain in patients with chronic low back pain . However , this study suggests that if strict criteria including pain relief and ability to perform prior painful movements is used as the st and ard for evaluating the effect of controlled local anesthetic blocks , the diagnostic validity of lumbar facet joint nerve blocks may be preserved Study Design This study is a prospect i ve cross-sectional analytic study . Objectives The authors determined the prevalence and clinical features of patients with pain stemming from the lumbar zygapophysial joints . Summary of Background Data Previous studies have demonstrated a wide range of prevalence for zygapophysial joint pain and conflicting results with regard to clinical signs . Methods One hundred and seventy-six consecutive patients with chronic low back pain were investigated with a series of screening zygapophysial joint blocks using lignocaine and confirmatory blocks using bupivacaine . Results Forty-seven percent of patients had a definite or greater response to the screening injection at one or more levels but only 15 % had a 50 % or greater response to a confirmatory block . Response to zygapophysial joint injection was not associated with any single clinical feature or set of clinical features . Conclusions The zygapophysial joint is an important source of pain but the existence of a “ facet syndrome ” must be question ed Study Design . Survey . Objective . The purpose of this research was to help determine whether sedation is indicated before lumbar and cervical interventional pain management procedures , and additionally , to determine whether benzodiazepams are effective at controlling anxiety for these procedures . Summary of Background Data . The use of sedation before diagnostic and therapeutic epidurals seems to vary widely and no guidelines have been issued that address whether sedation is indicated and for which patients . There is a need to provide periprocedural protocol s to provide the safest , most comfortable experience for the patient . Methods . Three hundred one consecutive spinal injection patients were given a choice to take oral or IV diazepam , or no sedation before a spinal injection . All participating patients filled in a vali date d anxiety question naire before the injection . Patients were asked after the injection whether they were satisfied with their decision regarding sedation and whether their anxiety was controlled effectively . Results . Fifty-eight percent of our patients chose to be se date d. Those patients who requested sedation were more anxious . The majority of patients were satisfied with their decision regarding  sedation  , and diazepam effectively controlled anxiety in 90 % of patients . Conclusion . Routine sedation does not seem to be required for patients receiving spinal injections , but more-anxious patients benefit from sedation before an injection . Benzodiazepams are effective in controlling anxiety for the majority of patients Chronic low back pain patients are seen in multiple practice setting s and managed with a multitude of therapeutic interventions . Studies conducted by various groups have made some generalizations in the literature describing low back pain patients . However , there are no studies evaluating the demographic features of patients presenting to therapeutic interventional pain medicine programs .  This prospect i ve study was undertaken to evaluate and explore various demographic features of patients with chronic low back pain presenting to a therapeutic interventional pain medicine program . Two hundred patients were studied , with evaluation of demographic features of age , mode of onset of pain , work status , history of surgery , and pain characteristics . The results showed that , among patients presenting to an interventional pain medicine program  , 17 % are over 65 years of age : they are predominantly women ; two thirds are either overweight or obese ; the mean duration of pain is 7 years , predominantly involving multiple regions , with an average  pain intensity of 7.6 , significant associated psychological conditions ; they have undergone multiple interventions , and were seen by , on average , six physicians ; and the majority of patients were not employed , with 31 % unemployed and 52 % disabled or retired BACKGROUND Zygapophysial or facet joint pain in patients suffering with chronic spinal pain without disc herniation or radiculopathy may be diagnosed with certainty by the use of controlled diagnostic blocks . But , in patients suffering with either lumbar or cervical facet joint pain , even this diagnostic approach may be confounded by false-positives when using a single diagnostic block . It may also be confounded by the administration of anxiolytics and narcotics prior to , or during , the controlled diagnostic facet joint blocks . The effect of sedation on the validity and potential differential results in patients suffering with combined cervical and lumbar facet joint pain has not been evaluated . OBJECTIVE To assess the effects of midazolam and fentanyl on the diagnostic validity of facet joint blocks in patients suffering with both cervical and lumbar facet joint pain . STUDY DESIGN R and omized , double-blind , placebo-controlled study . METHODS The design consisted of a placebo group receiving a sodium chloride solution and two experimental groups receiving either midazolam or fentanyl .  