Table 4

Studies evaluating physical examination findings and facet block results

StudyDesign/criteria for positive blockInterventionsFindings
Fairbank et al 37 Prospective
Subjective pain relief
IA (double blocks, one injection at symptomatic level, another at a random level)Responders: pain in the back and thigh; straight leg raising test causes back pain.
Non-responders: pain in the back and leg; straight leg raising test causes leg pain
Lewinnek and Warfield40 Retrospective
Partial or complete pain relief with resumption of activities immediately and at 3 months
IA (single block)Patients who had no other cause of LBP or sciatica and had a combination of facet degeneration, pain and tenderness, were more likely to initially respond to injection.
Helbig and Lee38 Retrospective
Subjective pain relief from hours to months
IA (single block)A 100-point scorecard was developed:
Back pain with groin or thigh pain: +30
Well-localized paraspinal tenderness: +20
Reproduction of pain with extension-rotation: +30
Significant corresponding radiographic changes: +20
Pain below the knee: −10
Individuals with high scores (≥60) were likely to be responders but a low score could not reliably predict negative response to facet joint injections.
Jackson et al 39 Prospective
Difference in pre- and post-pain scores associated with lumbar motion
IA (single block)There were no unique characteristics identified in patients who reported either no or increased pain after injection.
However, the following factors correlated significantly with greater postinjection pain relief: older age, a history of LBP, no leg pain, pain not aggravated by Valsalva maneuver, normal gait, no muscle spasm and pain on extension after forward flexion.
Lilius et al 41 Prospective
Outcomes (subjective, work and disability) were assessed at 3 months
IA steroid/anesthetic, IA saline or pericapsular steroid/anesthetic
(single block)
Inappropriate (non-organic physical) signs and symptoms and previous back surgery were associated with treatment failure.
Schwarzer et al 42 Prospective
≥50% pain relief after a confirmatory block
(double comparative diagnostic blocks)
Neither clinical features (range of motion and straight leg raising test) nor pain referral patterns could predict response to diagnostic blocks.
No patient with central/midline spinal pain responded to a confirmatory block.
Schwarzer et al 43 Prospective
≥50% LBP reduction to bupivacaine block×3 hours but no response to placebo
IA and placebo
(placebo controlled: normal saline to superficial muscle)
Similar history and examination features were seen in patients with or without facet joint pain.
Revel et al 44 Prospective
≥75% LBP reduction
IA (single block)Seven characteristics (Revel’s criteria) were more frequent in patients with pain relief from facet blocks: older age; absence of pain exacerbation by coughing, absence of pain exacerbation by lumbar hyperextension, absence of pain exacerbation by forward flexion and rising from forward flexion, absence of pain exacerbation by extension-rotation and pain relieved by recumbency.
Revel et al 45 Prospective, controlled
n=80–42 who received lidocaine
≥75% LBP reduction
IA local anesthetic or placebo (IA saline)The presence of at least five of the seven Revel’s criteria (above) including pain reduction by recumbency resulted in 92% sensitivity and 80% specificity.
Manchikanti et al 50 Prospective
≥75% pain reduction
(double comparative diagnostic blocks)
The prevalence of clinical findings (pain better by sitting/lying, pain worsened by sitting/standing/walking/coughing/lumbar spine range of motion, positive straight leg raising test and pain referral pattern) were similar between positive and negative block groups. Back pain with straight leg raising was weakly associated with positive blocks.
Manchikanti et al 52 Prospective
≥75% pain reduction
(double comparative diagnostic blocks, lidocaine±Sarapin±steroid, bupivacaine alone)
Back or leg pain during straight leg raising was negatively associated with pain relief from facet blocks.
Manchikanti et al 51 Prospective
≥75% pain reduction
(double comparative diagnostic blocks)
A large number of individual clinical characteristics did not correlate with facet mediated pain diagnosed by double blocks.
Young et al 46 Prospective
An injection produced concordant pain and ≥80% pain reduction
IA (single block)Absence of worsening LBP during rising from sitting was associated with a positive response to facet injections.
Centralization of pain was associated with negative response to facet injections.
Laslett et al 47 Prospective
≥75% pain relief or complete eradication of primary pain
(single block)
Revel’s criteria had low sensitivity and high specificity; therefore, the authors concluded they are not appropriate for screening purposes.
Age ≥65 years reached predictive significance with complete eradication of primary pain as a reference; no pain with cough/sneezing and no worsening of pain when rising from flexion approached predictive significance with ≥75% LBP relief as a reference.
Laslett et al 48 Prospective
≥75% pain reduction stratified in 5% increments
(single block)
CPR consist of combinations of seven characteristics: age ≥50; pain is least when walking/sitting; paraspinal pain; modified somatic perception questionnaire >13; positive extension-rotation test and absence of centralization.
When positive response to facet block is set at 95% pain reduction, four CPRs have 100% sensitivity, one CPR improved post-test probability by five-fold.
Cohen et al 54 Retrospective
Patient selection:
≥50% pain reduction
RFA success:
≥50% pain relief×6 months
MBB (single block)
RFA success patients were more likely to have paraspinal tenderness, whereas positive ‘facet loading’ (pain worsened by extension-rotation) and chronic opioid use were more prevalent in RFA failure patients.
DePalma et al 49 Retrospective
n=160–52 with lumbar facet joint pain
≥75% pain reduction
IA (double comparative diagnostic blocks)Paraspinal low back pain had a sensitivity of 95% and specificity of 25%. Lack of paraspinal tenderness suggested the facet joints were unlikely to be the source of axial LBP.
The diagnostic sensitivity of midline LBP is low for facet joint pain.
DePalma et al 15 Retrospective, n=157–49 with lumbar facet joint pain
≥75% pain reduction
MBB (double comparative blocks)Facet joint pain patients were more likely to be older than those with internal disc disruption, and more likely to be obese than those with sacroiliac joint pain.
Streitberger et al 55 Prospective
Patient selection:
Pain relief ≥50%, but one block had to result in ≥80% benefit
RFA success:
≥50% pain relief
MBB (double comparative diagnostic blocks with lidocaine and bupivacaine)
Only depression was associated with a shorter duration of RFA success.
Conger et al 56 Retrospective
≥80% concordant pain relief
RFA success: ≥50% pain relief at 6 months
MBB (double comparative diagnostic blocks with lidocaine and bupivacaine)
Older age and larger Cobb angle associated with RFA treatment success.
Cohen et al 57 Prospective
n=318 (63 with suspected facet joint pain)
Patient selection:
≥50% pain reduction after a block
RFA success:
≥50% pain relief×3 months
MBB (single block)
Number of Waddell signs inversely correlated with treatment outcomes. Factors associated with treatment success included older age, shorter duration of pain, lower baseline pain scores and functional disability, absence of secondary gain and not having concomitant pain and psychiatric conditions. Among concurrent comorbidities, the presence of pelvic or abdominal pain and depression were most strongly correlated with negative outcome.
  • Double comparative diagnostic blocks refer to two separate blocks with lidocaine and bupivacaine.

  • CPR, clinical prediction rule; IA, intra-articular injection; LBP, low back pain; MBB, medial branch block; RFA, radiofrequency ablation.