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Figure 4
Z Joint–Mediated Back Pain
Z joint–mediated back pain is the second most common etiology of low back
pain.1 The medial branches of the dorsal rami innervate the posterior
elements of the vertebrae and the corresponding segment of the multifidus
muscle. Pain arising from the Z joint can be diagnosed by injecting local
anesthetic into the Z joint directly, or by nerve block at the medial dorsal
rami branches with local anesthetic (Figure 4). Nerve block at the medial
branches supplying a Z joint is the preferred method of diagnosing Z joint
pain because this method has been validated;
30,31
intra-articular injections
have not been validated as a diagnostic method. This procedure is used as a
potential precursor to radiofrequency ablation of these nerves.
AP spinal radiograph demonstrates nerve blocks of the
medial branches of the dorsal rami at levels L3 and L4, and of the L5
dorsal ramus.
To make an accurate diagnosis of Z joint pain, dual blocks should be
performed on the same nerves on two separate occasions because of the
unacceptably high rate of false-positive results. The second injection should
be performed only if the first injection provided at least an 80% reduction in
pain for a time frame commensurate with the local anesthetic used. If the
second injection produces at least an 80% reduction in pain commensurate
with the duration of a local anesthetic, the Z joint can be attributed as the
cause of the patient’s pain. A positive response to dual diagnostic nerve
blocks predicts a positive response to radiofrequency neurotomy of these
nerves.
Complications associated with a medial branch block are minimal. These
include the general risks associated with any procedure that involves
puncture of the skin such as infection, bleeding, bruising, and pain. This
procedure is performed on the posterior spine and is thus distal to the
neuroaxis (that is, the spinal cord). This dramatically reduces the risk of
injury to the spinal cord directly by the needle or indirectly by injury to a
spinal cord radicular feeder vessel. Additional risks are associated with
therapeutic radiofrequency ablation because the goal is to create permanent
tissue damage; however, a detailed discussion is beyond the scope of this
chapter.
Sacroiliac Joint–Mediated Pain
SI joint pain as the etiology of axial low back pain is often overdiagnosed. SI
joint–mediated pain is not the most common cause of chronic low back pain.
One retrospective review of 358 patients demonstrated an approximate
18% prevalence rate of SI joint–mediated pain.1 The prevalence of pain
increased with age and prior lumbosacral fusion. However, accurate
diagnosis of SI joint–mediated pain can be difficult, and if dual nerve blocks
are used to confirm the diagnosis of low back pain, only 20% to 30% of
patients with expected SI joint pain will meet the diagnostic criteria based on
physical examination and imaging or with a history of lumbar fusion.
32,33
Diagnosing intra-articular SI joint pain as the etiology of low back pain via
history and physical examination is unreliable. Intra-articular SI joint
blockade is the most widely accepted procedure for the diagnosis of SI joint
pain.
Dual diagnostic blocks promote stricter criteria regarding the diagnosis of
SI joint–mediated low back pain by lowering the rate of false-positive results.
ISIS Guidelines5 state that at least 75% relief is needed to be considered a
positive response. Studies that used 50% to 74% relief as the cutoff had
higher rates of false-positive results.
34,35
Intra-articular blockade must be performed under image guidance
(fluoroscopy or CT) to ensure proper delivery of the anesthetic by means of
contrast administration through the spinal needle directly into the SI joint.
The use of ultrasonography to guide needle placement has been studied.
36
Only a small amount of anesthetic should be used to avoid aberrant flow and
false-positive findings.
The prognostic value of this procedure regarding outcomes with SI joint
fusion is not currently known. Favorable outcomes have been noted with
intra-articular corticosteroid injections after an appropriate response to dual
diagnostic nerve blockade.
37
Complications associated with intra-articular SI joint blockade are limited
to those associated with any intra-articular injection. Complications include
infection, bleeding, bruising, and additional pain.
Radiculopathy
The terms radiculopathy and radiculitis are often used interchangeably;
however, they should be properly and carefully differentiated. Radiculopathy
refers to pathology affecting a nerve root that may result in weakness,
decreased tone, diminished reflexes, and/or bodily dysfunction (such as
bladder incontinence). Radiculitis or radicular pain refers to irritation of the
nerve root but does not necessarily reflect a neurologic deficit. Irritation of
the nerve root is often what results in pain and abnormal sensation in a
dermatomal pattern. Radiculopathy and radiculitis can coexist, resulting in a
constellation of symptoms such as radicular pain in a dermatomal
distribution, with weakness affecting the musculature supplied by the
affected nerve root.
Figure 5
AP spinal radiograph demonstrates a selective nerve root
block at L5.
Radiculopathy and radiculitis are most commonly the sequelae of disk
herniation. Other causes of radiculopathy and radiculitis include canal and
foraminal stenosis and mass effect (such as Z joint cysts or tumors).
Advanced imaging, such as MRI, often helps determine the root cause of the
radiculopathy and/or radiculitis. When imaging demonstrates multilevel
spinal pathology or is inconclusive, additional diagnostic procedures
including electrodiagnostic studies and/or selective nerve root blocks
(SNRBs) may be needed to help determine the appropriate nerve root level
(Figure 5).