Patients included in the study had been diagnosed with facet joint pain using controlled comparative local anesthetic blocks  of the medial branches and L5 dorsal rami . They had been treated with lumbar and cervical facet joint nerve blocks and experienced good pain relief ; and were presenting for repeat treatment after a period of symptom relief . The study was performed in an interventional pain management practice in the United States ; a total of 60 patients participated with 20 patients r and omly allocated into each group . Outcome measures included numeric pain scores , proportion of pain relief , and ability to perform prior painful movements . OUTCOME MEASURES Outcomes were assessed at baseline and after the administration of 1 of the 3 solutions ( Group I , sodium chloride solution ; Group II , midazolam ; or Group III , fentanyl ) . RESULTS Overall , 50 % of the patients were relaxed or se date d in the placebo group , while 100 % of the patients in the midazolam and fentanyl groups were relaxed or se date d. As many as 10 % of the patients reported significant relief ( > = 80 % ) with the ability to perform prior painful movements . CONCLUSIONS Perioperative administration of sodium chloride , midazolam , or fentanyl can confound results in the diagnosis of combined cervical and lumbar facet joint pain . False-positive results with placebo or sedation may be seen in a small proportion of patients Study Design This prospect i ve study consisted of the evaluation of a double sacroiliac block in patients with low back pain . Objectives To determine the prevalence of sacroiliac pain in a selected population of patients suffering from low back pain , and to assess certain pain provocation tests . Summary of Background Data Previous studies have implicated the sacroiliac joint as a potential etiology of back and leg pain , but none has tested double anesthetic blocks in a prospect i ve fashion . Methods Fifty‐four patients with unilateral low back pain , pain mapping compatible with a sacroiliac origin , tenderness over the sacroiliac joint , and no obvious source of pain in the lumbar spine were selected for a double anesthetic block . The procedure consisted of a thorough clinical examination with a visual analog scale , testing of sacroiliac pain provocation tests followed by a first screening block with a short‐acting anesthetic . A second examination consisting of the same tests assessed the efficacy of the first block . If results were positive , a confirmatory block was performed . All blocks were performed under fluoroscopic guidance . Results Nineteen patients had a  positive response to the first block . Among them , 10 ( 18.5 % ) were temporarily relieved by the confirmatory block . No pain provocation test reached statistical significance . Conclusion The present study suggests the sacroiliac joint is an uncommon but real source of low back pain . The accuracy of some of the presumed “ sacroiliac pain provocation tests ” is question ed This prospect i ve study was design ed to determine the prevalence of lumbar facet joint pain in a consecutive series of patients with chronic low back pain treated at an interventional , multidisciplinary private pain management practice utilizing double diagnostic blocks , to determine the prevalence of false positive rate of uncontrolled facet joint blocks , and to determine the relationship of clinical features of responders and non-responders to double diagnostic blocks . One hundred and twenty patients with low back pain with or without lower extremity pain were selected . The procedure consisted of diagnostic blocks using lidocaine and bupivacaine on separate occasions , usually two weeks apart . Each facet joint nerve was infiltrated with either 0.4 to 0.6 ml of 1 % lidocaine ( Xylocaine(R ) ) or 1 % lidocaine ( Xylocaine(R ) ) and 0.25 % bupivacaine ( Marcaine(R ) ) . A definite response was defined as substantial with at least 75 % relief of pain in the symptomatic area following local anesthetic block . Confirmatory blocks using bupivacaine 0.25 % were performed at the same levels as the first injection if definite relief was obtained . The response to bupivacaine blocks which lasted longer than the lidocaine blocks was accepted as a positive response . All blocks were performed under fluoroscopic guidance . Eighty-one patients ( 67.5 % ) reported a definite response to lidocaine blocks . Confirmatory blocks with bupivacaine were performed in all 81 patients with 54 patients , i.e. 45 % of total sample or 66.6 % of lidocaine positive group reporting definite response with a false positive rate of 41 % . Prevalence and relationship of pain referral pattern in patients with and without facet joint pain confirmed by double blocks showed no significant correlation . We found no relationship between the history , physical findings , age , gender , trauma , duration of pain , and diagnostic blocks . However , history of previous surgery showed a negative correlation as only 29 % of the patients after previous surgery were positive in contrast to 51 % of the nonsurgical population . The results of this study echo previous concerns of reliability of uncontrolled single blocks , history , and clinical features . This study demonstrated that the facet joint is a source of pain in 45 % of the patients suffering with chronic low back pain in an interventional pain management setting in a private practice BACKGROUND The role of nonspecific treatment effects in the outcomes of patients receiving interventions for pain has been the subject of controversy and interest . While the administration of placebo and its effects have been widely studied , the role of placebo and nocebo effects of active agents administered prior to or during interventional techniques has not been explored . OBJECTIVES The evaluation of placebo and nocebo effects of sodium chloride solution and active agents ( midazolam and fentanyl ) administered during interventional techniques . STUDY DESIGN R and omized , placebo-controlled , evaluation . METHODS A total of 360 patients were divided into three groups , with Group I receiving placebo , Group II receiving midazolam , and Group III receiving fentanyl . At 3 months , information was obtained with regards to their impressions or the experience of the study , compared to their previous experiences with the treatment and sedation . They were asked to rate their experience as better , worse , or no change compared to their previous experience . RESULTS Between 13 % to 30 % of patients across all three groups of the study , rated their pain relief following injection as better than their previous experience . A smaller proportion , 3 % to 8 % , of patients in all three groups rated their experience following injection as worse than their previous experience . The majority of patients , 67 % to 79 % , regardless of group , described no significant differences as compared to their previous experiences with sedation and treatment for cervical or lumbar facet joint pain . CONCLUSION In patients undergoing interventional procedures , sodium chloride solution , midazolam , and fentanyl produced placebo effects in 13 % to 15 % , 15 % to 20 % , and 18 % to 30 % of the patients respectively . Similarly , a nocebo effect was seen in 5 % to 8 % of the patients in the sodium chloride group , 8 % of the patients in the midazolam group , and 3 % to 8 % of the patients in the fentanyl group . It is concluded that positive and negative effects may be seen either with placebo or active agents in 13 % to 30 % of the patients Facet joints have been described as an important source of low back pain . The value of medial branch blocks in the diagnosis of facet joint mediated pain is considered important . However , the therapeutic value of medial branch blocks has not been determined . This study was design ed to evaluate the duration of relief obtained and therapeutic value following controlled medial branch blocks with or without adjuvant agents Sarapin ( High Chemical Company , Levittown , PA ) and Depo-medrol ( Pharmacia and Upjohn Company , Kalamazoo , MI ) . The study population consisted of 180 consecutive patients seen in a single pain management practice , divided into three groups with 60 patients in each group . Group I was treated with local anesthetic only , Group II with the addition of Sarapin , and Group III with the addition of Depo-medrol along with Sarapin . The prevalence of facet joint pain in chronic low back pain was determined as 36 % , with a false-positive rate of 25 % . Comparison of duration of relief in days with each block in the three groups showed that the relief was significantly superior in Group III compared with Group I and Group II , whereas Group II was superior to Group Study Design The authors developed a diagnostic double‐blindfolded survey using placebo‐controlled local anesthetic blocks . Objective To determine the prevalence of cervical zygapophysial joint pain among patients with chronic neck pain ( more than 3 months ' duration ) after whiplash injury . Summary of Background Data The prevalence of cervical zygapophysial joint pain after whiplash has been studied by means of comparative local anesthetic blocks . The concern is that such blocks may be compromised by placebo responses and that prevalence estimates based on such blocks may exaggerate the importance of this condition . Methods Sixty‐eight consecutive patients referred for chronic neck pain after whiplash were studied . Patients with dominant headache were first screened with the use of comparative blocks of the C2‐C3 zygapophysial joint . Patients who had positive responses concluded investigations . Those who did not experience pain relief together with the patients with dominant neck pain proceeded to undergo placebo‐controlled local anesthetic blocks . Two different local anesthetics and a placebo injection of normal saline were administered in r and om order and under double‐blindfolded conditions . A positive diagnosis was made if the patient 's pain was completely and reproducibly relieved by each local anesthetic but not by the placebo injection . Results Among patients with dominant headache , comparative blocks revealed that the prevalence of C2‐C3 zygapophysial joint pain was 50 % . Among those without C2‐C3 zygapophysial joint pain , placebo‐controlled blocks revealed the prevalence of lower cervical zygapophysial joint pain to be 49 % . Overall , the prevalence of cervical zygapophysial joint pain ( C2‐C3 or below ) was 60 % ( 95 % confidence interval , 46 % , 73 % ) . Conclusion Cervical zygapophysial joint pain is common among patients with chronic neck pain after whiplash . This nosologic entity has survived challenge with placebo‐controlled , diagnostic investigations and has proven to be of major clinical importance BACKGROUND Based on responses to controlled diagnostic blocks of cervical facet joints , the prevalence of cervical facet joint pain in chronic neck pain has been shown to range from 54 % to 67 % , with false-positive results of 27 % to 63 % with a single diagnostic block . Other confounding factors cl aim ed to influence the diagnostic validity of cervical facet joint blocks include administration of anxiolytics and narcotics prior to or during the procedure . OBJECTIVE To evaluate the effect of midazolam and fentanyl on the validity of diagnosis of cervical facet joint pain . STUDY DESIGN R and omized , prospect i ve , double-blind , placebo-controlled evaluation . METHODS The study was undertaken in an interventional pain management practice . The design consisted of a placebo group receiving sodium chloride solution and two experimental groups receiving either midazolam or fentanyl .  