Electrodiagnostic studies such as electromyography and nerve conduction
velocity studies are used to determine nerve pathology, and can help
distinguish the location (for example, nerve root, plexopathy, distal
mononeuropathy, and peripheral neuropathy), chronicity, and severity of
nerve pathology. Electrodiagnostic studies will only demonstrate
abnormalities if a radiculopathy (physiologic change in nerve function) is
present, but results will be normal if only nerve irritation, or radiculitis, is
present.
Regarding radiculopathy, electrodiagnostic studies can be used to help
determine the specific nerve root level affected, especially when imaging
demonstrates multilevel pathology or is inconclusive. A drawback to
electromyography in the diagnosis of radiculopathy is that although highly
specific, sensitivity can be as low as 34%.38 In these situations, an SNRB can
help determine the nerve level involved.
SNRB is an anesthetic block performed at a specific nerve root level. A
needle is advanced to the neural foramen under fluoroscopic guidance,
contrast through the needle confirms placement, and an anesthetic is injected
to provide a temporary block to the specific nerve root level. Although
technically similar to transforaminal epidural steroid injections, the goal of a
SNRB is to block the nerve root only and minimize both injection into the
epidural space and spread of the anesthetic to other levels. Dissimilar to
electrodiagnostic studies, SNRB also can help in the diagnosis of radiculitis,
even when radiculopathy is not present. Multiple studies have determined the
specificity of SNRB to be 90% or higher,
39-41
and the sensitivity to be 85% or
higher.
39,41,42
One study reported a positive predictive value of 70% to 95%
for good surgical outcomes in patients who underwent surgery following
positive results for SNRB.41 The range in the positive predictive value is a
result of inclusion criteria; the positive predictive value decreases to 70% if
those who declined surgery are categorized as having had unsuccessful
surgery. One study reported that spinal nerve blockade did not predict
improved outcomes of surgery compared with MRI.43 However, negative
nerve blocks were predictors of poor outcome. Often, a corticosteroid is
injected after the anesthetic for therapeutic purposes.
Complications with SNRBs are rare, but they can be serious and include
infection, bleeding, bruising, increased pain, headache, dural puncture, and
permanent nerve lesion and/or paralysis. The neurologic risks increase the
more cephalad the procedure is performed (the risk increases as the procedure
level progresses from the lumbosacral nerve roots to levels at which the
spinal cord is present).
Summary
In addition to the history, physical examination, and imaging, the specific
diagnosis regarding the etiology of low back pain often can be facilitated by
diagnostic procedures. Diskography remains a controversial procedure in the
diagnosis of discogenic back pain and should be used only after other
diagnostic procedures, imaging, history, and physical examination have
rendered inconclusive results. Adherence to strict discographic guidelines can
result in favorable surgical outcomes.
Medial branch blocks for Z joint–mediated pain, intra-articular SI joint
blockade for SI joint pain and SNRB for radiculopathy and/or radicular pain
are procedures with high diagnostic and prognostic value and should be used
in the workup of low back pain when appropriate.
Key Study Points
Diskography, although controversial, can be a useful diagnostic procedure
with low false-positive rates, when performed using the strict criteria set
forth by the ISIS guidelines committee.
Evidence is mixed regarding whether diskography results in future disk
degeneration.
Anesthetic block of the medial branch of the dorsal ramus is the preferred
procedure for the diagnosis of Z joint–mediated pain.
Intra-articular anesthetic blockade with dual diagnostic blocks provides the
strictest criteria in the diagnosis of SI joint pain; injection must be
performed under fluoroscopic or CT guidance to ensure proper delivery of
anesthetic.
Studies have demonstrated that SNRB has high sensitivity and specificity
and can be used to help determine the level of nerve root pathology or
irritation if findings from the history, physical examination, imaging, and
electrodiagnostic studies are inconclusive.
Annotated References
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The intervertebral disks are the most common source of chronic low back pain in adults.
The younger the patient, the more likely it is that the disk is the pain generator. Facet
joint and SI joint–mediated pain is more prevalent in older patients.
2. Kang CH, Kim YH, Lee SH, et al: Can magnetic resonance imaging accurately predict
concordant pain provocation during provocative disc injection? Skeletal Radiol
2009;38(9):877-885.
3. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW: Abnormal magneticresonance scans of the lumbar spine in asymptomatic subjects: A prospective
investigation. J Bone Joint Surg Am 1990;72(3):403-408.
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Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J
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5. Bogduk N, ed: Practice Guidelines for Spinal Diagnostic and Treatment Procedures,
ed 2. San Francisco, CA, International Spine Intervention Society, 2013.
The most current evidence regarding spinal procedures is summarized, and descriptions
are provided on how to perform the procedures.
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Med 2013;14(6):813-836.
Discogenic pain can be diagnosed using strict operational criteria to reduce the
likelihood of false-positive results.
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