The patients included in the study were treated in the past and were presenting for repeat treatment after a significant period of symptom relief . OUTCOME MEASURES Outcomes were assessed at baseline and after the administration of 1 of the 3 solutions ( Group I , sodium chloride solution ; Group II , midazolam ; or Group III , fentanyl ) . Outcome measures included numeric pain scale , proportion of pain relief , and ability to perform prior painful movements . RESULTS Pain relief of > or = 80 % was noted in 5 % of the patients in Group I , 8 % in Group II , and 8 % in Group III . However , > or = 50 % relief was noted in 8 % of the patients in Group I , 13 % in Group II , and 27 % in Group III . Overall , 8 % of the patients in Group I , 13 % in Group II , and 27 % in Group III were able to perform movements which were painful prior to injection . CONCLUSION The administration of sedation with midazolam or fentanyl is a confounding factor in the diagnosis of cervical facet joint pain in patients with chronic neck pain . However , if > or = 80 % pain relief with ability to perform prior painful movements is used as the st and ard for evaluating the effect of controlled local anesthetic blocks , the diagnostic validity of cervical facet joint nerve blocks may be preserved Study Design . A survey of the prevalence of cervical zygapophysial jooint pain was conducted . Objectives . To determine the prevalence of cervical zygapophysial joint pain in patients with chronic neck pain after whiplash . Summary of Backgound Data . In a significant porportion of patients with whiplash , chronic , refractory neck pain develops . Provisional data suggests many of these patients have zygapophysial joint pain , but the diagnosis has been established by single , uncontrolled diagnostic blocks . Methods . Fifty consecutive , referred patients with chronic neck pain after whiplash injury were studid using double-blind , controlled , diagnotic blocks of the cervical zygapophysial joints . On separate occasions , the joint was blocked with either lignocaine or bupivacaine in r and om order . Results . A positive diagnosis was made only if both blocks relieved the patient 's pain and bupivacaine provided longer relief , Painful joints were identified in 54 % of the patients ( 95 % confidence interval , 40 % to 68 % ) . Conclusion . In this population , cervical zygapophysial joint pain was the most common source of chronic neck pain after whiplash Recent reports of provocative discography not only instill confusion , but also create numerous questions about its value in evaluating low back pain . It was reported that provocative discography produced pain in patients who were not suffering with low back pain but suffering with somatization disorder and depression . This study was design ed to evaluate 50 r and omly assigned patients , with 25 patients in Group I without somatization disorder and 25 patients in Group II with diagnosis of somatization disorder . In addition , depression , generalized anxiety disorder and combinations thereof were also evaluated . All patients underwent discography  , investigating two to three discs in each patient . All studies included a control level with a disc that did not produce the patient 's pain upon injection of contrast medium . Provocation with exact pain reproduction concordant with the symptom complex upon injection of contrast into the disc was considered positive . Any other response , with or without pain , was considered negative . Results showed positive provocative discography  in 46 % of the patients in the somatization group compared to 54 % in the non-somatization group ; in 46 % of patients with depression compared to 54 % of patients without depression ; in 15 of 30 patients with generalized anxiety disorder ; in 11 of 20 patients without generalized anxiety disorder ; and in 42 % of patients with combined somatization and depression , with negative discography in 58 % of the patients . It is concluded that provocative discography provides similar results in patients with or without somatization , with or without depression , with somatization but with or without depression or with other combinations of the psychological triad of somatization disorder , depression , and generalized anxiety disorder
BACKGROUND There is ongoing controversy regarding the validity of controlled diagnostic blocks due to variability in sensitivity , specificity , and accuracy .
Consequently , identification of false-positive rates , false-negative rates , and placebo responses is crucial .
The reasons described for false-positive responses to diagnostic anesthetic blocks are many ; however , sedation and psychological factors have been implied as causes .
Further , there is no consensus with regards to sedation prior to controlled diagnostic blocks and their influence on the accuracy and validity of a diagnosis .
STUDY DESIGN A systematic review of the literature evaluating the influence of sedation on diagnostic spinal interventional techniques .
OBJECTIVES To systematic ally assess the quality of clinical studies evaluating the diagnostic accuracy of controlled diagnostic blocks in the diagnosis of chronic spinal pain .